SELECTED PAPERS ON HYSTERIA AND OTHER PSYCHONEUROSES
Transcriber’s Note:
New original cover art included with this eBook is granted to the public domain.
BY
PROF. SIGMUND FREUD
VIENNA
AUTHORIZED TRANSLATION
BY
A. A. BRILL, Ph.D., M.D.
CHIEF OF NERVOUS DISPENSARY, BETH ISRAEL HOSPITAL; CLINICAL ASSISTANT, DEPARTMENT OF PSYCHIATRY AND NEUROLOGY, COLUMBIA UNIVERSITY; ASSISTANT IN MENTAL AND NERVOUS DISEASES, O. P. D., BELLEVUE HOSPITAL; ASSISTANT VISITING PHYSICIAN, HOSPITAL FOR NERVOUS DISEASES.
NEW YORK
THE JOURNAL OF NERVOUS AND MENTAL DISEASE
PUBLISHING COMPANY
1909
Copyright 1909, by
The Journal of Nervous and Mental Disease Publishing Company.
In the first place I wish to express my gratitude to Doctors
Frederick Peterson, William A. White, and Ernest Jones, for
their many helpful suggestions in the translation of this work.
This does not, however, imply that they are in any way responsible
for the numerous barbarisms found in the translation,
for this I, alone, ask the reader’s indulgence. For one thing, it
must be borne in mind that, aside from the subject-matter, Freud
is not easy to read, even in the original. Indeed, I feel quite
certain that only those who have read the original will best appreciate
the task of the translator. But no matter how devoid
of literary excellencies this translation may be, it can at least
claim one merit, to wit, it is a faithful reproduction of the
author’s thoughts. This is really all that should be required of a
translation.
The chapters contained in this book were taken from three
different volumes of the author’s works, published at different
intervals within the last fifteen years. Although the first four
chapters appear in the “Studien über Hysterie” which was published
by Breuer and Freud,[1] still only the first chapter, “The
Psychic Mechanism of Hysterical Phenomena,” was written conjointly
by both authors. The authorship of the other three
chapters belongs exclusively to Freud. The remaining six
chapters of the book were taken from Freud’s Collection of
Small Articles.[2]
It was by no means an easy task to compile in a single limited
volume Freud’s theories of the actual- and psychoneuroses.
Freud’s views are not only new and revolutionary, being based
on an entirely new psychology, but unless one is thoroughly
familiar with their development one is apt to misunderstand them.
To obviate this it was thought best to collect those chapters from
ivthe author’s works which fully illustrate his theories and at the
same time show the gradual evolution of his psychology.
That Freud’s views have undergone some changes, or rather
modifications, within the last fifteen years we readily admit; but
who will blame the surgeon for modifying or rejecting some
technique of his operation, if after years of careful work he
feels justified in so doing? Surely such an action merits applause
rather than reproach. It was only after carefully investigating
for years that Freud saw fit to change some of his
views, yet nothing was really totally discarded.
It is quite unnecessary to discuss here the whys and wherefores
of the modifications in question, these are fully explained in the
text. But it will not be mal à propos to say a few words concerning
the technique of the treatment.
For reasons given in the book the author has abandoned
hypnotism and used the pressure procedure, but this in turn was
given up because it was cumbersome for both doctor and patient
and proved to be utterly needless.
The technique is as follows: The patient lies on his back on a
lounge, the physician sitting behind the patient’s head at the head
of the lounge. In this way the patient remains free from all
external influences and impressions. The object is to avoid all
muscular exertion and distraction, thus allowing thorough concentration
of attention on the patient’s own psychic activities.
The patient is then asked to give a detailed account of his
troubles, after having been told before to repeat everything that
occurs to his mind, even such thoughts as may cause him embarrassment
or mortification. On listening to such a history one
invariably notices many memory gaps, both in reference to time
and causal relations. These the patient is urged to fill in by concentration
of attention on the subject in question, and by repeating
all the unintentional thoughts originating in this connection.
This is the so called method of “free association!” The patient
is required to relate all his thoughts in the order of their sequence
even if they seem irrelevant to him. He must do away with all
critique and remain perfectly passive. It is in this way that we
fathom the original meaning of the symptom. But as the
thoughts which originate in this manner are of a disagreeable
and painful nature they are pushed back with the greatest resistance.
vThis is further enhanced by the fact that the hysterical
symptom is the symbolic expression of the realization of a repressed
wish, and serves as a gratification for the patient. He
strives very hard, unconsciously of course, to retain the symptom,
as it is the only thing left to him from his former unattainable
conscious wishes and strivings. The object of the psychanalytic
treatment is to overcome all these resistances, and to
reconduct to the patient’s consciousness the thoughts underlying
the symptoms. Here lies the greatest difficulty, for just as in
the normal life and the dream, a psychoneurotic symptom is
merely a symbolic or cryptic expression of the original repressed
thoughts. Every hysterical symptom, every obsession, and every
phobia, has a definite meaning, and as was shown by Bleuler,[3]
Jung,[4] Riklin,[5] and others,[6] the same holds true for the psychoses
proper.
To discover the hidden mechanism, one must make use of the
author’s developed method of interpretation, that is, one must
look for symbolic actions, lapses in speech, memory, etc., and
above all, one must resort to the analysis of dreams, as they
give the most direct access to the unconscious. No one is really
qualified to use or judge Freud’s psychanalytic method who has
not thoroughly mastered the Traumdeutung,[7] the Psychopathologie
des Alltagsleben,[8] and the Drei Abhandlungen zur Sexualtheorie,[9]
and has not had considerable experience in analyzing his own
and other’s dreams and psychopathological actions. It is especially
in the Traumdeutung that Freud has fully developed his
psychanalytic technique and a perfect knowledge of which is the
sine qua non in the treatment. It is only by following Freud in
this manner that one can hope to solve the hitherto unsolved
riddles of the psychoneuroses and psychoses.
viThis treatment is more difficult than one can describe in a
preface. It not only presupposes a thorough knowledge of Freud
but an equal knowledge of normal and abnormal psychology.
Those who have not acquired this knowledge by reason of time
or otherwise may remember the words of the younger Pliny:
Ut enim de pictore scalptore fictore nisi artifex indicare, ita nisi
sapiens non potest perspicere sapientem.
A. A. Brill.
CHAPTER I. The Psychic Mechanism of Hysterical Phenomena. [10] ( Preliminary Communication. ) — I. — II. — III. — IV. — V.
1
Instigated by a number of accidental observations we have
investigated for a number of years the different forms and symptoms
of hysteria in order to discover the cause and the process
which provoked the phenomena in question for the first time,
in a great many cases years back. In the great majority of cases
we did not succeed in elucidating this starting point from the
mere history, no matter how detailed it might have been, partly
because we had to deal with experiences about which discussion
was disagreeable to the patients, but mainly because they really
could not recall them; often they had no inkling of the causal
connection between the occasioning process and the pathological
phenomenon. It was generally necessary to hypnotize the
patients and reawaken the memory of that time in which the
symptom first appeared, and we thus succeeded in exposing that
connection in a most precise and convincing manner.
This method of examination in a great number of cases has
furnished us with results which seem to be of theoretical as well
as of practical value.
It is of theoretical value because it has shown to us that in
the determination of the pathology of hysteria the accidental
moment plays a much greater part than is generally known and
recognized. It is quite evident that in “traumatic” hysteria it is
the accident which evokes the syndrome. Moreover in hysterical
crises, if patients state that they hallucinate in each attack the
same process which evoked the first attack, here too, the causal
connection seems quite clear. The state of affairs is more obscure
in the other phenomena.
Our experiences have shown us that the most varied symptoms
2which pass as spontaneous, or so to say idiopathic attainments
of hysteria, stand in just as stringent connection with the causal
trauma as the transparent phenomena mentioned. To such causal
moments we were able to refer neuralgias as well as the different
kinds of anesthesias often of years duration, contractures and
paralyses, hysterical attacks and epileptiform convulsions which
every observer has taken for real epilepsy, petit mal and tic-like
affections, persistent vomiting and anorexia, even the refusal
of nourishment, all kinds of visual disturbances, constantly recurring
visual hallucinations, and similar affections. The disproportion
between the hysterical symptom of years duration
and the former cause is the same as the one we are regularly
accustomed to see in the traumatic neurosis. Very often they
are experiences of childhood which have established more or
less intensive morbid phenomena for all succeeding years.
The connection is often so clear that it is perfectly manifest
how the causal event produced just this and no other phenomenon.
It is quite clearly determined by the cause. Thus let us take the
most banal example; if a painful affect originates while eating
but is repressed, it may produce nausea and vomiting and continue
for months as a hysterical symptom. A girl was anxiously
distressed while watching at a sick bed. She fell into a dreamy
state and experienced a frightful hallucination, and at the same
time her right arm hanging over the back of a chair became
numb. This resulted in a paralysis, contracture, and anesthesia
of that arm. She wanted to pray but could find no words, but
finally succeeded in uttering an English prayer for children.
Later, on developing a very grave and most complicated hysteria,
she spoke, wrote, and understood only English, whereas her
native tongue was incomprehensible to her for a year and a half.
A very sick child finally falls asleep. The mother exerts all her
will power to make no noise to awaken it, but just because she
resolved to do so she emits a clicking sound with her tongue
(“hysterical counter-will”). This was later repeated on another
occasion when she wished to be absolutely quiet, developing into
a tic which in the form of tongue clicking accompanied every
excitement for years. A very intelligent man was present while
his brother was anesthetized and his ankylosed hip stretched.
At the moment when the joint yielded and crackled he perceived
severe pain in his own hip which continued for almost a year.
3In other cases the connection is not so simple, there being only
as it were a symbolic relation between the cause and the pathological
phenomenon, just as in the normal dream. Thus psychic
pain may result in neuralgia, or the affect of moral disgust may
cause vomiting. We have studied patients who were wont to
make the most prolific use of such symbolization. In still other
cases such a determination is at first sight incomprehensible, yet
to this group belong the typical hysterical symptoms such as
hemianesthesia, contraction of visual field, epileptiform convulsions
and many others. The explanation of our views on this
group we have to reserve for the more detailed discussion of the
subject.
Such observations seem to demonstrate the pathogenic analogy
between simple hysteria and traumatic neurosis and justify a
broader conception of “traumatic hysteria.” The active etiological
factor in traumatic neurosis is really not the insignificant
bodily injury but the affect of the fright, that is, the psychic
trauma. In an analogous manner our investigations show that
the causes of many, if not of all, cases of hysteria can be
designated as psychic traumas. Every experience which produces
the painful affect of fear, anxiety, shame or of psychic
pain may act as a psychic trauma. Whether an experience becomes
of traumatic importance naturally depends on the person
affected as well as on the determination to be mentioned later. In
ordinary hysteria instead of one big trauma we not seldom find
many partial traumas, grouped causes which can be of traumatic
significance only when summarized and which belong together
in so far as they form small fragments of the sorrowful tale.
In still other cases apparently indifferent circumstances gain traumatic
dignity through their connection with the real effective
event or with a period of time of special excitability which they
then retain but which otherwise would have no significance.
Nevertheless the causal connection between the provoking
psychic trauma and the hysterical phenomena does not perhaps
resemble the trauma which as the agent provocateur would call
forth the symptom which would become independent and continue
to exist. We have to claim still more, namely, that the
psychic trauma or the memory of the same acts like a foreign
body which even long after its penetration must continue to influence
4like a new causative factor. The proof of this we see
in a most remarkable phenomenon which at the same time gives
to our discoveries a distinct practical interest.
We found, at first to our greatest surprise, that the individual
hysterical symptoms immediately disappeared without returning
if we succeeded in thoroughly awakening the memories of the
causal process with its accompanying affect, and if the patient
circumstantially discussed the process giving free play to the
affect. Affectless memories are almost utterly useless. The
psychic process originally rebuffed must be reproduced as vividly
as possible so as to bring it back into the statum nascendi and
then be thoroughly “talked over.” At the same time if we deal
with such exciting manifestations as convulsions, neuralgias and
hallucinations they appear once more with their full intensity
and then vanish forever. Functional attacks like paralyses and
anesthesias likewise disappear, but naturally without any appreciable
distinctness of their momentary aggravation.[11]
It is quite reasonable to suspect that one deals here with an
unintentional suggestion. The patient expects to be relieved of
his suffering and it is this expectation and not the discussion
that is the effectual factor. But this is not so. The first observation
of this kind in which a most complicated case of hysteria
was analyzed and the individual causal symptoms separately abrogated,
occurred in the year 1881, that is in a “pre-suggestive”
time. It was brought about through a spontaneous autohypnosis
of the patient and caused the examiner the greatest surprise.
In reversing the sentence: cessante causa cessat effectus, we
may conclude from this observation that the causal process continues
to act in some way even after years, not indirectly by means
5of a chain of causal connecting links but directly as a provoking
cause, just perhaps as in the awakened consciousness where the
memory of a psychic pain may later call forth tears. The hysteric
suffers mostly from reminiscences.[12]
It would seem at first rather surprising that long-forgotten
experiences should effect so intensively, and that their recollections
should not be subject to the decay into which all our
memories merge. We will perhaps gain some understanding of
these facts by the following examinations.
The blurring or loss of an affect of memory depends on a
great many factors. In the first place it is of great consequence
whether there was an energetic reaction to the affectful experience
or not. By reaction we here understand a whole series of
voluntary or involuntary reflexes, from crying to an act of
revenge, through which according to experience affects are discharged.
If the success of this reaction is of sufficient strength
it results in the disappearance of a great part of the affect.
Language attests this fact of daily observation, in such expressions
as “to give vent to one’s feeling,” to be “relieved by
weeping,” etc.
If the reaction is suppressed the affect remains united with the
memory. An insult retaliated, be it only in words, is differently
recalled than one that had to be taken in silence. Language
also recognizes this distinction between the psychic and physical
results and designates most characteristically the silently endured
suffering as “grievance.” The reaction of the person injured
to the trauma has really no perfect “cathartic” effect unless
it is an adequate reaction like revenge. But man finds a substitute
for this action in speech through which help the affect can
well nigh be ab-reacted[13] (“abreagirt”). In other cases talking
6in the form of deploring and giving vent to the torments of the
secret (confession) is in itself an adequate reflex. If such reaction
does not result through deeds, words, or in the lightest
case through weeping, the memory of the occurrence retains
above all the affective accentuation.
The ab-reaction (abreagiren), however, is not the only form
of discharge at the disposal of the normal psychic mechanism of
the healthy person who has experienced a psychic trauma. The
memory of the trauma even where it has not been ab-reacted
enters into the great complex of the association. It joins the
other experiences which are perhaps antagonistic to it and thus
undergoes correction through the other ideas. For example,
after an accident the memory of the danger and (dimmed)
repetition of the fright is accompanied by the recollection of the
further course, the rescue, and the consciousness of present
security. The memory of a grievance may be corrected by a
rectification of the state of affairs by reflecting upon one’s own
dignity and similar things. Thus the normal person is able to
cause a disappearance of the accompanying affect by means of
association.
In addition there appears that general blurring of impressions,
that fading of memories which we call “forgetting,” and which
above all wears out the affective ideas no longer active.
It follows from our observations that those memories which
become the causes of hysterical phenomena have been preserved
for a long time with wonderful freshness and with their perfect
emotional tone. As a further striking and a later realizable fact
we have to mention that the patients do not perhaps have the
same control of these as of their other memories of life. On the
contrary, these experiences are either completely lacking from
the memory of the patients in their usual psychic state or at most
exist greatly abridged. Only after the patients are questioned in
the hypnotic state do these memories appear with the undiminished
vividness of fresh occurrences. Thus one of our
patients in a hypnotic state reproduced with hallucinatory vividness
throughout half a year all that excited her during an acute
7hysteria on the same days of the preceding year. Her mother’s
diary which was unknown to the patient proved the faultless accuracy
of the reproduction. Another patient, partly in hypnosis
and partly in spontaneous attacks, went through with a hallucinatory
distinctness all experiences of a hysterical psychosis which
she passed through ten years before and for the greatest part of
which she was amnesic until its reappearance. She also showed
with surprising integrity and sentient force some etiologically
important memories of fifteen to twenty-five years’ duration
which on their return acted with the full affective force of new
experiences.
The reason for this we can only find in the fact that in all
the aforesaid relations these memories assume an exceptional
position in reference to disappearance. It was really shown that
these memories correspond to traumas which were not sufficiently
ab-reacted to (“abreagirt”). On closer investigation of the
reasons for this prevention we can find at least two series of
determinants through which the reaction to the trauma was discontinued.
To the first group we add those cases in which the patient
has not reacted to psychic traumas because the nature of
the trauma precluded a reaction as in the case of an irremediable
loss of a beloved person or because social relations made the
reaction impossible, or because it concerned things which the
patient wished to forget and which he therefore intentionally
inhibited and repressed from his conscious memory. It is just
those painful things which in the hypnotic state are found to
be the basis of hysterical phenomena (hysterical delirium of
saints, nuns, abstinent women, and well-bred children).
The second series of determinants is not conditioned by the
content of the memories but by the psychic states with which the
corresponding experiences in the patient have united. As a cause
of hysterical symptoms one really finds in hypnosis presentations
which are insignificant in themselves but which owe their preservation
to the fact that they originated during a severe paralyzing
affect like fright or directly in abnormal psychic conditions,
as in the semi-hypnotic dreamy states of reveries, in autohypnosis
and similar states. Here it is the nature of these conditions
which make a reaction to the incident impossible.
8To be sure both determinants may unite, and as a matter
of fact they often do. This is the case when a trauma in itself
effective occurs in a state of a powerful paralyzing affect or in a
transformed consciousness. But due to the psychic trauma it
may also happen that in many persons one of these abnormal
states occurs which in turn makes a reaction impossible.
What is common to both groups of determinants is the fact
that those psychic traumas which are not rectified by reaction are
also prevented from adjustment by associative elaboration. In
the first group it is due to the resolution of the patient who
wishes to forget the painful experiences and in this way, if
possible, to exclude them from association, and in the second
group the associative elaboration does not succeed because there
is no productive associative relationship between the normal and
pathological state of consciousness in which these presentations
originated. We shall soon have occasion to discuss more fully
these relationships.
Hence we can say, that the reason why the pathogenically
formed presentations retain their freshness and affective force is
because they are not subject to the normal waste through ab-reaction
and reproduction in conditions of uninhibited association.
When we discussed the conditions which, according to our
experience, are decisive in the development of hysterical phenomena
from psychic traumas, we were forced to speak of abnormal
states of consciousness in which such pathogenic presentations
originate, and we had to emphasize the fact that the
recollection of the effective psychic trauma is not to be found in
the normal memory of the patient but in the hypnotized memory.
The more we occupied ourselves with these phenomena the more
certain became our convictions that the splitting of consciousness,
so striking in the familiar classical cases of double consciousness,
exists rudimentarily in every hysteria, and that the tendency to
this dissociation, and with it the tendency towards the appearance
of abnormal states of consciousness which we comprehend
as “hypnoid states,” is the chief phenomenon of this neurosis. In
this view we agree with Binet and with both the Janets about
9whose most remarkable findings in anesthetics we have had no
experience.
Hence, to the often cited axiom, “Hypnosis is artificial
hysteria,” we would like to add another: “The existence of
hypnoid states is the basis and determination of hysteria.” These
hypnoid states in all their diversities agree among themselves and
with hypnosis in the fact that their emerged presentations are
very intensive but are excluded from the associative relations of
the rest of the content of consciousness. The hypnoid states are
associable among themselves, and their ideation may thus attain
various high degrees of psychic organization. In other respects
the nature of these states and the degree of their exclusiveness
differ from the rest of the conscious processes as do the various
states in hypnosis, which range from light somnolence to somnambulism,
and from perfect memory to absolute amnesia.
If such hypnoid states already exist before the manifested
disease they prepare the soil upon which the affect establishes the
pathogenic memories and their somatic resulting manifestations.
This behavior corresponds to the predisposed hysteria. But the
results of our observations show that a severe trauma (like that
of a traumatic neurosis) or a painful suppression (perhaps of a
sexual affect) may bring about a splitting of presentation groups
even in persons otherwise not predisposed. This would then be
the mechanism of the psychically acquired hysteria. Between
the extremes of these two forms we have to admit a series in
which the facility of dissociation in the concerned individuals and
the magnitude of the affect of the trauma vary inversely.
We are unable to give anything new concerning the formation
of the predisposed hypnoid states. We presume that they often
develop from “reveries” very common to the normal for which,
for example, the feminine handwork offers so much opportunity.
The questions why “the pathological associations” formed in
such states are so firm and why they exert a stronger influence
on the somatic processes than other presentations, all fall together
with the problem of the effectivity of hypnotic suggestions in
general. Our experiences in this matter do not show us anything
new, on the other hand they throw light on the contradiction
between the sentence “Hysteria is a psychosis” and the
fact that among hysterics one may meet persons of the clearest
10intellects, the strongest wills, greatest principles, and of the
subtlest minds. In these cases such characteristics are only
true for the waking thought of the person, for in his hypnotic
state he is alienated just as we are in the dream. Yet, whereas
our dream psychoses do not influence our waking state, the
products of hypnotic states project as hysterical phenomena into
the waking state.
Almost the same assertions that we have advanced in reference
to the continuous hysterical symptoms we may also repeat concerning
hysterical crises. As is known we have Charcot’s
schematic description of the “major” hysterical attack which
when complete shows four phases: (1) The epileptoid, (2) the
grand movements, (3) the emotional—attitudes passionnelles
(hallucinatory phase), and (4) the delirious. By shortening or
prolonging the attack and by isolating the individual phases
Charcot caused a succession of all those forms of the hysterical
attack which are really observed more frequently than the complete
grande attaque.
Our attempted explanation refers to the third phase, that is
the attitudes passionnelles. Wherever it is prominent it contains
the hallucinatory reproduction of a memory which was significant
for the hysterical onset. It is the memory of a grand trauma,
the so called κατ’ ἐξοχὴν of traumatic hysteria or of a series of
connected partial traumas found at the basis of the common
hysteria. Finally the attack may bring back that occurrence
which on account of its meeting with a moment of special predisposition
was raised to a trauma.
There are also attacks which ostensibly consist only of motor
phenomena and lack the passionnelle phase. If it is possible during
such an attack of general twitching, cataleptic rigidity or an
attaque de sommeil, to put one’s self en rapport with the patient,
or still better, if one succeeds in evoking the attack in a hypnotic
state, it will then be found that here, too, the root of it is the
memory of a psychic trauma, or of a series of traumas which
make themselves otherwise prominent in an hallucinatory phase.
A little girl had suffered for years from attacks of general convulsions
which could be and were taken for epileptic. She was
11hypnotized for purposes of differential diagnosis and she immediately
merged into one of her attacks. On being asked what
she saw she said, “The dog, the dog is coming,” and it was really
found that the first attack of this kind appeared after she was
pursued by a mad dog. The success of the therapy then verified
our diagnosis.
An official who became hysterical as a result of ill treatment
on the part of his employer suffered from attacks, during which
he fell to the floor raging furiously without uttering a word or
displaying any hallucinations. The attack was provoked in a
state of hypnosis and he then stated that he lived through the
scene during which his employer insulted him in the street and
struck him with a cane. A few days later he came to me complaining
that he had the same attack, but this time it was shown
in the hypnosis that he went through the scene which was really
connected with the onset of his disease; it was the scene in the
court room when he was unable to get satisfaction for the ill
treatment which he received, etc.
The memories which appear in hysterical attacks or which
can be awakened in them correspond in all other respects to the
causes which we have found as the basis of the continuous
hysterical symptoms. Like these they refer to psychic traumas
which were prevented from alleviation by ab-reaction or by
associative elaboration, like these they lack entirely or in their
essential components the memory possibilities of normal consciousness
and appear to belong to the ideation of hypnoid states
of consciousness with limited associations. Finally they are
also amenable to therapeutic proof. Our observations have often
taught us that a memory which has always evoked attacks becomes
incapacitated when in a hypnotic state it is brought to
reaction and associative correction.
The motor phenomena of the hysterical attack can partly be
interpreted as the memory of a general form of reaction of the
accompanying affect, or partly as a direct motor expression of
this memory (like the fidgeting of the whole body which even
infants make use of), and partly, like the hysterical stigmata—the
continuous symptoms—they are inexplainable on this assumption.
Of special significance for the hysterical attack is the aforementioned
theory, namely, that in hysteria there are presentation
12groups which come to light in hypnoid states which are
excluded from the rest of the associative process but are associable
among themselves, thus representing a more or less
highly organized rudimentary second consciousness, a condition
seconde. A persistent hysterical symptom therefore corresponds
to a projection of this second state into a bodily innervation
otherwise controlled by the normal consciousness. A hysterical
attack gives evidence of a higher organization of this second
state, and if of recent origin it signifies a moment in which this
hypnoid consciousness gained control of the whole existence, and
hence we have an acute hysteria, but if it is a recurrent attack
containing a memory we simply have a repetition of the same.
Charcot has already given utterance to the fact that the hysterical
attack must be the rudiment of a condition seconde. During
the attack the control of the whole bodily innervation is transferred
to the hypnoid consciousness. As familiar experiences
show, the normal consciousness is not always repressed, it may
even perceive the motor phenomena of the attack while the
psychic processes of the same escape its cognizance.
The typical course of a grave hysteria, as everybody knows, is
as follows: At first an ideation is formed in the hypnoid state
which after sufficient development gains control in a period of
“acute hysteria” of the bodily innervation and the existence of
the patient thus forming persistent symptoms and attacks, and
then with the exception of some remnants there is a recovery.
If the normal personality can regain the upper hand, all that
survived the hypnoid ideation then returns in hysterical attacks
and at times it reproduces, in the personality, states which are
again amenable to influences and capable of being affected by
traumas. Frequently a sort of equilibrium then results among
the psychic groups which are united in the same person; attack
and normal life go hand in hand without influencing each other.
The attack then comes spontaneously just as memories are wont
to come, it may also be provoked just as memories may be by
the laws of association. The provocation of the attack results
either through stimulating a hysterogenic zone or through a new
experience which by similarity recalls the pathogenic experience.
We hope to be able to show that there is no essential difference
between the apparently two diverse determinants, and that in both
cases the hyperesthetic memory is touched. In other cases there
13is a great lability of equilibrium, the attack appears as a manifestation
of the hypnoid remnant of consciousness as often as the
normal person becomes exhausted and incapacitated. We cannot
disregard the fact that in such cases the attack becomes denuded
of its original significance and may return as a contentless motor
reaction.
It remains a task for future investigation to discover what
conditions are decisive in determining whether a hysterical individuality
should manifest itself in attacks, in persistent symptoms,
or in a mingling of both.
We can now understand in what manner the psychotherapeutic
method propounded by us exerts its curative effect. It abrogates
the efficacy of the original not ab-reacted presentation of affording
an outlet to the strangulated affect through speech. It
brings it to associative correction by drawing it into normal consciousness
(in mild hypnosis) or it is done away with through
the physician’s suggestion just as happens in somnambulism with
amnesia.
We maintain that the therapeutic gain obtained by applying
this process is quite significant. To be sure we do not cure the
hysterical predisposition as we do not block the way for the
recurrence of hypnoid states; moreover, in the productive stage
of acute hysteria our procedure is unable to prevent the replacement
of the carefully abrogated phenomena by new ones. But
when this acute stage has run its course and its remnants continue
as persistent hysterical symptoms and attacks, our radical
method usually removes them forever, and herein it seems to
surpass the efficacy of direct suggestion as practiced at present
by psychotherapists.
If by disclosing the psychic mechanisms of hysterical phenomena
we have taken a step forward on the path so successfully
started by Charcot with his explanation and experimental imitation
of hystero-traumatic paralysis, we are well aware that in
doing this we have only advanced our knowledge in the mechanisms
of hysterical symptoms and not in the subjective causes of
hysteria. We have but touched upon the etiology of hysteria
and could only throw light on the causes of the acquired forms,
the significance of the accidental moments in the neurosis.
CHAPTER II. The Case of Miss Lucy R. — Epicrisis.
14
Towards the end of 1892 a friendly colleague recommended to
me a young lady whom he had been treating for chronic recurrent
purulent rhinitis. It was later found that the obstinacy of her
trouble was caused by a caries of the ethmoid. She finally complained
of new symptoms which this experienced physician could
no longer refer to local affections. She had lost all perception of
smell and was almost constantly bothered by one or two subjective
sensations of smell. This she found very irksome. In addition
to this she was depressed in spirits, weak, and complained of a
heavy head, loss of appetite, and an incapacity for work.
This young lady visited me from time to time during my office
hours—she was a governess in the family of a factory superintendent
living in the suburbs of Vienna. She was an English
lady of rather delicate constitution, anemic, and with the exception
of her nasal trouble was in good health. Her first statements
concurred with those of her physician. She suffered
from depression and lassitude, and was tormented by subjective
sensations of smell. Of hysterical signs, she showed a quite distinct
general analgesia without tactile impairment, the fields of
vision showed no narrowing on coarse testing with the hand, the
nasal mucous membrane was totally analgesic and reflexless,
tactile sensation was absent, and the perception of this organ was
abolished for specific as well as for other stimuli, such as ammonia
or acetic acid. The purulent nasal catarrh was then in
a state of improvement.
On first attempting to understand this case the subjective sensations
of smell had to be taken as recurrent hallucinations interpreting
persistent hysterical symptoms. The depression was
perhaps the affect belonging to the trauma and there must have
been an episode during which the present subjective sensations
were objective. This episode must have been the trauma, the
symbols of which recurred in memory as sensations of smell.
Perhaps it would be more correct to consider the recurring
15hallucinations of smell with the accompanying depression as
equivalents of hysterical attacks. The nature of recurrent hallucinations
really makes them unfit to take the part of continuous
symptoms, and this really did not occur in this rudimentarily developed
case. On the other hand it was absolutely to be expected
that the subjective sensations of smell would show such a specialization
as to be able to correspond in its origin to a very definite
and real object.
This expectation was soon fulfilled, for on being asked what
odor troubled her most she stated that it was an odor of burned
pastry. I could then assume that the odor of burned pastry really
occurred in the traumatic event. It is quite unusual to select
sensations of smell as memory symbols of traumas, but it is
quite obvious why these were here selected. She was afflicted
with purulent rhinitis, hence the nose and its perceptions were
in the foreground of her attention. All I knew about the life
of the patient was that she took care of two children whose
mother died a few years ago from a grave and acute disease.
As a starting point of the analysis I decided to use the “odor
of burned pastry.” I will now relate the history of this analysis.
It could have occurred under more favorable conditions, but as
a matter of fact what should have taken place in one session was
extended over a number of them. She could only visit me during
my office hours, during which I could devote to her but little of
my time. One single conversation had to be extended for over
a week as her duties did not permit her to come to me often from
such a distance, so that the conversation was frequently broken
off and resumed at the next session.
On attempting to hypnotize Miss Lucy R. she did not merge
into the somnambulic state. I therefore was obliged to forego
somnambulism and the analysis was made while she was in a
state not perhaps differing much from the normal.
I feel obliged to express myself more fully about the point
of the technique of my procedure. While visiting the Nancy
clinics in 1889 I heard Dr. Liébeault, the old master of hypnotism,
say, “Yes, if we had the means to put everybody into the somnambulic
state, hypnotism would then be the most powerful therapeutic
agent.” In Bernheim’s clinic it almost seemed that such
an art really existed and that it could be learned from Bernheim.
16But as soon as I tried to practice it on my own patients I noticed
that at least my powers were quite limited in this respect. Whenever
a patient did not merge into the somnambulistic state after
one to three attempts I possessed no means to force him into it.
However, the percentage of somnambulists in my experience were
far below that claimed by Bernheim.
Thus I had my choice, either to forbear using the cathartic
method in most of the cases suitable for it, or to venture the
attempt without somnambulism by using hypnotic influence in
light or even doubtful cases. It made no difference of what
degree (following the accepted scales of hypnotism) the hypnotism
was which did not correspond to somnambulism, for every
direction of suggestibility is independent of the other and nothing
is prejudicial towards the evocation of catalepsy, automatic
movements and similar phenomena for the purpose of facilitating
the awakening of forgotten recollections. I soon relinquished
the habit of deciding the degree of hypnotism, as in a great
number of cases it incited the patients’ resistance, and clouded the
confidence which I needed for the more important psychic work.
Moreover, in mild grades of hypnotism I soon tired of hearing,
after the assurance and command, “You will sleep, sleep now!”
such protests as, “But, Doctor, I am not sleeping.” I was then
forced to bring in the very delicate distinction, saying, “I do not
mean the usual sleep, I mean the hypnotic,—you see, you are
hypnotized, you cannot open your eyes”; or, “I really don’t
want you to sleep.” I, myself, am convinced that many of my
colleagues using psychotherapy know how to get out of such
difficulties more skilfully than I; they can proceed differently.
I, however, believe that if through the use of a word one can so
frequently become embarrassed, it is better to avoid the word
and the embarrassment. Wherever the first attempt did not produce
either somnambulism or a degree of hypnotism with pronounced
bodily changes, I dropped the hypnosis and demanded
only “concentration,” I ordered the patient to lie on his back
and close his eyes as a means of reaching this “concentration.”
With little effort I obtained as profound a degree of hypnotism
as was possible.
But inasmuch as I forbore using somnambulism, I perhaps
robbed myself of a preliminary stipulation without which the
17cathartic method seems inapplicable. For it is based on the
fact that in the altered state of consciousness the patients have at
their disposal such recollections and recognize such connections
which do not apparently exist in their normal conscious state.
Wherever the somnambulic broadening of consciousness lacks
there must also be an absence of the possibility of bringing about
a causal relation which the patient cannot give to the doctor as
something known to him, and it is just the pathogenic recollections
“which are lacking from the memory of the patients
in their usual psychic states or only exist in a most condensed
state” (preliminary communication).
My memory helped me out of this embarrassment. I, myself,
saw Bernheim adduce proof that the recollections of somnambulism
are only manifestly forgotten in the waking state and can
be readily reproduced by slight urging accompanied by hand
pressure which is supposed to mark another conscious state. He,
for instance, imparted to a somnambulist the negative hallucination
that he was no more present, and then attempted to make
himself noticeable to her by the most manifold and regardless
attacks, but was unsuccessful. After the patient was awakened
he asked her what he did to her during the time that she thought
he was not there. She replied very much astonished, that she
knew nothing, but he did not give in, insisting that she would
recall everything; and placed his hand on her forehead so that
she should recall things, and behold, she finally related all that
she did not apparently perceive in the somnambulic state and
about which she ostensibly knew nothing in the waking state.
This astonishing and instructive experiment was my model. I
decided to proceed on the supposition that my patients knew
everything that was of any pathogenic significance, and that all
that was necessary was to force them to impart it. When I
reached a point where to the question “Since when have you this
symptom?” or, “Where does it come from?” I receive the
answer, “I really don’t know this,” I proceeded as follows: I
placed my hand on the patient’s forehead or took her head between
my hands and said, “Under the pressure of my hand it
will come into your mind. In the moment that I stop the
pressure you will see something before you, or something will
pass through your mind which you must note. It is that which
18we are seeking. Well, what have you seen or what came into
your mind?”
On applying this method for the first time (it was not in the
case of Miss Lucy R.) I was surprised to find just what I wanted,
and I may say that it has since hardly ever failed me, it always
showed me the way to proceed in my investigations and enabled
me to conclude all such analyses without somnambulism. Gradually
I became so bold that when a patient would answer, “I see
nothing,” or “Nothing came into my mind,” I insisted that it
was impossible. They probably had the right thought but did
not believe it and repudiated it. I would repeat the procedure
as often as they wished, and every time they saw the same thing.
Indeed, I was always right; the patients had not as yet learned
to let their criticism rest. They repudiated the emerging recollection
or fancy because they considered it as a useless intruding
disturbance, but after they imparted it, it was always shown that
it was the right one. Occasionally after forcing a communication
by pressing the head three or four times I got such answer
as, “Yes, I was aware of it the first time, but did not wish to
say it,” or, “I hoped that it would not be this.”
