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Title: Collected papers, Volume I
Author: Sigmund Freud
Leopold Löwenfeld
Editor: Ernest Jones
Translator: Joan Riviere
Release date: October 24, 2026 [eBook #79856]
Language: English
Original publication: New York: The International Psycho-Analytical Press, 1924
Other information and formats: www.gutenberg.org/ebooks/79856
Credits: Stephen M. Kraus at readfreud.org/ (This file was produced from images generously made available by The Internet Archive)
*** START OF THE PROJECT GUTENBERG EBOOK COLLECTED PAPERS, VOLUME I ***
THE INTERNATIONAL
PSYCHO-ANALYTICAL
LIBRARY
EDITED BY ERNEST JONES
No. 7
------------------------------------------------------------------------
THE INTERNATIONAL PSYCHO-ANALYTICAL LIBRARY
No. 7.
COLLECTED PAPERS
VOL. I
BY
SIGM. FREUD, M.D., LL.D.
*
AUTHORIZED TRANSLATION
UNDER THE SUPERVISION OF
JOAN RIVIERE
THE INTERNATIONAL PSYCHO-ANALYTICAL PRESS
NEW YORK LONDON VIENNA
M C M X X I V
------------------------------------------------------------------------
COPYRIGHT 1924
------------------------------------------------------------------------
CONTENTS OF VOLUME I
PAGE
EDITORIAL PREFACE . . . . . . . . . . . . . . 3
EARLY PAPERS
I Charcot (1893) . . . . . . . . . . . . 9
II On the psychical mechanism of hysterical pheno-
mena (1893) . . . . . . . . . . . . . 24
III Some points in a comparative study of organic
and hysterical paralysis (1893) . . . . . . 42
IV The defence neuro-psychoses (1894) . . . . . 59
V The justification for detaching from neurasthenia
a particular syndrome: The anxiety-neurosis (1894) 76
VI A reply to criticisms on the anxiety-neurosis (1895) 107
VII Obsessions and phobias; their psychical mechanisms
and their ætiology (1895) . . . . . . . . 128
VIII Heredity and the ætiology of the neuroses (1896) 138
IX Further remarks on the defence neuro-psychoses
(1896) . . . . . . . . . . . . . . . 155
X The ætiology of hysteria (1896) . . . . . . 183
XI Sexuality in the ætiology of the neuroses (1898) 220
XII On psychotherapy (1904) . . . . . . . . . 249
XIII Freud's psycho-analytic method (1904) . . . . 264
XIV My views on the part played by sexuality in the
ætiology of the neuroses (1905) . . . . . . 272
*
ON THE HISTORY OF THE PSYCHO-ANALYTIC
MOVEMENT (1914) . . . . . . . . . . . . . 287
------------------------------------------------------------------------
EDITORIAL PREFACE {3}
To write a preface is often a perfunctory matter, but in the preface
to this series of Collected Papers we wish to direct the reader's
special attention to two cardinal considerations.
In the first place it should be said that these Collected Papers, of
which the present is the first volume, constitute the real basis of
Psycho-Analysis. All Professor Freud's other work and theories are
essentially founded on the clinical investigations of which these
papers are the only published record. It is unfortunate that the
English-speaking public should for years have had access only to what
may be called the superstructure of his work, the application of his
psycho-analytic method to the study of dreams, sexuality, totemism,
and so on, while the basis of it all remained buried in a foreign
tongue. It is now proposed to fill this central lacuna in English
psycho-analytical literature by publishing, in four or more volumes, a
translation of the _Sammlung kleiner Schriften zur
Neurosenlehre_. Incidentally it may be said that the papers in this
series have been re-grouped, in co-operation with Professor Freud, so
that they do not follow the same order as that of the German original.
This brings us to the second consideration. If the reader wishes to
extract the greatest profit from these volumes, it is quite essential
that he should constantly bear in mind the _date_ when each Paper was
written. The only really satisfactory way of acquiring a knowledge of
Professor Freud's writings is to follow the order of development of
his work. It is hardly possible otherwise to obtain a coherent picture
of the whole. To follow this development is not only a fascinating
study in itself, disclosing as it does a beautiful example of the way
in which ideas are gradually unfolded---and constantly extended and
modified---under the pressure of widening and deepening experience. It
also gives a conviction of the truly scientific nature of the author's
work, for the tentative "feeling forward" here revealed---now in one
direction, now in another, as occasion and opportunity present---is
the very antithesis of the promulgation of an _a priori_ philosophic
system such as has sometimes been ignorantly imputed to him. One
inflexible determination has always guided him, and that was the {4}
determination to keep ever in the closest contact with the actual
material daily brought before his observation, and not to be tempted
along side-tracks by speculations, however enticing these might
appear. His path lay through a jungle hitherto completely unexplored.
Rarely did his path follow a straight line for long: deviations,
détours, fresh departures were often necessary, and occasionally even
the retracing of his steps. No one will expect that in these
circumstances of exploring an unknown territory the pioneer's trail
would be orderly and regular in its progress, or that the path should
be everywhere beaten equally smooth; but that the progress has been a
real and inspiring one is attested by the host of workers now
following in his steps.
In his preface to the first volume of the _Sammlung kleiner Schriften_
Professor Freud writes:---"Whoever is familiar with the development of
human knowledge will hear without astonishment that I have passed
beyond some part of the views here presented and have learnt to modify
some others. Still I have been able to retain unchanged the greater
part, and do not really need to withdraw anything as completely
erroneous and quite worthless". He probably had in mind here
particularly the view that underwent most modification subsequently,
that concerning the importance of sexual traumas in infancy. Few
episodes in the history of scientific research provide a more dramatic
test of true genius than the occasion on which Professor Freud made
the devastating discovery that many of these traumas to which he had
been obliged to attach ætiological significance had never occurred
outside the imagination of the patients. The realization---so
modestly related in the last of the Early Papers (p. 276)---that an
imagined event could in certain psychological circumstances produce an
effect exactly equivalent to that of an actual event was one that only
an investigator gifted with a supreme feeling for psychology could
have achieved. Initial error led to a profound discovery. Most of
Professor Freud's alleged "inconsistencies" will be found to carry a
similar moral.
In the work of organizing the translations I have had the invaluable
assistance of Mrs. Riviere; they have also been carefully revised by
her as well as by myself. In this Frl. Anna Freud was very helpful,
and we wish to express our indebtedness to her.
------------------------------------------------------------------------
EARLY PAPERS {7}
------------------------------------------------------------------------
I {9}
CHARCOT[1]
(1893)
In the person of J. M. Charcot whom, after a life of happiness and fame,
a sudden death without suffering or illness took from us on the 16th of
August the young science of neurology has lost its most active promoter,
neurologists of all countries have been bereft of their teacher, and
France has lost prematurely one of its leading men. He was only
sixty-eight years of age; his bodily strength and mental vigour,
together with the hopes he so frankly expressed, seemed to promise him
that long life which has been granted to not a few of the thinkers of
this century. The imposing nine volumes of his _Œuvres Complètes_, in
which his pupils had collected his contributions to the science of
medicine and of neuropathology, the _Leçons du Mardi_, the yearly
reports of his clinic at the Salpêtrière, and other papers---all these
publications, though they will remain precious to his pupils and to
science, cannot take the place of the man who still had much to give and
to teach, whose personality and whose work no one ever approached
without learning from them.
He had a perfectly honest, human delight in his own great success and
used to speak freely about his early days and the road that he had
traversed. His scientific curiosity had been aroused early in life
when he was but a young house-physician by the abundance of material,
at that time utterly unintelligible, contained in the facts of {10}
neuropathology. At that period in his life, whenever he made the
rounds in the wards of the Salpêtrière (the asylum for women) with his
chief, when he saw all the wilderness of paralyses, tremors and spasms
for which no name or proper understanding existed forty years ago, he
would say, '_Faudrait y retourner et y rester_', and he kept his
word. As soon as he had become _médecin des hôpitaux_ (hospital
physician) his goal was to get into the Salpêtrière, into one of the
wards for nervous patients. Once there, he remained; instead of, as is
the privilege of French physicians, transferring in regular order from
hospital to hospital and from ward to ward, at the same time changing
his speciality.
Thus his first impression and the resolution to which it led
determined his whole future career. Having at his disposal a
considerable number of patients afflicted with chronic nervous disease
he was enabled to take full advantage of his peculiar talent. He was
not much given to cogitation, was not of the reflective type, but he
had an artistically gifted temperament---as he said himself, he was a
'_visuel_', a seer. He himself told us the following about his method
of working: he was accustomed to look again and again at things that
were incomprehensible to him, to deepen his impression of them day by
day, until suddenly understanding of them dawned upon him. Before his
mind's eye, order then came into the chaos apparently presented by the
constant repetition of the same symptoms; the new clinical pictures
which were characterized by the constant combination of certain
syndromes took shape; the complete and extreme cases, the 'types',
were then distinguishable with the aid of a specific kind of schematic
arrangement, and with these as a starting-point the eye could follow {11}
down the long line of the less significant cases, the '_formes
frustes_', showing some one or other peculiar feature of the type and
fading into the indefinite. He called this kind of mental work, in
which he had no equal, 'practising nosography' and he was proud of
it. He was heard to say that the greatest satisfaction man can
experience is to see something new, that is, to recognize it as new,
and he constantly returned with repeated observations to the subject
of the difficulties and the value of such 'seeing'. He wondered how it
happened that in the practice of medicine men could only see what they
had already been taught to see, he described how wonderful it was
suddenly to see new things---new diseases---although they were
probably as old as the human race; he said that he often had to admit
that he could now see many a thing which for thirty years in his wards
he had ignored. No physician will need to be reminded of the wealth of
new outlines which the science of neuropathology gained through his
efforts, and of the much greater keenness and accuracy in diagnosis
which was made possible by the aid of his observations. But to his
pupils, who made the rounds with him through the wards of the
Salpêtrière---that museum of clinical facts for the greater part named
and defined by him---he seemed a very Cuvier, as we see him in the
statue in front of the Jardin des Plantes, surrounded by the various
types of animal life which he had understood and described; or else he
reminded them of the myth of Adam, who must have experienced in its
most perfect form that intellectual delight so highly praised by
Charcot, when the Lord led before him the creatures of Paradise to be
named and grouped. {12}
Charcot never tired of defending the claims of the purely clinical task
of seeing and classifying phenomena, as against the encroaches of
theoretical medicine. One day a small group of foreign students brought
up in the ways of German orthodox physiology annoyed him by raising
objections to his clinical innovations. 'That cannot possibly be', one
of us interrupted him, 'that contradicts the theory of Young-Helmholtz.'
He did not reply, 'So much the worse for the theory, clinical facts rank
first', and so forth. But he did say---leaving us deeply impressed '_La
théorie, c'est bon, mais ça n'empêche pas d'exister_.'
For a long term of years Charcot held the chair of pathological
anatomy in Paris, carrying on as a side-issue his neuropathological
work and the lectures which rapidly made him famous abroad as well as
at home. It was fortunate, however, for neuropathology that the same
man could fulfil the functions of two incumbents; on the one hand he
created the clinical pictures by observations, and on the other he
proved that in the typical case as well as in the _forme fruste_ the
same anatomical changes were the foundation of the disease. It is
generally known how great the success of this anatomical-clinical
method was in the sphere of organic nervous disease, with tabes,
multiple sclerosis, amyotrophic lateral sclerosis, and so on. With
these chronic, not immediately fatal diseases, patient years of
waiting were often necessary before proof of the organic changes could
be established, and only in a hospital for incurables like the
Salpêtrière was it possible to keep and to watch the patients for such
long periods. As it happened, Charcot made his first discovery in this
field before he was in charge of a ward. During his student days
chance brought him into contact with a charwoman who suffered from a {13}
peculiar form of tremor and could not get work because of her
awkwardness. Charcot recognized her condition to be 'choreiform
paralysis', already described by Duchenne, of the origin of which,
however, nothing was known. In spite of her costing him a small
fortune in broken plates and platters, Charcot kept her for years in
his service and, when at last she died, could prove in the autopsy
that 'choreiform paralysis' was the clinical expression of multiple
cerebro-spinal sclerosis.
Pathological anatomy has to serve neuropathology in two ways: first,
to bring proof of morbid alterations, and secondly, to determine the
localization of these changes; we all know that in the last two
decades the second part of the task has aroused greater interest and
has been more actively advanced. In this field also Charcot
co-operated brilliantly, although the pioneer work was not done by
him; he followed to begin with the footsteps of our countryman Türck,
who is said to have lived and worked among us in comparative
obscurity. Later, after the two important discoveries which
inaugurated a new epoch in our knowledge of the 'localization of
nervous diseases'---namely, the stimulation tests of Hitzig-Fritsch
and Flechsig's work on the development of the spinal cord---his
lectures on localization were the best and most significant aid
towards co-ordinating the new theories with the clinical side and
making them available for clinical purposes. As regards the relation
of the muscular system to the motor area of the cerebrum, I should
like to remind the reader how long the specific mode and topography of
this connection was a matter of conjecture (common representation of
both extremities in the same areas, representation of the upper
extremity in the anterior, of the lower in the posterior central {14}
convolution: that is, vertical disposition), until at last continued
clinical investigations, with stimulation---as well as extirpation---
tests on human beings during surgical operations, decided the matter
in favour of Charcot's and Pitres' view, namely, that the middle third
of the central gyri mainly serves the representation of the arm, while
the upper third and the mesial portion serve the representation of the
leg; in other words, that the disposition in the motor areas is a
horizontal one.
It would not be possible to demonstrate Charcot's importance to the
science of neuropathology by enumerating particular achievements, for
during the last two decades there have been few questions of any
significance to the formulation and discussion of which the 'school of
the Salpêtrière' has not made contributions of signal importance. The
'school of the Salpêtrière' was, of course, Charcot himself; his
wealth of experience, his power of plastic description, his
transparent clearness of diction was easily recognizable in the papers
of every one of his pupils. Some members of this circle of young men
whom he gathered about him and made his partners in his work had
attained to consciousness of their own individuality, and won
celebrity on their own account, and one or other of them would now and
then advance an opinion that seemed to the master clever rather than
correct; this he would attack sarcastically enough in conversation and
in his lectures without, however, in any way injuring his affectionate
relation with the pupil. Charcot does indeed leave behind him a group
of pupils whose intellectual qualifications and whose work are pledges
that the practice of neuropathology in Paris will not readily descend
form the high level to which it was brought by him. {15}
In Vienna we have repeatedly found that an academic teacher of
intellectual importance is not also as a matter of course gifted with
that close personal influence on his students which expresses itself in
the formation of a numerous and important 'school'. If Charcot was more
favoured in this respect we must attribute it to his personal qualities
as a man, to the magic of his aspect and his voice, to the gracious
frankness of his manner after the first strangeness of a new relation
had worn off, to the readiness with which he placed everything at the
disposal of his pupils, and to his life-long loyalty to them. The hours
he spent in his wards were hours of fellowship and interchange of ideas
with his whole medical staff. He never shut himself off from them; the
youngest assistant had an opportunity of seeing him at work and might
interrupt him, and the same privilege was granted to the foreigners who
were never absent from his rounds in later years. Finally, his pupils
and assistants were regarded as part of his family in welcoming the
guests on the evenings when Madame Charcot---assisted by a highly gifted
daughter, not unlike her father---received a distinguished company in
her hospitable house.
In the year 1882 or 1883 the circumstances of Charcot's life and work
took on their final form. The idea had come to be generally realized
that the activity of this man was part of the national '_gloire_', to
be guarded all the more jealously since the unsuccessful war of
1870--1871. The government, headed by Charcot's old friend, Gambetta,
created for him a chair of neuropathology at the Faculty of Medicine,
which permitted him to give up his course in pathological anatomy,
and, in addition, founded for him a clinic with auxiliary scientific
departments at the Salpêtrière. '_Le service de M. Charcot_' now {16}
embraced (with the old wards of the chronic patients) several clinical
halls where men also were received, a large out-patient
department---the _consultation externe_---an histological laboratory,
a museum, an electro-therapeutic department, an eye-and-ear
department, and a special photographic studio. Each of these
institutions offered opportunities for attaching former assistants and
pupils permanently to the clinic in good positions. The
two-storey-high, weather-beaten buildings and the courts they enclosed
reminded the foreigner extraordinarily of our Allgemeines Krankenhaus
in Vienna, but the resemblance did not go very far. 'It is perhaps not
beautiful here', Charcot would say as he showed the visitor about his
domain, 'but you can find room for everything you want to do.'
Charcot stood at the zenith of his career when this abundance of
material for teaching and investigating was placed at his disposal. He
was an indefatigable worker, always the most industrious of the whole
group. His private practice, crowded with patients 'from Samarcand and
from the Antilles', could not divert him from his activities as a
teacher and investigator. This throng was assuredly not attracted
merely by the famous scientist, but as much or more by the great
physician, and by the sympathetic nature of the man, who always knew
how to give counsel, and could surmise and guess in those cases where
the present status of science did not permit him to know. He has often
been reproached on account of his therapeuty, which with its
multiplicity of prescriptions could not but offend a rationalistic
conscience: he simply continued the current and local methods
customary at that time and place, without deceiving himself much about
their effectiveness. Incidentally, he was not pessimistic in regard to {17}
therapeutic results and was ever willing to encourage at his clinic
experiments with new methods of treatment, which had but a short-lived
success, as others were quick to point out. As a teacher, Charcot was
positively fascinating; each of his lectures was a little masterpiece
in construction and composition, perfect in style, and so impressive
that the words spoken resounded in one's ears and the subject
demonstrated remained before one's eyes for the rest of the day. He
rarely made a demonstration with a single patient, but was accustomed
to present a whole group or a number of contrasting types which he
then compared with one another. In the hall in which he gave his
lectures hung a picture of the 'citizen' Pinel, causing the poor
insane of the Salpêtrière to be relieved of their chains; for after
having been the scene of so many horrors during the French Revolution,
the Salpêtrière had also witnessed this most humane innovation. Maître
Charcot himself made a strange impression during these lectures;
usually bubbling over with vivacity and cheerfulness, with witticisms
always on his lips, he would appear at such moments solemn and
serious, nay, even aged in his velvet cap; his voice seemed muffled,
and we almost understood how malicious strangers could accuse the
whole performance of theatricality. Those who expressed themselves in
this manner were probably accustomed to the lack of form in German
clinical lectures or else they forgot that Charcot, who gave only one
lecture a week, could prepare it carefully.
Charcot was very probably following a tradition of long standing with
this ceremonious lecture, in which everything was prepared and had to
happen as planned; nevertheless he felt the need of displaying his {18}
activity to his pupils in a less artificial setting. For this purpose
he made use of the out-patient department which he took charge of
personally in the so-called _Leçons du mardi_. There he examined
cases quite unknown to him, risked all the chance occurrences of an
interrogation, laid his authority aside and confessed at times that in
one case diagnosis was impossible, and that in another appearances had
deceived him. Never did he appear greater to his students than on
these occasions, when he thus did his best to lessen the distance
between teacher and pupils by giving them a complete and faithful
account of his own train of thought, by stating his doubts and
misgivings with the utmost frankness. The publication, at first in
French, now also in German of these improvised lectures of the years
1887 and 1888 has extended the circle of his admirers indefinitely;
nor has any other neuropathological work ever achieved greater success
among the medical public.
About the time that the clinic was instituted and the course in
pathological anatomy given up, there occurred a change in Charcot's
scientific interests to which we owe the best part of his work. He
explained that the theory of organic nervous diseases was for the
present fairly complete, and he began to turn his attention almost
exclusively to hysteria, thus suddenly focussing general attention on
this subject. This most enigmatic of all nervous diseases---no
workable point of view having yet been found from which physicians
could regard it---had just at this time come very much into discredit,
and this ill-repute related not only to the patients but was extended
to the physicians who treated this neurosis. The general opinion was
that anything may happen in hysteria; hysterics found no credit
whatsoever. First of all Charcot's work restored dignity to the
subject; gradually the sneering attitude, which the hysteric could {19}
reckon on meeting when she told her story, was given up; she was no
longer a malingerer, since Charcot had thrown the whole weight of his
authority on the side of the reality and objectivity of hysterical
phenomena. Charcot had repeated on a small scale the act of liberation
commemorated in the picture of Pinel which adorned the lecture hall of
the Salpêtrière. Now that the blind fear of being fooled by the poor
patient which had stood in the way of a serious study of the neurosis
was overcome, the question arose which mode of procedure would most
speedily lead to the solution of the problem. The wholly unprejudiced
observer might have found an opening in the following reflection: If I
find a person in a condition bearing all the marks of a painful
affect, crying, screaming, raving, I am led to surmise that a mental
process is going on in him of which these bodily phenomena are the
adequate expression. In such a case the normal person is capable of
telling us what is troubling him, but the hysteric would answer that
he did not know; and the problem at once arises: How comes it that the
hysteric is subject to an affect of the causes of which he claims to
know nothing? If we adhere to the conclusion that there must exist a
corresponding psychic process, and at the same time believe the
patient's assertion when he denies its existence, if we assemble all
the manifold signs which indicate that the patient nevertheless
behaves as though he knows the cause, if we search into the patient's
life and find therein a cause---a trauma---likely to create such an
affective expression---then indeed the solution is forced upon us that
the patient is in a peculiar mental condition in which his impressions
or memories are no longer all linked up one with the other, and in {20}
which it is possible for one memory to express its affect by means of
bodily phenomena without the other mental processes---the
ego---knowing about it or being able to interfere; and the
recollection of the well-known psychological difference between sleep
and the waking state might have lessened the strangeness of such an
hypothesis. Let no one object that the theory of dissociation of
consciousness as a solution of the enigma of hysteria is too
far-fetched to suggest itself to the untrained and unprejudiced
observer. In fact the Middle Ages had chosen this very solution, in
declaring possession by a demon to be the cause of hysterical
manifestations; all that would have been required was to replace the
religious terminology of those dark and superstitious times by the
scientific one of to-day.
Charcot did not choose this path in his explanation of hysteria,
though he drew plentifully from existing records of witchcraft trials
and of possession in order to show that the manifestations of neurosis
were the same then as they are now. He treated hysteria like any other
theme of neuropathology, gave the complete description of its
manifestations, showed that these had their own laws, and taught his
pupils to recognize the symptoms which make the diagnosis of hysteria
possible. He and his pupils occupied themselves in most careful tests
with the disturbances of sensibility caused by hysteria on the skin
and the deeper tissues, with the behaviour of the sense organs,
peculiarities of hysterical contractures and paralyses, trophic
disturbances and alterations of metabolism. The manifold forms of the
hysterical attack were described and a scheme drawn up which
represented the typical configuration of the attack of '_grande
hystérie_' in four stages, and permitted the correlation of the
commonly observed attacks of '_petite hystérie_' with the type. They {21}
also investigated the localization and frequency of the so-called
hysterogenic zones and their relation to the attacks, and so
on. Equipped with all this information about the manifestations of
hysteria it was possible to make a number of surprising discoveries;
it was found that hysteria was far commoner among men than had been
suspected, especially among working-men, and that certain conditions
which had been ascribed to alcoholic or lead poisoning were
hysterical. It was possible to include a large number of hitherto
unintelligible, unclassified affections under the head of hysteria,
and to distinguish the part played by hysteria in cases where the
neurosis was combined with other diseases, forming a complex clinical
picture. Most far-reaching in its influence was probably that research
work concerning the nervous diseases following upon traumas---the
traumatic neuroses---the conception of which is still under discussion
to-day; in all these affections Charcot successfully presented the
case for hysteria.
Since the latest extensions of the conception of hysteria had so
frequently led to a rejection of any ætiological diagnosis, the need
arose to investigate the ætiology of hysteria. Charcot laid down a
simple formula for this: heredity is the unique originating cause of
hysteria, which is therefore a form of degeneration, a member of the
'_famille névropathique_', all other ætiological factors playing the
part of precipitating causes, of '_agents provocateurs_'.
The building up of this great structure of doctrine was not, of
course, achieved without violent opposition. This was, however,
nothing but the barren objection of an older generation which disliked
making any change in its views. The younger group of
neuropathologists, in Germany as well, accepted Charcot's theories to
a greater or lesser extent. Charcot himself was quite convinced of {22}
the success of his teaching in regard to hysteria; if objections were
raised that the four stages of the attack, or that hysteria among men,
etc., were not observable outside France, he pointed out that he had
himself overlooked these things for a long time, and reasserted that
hysteria was the same everywhere and at all times. He disliked to hear
the French accused of being a far more nervous nation than other
peoples, and hysteria spoken of as their national foible; he was
delighted when a paper on a case of 'reflex epilepsy' in a German
grenadier could be diagnosed by him at a distance as one of hysteria.
At one point Charcot's work rose above the level of his general
treatment of hysteria and took a step which gives him for all time the
glory of being the first to elucidate hysteria. While he was occupied
with the study of hysterical paralyses appearing after traumas, the idea
occurred to him to reproduce by artificial means such paralyses as he
had previously carefully differentiated from organic disturbances; for
this purpose he took hysterical patients and placed them in a state of
somnambulism by hypnotism. He succeeded in producing a faultless
demonstration and proved thereby that these paralyses were the result of
specific ideas holding sway in the brain of the patient at moments of
special disposition. With this the mechanism of an hysterical phenomenon
was for the first time disclosed, and on this incomparably fine piece of
clinical research his own pupil Janet, and also Breuer and others, based
their theories of the neurosis which, while agreeing with the mediæval
view, replaces the 'demon' of priestly imagination by a psychological
formula.
Charcot's application of the phenomena of hypnosis to hysteria enabled
a very great advance to be made in this important sphere of hitherto {23}
neglected and despised facts, because the weight of his reputation put
an end once for all to doubts of the reality of hypnotic
manifestations. But this exclusively nosographic approach was not
suited to a purely psychological subject. Limiting the study of
hypnosis to hysterical patients, distinguishing between greater and
lesser hypnotism, establishing three stages of 'greater' hypnosis
distinguished by somatic signs---all these practices sank in the
estimation of contemporaries when Liébeault's pupil, Bernheim,
undertook the task of basing the theory of hypnotism on a broader
psychological foundation and of making suggestion the nucleus of
hypnosis. Only the opponents of hypnotism who content themselves with
hiding their own lack of experience behind some recognized authority
still cling to Charcot's pronouncements, and like to quote an
expression uttered in his last years denying that hypnosis has any
therapeutic efficacy whatever.
As for the ætiological theories which Charcot defended in his doctrine
of the '_famille névropathique_' and made the cornerstone of his whole
conception of nervous diseases, they too will probably soon need to be
probed into and corrected. So greatly did Charcot over-estimate heredity
as a cause that no loophole was left by which nervous disease could be
acquired; to syphilis he allotted only a modest place among the '_agents
provocateurs_'; nor did he, in ætiology or elsewhere, differentiate
sharply enough between the organic nervous affections and the neuroses.
The progress our science has made in additions to its knowledge will
inevitably diminish the value of much that Charcot has taught us, but
neither the passing of time nor the changing of ideas will diminish the
glory of the man whom we---in France and elsewhere---are mourning
to-day.
------------------------------------------------------------------------
II {24}
ON THE PSYCHICAL MECHANISM OF
HYSTERICAL PHENOMENA[2]
(In collaboration with Dr. Joseph Breuer, 1892)
I
Stimulated by a chance observation, we have for a number of years been
investigating the most varied types and symptoms of hysteria with
reference to the exciting cause, the event which evoked the phenomenon
in question for the first time, often many years before. In the great
majority of cases it is impossible to discover this starting-point by
straightforward interrogation of the patient, be it ever so thorough;
partly because it is often a matter of experiences which the patient
finds it disagreeable to discuss, but chiefly because he really does not
remember and has no idea of the causal connection between the exciting
occurrence and the pathological phenomenon. As a rule it is necessary to
hypnotise the patient and under hypnosis to arouse recollections
relating to the time when the symptom first appeared; one can then
succeed in revealing this connection in the clearest and most convincing
manner.
In a great number of cases this method of examination has yielded
results which appear to be valuable theoretically as well as
practically. From the theoretical point of view the results are
valuable because, for the pathology of hysteria, the accidental factor
is decisive to a far greater extent than is known or acknowledged. In {25}
regard to traumatic hysteria it is obviously the accident which has
evoked the syndrome; and when we learn from the utterances of patients
in hysterical attacks that they invariably hallucinate in every attack
a repetition of the original occurrence which evoked the first, the
causal connection then also becomes perfectly clear here. The question
is more obscure in the case of other phenomena.
Our experience has shown us, however, that the most varied symptoms,
usually regarded as spontaneous and, so to speak, idiopathic products of
hysteria, have just as strict a connection with the exciting trauma as
those mentioned above in which the relation of the two sets of facts to
one another is transparent. To exciting causes of this kind we have been
able to trace anæsthesias as well as neuralgias of the most varied kind,
often of many years duration, contractures and paralyses, hysterical
attacks and epileptoid convulsions which all observers had taken for
genuine epilepsy, _petit-mal_, symptoms of the nature of tics, chronic
vomiting and anorexia carried to the point of refusal of food, the most
varied disturbances of vision, constantly recurring visual
hallucinations---and the like. The disproportion between the many years
duration of an hysterical symptom and the single occurrence which evoked
it is similar to that which we are accustomed to see regularly in
traumatic neurosis; it was quite frequently in childhood that the events
occurred producing a more or less grave symptom which persisted from
that time onwards.
The connection is often so clear that it is quite evident how the
exciting event has happened to produce just this and no other
manifestation; the phenomenon is determined in a perfectly clear
manner by the cause; to take the most ordinary example, a painful {26}
affect, which was originally excited while eating but was suppressed,
produces nausea and vomiting, and this continues for months as
hysterical vomiting. A girl watching in harrowing anxiety at the
bedside of a sick person falls into a twilight state and has a
terrifying hallucination while her right arm which is hanging over the
back of the chair 'goes to sleep'; from this develops a paresis of
that arm with contracture and anæsthesia. She wants to pray but can
find no words; finally she succeeds in repeating an English prayer
which she learnt in childhood. Then later a severe and highly
complicated hysteria develops in which she can speak, write and
understand only English, while for a year and a half her mother-tongue
remains unintelligible to her.---A child who is very ill at last falls
asleep, and its mother tries her utmost to keep quiet and not to wake
it; but just in consequence of this resolution (hysterical
counterwill) she makes a clucking noise with her tongue. On another
occasion when she wishes to keep absolutely quiet this happens again,
and so a tic in the form of tongue-clicking develops which for a
number of years accompanies every excitement.---A highly intelligent
man assists while his brother's ankylosed hip is straightened under an
anæsthetic. At the instant when the joint gives way with a crack he
feels a violent pain in his own hip-joint which lasts for almost a
year; and so on.
In other cases the connection is not so simple; there exists only what
may be called a symbolic relation between the cause and the
pathological manifestation, such as normal people also fashion in
dreams; for example, a neuralgia links itself on to some mental
distress, or vomiting accompanies a feeling of moral disgust. We have
had under observation patients who habitually made extensive use of {27}
such symbolism. In yet other cases a determination of this kind is not
at the first glance clearly intelligible; to these belong precisely
the typical hysterical symptoms---hemianæsthesia, contraction of the
field of vision, epileptiform convulsions and the like. The exposition
of our theories concerning this group must be reserved for a more
detailed consideration of the subject.
Such observations seem to us to prove the pathogenic analogy between
ordinary hysteria and traumatic neurosis and to justify an extension
of the concept of traumatic hysteria. In traumatic neurosis the active
cause of illness is not the trifling bodily injury but the affect of
fright---the psychic trauma. Similarly, our investigations of many, if
not of the majority, of hysterical symptoms have revealed causes which
must be described as psychic traumas. Any experience which rouses the
distressing affects of fright, apprehension, shame, or psychical pain
can have this effect and it obviously depends on the sensitiveness of
the person concerned (as well as on a further condition which we will
refer to later) whether the experience acquires the importance of a
trauma. We not infrequently find in ordinary hysteria several partial
traumas instead of one grand trauma---a group of causes---which can
only achieve traumatic effectiveness by accumulation and which belong
together only in so far as they form parts of a whole painful
experience. In still other cases circumstances in themselves
apparently indifferent have attained an otherwise unexpected
importance as traumas, either on account of their conjunction with
really effective experiences or because they occurred at a moment of
special susceptibility. This importance they then retain henceforward. {28}
But the causal connection between the exciting psychical trauma and the
hysterical symptom is not of such a kind that the trauma (like an _agent
provocateur_) sets going a symptom which then becomes independent and
persists on its own account. On the contrary, we are of opinion that the
psychical trauma, or the memory of it, acts as a kind of foreign body
constituting an effective agent in the present even long after it first
penetrated; and we see the proof of this in a highly remarkable
phenomenon which also lends an important practical interest to these
results of our observations.
The discovery that we made, at first to our own great surprise, was
that when we had succeeded in bringing the exciting event to clear
recollection, and had also succeeded in arousing with it the
accompanying affect, and when the patient had related the occurrence
in as detailed a manner as possible and had expressed his feeling in
regard to it in words, the various hysterical symptoms disappeared at
once, never to return. Recollection without affect is nearly always
quite ineffective; the original psychical process must be repeated as
vividly as possible, brought into _statum nascendi_ and then 'talked
out'. In the case of excitation phenomena---contractures, neuralgias,
and hallucinations---the symptoms appear again during this repetition
in full intensity and then disappear for ever. Defects in functioning,
paralyses and anæsthesias disappear in the same way, the transitory
exacerbation not being of course perceptible in those cases.[3] {29}
One may be inclined to suspect that the explanation lies in
unintentional suggestion; the patient expects to be rid of his suffering
as a result of the treatment, and this expectation might be the
effective factor, not the 'talking out'. But this is not the fact; the
first observation of this kind was a highly complicated case of hysteria
having symptoms with distinct causes which were separately dispersed,
and was analysed on these lines in the year 1881, that is, in the
'pre-suggestion' era. It was made possible by spontaneous auto-hypnosis
on the part of the patient, and it occasioned the observer the greatest
surprise.
Inverting the phrase '_cessante causa cessat effectus_', we may well
conclude from these observations that the exciting experience continues
in some way to be effective even years after, not indirectly by means of
a chain of causes linking up with one another, but directly as the
actual exciting cause---just as, for instance, the recollection of
mental distress in full consciousness at some later period may stimulate
tears; we thus conclude that _hysterical patients suffer principally
from reminiscences_.[4]
II
It may at first appear strange that experiences long since past should
operate with such intensity, and that the memory of them should not {30}
succumb to the fate which we see overtaking all our memories; perhaps
these facts may become rather more comprehensible in the light of the
following considerations.
The fading of a memory or of its affect depends on several factors.
First and foremost it depends on whether an energetic reaction
(discharge of feeling) supervened on the affective experience or
not. By _reaction_ we here mean the whole range of voluntary and
involuntary reflexes, by which according to experience the affects are
habitually worked off---from weeping up to an actual act of
revenge. If this reaction occurs with sufficient intensity a great
part of the affect disappears; common speech bears witness to these
facts of every-day observation in the expressions 'to cry oneself
out', 'to storm oneself out (_sich austoben_)'. If the reaction is
suppressed the affect remains attached to the memory. An insult which
is returned, if only in words, is remembered differently from one
which had to be endured in silence. Common speech also recognizes
this difference in the psychical and bodily consequences, and most
characteristically designates silently endured suffering as a
_Kränkung_,[5] wound, injury, mortification. The reaction of an
injured person to the trauma has a really complete 'cathartic' effect
only if it takes the form of a fully adequate reaction, such as an act
of revenge. But man finds a surrogate for such an act in speech, by
the help of which the affect may be almost as effectually
'abreacted'. In other cases talking is itself sufficient as a reflex,
for example, complaining or relieving the burden of a secret (the
confessional!). If a reaction of this kind by word or deed, or in the {31}
mildest cases by tears, does not ensue, the memory of the occurrence
retains for a time its affective tone.
'Abreaction' is, however, not the only kind of solution at the disposal
of the normal psychical mechanism in a healthy person who has met with a
psychical trauma. Even if the memory is not abreacted it becomes merged
in the great complex of associations, and is then ranged alongside of
other experiences which perhaps contradict it; thus it undergoes
correction by means of other ideas. After an accident, for example, the
remembrance of the danger and the subsequent (weakened) reproduction of
the terror is accompanied by the memory of the sequel, of the rescue and
the consciousness of present security. The memory of an injury to the
feelings is corrected by an objective evaluation of the facts,
consideration of one's actual worth and the like, and thus the normal
man succeeds by means of associations in dissipating the accompanying
affect.
In addition to this there is also that general effacing of impressions,
that fading of recollection called 'forgetting', which tends more than
anything else to absorb ideas which have lost their affective tone.
Our observations have shown that those memories which give rise to
hysterical phenomena are retained with wonderful freshness and with
full affective tone for a long period. But we must mention as a
further striking fact, to be turned to account later, that these
recollections are not at the disposal of the patient in the way that
his more commonplace memories are. On the contrary, when the patient
is in his usual psychical condition these experiences are completely
absent from his memory or are present to it only in the most summary
manner. Only when patients are questioned under hypnosis do these {32}
memories recur with the undiminished vividness of recent events.
Thus for six months one of our patients under hypnosis reproduced with
hallucinatory vividness everything which had excited her on the
corresponding day of the previous year (during an acute hysteria); her
mother's diary, of which she knew nothing, attested the perfect accuracy
of the reproduction. Another patient lived through with hallucinatory
clearness---partly in hypnosis, partly in spontaneous attacks---all the
experiences of an hysterical psychosis which she had suffered from ten
years before, and in regard to which amnesia had been almost complete
until the moment of the re-emergence. Several ætiologically important
recollections dating back fifteen to twenty-five years were of
astonishing integrity, and intensity of feeling; on reproduction their
effect had the full force of new experiences.
As a reason for this we can only conjecture that these recollections
have met with an exceptional fate in reference to all the ordinary
processes of effacement discussed above, for we find that they relate to
traumas which have not been sufficiently abreacted; closer investigation
of the reasons which have prevented the operation of the latter then
shows us at least two groups of conditions under which reaction to the
trauma does not ensue.
In the first group we reckon those cases in which the patient has not
reacted to the psychical trauma because its nature excluded the
possibility of any such reaction, as in the case of the apparently
irretrievable loss of a loved person, or when social conditions made a
reaction impossible, or when the trauma concerned something which the
patient wished to forget and therefore deliberately repressed[6] and {33}
excluded from his conscious thoughts. Under hypnosis we discover
painful ideas of precisely this character underlying the hysterical
phenomena (e.g. in the hysterical deliria of saints and nuns, of
abstinent women and well-brought-up children).
The second group of conditions is not determined by the content of the
recollection, but by the mental condition of the patient at the moment
when the given experience occurred. That is to say, among the exciting
factors of hysterical symptoms we also discover under hypnosis ideas
which though not in themselves significant owe their preservation to the
circumstance that they happen to coincide with a seriously disabling
affect, for example, terror, or with a directly abnormal mental
condition, such as the half-hypnotic twilight state of day-dreaming,
auto-hypnosis, and the like. In these cases it is the nature of these
conditions which made a reaction to the experience impossible.
Naturally both determinants may and often do occur together. This
happens when a trauma effective enough in itself occurs during a state
of seriously disabling affect or of altered consciousness; but it seems
that in many persons an abnormal state of this kind is produced as the
result of a psychic trauma which then in its turn makes a reaction
impossible.
Both groups of determining conditions have this in common: that the
psychical traumas which are not resolved by reaction will also fail of
solution by means of associative absorption. In the first group the
patient's intention to do so causes him to forget the painful {34}
experiences and consequently to exclude them from association as far
as possible. In the second group the associative absorption does not
succeed because sufficient associative connection does not exist
between the normal state of consciousness and the pathological state
in which these ideas originally arose. We shall have immediate
occasion to go more closely into these conditions.
Thus it may be said that the ideas which have become pathogenic are
preserved with such freshness and affective force because the normal
process of absorption by abreaction and by reproduction in a state of
unrestrained association is denied them.
III
In describing the conditions which according to our experience are
decisive for the development of hysterical phenomena from psychical
traumas, we mentioned the abnormal states of consciousness in which
such pathological ideas arise; and we laid stress on the fact that the
recollection of the effective psychical trauma is not to be found in
the normal memory of the patient, but in his memory under
hypnosis. Indeed, the more we occupied ourselves with these phenomena
the more certain did our conviction become that that splitting of
consciousness, which is so striking in the well-known classical cases
of _double conscience_, exists in a rudimentary fashion in every
hysteria and that the tendency to this dissociation---and therewith to
the production of abnormal states of consciousness, which may be
included under the term '_hypnoid_'---is a fundamental manifestation
of this neurosis. This view is in agreement with those of Binet and
the two Janets; we have not had the opportunity, however, to confirm
their highly remarkable discoveries in reference to anæsthetic {35}
patients.
We should like therefore to supplement the often-quoted phrase 'hypnosis
is an artificial hysteria' with another---namely, 'the existence of
hypnoid states forms the foundation and condition of hysteria'. There is
one thing common to all these hypnoid states and to hypnosis, in spite
of all their differences---namely, that the ideas which emerge in them
are marked by great intensity of feeling but are cut off from
associative connection with the rest of the content of consciousness.
These hypnoid states are capable of association among themselves and the
ideas belonging to them may in this way attain different degrees of
psychical organization. Incidentally, however, the nature of these
states and the degree of their inaccessibility to the rest of conscious
processes would very probably vary in a fashion similar to that of
hypnosis, which ranges from light sleepiness to somnambulism, from
complete recollection to absolute amnesia.
If such hypnoid states exist before the manifest illness, they provide
a foothold upon which the affect establishes itself with its
pathogenic recollection and its subsequent somatic
manifestations. This situation corresponds to dispositional
hysteria. But our observations show that a severe trauma (such as that
in a traumatic neurosis) or a troublesome suppression (for instance,
of sexual affect) can effect a splitting of groups of ideas in people
previously free from it, and this would constitute the mechanism of
psychically acquired hysteria. Between the extremes of these two forms
we must recognize a series within which the readiness to dissociation
in the persons concerned and the volume of affect roused by the trauma
varies inversely. {36}
We have nothing new to say concerning the origin of dispositional
hypnoid states. They often develop, we believe, from the 'day-dreams' so
frequently met with also in healthy people, great opportunity for which
is provided, for instance, in the feminine occupation of needlework. The
question why the 'pathological associations' formed in such states are
so strong and why they influence somatic processes so much more strongly
than ideas habitually do is part of the problem of the operation of
hypnotic suggestion in general. Our experiences teach us nothing new on
this point; they do, however, illuminate the contradiction between the
statement 'hysteria is a psychosis' and the fact that one finds among
hysterics people with the clearest and most critical intellects, of
great strength of character and will-power. These characteristics in
such people are valid for their waking thoughts; in the hypnoid state
they become alienated from their conscious personalities as we all are
in dreams. But whereas our dream-psychoses do not influence our waking
existence the products of hypnoid states intrude as hysterical phenomena
into waking life.
IV
Almost the same conclusions that we have just formed concerning
hysterical symptoms of long duration may be repeated concerning
hysterical attacks. As is well known, we possess a schematic
description of the '_grande attaque_', worked out by Charcot,
according to which four phases may be recognized in a complete attack:
(1) the epileptoid, (2) that of violent movements, (3) that of
'_attitudes passionnelles_' (the hallucinatory phase), and (4) that of
the concluding delirium. According to Charcot, all the various forms
of an hysterical attack (which as a matter of fact are more frequently {37}
observed than the full _grande attaque_) are derived from a
shortening, lengthening, omission or isolation of these separate
phases.
Our attempt at explanation has to do with the third phase, the
_attitudes passionnelles_. When this is well-marked it will reveal
itself as an hallucinatory reproduction of a memory important for the
outbreak of the hysteria, i.e. the memory of the one grand trauma in
what is called _κατ' ἐξοχήν_ traumatic hysteria, or of a series of
inter-related partial traumas which lie at the root of ordinary
hysteria. The remaining alternative is that the attack will reproduce
those experiences which were raised to importance by happening to occur
at a time of special sensitivity to traumas.
