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diff --git a/75132-0.txt b/75132-0.txt new file mode 100644 index 0000000..8591525 --- /dev/null +++ b/75132-0.txt @@ -0,0 +1,8007 @@ + +*** START OF THE PROJECT GUTENBERG EBOOK 75132 *** + + + + + + SELECTED PAPERS ON HYSTERIA + AND + OTHER PSYCHONEUROSES + + 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. + + + + + CONTENTS. + + + PAGE. + TRANSLATOR’S PREFACE iii + CHAPTER. + I. THE PSYCHIC MECHANISM OF HYSTERICAL PHENOMENA 1 + II. THE CASE OF MISS LUCY R. 14 + III. THE CASE OF MISS ELISABETH V. R. 31 + IV. THE PSYCHOTHERAPY OF HYSTERIA 75 + V. THE DEFENSE NEURO-PSYCHOSES. A Tentative Psychological + Theory of Acquired Hysteria, many Phobias and Obsessions, + and Certain Hallucinatory Psychoses 121 + VI. ON THE RIGHT TO SEPARATE FROM NEURASTHENIA A DEFINITE + SYMPTOM-COMPLEX AS “ANXIETY NEUROSIS” 133 + VII. FURTHER OBSERVATIONS ON THE DEFENSE NEUROPSYCHOSES 155 + VIII. ON PSYCHOTHERAPY 175 + IX. MY VIEWS ON THE RÔLE OF SEXUALITY IN THE ETIOLOGY OF THE + NEUROSES 186 + X. HYSTERICAL FANCIES AND THEIR RELATIONS TO BISEXUALITY 194 + + + + + TRANSLATOR’S PREFACE. + + +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 the 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. This 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. + +This 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. + +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 which 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. + +In 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 like 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 of 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] + + + II. + +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 in 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 hysteria 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. + +To 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_. + + + III. + +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 whose 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 +intellects, 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. + + + IV. + +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 hypnotized 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 groups 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 is 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. + + + V. + +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. + + +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 +hallucinations of smell with the accompanying depression as equivalents +of hysterical attacks. The nature of recurrent hallucinations really +makes them unfit to take the part of continuous symptoms, and this +really did not occur in this rudimentarily developed case. On the other +hand it was absolutely to be expected that the subjective sensations of +smell would show such a specialization as to be able to correspond in +its origin to a very definite and real object. + +This expectation was soon fulfilled, for on being asked what odor +troubled her most she stated that it was an odor of burned pastry. I +could then assume that the odor of burned pastry really occurred in the +traumatic event. It is quite unusual to select sensations of smell as +memory symbols of traumas, but it is quite obvious why these were here +selected. She was afflicted with purulent rhinitis, hence the nose and +its perceptions were in the foreground of her attention. All I knew +about the life of the patient was that she took care of two children +whose mother died a few years ago from a grave and acute disease. + +As a starting point of the analysis I decided to use the “odor of burned +pastry.” I will now relate the history of this analysis. It could have +occurred under more favorable conditions, but as a matter of fact what +should have taken place in one session was extended over a number of +them. She could only visit me during my office hours, during which I +could devote to her but little of my time. One single conversation had +to be extended for over a week as her duties did not permit her to come +to me often from such a distance, so that the conversation was +frequently broken off and resumed at the next session. + +On attempting to hypnotize Miss Lucy R. she did not merge into the +somnambulic state. I therefore was obliged to forego somnambulism and +the analysis was made while she was in a state not perhaps differing +much from the normal. + +I feel obliged to express myself more fully about the point of the +technique of my procedure. While visiting the Nancy clinics in 1889 I +heard Dr. Liébeault, the old master of hypnotism, say, “Yes, if we had +the means to put everybody into the somnambulic state, hypnotism would +then be the most powerful therapeutic agent.” In Bernheim’s clinic it +almost seemed that such an art really existed and that it could be +learned from Bernheim. But as soon as I tried to practice it on my own +patients I noticed that at least my powers were quite limited in this +respect. Whenever a patient did not merge into the somnambulistic state +after one to three attempts I possessed no means to force him into it. +However, the percentage of somnambulists in my experience were far below +that claimed by Bernheim. + +Thus I had my choice, either to forbear using the cathartic method in +most of the cases suitable for it, or to venture the attempt without +somnambulism by using hypnotic influence in light or even doubtful +cases. It made no difference of what degree (following the accepted +scales of hypnotism) the hypnotism was which did not correspond to +somnambulism, for every direction of suggestibility is independent of +the other and nothing is prejudicial towards the evocation of catalepsy, +automatic movements and similar phenomena for the purpose of +facilitating the awakening of forgotten recollections. I soon +relinquished the habit of deciding the degree of hypnotism, as in a +great number of cases it incited the patients’ resistance, and clouded +the confidence which I needed for the more important psychic work. +Moreover, in mild grades of hypnotism I soon tired of hearing, after the +assurance and command, “You will sleep, sleep now!” such protests as, +“But, Doctor, I am not sleeping.” I was then forced to bring in the very +delicate distinction, saying, “I do not mean the usual sleep, I mean the +hypnotic,—you see, you are hypnotized, you cannot open your eyes”; or, +“I really don’t want you to sleep.” I, myself, am convinced that many of +my colleagues using psychotherapy know how to get out of such +difficulties more skilfully than I; they can proceed differently. I, +however, believe that if through the use of a word one can so frequently +become embarrassed, it is better to avoid the word and the +embarrassment. Wherever the first attempt did not produce either +somnambulism or a degree of hypnotism with pronounced bodily changes, I +dropped the hypnosis and demanded only “concentration,” I ordered the +patient to lie on his back and close his eyes as a means of reaching +this “concentration.” With little effort I obtained as profound a degree +of hypnotism as was possible. + +But inasmuch as I forbore using somnambulism, I perhaps robbed myself of +a preliminary stipulation without which the cathartic method seems +inapplicable. For it is based on the fact that in the altered state of +consciousness the patients have at their disposal such recollections and +recognize such connections which do not apparently exist in their normal +conscious state. Wherever the somnambulic broadening of consciousness +lacks there must also be an absence of the possibility of bringing about +a causal relation which the patient cannot give to the doctor as +something known to him, and it is just the pathogenic recollections +“which are lacking from the memory of the patients in their usual +psychic states or only exist in a most condensed state” (preliminary +communication). + +My memory helped me out of this embarrassment. I, myself, saw Bernheim +adduce proof that the recollections of somnambulism are only manifestly +forgotten in the waking state and can be readily reproduced by slight +urging accompanied by hand pressure which is supposed to mark another +conscious state. He, for instance, imparted to a somnambulist the +negative hallucination that he was no more present, and then attempted +to make himself noticeable to her by the most manifold and regardless +attacks, but was unsuccessful. After the patient was awakened he asked +her what he did to her during the time that she thought he was not +there. She replied very much astonished, that she knew nothing, but he +did not give in, insisting that she would recall everything; and placed +his hand on her forehead so that she should recall things, and behold, +she finally related all that she did not apparently perceive in the +somnambulic state and about which she ostensibly knew nothing in the +waking state. + +This astonishing and instructive experiment was my model. I decided to +proceed on the supposition that my patients knew everything that was of +any pathogenic significance, and that all that was necessary was to +force them to impart it. When I reached a point where to the question +“Since when have you this symptom?” or, “Where does it come from?” I +receive the answer, “I really don’t know this,” I proceeded as follows: +I placed my hand on the patient’s forehead or took her head between my +hands and said, “Under the pressure of my hand it will come into your +mind. In the moment that I stop the pressure you will see something +before you, or something will pass through your mind which you must +note. It is that which we are seeking. Well, what have you seen or what +came into your mind?” + +On applying this method for the first time (it was not in the case of +Miss Lucy R.) I was surprised to find just what I wanted, and I may say +that it has since hardly ever failed me, it always showed me the way to +proceed in my investigations and enabled me to conclude all such +analyses without somnambulism. Gradually I became so bold that when a +patient would answer, “I see nothing,” or “Nothing came into my mind,” I +insisted that it was impossible. They probably had the right thought but +did not believe it and repudiated it. I would repeat the procedure as +often as they wished, and every time they saw the same thing. Indeed, I +was always right; the patients had not as yet learned to let their +criticism rest. They repudiated the emerging recollection or fancy +because they considered it as a useless intruding disturbance, but after +they imparted it, it was always shown that it was the right one. +Occasionally after forcing a communication by pressing the head three or +four times I got such answer as, “Yes, I was aware of it the first time, +but did not wish to say it,” or, “I hoped that it would not be this.” + +By this method it was far more laborious to broaden the alleged narrowed +consciousness than by investigating in the somnambulic state, 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 that at the right number or name his +eyes will open themselves or that he will feel which number is the +correct one. In most cases the patients really decide on a definite date +and frequently enough (as in the case of Mrs. Cäcilie N.) it could be +ascertained from existing notes of that time that the date was correctly +recognized. At other times and in different patients it was shown from +the connection of the recollected facts that the dates thus found were +incontestable. A patient, for instance, after a date was found by +enumerating for her the dates, remarked, “This is my father’s birthday,” +and added “Of course I expected this episode [about which we spoke] +because it was my father’s birthday.” + +I can only slightly touch upon this theme. The conclusion which I wished +to draw from all these experiences is that the pathogenic important +experiences with all their concomitant circumstances are faithfully +retained in memory, even where they seem forgotten, as when the patient +seems unable to recall them.[14] + +After this long but unavoidable digression I now return to the history +of Miss Lucy R. As aforesaid, she did not merge into somnambulism when +an attempt was made to hypnotize her, but lay calmly in a degree of mild +suggestibility, her eyes constantly closed, the features immobile, the +limbs without motion. I asked her whether she remembered on what +occasion the smell perception of burned pastry originated.—“Oh, yes, I +know it well. It was about two months ago, two days before my birthday. +I was with the children (two girls) in the school room playing and +teaching them to cook, when a letter just left by the letter carrier was +brought in. From its postmark and handwriting I recognized it as one +sent to me by my mother from Glasgow and I wished to open it and read +it. The children then came running over, pulled the letter out of my +hand and exclaimed, ‘No you must not read it now, it is probably a +congratulatory letter for your birthday and we will keep it for you +until then.’ While the children were thus playing there was a sudden +diffusion of an intense odor. The children forgot the pastry which they +were cooking and it became burned. Since then I have been troubled by +this odor, it is really always present but is more marked during +excitement.” + +“Do you see this scene distinctly before you?”—“As clearly as I +experienced it.”—“What was there in it that so excited you?”—“I was +touched by the affection which the children displayed towards me.”—“But +weren’t they always so affectionate?”—“Yes, but I just got the letter +from my mother.”—“I can’t understand in what way the affection of the +little ones and the letter from the mother contrasted, a thing which you +appear to intimate.”—“I had the intention of going to my mother and my +heart became heavy at the thought of leaving those dear children.”—“What +is the matter with your mother? Was she so lonesome that she wanted you, +or was she sick just then and you expected some news?”—“No, she is +delicate but not really sick, and has a companion with her.”—“Why then +were you obliged to leave the children?”—“This house had become +unbearable to me. The housekeeper, the cook, and the French maid seemed +to be under the impression that I was too proud for my position. They +united in intriguing against me and told the grandfather of the children +all sorts of things about me, and when I complained to both gentlemen I +did not receive the support which I expected. I then tendered my +resignation to the master (father of the children) but he was very +friendly, asking me to reconsider it for two weeks before taking any +definite steps. It was while I was in that state of indecision that the +incident occurred. I thought that I would leave the house but have +remained.”—“Aside from the attachment of the children is there anything +particular which attracts you to them?”—“Yes, my mother is distantly +related to their mother and when the latter was on her death bed I +promised her to do my utmost in caring for the children, that I would +not forsake them, and be a mother to them, and this promise I broke when +offering my resignation.” + +The analysis of the subjective sensation of smell seemed completed. It +was once objective and intimately connected with an experience, a small +scene, in which contrary affects conflicted, sorrow at forsaking the +children, and the mortification which despite all urged her to this +decision. Her mother’s letter naturally recalled the motives of this +decision because she thought of returning to her mother. The conflict of +the affects raised this moment to a trauma and the sensation of smell +which was connected with it remained as its symbol. The only thing to be +explained was the fact that out of all the sensory perceptions of that +scene, the perception of smell was selected as the symbol, but I was +already prepared to use the chronic nasal affliction as an explanation. +On being directly questioned she stated that just at that time she +suffered from a severe coryza and could scarcely smell anything but in +her excitement she perceived the odor of burned pastry, it penetrated +the organically motived anosmia. + +As plausible as this sounded it did not satisfy me; there seemed to be +something lacking. There was no acceptable reason wherefore this series +of excitements and this conflict of affects should have led to hysteria. +Why did it not all remain on a normal psychological basis? In other +words, what justified the conversion under discussion? Why did she not +recall the scenes themselves instead of the sensations connected with +them which she preferred as symbols for her recollection? Such questions +might seem superfluous and impertinent when dealing with old hysterias +in whom the mechanism of conversion was habitual, but this girl first +acquired hysteria through this trauma, or at least through this slight +distress. + +From the analysis of similar cases I already knew that where hysteria is +to be newly acquired one psychic determinant is 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] + +“Why did you not wish to admit it to yourself? Were you ashamed because +you loved a man?”