By this method it was far more laborious to broaden the
alleged narrowed consciousness than by investigating in the
somnambulic state, but it made me independent of somnambulism
and afforded me an insight into the motives which are frequently
decisive for the “forgetting” of recollections. I am in position
to assert that this forgetting is often intentional and desired. It
is always only manifestly successful.
It appeared to me even more remarkable that apparently long
forgotten numbers and dates can be reproduced by a similar
process, thus proving an unexpected faithfulness of memory.
The insignificant choice which one has in searching for numbers
and dates especially allows us to take to our aid the familiar
axiom of the theory of aphasia, namely, that recognition is a
slighter accomplishment of memory than spontaneous recollection.
Hence to a patient who is unable to recall in what year, month
or day a certain event took place, enumerate the years during
which it might have occurred as well as the names of the twelve
months and the thirty-one days of the month, and assure him
19that at the right number or name his eyes will open themselves
or that he will feel which number is the correct one. In most
cases the patients really decide on a definite date and frequently
enough (as in the case of Mrs. Cäcilie N.) it could be ascertained
from existing notes of that time that the date was correctly
recognized. At other times and in different patients it was
shown from the connection of the recollected facts that the dates
thus found were incontestable. A patient, for instance, after a
date was found by enumerating for her the dates, remarked,
“This is my father’s birthday,” and added “Of course I expected
this episode [about which we spoke] because it was my father’s
birthday.”
I can only slightly touch upon this theme. The conclusion
which I wished to draw from all these experiences is that the
pathogenic important experiences with all their concomitant circumstances
are faithfully retained in memory, even where they
seem forgotten, as when the patient seems unable to recall them.[14]
20After this long but unavoidable digression I now return to the
history of Miss Lucy R. As aforesaid, she did not merge into
somnambulism when an attempt was made to hypnotize her, but
lay calmly in a degree of mild suggestibility, her eyes constantly
closed, the features immobile, the limbs without motion. I asked
her whether she remembered on what occasion the smell perception
of burned pastry originated.—“Oh, yes, I know it well. It
was about two months ago, two days before my birthday. I
was with the children (two girls) in the school room playing and
teaching them to cook, when a letter just left by the letter carrier
was brought in. From its postmark and handwriting I recognized
it as one sent to me by my mother from Glasgow and I
wished to open it and read it. The children then came running
over, pulled the letter out of my hand and exclaimed, ‘No you
must not read it now, it is probably a congratulatory letter for
21your birthday and we will keep it for you until then.’ While the
children were thus playing there was a sudden diffusion of an
intense odor. The children forgot the pastry which they were
cooking and it became burned. Since then I have been troubled
by this odor, it is really always present but is more marked during
excitement.”
“Do you see this scene distinctly before you?”—“As clearly
as I experienced it.”—“What was there in it that so excited
you?”—“I was touched by the affection which the children
displayed towards me.”—“But weren’t they always so affectionate?”—“Yes,
but I just got the letter from my mother.”—“I
can’t understand in what way the affection of the little ones and
the letter from the mother contrasted, a thing which you appear
to intimate.”—“I had the intention of going to my mother and
my heart became heavy at the thought of leaving those dear
children.”—“What is the matter with your mother? Was she
so lonesome that she wanted you, or was she sick just then and
you expected some news?”—“No, she is delicate but not really sick,
and has a companion with her.”—“Why then were you obliged
to leave the children?”—“This house had become unbearable to
me. The housekeeper, the cook, and the French maid seemed
to be under the impression that I was too proud for my position.
22They united in intriguing against me and told the grandfather of
the children all sorts of things about me, and when I complained
to both gentlemen I did not receive the support which I expected.
I then tendered my resignation to the master (father of the children)
but he was very friendly, asking me to reconsider it for
two weeks before taking any definite steps. It was while I was
in that state of indecision that the incident occurred. I thought
that I would leave the house but have remained.”—“Aside from
the attachment of the children is there anything particular which
attracts you to them?”—“Yes, my mother is distantly related to
their mother and when the latter was on her death bed I promised
her to do my utmost in caring for the children, that I would not
forsake them, and be a mother to them, and this promise I broke
when offering my resignation.”
The analysis of the subjective sensation of smell seemed completed.
It was once objective and intimately connected with an
experience, a small scene, in which contrary affects conflicted,
sorrow at forsaking the children, and the mortification which
despite all urged her to this decision. Her mother’s letter
naturally recalled the motives of this decision because she thought
of returning to her mother. The conflict of the affects raised
this moment to a trauma and the sensation of smell which was
connected with it remained as its symbol. The only thing to be
explained was the fact that out of all the sensory perceptions
of that scene, the perception of smell was selected as the symbol,
but I was already prepared to use the chronic nasal affliction as
an explanation. On being directly questioned she stated that
just at that time she suffered from a severe coryza and could
scarcely smell anything but in her excitement she perceived the
odor of burned pastry, it penetrated the organically motived
anosmia.
As plausible as this sounded it did not satisfy me; there seemed
to be something lacking. There was no acceptable reason wherefore
this series of excitements and this conflict of affects should
have led to hysteria. Why did it not all remain on a normal
psychological basis? In other words, what justified the conversion
under discussion? Why did she not recall the scenes themselves
instead of the sensations connected with them which she
preferred as symbols for her recollection? Such questions
23might seem superfluous and impertinent when dealing with old
hysterias in whom the mechanism of conversion was habitual, but
this girl first acquired hysteria through this trauma, or at least
through this slight distress.
From the analysis of similar cases I already knew that where
hysteria is to be newly acquired one psychic determinant is indispensible;
namely, that some presentation must intentionally be
repressed from consciousness and excluded from associative
elaboration.
In this intentional repression I also find the reason for the
conversion of the sum of excitement, be it partial or total. The
sum of excitement which is not to enter into psychic association
more readily finds the wrong road to bodily innervation. The
reason for the repression itself could only be a disagreeable feeling,
the incompatibility of one of the repressible ideas with the
ruling presentation-mass of the ego. The repressed presentation
then avenges itself by becoming pathogenic.
From this I concluded that Miss Lucy R. merged into that
moment of hysterical conversion, which must have been under the
determinations of that trauma which she intentionally left in the
darkness and which she took pains to forget. On considering her
attachment for the children and her sensitiveness towards the
other persons of the household, there remained but one interpretation
which I was bold enough to impart to her. I told her that
I did not believe that all these things were simply due to her
affection for the children, but that I thought that she was rather
in love with her master, perhaps unwittingly, that she really nurtured
the hope of taking the place of the mother, and it was for
that reason that she became so sensitive towards the servants
with whom she had lived peacefully for years. She feared lest
they would notice something of her hope and scoff at her.
She answered in her laconic manner: “Yes, I believe it is so.”—“But
if you knew that you were in love with the master, why
did you not tell me so?”—“But I did not know it, or rather, I
did not wish to know it. I wished to crowd it out of my mind,
never to think of it, and of late I have been successful.”[15]
24“Why did you not wish to admit it to yourself? Were you
ashamed because you loved a man?”—“O, no, I am not unreasonably
prudish; one is certainly not responsible for one’s
own feelings. I only felt chagrined because it was my employer
in whose service I was and in whose house I lived, and toward
whom I could not feel as independent as towards another. What
is more, I am a poor girl and he is a rich man of a prominent family,
and if anybody should have had any inkling about my feelings
they would have ridiculed me.”
After this I encountered no resistances in elucidating the origin
of this affection. She told me that the first years of her life in
that house were passed uneventfully. She fulfilled her duties
without thinking about unrealizable wishes. One day, however,
the serious, and very busy and hitherto very reserved master,
engaged her in conversation about the exigencies of rearing the
children. He became milder and more cordial than usual, he
told her how much he counted on her in the bringing up of his
orphaned children, and looked at her rather peculiarly. It was
in this moment that she began to love him, and gladly occupied
herself with the pleasing hopes which she conceived during that
conversation. However, as this was not followed by anything
else, and despite her waiting and persevering no other confidential
heart-to-heart talk followed, she decided to crowd it out of
her mind. She quite agreed with me that the look in connection
with the conversation was probably intended for the memory of
his deceased wife. She was also perfectly convinced that her
love was hopeless.
After this conversation I expected a decided change in her condition
but for a time it did not take place. She continued depressed
25and moody—a course of hydrotherapy which I ordered
for her at the same time refreshed her somewhat mornings. The
odor of burned pastry did not entirely disappear; though it became
rarer and feebler it appeared only, as she said, when she
was very much excited.
The continuation of this memory symbol led me to believe that
besides the principal scene it represented many smaller side traumas
and I therefore investigated everything that might have been
in any way connected with the scene of the burned pastry. We
thus passed through the theme of family friction, the behavior
of the grandfather and others, and with that the sensation of
burned odor gradually disappeared. Just then there was a
lengthy interruption occasioned by a new nasal affliction which
led to the discovery of the caries of the ethmoid.
On her return she informed me that she received many Christmas
presents from both gentlemen as well as from the household
servants, as if they were trying to appease her and wipe away
the recollection of the conflicts of the last months. These frank
advances made no impression on her.
On questioning her on another occasion about the odor of
burned pastry she stated that it had entirely disappeared, but
instead she was now bothered by another and similar odor like
the smoke of a cigar. This odor really existed before; it was
only concealed by the odor of the pastry but now appeared by
itself.
I was not very much pleased with the success of my treatment.
What occurred here is what a mere symptomatic treatment is
generally blamed for, namely, that it removes one symptom only
to make room for another. Nevertheless, I immediately set forth
to remove this new memory symbol by analysis.
This time I did not know whence this subjective sensation of
smell originated, nor on what important occasion it was objective.
On being questioned she said, “They constantly smoke at home,
I really don’t know whether the smell which I feel has any particular
significance.” I then proposed that she should try to
recall things under the pressure of my hands. I have already
mentioned that her recollections were plastically vivid, that she
was a “visual.” Indeed under the pressure of my hands a
picture came into her mind—at first only slowly and fragmentarily.
26It was the dining room of the house in which she waited
with the children for the arrival of the gentlemen from the factory
for dinner.—“Now we are all at the table, the gentlemen,
the French maid, the housekeeper, the children and I. It is the
same as usual.”—“Just keep on looking at that picture. It will
soon become developed and specialized.”—“Yes, there is a guest,
the chief accountant, an old gentleman who loves the children
like his own grandchildren, but he dines with us so frequently that
it is nothing unusual.”—“Just have patience, keep on looking
at the picture, something will certainly happen.”—“Nothing
happens. We leave the table, the children take leave and go with
us up to the second floor as usual.”—“Well?”—“It really is
something unusual, I now recognize the scene. As the children
take leave the chief accountant attempts to kiss them, but my
master jumps up and shouts at him, ‘Don’t kiss the children!’
I then experienced a stitch in the heart, and as the gentlemen
were smoking, this odor remained in my memory.”
This, therefore, was the second, deeper seated scene causing
the trauma and leaving the memory symbol. But why was this
scene so effective? I then asked her which scene happened first,
this one or the one with the burned pastry?—“The last scene happened
first by almost two months.”—“Why did you feel the stitch
at the father’s interference? The reproof was not meant for
you.”—“It was really not right to rebuke an old gentleman in
such manner who was a dear friend and a guest, it could have
been said quietly.”—“Then you were really affected by your master’s
impetuosity? Were you perhaps ashamed of him, or have
you thought, ‘If he could become so impetuous to an old friend
guest over such a trifle, how would he act towards me if I were
his wife?’”—“No, that is not it.”—“But still it was about his
impetuosity?”—“Yes, about the kissing of the children, he never
liked that.” Under the pressure of my hands there emerged a
still older scene which was the real effective trauma and which
bestowed on the scene with the chief accountant the traumatic
effectivity.
A few months before a lady friend visited the house and on
leaving kissed both children on the lips. The father, who was
present, controlled himself and said nothing to the lady, but
when she left he was very angry at the unfortunate governess.
27He said that he held her responsible for this kissing; that it was
her duty not to tolerate it; that she was neglecting her duties
in allowing such things, and that if it ever happened again he
would entrust the education of his children to some one else.
This occurred while she believed herself loved and waited for a
repetition of that serious and friendly talk. This episode shattered
all her hopes. She thought: “If he can upbraid and
threaten me on account of such a trifle, of which I am entirely
innocent, I must have been mistaken, he never entertained any
tenderer feelings towards me, else he would have been considerate.”—It
was evidently this painful scene that came to her as the
father reprimanded the chief accountant for attempting to kiss
the children.
On being visited by Miss Lucy R. two days after the last
analysis I had to ask her what pleasant things happened to her.
She looked as though transformed, she smiled and held her head
aloft. For a moment I thought that after all I probably mistook
the conditions and that the governess of the children had now
become the bride of the master. But she soon dissipated all my
suppositions, saying, “Nothing new happened. You really do
not know me. You have always seen me while I was sick and
depressed. I am otherwise always cheerful. On awaking yesterday
morning my burden was gone and since then I feel well.”—“What
do you think of your chances in the house?”—“I am
perfectly clear about that. I know that I have none, and I am
not going to be unhappy about it.”—“Will you now be able to get
along with the others in the house?”—“I believe so, because most
of the trouble was due to my sensitiveness.”—“Do you still love
the master?”—“Certainly I love him, but that does not bother
me much. One can think and feel as one wishes.”
I now examined her nose and found that the pain and the
reflex sensations had almost completely reappeared. She could
distinguish odors, but she was uncertain when they were very
intense. What part the nasal trouble played in the anosmia I
must leave undecided.
The whole treatment extended over a period of nine weeks.
Four months later I accidentally met the patient at one of our
summer resorts—she was cheerful and stated that her health
continued to be good.
28
I would not underestimate the aforesaid case even though it
only represents a young and light hysteria presenting but few
symptoms. Moreover, it seems to me instructive that even such
a slight neurotic affliction requires so many psychic determinants,
and on a more exhaustive consideration of this history I am
tempted to put it down as an illustration of that form of hysteria
which even persons not burdened by heredity may acquire if their
experiences favor it. It should be well noted that I do not speak
of a hysteria which may be independent of all predisposition;
such form does not probably exist, but we speak of such a predisposition
only after the person became hysterical, as nothing
pointed to it before this. A neuropathic disposition as commonly
understood is something different. It is determined even before
the disease by a number of hereditary burdens, or a sum of individual
psychic abnormalities. As far as I know none of these
moments could be demonstrated in the case of Miss Lucy R.
Her hysteria could therefore be called acquired and presupposes
nothing except probably a very marked susceptibility to acquire
hysteria, a characteristic about which we know hardly anything.
The chief importance in such cases lies in the nature of the
trauma, to be sure in connection with the reaction of the person
to the trauma. It is an indispensable condition for the acquirement
of hysteria that there should arise a relation of incompatibility
between the ego and some of its approaching presentations.
I hope to be able to show in another place how a variety of neurotic
disturbances originate from the different procedures which the
“ego” pursues in order to free itself from that incompatibility.
The hysterical form of defence, for which a special adaptation is
required, consists in converting the excitement into physical innervation.
The gain brought about by this process is the crowding
out of the unbearable presentation from the ego consciousness,
which then contains instead the physical reminiscences produced
by conversion—in our case the subjective sensation of smell—and
suffers from the affect which is more or less distinctly adherent
to these reminiscences. The situation thus produced is no
longer changeable, for changing and conversion annihilate the
conflict which helped towards the adjustment of the affect. Thus
29the mechanism producing hysteria corresponds on the one hand
to an act of moral faint heartedness, on the other hand it presents
itself as a protective arrangement at the command of the ego.
There are many cases in which it must be admitted that the defense
of the increased excitement through the production of hysteria
may actually have been most expedient, but more frequently
one will naturally come to the conclusion that a greater measure
of moral courage would have been an advantage to the individual.
Accordingly the real traumatic moment is that, in which the
conflict thrusts itself upon the ego and the latter decides to banish
it. Such banishment does not annihilate the opposing presentation
but merely crowds it into the unconscious. This process,
occurring for the first time, forms a nucleus and point of crystallization
for the formation of a new psychic group separated from
the ego, around which, in the course of time, everything collects
in accord with the opposing presentation. The splitting of consciousness
in such cases of acquired hysteria is thus a desired
and intentional one, and is often initiated by at least one arbitrary
act. But literally, something different happens than the individual
expects, he would wish to eliminate a presentation as though
it never came to pass but only succeeds in isolating it psychically.
The traumatic moment in the history of our patient corresponds
to the scene created by the master on account of the kissing of
the children. For the time being this scene remained without any
palpable effects, perhaps it initiated the depression and sensitiveness,
but I leave this open;—the hysterical symptoms, however,
commenced later in moments which can be designated as “auxiliary,”
and which may be characterized by the fact that in them
there is a simultaneous flowing together of both separated groups
just as in the broadened somnambulic consciousness. The first
of these moments in which the conversion took place in Miss
Lucy R., was the scene at the table when the chief accountant
attempted to kiss the children. The traumatic memory helped
along, and she acted as though she had not entirely banished her
attachment for her master. In other cases we find that these
different moments come together and the conversion occurs directly
under the influence of the trauma.
The second auxiliary moment repeated almost precisely the
30mechanism of the first. A strong impression transitorily reestablished
the unity of consciousness and the conversion takes
the same route opened to it in the first. It is interesting to note
that the symptom occurring second concealed the first so that
it could not be distinctly perceived until the second was eliminated.
The reversal of the succession of events to which also the
analysis must be adapted seems to me quite remarkable. In a
whole series of cases I found that the symptoms which came
later covered the first, and only the last thing in the analysis
contained the key to the whole.
The therapy here consisted in forcing the union of the dissociated
psychic groups with the ego consciousness. It is remarkable
that the success did not run parallel with the accomplished
work, the cure resulted suddenly only after the last part was
accomplished.
CHAPTER III. The Case of Miss Elisabeth v. R. — Epicrisis.
31
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
32over 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,
33refuses 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.
34We 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,
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
35lacking. 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
36be 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
37a 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.”
38From 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
39him 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
40pressure 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
41accompanied 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.
42In 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
43trouble 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
44showed 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
45in 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.
46Among 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
47Gastein 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
48cooperation 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
49there 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
50despair 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
51sleepless 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
52have 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
53understand 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
54not 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
55assured 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.
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
56from 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
57duties 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]
58I 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
59better 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.
60How 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
61it 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
62to 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
63in 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
64the 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
65friendliness, 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
66off 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
67the 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
68periosteal 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.
69I 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
70was 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
71many 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
72usual 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
73her 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
74“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]
CHAPTER IV. The Psychotherapy of Hysteria. — I. — II. — III.
75
In our “Preliminary Communication” we have stated that
while investigating the etiology of hysterical symptoms we have
also discovered a therapeutic method which we consider of practical
significance. “We found, at first to our very greatest
surprise, that the individual hysterical symptoms immediately
disappeared without returning if we succeeded in thoroughly
awakening the memories of the causal process with its accompanying
affect, and if the patient circumstantially discussed the
process giving free play to the affect” (p. 4).
We furthermore attempted to explain how our psychotherapeutic
method acts. “It does away with the effects of the
original not ab-reacted to ideas by affording an outlet to the
suppressed affect through speech. It brings it into associative
correction by drawing it into normal consciousness (in mild
hypnosis), or it is done away with through the physician’s suggestion
just as happens in somnambulism with amnesia” (p. 13).
Although the essential features of this method have been enumerated
in the preceding pages, a repetition is unavoidable, and I
shall now attempt to show connectedly how far reaching this
method is, its superiority over others, its technique, and its
difficulties.
I, for my part, may state that I can adhere to the “Preliminary
Communication,” but I must confess that after continuous occupation
for years with the problems therein touched, I was confronted
with new views, as a result of which the former material
underwent at least a partial change in grouping and conception.
It would be unjust to impute too much of the responsibility
for this development to my honored friend, J. Breuer. I
therefore take the weight of responsibility upon myself.
In attempting to use Breuer’s method of treating hysterical
symptoms in a great number of patients by investigation and
76ab-reaction in hypnosis, I encountered two obstacles, the pursuit
of which led me to change the technique as well as the conception.
(1) Not all persons were hypnotizable who undoubtedly
showed hysterical symptoms, and in whom there most probably
existed the same psychic mechanism. (2) I had to question
what essentially characterizes hysteria, and in what it differs
from other neuroses.
How I overcame the first difficulty, and what it taught me,
I will show later. I will first state what position I have taken in
my daily practice towards the second problem. It is very difficult
to examine a case of neurosis before it has been subjected to
a thorough analysis, such as would result only through the application
of Breuer’s method. But before we have such a
thorough knowledge we are obliged to decide upon the diagnosis
and kind of treatment. Hence the only thing remaining for me
was to select such cases for the cathartic method which could,
for the time being, be diagnosed as hysteria, and which showed
some or many stigmata, or the characteristic symptoms of
hysteria. Yet it sometimes happened that in spite of the diagnosis
of hysteria the therapeutic results were very poor, and even
the analysis revealed nothing of importance. At other times I
attempted to treat cases which no one took for hysteria by
Breuer’s method, and I found that I could influence them, and
even cure them. Such, for example, was my experience with
obsessions, the real obsessions of Westphal’s type, cases which
did not show a single feature of hysteria. Thus the psychic
mechanism revealed in the “Preliminary Communication” could
not be pathognomonic of hysteria. Nor could I for the sake of
this mechanism throw so many neuroses into the same pot with
hysteria. From all the investigated doubts I finally seized upon
a plan to treat all the other neuroses in question just like hysteria,
to investigate the etiology and the form of psychic mechanisms,
and to leave the diagnosis of hysteria to be dependent upon the
result of this investigation.
It thus happened that, proceeding from Breuer’s methods, I
occupied myself mostly with the etiology and the mechanism of
the neuroses. After a relatively brief period I was fortunate in
obtaining useful results. I then became cognizant of the fact
that if we may speak of a reason for the acquirement of neuroses
77the etiology must be sought for in the sexual moments. This
agrees with the fact that, generally speaking, various sexual
moments may also produce various pictures of neurotic disease.
Similarly we now venture to employ the etiology for the characteristics
of the neuroses, and build up a sharp line of demarcation
between the morbid pictures of the neuroses. If the
etiological characters constantly agreed with the clinical ones, this
was justified.
In this way it was found that neurasthenia really corresponds
to a monotonous morbid picture in which, as shown by the
analysis, “psychic mechanisms” play no part. From neurasthenia
we sharply distinguished the compulsion neurosis
(Zwangsneurose), [obsessions, doubts, impulses], the neurosis of
the genuine obsessions, in which we can recognize a complicated
psychic mechanism, an etiology resembling the one of hysteria,
and a far reaching possibility of an involution by psychotherapy.
On the other hand it seemed to me undoubtedly imperative to
separate from neurasthenia a neurotic symptom-complex which
depends on a totally divergent, strictly speaking, on a contrary
etiology. The partial symptoms of this complex have been recognized
by E. Hecker[27] as having a common character. They are
either symptoms, or equivalents, or rudiments of anxiety manifestations,
and it is for that reason that this complex, so different
from neurasthenia, was called by me anxiety neurosis. I
maintain that it originates from an accumulation of physical tension
which is in turn of a sexual origin. This neurosis, too, has
no psychic mechanism, but regularly influences the psychic life,
so that among its regular manifestations we have anxious expectation,
phobias, hyperesthesias to pain, and other symptoms.
This anxiety neurosis, as I take it, certainly corresponds in part
to the neurosis called hypochondria, which in some features resembles
hysteria and neurasthenia. Yet in none of the earlier
works can I consider the demarcation of this neurosis as correct,
and moreover, I find that the usefulness of the name hypochondria
is impaired by its close relation to the symptom of
“nosophobia.”
After I had thus constructed for myself the simple picture of
neurasthenia, anxiety neuroses, and obsessions, I turned my attention
78to the commonly occurring cases of neuroses which enter
into the diagnosis of hysteria. I now said to myself that it
would not do to mark a neurosis as hysterical on the whole,
merely because its symptom complex evinced some hysterical
signs. I could readily explain this practice by the fact that
hysteria is the oldest, the most familiar, and the most striking
neurosis under consideration, but still it was an abuse which
allowed the placing of many features of perversion and degeneration
under the caption of hysteria. Whenever a hysterical symptom,
such as anesthesia or a characteristic attack, could be discovered
in a complicated case of psychic degeneration, the whole
thing was called “hysteria,” and hence one could naturally find
united under this same trade mark the worst and most contradictory
features. As certain as this diagnosis was incorrect it is
also certain that our classification must be made from the
neurotic standpoint, and as we know neurasthenia, anxiety neurosis,
and similar conditions in the pure state, there is no need
of overlooking them in combination.
It seemed therefore that the following conception was more
warrantable. The neuroses usually occurring are generally to be
designated as “mixed.” Neurasthenia and anxiety neurosis can
be found without effort in pure forms, and most frequently in
young persons. Pure cases of hysteria and compulsion neurosis
“Zwangsneurose” (obsessions, doubts, impulses) are rare, they
are usually combined with an anxiety neurosis. This frequent
occurrence of mixed neuroses is due to the fact that their etiological
moments are frequently mixed, now only accidentally, and
now in consequence of a causal relation between the processes
which give rise to the etiological moments of the neuroses. This
can be sustained and proven in the individual cases without any
difficulty. But it follows from this that it is hardly possible to
take hysteria out of connection with the sexual neuroses, that
hysteria as a rule presents only one side, one aspect of the complicated
neurotic case, and that only, as it were, in the borderline
case can it be found and treated as an isolated neurosis. In a
series of cases we can perhaps say a potiori fit denominatio.
I shall now examine the cases reported to see whether they
speak in favor of my conception of the clinical dependence of
79hysteria. Breuer’s patient, Anna O.,[28] seems to contradict this
and exemplifies a pure hysterical disease. Yet this case which
became so fruitful for the knowledge of hysteria was never considered
by its observer under the guise of a sexual neurosis, and
hence cannot at present be utilized as such. When I began to
analyze the second patient, Mrs. Emmy v. N., the idea of a
sexual neurosis on a hysterical basis was far from my mind. I
had just returned from the Charcot school, and considered the
connection of hysteria with the sexual theme as a sort of insult—just
as my patients were wont to do. But when I today review
my notes on this case there is absolutely no doubt that I have to
consider it as a severe case of anxiety neurosis with anxious
expectations and phobias, which was due to sexual abstinence and
was combined with hysteria.
The third case, Miss Lucy R., could perhaps be called the first
borderline case of pure hysteria. It is a short episodic hysteria
based on an unmistakably sexual etiology. It corresponds to an
anxiety neurosis in an over-ripe, amorous girl, whose love was
too rapidly awakened through a misunderstanding. Yet the
anxiety neurosis could either not be demonstrated or had escaped
me. Case IV, Katharina,[29] is really a model of what I have called
virginal anxiety; it is a combination of an anxiety neurosis and
hysteria, the former produces the symptoms, while the latter
repeats them and works with them. At all events, it is a
typical case of many juvenile neuroses called “hysteria.” Case
V, Miss Elisabeth v. R., was again not investigated as a sexual
neurosis. I could only suspect that there was a spinal neurasthenia
at its basis but I could not confirm it. I must, however,
add that since then pure hysterias have become still rarer in my
experience. That in grouping together these four cases of
hysteria I could disregard in the discussion the decisive factors
of sexual neuroses was due to the fact that they were older
cases in which I had not as yet carried out the purposed and
urgent investigation for the neurotic sexual subsoil. Moreover
the reason for my reporting four instead of twelve cases of
80hysteria, the analysis of which would have confirmed our claims
of psychic mechanism for hysterical phenomena, is due to one
circumstance, namely that the analysis of these cases would have
simultaneously revealed them as sexual neuroses, though surely
no diagnostician would have denied them the name “hysteria.”
However, the discussion of such sexual neuroses would have
overstepped the limits of our joint publication.
I do not wish to be misunderstood and give the impression that
I refuse to accept hysteria as an independent neurotic affection,
that I conceive it only as a psychic manifestation of the anxiety
neurosis, that I ascribe to it “ideogenous” symptoms only, and
that I attribute the somatic symptoms, like hysterogenic points
and anesthesias, to the anxiety neurosis. None of these statements
are true. I believe that hysteria, purified of all admixtures,
can be treated independently in every respect except in
therapy. For in the treatment we deal with a practical purpose,
namely, we have to do away with the whole diseased state, and
even if the hysteria occurs in most cases as a component of a
mixed neurosis, the case merely resembles a mixed infection
where the task is to preserve life, and not merely to combat the
effect of one inciting cause of the disease.
I, therefore, find it important to separate the hysterical part in
the pictures of the mixed neuroses from neurasthenia, anxiety
neurosis, etc., for after this separation I can express concisely the
therapeutic value of the cathartic method. I would venture to
assert that—principally—it can readily dispose of any hysterical
symptom, whereas, as can be easily understood, it is perfectly
powerless in the presence of neurasthenic phenomena, and can
only seldom, and through detours, influence the psychic results of
the anxiety neurosis. Its therapeutic efficacy in the individual
case will depend on whether or not the hysterical components of
the morbid picture can claim a practical and significant position in
comparison to the other neurotic components.
Another limitation placed on the efficacy of the cathartic method
we have already mentioned in our “Preliminary Communication.”
It does not influence the causal determinations of hysteria, and
hence it can not prevent the origin of new symptoms in the place
of those removed. Hence, on the whole, I must claim a prominent
place for our therapeutic method in the realm of the therapy
81of neuroses, but I would caution against attaching any importance
to it, or putting it into practice outside of this connection.
As I am unable to give here a “Therapy of Neuroses” as would
be required by the practicing physician, the preceding statements
are put on a level with the deferred reference to a later communication;
still, for purposes of discussion and elucidation, I can
add the following remarks:
1. I do not claim that I have actually removed all the hysterical
symptoms which I have undertaken to influence by the cathartic
method, but I believe that the obstacles were due to the personal
circumstances of the cases, and not to the general principles. In
passing sentence, these cases of failure may be left out of consideration,
just as the surgeon puts aside all cases who die as a
result of narcosis, hemorrhage, accidental sepsis, etc., when deciding
upon a new technique. I will again consider the failures of
such origin in my later discussions on the difficulties and drawbacks
of this method.
2. The cathartic method does not become valueless simply
because it is symptomatic and not causal. For a causal therapy
is really in most cases only prophylactic; it stops the further
progress of the injury, but it does not necessarily remove the
products which have already resulted from it. To do this it
requires, as a rule, a second agent, and in cases of hysteria the
cathartic method is really unsurpassable for such purposes.
3. Where the period of hysterical production, or the acute
hysterical paroxysm, has subsided, and the only remnant manifestations
left are hysterical symptoms, the cathartic method fulfills
all indications, and achieves a full and lasting success. Such
a favorable constellation for the therapy does not seldom result
on the basis of the sexual life, in consequence of the marked
fluctuations in the intensity of the sexual desire and the complications
of the required determination for a sexual trauma.
Here the cathartic method accomplishes all that is required of it,
for the physician can not resolve to change a hysterical constitution.
He must rest content if he can remove the disease for
which such a constitution shows a tendency, and which can arise
through the assistance of external determinants. He must be
satisfied if the patient will again become capacitated. Moreover,
he can have some hopes for the future, if the possibility of a
82relapse be considered, for he knows the main character of the
etiology of the neuroses, namely, that their origin is mostly over-determined,
and that many moments must unite to produce this
result. He can hope that this union will not take place very
soon, if individual etiological moments remain in force.
It may be argued that in such subsided cases of hysteria the
remaining symptoms would spontaneously disappear without anything
else, but this can be answered by the fact that such spontaneous
cures very often terminate neither rapidly nor fully, and
that the cure will be extraordinarily advanced by the treatment.
Whether the cathartic treatment cures only that which is capable
of spontaneous recovery, or incidentally also, that which would
not cease spontaneously, that question may surely be left open for
the present.
4. Where we encounter an acute hysteria during the most
acute production of hysterical symptoms, and the consecutive
overwhelming of the ego by the morbid products (hysterical
psychosis), even the cathartic method will change little the expression
and course of the disease. One finds himself in the
same position to the neurosis as the doctor to an acute infectious
disease. For some time past, now beyond the reach of influence,
the etiological moments exerted a sufficient amount of effect,
which becomes manifest after overcoming the interval of incubation.
The affection can not be warded off, it has to run its
course, but meanwhile one must bring about the most favorable
conditions for the patient. If during such an acute period one
can remove the morbid products, the newly formed hysterical
symptoms, it may be expected that their places will be taken by
new ones. The physician will not be spared the depressing impression
of fruitless effort, the enormous expenditure of exertion,
and the disappointment of the relatives, to whom the idea of
the necessary duration of time of an acute neurosis is hardly as
familiar as in the analogous case of an acute infectious disease;
these, and many other things, will probably make most impossible
the consequent application of the cathartic method in the assumed
case. Nevertheless, it still remains to be considered whether,
even in an acute hysteria, the frequent removal of the morbid
products does not exercise a curative influence by supporting the
83normal ego which is occupied with the defense, and thus preventing
it from merging into a psychosis or into ultimate confusion.
That the cathartic method can accomplish something, even in an
acute hysteria, and that it can even reduce the new productions of
the morbid symptoms quite practically and noticeably, is undoubtedly
evident from the case of Anna O., in which Breuer
first learned to exercise this process.[30]
5. Where we deal with chronic progressive hysterias with
moderate or continued productions of hysterical symptoms, we
learn to regret the lack of a causally effective therapy, but we
also learn to value the indications of the cathartic method as a
symptomatic remedy. We then deal with an injury produced by
an etiology which continues to act chronically. We have to
strengthen the capacity for resistance of the nervous system of
our patient, and we must bear in mind that the existence of an
hysterical symptom signifies a weakening of resistance of the
nervous system, and represents a predisposing moment. From
the mechanism of monosymptomatic hysteria we know that a new
hysterical symptom generally originates as an addition to and
as an analogy of one already in existence. The location once
penetrated represents the weak spot which can be penetrated
again. The split off psychic group plays the part of the provoking
crystal from which a formerly omitted crystallization
emerges with great facility. To remove the already existing
symptoms, to do away with the psychic alterations lying at their
basis, is the return to the patients the full measure of their resistance
capacity, with which they are successfully able to resist the
noxious influences. One can do a great deal for the patient by
such long continued watchfulness and occasional “chimney-sweeping.”
6. I still have to mention the apparent contradiction arising
between the admission that not all hysterical symptoms are psychogenic,
and the assertion that they can all be removed by
psychotherapeutic procedures. The solution lies in the fact that
some of these non-psychogenic symptoms, though they represent
morbid symptoms, as, for instance, the stigmata, should nevertheless
not be designated as affections, and hence it cannot be practically
84noticed even if they remain after the treatment is finished.
Other symptoms of a similar nature seem to be taken along indirectly
by the psychogenic symptoms, for indirectly they really
depend on some psychic causation.
I shall now mention those difficulties and inconveniences of
our therapeutic method which are not evident from the preceding
histories, or from the following remarks concerning the technique
of the method.—I will rather enumerate and indicate than
carry them out. The process is toilsome and wearisome for the
physician, it presupposes a profound interest for psychological
incidents, as well as a personal sympathy for the patient. I could
not conceive myself entering deeply into the psychic mechanism
of a hysteria in a person who appeared to me common and disagreeable,
and who would not, on closer acquaintanceship, be able
to awaken in me human sympathy; whereas I can well treat a
tabetic or a rheumatic patient regardless of such personal liking.
Not less are the requisites on the patient’s side. The process is
especially inapplicable below a certain niveau of intelligence. It
is rendered extremely difficult wherever there is any tinge of
weakmindedness. It requires the full consent and the attention
of the patients, but, above all, their confidence, for the analysis
regularly leads to the inmost and most secretly guarded psychic
processes. A large proportion of the patients suitable for such
treatment withdraw from the physician as soon as they become
cognizant whither his investigations tend; to them the physician
remains a stranger. In others who have determined to give
themselves up to the physician and bestow their confidence upon
him, something usually voluntarily given but never demanded, in
all those, I say, it is hardly avoidable that the personal relation
to the physician should not become unduly prominent, at least for
some time. Indeed, it seems as if such an influence exerted by
the physician is a condition under which alone a solution of the
problem is made possible. I do not believe that it makes any
essential difference in this condition whether we make use of
hypnosis or have to avoid or substitute it. Yet fairness demands
that we emphasize the fact that although these inconveniences are
inseparable from our method, they, nevertheless, cannot be
charged to it. It is much more evident that they are formed
85in the preliminary states of the neurosis to be cured, and that
they then attach themselves to every medical activity which intensively
concerns itself with the patient, and produce in him a
psychic change. I could see no harm or danger in the application
of hypnosis even in those cases where it was used excessively.