But there are also attacks which seems to consist of nothing but motor
symptoms and in which the _phase passionnelle_ is lacking. If we can
succeed in establishing a _rapport_ with the patient during such
general clonic attacks, during tonic catalepsy, or during an _attaque
de sommeil_, or, better still, if we succeed in summoning up an attack
while the patient is under hypnosis, we find that these attacks too
are based on the memory of a psychic trauma or series of traumas which
usually finds expression in an hallucinatory phase. For instance, a
little girl has suffered for years from attacks of general convulsions
which might have been epilepsy and had in fact been taken for it. To
establish a differential diagnosis she was hypnotised and was promptly
seized by an attack. When asked: 'What do you see now?' she answered:
'The dog, the dog is coming!' Further enquiry revealed that the first
attack of the kind had appeared after she had been chased by a mad
dog. Therapeutic success later confirmed the diagnosis of a
psychogenic malady.---A clerk who had become hysterical in consequence {38}
of being assaulted by his superior suffered from attacks during which
he fell to the ground in a frenzy of rage, but without uttering a word
or betraying any signs of an hallucination. An attempt to produce the
attack under hypnosis proved successful, and the patient revealed that
he was again living through the situation in which his superior had
openly insulted him in the street and thrashed him with a stick. A few
days afterwards he returned complaining that the same attack had
occurred again, and this time he revealed under hypnosis that he had
been living through the situation which provoked the actual outbreak
of the disease, i.e. the trial in court where he failed to obtain
compensation for the injury.
The memories which come to the fore in hysterical attacks, or can be
wakened during them, correspond also in all other respects with the
exciting occurrences which we have found at the root of hysterical
symptoms of long duration. Like these, they relate to psychic traumas
which have remained unresolved by abreaction or by associative mental
operations; and like these, they---or at least their essential
constituents---are absent from the store of memories of which normal
consciousness is made up; they belong to the ideational content of
hypnoid states of consciousness with their narrow fields of association.
Finally, they also admit of the therapeutic test. Our observations have
often demonstrated that a memory of this kind which had hitherto
provoked such attacks lost this power as soon as it was brought during
hypnosis to a reaction or to associative readjustment.
The motor phenomena of hysterical attacks are to be explained partly
as a general mode of reaction to the affect which accompanies the
memory, and may be compared, for example, with the beating movements {39}
of all the limbs which even an infant makes use of for this purpose;
and partly as signifying direct emotional expressions of this memory;
although they also elude this explanation to some extent as do the
hysterical stigmata in chronic symptoms.
There is yet another aspect of the hysterical attack which reveals
itself in the light of the theory we have just indicated: that in
hysteria there are present ideational groups (arising in hypnoid
states) which, cut off from associative relations with the remainder
but associable _inter se_, establish a more or less highly organized
nucleus of a second consciousness, a _condition seconde_. An
hysterical symptom of long duration then corresponds to an intrusion
of this _condition seconde_ into the somatic innervations usually
controlled by normal consciousness; an hysterical attack, however,
gives evidence of a higher organization of this _condition seconde_
and, when of recent origin, signifies the moment at which this hypnoid
consciousness takes possession of the subject's whole personality
(i.e. an acute hysteria); but recurring attacks which contain a memory
signify a recurrence of this moment. Charcot has already suggested
that the hysterical attack is probably the nucleus of a _condition
seconde_. During the attack, control of the entire somatic innervation
has passed to the hypnoid consciousness. Experience shows that in
these cases normal consciousness is not always completely superseded;
it may even perceive the motor phenomena of the attack while the
psychic processes of the latter escape its notice.
The typical course of a severe hysteria is, as is well known, that
first an ideational content is formed in hypnoid states, which then,
when sufficiently developed, takes possession during a period of
'acute hysteria' of the somatic innervation and personality of the {40}
patient, creates chronic symptoms and attacks, and then recedes until
mere vestiges of it are left. If therefore the normal personality can
regain control, what remains of the hypnoid ideational contents then
returns in hysterical attacks and again temporarily produces in the
patient similar states, which are again susceptible themselves and
predisposing to the influence of traumas. A sort of equilibrium
between the psychical groups united in the same personality is then
frequently established; attacks and normal life exist side by side
without affecting one another. The attacks then arise spontaneously,
as memories commonly do; but they may also be provoked, just as any
memory may be aroused according to the laws of association.
Provocation of an attack occurs either by stimulation of an
hysterogenic zone or by a new experience resembling the pathogenic
experience. We hope to be able to show that no essential difference
exists between the two conditions, apparently so distinct; that in
both cases a hyperæsthetic memory has been stirred. In other cases
this equilibrium is very unstable; the attack appears as an expression
of the vestiges of hypnoid consciousness whenever the normal
personality is exhausted and powerless. It is not impossible that in
such cases the attack may be divested of its original significance and
may return as a motor reaction without content.
It remains a task for further enquiry to discover what are the
conditions determining whether in any given patient an hysteria will
take the form of attacks, or chronic symptoms, or a combination of both.
V
It is now clear how the method of psychotherapy which we have just
described leads to recovery. By providing an opportunity for the
pent-up affect to discharge itself in words the therapy deprives of {41}
its effective power the idea which was not originally abreacted; by
conducting it into normal consciousness (in light hypnosis) it brings
it into associative readjustment or else dispels it by means of the
physicians' suggestion, as happens in cases of somnambulism combined
with amnesia.
We regard the therapeutic effect achieved by employing this procedure as
important. We naturally cannot cure that element in hysteria which is
dispositional; we can do nothing against the return of hypnoid states.
Even during the productive state of an acute hysteria our procedure
cannot prevent the phenomena which have just been removed with such
difficulty being forthwith replaced by new ones. But when the acute
stage has passed off and its vestiges remain in the form of chronic
hysterical symptoms and attacks our method will frequently remove them
in turn, and the results are permanent because radical. It therefore
appears to us that in this respect it far surpasses the effect of
removal by direct suggestion which is now practised by
psychotherapeutists.
Although, by thus disclosing the psychical mechanism of hysterical
phenomena, we have now made a further step along the path which Charcot
first opened up so successfully with his explanations and experimental
imitations of hystero-traumatic paralyses, we nevertheless do not
conceal from ourselves that it is only the mechanism of the hysterical
symptom that has been brought within our grasp and not the inner causes
of hysteria. We have but touched upon the ætiology of hysteria and have
really only been able to throw light on the causes of its acquired
forms---the significance of the accidental factor for this neurosis.
------------------------------------------------------------------------
III {42}
SOME POINTS IN A COMPARATIVE STUDY
OF ORGANIC AND HYSTERICAL PARALYSES[7]
(1893)
In 1885 and 1886, when I was his pupil, Charcot was good enough to
entrust me with the task of making a comparative study of organic and
hysterical motor paralyses, based upon observations at the Salpêtrière,
which might serve to discover some of the common characteristics of
neuroses and lead to a conception of their nature. Accidental and
personal reasons prevented me from following his suggestion for a long
time; even now I only intend to give an account of some of the results
of my work, omitting the details needed for a complete demonstration of
my views.
I
I must begin with some remarks on the nature of organic paralyses,
which incidentally represent generally accepted conclusions. Clinical
neurology recognizes two forms of motor paralyses: periphero-spinal
(or bulbar) and cerebral. This distinction is entirely in harmony with
the facts of the nervous system, which show that there are only two
segments in the course of the motor fibres: one extending from the
periphery to the anterior horn cells of the spinal cord, and a second
which proceeds from here to the cerebral cortex. Modern
neuro-histology, based upon the work of Golgi, Ramón y Cajal,
Kölliker, etc., formulates these facts as follows: The path of fibres
conducting motor impulses consists of two neurones (a {43}
neuro-histological unit composed of a cell and its fibres) which meet
in intimate relation at the so-called motor cells of the anterior
horn. The essential clinical difference between these two types of
paralysis is the following: _Periphero-spinal paralysis is a paralysis
of individual elements while cerebral paralysis is a paralysis en
masse_. Types of the former are the facial palsy of Bell, the
paralysis in infantile anterior poliomyelitis, etc. Now in these
diseases each muscle, we might say each muscle fibre, may be paralysed
individually and in isolation. It depends only upon the site and
extent of the nerve lesion; there is, moreover, no definite rule
according to which one peripheral element escapes paralysis while
another is permanently subject to it.
Cerebral paralysis, on the other hand, is always a disease affecting a
considerable portion of the periphery, an extremity, a segment of it, or
a complicated motor apparatus. It never affects one muscle alone, as for
example, the biceps brachii or the tibialis; in any apparent exceptions
to this rule (cortical ptosis, for example) it is evident that the
muscles concerned are of the kind which in themselves fulfil a
particular function---in which they are the sole agents.
It may be noted that in cerebral paralyses affecting the extremities
distal segments always suffer more than proximal ones; the hand, for
example, is more paralysed than the shoulder. As far as I know, there is
no isolated cerebral paralysis of the shoulder in which the hand retains
its motor power, while the reverse is the rule in incomplete paralyses.
In a critical study of aphasia, published in 1891 (_Zur Auffassung der
Aphasien_, _Wien_, _1891_), I attempted to show that the cause of this
important difference between periphero-spinal and cerebral paralysis
was to be sought in the structure of the nervous system. Each element {44}
in the periphery corresponds to one in the grey substance, which is,
as Charcot expresses it, its neural terminus; the periphery is then,
so to say, projected on to the grey substance of the spinal cord,
point by point, element for element. I have proposed that the
particularized periphero-spinal paralysis should be named 'projection
paralysis'. The relation between the elements of the spinal cord and
those of the cortex is, however, different. The number of conducting
fibres would no longer suffice for a second projection of the
periphery, to the cortex. We must suppose that the fibres coming from
the spinal cord to the cortex no longer represent single peripheral
elements, but rather a group of them; on the other hand, a peripheral
element may correspond to several spino-cortical fibres. The change in
arrangement occurs at the point where the two segments of the motor
system meet.
Therefore I would say that the reproduction of the periphery in the
cortex is no longer an accurate one, point for point; it is not a true
projection. The relation is established so to say by representative
fibres, and I propose therefore to name the cerebral form of paralysis
'representation paralysis'.
Naturally, when a projection paralysis is total and very extensive, it
too becomes a paralysis _en masse_ and its striking distinctive
characteristic disappears. Cortical paralysis, on the other hand, which
is differentiated from the other cerebral paralyses by a greater
tendency to dissociation, nevertheless invariably presents the character
of a representation paralysis.
The other differences between projection paralysis and representation
paralysis are well known. Among them I may mention the preservation of
nutrition and of electrical reaction in the latter. Although {45}
clinically very important, these signs have not the theoretical
significance that is to be ascribed to the first differential trait
mentioned, i.e., whether the paralysis be one of individual elements
or _en masse_.
Hysteria has often been credited with the faculty of simulating the most
varied kinds of organic nervous diseases. The question arises whether it
can simulate accurately the characteristics of both types of organic
paralysis, whether there are hysterical projection paralyses and
hysterical representation paralyses, as in the organic symptomatology.
An important fact at once confronts us here. Hysteria never simulates
the periphero-spinal or projection paralyses; hysterical paralyses show
the characteristics of organic representation paralyses only. This is
indeed a very interesting fact, since Bell's palsy, musculo-spinal
paralysis, etc., are among the most common diseases of the nervous
system.
It should be noted in this connection, in order to avoid all confusion,
that I am dealing only with flaccid hysterical paralyses and not with
hysterical contractures. It seems to me impossible to apply the same
rules to both hysterical paralyses and hysterical contractures. The
contention that the paralysis never affects an isolated muscle (unless
such a muscle be the sole agent of a function), that the paralysis is
always _en masse_, agreeing in this respect with an organic cerebral
representation paralysis, can only be maintained in respect of flaccid
hysterical paralyses. Further, in regard to the nutrition and electrical
reactions of the paralysed part hysterical paralysis shows the same
characteristics as organic cerebral paralysis.
But although hysterical paralysis may be related in this way to
cerebral and especially to cortical paralysis, which exhibits a {46}
greater aptitude for dissociation, important distinctive traits are
not lacking between them. In the first place, it is not subject to the
constant fixed rule of organic cerebral paralyses, namely, that the
distal segment is always more extensively affected than the proximal
one. In hysteria, the shoulder or the thigh may be more seriously
paralysed than the hand or the foot. Movements may occur in the
fingers while the proximal part is still absolutely motionless. There
is not the least difficulty in producing artificially an isolated
paralysis of the thigh, of the leg, etc., and clinically we quite
frequently meet with these isolated paralyses which do not conform to
the rules of organic cerebral paralyses.
In this important respect hysterical paralysis is, so to speak,
intermediate in type between projection paralysis and representation
paralysis. On the one hand it does not possess all the characteristics
of dissociation and isolation proper to the former; on the other hand it
is by no means subject to the rules which strictly govern the latter.
With these reservations we may say that hysterical paralysis also is a
representation paralysis, but one possessing a special manner of
representation which remains to be discovered.[8]
II
As a step in this direction I propose to study the other traits which
differentiate hysterical paralysis from the most perfect form of {47}
cerebral organic paralysis---namely, cortical paralysis. The first of
these distinguishing characteristics has been mentioned, the fact that
hysterical paralysis may be much more dissociated and systematised
than cerebral paralysis. The symptoms of organic paralysis appear in
hysteria as if apportioned. Hysteria reproduces the common organic
hemiplegia (paralysis of the upper and lower extremities and of the
lower half of the face) only to the extent of imitating the paralysis
of the limbs; frequently it even splits off the paralysis of the arm
from that of the leg, exhibiting with the greatest ease paralysis in
the form of a monoplegia. It reproduces in an isolated form the motor
aphasia seen in the syndrome of organic aphasia and, as I have
observed in some unpublished cases, it can create a total aphasia
(motor and sensory) for a given language, without affecting in the
least the ability to understand and to speak another, a phenomenon
unheard-of in organic aphasia. This power of dissociation is again
manifested in those isolated paralyses in which one segment of a limb
is affected while other portions of the same limb are entirely intact,
and again, when one function is completely abolished (abasia astasia)
while another function performed by the same organ is unaffected. The
more complex the function in question, the more striking is this
dissociation. In organic disease, whenever several functions are
impaired in different degrees, it is always the most complex function,
the one most recently acquired, that is most extensively affected by
the paralysis.
In addition to the above, hysterical paralysis presents another
characteristic, which is, as it were, the hall-mark of the neurosis.
Indeed, as I heard Charcot say, hysteria is a malady with extravagant
manifestations, with a tendency to produce its symptoms in the {48}
severest possible degree. This characteristic is not met with only in
the paralyses but also in the contractures and anæsthesias. The
degree of distortion that may be produced by hysterical contractures
is well known and is hardly equalled in organic symptomatology. We
also know how frequently hysteria exhibits the absolute, profound
anæsthesias, of which the organic lesions only reproduce a faint
sketch. The same is true of the paralyses; they are often as complete
as is possible. The hysterical aphasic does not utter a word, while
the organic aphasic almost always retains a few syllables, 'yes',
'no', an oath, etc.; the paralysed arm is absolutely inert, and so
on. This characteristic is too well known to dwell on it at length. On
the other hand, it is known that in organic paralysis partial paresis
is always more common than complete paralysis.
Hysterical paralysis, then, shows an _exact delimitation_ and an
_excessive intensity_. It possesses these two qualities
simultaneously, and it is in this respect that it contrasts most
strongly with organic cerebral paralysis, in which these two
characteristics are never associated. Monoplegias do exist in organic
symptomatology also, but they are almost always monoplegias _a
potiori_ and not sharply delimited. If an arm is paralysed in
consequence of a cortical lesion, there is almost always a minor
concomitant affection of the face and leg; and if this complication is
no longer visible at a given period, it existed nevertheless at the
beginning of the disease. Cortical monoplegia is indeed always a
hemiplegia, of which one part or another has been more or less effaced
but still remains recognizable. To go further, let us suppose that the
paralysis has affected the arm alone, that it is a pure cortical {49}
monoplegia; in such a case we shall see that the paralysis is one of
moderate degree. As this monoplegia increases in degree, and as soon
as it becomes a total paralysis, it at once loses its characteristic
of being a pure monoplegia and will be accompanied by motor
disturbances in the leg or the face. _It cannot become a complete
paralysis and at the same time remain restricted in area_.
This is the very condition, however, that hysterical paralysis can
easily accomplish, as we may see daily in clinical work. For example, it
may affect the arm exclusively without showing a trace in the leg or the
face. Further, in the arm it is as complete as a paralysis can possibly
be, and this forms a striking contrast to organic paralysis, a
difference that gives occasion for serious reflection.
There are, of course, cases of hysterical paralysis in which the degree
of paralysis is not excessive and in which the dissociation offers
nothing remarkable. Such cases are recognized by other traits; but they
are cases that do not bear the typical stamp of neurosis and, since they
cannot teach us anything about the nature of the latter, are of no
interest for our present purpose.
Let me add a few remarks of minor importance, though they overstep the
limits of my subject.
To begin with, I may recall the fact that hysterical paralyses are
much more frequently accompanied by sensory disturbances than are
organic paralyses; such disturbances are altogether more profound and
frequent in neurosis than in organic disease. Nothing is more common
than hysterical anæsthesia or analgesia. Recollect, in contrast to
this, how obstinately sensation persists in cases of organic
lesion. If a peripheral nerve is cut, the anæsthesia will be less
extensive and intense than might be expected. When an inflammatory {50}
process attacks the spinal nerves or the spinal cord centres the
result always is that motility suffers in the first instance, while
sensibility remains or is merely diminished; for some part of the
nervous elements which have not been completely destroyed always
persists. With cerebral lesions the frequency and the permanency of
motor hemiplegia is well known, while the accompanying hemianæsthesia
is vague and transitory, and is not always present. Only a few special
localizations can produce a marked and lasting sensory disturbance
(_carrefour sensitif_), and even this fact is not free from doubt.
This difference in the nature of the sensory disturbances in organic
lesions and in hysteria is scarcely explicable with our present
knowledge. The solution of this problem would probably reveal the core
of the whole matter.
Another point that seems to me worthy of mention is that there are
some forms of cerebral paralysis which, just like the periphero-spinal
projection paralyses, are not found in hysteria. Paralysis of the
lower half of the face, the most frequent manifestation of organic
brain disease, should be mentioned first in this connection, and, if I
may be permitted to enter the field of sensorial disturbances,
homonymus lateral hemianopsia. I know that I run a risk in stating
that a given symptom does not exist in hysteria when the researches of
Charcot and his pupils are almost daily discovering new and hitherto
unsuspected symptoms. But I must take things as they are at the
moment. The existence of an hysterical facial paralysis is seriously
contested by Charcot, and, even if we believe those who vouch for it,
it is a very rare phenomenon. Hemianopsia has not as yet been seen in
hysteria, and I believe it never will be. {51}
Now how is it that hysterical paralyses closely simulate cortical ones
and yet differ from them in the distinctive characteristics that I have
attempted to enumerate, and what is the special type of representation
to which they conform? The answer to this question would embody a large
and important part of the theory of this neurosis.
III
Not the least doubt exists about the conditions controlling the
symptomatology of cerebral paralysis. They are the facts of
anatomy---the structure of the nervous system, the distribution of its
vessels and the inter-relation between these two sets of facts and the
nature of the lesion. We have said that the basis of the difference
between the projection paralysis and the representation paralysis lies
in the smaller number of fibres proceeding from the spinal cord to the
cortex in comparison with the number proceeding from the periphery to
the spinal cord. Again, every clinical detail of a representation
paralysis finds its explanation in some detail of cerebral anatomy and,
_vice versa_, we can deduce the structure of the brain from the clinical
characteristics of the paralyses. We believe that a perfect parallel
exists between these two series of facts.
Thus if cerebral paralysis does not show any great tendency to
dissociation, it is because the fibres conducting motor impulses run
too close together for a great part of their intra-cerebral course for
them to be injured individually. If cortical paralysis shows a greater
tendency to monoplegias, it is because the diameter of the conducting
bundle, brachial, crural, etc., goes on increasing up to the
cortex. If paralysis of the hand is the most complete of all the
cortical ones, it is, I believe, because the contralateral relation
between hemisphere and periphery is more nearly complete for the hand {52}
than for any other part of the body. If the distal segment of an
extremity suffers a greater degree of paralysis than a proximal
segment, it may be assumed that the representative fibres of the
distal segment are more numerous than those of the proximal one, so
that the influence of the cortex is more important for the former than
for the latter. If moderate-sized lesions of the cortex do not succeed
in producing pure monoplegias, we infer from this that the motor
centres of the cortex are not cleanly separated from one another by
indifferent areas, or that there are factors operating at a distance
(_Fernwirkungen_) which nullify the effect of an exact separation of
the centres.
Similarly, if disturbances of various functions are always found in a
mixed form in organic aphasia, this is explained by the fact that
branches of the same artery nourish all the speech centres, or, if the
view expressed in my critical study of aphasia is accepted, it is
because we are dealing, not with separate centres, but with a continuous
association area. In any event, there is always some reason to be found
in anatomy for these things.
The remarkable combinations which are so often observed in the
symptomatology of cortical paralyses (motor aphasia and right
hemiplegia, alexia and right hemianopsia) are explained by the proximity
of the injured centres. Hemianopsia itself, a symptom that seems curious
and strange to the unscientific mind, is only explicable by the crossing
of the fibres of the optic nerve at the chiasma; like all the details of
cerebral paralyses it is the clinical expression of an anatomical fact.
Since there cannot be more than one authentic cerebral anatomy, and
since that one is expressed in the clinical characteristics of {53}
cerebral paralyses, it is evidently impossible for that anatomy to
explain the distinctive traits of hysterical paralyses. For this
reason we should not draw conclusions about cerebral anatomy based
upon the symptomatology of these paralyses.
We must certainly turn our attention to the nature of the lesion to find
this difficult explanation. In organic paralyses the nature of the
lesion plays a secondary part, it is rather the extent and localization
of it that, under the given conditions of the structure of the nervous
system, produce the characteristics of organic paralysis we have
mentioned above. What can be the nature of the lesion in hysterical
paralysis which alone dominates the situation, independent of
localization, of extent, and of the anatomy of the nervous system?
Charcot constantly taught us that it is a cortical lesion, but one of a
purely dynamic or functional kind.
It is easy to understand the negative side of this proposition. It is
equivalent to affirming that no appreciable tissue changes will be
found _post mortem_; but regarded from a positive stand-point, it is
far from being devoid of ambiguity. After all, what is a dynamic
lesion? I am sure that many who read the works of Charcot think that
dynamic lesion is indeed a lesion, but a lesion of which no trace is
found after death, like œdema, anæmia, active hyperæmia. But the
latter, although they do not necessarily persist after death, are true
organic lesions, however insignificant and transitory. Paralyses
produced by lesions of this type partake, necessarily, of all the
characteristics of organic paralyses. Œdema and anæmia could no more
produce the dissociation and intensity of an hysterical paralysis than
could hæmorrhage and softening. The only difference would be that a {54}
paralysis produced by œdema, by vascular constriction etc., would be
less lasting than a paralysis caused by the destruction of nervous
tissue. All the other conditions are common to both, and the anatomy
of the nervous system will determine the characteristics of a
paralysis in a case of transitory anæmia no less than in a case of
permanent anæmia.
I do not think that these remarks are wholly uncalled-for. Reading
'there must be an hysterical lesion' in a given centre (the same centre
an organic lesion of which would produce the corresponding organic
syndrome) and recollecting that it is customary to localize the dynamic
hysterical lesion in the same way as the organic lesion, we are led to
believe that there lurks behind the expression 'dynamic lesion' the idea
of a lesion like œdema and anæmia, which are in fact transitory organic
affections. I maintain on the contrary that the lesion in hysterical
paralyses must be entirely independent of the anatomy of the nervous
system, since _hysteria behaves in its paralyses and other
manifestations as if anatomy were non-existent, or as if it had no
knowledge of it_.
Indeed, a good number of the features of hysterical paralyses justify
this statement. Hysteria is ignorant of the distribution of the nerves
and for this reason does not simulate the periphero-spinal or
projection paralyses; it is not acquainted with the optic chiasma and
consequently does not produce a hemianopsia. It regards the organs
according to the common popular meaning of their names: the leg is the
leg up to its insertion into the hip, the arm is the upper extremity
as mapped out by our clothing. It would see no reason for combining a
facial paralysis to a brachial one. An hysterical patient who loses
the power of speech has no motive for forgetting the meaning of {55}
language, since motor aphasia and word-deafness are not related in the
popular mind. On this point I must agree completely with the views
expressed by Janet in the latest numbers of the _Archives de
Neurologie_; hysterical paralyses demonstrate their truth just as well
as anæsthesias and psychic symptoms do.
IV
I shall now try finally to suggest what might be the lesion that causes
hysterical paralyses. I do not claim that I shall demonstrate what it
actually is; it is merely a matter of pointing out a line of thought
that may lead to a concept not in contradiction with the features of
hysterical paralysis, in so far as this differs from organic cerebral
paralysis.
I will take the word 'functional or dynamic lesion' in its proper sense:
'alteration in function or mechanism', alteration in a functional
attribute. Such an alteration, for example, would be a diminution in
excitability or in a physiological quality which in the normal state
remains constant or varies within fixed limits.
But it will be said that a functional alteration is only an organic one
considered from a different aspect. Let us suppose that nervous tissue
is in a state of transitory anæmia, its excitability will be diminished
by that circumstance; it is not possible by this means to avoid
considering organic lesions.
I will try to show that a functional alteration may exist without an
accompanying organic lesion, at least without a lesion capable of
detection even by means of the most delicate methods. In other words,
I will give an appropriate example of a primary functional change; to
do so, I only ask permission to pass over into the field of
psychology, which cannot be ignored in dealing with hysteria. {56}
With Janet I maintain that it is the common, popular idea of the organs
and of the body in general that is at work in hysterical paralyses as
well as in anæsthesias, etc. This idea is based, not upon a profound
knowledge of neuro-anatomy, but upon our tactile and, above all, our
visual perceptions. If it determines the characteristics of hysterical
paralysis the latter must prove to be ignorant and independent of any
idea of the anatomy of the nervous system. The lesion of hysterical
paralysis will be an alteration of the concept, of the idea 'arm', for
example. But what kind of alteration in regard to the concept is capable
of producing a paralysis?
Psychologically considered, the paralysis of the arm is embodied in the
fact that the concept 'arm' cannot enter into association with those
other ideas that make up the ego, of which the body of the individual is
an important part. The lesion, then, would consist in the abolition of
the accessibility of the concept 'arm' in association. The arm acts as
if it did not exist in the interplay of associations. Of course, if the
physical conditions corresponding with the concept 'arm' are profoundly
changed then the concept will also be lost, but I must show that it may
be inaccessible without being destroyed and without its physical
substratum (the nervous tissue of the corresponding cortical area) being
damaged.
I will commence with examples taken from ordinary life. A comic story
is told of a loyal subject who would no longer wash his hand because
his sovereign had touched it. The relation of this hand to the idea
'king' seems to be so important for the psychic life of this person
that he refused to let it enter into other relations. We obey the same
impulse when we break the glass in which we have drunk the health of a
newly-married couple. Ancient savage tribes, in burning the horse, the {57}
weapons, and even the wives of a deceased chief together with his
body, followed a similar idea that no one should touch them after
him. The motive for all these acts is clear. The affective value which
attaches to the first association is reluctant to let the object enter
into a new association with another object and consequently renders
the idea inaccessible to association.
If we now pass on to the field of the psychology of concepts we find
that this is not a simple comparison but an almost identical situation.
If the concept 'arm' is attached to an association of great affective
value it will be inaccessible to the free play of other associations.
The arm will be paralysed in proportion to the persistence of that
affective value or to the diminution in the latter effected by suitable
psychic measures. This is the solution of the problem that we have
raised; for in every case of hysterical paralysis we find that the
paralysed organ or the abolished function is engaged in a subconscious
association endowed with great affective value, and it may be
demonstrated that the arm becomes free as soon as this affective value
is removed. The concept 'arm' exists, then, in the physical substratum;
but it is not accessible to conscious associations and volition because
its entire associative affinity, so to speak, is saturated by a
subconscious association with the recollection of the event, of the
trauma, that produced the paralysis.
Charcot was the first to teach us that we must turn to psychology for
the explanation of the hysterical neurosis. Breuer and I have followed
his example in a preliminary paper.[9] In this paper we show that the
permanent symptoms of so-called non-traumatic hysteria (the stigmata
excepted) may be explained by the same mechanism that Charcot {58}
recognized in traumatic paralyses. But we also give the reasons why
these symptoms persist and why they can be cured by a special form of
hypnotic psychotherapy. Every occurrence, every psychic impression is
supplied with a certain affective value (_Affektbetrag_), of which the
ego rids itself either by means of a motor reaction or by a process of
mental association. If the person cannot or will not free himself of
this excess, the memory of the impression acquires the importance of a
trauma and becomes the cause of the permanent symptoms of
hysteria. When the impression remains subconscious its elimination is
impossible. We have called this theory: _Das Abreagieren der
Reizzuwächse_ (the abreaction of an accumulation of stimuli).
To sum up, I think that it is quite in harmony with our general
conception of hysteria, formed from the teachings of Charcot, to state
that the lesion in hysterical paralyses consists of nothing but the
inaccessibility of the concept of the organ or function to the
associations of the conscious ego; that this purely functional change
(the concept itself being intact) is caused by the fixation of that
concept in subconscious association with the memory of the trauma; and
that this concept cannot become free or accessible as long as the
affective value of the psychic trauma has not been eliminated by an
adequate motor reaction or a conscious psychic process. Even if this
mechanism does not take place, if a direct auto-suggestive idea is
always necessary in an hysterical paralysis, as in the traumatic cases
of Charcot, we have succeeded in showing what the nature of the lesion,
or rather of the change, in hysterical paralysis may be, so as to
explain the differences between it and organic cerebral paralysis.
------------------------------------------------------------------------
IV {59}
THE DEFENCE NEURO-PSYCHOSES[10]
An endeavour to provide a psycho-
logical theory of acquired hysteria,
many phobias and obsessions, and
certain hallucinatory psychoses.
(1894)
After a close study of several patients suffering from phobias and
obsessions a tentative explanation of these symptoms forced itself upon
me; and as it later enabled me successfully to divine the origin of
similar pathological ideas in other cases, I consider it worthy of
publication and of further tests. Along with this 'psychological theory
of phobias and obsessions', observation of these patients has resulted
in a contribution to the theory of hysteria, or rather an alteration in
it, which appears to account for an important characteristic common both
to hysteria and to the neuroses mentioned above. Further, I had
opportunities of gaining some insight into the psychological mechanism
of a form of disease that is undoubtedly of mental origin, and then
found that the tentative point of view I had adopted established an
intelligible connection between these psychoses and the two neuroses
mentioned. At the end of this essay I shall bring forward an hypothesis
which I have employed in all three cases.
I
Let me begin with the alteration that in my view we are called upon to
make in the theory of the hysterical neurosis. {60}
Since the publication of the fine work carried out by P. Janet, J.
Breuer and others, it may be taken as generally acknowledged that the
syndrome of hysteria, in so far as it permits of understanding up to the
present, justifies the concept of a splitting of consciousness, with the
formation of separate psychical groups; opinions are less definite,
however, concerning the origin of this splitting of consciousness and
the part which this character plays in the structure of the hysterical
neurosis.
According to Janet's theory[11] the splitting of consciousness is a
primary feature of the hysterical change. It is dependent on an inborn
weakness in the capacity for psychical synthesis, on the narrowness of
the 'field of consciousness' (_champ du conscience_) which in the form
of a psychic stigma is evidence of the degeneration of hysterical
persons.
In contradistinction to Janet's view, which seems to me to admit of many
and various objections, we have that advocated by J. Breuer in our joint
publication[12]. According to Breuer, the 'foundation and condition' of
hysteria is the occurrence of peculiar dream-like states of
consciousness with diminished capacity for association, for which he
suggests the name 'hypnoid states'. The splitting of consciousness is
then secondary and acquired; it occurs because the ideas which emerge in
hypnoid states are cut off from associative connection with the
remaining contents of consciousness.
I can now bring forward evidence of two other more extreme forms of
hysteria in which it is impossible to regard the splitting of
consciousness as primary in Janet's sense. In the first of these forms
I repeatedly succeeded in demonstrating that the splitting of the {61}
contents of consciousness is the consequence of a voluntary act on the
part of the patient; that is to say, it is instituted by an effort of
will, the motive of which is discoverable. By this I do not of course
mean that the patient intends to produce a splitting of his
consciousness; the patient's aim is a different one, but instead of
attaining its end it produces a splitting of consciousness.
In the third form of hysteria, as shown by the mental analysis of
intelligent patients, the splitting of consciousness plays an
insignificant part, or perhaps none at all. These are the cases in which
all that had happened was that the reaction to traumatic stimuli had
failed to occur, so that they are accordingly dissolved and cured by
'abreaction'[13]---they are the pure 'retention' hysterias.
In connection with what I have to say about phobias and obsessions I
shall here deal only with the second form of hysteria, which for reasons
that will soon be evident I shall designate as _defence hysteria_, and
distinguish by this name from _hypnoid_ and _retention hysteria_. I may
also provisionally represent my cases of defence hysteria as cases of
'acquired hysteria', because there was in them no question either of
grave hereditary taint or of individual atrophic degeneration.
These patients whom I analysed had enjoyed good mental health up to
the time at which an intolerable idea presented itself within the
content of their ideational life; that is to say, until their ego was
confronted by an experience, an idea, a feeling, arousing an affect so
painful that the person resolved to forget it, since he had no
confidence in his power to resolve the incompatibility between the {62}
unbearable idea and his ego by the processes of thought.
Such unbearable ideas develop in women chiefly in connection with sexual
experiences and sensations, and the patients can recollect with the most
satisfactory minuteness their efforts at defence---their resolution to
'push the thing out', not to think of it, to suppress it. I will give
from my experience some examples which I could easily multiply: A young
girl who disapproved of herself because while nursing her sick father
she had let her mind dwell on the thought of a young man who had made a
slight erotic impression on her; a governess who had fallen in love with
her employer and had resolved to thrust this affection from her mind
because it appeared to her incompatible with her pride; and so on.[14]
I do not of course assert that an effort of will to thrust such things
out of the mind is a pathological act, nor am I able to say whether and
in what manner intentional forgetting is successful in people who remain
healthy, although subject to similar mental impressions. I only know
that this kind of 'forgetting' did not succeed with the patients whom I
analysed, but led to various pathological reactions, giving rise either
to hysteria, or to an obsession, or to an hallucinatory psychosis. The
ability to bring about by an effort of will one of these states, which
are all of them associated with splitting of consciousness, is to be
regarded as the manifestation of a pathological disposition---which,
however, is not necessarily identical with personal or hereditary
'degeneration'.
In regard to the intermediate processes between the patient's effort
of will and the onset of the neurotic symptom, I have formed an
opinion which may be expressed in the customary psychological {63}
abstractions somewhat as follows: The task which the ego undertakes in
defence---of treating the unbearable idea as '_non arrivée_'---is
absolutely insoluble; both the memory-trace and the affect attached to
the idea are there once and for all, and it is no longer possible to
extirpate them. But it amounts to an approximate fulfilment of this
task if the ego succeeds in transforming a strong idea into a weak
one, in depriving it of its affect---the quantity of excitation with
which the idea is charged. The weak idea will then make practically no
demands on the work of association; the quantity of excitation,
however, which is then detached from the idea, must be utilized in
another direction.
Up to this point the processes are the same in hysteria and in phobias
and obsessions; from now onwards their ways diverge. In hysteria the
unbearable idea is rendered innocuous by the quantity of excitation
attached to it being transmuted into some bodily form of expression, a
process for which I should like to propose the name of _conversion_.
The conversion may be either total or partial, and it proceeds along
the line of the motor or sensory innervation that is more or less
intimately related to the traumatic experience. Thus the ego succeeds
in resolving the incompatibility within itself; but instead it has
burdened itself with a memory-symbol, which dwells in consciousness,
like a sort of parasite, either in the form of a persistent motor
innervation or else as a constantly recurring hallucinatory sensation,
and remains until a reversion takes place in the opposite
direction. The memory-trace of the repressed idea is not, however,
annihilated by this process; on the contrary, from now onwards it
forms the nucleus of a secondary psychical group. {64}
I will only add a few more words to this conception of the
psycho-physical processes in hysteria. When once such a nucleus of an
hysterical splitting has been formed owing to a 'traumatic' factor it
will be developed by the influence of other factors (which might be
called 'auxiliary traumatic' factors) as soon as an impression of a
similar kind, subsequently experienced, succeeds in breaking through the
barriers erected by the will, in furnishing the weakened idea with fresh
affect and in re-establishing for a time an associative connection
between the two psychical groups---until a further conversion creates a
defence against it. The distribution of excitation thus brought about in
hysteria proves as a rule an unstable one; the excitation which is
directed into a wrong channel (into somatic innervation) now and then
finds its way back to the idea from which it was detached, and then
compels the subject either to undertake the work of associative
absorption or else to discharge it by the way of hysterical attacks---a
conclusion which is supported by the familiar opposition between the
hysterical attack and chronic symptoms. Breuer's cathartic method
achieves its results by deliberately effecting such a re-transmutation
of the excitation from the somatic into the mental field, in order then
to enforce a resolution of the opposed elements by a process of thought
and a discharge of the excitation in speech.
The conclusion that the splitting of consciousness in acquired
hysteria is based on an act of will also explains with surprising
simplicity the remarkable fact that hypnosis regularly widens the
narrowed consciousness of the hysteric and makes the psychical group
which has been split off accessible. Indeed, we know it to be a
peculiarity of all sleep-like conditions that they abrogate that
distribution of excitation upon which the 'will' of the conscious {65}
personality depends.
Thus we can see that the characteristic factor in hysteria is not to be
found in the splitting of consciousness but in the _capacity for
conversion_, and we may assume that the psycho-physical capacity to
transmute such large quantities of excitation into somatic innervation
is an important element of the disposition to hysteria, which in other
respects is still unknown.
This capacity does not in itself preclude mental health and leads to
hysteria only where there is some mental incompatibility or an
accumulation of excitation. With this new turn in the theory Breuer and
I approach Oppenheim's[15] and Strümpell's[16] well-known definition
of hysteria, and recede from Janet[17] who assigns too great importance
to the splitting of consciousness as a characteristic of hysteria. The
presentation here given may claim to have rendered the relation between
conversion and the hysterical splitting of consciousness intelligible.
II
If the capacity for conversion does not exist in a person predisposed
to hysteria and yet the separation of its affect from an unbearable
idea is nevertheless undertaken as a defence against the latter, then {66}
this affect must persist in the psychical sphere. Thus weakened, the
idea remains present in consciousness, detached from all associations;
but its affect, now freed from it, attaches itself to other ideas
which are not in themselves unbearable, but which through this 'false
connection' grow to be obsessions. This is shortly the psychological
theory of obsessions and phobias which I mentioned to start with.
I will now enumerate the various elements necessary to the structure of
this theory that admit of direct proof, and then describe those that I
have myself supplied. Apart from the final result of the process, that
is, the obsession, it is possible in the first place to demonstrate the
ultimate source of the affect which is now falsely attached to some
other idea. In all the cases I have analysed it was in the sexual life
that a painful affect---of precisely the same quality as that attaching
to the obsession---had originated. On theoretical grounds it is not
impossible that this affect may at times arise in other spheres; I have
merely to state that hitherto I have not discovered any other origin of
it. Incidentally, it is easy to see that it is precisely in regard to
the sexual life that unbearable ideas most frequently arise.
Further, we have the most unequivocal utterances on the part of
patients in proof of the effort of will, the attempt at defence, upon
which the theory lays emphasis; and in at least a number of cases the
patients themselves will inform us of the fact that the phobia or
obsession first made its appearance after this effort of will had
apparently succeeded in its aim. 'Once something very disagreeable
happened to me, and I did my utmost to thrust it out of my mind, to
think no more about it. Finally I succeeded, but then I got this,
which since then I have never been rid of.' With these words a patient {67}
confirmed the chief points of the theory I have developed here.
Not all those who suffer from obsessions are themselves so clear about
the origin of them. As a rule, when one draws these patients' attention
to the original idea of a sexual nature, the answer is, 'It can't come
from that; indeed, I thought very little about that. For a moment I was
scared, but I turned my mind to something else and since then it hasn't
troubled me.' In this frequent objection we have a proof that the
obsession represents a substitute or surrogate for the unbearable sexual
idea, and has taken its place in consciousness.
Between the patient's effort of will which successfully represses the
intolerable sexual idea, and the appearance of the obsessional idea,
which though having little intensity in itself is now endowed with
incomprehensibly strong affect, there lies a gap which the theory here
developed aims at filling in. The detachment of the sexual idea from its
affect and the connection of the latter with another idea, suited to it
but not intolerable, are processes which occur outside
consciousness---they may be presumed but they cannot be proved by any
clinical-psychological analysis. Perhaps it would be more correct to
say: These processes are not of a psychical nature at all, but are
physical processes the psychical consequences of which are so
represented as if what is expressed by the words 'detachment of the idea
from its affect and false connection of the latter' had really happened.
Alongside the cases which show the unbearable sexual idea followed
subsequently by the obsession, there is another series in which
obsessions and painful sexual ideas are present simultaneously. We
cannot very well call the latter 'sexual obsessions', for _one_
essential feature of obsessions is missing from them; they are fully {68}
justified, whereas the painfulness of the ordinary obsession
constitutes a problem for both physician and patient. So far as I
have been able to see in cases of this kind, it appears that in them a
perpetual defence is going on against sexual ideas continually arising
anew; that is, we are here concerned with an operation that has not
yet been completed.
As long as they are conscious of the sexual origin of their obsessions,
the patients often keep them concealed. When they complain about them,
they as a rule express their astonishment that they are subject to the
affect in question---that they feel anxious, or that they have such and
such an impulse, and so on. To the experienced physician this affect
appears, on the contrary, to be justified and comprehensible; he only
finds it surprising that an affect of that kind should be associated
with an inappropriate idea. The affect of the obsession appears to him,
in other words, to be _dislocated_ or _transposed_, and if he is
proceeding on the assumptions here laid down he can in a great number of
cases attempt its re-translation into the sexual.
Any idea which is either suited by nature to be associated with an
affect of this quality or else bears a certain relation to the
unbearable idea---in consequence of which it appears practicable to
employ it as a surrogate for the latter---may be made use of in
secondary connection with the detached affect. Thus for example, an
unattached anxiety, the sexual origin of which the patient is unable
to recall, will seize upon the common primary phobias of mankind in
regard to animals, thunderstorms, darkness and the like, or upon
things which are manifestly associated with the sexual in some way or
other, such as urination, defæcation, defilement and contagion
generally. {69}
The ego gains considerably less advantage by choosing the method of
_transposition_ of affect as a measure of defence than it does by the
hysterical conversion of psychical excitation into somatic innervation.
The affect which the ego had to endure remains unchanged and
undiminished, just as before---the only difference being that the
unbearable idea is suppressed and cut off from recollection. The
repressed ideas then form again the nucleus of a second psychical group,
which, as it seems to me, is accessible even without the aid of
hypnosis. If in phobias and obsessions the striking symptoms which in
hysteria accompany the formation of an independent psychical group fail
to appear, this is probably because in the former the whole
transformation takes place within the psychical sphere---the relation
between psychical excitation and somatic innervation has undergone no
change.
To illustrate what has been said concerning obsessions I will give a few
examples, which are probably typical:
1. A young girl suffered from obsessive reproaches. If she read in the
papers about counterfeiting coinage the thought occurred to her that
she also had forged coins; if an unknown criminal had committed a
murder she asked herself anxiously whether she had not done the
deed. At the same time she was quite conscious of the absurdity of
these obsessive reproaches. This sense of guilt gained for a time such
an influence over her that her critical faculty was stifled, so that
she accused herself to her relations and her physician of having
really committed all these crimes (psychosis through simple
intensification---overwhelming-psychosis---_Überwältigungspsychose_). A
close examination then revealed the source in which her sense of guilt
arose: Accidentally stimulated by a voluptuous sensation, she had {70}
allowed herself to be led astray by a friend into masturbation and had
practised it for years, with full knowledge of her wrong-doing and
accompanied by most intense self-reproaches, which as usual were of no
avail. An excessive indulgence after attending a ball had evoked the
intensification leading to the psychosis. After a few months of
treatment and close watching the patient was cured.
2. Another young girl had suffered from the dread of being forced to
pass water and wet herself ever since the time when an impulse of this
kind had really obliged her to leave a concert during a performance.