—“O, no, I am not unreasonably prudish; one is +certainly not responsible for one’s own feelings. I only felt chagrined +because it was my employer in whose service I was and in whose house I +lived, and toward whom I could not feel as independent as towards +another. What is more, I am a poor girl and he is a rich man of a +prominent family, and if anybody should have had any inkling about my +feelings they would have ridiculed me.” + +After this I encountered no resistances in elucidating the origin of +this affection. She told me that the first years of her life in that +house were passed uneventfully. She fulfilled her duties without +thinking about unrealizable wishes. One day, however, the serious, and +very busy and hitherto very reserved master, engaged her in conversation +about the exigencies of rearing the children. He became milder and more +cordial than usual, he told her how much he counted on her in the +bringing up of his orphaned children, and looked at her rather +peculiarly. It was in this moment that she began to love him, and gladly +occupied herself with the pleasing hopes which she conceived during that +conversation. However, as this was not followed by anything else, and +despite her waiting and persevering no other confidential heart-to-heart +talk followed, she decided to crowd it out of her mind. She quite agreed +with me that the look in connection with the conversation was probably +intended for the memory of his deceased wife. She was also perfectly +convinced that her love was hopeless. + +After this conversation I expected a decided change in her condition but +for a time it did not take place. She continued depressed and moody—a +course of hydrotherapy which I ordered for her at the same time +refreshed her somewhat mornings. The odor of burned pastry did not +entirely disappear; though it became rarer and feebler it appeared only, +as she said, when she was very much excited. + +The continuation of this memory symbol led me to believe that besides +the principal scene it represented many smaller side traumas and I +therefore investigated everything that might have been in any way +connected with the scene of the burned pastry. We thus passed through +the theme of family friction, the behavior of the grandfather and +others, and with that the sensation of burned odor gradually +disappeared. Just then there was a lengthy interruption occasioned by a +new nasal affliction which led to the discovery of the caries of the +ethmoid. + +On her return she informed me that she received many Christmas presents +from both gentlemen as well as from the household servants, as if they +were trying to appease her and wipe away the recollection of the +conflicts of the last months. These frank advances made no impression on +her. + +On questioning her on another occasion about the odor of burned pastry +she stated that it had entirely disappeared, but instead she was now +bothered by another and similar odor like the smoke of a cigar. This +odor really existed before; it was only concealed by the odor of the +pastry but now appeared by itself. + +I was not very much pleased with the success of my treatment. What +occurred here is what a mere symptomatic treatment is generally blamed +for, namely, that it removes one symptom only to make room for another. +Nevertheless, I immediately set forth to remove this new memory symbol +by analysis. + +This time I did not know whence this subjective sensation of smell +originated, nor on what important occasion it was objective. On being +questioned she said, “They constantly smoke at home, I really don’t know +whether the smell which I feel has any particular significance.” I then +proposed that she should try to recall things under the pressure of my +hands. I have already mentioned that her recollections were plastically +vivid, that she was a “visual.” Indeed under the pressure of my hands a +picture came into her mind—at first only slowly and fragmentarily. It +was the dining room of the house in which she waited with the children +for the arrival of the gentlemen from the factory for dinner.—“Now we +are all at the table, the gentlemen, the French maid, the housekeeper, +the children and I. It is the same as usual.”—“Just keep on looking at +that picture. It will soon become developed and specialized.”—“Yes, +there is a guest, the chief accountant, an old gentleman who loves the +children like his own grandchildren, but he dines with us so frequently +that it is nothing unusual.”—“Just have patience, keep on looking at the +picture, something will certainly happen.”—“Nothing happens. We leave +the table, the children take leave and go with us up to the second floor +as usual.”—“Well?”—“It really is something unusual, I now recognize the +scene. As the children take leave the chief accountant attempts to kiss +them, but my master jumps up and shouts at him, ‘Don’t kiss the +children!’ I then experienced a stitch in the heart, and as the +gentlemen were smoking, this odor remained in my memory.” + +This, therefore, was the second, deeper seated scene causing the trauma +and leaving the memory symbol. But why was this scene so effective? I +then asked her which scene happened first, this one or the one with the +burned pastry?—“The last scene happened first by almost two +months.”—“Why did you feel the stitch at the father’s interference? The +reproof was not meant for you.”—“It was really not right to rebuke an +old gentleman in such manner who was a dear friend and a guest, it could +have been said quietly.”—“Then you were really affected by your master’s +impetuosity? Were you perhaps ashamed of him, or have you thought, ‘If +he could become so impetuous to an old friend guest over such a trifle, +how would he act towards me if I were his wife?’”—“No, that is not +it.”—“But still it was about his impetuosity?”—“Yes, about the kissing +of the children, he never liked that.” Under the pressure of my hands +there emerged a still older scene which was the real effective trauma +and which bestowed on the scene with the chief accountant the traumatic +effectivity. + +A few months before a lady friend visited the house and on leaving +kissed both children on the lips. The father, who was present, +controlled himself and said nothing to the lady, but when she left he +was very angry at the unfortunate governess. He said that he held her +responsible for this kissing; that it was her duty not to tolerate it; +that she was neglecting her duties in allowing such things, and that if +it ever happened again he would entrust the education of his children to +some one else. This occurred while she believed herself loved and waited +for a repetition of that serious and friendly talk. This episode +shattered all her hopes. She thought: “If he can upbraid and threaten me +on account of such a trifle, of which I am entirely innocent, I must +have been mistaken, he never entertained any tenderer feelings towards +me, else he would have been considerate.”—It was evidently this painful +scene that came to her as the father reprimanded the chief accountant +for attempting to kiss the children. + +On being visited by Miss Lucy R. two days after the last analysis I had +to ask her what pleasant things happened to her. She looked as though +transformed, she smiled and held her head aloft. For a moment I thought +that after all I probably mistook the conditions and that the governess +of the children had now become the bride of the master. But she soon +dissipated all my suppositions, saying, “Nothing new happened. You +really do not know me. You have always seen me while I was sick and +depressed. I am otherwise always cheerful. On awaking yesterday morning +my burden was gone and since then I feel well.”—“What do you think of +your chances in the house?”—“I am perfectly clear about that. I know +that I have none, and I am not going to be unhappy about it.”—“Will you +now be able to get along with the others in the house?”—“I believe so, +because most of the trouble was due to my sensitiveness.”—“Do you still +love the master?”—“Certainly I love him, but that does not bother me +much. One can think and feel as one wishes.” + +I now examined her nose and found that the pain and the reflex +sensations had almost completely reappeared. She could distinguish +odors, but she was uncertain when they were very intense. What part the +nasal trouble played in the anosmia I must leave undecided. + +The whole treatment extended over a period of nine weeks. Four months +later I accidentally met the patient at one of our summer resorts—she +was cheerful and stated that her health continued to be good. + + + EPICRISIS. + +I would not underestimate the aforesaid case even though it only +represents a young and light hysteria presenting but few symptoms. +Moreover, it seems to me instructive that even such a slight neurotic +affliction requires so many psychic determinants, and on a more +exhaustive consideration of this history I am tempted to put it down as +an illustration of that form of hysteria which even persons not burdened +by heredity may acquire if their experiences favor it. It should be well +noted that I do not speak of a hysteria which may be independent of all +predisposition; such form does not probably exist, but we speak of such +a predisposition only after the person became hysterical, as nothing +pointed to it before this. A neuropathic disposition as commonly +understood is something different. It is determined even before the +disease by a number of hereditary burdens, or a sum of individual +psychic abnormalities. As far as I know none of these moments could be +demonstrated in the case of Miss Lucy R. Her hysteria could therefore be +called acquired and presupposes nothing except probably a very marked +susceptibility to acquire hysteria, a characteristic about which we know +hardly anything. The chief importance in such cases lies in the nature +of the trauma, to be sure in connection with the reaction of the person +to the trauma. It is an indispensable condition for the acquirement of +hysteria that there should arise a relation of incompatibility between +the ego and some of its approaching presentations. I hope to be able to +show in another place how a variety of neurotic disturbances originate +from the different procedures which the “ego” pursues in order to free +itself from that incompatibility. The hysterical form of defence, for +which a special adaptation is required, consists in converting the +excitement into physical innervation. The gain brought about by this +process is the crowding out of the unbearable presentation from the ego +consciousness, which then contains instead the physical reminiscences +produced by conversion—in our case the subjective sensation of smell—and +suffers from the affect which is more or less distinctly adherent to +these reminiscences. The situation thus produced is no longer +changeable, for changing and conversion annihilate the conflict which +helped towards the adjustment of the affect. Thus the mechanism +producing hysteria corresponds on the one hand to an act of moral faint +heartedness, on the other hand it presents itself as a protective +arrangement at the command of the ego. There are many cases in which it +must be admitted that the defense of the increased excitement through +the production of hysteria may actually have been most expedient, but +more frequently one will naturally come to the conclusion that a greater +measure of moral courage would have been an advantage to the individual. + +Accordingly the real traumatic moment is that, in which the conflict +thrusts itself upon the ego and the latter decides to banish it. Such +banishment does not annihilate the opposing presentation but merely +crowds it into the unconscious. This process, occurring for the first +time, forms a nucleus and point of crystallization for the formation of +a new psychic group separated from the ego, around which, in the course +of time, everything collects in accord with the opposing presentation. +The splitting of consciousness in such cases of acquired hysteria is +thus a desired and intentional one, and is often initiated by at least +one arbitrary act. But literally, something different happens than the +individual expects, he would wish to eliminate a presentation as though +it never came to pass but only succeeds in isolating it psychically. + +The traumatic moment in the history of our patient corresponds to the +scene created by the master on account of the kissing of the children. +For the time being this scene remained without any palpable effects, +perhaps it initiated the depression and sensitiveness, but I leave this +open;—the hysterical symptoms, however, commenced later in moments which +can be designated as “auxiliary,” and which may be characterized by the +fact that in them there is a simultaneous flowing together of both +separated groups just as in the broadened somnambulic consciousness. The +first of these moments in which the conversion took place in Miss Lucy +R., was the scene at the table when the chief accountant attempted to +kiss the children. The traumatic memory helped along, and she acted as +though she had not entirely banished her attachment for her master. In +other cases we find that these different moments come together and the +conversion occurs directly under the influence of the trauma. + +The second auxiliary moment repeated almost precisely the mechanism of +the first. A strong impression transitorily 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. + + +In the fall of 1892 I was requested by a friendly colleague to examine a +young lady who had suffered from pains in her legs for over two years +and who walked badly. He also added that he diagnosed the case as +hysteria, though none of the usual symptoms of the neurosis could be +found. He stated that he knew something of the family and that the last +few years had brought them much misfortune and little pleasure. At first +the father of the patient died, then the mother underwent a serious +operation for the eyes, and soon thereafter a married sister succumbed +to a chronic cardiac affection after childbirth. Our patient had taken +an active part in all the afflictions and in all the nursings of the +sick. I made no further progress into the case after I had seen the +twenty-four-year-old patient for the first time. She seemed intelligent +and psychically normal and her affliction, which interfered with her +social relations and pleasure, she bore with a happy mien, thus vividly +recalling the “belle indifference” of hysterics. She walked with the +upper part of her body bent forward, but without any support; her gait +did not correspond to any known pathological gait and it was in no way +strikingly bad. She complained of severe pains on walking, of early +fatigue in walking as well as standing, and after a brief period she +would seek rest in which the pains became diminished but they by no +means disappeared. The pain was of an indefinite nature—one could assume +it to be a painful fatigue. The seat of the pain was given as a quite +extensive but indefinitely circumscribed location on the superficial +surface of the right thigh. It was from this area that the pains +radiated and where they were of the greatest intensity. Here, too, the +skin and muscles were especially sensitive to pressure and pinching, +while needle pricks were rather indifferently perceived. The same +hyperalgesia of the skin and muscles was demonstrable, not only in this +area, but over almost the entire surface of both legs. The muscles were +perhaps more painful than the skin, but both kinds of pains were +unmistakably most pronounced over the thighs. The motor power of the +legs was not diminished, the reflexes were of average intensity and all +other symptoms were lacking, so that there was no basis for the +assumption of a serious organic affection. The disease developed +gradually during two years and changed considerably in its intensity. + +I did not find it easy to determine the diagnosis, but for two reasons I +concluded to agree with my colleague. First, because it was rather +peculiar that such a highly intelligent patient should not be able to +give anything definite about the character of her pains. A patient +suffering from an organic pain, if it is not accompanied by any +nervousness will be able to describe it definitely and calmly; it may +perhaps be lancinating, appearing at certain intervals, extending from +this to that location, and in his opinion it may be evoked by this or +that influence. The neurasthenic describing his pain gives the +impression of being occupied with some difficult mental problem reaching +far beyond his powers. His features are tense and distorted as though +under the domination of a painful affect, his voice becomes shriller, he +struggles for expression, he rejects all designations that the physician +makes for his pains, even though they are undoubtedly afterwards found +as appropriate. He is ostensibly of the opinion that language is too +poor to give expression to his feelings. His sensations are something +unique, they never existed before so that they can not be exhaustively +described. He never tires of constantly adding new details and when he +has to stop he is surely controlled by the impression that he was +unsuccessful in making himself understood to the physician. All this is +due to the fact that his pains absorb his whole attention. In the case +of Miss v. R. we had just the opposite behavior and we had to conclude +from this that she attributed sufficient significance to the pain, but +that her attention was concentrated on something else of which the pains +were the accompanying phenomena, perhaps on thoughts and sensations +which were connected with the pain. + +A still greater determination for the conception of the pain must +however, be found in a second moment. If we irritate a painful area in a +patient suffering from an organic disease or neurasthenia his +physiognomy will show a definite expression of discomfort or of physical +pain. Furthermore, the patient winces, refuses to be examined and +assumes a defensive attitude. With Miss v. R. when the hyperalgesic skin +or muscles of her legs were pinched or pressed her face assumed a +peculiar expression approaching nearer pleasure than pain, she cried out +and—I had to think of a pleasurable tickling—her face reddened, she +threw her head backward, closed her eyes, and her body bent backward; +all this was not very distinct but sufficiently marked so that it could +only agree with the conception that her affliction was a hysteria and +that the irritation touched a hysterogenic zone. + +Her mien was not in accord with the pain which the pinching of the +muscles and skin were supposed to excite. It probably harmonized better +with the content of the thoughts which were behind the pain and which +were evoked in the patient by irritating that part of the body +associated with them. I have repeatedly observed similar significant +expressions on irritating hyperalgesic zones in unmistakable cases of +hysteria. The other gestures evidently corresponded to the slightest +indications of a hysterical attack. + +We could not at that time find any explanation for the unusual +localization of the hysterogenic zone. That the hyperalgesia chiefly +concerned the muscles gave material for reflection. The most frequent +affliction causing the diffuse and local pressure sensitiveness of the +muscles is the rheumatic infiltration of the same, the common chronic +muscular rheumatism about which aptitude to mask nervous affections I +have already spoken. The consistency of the painful muscles in Miss v. +R. did not contradict this assumption, as there were many hard cords in +the muscle masses which seemed to be especially sensitive. There was +probably also an organic change in the muscles, in the assumed sense, +upon which the neurosis rested and which significance was markedly +exaggerated by the neurosis. + +The therapy followed out was based on a supposition of a mixed +affection. We recommended the continuation of a systematic massage and +faradization of the sensitive muscles without regard to the pain +produced, and in order to remain in communication with the patient I +undertook the treatment of her legs by means of strong Franklin’s +sparks. To her question whether she should force herself to walk we +answered decidedly in the affirmative. + +We thus attained a slight improvement. She particularly liked the +painful shocks of the influence machine and the stronger they were the +more they seemed to suppress her pains. My colleague meanwhile prepared +the soil for the psychic treatment, and when after four weeks of sham +treatment I proposed the same and gave the patient some explanations +concerning the procedures and its effects I found a ready understanding +and only slight resistances. + +The work which then began became eventually the most arduous that ever +befell my lot, and the difficulty of giving an account of this work +ranks well with the obstacles that had to be overcome. For a long time, +too, I did not understand the connection between the history of the +disease and the affliction, a thing which should really have been caused +and determined by this row of events. + +When one undertakes a cathartic treatment he at first asks himself +whether the patient understands the origin and cause of her suffering. +If that is so one does not need any special technique to cause her to +reproduce the history of her ailment. The interest shown in her, the +understanding which we foreshadow, the hope of recovery extended to her, +all these will induce the patient to give up her secrets. With Miss +Elisabeth it seemed probable to me right from the very beginning that +she was conscious of the reasons for her suffering, that she had only a +secret but no foreign body in consciousness. On looking at her one had +to think of the poet’s words, + + “That mask indicates a hidden meaning.”