The causes for the harm produced lay elsewhere and deeper.
When I review the therapeutic efforts of those years since the
communications of my honored teacher and friend, J. Breuer,
gave me the cathartic method, I believe that I have more often
produced good than harm, and brought about some things which
could not have been produced by any other therapeutic means.
On the whole it was, as expressed in the “Preliminary Communication,”
“a distinct therapeutic gain.”
I must mention still another gain in the application of this
method. No severe case of complicated neurosis, with either an
excessive or slight tinge of hysteria can better be explained than
by subjecting it to an analysis by Breuer’s method. In making
this analysis I find that whatever shows the hysterical mechanism
disappears first, while the rest of the manifestations I meanwhile
learn to interpret and refer to their etiology. I thereby gained
the essential factors indicated by the instrument of the therapy of
the neurosis in question. When I think of the usual differences
between my opinion of a case of neurosis before and after such
an analysis, I am almost tempted to maintain that the analysis is
indispensable for the knowledge of a neurotic disease. I have
furthermore made it a practice of applying the cathartic psychotherapy
in conjunction with a rest cure, which when required is
changed to a full Weir-Mitchell treatment. This advantage lies
in the fact that, on the one side I avoid the very disturbing intrusion
of new psychic impressions produced during psychotherapy;
on the other hand, I exclude the monotony of the Weir-Mitchell
treatment, during which the patient not seldom merges
into harmful reveries. One might expect that the very considerable
psychic labor often imposed upon the patient during the
cathartic cure, and the excitement resulting from the reproduction
of traumatic events, would run counter to the sense of the Weir-Mitchell
rest cure, and would prevent the successes which one
is wont to obtain from it. But the contrary happens; through
the combination of the Breuer and the Weir-Mitchell therapy, we
86obtain all the physical improvements which we expect from the
latter, and such marked psychic improvement as never occurs in
the rest cure without psychotherapy.
I will now add to my former observations that in attempting
to use Breuer’s method in greater latitude I met this difficulty—although
the diagnosis was hysteria, and the probabilities spoke
in favor of the prevalence of the psychic mechanism described by
us, yet a number of patients could not be put into the hypnotic
state. The hypnosis was necessary to broaden consciousness so
as to find the pathogenic reminiscences which do not exist in the
ordinary consciousness. I, therefore, was forced to either give
up such patients, or to bring about this broadening by other
means.
The reason why one person is hypnotizable and another not
I could no more explain than others, and hence I could not start
on a causal way towards the removal of the difficulties. I also
observed that in some patients the obstacle was still more marked,
as they even refused to submit to hypnosis. The idea then occurred
to me that both cases might be identical, and that in both
it might merely be an unwillingness. Those who entertain a
psychic inhibition against hypnotism are not hypnotizable, it
makes no difference whether they utter their unwillingness or
not. It is not fully clear to me whether I can firmly adhere to
this conception or not.
It was, therefore, important to avoid hypnotism and yet to
obtain the pathogenic reminiscences. This I attained in the following
manner:
On asking my patients during our first interview whether they
remembered the first motive for the symptom in question, some
said that they knew nothing, while others thought of something
which they designated as an indistinct recollection, yet were
unable to pursue it. I then followed Bernheim’s example of
awakening the apparently forgotten impressions obtained during
somnambulism (see the case of Miss Lucy). I urged them by
assuring them that they did know it, and that they will recall it,
etc., and thus some thought of something, while in others the
recollections went further. I became still more pressing, I
87ordered the patient to lie down and voluntarily shut his eyes so
as to “concentrate” his mind, causing thereby at least a certain
similarity to hypnosis, and I then discovered that without any
hypnosis there emerged new and retrospective reminiscences
which probably belonged to our theme. Through such experiences
I gained the impression that through urging alone it would
really be possible to bring to light the definitely existing pathogenic
series of ideas; and as this urging necessitated much exertion
on my part, and showed me that I had to overcome a resistance,
I, therefore, formulated this whole state of affairs into the
following theory: Through my psychic work I had to overcome a
psychic force in the patient which opposed the pathogenic idea
from becoming conscious (remembered). It then became clear
to me that this must really be the same psychic force which
assisted in the origin of the hysterical symptom, and at that time
prevented the pathogenic idea from becoming conscious. What
kind of effective force could here be assumed, and what motive
could have brought it into activity? I could easily formulate an
opinion, for I already had some complete analyses at my disposal
in which I found examples of pathogenic, forgotten, and repressed
ideas. From these I could judge the general character of
such ideas. They were altogether of a painful nature, adapted
to provoke the affects of shame, reproach, of psychic pain, and the
feeling of injury; they were altogether of that kind which one
would not like to experience and prefers to forget.
From all these the thought of defense resulted as if simultaneously.
Indeed, it is generally admitted by all psychologists
that the assumption of a new idea (assumption in the sense
of belief, judgment of reality), depends on the mode and drift of
the ideas already united in the ego. For the process of the
censor, to which the newly formed ideas are subjected, special
technical names have been created. An idea entered into the ego
of the patient which proved to be unbearable and evoked a power
of repulsion on the part of the ego, the purpose of which was a
defense against this unbearable idea. This defense actually succeeded,
and the idea concerned was crowded out of consciousness
and out of the memory, so that its psychic trace could not apparently
be found. Yet this trace must have existed. When
I made the effort to direct the attention to it, I perceived as a
88resistance the same force which showed itself as repulsion in the
genesis of the symptom. If I could now make it probable that the
idea became pathogenic in consequence of the exclusion and
repression, the chain would seem complete. In many epicrises of
our histories, and in a small work concerning the defense neuropsychoses
(1894), I have attempted to indicate the psychological
hypotheses with the help of which this connection also—the fact
of conversion—can be made clear.
Hence, a psychic force, the repugnance of the ego, has originally
crowded the pathogenic idea from the association, and now
opposes its return into the memory. The not knowing of the
hysterics was really a—more or less conscious—not willing to
know, and the task of the therapeutist was to overpower this
resistance of association by psychic labor. Such accomplishment
is, above all, brought about by “urging,” that is, by applying a
psychic force in order to direct the attention of the patient on the
desired traces of ideas. It does not, however, stop here, but as I
will show, it assumes new forms in the course of the analysis,
and calls to aid more psychic forces.
I shall, above all, still linger at “the urging.” One cannot go
very far with such simple assurances as, “You do know it, just
say it,” or “It will soon come to your mind.” After a few sentences
the thread breaks, even in the patient who is in a state of
concentration. We must not, however, forget that we deal
everywhere here with a quantitative comparison, with the struggle
between motives of diverse force and intensity. The urging of
the strange and inexperienced physician does not suffice for the
“association resistance” in a grave hysteria. One must resort to
more forceful means.
In the first place I make use of a small technical artifice. I
inform the patient that I will in the next moment exert pressure
on his forehead, I assure him that during this pressure he will see
some reminiscence in the form of a picture, or some thought will
occur to him, and I oblige him to communicate to me this picture
or this thought, no matter what it may be. He is not supposed
to hold it back because he may perhaps think that it is not the
desired or the right thing, or because it is too disagreeable to say.
There should be neither criticism nor reserve on account of affect
or disregard. Only thus could we find the things desired, and
89only thus have we unfailingly found them. I then exert pressure
for a few seconds on the forehead of the patient lying in front of
me, and after stopping the pressure, I ask in a calm tone, as if
any disappointment is out of the question, “What have you
seen?” or, “What occurred to your mind?”
This method[31] taught me a great deal and led me to the goal
every time. Of course I know that I can substitute this pressure
on the forehead by any other sign, or any other physical influence,
but as the patient lies before me the pressure on the forehead,
or the grasping of his head between my two hands, is the most
suggestive and most convenient thing that I could undertake for
this end. To explain the efficacy of this artifice, I may perhaps
say that it corresponds to a “momentary reinforced hypnosis”;
but the mechanism of hypnosis is so enigmatical to me that I
would not like to refer to it as an explanation. I rather think
that the advantage of the process lies in the fact that through it
I dissociate the attention of the patient from his conscious quest
and reflection, in brief, from everything upon which his will can
manifest itself. This resembles the process of staring at a
crystal globe, etc. The fact, that under the pressure of my hand
there always appears that which I am looking for, teaches that the
supposedly forgotten pathogenic ideas always lie ready, “close by,”
being attainable through easily approachable associations, and all
that is necessary is to clear away some obstacle. This obstacle
again seems to be the person’s will, and different persons learn
to discard their premeditations, and to assume a perfectly objective
attitude toward the psychic processes within them.
It is not always a “forgotten” reminiscence which comes to
the surface under the pressure of the hand; in the rarest cases
the real pathogenic reminiscences can be superficially discovered.
More frequently an idea comes to the surface which is a link between
the starting idea and the desired pathogenic one of the
association chain, or it is an idea forming the starting point of a
new series of thoughts and reminiscences, at the end of which the
pathogenic idea exists. The pressure, therefore, has really not
revealed the pathogenic idea, which, if torn from its connections
without any preparation, would be incomprehensible; but it has
90shown the way to it, and indicated the direction towards which
the investigation must proceed. The idea which is at first
awakened through the pressure may correspond to a familiar
reminiscence which was never repressed. If the connection becomes
torn on the road to the pathogenic idea, all that is necessary
for the reproduction of a new orientation and connection is a
repetition of the procedure, that is, of the pressure.
In still other cases the pressure of the hand awakens a reminiscence
well known to the patient, which appearance, however,
causes him surprise because he had forgotten its relation to the
starting idea. In the further course of the analysis this relation
becomes clear. From all these results of the pressure one receives
a delusive impression of a superior intelligence external to
the patient’s consciousness, which systematically holds a large
psychic material for definite purposes, and has provided an ingenious
arrangement for its return into consciousness. I presume,
however, that this unconscious second intelligence is really
only apparent.
In every complicated analysis one works repeatedly, nay continuously,
with the help of this procedure (pressure on the forehead),
which leads us from the place where the patient’s conscious
reconductions become interrupted, showing us the way over
reminiscences which remained known, and calling our attention to
connections which have merged into forgetfulness. It also
evokes and connects memories which have for years been withdrawn
from the association, but can still be recognized as memories;
and finally, as the highest performance of reproduction, it
causes the appearance of thoughts which the patient never wishes
to recognize as his own, which he does not remember, although
he admits that they are inexorably demanded by the connection,
and is convinced that just these ideas cause the termination of the
analysis and the cessation of the symptoms.
I will now attempt to give a series of examples showing the
excellent achievements of this procedure. I treated a young
lady who suffered for six years from an intolerable and protracted
nervous cough, which apparently was nurtured by every
common catarrh, but must have had its strong psychic motives.
Every other remedy had long since shown itself to be powerless,
and I therefore attempted to remove the symptom by psychoanalysis.
91All that she could remember was that the nervous
cough began at the age of fourteen while she boarded with her
aunt. She remembered absolutely no psychic excitement during
that time, and did not believe that there was a motive for her
suffering. Under the pressure of my hand, she at first recalled
a large dog. She then recognized the memory picture; it was
her aunt’s dog which was attached to her, and used to accompany
her everywhere, and without any further aid it occurred to
her that this dog died and that the children buried it solemnly;
and on the return from this funeral her cough appeared. I asked
her why she began to cough, and after helping her with the pressure,
the following thought occurred to her: “Now I am all
alone in this world; no one loves me here; this animal was my
only friend, and now I have lost it.” She then continued her
story. “The cough disappeared when I left my aunt, but reappeared
a year and a half later.”—“What was the reason for it?”—“I
do not know.”—I again exerted some pressure on the forehead,
and she recalled the news of her uncle’s death during which
the cough again manifested itself, and also recalled a train of
thought similar to the former. The uncle was apparently the
only one in the family who sympathized with and loved her.
That was, therefore, the pathogenic idea: “People do not love
her; everybody else is preferred; she really does not deserve to be
loved,” etc. To the idea of love there clung something which
caused a marked resistance to the communication. The analysis
was interrupted before this explanation.
Some time ago I attempted to relieve an elderly lady of her
anxiety attacks, which considering their characteristic qualities,
were hardly adapted to such influence. Since her menopause
she had become extremely religious, and always received me as if
I were the Devil. She was always armed with a small ivory crucifix
which she hid in her hand. Her attacks of anxiety, which
bore the hysterical character, could be traced to her early girlhood,
and were supposed to have originated from the application of
an iodine preparation used to reduce a moderate swelling of the
thyroid. I naturally repudiated this origin, and sought to substitute
it by another which was in better harmony with my views
concerning the etiology of neurotic symptoms. To the first
92question for an impression of her youth which would stand in
causal connection to the attacks of anxiety, there appeared under
the pressure of my hand the reminiscence of reading a so called
devotional book wherein piously enough there was some mention
of the sexual processes. The passage in question made an impression
on this girl, which was contrary to the intention of the
author. She burst into tears and flung the book away. That
was before the first attack of anxiety. A second pressure on the
forehead of the patient evoked the next reminiscence, it referred
to her brother’s teacher who showed her great respect, and for
whom she entertained a warmer feeling. This reminiscence culminated
in the reproduction of an evening in her parents’ home,
during which they all sat around the table with the young man,
and delightfully enjoyed themselves in a lively conversation.
During the night following this evening she was awakened by
the first attack of anxiety which surely had more to do with some
resistance against a sensual feeling than perhaps with the coincidently
used iodine. In what other way could I have succeeded
in revealing in this obstinate patient, prejudiced against me and
every worldly remedy, such a connection contrary to her own
opinion and assertion?
On another occasion I had to deal with a young happily married
woman, who as early as in the first years of her girlhood,
was found every morning for some time in a state of lethargy,
with rigid members, opened mouth, and protruding tongue. Similar
attacks, though not so marked, recurred at the present time
on awakening. A deep hypnosis could not be produced, so that
I began my investigation in a state of concentration, and assured
her during the first pressure that she would see something that
would be directly connected with the cause of her condition during
her childhood. She acted calmly and willingly, she again saw
the residence in which she had passed her early girlhood, her
room, the position of her bed, the grandmother who lived with
them at the time, and one of her governesses whom she dearly
loved. There was then a succession of small, quite indifferent
scenes, in these rooms, and among these persons, the conclusion
of which was the leave taking of the governess who married from
the home. I did not know what to start with these reminiscences;
93I could not bring about any connection between them and the
etiology of the attacks. To be sure the various circumstances
were recognized as having occurred at the same time at which
the attacks first appeared.
Before I could continue the analysis, I had occasion to talk to
a colleague, who, in former years, was my patient’s family physician.
From him I obtained the following explanation: At the
time that he treated the mature and physically very well developed
girl for these first attacks, he was struck by the excessive affection
in the relations between her and her governess. He became suspicious
and caused the grandmother to watch these relations.
After a short while the old lady informed him that the governess
was wont to pay nightly visits to the child’s bed, and that
quite regularly after such visits the child was found in the morning
in an attack. She did not hesitate to bring about the quiet
removal of this corruptress of youth. The children, as well as
the mother, were made to believe that the governess left the house
in order to get married.
The treatment, which was above all successful, consisted in informing
the young woman of the explanations given to me.
Occasionally the explanations, which one obtains by the pressure
procedure, follow in very remarkable form, and under circumstances
which make the assumption of an unconscious intelligence
appear even more alluring. Thus I recall a lady who
suffered for years from obsessions and phobias, and who referred
the origin of her trouble to her childhood, but could mention nothing
to which it could have been attributed. She was frank and
intelligent, and evinced only a very slight conscious resistance.
I will add here that the psychic mechanism of obsessions is very
closely related to that of hysterical symptoms, and that the technique
of the analysis in both is the same.
On asking the lady whether she had seen or recalled anything
under the pressure of my hand, she answered, “Neither, but a
word suddenly occurred to me.”—“A single word?”—“Yes, but
it is too foolish.”—“Just tell it.”—“Teacher.”—“Nothing more?”—“No.”
I exerted pressure a second time, and again a single
word flashed through her mind: “Shirt.”—I now observed that
we have dealt with a new mode of replying, and by repeated pressure
94I evoked the following apparently senseless series of words:
Teacher—shirt—bed—city—wagon. I asked, “What does all
that mean?” She reflected for a moment, and it then occurred
to her that “it can only refer to this one incident which now
comes to my mind. When I was ten years old my older sister of
twelve had an attack of frenzy one night, and had to be bound,
put in a wagon and taken to the city. I remember distinctly that
it was the teacher who overpowered her and accompanied her to
the asylum.”—We then continued this manner of investigation,
and received from our oracle another series of words which,
though we could not altogether interpret, could nevertheless be
used as a continuation of this story, and as an appendix to a second.
The significance of this reminiscence was soon clear. The
reason why her sister’s illness made such an impression on her
was because they both shared a common secret. They slept in the
same room, and one night they both submitted to a sexual assault
by a certain man. In discovering this sexual trauma of early
youth, we revealed not only the origin of the first obsession but
also the trauma which later acted pathogenically.—The peculiarity
of this case lies only in the appearance of single catch words
which we had to elaborate into sentences, for the irrelevance and
incoherence found in these oracle like uttered words adhere to all
ideas and scenes which generally occur as a result of pressure.
On further investigation it is regularly found that the seemingly
disconnected reminiscences are connected by close streams of
thought, and that they lead quite directly to the desired pathogenic
moment.
With pleasure do I therefore recall a case of analysis in which
my confidence in the results of pressure was splendidly justified.
A very intelligent, and apparently very happy, young woman consulted
me for persistent pain in her abdomen which yielded to no
treatment. I found that the pain was situated in the abdominal
wall and was due to palpable muscular hardening, and I ordered
local treatment.
After months I again saw the patient who said that “the
former pain disappeared after following the treatment and remained
away a long time, but now it has reappeared as a nervous
pain. I recognize it by the fact that I do not perceive it now on
motion as before, but only during certain hours, as for example,
95in the morning on awakening, and during certain excitements.”
The patient’s diagnosis was quite correct. It was now important
to discover the cause of this pain, but in this she could not assist
me in her uninfluenced state. When, in a state of concentration
and under the pressure of my hand, I asked her whether anything
occurred to her, or whether she saw anything, she began to
describe her visual pictures. She saw something like a sun with
rays, which I naturally had to assume to be a phosphene produced
by pressure on the eyes. I expected that the useful pictures
would follow, but she continued to see stars of a peculiar
pale blue light, like moonlight, etc., and I believed that she merely
saw glittering, shining, and twinkling spots before the eyes. I
was already prepared to add this attempt to the failures, and I
was thinking how I could quietly withdraw from this affair,
when my attention was called to one of the manifestations which
she described. She saw a big black cross which was inclined,
the edges of which were surrounded by a subdued moonlike light
in which all the pictures thus far seen were shining, and upon the
arm there flickered a little flame that was apparently no longer a
phosphene. I continued to listen. She saw numerous pictures in
the same light, peculiar signs resembling somewhat sanscrit. She
also saw figures like triangles, among which there was one big
triangle, and again the cross. I now thought of an allegorical interpretation,
and asked, “What does this cross mean?”—“It is
probably meant to interpret pain,” she answered. I argued, saying,
that “by cross one usually understands a moral burden,”
and asked her what was hidden behind that pain. She could not
explain that and continued looking. She saw a sun with golden
rays which she interpreted as God, the primitive force; she then
saw a gigantic lizard which she examined quizzically but without
fear; then a heap of snakes, then another sun but with mild silvery
rays, and in front of it, between her own person and this
source of light, there was a barrier which concealed from her the
center of the sun.
I knew for some time that we dealt here with allegories,
and I immediately asked for an explanation of the last picture.
Without reflecting she answered: “The sun is perfection, the
ideal, and the barrier represents my weaknesses and failings
which stand between me and the ideal.”—“Indeed, do you reproach
96yourself? Are you dissatisfied with yourself?”—“Yes.”—“Since
when?”—“Since I became a member of the Theosophical
Society and read the writings edited by it. I have always
had a poor opinion of myself.” “What was it that made the
last strongest impression upon you?”—“A translation from the
sanscrit which now appears in serial numbers.” A minute later
I was initiated into her mental conflicts, and into her self reproaches.
She related a slight incident which gave occasion
for a reproach, and in which, as a result of an inciting conversion,
the former organic pain at first appeared.—The pictures which I
had at first taken for phosphenes were symbols of occultistic
streams of thought, perhaps plain emblems from the title pages
of occultistic books.
I have thus far so warmly praised the achievements of the pressure
procedure, and have so entirely neglected the aspect of the
defense or the resistance, that I certainly must have given the
impression that by means of this small artifice one is placed in
position to become master of the psychic resistances against the
cathartic cure. But to believe this would be a gross mistake.
Such advantages do not exist in the treatment so far as I can see;
here, as everywhere else, great change requires much effort. The
pressure procedure is nothing but a trick serving to surprise for
awhile the defensive ego, which in all graver cases recalls its
intentions and continues its resistance.
I need only recall the various forms in which this resistance
manifested itself. In the first place, the pressure experiment usually
fails the first or second time. The patient then expresses
himself disappointed, saying, “I believed that some idea would
occur to me, but I only thought so; as attentive as I was nothing
came.” Such attitudes assumed by the patient are not yet to be
counted as a resistance; we usually answer to that, “You were
really too anxious, the second time things will come.” And they
really come. It is remarkable how completely the patients—even
the most tractable and the most intelligent—can forget the agreement
which they have previously entered into. They have promised
to tell everything that occurs to them under the pressure of
the hand, be it closely related to them or not, and whether it is
agreeable to them to say it or not; that is, they are to tell everything
97without any choice, or influence by critique or affect. Yet
they do not keep their promise, it is apparently beyond their
powers. The work repeatedly stops, they continue to assert that
this time nothing came to their mind. One needs not believe
them, and one must always assume, and also say, that they hold
back something because they believe it to be unimportant, or perceive
it as painful. One must insist, repeat the pressure, and assume
an assured attitude until one really hears something. The
patient then adds, “I could have told you that the first time.”—“Why
did you not say it?”—“I could not believe that that could
be it. Only after it returned repeatedly have I decided to tell it;”
or, “I had hoped that it would not be just that, that I could
spare myself from saying it, but only after it could not be repressed
have I noticed that I could not avoid it.”—Thus the patient
subsequently betrays the motives of a resistance which he
did not at first wish to admit. He apparently could not help
offering resistances.
It is remarkable under what subterfuges these resistances are
frequently hidden. “I am distracted today”; “the clock or the
piano playing in the next room disturbs me,” they say. I became
accustomed to answer to that, “Not at all, you simply
struck against something that you do not willingly wish to say.
That does not help you at all. Just stick to it.”—The longer the
pause between the pressure of my hand and the utterance of the
patient, the more suspicious I become, and the more is it to be
feared that the patient arranges what comes to his mind, and distorts
it in the reproduction. The most important explanations
are frequently ushered in as superfluous accessories, just as the
princes of the opera who are dressed as beggars. “Something
now occurred to me, but it has nothing to do with it. I only tell
it to you because you wish to know everything.” With this introduction
we usually obtain the long desired solution. I always
listen when I hear a patient talk so lightly of an idea. That the
pathogenic idea should appear of so little importance on its reappearance
is a sign of the successful defense. One can infer from
this of what the process of defense consisted. Its object was to
make a weak out of a strong idea, that is, to rob it of its affect.
Among other signs the pathogenic memories can also be recognized
by the fact that they are designated by the patient as unessential,
98and yet are only uttered with resistance. There are also
cases where the patient seeks to disavow the recollections, even
while they are being reproduced, with such remarks as these:
“Now something occurred to me, but apparently you talked it
into me;” or, “I know what you expect to this question, you
surely think that I thought of this and that.” An especially
clever way of shifting is found in the following expression:
“Now something really occurred to me, but it seems to me as if
I added it, and that it is not a reproduced thought.”—In all these
cases I remain inflexibly firm, I admit none of these distinctions,
but explain to the patient that these are only forms and subterfuges
of the resistance against the reproduction of a recollection
which in spite of all we are forced to recognize.
One generally experiences less trouble in the reproduction of
pictures than thoughts. Hysterical patients who are usually
visual are easier to manage than patients suffering from obsessions.
Once the picture emerges from the memory we can hear
the patient state that as he proceeds to describe it, it proportionately
fades away and becomes indistinct; the patient wears it out,
so to speak, by transforming, it into words. We then orient
ourselves through the memory picture itself in order to find the
direction towards which the work should be continued. We say
to the patient, “Just look again at the picture, has it disappeared?”—“As
a whole, yes, but I still see this detail.”—“Then this must
have some meaning, you will either see something new, or this
remnant will remind you of something.” When the work is
finished the visual field becomes free again, and a new picture
can be called forth; but at other times such a picture, in spite of
its having been described, remains persistently before the inner
eye of the patient, and I take this as a sign that he still has something
important to tell me concerning its theme. As soon as
this has been accomplished, the picture disappears like a wandering
spirit returning to rest.
It is naturally of great value for the progress of the analysis
to carry our point with the patient, otherwise we have to depend
on what he thinks is proper to impart. It, therefore, will be
pleasant to hear that the pressure procedure never failed except
in a single case which I shall discuss later, but which I can now
characterize by the fact that there was a special motive for the resistance.
99To be sure, it may happen under certain conditions
that the procedure may be applied without bringing anything to
light; as, for example, we may ask for the further etiology of a
symptom when the same has already been exhausted; or, we
may investigate for the psychic genealogy of a symptom, perhaps
a pain, which really was of somatic origin. In these cases the
patient equally insists that nothing occurred to him, and he is
right. We should strive to avoid doing an injustice to the patient
by making it a general rule not to lose sight of his features while
he calmly lies before us during the analysis. One can then
learn to distinguish, without any difficulty, the psychic calm in the
real non appearance of a reminiscence from the tension and
emotional signs under which the patient labors in trying to disavow
the emerging reminiscences for the purpose of defense.
The differential diagnostic application of the pressure procedure
is really based on such experiences.
We can see, therefore, that even with the help of the pressure
procedure the task is not an easy one. The only advantage
gained is the fact that we have learned from the results of this
method in what direction to investigate, and what things we
have to force upon the patient. For some cases that suffices,
for the question is really to find the secret, and tell it to the patient,
so that he is usually then forced to relinquish his resistance.
In other cases more is necessary; here the surviving resistance
of the patient manifests itself by the fact that the connections
become torn, the solutions do not appear, and the recalled pictures
come indistinctly and incompletely. On reviewing, at a later
period, the earlier results of an analysis, we are often surprised
at the distorted aspects of all the occurrences and scenes which
we have snatched from the patient by the pressure procedure. It
usually lacks the essential part, the relations to the person or to
the theme, and for that reason the picture remained incomprehensible.
I will now give one or two examples showing the effects
of such a censoring during the first appearance of the pathogenic
memories. The patient sees the upper part of a female body on
which a loose covering fits carelessly, only much later he adds to
this torso the head, and thereby betrays a person and a relationship.
Or, he relates a reminiscence of his childhood about two
boys whose forms are very indistinct, and to whom a certain mischievousness
100was attributed. It required many months and considerable
progress in the course of the analysis before he again
saw this reminiscence and recognized one of the children as himself
and the other as his brother. What means have we now at
our disposal to overcome this continued resistance?
We have but few, yet we have almost all those by which one
person exerts a psychic influence on the other. In the first place
we must remember that psychic resistance, especially of long continuance,
can only be broken slowly, gradually, and with much
patience. We can also count on the intellectual interest which
manifests itself in the patient after a brief period of the analysis.
On explaining and imparting to him the knowledge of the
marvelous world of psychic processes, which we have gained
only through such analysis, we obtain his collaboration, causing
him to view himself with the objective interest of the
investigator, and we thus drive back the resistance which
rests on an affective basis. But finally—and this remains
the strongest motive force—after the motives for the defense
have been discovered, we must make the attempt to reduce or
even substitute them by stronger ones. Here the possibility of
expressing the therapeutic activity in formulæ ceases. One does
as well as he can as an explainer where ignorance has produced
timorousness, as a teacher, as a representative of a freer and
more superior world-conception, and as confessor, who through
the continuance of his sympathy and his respect, imparts, so to
say, absolution after the confession. One endeavors to do something
humane for the patient in so far as the range of one’s own
personality and the measure of sympathy which one can set apart
for the case allows. It is an indispensable prerequisite for such
psychic activities to have approximately discovered the nature
of the case and the motives of the defense here effective. Fortunately
the technique of the urging and the pressure procedure
take us just so far. The more we have solved such enigmas the
easier will we discover new ones, and the earlier will we be able
to manage the actual curative psychic work. For it is well to
bear in mind that although the patient can rid himself of an hysterical
symptom only after reproducing and uttering under emotion
its causal pathogenic impressions, yet the therapeutic task
merely consists in inducing him to do it, and once the task has
101been accomplished there remains nothing for the doctor to correct
or abolish. All the contrary suggestions necessary have already
been employed during the struggle carried on against the
resistance. The case may be compared to the unlocking of a
closed door, where, as soon as the door knob has been pressed
downward, no other difficulties are encountered in opening the
door.
Among the intellectual motives employed for the overcoming
of the resistance one can hardly dispense with one affective
moment, that is, the personal equation of the doctor, and in a
number of cases, this alone will be able to break the resistance.
The conditions here do not differ from those found in any other
branch of medicine, and one should not expect any therapeutic
method to fully disclaim the assistance of this personal moment.
In view of the discussions in the preceding section concerning
the difficulty of my technique, which I have unreservedly exposed,—I
have really collected them from my most difficult cases,
though it will often be easier work—in view then of this state of
affairs everybody will wish to ask whether it would not be more
suitable, instead of all these tortures, to apply oneself more energetically
to hypnosis, or to limit the application of the cathartic
method to only such cases as can be placed in deep hypnosis. To
the latter proposition I should have to answer that the number
of patients available for my skill would shrink considerably; but
to the former advice I will advance the supposition that even where
hypnosis could be produced the resistance would not be very much
lessened. My experiences in this respect are not particularly extensive,
so that I am unable to go beyond this supposition, but
wherever I achieved a cathartic cure in the hypnotic state I found
that the work devolved upon me was not less than in the state
of concentration. I have only recently finished such a treatment
during which course I caused the disappearance of a hysterical
paralysis of the legs. The patient merged into a state, psychically
very different from the conscious, and somatically distinguished
by the fact that she was unable to open her eyes or rise without
my ordering her to do so; and still I never had a case showing
greater resistance than this one. I placed no value on these physical
102signs, and toward the end of the ten months’ treatment they
really became imperceptible. The condition of the patient during
our work has therefore lost nothing of its psychic peculiarities,
such as the ability to recall the unconscious and its very peculiar
relation to the person of the physician. To be sure, in the history
of Mrs. Emmy v. N. I have described an example of a cathartic
cure accomplished in a profound somnambulism in which the resistance
played almost no part. But nothing that I obtained from
this woman would have required any special effort; I obtained
nothing that she could not have told me in her waking state after
a longer acquaintanceship and some esteem. The real causes of
her disease, which were surely identical with the causes of her relapses
after my treatment, I have never found—it was my first attempt
in this therapy—and when I once asked her accidentally for
a reminiscence which contained a fragment of the erotic, I found
her just as resistant and unreliable in her statements as any one
of my later non-somnambulic patients. This patient’s resistance,
even in the somnambulic state, against other requirements
and exactions I have already discussed in her history. Since I
have witnessed cases who, even in deep somnambulism were absolutely
refractory therapeutically despite their obedience in everything
else, I really became skeptical as to the value of hypnosis
for the facilitation of the cathartic treatment. A case of this
kind I have reported in brief,[32] and could still add others.
In our discussion thus far, the idea of resistance has thrust
itself to the foreground. I have shown how, in the therapeutic
work, one is led to the conception that hysteria originates through
the repression of an unbearable idea from a motive of defense,
that the repressed idea remains as a weak (mildly intensive) reminiscence,
and that the affect snatched from it is used for a
somatic innervation, that is, conversion of the excitement. By
virtue of its repression the idea becomes the cause of morbid
symptoms, that is pathogenic. A hysteria showing this psychic
mechanism may be designated by the name of “defense hysteria,”
but both Breuer and myself have repeatedly spoken of two other
kinds of hysterias which we have named hypnoid and retention hysteria.
103The first to reveal itself to us was really the hypnoid-hysteria,
for which I can mention no better example than Breuer’s
case of Miss Anna O.[33] For this form of hysteria Breuer gives
an essentially different psychic mechanism than for the form
which is characterized by conversion. Here the idea becomes
pathogenic through the fact that it is conceived in a peculiar
psychic state, having remained from the very beginning external
to the ego. It therefore needs no psychic force to keep it away
from the ego, and it need not awaken any resistance when, with
the help of the somnambulic psychic authority, it is initiated into
the ego. The history of Anna O. really shows no such resistance.
I held this distinction as so essential that it has readily induced
me to adhere to the formation of the hypnoid-hysteria. It is however
remarkable that in my own experience I encountered no genuine
hypnoid-hysteria, whatever I treated changed itself into a defense
hysteria. Not that I have never dealt with symptoms which
manifestly originated in separated conscious states, and therefore
were excluded from being accepted into the ego. I found this
also in my own cases, but I could show that the so called hypnoid
state owed its separation to the fact that a split off psychic group
originated before, through defense. In brief, I cannot suppress
the suspicion that hypnoid and defense hysteria meet somewhere
at their roots, and that the defense is the primary thing; but I
know nothing about it.
Equally uncertain is at present my opinion concerning the retention hysteria
in which the therapeutic work is also supposed to
follow without any resistance. I had a case which I took for a
typical retention hysteria, and I was pleased over the anticipation
of an easy and certain success; but this success did not come as
easy as the work really was. I therefore presume, and again with
all caution appropriate to ignorance, that in retention hysteria, too,
we can find at its basis a fragment of defense which has thrust
the whole process into hysteria. Let us hope that new experiences
will soon decide whether I am running into the danger of
one-sidedness and error in my tendency to spread the conception
of defense for the whole of hysteria.
Thus far I have dealt with the difficulties and technique of the
104cathartic method, I would now like to add a few indications showing
how one makes an analysis with technique. For me this is a
very interesting theme, but I do not expect that it will excite similar
interest in others who have not practiced such analyses.
Properly speaking we shall again deal with the technique, but this
time with those difficulties concerning which the patient cannot
be held responsible, and which must in part be the same in a hypnoid
and a retention hysteria as well as in the defense hysteria
which I have in mind as a model. I start on this last fragment of
discussion with the expectation that the psychic peculiarities revealed
here might sometime attain a certain value as raw material
for an intellectual dynamics.
The first and strongest impression which one gains through
such an analysis is surely the fact that the pathogenic psychic
material, apparently forgotten and not at the disposal of the ego,
playing no rôle in the association and in memory, still lies ready
in some manner and in proper and good order. All that is necessary
is to remove the resistances blocking the way. Barring
that, everything is known as we know anything else, the proper
connections of the individual ideas among themselves and with
the nonpathogenic are frequently recalled and are present; they
have been produced in their time and retained in memory. The
pathogenic psychic material appears as the property of an intelligence
which is not necessarily inferior to the normal ego.
The semblance of a second personality is often most delusively
produced. Whether this impression is justified, whether the arrangements
of the psychic material resulting after the adjustment
is not transferred back into the time of the disease, these are questions
which I do not like to consider in this place. One cannot
easily and intuitively describe the experiences resulting from these
analyses as if he placed himself in the position, which one can
only take a survey of after their disappearance.
The condition is usually not so simple as one represents it in
special cases, as, for example, in a single case in which a symptom
originates through a serious trauma. We frequently deal not with
a single hysterical symptom but with a number of the same which
are partially independent of one another and partially connected.