This phobia had gradually made her completely unable to enjoy herself
or to go into society. She only felt well if there was a closet near
at hand to which she could have access without arousing attention. Any
organic complaint justifying this lack of confidence in her control of
the bladder was excluded; at home under quiet conditions and at night
the urgency did not arise. A penetrating enquiry showed that the
urgency had appeared for the first time in the following
circumstances: A gentleman to whom she was not indifferent had been
sitting not far from her at the concert; she began to think about him
and to imagine how she would sit beside him as his wife. During this
erotic reverie she had that bodily sensation which is to be compared
with erection in men and which in her case---I do not know if it is
always so---ended with a slight desire to micturate. She became
greatly frightened by the sexual sensation, to which she was otherwise
quite accustomed, because she had resolved within herself to overcome
her affection for this man as well as for all others, and the next
moment the affect transferred itself to the accompanying desire to
micturate and compelled her to leave the hall after a very painful {71}
struggle. In her life she was so prudish that she positively shuddered
at anything sexual and could not even contemplate the thought of
marrying; on the other hand, she was sexually so hyperæsthetic that
during every erotic reverie, which she willingly indulged in, that
pleasurable sensation appeared. The erection was always accompanied by
the desire to micturate which, up to the time of the scene at the
concert, had made no impression on her. Treatment led to a nearly
complete mastery of the phobia.
3. A young woman who in five years of married life had had only one
child complained to me of an obsessive impulse to throw herself from the
window or balcony, and also of the fear of stabbing her child which
seized her at the sight of a sharp knife. She confessed that marital
relations seldom occurred, and only with precautions against conception;
but she added that this was no privation to her as she was not of a
sensual nature. I ventured to tell her that at the sight of a man she
had erotic ideas and that she had therefore lost confidence in herself
and regarded herself as a depraved person, capable of anything. The
re-translation of the obsession into the sexual was successful; in tears
she confessed at once to her long-concealed misery in her marriage and
later on related in addition some painful thoughts of an unchanged
sexual nature, such as the often-recurring sensation of something
forcing itself under her skirts.
I have turned experiences of this kind to therapeutic advantage by
re-directing the attention of patients with phobias and obsessions, in
spite of all their protestations, back to the repressed sexual ideas
and, where feasible, in blocking the source whence they arose. I {72}
naturally cannot assert that _all_ phobias and obsessions arise in the
manner here described; for, first, my experience of them embraces only
a limited number as compared with the relative frequency of these
neuroses, and secondly, I myself know that these 'psychasthenic'
symptoms, as Janet terms them, are not all to be estimated alike.[18]
There are, for example, pure hysterical phobias. I believe, however,
that the mechanism of transposition of affect will be found to exist
in the great majority of phobias and obsessions; and I would therefore
urge that these neuroses, which are as often found in an isolated form
as combined with hysteria or neurasthenia, should not be loosely
classified together with ordinary neurasthenia, in which there is
absolutely no ground for assuming a psychical mechanism of the
principal symptoms.
III
In both the cases described above defence against an unbearable idea
was effected by detachment of its affect from it; the idea itself
remained in consciousness, although weakened and isolated. Now there
exists a very much more energetic and successful kind of defence,
which takes the following form: the ego rejects the unbearable idea
together with its associated affect and behaves as if the idea had
never occurred to the person at all. But, as soon as this process has
been successfully carried through, the person in question will have
developed a psychosis, and his state can only be described as one of
'hallucinatory confusion'. A single example will serve to illustrate {73}
this.
A young girl gave her first impulsive affection to a man and firmly
believed in the return of her love. As a matter of fact she was
mistaken; the young man had another motive for visiting the house.
Disappointments were not spared her; first of all she defended herself
against her experiences by means of hysterical conversion, thus
preserving her belief that he would one day come and seek her hand; but
at the same time she felt unhappy and ill on account of incomplete
conversion and of the perpetual experience of fresh painful impressions.
Finally on a certain day, the day of a family festival, she waited for
him in a state of intense excitement. The day wore on without his
coming; after all the trains by which he could arrive had gone by, her
condition passed into one of hallucinatory confusion. He _is come_, she
hears his voice in the garden, hastens downstairs in her night-dress to
receive him. From that time she lived for two months in a happy dream,
of which the content was that he is there, ever by her side, everything
is as it was a little while ago (before the time of the disappointment
against which she had so strenuously defended herself). The hysteria and
the depression of spirits were both overcome; nothing of the latter
period of doubt and suffering was alluded to during her illness; she was
happy as long as she was left undisturbed, and only raved when some
circumstance of her surroundings prevented her from carrying out the
logical promptings of her blissful dream. This psychosis, which at the
time of its occurrence had been unintelligible, was explained ten years
later with the aid of an hypnotic analysis.
The fact to which I now wish to call attention is that the content of
such an hallucinatory psychosis consists precisely in the accentuation {74}
of the very idea which was first threatened by the experience
occasioning the outbreak of the illness. One is therefore justified
in saying that the ego has averted the unbearable idea by a flight
into psychosis; and the process by which this result is obtained again
withdraws itself out of range of self-perception as well as of
psychological-clinical analysis. It is to be regarded as the
expression of a high degree of pathological predisposition and may
perhaps be described somewhat as follows: The ego has broken away from
the unbearable idea; but, the latter being inseparably bound up with a
part of reality, in so far as the ego achieves this result it has also
cut itself loose from reality, totally or in part. In my opinion, this
is the condition under which certain ideas acquire hallucinatory
vividness, and consequently when this form of defence is successfully
carried through the person finds himself in a state of hallucinatory
confusion.
I have very few analyses of psychoses of this kind at my disposal; but I
think we must here be concerned with a type of psychical illness that is
very frequently developed, for in no insane asylum are analogous
examples wanting---for instance, the mother who, falling ill after the
loss of her baby, is to be seen incessantly rocking a log of wood in her
arms, or the jilted bride arrayed in all her finery who has for years
been awaiting her betrothed.
It is perhaps not superfluous to point out that the three modes of
defence here described, together with the three forms of illness to
which they lead, may all be combined in the same person. The
simultaneous appearance of phobias and hysterical symptoms, observed
so often in practice, is one of those factors which render it
difficult to distinguish hysteria in a clear-cut manner from other {75}
neuroses, and make it necessary to set up the category of 'mixed
neuroses'. To be sure, hallucinatory confusion is not often compatible
with a continuance of hysteria, nor of obsessions, as a rule. On the
other hand, it is not rare for a defence psychosis to break out
episodically in the course of an hysterical or mixed neurosis.
I should like finally to dwell for a moment on the hypothesis which I
have made use of in the exposition of the defence neuroses. I mean the
conception that among the psychic functions there is something which
should be differentiated (an amount of affect, a sum of excitation),
something having all the attributes of a quantity---although we possess
no means of measuring it---a something which is capable of increase,
decrease, displacement and discharge, and which extends itself over the
memory-traces of an idea like an electric charge over the surface of the
body. We can apply this hypothesis, which by the way already underlies
our theory of 'abreaction',[19] in the same sense as the physicist
employs the conception of a fluid electric current. For the present it
is justified by its utility in correlating and explaining diverse
psychical conditions.
------------------------------------------------------------------------
V {76}
THE JUSTIFICATION FOR DETACHING
FROM NEURASTHENIA A PARTICULAR
SYNDROME: THE ANXIETY-NEUROSIS[20]
(1894)
It is difficult to say anything of general validity concerning
neurasthenia so long as we allow this name to cover all that Beard
included under the term. In my opinion, nothing but gain to
neuropathology can result if we make an attempt to distinguish from
neurasthenia proper all those neurotic disturbances of which the
symptoms, on the one hand, are more closely related to one another
than to the typical symptoms of neurasthenia (headache, spinal
irritation, and dyspepsia with flatulence and constipation) and, on
the other hand, show in their ætiology and their mechanism essential
differences from typical neurasthenia. If we accept this plan we shall
soon obtain a more or less uniform picture of neurasthenia; and shall
then be in a position to differentiate more sharply than had hitherto
been possible between neurasthenia proper and various kinds of
pseudo-neurasthenia, such as the clinical picture of the organically
determined nasal reflex neurosis, the nervous disorders of the
cachexias and arterio-sclerosis, the early stages of general paralysis
of the insane and of the psychoses. Further, it will be possible---as
Möbius proposed---to eliminate many of the nervous conditions of the
hereditarily degenerate; and we shall also find good reason to include {77}
under melancholia many neuroses (especially intermittent and periodic
types) which are to-day called neurasthenia. But the most decisive
change of all will be introduced if we decide to distinguish from
neurasthenia the syndrome I here propose to describe, which fulfils
with unusual completeness the conditions set forth above. The symptoms
of this syndrome are clinically much more closely related to one
another than to those of neurasthenia proper (that is, they frequently
appear together and replace each other during the course of the
illness), while the ætiology and mechanism of this neurosis are
essentially different from what remains of true neurasthenia after
this subtraction has been made from it.
I call this syndrome 'Anxiety-Neurosis', because all its component
elements can be grouped round the central symptom of 'morbid anxiety'
and because individually they each have a definite connection with
this. I believed that this conception of the symptoms of the
anxiety-neurosis had originated with myself until an interesting paper
by E. Hecker[21] came into my hands, in which I found the same idea
expounded with the most satisfying clearness and
completeness. Although Hecker recognizes certain symptoms as
equivalents or incomplete manifestations of an anxiety-attack, he does
not separate them from neurasthenia as I propose to do; this is
evidently due to his not having taken into account the difference in
the ætiological conditions of the two forms of disease. When this
last difference between them is fully recognized, we have no longer {78}
any motive for designating anxiety symptoms by the same term as those
of neurasthenia proper; for the purpose served by giving a name,
however arbitrary it may be in other respects, is above all that of
enabling us more easily to form generalizations.
I. CLINICAL SYMPTOMATOLOGY OF ANXIETY-NEUROSIS
What I call 'anxiety-neurosis' manifests itself in a partial and in a
complete form, and may be met with either as an isolated state or
combined with other neuroses. The cases which are more or less complete
and at the same time isolated are naturally those which in particular
give support to the idea that anxiety-neurosis is a clinical entity. In
other cases where there is a complex of symptoms corresponding to a
mixed neurosis, we have to distinguish and separate from it those
symptoms which belong neither to neurasthenia nor to hysteria and so on,
but to anxiety-neurosis.
The clinical picture of anxiety-neurosis comprises the following
symptoms:
1. _General irritability_. This is a common nervous symptom and as
such belongs to many nervous conditions. I include it here because it
invariably appears with anxiety-neurosis and is important
theoretically. An increase of irritability always signifies an
accumulation of excitation or an inability to tolerate such an
accumulation, that is, an absolute or a relative accumulation of
excitation. One form of expression of this increase of
irritability---auditory hyperæsthesia---seems to me worthy of special
mention; this undue sensitiveness to noise is undoubtedly explicable
on the basis of the close inborn connection between auditory
impressions and fright. Auditory hyperæsthesia is frequently a cause
of sleeplessness, more than one form of which belongs to the {79}
anxiety-neurosis.
2. _Anxious expectation_. I cannot better describe the condition I have
in mind than by this name and by appending a few examples. A woman who
suffers from anxious expectation will imagine every time her husband
coughs, when he has a cold, that he is going to have influenzal
pneumonia, and will at once see his funeral in her mind's eye. If when
she is coming towards the house she sees two people standing by her
front door, she cannot avoid the thought that one of her children has
fallen out of the window; if the bell rings, then someone is bringing
news of a death, and so on; whereas on all these occasions there is no
particular ground for exaggerating a mere possibility.
Anxious expectation of course fades off imperceptibly into normal
anxiousness. It comprises all that is covered by the word
'nervousness'---apprehensiveness, the tendency to look on the dark side
of things; but at every opportunity it exceeds the limits of this
plausible form of nervousness and is frequently recognized by the
patient himself as a kind of compulsion. For one form of anxious
expectation---that relating to one's own health---we may reserve the old
term _hypochondria_. Hypochondria does not always coincide with a high
degree of anxious expectation; in general it requires as a preliminary
condition the presence of paræsthesias and disagreeable bodily
sensations, and therefore hypochondria is the form favoured by true
neurasthenics when they fall victims to anxiety-neurosis, as they often
do.
The tendency to _pangs of conscience_, scrupulousness and pedantry may
be a further expression of anxious expectation, a tendency which is
especially frequent among morally sensitive people and likewise ranges {80}
from the normal to an exaggeration known as _folie du doute_.
Anxious expectation is the nuclear symptom of this neurosis; it clearly
reveals, too, something of the theory of it. We may perhaps say that
there is here _a quantum of anxiety in a free-floating condition_, which
in any state of expectation controls the selection of ideas, and is ever
ready to attach itself to any suitable ideational content.
3. This is not the only way in which apprehensiveness---which is not
usually present in consciousness but is ever lying in wait---can express
itself. It can, on the contrary, erupt suddenly into consciousness
without being called forth by any train of thought, and thus bring about
an _anxiety-attack_. An anxiety-attack of this kind either consists of a
feeling of anxiety alone without any associated idea, or associated with
the nearest interpretation, such as sudden death, a stroke, or
approaching insanity; or else the feeling of anxiety is combined with
paræsthesias (similar to the hysterical aura); or finally, together with
the feeling of anxiety there is an accompanying disturbance of any one
or more of the bodily functions, such as respiration, heart's action,
vasomotor innervation, or glandular activity. The patient lays stress on
one or other of these symptoms, and complains of 'heart-spasms',
'difficulty in breathing', 'drenching sweats', 'ravenous hunger' and the
like; and in his description the feeling of anxiety frequently recedes
into the background or is described quite vaguely as a 'feeling of
illness', of 'distress', and so on.
4. It is interesting, and important diagnostically, that the degree to
which these elements are combined in anxiety-attacks varies
extraordinarily, and that almost every accompanying symptom can alone
constitute the attack just as well as the anxiety itself can. There {81}
are consequently _rudimentary anxiety-attacks_ and _equivalents of an
anxiety-attack_ (all probably having the same meaning), showing a
manifold and hitherto little appreciated variety of forms. A closer
study of these larval anxiety-states (Hecker) and their diagnostic
differentiation from other attacks should soon become a necessary
piece of work in neuropathology.
I will here append a list including only those types of anxiety-attack
known to me:
_a_. Attacks accompanied by disturbances of the _heart's action_, such
as palpitation, either with transitory arhythmia, or with tachycardia of
longer duration that may end in grave weakness of the heart, the
differentiation from organic morbus cordis never being easy; or
pseudo-angina pectoris---diagnostically a delicate problem!
_b_. Attacks accompanied by disturbances of _respiration_, several forms
of nervous dyspnœa, attacks similar to asthma, and the like. I would
emphasize that even these attacks are not always accompanied by
recognizable anxiety.
_c_. Attacks of _sweating_, often nocturnal.
_d_. Attacks of _tremor_ and _shuddering_, which are only too easily
confounded with hysteria.
_e_. Attacks of _ravenous hunger_, often accompanied by giddiness.
_f_. Attacks of sudden _diarrhœa_.
_g_. Attacks of locomotor _vertigo_.
_h_. Attacks of so-called _congestion_, practically embracing all that
has been called vasomotor neurasthenia.
_i_. Attacks of _paræsthesias_ (but these seldom occur without anxiety
or some similar feeling of distress). {82}
5. _Awakening in fright_ (the _pavor nocturnus_ of adults), which is
usually combined with morbid anxiety, dyspnœa, sweating and the like, is
very frequently nothing but a variety of the anxiety attack. This
disturbance conditions a second type of sleeplessness which also lies
within the compass of anxiety-neurosis.---I have no doubt in my own mind
that the _pavor nocturnus_ of children also includes a type which
belongs to anxiety-neurosis. The hysterical tinge, i.e. the coupling of
morbid anxiety with the reproduction of some appropriate experience of
dream, gives the _pavor nocturnus_ of children the appearance of being
something distinct; but it also appears in a pure form without dream or
recurring hallucination.
6. _Vertigo_ takes a prominent place in the group of symptoms of the
anxiety-neurosis. Its mildest form is better described as giddiness; and
its graver manifestations, 'attacks of vertigo' (with or without
anxiety), constitute one of the most momentous symptoms of this disease.
The dizziness of the anxiety-neurosis is neither rotatory nor is it
confined to particular planes or directions as is Menière's vertigo. It
belongs to the class of locomotor or co-ordinatory dizziness, as do the
cases of oculo-motor paralysis; it consists of a specific discomfort
accompanied by the feeling that the ground is rocking, the legs giving
way, that one can't keep upright because one's legs are as heavy as lead
and are shaking and wobbling. This dizziness never leads to a fall. I
venture, however, to assert that a profound fainting fit may supervene
in the place of an attack of vertigo of this kind. Other swoon-like
conditions in anxiety-neurosis appear to result from cardiac collapse.
An attack of vertigo is not seldom accompanied by the worst kind of
morbid anxiety, and is frequently attended by cardiac and respiratory {83}
disturbances. According to my observations the vertigo produced by
heights, mountains and precipices also frequently belongs to the
anxiety-neurosis; further, I do not know whether one would not be
justified in recognizing alongside this the existence of a vertigo of
gastric origin.
7. On the basis of chronic apprehensiveness (anxious expectation) on
the one hand, and a tendency to attacks of vertigo with anxiety on the
other, two groups of typical phobias develop, the first relating to
common physiological dangers, the other to locomotion. To the first
group belongs the fear of snakes, thunderstorms, darkness, vermin, and
so on, as well as the typical moral over-sensitiveness, and the forms of
'_folie du doute_'; the available anxiety is here used simply to
exaggerate the aversions which are implanted instinctively in everyone.
Usually, however, a phobia with obsessive strength arises only when,
added to such an instinctive aversion, a reminiscence of an experience
in which the anxiety could come to expression supervenes---for example,
after the patient has actually experienced a thunderstorm in the open
air. To attempt to explain such cases as mere continuations of strong
impressions would be incorrect; what makes these experiences significant
and their retention in memory of long duration is indeed simply the
anxiety, which both originally and subsequently thus found a means of
expression. In other words, such impressions remain potent only in cases
where 'anxious expectation' is present.
The other group includes _agoraphobia_ with all its accessory forms,
collectively characterized by their relation to movement. We
frequently find a precursory attack of vertigo as the foundation of
the phobia; but I do not believe that one can postulate this every {84}
time. Occasionally we see that after a first attack of giddiness
without anxiety locomotion still continues possible without hindrance,
although henceforth constantly accompanied by the sensation of
giddiness; but that under certain conditions, such as being alone, in
narrow streets and so on, locomotion becomes impossible when once
anxiety has become combined with an attack of vertigo.
The relation of these phobias to those of the obsessional neurosis, the
mechanisms of which I have discussed in an earlier paper[22] in this
Journal, is of the following kind: the correspondence between them is
that in both an idea becomes obsessive in consequence of its being
connected with an unattached affect. The mechanism of _transposition of
affect_ holds good therefore for both kinds of phobia; but in the
phobias of the anxiety-neurosis (1) this affect is always the same,
always that of anxiety; (2) it does not originate in a repressed idea,
proves not reducible further by psychological analysis, and is also not
amenable to psychotherapy. The mechanism of substitution does not
therefore hold good for the phobias of the anxiety-neurosis.
Both kinds of phobias (or obsessional ideas) frequently appear side by
side, although the atypical phobias which are based on obsessional
ideas need not necessarily develop on the basis of an
anxiety-neurosis. A very frequent, apparently complicated mechanism
makes its appearance when the content of an originally simple phobia
of the anxiety-neurosis type is replaced by another idea, the
substitution being then subsequently added to the phobia. The
'protective measures' originally directed towards combating the phobia
are the ideas most frequently employed as substitutions. Thus, for {85}
example, 'brooding mania' arises from the patient's effort to disprove
that he is crazy, as his hypochondriacal phobia maintains: the
hesitations and doubts, and still more the repetitions, of _folie du
doute_, arise from a justifiable doubt about his own powers of correct
reasoning, since he is aware of the persistent disturbance of the
obsessional idea; and so on. We can therefore assert that many
syndromes of the obsessional neurosis, such as _folie du doute_ and
the like, are also clinically, though not conceptually, to be reckoned
as belonging to the anxiety-neurosis.[23]
8. Digestive processes are subject to only a few disturbances in
anxiety-neurosis, but these are characteristic. Sensations such as
nausea and biliousness are not at all rare, and the symptom of ravenous
hunger can, by itself or in combination with others (congestions),
constitute a rudimentary anxiety-attack; as a chronic condition
analogous to anxious expectation we find a tendency to diarrhœa which
has given rise to the queerest diagnostic mistakes. If I am not
mistaken, it is this diarrhœa to which Möbius[24] has recently called
attention in a short paper. I conjecture further that Peyer's reflex
diarrhœa, which he derives from the disorders of the prostate,[25] is
nothing but this diarrhœa of anxiety-neurosis. The deception of a reflex
relationship comes about because the same factors which are active in
the origin of such prostatic affections also come into play in the
ætiology of anxiety-neurosis.
The behaviour of the gastro-intestinal tract in anxiety-neurosis
presents a sharp contrast to the influence of neurasthenia on those
functions. Mixed cases often show the well-known 'alternation of {86}
diarrhœa and constipation'. The urgent need to micturate that occurs
in the anxiety-neurosis is analogous to this diarrhœa.
9. The _paræsthesias_ which may accompany attacks of vertigo or anxiety
are interesting in that they (as also the sensations of the hysterical
aura) become associated in a definite sequence; but I find that, in
contrast to those of hysteria, these associated sensations are atypical
and changing. A further similarity to hysteria ensues because a kind of
_conversion_[26], which may otherwise easily be overlooked, to bodily
sensations takes place in anxiety-neurosis, e.g. a conversion which
takes effect in rheumatic muscles. Quite a number of rheumatic persons,
so-called, who moreover are demonstrable as such, in reality suffer from
anxiety-neurosis. Along with this increased sensitiveness to pain I have
observed in a series of cases of anxiety-neurosis a tendency to
_hallucinations_ which could not be explained as hysterical.
10. Several of the symptoms mentioned which accompany or take the place
of an anxiety-attack appear also in a chronic form. They are then still
less easy to recognize, since the accompanying anxious sensation is less
clearly recognizable than in anxiety-attacks. This is particularly true
of diarrhœa, vertigo, paræsthesias. Just as an attack of vertigo may be
replaced by a fainting-fit, so may chronic giddiness be replaced by a
constant feeling of sinking to the ground, exhaustion, etc.
II. THE INCIDENCE AND ÆTIOLOGY OF ANXIETY-NEUROSIS
In many cases of anxiety-neurosis no ætiology is recognizable at
all. It is remarkable that in such cases evidence of a grave {87}
hereditary taint is seldom difficult to establish.
But where there are grounds for regarding the neurosis as an acquired
one, careful enquiry to that end reveals a series of injurious
conditions (_noxiæ_) and influences within the sexual life as important
factors in the ætiology. At first sight these appear to be very various
in their nature but they soon disclose their common character, which
explains the fact that they always have the same effect on the nervous
system; further, they are either present alone or together with other
'ordinary' injurious factors, which latter may be regarded as having a
contributory effect. As this sexual ætiology of the anxiety-neurosis is
so very commonly demonstrable I feel justified _for the purpose of this
short paper_ in disregarding cases with a doubtful or a different
ætiology.
In setting forth in greater detail the ætiological conditions under
which anxiety-neurosis makes its appearance it will be advisable to
treat of men and women separately. Anxiety-neurosis appears in female
persons---disregarding for the moment their predisposition---in the
following cases:
_a_. as _virginal anxiety or anxiety in adolescents_. A number of
unambiguous observations has shown me that anxiety-neurosis can be
evoked in maturing girls by their first meeting with the sexual problem,
that is, by any more or less sudden revelation of what had hitherto been
hidden, for example, seeing the sexual act, or hearing or reading
something of that nature; in these cases anxiety-neurosis is typically
combined with hysteria;
_b_. as _anxiety in the newly-married_. Young married women who remain
anæsthetic during the first acts of intercourse often fall ill of an
anxiety-neurosis which again disappears as soon as the anæsthesia {88}
gives way to normal sensitivity. Since the majority of young women
remain healthy during a temporary anæsthesia of this kind, there are
conditions necessary to the outbreak of this anxiety, which I will
mention later;
_c_. as anxiety in women whose husbands suffer from ejaculatio præcox or
from impaired potency; and
_d_. whose husbands practise coitus interruptus or reservatus. These
cases belong together, for on analysing a large number of examples it is
easy to convince oneself that they depend simply on whether the wife
obtains satisfaction in coitus or not. The latter case provides the
condition for the genesis of an anxiety-neurosis. On the other hand, the
wife is saved from neurosis if the husband who is afflicted with
ejaculatio præcox can immediately repeat the congress with a better
result. Congressus reservatus by means of condoms is not injurious to
the wife if she is very quickly roused and the husband very potent; if
not, this kind of contraception is no less injurious than the others.
Coitus interruptus is almost always harmful; though only for the wife
when the husband practises it regardlessly, that is to say, when he
interrupts coitus as soon as _he_ is near to ejaculation without
troubling himself about the stage of his wife's excitement. If on the
other hand the husband waits for his wife's satisfaction then the coitus
will be equivalent to the normal for her---but the husband will become a
sufferer from anxiety-neurosis. I have collected and analysed a great
number of observations which have provided the material for these
conclusions;
_e_. as _anxiety in widows and voluntarily abstinent persons_, often
found in typical combination with obsessional ideas; {89}
_f_. as anxiety in the _climacteric_ during the last great increase of
sexual need.
Cases _c_., _d_., and _e_. embrace the conditions under which
anxiety-neurosis in the female sex most frequently arises and is least
dependent on hereditary predisposition. On the basis of these cases of
anxiety-neurosis---curable, acquired cases---I shall try to prove that
the injurious sexual condition (_noxia_) discovered in them really
represents the ætiological factor of this neurosis. Before doing so,
however, I will go on to discuss the sexual conditions for
anxiety-neurosis in men. I propose to set up the following groups, which
all have their analogies among women:
_a_. anxiety of the voluntarily _abstinent_, frequently combined with
_defence_ symptoms (obsessional ideas, hysteria). The motives which are
decisive for intentional abstinence bring it about that a number of
hereditarily-disposed or eccentric persons, etc. belong to this
category;
_b_. anxiety in men during _frustrated excitement_ (during an engagement
to marry), in persons who (from fear of the consequences of sexual
intercourse) content themselves with handling or gazing at the woman.
This group of conditions (which by the way applies equally to the other
sex: engagement, relationships involving sexual forbearance) furnishes
the purest cases of the neurosis;
_c_. anxiety in men who practise coitus interruptus. As has been said
already, coitus interruptus is harmful to the woman when it is
practised without regard to her satisfaction; but it becomes harmful
to the man if, in order to provide satisfaction for the woman, he
voluntarily controls coitus and delays the ejaculation. It thus
becomes intelligible that as a rule only _one_ partner of a married
couple practising coitus interruptus falls ill. Incidentally, coitus {90}
interruptus but rarely leads to a pure anxiety-neurosis in men; there
usually results a combination of it with neurasthenia;
_d_. anxiety in _ageing men_. There are men who have a climacteric like
women and who develop anxiety-neurosis at the time of their waning
potency and increased libido.
Finally I must add two other cases which are valid for both sexes:
_e_. The neurasthenics who after practising masturbation fall victims to
anxiety-neurosis as soon as they desist from their form of sexual
gratification. These persons have rendered themselves particularly
incapable of tolerating abstinence.
I observe here that in order to understand the anxiety-neurosis it is
important to realize that any pronounced manifestation of it occurs only
among men who are still potent and among women who are not anæsthetic.
Among neurasthenics whose potency has already been seriously diminished
by masturbation, the anxiety-neurosis resulting from abstinence is of a
very meagre character and confines itself as a rule to hypochondria and
mild chronic dizziness. The majority of women are to be regarded as
'potent'; a really impotent, i.e. really anæsthetic, woman is likewise
only mildly affected by anxiety-neurosis and tolerates the injurious
sexual conditions described surprisingly well.
How far beyond this we may be justified in postulating a constant
relation between particular ætiological factors and particular symptoms
in the complex of anxiety-neurosis, I do not yet wish to express any
opinion.
_f_. The last of the ætiological conditions I have to bring forward
appears at first sight not to be of a sexual nature at {91}
all. Anxiety-neurosis also arises (in both sexes) as a result of the
factor of over-work or exhausting exertion, for example, nights of
watching, sick-nursing, or even after severe illness.
The principal objection to my proposition of a sexual ætiology for the
anxiety-neurosis will probably run as follows: abnormal conditions in
the sexual life of the kind mentioned are found so very frequently that
they must be forthcoming wherever one looks for them. Their presence in
the cases of anxiety-neurosis quoted does not therefore prove that the
ætiology of this neurosis is to be found in them. The number of people,
moreover, who practise coitus interruptus, etc., is incomparably greater
than the number of those afflicted with anxiety-neurosis and the great
majority of the former tolerate this unhealthy condition quite well.
To this I have to reply that we should certainly not be right in
expecting to find in the neuroses an ætiological factor of _rare_
occurrence, seeing how very great their frequency admittedly is,
especially that of anxiety-neurosis; also that it actually fulfils a
postulate of pathology if in an ætiological enquiry the ætiological
factor is proved to be more frequent than its effect, since for the
latter other conditions are also required (disposition, summation of
specific ætiological factors, reinforcement by other 'ordinary'
injurious factors); and further, that detailed exploration of suitable
cases of anxiety-neurosis proves beyond question the importance of the
sexual factor. I will here confine myself to the ætiological factor of
coitus interruptus only and to adducing certain observations which
confirm it.
1. So long as an anxiety-neurosis in young married women is not yet
established, but only appears sporadically and disappears again {92}
spontaneously, it is possible to demonstrate that every such wave of
the neurosis is traceable to a coitus lacking in satisfaction. Two
days after this experience, or in persons of little resistance, on the
next day, an attack of anxiety or vertigo regularly appears, bringing
in its train the other symptoms of the neurosis, which all again
disappear together with the attack if marital relations occur
sufficiently seldom. A chance absence from home on the part of the
husband, or a holiday in the mountains necessitating the separation of
the couple, have a good effect; the gynæcological treatment that is
usually resorted to in the first instance is beneficial because
marital relations are broken off while it lasts. Strange to say,
however, the success of local treatment is but transitory---and even
in the mountains the neurosis reappears as soon as the husband in his
turn arrives; and so forth. When a physician who understands this
ætiology advises a patient in whom the neurosis is not yet established
to substitute normal relations for coitus interruptus a _therapeutic_
test of the statements made here is supplied. The anxiety is removed
and does not return again without a fresh cause of a similar nature.
2. In the history of many cases of anxiety-neurosis both among men and
women we find a striking fluctuation in the intensity of the clinical
symptoms, and even in the appearance and disappearance of the whole
condition. One year, they will say, was pretty good, the next was
frightful; on one occasion the improvement coincided with a certain
treatment which however on the next attack turned out quite useless;
and so on. Now if we enquire into the number and sequence of the
children and compare this record with the history of the neurosis a
simple solution results---the periods of improvement and well-being {93}
coincide with the wife's pregnancies, during which of course the need
for contraception was no longer present. The treatment that had been
so beneficial to the man, however, regardless of whether it was at
Pfarrer Kneipp's or at a hydrotherapeutic sanatorium, was the one
after which his wife had become pregnant.
3. From the anamnesis of patients we frequently find that the symptoms
of anxiety-neurosis have at some definite time supplanted the symptoms
of some other neurosis, for instance, neurasthenia, and have taken their
place. In such a case it can quite regularly be proved that, shortly
before the change in the clinical picture, a corresponding change had
taken place from one to another of the various kinds of unhealthy sexual
conditions possible.
Observations of this kind can be supplemented to any extent at
pleasure, positively compelling the physician to acknowledge a sexual
ætiology for a certain category of cases; other cases, however, which
would otherwise remain quite unintelligible, can at least be
understood without difficulty and classified by employing the sexual
ætiology as a key to them. These are those very numerous cases in
which we find everything that is also present in the previous
category---the clinical symptoms of anxiety-neurosis on the one hand,
and the specific factor of coitus interruptus on the other---but where
something else has interposed itself as well, namely, a long interval
between the ætiology we assume and its effect, and perhaps also
ætiological factors of a non-sexual nature too. Take, for example, a
man who has a heart-attack after receiving news of his father's death
and from that time onwards suffers from anxiety-neurosis. The case is
not clear, for the man was not nervous before this event; the death of {94}
the father who was well advanced in years did not occur under any
special circumstances, and one must admit that the normal, expected
decease of an aged father is not an experience which usually causes
illness in a healthy adult. Perhaps the ætiological analysis will be
clearer if I add that this man had for eleven years practised coitus
interruptus and always with regard for his wife's satisfaction. The
clinical symptoms at least are identical with those that appear in
other persons after an unhealthy condition of the same sexual nature
lasting for a short period and without the interpolation of another
trauma. Other cases must be estimated similarly, that of a woman in
whom anxiety-neurosis broke out after the loss of a child, or that of
a student whose studies preparatory to his qualifying examination were
interrupted by an anxiety-neurosis. I do not find that the effect in
these cases is explained by the ostensible ætiology. One is not
necessarily 'over-worked' by close study, and a healthy mother usually
reacts only with normal grief to the loss of a child. More
particularly, too, I should expect that the student would develop
cephalasthenia through over-work, and the mother in our example
hysteria. That they both develop an anxiety-neurosis induces me to lay
emphasis on the fact that the mother had lived for eight years in
marital coitus interruptus, and that the student had for three years
had a passionate love-relationship with a 'respectable' girl whom he
dared not allow to conceive.
These considerations lead to the conclusion that the specific sexual
_noxia_ contained in coitus interruptus at least disposes the person
concerned to acquire it in those cases where it is not in itself
enough to induce anxiety-neurosis. The neurosis then breaks out as {95}
soon as the influence of another ordinary injurious factor is added to
the latent effect of the specific factor; the former can _reinforce
the specific factor quantitatively but cannot replace it
qualitatively_. The specific factor always remains decisive for the
form taken by the neurosis. I hope to be able to prove this statement
in regard to the ætiology of the neuroses also on a wider scale.
Some few pages back I mentioned an assumption which is not improbable in
itself---namely, that a _noxia_ such as coitus interruptus attains its
effect by _summation_. According to the disposition of the person
concerned and the other burdens on his nervous system, a longer or
shorter time will be required before the effect of this summation
becomes evident. Those persons who tolerate coitus interruptus
apparently without harmful results are in reality becoming thereby
disposed to the disorder of anxiety-neurosis, which may break out either
at any time spontaneously or after an ordinary and otherwise
insufficient trauma; just as the chronic alcoholic will in the end
develop a cirrhosis or other illness as an effect of summation, or under
the influence of a fever will go down with a delirium.
III. ATTEMPTS TO FORMULATE A THEORY OF THE
ANXIETY-NEUROSIS
The following considerations can only claim the value of a preliminary
tentative attempt at a theory; criticism of them should not affect the
reader's acceptance of the _facts_ set forth above. Moreover, this
'Theory of Anxiety-Neurosis' represents only a fragment of a more
comprehensive presentation of the neuroses which increases the
difficulty of assessing its value.
The material already brought forward in regard to the anxiety-neurosis
has provided a few openings for some insight into its mechanism. In {96}
the first place it was surmised that we are here dealing with an
accumulation of excitation; secondly, there was the exceedingly
important fact that the anxiety, which underlies all the clinical
symptoms of this neurosis, _is not derived from any psychical
source_. A psychical origin would be present, for example, if we found
as the basis of an anxiety-neurosis a single or repeated shock,
justified by the circumstances, which had subsequently become the
source of the readiness to anxiety. But this is not what we find; an
hysteria or a traumatic neurosis may develop as a result of a single
shock---an anxiety-neurosis never. Since among the causes of
anxiety-neurosis coitus interruptus forces itself so much into the
foreground, I thought at first that the source of the continual
anxiety might lie in the fear, revived with every act, that the method
might miscarry and be followed by conception. But I have found that
this state of mind either in man or woman during coitus interruptus is
irrelevant for the genesis of anxiety-neurosis; that women who at
bottom are indifferent to the consequences of a possible conception
are just as liable to the neurosis as those who shudder at the
possibility, and that all depends on which of the partners forfeits
satisfaction in this method of intercourse.
A further indication is furnished by the observation, not before
mentioned, that in whole groups of cases anxiety-neurosis is
accompanied by a very noticeable abatement of sexual libido,[27]
i.e. of _psychical desire_; so that, on being told that their
sufferings result from 'insufficient satisfaction', patients regularly {97}
answer that that is impossible, because all their need for it has now
disappeared. From all these data: that an accumulation of excitation
is involved; that the anxiety which probably represents this
accumulated excitation is of somatic origin, so that it is somatic
excitation which is accumulated; further, that the somatic excitation
is of a sexual nature and that a decline in the psychical share in the
sexual process goes along with it---all these data prepare our minds
for the statement that _the mechanism of anxiety-neurosis is to be
sought in the deflection of somatic sexual excitation from the
psychical field, and in an abnormal use of it, due to this
deflection_.
This conception of the mechanism of anxiety-neurosis becomes clearer
if we accept the following view of the sexual process, which relates
primarily to men. In the sexually mature male organism somatic sexual
excitation is produced---probably continuously---and periodically acts
as a psychical stimulus. In order to define this idea more clearly,
let us interpolate that this somatic sexual excitation takes the form
of pressure on the walls of the vesiculæ seminales which are lined
with nerve-endings; this visceral excitation will then actually
develop continuously, but only when it reaches a certain height will
it be sufficient to overcome the resistance in the paths of conduction
to the cerebral cortex and express itself as a psychical
stimulus. Thereupon the constellation of sexual ideas existing in the
mind becomes charged with energy and a psychical state of libidinous
tension comes into existence, bringing with it the impulse to relieve
this tension. The necessary psychical relief can only be effected by
what I shall describe as a _specific_ or _adequate activity_. For the
male sexual impulse this adequate activity consists in a complicated
spinal reflex act resulting in the relief of the tension at these {98}
nerve-endings and in all the preparatory psychical processes necessary
to induce this reflex. Nothing but the adequate activity would be
effective; for, once it has reached the required level, the somatic
sexual excitation is continuously transmuted into psychical
excitation; the activity which will free the nerve-endings from
burdensome pressure and so abolish the whole of the somatic excitation
present, thus allowing the subcortical tracts to re-establish their
resistance, must absolutely be carried into operation.
I will refrain from describing more complicated forms of the sexual
process in this manner. I will only add the statement that in essentials
this formula is applicable also to women, notwithstanding the confusion
introduced into the problem by all the artificial arresting and stunting
that the female sexual impulse undergoes. In women also we must
postulate a somatic sexual excitation, and a condition in which this
excitation becomes a psychical stimulus, evoking libido and the impulse
to a specific activity to which sensual pleasure is attached. Where
women are concerned, however, we cannot state what is the process
analogous to the relief of tension in the vesiculæ seminales.
The ætiology of neurasthenia proper as well as of anxiety-neurosis can
now be brought within the compass of this conception of the sexual
process. Neurasthenia arises whenever a less adequate relief
(activity) takes the place of the adequate one, thus, when
masturbation or spontaneous emission replaces normal coitus under the
most favourable conditions; while anxiety-neurosis is produced by all
those factors which prevent the somatic sexual excitation from being
assimilated psychically. The clinical symptoms of anxiety-neurosis {99}
appear when the somatic sexual excitation that is deflected from the
mind is expended subcortically in quite inadequate reactions.
I shall now try to test the ætiological conditions of anxiety-neurosis
given above, in order to see whether they show the common character I
have ascribed to them. The first ætiological factor in men that I
mentioned is voluntary abstinence. Abstinence consists in foregoing
the specific activity which otherwise follows upon libido. Privation
of this kind can have two consequences, namely, that the somatic
excitation becomes augmented by accumulation, and secondly, that it is
then dissipated along other paths, through which it may find its
discharge more easily than along the path to the mind. Libido will
therefore subside again and the excitation will express itself instead
subcortically as anxiety. In cases where libido does not subside or
where the somatic excitation is expended by a short cut in emissions,
or where it actually becomes exhausted in consequence of being
restrained, anything else may arise, but not
anxiety-neurosis. Abstinence leads to anxiety-neurosis in the way
described. Abstinence is also the agent in the second ætiological
group, that of frustrated excitement. The third case, that of coitus
reservatus with regard for the woman, acts by disturbing the psychical
state of preparedness for the sexual process, in that it adds to the
task of dealing with the sexual affect another, a deflecting,
psychical task. In consequence of this psychical deflection libido
also gradually subsides, the further developments being then the same
as in abstinence. Anxiety in ageing men (the male climacteric)
requires another explanation. There is no reduction in libido here;
but, just as during the climacteric in women, such an increase in the {100}
production of somatic excitation occurs that the psyche proves
relatively unable to master it.
There is no greater difficulty in bringing the ætiological conditions in
women within the scope of our theory than in the case of men. Virginal
anxiety is a particularly clear example; the constellations of ideas to
which the somatic sexual excitation should become attached are not yet
sufficiently developed. In anæsthetic newly-married women anxiety only
appears when the first acts of intercourse arouse a sufficient quantity
of somatic excitation. When local indications of the state of excitement
(such as spontaneous local sensations, desire to micturate and the like)
are lacking, then anxiety is also absent. In cases where intercourse
involves ejaculatio præcox or coitus interruptus, the explanation is
similar to that given for men---libido gradually declines from the
psychically unsatisfying act, while the excitation called forth by the
act is expended subcortically. An _estrangement_ between the somatic and
the psychical in the course taken by sexual excitation is established
sooner and is more difficult to remove in women than in men. In
widowhood and in voluntary abstinence, as also in the climacteric, the
process is the same in women as in men; although in abstinence there
must also be the additional factor of an intentional repression of
sexual ideas which the abstinent woman battling with desire must
frequently resolve upon, and similarly, at the time of the menopause,
the detestation with which the ageing woman regards the unduly increased
libido must come into operation.
The two last ætiological conditions enumerated also seem to fall into
line without difficulty.
The tendency to anxiety in masturbators who have become neurasthenic {101}
is explained by the fact that these persons very easily pass into a
condition of 'abstinence' after they have for so long been accustomed
immediately to discharge every access of somatic excitation, however
small, although not in a normal manner. Finally, the last case, in
which anxiety-neurosis arises from serious illness, overwork,
exhausting sick-nursing, etc., may be brought into relation with the
mode of action of coitus interruptus and then find a simple
interpretation: by reason of the deflection of interest the mind is no
longer capable of mastering the somatic sexual excitation, a task
which is continuously incumbent on it. We know to what a low level
libido can sink under these conditions; and we have here an excellent
example of a _neurosis which has, it is true, no sexual ætiology, but
nevertheless shows a sexual mechanism_.
The theory here developed shows the symptoms of anxiety-neurosis to be
in some measure _surrogates_ for the specific activity which should
follow upon sexual excitation, but has not done so. In further
corroboration of this I may point out that even in normal coitus the
excitation expresses itself also in accelerated breathing, palpitations,
sweating, congestion and so on. In the corresponding anxiety-attacks of
our neurosis we see the dyspnœa, palpitations, etc. of coitus in an
isolated and exaggerated form.
The question may now be asked: Why does the nervous system under such
conditions---of psychical incapacity to master sexual
excitation---take on the particular affective state of anxiety? The
reply may be indicated somewhat as follows: The psyche develops the
affect of anxiety when it feels itself incapable of dealing (by an
adequate reaction) with a task (danger) approaching it externally; it {102}
develops the neurosis of anxiety when it feels itself unequal to the
task of mastering (sexual) excitation arising endogenously. That is to
say, _it acts as if it had projected this excitation into the outer
world_. The affect and the neurosis corresponding to it stand in a
close relation to each other; the first is the reaction to an
exogenous, the second to an analogous, endogenous, excitation. The
affect is a state which passes rapidly, the neurosis is a chronic
state; because an exogenous excitation acts like a single shock, an
endogenous one like a constant pressure. _The nervous system reacts to
an internal source of excitation with a neurosis, just as it reacts to
an analogous external one with a corresponding affect_.
IV. RELATION TO OTHER NEUROSES
There are still a few words to be said concerning the relation of
anxiety-neurosis to the other neuroses in respect of its incidence and
its inner connections with them.
The purest cases of anxiety-neurosis are as a rule the most developed.