[16] + +At first I could thus forego hypnosis, reserving it, however, for future +use if in the course of the confession conditions should arise for which +explanation the memory would not perhaps suffice. Thus in this first +complete analysis of a hysteria which I had undertaken, I reached a +process of treatment which later I raised into a method and employed it +consciously in the process of removing by strata the pathogenic psychic +material which we used to compare with the technique of excavating a +buried city. I at first allowed the patient to relate to me what was +known to her, paying careful attention wherever a connection remained +enigmatical or where a link in the chain of causation seemed to be +lacking. Later I penetrated into the deeper strata of memory by using +for those locations hypnotic investigation or a similar technique. The +presupposition of the whole work was naturally the expectation that a +perfect and sufficient determination could be demonstrated. The means of +the deeper investigation will soon be discussed. + +The history which Miss Elisabeth gave was very dull and was woven of +manifold painful experiences. During this recital she was not in a +hypnotic state; I merely asked her to lie down and keep her eyes closed. +I however made no objection if she from time to time opened her eyes, +changed her position or sat up. Whenever she entered more deeply into a +part of her history she seemed to merge spontaneously into a condition +resembling a hypnotic state. She then remained motionless and kept her +eyes firmly closed. + +I shall now reproduce the results of the superficial strata of her +memory. As the youngest of three daughters she spent her youth with her +parents, to whom she was devotedly attached, on their estate in Hungary. +Her mother’s health was frequently disturbed by an affliction of her +eyes and also by nervous conditions. It thus happened that she became +especially and devotedly attached to her jovial and broadminded father +who was wont to say that this daughter took the place of both a son and +friend with whom he could exchange his thoughts. As much as the girl +gained in mental stimulation in consequence of this intercourse it did +not escape the father that her psychic constitution deviated from that +ideal which one so much desires to see in a girl. Jocosely he called her +pert and disputatious. He warned her against being too confident in her +judgments, against her tendencies to tell the truth regardlessly to +everybody, and expressed his opinion that she would find it difficult to +get a husband. As a matter of fact she was very discontented with her +girlhood; she was filled with ambitious plans, wishing to study or +obtain a musical education, and revolted at the thought of being forced +to give up her inclination to sacrifice her freedom of judgment on +account of marriage. Meanwhile she was proud of her father, of the +regard and social position of her family, and jealously guarded +everything connected with these matters. The indifference with which she +treated her mother and older sisters, as will be shown, was considered +by her parents to be due to the blunter side of her character. + +The age of the girls impelled the family to move into the metropolis, +where for a time Elisabeth enjoyed the richer and gayer life. But then +came the calamity which destroyed the happiness of the home. The father +either concealed or overlooked a chronic cardiac affection, and one day +he was brought home in an unconscious state after the first attack of +edema of the lungs. This was followed by an illness of one and a half +years, during which Elisabeth took the most prominent part in nursing +him. She slept in her father’s room, awoke at night at his call, watched +over him faithfully during the day, and forced herself to appear +cheerful while he went through a hopeless condition with amiable +resignation. The beginning of her affection must have been connected +with this time of her nursing, for she could recall that during the last +half year of this care she had to remain in bed on one occasion for a +day and a half on account of severe pain in the leg. She maintained, +however, that these pains soon passed away and excited neither worry nor +attention. As a matter of fact it was two years after the death of her +father that she began to feel sick and became unable to walk on account +of pain. + +The gap which the father left in the life of this family consisting of +four women, the social solitude, the cessation of so many relations +which promised stimulation and pleasure, the increased infirmity of the +mother, all these clouded the mood of our patient, but simultaneously +stimulated a warm desire that the family might soon find a substitute +for the lost happiness and urged her to concentrate her entire devotion +and care on the surviving mother. At the end of the mourning year the +eldest sister married a talented and ambitious man of notable position, +who by his mental capacity seemed to be destined for a great future, but +who, however, very soon developed a morbid sensitiveness and egotistic +perseveration of moods, and dared to show his disregard for the old lady +in the family circle. That was more than Elisabeth could endure. She +felt herself called upon to take up the fight against her brother-in-law +whenever he gave occasion for it, while the other women took lightly the +outburst of his excited temperament. To her it was a painful +disillusionment to find that the reconstruction of the old family +happiness experienced such a disturbance. She could not forgive her +married sister because with feminine docility she strove to avoid +espousing her cause. Thus a whole series of scenes remained in +Elisabeth’s memory to which were attached a number of partially uttered +grievances against her first brother-in-law. But what she reproached him +most for was the fact that for the sake of a promotion in view he moved +with his small family to a distant city in Austria and thus increased +the lonesomeness of her mother. On this occasion Elisabeth distinctly +felt her inability and helplessness to afford her mother a substitute +for the lost happiness, and the impossibility of following out the +resolution made at the death of her father. + +The marriage of the second sister seemed to promise more for the future +of the family. The second brother-in-law, although not of the same +mental calibre as the first, was a man after the heart of delicate +ladies, and his behavior reconciled Elisabeth to the matrimonial +institution and to the thought of the sacrifice connected with it. What +is more the second couple remained near her mother, and the child of +this brother-in-law and the second sister became Elisabeth’s pet. +Unfortunately the year during which the child was born was clouded by +another event. The visual affliction of the mother demanded many weeks’ +treatment in a dark room, in which Elisabeth participated. Following +this an operation proved necessary and the excitement connected with +this occurred at the same time that the first brother-in-law made +preparations to move. Finally the operation, skilfully performed, proved +successful, and the three families met at a summer resort. There +Elisabeth, exhausted by the worries of the past months, had the first +opportunity to recuperate from the effects of the suffering and anxiety +that the family had undergone since the death of her father. + +But during the time spent at this resort Elisabeth was attacked by the +pain and weakness. Afterwards, the pains, which had become noticeable +for a short while some time previously, manifested themselves severely +for the first time after taking a warm bath at a small watering place. +In connection with this it was thought that a long walk, really a walk +of half a day, a few days, previously, had some connection with the +onset of the pains. This readily produced the impression that Elisabeth +at first became “fatigued” and then “caught cold.” + +From this time on Elisabeth became the patient in the family. Following +the advice of the physician she spent the rest of the summer in the +watering place at Gastein, whither she went with her mother, but not +without having a new worriment to think about. The second sister was +again pregnant and information as to her condition was quite +unfavorable, so that Elisabeth could hardly decide to take the journey +to Gastein. After barely two weeks at Gastein both mother and sister +were recalled as the patient at home did not feel well. + +An agonizing journey, which for Elisabeth was a mixture of pain and +anxious expectations, was followed by certain signs at the home railroad +station which forebode the worst, and then on entering the chamber of +the patient they were confronted with the reality—that they arrived too +late to take leave of the dying one. + +Elisabeth not only suffered from the loss of this sister whom she dearly +loved but was also grieved by the thoughts caused by her death and the +changes which it caused. The sister had succumbed to heart trouble which +was aggravated by the pregnancy. + +She then conceived the thought that the heart trouble was the paternal +inheritance. It was then recalled that in her early childhood the +deceased went through an attack of chorea with a slight heart affection. +The family then blamed themselves and the physicians for permitting the +marriage. They could not spare reproaches to the unfortunate widower for +impairing the health of his wife by two successive pregnancies without +any pause. The sad thought that this happiness should terminate thus, +after the rare conditions for a happy marriage had been found, +thereafter constantly occupied Elisabeth’s mind. Moreover, she again saw +everything fail that she had planned for her mother. The widowed +brother-in-law was inconsolable and withdrew from his wife’s family. It +seemed that his own family from whom he was estranged during his short +and happy married life took advantage of the opportunity to again draw +him into their own circle. There was no way of maintaining the former +union; to live together with the mother-in-law was improper out of +regard for the unmarried sister-in-law, and inasmuch as he refused to +relinquish the child, the only legacy of the deceased, to the two +ladies, he for the first time gave them the opportunity of accusing him +of heartlessness. Finally, and that was not the least painful thing, +Elisabeth received some indefinite information concerning a disagreement +between the two brothers-in-law, the occasion for which she could only +surmise. It seemed as if the widower made some requests concerning +financial matters which the other brother-in-law considered +unjustifiable, and thought, that in view of the recent sorrow of his +mother, it was nothing but an evil extortion. This then was the history +of the young woman of ambitious and loving disposition. Resentful of her +fate, embittered over the failures of her little plans to restore the +lustre of the home; of her beloved ones, some being dead, some away, and +some estranged— without any inclination to seek refuge in the love of a +strange man, she lived thus for a year and a half nursing her mother and +her pains, separated from almost, all social intercourse. + +If we forget the greater sufferings and place ourselves in this girl’s +position, we can but extend to Miss Elisabeth our hearty sympathy. But +what is the physician’s interest in this sorrowful tale; what is its +relation to her painful and her weak gait; what outlook is there for +explaining and curing this case by the knowledge which we perhaps +obtained from these psychic traumas? + +For the physician this confession of the patient signified at first a +great disappointment, for to be sure it was a history composed of banal +mental shocks from which we could neither explain why the patient became +afflicted with hysteria nor how the hysteria assumed the form of the +painful abasia. It explained neither the causation nor the determination +of the hysteria in question. We could perhaps assume that the patient +had formed an association between her psychically painful impressions +and bodily pains which she accidentally perceived simultaneously, and +that now she made use in her memory of the physical sensation as a +symbol for the psychic. What motive she had for this substitution and in +what moment this came about remained unexplained. To be sure, these were +questions whose nature was not familiar to the physicians. For it was +customary to content one’s self with the information and to assume that +the patient was constitutionally hysterical and that under the intensive +pressure of any kind of excitement hysterical symptoms could develop. + +Even less than for the explanation did this confession offer for the +treatment of the case. One could not conceive what beneficial influence +Miss Elisabeth could derive from recounting sad familiar family +experiences of the past years to a stranger who could give her in return +only moderate sympathy, nor could we perceive any improvement after the +confession. During the first period of the treatment the patient never +failed to repeat to her physician: “I continue to feel ill, I have the +same pains as before,” and when she accompanied this by a crafty and +malicious glance, I could perhaps recall the words which old Mr. v. R. +was wont to utter concerning his favorite daughter: “She is frequently +pert and disputatious,” but after all I had to confess that she was +right. + +Had I given up the patient at this stage of the psychic treatment the +case of Miss Elisabeth v. R. would have been quite unimportant for the +theory of hysteria. Nevertheless, I continued my analysis because I felt +sure that an understanding of the causation as well as the determination +of the hysterical symptoms could be gained from the deeper strata of +consciousness. + +I therefore decided to put the direct question to the broadened +consciousness of the patient, in order to find out with what psychic +impression the origin of the pain in the legs was connected. + +For this purpose the patient should have been put in deep hypnosis. But +unhappily I had to realize that all my procedures in that direction +could put the patient in no other state of consciousness than that in +which she gave me her confession. Still I was very pleased that this +time she abstained from triumphantly remonstrating with the words: “You +see, I really do not sleep, I cannot be hypnotized.” In such despair I +conceived the idea of making use of the trick of pressing the head, the +origin of which I have thoroughly discussed in the preceding +contribution concerning Miss Lucy. This was done by requesting the +patient to unfailingly inform me of what came before her mind’s eye or +passed through her memory at the moment of the pressure. For a long time +she was silent, and then admitted that on my pressure she thought of an +evening in which a young man had accompanied her home from some social +affair. She also thought of the conversation that passed between them, +and her feelings on returning home to nurse her father. + +With this first mention of the young man a new shaft was opened, the +content of which I now gradually brought out. We dealt here rather with +a secret, for with the exception of a mutual friend, no one knew +anything of the relation and the hopes connected with it. It concerned +the son of an old friend who was formerly one of their neighbors. The +young man having become an orphan attached himself with great devotion +to her father; he was guided in his career by his advice, and this +veneration for the father was extended to the ladies of the family. +Numerous reminiscences of repeated joint readings, exchange of thoughts +and utterances on his side marked the gradual growth of her conviction +that he loved and understood her and that a marriage with him would not +impose the sacrifice that she feared. Unhappily he was but little older +than she and as yet was far from being independent. She however firmly +resolved to wait for him. + +With the serious illness of her father, and the necessity of her nursing +him their relations became less frequent. The evening which she at first +recalled marked the height of her feeling, but even then there was no +exchange of ideas between them on the subject. It was only at the urging +of her family that she consented to leave the sick bed that evening and +go to an affair where she was to meet him. She wished to hasten home +early but was forced to remain, only yielding on his promising to +accompany her home. At no time had she entertained such a tender regard +for him as during this walk, but after returning home at a late hour in +this blissful state and finding the condition of her father aggravated +she bitterly reproached herself for having sacrificed so much time for +her own amusement. It was the last time that she left her sick father +for a whole evening; her friend she saw but seldom after this. After the +death of her father he seemed to hold himself aloof out of respect for +her sorrow and then business affairs drew him into other spheres. +Gradually she came to the realization that his interest in her was +suppressed by other feelings and that he was lost to her. This failure +of her first love pained her as often as she thought of it. + +In this relationship and in the scene caused by it, I was to seek the +causation of the first hysterical pain. A conflict, or a state of +incompatibility arose through the contrast between the happiness which +she had not at that time denied herself and the sad condition in which +she found her father upon her arrival home. As a result of this conflict +the erotic presentations were repressed from the associations, and the +affect connected with them was made use of in aggravating or reviving a +simultaneously (or somewhat previously) existing physical pain. It was +therefore the mechanism of a conversion for the purpose of defense as I +have shown circumstantially in another place.