We must not expect a single traumatic reminiscence whose nucleus
is a single pathogenic idea, but we must be ready to assume
105a series of partial traumas and a concatenation of pathogenic
streams of thought. The monosymptomatic traumatic hysteria is,
as it were, an elementary organism, it is a single being in comparison
to the complicated structure of a grave hysterical neurosis
as is generally encountered.
The psychic material of such hysteria presents itself as a multidimensional
formation of at least triple stratification. I hope to
be able to soon justify this figurative expression. First of all
there is a nucleus of such reminiscences (either experiences or
streams of thought) in which the traumatic moment culminated,
or in which the pathogenic idea has found its purest formation.
Around this nucleus we often find an incredibly rich mass of other
memory material which we have to elaborate by the analysis in the
triple arrangement mentioned before. In the first place, there is
an unmistakable linear chronological arrangement which takes
place within every individual theme. As an example of this I can
only cite the arrangements in Breuer’s analysis of Anna O. The
theme is that of becoming deaf, of not hearing,[34] which then becomes
differentiated according to seven determinants, and under
each heading there were from ten to one hundred single reminiscences
in chronological order. It was as if one should take up
an orderly kept record. In the analysis of my patient, Emmy v.
N., there were similar if not so many memory sub-divisions; they
formed quite a general event in every analysis. They always occurred
in a chronological order which was as definitely reliable as
the serial sequences of the days of the week or the names of the
months in psychically normal individuals. They increased the
work of the analysis through the peculiarity of reversing the
series of their origin in the reproduction; the freshest and the
most recent occurrence of the accumulation occurred first as a
“wrapper,” and that with which the series really began gave the
impression of the conclusion.
The grouping of similar reminiscences in a multiplicity of
linear stratifications, as represented in a bundle of documents,
in a package, etc., I have designated as the formation of a
theme. These themes now show a second form of arrangement.
I cannot express it differently than by saying that they are concentrically
106stratified around the pathogenic nucleus. It is not difficult
to say what determines these strata, and according to what
decreasing or increasing magnitude this arrangement follows.
They are layers of equal resistance tending towards the nucleus,
accompanied by zones of similar alteration of consciousness into
which the individual themes extend. The most peripheral layers
contain those reminiscences (or fascicles) of the different themes
which can readily be recalled and were always perfectly conscious.
The deeper one penetrates the more difficult it becomes to recognize
the emerging reminiscences until one strikes those near the
nucleus which the patient disavows, even at the reproduction.
As we shall hear later it is the peculiarity of the concentric
stratification of the pathogenic psychic material which gives to
the course of such an analysis its characteristic features. We
must now mention the third and most essential arrangement concerning
which a general statement can hardly be made. It is the
arrangement according to the content of thought, the connection
through the logical thread reaching to the nucleus which might in
each case correspond to a special, irregular, and manifoldly devious
road. This arrangement has a dynamic character in contradistinction
to both morphological stratifications mentioned before.
Whereas, in a spacially formed scheme the latter would
be represented by rigid, arched, and straight lines, the course of
the logical concatenation would have to be followed with a wand,
over the most tortuous route, from the superficial into the deep
layers and back, generally, however, progressing from the peripheral
to the central nucleus, and touching thereby all stations;
that is, its movement is similar to the zigzag movement of the
knight in the solution of a chess problem.
I will still adhere for a moment to the last comparison in order
to call attention to a point in which it does not do justice to the
qualities of the thing compared. The logical connection corresponds
not only to a zigzag-like devious line, but rather to a ramifying
and especially to a converging system of lines. It has a
junction in which two or more threads meet only to proceed
thence united, and, as a rule, many threads running independently,
or here and there connected by by-paths, open into the nucleus.
To put it in different words, it is very remarkable how frequently
a symptom is manifoldly determined, that is, over-determined.
107I will introduce one more complication, and then my effort to
illustrate the organization of the pathogenic psychic material will
be achieved. It can happen that we may deal with more than
one single nucleus in the pathogenic material, as, for example,
when we have to analyze a second hysterical outbreak having its
own etiology but which is still connected with the first outbreak
of an acute hysteria which has been overcome years before. It
can readily be imagined what strata and streams of thought
must be added in order to produce a connection between the two
pathogenic nuclei.
I will still add a few observations to the picture obtained of the
organization of the pathogenic material. We have said of this
material that it behaves like a foreign body, and that the therapy
also acts like the removal of a foreign body from the living tissues.
We are now in position to consider the shortcomings of
this comparison. A foreign body does not enter into any connection
with the layers of tissue surrounding it, although it
changes them and produces in them a reactive inflammation. On
the other hand, our pathogenic psychic group does not allow
itself to be cleanly shelled out from the ego, its outer layers radiate
in all directions into the parts of the normal ego, and really
belong to the latter as much as to the pathogenic organization.
The boundaries between both become purely conventional in the
analysis, being placed now here, now there, and in certain locations
no demarcation is possible. The inner layers become more
and more estranged from the ego without showing a visible beginning
of the pathogenic boundaries. The pathogenic organization
really does not behave like a foreign body, but rather like an
infiltration. The infiltrate must, in this comparison, be assumed
to be the resistance. Indeed, the therapy does not consist in extirpating
something—psychotherapy cannot do that at present—but
it causes a melting of the resistance, and thus opens the way
for the circulation into a hitherto closed territory.
(I make use here of a series of comparisons all of which have
only a very limited resemblance to my theme, and do not even
agree among themselves. I am aware of that, and I am not in
danger of over-estimating their value; but, as it is my intention to
illustrate the many sides of a most complicated and not as yet
depicted idea, I therefore take the liberty of dealing also in the
108following pages with comparisons which are not altogether free
from objections.)
If, after a thorough adjustment, one could show to a third
party the pathogenic material in its present recognized, complicated
and multidimensional organization, he would justly propound
the question, “How could such a camel go through the
needle’s eye?” Indeed, one does not speak unjustly of a “narrowing
of consciousness.” The term gains in sense and freshness
for the physician who accomplishes such an analysis. Only one
single reminiscence can enter into the ego consciousness; the
patient occupied in working his way through this one sees nothing
of that which follows, and forgets everything that has already
wedged its way through. If the conquest of this one pathogenic
reminiscence strikes against impediments, as for example, if the
patient does not yield the resistance against it, but wishes to
repress or distort it, the strait is, so to speak, blocked; the work
comes to a standstill, it cannot advance, and the one reminiscence
in the breach confronts the patient until he takes it up into the
breadth of his ego. The whole spacially extended mass of the
pathogenic material is thus drawn through a narrow fissure and
reaches consciousness as if disjointed into fragments or strips,
and it is the task of the psychotherapist to recompose it into the
conjectured organization. He who desires still more comparisons
may think here of a Chinese puzzle.
If one is about to begin an analysis in which one may expect
such an organization of the pathogenic material, the following
results of experience may be useful: It is perfectly hopeless to
attempt to make any direct headway towards the nucleus of the
pathogenic organization. Even if it could be guessed the patient
would still not know what to start with the explanation given to
him, nor would it change him psychically.
There is nothing left to do but follow up the periphery of the
pathogenic psychic formation. One begins by allowing the
patient to relate and recall what he knows, during which one can
already direct his attention, and through the application of the
pressure procedure slight resistances may be overcome. Whenever
a new way is opened through pressure it can be expected that
the patient will continue it for some distance without any new
resistance.
109After having worked for a while in such manner a coöperating
activity is usually manifested in the patient. A number of reminiscences
now occur to him without any need of questioning or
setting him a task. A way has thus been opened into an inner
strata, within which the patient now spontaneously disposes of the
material of equal resistance. It is well to allow him to reproduce
for a while without being influenced; of course, he is unable to
reveal important connections, but he may be allowed to clear
things within the same stratum. The things which he thus reproduces
often seem disconnected, but they give up the material
which is later revived by the recognized connections.
One has to guard here in general against two things. If the
patient is checked in the reproduction of the inflowing ideas,
something is apt to be “buried” which must be uncovered later
with great effort. On the other hand one must not overestimate
his “unconscious intelligence,” and one must not allow it to direct
the whole work. If I should wish to schematize the mode of
labor, I could perhaps say that one should himself undertake the
opening of the inner strata and the advancement in the radial
direction, while the patient should take care of the peripheral
extension.
The advancement is brought about by the fact that the resistance
is overcome in the manner indicated above. As a rule, however,
one must at first solve another problem. One must obtain
a piece of a logical thread by which direction alone one can hope
to penetrate into the interior. One should not expect that the
voluntary information of the patient, the material which is mostly
in the superficial strata, will make it easy for the analyzer to
recognize the locations where it enters into the deep, and to which
points the desired connections of thought are attached. On the
contrary, just this is cautiously concealed, the assertion of the
patient sounds perfect and fixed in itself. One is at first confronted,
as it were, by a wall which shuts off every view, and
gives no suggestion of anything hidden behind it.
If, however, one views with a critical eye the assertion obtained
from the patient without much effort and resistance, one will unmistakably
discover in it gaps and injuries. Here the connection
is manifestly interrupted and is scantily completed by the patient
by an expression conveying quite insufficient information. Here
110one strikes against a motive which in a normal person would be
designated as flimsy. The patient refuses to recognize these gaps
when his attention is called to them. The physician, however,
does well to seek under these weak points access to the material
of the deeper layers and to hope to discover just here the threads
of the connections which he traces by the pressure procedure.
One, therefore, tells the patient, “You are mistaken, what you
assert can have nothing to do with the thing in question; here we
will have to strike against something which will occur to you
under the pressure of my hand.”
The hysterical stream of thought, even if it reaches into the
unconscious, may be expected to show the same logical connections
and sufficient causations as those that would be formed
in a normal individual. A looseness of these relationships does
not lie within the sphere of influence of the neurosis. If the association
of ideas of neurotics, and especially of hysterics, makes
a different impression, if the relation of the intensities of different
ideas does not seem to be explainable here on psychological
determinants alone, we know that such manifestations are due to
the existence of concealed unconscious motives. Such secret motives
may be expected wherever such a deviation in the connection,
or a transgression from the normally justified causations
can be demonstrated.
To be sure one must free himself from the theoretical prejudice
that one has to deal with abnormal brains of dégénerés and deséquilibrés,
in whom the freedom of overthrowing the common psychological
laws of the association of ideas is a stigma, or in whom
a preferred idea without any motive may grow intensively excessive,
and another without psychological motives may remain
indestructible. Experience shows the contrary in hysteria; as
soon as the hidden—often unconsciously remaining—motives have
been revealed and brought to account there remains nothing in
the hysterical thought connection that is enigmatical and anomalous.
Thus by tracing the breaches in the first statements of the
patient, which are often hidden by “false connections,” one gets
hold of a part of the logical thread at the periphery, and thereafter
continues the route by the pressure procedure.
Very seldom do we succeed in working our way into the inner
111strata by the same thread, usually it breaks on the way when the
pressure fails, giving up either no experience, or one which cannot
be explained or be continued despite all efforts. In such a
case we soon learn how to protect ourselves from the obvious confusion.
The expression of the patient must decide whether one
really reached an end or encountered a case needing no psychic
explanation, or whether it is the enormous resistance that halts
the work. If the latter cannot soon be overcome, it may be
assumed that the thread has been followed into a strata which is
as yet impenetrable. One lets it fall in order to grasp another
thread which may, perhaps, be followed up just as far. If one
has followed all the threads into this strata, if the knottings have
been reached through which no single isolated thread can be followed,
it is well to think of seizing anew the resistances on hand.
One can readily imagine how complicated such a work may become.
By constantly overcoming the resistance, one pushes his
way into the inner strata, gaining knowledge concerning the accumulative
themes and passing threads found in this layer; one
examines as far as he can advance with the means at hand, and
by means of the pressure procedure he gains first information
concerning the content of the next strata.
The threads are dropped, taken up again, and followed up until
they reach the juncture; they are always retrieved, and by following
a memory fascicle one reaches some by-way which finally
opens again. In this manner it is possible to leave the work,
layer by layer, and advance directly on the main road to the
nucleus of the pathogenic organization. Thus the fight is won
but not finished. One has to follow up the other threads and
exhaust the material; but now the patient helps again energetically,
for his resistance has mostly been broken.
In these later stages of the work it is of advantage if one can
surmise the connection and tell it to the patient before it has been
revealed. If the conjecture is correct the course of the analysis
is accelerated, but even an incorrect hypothesis helps, for it urges
the patient to participate and elicits from him energetic refutation,
thus revealing that he surely knows better.
One, thereby, becomes astonishingly convinced, that it is not
possible to press upon the patient things which he apparently does
not know, or to influence the results of the analysis by exciting
112his expectations. I have not succeeded a single time in altering
or falsifying the reproductions of memory or the connections of
events by my predictions; had I succeeded it surely would have
been revealed in the end by a contradiction in the construction.
If anything occurred as I predicted, the correctness of my conjecture
was always attested by numerous trustworthy reminiscences.
Hence, one must not fear to express his opinion to the
patient concerning the connections which are to follow; it does
no harm.
Another manifestation which can be repeatedly observed refers
to the patient’s independent reproductions. It can be asserted
that not a single reminiscence comes to the surface during such an
analysis which has no significance. An interposition of irrelevant
memory pictures having no connection with the important associations
does not really occur. An exception not contrary to the
rule may be postulated for those reminiscences which, though in
themselves unimportant, are indispensable as intercalations, since
the associations between two related reminiscences passed through
them only.—As mentioned above, the period during which a
reminiscence abides in the pass of the patient’s consciousness is
directly proportionate to its significance. A picture which does
not disappear requires further consideration; a thought which
cannot be abolished must be followed further. A reminiscence
never recurs if it has been adjusted, a picture spoken away cannot
be seen again. However, if that does happen it can be definitely
expected that the second time the picture will be joined by a new
content of thought, that the idea will contain a new inference
which will show that no perfect adjustment has taken place. On
the other hand, a recurrence of different intensities, at first
vaguely then quite plainly, often occurs, but it does not, however,
contradict the assertion just advanced.
If the object of the analysis is to remove a symptom (pains,
symptoms like vomiting, sensations and contractures) which is
capable of aggravation or recurrence, the symptom shows during
the work the interesting and not undesirable phenomenon of
“joining in the discussion.” The symptom in question reappears,
or appears with greater intensity, as soon as one penetrates into
the region of the pathogenic organization containing the etiology
of this symptom, and it continues to accompany the work with
113characteristic and instructive fluctuations. The intensity of the
same (let us say of a nausea) increases the deeper one penetrates
into its pathogenic reminiscence; it reaches its height shortly
before the latter has been expressed, and suddenly subsides or
disappears completely for a while after it has been fully expressed.
If through resistance the patient delays the expression,
the tension of the sensation of nausea becomes unbearable, and, if
the expression cannot be forced, vomiting actually sets in. One
thus gains a plastic impression of the fact that the vomiting takes
the place of a psychic action (here that of speaking) just as was
asserted in the conversion theory of hysteria.
The fluctuation of intensity on the part of the hysterical
symptom recurs as often as one of its new and pathogenic reminiscences
is attacked; the symptom remains, as it were, all the
time the order of the day. If it is necessary to drop for awhile
the thread upon which this symptom hangs, the symptom, too,
merges into obscurity in order to emerge again at a later period
of the analysis. This play continues until, through the completion
of the pathogenic material, there occurs a definite adjustment
of this symptom.
Strictly speaking the hysterical symptom does not behave here
differently than a memory picture or a reproduced thought which
is evoked by the pressure of the hand. Here, as there, the adjustment
necessitates the same obsessing obstinacy of recurrence
in the memory of the patient. The difference lies only in the
apparent spontaneous appearance of the hysterical symptom,
whereas one readily recalls having himself provoked the scenes
and ideas. But in reality the memory symbols run in an uninterrupted
series from the unchanged memory remnants of affectful
experiences and thinking-acts to the hysterical symptoms.
The phenomenon of “joining in the discussion” of the hysterical
symptom during the analysis carries with it a practical inconvenience
to which the patient should be reconciled. It is quite
impossible to undertake the analysis of a symptom in one stretch
or to divide the pauses in the work in such a manner as to
precisely coincide with the resting point in the adjustment.
Furthermore, the interruption which is categorically dictated by
the accessory circumstances of the treatment, like the late hour,
etc., often occurs in the most awkward locations, just when some
114critical point could be approached or when a new theme comes to
light. These are the same inconveniences which every newspaper
reader experiences in reading the daily fragments of his newspaper
romance, when, immediately after the decisive speech of
the heroine, or after the report of a shot, etc., he reads, “To
be continued.” In our case the raked-up but unabolished theme,
the at first strengthened but not yet explained symptom, remains
in the patient’s psyche, and troubles him perhaps more than
before.
But the patient must understand this as it cannot be differently
arranged. Indeed, there are patients who during such an
analysis are unable to get rid of the theme once touched; they are
obsessed by it even during the interval between the two treatments,
and as they are unable to advance alone with the adjustment,
they suffer more than before. Such patients, too, finally
learn to wait for the doctor, postponing all interest which they
have in the adjustment of the pathogenic material for the hours
of the treatment, and they then begin to feel freer during the
intervals.
The general condition of the patient during such an analysis
seems also worthy of consideration. For a while it remains uninfluenced
by the treatment expressing the former effective
factors. But then a moment comes in which the patient is seized,
and his interest chained and from that time his general condition
becomes more and more dependent on the condition of the work.
Whenever a new explanation is gained and an important contribution
in the chain of the analysis is reached, the patient feels relieved
and experiences a presentiment of the approaching deliverance;
but at each standstill of the work, at each threatening
entanglement, the psychic burden which oppresses him grows, and
the unhappy sensation of his incapacity increases. To be sure,
both conditions are only temporary, for the analysis continues
disdaining to boast of a moment of wellbeing, and continues
regardlessly over the period of gloominess. One is generally
pleased if it is possible to substitute the spontaneous fluctuations
in the condition of the patient by such as one himself provokes
and understands, just as one prefers to see in place of the spontaneous
discharge of the symptoms that order of the day which
corresponds to the condition of the analysis.
115Usually the deeper one penetrates into the above described
layers of the psychic structure the more obscure and difficult the
work will at first become. But once the nucleus is reached light
ensues, and there is no more fear that a marked gloom will be
cast over the condition of the patient. However, the reward of
the labor, the cessation of the symptoms of the disease can only
be expected when the full analysis of every individual symptom
has been accomplished; indeed where the individual symptoms
are connected through many junctures one is not even encouraged
by partial successes during the work. By virtue of the great
number of existing causal connections every unadjusted pathogenic
idea acts as a motive for the complete creation of the
neurosis, and only with the last word of the analysis does the
whole picture of the disease disappear, just as happens in the
behavior of the individual reproduced reminiscence.
If a pathogenic reminiscence or a pathogenic connection which
was previously withdrawn from the ego consciousness is revealed
by the work of the analysis and inserted into the ego,
one can observe in the psychic personality which was thus enriched
the many ways in which it gives utterance to its gain.
Especially does it frequently happen that after the patients have
been painstakingly forced to a certain knowledge, they say:
“Why I have known that all the time, I could have told you that
before.” Those who have more insight recognize this afterwards
as a self deception and accuse themselves of ungratefulness. In
general the position that the ego takes towards the new acquisition
depends upon the strata of the analysis from which the
latter originates. Whatever belongs to the outermost layers is
recognized without any difficulty, for it always remained in the
possession of the ego, and the only thing that was new to the
ego was its connection with the deeper layers of the pathogenic
material. Whatever is brought to light from these deeper layers
also finds appreciation and recognition, but frequently only after
long hesitation and reflection. Of course, visual memory pictures
are here more difficult to deny than reminiscences of mere
streams of thought. Not very seldom the patient will at first
say, “It is possible that I thought of that, but I cannot recall it,”
and only after a longer familiarity with this supposition recognition
will appear. He then recalls and even verifies by sight
116associations that he once really had this thought. During the
analysis I make it a point of holding the value of an emerging
reminiscence independent of the patient’s recognition. I am not
tired of repeating that we are obliged to accept everything that
we bring to light with our means. Should there be anything
unreal or incorrect in the material thus revealed, the connection
will later teach us to separate it. I may add that I rarely ever
have occasion to subsequently withdraw the recognition from a
reminiscence which I had preliminarily admitted. In spite of the
deceptive appearance of an urgent contradiction, whatever came
to the surface finally proved itself correct.
Those ideas which originate in the deepest layer, and from the
nucleus of the pathogenic organization, are only with the greatest
difficulty recognized by the patient as reminiscences. Even after
everything is accomplished, when the patients are overcome by
the logical force and are convinced of the curative effect accompanying
the emerging of this idea—I say even if the patients
themselves assume that they have thought “so” and “so” they
often add, “but to recall, that I have thought so, I cannot.” One
readily comes to an understanding with them by saying that these
were unconscious thoughts. But how should we note this state
of affairs in our own psychological views? Should we pay no
heed to the patient’s demurring recognition which has no motive
after the work has been completed; should we assume that it was
really a question of thoughts which never occurred, and for which
there is only a possibility of existence so that the therapy would
consist in the consummation of a psychic act which at that time
never took place? It is obviously impossible to state anything
about it, that is, to state anything concerning the condition of the
pathogenic material previous to the analysis, before one has thoroughly
explained his psychological views especially concerning the
essence of consciousness. It is a fact worthy of reflection that in
such analyses one can follow a stream of thought from the conscious
into the unconscious (that is, absolutely not recognized as
a reminiscence) thence draw it for some distance through the
consciousness, and again see it end in the unconscious; and still
this variation of the psychic elucidation would change nothing in
it, in its logicalness, and in a single part of its connection. Should
I then have this stream of thought freely before me, I could not
117conjecture what part was, and what part was not recognized by
the patient as a reminiscence. In a measure I see only the points
of the stream of thought merging into the unconscious, just the
reverse of that which has been claimed for our normal psychic
processes.
I still have another theme to treat which plays an undesirably
great part in the work of such a cathartic analysis. I have
already admitted the possibility that the pressure procedure may
fail and despite all assurance and urging it may evoke no reminiscences.
I also stated that two possibilities are to be considered,
there is really nothing to evoke in the place where we
investigate—that can be recognized by the perfectly calm expression
of the patient—or, we have struck against a resistance to be
overcome only at some future time. We are confronted with a
new layer into which we cannot as yet penetrate, and this can
again be read from the drawn and psychic exertion of the patient’s
expression. A third cause may be possible which also indicates
an obstacle, not as to the purport, but externally. This cause
occurs when the relation of the patient to the physician is disturbed,
and signifies the worst obstacle that can be encountered.
One may consider that in every more serious analysis.
I have already alluded to the important rôle falling to the personality
of the physician in the creation of motives which are to
overcome the psychic force of the resistance. In not a few cases,
especially in women and where we deal with the explanation of
erotic streams of thought, the cooperation of the patient becomes
a personal sacrifice which must be recompensed by some kind of
a substitute of love. The great effort and the patient friendliness
for the physician suffice as such substitutes. If this relation of
the patient to the physician is disturbed the readiness of the
patient fails; if the physician desires information concerning the
next pathogenic idea, the patient is confronted by the consciousness
of the unpleasantness which has accumulated in her against
the physician. As far as I have discovered this obstacle occurs in
three principal cases:
1. In personal estrangement, if the patient believes herself
slighted, disparaged and insulted, or if she hears unfavorable
accounts concerning the physician and his methods of treatment.
118This is the least serious case. The obstacle can readily be overcome
by discussion and explanation, although the sensitiveness
and the suspicion of hysterics can occasionally manifest itself in
unsuspected dimensions.
2. If the patient is seized with the fear that she becomes too
accustomed to her physician, that in his presence she loses her
independence and could even become sexually dependent upon
him; this case is more significant because it is less determined
individually. The occasion for this obstacle lies in the nature
of the therapeutic distress. The patient has now a new motive
to resist which manifests itself, not only in a certain reminiscence
but at each attempt of the treatment. Whenever the pressure
procedure is started the patient usually complains of headache.
Her new motive for the resistance remains to her for the most
part unconscious, and she manifests it by a newly created hysterical
symptom. The headache signifies the aversion towards
being influenced.
3. If the patient fears lest the painful ideas emerging from the
content of the analysis would be transferred to the physician.
This happens frequently, and, indeed, in many analyses it is a
regular occurrence. The transference to the physician occurs
through false connections.[35] I must here give an example. The
origin of a certain hysterical symptom in one of my hysterical
patients was the wish she entertained years ago which was immediately
banished into the unconscious, that the man with whom
she at that time conversed would heartily grasp her and force a
kiss on her. After the ending of a session such a wish occurred
to the patient in reference to me. She was horrified and spent
a sleepless night, and at the next session, although she did not
refuse the treatment she was totally unfit for the work. After
I had discovered the obstacle and removed it, the work continued.
The wish that so frightened the patient appeared as the next
pathogenic reminiscence, that is, as the one now required by the
logical connection. It came about in the following manner:
The content of the wish at first appeared in the patient’s consciousness
without the recollection of the accessory circumstances
which would have transferred this wish into the past. By the
119associative force prevailing in consciousness the existing wish
became connected with my own person, with which the patient
could naturally occupy herself, and in this mesalliance—which I
call a false connection—the same affect became reawakened which
originally urged the patient to banish this clandestine wish. As
soon as I discovered this I could presuppose every similar claim
on my personality to be another transference and false connection.
It is remarkable how the patient falls a victim to deception on
every new occasion.
No analysis can be brought to an end if one does not know how
to meet the resistances resulting from the causes mentioned. The
way can be found if one bears in mind that the new symptom
produced after the old model should be treated like the old symptoms.
In the first place it is necessary to make the patient conscious
of the obstacle. In one of my patients, in whom the pressure
symptoms suddenly failed and I had cause to assume an unconscious
idea like the one mentioned in 2, I met it for the first
time with an unexpected attack. I told her that there must have
originated some obstacle against the continuation of the treatment
and that the pressure procedure has at least the power to
show her the obstacle, and then pressed her head. She then said,
surprisingly, “I see you sitting here on the chair, but that is nonsense,
what can that mean?”—But now I could explain it.
In another patient the obstacle did not usually show itself
directly on pressure, but I could always demonstrate it by taking
the patient back to the moment in which it originated. The
pressure procedure never failed to bring back this moment. By
discovering and demonstrating the obstacle, the first difficulty was
removed, but a greater one still remained. The difficulty lay in
inducing the patient to give information where there was an
obvious personal relation and where the third person coincided
with the physician. At first I was very much annoyed about the
increase of this psychic work until I had learned to see the lawful
part of this whole process, and I then also noticed that such a
transference does not cause any considerable increase in the work.
The work of the patient remained the same, she perhaps had to
overcome the painful affect of having entertained such a wish,
and it seemed to be the same for the success whether she took
this psychic repulsion as a theme of the work in the historical
120case or in the recent case with me. The patients also gradually
learned to see that in such transferences to the person of the
physician they generally dealt with a force or a deception which
disappeared when the analysis was accomplished. I believe, however,
that if I should have delayed in making clear to them the
nature of the obstacle, I would have given them a new, though a
milder, hysterical symptom for another spontaneously developed.
I now believe that I have sufficiently indicated how such
analyses should be executed, and the experiences connected with
them. They perhaps make some things appear more complicated
than they are, for many things really result by themselves during
such work. I have not enumerated the difficulties of the work
in order to give the impression that in view of such requirements
it pays for the physician and patient to undertake a cathartic
analysis only in the rarest cases. I allow my medical activities to
be inflected by the contrary suppositions.—To be sure I am
unable to formulate the most definite indications for the application
of the here discussed therapeutic method without entering
into the valuation of the more significant and more comprehensive
theme of the therapy of the neuroses in general. I have often
compared the cathartic psychotherapy to surgical measures, and
designated my cures as psychotherapeutic operations; the analogies
follow the opening of a pus pocket, the curetting of a
carious location, etc. Such an analogy finds its justification, not
so much in the removal of the morbid as in the production of
better curative conditions for the issue of the process.
When I promised my patients help and relief through the
cathartic method, I was often obliged to hear the following objections:
“You say, yourself, that my suffering has probably to
do with my own relation and destinies. You cannot change any
of that. In what manner, then, can you help me?” To this I
could always answer: “I do not doubt at all that it would be
easier for destiny than for me to remove your sufferings, but you
will be convinced that much will be gained if we succeed in transforming
your hysterical misery into everyday unhappiness, against
which you will be better able to defend yourself with a restored
nervous system.”
CHAPTER V. The Defense Neuro-psychoses. A Tentative Psychological Theory of Acquired Hysteria, many Phobias and Obsessions, and Certain Hallucinatory Psychoses. — I. — II — III.
121
After an exhaustive study of many nervous patients afflicted
with phobias and obsessions a tentative explanation of these symptoms
urged itself upon me. This helped me afterwards happily to
divine the origin of such morbid ideas in new and other cases, and
I therefore believe it worthy of reporting and further examination.
Simultaneously with this “psychological theory of phobias
and obsessions,” the examination of these patients resulted in a
contribution to the theory of hysteria, or rather in an alteration of
the same, which seems to imply an important and common character
to hysteria as well as the mentioned neuroses. Furthermore,
I had the opportunity to look into the psychological mechanism of
a form of indubitable psychic disease and found that my attempted
observation shows an intelligible connection between
these psychoses and the two neuroses mentioned. At the conclusion
of this theme I will describe the supporting hypothesis which
I have used in all three cases.
I am beginning with that alteration which seems to be necessary
for the theory of the hysterical neuroses.
That the symptom-complex of hysteria as far as it can be understood,
justifies the assumption of a splitting of consciousness
with the formation of separate psychic groups, has attained general
recognition since P. Janet, J. Breuer, and others have given
out their interesting work. Less understood are the opinions concerning
the origin of this splitting of consciousness and concerning
the rôle played by this character in the structure of the hysterical
neuroses.
According to Janet’s[36] theory, the splitting of consciousness is a
122primary feature of the hysterical alteration. It is due to a congenital
weakness of the capacity for psychic synthesis, and to a
narrowing of the “field of consciousness” (champ du conscience)
which as a psychic stigma proves the degeneration of hysterical
individuals.
In contradistinction to Janet’s views, which in my opinion admit
the most manifold objections, are those advocated by J. Breuer
in our joint communication. According to Breuer, the “basis
and determination” of hysteria is the occurrence of peculiar
dream-like conscious states with a narrowed association capacity,
for which he proposes the name “hypnoid states.” The splitting
of consciousness is secondary and acquired, and originates because
the ideas emerging in the hypnoid states are isolated from
associative communication with the rest of consciousness.
I can now demonstrate two other extreme forms of hysteria in
which it is impossible to show that the splitting of consciousness
is primary in the sense of Janet. In the first of these forms I
could repeatedly show that the splitting of the content of consciousness
was an arbitrary act of the patient, that is, it was
initiated through an exertion of the will which motive can be
stated. I naturally do not maintain that the patient intended to
produce a splitting of his consciousness; the patient’s intention
was different, but instead of attaining its aim it provoked a splitting
of consciousness.
In the third form of hysteria, as we have demonstrated by psychic-analysis
of intelligent patients, the splitting of consciousness
plays only an insignificant and perhaps really no rôle. This includes
those cases in which there had been no reaction to the traumatic
stimulus and which were then adjusted and cured by ab-reaction.
They are the pure retention hysterias.
In connection with the phobias and obsessions I have only to
deal here with the second form of hysteria which for reasons to
be presently explained I will designate as defense hysteria and
thus distinguish it from the hypnoid and retention hysterias. Preliminarily
I am able to call my cases of defense hysteria
“acquired” hysterias for they show neither marked hereditary
taints nor any degenerative disfigurements.
In those patients whom I have analyzed there existed psychic
health until the moment in which a case of incompatibility occurred
123in their ideation, that is, until there appeared an experience,
idea, or feeling which evoked such a painful affect that the
person decided to forget it because he did not trust his own
ability to remove the resistance between the unbearable ideas and
his ego.
Such incompatible ideas originate in the feminine sex on the
basis of sexual experiences and feelings. With all desired precision
the patients recall their efforts of defense, their intention
“to push it away,” not to think of it, to repress it. As appropriate
examples I can easily cite the following cases from my own experience:
A young lady reproached herself because, while nursing
her sick father, she thought of a young man who made a slight
erotic impression on her; a governess fell in love with her employer
and decided to crowd it out of her mind because it was
incompatible with her pride, etc.
I am unable to maintain that the exertion of the will, in crowding
such thoughts out of one’s mind, is a pathological act, nor am
I able to state whether and how, the intentional forgetting succeeds
in those persons who remain well under the same psychic
influences. I only know that in the patients whom I analyzed such
“forgetting” was unsuccessful and led to either a hysteria, obsession,
or a hallucinatory psychosis. The ability to produce, by
the exertion of the will one of these states all of which are connected
with the splitting of consciousness, is to be considered as
the expression of a pathological disposition, but it need not necessarily
be identified with personal or hereditary “degeneration.”
Over the road leading from the patient’s exertion of the will to
the origin of a neurotic symptom I formed a conception which in
the current psychological abstractions may be thus expressed: The
task assumed by the defensive ego to treat the incompatible idea
as “non arrivée” can not be directly accomplished. The memory
trace as well as the affect adhering to the idea are here and can
not be exterminated. The task can however, be brought to an
approximate solution if it is possible to change the strong idea
into a weak one and to take away the affect or sum of excitement
which adheres to it. The weak idea will then exert almost no
claims on the association work; but the separated sum of excitement
must be utilized in another direction.
Thus far the processes are the same in hysteria, in phobias and
124obsessions, but from now on their ways part. The unbearable
idea in hysteria is rendered harmless because the sum of excitement
is transformed into physical manifestations, a process for
which I would like to propose the term conversion.
The conversion may be total or partial, and follows that motor
or sensory innervation which is either ultimately or more loosely
connected with the traumatic experience. In this way the ego
succeeds in freeing itself from opposition but instead it becomes
burdened with a memory symbol which remains in consciousness
as an unadjusted motor innervation, or as a constantly recurring
hallucinatory sensation similar to a parasite. It thus remains
fixed until a conversion takes place in the opposite direction. The
memory symbol of the repressed idea does not perish, but from
now on forms the nucleus for a second psychic group.
I will follow up this view of the psycho-physical processes in
hysteria with a few more words. If such a nucleus for an hysterical
splitting is once formed in a “traumatic moment” it then
increases in other moments which might be designated as “auxiliary
traumatic” as soon as a newly formed similar impression
succeeds in breaking through the barrier formed by the will and in
adding new affects to the weakened idea, and in forcing for a
while the associative union of both psychic groups until a new
conversion produces defense. The condition thus attained in
hysteria in regard to the distribution of the excitement, proves
to be unstable in most cases. As shown by the familiar contrast
of the attacks and the persistent symptoms, the excitement which
was pushed on a false path (in the bodily innervation) now and
then returns to the idea from which it was discharged and forces
the person to associative elaboration or to adjustment in hysterical
attacks. The effect of Breuer’s cathartic method consists in the
fact that it consciously reconducts the excitement from the physical
into the psychic spheres and then forces an adjustment of
the contradiction through intellectual work, and a discharge of
the excitement through speech.
If the splitting of consciousness in acquired hysteria is due to
an act of volition we can explain with surprising simplicity the remarkable
fact that hypnosis regularly broadens the narrowed
consciousness of hysteria, and causes the split off psychic groups
to become accessible. For we know that it is peculiar to all
125sleep-like states to remove that distribution of excitement which
depends on the “will” of the conscious personality.
We accordingly recognize that the characteristic moment of
hysteria is not the splitting of consciousness but the ability of
conversion, and as an important part of the hitherto unknown disposition
of hysteria we can mention the psycho-physical adaptation
for the transference of a great sum of excitement into bodily
innervation.
The adaptation does not in itself exclude psychic health, and
leads to hysteria only in event of a psychic incompatibility or
accumulation of excitement. With this turn, we—Breuer and I—come
near to the familiar definitions of hysteria of Oppenheim[37]
and Strümpel,[38] and deviate from Janet,[39] who assigns to the splitting
of consciousness too great a rôle in the characteristics of
hysteria. The description here given can lay claim to the fact
that it explains the connection between the conversion and the
hysterical splitting of consciousness.