These cases are found among young and sexually potent persons; they show
a uniform ætiology and no very long duration.
More frequently, however, anxiety symptoms occur contemporaneously and
in combination with those of neurasthenia, hysteria, obsessions and
melancholia. If because of this clinical confusion we are to refrain
from distinguishing anxiety-neurosis as a self-contained unity, then to
be logical we should have in addition to renounce the distinction
between hysteria and neurasthenia which has been acquired so
laboriously.
For the analysis of 'mixed neuroses' I can advocate the following
important formula: _Wherever a mixed_ _neurosis exists a combination {103}
of several specific ætiologies may be discovered_.
The number of ætiological factors which conditions a mixed neurosis may
occur quite fortuitously; for instance, if a fresh injurious factor adds
its effect to those already existing, e.g. a woman who had always been
hysterical begins at a certain point in her married life to experience
coitus reservatus and then acquires anxiety-neurosis in addition to her
hysteria; a man who had previously been in the habit of masturbating,
and had become neurasthenic, becomes engaged to be married and is
sexually roused during the intimacy with his fiancée, and then acquires
anxiety-neurosis in addition to his neurasthenia.
In other cases the number of ætiological factors is no accident; on the
contrary, some one of them has brought another into activity; for
example, a woman whose husband practises coitus reservatus without
regard to her satisfaction finds herself compelled to relieve by
masturbation the distressing excitation aroused by the act, as a result
of which she develops an anxiety-neurosis, but not in a pure form,
showing at the same time symptoms of neurasthenia; another woman in the
same injurious situation will have to battle with lewd thoughts and
visions, against which she struggles to defend herself, and will in this
way develop obsessional ideas as well as the anxiety-neurosis as a
result of coitus interruptus; lastly, a third woman's husband will lose
his attraction for her in consequence of coitus interruptus and she will
develop an affection for another man which she carefully keeps secret,
as a result of which we find a mixture of anxiety-neurosis and hysteria.
In a third category of mixed neuroses the interrelation of the
symptoms is even closer, in that the very same ætiological determinant {104}
regularly and simultaneously evokes both neuroses. Thus for example,
the sudden sexual revelation which is active in cases of virginal
anxiety always gives rise to hysteria as well as anxiety-neurosis;
cases of voluntary abstinence are for the most part from the beginning
united with true obsessional ideas; coitus interruptus never seems to
me to be able to provoke a pure anxiety-neurosis in men, but always a
combination of it with neurasthenia; and so on.
It follows from these considerations that the ætiological conditions for
the incidence of the neuroses must be distinguished more clearly from
their specific ætiological factors. The former, for example, coitus
interruptus, masturbation and abstinence, are still capable of various
interpretations; each one of them can produce many neuroses; only the
ætiological factors into which they can be resolved, such as _inadequate
relief_, _psychical inadequacy_, _defence by substitution_, have an
unequivocal and specific relation to the ætiology of the individual
great neuroses.
------------------------------------------------------------------------
In its essence anxiety-neurosis presents the most interesting
similarities to and differences from the other great neuroses,
particularly neurasthenia and hysteria. It shares with neurasthenia
its main characteristic: the source of the excitation, the inciting
factor in the disturbance, is somatic in nature, whereas in hysteria
and the obsessional neurosis it is psychical in nature. In other
respects we see rather a kind of antithesis between the symptoms of
neurasthenia and those of anxiety-neurosis which may be summed up in
the words: impoverishment or accumulation of excitation
respectively. This antithesis does not prevent the two neuroses from
being combined with one another, but is nevertheless clearly {105}
demonstrated by the fact that the most extreme forms of both neuroses
are also the purest.
In symptomatology anxiety-neurosis and hysteria have many points in
common, which need to be better appreciated. The appearance of
symptoms either in a chronic form or as attacks, the paræsthesias
grouped like aurœ, the hyperæsthesias and points of pressure which are
found in certain surrogates of the anxiety-attack (dyspnœa and
heart-attacks), the exacerbation (through conversion) of pains perhaps
having an organic basis---these and other common features even permit
the conjecture that much of what we attribute to hysteria may with
more justification be laid at the door of anxiety-neurosis. If we go
into the mechanism of the two neuroses so far as it has been possible
to discover it up to the present, aspects come to light which suggest
that anxiety-neurosis is actually the somatic counterpart of
hysteria. In each of them there is an accumulation of
excitation---which perhaps accounts for the similarity of the symptoms
already described; in each of them there is a _psychical inadequacy as
a consequence of which abnormal somatic processes come about_. In each
of them there occurs a deflection of excitation to the somatic field
instead of psychical assimilation of it; the difference is merely
this, that in anxiety-neurosis the excitation (in the displacement of
which the neurosis expresses itself) is purely somatic (the somatic
sexual excitation), whereas in hysteria it is purely psychical (evoked
by conflict). Little wonder then that hysteria and anxiety-neurosis
are regularly combined with one another, as in 'virginal anxiety' or
'sexual hysteria', and that hysteria simply borrows a number of its
symptoms from the anxiety-neurosis. These intimate relations between {106}
anxiety-neurosis and hysteria provide a new argument for demanding the
distinction of anxiety-neurosis from neurasthenia; for if this
distinction is not admitted then neither are we justified in
maintaining the distinction between neurasthenia and hysteria which
was so laboriously come by and is so indispensable for the theory of
the neuroses.
------------------------------------------------------------------------
VI {107}
A REPLY TO CRITICISMS ON THE ANXIETY-
NEUROSIS[28]
(1895)
In No. 2 of Mendel's _Neurologisches Zentralblatt_ 1895, I published a
short paper in which I ventured an attempt to distinguish a series of
nervous states from neurasthenia and give them independence under the
name of 'Anxiety-Neurosis'.[29] I was led to do so by finding a
constant combination of certain clinical and ætiological characters,
which may always decide us to make such distinctions. I found, as E.
Hecker[30] had done before me, that the neurotic symptoms in question
could all be united under the head of 'pertaining to the expression of
_anxiety_'; and I was able to add from my study of the ætiology of the
neuroses that these component parts of the complex 'anxiety-neurosis'
show special ætiological conditions which are almost the opposite of
the ætiology of neurasthenia. My observations had shown me that in the
ætiology of the neuroses (at least of the acquired and acquirable
forms) sexual factors play a predominant part, hitherto far too little
appreciated; so that the assertion: 'the ætiology of the neuroses lies
in sexuality', with all its necessary inexactness _per excessum et
defectum_, nevertheless comes nearer to the truth than the other
doctrines ruling at the present time. A further statement to which {108}
experience forced me was to the effect that the various sexual noxiæ
were not to be found indifferently in the ætiology of all neuroses,
but that there were evidently special relationships of particular
noxiæ to particular neuroses. I thought I could assume, therefore,
that I had discovered the specific causes of the different neuroses. I
then sought to comprehend in a short formula the peculiarity of the
sexual noxiæ which constitute the ætiology of anxiety-neurosis, and
arrived at the statement, dependent on my idea of the sexual process
(see pp. 98--9): Anxiety-neurosis is produced by anything which
withholds somatic sexual tension from the psychical and interferes
with its elaboration within the psychical field. If we refer to the
concrete circumstances in which this factor expresses itself, we come
to the conclusion that voluntary or involuntary abstinence, sexual
intercourse with incomplete gratification, coitus interruptus, the
deflection of psychical interest from sexuality and so on, are the
specific ætiological factors of the states I have called
anxiety-neurosis.
When I published the paper mentioned above, I in no way deceived
myself about its power to arouse conviction. In the first place I knew
that I had only given a scanty, incomplete presentation---one that was
even in parts difficult to comprehend; it was perhaps just sufficient
to arouse the reader's expectation. I had besides adduced hardly any
examples and quoted no statistics; the technique of collecting the
case-histories was not touched on; no provision was made to avoid
misunderstandings; other objections than the most obvious ones were
not considered; and concerning the theory itself, only the main theme
was brought into prominence and its limitations were
disregarded. Accordingly, everyone was justified in forming his own {109}
judgement upon the conclusiveness of the whole proposition. I had to
look forward, moreover, to yet another source of disagreement. I know
very well that I have advanced nothing new by suggesting the 'sexual
ætiology' of the neuroses, that undercurrents in medical literature
acknowledging these facts have never been absent, and that the
official medicine of the schools has actually been aware of them
also. But the last has behaved, however, as if it knew nothing about
it, making no use of its knowledge, and deducing nothing from it. Such
conduct must surely have a deep-rooted cause, originating perhaps in a
kind of aversion from looking into sexual matters, or in a reaction
against older attempts at explanation which were regarded as
outworn. At all events, anyone who ventures to make something credible
to others who could without any trouble have discovered it for
themselves, must be prepared to meet with opposition.
With such a state of affairs it would perhaps have been more expedient
not to answer critical objections until I had expressed myself in
greater detail upon the complicated theme itself and had made myself
more intelligible. Nevertheless I cannot resist the motives which
induce me immediately to join issue with a recent criticism of my
theory of anxiety-neurosis. I do this because the writer, L. Löwenfeld
(Munich), the author of _Pathologie und Therapie der Neurasthenie und
Hysterie_, is one whose judgement probably has great weight with the
medical public, and because of a mistaken conception which Löwenfeld
imputes to me; and also because I wish at once to combat the idea that
my theory is to be overthrown so very easily by the first casual and
impromptu objections. {110}
Löwenfeld correctly discovers at a glance the essence of my work to be
my assertion that anxiety symptoms are due to a specific and uniform
ætiology of a sexual nature. If this cannot be established as a fact
then the principal reason for distinguishing an independent
anxiety-neurosis from neurasthenia also falls to the ground. There
remains, however, one difficulty to which I called attention---namely,
that anxiety symptoms have manifest relations also to hysteria; so that
the decision as Löwenfeld would have it brings the distinction between
hysteria and neurasthenia to grief; though this difficulty is obviated
by reference to heredity as the common cause of all the neuroses, a
point which will be discussed later.
Now by what arguments does Löwenfeld support the case against my theory?
1. I have emphasized as a point essential for comprehension of the
anxiety-neurosis that the anxiety of that condition does not admit of a
psychic derivation, that is, that the anxious expectation which
constitutes the nucleus of the neurosis cannot be acquired through a
single or repeated affect of fright which is justified psychically.
Fright, as I have pointed out, may result in hysteria or a traumatic
neurosis, but not in an anxiety-neurosis. It is easy to see that this
negation is simply the obverse of my assertion (with a positive
content): the anxiety of my neurosis represents a somatic sexual tension
deflected from the psychical field where it would otherwise have made
itself felt as libido.
Against this, Löwenfeld lays stress on the fact that in a series of
cases 'anxiety states appear immediately or shortly after a mental
shock (fright alone, or accidents accompanied by fright) and that
these circumstances make the co-operation of sexual noxiæ of the kind {111}
mentioned at least most improbable.' He gives in brief, as a
particularly pregnant example, one observation of a patient out of
many. This example relates to a woman aged thirty, married for four
years, of tainted stock, who had undergone a first difficult
confinement a year before. A few weeks after it her husband had an
attack of illness which frightened her exceedingly and in her
excitement she ran about the cold room in her chemise. From that time
onward she was ill, first with anxiety and palpitations in the
evenings, later with attacks of convulsive trembling, and in further
sequence phobias and the like---the picture of a fully-developed
anxiety-neurosis. 'Here', concludes Löwenfeld, 'the anxiety states are
manifestly of psychic origin consequent on a single shock.'
I do not doubt that my honoured critic can produce many similar cases;
I myself can supply a long series of analogous examples. Anyone who
had not seen such very common cases of the outbreak of
anxiety-neurosis following upon a mental shock could not regard
himself as qualified to discuss the question of anxiety-neurosis. I
will only observe in this connection that neither shock nor anxious
expectation is necessarily always demonstrable in the ætiology of such
cases; any other emotion will serve as well. If I hurriedly call to
mind a few cases from recollection there occurs to me that of a man of
forty-five who first had an anxiety-attack (with cardiac collapse) on
receiving the news of the death of his aged father: from that time
onwards a complete and typical anxiety-neurosis with agoraphobia
developed; further, a young man who fell a victim to the same neurosis
on account of the disagreements between his young wife and his mother,
and developed the agoraphobia afresh after every domestic quarrel; a {112}
student who was rather an idler and had his first anxiety-attacks
during a period of hard cramming under the spur of paternal
displeasure; a woman, herself childless, who fell ill in consequence
of anxiety concerning the health of her small niece, and so on. As to
the facts themselves which Löwenfeld employs against me there cannot
be the slightest doubt.
It is otherwise with their interpretation! Are we then without further
ceremony to accept the _post hoc ergo propter hoc_ conclusion and save
ourselves all critical consideration of the raw material? Surely we
are acquainted with examples enough in which the final exciting factor
cannot keep up its reputation as _causa efficiens_ in the face of
critical analysis? Take the relation between trauma and gout, as an
example. The rôle of a trauma in provoking an attack of gout in the
injured limb is probably not different from the part it plays in the
ætiology of tabes and general paralysis of the insane; only in the
case of gout everyone would see that it is absurd to say the trauma
has 'caused' the gout, instead of provoked it. It should make us
cautious when we meet with ætiological factors of such a
kind---ordinary factors, I should like to call them---in the ætiology
of the most varied forms of illness. Emotion, such as fright, is also
an ordinary factor of this kind; fright can evoke chorea, apoplexy,
paralysis agitans and what not, just as well as an
anxiety-neurosis. Now I should certainly not continue to argue along
these lines, that because of their prevalence the ordinary factors do
not satisfy our requirements, and therefore there must be specific
causes besides; it would beg the question at issue. But I am justified
in concluding as follows: If a single specific cause can be proved in
the ætiology of all or almost all cases of anxiety-neurosis, then our {113}
view will not necessarily be erroneous because the outbreak of illness
only occurs under the influence of some one or other ordinary factor,
such as emotion.
So it was in my cases of anxiety-neurosis. The man who fell
ill---inexplicably---after receiving the news of his father's death (I
make this interpolated comment because this death was not unexpected and
did not occur in unusual or tragic circumstances) had for eleven years
practised coitus interruptus with his wife whom he usually endeavoured
to satisfy; the young man who could not tolerate the quarrels between
his wife and his mother had practised withdrawal with his young wife
from the beginning, in order to save them the burden of offspring; the
student who developed anxiety-neurosis through overwork, instead of
cerebrasthenia as we should expect, had for three years had a
relationship with a girl whom he dared not let become pregnant; the
woman who had no children herself and fell ill of anxiety-neurosis owing
to the illness of a niece was married to an impotent man and had never
been sexually gratified; and so on. Not all these cases are equally
clear nor prove my theory with equal force; but if I add them to the
very considerable series of cases in which the ætiology shows nothing
but the specific factor, they conform without a dissentient note to the
theory I have put forward and make it possible for us to extend our
ætiological comprehension beyond the boundaries which have existed
hitherto.
If anyone wishes to prove to me that I have unduly neglected the
significance of ordinary ætiological factors in the foregoing
discussion, he must confront me with observations in which my specific
factor is lacking, that is, with cases in which, although the _vita {114}
sexualis_ is (more or less) normal, anxiety-neurosis breaks out after
a mental shock. Now let us see whether Löwenfeld's case fulfils this
condition. My worthy opponent has manifestly not clearly recognized
this necessity in his own mind, otherwise he would not have left us so
completely in the dark concerning the _vita sexualis_ of his
patient. I will leave on one side the fact that the case of the lady
of thirty is obviously complicated by an hysteria, about the psychical
origin of which I should be the last to have any doubt; I naturally
admit without protest the presence of an anxiety-neurosis alongside
this hysteria. But before I make use of a case as evidence either for
or against my theory of the sexual ætiology of the neuroses I must
study the sexual conduct of the patient more thoroughly than Löwenfeld
has done here. I should not be contented with the conclusion that,
because the lady had the mental shock shortly after a confinement,
coitus interruptus had probably played no part during the previous
year and that therefore no sexual noxiæ had arisen here. I know of
cases of women who become pregnant year after year and develop
anxiety-neurosis because---_incredibile dictu_---all sexual relations
ceased after pregnancy had set in; so that in spite of having many
children they might have lived all the years of their married life in
sexual privation. It is known to every physician that women do
conceive from men whose potency is very feeble and who are not able to
give them satisfaction; and finally there are many women who are
afflicted with a congenital anxiety-neurosis, that is to say, are
endowed with a _vita sexualis_ (or develop it without demonstrable
external provocation) of the kind usually acquired by coitus
interruptus and similar noxiæ---a consideration which upholders of
the ætiology of heredity ought to take into account. In a number {115}
of these women we are able eventually to discover a past history of a
hysterical illness in their youth, which has affected the _vita
sexualis_ ever since or has established a deflection of sexual tension
away from the psychical field. Women with this kind of sexuality are
incapable of real satisfaction, even in normal coitus, and develop
anxiety-neurosis either spontaneously or after further effective
factors have supervened. Which of all these factors mentioned could
have contributed to Löwenfeld's case I do not know; but I repeat that
this case is evidence against me only if the lady who responded to a
single fright with an anxiety-neurosis had previously enjoyed a normal
_vita sexualis_.
It is impossible to pursue ætiological research by means of the
anamnesis of patients if we accept the patient's account as he gives it
or are satisfied with what he volunteers. If syphilidologists allowed
themselves to depend upon the declarations of their patients, when
endeavouring to trace an initial infection of the genitalia back to an
act of sexual intercourse, they would have to attribute an imposing
number of chancres to a chill in persons who protest their virginity,
and gynæcologists would have little difficulty in confirming the miracle
of parthenogenesis among their unmarried clients. I hope that some day
the idea will gain admittance that neuropathologists too may be subject
to similar ætiological prejudices in the work of collecting the
case-histories of the great neuroses.
2. Löwenfeld further says that he has repeatedly seen anxiety-states
appear and disappear where a change in the sexual life had certainly
not taken place, but where there were other factors in play. {116}
I too have had exactly the same experience, but I was not misled by
it. I too have brought anxiety-attacks to an end by psychical
treatment, improvement of the patient's general condition and so on. I
have naturally not concluded from this that lack of treatment was the
cause of anxiety-attacks. Not that I would credit Löwenfeld with a
conclusion of this kind, to be sure; my joking remark is only intended
to show that the state of affairs may easily be so complicated as to
nullify his objection completely. I have not found any difficulty in
harmonizing the fact brought forward here with the theory of a
specific ætiology of anxiety-neurosis. It will readily be granted that
ætiological factors exist which, in order to become effective, must
act with a certain intensity (or quantity) and over a certain length
of time, which therefore _summate_; the effects of alcohol are a
standard example of illness produced by summation. Accordingly we must
reckon with a space of time in which the specific ætiology is at work,
but during which its effects are not yet manifest. During such a
period the person is not yet ill, but he is disposed to a particular
illness---in this case to anxiety-neurosis---and as soon as the
'ordinary' noxia supervenes it can excite the outbreak of the neurosis
just as well as a further increase in operation of the specific
noxia. We can also express this as follows: It is not sufficient for
the specific ætiological factor to exist; a certain measure of it must
also be reached, and in attaining this measure a degree of the
specific noxia can be made up by an amount of 'ordinary' injurious
factors. If the last is again eliminated, the level of the specific
ætiological factor falls below the threshold; the symptoms recede
again. The entire therapy of the neuroses rests upon the fact that the
total load upon the nervous system, to which the latter is succumbing, {117}
can be reduced below this level by very various influences on the
combination of ætiological factors. No conclusions can be drawn from
this state of things in regard to the presence or absence of a
specific ætiology.
These considerations are surely indisputable and assured. Anyone who
does not think them sufficient may permit the following argument to
weigh with him. According to the views of Löwenfeld and many others the
ætiology of anxiety states lies in heredity. Now heredity can certainly
not be altered; if anxiety-neurosis is curable by treatment we (and
Löwenfeld too) ought to conclude that heredity cannot account for its
ætiology.
For the rest, I might have been spared defending myself against both
of Löwenfeld's objections if my worthy opponent had bestowed greater
attention upon my paper itself. Both objections are anticipated in it
and answered (p. 92 ff.); I could only repeat here what I said there;
I have even purposely analysed the same cases of illness
afresh. Further, the ætiological formulæ upon which I had previously
laid weight are contained in the text of my former paper. I will
repeat them once again here. I maintain that: _There exists a specific
ætiological factor for the anxiety-neurosis which in taking effect can
be reinforced quantitatively by 'ordinary' injurious factors but
cannot be replaced by them qualitatively_. Further: _This specific
factor determines more than anything the type of neurosis; whether a
neurotic illness occurs at all depends on the total load on the
nervous system_ (_in relation to its capacity to carry the load_). As
a rule neuroses are _overdetermined_; that is to say, several factors
in their ætiology operate together. {118}
3. I shall have less trouble in refuting Löwenfeld's next comments
because on the one hand they have little to do with my theory and on the
other because they call attention to difficulties which I acknowledge.
Löwenfeld says: 'The Freudian theory is totally insufficient to explain
the appearance and non-appearance of individual anxiety-attacks. If
anxiety states, i.e. the clinical symptoms of anxiety-neurosis, occurred
solely through subcortical accumulation of somatic sexual excitation and
through abnormal expenditure of the same, then everyone subject to
anxiety states would have an attack from time to time so long as no
alteration took place in his sexual life, just as the epileptic has his
attack of _grand et petit mal_; but this, as every-day experience shows,
is by no means so. Anxiety-attacks occur for the most part only on
definite occasions. If the patient avoids these or knows how to paralyse
their influence by means of any precaution, then he remains exempt from
anxiety-attacks, whether he habitually practises coitus interruptus or
abstinence or enjoys a normal _vita sexualis_.'
Now there is a great deal to be said about this. In the first place
Löwenfeld forces my theory to a conclusion which is not inherent in
it. That the process must be the same with an accumulation of somatic
sexual excitation as with an accumulation of the stimuli resulting in
an epileptic convulsion is a far too detailed proposition, for which I
have given no occasion; and it is not the sole one which offers
itself. I need only assume that the nervous system possesses the power
to master a certain amount of somatic sexual excitation even when this
is deflected from its purpose, and that disturbances then occur only
if the _quantum_ of this excitation suddenly undergoes an
increase---and Löwenfeld's claim would be quashed. I have not ventured {119}
to extend my theory far in that direction; chiefly because I did not
expect to find reliable support on the way. I will merely indicate
that we should not conceive the production of sexual tension to be
independent of its expenditure; that in normal sexual life this
production, when stimulated by the sexual object, takes a form
essentially different from that which it has in psychic repose, and so
on.
It must be admitted that the conditions here are in all probability
different from those obtaining in the tendency to epileptic convulsion,
and that they are not yet wholly correlated with the theory of an
accumulation of somatic sexual excitation.
To Löwenfeld's further assertion---that anxiety-attacks only appear
under certain conditions and fail to appear when these are avoided,
whatever the _vita sexualis_ of those concerned---we may urge in
contradiction that Löwenfeld manifestly has in mind only the anxiety
of _phobias_, as is shown by the examples appended to the part of his
essay which I have quoted. He says not a word concerning spontaneous
anxiety-attacks, taking the form of dizziness, palpitation, dyspnœa,
trembling, sweating, etc. My theory, however, seems quite equal to
explaining the appearance and non-appearance of these anxiety-attacks.
The semblance of periodicity in the onset of anxiety states may be
found in a great number of such cases of anxiety-neurosis, similar to
that observed in epilepsy, only that here the mechanism of this
periodicity is more perspicuous. On closer examination we find with
great regularity an exciting sexual occurrence (that is, one capable
of releasing somatic sexual excitation), recurring at definite and
often quite constant intervals of time, to which the anxiety-attack is
related. In abstinent women this part is played by menstrual {120}
excitation, and in both men and women by recurrent nocturnal
pollutions and above all by sexual intercourse itself (injurious when
it is incomplete), which transfers its own periodicity to the
anxiety-attacks resulting from it. If anxiety-attacks occur apart from
the usual periodicity, it is usually possible to trace them back to an
occasional cause of more rare and irregular incidence, to a single
sexual experience, something read, a visual impression, or the
like. The interval I referred to varies from a few hours up to two
days: it is the same as that which in other persons is followed by the
well-known sexual migraine, due to the same causes, which has an
undoubted connection with the symptom-complex of anxiety-neurosis.
Besides these there are plenty of cases in which a single anxiety state
is provoked by an ordinary factor, i.e. by excitement of any kind. The
same mechanism of displacement thus holds good for the ætiology of a
single anxiety-attack as for the causation of a whole neurosis. That the
anxiety of phobias answers to different conditions is not very
remarkable; phobias have a more complicated structure than purely
somatic anxiety-attacks. In them the anxiety is connected with a
definite ideational or conceptional content, and the chief condition for
the development of this anxiety comes into being when this psychical
content is aroused. The anxiety is then 'released', just as, for
example, sexual tension is released by the awakening of libidinous
ideas; this process, however, is not yet clearly elucidated in its
relation to the theory of anxiety-neurosis.
I see no reason why I should try to conceal the gaps and weaknesses in
my theory. The main point in the problem of phobias seems to me that
_phobias do not occur at all when the vita sexualis is normal_, that {121}
is, when the specific determinant is absent; by this specific
determinant we mean a disturbance of the _vita sexualis_ by deflection
of the somatic away from the psychical field. However obscure
otherwise the mechanism of phobias may be, my theory is only to be
gainsaid by evidence of phobias occurring together with a normal _vita
sexualis_, or even together with some disturbance of it that is not
specific.
4. I now pass on to a remark made by my esteemed critic which I cannot
leave uncontradicted. I had written in my essay on anxiety-neurosis
(loc. cit. p. 86):
'In many cases of anxiety-neurosis no ætiology is recognizable at all.
It is remarkable that in such cases evidence of a grave hereditary taint
is seldom difficult to establish. But where there are grounds for
regarding the neurosis as an acquired one, careful enquiry directed to
that end reveals a series of injurious conditions (noxiæ) and influences
within the sexual life as important factors in the ætiology...'
Löwenfeld quotes this paragraph and adds the following comment:
'According to this Freud always appears to regard a neurosis as
"acquired" whenever exciting causes are discoverable.'
If this meaning is readily conveyed by my text then the latter gives a
very distorted expression of my thoughts. Let me point out that in the
preceding paragraphs I have shown myself far stricter than Löwenfeld
in assessing the importance of exciting causes. If I myself were to
explain the meaning of my statement I should do so by adding to it,
after the conditional: '_But where we have ground for regarding the
neurosis as acquired_', the phrase: '_because the evidence_ (mentioned
in the previous sentence) _of hereditary taint is not forthcoming_.'
The meaning is: I hold a case to be acquired in which heredity is not
demonstrable. I behave in this respect just as everyone else does, {122}
perhaps with the slight difference that others will also explain a
case as conditioned by heredity where no heredity exists, so that they
overlook the entire category of acquired neuroses. But this difference
runs in my favour. I admit however that I am myself to blame for this
misunderstanding on account of the way I expressed myself in the first
sentence: 'an ætiology cannot be found at all.' I shall also certainly
be told that I have created useless trouble for myself by searching
for specific causes of the neuroses. It will be said that the real
ætiology of anxiety-neurosis, as of the neuroses in general, is
already known to be that of heredity, and two real causes cannot exist
side by side. Am I prepared to deny the ætiological rôle of heredity?
If not, all other ætiologies must be equally valid or equally
invalid---merely exciting causes.
I do not share this view concerning the ætiological rôle of heredity
and, since on my short paper on anxiety-neurosis I have dealt less with
this theme than with any other, I shall try to some extent to make good
this omission and to efface the impression that in the composition of my
paper I had not given equal consideration to all the inter-related
problems.
I think we can effect a presentation of the probably very complicated
ætiological conditions which exist in the pathology of the neuroses, if
we establish the following ætiological concepts:
(_a_) _Predisposition_, (_b_) _Specific Cause_, (c) _Contributory Cause_
and, as a term not equivalent to the former (_d_) _Exciting_ or
_Releasing Cause_.
In order to satisfy all possibilities let us assume that we are
dealing with ætiological factors capable of quantitative alterations,
and consequently of increase or decrease. {123}
If we may use the conception of a compound ætiological formula which
must be fulfilled if the effect is to take place, then we may designate
as exciting or releasing cause that which last makes its appearance in
the formula, so that it immediately precedes the manifestation of the
effect. It is this temporal element alone which constitutes the essence
of an incitement; each of the other factors can in individual cases play
the part of an incitement, and this part can even alternate within this
same ætiological conglomeration.
The factors which are to be described as predisposition are those in
whose absence the effect would never come about; but which, however, are
incapable of alone bringing about the effect, no matter to what degree
they may be present. For the specific cause is lacking.
The _specific cause_ is one which is never absent when the effect
actually takes place, and which also suffices, in the required quantity
or intensity, to bring about the effect, provided that the
predisposition is present as well.
As _contributory causes_ we may comprehend such factors as are not
necessarily present every time nor able in any degree to produce the
effect alone, but which co-operate with the predisposition and the
specific ætiological cause to make up the ætiological formula.
The peculiar position of the contributory or auxiliary causes seems
clear; but how are we to distinguish between predisposition and specific
causes, since both are indispensable and no one of them alone is
sufficient as a cause?
In these circumstances the following considerations would seem to make
a decision possible. Among the 'indispensable causes' we find several
which are also present in the ætiological formulæ of many other {124}
conditions beside anxiety-neurosis, thus showing that they have no
particular relation to individual disorders; _one_ of these causes,
however, stands out with special prominence, in that it is found in no
other or in very few ætiological formulæ, and this has a claim to be
called the _specific_ cause of the disease in question. Further,
predisposing factors and specific causes are particularly clearly
distinguished in cases where the former have the quality of long
duration and little alteration in their condition, whereas the
specific cause corresponds to a factor which has recently come into
action.
I will attempt to give an example of this complete ætiological scheme:
_Effect_: Phthisis pulmonum.
_Predisposition_: For the most part an hereditary disposition of the
organs concerned.
_Specific Cause_: Koch's bacillus.
_Contributory Causes_: Everything that lowers resistance; emotion as
well as infections or colds.
The scheme for the ætiology of anxiety-neurosis seems to me to run
similarly, thus:
_Predisposition_: Heredity.
_Specific Cause_: A sexual factor in the sense of a deflection of sexual
tension from the psychical field.
_Contributory Causes_: All 'ordinary' injurious factors: emotion,
fright, as well as physical exhaustion through illness or over-exertion.
If I go into this ætiological formula for the anxiety-neurosis in
greater detail I can add the following remarks: Whether a special
personal disposition (which need not necessarily be ascribed to
heredity) is unconditionally required in anxiety-neurosis or whether
every normal person can develop that neurosis if there should be a
quantitative increase of the specific factor, I am not able to decide {125}
with certainty, but I incline strongly to the latter
view.---Hereditary disposition is the most important determinant of
anxiety-neurosis, but not an _indispensable_ one, since it is lacking
in a series of borderline cases.---The specific sexual factor is in
the very great majority of cases to be demonstrated with certainty; in
a series of cases (congenital) it is not distinguishable from the
hereditary determinant, but comes to expression with it; that is to
say, these persons are endowed with a peculiarity of the _vita
sexualis_ as a stigma (being psychically unequal to the task of
mastering somatic sexual tension), which in other cases must be
acquired before the patient can fall ill of this neurosis. In another
series of border-line cases the specific factor is contained in a
contributory one, for example, if the psychical inadequacy mentioned
above comes about in consequence of exhaustion, etc. All these cases
fall into shifting series, not discrete categories; through all of
them, however, runs one common factor---the same behaviour in regard
to sexual tension, and for most of them the distinction between
predisposition, specific and contributory causes is valid, in
conformity with the completion of the ætiological formula given above.
When I consult my experience for the purpose I cannot find that an
antithetic relation exists between hereditary disposition and the
specific sexual factor in anxiety-neurosis. On the contrary, the two
ætiological factors reinforce and complement each other. The sexual
factor is _as a rule_ effective only with those persons who are also
endowed with an hereditary taint; heredity alone is not usually able
to produce an anxiety-neurosis, but waits for the incidence of a
sufficient quantity of the specific sexual noxia. The existence of an {126}
hereditary factor does not spare us therefore the search for a
specific factor, upon which, incidentally, all therapeutic interest
also depends. For where are we to begin therapeutically with an
hereditary ætiology? It has always been present in the patient and
will continue in him until his end is come. Taken by itself it cannot
explain either the episodic outbreak of a neurosis or the cessation of
one through treatment. It is nothing but a condition of the
neurosis---an incalculably important one, it is true; but one that is
nevertheless overestimated, to the disadvantage of therapy and
theoretical comprehension. One has only to think, by way of contrast,
of the cases of familial nervous diseases (chorea chronica, Thomsen's
disease and so on) in which heredity unites in itself all the
ætiological determinants.
In conclusion I desire to repeat the few statements in which I am
accustomed, as a first approximation to the truth, to express the
inter-relation of the different ætiological factors:
1. Whether a neurotic illness _occurs at all_ depends upon a
quantitative factor, upon the total load on the nervous system in
relation to its capacity for resistance. Anything which can keep this
factor below a certain threshold, or bring it back below it, is
effective therapeutically, since the ætiological formula is thus kept
unfulfilled.
What is meant by 'total load' or 'capacity for resistance' could be
explained in greater detail on the basis of certain hypotheses
concerning nerve function.
2. To what _extent_ the neurosis develops depends in the first place
on the measure of hereditary taint. Heredity acts like a multiplier
introduced into the circuit, which increases the deflection of the
needle many times. {127}
3. But what _form_ the neurosis takes---the direction of
deflection---is determined only by the specific ætiological factor
arising in the sexual life.
I hope that on the whole, although I am myself conscious of the many
still unsolved difficulties of the subject, my theory of
anxiety-neurosis will prove more fruitful for the elucidation of the
neuroses than Löwenfeld's attempt to account for the same facts by
reference to 'a combination of neurasthenic and hysterical symptoms in
the form of attacks'.
------------------------------------------------------------------------
VII {128}
OBSESSIONS AND PHOBIAS:
THEIR PSYCHICAL MECHANISMS AND THEIR
ÆTIOLOGY[31]
(1895)
I shall begin by challenging two assertions often found repeated with
regard to the syndromes: obsessions and phobias. I must state, first,
that they should not be included under neurasthenia proper, since the
patients afflicted with these symptoms are often neurasthenics, but as
often not; and secondly, that we are not justified in regarding them as
the effect of mental degeneration, because they are found in persons no
more degenerate than the majority of neurotics in general, because at
times they improve, and indeed at times we even succeed in curing
them.[32]
Obsessions and phobias are separate neuroses, with a special mechanism
and ætiology which I have succeeded in demonstrating in a certain number
of cases, and which, I hope, will prove similar in a large number of new
cases.
As regards classification of the subject, I propose to exclude a group
of intense obsessions which are nothing but memories, unaltered images
of important experiences. As an example, I will cite Pascal's
obsession: he always thought he saw an abyss on his left hand 'after {129}
he had nearly been thrown into the Seine in his coach'. These
obsessions and phobias, which might be called _traumatic_, are allied
to the symptoms of hysteria.
Apart from this group we must distinguish: (_a_) obsessions proper;
(_b_) phobias. The essential difference between them is the following:
Two components are found in every obsession: (1) an idea that forces
itself upon the patient; (2) an associated emotional state. Now in the
group of phobias this emotional state is always one of 'morbid anxiety',
while in true obsessions other emotional states, such as doubt, remorse,
anger, may occur in the same capacity as fear does in the phobias. I
will first attempt to explain the remarkable psychological mechanism of
true obsessions, a mechanism quite different from that of the phobias.
I
In many true obsessions it is quite plain that the emotional state is
the chief element, since this state persists unchanged while the idea
associated with it varies. The girl in Case 1 quoted below, for example,
felt remorse in some degree for all sorts of reasons---for having
stolen, for having ill-treated her sisters, for having counterfeited
money, etc. Persons who doubt have many doubts at the same time or
consecutively. In them it is the emotional state which remains constant;
the idea changes. In other cases the idea, too, seems fixed, as in Case
4, the girl who persecuted servants in the household with an
incomprehensible hatred, constantly changing the individual object,
however.
Now a careful psychological analysis of these cases shows that the
emotional state, as such, is always justified. Case 1, the girl who
suffered from remorse, had good reasons for it; the women in Case 3
who doubted their resistance against temptation knew very well {130}
why. The girl in Case 4, who detested servants, was justified in
complaining, etc. Only, and it is in these two characteristics that
the pathological sign lies, (1) the emotional state persists
continually, and (2) the associated idea is no longer the appropriate
original one, ætiologically related to the obsession, but is one which
replaces it, a substitute for it.
The proof of this is the fact that we can always find in the previous
history of the patient, at the beginning of the obsession, the original
idea that has been replaced. The replaced ideas all have common
attributes; they correspond to really painful experiences in his sexual
life which the person is striving to forget. He succeeds merely in
replacing the irreconcilable idea by another ill-adapted to the
emotional state, which for its part remains unchanged. It is this
incongruity between the emotional state and the associated idea that
accounts for the absurdity so characteristic of obsessions. I will now
bring forward my observations and conclude with a tentative theory and
explanation.
_Case 1_. A girl reproached herself for things which she knew were
absurd, for having stolen, for having counterfeited money, for having
dabbled in magic, etc. according to whatever she had been reading during
the day.
_Reinstatement of the replaced idea_. She reproached herself with the
onanism she had been practising secretly without being able to renounce
it. She was cured by careful surveillance which prevented her
masturbating.
_Case 2_. A young man, a medical student, suffered from an analogous
obsession. He reproached himself for all sorts of immoral acts: for
having killed his cousin, for having violated his sister, for having {131}
set fire to a house, etc. He got to the point of having to turn round
in the street to see if he had not killed the last passer-by.
_Reinstatement_. He had been much affected by reading in a quasi-medical
book that onanism, to which he was addicted, destroyed one's morale.
_Case 3_. Several women complained of an impulsion to throw themselves
out of the window, to cut their children with knives, scissors, etc.
_Reinstatement_. Typical temptation-obsessions.---They were women who,
not being at all satisfied in marriage, had to struggle against the
desires and voluptuous ideas that haunted them in the presence of men.
_Case 4_. A girl who was perfectly sane and very intelligent displayed
an uncontrollable hatred against servants in the household. It had been
provoked by an impertinent servant, and had been transferred from
servant to servant, to a degree that rendered housekeeping impossible.
The feeling was a mixture of hate and disgust. As a reason for it she
stated that the vulgarity of these girls sullied her idea of love.
_Reinstatement_. This girl had accidentally been witness of an amorous
scene in which her mother had taken part. She had hidden her face, had
stopped up her ears, and had done her utmost to forget it, as it
disgusted her and made her feel quite unable to remain with her mother
whom she loved tenderly. She succeeded in her efforts; but her anger at
the person who had profaned her idea of love continued to exist within
her, and this emotional state soon linked itself to the image of a
person who could be a substitute for her mother.
_Case 5_. A young girl had become almost completely isolated on
account of an obsessive fear of incontinence of urine. She could no {132}
longer leave her room or receive visitors without having urinated a
number of times. When at home or entirely alone the fear did not
trouble her.
_Reinstatement_. It was an obsession of temptation or mistrust. She did
not mistrust her bladder, but her resistance against amorous
inclinations. The origin of the obsession shows this well. She had once
in a theatre, at the sight of a man who pleased her, felt an amorous
desire, accompanied (as spontaneous pollutions in women always are) by
the desire to urinate. She was obliged to leave the theatre, and from
that moment on she was a prey to the fear of reproducing the same
sensation, but the desire to urinate had replaced the amorous one. She
was completely cured.
Although the cases enumerated show varying degrees of complexity, they
have the following in common: the original (intolerable) idea has been
replaced by another idea, the substituted idea. In the cases which I now
append the original idea has also been replaced, but not by another
idea; it has been replaced by acts or impulses which originally served
as measures of relief or as _protective_ procedures, and are now
incongruously associated with an emotional state that does not fit them,
but that has persisted in its original form and was also originally
justified.
_Case 6_. Obsession of arithmomania.---A woman became obliged to count
the boards in the floor, the steps in the staircase, etc.---acts which
she performed in a state of ridiculous distress.
_Reinstatement_. She had begun the counting in order to turn her mind
from obsessive ideas of temptation. She had succeeded in so doing, but
the impulse to count had replaced the original obsession. {133}
_Case 7_. Obsessive brooding and speculating.---A woman suffered from
attacks of this obsession that ceased only when she was ill, and then
gave place to hypochondriacal fears. The theme of her worry was always a
part or function of her body, for example, respiration: Why must I
breathe? What if I try not to breathe? etc.
_Reinstatement_. At the very beginning she had suffered from the fear of
becoming insane, a hypochondriacal phobia common enough among women who
are not satisfied by their husbands, as she was not. To assure herself
that she was not going mad, that she still possessed her mental
faculties, she had begun to catechize herself and busy herself with
serious problems. This quieted her at first, but with time the habit of
speculation replaced the phobia. For more than fifteen years periods of
fear (pathophobia) and of obsessive speculating had alternated in her.
_Case 8_. _Folie du doute_. Doubting mania.---Several cases showed the
typical symptoms of this obsession but were explained very simply. These
persons had suffered or were still suffering from various obsessions,
and the knowledge that the obsessions had disturbed all their acts and
had many a time interrupted their train of thought provoked a legitimate
doubt about the reliability of their memory. The confidence of each one
of us would be shaken, and we should all of us have to re-read a letter
or repeat a calculation if our attention had been distracted several
times during the performance. Doubt is a quite logical result when
obsessions are present.
_Case 9_. _Folie du doute_ (Hesitation).---The girl in Case 4 had
become extremely slow in performing all ordinary everyday actions,
particularly in her toilet. She took hours to tie her shoe-laces or to
clean her finger-nails. As an explanation she stated that she could {134}
not make her toilet while obsessive ideas occupied her, nor
immediately after. As a result, she had become accustomed to wait a
definite period after each return of the obsessive idea.
_Case 10_. _Folie du doute_. Fear of paper.---A young woman had suffered
scruples after having written a letter; at the same time she collected
all the pieces of paper she saw, which she explained by confessing to a
love which she had formerly refused to admit. As she was constantly
repeating her lover's name, she was seized with a fear that the name
might have slipped off the end of her pen, that she might have written
it upon some bit of paper in a pensive moment.[33]
_Case 11_. Mysophobia.---A woman who washed her hands constantly and
touched door-handles only with her elbow.
_Reinstatement_. The case of Lady Macbeth. The washing was symbolic,
designed to replace by physical purity the moral purity which she
regretted having lost. She tormented herself with remorse for conjugal
infidelity, the memory of which she had resolved to banish from her
mind. She also washed her genitalia.
As regards the theory and explanation of this substitution, I will
content myself with answering three questions that arise here.
1. How does this substitution come about?
It seems to be the expression of a special mental disposition. At
least, a 'similar heredity' is often enough found in obsessional
cases, as in hysteria. Thus the patient in my second case related to
me that his father had suffered from similar symptoms. He once {135}
introduced me to a second cousin who had obsessions and convulsive
tic, and to his sister's daughter, aged eleven, who already showed
obsessions (probably of remorse).
2. What is the motive for this substitution?
I think it may be regarded as a defensive reaction (_Abwehr_) of the ego
against the intolerable idea. Among my patients several remember a
deliberate effort to banish the idea or the painful recollection of the
voice of conscience. (See Cases 3, 4, II.) In other cases the repugnance
is banished by an unconscious process that has left no trace in the
patients' memory.
3. Why does the emotional state that is attached to the obsessive idea
persist instead of vanishing like other conditions of the ego?
This question may be answered by applying to it the theory of the
genesis of hysterical symptoms developed by Breuer and myself.[34] I
will here only remark that by the very fact of the substitution the
disappearance of the emotional state is rendered impossible.
II
In addition to these two groups of true obsessions there is the class of
'phobias', which must now be considered. I have already mentioned the
great difference between obsessions and phobias: that in the latter the
emotion is always one of anxiety, fear. I might add that obsessions are
varied and more individualized, phobias are more uniform and typical.
But this distinction is not all-important.