[17] + +To be sure, we have room here for all kinds of observations. I must +assert that I was unsuccessful in demonstrating from her memory that the +conversion took place in the moment of her returning home. I therefore +investigated for similar experiences which might have occurred while she +was nursing her father, and I evoked a number of scenes, among which was +one during which she had to jump out of bed with bare feet in a cold +room to respond to the repeated calls of her father. I was inclined to +attribute to this moment a certain significance, for in addition to +complaining of pain in her legs she also complained of tormenting +sensations of coldness. Nevertheless, here, too I could not with +certainty lay hold of the scene which could be indicated as the scene of +conversion. This led me to admit that there was here some gap, when I +recalled the fact that the hysterical pains in the legs were really not +present at the time she nursed her father. From her memory she recalled +only a single attack of pain lasting a few days to which at that time +she paid no attention. I then directed my attention to the first +appearance of the pains. In this respect I was successful in awakening a +perfect memory. They came on just at the time of a relative’s visit whom +she could not receive because she was ill in bed, and who had the +misfortune to find her ill in bed on another occasion two years later. +But the search for the psychic motive of these first pains failed as +often as repeated. I believed that I could assume that these first pains +were due to a slight rheumatic attack and really had no psychic basis, +and I also discovered that this organic trouble was the model for the +later hysterical imitation, at all events that it occurred before the +scene of being accompanied home. That these mild organic pains could +continue for some time without her paying much attention to them is +quite possible when we consider the nature of the disease. The obscurity +resulting from this, namely, that the analysis pointed to a conversion +of psychic excitement into bodily pain at a time when such pain was +certainly not perceived and not recalled—this problem I hope to be able +to solve in later considerations and by other examples.[18] + +With the discovery of the motive for the first conversion we began a +second more fruitful period of the treatment. In the first place very +soon afterward the patient surprised me with the statement that she now +knew why the pains always radiated from that definite location on the +right thigh and were most painful there. This is really the place upon +which her father’s leg rested every morning while she changed the +bandages of his badly swollen leg. That occurred hundreds of times, and +strange to say she did not think of this connection until today. She +thus gave me the desired explanation of the origin of an atypical +hysterogenic zone. Furthermore during our analysis her painful legs +always commenced to “join in the discussion.” I mean the following +remarkable state of affairs: The patient was as a rule free from pain +when we began our work, but as soon as I evoked some recollection by +question or by pressure of the head she at first reported some pain +usually of a very vivid nature, and then winced and placed her hand on +the painful area. This awakened pain remained constant as long as the +patient was controlled by the recollection, reaching its height when she +was about to utter the essential and critical part of her communication, +and disappearing with the last words of the statement. I gradually +learned to use this awakened pain as a compass. Whenever she was moody +or claimed to have pains I knew that she had not told me everything, and +urged a continuation of the confession until the pain was “spoken away.” +Then only did I awaken a new recollection. + +During this period of ab-reaction, the patient’s condition showed such a +striking improvement both somatically and psychically that I used to +remark half jokingly that during each treatment I carried away a certain +number of pain motives, and that when I had cleaned them all out she +would be well. She soon reached a stage during which she had no pain +much of the time; she consented to walk a great deal and to give up her +hitherto condition of isolation. During the analysis I followed up now +the spontaneous fluctuations of her condition and now some fragments of +her sorrowful tale which in my opinion I had not sufficiently exhausted. +In this work I made some interesting discoveries the principles of which +I could later verify in other patients. + +In the first place it was found that the spontaneous fluctuations never +occurred unless provoked associatively by the events of the day. On one +occasion she heard of an illness in the circle of her acquaintances +which recalled to her a detail in the illness of her father. On another +occasion the child of her deceased sister visited her and its +resemblance to its mother recalled many painful incidents. On still +another occasion it was a letter from her absent sister showing +distinctly the influence of the inconsiderate brother-in-law, and this +awakened a pain causing the reproduction of a family scene heretofore +not reported. + +As she never reproduced the same pain motives twice we were justified in +the expectation that the stock would in time become exhausted. I never +prevented her from merging into a situation tending to evoke new +memories which had not as yet come to the surface. Thus for example I +sent her to the grave of her sister, or I urged her to go in society +where she was apt to meet her youthful friend who happened to be in the +city. + +In this manner I obtained an insight into the mode of origin of a +hysteria which could be designated as monosymptomatic. I found, for +example, that the right leg became painful during our hypnosis when we +dealt with memories relating to the nursing of her father, to her young +friend, and to other memories occurring during the first period of the +pathogenic term; while the pain in the left leg came on as soon as I +evoked the memory of her lost sister, of both brothers-in-law, in brief +of any impression relating to the second half of the history. My +attention having been called to that by this constant behavior I went +further in my investigations and gained the impression that perhaps +detailization went still further and that every new psychic cause of +painful feeling might have some connection with a differently located +painful area in the legs. The original painful location on the right +thigh referred to the nursing of her father, and as the result of new +traumas the painful area then grew by apposition so that strictly +speaking we had here not one single physical symptom connected with a +multiform psychic memory complex but a multiplicity of similar symptoms +which on superficial examination seemed to be fused into one. To be sure +I have not followed out the demarcations of the individual psychic +causes corresponding to the pain zones for I found that the patient’s +attention was turned away from these relations. + +Notwithstanding this I directed further interest to the mode of +construction of the whole symptom-complex of the abasia upon this +painful zone, and with this view in mind I asked such questions as this: +“What is the origin of the pains in walking and standing, or on lying?” +She answered these questions partially uninfluenced, partially under the +pressure of my hand. We thus obtained two results. In the first place +she grouped all scenes connected with painful impressions according to +their occurrence, sitting, standing, etc. Thus, for example, she stood +at the door when her father was brought home with his cardiac attack and +in her fright remained as though rooted to the spot. To this first +quotation “fright while standing” she connected more recollections up to +the overwhelming scene when she again stood as if pinned near the death +bed of her sister. The whole chain of reminiscences should justify the +connection of the pain with standing up, and could also serve as an +association proof, only one had to bear in mind the fact that in all +these occasions we must demonstrate another moment which had served to +direct the attention—and as a further result the conversion—just on the +standing, walking, sitting, etc. The explanation for this direction of +attention could hardly be sought in other connections than in the fact +that walking, standing, and lying are connected with capabilities and +conditions of those members which here bore the painful zones; namely, +the legs. We could then easily understand the connection between the +astasia-abasia and the first scene of conversion in this history. + +Among the scenes which in consequence of this review had made the +walking painful one which referred to a walk she had taken in company, +at the watering place, which apparently lasted too long, stood out most +prominently. The deeper circumstances of this occurrence revealed +themselves only hesitatingly and left many a riddle unsolved. She was in +an especially good humor and gladly joined the circle of friendly +persons; it was a lovely day, not too warm, her mother remained at home; +her older sister had already departed, the younger one felt indisposed +but did not wish to mar her pleasure. The husband of the second sister +at first declared that he would remain at home with his wife, but +finally went along for her (Elisabeth’s) sake. This scene seemed to have +a great deal to do with the first appearance of the pains, for she +recalled that she returned home from the walk very fatigued and with +severe pains, she could not however say definitely whether she had +perceived the pains before this. I took for granted that if she had +suffered any pain she would have hardly resolved to enter upon this long +walk. On being questioned whence the pains originated on this walk she +answered rather indefinitely saying that the contrast between her +solitude and the married happiness of her sick sister, of which she was +constantly reminded by the behavior of her brother-in-law, was painful +to her. + +Another closely related scene played a part in the connection of the +pain with sitting. It was a few days later, her sister and +brother-in-law had already departed and she found herself in an +excitable longing mood. She arose in the morning and ascended a small +hill which they were wont to visit together and which afforded the only +pretty view. There she sat down on a stone bench giving free play to her +thoughts. Her thoughts again concerned her lonesomeness, the fate of her +family, and she now frankly admitted that she entertained the eager wish +to become as happy as her sister. After this morning’s meditation she +returned home with severe pains. In the evening of the same day she took +the bath, after which the pains definitely appeared and continued +persistently. + +We could further ascertain with great certainty that the pains on +walking and standing diminished in the beginning on lying down. Only +after hearing of her sister’s illness and on leaving Gastein in the +evening, spending a sleepless night in the sleeping car, and being +tormented simultaneously by the worries concerning her sister and +violent pains, it was only then that the pains appeared for the first +time while she was lying down, and throughout that time lying down was +even more painful than walking or standing. + +Thus the painful sphere grew by apposition first because every new +pathogenically affecting theme occupied a new region of the legs, +second, every one of the impressionable scenes left a trace because it +produced a lasting, always more cumulative, “occupation” of the +different functions of the legs, thus connecting these functions with +the sensations of pain. There was unmistakably, however, still a third +mechanism which furthered the production of astasia-abasia. When the +patient finished the recitation of a whole series of events with the +plaint that she then perceived pain in “standing alone,” and when in +another series referring to the unfortunate attempt of bringing about +new conditions in the family she was not tired of repeating that the +painful in that was the feeling of her helplessness, the sensation that +she “could make no headway,” I had to admit that her reflections +influenced the formation of the abasia, and had to assume that she +directly sought a symbolic expression for her painfully accentuated +thoughts and had found it in the aggravation of her pains. That somatic +symptoms of hysteria could originate through such symbolization we have +already asserted in our Preliminary Communication, and in the epicrisis +to this history. I will give some examples of conclusive evidence. In +Miss Elisabeth v. R. the psychic mechanism of the symbolization was not +in the foreground, it had not produced the abasia, but everything +pointed to the fact that the already existing abasia had in this way +undergone a considerable reinforcement. Accordingly this abasia as I met +it in the stage of development was not only to be compared to a +psychically associative paralysis of function but also to a symbolic +paralysis of function. + +Before I continue with the history of my patient I will add something +about her behavior during the second period of the treatment. Throughout +this whole analysis I made use of the method of evoking pictures and +ideas by pressing the head, a method therefore, which would be +inapplicable without the full cooperation and voluntary attention of the +patient. At times it was really surprising how promptly and how +infallibly the individual scenes belonging to one theme succeeded each +other in chronological order. It was as if she read from a long picture +book the pages of which passed in review before her eyes. At other times +there seemed to be inhibitions, of what kind I could not at that time +surmise. When I exerted some pressure she maintained that nothing came +into her mind. I repeated the pressure and told her to wait, but still +nothing would come. At first when such obstinacy manifested itself I +determined to discontinue the work and to try again, as the day seemed +unpropitious. Two observations, however, caused me to change my +procedure. Firstly, because such failure of this method only occurred +when I found Elisabeth cheerful and free from pain and never when she +had a bad day; secondly, because she frequently made assertions of +seeing nothing after the lapse of a long pause during which her tense +and occupied mind betrayed to me some psychic process within. I +therefore decided to assume that the method had never failed, that under +the pressure of my hands Elisabeth had each time perceived some idea or +had seen some picture but that she was not always ready to inform me of +it and attempted to repress the thing evoked. I could think of two +motives for such concealment; either Elisabeth subjected the idea that +came to her mind to a criticism to which she was not entitled, thinking +it not sufficiently important and unfit as an answer to the question, or +she feared to say it because that statement was too disagreeable to her. +I therefore proceeded as if I were perfectly convinced of the +reliability of my technique. Whenever she asserted that nothing came +into her mind, I did not let that pass. I assured her that something +must have come to her but that perhaps she was not attentive enough, +that I was quite willing to repeat the pressure. I also told her not to +entertain any doubts concerning the correctness of the idea presenting +itself to her mind, that that was not any of her concern; that it was +her duty to remain perfectly objective and to tell whatever came into +her mind, be it suitable or not, and I ended by saying that I knew well +that something did come which she concealed from me and that as long as +she would continue to do so she would not get rid of her pains. After +such urging I found that there was really no pressure that remained +unsuccessful. I then had to assume that I correctly recognized the state +of affairs, and indeed I won through