In a predisposed person if there is no adaptation for conversion,
and still for the purpose of defense a separation of the unbearable
idea from its affect is undertaken, the affect must then remain in
the psychic sphere. The weakened idea remains apart from all
association in consciousness, but its freed affect attaches itself to
other not in themselves unbearable ideas, which on account of this
“false” connection become obsessions. This is in brief the psychological
theory of the obsessions and phobias concerning which
I have spoken above.
126I will now state what parts demanded in this theory can be directly
demonstrated and what parts I have supplemented. Besides
the end product of the process, the obsession, we can in the
first place directly demonstrate the source from which the affect
in the false connection originates. In all cases that I have analyzed
it was the sexual life that has furnished a painful affect
of precisely the same character as the one attached to the obsession.
It is not theoretically excluded that this affect could not
occasionally originate in other spheres, but I must say that thus
far I have found no other origin. Moreover, one can readily
understand that it is precisely the sexual life which furnishes the
most manifold occasions for the appearance of unbearable ideas.
Moreover, the exertion of the will, the attempt at defence,
upon which this theory lays stress is demonstrated by the most
unequivocal utterances of the patients. At least in a number of
cases the patients themselves inform us that the phobia or obsession
appeared only after the exertion of the will manifestly gained
its point. “Something very disagreeable happened to me once
and I have exerted all my power to push it away, not to think of
it. When I have finally succeeded I have gotten the other thing
instead, which I have not lost since.” With these words a patient
verified the main points of the theory here developed.
Not all who suffer from obsessions are so clear concerning the
origin of the same. As a rule when we call the patient’s attention
to the original idea of a sexual nature we receive the following
answer: “It could not have come from that. Why I have not
thought much about it. For a moment I was frightened, then I
distracted myself and since then it has not bothered me.” In
this, so frequent objection, we have the proof that the obsession
represents a compensation or substitute for the unbearable sexual
idea, and that it has taken its place in consciousness.
Between the patient’s exertion of the will which succeeds in
repressing the unacceptable sexual idea and the appearance of the
obsession, which though in itself of little intensity, is here furnished
with inconceivably strong affect, there is a yawning gap
which the theory here developed will fill. The separation of the
sexual idea from its affect and the connection of the latter with
another suitable but not unbearable idea—these are processes
which take place unconsciously which we can only presume but not
127prove by any clinico-psychological analysis. Perhaps it would be
more correct to say that these are not really processes of a psychic
nature but physical processes of which the psychic result so presents
itself that the expressions “separation of the idea from its
affect and false connection of the latter,” seem actual occurrences.
Besides the cases evincing in turn the sexual unbearable idea
and the obsession we find a series of others in which there are
simultaneously obsessions and painfully accentuated sexual ideas.
It will not do very well to call the latter “sexual obsessions”;
they lack the essential character of obsessions in proving themselves
fully justified, whereas the painfulness of the ordinary obsession
is a problem for the doctor as well as the patient. From
the amount of insight that could be obtained in such cases, it
seems that we deal here with a continued defense against sexual
ideas which are constantly renewed, a work heretofore not accomplished.
As long as the patients are aware of the sexual origin of their
obsessions they often conceal them. If they complain they generally
express surprise that this affect underlies the symptoms, at
being afraid, and at having certain impulses, etc. To the experienced
physician, however, the affect appears justified and intelligible;
he finds the striking part only in the connection of
such an affect with an idea unworthy of it. In other words the
affect of the obsession appears to him as one dislocated or transposed,
and if he has accepted the observations here laid down he
can in a great many cases of obsessions attempt a retranslation
into the sexual.
Any idea which either through its character may be combinable
with an affect of such quality or which bears a certain relation to
the unbearable by virtue of which it seems fit as a substitute for
the same, may be used for the secondary connection of the freed
affect. Thus, for example, freed anxiety, the sexual origin of
which can not be recalled, attaches itself to the common primary
phobias of man for animals, thunderstorms, darkness, etc., or to
things which are unmistakably in some way associated with the
sexual, such as urination, defecation, pollutions and infections.
The advantage gained by the ego in the transposition of the
affect for the purpose of defense is considerably less than in the
hysterical conversion of psychic excitement into somatic innervation.
128The affect under which the ego has suffered remains now
as ever unchanged and undiminished, but the unbearable idea is
suppressed and excluded from memory. The repressed ideas
again form the nucleus of a second psychic group which I believe
can be accessible without having recourse to hypnotism. That
in the phobias and obsessions there appear none of the striking
symptoms which in hysteria accompany the formation of an independent
psychic group, is due to the fact that in the former
case the whole transformation remains in the psychic sphere and
the somatic innervation experiences no change.
What I have here said concerning obsessions I will explain by
some examples which are probably of a typical nature:
1. A young girl suffers from obsessive reproaches. If she
reads anything in the journal about false coiners she conceives
the thought that she too, made counterfeit money; if a murder
was anywhere committed by an unknown assassin she anxiously
asked herself whether she had not committed this crime. At the
same time she is perfectly aware of the absurdity of these obsessive
reproaches. For a time the consciousness of her guilt gained
such a power over her that her judgment was suppressed, and she
accused herself before her relatives and physician of having really
committed all these crimes (Psychosis through simple aggravation—overwhelming
psychosis—Uberwältigungspsychose). A thorough
examination revealed the source of the origin of this guilty
conscience. Accidentally incited by a sensual feeling she allowed
herself to be allured by a friend to masturbate. She practiced it
for years with the full consciousness of her wrong doing, and
under the most violent but useless self reproaches.—The girl was
cured after a few months’ treatment and strict watching.
2. Another girl suffered from the fear of getting sudden desires
of micturition and of being forced to wet herself. This began
after such a desire had really forced her to leave a concert hall
during the performance. This phobia had gradually caused her
to become quite incapable of any enjoyment and social relationship.
She felt secure only when she knew that there was a toilet
in the neighborhood to which she could repair unobserved. An
organic suffering which might have justified this lack of confidence
of the control of the bladder was excluded. At home
among quiet surroundings and during the night there was no such
129desire to micturate. Detailed examination showed that the desire
to micturate appeared for the first time under the following conditions:
A gentleman to whom she was not indifferent took a
seat in the concert hall not far from her. She began to think and
to picture to herself how she would sit near him as his wife. In
this erotic revery she experienced that physical feeling which
must be compared to erection in the man, and which in her—I
do not know whether it is general—ended in a slight desire to
micturate. She now became extremely frightened over her otherwise
accustomed sexual sensation because she had determined to
overcome this as well as every desire, and in the next moment the
affect transposed itself to the accompanying desire to micturate
and forced her to leave the hall after a very painful struggle.
In her life she was so prudish that she experienced an intensive
horror for all things sexual, and could not conceive the thought of
ever marrying; on the other hand she was sexually so hyperesthetic
that during every erotic revery, which she gladly allowed
herself, there appeared sensual feeling. The erection was always
accompanied by the desire to micturate, and up to the time of the
scene in the concert hall it had made no impression on her. The
treatment led to an almost complete control of the phobia.
3. A young woman who had only one child after five years of
married life complained of obsessive impulses to throw herself
from the window or balcony, and of fears lest at the sight of a
sharp knife she might kill her child. She admitted that the marriage
relations were seldom practised and then only with caution
against conception; but she added that she did not miss this as she
was not of a sensual nature. I then ventured to tell her that at
the sight of a man she conceives erotic ideas, and that she therefore
lost confidence in herself and imagined herself a depraved
person fit for anything. The retranslation of the obsession into
the sexual was successful; weeping, she soon admitted her long
concealed marital misery, and then mentioned painful ideas of an
unchanged sexual character such as the often recurring sensation
of something forcing itself under her skirts.
I have made use of such experiences in the therapy of phobias
and obsessions, and despite the patient’s resistances I have redirected
the attention to the repressed sexual ideas, and wherever
feasible I have blocked the sources from which the same originated.
130To be sure I cannot maintain that all phobias and obsessions
originate in the manner here revealed; first, my experience,
in proportion to the abundance of these neuroses, embraces only
a limited amount, and second, I, myself, know that these “psychasthenic”
symptoms (according to Janet’s designation) are not all
of the same value.[40] Thus, for instance, there are pure hysterical
phobias. But I believe that the mechanism of the transposition
of the affect will be demonstrated in the greater part of the phobias
and obsessions, and I must assert that these neuroses, which
are found just as often isolated as combined with hysteria and
neurasthenia, are not to be thrown together with the ordinary
neurasthenia for which fundamental symptom a psychic mechanism
is not all to be assumed.
In both cases thus far considered the defense of the unbearable
idea was brought about by the separation of the same from its
affect; the idea though weakened and isolated remained in consciousness.
There exists, however, a far more energetic and more
successful form of defense wherein the ego misplaces the unbearable
idea with its affect, and behaves as though the unbearable
idea had never approached the ego. But at the moment when
this is brought about the person suffers from a psychosis which
can only be classified as an “hallucinatory confusion.” A single
example will explain this assertion. A young girl gives her first
impulsive love to a man who she firmly believed reciprocated her
love. As a matter of fact she was mistaken; the young man had
other motives for visiting her. It was not long before she was
disappointed; at first she defended herself against it by converting
hysterically the corresponding experience, and thus came to believe
that he would come some day to ask her in marriage; but in
consequence of the imperfect conversion and the constant pressure
of new painful impressions, she felt unhappy and ill. She finally
expects him with the greatest tension on a definite day, it is the
131day of a family reunion. The day passes but he does not come.
After all the trains on which he could have come have passed she
suddenly merged into an hallucinatory confusion. She thought
that he did come, she heard his voice in the garden, and hastened
down in her night gown to receive him. For two months after
she lived in a happy dream, the content of which was that he was
there, that he was always with her, and that everything was as
before (before the time of the painfully defended disappointment).
The hysteria and depression were thus conquered; during
her sickness she never mentioned anything about the last period
of doubt and suffering; she was happy as long as she was left
undisturbed, and frenzied only when a regulation of her environment
prevented her from accomplishing something which she
thought quite natural as a result of her blissful dream. This
psychosis, unintelligible as it was in its time, was revealed ten
years later through hypnotic analysis.
The fact to which I call attention is this: That the content of
such an hallucinatory psychosis consists in directly bringing into
prominence that idea which was threatened by the motive of the
disease. One is therefore justified in saying that through its
flight into the psychosis the ego defended the unbearable idea;
the process through which this has been brought about withdraws
itself from self perception as well as from the psychological-clinical
analysis. It is to be considered as the expression of a higher
grade of pathological disposition, and can perhaps be explained as
follows: The ego tears itself away from the unbearable idea, but
as it hangs inseparably together with a part of reality, the ego
while accomplishing this performance also detaches itself wholly
or partially from reality. The latter is, in my opinion the condition
under which hallucinatory vividness is decreed to particular
ideas, and hence after very successful defense the person finds
himself in a hallucinatory confusion.
I have but very few analyses of such psychoses at my disposal;
but I believe that we deal with a very frequently employed type
of psychic illness. For analogous examples such as the mother
who becoming sick after the loss of her child continues to rock
in her arms a piece of wood, or the jilted bride who in full dress
expects her bridegroom, can be seen in every insane asylum.
It will perhaps not be superfluous to mention that the three
132forms of defense here considered, and hence the three forms of
disease to which this defense leads may be united in the same
person. The simultaneous occurrence of phobias and hysterical
symptoms, so frequently observed in praxis, really belongs to those
moments which impede a pure separation of hysteria from other
neuroses and urge the formation of the “mixed neuroses.” To
be sure the hallucinatory confusion is not frequently compatible
with the continuation of hysteria and not as a rule with obsessions;
but on the other hand it is not rare that a defense psychosis
should episodically break through the course of a hysteria or
mixed neurosis.
In conclusion I will mention in few words the subsidiary idea
of which I have made use in this discussion of the defense neuroses.
It is the idea that there is something to distinguish in all
psychic functions (amount of affect, sum of excitement), that
all qualities have a quantity though we have no means to measure
the same—it is something that can be increased, diminished, displaced,
and discharged, and that extends over the memory traces
of the ideas perhaps like an electric charge over the surface of the
body.
This hypothesis, which also underlies our theory of “ab-reaction”
(“Preliminary Communication”), can be used in the same
sense as the physicist uses the assumption of the current of electric
fluid. It is preliminarily justified through its usefulness in the
comprehension and elucidation of diverse psychic states.
CHAPTER VI. On the Right to Separate from Neurasthenia a Definite Symptom-complex as “Anxiety Neurosis” ( Angstneurose ). — I. Clinical Symptomatology of Anxiety Neurosis. — II. The Occurrence and Etiology of Anxiety Neurosis. — III. Addenda to the Theory of Anxiety Neurosis. — IV. The Relations to Other Neuroses.
133
It is difficult to assert anything of general validity concerning
neurasthenia as long as this term is allowed to express all that for
which Beard used it. I believe that neuropathology can only gain
by an attempt to separate from the actual neurosis all those
neurotic disturbances the symptoms of which are on the one hand
more firmly connected among themselves than to the typical
neurasthenic symptoms, such as headache, spinal irritation, dyspepsia
with flatulence and constipation, and which on the other
hand show essential differences from the typical neurasthenic
neurosis in their etiology and mechanism. If we accept this plan
we will soon gain quite a uniform picture of neurasthenia. We
will soon be able to differentiate—sharper than we have hitherto
succeeded—from the real neurasthenia the different pseudoneurasthenias,
such as the organically determined nasal reflex
neurosis, the neurotic disturbances of cachexias and arteriosclerosis,
the early stages of progressive paralysis, and of some
psychoses. Furthermore, following the proposition of Moebius,
some status nervosi of hereditary degenerates will be set aside
and we will also find reasons for ascribing some of the neuroses
which are now called neurasthenia to melancholia, especially those
of an intermittent or periodic nature. But we force the way
into the most marked changes if we decide to separate from
neurasthenia that symptom-complex which I shall hereafter describe
and which especially fulfills the conditions formulated
above. The symptoms of this complex are clinically more related
to one another than to the real neurasthenic symptoms, that is,
they frequently appear together and substitute one another in the
course of the disease, and both the etiology as well as the mechanism
of this neurosis differs basically from the etiology and the
134mechanism of the real neurasthenia which remains after such a
separation.
I call this symptom-complex “anxiety neurosis” (Angstneurose)
because the sum of its components can be grouped around the
main symptom of anxiety, because each individual symptom shows
a definite relation to anxiety. I believed that I was original in
this conception of the symptoms of anxiety neurosis until an
interesting lecture by E. Hecker[41] fell into my hands. In this
lecture I found the description of the same interpretation with all
the desired clearness and completeness. To be sure, Hecker does
not separate the equivalents or rudiments of the attack of anxiety
from neurasthenia as I intend to do; but this is apparently due
to the fact that neither here nor there has he taken into account
the diversity of the etiological determinants. With the knowledge
of the latter difference every obligation to designate the
anxiety neurosis by the same name as the real neurasthenia disappears,
for the only object of arbitrary naming is to facilitate
the formulation of general assertions.
What I call “anxiety neurosis” can be observed in complete or
rudimentary development, either isolated or in combination with
other neuroses. The cases which are in a measure complete, and
at the same time isolated, are naturally those which especially corroborate
the impression that the anxiety neurosis possesses
clinical independence. In other cases we are confronted with the
task of selecting and separating from a symptom-complex which
corresponds to a “mixed neurosis,” all those symptoms which do
not belong to neurasthenia, hysteria, etc., but to the anxiety
neurosis.
The clinical picture of the anxiety neurosis comprises the following
symptoms:
1. General Irritability.—This is a frequent nervous symptom,
common as such to many nervous states. I mention it here because
135it constantly occurs in the anxiety neurosis and is of theoretical
significance. For increased irritability always points to an
accumulation of excitement or to an inability to bear accumulation,
hence to an absolute or relative accumulation of excitement.
The expression of this increased irritability through an auditory
hyperesthesia is especially worth mentioning; it is an over sensitiveness
for noises, which symptom is certainly to be explained
by the congenital intimate relationship between auditory impressions
and fright. Auditory hyperesthesia is frequently found
as a cause of insomnia, of which more than one form belongs to
anxiety neurosis.
2. Anxious Expectation.—I can not better explain the condition
that I have in mind, than by this name and by some appended
examples. A woman, for example, who suffers from anxious
expectation thinks of influenza-pneumonia whenever her husband
who is afflicted with a catarrhal condition has a coughing spell;
and in her mind she sees a passing funeral procession. If on her
way home she sees two persons standing together in front of her
house she can not refrain from the thought that one of her
children fell out of the window; if she hears the bell ring she
thinks that someone is bringing her mournful tidings, etc.; yet in
none of these cases is there any special reason for exaggerating
a mere possibility.
The anxious expectation naturally reflects itself constantly in the
normal, and embraces all that is designated as “uneasiness and a
tendency to a pessimistic conception of things,” but as often as
possible it goes beyond such a plausible uneasiness, and it is frequently
recognized as a part of constraint even by the patient
himself. For one form of anxious expectation, namely, that
which refers to one’s own health, we can reserve the old name of
hypochondria. Hypochondria does not always run parallel with
the height of the general anxious expectation; as a preliminary
stipulation it requires the existence of paresthesias and annoying
somatic sensations. Hypochondria is thus the form preferred
by the genuine neurasthenics whenever they merge into the
anxiety neurosis, a thing which frequently happens.
As a further manifestation of anxious expectation we may
mention the frequent tendency observed in morally sensitive
persons to pangs of conscience, scrupulosity, and pedantry, which
136varies as it were, from the normal to its aggravation as doubting
mania.
Anxious expectation is the most essential symptom of the
neurosis; it also clearly shows a part of its theory. It can perhaps
be said that we have here a quantum of freely floating anxiety
which controls the choice of ideas by expectation and is forever
ready to unite itself with any suitable ideation.
3. This is not the only way in which the anxiousness, usually
latent but constantly lurking in consciousness, can manifest itself.
On the contrary it can also suddenly break into consciousness
without being aroused by the issue of an idea, and thus provoke
an attack of anxiety. Such an attack of anxiety consists of
either the anxious feeling alone without any associated idea, or of
the nearest interpretation of the termination of life, such as the
idea of “sudden death” or threatening insanity; or the feeling of
anxiety becomes mixed with some paresthesia (similar to the
hysterical aura); or finally the anxious feeling may be combined
with a disturbance of one or many somatic functions, such as
respiration, cardiac activity, the vasomotor innervation, and the
glandular activity. From this combination the patient renders
especially prominent now this and now the other moment. He
complains of “heartspasms,” “heavy breathing,” “profuse perspiration,”
“inordinate appetite,” etc., and in his description the
feeling of anxiety is put to the background or it is rather vaguely
described as “feeling badly,” “uncomfortably,” etc.
4. What is interesting and of diagnostic significance is the fact
that the amount of admixture of these elements in the attack of
anxiety varies extraordinarily, and that almost any accompanying
symptom can alone constitute the attack as well as the anxiety
itself. Accordingly there are rudimentary attacks of anxiety,
and equivalents for the attack of anxiety, probably all of equal
significance in showing a profuse and hitherto little appreciated
richness in forms. A more thorough study of these larvated
states of anxiety (Hecker) and their diagnostic division from
other attacks ought soon to become the necessary work for the
neuropathologist.
I now add a list of those forms of attacks of anxiety with
which I am acquainted. There are attacks:
(a) With disturbances of heart action, such as palpitation with
137transitory arrythmia, with longer continued tachycardia up to
grave states of heart weakness, the differentiation of which from
organic heart affection is not always easy; among such we have
the pseudo-angina pectoris, a delicate diagnostic sphere!
(b) With disturbances of respiration, many forms of nervous
dyspnoea, asthma-like attacks, etc. I assert that even these attacks
are not always accompanied by conscious anxiety;
(c) Of profuse perspiration, often nocturnal;
(d) Of trembling and shaking which may readily be mistaken
for hysterical attacks;
(e) Of inordinate appetite, often combined with dizziness;
(f) Of attack-like appearing diarrhoea;
(g) Of locomotor dizziness;
(h) Of so called congestions, embracing all that was called
vasomotor neurasthenia; and,
(i) Of paresthesias (These are seldom without anxiety or a
similar discomfort).
5. Very frequently the nocturnal frights (pavor nocturnus of
adults) usually combined with anxiety, dyspnoea, perspiration, etc.,
is nothing other than a variety of the attack of anxiety. This
disturbance determines a second form of insomnia in the sphere
of the anxiety neurosis. Moreover I became convinced that even
the pavor nocturnus of children evinces a form belonging to the
anxiety neurosis. The hysterical tinge and the connection of
the fear with the reproduction of appropriate experience or
dream, makes the pavor nocturnus of children appear as something
peculiar, but it also occurs alone without a dream or a recurring
hallucination.
6. “Vertigo.”—This in its lightest forms is better designated
as “dizziness,” assumes a prominent place in the group of
symptoms of anxiety neurosis. In its severer forms the “attack
of vertigo,” with or without fear, belongs to the gravest symptoms
of the neurosis. The vertigo of the anxiety neurosis is
neither a rotatory dizziness nor is it confined to certain planes or
lines like Menier’s vertigo. It belongs to the locomotor or coordinating
vertigo, like the vertigo in paralysis of the ocular
muscles; it consists in a specific feeling of discomfort which is
accompanied by sensations of a heaving ground, sinking legs, of
the impossibility to continue in an upright position, and at the
138same time there is a feeling that the legs are as heavy as lead, they
shake, or give way. This vertigo never leads to falling. On the
other hand, I would like to state that such an attack of vertigo
may also be substituted by a profound attack of syncope. Other
fainting-like states in the anxiety neurosis seem to depend on a
cardiac collapse.
The vertigo attack is frequently accompanied by the worst kind
of anxiety and is often combined with cardiac and respiratory
disturbances. Vertigo of elevations, mountains and precipices,
can also be frequently observed in anxiety neurosis; moreover, I
do not know whether we are still justified in recognizing a
vertigo “a stomacho laeso.”
7. On the basis of the chronic anxiousness (anxious expectation)
on the one hand, and the tendency to vertiginous attacks
of anxiety on the other, there develop two groups of typical
phobias; the first refers to the general physiological menaces,
while the second refers to locomotion. To the first group belong
the fear for snakes, thunderstorms, darkness, vermin, etc., as well
as the typical moral overscrupulousness, and the forms of doubting mania.
Here the available fear is merely used to strengthen
those aversions which are instinctively implanted in every man.
But usually a compulsively acting phobia is formed only after a
reminiscence is added to an experience in which this fear could
manifest itself; as, for example, after the patient has experienced
a storm in the open air. To attempt to explain such cases as
mere continuations of strong impressions is incorrect. What
makes these experiences significant and their reminiscences durable
is after all only the fear which could at that time appear and
can also appear today. In other words such impressions remain
forceful only in persons with “anxious expectations.”
The other group contains agoraphobia with all its accessory
forms, all of which are characterized by their relation to locomotion.
As a determination of the phobia we frequently find a
precedent attack of vertigo; I do not think that it can always
be postulated. Occasionally, after a first attack of vertigo without
fear, we see that though locomotion is always accompanied by
the sensation of vertigo, it remains possible without any restrictions,
but as soon as fear attaches itself to the attack of
vertigo, locomotion fails, under the conditions of being alone,
narrow streets, etc.
139The relation of these phobias to the phobias of obsessions,
which mechanism I discussed above,[42] is as follows: The agreement
lies in the fact that here as there, an idea becomes obsessive
through its connection with an available affect. The mechanism
of transposition of the affect therefore holds true for both kinds
of phobias. But in phobias of the anxiety neurosis this affect is
(1) a monotonous one, it is always one of anxiety; (2) it does
not originate from a repressed idea, and on psychological analysis
it proves itself not further reducible, nor can it be attacked
through psychotherapy. The mechanism of substitution does
not therefore hold true for the phobias of anxiety neurosis.
Both kinds of phobias (or obsessions) often occur side by side,
though the atypical phobias which depend on obsessions need
not necessarily develop on the basis of anxiety neurosis. A very
frequent, ostensibly complicated mechanism appears if the content
of an original simple phobia of anxiety neurosis is substituted by
another idea, the substitution is then subsequently added to the
phobia. The “protective measures” originally employed in combatting
the phobia are most frequently used as substitutions.
Thus, for example, from the effort to provide oneself with
counter evidence that one is not crazy, contrary to the assertion
of the hypochondriacal phobia, there results a reasoning mania.
The hesitations, doubts, and the many repetitions of the folie du
doute originate from the justified doubt concerning the certainty
of one’s own stream of thoughts, for, through the compulsive
like idea one is surely conscious of so obstinate a disturbance,
etc. It may therefore be claimed that many syndromes of compulsion
neurosis, like folie du doute and similar ones, can clinically,
if not notionally be attributed to anxiety neurosis.[43]
8. The digestive functions in anxiety neurosis are subject to
very few but characteristic disturbances. Sensations like nausea
and sickly feeling are not rare, and the symptom of inordinate
appetite alone or with other congestions, may serve as a rudimentary
attack of anxiety. As a chronic alteration analogous to
the anxious expectations one finds a tendency to diarrhea which
has occasioned the queerest diagnostic mistakes. If I am not
mistaken it is this diarrhea to which Moebius[44] has recently called
140attention in a small article. I believe, moreover, that Peyer’s[45]
reflex diarrhea which he attributes to a disease of the prostate
is nothing other than the diarrhea of anxiety neurosis. The
deceptive reflex relation is due to the fact that the same factors
which are active in the origin of such prostatic affections also
come into play in the etiology of anxiety neurosis.
The behavior of the gastro-intestinal function in anxiety
neurosis shows a sharp contrast to the influence of this same
function in neurasthenia. Mixed cases often show the familiar
“fluctuations between diarrhea and constipation.” The desire to
urinate in anxiety neurosis is analogous to the diarrhea.
9. The paresthesias which accompany the attack of vertigo or
anxiety are interesting because they associate themselves into a
firm sequence, similar to the sensations of the hysterical aura.
But in contrast to the hysterical aura I find these associated sensations
atypical and changeable. Another similarity to hysteria
is shown by the fact that in anxiety neurosis a kind of conversion[46]
into bodily sensations, as for example into rheumatic muscles,
takes place which otherwise can be overlooked at one’s pleasure.
A large number of so called rheumatics, who are moreover
demonstrable as such, really suffer from an anxiety neurosis.
Besides this aggravation of the sensation of pain I have observed
in a number of cases of anxiety neurosis a tendency towards
hallucinations which could not be explained as hysterical.
10. Many of the so called symptoms which accompany or substitute
the attack of anxiety also appear in a chronic manner.
They are then still less discernible, for the anxious feeling accompanying
them appears more indistinct than in the attack of
anxiety. This especially holds true for the diarrhea, vertigo, and
paresthesias. Just as the attack of vertigo can be substituted by
an attack of syncope, so can the chronic vertigo be substituted by
the continuous feeling of feebleness, lassitude, etc.
In some cases of anxiety neurosis no etiology can readily be
ascertained. It is noteworthy that in such cases it is seldom
difficult to demonstrate a marked hereditary taint.
141Where we have reason to assume that the neurosis is acquired
we can find by careful and laborious examination that the etiologically
effective moments are based on a series of injuries and
influences from the sexual life. These at first appear to be of a
varied nature but easily display the common character which explains
their homogeneous effect on the nervous system. They
are found either alone or with other banal injuries to which a
reinforcing effect can be attributed. This sexual etiology of
anxiety neurosis can be demonstrated so preponderately often
that I venture for the purpose of this brief communication to set
aside all cases of a doubtful or different etiology.
For the more precise description of the etiological determinations
under which anxiety neurosis occurs, it will be advisable to
treat separately those occurring in men and those occurring in
women. Anxiety neurosis appears in women—disregarding their
predisposition—in the following cases:
(a) As virginal fear or anxiety in adults. A number of unequivocal
observations showed me that an anxiety neurosis, which
is almost typically combined with hysteria, can be evoked in
maturing girls, at the first encounter with the sexual problem, that
is at the sudden revelation of the things hitherto veiled, by either
seeing the sexual act, or by hearing or reading something of that
nature;
(b) As fear in the newly married. Young women who remain
anesthetic during the first cohabitation not seldom merge into
an anxiety neurosis which disappears after the anesthesia is displaced
by the normal sensation. As most young women remain
undisturbed through such a beginning anesthesia, the production
of this fear requires determinants which I will mention;
(c) As fear in women whose husbands suffer from ejaculatio
precox or from diminished potency; and,
(d) In those whose husbands practice coitus interruptus or
reservatus. These cases go together, for on analyzing a large
number of examples one can easily be convinced that they only
depend on whether the woman attained gratification during coitus
or not. In the latter case one finds the determinant for the
origin of anxiety neurosis. On the other hand the woman is
spared from the neurosis if the husband afflicted by ejaculatio
precox can repeat the congress with better results immediately
142thereafter. The congressus reservatus by means of the condom
is not injurious to the woman if she is quickly excited and the
husband is very potent; in other cases the noxiousness of this
kind of preventive measure is not inferior to the others. Coitus
interruptus is almost regularly injurious; but for the woman it
is injurious only if the husband practices it regardlessly, that is,
if he interrupt coitus as soon as he comes near ejaculating without
concerning himself about the determination of the excitement of
his wife. On the other hand if the husband waits until his wife
is gratified, the coitus has the same significance for the latter
as a normal one; but then the husband becomes afflicted with an
anxiety neurosis. I have collected and analyzed a number of
cases which furnished the material for the above statements.
(e) As fear in widows and intentional abstainers, not seldom
in typical combination with obsessions; and,
(f) As fear in the climacterium during the last marked enhancement
of the sexual desire.
The cases (c), (d), and (e), contain the determinants under
which the anxiety neurosis originates in the female sex, most
frequently and most independently, of hereditary predisposition.
I will endeavor to demonstrate in these—curable, acquired—cases
of anxiety neurosis that the discovered sexual injuries really
represent the etiological moments of the neurosis. But before
proceeding I will mention the sexual determinants of anxiety
neurosis in men. I would like to formulate the following groups,
every one of which finds its analogy in women:
(a) Fear of the intentional abstainers; this is frequently combined
with symptoms of defense (obsessions, hysteria). The
motives which are decisive for intentional abstinence carry along
with them the fact that a number of hereditarily burdened eccentrics,
etc., belong to this category.
(b) Fear in men with frustrated excitement (during the engagement
period), persons who out of fear for the consequences
of sexual relations satisfy themselves with handling or looking at
the woman. This group of determinants which can moreover be
transferred to the other sex—engagement periods, relations with
sexual forbearance—furnish the purest cases of the neurosis.
(c) Fear in men who practice coitus interruptus. As observed
above, coitus interruptus injures the woman if it is practiced
143regardless of the woman’s gratification; it becomes injurious to
the man, if in order to bring about the gratification in the woman
be voluntarily controls the coitus by delaying the ejaculation. In
this manner we can understand why it is that in couples who
practice coitus interruptus it is usually only one of them who
becomes afflicted. Moreover the coitus interruptus only rarely
produces in man a pure anxiety neurosis, usually it is a mixture
of the same with neurasthenia.
(d) Fear in men in the senium. There are men who show a
climacterium like women, and merge into an anxiety neurosis at
the time when their potency diminishes and their libido increases.
Finally I must add two more cases holding true for both sexes:
(e) Neurasthenics merge into anxiety neurosis in consequence
of masturbation as soon as they refrain from this manner of
sexual gratification. These persons have especially made themselves
unfit to bear abstinence.
What is important for the understanding of the anxiety
neurosis is the fact that any noteworthy development of the same
occurs only in men who remain potent, and in non-anesthetic
women. In neurasthenics, who on account of masturbation have
markedly injured their potency, anxiety neurosis as a result of
abstinence occurs but rarely and limits itself usually to hypochondria
and light chronic dizziness. The majority of women
are really to be considered as “potent”; a real impotent, that is,
a real anesthetic woman, is also inaccessible to anxiety neurosis,
and bears strikingly well the injuries cited.
How far we are perhaps justified in assuming constant relations
between individual etiological moments and individual
symptoms from the complex of anxiety neurosis, I do not care
to discuss here.
(f) The last of the etiological determinants to be mentioned
seems, in the first place, really not to be of a sexual nature.
Anxiety neurosis originates in both sexes through the moment of
overwork, exhaustive exertion, as for instance, after sleepless
nights, nursing the sick, and even after serious illnesses.
The main objection against my formulation of a sexual etiology
of the anxiety neurosis will probably be to the purport that such
abnormal relations of the sexual life can be found so very often
144that wherever one will look for them they will be found near at
hand. Their occurrence, therefore, in the cases cited of anxiety
neurosis does not prove that the etiology of the neurosis was
revealed in them. Moreover, the number of persons practicing
coitus interruptus, etc., is incomparably greater than the number
of those who are burdened with anxiety neurosis, and the overwhelming
number of the first are quite well in spite of this
injury.
To this I can answer that we certainly ought not to expect a
rarely occurring etiological moment in the conceded enormous
frequency of the neurosis, and especially anxiety neurosis;
furthermore, that it really fulfills a postulate of pathology if on
examining an etiology the etiological moments can be more frequently
demonstrated than their effects, for, for the latter still
other determinants (predisposition, summation of the specific
etiology, reinforcement through other banal injuries) could be
demanded; and furthermore, that the detailed analysis of suitable
cases of anxiety neurosis show quite unequivocally the significance
of the sexual moment. I shall, however, here confine myself
to the etiological moment of coitus interruptus, and I will
render prominent obvious individual experiences.
1. As long as the anxiety neurosis in young women is not yet
constituted but appears in fragments which again spontaneously
disappear, it can be shown that every such turn of the neurosis
depends on a coitus with lack of gratification. Two days after
this influence, and in persons of little resistance the day after,
there regularly appears the attack of anxiety or vertigo to which
all the other symptoms of the neurosis attach themselves, only to
separate again on rarer marriage relations. An unexpected
journey of the husband, a sojourn in the mountains causing a
separation of the married couple, does good; the benefit from a
course of gynecological treatment is due to the fact that during
its continuation the marriage relations are stopped. It is noteworthy
that the success of a local treatment is only transitory, the
neurosis reappears while in the mountains if the husband joins his
wife for his own vacation, etc. If, in a not as yet constituted
neurosis, a physician aware of this etiology causes a substitution
of the coitus interruptus by normal relations there results a
therapeutic proof of the assertion here formulated. The anxiety
145is removed and does not return unless there be a new or similar
cause.
2. In the anamnesis of many cases of anxiety neurosis we find
in both men and women a striking fluctuation in the intensity of
the appearances in both the coming and going of the whole condition.
This year was almost wholly good, the following was
terrible, etc.; on one occasion the improvement occurred after a
definite treatment which, however, failed to produce a response
at the next attack. If we inform ourselves about the number and
the sequence of the children, and compare this marriage chronicle
with the peculiar course of the neurosis, the result of the simple
solution shows that the periods of improvement or well being corresponded
with the pregnancies of the woman during which,
naturally, the occasions for preventive relations were unnecessary.
The treatment which benefited the husband, be it Father
Kneip’s or the hydrotherapeutic institute, was the one which he
has taken after he found his wife was pregnant.
3. From the anamnesis of the patients we often find that the
symptoms of the anxiety neurosis are relieved at a certain time by
another neurosis, perhaps a neurasthenia which has supplanted it.
It can then be regularly demonstrated that shortly before this
change of the picture there occurred a corresponding change in
the form of a sexual injury.
Whereas such experiences, which can be augmented at pleasure,
plainly obtrude upon the physician the sexual etiology for a certain
category of cases, other cases which would have otherwise
remained incomprehensible can at least without gainsaying be
solved and classified by the key of the sexual etiology. We refer
to those numerous cases in which everything exists that has been
found in the former category, such as the appearance of anxiety
neurosis on the one hand, and the specific moment of the coitus
interruptus on the other, but yet something else slips in, namely, a
long interval between the assumed etiology and its effect, and
perhaps other etiological moments of a non-sexual nature. We
have here, for example, a man who was seized with an attack
of palpitation on hearing of his father’s death, and who since
that time suffered from an anxiety neurosis. The case cannot
be understood, for up to that time this man was not nervous.
The death of the father, well advanced in years, did not occur
146under any peculiar circumstances, and it must be admitted that
the natural expected death of an aged father does not belong to
those experiences which are wont to make a healthy adult sick.