Among the phobias two groups may be differentiated, according to the
nature of the object feared: (1) common phobias, an exaggerated fear {136}
of all those things that everyone detests or fears to some extent:
such as night, solitude, death, illness, dangers in general, snakes,
etc.; (2) specific phobias, the fear of special circumstances that
inspire no fear in the normal man; for example, agoraphobia and the
other phobias of locomotion. It is interesting to note that these
phobias have not the obsessive feature that characterizes true
obsessions and the common phobias. The emotional state appears in them
only under special conditions which the patient carefully avoids.
The mechanism of phobias is entirely different from that of obsessions.
Substitution is no longer the predominant feature in the former;
psychological analysis reveals no intolerable replaced idea in them.
Nothing is ever found but the _anxiety state_ which, by a sort of
selection, brings up all the ideas adapted to become the subject of the
phobia. In the case of agoraphobia, etc., we often find the recollection
of a state of _panic_; and what the patient actually fears is a
repetition of such an attack under those special conditions in which he
believes he cannot escape it.
The fear of this emotional state, which underlies all phobias, is not
derived from any memory whatever; we must ask what the source of this
overpowering nervous state can be.
I hope to be able to demonstrate, on another occasion, that there is
some reason for distinguishing a special neurosis, the
anxiety-neurosis,[35] of which the chief symptom is this emotional
state. I shall then enumerate its various symptoms and lay stress on
those which differentiate this neurosis from neurasthenia, with which
it is now confounded. Phobias, then, are a part of the {137}
anxiety-neurosis, and are almost always accompanied by other symptoms
belonging to it.
The anxiety-neurosis has a sexual origin too, as far as I can see, but
it does not attach itself to ideas taken from sexual life; properly
speaking, it has no psychical mechanism. Its specific cause is the
accumulation of sexual tension, produced by abstinence or by frustrated
sexual excitation (using the term as a general formula for the effects
of coitus reservatus, of relative impotence in the husband, of
excitation without satisfaction in engaged couples, of enforced
abstinence, etc.).
It is under such conditions, extremely frequent in modern civilized
society, especially among women, that anxiety-neurosis develops; phobias
are a psychical manifestation of it.
In conclusion I will state that combinations of a phobia and an
obsession proper may co-exist, and that indeed this is a very frequent
occurrence. We may find that a phobia had developed at the beginning of
the disease as a symptom of anxiety-neurosis. The thought-content of the
phobia accompanying the state of fear may be replaced by another idea or
perhaps by a _protective procedure_ that lessens the fear. Case 7
(obsessive speculating) presents a neat example of this group, a phobia
coupled with a true obsession evolved by substitution.
------------------------------------------------------------------------
VIII {138}
HEREDITY AND THE ÆTIOLOGY OF THE
NEUROSES[36]
(1896)
I am addressing the pupils of J. M. Charcot especially to bring to their
attention some objections to the theory concerning the ætiology of the
neuroses which was passed on to us by our master.
The part ascribed to neurotic heredity in this theory is well known. It
is the only true and indispensable cause of nervous disease; other
ætiological factors may aspire only to the title of precipitating
causes. Thus the master himself and his pupils, Guinon, Gilles de la
Tourette, Janet and others, have promulgated this doctrine for the major
neurosis, hysteria; I believe that the same opinion is held in France
and to some extent everywhere for the other neuroses, although it has
not been laid down quite so solemnly and decidedly for conditions
analogous to hysteria.
For a long time I have entertained suspicions in this matter, but I had
to wait to find corroborating facts in my daily medical experience. My
objections are now of two kinds, arguments based upon facts and
arguments of a more speculative order. I will begin with the former,
arranging them according to the importance that I ascribe to them.
I. (_a_) Sometimes diseases which are often enough foreign to the
sphere of neuropathology and which do not necessarily depend upon
disease of the nervous system have been considered nervous and {139}
indicative of neuropathic heredity. Thus, true facial neuralgias and
many headaches have been considered nervous which are caused rather by
post-infectious pathological changes and by suppuration in the nasal
sinuses. I am convinced that these patients would profit if we were
more often to leave the treatment of these conditions to rhinologists.
(_b_) All nervous diseases found in the patient's family, without
reference to their frequency or their gravity, have been accepted as
justifying the accusation of nervous hereditary taint. Does not this
point of view seem to imply a sharp distinction between families that
are free from any nervous predisposition and families that are subject
to it without limit or restriction? And do not the facts speak rather in
favour of the opposite opinion, namely, that there are transitions and
degrees of nervous predisposition and that no family escapes it
entirely?
(_c_) Our opinion as to the ætiological rôle of heredity in nervous
disease must assuredly be the result of an impartial statistical study
and not of a _petitio principii_. Until this study has been made, the
existence of acquired neuropathies should be considered as probable as
that of hereditary neuropathies. But if the existence of neuropathies
acquired by persons not predisposed to them is possible, it can no
longer be denied that some of the nervous diseases found among the
relatives of our patients may have such an origin. They can then no
longer be called upon as conclusive proofs of the hereditary
predisposition that is imputed to the patient by virtue of his family
history, for a retrospective diagnosis of the diseases of ancestors or
of absent members of the family is only very rarely successful. {140}
(_d_) Those who are adherents of the view of Fournier and of Erb,
concerning the part played by syphilis in the causation of tabes
dorsalis and in progressive paralysis, have learned that powerful
ætiological factors must be recognized the presence of which is
indispensable in the pathogenesis of certain diseases that heredity
alone could not cause. Charcot remained to the end, however, as I
learned through a private letter from him, strictly opposed to
Fournier's theory, which, nevertheless, gains ground day by day.
(_e_) There is no doubt that certain neuropathies may develop in a man
who was perfectly sound and of untainted family. One observes this every
day in Beard's neurasthenia; if neurasthenia were limited to predisposed
people, it would never have gained the importance and prevalence with
which we are familiar.
(_f_) In nervous pathology there is a so-called similar and a
so-called dissimilar heredity. No fault will be found with the former
concept; it is even very remarkable that in the affections that depend
upon similar heredity (Thomsen's disease, Friedreich's disease,
Huntington's chorea, the myopathies, etc.), no trace of any accessory
ætiological factor is ever found. But the much more important concept
of dissimilar heredity has gaps that must be filled out to arrive at a
satisfactory solution of the ætiological problems. They consist of the
fact that members of the same family prove to be afflicted with the
most varied forms of nervous disease, functional and organic, without
our being able to discover a law that determines the substitution of
one disease for another or the order in which they follow one another
in successive generations. There are in these families, beside the
affected members, persons who remain sound. The theory of dissimilar {141}
heredity tells us neither why one person carried the same hereditary
taint without succumbing to it, nor why another selects, among the
diseases that constitute the great family of neuropathies, one
particular nervous affection instead of another, hysteria instead of
epilepsy, insanity, etc. Since there is no such thing as chance in the
pathogenesis of nervous disease any more than elsewhere, it must be
admitted that it is not heredity that controls the choice of a
neuropathy developing in a member of a predisposed family, and that
there is ground for suspecting the existence of other ætiological
factors of a less incomprehensible nature which deserve to rank as the
specific ætiology of any such nervous disease. Without the existence
of this special ætiological factor heredity would have been powerless;
it would have lent itself to the production of a different neuropathy
if the specific ætiology in a given case had been replaced by any
other.
II\. These specific, determining causes of neuropathy have been too
little investigated, for the vision of physicians has been dazzled by
the imposing prospect of the hereditary factor in ætiology.
Nevertheless, they are well worth making the object of careful study;
although their pathogenic power may be in general only auxiliary to that
of heredity, great practical interest centres on the understanding of
this specific ætiology. It affords a point of attack for our therapeutic
efforts, while hereditary predisposition, predetermined for the patient
from birth, frustrates all our efforts by the strength of its position.
I have been engaged for years in a study of the ætiology of the major
neuroses (functional nervous states analogous to hysteria), and in
what follows I shall report the result of these studies. In order to {142}
avoid all possible misunderstanding, I shall begin by making two
observations on the nosography of the neuroses and on their ætiology
in general.
I had to start my work with an innovation in nosography. I have found
reason to place the obsessional neurosis upon the same footing as
hysteria, as an independent and autonomous disease, although the
majority of authors classify obsessions among the syndromes comprising
mental degeneration or else confound them with neurasthenia. I have
learned, by examining their mental mechanism, that these disorders are
much more closely allied to hysteria than one would have believed.
Hysteria and the obsessional neurosis form the first group of the major
neuroses that I studied. The second contains Beard's neurasthenia, which
I split up into two functional conditions differentiated both
ætiologically and symptomatologically: neurasthenia proper and
anxiety-neurosis---a term, by the way, which does not altogether please
me. I have given detailed reasons for this differentiation, which I
consider necessary, in a paper published in 1895.[37]
As for the ætiology of the neuroses, I think we should recognize that
the various ætiological factors, differing in their importance and in
the way in which they are related to the effect they produce, may be
arranged theoretically in three classes: (1) _Conditions_ that are
indispensable for the production of the disease in question, but which
are of a universal nature and occur as well in the ætiology of many
other diseases. (2) _Concurrent causes_ that share with the conditions
in group (1) the characteristic of entering into the causation of
other diseases as well as into that of the disease in question, but
which are not indispensable for the production of the latter {143}
disease. (3) _Specific causes_ just as indispensable as the first
conditions but appearing only in the ætiology of the disease for which
they are specific.
Now, in the pathogenesis of the major neuroses heredity plays the part
of a _condition_, potent in all cases and even indispensable in the
majority of them. It cannot do without the assistance of the specific
causes; but the importance of hereditary predisposition is demonstrated
by the fact that the same specific causes operating on a sound person
would produce no manifest pathological effect, while its presence in a
predisposed person will precipitate a neurosis, the development of which
will in intensity and extent be proportional to the degree of hereditary
predisposition.
The action of heredity is comparable to that of a multiplier in an
electric circuit, which increases the visible deviation of the needle
but which cannot determine its direction.
There is another point to be noted in the relations between the
hereditary condition and the specific causes of the
neuroses. Experience shows, as might have been anticipated, that among
the problems of ætiology that of the quantitative relationship of the
ætiological factors to one another should not be neglected. But one
would not have guessed the fact which seems to follow from my
observations, that heredity and the specific causes may replace one
another quantitatively, that the same pathological effect will be
produced by the co-existence of a very grave specific ætiology and a
moderate degree of predisposition as by that of a severe neuropathic
heredity with a slight specific factor. So that it is merely a quite
possible extreme in this series when one finds cases of neurosis in
which a tangible degree of hereditary predisposition is looked for in {144}
vain, provided that this deficiency is compensated for by a powerful
specific factor.
As _concurrent or accessory causes_ all those 'ordinary' factors found
elsewhere may be mentioned: mental excitement, physical exhaustion,
acute illness, intoxication, traumatic accidents, intellectual overwork,
etc. I would maintain that none of them, not even the last, enters
regularly or necessarily into the ætiology of neuroses, well knowing
that the enunciation of this opinion is in direct opposition to a theory
regarded as universal and incontestable. Since Beard declared
neurasthenia to be the product of our modern civilization he has found
only believers; but it is impossible for me to accept this opinion. A
painstaking study of the neuroses has taught me that the specific
ætiology of the neuroses has escaped Beard's attention.
I do not wish to underestimate the ætiological importance of these
every-day factors. They are very varied, of frequent occurrence, and
most often blamed by the patient; they are more manifest than the
_specific causes_, which are either concealed or not understood. They
often fulfil the function of precipitating causes bringing the hitherto
latent neurosis to the surface; and a practical interest attaches to
them, since consideration of these ordinary causes may furnish a basis
for a therapy that does not aim at a radical cure, but contents itself
with reducing the disease to its previous latent state.
But a constant and intimate relation between a given ordinary cause
and a given nervous affection cannot be established; mental
excitement, for example, is found as often in the ætiology of
hysteria, of obsessions, of neurasthenia, as in that of epilepsy,
Parkinson's disease, diabetes, and numerous others. {145}
The ordinary concurrent causes can also replace the specific ætiology
quantitatively, but can never completely supplant it. There are numbers
of cases in which hereditary predisposition and the specific factor
constitute the entire ætiology, the ordinary causes being absent. In
other cases the indispensable ætiological factors are not strong enough
in themselves to precipitate the neurosis and a state of apparent good
health may be maintained for a long time, a state that is really one of
neurotic predisposition. It requires only the added effect of an
ordinary cause to make the neurosis become manifest. It must be noted,
however, that in such circumstances the nature of the supervening
ordinary factor, whether it be excitement, trauma, infectious disease,
or any other, is entirely a matter of indifference; the pathological
result does not vary in accordance with it, and the nature of the
neurosis will always be determined by the pre-existing specific cause.
What then are the specific causes that produce neuroses? Is there only
one or are there several? And can a constant ætiological relationship be
established between a given cause and a given neurosis so that each
major neurosis may be referred to a particular ætiology?
Supported by a painstaking investigation of the facts, I wish to affirm
that this hypothesis agrees well with the truth, that each of the major
neuroses mentioned has as its immediate cause a special disturbance of
the nervous economy, and that these pathological functional changes
_betray, as their common source, the sexual life of the person
concerned, either a disturbance of his present sexual life or important
events in his past life_.
This is, strictly speaking, not a new, unheard-of proposition. It has
always been admitted that sexual disturbances were among the causes of {146}
nervousness, but they were grouped together on a level with other
precipitating causes as subordinate to heredity; their ætiological
importance was restricted to a limited number of the cases
studied. Physicians had even acquired the habit of not looking for
them if the patient did not himself accuse them. The distinctive
characteristic of my point of view lies in my raising the sexual
factors to the rank of specific causes, in my recognizing their
influence in all cases of neurosis, and finally in my finding a
constant parallelism, proof of a special ætiological relationship,
between the nature of the sexual factor and the kind of neurosis.
I am quite sure that this theory will provoke a storm of contradiction
from my fellow physicians. But this is not a fitting occasion to present
the data and observations that have imposed my conviction on me, nor to
explain the strict meaning of the somewhat vague term 'disturbances of
nervous economy'. This will be done, I hope as thoroughly as possible,
in a work that I am preparing on the subject. In this paper I shall
confine myself to the presentation of my results.
Pure neurasthenia, which after it has been differentiated from
anxiety-neurosis presents a monotonous clinical picture (exhaustion,
sense of pressure on the head, flatulent dyspepsia, constipation, spinal
paræsthesias, sexual weakness, etc.), admits of only two specific
ætiological factors, excessive onanism and spontaneous emissions.
The prolonged and intense effect of this pernicious form of sexual
satisfaction alone suffices to produce neurasthenia, or else it stamps
the subject with the specific neurasthenic habitus which later is made
manifest under the influence of a chance accessory cause. I have also {147}
met persons who showed the signs of a neurasthenic constitution, but
in whom I did not succeed in demonstrating the ætiology just
mentioned; I was able at least to prove, however, that in these
patients the sexual function had never developed to a normal
degree. They seemed to be endowed by heredity with a sexual
organization analogous to that which arises in the neurasthenic as a
result of onanism.
The anxiety-neurosis, the clinical picture of which is much richer
(irritability, states of anxious expectation, phobias, more or less
severe panics, fear, vertigo, trembling, sweats, congestion, dyspnœa,
tachycardia, etc.; chronic diarrhœa, chronic locomotor vertigo,
hyperæsthesia, insomnia, etc.)[38] is easily shown to be the specific
result of various disturbances of sexual life, all having a common
trait. Forced abstinence, frustrated sexual excitement (not gratified by
sexual intercourse), incomplete or interrupted coitus (not attaining
gratification), sexual efforts that exceed the psychical capacity of the
person, etc., all these factors, all too common in modern life, seem to
unite in disturbing the equilibrium of psychical and somatic functions
in sexual activity, and in hindering the psychical co-operation
necessary to relieve the nervous economy from sexual tension.
These considerations, which contain perhaps the nucleus of a
theoretical explanation of the functional mechanism of the neurosis in
question, arouse the suspicion that a complete and really scientific
demonstration of the matter is not at the moment possible, and that
the problem of the physiology of the sexual life will first have to be
approached from a new angle. {148}
I will conclude by stating that the presence of hereditary
predisposition is not indispensable in the pathogenesis of neurasthenia
and of the anxiety-neurosis. This is the result of daily observation; if
the hereditary factor is present, however, the development of the
neurosis will be strongly influenced thereby.
In the second class of major neuroses, hysteria and the obsessional
neurosis, the solution of the ætiological problem is surprisingly simple
and uniform. I owe my conclusions to the use of the new
psycho-analytic[39] method, the probing procedure of J. Breuer, a
method that is somewhat subtle but irreplaceable, so fruitful has it
proved to be in explaining obscure unconscious mental processes. By
means of this method, which cannot be explained here,[40] hysterical
symptoms are traced to their origin, which invariably proves to be an
experience in the person's sexual life well adapted to produce a painful
emotional reaction. Going back into the patient's life step by step,
guided always by the structural connection between symptoms, memories,
and associations, I finally came to the starting-point of the
pathological process; and I had to realize that the same factor was at
the bottom of all the cases subjected to analysis, namely, the effect of
an agent that must be accepted as the specific cause of hysteria.
It is indeed a memory connected with the person's sexual life, but one
that presents two extremely important features. The event, the
unconscious image of which the patient has retained, is a premature
sexual experience with actual stimulation of the genitalia, the result
of sexual abuse practised by another person, and the period of life in {149}
which this fateful event occurs is early childhood, up to the age of
eight to ten, before the child has attained sexual maturity.
_A passive sexual experience before puberty:_ this is the specific
ætiology of hysteria.
I will at once supplement these conclusions by some detailed facts and
some explanatory remarks, so as to combat the doubt that I anticipate. I
have been able to analyse thirteen cases of hysteria completely. Three
of this number were true combinations of hysteria with an obsessional
neurosis (I do not say hysteria with obsessions). The experience
mentioned above was not lacking in a single case; it was present either
as a brutal attempt committed by an adult or as a less sudden and less
repugnant seduction, having however the same result. In seven cases out
of the thirteen we were dealing with a liaison between children, sexual
relations between a little girl and a boy slightly older, generally her
brother who had himself been the victim of an earlier seduction. These
liaisons were sometimes continued for years, up to puberty, the boy
repeating upon the little girl without alteration those practices that
he had himself experienced at the hands of a servant or governess;
because of this origin they were often of a disgusting kind. In some
cases there had been both assaults and an infantile liaison or repeated
brutal abuse.
The date of the premature experience was variable: in two cases it
went back to the second year (?) of the child; in my observations the
age of predilection was the fourth or fifth year. It may be a matter
of chance, but I have the impression from them that a passive sexual
experience occurring after the age of eight or ten can no longer be
the foundation of a neurosis. {150}
How can one be convinced of the truth of these confessions made in
analysis and said to be memories preserved since early childhood, and
how can we protect ourselves against the inclination to fabricate and
the facility for invention ascribed to hysterics? I would charge myself
with blameworthy credulity if I did not offer more convincing proofs.
But the fact is that patients never relate these histories
spontaneously, and never suddenly offer, in the course of the treatment,
the complete recollection of such a scene to the physician. The mental
image of the premature sexual experience is recalled only when most
energetic pressure is exerted by the analytic procedure, against strong
resistance; so that the recollection has to be extracted bit by bit from
the patients, and while it comes back into consciousness they fall prey
to emotions difficult to simulate.
If we remain uninfluenced by the patient's behaviour and are able to
follow impartially, in detail, the psycho-analysis of a case of
hysteria, we are finally convinced ourselves.
The premature experience in question has left a permanent imprint upon
the history of the case, being represented in it by a mass of symptoms
and peculiar features that permit of no other explanation; the delicate
but firm inter-relationship of the structural elements of the neurosis
compel us to accept this view; the therapeutic result is retarded if we
do not go so deep as this; no other choice exists then except that of
rejecting or believing the whole matter.
Is it to be believed that a premature sexual experience of this kind,
undergone by a person whose sex is scarcely differentiated, may become
the starting-point of a permanent mental abnormality like hysteria?
And further, how would such a view harmonize with our present
conception of the psychical mechanism of that neurosis? A satisfactory {151}
reply can be given to the first question: it is just because the
subject is a child that premature sexual stimulation produces little
or no effect at the time, but a mental impression of it is
retained. Later, at puberty, when the sexual organs have developed a
degree of activity immeasurably greater than that of childhood, this
unconscious mental impression is somehow or other reawakened. Owing to
the changes produced by puberty the memory will exercise a power which
was entirely lacking when the experience itself took place; _the
memory will produce the same result as if it were an actual event_. We
have, so to speak, _the subsequent effect of a sexual trauma_.
As far as I know, the reawakening of a sexual recollection after
puberty, the event itself having occurred at a time antedating this
period, affords the only psychological conjunction in which the effect
of a memory surpasses that of the event itself. But it is an abnormal
constellation, which attacks the mind at a weak point and necessarily
produces a pathological result.
I believe that this inverse relation between the psychical effect of the
recollection and that of the event contains the reason why the memory
has remained unconscious.
We thus approach a very complex psychical problem, one which, however,
if duly appreciated promises to throw a flood of light some day upon the
most intricate problems of mental life.
The ideas set forth here, based upon the results of psycho-analysis,
namely, that the memory of a premature sexual experience is always
found as the specific cause of hysteria, do not agree with Janet's
psychological theory of the neurosis, nor with any other; but they {152}
harmonize perfectly with my own hypotheses, described elsewhere, on
the 'defence neuroses'.
All events occurring after puberty to which an influence on the
development of hysteria and the formation of its symptoms must be
ascribed are only concurrent causes, '_agents provocateurs_' in the
words of Charcot, to whom neuropathic heredity occupied the position
that I claim for premature sexual experiences. These accessory factors
are not subject to the strict rules that govern the specific causes;
analysis demonstrates beyond question that they produce a pathological
effect in hysteria only by virtue of their ability to awaken the
unconscious mental impression of the infantile experience. It is also
because of their connection with the original pathogenic impression and
by its magnetism, so to speak, that the memory of them becomes
unconscious in turn, and is able to assist the growth of a mental
process withdrawn from the influence of conscious processes.
The obsessional neurosis arises from a specific cause closely
analogous to that of hysteria. A premature sexual experience, which
has occurred before puberty and the memory of which becomes active
during or after that period, is also found here and the same
observations and arguments made in reference to hysteria apply to
cases of this neurosis (six cases, three pure forms). There is only
one difference that seems of capital importance. At the base of the
ætiology of hysteria we found a passive sexual experience undergone
with indifference or with a slight degree of disgust or fright. In the
obsessional neurosis we are concerned, on the other hand, with an
experience that was pleasurable, with a sexual aggression inspired by
desire (in the case of the boy) or with a pleasurable participation in {153}
sexual acts (in the case of the little girl). The obsessive ideas,
whose inner meaning is made recognizable by analysis, reduced, so to
speak, to their simplest form, are nothing but reproaches that the
patient makes to himself because of that premature sexual pleasure,
but reproaches disguised by an unconscious psychical work of
transformation and substitution.
The very fact that this sexual aggression occurs at such a tender age
seems to betray the effect of a previous seduction, which would result
in precocity of sexual desire. Analysis has confirmed this suspicion in
the cases I have treated. In this way an interesting fact always present
in these obsessional cases is explained, namely, the regular way in
which the clinical picture is complicated by a certain number of purely
hysterical symptoms.
The importance of the active sexual attitude as a cause of obsessions,
and that of the passive attitude in the pathogenesis of hysteria, seems
to give the reason of hysteria's close association with the female sex
and of the preference of the male for the obsessional neurosis. One
sometimes comes across a pair of neurotics who had a liaison in early
childhood, the man suffering from obsessions, the woman from hysteria;
if we are dealing with brother and sister we may mistake for the result
of heredity what is really derived from premature sexual experience.
There are, unquestionably, pure and isolated cases of hysteria and
obsessional neurosis, independent of neurasthenia and
anxiety-neurosis, but they are not the rule. More frequently, the
psychoneurosis appears as accessory to the neurasthenic neuroses,
having been provoked by the latter and following their decline. This
happens because the specific causes of the latter, current
disturbances of the sexual life, act at the same time as accessory {154}
causes of the psychoneuroses, the specific cause of which, the memory
of an early sexual experience, they reawaken and revive.
As for neurotic heredity, I am far from being able to estimate
accurately its influence in the ætiology of the neuroses. I admit that
its presence is indispensable in serious cases; I doubt whether it is a
_sine qua non_ in mild cases, but I am convinced that neurotic heredity
alone cannot cause a psychoneurosis if the specific ætiology of the
latter, premature sexual stimulation, be lacking. I even believe that
the question which of the two neuroses, hysteria or obsessional
neurosis, will develop in a given case is determined not by heredity but
by the particular nature of the early sexual experience in childhood.
------------------------------------------------------------------------
IX {155}
FURTHER REMARKS ON THE DEFENCE
NEURO-PSYCHOSES[41]
(1896)
In a short paper[42] published in 1894 I included hysteria, obsessions
and certain cases of acute hallucinatory confusion under one heading
as 'Defence Neuro-Psychoses'. I did this because one point of view
showed itself as applying in common to all these affections: their
symptoms arise through the psychical mechanism of (unconscious)
defence, that is, through an attempt to repress an intolerable idea
which was in painful opposition to the patient's ego. In a book since
published by Dr. J. Breuer and myself (_Studien über Hysterie_) I have
been able by quoting clinical observations to elucidate and illustrate
what is meant by this psychical process of 'defence' or
'repression'. Information may also be found in it concerning the
toilsome but completely reliable method of psycho-analysis which I use
in making these investigations and by which at the same time the
investigations serve a therapeutic purpose.
My experiences in the last two years of work have strengthened me in
my surmise that defence is the nucleus of the psychic mechanism of the
neuroses under discussion and have also made it possible for me to
give this psychological theory a clinical basis. To my own surprise I
came unexpectedly upon a few simple but narrowly definable solutions {156}
of the problems contained in the neuroses and in the following paper I
will give a short preliminary account of them. I cannot in this kind
of communication bring forward the evidence on which my statements are
based, but I hope to fulfil this obligation in a more detailed
presentation.
I. THE 'SPECIFIC' ÆTIOLOGY OF HYSTERIA
In earlier publications Breuer and I have already expressed the opinion
that the symptoms of hysteria can be understood only by tracing them
back to 'traumatic' experiences and that these psychical traumas are
related to the patient's sexual life. What I have to add here, as a
uniform result of my analysis of thirteen cases of hysteria, concerns on
the one hand the nature of these sexual traumas, and on the other hand
the period of life in which they occur. The occurrence at any time of
life of an experience in some way touching on the sexual life, which
then becomes pathogenic on account of the generation and suppression of
a painful affect, does not suffice to bring about a hysteria. _These
sexual traumas must on the contrary occur in early childhood_ (_before
puberty_) _and they must consist in actual excitation of the genital
organs_ (_coitus-like processes_).
I have found this specific determinant of hysteria---_sexual passivity
in the pre-sexual period_---present in all the cases of hysteria
analysed (including two men). I need here only allude to the great
reduction in the importance of the factor of hereditary disposition
which is effected by thus establishing accidental ætiological factors
as a necessary condition; moreover, we are also thus provided with a
clue to the reason for the much greater frequency of hysteria in the {157}
female sex, which even in childhood is more likely to provoke sexual
assaults.
The more obvious objections to this theory will probably be the
following: that sexual assaults on small children occur too frequently
for them to be of great ætiological importance when they can be
confirmed; or else that such experiences must remain ineffective for the
very reason that they happen to a sexually undeveloped person; further,
that one must guard against instigating patients to ostensible
reminiscences of this kind by a cross-examination and guard against
believing the romances which they themselves invent. In reply to the
latter objections we may ask the favour that on this obscure topic no
one should pass too certain a judgement before he has himself practised
the only method which can throw light upon it---psycho-analysis, the
method of making conscious what was previously unconscious.[43] The
essential element in the first-mentioned objections is disposed of when
we remember that it is not the experience itself which acts
traumatically, but the memory of it when this is re-animated after the
subject has entered upon sexual maturity.
My thirteen cases of hysteria were all of them severe; all of them had
symptoms of many years duration, a few after long and fruitless
treatment in institutions. The infantile traumas which analysis
discovered in these severe cases must without exception be described
as grave sexual injuries; some of them were absolutely appalling. Most
prominent among the people who were guilty of these abuses with all
their serious consequences were nursemaids, governesses, or domestic {158}
servants, to whose care children are all too thoughtlessly abandoned,
and teachers and tutors appear regrettably often; in seven of the
thirteen cases, however, the assaults were perpetrated by innocent
childish assailants, mostly brothers, who had for years carried on
some kind of sexual relation with somewhat younger sisters. The course
of events was probably in all cases similar to that which we were able
to follow with certainty in some individual cases---namely, the boy
was first misused by a person of the female sex, by which his libido
was prematurely awakened and then a few years later he committed a
sexual aggression reproducing exactly the procedure to which he
himself had been subjected.
I must exclude active masturbation from the list of sexual noxiæ
occurring in early childhood that are pathogenic for
hysteria. Although indeed it may be very frequently found in cases of
hysteria, this is due to the circumstance that masturbation is much
more often the consequence of abuse or seduction than is generally
supposed. It is by no means rare for both of the young couple to fall
ill of a defence neurosis at a later date, the brother with
obsessions, the sister with hysteria, which naturally gives the
appearance of a familial neurotic disposition. This pseudo-heredity,
however, is explained now and then in surprising ways; on one occasion
I was able to observe a brother, sister and a somewhat older male
cousin who were all ill. I learnt from the analysis which I undertook
with the brother that he suffered from self-reproaches for being the
cause of his sister's illness; he had been seduced by his cousin, who
in his turn---as was known in the family---had himself been the victim
of his nursemaid. {159}
I cannot say for certain up to what age-limit sexual injury falls within
the ætiology of hysteria; but I doubt whether sexual passivity after the
eighth to tenth year can evoke repression in the absence of previous
experiences of the same kind. The lower limit extends as far as memory
itself, that is, therefore, to the tender age of from one and a half to
two years! (Two cases.) In a number of my cases the sexual trauma (or
series of traumas) occurred in the third or fourth year. I should not
myself give credence to these singular revelations if they had not been
proved worthy of belief by the part they played in the subsequent
development of the neurosis. In every case a number of morbid symptoms,
habits, and phobias is only to be accounted for by going back to these
experiences of childhood, and the logical structure of the neurotic
manifestations makes it impossible to reject these faithfully preserved
memories which emerge from among the experiences of childhood. It would,
indeed, be quite useless to question an hysteric outside analysis about
these traumas in childhood; their traces are never to be found in
conscious memory, only in the symptoms of illness.
All the experiences and excitements which in the period of life after
puberty prepare the way for or occasion the outbreak of hysteria can
be proved to act only because they awaken the memory-trace of those
traumas in childhood; this memory-trace does not become conscious but
leads to a liberation of the affect and to repression. In close accord
with this view of the part played by the traumas occurring in later
life is the circumstance that they are not subject to the strict
conditions governing the traumas of childhood, but may vary in
intensity and quality from actual sexual assaults to mere sexual
overtures, witnessing sexual acts by others, or being told about {160}
sexual matters.[44]
In my first paper on the defence neuroses it was left unexplained how
the efforts of previously healthy persons to forget some traumatic
experience of this kind could have the result of really producing the
repression intended and of thereby opening the door to a defence
neurosis. It could not lie in the nature of the experiences, because
other people remain well in spite of similar incitements to illness.
Hysteria could not therefore be fully explained as the effect of the
trauma; one had to acknowledge that the disposition to hysterical
reaction had already existed before the trauma.
Now the subsequent effect of an infantile sexual trauma can fill the
place either totally or partially of this indefinite hysterical
disposition. 'Repression' of the memory of a painful sexual experience
in maturer years is possible only for those people in whom this
experience can re-activate the memory-trace of an infantile
trauma.[45] {161}
Obsessional ideas likewise presuppose a sexual experience in childhood
(different in nature from that in hysteria). The ætiology of the two
defence neuro-psychoses now presents the following relation to the
ætiology of the two simple neuroses---neurasthenia and anxiety-neurosis.
The latter are direct results of the sexual noxiæ themselves, as I have
shown in a paper on the anxiety-neurosis (1895);[46] the two defence
neuroses are the indirect consequences of sexual noxiæ occurring before
the onset of sexual maturity, that is, consequences of the psychical
memory-traces of these noxiæ. The current causes which produce
neurasthenia and anxiety-neurosis frequently play at the same time the
part of inciting causes in the defence neuroses; on the other hand, the
specific causes of the defence neuroses---the traumas of childhood---can
at the same time lay the foundations of a neurasthenia which will
develop later. Finally, it not infrequently happens that a neurasthenia
or anxiety-neurosis is maintained, not by the current sexual noxiæ, but
only by the continuous effect of the memory of the childhood-traumas.
II. THE NATURE AND MECHANISM OF THE OBSESSIONAL
NEUROSIS
In the ætiology of the obsessional neurosis sexual experiences in
early childhood play the same part as in hysteria; it is here, {162}
however, no longer a question of sexual passivity, but rather of
aggressive acts performed with pleasure and of pleasurable
participation in sexual acts---of sexual activity, therefore. This
difference in the ætiological conditions explains why the obsessional
neurosis appears to favour the male sex.
In all my cases of obsessional neurosis I have, moreover, found a
_substratum of hysterical symptoms_ which can be traced back to a scene
of sexual passivity of earlier date than the pleasurable activity. I
surmise that this coincidence is a regular one and that early sexual
aggressivity always implies a previous experience of seduction.
Nevertheless, I can as yet give no complete presentation of the ætiology
of the obsessional neurosis; I simply have the impression that the
decision whether hysteria or obsessional neurosis will arise on the
basis of the infantile traumas depends on _temporal_ factors in the
development of the libido.
The nature of the obsessional neurosis permits of description in a
simple formula:---Obsessions _are always reproaches re-emerging in a
transmuted form under repression_---_reproaches which invariably relate
to a sexual deed performed with pleasure in childhood_. To illustrate
this statement it will be necessary to give a description of the typical
course of an obsessional neurosis.
In the first period, that of childish immorality, occur the
experiences containing the germ of the neurosis which develops later;
first of all in very early childhood the experiences of sexual
seduction that make subsequent repression possible, then the deeds of
sexual aggression against the opposite sex which appear later as acts
to which self-reproach becomes attached. {163}
This period is brought to a close by the onset of sexual 'maturity',
often itself premature. No self-reproach becomes connected with the
memories of those pleasurable activities, and the relation with the
initial passive experience makes it possible to repress them and
substitute for them a _primary defence-symptom_---often only after
conscious and remembered efforts. Conscientiousness, shame and
self-distrust are the kind of symptoms which introduce the third period,
that of apparent health, or better, that of _successful defence_.
The next period, that of illness, is distinguished by the _return of the
repressed memories_, i.e. by failure of the defence; it is doubtful
whether the awakening of these memories usually occurs accidentally or
spontaneously or as a kind of by-product in consequence of current
sexual disturbances. The re-animated memories and the self-reproach
which is built up on them, however, never appear in consciousness
unchanged. The obsessional idea and the obsessive affects which appear
in consciousness and take the place of the pathogenic memory in
conscious life are _compromise-formations_ between the repressed and the
repressing ideas.
In order to describe clearly and with probable accuracy the processes
of repression, the return of the repressed, and the formation of
pathological compromise-ideas, one must resolve upon quite definite
concepts in regard to the substratum underlying mental processes and
consciousness. So long as one avoids this one must be content with the
following rather figurative remarks: There are two forms of the
obsessional neurosis, according to whether the memory-content alone of
the deed which evokes reproach has forced itself into consciousness,
or whether the affect of reproach attaching to it is also present. To {164}
the first class belong the typical cases of obsessional ideas, in
which the patient's attention is directed to the content, an
indefinite affect of discomfort merely being felt, whereas the affect
of self-reproach would alone be suited to the content of the
obsessional idea. The content of the obsessive act in childhood is
changed in a twofold manner before it emerges as an obsessional idea:
first, something present is substituted for something past, secondly,
something sexual is replaced by something analogous but not
sexual. Both these alterations are the effect of the tendency to
repression, still in operation---a tendency which we should ascribe to
the 'ego'. The influence of the reanimated pathogenic memory is shown
by the fact that the content of the obsessional idea is still partly
identical with what is repressed, or is derived from it by means of a
logical train of thought. If one reconstructs by means of the
psycho-analytic method the development of a single obsessional idea
one finds that two different trains of thought have been stirred by a
recent impression; the one which proceeds _via_ the repressed memory
proves to be as correctly and logically formed as the other, although
it is incapable of becoming conscious and is insusceptible of
correction. If the results of the two psychical operations do not
harmonize what happens is not a logical reconciliation of the
contradiction between the two, but instead, alongside the normal
thought-process, there appears in consciousness, as a compromise
between the resistance and the pathological thought-process, an
apparently absurd obsessional idea. If both trains of thought point to
the same end they reinforce each other, so that we find a normally
developed thought-process now behaving psychically like an obsessional
idea. _Wherever a neurotic compulsion makes its appearance in {165}
psychical life it arises in repression_. Obsessional ideas have, so to
say, a forced currency psychically, not on account of their intrinsic
value, but on account of the source from which they arise or which has
furnished a contribution to their value.
The second form of obsessional neurosis comes about if what has
compelled representation for itself in conscious mental life is not
the repressed memory-content but the self-reproaches that are likewise
repressed. The affect of reproach can with the aid of some psychical
reinforcement transmute itself into any other unpleasant affect; when
this has happened there is nothing to hinder the substituted affect
any longer from becoming conscious. Thus _self-reproach_ (for having
performed a sexual deed in childhood) can easily transform itself into
_shame_ (lest another person should come to hear about it), into
_hypochondriacal anxiety_ (lest some bodily injury should result from
the action which evoked the self-reproach), into _dread of the
community_ (fear of punishment by the world at large for the lapse),
into _religious anxiety_, into _delusions of reference_ (dread of
betraying the deed), into _dread of temptation_ (justified mistrust in
the personal strength of moral resistance), and so on. Together with
this the memory of the deed which evokes reproach may either be
represented in consciousness too, or be completely withheld---a fact
which renders exact diagnosis much more difficult. Many cases which on
superficial examination would be regarded as ordinary (neurasthenic)
hypochondria belong to this group of obsessional affects; so-called
'periodic neurasthenia' or 'periodic melancholia' in particular
appears to be reducible with unexpected frequency to obsessional
affects and obsessional ideas---a recognition that is therapeutically {166}
by no means unimportant.
In addition to these compromise-symptoms, which signify the return of
the repressed and consequently a collapse of the defence originally
aimed at, the obsessional neurosis forms a series of further symptoms
quite different in origin. The ego seeks to ward off those derivatives
of the original repressed memory and in this struggle for defence
creates symptoms which may be grouped together as '_secondary defence_'
symptoms. These are all '_protective measures_' which had already
performed good service in the struggle with the obsessional ideas and
affects. If these aids to defence are really successful in once more
repressing the symptoms due to the return of the repressed which have
been forced upon the ego, then the compulsion is transferred to the
protective measures themselves and creates a third form of 'obsessional
neurosis'---that of _obsessive actions_. These are never primary, never
anything but defensive; they never contain anything of an aggression;
psychical analysis of them shows that---in spite of all their
oddity---they are to be fully explained by tracing them back to the
obsessive memory which they are combating.
To take one example only: an eleven-year-old boy had instituted the
following obsessive ceremonial before going to bed. He did not sleep
until he had told his mother in the minutest detail all the events of
the day; there must be no scraps of paper or other rubbish on the
carpet of the bedroom; the bed must be pushed right up to the wall;
three chairs must stand by it and the pillows must lie in a particular
way. In order to get to sleep he himself must first kick out a certain
number of times with both legs and then lie on his side.---This was
explained in the following manner: years before a servant-girl who had {167}
to put the handsome boy to bed took the opportunity of lying upon him
and abusing him sexually. Later on when this memory was awakened by a
recent experience, it manifested itself in consciousness in the form
of a compulsion to perform the ceremonial described; its meaning was
easily guessed and was established point by point by means of
psycho-analysis: the chairs by the bedside and pushing the bed against
the wall---so that no one could later come near the bed; the pillows
arranged in a certain way---so that they should be arranged
differently from the way they were on that evening; kicking the
legs---pushing away the person lying on him; sleeping on his
side---because in the scene he lay on his back; the circumstantial
confession to his mother---because he had concealed from her this and
other sexual experiences in obedience to his seductress; finally,
keeping clean the floor of his bedroom---because this was the
principal reproach that he had previously had to endure from his
mother.
Secondary defence against obsessional ideas may be brought about by an
enforced diversion on to other thoughts, in content as different as
possible; therefore when this succeeds _obsessive speculating_ results
and the thoughts are regularly occupied with abstract, transcendental
topics, because the repressed ideas were always of a sensual kind. Or
else the patient tries to master each particular idea by logic and by
appeals to his conscious memory; this leads to _obsessive thinking_,
the _compulsion to test everything_, and to _folie du doute_. The
patient's preference for perception over memory in making these tests
first leads him, and later compels him, to amass and preserve all
objects with which he comes into contact. Secondary defence against {168}
the obsessional affects calls into being a still wider series of
protective measures, which may be transformed into obsessive
acts. These may be grouped according to their tendencies:
_penitential_ measures (burdensome ceremonials, the observation of
numbers) _precautionary_ measures (all kinds of phobias,
superstitions, pedantry, exaggeration of the primary symptom of
conscientiousness), _dread of betrayal_ (collecting paper,
misanthropia), _hebetude_ (dipsomania). Among these obsessive actions
and impulses the phobias play the greatest part in circumscribing the
patient's life.
There are cases in which one can observe the way in which the compulsion
transfers itself from the idea or from the affect on to the defensive
measure; others in which the compulsion oscillates periodically between
the symptom due to the return of the repressed and the symptom of
secondary defence; and still other cases in which no obsessional idea is
formed at all, but in which the repressed memory is replaced forthwith
by the apparently primary defensive measure. The stage which is
otherwise attained only after a defensive battle and which concludes the
development of an obsessional neurosis is here reached in one leap.
Severe cases of this disease end in the obsessive ceremonial becoming
firmly established, in a general _folie du doute_, or in an eccentric
way of life conditioned by phobias.
That the obsessional idea and all its derivatives find no credence is
probably due to the fact that the defence-symptom of
_conscientiousness_ is formed at the onset of repression, and that
this symptom has a similar obsessional value. The certainty that a
moral life has been lived throughout the whole period of successful
defence makes it impossible to give credence to the self-reproach
involved in the obsessional idea. Only transitorily, upon the {169}
appearance of a new obsessional idea or now and then in a condition of
melancholic exhaustion of the ego, do the morbid symptoms of the
return of the repressed compel belief. The 'compulsion' of the
psychical productions here described has in general nothing to do with
belief in them and is also not to be confounded with that factor which
one designates as the 'strength' or 'intensity' of an idea. Its
essential character is rather its insolubility through conscious
psychical activity, and this character undergoes no change whether the
idea to which the compulsion adheres is strongly or weakly, more or
less intensely, 'suffused', 'endowed with cathexis', and so on.
The cause of this invulnerability of the obsessional idea or its
derivatives, however, is only its connection with the repressed memory
of early childhood; for if it is possible to succeed in making this
connection conscious---and psycho-therapeutic methods appear to be
already competent to do so---we find that at the same time the
compulsion is removed.
III. ANALYSIS OF A CASE OF CHRONIC PARANOIA
For a long time I have entertained the suspicion that paranoia, or
groups of cases belonging to it, is also a defence-psychosis; that is
to say, that it results from the repression of painful memories, as do
hysteria and obsessions, and that the form of the symptoms is
determined by the content of the repressed memory. A special path or
mechanism of repression, however, must be peculiar to paranoia; just
as in hysteria the repression is effectively established by means of
_conversion_ into bodily innervation, and in the obsessional neurosis
by means of _substitution_ (displacement along certain associated
channels). I observed several cases which favoured this view, but had {170}
found none which proved it until I had the opportunity some months ago
through the kindness of Dr. J. Breuer of undertaking psycho-analytic
treatment of an intelligent woman, aged thirty-two, in whose case the
diagnosis of chronic paranoia was undeniable. I am already here
reporting a few of the points which it was possible to obtain light
upon in the course of this piece of work, because I have no
opportunity of studying paranoia except in very isolated cases, and
because I consider it possible that these observations may induce a
psychiatrist more favourably situated than I to bring the factor of
'defence' into its rightful place in the discussion, now so brisk, on
the nature and psychical mechanism of paranoia. On the basis of a
single observation I should naturally not think of going further than
some such conclusion as this: this case is a defence-psychosis and in
the category of paranoia there are probably others like it.