this analysis perfect confidence in +my technique. It often happened that only after the third pressure did +she make a statement then added “Why I could have told you that the +first time”—“Indeed why did you not say it”—“I thought that it was not +correct:” or “I thought that I could avoid it, but it recurred each +time.” During this difficult work I began to attach a profounder +significance to the resistance which the patient showed in the +reproduction of her recollections, and I carefully compared those +occasions in which it was especially striking. + +I now come to the description of the third period of our treatment. The +patient felt better, she was psychically unburdened and more capable, +but the pains were manifestly not removed, reappearing from time to time +with the old severity. The imperfect cure went hand in hand with the +imperfect analysis, as yet I did not know in what moment and through +what mechanisms the pains originated. During the reproduction of the +most manifold scenes of the second period and the observation of the +patient’s resistance towards the reproduction, I formed a definite +suspicion which I did not then dare to use as a basis for my action. An +accidental observation turned the issue. While working with the patient +one day I heard the steps of a man in the adjacent room and a rather +pleasant voice asking some questions. My patient immediately arose +requesting me to discontinue the treatment for the day because she heard +her brother-in-law who just arrived asking for her. Before this +disturbance she was free from pains, but thereafter she betrayed by her +mien and gait the sudden appearance of violent pains. This strengthened +my suspicion and I decided to elicit the decisive explanation. + +I questioned her concerning the circumstances and causes of the first +appearance of the pains. Her thoughts were directed to the summer resort +in that watering place where she had been before taking the journey to +Gastein. A number of scenes were reproduced which had already been +treated less exhaustively. They recalled her frame of mind at that time, +the exhaustion following the worriment about her mother’s vision and the +nursing of her mother during the time of the operation and her final +despair at being unable as a lonesome girl to enjoy life or to +accomplish anything in life. Until then she felt strong enough to +dispense with the help of a man, but now she was controlled by a feeling +of her womanly weakness, a yearning for love in which, to put it in her +own words, “her obdurate self began to soften.” In such humor the happy +marriage of her younger sister made the profoundest impression on her. +She thought how affectionately he cared for her, how they understood +each other with a mere glance, and how sure they seemed to be of each +other. It was truly regrettable that the second pregnancy followed so +quickly the first and her sister knew that this was the cause of her +suffering but how willingly she endured it and all because he was the +cause of it. The brother-in-law did not at first wish to participate in +the walk which was so intimately connected with Elisabeth’s pain; he +preferred to remain home with his sick wife, but the latter urged him +with a glance to go because she thought that would give Elisabeth +pleasure. Elisabeth remained with him throughout the whole walk; they +spoke about the most varied and intimate things; she found herself in +thorough accord with all he said, and she became overwhelmed with the +desire to possess a man like him. This was followed by a scene a few +days later, when, on the morning after their departure, she visited the +point commanding the beautiful view which had been their favorite walk. +There she seated herself upon a stone and again dreamed of her sister’s +happiness and of a man like her brother-in-law who could engage her +affections. When she arose she had pains which again disappeared, and +only in the afternoon after having taken the warm bath did they +reappear, remaining ever since. I attempted to investigate the thoughts +which occupied her mind while taking the bath, but all I could obtain +was that the bath house recalled her absent sister because she had lived +in the same house. + +For some time the state of affairs was clear to me. Absorbed in +painfully sweet recollections she was wholly unconscious of the drift of +her thoughts and continued to reproduce her reminiscences, the time in +Gastein, the worry connected with the expectations of the letter, +finally the information of her sister’s illness, the long wait until the +evening when she could first leave Gastein, the journey with its +tormenting uncertainties during a sleepless night—all these moments were +accompanied by a violent aggravation of the pain. I asked her if during +the journey she thought of the sad possibility which she afterward found +realized. She answered that she carefully avoided the thought but that +in her opinion her mother expected the worst from the very beginning. +This was followed by the reminiscences of her arrival in Vienna—the +impressions which she received from the relatives at the station, the +short journey from Vienna to the neighboring summer resort where her +sister lived, the arrival in the evening, the hasty walk through the +garden to the door of the little garden pavilion—a silence in the house, +the oppressive darkness, the fact of not having been received by the +brother-in-law. She then recalled standing before the bed seeing the +deceased, and in the moment of the awful certainty that the beloved +sister had died without having taken leave of them and without having +her last days eased through their nursing—in that very moment another +thought flashed through Elisabeth’s brain which now peremptorily +repeated itself. The thought which flashed like dazzling lightning +through the darkness was, “Now he is free again, and I can become his +wife.” + +Of course, now everything was clear. The analyzer’s effort was richly +repaid. The ideas of the “defense” (abwehr) against an unbearable +presentation, the origin of hysterical symptoms through conversion of +psychic into physical excitement, the formation of a separate psychic +group by an arbitrary act, leading to the defense—all these were in that +moment palpably presented before my eyes. Thus and thus alone did things +happen here. This girl entertained an affectionate regard for her +brother-in-law against the acceptance of which into her consciousness +her whole moral being struggled. She succeeded in sparing herself the +painful consciousness that she was in love with her sister’s husband by +creating for herself instead bodily pains, and in the moment when this +certainty wished to thrust itself into her consciousness (while she +walked with him, during that morning reverie, in the bath, and before +her sister’s bed) her pains originated by means of a successful +conversion into the somatic. When she came under my care there was +already a complete isolation from her consciousness of the presentation +group referring to this love, else, I believe that she would never have +agreed to such a treatment. The resistance which she repeatedly brought +forth during the reproduction of traumatically produced scenes really +corresponded to the energy with which the unbearable presentation had +been crowded out from the association. + +For the therapeutist there now came a sorry time. The effect of the +resumption of that repressed presentation was a crushing one for the +poor child. When I summed up the whole situation with these prosaic +words: “you were really for a long time in love with your +brother-in-law,” she complained of the most horrible pains at that +moment; she made another despairing effort to reject the explanation, +saying that it was not true, that I suggested it to her, it could not +be, she was incapable of such baseness, and that she would never forgive +herself for it. It was quite easy to prove to her that her own +information allowed no other interpretation, but it took a long time +before the two reasons that I offered for consolation, namely, that one +is not responsible for one’s feelings and that her behavior, her +sickness under those circumstances was sufficient proof of her moral +nature—I say it took a long time before these consolations made an +impression on her. I was now forced to pursue more than one course in +order to calm the patient. In the first place I wished to give her the +opportunity to rid herself by ab-reaction of the material long since +accumulated. We investigated the first impressions of the relations with +her brother-in-law, the beginning of those unconsciously kept +affectionate regards. We found here all those little indications and +forebodings which on a retrospective view showed a fully developed +passion. On his first visit to the house he mistook her for his destined +bride and greeted her before he greeted her older and homely sister. One +evening they entertained each other so vivaciously and seemed to +understand each other so well that the bride interrupted them with this +half serious remark: “You two, indeed, would have suited each other very +nicely.” On another occasion while in a gathering who were ignorant of +the engagement the conversation drifted to the young man, and a young +lady indiscreetly remarked about a blemish in his shape, a juvenile +joint affliction. The bride herself remained calm while Elisabeth flew +into a passion, and with an ardor which even she herself could not +afterward understand she defended the straight form of her future +brother-in-law. While we worked our way through these reminiscences it +became clear to Elisabeth that her affection for her brother-in-law had +slumbered in her for a long time, perhaps since the beginning of their +relations, and had concealed itself so long under the mask of a mere +kinsmanlike affection as only her very delicate family feeling would +allow. + +This ab-reaction benefited her much but I was able to give her still +more relief by taking a friendly interest in her present state of +affairs. With this object in view I sought an interview with Mrs. v. R. +whom I found to be an intelligent and refined lady whose courage to face +life, however, was somewhat lessened through the last misfortune. From +her I learned that the accusation of rude extortion which the older +brother-in-law had brought against the widower, and which was so painful +to Elisabeth, had to be retracted on closer investigation. The character +of the young man remained untarnished, it was merely a misunderstanding, +an easily conceived difference of opinion concerning the valuation of +money that could arise between the merchant, to whom money is only a +working tool, and the official—that is all there was to this seemingly +so painful incident. I begged the mother to give Elisabeth all +explanations that she might hereafter need, and to offer her in the +future that opportunity for unburdening her mind to which I had +accustomed her. + +Naturally I was also anxious to know what chance there was for the +fulfilment of the girl’s present conscious wish. Here things were less +favorable! The mother stated that for some time she had had an inkling +of Elisabeth’s affection for her brother-in-law, of course she did not +know that it existed during the lifetime of her sister. Whoever saw them +both in friendly intercourse—of late, to be sure, only seldom—could +entertain no doubt of the girl’s anxiety to please him. However, neither +she, her mother, nor the advisers of the family showed any particular +inclination to bring about a matrimonial union between the two. The +health of the young man had not been very good and had received a +setback through the death of his beloved wife, and it was not at all +certain that he had sufficiently recovered from the shock to enter into +a new matrimony. It was quite probable that this was the reason for his +reserve, perhaps also because he was not sure of his position, and +wished to avoid all obvious gossip. With such a reserve on both sides +the solution for which Elisabeth was yearning was likely to fail. + +I informed the girl of everything that I had heard from her mother and +had the satisfaction of seeing her benefited by the explanation +concerning the money affair. On the other hand, I expected her to bear +calmly the uncertainties of her future which could not be set aside. The +advancing summer compelled us to bring the treatment to an end. She now +felt better, and since we had discussed the causes to which the pain +could be traced she no longer complained of pain. We both felt that the +work was done, although I thought that the ab-reaction of the suppressed +love was really not as complete as it should have been. I regarded her +as cured and urged her to continue independently the solution after the +way had been cleared, to which she agreed. She left with her mother for +a summer resort where they were to join the older sister and her family. + +I still have something more to report about the further course of Miss +Elisabeth v. R.’s disease. A few weeks after our parting I received a +despairing letter from her mother informing me that at the first attempt +to draw Elisabeth into a conversation about her love affairs she became +very excited and refused to talk, and since then had suffered from +violent pains. She was very indignant at my having betrayed her +confidence and was perfectly inaccessible so that the treatment seemed a +complete failure. She wished to know what was to be done, for of me she +would hear nothing. I made no reply. It was to be expected that after +she was relieved from my discipline she would make another attempt to +reject her mother’s interference and return to her inaccessibility. I +was, however, quite certain that everything would adjust itself and that +my efforts had not been in vain. Two months later they returned to +Vienna and the colleague to whom I was grateful for the case informed me +that Elisabeth was perfectly well, and that her behavior was normal +although occasionally she had slight pains. Since then she has +repeatedly sent me similar messages, each time promising to visit me, +which she has never done. This is quite characteristic of the personal +relationship formed during such treatment. My colleague then assured me +that she could be considered cured. The relation of the brother-in-law +to the family underwent no change. + +In the spring of 1894 I was informed that she would be present at a +private ball to which I could gain access. I did not let the opportunity +escape me and saw my former patient gliding along in a rapid dance. +Since then, following her own inclination, she has married a stranger. + + + EPICRISIS. + +I was not always a psychotherapist but like other neuropathologists I +was educated to the use of focal diagnosis and electrical prognosis so +that even I myself am struck by the fact that the histories of the +diseases which I write read like novels and, as it were, dispense with +the serious features of the scientific character. Yet I must console +myself with the fact that the nature of the subject is apparently more +responsible for this issue than my own predilection. Focal diagnosis and +electrical reactions are really not important in the study of hysteria, +whereas a detailed discussion of the psychic processes, as one is wont +to receive it from the poet, and the application of a few psychological +formulæ, allows one to gain an insight into the course of events of +hysteria. Such histories should be considered like psychiatrical ones, +but they have the advantage over the latter in the fact that they give +the intimate connection between the history of the disease and the +morbid symptoms, a thing for which we still look in vain in the +biographies of other psychoses. + +With the description of the treatment I endeavored to interweave the +explanations which I gave about the case of Miss Elisabeth v. R. and it +will perhaps be superfluous to summarize here the essential features. I +have discussed the character of the patient and the features which +repeat themselves in so many hysterics, and which we really can not +consider as degenerative. I mentioned the talent, the ambition, the +moral sensitiveness, the immense yearning for love which found its +gratification in the family, the independence of her nature reaching +beyond the womanly ideal which manifested itself largely by obstinacy, +readiness for fight, and inaccessibility. According to the information +of my colleague no hereditary taints could be shown on either side of +the family. Her mother, to be sure, suffered for years from some +indefinite neurotic depression, but her brothers and sisters, her father +and his family belonged to the even-tempered and not to the nervous. +There was no serious case of neuropsychosis in the nearest relatives. + +This nature was acted upon by painful emotions, the foremost of which +was the debilitating influence of a long attendance upon her beloved +sick father. + +That nursing of the sick plays such a significant rôle in the histories +of hysterias has its good reasons. A number of effective moments which +are found here are quite obvious, namely, the disturbance of the +physical health through interrupted sleep, neglect of nourishment, and +the reaction of a constantly gnawing worriment on the vegetative +functions; but the most important factor, however, is, in my estimation, +to be found elsewhere. He whose mind is occupied with the hundred +different tasks of nursing which succeed each other continuously for +weeks and months, becomes accustomed, on the one hand, to suppress all +signs of his own emotions, and on the other, his attention is soon +turned away from his own impressions because he has neither the time nor +strength to do them justice. Thus the nurse accumulates for himself an +over abundance of affective impressions which he barely perceived +clearly enough, at any rate they were not weakened by ab-reaction, that +is, he creates for himself the material for a retention hysteria. If the +patient recovers these impressions naturally become reduced in value, +but if he dies and the period of mourning comes during which only that +which refers to the deceased seems of value, the impressions waiting for +discharge appear in turn, and after a brief pause of exhaustion the +hysteria, the germ of which originated during the nursing, bursts forth. + +The same subsequent discharge of traumas accumulated during nursing is +occasionally encountered where the general impression of the disease +does not ensue, and yet the mechanism of hysteria can be noticed. Thus, +I know a highly gifted but slightly nervous lady whose whole personality +suggests the hysteric though she never became a burden to the doctor and +was never obliged to interrupt the exercise of her duties. This lady had +nursed three or four of her beloved ones until their death, causing her +each time complete physical exhaustion, yet these sad duties never made +her ill. However, shortly after the death of the patient she began the +work of reproduction, bringing again to her view the scenes of the +disease and death. Each day—one might say at her leisure—she went over +again every impression, crying and consoling herself. Such adjustment +she passed through daily in conjunction with her usual duties, without, +however confusing the two activities. Everything passed before her +chronologically. Whether the memory work of one day precisely +corresponded to a day of the past I am unable to say. I presume that it +depended on the leisure which was allowed to her by the current affairs +of the household. + +Aside from this “subsequent tear” which attached itself to these deaths +at short intervals, this lady periodically observed annual anniversaries +representing the time of the various catastrophes, and here her vivid +visual reproduction and her affective manifestations followed faithfully +the date. Thus, for example, I found her in tears, and on sympathetic +inquiry as to what occurred that day, she half irritably remarked, +“Nothing on that day except that Professor N. was again here and gave us +to understand that things were hopeless—at that time I had no time to +cry.” She referred to the last illness of her husband who died three +years before. It would have been very interesting to know whether she +always repeated the same scenes on these recurring anniversaries, or +whether as I suppose in the interest of my theory other details +presented themselves each time for ab-reaction. I was however, unable to +find anything definite about that; the wise and courageous woman was +ashamed of the intensity with which those reminiscences acted upon +her.