The etiological analysis will perhaps seem clearer if I add that
out of regard for his wife this man practiced coitus interruptus
for eleven years. At all events the manifestations are precisely
the same as those appearing in other persons after a short sexual
injury of this nature, and without the intervention of another
trauma. The same judgment may be pronounced in the case of
a woman who merges into an anxiety neurosis after the death
of her child, or in the case of the student who becomes disturbed
by an anxiety neurosis while preparing for his final state examination.
I find that here, as there, the effect is not explained by the
reported etiology. One must not necessarily “overwork” himself
studying, and a healthy mother is wont to react to the death
of her child with normal grief. But, above all, I would expect
that the overworked student would acquire a cephalasthenia, and
the mother in our example a hysteria. That both became
afflicted with anxiety neurosis causes me to attach importance to
the fact that the mother lived for eight year in marital coitus
interruptus, and that the student entertained for three years a
warm love affair with a “respectable” girl whom he was not
allowed to impregnate.
These examples tend to show that where the specific sexual
injury of the coitus interruptus is in itself unable to provoke an
anxiety neurosis it at least predisposes to its acquisition. The
anxiety neurosis then comes to light as soon as the effect of
another banal injury enters into the latent effect of the specific
moment. The former can quantitatively substitute the specific
moment but not supplant it qualitatively. The specific moment
always remains that which determines the form of neurosis. I
hope to be able to prove to a greater extent this proposition for
the etiology of the neurosis.
Furthermore, the last discussions contain the, not in itself, improbable
assumption that a sexual injury like coitus interruptus
asserts itself through summation. The time required before the
effect of this summation becomes visible depends upon the predisposition
of the individual and the former burdening of his
nervous system. The individuals who bear coitus interruptus
147manifestly without disadvantage really become predisposed by
it to the disturbance—anxiety neurosis—which can at any time
burst forth spontaneously or after a banal, otherwise inadequate,
trauma, just as the chronic alcoholic finally develops a cirrhosis
or another disease by summation, or under the influence of a
fever he merges into a delirium.
The following discussions claim nothing but the value of a first
tentative experiment, which judgment should not influence the acceptance
of the facts mentioned above. The estimation of this
“Theory of Anxiety Neurosis” is rendered still more difficult
by the fact that it merely corresponds to a fragment of a more
comprehensive representation of the neuroses.
The facts hitherto expressed concerning the anxiety neurosis
already contain some starting points for an insight into the mechanism
of this neurosis. In the first place it contains the assumption
that we deal with an accumulation of excitement, and
then the very important fact that the anxiety underlying the manifestations
of the neurosis is not of psychic derivation. Such,
for example, would exist if we found as a basis for the anxiety
neurosis a justified fright happening once or repeatedly which
has since supplied the source of the preparedness for the anxiety
neurosis. But this is not the case; a former fright can perhaps
cause a hysteria or a traumatic neurosis but never an anxiety
neurosis. As the coitus interruptus is rendered so prominent
among the causes of anxiety neurosis I have thought at first that
the source of the continuous anxiety was perhaps the repeated
fear during the sexual act lest the technique will fail and conception
follow. But I have found that this state of mind of the man
or woman during the coitus interruptus plays no part in the origin
of anxiety neurosis, that the women who are really indifferent to
the possibilities of conception are just as exposed to the neurosis
as those who are trembling at the possibility of it, it all depends
on which person suffers the loss of sexual gratification.
Another starting point presents itself in the as yet unmentioned
observation that in a whole series of cases the anxiety neurosis
goes along with the most distinct diminution of the sexual libido
or the psychic desire, so that on revealing to the patients that their
148affliction depends on “insufficient gratification,” they regularly
reply that this is impossible as just now their whole desire is extinguished.
The indications that we deal with an accumulation
of excitement, that the anxiety which probably corresponds to
such accumulated excitement is of somatic origin, so that somatic
excitement becomes accumulated, and furthermore, that this somatic
excitement is of a sexual nature, and that it is accompanied
by a decreased psychic participation in the sexual processes—all
these indications, I say, favor the expectation that the
mechanism of the anxiety neurosis is to be found in the deviation
of the somatic sexual excitement from the psychic, and in the abnormal
utilization of this excitement occasioned by the former.
This conception of the mechanism of anxiety neurosis will become
clearer if one accepts the following view concerning the
sexual process in man. In the sexually mature male organism,
the somatic sexual excitement is—probably continuously—produced,
and this becomes a periodic stimulus for the psychic life.
To make our conceptions clearer we will add that this somatic
sexual excitement manifests itself as a pressure on the wall of the
seminal vesicle which is provided with nerve endings. This
visceral excitement thus becomes continuously increased, but not
before attaining a certain height is it able to overcome the resistances
of the intercalated conduction as far as the cortex, and
manifest itself as psychic excitement. Then the group of sexual
ideas existing in the psyche becomes endowed with energy and
results in a psychic state of libidinous tension which is accompanied
by an impulse to remove this tension. Such psychic unburdening
is possible only in one way which I wish to designate
as specific or adequate action. This adequate action for the male
sexual impulse consists of a complicated spinal reflex-act which
results in the unburdening of those nerve endings, and of all
psychically formed preparations for the liberation of this reflex.
Anything else except the adequate action would be of no avail,
for after the somatic sexual excitement has once reached the
liminal value, it continuously changes into psychic excitement;
that must by all means occur which frees the nerve endings
from their heavy pressure, and thus abolish the whole somatic
excitement existing at the time and allow the subcortical conduction
to reestablish its resistance.
149I will desist from presenting in a similar manner more complicated
cases of the sexual process. I will merely formulate the
statement that this scheme can essentially be transferred to the
woman despite the problem of the perplexity, artificial retardation,
and stunting of the female sexual impulse. In the woman,
too, it can be assumed that there is a somatic sexual excitement
and a state in which this excitement becomes psychic, evoking
libido and the impulse to specific action which is accompanied by
the sensual feeling. But we are unable to state what analogy
there may be in the woman to the unburdening of the seminal
vesicles.
We can bring into the bounds of this representation of the
sexual process the etiology of actual neurasthenia as well as of
the anxiety neurosis. Neurasthenia always originates whenever
the adequate (action) unburdening is replaced by a less adequate
one, like the normal coitus under the most favorable conditions,
by a masturbation or spontaneous pollution; while anxiety neurosis
is produced by all moments which impede the psychic elaboration
of the somatic sexual excitement. The manifestations of
anxiety neurosis are brought about by the fact that the somatic
sexual excitement diverted from the psyche expends itself subcortically
in not at all adequate reactions.
I will now attempt to test the etiological determinants suggested
before in order to see whether they show the common character
formulated by me. As the first etiological moment for the
man, I have mentioned intentional abstinence. Abstinence consists
in foregoing the specific action which results from the libido.
Such foregoing may have two consequences, namely that the
somatic excitement accumulates, and then, what is more important,
is the fact that it becomes diverted to another route where there
is more chance for discharge than through the psyche. It will
then finally diminish the libido and the excitement will manifest
itself subcortically as anxiety. Where the libido does not become
diminished, or the somatic excitement is expended in pollutions, or
where it really becomes exhausted in consequence of repulsion,
everything else except anxiety neurosis is formed. In this manner
abstinence leads to anxiety neurosis. But abstinence is also
the active process in the second etiological group of frustrated excitement.
The third case, that of the considerate coitus reservatus,
150acts through the fact that it disturbs the psychic preparedness
for the sexual discharge by establishing beside the subjugation
of the sexual affect, another distracting psychic task.
Through this psychic distraction, too, the libido gradually disappears
and the further course is then the same as in the case of
abstinence. The anxiety in old age (climacterium of men) requires
another explanation. Here the libido does not diminish,
but just as in the climacterium of women, such an increase takes
place in the somatic excitement that the psyche shows itself relatively
insufficient for the subjugation of the same.
The subsummation of the etiological determinants in the
woman, under the aspect mentioned, does not afford any greater
difficulties. The case of the virginal fear is especially clear.
Here the group of ideas with which the somatic sexual excitement
should combine are not as yet sufficiently developed. In
anesthetically newly married the anxiety appears only if the first
cohabitations awakened a sufficient amount of somatic excitement.
Where the local signs of such excitability (like spontaneous
feelings of excitement, desire to micturate, etc.) are lacking, the
anxiety, too, stays away. The case of ejaculatio precox or coitus
interruptus is explained similarly to that in the man by the fact
that the libido gradually disappears in the psychically ungratified
act, whereas the excitement thereby evoked is subcortically expended.
The formation of an estrangement between the somatic
and psychic in the discharge of the sexual excitement succeeds
quicker in the woman than in the man and is more difficult to
remove. The case of widowhood or voluntary abstinence, as well
as the case of climacterium adjusts itself in the woman as in the
man, but in the case of abstinence there surely is in addition the
intentional repression of the sexual ideas, for an abstinent woman
struggling with temptation must often decide to suppress it.
The abhorrence perceived by an elderly woman during her menopause
against the immensely increased libido can have a similar
effect.
The two etiological determinants mentioned last can also be
classified without any difficulty.
The tendency to anxiety of the masturbator who becomes neurasthenic
is explained by the fact that these persons so easily merge
into the state of abstinence after they have for long been accustomed
151to afford a discharge, to be sure an incorrect one, for every
little quantity of somatic excitement. Finally the last case, the
origin of anxiety neurosis through a severe illness, overwork, exhaustive
nursing, etc., in addition to the efficacy of coitus interruptus
readily permits a free interpretation. Through deviation the
psyche becomes here insufficient for the subjugation of the somatic
sexual excitement, a task which continuously devolves upon it.
We know how deeply the libido can sink under the same conditions,
and we have here a nice example of a neurosis which
although not of a sexual etiology still evinces a sexual mechanism.
The conception here developed represents the symptoms of
anxiety neurosis in a measure as a substitute for the omitted
specific action to the sexual excitement. As a further corroboration
of this I recall that also in normal coitus the excitement
expends itself in respiratory acceleration, palpitation, perspiration,
congestion, etc. In the corresponding attack of anxiety of our
neurosis we have before us the dyspnoea, the palpitation, etc.,
of the coitus in an isolated and aggravated manner.
It can still be asked why the nervous system merges into a
peculiar affective state of anxiety under the circumstances of
psychic inadequacy for the subjugation of the sexual excitement?
A hint to the answer is as follows: The psyche merges into the
affect of fear when it perceives itself unable to adjust an externally
approaching task (danger) by corresponding reaction; it
merges into the neurosis of anxiety when it finds itself unable to
equalize the endogenously originated (sexual) excitement. The
psyche, therefore, behaves as if projecting this excitement externally.
The affect and the neurosis corresponding to it stand in
close relationship to each other; the first is the reaction to an exogenous,
the latter the reaction to an analogous endogenous excitement.
The affect is a rapidly passing state, the neurosis is
chronic because the exogenous excitement acts like a stroke happening
but once, while the endogenous acts like a constant force.
The nervous system reacts in the neurosis against an inner source
of excitement just as it does in the corresponding affect against
an analogous external one.
152
A few observations still remain to be mentioned on the relations
of the anxiety neurosis to the other neuroses in reference to
occurrence and inner relationship.
The purest cases of anxiety neurosis are also usually the most
pronounced. They are found in potent young individuals with a
uniform etiology, and where the disease is not of long standing.
To be sure, the symptoms of anxiety are found more frequently
as a simultaneous and common occurrence with those
of neurasthenia, hysteria, compulsive ideas, and melancholia. If
on account of such clinical mixtures one hesitates in recognizing
anxiety neurosis as an independent unity, he will also have to
abandon the laboriously acquired separation of hysteria and neurasthenia.
For the analysis of the “mixed neuroses” I can advocate the
following proposition: Where a mixed neurosis exists, an involvement
of many specific etiologies can be demonstrated.
Such a multiplicity of etiological moments determining a mixed
neurosis can only come about accidentally, if the activities of a
newly formed injury are added to those already existing. Thus,
for example, a woman who was at all times a hysteric begins to
practice coitus reservatus at a certain period of her married life,
and adds an anxiety neurosis to her hysteria; a man who had
masturbated and become neurasthenic, becomes engaged and excites
himself with his fiancée so that a fresh anxiety neurosis
allies itself to his neurasthenia.
The multiplicity of etiological moments in other cases is not
accidental, one of them has brought the other into activity. Thus
a woman, with whom her husband practices coitus reservatus
without regard to her gratification, finds herself forced to finish
the tormenting excitement following such an act with masturbation,
as a result of which she shows an anxiety neurosis with
symptoms of neurasthenia. Under the same noxiousness another
woman has to contend with lewd pictures against which she
wishes to defend herself, and in this way the coitus interruptus
will cause her to acquire obsessions along with the anxiety neurosis.
Finally a third woman, as a result of coitus interruptus
loses her affection for her husband and forms another which she
153secretly guards, and as a result she evinces a mixture of hysteria
and anxiety neurosis.
In a third category of mixed neuroses the connection of the
symptoms is of a still more intimate nature, as the same etiological
determinants regularly and simultaneously evoke both neuroses.
Thus, for example, the sudden sexual explanation which
we have found in virginal fear always produces hysteria, too;
most causes of intentional abstinence connect themselves in the
beginning with actual obsessions; and it seems to me that the
coitus interruptus of men can never provoke a pure anxiety
neurosis, but always a mixture of the same with neurasthenia,
etc.
It follows from this discussion that the etiological determinants
of the occurrence must moreover be distinguished from the specific
etiological moments of neurasthenia. The first moments,
as for example the coitus interruptus, masturbation, and abstinence,
are still ambiguous, and can each produce different neuroses;
and it is only the etiological moments abstracted from
them, like the inadequate unburdening, psychic insufficiency,
and defense with substitution, that have an unambiguous and
specific relation to the etiology of the individual great neuroses.
In its intrinsic property, anxiety neurosis shows the most interesting
agreements and differences when compared with the
other great neuroses, particularly when compared with neurasthenia
and hysteria. With neurasthenia it shares one main character,
namely, that the source of excitement, the cause of the
disturbance, lies in the somatic rather than in the psychic sphere
as in the case of hysteria and compulsion neurosis. For the rest
we can recognize a kind of contrast between the symptoms of
neurasthenia and anxiety neurosis, which can be expressed in the
catchwords, accumulation and impoverishment of excitement.
This contrast does not hinder the two neuroses from combining
with each other, but shows itself in the fact that the most extreme
forms in both cases are also the purest.
When compared with hysteria anxiety neurosis shows in the
first place a number of agreements in the symptomatology
the valuation of which is still unsettled. The appearance of the
manifestations as persistent symptoms or attacks, the aura-like
grouped paresthesias, the hyperesthesias and pressure points can
154be found in certain substitutes for the anxiety attack, as in dyspnoea
and palpitation, the aggravation of the perhaps organically
determined pains (by conversion)—these and other joint features
lead to the supposition that some things which are ascribed to
hysteria can with full authority be fastened to anxiety neurosis.
But if we enter into the mechanism of both neuroses, as far as
it can at present be penetrated, we find aspects which make it
appear that the anxiety neurosis is really the somatic counterpart
to hysteria. Here as there we have accumulation and excitement—on
which is perhaps based the similarity of the aforementioned
symptoms—; here as there we have a psychic insufficiency which
results from abnormal somatic processes; and here as there we
have instead of a psychic elaboration a deviation of the excitement
into the somatic. The difference only lies in the fact that
the excitement, in which displacement the neurosis manifests
itself, is purely somatic (somatic sexual excitement) in anxiety
neurosis, while in hysteria it is psychic (evoked through a conflict).
Hence it is not surprising that hysteria and anxiety neurosis
lawfully combine with each other, as in the “virginal fear”
or in the “sexual hysteria,” and that hysteria simply borrows a
number of symptoms from anxiety neurosis, etc. This intimate
relationship between anxiety neurosis and hysteria furnishes us
with a new argument for demanding the separation of anxiety
neurosis from hysteria, for if this be denied, one will also be
unable to maintain the so painstakingly acquired distinction between
neurasthenia and hysteria, so indispensable for the theory
of the neuroses.
CHAPTER VII. Further Observations on the Defense Neuropsychoses. — I. The “Specific” Etiology of Hysteria. — II. The Essence and Mechanism of Compulsion Neurosis. — III. Analysis of a Case of Chronic Paranoia.
155
Under the caption of “Defense Neuropsychoses” I have comprised
hysteria, obsessions, as well as certain cases of acute hallucinatory
confusion.[47] All these affections evince one common
aspect in the fact that their symptoms originated through the
psychic mechanism of (unconscious) defense, that is, through the
attempt to repress an unbearable idea which appeared in painful
contrast to the ego of the patient. I was also able to explain
and exemplify by cases reported in the preceding chapters in
what sense this psychic process of “defense” or “repression” is
to be understood. I have also discussed the laborious but perfectly
reliable method of psychoanalysis of which I make use
in my examinations, and which at the same time serves as a
therapy.
My experiences during the last two years have strengthened
my predilection for making the defense the essential point in the
psychic mechanism of the mentioned neuroses, and on the other
hand have permitted me to give a clinical foundation to the
psychological theory. To my surprise I have discovered some
simple but sharply circumscribed solutions for the problem of the
neuroses which I shall provisionally briefly report in the following
pages. It would be inconsistent with this manner of reporting
to add to the assertions the required proofs, but I hope to be
able to fulfill this obligation in a comprehensive discussion.
That the symptoms of hysteria become comprehensible only
through a reduction to “traumatically” effective experiences, and
that these psychic traumas refer to the sexual life has already
been asserted by Breuer and me in former publications. What
I have to add today as a uniform result of thirteen analyzed cases
of hysteria concerns, on the one hand, the nature of these sexual
traumas, and on the other, the period of life in which they occurred.
156An experience occurring at any period of life, touching
in any way the sexual life, and then becoming pathogenic through
the liberation and suppression of a painful affect is not sufficient
for the causation of hysteria. It must on the contrary belong
to the sexual traumas of early childhood (the period of life
before puberty), and its content must consist in a real irritation
of the genitals (coitus-like processes).
This specific determination of hysteria—sexual passivity in
pre-sexual periods—I have found fulfilled in all analyzed cases
of hysteria (among which were two men). To what extent the
determination of the accidental etiological moment diminishes the
requirement of the hereditary predisposition needs only be intimated.
We can, moreover, understand the disproportionately
greater frequency of hysteria in the female sex, as even in childhood
this sex is more subject to sexual assaults.
The objection most frequently advanced against this result
may be to the purport, that sexual assaults on little children occur
too frequently to give an etiological value to its verification, or
that such experiences must remain ineffectual just because they
concern a sexually undeveloped being; and that one must moreover
be careful not to obtrude upon the patient through the examination
such alleged reminiscences or believe in the romances
which they themselves fabricate. To the latter objections I hold
out the request that no one should really judge with great certainty
this obscure realm unless he has made use of the only
method which can clear it up (the method of psychoanalysis for
bringing to consciousness the hitherto unconscious[48]). The essential
point in the first doubts is settled by the observation that
it really is not the experiences themselves that act traumatically,
but their revival as reminiscences after the individual has entered
into sexual maturity.
My thirteen cases of hysteria were throughout of the graver
kind, they were all of long duration, and some had undergone a
lengthy and unsuccessful asylum treatment. Every one of the
infantile traumas which the analysis revealed for these severe
cases had to be designated as marked sexual injuries; some of
157them were indeed abominable. Among the persons who were
guilty of such serious abuse we have in the first place nurses,
governesses, and other servants to whom children are left much
too carelessly, then in regrettable frequency come the teachers;
but in seven of the thirteen cases we dealt with innocent childish
offenders, mostly brothers who for years entertained sexual relations
with their younger sisters. The course of events always
resembled some of the cases which could with certainty be tracked,
namely, that the boy had been abused by a person of the feminine
sex, thus awakening in him prematurely the libido, and that after
a few years he repeated in sexual aggression on his sister the
same procedures to which he himself was subjected.
I must exclude active masturbation from the list of sexual injuries
of early childhood as being pathogenic for hysteria. That
it is so very frequently found associated with hysteria is due to the
fact that masturbation in itself is more frequently the result of
abuse or seduction than one supposes. It not seldom happens
that both members of a childish pair later in life become afflicted
by defense neuroses, the brother by obsessions and the sister by
hysteria, which naturally gives the appearance of a familial neurotic
predisposition. This pseudo-heredity is now and then
solved in a surprising manner. I have had under observation
a brother, sister, and a somewhat older cousin. The analysis
which I have undertaken with the brother showed me that he
suffered from reproaches for being the cause of his sister’s
malady; he himself was corrupted by his cousin, concerning
whom it was known in the family that he fell a victim to his
nurse.
I can not definitely state up to what age sexual damage occurs
in the etiology of hysteria, but I doubt whether sexual passivity
can cause repression after the eighth and tenth year unless qualified
for it by previous experiences. The lower limit reaches as
far as memory in general, that is, to the delicate age of one and
one half or two years! (two cases). In a number of my cases
the sexual trauma (or the number of traumas) occurred during
the third and fourth year of life. I myself would not lend credence
to this peculiar discovery if it were not for the fact that the
later development of the neurosis furnished it with full trustworthiness.
In every case there are a number of morbid symptoms,
158habits and phobias which are only explainable by returning
to those youthful experiences, and the logical structure of the
neurotic manifestation makes it impossible to reject the faithfully
retained memories of childhood. Except through psychoanalysis
it is of no avail to ask a hysterical patient about these infantile
traumas; their remains can only be found in the morbid symptoms
and not in conscious memory.
All the experiences and excitements which prepare the way for,
or occasion the outburst of, hysteria in the period of life after
puberty evidently act through the fact that they awaken the memory
remnants of those infantile traumas which do not become
conscious but lead to the liberation of affect and repression. It
is quite in harmony with this rôle of the later traumas not to be
subject to the strict limitation of the infantile traumas, but that
both in intensity and quality they can vary from an actual sexual
assault to a mere approximation of the sexual, such as perceiving
the sexual acts of others, or receiving information concerning
sexual processes.[49]
In my first communication on the defense neuropsychoses I
failed to explain how the exertion of a hitherto healthy individual
to forget such traumatic happenings would result in the real intentional
repression, and thus open the door for the defense neurosis.
It can not depend on the nature of the experience, as other
persons remain unaffected despite the same motives. Hysteria
cannot therefore be fully explained by the effect of the trauma,
and we are forced to admit that the capacity for hysteria already
existed before the trauma.
This indefinite hysterical predisposition can now wholly or partially
be substituted by the posthumous effect of the infantile
sexual trauma. The “repression” of the memory of a painful
sexual experience of maturer years can take place only in persons
159in whom this experience can bring into activity the memory
remnants of an infantile trauma.[50]
The prerequisite of obsessions is also a sexual infantile experience,
but of a different nature than that of hysteria. The
etiology of both defense neuropsychoses now shows the following
relation to the etiology of both simple neuroses, neurasthenia
and anxiety neurosis. As I have shown above, both the latter
neuroses are the direct results of the sexual noxas alone, while
both defense neuroses are the direct results of sexual noxas which
acted before the appearance of sexual maturity, that is, they are
the results of the psychic memory remnants of these noxas. The
actual causes producing neurasthenia and anxiety neurosis simultaneously
play the rôle of inciting causes of the defense neuroses,
and on the other hand, the specific causes of the defense neuroses,
the infantile traumas, may simultaneously prepare the soil for
the later developing neurasthenia. Finally it not seldom happens
that the existence of a neurasthenia or anxiety neurosis is only
preserved by continued recollection of an infantile trauma rather
than by actual sexual injuries.
160
Sexual experiences of early childhood have the same significance
in the etiology of the compulsion neurosis as in hysteria,
still we no longer deal here with sexual passivity but with pleasurably
accomplished aggressions, and with pleasurably experienced
participation in sexual acts, that is, we deal here with
sexual activity. It is due to this difference in the etiological relations
that the masculine sex seems to be preferred in the compulsion
neurosis.
In all my cases of compulsion neurosis I have found besides a
subsoil of hysterical symptoms which could be traced to a pleasurable
action of sexual passivity from a precedent scene. I presume
that this coincidence is a lawful one, and that premature
sexual aggression always presupposes an experience of seduction.
But I am unable to present as yet a complete description of the
etiology of the compulsion neurosis. I only believe that the final
determination as to whether a hysteria or compulsion neurosis
should originate on the basis of infantile traumas depends on the
temporal relation of the development of the libido.
The essence of the compulsion neurosis may be expressed in
the following simple formula: Obsessions are always transformed
reproaches returning from consciousness which always
refer to a pleasurably accomplished sexual action of childhood.
In order to elucidate this sentence it will be necessary to describe
the typical course of compulsion neurosis.
In a first period—period of childish immorality—the events
containing the seeds of the later neurosis take place. In the earliest
childhood there appear at first the experiences of sexual seduction
which later makes the repression possible, and this is followed
by the actions of sexual aggressions against the other sex
which later manifest themselves as actions of reproach.
This period is brought to an end by the appearance of the—often
self ripened—sexual “maturity.” A reproach then attaches
itself to the memory of that pleasurable action, and the connection
with the initial experience of passivity makes it possible—often
only after conscious and recollected effort—to repress it and replace
it by a primary symptom of defense. The third period, that
of apparent healthiness but really of successful defense, begins
with the symptoms of scrupulousness, shame and diffidence.
161The next period, the disease is characterized by the return of
the repressed reminiscences, hence, by the failure of the defense;
but it remains undecided whether the awakening of the same is
more frequently accidental and spontaneous, or whether it appears
in consequence of actual sexual disturbances, that is, as additional
influences of the same. But the revived reminiscences
and the reproaches formed from them never enter into consciousness
unchanged, but what becomes conscious as an obsession and
obsessive affect and substitutes the pathogenic memory in the
conscious life, are compromise formations between the repressed
and the repressing ideas.
In order to describe clearly and probably convincingly the processes
of repression, the return of the repression, and the formation
of the pathological ideas of compromise, we would have to
decide upon very definite hypotheses concerning the substratum
of the psychic occurrence and consciousness. As long as we
wish to avoid it we will have to rest content with the following
rather figuratively understood observations. Depending on
whether the memory content of the reproachful action alone
forces an entrance into consciousness or whether it takes with it
the accompanying reproachful affect, we have two forms of compulsion
neurosis. The first represents the typical obsessions, the
content of which attracts the patient’s attention; only an indefinite
displeasure is perceived as an affect, whereas, for the content
of the obsession the only suitable affect would be one of reproach.
The content of the obsession is doubly distorted when compared
to the content of the infantile compulsive act. First, something
actual replaces the past experience, and second, the sexual is
substituted by an analogous non-sexual experience. These two
changes are the results of the constant tendency to repression still
in force which we will attribute to the “ego.” The influence
of the revived pathogenic memory is shown by the fact that the
content of the obsession is still partially identical with the repressed,
or can be traced to it by a correct stream of thought.
If, with the help of the psychoanalytic method, we reconstruct
the origin of one individual obsession we find that one actual impression
instigated two diverse streams of thought, and that the
one which passed over the repressed memory, though incapable
of consciousness and correction, proves to be just as correctly
162formed logically as the other. If the results of the two psychic
operations disagree, the contradiction between the two may never
be brought to logical adjustment, but as a compromise between
the resistance and the pathological result of thought an apparently
absurd obsession enters into consciousness beside the normal result
of the thought. If both streams of thought yield the same
result, they reinforce each other so that the normally gained result
of thought now behaves psychically like an obsession. Wherever
neurotic compulsion manifests itself psychically it originates
from repression. The obsessions have, as it were, a psychical
course of compulsion which is due, not to their own validity,
but to the source from which they originate, or to the source
which furnishes a part of their validity.
A second form of compulsion neurosis results if the repressed
reproach and not the repressed content of memory forces a replacement
in the conscious psychic life. Through a psychic admixture,
the affect of the reproach can change itself into any
other affect of displeasure, and if this occurs there is nothing to
hinder the substituting affect from becoming conscious. Thus,
the reproach (of having performed in childhood some sexual
actions) may be easily transformed into shame (if some one else
becomes aware of it), into hypochondriacal anxiety (because of
the physical harmful consequences of those reproachful acts), into
social anxiety (fearing punishment from others), into religious
anxiety, into delusions of observation (fear of betraying those
actions to others), into fear of temptations (justified distrust in
one’s own moral ability of resistance), etc. Besides, the memory
content of the reproachful action may also be represented in
consciousness, or it may be altogether concealed, which makes
the diagnosis very difficult. Many cases which on superficial
examination are taken as ordinary (neurasthenic) hypochondria
often belong to this group of compulsive affects; the very frequently
so called “periodic neurasthenia” or “periodic melancholia”
especially seem to be explained by compulsive affects or
obsessions, a recognition not unimportant therapeutically.
Beside these compromise symptoms which signify the return
of the repression and hence a failure of the originally achieved
defense, the compulsion neurosis forms a series of other symptoms
of a totally different origin. The ego really tries to defend
163itself against those descendants of the initial repressed reminiscence,
and in this conflict of defense it produces symptoms which
may be comprehended as “secondary defense.” These are throughout
“protective measures” which have performed good service
in the struggle carried on against the obsessions and the obsessing
affects. If these helps in the conflict of the defense really succeed
in repressing anew the symptoms of return obtruding themselves
on the ego, the compulsion then transmits itself on the protective
measures themselves and produces a third form of the “compulsion
neurosis,” the compulsive action. These are never primary,
they never contain anything else but a defense, never an aggression.
Psychic analysis shows that despite their peculiarity they
can always be fully explained by reduction to the compulsive reminiscence
which they oppose.[51]
The secondary defense of the obsessions can be brought about
by a forcible deviation to other thoughts of possibly contrary
content; hence, in case of success there is a compulsive reasoning,
regularly concerning abstract and transcendental subjects, because
the repressed ideas always occupied themselves with the sensuous.
164Or the patient tries to become master of every compulsive idea
through logical labor and by appealing to his conscious memory;
this leads to compulsive thinking and examination and to doubting
mania. The priority of the perception before the memory in
these examinations at first induce and then force the patient to
collect and preserve all objects with which he comes in contact.
The secondary defense against the compulsive affects results in a
greater number of defensive measures which are capable of being
transformed into compulsive actions. These can be grouped according
to their tendency. We may have measures of penitence
(irksome ceremonial and observation of numbers), of prevention
(diverse phobias, superstition, pedantry, aggravation of the primary
symptom of scrupulousness), measures of fear of betrayal
(collecting papers and shyness), and measures of becoming unconscious
(dipsomania). Among these compulsive acts and impulses
the phobias play the greatest part as limitations of the
patient’s existence.
There are cases in which we can observe how the compulsion
becomes transferred from the idea or affect to the measure, and
other cases in which the compulsion oscillates between the returning
symptoms of secondary defense. But there are also cases in
which no obsessions are really formed, but the repressed reminiscence
immediately becomes replaced by the apparent primary
defensive measure. Here that stage is attained at a bound which
otherwise ends the course of the compulsion neurosis only after
the conflict of the defense. Grave cases of this affection end
either with a fixation of ceremonial actions, general doubting
mania, or in an existence of eccentricity conditioned by phobias.
That the obsessions and everything derived from them are not
believed is probably due to the fact that the defense symptom of
scrupulousness was formed during the first repression and gained
compulsive validity. The certainty of having lived morally
throughout the whole period of the successful defense makes it
impossible to give credence to the reproach which the obsession
really involves. Only transitorily during the appearance of a new
obsession, and now and then in melancholic exhaustive states of
the ego do the morbid symptoms of the return also enforce the
belief. The “compulsion” of the psychic formations here described
has in general nothing to do with the recognition through
165belief, and is not to be mistaken for that moment which is designated
as “strength” or “intensity” of an idea. Its main characteristic
lies in its inexplicableness through psychic activities of
conscious ability, and this character undergoes no change whether
the idea to which the compulsion is attached is stronger or weaker,
more or less intensively “elucidated,” “supplied with energy,”
etc.
The reason for the unassailableness of the obsession or its
derivative is due only to its connection with the repressed memory
of early childhood, for as soon as we succeed in making it conscious,
for which the psychotherapeutic methods already seem
quite sufficient, the compulsion, too, becomes detached.
For some length of time I entertained the idea that paranoia
also—or the group of cases belonging to paranoia—is a defense
psychosis, that is, like hysteria and obsessions it originates from
the repression of painful reminiscences, and that the form of its
symptoms is determined by the content of the repression. A
special way or mechanism of repression must be peculiar to
paranoia perhaps just as in hysteria which brings about the repression
by way of conversion into bodily innervation, and
perhaps like obsessions in which a substitution is accomplished
(displacement along certain associative categories). I observed
many cases which seemed to favor this interpretation, but I had
not found any which demonstrated it until a few months ago
when, through the kindness of Dr. J. Breuer, I subjected to
psychoanalysis, with therapeutic aims, an intelligent woman of
32, whom no one will be able to refuse to designate as a chronic
paranoiac. I report here some explanations gained in this work,
because I have no prospects of studying paranoia except in very
isolated examples, and because I think it possible that these
observations may instigate a psychiatrist for whom conditions are
more favorable, to give due justice to the moment of defense in
the present animated discussion on the nature and psychic mechanism
of paranoia. It is of course far from my thoughts to wish
to show from the following single observation anything but that
this case is a defense psychosis, and that in the group of
“paranoia” there may be still others of a similar nature.
166Mrs. P. thirty-two years old, married three years. She is the
mother of a two-year-old child, and does not descend from nervous
parents; but her sister and brother whom I know, are also neurotic.
It was doubtful whether she was not transitorily depressed
and mistaken in her judgment in the middle of her twentieth year.
During the last years she was healthy and capacitated until she
evinced the first symptoms of the present illness, six months after
the birth of her child. She became secluded and suspicious,
showing a disinclination towards social relations with the relatives
of her husband, and complained that the neighbors in the
little town now behaved towards her in a rather impolite and regardless
manner. Gradually these complaints grew in intensity,
she thought that there was something against her, though she
had no notion what it could be. But there was no doubt that all
the relatives and friends denied her respect, and did everything
to aggravate her. She was trying very hard to find out whence
this came but could not discover anything. Some time later she
complained that she was watched, that her thoughts were guessed,
and that everything that happened in her house was known.
One afternoon she suddenly conceived the thought that she was
watched during the evening while undressing. Since then she
applied while undressing the most complicated precautionary
measures. She slipped into her bed in the darkness and undressed
only under cover. As she avoided all social relations,
and took but little nourishment, and was very depressed, she was
sent in the summer of 1895 to a hydrotherapeutic institute.
There new symptoms appeared and reinforced those already
existing. As early as the spring, while she was alone with the
servant girl, she suddenly perceived a sensation in her lap, and
thought that the servant girl then had an unseemly thought.
This sensation became more frequent in the summer, it was almost
continuous, and she felt her genitals “as if one feels a heavy
hand.” She then began to see pictures which frightened her;
they were hallucinations of female nakedness, especially an exposed
woman’s lap with hair; occasionally she also saw male
genitals. The picture of the hairy lap and the organic sensation
in the lap usually came conjointly. The pictures became very
aggravating, as she regularly perceived them when she was in
the company of a woman, and the thought accompanying them
167was that she sees the woman in an indecent exposure, and that in
the same moment the woman sees the same picture of her (!)
Simultaneously with these visual hallucinations, which, after
their first appearance in the asylum, disappeared again for many
months, she began to be troubled with voices which she did not
recognize and could not explain. When she was in the street
she heard, “This is Mrs. P.—Here she goes.—Where does she
go?”. Every one of her movements and actions were commented
upon. Occasionally she heard threats and reproaches. All these
symptoms became worse when she was in society, or even in the
street; she therefore hesitated about going out; she also stated that
she experienced nausea for food, and as a result she became reduced
in vitality.
I obtained this from her when she came under my care in the
winter of 1895. I present this case in detail in order to make the
impression that we really deal here with a very frequent form
of chronic paranoia, which diagnosis will agree with the details
of the symptoms and their behavior to be mentioned later. At
that time she either concealed from me the delusions for the
interpretation of the hallucinations or they really had not as yet
occurred. Her intelligence was undiminished. It was reported
to me as peculiar that she had a number of rendezvous with her
brother who lived in the neighborhood, in order to confide something
to him, but this she never told him. She never spoke
about her hallucinations, and towards the end she did not say
much about the aggravations and persecutions from which she
suffered. What I have to report about this patient concerns the
etiology of the case and the mechanism of the hallucinations.