Frau P., thirty-two years of age, three years married and the mother
of a two-year-old child, was born of parents who were not nervous; her
brother and sister I knew, however, to be also neurotic. It is
doubtful whether she was not temporarily depressed and confused in her
judgement in her twenties; in later years she was healthy and active
until six months after the birth of her child when she showed the
first symptoms of her present illness. She became uncommunicative and
distrustful, showed a disinclination to meet her husband's family and
complained that the neighbours in the small town where she lived had
changed towards her and were now rude and disagreeable. By degrees
these complaints increased in intensity, though not in definiteness:
people had something against her, although she had no notion what it
could be; there was not the slightest doubt that everyone---relations {171}
and friends---had ceased to respect her, and that they did all sorts
of things to wound her; she racked her brains to find the reason for
this, but could not discover it. Somewhat later she complained that
she was being watched, that people read her thoughts, that they knew
everything that went on in her house. One afternoon she suddenly got
the idea that people watched her undressing at night. From that time
onwards she employed the most complicated precautions when undressing,
slipping into bed in the dark and undressing under the
bedclothes. Since she cut herself off from the world, ate little, and
was very depressed, she was sent in the summer of 1895 to a
hydrotherapeutic institution. There new symptoms appeared and those
she already had became exacerbated. In the previous spring when alone
one day with a housemaid she had suddenly had a sensation in her
genitals and the idea came into her mind that the girl had just then
had an improper thought. This sensation became more frequent in the
summer and was almost continuous, her genitals felt 'as if there was a
heavy hand there'. Then she began to see images which horrified
her---hallucinations of naked females, in particular an uncovered
vulva with hair; occasionally male genitals as well. The vision of the
hairy vulva and the physical sensation in the genital organs usually
occurred simultaneously. These images were very tormenting to her, for
they recurred regularly whenever she was in the company of a woman,
and she supposed that she was seeing the woman in a state of most
unseemly nakedness and that at the same moment the woman was having
the same vision of her (!). Simultaneously with these visual
hallucinations, which after their first appearance in the institution
disappeared again for several months, voices which she did not {172}
recognize and which she could not explain began to pester her; when
she was in the street they said, 'That is Frau P. There she goes!
Where's she going?' Some one commented on her every movement and
action, occasionally she heard threats and reproaches. All these
symptoms became worse if she was among several people or even when she
was in the street; she therefore refused to go out and then declared
that eating disgusted her, so that her condition became rapidly worse.
I gathered this from her when she came to Vienna in the winter of 1895
to be treated by me. I have described the case circumstantially in order
to demonstrate that we are really dealing here with a quite frequent
type of chronic paranoia; the details of the symptoms and of her conduct
which will be adduced later will also support this conclusion. At the
time she concealed from me any delusions concerning the meaning of the
hallucinations or perhaps they had really not yet been formed; her
intelligence was unimpaired; the only unusual thing I was informed of
was that she had repeatedly made appointments with her brother, who
lived in the neighbourhood, in order to tell him something important but
had never actually told him anything. She never spoke about her
hallucinations and towards the end said practically nothing about the
grievances and persecutions which she suffered from.
What I have to report about this patient concerns the ætiology of the
case and the mechanism of her hallucinations. I discovered the
ætiology while I was applying Breuer's method, exactly as in a case of
hysteria, for the investigation and removal of the hallucinations. I
started from the assumption that there must be in this case of
paranoia unconscious thoughts and repressed memories, as there were in {173}
the two other defence neuroses which were known to me---unconscious
thoughts and repressed memories which might be brought to
consciousness as in the other cases by overcoming a certain
resistance. The patient at once confirmed my expectation by behaving
under analysis exactly like, for example, an hysteric; in a state of
attention under the pressure of my hand[47] thoughts came into her
mind which she did not remember ever to have had, which at first she
did not understand and which were quite contrary to her
expectations. The presence of significant unconscious ideas was thus
demonstrated in a case of paranoia too, and I had hopes of tracing
back the compulsion of the paranoia also to repression. The only
peculiar thing was that the thoughts arising in the unconscious were
usually heard inwardly or hallucinated in the same way as she had
heard the voices.
About the origin of the visual hallucinations or at least of the vivid
images I gathered the following: The vision of the female genitals came
almost always in connection with the organic sensation in her own
genitals; but the latter was much more constant and very often occurred
without the vision.
The first of these images had appeared in the hydrotherapeutic
establishment a few hours after she had actually seen a number of
women naked in the bathing-room, and proved therefore to be a simple
reproduction of a real impression. It was to be presumed that it had
been repeated only because great interest had been taken in it. She
then said she had at the time felt shame for those women; she had
herself been ashamed to be seen naked as long as she could remember. I
had to regard this shame as something obsessive and concluded that {174}
according to the defence-mechanism an experience had been repressed
for which she did _not_ feel shame; so I required her to let any
memories come up relating to the topic of shame. She promptly
reproduced a series of scenes from her seventeenth back to her eighth
year in which she had been ashamed of her nakedness in the presence of
her mother while bathing, her sister, or the family physician; the
series, however, ended in a scene in her sixth year in which she
undressed in the nursery on going to bed without feeling shame about
her brother's presence. On being questioned she informed me that such
scenes had often occurred and that the brother and sister had for
years had the habit of showing themselves to each other naked before
going to bed. I now understood the significance of the sudden idea
that someone was watching her when she was going to bed. It was an
unaltered fragment of the old memory evoking self-reproach and she was
now making up for the shame which she had not felt as a child.
The conjecture that we were concerned with an affair between children,
as so frequently also in the ætiology of hysteria, was strengthened by
further progress in the analysis, which at the same time yielded
solutions for several of the details frequently recurring in the
clinical picture of paranoia. The beginning of her depression occurred
at the time of a quarrel between her husband and her brother in
consequence of which the latter no longer came to the house. She had
always been very fond of this brother and missed him greatly when this
happened. Further, she also referred to a certain period in her
illness at which for the first time 'everything became clear to
her'---that is to say, the time when she became convinced of the truth
of her conjecture that she was generally scorned and deliberately {175}
insulted. This certainty came upon her during a visit from a
sister-in-law, who in the course of conversation remarked casually,
'If anything of that kind happened to me I should simply shrug my
shoulders'. Frau P. at first received this remark with indifference,
but later, after the visitor had left, it occurred to her that the
words contained a reproach, as if _she_ was wont to make light of
serious things; and from that moment she felt sure that she was the
victim of universal slander. When I questioned her why she felt
justified in applying these words to herself, she replied that it was
the tone in which her sister-in-law had spoken which (although only
later) had convinced her of it---a characteristically paranoiac
detail. I now urged her to recollect the remarks which her
sister-in-law had made _before_ the expression complained of, and I
learnt that the sister-in-law had related that in her home there had
been all sorts of difficulties with the _brothers_, and had added the
wise comment: 'In every family things occur over which one would
gladly draw a veil, but if anything of the kind happened to me I
should think nothing of it'. Frau P. had now to admit that her
depression was related to these sentences before the last
remark. Since she had repressed both the two sentences which might
have aroused the memory of her relations with her brother and had
retained in memory only the insignificant last sentence, she had had
to connect her idea that her sister-in-law was intending a reproach
against her with this last sentence; and as its contents offered no
support to this interpretation she turned from the contents to the
_tone_ in which these words were spoken. Probably a typical piece of
evidence that the misinterpretations of paranoia are based upon
repression. {176}
Her singular conduct in fixing appointments with her brother in which
she had nothing to say to him was explained in a surprising way. Her
explanation was that she thought that if she could only look at him he
would understand her suffering because he knew the cause of it. Now
since this brother was actually the only person who could know of the
ætiology of her illness, it became clear that she had been acting in
accordance with a motive which she did not herself consciously
understand, but which was seen to be completely justified as soon as a
meaning from the unconscious was supplied.
I then succeeded in inducing her to reproduce the various scenes in
which the sexual relations with her brother had culminated (they had
lasted certainly not less than from her sixth to her tenth
year). During this work of reproduction the organic feeling in the
genitals 'joined in the discussion'---a regular occurrence during the
analysis of the memory-fragments of hysterics. The vision of naked
female genitals (now, however, of childish proportions and without
hair) appeared or stayed away according to whether the scene in
question had occurred in bright light or in the dark. Her disgust in
regard to eating, too, was explained by a repulsive detail in these
proceedings. After we had come to an end of these scenes the
hallucinatory sensations and visions disappeared and, up to the
present at least, have not returned.[48] {177}
I had discovered, therefore, that these hallucinations were nothing else
but parts of the content of repressed experiences of
childhood---symptoms of the return of the repressed.
I now directed my attention to the analysis of the voices. In the first
place it had to be explained why such an indifferent content as 'Here
comes Frau P.', 'She's looking for a house now', and the like, could be
so distressing to her; then I turned to the question how these
particular harmless sentences had come to be selected for hallucinatory
reinforcement. From the first it was clear that these 'voices' could not
be hallucinatory reproductions of memories like the images and
sensations, but were rather thoughts that had been 'said aloud'.
The first time that she heard the voices occurred under the following
circumstances: she had been reading O. Ludwig's novel, _Die
Heiterethei_, finding it very thrilling, and had noticed that while
reading thoughts kept creeping into her mind. Immediately afterwards
she went a walk along a country road and suddenly the voices said to
her as she walked past a peasant's cottage: 'That's what Heiterethei's
house looked like! There's the spring and there's the shrubbery! How
happy she was in spite of all her poverty!' Then the voices repeated
to her whole paragraphs from the book she had just read; but it was {178}
still quite unintelligible why the house, shrubbery and spring
of Heiterethei, and just the most trifling and irrelevant parts of the
novel should be forced on her attention with such pathological
intensity. However, the solution of the puzzle was not difficult. The
analysis showed that during her reading her mind had wandered and she
had become excited by totally different passages in the book. Against
this material---analogies between the couple in the novel and herself
and her husband, memories of intimacies in her married life and family
secrets---there arose a repressing resistance, because it was
connected by easily demonstrable trains of thought with her sexual
dread and finally amounted to an awakening of the old
childhood-experience. In consequence of the censorship exercised by
the repression the harmless and idyllic passages, which were connected
with the proscribed ones by contrast and also by proximity, became
strengthened in consciousness and were able to 'say themselves
aloud'. The first of the repressed ideas, for instance, related to the
gossip among the neighbours to which the heroine, who lived all alone,
was exposed. She easily discovered the analogy with herself in this;
she also lived in a small place, saw no one, and thought herself
despised by her neighbours. This distrust of her neighbours had a
foundation in real experience; for when she was first married she had
at first been obliged to be content with a small dwelling, and the
wall of the bedroom against which the bed of the young couple stood
adjoined a room of the neighbours. Great sexual shyness first awoke in
her at the time of her marriage---obviously by its rousing memories of
the affair in her childhood when the two children played at man and
wife; she was continually apprehensive lest the neighbours should
distinguish words and noises through the intervening wall, and this {179}
shame turned itself into suspicions of the neighbours in her mind.
The voices therefore owed their origin to the repression of thoughts
which, if followed to their conclusion, really signified self-reproaches
in regard to experiences which had a significance analogous to that of
the trauma in childhood; they were accordingly symptoms of the return of
the repressed, at the same time, however, a compromise between the
resistance of the ego and the strength of the idea under repression,
which in this case had brought about an absolutely unrecognizable
distortion. In other instances where I had an opportunity to analyse the
voices in Frau P.'s case the distortion was not so great; nevertheless,
the words always had the character of diplomatic indefiniteness; the
distressing allusion was usually closely hidden, the connection between
the particular sentences being disguised by a strange tone of voice,
unusual forms of speech, and the like---characteristics common to the
auditory hallucinations of paranoiacs and in which I see traces of the
compromise-distortion. The remark, 'There goes Frau P., she's looking
for a house' signified, for example, a threat that she would never be
well again, because I had promised her that after treatment she would be
able to return to the small town where her husband's business was;---she
had taken a lodging in Vienna for some months.
In isolated instances Frau P. was also aware of more definite threats,
for example, as proceeding from her husband's relations, but they were
always so mildly expressed as to be in marked contrast to the pain
which they caused her. In view of what is known about paranoia I am
inclined to believe that gradual weakening of the resistance which is
designed to keep the self-reproaches under takes place; so that {180}
finally the defence fails completely and the original reproach, the
actual insulting word against which protection is being sought,
returns in its original form. I do not know however whether this is a
regular process, whether the censorship exerted over the reproaching
speeches may not sometimes be absent from the beginning, or may not
sometimes persist to the end.
It only remains for me now to turn to account what has been learned
from this case of paranoia in a comparison between paranoia and the
obsessional neurosis. In each of them repression has proved to be the
nucleus of the psychical mechanism, and in each of them the repressed
content is a sexual experience in childhood. And in this case of
paranoia, too, every compulsion comes from repression; the symptoms of
paranoia may be classified in the same way that has proved justifiable
in regard to the obsessional neurosis. Part of the symptoms again
originate in a primary defence---namely, all the delusions of
distrust, suspicion and persecution by others. In the obsessional
neurosis the initial self-reproach has undergone repression by the
formation of the primary symptom: _self-distrust_. The self-reproach
is thereby recognized as justified and, in compensation, a recognition
of the conscientiousness in the healthy interval serves as a
protection against belief in the reproaches when they return in the
form of obsessions. In paranoia the reproach is repressed in a manner
which may be described as _projection_;[49] by the defence-symptom of
_distrust directed against others_ being erected; in this way
recognition of the reproach is withheld, and, as if in return,
protection is lost against the self-reproaches which reappear in the
delusions. {181}
Other symptoms of my case of paranoia are to be described as symptoms of
the return of the repressed and bear traces, as do those of the
obsessional neurosis also, of a compromise which alone makes its entry
into consciousness possible. Such are, for instance, the delusion that
she is being observed while undressing, the visions, the sensory
hallucinations and the hearing of voices. In the delusion mentioned,
almost unaltered memories are present, which are only indefinite because
a part of their content is omitted. The return of the repressed in
visual images approximates more to the character of hysteria than to
that of obsessional neurosis; although hysteria is wont to repeat its
memory-symbols without modification, whereas the paranoiac
memory-hallucination undergoes a distortion similar to that of the
obsessional neurosis---an analogous current image takes the place of the
repressed one (the genitals of an adult woman instead of that of a
child, the hair on the former being particularly prominent because it
was lacking in the original impression). A circumstance quite peculiar
to paranoia and one that cannot be cleared up in this comparison is that
the repressed reproaches return as thoughts spoken aloud. They must
thereby suffer a two-fold distortion, first, through a censorship, which
leads to their substitution by other associated ideas or to a disguise
by indefinite kinds of expressions, and secondly, through their relation
to current experiences which are merely analogous to the original.
The third group of symptoms found in the obsessional neurosis, those
of a secondary defence, cannot be present in paranoia as such; because
the symptoms of the return of the repressed are not opposed by any
defence---indeed, they find acceptance. Paranoia, on the other hand, {182}
turns to another source in forming symptoms; the delusions which by
means of a compromise succeed in becoming conscious (symptoms of the
return of the repressed) absorb the thought-processes of the ego until
they finally become accepted without contradiction. Since the
delusions themselves are not to be influenced, the ego must
accommodate itself to them; and thus the combinatory
delusion-formations, such as _interpretation-delusions_ ending in a
_change within the ego_, correspond to the secondary defence in the
obsessional neurosis. My case was in this respect not fully developed;
at that time there was no sign of the attempts at interpretation which
appeared later. But I do not doubt that it will still be possible to
arrive at further important results if psycho-analysis is applied also
to this stage of paranoia. It might then be proved that the so-called
_weakness of memory_ in paranoiacs is a tendencious manifestation,
that is, that it is based upon repression and serves the ends of
repression. Finally, even memories which are not in the least
pathogenic, but which stand in contradiction to that change within the
ego that the symptoms of the return of the repressed so tyrannically
demand, become repressed and replaced.
------------------------------------------------------------------------
X {183}
THE ÆTIOLOGY OF HYSTERIA[50]
(1896)
I
When we endeavour to form some opinion about the causation of a morbid
condition such as that of hysteria we first of all adopt the method of
anamnestic enquiry, examining the patient or his friends about the
harmful influences to which they themselves trace the appearance of
the particular neurotic symptoms. The value of what we discover in
this way is, of course, impaired by all the various circumstances
which commonly conceal from a patient the knowledge of his own
condition---his lack of scientific understanding of ætiological
influences, the fallacy _post hoc_, _ergo propter hoc_, the distress
it causes him to think or speak of certain noxiæ and traumas. Hence,
in making any such enquiry we adhere to the principle of not adopting
the patients' belief without a thorough critical examination and not
allowing them to lay down for us our scientific opinion upon the
ætiology of the neurosis. Although on the one hand we acknowledge
certain constantly recurring statements, as that the hysterical
condition is a long-persisting effect of an emotional disturbance
which once took place, we have on the other hand introduced into the
ætiology of hysteria a factor which the patient himself never cites
and only reluctantly admits---namely, the disposition inherited from {184}
his parents. You know that in the opinion of the influential school of
Charcot heredity alone is to be recognized as the real cause of
hysteria, whilst all other harmful influences of the most varying kind
and intensity only play the part of exciting causes, of '_agents
provocateurs_'.
You will readily admit that it would be desirable to find another way of
arriving at the ætiology of hysteria, one in which we should feel less
dependent on the statements of the patients themselves. The
dermatologist, for instance, is able to recognize the luetic character
of a sore from the nature of its edges, of the crust upon it and from
its shape, without being misled by the protestation of the patient who
denies any source of infection. In forensic medicine, the physician can
explain how an injury has been caused, even without any information from
the injured person. Now in hysteria there exists a similar possibility
of penetrating from the symptoms to knowledge of their causes. As for
what concerns the relation which the method to be employed bears to the
older method of anamnestic enquiry, I will put before you a simile taken
from an advance which has in fact been made in another field of work.
Imagine that an explorer comes in his travels to a region of which but
little is known and that there his interest is aroused by ruins
showing remains of walls, fragments of pillars and of tablets with
obliterated and illegible inscriptions. He may content himself with
inspecting what lies there on the surface and with questioning the
people who live near by, perhaps semi-barbaric natives, about what
tradition tells of the history and meaning of these monumental
remains, and taking notes of their statements---and then go his
way. But he may proceed differently; he may have come equipped with {185}
picks, shovels and spades, and may press the inhabitants into his
service and arm them with these tools, make an onslaught on the ruins,
clear away the rubbish and, starting from the visible remains, may
bring to light what is buried. If his work is crowned with success,
the discoveries explain themselves; the ruined walls are part of the
ramparts of a palace or a treasure-house, from the ruined pillars a
temple can be constructed, the many inscriptions, which by good luck
may be bilingual, reveal an alphabet and a language, and when
deciphered and translated may yield undreamed-of information about the
events of the past, to commemorate which these monuments were
built. _Saxa loquuntur!_
If one tries in something the same way to let the symptoms of a case of
hysteria tell the tale of the development of the disease, we must start
from the momentous discovery of J. Breuer: that the symptoms of hysteria
(apart from stigmata) are determined by certain experiences of the
patient's which operate traumatically and are reproduced in his psychic
life as memory-symbols of these experiences. We must adopt Breuer's
method---or one of a similar kind---in order to lead the patient's
attention from the symptom back to the scene in and through which it
originated; and having thus discovered it, we proceed when the traumatic
scene is reproduced to correct the original psychical reaction to it and
thus remove the symptom.
It is no part of my intention to-day to treat of the difficult
technique of this therapeutic method or the psychological revelations
it has achieved. I had to start from this point, simply because
analyses conducted on Breuer's method seem at the same time to open up
the way to the causes of hysteria. If we subject a large number of
symptoms in many people to this analysis, we shall come to know of a {186}
correspondingly large number of traumatically operative scenes. We
have learnt to recognize in these experiences the efficient causes of
hysteria; hence we may hope to discover from the study of these
traumatic scenes by what influences and in what ways hysterical
symptoms are produced.
That this expectation is justified follows from the fact that Breuer's
theses, when put to the test in more numerous cases, prove to be
actually correct. But the way from the symptoms of hysteria to its
ætiology is longer and introduces us to all sorts of unexpected
connections.
For let us be quite clear that tracing an hysterical symptom back to a
traumatic scene assists our understanding only if the scene in
question fulfils two conditions---if it possesses the required
_determining quality_ and if we can credit it with the necessary
_traumatic power_. Let me give an illustration instead of a mere
explanation of terms. Suppose that the symptom in question is that of
hysterical vomiting, we think we can apprehend its cause (or at any
rate leave only a certain part unexplained) if analysis traces the
symptom to an experience which justifiably gave rise to a high degree
of disgust, for instance the sight of a decomposing corpse. Supposing,
instead of this, analysis traces back the vomiting to some great
shock, e.g. a railway accident, this explanation will be
unsatisfactory and we shall have to ask ourselves how it is that the
shock led to the particular symptom of vomiting. This derivation of
the symptom lacks determining quality. We have another instance of an
unsatisfactory explanation when the vomiting is said to have
originated in eating a fruit which had a rotten spot in it. Then the
vomiting is indeed determined by disgust, but we cannot understand how {187}
the disgust in this case could be so powerful as to perpetuate itself
in an hysterical symptom; the experience lacks traumatic power.
Now let us consider to what extent the traumatic scenes of hysteria
which are revealed in analysis fulfil the two above requirements in a
large number of symptoms and cases. Here we encounter our first great
disappointment. It does sometimes happen that the traumatic scene in
which the symptom originated really possesses both properties which we
require in order to understand the symptom: determining quality and
traumatic force. But far oftener---incomparably so---we find realized
one of three other possibilities which are very difficult to understand:
either the scene indicated by analysis in which the symptom first made
its appearance seems to us not qualified to determine the symptom, for
its content bears no relation to the form of that symptom; or the
ostensibly traumatic experience whose content is so related proves to be
a normally harmless impression, one which ordinarily would have no
effect; or finally the 'traumatic scene' disconcerts us in both
directions, appearing both harmless and altogether unrelated to the
peculiar form of the hysterical symptom.
(Here I may remark in passing that Breuer's conception of the origin
of hysterical symptoms is not affected by the discovery of traumatic
scenes which represent experiences in themselves insignificant. For
Breuer assumed---in agreement with Charcot---that even a harmless
experience may acquire the significance of a trauma and may develop
determining power when the subject is in a particular psychic
condition, the so-called _hypnoid state_. I find, however, that often
there are no grounds for presupposing such hypnoid states. What is {188}
definite is that the theory of hypnoid states contributes nothing to
the solution of the other difficulties, namely, that so often the
traumatic scenes are lacking in determining quality.)
Moreover, this first disappointment in the practice of Breuer's method
is followed immediately by another which must be specially grievous to a
physician. Such derivations as these which do not contribute to our
understanding of the case in respect of determining quality and
traumatic force are also of no therapeutic advantage; the patient keeps
his symptoms unaltered, in spite of the first result yielded by
analysis. You will understand how great the temptation then is to go no
further with work which, apart from this, is laborious.
But perhaps we only need a fresh inspiration to help us out of our
dilemma and lead to valuable results. Here it is:---we know indeed
through Breuer that hysterical symptoms may be resolved if, starting
from them, we can find our way back to the memory of a traumatic
experience. If the memory so revealed does not answer our
expectations, possibly we must pursue the same path a little further;
perhaps there is hidden behind the first traumatic scene the
recollection of a second, which satisfies our requirements better and
the reproduction of which has a better therapeutic result, so that the
scene first discovered has only the significance of a link in the
chain of association. And perhaps this situation repeats itself,
inoperative scenes being in several places interpolated as necessary
transitions in the reproduction, till finally, starting from the
hysterical symptom, we arrive at the scene which really operates
traumatically and is in every respect, from both the therapeutic and
the analytic point of view, satisfactory. Well, this supposition is {189}
correct. When the scene first revealed does not satisfy our
requirements, we say to the patient that this experience does not
explain anything, but that there must be hidden behind it an earlier
and more significant experience, and, following the same technique, we
direct his attention to that strand in the associations which unites
both memories---that which we have found and that which we have still
to find.[51] Continuation of the analysis then leads in every instance
to the reproduction of new scenes of the kind we should expect; for
example, to instance again the case of hysterical vomiting which I
selected before and which was first referred by analysis to the shock
of a railway accident. Now although this experience lacks the
determining quality, I find on further analysis that this accident
woke the memory of another which had happened previously, in which the
patient had not, it is true, been himself involved, but which was the
occasion of his seeing a corpse, a sight which aroused in him horror
and disgust. It is as though the combined influence of these two
scenes led to the fulfilment of our two postulates, the one experience
supplying, in the shock, the traumatic force and the other, in its
content, the determining influence. The other instance, where the
vomiting was traced to eating an apple in which there was a rotten
spot, is amplified through analysis somewhat as follows: the rotting
apple roused the memory of a former experience of picking up fallen
apples in a garden when the patient happened to come on the loathsome
carcase of an animal. {190}
I will not again return to these examples, for I must admit that they
are not taken from any case in my experience, but that I invented them,
and most probably they are bad inventions; I myself regard such
explanations of hysterical symptoms as impossible. But there were
several reasons why I had to make up examples, and one reason I can
state at once. The real examples are all of them far and away more
complicated; to relate a single one of them in detail would occupy the
whole of this lecture hour. The chain of associations has always more
than two links; the traumatic scenes do not form simple rows like a
pearl necklace, but they branch out and are interconnected like
genealogical trees, a new experience being influenced by two or more
earlier ones in the form of memories; in short, to give an account of
the resolution of a single symptom is practically synonymous with the
task of giving a complete history of a case.
But now I must not neglect to lay special emphasis on the one conclusion
derived, quite unexpectedly, from analytic work by means of these chains
of recollections. We have found out that no hysterical symptom can
originate in one real experience alone, but that in every instance the
memory roused by association co-operates with earlier experiences in
causing the symptom. If this conclusion is (as I believe) _without
exception_ correct, it indicates the foundation upon which a
psychological theory of hysteria is to be built.
You might think that those rare instances in which analysis can trace
the symptom immediately to a traumatic scene of satisfactory
determining quality and traumatic force and, by so tracing it, at the
same time remove it (as described in Breuer's history of the case of
Anna O.) would surely constitute powerful objections to the general {191}
validity of the conclusion just propounded. Certainly it looks as if
that were so; but I can assure you I have the best of reasons for
assuming that even in these cases there exists a chain of operative
memories which stretches far back behind the traumatic scene, even
though the reproduction of the latter alone may result in the removal
of the symptom.
In my opinion it is really astonishing that hysterical symptoms should
arise only where memories are at work, especially when we reflect that
these memories, according to all the statements of the patients
themselves, did not come into consciousness at the moment when the
symptom first made its appearance. Here is food for much reflection, but
for the present we must not let these problems deflect the course of our
discussion of the ætiology of hysteria. Rather we must ask ourselves:
where shall we get to if we follow the chain of associated memories
revealed to us by analysis? How far do they go? Is there any point at
which they come naturally to an end? Do they perhaps lead to experiences
which are in any way similar, whether by relation of time or of content,
so that in these universally similar factors we may discern that
ætiology of hysteria for which we are seeking?
My experience up till now enables me already to answer these
questions. Taking a case which presents several symptoms, from
whatever symptom we start we arrive by means of analysis at a series
of experiences the memories of which are linked together by
association. At first the memory-chains are distinct from one another
as they lead backwards, but, as we said before, they branch out; from
a single scene two or more memories may be reached at the same time,
and from these again there issue side-chains the single links of which {192}
may in their turn be joined by association to links of the main
chain. The metaphor of a family tree of which the members have also
intermarried is really not a bad one. Other complications in the
linking up of the chains arise from the circumstance that a single
scene in the same chain may be several times recalled to memory, so
that it is related in more than one way to a later scene, and may
prove both to be directly connected with it and also to be joined by
means of intermediate links. In short, the connection is by no means a
simple one, and the fact that the scenes are discovered in reverse
chronological order (the very feature which justifies our comparison
with the excavation of ruins) certainly does not contribute to a more
rapid understanding of the process.
New complications are met if the analysis is pursued further. The
chains of associations for the separate symptoms then begin to enter
into relation with one another; the family trees intertwine. When we
come to a certain experience in the memory-chain which has reference,
for instance, to the symptom of vomiting, besides the backward-leading
links in this chain, there is revived a memory which belongs to
another chain and which is the basis of another symptom, perhaps that
of headaches. So that experience belongs to both series and thus
constitutes a _nodal point_, several of which are to be found in every
analysis. Its clinical correlation may perhaps be that from a certain
time on the two symptoms occur together, symbiotically, really without
any inner mutual dependence. Still further back we find nodal points
of another sort. There the chains of associations converge; we find
experiences in which two or more symptoms have originated. One chain {193}
has attached itself to one detail of the scene and a second chain to
another detail.
But the most important result arrived at by such a consistent pursuit of
analysis is this: whatever case and whatever symptom we take as our
starting-point, _in the end we infallibly come to the realm of sexual
experience_. So here for the first time we would seem to have discovered
an ætiological condition of hysterical symptoms.
From previous experience I can foresee that it is just against this
conclusion or against its universal validity that your opposition will
be directed. Perhaps it would be more correct to say: your inclination
to opposition, for probably none of you can refer to investigations
which, if the same method had been employed, would have yielded a
different result. On the actual matter in dispute I will only remark
that in my case at least there was no preconceived opinion which led
me to single out the sexual factor in the ætiology of hysteria. The
two investigators as whose pupil I began my work on the subject,
Charcot and Breuer, emphatically had no such presupposition, in fact
they had a personal disinclination to it which I originally
shared. Only the most laborious and detailed investigations have
converted me, and that slowly enough, to the opinion which I defend
to-day. If you subject to the closest scrutiny my assertion that the
ætiology of hysteria is to be sought in the sexual life, it amounts to
the statement that I can assure you that, in some eighteen cases of
hysteria, I was able to recognize this connection to hold for every
single symptom and, when circumstances permitted, to confirm the fact
by therapeutic success. You may of course object that the nineteenth
and twentieth analyses would perhaps show that hysterical symptoms can {194}
be derived from other sources also, and that thus the validity of the
sexual ætiology would not be universal but would be reduced to 80 per
cent. By all means let us wait and see, but since those eighteen cases
are at the same time _all_ those which I was able to analyse, and
since nobody picked them out to please me, you will understand that I
do not share any such expectation, but am prepared to let my belief
outrun the evidential force of my discoveries up to the present
time. Besides, I am influenced by yet another motive, which for the
moment is of merely subjective value. In the single attempt to explain
the physiological and psychical mechanism of hysteria that I have made
for the purpose of embracing the results of my observations, I have
found the participation of sexual impulses an indispensable
hypothesis.
So, the memory-chains having converged, we come at last to sexual
things and to some few experiences which for the most part occur at
the same period of life, namely, the age of puberty. In these
experiences we are to find the ætiology of hysteria and through them
learn to understand how hysterical symptoms originate. But here we
meet with a fresh disappointment and a grave one. It is true that
these experiences which have been discovered and extracted from the
whole mass of memories with such difficulty and seemed to be the
ultimate traumata, have two characteristics in common: they are sexual
and they occur at the time of puberty, but otherwise they are very
different in kind and unequal in importance. In some cases it was a
matter of experiences which must be recognized as serious
traumata---an attempt at rape, revealing at one blow to the immature
girl the whole brutality of sexual desire; or the involuntary
witnessing of sexual acts on the part of the parents, which at one and {195}
the same time reveals unsuspected ugliness and wounds both the
childish and the moral sensibility; and so forth. In other cases these
experiences are astonishingly trivial. The experience on which the
neurosis of one of my patients was shown to be based was that a boy
friend had stroked her hand caressingly and on another occasion had
pressed his leg against her dress as they sat side by side at table,
his expression at the same time leading her to guess that this was
something forbidden. With another young lady, hearing a riddle which
suggested an obscene answer actually sufficed to call forth the first
anxiety-attack with which the illness began. Clearly, discoveries such
as these are not favourable to an understanding of the cause of
hysterical symptoms. If both serious and trifling occurrences,
experiences undergone by the patient in person as well as visual
impressions and verbal communications may be recognized as the
ultimate traumata of hysteria, we may perhaps put forward the
explanation that hysterics are peculiarly constituted human
beings---probably on account of some hereditary disposition or process
of degeneration---in whom the shrinking from sexuality which normally
plays a certain part at the age of puberty is developed to a
pathological extent and is permanently retained; so to speak, persons
who are not adequate mentally to the demands of sexuality. It is true
that in this statement we pass over hysteria in men; but, even without
such an obvious objection, it would scarcely be a very great
temptation to halt at this solution. We are only too conscious
intellectually that we have here something only half understood,
something obscure and unsatisfactory.
Luckily for our explanation, certain of these sexual experiences at
puberty display a further inadequacy likely to stimulate us to {196}
continue our analytic work. For we find that these experiences may
also too lack the determining quality, though this is much rarer than
in the traumatic scenes of later life. So, for example, the two
patients whom I spoke of above as cases in which the experiences of
puberty were actually harmless began, in consequence of those
experiences, to suffer from peculiar painful sensations in the genital
organs. These sensations had persisted as main symptoms of the
neurosis, but it could not be shown that they were determined either
by the scenes at puberty or by later ones; certainly they were neither
normal organic sensations nor manifestations of sexual
excitation. Does it not then seem obvious to say that we must look for
the determining quality of these symptoms in yet other experiences,
dating from an even earlier period; that here, for the second time, we
must follow that saving inspiration which led us before from the first
traumatic scenes to the memory-chains? To be sure, by so doing, we get
back to the time of earliest childhood, the time before the sexual
life developed, and this would seem to involve abandoning our sexual
ætiology. But have we no right to assume that even the age of
childhood is not without delicate sexual excitations, more, that
perhaps the later sexual development is decisively influenced by
childish experiences? Injuries sustained by an organ as yet immature,
or a function in process of development, do indeed so often cause
graver and more lasting effects than can ensue in riper years. Perhaps
the abnormal reaction to sexual impressions which surprises us in
hysterics at puberty is always due to such sexual experiences in
childhood, experiences which might then prove to be significant and
similar in kind? We should then come to the view that certain {197}
things must be regarded as having been acquired in early life which
hitherto have been laid to the charge of some by no means clearly
understood hereditary predisposition. And, since infantile experiences
of a sexual nature can surely manifest a psychic influence only
through their memory-traces, would not this view bear out in a
gratifying manner the result reached in analysis---namely, that the
influence of memories is essential for the production of hysterical
symptoms?
II
You will doubtless have suspected that I should not have developed
this last train of thought at such length, if I had not wished to
prepare you for the idea that this path alone, after our many delays,
can lead us to the goal. For now we really stand at the end of our
lengthy and laborious analytic work and find fulfilled here all that
we have so far maintained and expected. When we are persevering enough
to carry our analysis back into early childhood, to the very furthest
point which human memory can reach, we thereby in every instance cause
the patient to reproduce the experiences which, on account both of
their special features and of their relation to subsequent morbid
symptoms, must be regarded as the ætiology for which we are
looking. These _infantile_ experiences are once more _sexual_ in
content, but are far more uniform in kind than was the case in the
scenes of puberty which we had lately discovered; it is now no longer
a question of sexual thoughts being awakened by any chance sensory
impression, but of sexual experiences undergone by the patient
personally, of sexual intercourse (in a wide sense). You will admit
that the importance of such scenes needs no further argument; to this {198}
you may now add that in the details of this scene you can invariably
discover the determining factors which were perhaps still lacking in
those other scenes that had taken place later and were reproduced
earlier.
I put forward the proposition, therefore, that at the bottom of every
case of hysteria will be found one or more experiences of premature
sexual experience, belonging to the first years of childhood,
experiences which may be reproduced by analytic work though whole
decades have intervened. I believe this to be a momentous revelation,
the discovery of a _caput Nili_ of neuropathology, but I hardly know
from what point to continue the discussion of the situation. Shall I set
out before you the actual material I have obtained from the analyses I
have conducted, or ought I not rather first of all to try to meet the
mass of objections and doubts which I am probably right in supposing to
be at this moment absorbing your attention? I choose the latter course;
perhaps we shall then be able to dwell on the facts with a more
objective mind.
(_a_) Anyone who is altogether opposed to the psychological conception
of hysteria, who is unwilling to give up the hope of one day tracing its
symptoms to 'finer anatomical changes' and has rejected the view that
the material foundations of hysterical changes must necessarily be
similar in kind to those of our normal mental processes---anyone who
adopts this attitude will naturally put no faith in the results of our
analyses; but the difference in principle between his premisses and ours
absolves us from any obligation to convince him on single points.
But someone else, less determined to reject psychological theories of
hysteria, will when considering our analytical results be tempted to {199}
ask what degree of certainty the application of psycho-analysis
involves; whether it is not very possible either that the physician
forces such scenes upon the docile patient, alleging them to be
recollections, or that the patient tells him things which he has
purposely invented or spontaneous phantasies which the physician
accepts as genuine facts. Well, my answer is that the general
misgiving about the reliability of the psycho-analytic method can be
appraised and removed only when a complete presentation of its
technique and results is available; doubts about the genuine nature of
the infantile sexual scenes, however, can be deprived of their force
here and now by more than one argument. In the first place, the
behaviour of the patients who reproduce these infantile experiences is
in every respect incompatible with the assumption that the scenes are
anything but a most distressing reality which is recalled with the
utmost reluctance. Before they are analysed, the patients know nothing
of these scenes; they are generally indignant if we tell them that
something of the sort is now coming to light; they can be induced only
under the very strongest compulsion of the treatment to engage in
reproducing the scenes; whilst calling these infantile experiences
into consciousness they experience the most violent sensations, of
which they are ashamed and which they endeavour to hide, and they
still try, even after going through them again in so convincing a
fashion, to withhold belief by emphasizing the fact that they have no
feeling of recollecting these scenes as they had in the case of other
forgotten material.
Now this last attitude on their part seems absolutely decisive. Why
should patients assure me so emphatically of their unbelief, if from
any motive they had invented the very things that they wish to {200}
discredit?
It is less easy to refute the charge that the physician forces
reminiscences of this sort upon the patient and influences him by
suggestion to imagine and recount them; nevertheless I think this
position is just as untenable. I have never yet succeeded in forcing on
a patient a scene that I expected to find in such a way that he appeared
to live through it again with all the appropriate emotions; perhaps
others are more successful.
There is however a whole series of further evidence which vouches for
the reality of the infantile sexual scenes. First, they display just the
uniformity in certain details that would necessarily follow from the
identically-recurring conditions of the existence of these experiences;
otherwise we should have to believe in a secret conspiracy between the
individual patients. And again, patients often describe them as if they
were harmless events, the significance of which they obviously do not
perceive, for if they did they would be shocked; or they mention details
to which they attach no importance but which only someone with
experience of life knows of and can appreciate as subtle indications of
reality.
Such occurrences strengthen the impression that patients must actually
have experienced what they reproduce under the compulsion of analysis
as scenes from childhood, and we have yet another and even more
convincing proof when we examine the relation of the infantile scenes
to the content of the whole subsequent history of the illness. Just as
when putting together children's picture-puzzles, we finally after
many attempts become absolutely certain which piece belongs to the gap
not yet filled---because only that particular piece at the same time
completes the picture and can be fitted in with its irregular edges to {201}
the edges of the other pieces in such a way as neither to leave a
space nor to overlap---so the content of the infantile scenes proves
to be an inevitable completion of the associative and logical
structure of the neurosis; and only after they have been inserted does
its origin become evident---one might often say, self-evident.
Without wishing to lay special stress on the fact, I will add that in a
number of cases the therapeutic test also speaks for the genuine nature
of the infantile scenes. There are cases in which a complete or partial
cure can be achieved without going down as far as the infantile
experiences; others in which there is no success at all until the
analysis comes to its natural end with the discovery of the earliest
traumata. I think that in the former cases we are not secure against
relapses; my belief is that a complete psycho-analysis implies the
radical cure of a case of hysteria. However, do not let us here
anticipate what experience will show.
There would be yet one more proof, one which is really unassailable,
of the genuineness of the childish sexual experiences---namely, the
confirmation of the statements of the person analysed by the account
of someone else who is, or is not, under treatment. These two persons
must have taken part in the same experience in their childhood,
perhaps had stood in a sexual relation to one another. Such relations
between children are, as you will hear in a moment, by no means rare;
moreover, it quite often happens that both persons concerned suffer
subsequently from neuroses; and yet I regard it as a fortunate
accident that I have had objective confirmation of this kind in two
out of my eighteen cases. In one instance, the brother, who had not
fallen ill, of his own accord confirmed for me not, it is true, the {202}
earliest sexual experiences with his sister, the patient, but at least
scenes of this kind from their later childhood and the fact of sexual
relations dating further back. Another time it happened that two women
whom I was treating had as children had sexual intercourse with the
same man, when certain scenes had occurred in which all three took
part. A particular symptom which could be traced to these childish
experiences had been developed in both cases and bore witness to this
common experience.
(_b_) Sexual experiences in childhood consisting of stimulation of the
genitals, coitus-like activities, etc. are therefore in the final
analysis to be recognized as the traumata from which proceed
hysterical reactions against experiences at puberty and hysterical
symptoms themselves. Two objections which contradict each other are
sure to be raised from different quarters against this statement. Some
will say that such sexual abuses, practised on children or by children
on one another, happen too seldom to be regarded as conditioning so
common a neurosis as hysteria; others will perhaps maintain that such
experiences are, on the contrary, very frequent, far too frequent for
us to ascribe ætiological significance to them where their existence
is proved. Further, it will be urged that it is easy enough on
enquiry to find people who remember scenes of sexual seduction and
abuse in their childhood, but yet have never suffered from hysteria;
finally, as a weighty argument, that in the lower strata of the
population hysteria certainly does not appear more frequently than in
the highest, while surely everything goes to show that the rule of
keeping a child from everything sexual is transgressed far more
commonly among the proletariat. {203}
Let us begin our defence with the easier part of our task. It seems to
me certain that our children are far oftener exposed to sexual
aggressions than we should suppose, judging by the scanty precautions
taken by parents in this matter. When I first made enquiries about what
was known on the subject, I learnt from colleagues that there are
several publications by children's physicians in which the frequency of
sexual practices by nurses and attendants with their charges, even with
infants, is complained of and in the last few weeks I have come across a
study by Dr. Stekel of Vienna on 'Coitus in Childhood.'[52] I have not
had time to collect other published evidence, but even if only isolated
testimony were forthcoming, we might expect that increased attention to
this subject would confirm the great frequency of sexual experiences and
sexual activity in childhood.
Lastly, the results of my analysis may speak for themselves. In all
the eighteen cases (of pure hysteria and hysteria combined with
obsessions: six men and twelve women) I have, as I said, discovered
such sexual experiences in childhood. I may divide my cases into three
groups, according to the source of the sexual excitation. In the first
group it was a question of assaults---single or at any rate isolated
instances of abuse by grown-up strangers (who took care to avoid gross
mechanical injury) where consent by the children did not enter into
the matter and the first and preponderating result of the experience
was terror. A second group consists of those far more numerous cases
in which some adult attendant of the child---a maid, nurse, governess,
teacher, unhappily only too often a near relation---initiated the
child into sexual intercourse and maintained a regular love-relation {204}
with him, often for years, which had its mental counterpart. To the
third group belong finally the real child-relations, sexual relations
between two children of different sex, mostly between brother and
sister, which are often continued past the age of puberty and have
far-reaching consequences for the two concerned. In most of my cases I
could trace the combined influences of two or more such ætiologies; in
certain instances the accumulation of sexual experiences from
different quarters was really amazing. You will understand this
peculiarity in my observations more easily when you consider that the
cases were all of severe forms of neurosis involving almost complete
incapacity for life.
Where there had been a relation between two children I was sometimes
able to prove that the boy---who played the aggressive part---had
previously been seduced by a woman, and that then, urged on by his
prematurely aroused libido and in consequence of the obsessive memory,
he tried to repeat with the little girl exactly the same practices as he
had learnt from the adult, without attempting any independent
modification in the form of the sexual activity.