[19] + +I again repeat that this woman was not sick, that subsequent +ab-reaction, despite all resemblance, is still not a hysterical process; +one may ask why, after one nursing there results a hysteria and after +another none. It cannot lie in personal predisposition for the lady that +I have in mind showed it very remarkably. + +I now return to Miss Elisabeth v. R. While nursing her father there +occurred for the first time an hysterical symptom in the form of a pain +in a definite location on the right thigh. The mechanism of this symptom +is fully explained on an analytical basis. It occurred in a moment +during which the ideas of her duties towards her sick father came into +conflict with the content of her erotic yearning which she then +entertained. Under vivid self reproach she decided in favor of the +former and created for herself the hysterical pain. According to the +conception explained by the theory of conversion in hysteria, the +process could be described as follows: She repressed the erotic idea +from her consciousness and changed the sum of the affect into somatic +sensations of pain. Whether this first conflict occurred only once, or +repeated itself is not clear. The latter is more probable. Quite a +similar conflict—of a higher moral significance, and even better +demonstrated by the analysis—repeated itself after years and led to the +aggravation of the same pain and to its dissemination beyond its +original limits. Again, it was an erotic idea which came into conflict +with all her moral conceptions, for her affection for her +brother-in-law, both during the life and after the death of her sister, +and the thought that she should yearn just for this man, was to her very +disagreeable. This analysis gives detailed information about this +conflict which represents the pivotal point in the history of her +malady. The patient’s affection for her brother-in-law might have begun +to germinate long ago, but in favor of its development was the physical +exhaustion through the recent nursing, and her moral exhaustion through +years of disillusionment which then began to break down her reserve and +she confessed to herself the need of the love of a man. During a +friendly intercourse continuing for weeks (in the summer resort) this +erotic inclination reached its full development simultaneously with the +pain. The analysis shows a special psychic condition of the patient at +that time, which in connection with her inclination and the pain, seems +to afford an understanding of the process in the sense of the conversion +theory. + +I place reliance on the opinion that the patient’s affection for her +brother-in-law, intensive as it was, was not clearly known to her except +on certain rare occasions and then only momentarily. If that were not so +she would have become conscious of the inconsistency between this +fondness and her moral ideas and would have had to endure the same +mental agony which I saw her suffer after the analysis. Her +reminiscences gave us no information concerning such suffering. These +she spared herself and as a result the love itself did not become clear +to her. At that time, as well as during the analysis, her love for her +brother-in-law existed in the form of a foreign body in her +consciousness without entering into any relationship with her other +ideation. In reference to this love there existed the peculiar condition +of knowing and simultaneously not knowing, it was the condition of the +split off psychic group. When we assert that this love was not “clearly +known” to her we mean exactly what we say. We do not mean a lower +quality or a lesser degree of consciousness, but a separation of the +free associative thinking process from the rest of ideation. + +How does it come about that such an intensively accentuated presentation +group should be kept so isolated? As a rule the rôle played by an idea +in the association really increases with the sum of its affect. + +This question can be answered if we bear in mind two facts which we can +make use of as a safeguard: (1) That the hysterical pains originated +simultaneously with the formation of these separate psychic groups, (2) +that the patient exerted great resistance against the attempt to bring +about the association between the separate psychic groups and the rest +of the content of consciousness, and when the union was finally effected +she perceived excessive psychic pain. Our conception of hysteria brings +together these two moments with the fact of the splitting of +consciousness, for (2) contains the indication for the motive for the +splitting of consciousness while (1) shows the mechanism of the same. +The motive was that of defense, it was the striving of the whole ego to +agree with this presentation group and the mechanism was that of +conversion, that is, instead of psychic pains which she spared herself +there appeared physical pains. Thus a transformation occurred through +which gain the patient had escaped an unbearable psychic state, though +it was at the cost of a psychic anomaly in the form of a splitting of +consciousness and a physical suffering, pains, upon which an +astasia-abasia was constructed. + +To be sure I can give no instruction as to how one can bring about such +a conversion. It is not apparently done as one intentionally does an +arbitrary action, it is a process which is executed in the individual +under the impulse of the motive of defense if an adaptation for it +exists in his organization or is brought about by temporary +modification. + +One has the right to attack the theory more closely by asking what it is +that is transformed into physical pains. The cautious reply will be +something out of which psychic pains could have and should have been +formed. If we wish to venture further and attempt a kind of algebraic +formulation of the presentation mechanism we may attribute to the +presentation complex of this unconsciously remaining love a certain +amount of affect and designate the latter quantity as the thing +converted. Direct deduction of this conception would be the fact that +the “unconscious love” has through such conversion forfeited so much of +its intensity that it was reduced to a weak idea. Its existence as a +separate psychic group would only be made possible through such +weakening. Yet this present case is not suitable to afford us any +clearness in this delicate matter. It probably corresponds to an +imperfect conversion only. From other cases it seems quite probable that +perfect conversions also occur and that in these the unbearable idea +actually becomes repressed as only an idea of very little intensity +could be repressed. After an associative union has been consummated the +patients assure us that since the origin of the hysterical symptoms +their unbearable thoughts never occupied their minds. + +I have stated above that on certain occasions, though only transitorily, +the patient consciously recognized the love for her brother-in-law. Such +a moment occurred when for example, at the death bed of her sister the +thought flashed through her mind, “Now he is free and I can become his +wife.” I must discuss the significance of these moments for the +conception of the whole neurosis. However, I think that the assumption +of a defense hysteria (abwehr hysterie) includes the requisite that at +least one such moment has already occurred. For consciousness does not +know in advance when such an unbearable idea will present itself. The +unbearable idea which with its appendix is later excluded for the +formation of a separate psychic group must have been originally in the +mind, otherwise no conflict would have resulted leading to its +exclusion.[20] Just such moments should be designated as “traumatic.” It +is in them that the conversion takes place which results in the +splitting of consciousness and the hysterical symptoms. Everything tends +to show that in Miss Elisabeth v. R. there were a number of such moments +(the scenes of the walking, morning meditation, bath, and at the bed of +her sister) and perhaps new moments of this kind occurred during the +treatment. The multiplicity of such traumatic moments is made possible +by the fact that an experience similar to the one which at first +initiated the unbearable idea, introduces new emotions to the separated +psychic groups and thus transitorily abolishes the success of the +conversion. The ego is forced to occupy itself with this suddenly +enforced and lighted-up idea, and then to restore the former state by +means of new conversions. Miss Elisabeth who was in constant relation +with her brother-in-law must have been particularly exposed to the +appearance of new traumas. + +I must now occupy myself with the point which I have designated as a +difficulty for the understanding of the afore mentioned history. On the +analytical basis I assume that the first conversion took place in the +patient while she nursed her father, at the time when her duties as +nurse came into conflict with her erotic yearnings, and that this +process was the prototype for the later ones which led to the outbreak +of the disease in the Alpine watering place. But then we have it from +the patient’s statement that at the time of nursing and the period +following which I designated as the “first period” she had not suffered +at all from the pains and weakness. To be sure, during the illness of +her father she was once bedridden for a few days with pains in her legs, +but it is doubtful whether this attack already belonged to the hysteria. +A causal relation between these first pains and any psychic impressions +could not be demonstrated by analysis; it is possible, even probable, +that at that time we dealt with a common rheumatic muscular pain. Even +if we should assume that this first attack of pain was the result of a +hysterical conversion in consequence of the rejection of the erotic +thoughts then existing, the fact nevertheless remains that the pains +disappeared after a few days so that the patient actually behaved +differently than she did during the analysis. During the reproduction of +the so called first period all her statements concerning the illness and +death of her father, the impressions relating to her first +brother-in-law, etc., all these were accompanied by manifestations of +pain, while at the time she really experienced these impressions she +perceived no pains. Is this not a contradiction tending to considerably +diminish the confidence in the explanatory value of such an analysis? + +I believe that I can explain the contradiction by assuming that the +pains—the product of the conversion—did not originate while the patient +experienced the impressions during the first period, but subsequently, +that is in the second period when the patient reproduced these +impressions in her mind. The conversion did not follow the fresh +impressions but the memories of them. I even believe that such a process +is not at all unusual in hysteria and regularly participates in creating +hysterical symptoms. Nevertheless, as such an assertion does not seem +plausible I shall attempt to make it more credible by citing other +experiences. + +It once happened to me during a similar analysis that a new hysterical +symptom was formed during the treatment so that I could attempt its +removal on the day after its origin. + +I will describe the essential features of the history of this patient. +They are simple but not without interest. + +Miss Rosalia H., twenty-three years old, who for a number of years made +great effort to educate herself as a singer, complained that her +beautiful voice did not obey her in certain notes. There appeared +choking and tightening sensations in the throat so that the tones +sounded strained, and her teacher could therefore not allow her to +appear in public. Although this imperfection affected only her middle +notes it could not be explained to be due to a defect of her vocal +organs, for at times this disturbance was absent and her teacher was +very pleased with her, but at other times the slightest excitement, +seemingly without any provocation, evoked the choking sensation, and +prevented free expansion of the voice. It was not difficult to recognize +in this annoying sensation an hysterical conversion. Whether there +really appeared a contracture of certain muscles of the vocal chords I +have not verified.[21] In the hypnotic analysis which I undertook with +this girl I found out the following concerning her vicissitudes and her +ailments occasioned through them. She became an orphan at an early age +and was brought up at the house of an aunt who had many children of her +own, and she thus shared the life of a most unfortunate family. The +husband of this aunt, seemingly a pathological personality, abused his +wife and children in the most brutal manner and especially pained her by +his sexual preference for the servant girl in the house. This became +even more obnoxious as the children grew older. When the aunt died +Rosalia became the protectress of the orphaned children who were +harassed by their father. She took her duties seriously, fought through +all conflicts and had to exert her greatest efforts to suppress the +manifestations of her contempt for her uncle. It was then that the +choking sensation in her throat originated. Whenever she was compelled +to swallow an affront, whenever she had to remain silent on hearing a +provoking accusation she perceived a scratching in her throat, the +tightening and failure of her voice, in brief she had all the localized +sensations in her larynx and pharynx which now disturbed her in singing. +It was conceivable that she sought the possibility of making herself +independent in order to escape the excitement and painful impressions +which were daily occurrences in her uncle’s house. An efficient music +teacher took an unselfish interest in her, assuring her that her voice +entitled her to choose the profession of singing. She began secretly to +take lessons of him and because she often went for her lessons with the +choking sensation in her throat following some violent scene in the +house, a connection was formed between the singing and the hysterical +paresthesia for which a way was prepared by the sensitiveness of the +organ during singing. The apparatus of which she should have had free +control was filled with the remnants of innervation after those numerous +scenes of repressed excitement. Since then she has left the house of her +uncle, having moved to another city so as to be away from the family, +but her ailments were not benefited by it. No other hysterical symptoms +were discovered in this pretty and unusually bright girl. + +I endeavored to cure this “retention hysteria” by a reproduction of all +the exciting impressions and by subsequent ab-reaction. I afforded her +the opportunity of railing against her uncle in long speeches and of +telling him the bare truth to his face, etc. The treatment benefited +her, but unfortunately she lived here under quite unfavorable +conditions. She had no luck with her relatives. She was the guest of +another uncle who treated her with friendliness, but just for that +reason she incurred the displeasure of her aunt. The latter believed +that her husband evinced too marked an interest in his niece and made it +a point of opposing the girl’s stay in Vienna. She herself in her youth +was obliged to relinquish a desire of becoming an artist and was now +jealous of her niece because she had the opportunity to develop her +talent not considering that it was not mere desire but a wish to become +independent which led her niece to take this step. Rosalia felt so +uncomfortable in the house that she for instance, did not dare to sing +or play the piano when her aunt was within hearing distance, and +carefully avoided either singing or playing anything for her aged +uncle—brother of her mother—whenever her aunt was home. While I was +endeavoring to efface the traces of the old excitements, new ones +originated through