I discovered the etiology by applying Breuer’s method exactly as
in hysteria, for the investigation and removal of the hallucinations.
I started with the presupposition that just as in the two
other defense neuroses known to me this paranoia must contain
unconscious thoughts and repressed reminiscences which
have to be brought to consciousness, in the same manner as
in the others, by overcoming a certain resistance. The patient
immediately corroborated this expectation by behaving during
the analysis exactly like a hysteric, and under attention to
the pressure of my hand she reproduced thoughts which she
could not remember having had, which she at first could not understand,
168and which contradicted her expectations. The occurrence
of important unconscious ideas was therefore also demonstrated
in a case of paranoia, and I could hope to reconduct
the compulsion of paranoia to repression. It was only peculiar
that the assertions which originated in the unconscious were usually
heard inwardly or hallucinated by her as her voices.
Concerning the origin of the visual hallucinations, or at least
the vivid pictures, I discovered the following: The picture of the
female lap occurred almost always together with the organic
sensation in the lap. The latter, however, was more constant and
often occurred without the picture.
The first pictures of feminine laps appeared in the hydrotherapeutic
institute a few hours after she had actually seen a
number of women naked in the bath house. They were therefore
only simple reproductions of a real impression. It may be assumed
that these impressions repeated themselves because something
of great interest was connected with them. She stated that
she was at that time ashamed of these women, and that since
she recalled it she is ashamed of having been seen naked. Having
been obliged to look upon this shame as something compulsive,
I concluded that according to the mechanism of defense
an experience must have here been repressed in which she was
not ashamed, and I requested her to allow those reminiscences
to emerge which belonged to the theme of shame. She promptly
reproduced a series of scenes from her seventeenth to her eighth
year, during which while bathing before her mother, her sister,
and her physician she was ashamed of her nakedness. This
series, however, reached back to a scene in her sixth year when
she undressed in the children’s room before going to sleep without
feeling ashamed of her brother who was present. On questioning
her it was found that there were a number of such scenes,
and that for years the brothers and sisters were in the habit of
showing themselves naked to one another before retiring. I
now understood the significance of the sudden thought of being
watched on going to sleep. It was an unchanged fragment of
the old reproachful reminiscence, and she was now trying to
make up in shame what she lost as a child.
The supposition that we dealt here with an amour of childhood
so frequent in the etiology of hysteria was strengthened by the
169further progress of the analysis which also showed simultaneous
solutions for individual frequently recurring details in the picture
of paranoia. The beginning of her depression commenced at the
time of a disagreement between her husband and her brother on
account of which the latter no longer visited her. She was always
much attached to this brother and missed him very much
at this time. Besides this she spoke about a moment in the history
of her disease during which for the first time “everything
became clear,” that is, during which she became convinced that
her assumption about being generally despised and intentionally
annoyed was true. She gained this assurance during a visit of
her sister-in-law, who in the course of conversation dropped
the words, “If such a thing should happen to me I would not
mind it.” Mrs. P. at first took this utterance unsuspectingly,
but when her visitor left her it seemed to her that these words
contained a reproach meaning that she was in the habit of taking
serious matters lightly, and since that hour she was sure that
she was a victim of common slander. On asking her why
she felt justified in referring those words to herself she answered
that the tone in which her sister-in-law spoke convinced her of
it—to be sure subsequently—This is really a characteristic detail
of paranoia. I now urged her to recall her sister-in-law’s conversation
before the accusing utterance, and it was found that she
related that in her father’s home there were all sorts of difficulties
with the brothers, and added the wise remark, “In every family
many things happen which one would rather keep under
cover, and that if such a thing should happen to her she would
take it lightly.” Mrs. P. had to acknowledge that her depression
was connected with the sentences before the last utterance.
As she repressed both sentences which could recall her relations
with her brother, and retained only the last meaningless one, she
was forced to connect with it the feeling of being reproached by
her sister-in-law; but, inasmuch as the contents of this sentence
offered absolutely no basis for such assumption she disregarded
it and laid stress on the tone with which the words were pronounced.
It is probably a typical illustration for the fact that the
misinterpretations of paranoia depend on repression.
In a most surprising manner it also explains her peculiar behavior
in making appointments with her brother and then refusing
170to tell him anything. Her explanation was that she
thought that if she only looked at him he must understand her
suffering, as he knew the cause of it. As this brother was really
the only person who could know anything about the etiology of
her disease it followed that she acted from a motive which,
though she did not consciously understand, seemed perfectly
justified as soon as a new sense was put on it from the unconscious.
I then succeeded in causing her to reproduce different scenes
the culminating points of which were the sexual relations with
her brother at least from her sixth to her tenth year. During
this work of reproduction the organic sensation in the lap “joined
in the discussion,” precisely as regularly observed in the analysis
of memory remnants of hysterical patients. The picture of a
naked female lap (but now reduced to childish proportions and
without hair) immediately appeared or stayed away in accordance
with the occurrence of the scene in question in full light or in
darkness. The disgust for eating, too, was explained by a repulsive
detail of these actions. After we had gone through this
series, the hallucinatory sensations and pictures disappeared without
having thus far returned.[52]
I have thus learned that these hallucinations were nothing other
than fragments from the content of the repressed experiences of
childhood, that is, symptoms of the return of the repressed material.
I now turned to the analysis of the voices. Here it must before
all be explained why such indifferent remarks as, “Here
goes Mrs. P.—She now looks for apartments, etc.” could be so
painfully perceived, and how these harmless sentences managed
to become distinguished by hallucinatory enforcement. To begin
with, it was clear that these “voices” could not be hallucinatory
reproduced reminiscences like the pictures and sensations, but
rather thoughts which “became loud.”
She heard the voices for the first time under the following
circumstances. With great tension she read the pretty story,
171“The Heiterethei” by O. Ludwig, and noticed that while reading
she was preoccupied with incoming thoughts. Immediately after
she took a walk on the highway and suddenly while passing a
peasant’s cottage the voices told her, “That is how the house of
the Heiterethei looked! Here is the well, and here is the bush!
How happy she was in all her poverty!” The voices then repeated
whole paragraphs of what she had just read, but it remained
incomprehensible why house, bush, and well of the Heiterethei,
and just such indifferent and most irrelevant passages of
the romance should have obtruded themselves upon her attention
with pathological strength. The analysis showed that while reading
she at the same time entertained extraneous thoughts, and that
she was excited by totally different passages of the book. Against
this material analogy between the couple of the romance and
herself and her husband, the reminiscence of intimate things of
her married life and family secrets, against all these there arose a
repressive resistance because they were connected with her sexual
shyness by very simple and demonstrable streams of thought,
and finally resulted in the awakening of old experiences of childhood.
In consequence of the censorship exercised by the repression
the harmless and idyllic passages connected with the objectionable
ones by contrast and vicinity, became reinforced in consciousness,
enabling them to become audible. For example, the
first repressed thought referred to the slander to which the secluded
heroine was subjected by her neighbors. She readily
found in this an analogy to herself. She, too, lived in a small
place, had no intercourse with anybody and considered herself
despised by her neighbors. The suspicion against the neighbors
was founded on the fact that in the beginning of her married
life she was obliged to content herself with a small apartment.
The wall of the bedroom, near which stood the nuptial bed of the
young couple, adjoined the neighbors’ room. With the beginning
of her marriage there awakened in her a great sexual shyness.
This was apparently due to an unconscious awakening of some
reminiscences of childhood of having played husband and wife.
She was very careful lest the neighbors might hear through the
adjacent wall either words or noises and this shyness changed
into suspicion against the neighbors.
The voices therefore owed their origin to the repression of
172thoughts which in the last analysis really signified reproaches on
the occasion of an experience analogous to the infantile trauma;
they were accordingly symptoms of the return of the repression,
but at the same time they were results of a comparison between
the resistance of the ego and the force of the returning repression
which in this case produce a distortion beyond recognition. On
other occasions when analyzing voices in Mrs. P. the distortion
was less marked, still the words heard always showed a character
of diplomatic uncertainty. The annoying allusion was generally
deeply hidden, the connection of the individual sentences was
masked by a strange expression, unusual forms of speech, etc.,
characteristics generally common to the auditory hallucinations
of paranoiacs, and in which I noticed the remnant of the compromise
distortion. The expression, “There goes Mrs. P., she
is looking for apartments in the street,” signified, for example,
the threat that she will never recover, for I promised her that
after the treatment she would be able to return to the little city
where her husband was employed. She rented temporary quarters
in Vienna for a few months.
On some occasions Mrs. P. also perceived more distinct threats,
for example, concerning the relatives of her husband, the restrained
expression of which still continued to contrast with the
grief which such voices caused her. Considering all that we
otherwise know of paranoiacs I am inclined to assume a gradual
relaxation of that resistance which weakens the reproaches so
that finally the defense fails completely and the original reproach,
the insulting word, which one wanted to save himself returns in
unchanged form. I do not, however, know whether this is a constant
course, whether the censor of the expressions of reproach
can not from the beginning stay away, or persist to the end.
It is left for me to utilize the explanations gained in this case
of paranoia for the comparison of paranoia with compulsion neurosis.
Here, as there, the repression was shown to be the nucleus
of the psychic mechanism, and in both cases the repression is a
sexual experience of childhood. The origin of every compulsion
in this paranoia is in the repression, and the symptoms of paranoia
allow a similar classification as the one found justified in
compulsion neurosis. Some symptoms also originate from the
primary defense among which are all delusions of distrust, suspicion
173and persecution by others. In the compulsion neurosis
the initial reproach became repressed through the formation of
the primary symptom of defense, self-distrust, moreover, the reproach
was recognized as justified, and for the purpose of adjustment
the validity acquired by the scrupulousness during the
normal interval now guards against giving credence to the returning
reproach in the form of an obsession. By the formation
of the defense symptom of distrust in others, the reproach in paranoia
is repressed in a way which may be designated as projection;
the reproach is also deprived of recognition, and as a retaliation
there is no protection against the returning reproaches
contained in the delusions.
The other symptoms in my case of paranoia are therefore to
be designated as symptoms of the return of the repression, and
as in the compulsion neurosis they show the traces of the compromise
which alone permits an entrance into consciousness.
Such are the delusions of being observed while undressing, the
visual hallucinations, the perceptual hallucinations and the hearing
of voices. The memory content existing in the delusion mentioned
is almost unchanged and appears only uncertain through
utterance. The return of the repression into visual pictures
comes nearer to the character of hysteria than to the character of
compulsion neurosis; still, hysteria is wont to repeat its memory
symbols without modification, whereas the paranoiac memory hallucination
undergoes a distortion similar to those in compulsion
neurosis. An analogous modern picture takes the place of the
one repressed (instead of a child’s lap it was the lap of a woman
upon which the hairs were particularly distinct because they were
absent in the original impression). Quite peculiar to paranoia
but no further elucidated in this comparison is the fact that the
repressed reproaches return as loud thoughts, this must yield to
a double distortion: (1) a censor, which either leads to a replacement
through other associated thoughts or to a concealment
by indefinite expressions, and (2) the reference to the modern
which is merely analogous to the old.
The third group of symptoms found in compulsion neurosis,
the symptoms of the secondary defense, cannot exist as such in
paranoia, for no defense asserts itself against the returning
symptoms which really find credence. As a substitute for this
174we find in paranoia another source of symptom formation; the
delusions (symptoms of return) reaching consciousness through
the compromise demand a great deal of the thinking work of the
ego until they can be unconditionally accepted. As they themselves
are not to be influenced the ego must adapt itself to them,
and hence the combining delusional formation, the delusion of interpretation
which results in the transformation of the ego, corresponds
here to the symptoms of secondary defense of compulsion
neurosis. In this respect my case was imperfect as it did
not at that time show any attempt at interpretation, this only
appeared later. I do not doubt, however that if psychoanalysis
were also applied to that stage of paranoia, another important result
would be established. It would probably be found that even
the so called weakness of memory in paranoiacs is purposeful,
that is, it depends on the repression and serves its purpose. Subsequently
even those nonpathogenic memories which stand in opposition
to the transformation of the ego become repressed and
replaced; this the symptoms of return imperatively demand.
CHAPTER VIII. On Psychotherapy. [53]
175
Gentlemen:
It is almost eight years since, at the request of your deceased
chairman, Prof. v. Reder, I had the pleasure of speaking in your
midst on the subject of hysteria. Shortly before (1895) I had
published the “Studien über Hysterie” together with Dr. J.
Breuer, and on the basis of a new knowledge for which we are
thankful to this investigator, I have attempted to introduce a new
way of treating the neurosis. Fortunately, I can say that the
endeavors of our “Studies” have met with success, and that the
ideas which they advocate concerning the effects of psychic traumas
through the restraint of affects and the conception of the
hysterical symptom as a result of a displacement of excitement
from the psychic to the physical—ideas for which we have
created the terms “ab-reaction” and “conversion”—are today
generally known and understood. At least in German-speaking
countries there are no descriptions of hysteria which do not to a
certain extent take cognizance of them, and no colleague who
does not at least partially follow this theory. And yet as long
as they were new these theories and these terms must have
sounded strange enough!
I can not say the same thing about the therapeutic procedure
which we have proposed to our colleagues together with our
theory. It still struggles for recognition. This may have its
special reasons. The technique of the procedure was at that time
still rudimentary. I was unable to give those indications to the
medical reader of the book which would enable him to perform
such a treatment. But surely there were other causes of a general
nature. To many physicians psychotherapy even today appears
as a product of modern mysticism, and in comparison to
our physico-chemical remedies the application of which is based
on physiological insight, psychotherapy appears quite unscientific
176and unworthy of the interest of a natural philosopher. You will
therefore allow me to present to you the subject of psychotherapy,
and to point out to you what part of this verdict can be designated
as unjust or erroneous.
In the first place let me remind you that psychotherapy is not
a modern therapeutic procedure. On the contrary it is one of
the oldest remedies used in medicine. In Lëwenfeld’s instructive
work (Lehrbuch der gesamten Psychotherapie) you can find the
methods employed in primitive and ancient medicine. Most of
them were of a psychotherapeutic nature. In order to cure a
patient he was transferred into a state of “credulous expectation”
which acts in a similar manner even today. Even after the doctors
found other remedial agents psychotherapeutic endeavors
never disappeared from this or that branch of medicine.
Secondly, I call your attention to the fact that we doctors really
can not abandon psychotherapy if only because another very much
to be considered party in the treatment—namely the patient—has
no intention of abandoning it. You know how much we owe
to the Nancy school (Liébault, Bernheim) for these explanations.
Without our intention, an independent factor from the patient’s
psychic disposition enters into the activity of every remedial agent
introduced by the doctor, acting mostly in a favorable sense but
often also in an inhibiting sense. We have learned to apply to
this factor the word “suggestion,” and Moebius taught us that
the failures of some of our remedies are to be ascribed to the disturbing
influences of this very powerful moment. You doctors,
all of you, constantly practice psychotherapy, even when you do
not know it, or do not intend it, but it has one disadvantage, you
leave entirely to the patient the psychic factor of your influence.
It then becomes uncontrollable, it can not be divided into doses
and can not be increased. Is it not a justified endeavor of the
doctor to become master of this factor, to make use of it intentionally,
to direct and enforce it? It is nothing other than that,
that scientific psychotherapy expects of you.
In the third place, gentlemen, I wish to refer you to the well
known experience, namely, that certain maladies and particularly
the psychoneuroses, are more accessible to psychic influences
than to any other medications. It is no modern talk but a dictum
of old physicians that these diseases are not cured by the drug,
177but by the doctor, to wit, by the personality of the physician in
so far as it exerts a psychic influence. I am well aware, gentlemen,
that you like very much the idea which the aesthete Vischer,
in his parody on Faust (Faust, der Tragödie, III Teil) endowed
with a classical expression: “I know that the physical often acts
on the moral.”
But would it not be more adequate and frequently more correct
to influence the moral part of the person with the moral, that is,
with psychic means?
There are many ways and means of psychotherapy. All
methods are good which produce the aim of the therapy. Our
usual consolation, “You will soon be well again,” with which we
are so generous to our patients, corresponds to one of the
psychotherapeutic methods, only that on gaining a profounder
insight into the neuroses we are not forced to limit ourselves to
this consolation alone. We have developed the technique of
hypnotic suggestion, of psychotherapy through diversion, through
practice, and through the evocation of serviceable affects. I do
not disdain any of them, and would practice them all under
suitable conditions. That I have in reality restricted myself to a
single therapeutic procedure, to the method called by Breuer
“cathartic,” which I prefer to call “analytic,” is simply due to
subjective motives which guided me. Having participated in the
elaboration of this therapy I feel it a personal duty to devote
myself to its investigation, and to the final development of its
technique. I maintain that the analytic method of psychotherapy
is one which acts most penetratingly, and carries farthest;
through it one can produce the most prolific changes in the
patient. If I relinquish for a moment the therapeutic point of
view, I can assert that it is the most interesting, and that it alone
teaches us something concerning the origin and the connection
of the morbid manifestations. Owing to insights which it opens
for us into the mechanism of the psychic malady, it can even lead
us beyond itself, and show us the way to still other kinds of
therapeutic influences.
Allow me now to correct some errors, and furnish some explanations
concerning this cathartic or analytic method of psychotherapy.
(a) I notice that this method is often mistaken for the hypnotic
178suggestive treatment. I notice this by the fact that quite
frequently colleagues whose confidant I am not by any means,
send patients to me, refractory patients of course, with the
request that I should hypnotize them. Now, for eight years I
have not practiced hypnotism (individual cases excluded) as a
therapeutic aim, and hence I used to return the patients with
the advice that he who relies on hypnosis should do it himself.
In truth, the greatest possible contrast exists between the suggestive
and the analytic technique, that contrast which the great
Leonardo da Vinci has expressed for the arts in the formulæ per
via di porre and per via di levare. Said Leonardo, “the art of
painting works per via di levare, that is to say, places little
heaps of paint where they have not been before on the uncolored
canvas; sculpturing, on the other hand, goes per via di levare,
that is to say, it takes away from the stone as much as covers
the surface of the statue therein contained.” Quite similarly,
gentlemen, the suggestive technique acts per via di porre, it does
not concern itself about the origin, force, and significance of the
morbid symptoms, but puts on something, to wit, the suggestion
which it expects will be strong enough to prevent the pathogenic
idea from expression. On the other hand the analytic therapy
does not wish to put on anything, or introduce anything new,
but to take away, and extract, and for this purpose it concerns
itself with the genesis of the morbid symptoms, and the psychic
connection of the pathogenic idea the removal of which is its aim.
This manner of investigation has considerably furthered our understanding.
I have so early given up the technique of suggestion,
and with it hypnosis, because I despaired of making the suggestion
as strong and persistent as would be necessary for a lasting
cure. In all grave cases I noticed that the suggestions which
were put on crumbled off again, and then the disease, or one
replacing it, reappeared. Besides, I charge this technique with
concealing from us the psychic play of forces, for example, it
does not permit us to recognize the resistance with which the
patients adhere to their malady, with which they also strive
against the recovery, and which alone can give us an understanding
of their behavior in life.
(b) It seems to me that a very widespread mistake among my
colleagues is the idea that the technique of the investigation for
179the causes of the disease and the removal of the manifestations
by this investigation is easy and self-evident. I concluded this
from the fact that of the many who interest themselves in my
therapy and express a definite opinion on the same, no one has
yet asked me how I do it. There can only be one reason for it,
they believe there is nothing to ask, that it is a matter of course.
I occasionally also hear with surprise that in this or that division
of the hospital a young interne is requested by his chief to undertake
a “psychoanalysis” with a hysterical woman. I am convinced
that he would not entrust him with the examination of an
extirpated tumor without previously assuring himself that he is
acquainted with the histological technique. Likewise I am informed
that this or that colleague has made appointments with a
patient for psychic treatment, whereas I am certain that he does
not know the technique of such a treatment. He must, therefore,
expect that the patient will bring him her secrets, or he
seeks salvation in some kind of a confession or confidence. I
should not wonder if the patient thus treated would rather be
harmed than benefited. The mental instrument is really not at
all easy to play. On such occasions I can not help but think of
the speech of a world-renowned neurotic, who really never came
under a doctor’s treatment, and only lived in the fancy of the
poet. I mean Prince Hamlet of Denmark. The king has sent
the two courtiers, Rosencrantz and Guildenstern, to investigate
him and rob him of his secret. While he defended himself, pipes
were brought on the stage. Hamlet took a pipe and requested
one of his tormentors to play on it, saying that it is as easy to
play as lying. The courtier hesitated because he knew no touch
of it, and as he could not be moved to attempt to play the pipe,
Hamlet finally burst forth: “Why, look you now, how unworthy
a thing you make of me! You would play upon me; you would
seem to know my stops; you would pluck out the heart of my
mystery; you would sound me from my lowest note to the top of
my compass; and there is much music, excellent voice, in this
little organ, yet you cannot make it speak. ’Sblood! do you
think I am easier to be played on than a pipe? Call me what
instrument you will, though you can fret me, you cannot play
upon me.” (Act III, Scene 2.)
(c) You will have surmised from some of my observations
180that the analytic cure contains qualities which keep it away from
the ideal of a therapy. Tuto, cito, iucunde; the investigation and
examination does not really mean rapidity of success, and the
allusion to the resistance has prepared you for the expectation of
inconveniences. Certainly the psychoanalytic method lays high
claims on the patient as well as the physician. From the first it
requires the sacrifice of perfect candor, it takes up much of his
time, and is therefore also expensive; for the physician it also
means the loss of much time, and due to the technique which he
has to learn and practice, it is quite laborious. I even find it
quite justified to employ more suitable remedies as long as there
is a prospect to achieve something with them. It comes to this
point only: if we gain by the more laborious and cumbersome
procedure considerably more than by the short and easy one, the
first is justified despite everything. Just think, gentlemen, by
how much the Finsen therapy of lupus is more inconvenient and
expensive than the formerly used cauterization and scraping, and
yet it means a great progress, merely because it achieves more, it
actually cures the lupus radically. I do not really wish to carry
through the comparison, but psychoanalysis can claim for itself
a similar privilege. In reality I could develop and test my therapeutic
method in grave and in the gravest of cases only; my
material at first consisted of patients who tried everything unsuccessfully,
and had spent years in asylums. I hardly gained
enough experience to be able to tell you how my therapy behaves
in those lighter, episodically appearing diseases which we see
cured under the most diverse influences, and also spontaneously.
The psychoanalytic method was created for patients who are
permanently incapacitated, and its triumph is to make a gratifying
number of such, permanently capacitated. Against this
success all expense is insignificant. We can not conceal from
ourselves what we were wont to disavow to the patient, namely,
that the significance of a grave neurosis for the individual subjected
to it is not less than any cachexia or any of the generally
feared maladies.
(d) In view of the many practical limitations which I have
encountered in my work, I can hardly definitely enumerate the
indications and contraindications of this treatment. However,
I will attempt to discuss with you a few points:
1811. The former value of the person should not be overlooked
in the disease, and you should refuse a patient who does not
possess a certain degree of education, and whose character is
not in a measure reliable. We must not forget that there are
also healthy persons who are good for nothing, and that if they
only show a mere touch of the neurosis, one is only too much
inclined to blame the disease for incapacitating such inferior
persons. I maintain that the neurosis does not in any way stamp
its bearer as a dégéneré, but that frequently enough it is found
in the same individual associated with the manifestations of
degeneration. The analytic psychotherapy is therefore no procedure
for the treatment of neuropathic degeneration, on the contrary
it is limited by it. It is also not to be applied in persons
who are not prompted by their own suffering to seek the treatment,
but subject themselves to it by order of their relatives.
The characteristic feature upon which the usefulness of the
psychoanalytic treatment depends, the educability, we will still
have to consider from another point of view.
2. If one wishes to take a safe course he should limit his
selection to persons of a normal state, for, in psychoanalytic procedures,
it is from the normal that we seize upon the morbid.
Psychoses, confusional states, and marked (I might say toxic)
depressions, are unsuitable for analysis, at least as it is practiced
today. I do not think it at all impossible that with the proper
changes in the procedure it will be possible to disregard this
contraindication, and thus claim a psychotherapy for the psychoses.
3. The age of the patient also plays a part in the selection for
the psychoanalytic treatment. Persons near or over the age of
fifty lack, on the one hand, the plasticity of the psychic processes
upon which the therapy depends—old people are no longer
educable—and on the other hand, the material which has to be
elaborated, and the duration of the treatment is immensely increased.
The earliest age limit is to be individually determined;
youthful persons, even before puberty, are excellent subjects for
influence.
4. One should not attempt psychoanalysis when it is a question
of rapidly removing a threatening manifestation, as, for example,
in the case of an hysterical anorexia.
182You have now gained the impression that the sphere of application
of the analytic psychotherapy is a very limited one, for you
really heard me enumerate nothing but contraindications. Nevertheless,
there remain sufficient cases and morbid states, such as
all chronic forms of hysteria with remnant manifestations, the
extensive realms of compulsive states, abulias, etc., on which
this therapy can be tried.
It is pleasing that particularly the worthiest and highest developed
persons can thus be most helped. Where the analytic
psychotherapy has accomplished but little one can cheerfully
assert that any other treatment would have certainly resulted in
nothing.
(e) You will surely wish to ask me about the possibility of
doing harm through the application of psychoanalysis. To this I
will reply that if you will judge justly you will meet this procedure
with the same critical good-feeling as you have met our
other therapeutic methods, and doing this you will have to agree
with me that a rationally executed analytic treatment entails no
dangers for the patient. One who, like a layman, is accustomed
to ascribe to the treatment everything occurring during the
disease, will probably judge differently. It is really not so long
since our hydrotherapeutic asylums met with similar opposition.
Thus one who was advised to go to such an asylum became
thoughtful because he had an acquaintance who entered the
asylum as nervous and there become insane. As you surmise
we deal with cases of initial general paresis who in the first stages
could still be sent to hydrotherapeutic asylums, and who there
merged into the irresistible course leading to manifest insanity.
For the layman the water was the cause and author of this sad
transformation. Where it is a question of unfamiliar influences,
even doctors are not free from such mistaken judgment. I recall
having once attempted to treat a woman by psychotherapy who
passed a great part of her existence by alternating between mania
and melancholia. I began to treat her at the end of a melancholia
and everything seemed to go well for two weeks, but in the
third week she was again merging into a mania. It was surely a
spontaneous alteration of the morbid picture, for two weeks is
no time in which anything can be accomplished by psychotherapy,
but the prominent—now deceased—physician who saw the case
183with me could not refrain from remarking that this decline must
have been due to the psychotherapy. I am quite convinced that
he would have been more critical under different conditions.
(f) In conclusion, gentlemen, I must say to myself that it will
not do to lay claim to your attention so long in favor of the
analytic psychotherapy without telling you of what this treatment
consists, and on what it is based. To be sure I can only indicate
it as I have to be brief. This therapy is founded on the understanding
that unconscious ideas—or rather the unconsciousness
of certain psychic processes—are the main causes of a morbid
symptom. We share this conviction with the French school
(Janet) which moreover by gross schematization reduces the
hysterical symptom to an unconscious idée fixe. Do not fear
now that we will thus merge too far into the obscurest philosophy.
Our unconscious is not quite the same as that of the philosophers
and what is more, most philosophers wish to know nothing of
the “psychical unconscious.” But if you will put yourselves in
our position, you will understand that the interpretation of this
unconscious, in patients’ psychic life, into the conscious, must
result in a correction of their deviation from the normal, and in
an abrogation of the compulsion controlling their psychic life.
For the conscious will reaches as far as the conscious psychic
processes and every psychic compulsion is substantiated by the
unconscious. You need never fear that the patient will be
harmed by the emotion produced in the entrance of his unconscious
into consciousness, for you can theoretically readily understand
that the somatic and affective activity of the emotion which
became conscious can never become as great as those of the unconscious.
For we only control all our emotions by directing
upon them our highest psychic activities which are connected
with consciousness.
We can still choose another point of view for the understanding
of the psychoanalytic treatment. The revealing and interpreting
of the unconscious takes place under constant resistance
on the part of the patient. The emerging of the unconscious
is connected with displeasure and owing to this displeasure
it is continuously repulsed by the patient. It is upon this conflict
in the patient’s psychic life that you encroach, and if you
succeed in prevailing upon him to accept something, for motives
184of better insight, which he has thus far repulsed (repressed) on
account of the automatic adjustment of displeasure, you have
achieved in him a piece of educational work. For it is really an
education if you can induce a person to leave his bed early in the
morning despite his unwillingness to do so. As such an after
training for the overcoming of inner resistances you can conceive
the psychoanalytic treatment in quite a general manner.
But in no sphere of the nervous patients is such an after training
so essential as in the psychic elements of their sexual life.
For nowhere have culture and education produced as much harm
as here, and it is here, as experience will show you, that the controlling
etiologies of the neuroses are found. The other etiological
element, the constitutional contribution, is really given
to us as something immutable. But this gives rise to an important
demand on the doctor. Not only must he be of unblemished
character—“morality is really a matter of course” as
the principal person in Th. Vischer’s “Auch Einer” used to say—but
he must have overcome in his own personality the mixture
of lewdness and prudishness with which so many others are wont
to meet the sexual problems.
This is perhaps the place for another observation. I know
that the emphasis which I laid on the sexual rôle in the origin of
the psychoneuroses has become widely known. But I also know
that restriction and nearer determinations are of little use with
the great public; the multitude has little room in its memory, and
generally retains from a statement the bare nucleus, thus creating
for itself an easily remembered extreme. The same might
also have happened to some physicians when the faint notion that
they have of my theory is that I trace back the neurosis in the last
place to sexual privation. Of such there is surely no dearth
under the vital conditions of our society. But if that supposition
were true would it not seem obvious that in order to avoid the
roundabout way of the psychic treatment and tend directly
towards the cure, we should directly recommend sexual participation
as the remedy? I really do not know what could induce
me to suppress these conclusions if they were justified. But
the state of affairs is different. The sexual need or privation is
merely one of the factors playing a part in the mechanism of the
neurosis, and if it alone existed the result would not be a disease
185but a dissipation. The other equally indispensable factor, which
one is only too ready to forget, is the sexual repugnance of neurotics,
their inability to love; it is that psychic feature which I
have designated as “repression.” It is only from the conflict
between the two strivings that the neurotic malady originates, and
it is for this reason that the advice for sexual participation in the
psychoneuroses can really only seldom be designated as good.
Allow me to conclude with this guarded remark. Let us hope
that with an interest for psychotherapy, purified of all hostile
prejudice, you will help us to do some good in the treatment of
the severe cases of psychoneuroses.
CHAPTER IX. My Views on the Rôle of Sexuality in the Etiology of the Neuroses. [54]
186
I am of the opinion that my theory on the etiological significance
of the sexual moment in the neuroses can be best appreciated
by following its development. I will by no means make
any effort to deny that it passed through an evolution during
which it underwent a change. My colleagues can find the assurance
in this admission that this theory is nothing other than the
result of continued and painstaking experiences. In contradistinction
to this whatever originates from speculation can certainly
appear complete at one go and continue unchanged.
Originally the theory had reference only to the morbid pictures
comprehended as “neurasthenia,” among which I found two
types which occasionally appeared pure, and which I described
as “actual neurasthenia” and “anxiety neurosis.” For it was
always known that sexual moments could play a part in the
causation of these forms, but they were found neither regularly
effective, nor did one think of conceding to them a precedence
over other etiological influences. I was above all surprised at
the frequency of coarse disturbances in the vita sexualis of
nervous patients. The more I was in quest of such disturbances,
during which I remembered that all men conceal the truth in
things sexual, and the more skilful I became in continuing the
examination despite the incipient negation, the more regularly
such disease-forming moments were discovered in the sexual life,
until it seemed to me that they were but little short of universal.
But one must from the first be prepared for similar frequent
occurrences of sexual irregularities under the stress of the social
relations of our society, and one could therefore remain in doubt
as to what part of the deviation from the normal sexual function
is to be considered as a morbid cause. I could therefore only
place less value on the regular demonstration of sexual noxas
than on other experiences which appeared to me to be less
187equivocal. It was found that the form of the malady, be it
neurasthenia or anxiety neurosis, shows a constant relation to the
form of the sexual injury. In the typical cases of neurasthenia
we could always demonstrate masturbation or accumulated pollutions,
while in anxiety neurosis we could find such factors as
coitus interruptus, “frustrated excitement,” etc. The moment
of insufficient discharge of the generated libido seemed to be
common to both. Only after this experience, which is easy to
gain and very often confirmed, had I the courage to claim for the
sexual influences a prominent place in the etiology of the
neurosis. It also happened that the mixed forms of neurasthenia
and anxiety neurosis occurring so often, showed the admixture
of the etiologies accepted for both, and that such a bipartition in
the form of the manifestations of the neurosis seemed to accord
well with the polar characters of sexuality (male and female).
At the same time, while I assigned to sexuality this significance
in the origin of the simple neurosis, I still professed for the
psychoneuroses (hysteria and obsessions) a purely psychological
theory in which the sexual moment was no differently considered
than any other emotional sources. Together with J. Breuer, and
in addition to observations which he has made on his hysterical
patients fully a decade before, I have studied the mechanism of
the origin of hysterical symptoms by the awakening of memories
in hypnotic states. We obtained information which permitted us
to cross the bridge from Charcot’s traumatic hysteria to the
common non-traumatic hysteria. We reached the conception
that the hysterical symptoms are permanent results of psychic
traumas, and that the amount of affect belonging to them was
pushed away from conscious elaboration by special determinations,
thus forcing an abnormal road into bodily innervation.
The terms “strangulated affect,” “conversion,” and “ab-reaction,”
comprise the distinctive characteristics of this conception.
In the close relations of the psychoneuroses to the simple
neuroses, which can go so far that the diagnostic distinction is
not always easy for the unpracticed, it could happen that the
cognition gained from one sphere has also taken effect in the
other. Leaving such influences out of the question, the deep
study of the psychic traumas also leads to the same results. If
by the “analytic” method we continue to trace the psychic
188traumas from which the hysterical symptoms are derived, we
finally reach to experiences which belong to the patient’s childhood,
and concern his sexual life. This can be found even in such
cases where a banal emotion of a non-sexual nature has occasioned
the outburst of the disease. Without taking into account
these sexual traumas of childhood we could neither explain the
symptoms, find their determination intelligible, nor guard against
their recurrence. The incomparable significance of sexual experiences
in the etiology of the psychoneuroses seems therefore
firmly established, and this fact remains until today one of the
main supports of the theory.
If we represent this theory by saying that the course of the life
long hysterical neurosis lies in the sexual experiences of early
childhood which are usually trivial in themselves, it surely would
sound strange enough. But if we take cognizance of the historical
development of the theory, and transfer the main content
of the same into the sentence: hysteria is the expression of a
special behavior of the sexual function of the individual, and that
this behavior was already decisively determined by the first
effective influences and experiences of childhood, we will perhaps
be poorer in a paradox but richer in a motive for directing our
attention to a hitherto very neglected and most significant aftereffect
of infantile impressions in general.
As I reserve the question whether the etiology of hysteria (and
compulsion neurosis) is to be found in the sexual infantile experiences
for a later more thorough discussion, I now return to the
construction of the theory expressed in some small preliminary
publications in the years 1895–1896.[55] The bringing into prominence
of the assumed etiological moments permitted us at the
time to contrast the common neuroses which are maladies with
an actual etiology, with the psychoneuroses which etiology was
in the first place to be sought in the sexual experiences of remote
times. The theory culminates in the sentence: In a normal vita
sexualis no neurosis is possible.