So I am inclined to assume that without previous seduction children
cannot find the way to acts of sexual aggression. The foundation of
the neurosis would accordingly have been laid in childhood by adults,
and the children themselves have transmitted to one another the
disposition to suffer later from hysteria. I ask you to pause for a
moment upon the special frequency of sexual relations in childhood
between brothers and sisters, or cousins, due to the opportunity
afforded by their being constantly together; now suppose that ten or
fifteen years later several of the younger generation of the same {205}
family are found to be ill, and then ask yourselves whether this
familial type of neurotic manifestation would not naturally lead us to
assume an hereditary disposition, where there is actually only
_pseudo-heredity_, a transmission or infection having taken place in
childhood.
Now let us turn to the other objection which is based upon the very
frequency---freely admitted---of infantile sexual experiences and the
fact that many people who have not developed hysteria remember such
scenes.
We shall reply in the first place that excessive frequency in an
ætiological factor cannot possibly be used as an objection to its
ætiological significance. Is not the tubercle bacillus ubiquitous,
inhaled by many more human beings than suffer from tuberculosis? And is
its ætiological significance impaired by the fact that it clearly needs
the concurrence of other factors to produce the disease that is its
specific effect? It is enough to establish it as the specific cause that
tuberculosis is never found where the bacillus is not active. The same
is probably true of our problem also. It makes no difference that many
people go through infantile sexual experiences without developing
hysteria, so long as all those who do become hysterics have had such
experiences. The radius of an ætiological factor may be wider, but not
less wide than its effect. Not everyone who touches or comes near a
smallpox patient develops smallpox, and yet infection from an actual
case of it is almost the only known ætiology of the disease.
Of course if infantile sexual activity were an almost universal
occurrence, it would prove nothing to find it in every case. But
first, such a statement would be a grave exaggeration, and secondly,
the ætiological pretensions of infantile scenes rest not only on their {206}
constant appearance in the anamnesis of hysterics, but above all on
the evidence of the associative and logical connections between these
scenes and the hysterical symptoms, connections which would be as
clear as daylight to you if you had the complete history of the
illness.
What are the other factors that are necessary to the 'specific
ætiology' of hysteria in order actually to produce the neurosis? Now
this is really a theme in itself, one which I do not propose to
discuss; today I need only indicate the point of contact at which the
sides of the question---the specific and the subsidiary ætiology---fit
into one another. Probably a considerable number of factors will have
to be considered: inherited and personal constitution; the importance
of the infantile sexual experiences in themselves and particularly
their number---a short relation with a boy outside the patient's
family to whom she later becomes indifferent will not have so powerful
an effect as intimate sexual relations with a brother lasting for
several years. In the ætiology of the neurosis quantitative
conditions are just as important as qualitative; there are thresholds
which have to be crossed if the illness is to manifest
itself. Moreover, I myself do not regard the ætiological series
mentioned above as complete, nor do I think it solves the problem why
hysteria is not more common in the lower classes. (You will remember,
by the way, how surprisingly frequent Charcot declared it to be in the
_men_ of the working classes.) But I may also remind you that I myself
a few years ago indicated a factor hitherto but little remarked, to
which I ascribe the leading part in the production of hysteria _after_
puberty. At that time I put forward the view that the outbreak of
hysteria may almost invariably be traced to a _psychic conflict_, {207}
arising through an unbearable idea having called up the _defences_ of
the ego and demanding repression. In what circumstances this attempt
at defence has the pathological effect of actually thrusting into the
unconscious a memory painful to the ego and creating an hysterical
symptom in its place I could not at that time say. I can complete my
statement to-day: The defence achieves its purpose of thrusting the
unbearable idea out of consciousness, if in the (hitherto normal)
person concerned infantile sexual scenes exist in the form of
unconscious memories and if the idea to be repressed can be brought
into logical or associative connection with any such infantile
experience.
Since the ego's attempt at defence depends on the whole moral and
intellectual development of the person concerned, the fact that hysteria
is so much rarer in the lower classes than would follow from its
specific ætiology is no longer entirely incomprehensible.
Let us go back once more to the last group of objections, the answer
to which has led us so far afield. We have heard and acknowledged that
there are many people who have a very clear recollection of infantile
sexual experiences and yet do not suffer from hysteria. This objection
has really no weight at all, but it provides an occasion for a
valuable comment. People of this type _should_ not (according to our
understanding of neurosis) be hysterical at all, at least not in
consequence of scenes which they consciously remember. In our patients
these memories are never conscious; we cure their hysteria, however,
by converting their unconscious memories of infantile scenes into
conscious recollection. We could not in any way alter the fact that
they had such memories nor need we. From this you perceive that it is {208}
not merely a question of the existence of the infantile sexual
experiences, but that a certain psychological condition enters into
the case. These scenes must exist as _unconscious memories_; only so
long and in so far as they are unconscious can they produce and
maintain hysterical symptoms. But upon what the consciousness or
unconsciousness of these memories depends, whether it be conditioned
by their content, or by the time at which they occur, or by some later
influences, is a fresh problem which we will take care to avoid. Let
me just remind you that the first result of analysis is embodied in
the conclusion: hysterical symptoms are derivatives of memories
operating unconsciously.
(_c_) If we hold fast to the assumption that infantile sexual
experiences are the fundamental condition of hysteria---constitute, if
I may say so, the _disposition_ to that disease---they yet do not
produce hysterical symptoms directly, for in the first instance they
have no effect and exercise a pathogenic influence only later when
they are roused after puberty in the form of unconscious
memories---then we have to deal with the numerous observations which
prove that hysterical illness may already make its appearance in
childhood and before puberty. But this difficulty is solved when we
examine more closely the particulars gathered in analysis about the
period when these infantile sexual experiences took place. We then
find that in our severe cases the formation of hysterical symptoms
begins, not exceptionally but regularly, with the eighth year, and
that those sexual experiences which show no direct result invariably
date further back, to the third and fourth or even the second
year. Since in no single instance does the chain of effective
experiences break off with the eighth year, I must assume that this {209}
time of life, the period of growth in which the second dentition
occurs, forms a boundary line for hysteria, which cannot be caused
when once this line is passed. Anyone who has not had sexual
experiences before this cannot be disposed to hysteria after this;
anyone who has had them is ready to develop hysterical symptoms. The
isolated instances of the occurrence of hysteria on the other side of
the dividing line of age (before eight years) may be interpreted as
evidence of premature development. The existence of this dividing line
has probably some connection with processes of development in the
sexual system. Premature sexual development on the physical side may
often be observed and we may even suppose that it may in general be
promoted by premature sexual excitation.
So we have an indication that a certain infantile condition of the
psychic functions, as of the sexual system, is necessary in order that a
sexual experience occurring within this period should subsequently, in
the form of a memory, exercise a pathogenic influence. Still I do not as
yet venture to make any more precise statement about the nature of this
psychic infantilism and its temporal limits.
(_d_) Another of our critics might possibly take exception to the idea
that the memory of infantile sexual experiences should have so
tremendous a pathogenic effect, while the experience itself had none.
True, we are not accustomed to find that a memory-picture has a power
that the real impression lacked. Here, however, we note, by the way,
with what consistency the proposition that symptoms can only proceed
from memories is borne out in hysteria. All the later scenes at which
the symptoms begin are not the causative ones: those which really are
causative do not at first have any effect. But here we are confronted {210}
by a problem which we may justifiably keep separate from our main
theme. We feel indeed that synthesis is required of us when we reflect
upon the number of remarkable conditions we have come to recognize:
that in order to form an hysterical symptom there must be an effort of
defence against a painful idea; that this idea must be shown to have
an associative and logical connection with an unconscious memory, many
or few links being present, all of which remain unconscious too for
the time being; that the content of the unconscious memory must be
sexual; that that content is an experience which occurred at a certain
infantile period of life; and we cannot help asking how it comes about
that this memory of an experience which was harmless at the time can
subsequently have the abnormal effect of conducting to a pathological
issue a psychic process like that of defence, while itself remaining
all the time unconscious.
But one must say to oneself that this is a purely psychological problem,
the solution of which may perhaps require certain assumptions about
normal psychic processes and the part played in them by consciousness;
for the time, however, it may remain unsolved without robbing of its
value the insight so far acquired into the ætiology of hysterical
phenomena.
III
The problem I have just formulated concerns the _mechanism_ of
hysterical symptom-formation. But I have to present the causation of
these symptoms without taking this mechanism into consideration, and
the conclusions are consequently bound to forfeit something in
clearness and completeness. Let us go back to the part played by the {211}
infantile sexual scenes. I am afraid that I may have misled you in the
direction of over-estimating their power to form symptoms. So I will
again emphasize the fact that every case of hysteria displays symptoms
which are determined not by infantile, but by later, often by recent
experiences. Other symptoms, of course, date from the very earliest
experiences, have, so to speak, the longest pedigree. Such are
especially the numerous and manifold sensations and paræsthesias of
the genital organs and other parts of the body, sensations which
simply correspond to those belonging to the infantile scenes,
reproduced in hallucinatory fashion and often intensified to a painful
degree.
Another series of exceedingly common hysterical phenomena---painful
bladder pressure, painful sensations in defecation, intestinal
disturbances, choking and vomiting, indigestion and nausea---could
similarly be recognized in my analyses (and that with surprising
regularity) as derivatives of the same childhood-experiences and were
explained without difficulty by certain invariable features of these
episodes. Now the feeling of a sexually normal human being recoils
from the idea of these infantile sexual scenes, containing, as they
do, all the abuses known to libertines and impotent persons, whose
sexual practices include the improper use of the mouth and the
rectum. The physician's astonishment at this soon gives place to
complete understanding. We cannot expect that people who do not
scruple to gratify their sexual desires upon children will be repelled
by any lack of refinement in the manner of that gratification, and the
natural sexual impotence of childhood inevitably impels towards those
surrogate activities to which the adult degrades himself in the case {212}
of acquired sexual impotence. All the peculiar circumstances in which
the ill-matched pair carry on their love-relation: the adult---who
cannot escape his share in the mutual dependence inherent in a sexual
relation and yet is endued with complete authority and the right of
punishment, and can exchange the one rôle for the other in unbridled
gratification of his moods; the child---helpless victim of this
capriciousness, prematurely awakened to every kind of sensation and
exposed to every kind of disappointment, often interrupted in the
practice of the sexual activities assigned to him by his imperfect
control of his natural needs---all these grotesque, yet tragic,
incongruities become stamped upon the further development of the
person concerned and his neurosis, manifesting themselves in
innumerable lasting consequences which deserve to be carefully traced
out. Where the relation is one between two children, the character of
the sexual scenes is still repulsive, since every relation of the sort
between children postulates a previous seduction of one of them by an
adult. The psychic consequences of such a childhood-relation are quite
extraordinarily far-reaching; the two persons remain all their lives
united by an invisible bond.
Sometimes it is the accidental circumstances of these infantile sexual
scenes which in later years exercise a determining influence upon the
symptoms of the neurosis. Thus in one of my cases the circumstance
that the child was required to stimulate the genitals of an adult
woman with his foot sufficed for years to fix neurotic attention on
the legs and their functions and finally to produce an hysterical
paraplegia. In another case a patient suffering from anxiety-attacks
which tended to come on at certain hours of the day could not be
calmed unless one particular sister remained at her side. It would {213}
have remained a problem why she would not allow this one of her many
sisters to leave her, had not analysis revealed that formerly the man
who seduced the patient used to ask every time he came whether this
sister, from whom he anticipated an interruption, was at home.
It may happen that the determining power of the infantile scenes
disguises itself so effectually that it would certainly be overlooked in
a superficial analysis. We imagine that we have found the explanation of
a certain symptom in the content of one of the later scenes, but in the
course of the analysis we come upon the same content in one of the
infantile scenes, so that finally we have to admit that after all the
later scene owes its power of determining the symptoms only to its
agreement with the earlier one. I do not wish for this reason to
represent the later scene as of no importance; if my task were to
discuss the laws of hysterical symptom-formation, I should have to
recognize as one of these laws that the idea chosen as the basis of a
symptom will be one which various factors combine to arouse and which is
stirred up from several directions simultaneously;---a state of affairs
I have elsewhere tried to formulate by saying that _hysterical symptoms
are over-determined_.
One thing more. It is true that so far I have set aside the relation
between recent and infantile ætiology as a theme apart; nevertheless I
cannot leave the subject without making at least one remark on this
point. You will admit that there is one fact in particular which is
apt to mislead us in the understanding of the psychology of hysterical
phenomena, which so often seem to warn us not to judge by the same
standard psychic acts in hysterics and in normal people. I refer to {214}
the discrepancy between psychic excitation and psychic reaction which
we observe in hysterics and for which we try to account by assuming in
them a general abnormal sensibility to stimulation; we often attempt
to explain it in terms of physiology, as though in such patients
certain organs of the brain which serve to transmit stimuli were in a
peculiar morbid state (something like the spinal centres of a frog
which has been injected with strychnine) or else had withdrawn from
the influence of the higher, inhibiting centres, as in animals
experimented upon in vivisection. Here and there either of these
conceptions may be a perfectly valid explanation of hysterical
phenomena: I do not deny it. But the most important part of the
phenomenon, that is, of the abnormal, exaggerated, hysterical reaction
to psychic stimuli admits of another explanation, supported by
countless instances taken from the analyses of patients. This
explanation is as follows: the reaction of hysterics only appears
exaggerated; it is bound to appear so to us, because we know only a
small part of the motive forces behind it.
In reality, this reaction is proportionate to the exciting stimulus, and
therefore normal and psychologically intelligible. We immediately
perceive this when analysis has added to the manifest causes of which
the patient is conscious those other causes which have contributed to
the result, though the patient knows nothing about them and is therefore
unable to tell us anything.
I could spend hours demonstrating the validity of this important
assertion for the whole range of psychic activity in hysterics, but
here I must confine myself to a few examples. You will remember the
mental 'hypersensitiveness' so common in hysterics, which leads them {215}
to react to the least suggestion of depreciation as to a deadly
insult. Now what would you think if you observed such a readiness to
take offence in two normal people, for instance husband and wife? You
would certainly infer that the conjugal scene you witnessed was not
simply the result of the present trifling occasion, but that, for a
long time, inflammable material had been accumulating and that the
whole mass had now been brought to an explosion by this last shock.
Now apply this train of thought to hysterics. It is not the last, in
itself infinitesimal, mortification which produces the fit of crying,
the outbreak of despair, the attempted suicide---regardless of the
axiom that effect must be proportioned to cause, but this trivial
actual mortification has roused and set working the memories of so
many, far more intense, previous mortifications, behind all of which
lies the memory of a serious one in childhood, one which the patient
never got over. Or, when a young girl reproaches herself most bitterly
for allowing a boy secretly to caress her hand, and from that moment
is the victim of neurosis, you can of course explain it by pronouncing
her to be an abnormal, eccentric, hypersensitive person; but you will
take a different view when analysis shows that the touch reminded her
of a similar one felt in very early youth, which was part of a less
harmless story, so that really the reproaches belong to that former
occasion. Finally, the problem of hysterogenic areas is another of
the same kind; if you touch one particular spot, you do something you
did not intend: i.e. you wake a memory which may bring on an
hysterical attack, and since you know nothing of the psychic
connecting link you refer the attack directly to your touch. The
patients are equally ignorant and therefore fall into similar errors; {216}
they constantly establish 'false connections' between the last recent
cause of which they are conscious and the effect which depends on so
many intermediate links. But if the physician succeeds in linking up
the unconscious and the conscious determinants of an hysterical
reaction, he nearly always has to recognize that this seemingly
exaggerated reaction is appropriate and is abnormal only in form.
You may now rightly object to this justification of the hysterical
reaction to psychic stimuli that it is none the less abnormal, for why
do healthy people behave differently? Why do not all the long-past
excitations in them also combine afresh to operate when there is a real
new excitation? We do indeed get the impression that in hysterics all
the former experiences, to which there has so often already been such a
violent reaction, retain their power of producing an effect, as though
these people were incapable of discharging psychic stimuli. That is so;
we must indeed assume something of the sort. Do not, however, forget
that the former experiences of hysterics become operative on some actual
occasion, in the form of _unconscious memories_. It seems as though the
difficulty of discharge, the impossibility of transforming an actual
impression into a powerless memory, was related to the nature of the
unconscious part of the mind. You see that the rest of the problem is
again psychology, a psychology too for which philosophers have done
little to prepare the way.
To this psychology, which has yet to be constructed to meet our
requirements---the future _pathopsychology_---I must also refer you
when in conclusion I tell you something which at first will make you
apprehensive lest it should confuse our dawning understanding of the
ætiology of hysteria. For I must state that the ætiological rôle of {217}
infantile sexual experiences is not confined to hysteria, but holds
good equally for the remarkable obsessional neurosis and perhaps even
for the different forms of chronic paranoia and other functional
psychoses. I express myself on this point less definitely, because I
have analysed far fewer cases of obsessional neurosis than of
hysteria; I have actually only a single full analysis and several
fragmentary ones of cases of paranoia to which to refer. But what I
discovered in these cases seemed to me reliable evidence and gave me
confident expectations for future cases. You will perhaps remember
that I had already placed both hysteria and obsessions under the
single heading of 'defence neuroses', even before I knew of common
features in the infantile ætiology of both. Now I must add---though
this is a thing which of course need not be of general
occurrence---that every one of my cases of obsessional neurosis
revealed a substratum of hysterical symptoms, mainly sensations and
pains, which were traced to those earliest experiences of
childhood. What then determines whether the subsequent developments of
the infantile sexual scenes shall take the form of hysteria or
obsessional neurosis, or even paranoia, when the other pathogenic
factors supervene? These additions to our knowledge would seem to
diminish the ætiological significance of these scenes, for the
ætiological relation would lose its specific character.
I am not yet able to give a positive answer to this question. The
number of cases I have analysed is not large enough, nor have the
conditioning factors been sufficiently various. So far I have noted
that obsessional ideas can regularly be shown by analysis to be
disguised and transformed self-reproaches for sexual aggressions in
childhood, that they are therefore more frequently met with in men {218}
than in women, and that men develop them more often. From this I might
conclude that the character of the infantile scenes---whether the
experience was pleasurable or was merely passively submitted to---has
a determining influence upon the choice of the subsequent neurosis,
but again I do not wish to underestimate the significance of the age
at which these childish activities take place, and of certain other
factors. On these points we need discussion of further analyses to
guide us to a conclusion; but when it becomes clear which are the
decisive factors in the choice between the possible forms of defence
neurosis, the mechanism by which that particular form develops will
once more be a purely psychological problem.
I have now come to the end of my subject for today's discussion. I am
prepared for contradiction and unbelief, and will therefore say one
thing more in support of my position. Whatever you may think of my
conclusions, I have the right to ask you not to look upon them as the
fruit of idle speculation. They are based on laborious individual
examination of patients, which in most cases has taken a hundred hours
and more of work. Even more important to me than your estimation of my
results is the direction of your attention to the method I have used,
which is novel, difficult to handle and yet irreplaceable for
scientific and therapeutic purposes. I am sure you will realize that
one cannot gainsay the conclusions reached by the use of this
modification of Breuer's original method if one neglects that method
and uses only the ordinary one of questioning the patient. To do so
would be like trying to refute the discoveries of histological
technique by the aid of macroscopic investigations. Since the new
method of research gives access to a new element in psychic processes, {219}
namely, to that which remains unconscious or, to use Breuer's
expression, is _incapable of entering consciousness_, it beckons to us
with the hope of a new and better understanding of all functional
mental disturbances. I cannot believe that psychiatry will long hold
back from this new path to knowledge.
------------------------------------------------------------------------
XI {220}
SEXUALITY IN THE ÆTIOLOGY OF THE
NEUROSES[53]
(1898)
Detailed investigations during the last few years have led me to the
conviction that factors arising in sexual life represent the nearest and
practically the most momentous causes of every single case of nervous
illness. This theory is not entirely novel; a certain amount of
ætiological importance has always been allowed to sexual factors by all
writers on the subject. Many of the side-currents of medicine assure us
of a cure for 'sexual complaints' and for 'nervous debility' in one and
the same breath. Once its validity is no longer denied, it will not be
hard, therefore, to dispute the originality of the theory.
In several short papers which have appeared in the last few years in
the _Neurologisches Zentralblatt_, the _Revue Neurologique_ and the
_Wiener klinische Rundschau_, I have endeavoured to give some account
of the material and the points of view which offer scientific support
to the doctrine of the 'sexual ætiology of the neuroses'. Detailed
presentation of them, however, has not yet been undertaken, mainly
because, while attempting to explain the observed actual
interrelations between the phenomena, new problems arise, for the
solution of which the necessary preliminary researches are lacking. It
does not seem to me, however, at all premature to attempt to direct
the attention of practitioners to the circumstances that, as I {221}
maintain, exist, so that they may convince themselves of the accuracy
of my conclusions and at the same time of the benefits to be derived
in medical practice by a knowledge of them.
I know that efforts will be made, based upon arguments of an ethical
nature, to prevent physicians from pursuing this topic further. Anyone
who wishes to assure himself whether or not his patients' neuroses are
really connected with their sexual life cannot avoid the necessity of
questioning them about it and demanding a truthful account from them.
But in this, it is asserted, lies the danger, both for the individual
and for society. I hear it said that a physician has no right to intrude
upon his patients' privacy in sexual matters, or to wound their modesty
(especially that of his women patients) so grossly as such an
interrogation would do. His clumsy hand would only ruin family
happiness, and with youthful patients destroy innocence and undermine
the authority of parents; with adults he would become the uncomfortable
possessor of disquieting knowledge and his relations with his patients
would suffer in consequence. It is therefore his ethical duty to hold
himself aloof from the whole question of their sexual life.
One may well reply to this that it is nothing but prudery, concealing
scanty justification behind very weak arguments, and is unworthy of a
medical man. If factors arising in sexual life are definitely
recognizable as causes of disease, then investigation and discussion
of them come on this ground alone without further ado into the range
of a physician's professional duty. The offence against modesty which
he thereby commits is no different and no worse, I imagine, than when {222}
he insists on examining a woman's genital organs in order to treat a
local affection---a demand which his training itself binds him to
make. Even to-day one hears that older women whose youth was spent in
country places often become reduced by excessive genital hæmorrhages
to a state of severe prostration, because they cannot make up their
minds to permit a physician to see them uncovered. As a result of the
educative influence exercised in the course of a single generation by
the medical world upon the general public, an objection of this kind
is only in the rarest cases exhibited by young women at the present
time. Whenever it does occur it is condemned as unreasonable
prudishness---modesty out of place---and the husband might well ask:
'Are we living in Turkey, where a sick wife may only show her arm to a
doctor through a hole in the wall?'
It is not true that interrogation and communications referring to sexual
matters give the physician a dangerous power over his patient. The same
objection might with more justification have been alleged in earlier
days against the use of anæsthetics, which deprive the patient of
consciousness and will-power and leave it to the physician to decide
when and whether they are to return. And yet we cannot do without
anæsthetics to-day, because they enable the physician to render help
better than anything else; he has taken over the responsibility for them
along with his other weighty professional duties.
A physician can always do harm if he is clumsy or unscrupulous, no
more and no less in probing into the sexual life of his patients than
in other directions. Naturally, if anyone discovers by a meritorious
endeavour to arrive at self-knowledge that he is deficient in the
tact, seriousness and discretion necessary for interrogating neurotic {223}
patients, if anyone knows that revelations of a sexual character will
evoke in himself only lewd thoughts instead of scientific interest, he
will do right to keep away from the subject of the ætiology of the
neuroses. We only ask in addition that he should avoid treatment of
nervous patients altogether.
Neither is it true that patients themselves raise insuperable
objections to an investigation of their sexual life. After some slight
hesitation, grown-up persons usually adjust themselves to the
situation by saying: 'I am at the doctor's; I can say anything to
him.' Numerous women who find it difficult enough to go through life
with the task of concealing their sexual feelings are relieved to find
that to the physician their recovery is the paramount issue, and are
grateful to him for allowing them for once to behave quite naturally
in regard to sexual matters. A dim comprehension of the overwhelming
importance of sexual factors in producing neurosis (a recognition
which I am trying to formulate anew for medical science) seems
actually never to have quite passed out of the consciousness of the
laity. How often do scenes like this take place: A married couple
comes for consultation, one of the two suffering from neurosis. After
some introductory remarks and explanations to the effect that no
conventional barriers should be allowed to interfere when a physician
wishes to help in such a case, and so forth, one tells them one's
surmise that the origin of the malady will be found to lie in an
unnatural and harmful form of sexual intercourse, which they have
probably been practising since the wife's last confinement. Physicians
are not in the habit of concerning themselves with these matters, but
this attitude on their part is ill-advised, not withstanding the fact
that patients don't wish to discuss these things; and so forth. Then {224}
one partner nudges the other and says, 'You see, I told you all along
it would make me ill', and the other partner answers, 'Well, I know, I
thought so too, but what is one to do?'
In certain other circumstances, such as, for instance, with young girls
who are systematically trained to conceal their sexual life, the
physician will have to content himself with a very modest measure of
sincerity in the patient's admissions. But an important consideration
that has to be taken into account on the other side is that an
experienced physician does not meet his patients unprepared and as a
rule asks of them not elucidation but merely confirmation of his
surmises. Anyone who will follow these indications of mine, in the
matter of how the morphology of the neuroses is to be regarded and
translated into ætiological terms, will require but little more in the
way of confessions from his patients; in the very description of their
symptoms, which they volunteer only too readily, they will usually have
acquainted him with the sexual factors hidden behind.
It would be a great advantage if patients could know the extent to
which physicians will henceforth be able to interpret their neurotic
complaints with certainty, and to infer from them the sexual ætiology
at work; it would undoubtedly stimulate them, from the moment they
have made up their minds to seek relief for their troubles, to throw
off their secretiveness. Moreover, it is to the interest of us all
that a higher measure of sincerity in sexual matters should obtain
among us than is demanded at the present time. Sexual morality can
only gain by this; in matters of sexuality at present we are all,
every one of us, hypocrites, whether we be ill or well. It will only {225}
be advantageous if a certain amount of tolerance in sexual matters
results from more widespread honesty in this regard.
Medical practitioners have usually very little interest in many of the
questions discussed among neuropathologists with regard to the neuroses:
for instance, whether it is justifiable to differentiate strictly
between hysteria and neurasthenia, whether a hystero-neurasthenia may
also be distinguished beside these forms, whether obsessional ideas
should be classified with neurasthenia or recognized as a special form
of neurosis, and so on. In actual life such distinctions may well be a
matter of indifference if nothing further results from the decision---no
deeper insight, no landmark pointing out a direction for therapeutic
efforts---so long, too, as the patient is invariably sent off to a
hydrotherapeutic establishment---or told that there is nothing the
matter with him! It would be otherwise, however, if the point of view
advanced here about the causative relations between sexuality and the
neuroses were adopted; fresh interest is then aroused by the
symptomatology of the various neurotic ailments, and an ability to
analyse the complicated picture correctly into its component parts and
to classify these correctly becomes of practical importance. For the
morphology of neurosis may be translated into its ætiology with very
little difficulty, and with a knowledge of the latter new therapeutic
indications spring to life as a matter of course.
Now it is always possible, in every instance, by careful consideration
of the symptoms to reach a decision which is important, namely,
whether the case bears the characteristic marks of neurasthenia or of
some form of psychoneurosis (hysteria, obsessions). (Very frequently
composite-formations occur, in which signs of neurasthenia are {226}
intermingled with those of a psychoneurosis; we will, however, leave
consideration of them till later.) Only in the various forms of
neurasthenia does interrogation result in disclosing the ætiological
factors belonging to sexual life; these factors are naturally known to
the patient and belong to the present, or more properly, to the period
since maturity (although this limitation in time does not cover all
cases). With cases of psychoneurosis an interrogation of this kind has
little result, though it may perhaps gain for us a knowledge of
factors which must be recognized as exciting or contributory and may
or may not be related to sexual life. When they are so related they
manifest themselves as of the same type as the ætiological factors of
neurasthenia, that is, they entirely lack any specific relation to the
cause of the psychoneurosis. And yet the ætiology of the
psychoneuroses, too, in every instance lies in the patient's sexual
life. By a curious by-path, which will be considered later, it is
possible to arrive at a knowledge of this ætiology and to understand
why the patient could not tell us anything about it; for the events
and influences which lie at the root of every psychoneurosis belong
not to the present time, but to a long-past period, to a prehistoric
period of life, so to say---to early childhood, and that is why the
patient knows nothing of them. He has---but only in a certain
sense---forgotten them.
Thus we have a sexual ætiology in all cases of neurosis; in
neurasthenia, however, this is of present-day origin, whereas in the
psychoneuroses the factors belong to infancy; this is the first
important contrast in the ætiology of the neuroses. A second contrast
appears when we take account of a distinction in the symptomatology of
neurasthenia itself. On the one hand, we find cases in which definite {227}
symptoms characteristic of neurasthenia are conspicuous: cranial
pressure, tendency to fatigue, dyspepsia, constipation, irritation of
the spine, and so forth. On the other hand, in certain cases these
indications are of minor importance and the syndrome is composed of
other symptoms which all show a relation to one main symptom, to
'anxiety' (free-floating anxiety, restlessness, expectant anxiety,
complete, rudimentary or supplementary anxiety-attacks, locomotor
vertigo, agoraphobia, sleeplessness, exacerbation of pains, etc.). I
have left to the former type of neurasthenia its designation, but have
distinguished the second as 'anxiety-neurosis' and have justified this
separation elsewhere, there also taking into account the fact that
both neuroses commonly appear together. For the present purpose it is
sufficient to emphasize that a distinction in the ætiology runs
parallel with a symptomatic differentiation in the two
forms. Neurasthenia may always be traced back to a condition of the
nervous system such as is induced by excessive masturbation, or may
arise spontaneously on account of frequent emissions. In the
anxiety-neurosis there may regularly be found conditions relating to
the sexual life which all have in common the element of abstinence or
of incomplete satisfaction: such as coitus interruptus, abstinence
with strong libido, so-called frustrated excitation, and so forth. In
the short paper intended to introduce the anxiety-neurosis I put
forward the view that anxiety actually was libido diverted from its
usual course.
Wherever symptoms of neurasthenia are mingled in any one case with
those of anxiety-neurosis, that is, where a composite-formation
appears, the thesis (which has been empirically arrived at) may be
adopted that a combination of neuroses represents the co-operation of {228}
several ætiological factors; in every instance this expectation is
confirmed. It would be well worth while to discuss in detail how often
these ætiological factors are closely interwoven organically by the
interrelation of sexual processes, as, for instance, coitus
interruptus or insufficient potency of the husband with masturbation.
Having accurately diagnosed a case of neurasthenic neurosis under
observation, and correctly classified its symptoms, one may proceed to
transpose into ætiology the symptomatological knowledge so gained and
may fearlessly require the patient's confirmation of one's surmises.
Denial at the beginning should not mislead the physician; every
resistance is finally overcome by firmly insisting on what has been
inferred, and by emphasizing the unshakable nature of one's convictions.
In this manner one learns all kinds of things about the sexual life of
men and women which might well fill a useful and instructive volume; we
learn, too, to regret from every point of view that scientific knowledge
of sexual matters is still regarded as opprobrious. Since minor
digressions from the normal _vita sexualis_ are much too frequent for
the discovery of them to constitute a factor of much importance, only
serious and long-continued abnormality in the sexual life of neurotic
patients will be allowed to weigh as an explanatory agent; and, also, it
may safely be regarded as an imaginary danger that a patient who is
psychically normal could be induced by a physician's persistence to
accuse himself falsely of sexual misdemeanours.
If we proceed in this manner with our patients we also gain the
conviction that no cases of neurasthenia are negative in respect to a
sexual ætiology. In my mind, at least, the conviction has become so {229}
fixed that I have turned to account the negative result of an
interrogation in making a diagnosis; that is, I have concluded that
such negative cases could not be neurasthenia. In this way I arrived
in several instances at a diagnosis of general paralysis instead of
neurasthenia, because it was not possible to demonstrate the frequent
masturbation required according to my theory; and the further course
of these cases confirmed my judgement as correct. In another instance
when the patient, in the absence of any apparent organic lesions,
complained of cranial pressure, headache and dyspepsia and met my
suspicions regarding his sexual life with honesty and serene
certainty, it occurred to me to suspect a latent suppuration in one of
the nasal sinuses, and a specialist colleague of mine confirmed this
conclusion---which I had arrived at through the negative results of
the interrogation on the sexual life---by relieving the patient of his
ailment through the removal of putrid matter from the antrum.
The illusion that negative cases do exist, in spite of all this, can
arise in other ways as well. Sometimes interrogation reveals a normal
sexual life in persons whose neurosis, superficially viewed, really
resembles neurasthenia or anxiety-neurosis very closely. More
penetrating investigation, however, regularly reveals the true state
of affairs. Behind such cases, which have been taken for neurasthenia,
there lies a psychoneurosis: an hysteria or obsessional neurosis.
Hysteria in particular, which apes so many organic affections, can
with ease assume the appearance of one of the forms of actual neurosis
by giving hysterical value to the symptoms of the latter. Such forms
of hysteria coming under the guise of neurasthenia are not even very
infrequent. To fall back on a psychoneurosis wherever neurasthenia {230}
shows a negative result sexually is, however, not a cheap way out of
the difficulty, and the proof that it is so lies in the only process
which unmasks hysteria completely---namely, in the method of
psycho-analysis, which will be discussed later.
There may, however, be many who are quite willing to take the sexual
ætiology into account with their neurasthenic patients, but who will
yet regard it as going too far if they are not required to consider as
well the other factors which are always mentioned by medical writers
as the causes of neurasthenia. Now it would never occur to me to
suggest that we should substitute a sexual ætiology in the neuroses
for all the others and thereby declare the latter entirely
inoperative. That would be a misunderstanding of my attitude. What I
mean is simply that the sexual factors, which have hitherto not been
properly estimated, are to be taken into account in addition to all
the well-known ætiological factors mentioned by the medical authors,
which have probably been quite correctly recognized as such. These
sexual factors, however, according to my view of them, deserve a
special position in the series of ætiological factors. For they alone
are never absent in any case of neurasthenia; they alone are capable
of producing neurosis without other contributory factors, so that
these other factors seem to be reduced to the position of a
supplementary or auxiliary ætiology; they alone permit the physician
to recognize the constant interrelation between the manifold forms in
which they appear and the many varieties of clinical pictures. When,
on the other hand, I review the cases in which neurasthenia has
apparently developed because of over-work or emotional excitement, or
as the after-effect of typhoid fever and similar diseases, the various {231}
symptoms they show appear to have nothing in common; I am not able to
form any expectation about the symptoms from the special character of
the ætiology, nor can I derive anything about the ætiology at work
from the clinical picture presented.
The sexual factors are also those which most readily lend themselves
as starting-points for therapeutic efforts. Heredity is doubtless a
momentous factor when it is present; it can enable a serious morbid
effect to develop where otherwise only an insignificant one would have
appeared. But heredity is not amenable to the influence of the
physician; every human being has his own hereditary morbid tendencies
from birth; we cannot alter anything in them. Nor should we forget
that, precisely in the ætiology of neurasthenia, we are bound of
necessity to forego the first place to the influences of heredity;
neurasthenia, both forms of it, is among those diseases which anyone
may readily acquire without being hampered by heredity. If it were
otherwise, the prodigious increase in neurasthenia of which all
writers on medical subjects complain would be inconceivable. As far as
civilization is concerned, too, it is possible that these authorities
may be judging correctly in so often reckoning the causation of
neurasthenia in the list of its crimes (although this probably comes
about in a very different way from that which they suppose); yet the
state of our civilization again is unalterable for the
individual. Incidentally, this factor, being as it is of the same
importance for all the members of one community, can in no way explain
the fact of selection in the incidence of the disease. The physician
himself actually lives, unaffected by neurasthenia, under the same
conditions in this apparently morbific civilization as the {232}
neurasthenic patient whom he is to treat.---The significance of
exhausting influences remains intact, after allowing for the
limitation mentioned above. But the factor of 'over-work', which
physicians are so fond of allowing their patients to regard as the
cause of their neuroses, is unduly misused. It is quite true that
anyone who has become disposed to neurasthenia through an injurious
mode of sexual life tolerates intellectual work and the emotional
stress of existence very badly, but it never happens that work or
excitement alone makes anyone neurotic. Intellectual effort is rather
a protection against neurasthenic illness; the most unremitting of
intellectual workers are precisely the people who remain untouched by
neurasthenia, and what neurasthenics call 'dangerous over-work' does
not as a rule deserve the name of 'brain work' at all, regarded either
qualitatively or quantitatively. Physicians will have to accustom
themselves to explain to an official who has been 'over-done' at the
office, or to a housewife whose duties in her home have become too
much for her, that they have fallen ill not because they have tried to
fulfil tasks which for the brain of a civilized person are really
quite easy, but because all the time they have sorely neglected and
played havoc with their sexual life.
Further, the sexual ætiology alone makes it possible to comprehend all
the details of the clinical history of neurasthenics, the mysterious
improvement in the course of the illness and the equally
incomprehensible relapses, both of which are usually referred by
physicians and patients to the therapy that has been undertaken. In my
records, embracing the histories of more than two hundred cases, there
is, for example, the story of a man who, when the treatment prescribed
by the family physician had failed, had recourse to Father Kneipp and, {233}
beginning with this therapy, showed an extraordinary improvement in
the very middle of his illness. A year later, however, the troublesome
symptoms grew worse and he again sought relief at Wörishofen, but the
second treatment failed to bring any improvement. A glance into the
history of this patient's family affairs solved the double riddle. Six
and a half months after his first return from Wörishofen the patient's
wife gave birth to a child (in fact, without knowing it, he had left
her at the beginning of a pregnancy) and after his return he was able
to have normal intercourse with her. At the close of this period,
which was beneficial to his neurosis, his ailment was rekindled by
recourse to coitus interruptus again, so that the second treatment was
bound to show negative results, for the pregnancy mentioned above was
the last that occurred.
Another case in which a similar unexpected influence of treatment
called for explanation took an even more instructive form; for a
strange alternation in the symptoms of the neurosis showed itself. A
young neurotic patient had been sent by his physician for a typical
neurasthenia to a well-conducted hydrotherapeutic establishment. In
this establishment his condition at first improved so much that he was
justifiably expected soon to depart as a grateful convert to
hydrotherapeutic methods. In the sixth week a sudden change occurred;
the patient 'couldn't stand the water any longer', became more and
more nervous, and finally left the establishment after two more weeks,
dissatisfied and unrelieved of his trouble. When he complained to me
about the deceptive action of the therapy, I asked him a few questions
about the symptoms which had set in during it. Strange to say, there
had been a complete change in them. He had come to the sanatorium {234}
complaining of cranial pressure, lassitude and dyspepsia; the
disturbances in the course of the treatment had been excitement,
attacks of dyspnœa, locomotor vertigo and troubled sleep. Now I was
able to tell the patient: 'You are not fair to hydrotherapy. You fell
ill, as you know yourself, on account of long-continued
masturbation. In the sanatorium you gave up this form of gratification
and therefore improved rapidly. But when you felt well you unwisely
sought the company of a lady, let us say one of your fellow-patients,
and started a relationship with her which without normal satisfaction
could only lead to excitement. The beautiful walks in the
neighbourhood of the institution gave you many opportunities. Your
relapse is due to this relationship, and not to a sudden inability to
tolerate hydrotherapy. From your present condition I should conclude,
by the way, that you are continuing this relationship here in town as
well.' I can assure the reader that the patient confirmed my
supposition point for point.
The present treatment of neurasthenia, carried out perhaps most
successfully in hydrotherapeutic establishments, aims at amelioration
of the nervous condition by means of two factors, rest and
recuperation. I know of nothing against this therapy, except that it
does not take into account the circumstances of the patient's sexual
life. According to my experience, it would be highly desirable for the
medical directors of such establishments to become fully aware that
they are dealing not with victims of civilization or of heredity,
but---_sit venia verbo_---with persons disabled by their
sexuality. They would then, on the one hand, more readily find
explanations both for their successes as well as their failures, and {235}
on the other hand, achieve new results, which are now dependent upon
chance or upon the patient's undirected course of action. If a
neurasthenic woman suffering from anxiety is taken away from home and
sent to a hydrotherapeutic establishment, freed from all duties, able
to bathe, to take gymnastic exercise and plenty of food, one is
naturally inclined to give the credit for the splendid improvement
which often sets in within a few weeks or months to the quiet life
which the patient has been enjoying and to the invigoration which
hydrotherapy has brought about. That may be so: but it is apt to be
overlooked, that with the separation from home there is also an
interruption in marital relations and that it is precisely this
temporary removal of the originating cause of the ailment which makes
it possible for her to recuperate under the influence of favourable
treatment. Neglect of this point of view in regard to the ætiology
avenges itself, too, when the apparently satisfactory cure proves to
be a very transitory one. Soon after the patient has returned to her
ordinary way of life, the symptoms of the trouble reappear and force
her from time to time to spend a part of her existence unproductively
in establishments of this kind, or else to turn in another direction
for hope of recovery. It is therefore clear that in neurasthenia the
therapy must take its starting-point within the radius of the
patient's ordinary existence, and not in sanatoria.
This ætiological theory will also explain the source of failures which
medical superintendents of sanatoria would greatly like to
prevent---failures of the treatment within the establishment itself.
Masturbation among grown-up girls and adult men is far more frequent
than is commonly supposed and has a harmful effect not only by {236}
producing neurasthenic symptoms, but also because the patient is kept
under the oppression of a secret which he feels to be
shameful. Physicians who are not accustomed to translate neurasthenia
into masturbation account for the diseased condition by referring it
back to some catchword like anæmia, over-work, and so on, and then
expect the patient to recover after undergoing a therapy devised to
remedy such things. To their astonishment, however, periods of
improvement alternate with periods in which all the symptoms grow
worse and are accompanied by severe depression. The outcome of such a
therapy is generally doubtful. If the physician knew that all the time
the patient was struggling with this bad habit and is in despair
because he has once again been overcome by it, if he understood how to
relieve the patient of his secret, to diminish its importance in the
patient's eyes and to support him in his fight against the habit, the
success of the therapeutic efforts might well be assured.
To induce the patient to abandon the habit of masturbation is only one
of the new therapeutic tasks which confronts the physician upon
consideration of a sexual ætiology, and this one seems, in common with
every other attempt to wean people from some form of indulgence,
practicable only in an institution under medical supervision. Left to
himself, whenever things are at all depressing the masturbator usually
turns to the gratification that he finds so easy and
comforting. Medical treatment can then only set itself the goal of
leading the neurasthenic who has recovered his health back to normal
forms of sexual satisfaction; for, once it has been aroused and
satisfied for any length of time, sexual need is not to be silenced
again but can only be transferred to another object. Incidentally, the {237}
same thing applies to all abstinence-treatments, which will succeed
only superficially as long as physicians content themselves with
removing the narcotic from the patient without troubling about the
source of this imperative need for the drug. 'Habit' is merely an
empty phrase without any explanatory significance; not everybody who
has occasion to take morphine, cocaine, chloral-hydrate and the like
for a space of time thereby acquires a craving for them. More
searching examination generally shows that these narcotics are
intended as substitutes (directly or indirectly) for the missing
sexual gratification, and wherever normal sexual life cannot be
re-established a patient who has been weaned from his habit may be
expected quite certainly to slide back into it.
The other task set the physician by this ætiology refers to the
anxiety-neurosis; it consists in bringing the patient to abandon all
injurious varieties of sexual intercourse and to enter into normal
sexual relations. As will be readily understood, this duty falls to the
lot of the patient's confidential adviser, that is, the family
physician, who is seriously at fault in his duty to the patient if he
considers it beneath his dignity to meddle in such matters.
Since he has most often to deal with married couples in these
instances, he at once finds his efforts confronted by the current
malthusian tendencies to limit the offspring of marriage. I have not
the least doubt that these principles are gaining ground more and more
among our middle classes; I have come across couples who began to
practise the prevention of conception as soon as the first child was
born, and others who intended that sexual intercourse should accord
with these principles from the wedding-night itself. The problem of
malthusianism is a far-reaching and complicated one; I have no {238}
intention of treating it here in the exhaustive manner which would
really be necessary for the therapy of the neuroses. I shall only
discuss how a physician who recognizes the importance of sexual
ætiology in the neuroses can best face this problem.