these relations with her host and finally interfered +with the success of my treatment and prematurely interrupted the cure. + +One day the patient came to me with a new symptom hardly twenty-four +hours old. She complained of a disagreeable prickling sensation in the +fingertips which had manifested itself every few hours since the day +before and forced her to make very peculiar jerky movements with the +fingers. I could not see the attack, otherwise I would have guessed its +meaning on seeing the finger movements but I immediately endeavored to +trace through hypnotic analysis the causation of this symptom (it was +really a minor hysterical attack). As the whole thing only existed for a +short time I hoped to be able to explain it and quickly remove it. To my +surprise without any hesitation she reproduced in chronological order a +whole row of scenes beginning in her early childhood. All these had +perhaps the same characteristics in the fact that she had suffered an +injustice without defense, something which could make her fingers jerk, +for example, scenes like the one of being forced to hold out her hand in +school while her teacher struck it with a ruler. But they were all banal +causes the right of which to enter into the etiology of an hysterical +symptom I have already opposed. It was different, however, with one +scene of her early girlhood which was connected with the others. The bad +uncle who suffered from rheumatism asked her to massage his back. She +did not dare refuse him. He was in bed while she was doing it and +suddenly threw off the covers, jumped up, attempting to get hold of her +and throw her down. Naturally she stopped the massage and in a moment +escaped and locked herself within her own room. She evidently did not +like to recall this experience and could not say whether she had seen +anything when the man suddenly exposed himself. The sensations of the +fingers could be explained as due to the suppressed impulse to punish +him, or it might simply have originated from the fact that she was at +that time massaging him. Only after this scene did she begin to talk +about the one experienced yesterday after which the sensitiveness and +jerkiness of the fingers appeared as a recurring memory symbol. The +uncle with whom she now lived begged her to play something for him. She +sat at the piano and accompanied herself singing, believing that her +aunt was out. Suddenly she appeared in the doorway, Rosalie jumped up, +closed the piano, and flung away the sheet of music. We can guess what +memories came to her mind, and the train of thought which she tried to +ward off at that moment, for the exasperation brought on by the unjust +accusation should have really urged her to leave the house, but on +account of her illness she was forced to remain in Vienna and had no +other shelter. The movement of the fingers which I saw during the +reproduction of this scene resembled a continuous jerking as if one +literally and figuratively would reject something like throwing away a +sheet of music or rejecting an unreasonable demand. + +She was quite positive in her assurance that she did not perceive the +symptom before, that it was not caused by the scenes previously related. +Was there anything else to be assumed except that the scene experienced +yesterday had in the first place awakened the recollection of a former +similar content and that then the formation of a memory symbol for the +whole group of recollections took place? The conversion was on the one +hand furnished with newly experienced affects, on the other with +recollected affects. + +When we consider this state of affairs we must admit that in the origin +of hysterical symptoms such a process is the rule rather than the +exception. Whenever I seek for the determinants of such states I +frequently find not a single but a group of similar traumatic motives. +In some cases it could be ascertained that this particular symptom had +already existed for a short time after the first trauma and then +subsided, but reappeared after the next trauma and become fixed. Yet no +real distinction can be made between the temporary appearance and the +latency after the first motives. In a large majority of cases it was +also found that the first traumas had left no symptoms, while a later +trauma of the same kind produced a symptom for the origin of which the +cooperation of the former motives could not be dispensed with and for +the solution of which it really required a consideration of all the +motives. Translating this into the language of the conversion theory we +will say that this undeniable fact of the summation of the traumas and +the erstwhile latency of the symptoms simply means that the conversion +can be brought about from a fresh as well as from a remembered affect, +and this assumption fully explains the contradiction which seems to +exist in the history and analysis of Miss Elisabeth v. R. + +There is no question that normal persons carry in their consciousness in +considerable numbers the continuation of ideas with unadjusted affects. +The theory which I just asserted merely approximates the behavior of +hysteria to the normal. It is apparently reduced to a quantitative +moment; it is simply a question of how many such affective strains an +organization can endure. Even a hysterical person will be able to retain +a certain amount in an unadjusted state, but if through a summation of +similar motives it increases beyond the individual’s endurance, the +impetus for conversion is formed. It is therefore no singular theory but +almost a postulate to say that the formation of hysterical symptoms may +also be brought about at the cost of recollected affects. + +I have now occupied myself with the motive and mechanism of this case of +hysteria, it still remains to discuss the determination of the +hysterical symptoms. Why should just the pains in the legs be selected +to represent the psychic pains? The circumstances of the case point to +the fact that this somatic pain was not created by the neurosis but was +merely utilized, aggravated, and retained by it. I will add that in most +of the cases of hysterical algias into which I have been able to gain an +insight the conditions were similar, that is, there was to begin with +always a real organically founded pain. It is always the most common, +the most widespread pains of humanity that seem to be most frequently +called upon to play a part in hysteria. Among the most common are the +periosteal and neuralgic pains of the teeth, headaches which originate +from so many different sources, and not in a lesser degree the so often +mistaken rheumatic pains of the muscles. The first attack of pain which +Miss Elisabeth v. R. had while she nursed her father, I consider to have +been organically determined, for I received no information when I +investigated for its psychic motive, and I admit that I am inclined to +attribute differential diagnostic significance to my methods of evoking +hidden memories if they are carefully applied. This original rheumatic +pain[22] became in the patient the memory symbol for her painful psychic +emotions, and as far as I can see, for more than one reason. First and +principally because it existed in consciousness almost simultaneously +with the other excitements, and second because it was or could be +connected in many ways with the ideation of that time. At all events it +was perhaps a remote consequence of the nursing, of her want of +exercise, and the poor nutrition entailed by her duties as nurse. But +this hardly became clear to the patient and what is more important is +the fact that she had to perceive it during significant moments of the +nursing, as for example, when she jumped out of bed in the cold room to +respond to her father’s call. Even more decisive for the direction taken +by the conversion must have been the other manner of associative +connection, namely, the fact that for many days one of her painful legs +came in contact with the swollen leg of her father during the changing +of bandages. The location on the right leg distinguished by this contact +remained henceforth the focus and starting point of the pains, an +artificial hysterogenic zone the origin of which can be plainly seen in +this case. + +If any one should be surprised at the associative connection between +physical pain and psychic affect, thinking it to be too manifold and +artificial, I should answer that such surprise is just as unfair as to +be surprised over the fact “that just the richest in the world possess +most money.” Where prolific connections do not exist there is naturally +no formation of hysterical symptoms, and conversion does not find its +way. I can also state that in reference to determinations the case of +Miss Elisabeth v. R. belongs to the simpler ones. In the case of Mrs. +Cäcilie M.[23] particularly, I had to solve the most intricate knots of +this kind. + +I have already discussed in the history of the case how the +astasia-abasia of our patient was built up on those pains after the +conversion had taken definite direction. But there, too, I have +expressed the opinion that the patient has created or aggravated the +disturbance of function through symbolization. For her dependence and +helplessness to change anything in the circumstances she found a somatic +expression in the astasia-abasia, and the expressions “to make no +headway,” “to have no support,” etc., formed the bridge for this new act +of conversion. I will endeavor to support this conception by other +examples. + +Conversion on the basis of coincidence in otherwise existing associative +connections seems to exert the slightest claims on the hysterical +predisposition; on the other hand conversion through symbolization seems +to require a higher grade of hysterical modification, a fact also +demonstrated in Miss Elisabeth in the later stages of her hysteria. The +prettiest examples of symbolization I have observed in Mrs. Cäcilie +M.,[24] whom I can call my most difficult and most instructive case. I +have already mentioned that this history does not unfortunately lend +itself to detailed reproduction. + +Among other things Mrs. Cäcilie also suffered from a most violent facial +neuralgia which appeared suddenly two or three times during the year and +persisted for from five to ten days, resisting every remedy, and ceased +as if cut off. It limited itself to the second and third branches of the +trigeminus, and as there was undoubtedly an excess of urates in the +urine, and as a not very “clear acute rheumatism” played a certain part +in the patient’s history it was reasonable to assume that we dealt with +a gouty neuralgia. This opinion was also shared by the consulting +physicians who saw every attack. The neuralgia was treated with the +methods in vogue, such as electric pencilling, alkaline waters and +purgatives, but it always remained uninfluenced until it was convenient +to make room for another symptom. In former years—the neuralgia was +fifteen years old—the teeth were accused of preserving it and were +condemned to extraction, and one fine morning under narcosis the +execution of seven of the culprits took place. That did not run so +smoothly as the teeth were so firm that most of the roots were left +behind. This cruel operation was followed by neither temporary nor +permanent relief. At that time the neuralgia raged for months. Even +while under my care whenever she had neuralgia the dentist was called +and he always declared he found diseased roots. He commenced to get +ready for such work but usually he was soon interrupted, for the +neuralgia suddenly ceased and with it the desire for the dentist. During +the intervals the teeth did not ache at all. One day just while another +attack was raging I put the patient into a hypnotic condition and placed +an energetic interdiction on the pains, and from that moment they +ceased. I then began to doubt the genuineness of this neuralgia. + +About a year after this hypnotic remedial success the condition of Mrs. +Cäcilie M. took a new and surprising turn. There suddenly appeared other +states than those that had been characteristic of the last years, but +after some reflection the patient declared that all these conditions had +existed in her before and were really scattered over the long period of +her disease (thirty years). Indeed a surprising abundance of hysterical +incidents were unrolled which the patient was able to localize correctly +in the past and soon the frequently very entangled thought connections +which determined the sequence of these incidents became recognizable. It +was like a series of pictures with an explanatory text. Pitres, on +describing his délire ecmnésique must have had in mind a similar case. +The way such a hysterical condition belonging to the past was reproduced +was most remarkable. In the first place while the patient was in the +best of condition there appeared a pathological mood of special coloring +which was regularly mistaken by the patient and was referred to a banal +occurrence of the last hours. This increasing obnubilation of +consciousness was followed by hysterical symptoms, such as +hallucinations, pains, convulsions, and long declamations, and finally +an event of the past attached itself to this hallucinatory manifestation +which could explain the initial mood and determine the occasional +symptoms. With this last part of the attack lucidity returned, the +ailments disappeared as if by magic and good health again existed—until +the next attack which was half a day later. Usually I was called at the +height of this condition. I produced hypnosis, evoked a reproduction of +the traumatic events, and by artificial aid I curtailed the attack. +Having gone through with the patient many hundreds of such cycles, I +obtained the most instructive explanations concerning the determinants +of hysterical symptoms. The joint observation with Breuer of this +remarkable case was also the chief motive for the publication of our +“Preliminary Communication.” + +In this connection it finally came to the reproduction of the facial +neuralgia which I myself had still treated as actual attacks. I was +desirous of knowing whether we would find here a psychic causation. When +I attempted to evoke the traumatic scene, the patient soon imagined +herself in a period during which she felt marked psychic sensitiveness +against her husband. She related a conversation with him and a remark +that he made which aggravated her very much. She then suddenly grasped +her cheek, crying aloud with pain, and said, “That was like a slap in +the face”—with this both the attack and the pain came to an end. There +is no doubt that here, too, we dealt with a symbolization. She had felt +as if she really received a slap in the face. Now everybody will ask how +the sensation of “a slap in the face” can lead to the manifestations of +a trigeminal neuralgia, to its limiting itself to the second and third +branch, and to its being aggravated on opening the mouth and mastication +(not by talking!). + +The following day the neuralgia reappeared, but this time it could be +solved by the reproduction of another scene the content of which equally +showed a supposed insult. This process continued for nine days; from the +result it seemed that for years, aggravations, especially through words, +produced new attacks of this facial neuralgia by way of symbolization. + +But finally we also succeeded in reproducing the first attack of the +neuralgia which occurred more than fifteen years before. Here there was +no symbolization but a conversion through coincidence. It was a painful +sight which recalled to her mind a reproach and this caused her to +repress another series of thoughts. We have here, then, a case of +conflict and defense, and the origin of the neuralgia in this moment +could not be explained if we do not wish to assume that she then +suffered from slight toothache or facial pains, a thing not improbable, +as she was then in the first months of pregnancy. + +The result of the explanation showed that this neuralgia became the mark +of a definite psychic excitement through the usual road of conversion +but that afterward it could be awakened through associative +reminiscences of thoughts and symbolic conversions. It was really the +same procedure as encountered in Miss Elisabeth v. R. + +I will now introduce another example which will illustrate the efficacy +of symbolization under other determinants. On one occasion Mrs. Cäcilie +M. was tormented by a violent pain in her right heel, experiencing +stinging sensations which made walking impossible. The analysis +conducted us to a time when the patient was in a foreign institution. +For eight days she lay in her room, and for the first time the house +physician was to take her to the dining room. The pain came on while the +patient took the physician’s arm on leaving the room. It disappeared +during the reproduction of this scene while she remarked that at that +time she feared lest she would not make the “proper impression” on this +strange society[25] (“rechte Auftreten”). + +This seems a striking, almost comical example for the origin of +hysterical symptoms through symbolization by means of an expression of +speech. But a closer investigation of the circumstances of that moment +will favor another conception. The patient at that time suffered from +pain in her feet on account of which she remained in bed, and we can +only assume that the fear which obsessed her on taking the first steps +produced from the simultaneously existing pains the one symbolically +appropriate symptom in the right heel so as to form it into a psychic +algia and to particularly fit it for long duration. + +Notwithstanding the fact that the mechanism of symbolization in these +examples seems to be crowded to second rank, that which certainly +corresponds to the rule, I have still other examples at my disposal +which seem to demonstrate the origin of hysterical symptoms through +symbolization only. One of the best is the following example which again +refers to Mrs. Cäcilie M. At the age of fifteen she once lay in bed +watched by her austere grandmother. The girl suddenly cried out +complaining of having perceived a pain in the forehead between the eyes +which thereafter continued for weeks. On analyzing this pain, which was +reproduced after almost thirty years, she