If I still consider today this sentence as correct it is really
not surprising that after ten years labor on the knowledge of
these relations I passed a good way beyond my former point of
189view, and that I now think myself in a position to correct by
detailed experience the imperfections, the displacements, and the
misconceptions, from which this theory then suffered. By chance
my former rather meagre material furnished me with a great
number of cases in which infantile histories, sexual seduction by
grown-up persons or older children, played the main rôle. I
overestimated the frequency of these (otherwise not to be
doubted) occurrences, the more so because I was then in no position
to distinguish definitely the deceptive memories of hysterical
patients concerning their childhood, from the traces of the real
processes, whereas, I have since then learned to explain many a
seduction fancy as an attempt at defense against the reminiscence
of their own sexual activity (infantile masturbation). The emphasis
laid on the “traumatic” element of the infantile sexual
experience disappeared with this explanation, and it remained
obvious that the infantile sexual activities (be they spontaneous
or provoked) dictate the course of the later sexual life after maturity.
The same explanation which really corrects the most significant
of my original errors perforce also changed the conception
of the mechanism of the hysterical symptoms. These no
longer appeared as direct descendants of repressed memories of
sexual infantile experiences, but between the symptoms and the
infantile impressions there slipped in the fancies (confabulations
of memory) of the patients which were mostly produced during
the years of puberty and which on the one hand, are raised from
and over the infantile memories, and on the other, are immediately
transformed into symptoms. Only after the introduction
of the element of hysterical fancies did the structure of the neurosis
and its relation to the life of the patient become transparent.
It also resulted in a veritable surprising analogy between these
unconscious hysterical fancies and the romances which became
conscious as delusions in paranoia.
After this correction the “infantile sexual traumas” were in a
sense supplanted by the “infantilism of sexuality.” A second
modification of the original theory was not remote. With the
accepted frequency of seduction in childhood there also disappeared
the enormous emphasis of the accidental influences of sexuality
to which I wished to shift the main rôle in the causation of
the disease without, however, denying constitutional and hereditary
190moments. I even hoped to solve thereby the problem of the
selection of the neurosis, that is, to decide by the details of the sexual
infantile experience, the form of the psychoneurosis into which
the patient may merge. Though with reserve I thought at that
time that passive behavior during these scenes results in the specific
predisposition for hysteria, while active behavior results in
compulsion neurosis. This conception I was later obliged to
disclaim completely though some facts of the supposed connection
between passivity and hysteria, and activity and compulsion neurosis,
can be maintained to some extent. With the disappearance
of the accidental influences of experiences, the elements of constitution
and heredity had to regain the upper hand, but differing
from the view generally in vogue I placed the “sexual constitution”
in place of the general neuropathic predisposition. In
my recent work, “Three Contributions to the Sexual Theory.”[56] I
have attempted to discuss the varieties of this sexual constitution,
the components of the sexual impulse in general, and its origin
from the contributory sources of the organism.
Still in connection with the changed conception of the “sexual
infantile traumas,” the theory continued to develop in a course
which was already indicated in the publications of 1894–1896.
Even before sexuality was installed in its proper place in the etiology,
I had already stated as a condition for the pathogenic efficaciousness
of an experience that the latter must appear to the
ego as unbearable and thus evoke an exertion for defense. To
this defense I have traced the psychic splitting—or as it was
then called the splitting of consciousness—of hysteria. If the
defense succeeded, the unbearable experience with its resulting
affect was expelled from consciousness and memory; but under
certain conditions the thing expelled which was now unconscious,
developed its activity, and with the aid of the symptoms and their
adhering affect it returned into consciousness, so that the disease
corresponded to a failure of the defense. This conception had
the merit of entering into the play of the psychic forces, and
hence approximate the psychic processes of hysteria to the normal
instead of shifting the characteristic of the neurosis into an
enigmatic and no further analyzable disturbance.
Further inquiries among persons who remained normal furnished
191the unexpected result, that the sexual histories of their childhood
need not differ essentially from the infantile life of neurotics,
and that especially the rôle of seduction is the same in the
former, so the accidental influences receded still more in comparison
to the moments of “repression” (which I began to use instead
of “defense”). It really does not depend on the sexual
excitements which an individual experiences in his childhood
but above all on his reactions towards these experiences, and
whether these impressions responded with “repression” or not.
It could be shown that spontaneous sexual manifestations of
childhood were frequently interrupted in the course of development
by an act of repression. The sexual maturity of neurotic
individuals thus regularly brings with it a fragment of “sexual
repression” from childhood which manifests itself in the requirements
of real life. Psychoanalyses of hysterical individuals show
that the malady is the result of the conflict between the libido and
the sexual repression, and that their symptoms have the value of
a compromise between both psychic streams.
Without a comprehensive discussion of my conception of repression
I could not explain any further this part of the theory.
It suffices to refer here to my “Three Contributions to the Sexual
Theory,” where I have made an attempt to throw some light on
the somatic processes in which the essence of sexuality is to be
sought. I have stated there that the constitutional sexual predisposition
of the child is more irregularly multifarious than one
would expect, that it deserves to be called “polymorphous-perverse,”
and that from this predisposition the so called normal
behavior of the sexual functions results through a repression of
certain components. By referring to the infantile character of
sexuality, I could form a simple connection among normal, perversions,
and neurosis. The normal resulted through the repression
of certain partial impulses and components of the infantile
predisposition, and through the subordination of the rest under the
primacy of the genital zones for the service of the function of
procreation. The perversions corresponded to disturbances of
this connection due to a superior compulsive like development of
some of the partial impulses, while the neurosis could be traced
to a marked repression of the libidinous strivings. As almost
all perversive impulses of the infantile predisposition are demonstrable
192as forces of symptom formation in the neurosis, in which,
however, they exist in a state of repression, I could designate the
neurosis as the “negative” of the perversion.
I think it worth emphasizing that with all changes my ideas on
the etiology of the psychoneuroses still never disavowed or
abandoned two points of view, to wit, the estimation of sexuality
and infantilism. In other respects we have in place of the accidental
influences the constitutional moments, and instead of the
pure psychologically intended defense we have the organic “sexual
repression.” Should anybody ask where a cogent proof can
be found for the asserted etiological significance of sexual factors
in the psychoneuroses, and argue that since an outburst of these
diseases can result from the most banal emotions, and even from
somatic causes, a specific etiology in the form of special experiences
of childhood must therefore be disavowed; I mention as
an answer for all these arguments the psychoanalytic investigation
of neurotics as the source from which the disputed conviction
emanates. If one only makes use of this method of investigation
he will discover that the symptoms represent the whole or a partial
sexual manifestation of the patient from the sources of the
normal or perverse partial impulses of sexuality. Not only does
a good part of the hysterical symptomatology originate directly
from the manifestations of the sexual excitement, not only are a
series of erogenous zones in strengthening infantile attributes
raised in the neurosis to the importance of genitals, but even the
most complicated symptoms become revealed as the converted
representations of fancies having a sexual situation as a content.
He who can interpret the language of hysteria can understand
that the neurosis only deals with the repressed sexuality. One
should, however, understand the sexual function in its proper
sphere as circumscribed by the infantile predisposition. Where
a banal emotion has to be added to the causation of the disease,
the analysis regularly shows that the sexual components of the
traumatic experience, which are never missing, have exercised the
pathogenic effect.
We have unexpectedly advanced from the question of the causation
of the psychoneuroses to the problem of its essence. If we
wish to take cognizance of what we discovered by psychoanalysis
we can only say that the essence of these maladies lies in disturbances
193of the sexual processes, in those processes in the organism
which determine the formation and utilization of the sexual libido.
We can hardly avoid perceiving these processes in the last place
as chemical, so that we can recognize in the so called actual neuroses
the somatic effects of disturbances in the sexual metabolism,
while in the psychoneuroses we recognize besides the psychic
effects of the same disturbances. The resemblance of the neuroses
to the manifestations of intoxication and abstinence following
certain alkaloids, and to Basedow’s and Addison’s diseases,
obtrudes itself clinically without any further ado, and just as these
two diseases should no more be described as “nervous diseases,”
so will the genuine “neuroses” soon have to be removed from
this class despite their nomenclature.
Everything that can exert harmful influences in the processes
serving the sexual function therefore belongs to the etiology of
the neurosis. In the first place we have the noxas directly affecting
the sexual functions insofar as they are accepted as injuries
by the sexual constitution which is changeable through culture
and breeding. In the second place, we have all the different
noxas and traumas which may also injure the sexual processes by
injuring the organism as a whole. But we must not forget that
the etiological problem in the neuroses is at least as complicated
as in the causation of any other disease. One single pathogenic
influence almost never suffices, it mostly requires a multiplicity
of etiological moments reinforcing one another, and which can
not be brought in contrast to one another. It is for that reason
that the state of neurotic illness is not sharply separated from the
normal. The disease is the result of a summation, and the
measure of the etiological determinations can be completed from
any one part. To seek the etiology of the neurosis exclusively in
heredity or in the constitution would be no less one sided than to
attempt to raise to the etiology the accidental influences of sexuality
alone, even though the explanations show that the essence
of this malady lies only in a disturbance of the sexual processes
of the organism.
CHAPTER X. Hysterical Fancies and their Relations to Bisexuality. [57]
194
The delusional formations of paranoiacs containing the greatness
and sufferings of their own ego, which manifest themselves
quite typically in almost monotonous forms are universally
familiar. Furthermore, through numerous communications we
became acquainted with the peculiar organizations by means of
which certain perverts put into operation their sexual gratifications,
be it in fancy or reality. On the other hand it may sound
rather novel to some to hear that quite analogous psychic formations
regularly appear in all psychoneuroses, especially in hysteria,
and that these so called hysterical fancies show important relations
to the causation of the neurotic symptoms.
Of the same source and of the normal prototype are all these
fantastic creations, so called reveries of youth, which have already
gained a certain consideration in the literature, though not a sufficient
one.[58] They are perhaps equally frequent in both sexes; in
girls and women they seem to be wholly of an erotic nature, while
in men they are of an erotic or ambitious nature. Yet even in
men the significance of the erotic moment is not to be put in the
second place, for on examining more closely the reveries of men
we generally learn that all these heroic acts are accomplished,
that all these successes are acquired in order to please a woman
and to be preferred to other men.[59] These fancies are wish gratifications
which emanate from privation and longing. They are
justly named “day dreams” for they give the key for the understanding
195of night dreams in which the nucleus of the dream formation
is produced by just such complicated, disfigured day
fancies which are misunderstood by the conscious psychic judgment.[60]
These day dreams are garnished with great interest, are cautiously
nurtured, and coyly guarded, as if they were numbered
among the most intimate estates of personality. On the street,
however, the day dreamer can be readily recognized by a sudden,
as if absent minded smile, by talking to himself, or by a running-like
acceleration of his gait wherein he designates the acme of
the imaginary situation.
All hysterical attacks which I have been thus far able to examine
proved to be such involuntary incursions of day dreams. Observation
leaves no doubt that such fancies may exist as unconscious
or conscious and whenever they become unconscious they may
also become pathogenic, that is, they may express themselves in
symptoms and attacks. Under favorable conditions it is possible
for consciousness to seize such unconscious fancies. One of my
patients whose attention I have called to her fancies narrated
that once while in the street she suddenly found herself in tears,
and rapidly reflecting over the cause of her weeping the fancy
became clear to her. She fancied herself in delicate relationship
with a piano virtuoso familiar in the city, but whom she did not
know personally. In her fancy she bore him a child (she was
childless), and he then deserted her, leaving her and her child in
misery. At this passage of the romance she burst into tears.
The unconscious fancies are either from the first unconscious,
having been formed in the unconscious, or what is more frequently
the case they were once conscious fancies, day dreams,
and were then intentionally forgotten, merging into the unconscious
by “repression.” Their content then either remained the
same or underwent a transformation, so that the present unconscious
fancy represents a descendant of the once conscious one.
The unconscious fancy stands in a very important relation to the
sexual life of the person, it is really identical with that fancy
which helped it towards sexual gratification during a period of
masturbation. The masturbating act (in the broader sense the
onanistic) then consisted of two parts, the evocation of the fancy,
196and the active performance of self gratification at the height of
the same. This combination is familiarly in itself a soldering.[61]
Originally this action was a purely auto-erotic undertaking for
the pleasure obtained from a certain so called erogenous part of
the body. Later this action blended with a wish presentation
from the sphere of the object loved, and served for a partial
realization of the situation in which this fancy culminated. If,
then, the person forgoes in this manner the masturbo-fantastic
gratification, the action remains undone, the fancy, however,
changes from a conscious to an unconscious one. If no other
manner of sexual gratification occurs, if the person remains abstinent
and does not succeed in sublimating his libido, that is, in
diverting the sexual excitement to a higher aim, we then have the
conditions for the refreshment of the unconscious fancy; it grows
exuberantly and with all the force of the desire for love at least
a fragment of its content becomes a morbid symptom.
The unconscious fancies are then the nearest psychical first
steps of a whole series of hysterical symptoms. The hysterical
symptoms are nothing other than unconscious fancies brought to
light by “conversion,” and insofar as they are somatic symptoms
they are frequently enough taken from the spheres of the sexual
feelings and motor innervations which originally accompanied the
former still conscious fancies. In this way the disuse of onanism
is really made retrograde, and the final aim of the whole pathological
process, the restoration of the primary sexual gratification,
though it never becomes perfect, in a manner always achieves a
certain approximation.
The interest of him who studies hysteria turns directly from the
symptoms to the fancies from which the former originate. The
technique of psychoanalysis gives the means of finding out from
the symptoms the unconscious fancies, and then of bringing
them back to the patient’s consciousness. In this way it was
found that the unconscious fancies of hysterics perfectly correspond
in content to the consciously performed gratification situations
of perverts. Those who lack examples of such nature
need only recall the historical managements of the Roman Caesars
whose frenzies were naturally only conditioned by the unrestricted
fullness of the fancy creators. The delusional formations of
197paranoiacs are of the same nature, they are fancies which directly
become conscious, and which are borne by the masochistic-sadistic
components of the sexual impulse. Complete counterparts of
these can also be found in certain unconscious fancies of hysterics.
It is a familiar, practically significant fact that hysterics express
their fancies not as symptoms but in conscious realization, and in
this way they feign and commit murders, assaults, and sexual aggressions.
All that can be found out about the sexuality of the psychoneurotic
can be ascertained by the psychoanalytic examination which
leads from the obtrusive symptoms to the hidden unconscious
fancies; herein, too, is the fact, the communication of which will
be put in the foreground of this short preliminary publication.
Probably in view of the difficulties which prevent the effort of
the unconscious fancies from expressing themselves, the relation
between the fancies to the symptoms is not simple but rather
manifoldly complicated.[62] As a rule, that is, in a fully developed
and a long standing neurosis, a symptom does not correspond to
an individual unconscious fancy, but to a number of such, and
indeed it is not arbitrary but in lawful combination. To be sure
in the beginning of the disease all these complications are not
developed.
For the sake of general interest I pass over the connection of
this communication and insert a series of formulæ which strive to
progressively exhaust the nature of hysteria. They do not contradict
one another but correspond partly to more complete and
sharper conceptions, and partly to the use of different points of
view.
1. The hysterical symptom is the memory symbol of certain
efficacious (traumatic) impressions and experiences.
2. The hysterical symptom is the compensation by conversion
for the associative return of the traumatic experience.
3. The hysterical symptom—like all other psychic formations—is
the expression of a wish realization.
4. The hysterical symptom is the realization of an unconscious
fancy serving as a wish fulfilment.
1985. The hysterical symptom serves as a sexual gratification, and
represents a part of the sexual life of the individual (corresponding
to one of the components of his sexual impulse).
6. The hysterical symptom, in a fashion, corresponds to the
return of the sexual gratification which was real in infantile life
but had been repressed since then.
7. The hysterical symptom results as a compromise between two
opposing affects or impulse incitements, one of which strives to
bring to realization a partial impulse, or a component of the
sexual constitution, while the other strives to suppress the same.
8. The hysterical symptom may undertake the representation
of diverse unconscious non-sexual incitements, but can not lack
the sexual significance.
It is the seventh among these determinations which expresses
most exhaustively the essence of the hysterical symptom as a realization
of an unconscious fancy, and it is the eighth which properly
designates the significance of the sexual moment. Some of
the preceding formulæ are contained as first steps in this formula.
In view of these relations between symptoms and fancies one
can readily reach from the psychoanalysis of the symptoms to the
knowledge of the components of the sexual impulse controlling
the individual, just as I have shown in the “Three Contributions
to the Sexual Theory.” But in some cases this examination
gives rather unexpected results. It shows that many symptoms
can not be solved by one unconscious sexual fancy or by a series
of fancies in which the most significant and most primitive is of
a sexual nature, but in order to solve the symptom two sexual
fancies are required, one of the masculine and one of the feminine
character, so that one of these fancies arises from a homosexual
impulse. The axiom pronounced in formula seven is in no way
effected by this novelty, so that a hysterical symptom necessarily
corresponds to a compromise between a libidinous and a repressed
emotion, but besides that, it can correspond to a union of two
libidinous fancies of contrary sex characters.
I refrain from giving examples for this axiom. Experience
has taught me that short analyses compressed into the form of an
abstract can never make the demonstrable impression for which
they were intended. The communication of fully analyzed cases
must be reserved for another place.
199I therefore content myself in formulating the axiom and in
elucidating its significance:
9. An hysterical symptom is the expression, on the one hand,
of a masculine, and on the other hand of a feminine unconscious
sexual fancy.
I expressly observe that I am unable to adjudge to this axiom
the similar general validity that I claimed for the other formulæ.
As far as I can see it is met neither in all symptoms of a single
case, nor in all cases. On the contrary it is not difficult to find
cases in which the contrary sexual emotions have found separate
symptomatic expression, so that the symptoms of hetero- and
homosexuality can be as sharply distinguished from each other as
the fancies hidden behind them. Nevertheless, the relation
claimed in the ninth formula occurs frequently enough, and
wherever it is found it is of sufficient significance to merit a
special formulation. It seems to me to signify the highest stage
of complexity to which the determination of hysterical symptoms
can reach, and can only be expected in a long standing neurosis
and where a great amount of organization has occurred.[63]
The demonstrable bisexual significance of hysterical symptoms
occurring in many cases is indeed an interesting proof for the
assertion formulated by me that the supposed bisexual predisposition
of man can be especially recognized in psychoneurotics by
means of psychoanalysis.[64] Quite an analogous process from the
same sphere is that in which the masturbator in his conscious
fancies attempts to live through in his imagination the fancied
situations of both the man and the woman. Other counterparts
are found in certain hysterical crises in which the patients play
both rôles lying at the basis of sexual fancies; thus, for example,
one of the cases under my observation presses his garments to his
body with one arm (as woman), and with the other arm he attempts
to tear them off (as man). This contradictory simultaneity
determines most of the incomprehensibility of the situation
otherwise so plastically represented in the attack, and is excellently
200suited for the concealment of the effective unconscious
fancy.
In psychoanalytical treatment it is very important to be prepared
for the bisexual significance of a symptom. It should
not be at all surprising or misleading when a symptom remains
apparently undiminished in spite of the fact that one of its
sexual determinants is already solved. Perhaps it is still supported
by the unsuspected contrary sexual. Furthermore, during
the treatment of such cases we can observe how the patient
makes use of this convenience. During the analysis of the one
sexual significance he continually switches his thoughts into the
sphere of the contrary significance just as if onto a neighboring
track.
1. Studien über Hysterie von Jos. Breuer und Sigm. Freud. Leipzig und
Wien, Franz Deuticke, 1895. 2nd ed., 1909.
2. Sammlung kleiner Schriften zur Neurosenlehre, Vols. I. and II.
Leipzig und Wien, Deuticke, 1906, and 1909.
3. Bleuler, Freudsche Mechanismen in der Symptomatologie der Psychosen,
Psychiatrisch-Neurolog. Wochenschrift, 1906, Nrs. 35 and 36.
4. Jung, The Psychology of Dementia Præcox, Nervous and Mental
Disease Monograph Series, Nr. 3.
5. Riklin, Psychiatrisch-Neurolog. Wochenschrift, 1905, Nr. 46.
6. Brill, Psychological Factors in Dementia Præcox, Journal of Abnormal
Psychology, Vol. III, Nr. 4, and A Case of Schizophrenia, American
Journal of Insanity, Vol. LXVI, No. 1.
10. Written in collaboration with Dr. Joseph Breuer.
11. The possibility of such a therapy was clearly recognized by Delboeuf
and Binet, as is shown by the accompanying quotations: Delboeuf, Le
magnétisme animal, Paris, 1889: “On s’expliquerait des lors comment le
magnétiseur aide à guérison. Il remet le sujet dans l’état où le mal s’est
manifesté et combat par la parole le même mal, mais renaissant.” (Binet,
Les altérations de la personnalité, 1892, p. 243): “... peut-être verra-t-on
qu’en reportant le malade par un artifice mental, au moment même ou
le symptome a apparu pour la premiere fois, on rend ce malade plus
docile a une suggestion curative.” In the interesting book of Janet,
L’Automatism Psychologique, Paris, 1889, we find the description of a
cure brought about in a hysterical girl by a process similar to our method.
12. We are unable to distinguish in this preliminary contribution what
there is new in this content and what can be found in such other authors
as Moebius and Strümpel who present similar views on hysteria. The
greatest similarity to our theoretical and therapeutical accomplishments we
accidentally found in some published observations of Benedict which we
shall discuss hereafter.
13. The German abreagiren has no exact English equivalent. It will therefore
be rendered throughout the text by “ab-react,” the literal meaning
is to react away from or to react off. It has different shades of meaning,
from defense reaction to emotional catharsis, which can be discerned from
the context.
14. As an example of the technique mentioned above, that is, of investigating
in a non-somnambulic state or where consciousness is not broadened,
I will relate a case which I analyzed recently. I treated a woman of
thirty-eight who suffered from an anxiety neurosis (agoraphobia, fear of
death, etc.). Like many patients of that type she had a disinclination to
admit that she acquired this disease in her married state and was quite
desirous of referring it back to early youth. She informed me that at
the age of seventeen when she was in the street of her small city she had
the first attack of vertigo, anxiety, and faintness, and that these attacks
recurred at times up to a few years ago when they were replaced by her
present disease. I thought that the first attacks of vertigo, in which the
anxiety was only blurred, were hysterical and decided to analyze the
same. All she knows is that she had the first attack when she went out
to make purchases in the main street of her city.—“What purchases did
you wish to make?”—“Various things, I believe it was for a ball to which
I was invited.”—“When was the ball to take place?”—“I believe two days
later.”—“Something must have happened a few days before this which
excited you, and which made an impression on you.”—“But I don’t know,
it is now twenty-one years.”—“That does not matter, you will recall it.
I will exert some pressure on your head and when I stop it you will
either think of or see something which I want you to tell me.” I went
through this procedure, but she remained quiet.—“Well, has nothing
come into your mind?”—“I thought of something, but that can have no
connection with it.”—“Just say it.”—“I thought of a young girl who is
dead, but she died when I was eighteen, that is, a year later.”—“Let us
adhere to this. What was the matter with your friend?”—“Her death
affected me very much, because I was very friendly with her. A few
weeks before another young girl died, which attracted a great deal of
attention in our city, but then I was only seventeen years old.”—“You
see, I told you that the thought obtained under the pressure of the hands
can be relied upon. Well now, can you recall the thought that you had
when you became dizzy in the street?”—“There was no thought, it was
vertigo.”—“That is quite impossible, such conditions are never without
accompanying ideas. I will press your head again and you will think of
it. Well, what came to your mind?”—“I thought, ‘now I am the third.’”—“What
do you mean?”—“When I became dizzy I must have thought,
now I will die like the other two.”—“That was then the idea, during the
attack you thought of your friend, her death must have made a great impression
on you.”—“Yes, indeed, I recall now that I felt dreadful when I
heard of her death, to think that I should go to a ball while she lay dead,
but I anticipated so much pleasure at the ball and was so occupied with
the invitation that I did not wish to think of this sad event.” (Notice
here the intentional repression from consciousness which caused the
reminiscences of her friend to become pathogenic.)
The attack was now in a measure explained, but I still needed the
occasional moment which just then provoked this recollection, and accidentally
I formed a happy supposition about it.—“Can you recall through
which street you passed at that time?”—“Surely, the main street with
its old houses, I can see it now.”—“And where did your friend live?”—“In
the same street. I had just passed her house and was two houses
farther when I was seized with the attack.”—“Then it was the house
which you passed that recalled your dead friend, and the contrast which
you then did not wish to think about that again took possession of you.”
Still I was not satisfied, perhaps there was something else which provoked
or strengthened the hysterical disposition in a hitherto normal girl.
My suppositions were directed to the menstrual indisposition as an appropriate
moment, and I asked, “Do you know when during that month you
had your menses?”—She became indignant: “Do you expect me to know
that? I only know that I had them then very rarely and irregularly.
When I was seventeen I only had them once.”—“Well let us enumerate
the days, months, etc., so as to find when it occurred.”—She with certainty
decided on a month and wavered between two days preceding a
date which accompanied a fixed holiday.—Does that in any way correspond
with the time of the ball?—She answered quietly: “The ball was on this
holiday. And now I recall that I was impressed by the fact that the only
menses which I had had during the year occurred just when I had to go to
the ball. It was the first invitation to a ball that I had received.”
The combination of the events can now be readily constructed and the
mechanism of this hysterical attack readily viewed. To be sure the result
was gained after painstaking labor. It necessitated on my side full confidence
in the technique and individual directing ideas in order to reawaken
such details of forgotten experiences after twenty-one years in
a sceptical and awakened patient. But then everything agreed.
15. A better description of this peculiar state in which one knows something
and at the same time does not know it, I could never obtain. It
can apparently be understood only if one has found himself in such a
state. I have at my disposal a very striking recollection of this kind
which I can vividly see. If I make the effort to recall what passed
through my mind at that time my output seems very poor. I saw at that
time something which was not at all appropriate to my expectations, and
what I saw did not in the least divert me from my definite purpose,
whereas this perception ought to have done away with my purpose. I
did not become conscious of this contradiction nor did I remark the affect
of the repulsion to which it was undoubtedly due that this perception did
not attain any psychic validity. I was struck with that form of blindness
in seeing eyes, which one admires so much in mothers towards their
daughters, in husbands towards their wives, and in rulers towards their
favorites.
16. It will be shown that, notwithstanding, I erred.
17. Die Abwehr-Neuropsychosen, Neurologisches Centralblatt, 1 June,
1894.
18. I can neither exclude nor prove that this pain, especially of the thighs,
was of a neurasthenic nature.
19. To my surprise I once discovered that such subsequent ab-reaction—through
other impressions than nursing—may form the content of an
otherwise enigmatic neurosis. It was the case of a pretty girl of nineteen,
Miss Matilda H. whom I first saw with an incomplete paralysis of the
legs, and months afterward I was again called because her character had
changed. She was depressed and tired of living, entertaining lack of
consideration for her mother, and was irritable and inapproachable. The
whole picture of the patient did not seem to me to be that of an ordinary
melancholia. She could easily be put into a somnambulic state, and I
made use of this peculiarity to impart to her each time commands and
suggestions to which she listened in her profound sleep and responded
with profuse tears, but which, however, caused but little change in her
condition. One day while hypnotized she became talkative and informed
me that the reason for her depression was the breaking of her betrothal
many months before. She stated that on closer acquaintance with her
fiance the things displeasing to her and her mother became more and
more evident. On the other hand, the material advantages of the engagement
were too tangible to make the decision of a rupture easy, thus, both
of them hesitated for a long time. She then merged into a condition of
indecision in which she allowed everything to pass apathetically, and
finally her mother pronounced for her the decisive “no.” Shortly after,
she awoke as from a dream and began to occupy herself fervently with
the thoughts about the broken betrothal, she began to weigh the pros and
cons, a process which she continued for some time. At present she continues
to live in that time of doubt, and entertains daily the moods and
the thoughts which would have been appropriate for that day. The
irritability against her mother could only be explained if we took into
consideration the circumstances that existed on that decisive day. Next
to this thought activity she found her present life a mere phantom just
like a dream. I did not again succeed in getting the girl to talk—I continued
my exhortations during deep somnambulism. I saw her each time
burst into tears without however receiving any answer from her. But
one day, it was near the anniversary of the engagement, the whole state
of depression disappeared. This was attributed to my great hypnotic cure.
20. It is different in a hypnoid-hysteria. Here the content of the separate
psychic groups may never have been in the ego consciousness.
21. I had under my observation another case in which a contracture of the
masseters made it impossible for the artist to sing. The young lady in
question through painful experiences in the family was forced to go on
the stage. While in Rome rehearsing, in great excitement she suddenly
perceived the sensation of being unable to close her opened mouth and
sank fainting to the floor. The physician who was called closed her jaws
forcibly, but the patient since that time was unable to open her jaws more
than a finger’s breadth and had to give up her newly chosen profession.
When she came under my care many years later, the motives for that
excitement were apparently over for some time, for massage in a light
hypnosis sufficed to open her mouth widely. The lady has since sung
in public.
25. The literal translation of Auftreten is to press down by treading.
26. In conditions of profounder psychic changes we apparently find a
symbolic stamp (mark) of the more artificial usage of language in the
form of emblematic pictures and sensations. There was a time in Mrs.
Cäcilie M. during which every thought was changed into an hallucination,
and which solution frequently afforded great humor. She at that time
complained to me of being troubled by the hallucination that both her
physicians, Breuer and I, were hanged in the garden on two nearby trees.
The hallucination disappeared after the analysis revealed the following
origin: The evening before Breuer refused her request for a certain
drug. She then placed her hopes on me but found me just as inflexible.
She was angry at both of us, and in her affect she thought, “They are
worthy of each other, the one is a pendant of the other!”
27. E. Hecker, Centralblatt für Nervenheilkunde, Dec., 1893.
28. See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und
Wien, 1895, p. 15.
29. See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und
Wien, 1895, p. 106.
30. See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und
Wien, 1895, p. 15.
31. As mentioned in the preface the author has long since discarded this
pressure procedure.—Translator’s note.
32. See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und
Wien, 1895, p. 85.
34. See Breuer und Freud, Studien über Hysterie. Deuticke, Wien und
Leipzig, 1895, p. 28.
35. See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und
Wien, 1895, p. 55.
36. État mental des hystériques, Paris, 1893 and 1894. Quelques définitions
récentes de l’hystérie, Arch. de Neurol., 1893, XXXV-VI.
37. Oppenheim: Hysteria is an exaggerated expression of emotion. But
the “expression of emotion” represents that amount of psychic excitement
which normally experiences conversion.
38. Strümpel: The disturbance of hysteria lies in the psycho-physical, there
where the physical and psychical are connected with each other.
39. Janet, in the second chapter of his spirited essay “Quelques definitions,”
etc., has treated the objection that the splitting of consciousness
belongs also to the psychoses and the so called psychaesthenia, but in my
opinion he has not satisfactorily solved it. It is essentially this objection
which urged him to call hysteria a form of degeneration. But through
no characteristic is he able to separate sufficiently the hysterical splitting
of consciousness from the psychopathic, etc.
40. The group of typical phobias, for which agoraphobia is a prototype,
cannot be reduced to the psychic mechanisms here developed. Furthermore
the mechanism of agoraphobia deviates in one decisive point from
that of the real obsessions and from phobias based on such. Here there
is no repressed idea from which the affect of fear has been separated.
The fear of this phobia has another origin.
41. E. Hecker, Über larvierte und abortive Angstzustände bei Neurasthenie,
Centralblatt für Nervenheilkunde, December, 1893.—Anxiety is
made particularly prominent among the chief symptoms of neurasthenia
by Kaan, Der neurasthenische Angstaffekt bei Zwangsvorstellungen und
der primordiale Grübelzwang, Wien, 1893.
42. Die Abwehr-Neuropsychosen, Neurol. Centralbl., 1894, Nr. 10 u. 11.
43. Obsession et phobies, Révue neurologique, 1895.
48. I myself surmise that the so frequently fabricated assaults of hysterical
persons are obsessional confabulations emanating from the memory
traces of infantile traumas.
49. In an article on the anxiety neurosis (Neurologisches Centralblatt,
1895, Nr. 2) I stated that “an anxiety neurosis which can almost typically
be combined with hysteria can be evoked in maturing girls at the first
encounter with the sexual problem.” I know today that the occasion in
which such virginal anxiety breaks out does not really correspond to the
first encounter with sexuality, but that in such persons there was in
childhood a precedent experience of sexual passivity which memory was
awakened at the “first encounter.”
50. A psychological theory of the repression ought also to inform us why
only ideas of a sexual content can be repressed. It may be formulated
as follows: It is known that ideas of a sexual content produce exciting
processes in the genitals resembling the actual sexual experience. It may
be assumed that this somatic excitement becomes transformed into psychic.
As a rule the activity referred to is much stronger at the time of the
occurrence than at the recollection of the same. But if the sexual experience
takes place during the time of sexual immaturity and the recollection
of the same is awakened during or after maturity, the recollection
then acts disproportionately more exciting than the previous experience,
for puberty has in the mean time incomparably increased the reactive
capacity of the sexual apparatus. But such an inverse proportion seems
to contain the psychological determination of repression. Through the
retardation of the pubescent maturity in comparison with the psychic
function, the sexual life offers the only existing possibility for that inversion
of the relative efficacy. The infantile traumas subsequently act
like fresh experiences, but they are then unconscious. Deeper psychological
discussions I will have to postpone for another time. I moreover
call attention to the fact that the here considered time of “sexual maturity”
does not coincide with puberty, but occurs before the same (eight
to ten years).
51. One example instead of many: An eleven-year-old boy has obsessively
arranged for himself the following ceremonial before going to bed: He
could not fall asleep unless he related to his mother most minutely all
experiences of the day; not the smallest scrap of paper or any other rubbish
was allowed in the evening on the carpet of his bedroom. The bed
had to be moved close to the wall, three chairs had to stand in front of it,
and the pillows had to lie in just such a position. In order to fall asleep
he had to kick with both legs a number of times, and then had to lie on
the side. This was explained as follows: Years before while putting
this pretty boy to sleep, the servant girl made use of this opportunity to
lay over him and assault him sexually. When this reminiscence was later
awakened by a recent experience it made itself known to consciousness
by the compulsion in the above mentioned ceremonial which sense could
really be surmised and the details verified by psychoanalysis. The chairs
before the bed which was close to the wall—so that no one could have
access to it; the arrangement of the pillows in a definite manner—so that
they should be differently arranged than they were on that evening; the
motion with the legs—to kick away the person lying on him; sleeping on
the side—because during that scene he lay on his back; the detailed confession
to his mother—because in consequence of the prohibition of his
seductress he concealed from his mother this and other sexual experiences;
finally, keeping the floor of his bedroom clean—because this
was the main reproach which he had to hear from his mother up to that
time.
52. When the meagre success of this treatment was later removed by an
exacerbation, she did not again see the offensive pictures of strange
genitals, but she had the idea that strangers saw her genitals as soon as
they were behind her.
53. Lecture delivered before the Vienna Medic. Doktorenkollegium, on
December 12, 1904.
54. From Löwenfeld, “Sexualleben und Nervenleiden,” IV ed., 1906.
55. See Chapter VII, and Zur Aetiologie der Hysterie, Wiener, Klinische
Rundschau, 1896.
57. Zeitschrift für Sexualwissenschaft, herausgegeben von Hirschfeld, I,
1908.
58. Compare Breuer and Freud Studien über Hysterie, 1895. P. Janet,
Névroses et ideés fixes, I (Les rêveries subconscientes), 1898. Havelock
Ellis, Sexual Impulse and Modesty (German by Kötscher), 1900. Freud,
Traumdeutung, 1906, 2d ed., 1909. A. Pick, Über pathologische Träumerei
und ihre Beziehungen zur Hysteria, Jahrbuch für Psychiatrie und Neurologie,
XIV, 1896.
59. H. Ellis similarly expresses himself, l. c., p. 185.
61. Compare Freud, Three Contributions to the Sexual Theory, 1895.
62. The same thing holds true for the relation between the “latent”
thoughts of the dream and the elements of the manifest content of the
dream. See the Chapter on the “Work of the Dream” in the author’s
Traumdeutung.
63. Indeed J. Sadger, who recently discovered this sentence in question,
independently by psychoanalysis, claims for it a general validity (Die
Bedeutung der psychoanalytische Methode nach Freud, Centralbl. f. Nerv.
u. Psych., Nr. 229.)