stated that her grandmother +gazed at her so “piercingly” that it seemed as if her look penetrated +deeply into her brain. She was really afraid of being looked upon +suspiciously by this old lady. On reproducing this thought she burst +into loud laughter and the pain ceased. Here I find nothing other than +the mechanism of symbolization which in a way stands midway between the +mechanism of auto-suggestion and that of conversion. + +The study of Mrs. Cäcilie M. gave me the opportunity to gather a +collection of such symbolizations. A whole series of physical sensations +which were otherwise looked upon as organically determined were of a +psychic origin, or at least furnished with a psychic interpretation. A +certain number of her experiences were accompanied by a piercing +sensation in the region of the heart (“I felt a stitch in my heart”). +The piercing headache of hysteria was undoubtedly, in her case, to be +interpreted as thought pains (“something sticks in my head”), and it +disappeared each time when the problem in question was solved. The +sensation of the hysterical aura in the throat, when it manifested +itself during an aggravation, ran parallel with the thought, “I have to +swallow that.” There was a whole series of parallel running sensations +and ideas in which it was now the sensation evoking the idea as an +interpretation and now the idea which produced the sensation by +symbolization, and not seldom it remained obscure which was the primary +element of the two. + +In no other patient was I able to find such a prolific application of +symbolization. To be sure, Mrs. Cäcilie M. was a person of quite unusual +and of a special artistic temperament whose highly developed sense for +form manifested itself in very beautiful poems. I maintain, however, +that if a hysteria creates through symbolization a somatic sensation for +the emotionally accentuated presentation, it is due less to individual +and arbitrary things than one supposes. When during an offending +harangue she takes literally such phrases as “stitch in the heart” or +“slap in the face,” and perceives them as real occurrences she practices +no facetious misuse but only revives the sensations to which this phrase +thanks its existence. For how does it happen that in speaking of an +aggrieved person we use such expressions as “he experienced a ‘stitch in +his heart,’” if the mortification was not actually accompanied by a +precordial sensation that could be so interpreted and recognized? Is it +not probable that the phrase “to swallow something” applied to an +unreturned insult really originates from the sensation of innervation +appearing in the pharynx when one forces back his speech thus preventing +a reaction to the insult? All these sensations and innervations belong +to the “expression of the emotions,” which as Darwin taught us, +originally consisted of sensible and expedient actions; at present most +of them may be so weakened that their expression in speech seems to us +like a figurative transformation, but very probably all this was once +meant literally, and hysteria is justified in reconstructing the +original literal sense for its stronger innervation. Indeed, perhaps it +is improper to say that it creates such sensations through +symbolization, perhaps it has not taken the usage of speech as a model, +but both originated from a common source.[26] + + + + + CHAPTER IV. + THE PSYCHOTHERAPY OF HYSTERIA. + + +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. + +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 ab-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 the 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 to +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 hysteria. 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 hysteria, 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 of 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 relapse 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 normal +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 noticed 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 in 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 obtain all +the physical improvements which we expect from the latter, and such +marked psychic improvement as never occurs in the rest cure without +psychotherapy. + + + II. + +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 ordered 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 resistance 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 only 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 shown 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. All 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 question 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; I 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 I 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, in 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 yourself? 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 without 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, and 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. To 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 was 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 been 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. + + + III. + +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 signs, 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. The 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 +cathartic 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 a 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 stratified 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. + +I 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 following 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. + +After 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 one 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 strata 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 his 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 characteristic 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 +critical 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. + +Usually 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 +associations 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 conjecture +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. This 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 associative 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 case 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. + + +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. + +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 +primary 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 in 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 +obsessions, 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 sleep-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. + + + II + +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. + +I 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 prove 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. The 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 +desire 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. To 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. + + + III. + +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 day 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 forms 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). + + +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 mechanism 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. + + + I. CLINICAL SYMPTOMATOLOGY OF ANXIETY NEUROSIS. + +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 it 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 varies 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 +transitory 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 same +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. + +The 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 attention 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. + + + II. THE OCCURRENCE AND ETIOLOGY OF ANXIETY NEUROSIS. + +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. + +Where 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 thereafter. 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 regardless 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 that 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 is 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 under 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 manifestly 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. + + + III. ADDENDA TO THE THEORY OF ANXIETY NEUROSIS. + +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 +affliction 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. + +I 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, acts 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 to 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. + + + IV. THE RELATIONS TO OTHER NEUROSES. + +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 secretly +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 be 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. + + +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. + + + I. THE “SPECIFIC” ETIOLOGY OF HYSTERIA. + +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. An 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 them 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, habits 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 in 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. + + + II. THE ESSENCE AND MECHANISM OF COMPULSION NEUROSIS. + +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. + +The 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 formed 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 itself 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. Or 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 +belief, 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. + + + III. ANALYSIS OF A CASE OF CHRONIC PARANOIA. + +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. + +Mrs. 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 was 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, and 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 further +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 to 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, “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 thoughts +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 and 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 we 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] + + + _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 and +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, but 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 +suggestive 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 the 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 that 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: + +1. 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. + +You 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 with 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 of 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 but 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] + + +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 +equivocal. 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 traumas 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 view, 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 moments. 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 the +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 as 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 of 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] + + +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 of 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, and 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 paranoiacs +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. + +5. 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. + +I 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 suited 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. + +----- + +Footnote 1: + + Studien über Hysterie von Jos. Breuer und Sigm. Freud. Leipzig und + Wien, Franz Deuticke, 1895. 2nd ed., 1909. + +Footnote 2: + + Sammlung kleiner Schriften zur Neurosenlehre, Vols. I. and II. Leipzig + und Wien, Deuticke, 1906, and 1909. + +Footnote 3: + + Bleuler, Freudsche Mechanismen in der Symptomatologie der Psychosen, + Psychiatrisch-Neurolog. Wochenschrift, 1906, Nrs. 35 and 36. + +Footnote 4: + + Jung, The Psychology of Dementia Præcox, Nervous and Mental Disease + Monograph Series, Nr. 3. + +Footnote 5: + + Riklin, Psychiatrisch-Neurolog. Wochenschrift, 1905, Nr. 46. + +Footnote 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. + +Footnote 7: + + Freud, Deuticke, 1909. + +Footnote 8: + + Freud, Karger, 1907. + +Footnote 9: + + Freud, Deuticke, 1905. + +Footnote 10: + + Written in collaboration with Dr. Joseph Breuer. + +Footnote 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. + +Footnote 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. + +Footnote 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. + +Footnote 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. + +Footnote 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. + +Footnote 16: + + It will be shown that, notwithstanding, I erred. + +Footnote 17: + + Die Abwehr-Neuropsychosen, Neurologisches Centralblatt, 1 June, 1894. + +Footnote 18: + + I can neither exclude nor prove that this pain, especially of the + thighs, was of a neurasthenic nature. + +Footnote 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. + +Footnote 20: + + It is different in a hypnoid-hysteria. Here the content of the + separate psychic groups may never have been in the ego consciousness. + +Footnote 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. + +Footnote 22: + + But perhaps spinal neurasthenic? + +Footnote 23: + + See Studien über Hysterie, p. 57, footnote. + +Footnote 24: + + l. c. + +Footnote 25: + + The literal translation of Auftreten is to press down by treading. + +Footnote 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!” + +Footnote 27: + + E. Hecker, Centralblatt für Nervenheilkunde, Dec., 1893. + +Footnote 28: + + See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und + Wien, 1895, p. 15. + +Footnote 29: + + See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und + Wien, 1895, p. 106. + +Footnote 30: + + See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und + Wien, 1895, p. 15. + +Footnote 31: + + As mentioned in the preface the author has long since discarded this + pressure procedure.—Translator’s note. + +Footnote 32: + + See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und + Wien, 1895, p. 85. + +Footnote 33: + + l. c., p. 15. + +Footnote 34: + + See Breuer und Freud, Studien über Hysterie. Deuticke, Wien und + Leipzig, 1895, p. 28. + +Footnote 35: + + See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und + Wien, 1895, p. 55. + +Footnote 36: + + État mental des hystériques, Paris, 1893 and 1894. Quelques + définitions récentes de l’hystérie, Arch. de Neurol., 1893, XXXV-VI. + +Footnote 37: + + Oppenheim: Hysteria is an exaggerated expression of emotion. But the + “expression of emotion” represents that amount of psychic excitement + which normally experiences conversion. + +Footnote 38: + + Strümpel: The disturbance of hysteria lies in the psycho-physical, + there where the physical and psychical are connected with each other. + +Footnote 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. + +Footnote 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. + +Footnote 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. + +Footnote 42: + + Die Abwehr-Neuropsychosen, Neurol. Centralbl., 1894, Nr. 10 u. 11. + +Footnote 43: + + Obsession et phobies, Révue neurologique, 1895. + +Footnote 44: + + Moebius, Neuropathologische Beiträge, 1894, 2. Heft. + +Footnote 45: + + Peyer, Die nervösen Affektionen des Darmes, Wiener Klinik, Jänner, + 1893. + +Footnote 46: + + Freud, Abwehr-Neuropsychosen. + +Footnote 47: + + Neurologisches Centralblatt, 1896, Nr. 10. + +Footnote 48: + + I myself surmise that the so frequently fabricated assaults of + hysterical persons are obsessional confabulations emanating from the + memory traces of infantile traumas. + +Footnote 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.” + +Footnote 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). + +Footnote 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. + +Footnote 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. + +Footnote 53: + + Lecture delivered before the Vienna Medic. Doktorenkollegium, on + December 12, 1904. + +Footnote 54: + + From Löwenfeld, “Sexualleben und Nervenleiden,” IV ed., 1906. + +Footnote 55: + + See Chapter VII, and Zur Aetiologie der Hysterie, Wiener, Klinische + Rundschau, 1896. + +Footnote 56: + + An English translation in preparation. + +Footnote 57: + + Zeitschrift für Sexualwissenschaft, herausgegeben von Hirschfeld, I, + 1908. + +Footnote 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. + +Footnote 59: + + H. Ellis similarly expresses himself, l. c., p. 185. + +Footnote 60: + + Compare Freud, Traumdeutung, 2d ed., p. 302. + +Footnote 61: + + Compare Freud, Three Contributions to the Sexual Theory, 1895. + +Footnote 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. + +Footnote 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.) + +Footnote 64: + + Three Contributions to the Sexual Theory. + +------------------------------------------------------------------------ + + + + + TRANSCRIBER’S NOTES + + + Page Changed from Changed to + + 10 the so called χατ’ εξοχὴν of the so called κατ’ ἐξοχὴν of + traumatic hysteria or of a traumatic hysteria or of a + series of series of + + 65 scenes like the one of being scenes like the one of being + forced to hold our her hand in forced to hold out her hand in + + 123 be identified with personel or be identified with personal or + hereditary “degeneration.” hereditary “degeneration.” + + ● Typos fixed; non-standard spelling and dialect retained. + ● Used numbers for footnotes, placing them all at the end of the last + chapter. + ● Enclosed italics font in _underscores_. + + + +*** END OF THE PROJECT GUTENBERG EBOOK 75132 *** |