Obviously, the worst thing he can do is to ignore it, no matter under
what pretence. A thing that is necessary cannot be beneath my
professional dignity, and it is necessary to give the assistance of
medical advice to a married couple who are planning to limit their
offspring, if you wish to prevent one or both of the partners being
exposed to a neurosis. It cannot be denied that contraceptive measures
become a necessity in married life at some time or other, and
theoretically it would be one of the greatest triumphs of mankind, one
of the most tangible liberations from the bondage of nature to which we
are subject, were it possible to raise the responsible act of
procreation to the level of a voluntary and intentional act, and to free
it from its entanglement with an indispensable satisfaction of a natural
desire.
A clear-sighted physician will therefore take it upon himself to
decide under what conditions the use of contraceptive measures is
justified, and will require to distinguish between the harmful and the
harmless forms among these measures. Everything is harmful that
hinders the fulfilment of gratification; it is well-known, however,
that at present we possess no method of preventing conception which
satisfies all the requirements which may properly be asked of it, that
is, which is certain, convenient, does not diminish pleasurable
sensation during coitus, nor wound feminine sensibilities. This is a
practical problem which physicians might well apply their energy to {239}
solve; they would thereby reap great gratitude. Anyone who could fill
this gap in our medical technique would be the means of preserving the
joy of living and good health for countless men and women, though it
is true he would at the same time have initiated a profound change in
our social conditions.
This does not exhaust the list of the sources of inspiration which lie
in a recognition of the sexual ætiology of the neuroses. The main
benefit which we obtain from it for neurasthenia falls in the sphere
of prophylaxis. If masturbation is the cause of neurasthenia in youth,
and later on also has its ætiological significance in the
anxiety-neurosis by its action in reducing potency, then the
prevention of masturbation in both sexes is a task that deserves more
attention than it has received up to the present time. On considering
both the slight and the serious disabilities that have their root in
neurasthenia, which is apparently growing more and more prevalent, it
becomes evident that it is positively to the public interest _that men
should enter upon sexual relations with full potency_. In matters of
prophylaxis, however, the individual is almost helpless. The whole
community must take an interest in the matter and give its assent to
the construction of measures valid for all. At present we are still
far removed from a state of things holding out such hope of relief, so
that the increase in neurasthenia may quite rightly be accounted to
our civilization. There is a great deal which must be changed. The
opposition of a generation of physicians who can no longer remember
their own youth must be broken down, the pride of fathers who are
unwilling to descend to the level of common humanity in the eyes of
their children will have to be overcome, the unreasonable prudery of {240}
mothers, who at present quite generally regard it as an
incomprehensible and also undeserved stroke of fate that 'just their
children should be nervous', would have to be met. Above all, popular
opinion would have to make room for the discussion of problems of
sexual life; it must become possible to speak of such things without
being stamped as a disturber of the peace or as a person whose aim is
to arouse the lower instincts. And so there still remains plenty of
work in this direction for the next century---in which our
civilization will have to learn to become compatible with the claims
of our sexuality!
The value of a correct diagnostic differentiation between the
psychoneuroses and neurasthenia is also shown by the fact that the
former need to be regarded differently in practice and require special
therapeutic measures. Psychoneuroses appear under two kinds of
conditions, either independently or in the wake of actual neuroses
(neurasthenia and anxiety-neurosis). In these latter cases we are
dealing with a new type, incidentally very frequent, of mixed
neurosis. The ætiology of the actual neuroses has become a
supplementary ætiology of the psychoneuroses, and a clinical picture
results in which, for example, anxiety-neurosis predominates, but
which in other respects shows features of real neurasthenia, of
hysteria and of the obsessional neurosis. Even when faced with such a
combination, it is not profitable to abandon the distinctions between
the various single clinical pictures of neuroses, since it is really
not so very difficult to analyse the result into the following
constituents: The predominance of the anxiety-neurosis shows that the
morbid condition has arisen under the influence of an actual sexual
noxia. The person concerned was, however, besides this, predisposed by {241}
a particular ætiology to one or more forms of psychoneurosis, and
would have developed a psychoneurosis at some time or other, either
spontaneously or under the influence of some other weakening
cause. Thus the still lacking supplementary ætiology of the
psychoneurosis has been supplied by the current ætiology of the
anxiety-neurosis.
For such cases it has quite correctly come to be a therapeutic practice
to disregard the psychoneurotic components in the clinical picture and
to treat exclusively the 'actual' neurosis. In very many cases it is
possible to overcome the accompanying neurosis if the neurasthenic
condition is handled in the right manner. A different estimate is
required in those cases of psychoneurosis which appear either
spontaneously or at the close of a long illness composed of neurasthenia
and psychoneurosis, and remain as an independent condition. When I speak
of the 'spontaneous' appearance of a psychoneurosis, I do not mean, for
example, that every ætiological element is lacking after anamnestic
research. Though that may well be so, it may also be that attention is
drawn to some more commonplace factor, for instance, an emotional
crisis, an enfeebled condition after organic illness and the like. It
must, however, be remembered with all these cases that the real ætiology
of the psychoneuroses does not rest upon these factors, but remains
outside the reach of ordinary anamnestic examination.
As is well known, this is the gap that some have attempted to bridge
by the assumption of a special neuropathic temperament which, if it
existed, would indeed not leave much hope for the success of any
therapy with these morbid conditions. The neuropathic disposition
itself is conceived of as a sign of general degeneration and then this {242}
convenient term is levelled broadcast against the poor sufferers whom
medical men are quite powerless to aid. Fortunately, this is not at
all the true state of affairs. Although the neuropathic temperament
doubtless exists, I deny that it is adequate alone to produce a
psychoneurosis. Moreover, I must further deny that a neuropathic
temperament in conjunction with the contributory causes exciting an
outbreak of illness in adult life together represent a sufficiently
adequate ætiology of psychoneurosis. In referring the fate of an
individual who shows a morbid condition back to the experiences of his
ancestors we have gone too far; we have forgotten that between
conception and maturity there lies a long and important period in the
life of a man---childhood---in which the seeds of later disease may be
acquired. That is what in fact happens with the psychoneuroses. Their
real ætiology is to be found in experiences during childhood, and
again---exclusively, too---in those impressions which have to do with
sexual matters. We do wrong entirely to ignore the sexual life of
children; in my experience children are capable of all the mental and
many of the physical activities. Just as the whole sexual apparatus of
man is not comprised in the external genital organs and the two
reproductive glands, so his sexual life does not begin only with the
onset of puberty, as to casual observation it may appear to do. It is
true, however, that the organization and evolution of the species man
strives to prevent extensive sexual activity during childhood;
apparently the sexual instincts of the human animal are to be stored
up in order that at the time of their release at puberty they may
serve important cultural ends (W. Fliess). It is perhaps possible to
understand, through considerations of this kind, why sexual {243}
experiences in childhood are bound to have a pathogenic effect. This
effect, however, displays itself only in the slightest degree at the
actual time of their occurrence; far more important is their
subsequent effect, which can show itself only in later periods of
maturity. This subsequent effect can only originate in the mental
traces which have been left behind by the infantile sexual
experiences. In the interval between the occurrence of these
experiences and their reproduction (we ought rather to say the later
intensification of the libidinous impulses aroused by them) not only
the physical sexual but also the mental apparatus has undergone an
important development, and therefore an abnormal mental reaction now
follows upon the effect produced by these earlier sexual experiences;
that is, psychopathological formations appear.
In these introductory remarks I can only mention the main elements on
which the theory of the psychoneuroses is based: the subsequence of the
effect, the infantile condition of the sexual apparatus and of the
mental organism. In order to attain full comprehension of the mechanism
by which the psychoneuroses come into being, more detailed exposition
would be necessary; above all, it would be indispensable to regard as
credible certain assumptions concerning the composition of the mental
instrument and the way in which it works, which seem to me to be novel.
In a book on the interpretation of dreams at which I am now working, I
shall find occasion to touch upon these principles of a psychology of
the neuroses. For dreams belong to the same category of
psychopathological formations as the _idée fixe_ of hysteria, obsessions
and delusions.
Since the manifestations of the psychoneuroses arise through the
subsequent action of unconscious mental traces, they are amenable to {244}
psychotherapy, which, however, must seek other methods than the only
one followed so far, that of suggestion with or without hypnosis. In
recent years I have worked out almost completely a therapeutic
procedure, based on the 'cathartic' method initiated by J. Breuer,
which I intend to call the 'psycho-analytic' method; I owe countless
successes to it and may reasonably hope to increase its effectiveness
considerably yet. The first account of this method---its technique and
applicability---was given in the _Studien über Hysterie_ written in
conjunction with J. Breuer and published in 1895. Much of it, I may
say, has since then been altered for the better. Whereas at that time
we modestly declared that we could undertake to remove only the
symptoms of hysteria and not the disease itself, I have since
perceived that this distinction is without significance, so that the
prospect of an effectual cure of hysteria and obsessions lies ahead. I
have therefore been most interested to read statements like the
following in the writings of my colleagues: 'In this case the
ingenious method devised by Breuer and Freud has failed', or 'The
method has not fulfilled the promise it seemed originally to hold
out'. On these occasions I have had something of the sensations of a
man who comes across an obituary notice of himself in the newspapers,
but ventures to feel reassured by his better knowledge of the
situation. For the method is so difficult that serious study of it is
indispensable, and I cannot remember that any one of my critics
expressed any wish to learn it from me; nor do I believe that they
have applied themselves to the matter, as I have done, with sufficient
intensity to come upon it of their own accord. The remarks in the
_Studien über Hysterie_ are totally inadequate to give the reader a
mastery of this technique, nor are they in any way intended to {245}
furnish complete instruction in it.
The psycho-analytic method is not at present applicable to all cases; I
recognize the following limitations in regard to it: it demands a
certain measure of clearsightedness and maturity in the patient and is
therefore not suited for youthful persons or for adults who are
feeble-minded or uneducated. With persons who are too far advanced in
years it fails because, owing to the accumulation of material, so much
time would be required that the end of the cure would be reached at a
period of life in which much importance is no longer attached to nervous
health. And finally it is possible only if the patient is capable of a
normal mental condition from the vantage-point of which he may overlook
the pathological material. During an hysterical confusion or
interpolated mania or melancholia nothing can be effected by
psycho-analytic means. Such cases can, nevertheless, be subjected to the
treatment after the violent manifestations have yielded to the customary
methods. In practice, the chronic cases of psychoneuroses are altogether
more tractable by this method than cases with acute crises, in which the
greatest weight is naturally laid on the speed with which the latter can
be subdued. Hysterical phobias and the different forms of obsessional
neurosis are consequently the most favourable field of work for this new
therapy.
That the method is restricted by these limitations is to a great
extent explicable by the conditions under which I had to work it
out. My material does in fact consist of chronic nervous cases
recruited from the more cultivated classes. I consider it very
probable that supplementary methods may be arrived at for treating
young persons and for those who seek relief in hospitals. I should {246}
also mention that up to the present I have tried my treatment
exclusively on severe cases of hysteria and obsessional neurosis; I
cannot tell how it would react on those slight cases which appear to
be cured in a few months by some neutral kind of treatment. It will
readily be understood that a new therapy which requires many
sacrifices can reckon on only such patients as have already tried the
generally accepted methods without success, or by those whose
condition justified the inference that they could expect nothing from
these apparently more convenient and shorter therapeutic methods. I
was obliged to attack at once the hardest tasks with imperfect
instruments; the test has therefore proved all the more convincing.
The essential difficulties which still stand in the way of the
psycho-analytic method of cure are due, not to its own character, but
rather to the lack of comprehension among laymen and physicians in
regard to the real character of the psychoneuroses. It is only an
inevitable corollary of this complete ignorance that physicians should
consider themselves justified in consoling the patient or in persuading
him to try various therapeutic measures with the most flimsy assurances,
'Come to my sanatorium for six weeks and you will get rid of your
symptoms (phobias, obsessions and the like).' Sanatoria are, as a matter
of fact, indispensable for subduing acute conditions arising in the
course of a psychoneurosis and effect this by means of diversion, care
and rest; towards removing chronic conditions they achieve nothing, and
this is as true of the distinguished sanatoria which are supposed to be
scientifically conducted as of ordinary hydrotherapeutic establishments.
It would be more dignified as well as more helpful to the patient (who
after all has somehow to reconcile himself to his ailments) if {247}
physicians would tell the truth as they see it day by day: the
psychoneuroses as a genus are by no means slight illnesses. When
hysteria has once begun no one can foretell when it will end. One
mostly seeks in vain to comfort oneself with the prophecy, 'Some day
it will suddenly come to an end.' Often enough recovery proves to be a
mere compromise, a condition of mutual toleration between the sound
and the unsound elements in the patient, or comes about by way of the
transformation of the symptom into a phobia. An hysteria in a young
girl, which has with difficulty been relieved, will be resuscitated,
after a short interruption due to a new-found happiness, in the
hysteria of the wife; with one difference, that this time another
person, the husband, will be impelled by his own interests to keep
silent about the illness. Even if no manifest incapacity for life
results, there almost always follows a loss of power to make free use
of the energies of the mind. Obsessions recur again and again during
the patient's whole life; phobias and other restrictions of will-power
have hitherto proved inaccessible to every kind of treatment. All
these facts are kept from the knowledge of the public, so that the
father of an hysterical girl is horrified when he is told that he
ought to consent to a year's treatment for his daughter, though the
illness may perhaps be of only a few months' duration. The layman is
deeply convinced inwardly of the unnecessariness, so to speak, of all
these psychoneuroses, and therefore regards the course of the disease
with little patience and is unwilling to make sacrifices for the
treatment. He behaves more reasonably with a case of typhoid lasting
three weeks, or a fracture which requires six months to heal, or he
regards it as proper that orthopædic treatment should be undergone for
several years when his child shows the first signs of curvature {248}
of the spine; and the difference in his behaviour is due to the better
understanding shown by physicians in these matters, about which they
honestly impart their knowledge to the lay public. Sincerity on the
part of physicians and tractability in the public will be achieved in
regard to the psychoneuroses also, when once insight into the
essential character of these complaints becomes the common property of
medicine. A thorough psychotherapeutic treatment of these ailments
will no doubt always require a special training and will be
incompatible with other kinds of medical practice. As a compensation,
this group of physicians, which in the future will doubtless be a
large one, has before it the prospect of noteworthy achievements and
of a gratifying insight into the mental life of mankind.
------------------------------------------------------------------------
XII {249}
ON PSYCHOTHERAPY[54]
(1904)
About eight years have passed since I had the opportunity, on the
invitation of your lamented chairman, Professor von Reder, of speaking
here on the subject of hysteria. Shortly before that occasion I had
published, in 1895, in collaboration with Dr. Joseph Breuer, the
_Studien über Hysterie_ in which, on the basis of the new knowledge
which we owe to this investigator, an attempt was made to introduce a
novel therapy for the neuroses. Fortunately, I may say, the efforts of
our 'Studies' have been successful; the ideas expressed in them
concerning the action of psychical traumas through retention of
affect, as well as the conception of hysterical symptoms which
explains them as the result of an emotion transposed from the realm of
the mental to the physical---ideas for which we created the terms
'abreaction' and 'conversion'---are to-day generally known and
understood. There is, at least in German-speaking countries, no
presentation of hysteria to-day that does not to some extent take them
into account, and we have no colleagues who do not follow at least for
a short distance the road pointed out by us. And yet, while they were
still new, these propositions and the terms for them must have sounded
not a little strange! {250}
I cannot say the same of the therapeutic method which was introduced to
our colleagues at the same time as our theory; it is still struggling
for recognition. There may be special reasons for this. At that time the
technique of the process was as yet undeveloped; it was impossible for
me to give medical readers of the book the directions necessary to
enable them to carry through this method of treatment completely. But
causes of a general nature have certainly also played a part. To many
physicians, even to-day, psychotherapy seems to be the offspring of
modern mysticism and, compared with our physico-chemical specifics which
are applied on the basis of physiological knowledge, appears quite
unscientific and unworthy of the attention of a serious investigator.
Allow me, therefore, to defend the cause of psychotherapy before you,
and to point out to you what may be described as unjust or mistaken in
this condemnation of it.
In the first place, let me remind you that psychotherapy is in no way a
modern method of healing. On the contrary, it is the most ancient form
of therapy in medicine. In Löwenfeld's instructive work (_Lehrbuch der
gesamten Psychotherapie_) many of the methods of primitive and ancient
medical science are described. The majority of them must be classed
under the head of psychotherapy; in order to effect a cure a condition
of 'expectant faith' was induced in sick persons, the same condition
which answers a similar purpose for us to-day. Even since physicians
have come upon other therapeutic agents, psychotherapeutic endeavours of
one kind or another have never completely disappeared from medicine.
Secondly, let me draw your attention to the fact that we physicians
cannot discard psychotherapy altogether, simply because the other
person so intimately concerned in the process of recovery---the {251}
patient---has no intention of giving it up. You will know of the
increase in knowledge on this subject that we owe to the Nancy school,
to Liébeault and Bernheim. An element dependent on the psychical
disposition of the patient enters as an accompanying factor, without
any such intention on our part, into the effect of every therapeutic
process initiated by a physician; most frequently it is favourable to
recovery, but often it acts as an inhibition. We have learned to use
the word 'suggestion' for this phenomenon, and Möbius has taught us
that the unreliability which we deplore in so many of our therapeutic
measures may be traced back actually to the disturbing influence of
this very powerful factor. All physicians, therefore, yourselves
included, are continually practising psychotherapy, even when you have
no intention of doing so and are not aware of it; it is
disadvantageous, however, to leave entirely in the hands of the
patient what the mental factor in your treatment of him shall be. In
this way it is uncontrollable; it can neither be measured nor
intensified. Is it not then a justifiable endeavour on the part of a
physician to seek to control this factor, to use it with a purpose,
and to direct and strengthen it? This and nothing else is what
scientific psychotherapy proposes.
And, in the third place, I would remind you of the well-known
experience that certain diseases, in particular the psychoneuroses,
are far more readily accessible to mental influences than to any other
form of medication. It is not a modern dictum but an old saying of
physicians that these diseases are not cured by the drug but by the
physician, that is by the personality of the physician, inasmuch as
through it he exerts a mental influence. I am well aware that you {252}
favour the view which Vischer, the professor of æsthetics, expressed
so well in his parody of Faust:
> "Ich weiß, das Physikalische\
> Wirkt öfters aufs Moralische"[55].
But is it not more reasonable and more likely to happen that moral, that
is, mental means can influence the moral side of a human being?
There are many ways and means of practising psychotherapy. All that
lead to recovery are good. Our usual word of comfort, which we
dispense very liberally to our patients---'Never fear, you will soon
be all right again'---corresponds to one of these psychotherapeutic
methods; only, now that deeper insight has been won into the neuroses,
we are no longer forced to confine ourselves to the word of
comfort. We have developed the technique of hypnotic suggestion, and
psychotherapy by diversion of attention, by exercise, and by eliciting
suitable affects. I despise none of these methods and would use them
all under proper conditions. If I have actually come to confine myself
to one form of treatment, to the method that Breuer called
_cathartic_, which I myself prefer to call 'analytic', it is because I
have allowed myself to be influenced by purely subjective
motives. Because of the part I have played in founding this therapy, I
feel a personal obligation to devote myself to closer investigation of
it and to the development of its technique. And I may say that the
analytic method of psychotherapy is the one that penetrates most
deeply, and carries farthest, the one by means of which the most
extensive transformations can be wrought in patients. Putting aside
for a moment the therapeutic point of view, I may also say of it that {253}
it is the most interesting method, the only one which informs us at
all about the origin and interrelation of morbid manifestations. Owing
to the insight which we gain into mental illness by this method, it
alone should be capable of leading us beyond its own limits and of
pointing out the way to other forms of therapeutic influence.
Permit me now to correct several mistakes that have been made in regard
to this cathartic or analytic method of psychotherapy, and give a few
explanations on the subject.
(_a_) I have observed that this method is very often confounded with
hypnotic treatment by suggestion; I have noticed this because it
happens comparatively often that colleagues who do not ordinarily
confide their cases to me send me patients---refractory patients, of
course---with a request that I should hypnotise them. Now I have not
used hypnosis for therapeutic purposes for the last eight years
(except for a few special experiments) so that I habitually send back
these cases with the recommendation that anyone who relies upon
hypnosis may perform it himself. There is, actually, the greatest
possible antithesis between suggestive and analytic technique---the
same antithesis that in regard to the fine arts the great Leonardo da
Vinci summed up in the formulas: _Per via di porre_ and _per via di
levare_. Painting, says Leonardo, works _per via di porre_, for it
applies a substance---particles of colour---where there was nothing
before, on the colourless canvas; sculpture, however, proceeds _per
via di levare_, since it takes away from the rough stone all that
hides the surface of the statue contained in it. The technique of
suggestion aims in a similar way at proceeding _per via di porre_; it
is not concerned with the origin, strength and meaning of the morbid {254}
symptoms, but instead, it superimposes something---a suggestion---and
expects this to be strong enough to restrain the pathogenic idea from
coming to expression. Analytic therapy, on the other hand, does not
seek to add or to introduce anything new, but to take away something,
to bring out something; and to this end concerns itself with the
genesis of the morbid symptoms and the psychical context of the
pathogenic idea which it seeks to remove. It is by the use of this
mode of investigation that analytic therapy has increased our
knowledge so notably. I gave up the suggestive technique, and with it
hypnosis, so early in my practice because I despaired of making
suggestion powerful and enduring enough to effect permanent cures. In
all severe cases I saw the suggestions which had been applied crumble
away again; and then the disease or some substitute for it
returned. Besides all this I have another reproach against this
method, namely, that it conceals from us all insight into the play of
mental forces; it does not permit us, for example, to recognize the
_resistance_ with which the patient clings to his disease and thus
even fights against his own recovery; yet it is this phenomenon of
resistance which alone makes it possible to comprehend his behaviour
in daily life.
(_b_) It seems to me that among my colleagues there is a widespread
and erroneous impression that this technique of searching for the
origins of the symptoms and removing the manifestations by means of
this investigation is a easy one which can be practised off-hand, as
it were. I conclude this from the fact that not one of all those who
show an interest in my therapy and pass definite judgements upon it
has ever asked me how I actually go about it. There can be but one {255}
reason for this, namely, that they think there is nothing to enquire
about, that the thing is perfectly obvious. Again, I am now and then
astonished to hear that in this or that ward of a hospital a young
assistant has received an order from his chief to undertake a
'psycho-analysis' of an hysterical patient. I am sure he would not be
allowed to examine an extirpated tumour until he had convinced his
chiefs that he was conversant with histological technique. Similarly,
a report reaches my ears that this or that colleague has arranged
appointments with a patient in order to undertake a mental treatment
of the case, though I am certain that he knows nothing of the
technique of any such therapy. His expectation must be therefore that
the patient will offer him his secrets as a present, as it were, or
perhaps he looks for salvation in some sort of confession or
confidence. I should not be surprised if an invalid were injured
rather than benefited by being treated in such a fashion. For it is
not so easy to play upon the instrument of the soul. I am reminded at
this point of a world-famed neurotic, although certainly he was never
treated by a physician but existed only in a poet's imagination: I
mean Hamlet, Prince of Denmark. The King appointed the two courtiers,
Rosenkranz and Guildenstern, to follow him, to question him and drag
from him the secret of his depression. He wards them off; then flutes
are brought on the stage and Hamlet, taking one of them, begs one of
his torturers to play upon it, telling him that it is as easy as
lying. The courtier excuses himself for he knows no touch of the
instrument, and when he cannot be persuaded to try it, Hamlet finally
breaks out with these words: 'Why, look you now, how unworthy a thing
you make of me, you would play upon me.---You would pluck out the {256}
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_) From certain of my remarks you will have gathered that there are
many characteristics in the analytic method which prevent it from
being an ideal form of therapy. _Tuto, cito, jucunde_: investigation
and probing do not indicate speedy results, and the resistance already
mentioned would prepare you to expect unpleasantness in various ways.
Psycho-analytic treatment certainly makes great demands upon the
patient as well as upon the physician. From the patient it requires
perfect sincerity---a sacrifice in itself; it absorbs time and is
therefore also costly; for the physician it is no less time-absorbing,
and the technique which he must study and practise is fairly
laborious. I consider it quite justifiable to resort to more
convenient methods of healing as long as there is any prospect of
attaining anything by their means. That, after all, is the only point
at issue. If the more difficult and lengthy method accomplishes
considerably more than the short and easy one, then, in spite of
everything, the use of the former has its justification. Just consider
how much more inconvenient and costly is the Finsen therapy of lupus
than the method of cauterizing and scraping previously employed; and
yet the use of the former signifies a considerable advance, for it
performs a radical cure. Although I do not wish to carry this
comparison to all lengths, the psycho-analytic method may claim a
similar privilege. Actually, I have been able to elaborate and to test {257}
my therapeutic method only on severe, nay, the severest cases; at
first my material consisted entirely of patients who had tried
everything else without success, and had spent long years in
sanatoria. I have scarcely been able to bring together sufficient
material to enable me to say how my method would work with those cases
of lighter, episodically appearing invalidism which we see recover
under all kinds of influences and even spontaneously. Psycho-analytic
therapy was created through and for the treatment of patients
permanently unfitted for life, and its great triumph has been that by
its measures a satisfactorily large number of these have been rendered
permanently fit for existence. In the face of such an achievement all
the effort expended seems trivial. We cannot conceal from ourselves
what, as physicians, we are in the habit of denying to our patients,
namely, that a severe neurosis is no less serious for the sufferer
than any cachexia, any of the dreaded major diseases.
(_d_) The conditions under which this method is indicated, or
contra-indicated, can scarcely be definitely laid down as yet, because
of the many limitations to which the scope of my activities have been
subjected in practice. Nevertheless, I will attempt to discuss a few of
them here:
1. It is important that the morbid condition of the patient should not
be allowed to blind one in making an estimate of his whole
personality; those patients who do not possess a reasonable degree of
education and a fairly reliable character should be refused. It must
not be forgotten that there are healthy persons as well as unhealthy
ones who are good for nothing in life, and that there is much too
prompt an inclination to ascribe to their malady everything which {258}
makes such people unfit, if they show the slightest symptoms of a
neurosis. In my opinion a neurosis is by no means a stamp of
degeneracy, though it may often enough be found in one person in
conjunction with the manifestations of degeneration. Now analytic
psychotherapy is not a process suited to the treatment of neuropathic
degeneration; on the contrary, degeneracy acts as a hindrance to its
effectiveness. Nor is the method applicable to any who are not urged
to seek a cure by their own sufferings, but who undergo treatment only
because they are forced into it by the authority of relatives. The
qualification which is the determining factor of fitness for
psycho-analytic treatment---that is, whether the patient is
educable---must be discussed from yet another standpoint.
2. To be quite safe, one should limit one's choice of patients to those
who possess a normal mental condition, since in the psycho-analytic
method this is used as a foothold from which to obtain control of the
morbid manifestations. Psychoses, states of confusion and deeply-rooted
(I might say toxic) depression are therefore not suitable for
psycho-analysis; at least not for the method as it has been practised up
to the present. I do not regard it as by any means impossible that by
suitable changes in the method we may succeed in advancing beyond these
hindrances---and so be able to initiate a psychotherapy of the
psychoses.
3. The age of patients has this importance in determining their
fitness for psycho-analytic treatment, that, on the one hand, near or
above the fifties the elasticity of the mental processes, on which the
treatment depends, is as a rule lacking---old people are no longer
educable---and, on the other hand, the mass of material to be dealt
with would prolong the duration of the treatment indefinitely. In the {259}
other direction the age limit can be determined only individually;
youthful persons, even under the age of adolescence, are often
exceedingly amenable to influence.
4. Psycho-analysis should not be attempted when the speedy removal of
dangerous symptoms is required, as for example, in a case of hysterical
anorexia.
By this time you will have received the impression that the field of
analytic psychotherapy is a very narrow one, since you have really heard
nothing from me except the indications which point against it. There
remain, however, cases and types of disease enough on which this therapy
may be tested, as for instance, all chronic forms of hysteria with
residual manifestations, the broad field of obsessive conditions,
aboulias, and the like.
It is gratifying that precisely the most valuable and most highly
developed persons are best suited for these curative measures; and one
may also safely claim that in cases where analytic psychotherapy can
achieve but little, any other therapy would certainly not have been able
to effect anything.
(_e_) You will no doubt wish to enquire about the possibility of doing
harm by undertaking a psycho-analysis. In reply to this I may say that
if you are willing to judge impartially, if you will consider this
procedure in the same spirit of critical fairness that you show to our
other therapeutic methods, you will have to agree with me that no
injury to the patient is to be feared when the treatment is conducted
with real comprehension. Anyone who is accustomed, like the lay
public, to blame the treatment for whatever happens during an illness
will doubtless judge differently. It is not so very long ago since the {260}
same prejudice was directed against our hydropathic
establishments. Many a patient who was advised to go into an
establishment of the kind hesitated because he had known someone who
had entered the place as a nervous invalid and had become insane
there. As you will imagine, these were cases of early general
paralysis that could still in the first stage be sent to a hydropathic
establishment; once there, they had run their inevitable course until
manifest mental derangement supervened: but the public blamed the
water as the originator of this disastrous change. When it is a matter
of new kinds of therapeutic influence even physicians are not always
free from such errors of judgement. I recall once making an attempt at
psychotherapy with a woman who had passed the greater part of her life
in a state alternating between mania and melancholia. I took on the
case at the close of a period of melancholia and for two weeks things
seemed to go smoothly; in the third week we were already at the
beginning of the next attack of mania. This was undoubtedly a
spontaneous transformation of the symptoms, since in two weeks
analytic psychotherapy cannot accomplish anything. And yet the eminent
physician (now deceased) who saw the case with me could not refrain
from the remark that psychotherapy was probably to blame for this
'relapse'. I am quite convinced that he would have shown himself
possessed of more critical judgement in other circumstances.
(_f_) Finally, I must confess that it is hardly fair to take up your
attention for so long on the subject of psycho-analytic therapy
without telling you in what this treatment consists and on what it is
based. Still, as I am forced to be brief, I can only hint at
this. This therapy, then, is based on the recognition that unconscious {261}
ideas---or better, the unconsciousness of certain mental
processes---constitutes the direct cause of the morbid symptoms. We
hold this opinion in common with the French school (Janet) which, by
the way, owing to too crude a schematization, refers the cause of
hysterical symptoms to an unconscious _idée fixe_. Now please do not
be afraid that this is going to land us in the depths of philosophical
obscurities. Our unconscious is not quite the same thing as that of
philosophers and, moreover, the majority of philosophers decline all
knowledge of 'unconscious mentality'. If, however, you will look at
the matter from our point of view, you will understand that the
transformation of this unconscious material in the mind of the patient
into conscious material must have the result of correcting his
deviation from normality and of lifting the compulsion to which his
mind has been subjected. For conscious will-power governs only the
conscious mental processes, and every mental compulsion is rooted in
the unconscious. Nor need you ever fear that the patient will be
harmed by the shock accompanying the introduction of the unconscious
into consciousness, for you can convince yourselves theoretically that
the somatic and emotional effect of an impulse that has become
conscious can never be so powerful as that of an unconscious one. It
is only by the application of our highest mental energies, which are
bound up with consciousness, that we can command all our impulses.
There is, however, another point of view which you may take up in
order to understand the psycho-analytic method. The discovery of the
unconscious and the introduction of it into consciousness is performed
in the face of a continuous _resistance_ on the part of the
patient. The process of bringing this unconscious material to light is {262}
associated with 'pain' (_Unlust_), and because of this pain the
patient again and again rejects it. It is for you then to interpose in
this conflict in the patient's mental life. If you succeed in
persuading him to accept, by virtue of a better understanding,
something that up to now, in consequence of this automatic regulation
by pain, he has rejected (repressed), you will then have accomplished
something towards his education. For it is an education even to induce
a person who dislikes leaving his bed early in the morning to do so
all the same. Psycho-analytic treatment may in general be conceived
of as such a _re-education in overcoming internal
resistances_. Re-education of this kind is, however, in no respect
more necessary to nervous patients than in regard to the mental
element in their sexual life. For nowhere else have civilization and
education done so much harm as in this field, and this is the point,
as experience will show you, at which to look for those ætiologies of
the neuroses that are amenable to influence; since the other
ætiological factor, the constitutional component, consists of
something fixed and unalterable. And from this it comes that one
important qualification is required of the physician in this work: not
only must his own character be irreproachable---'As to morals, that
goes without saying', as the hero of Vischer's novel _Auch Einer_ was
wont to say---but he must also have overcome in his own mind that
mixture of lewdness and prudery with which, unfortunately, so many
people habitually consider sexual problems.
At this juncture another remark is perhaps not out of place. I know
that the emphasis which I lay upon the part played by sexuality in
creating the psychoneuroses has become generally known. But I know, {263}
likewise, that qualifications and exact particularization are of
little use to the general public; there is very little room in the
memory of the multitude; it really only retains an undigested kernel
of any proposition and fabricates an extreme version which is easy to
remember. It may be that this has happened with many physicians, too,
so that they vaguely apprehend the content of my doctrine to be that I
regard sexual privation as the ultimate cause of the neuroses. In the
conditions of life in modern society there is certainly no lack of
sexual privation. This being so, would it not be simpler to aim
directly at recovery by recommending the satisfaction of sexual needs
as a therapeutic measure, instead of undertaking the circuitous path
of mental treatment? I know of nothing which could impel me to
suppress such an inference if it were justified. The real state of
things, however, is otherwise. Sexual need and privation are merely
one factor at work in the mechanism of neurosis; if there were no
others the result would be dissipation, not disease. The other, no
less essential, factor, which is all too readily forgotten, is the
neurotic's aversion from sexuality, his incapacity for loving, that
feature of the mind which I have called 'repression'. Not until there
is a conflict between the two tendencies does nervous illness break
out, and therefore to counsel the active gratification of sexual needs
in the psychoneuroses can only very rarely be described as good
advice.
Let me conclude with the following defensive remark. We will hope that,
when freed from every prejudice, your interest in psychotherapy may lend
us support in this way---that you also will then achieve success even
with severe cases of psychoneurosis.
------------------------------------------------------------------------
XIII {264}
FREUD'S PSYCHO-ANALYTIC METHOD[56]
(1904)
The particular method of psychotherapy which Freud practises and terms
psycho-analysis is an outgrowth of the so-called cathartic treatment
discussed by him in collaboration with J. Breuer in the _Studien über
Hysterie_, published in 1895. This cathartic therapy was Breuer's
invention and was first employed by him when treating an hysterical
patient about ten years before; in so doing he had obtained an insight
into the pathogenesis of her symptoms. At the personal suggestion of
Breuer, Freud revived this method and tried it with a large number of
patients.
The cathartic mode of treatment presupposed that the patient could be
hypnotised and was based on the widening of consciousness which occurs
in hypnosis. Its goal was to remove the morbid symptoms, and it
attained this end by making the patient revert to the psychic state in
which the symptom had appeared for the first time. In this state there
came up in the hypnotised patient's mind memories, thoughts and
impulses which had previously dropped out of his consciousness, and,
as soon as he had related these to the physician, accompanying this
expression with intense emotion, the symptom was overcome and its
return done away with. This experience, which could regularly be
made, was taken by the authors in their joint paper to signify that {265}
the symptom represents suppressed processes which had not reached
consciousness, that is, that it represents a transformation
('conversion') of these processes. They explained the therapeutic
effectiveness of their treatment by the discharge of the previously
'strangulated' affect attaching to the suppressed mental acts
('abreaction'). But in practice the simple outline of the therapeutic
operation was almost always complicated by the circumstance that it
was not a single ('traumatic') impression, but in most cases a series
of impressions---to be viewed in its entirety only with
difficulty---which had participated in the creation of the symptom.
The main characteristic of the cathartic method, in contrast to all
other methods used in psychotherapy, consists in the fact that its
therapeutic efficacy does not lie in the suggestive prohibitive command
of the physician. The expectation is rather that the symptoms will
disappear automatically as soon as the operation, based on certain
hypotheses concerning the psychic mechanism, succeeds in diverting the
course of mental processes from the direction which previously had found
an outlet in the formation of the symptom.
The changes which Freud introduced in Breuer's cathartic method of
treatment were at first changes in technique; these, however, brought
about new results and have finally necessitated a different though not
contradictory conception of the therapeutic task.
The cathartic method had already renounced suggestion; Freud went one
step further and gave up hypnosis as well. At the present time he
treats his patients as follows: without exerting any other kind of
influence he invites them to recline in a comfortable position on a {266}
couch, while he himself is seated on a chair behind them outside their
field of vision. He does not ask them to close their eyes, and avoids
touching them as well as any other form of procedure which might
remind them of hypnosis. The consultation thus proceeds like a
conversation between two equally wakeful persons, one of whom is
spared every muscular exertion and every distracting sensory
impression which might draw his attention from his own mental
activity.
Since it depends upon the will of the patient whether he is to be
hypnotised or not, no matter what the skill of the physician may be, and
since a large number of neurotic patients cannot be hypnotised by any
means whatever, it followed that with the abandonment of hypnosis the
applicability of the treatment was assured to an unlimited number of
patients. On the other hand, the widening of consciousness, which had
supplied the physician with just that psychic material of memories and
images by the help of which the transformation of the symptoms and the
liberation of the affects was accomplished, was now missing. Unless a
substitute could be found for this missing element all therapeutic
effect was out of the question.
Freud now found an entirely adequate substitute in the 'associations' of
the patients; that is, in the involuntary thoughts most frequently
regarded as disturbing elements and therefore ordinarily pushed aside
whenever they cross an intention of following a definite train of
thought.
In order to secure these ideas and associations he asks the patient to
'let himself go' in what he says, 'as you would do in a conversation
which leads you "from cabbages to kings".' Before he asks them for a
detailed account of their case-history he admonishes them to relate {267}
everything that passes through their minds, even if they think it
unimportant or irrelevant or nonsensical; he lays special stress on
their not omitting any thought or idea from their story because to
relate it might be embarrassing or painful to them. In the task of
collecting this material of otherwise neglected ideas Freud made the
observations which became the determining factors of his entire
theory. There were gaps in the patient's memory even in narrating his
case: actual occurrences were forgotten, the chronological order was
confused, or causal connections of events were broken, yielding
unintelligible effects. No neurotic case-history is without amnesia of
some kind or other. If the patient is urged to fill these gaps in his
memory by serious application of his attention it is noticed that all
the ideas which occur to him are pushed back by him with all critical
means available, until at last he feels actual discomfort when the
memory has really returned. From this experience Freud concludes that
the amnesias are the result of a process which he calls _repression_
and the motivation of which he finds in feelings of 'pain'
(_Unlust_). The psychical forces which have brought about this
repression are traceable, according to him, to the _resistance_ which
operates against the reintegration of these memories.
The factor of resistance has become one of the cornerstones of his
theory. The ideas otherwise pushed aside with all kinds of excuses---as
those mentioned above---he regards as derivatives of the repressed
psychical manifestations (thoughts and impulses), as distortions of
these because of the resistance which is exerted against their
reproduction.
The greater the resistance, the greater is the distortion. The value
for the therapeutic technique of these unintentional thoughts lies in {268}
their relation to the repressed psychical material. If one possesses a
procedure which makes it possible to arrive at the repressed from the
associations, at the distorted material from the distortions, then
what was formerly unconscious in mental life may be made accessible to
consciousness even without hypnosis.
Freud has developed on this basis an art of interpretation which takes
on the task of freeing, as it were, the pure metal of the repressed
thoughts from the ore of the unintentional ideas. The objects of this
work of interpretation are not only the patient's ideas but also his
dreams, which open up the straightest road to the knowledge of the
unconscious, his unintentional as well as his purposeless actions
(symptomatic acts) and the blunders he makes in every-day life (slips of
the tongue, erroneous acts, and the like). The details of this technique
of interpretation or translation have not yet been published by Freud.
According to the hints he has given they comprise a number of rules,
reached empirically, of how the unconscious material may be
reconstructed from the associations, directions how to interpret the
fact when the patient's ideas cease to flow, and experience concerning
the most important typical resistances that arise in the course of such
a treatment. A bulky volume called _Die Traumdeutung_, published by
Freud in 1900, may be regarded as the forerunner of an initiation into
his technique.
From these remarks concerning the technique of the psycho-analytic
method the conclusion could be drawn that its inventor has given
himself needless trouble and has made a mistake in abandoning the less
complicated hypnotic mode of procedure. However, in the first place,
the technique of psycho-analysis is much easier in practice once one
has learnt it than any description of it would indicate, and secondly, {269}
there is no other way which leads to the desired goal, so the hard
road is still the shortest one to travel. The objection to hypnosis is
that it conceals the resistance and for this reason has obstructed the
physician's insight into the play of psychic forces. Hypnosis does not
do away with the resistance but only avoids it and therefore yields
only incomplete information and transitory therapeutic success.
The task which the psycho-analytic method tries to perform may be
formulated in different ways, which are, however, in their essence
equivalent. It may, for instance, be stated thus: the task of the cure
is to remove the amnesias. When all gaps in memory have been filled
in, all the enigmatic products of mental life elucidated, the
continuance and even the renewal of the morbid condition is
impossible. Or the formula may be expressed in this fashion: all
repressions are to be undone; the mental condition is then the same as
if all amnesias are removed. Another formulation reaches further; the
problem consists in making the unconscious accessible to
consciousness, which is done by overcoming the resistances. But it
must be remembered that such an ideal condition is not present even in
the normal and further that it is only rarely possible to carry the
treatment to a point approaching this condition. Just as health and
sickness are not qualitatively different from each other but are only
gradually separated in an empirically determined way, so the aim of
the treatment will never be anything else but the practical recovery
of the patient, the restoration of his ability and capacity for
enjoyment and an active life. In a cure which is incomplete or in
which success is not perfect, one at any rate achieves a considerable {270}
improvement in the general mental condition, while the symptoms
(though now of smaller importance to the patient) may continue to
exist without stamping him as an invalid.
The therapeutic process remains the same, apart from insignificant
modifications, for all the symptom-formations of the varied
manifestations of hysteria, and all forms of the obsessional neurosis.
This does not imply, however, that there can be an unlimited application
of this method. The nature of the psycho-analytic method involves
indications and contraindications with respect to the person to be
treated as well as with respect to the clinical picture. Chronic cases
of psychoneuroses with few violent or dangerous symptoms are the most
favourable ones for psycho-analysis: so in the first place all forms of
the obsessional neurosis, obsessive thinking and acting, and cases of
hysteria in which phobias and aboulias play the most important part;
further, all somatic expressions of hysteria whenever they do not, as in
anorexia, require the physician to attend promptly to the speedy removal
of symptoms. In acute cases of hysteria it will be necessary to await a
calmer stage; in all cases where nervous exhaustion dominates the
clinical picture a treatment which in itself demands effort, brings only
slow improvement and for a time cannot consider the persistence of the
symptoms, is to be avoided.
Various qualifications are demanded in the person if he is to be
beneficially affected by psycho-analysis. To begin with, he must be
capable of a psychically normal condition; during periods of confusion
or melancholic depression nothing can be accomplished even in cases of
hysteria. Furthermore, a certain measure of natural intelligence and
ethical development may be required of him; with worthless persons the
physician soon loses the interest which makes it possible for him to {271}
enter profoundly into the mental life of the patient. Deep-rooted
malformations of character, traits of an actually degenerative
constitution show themselves during treatment as sources of a
resistance that can scarcely be overcome. In this respect the
constitution of the patient does in fact set a limit to the curative
effect of psychotherapy. If the patient's age is near or above the
fifties the conditions for psycho-analysis become unfavourable. The
mass of psychical material can then no longer be thoroughly inspected;
the time required for recovery is too long; and the ability to undo
psychic processes begins to grow weaker.
In spite of all limitations the number of persons suitable for
psycho-analytic treatment is extraordinarily large and the extension
which has come to our therapeutic knowledge from this method is,
according to Freud, very considerable. Freud requires long periods, six
months to three years, for an effective treatment; yet he informs us
that up to the present, from various circumstances which may easily be
divined, he has for the most part been in a position to try his
treatment only on very severe cases; patients have come to him after
many years of illness, completely incapacitated for life, and after
being disappointed by all kinds of treatments have had recourse to his
new and much-suspected method as to a last resort. In cases of less
severe illness the duration of the treatment might well be much shorter,
and momentous advantage in the way of prevention for the future might be
gained.
------------------------------------------------------------------------
XIV {272}
MY VIEWS ON THE PART PLAYED BY
SEXUALITY IN THE ÆTIOLOGY OF THE
NEUROSES[57]
(1905)
I am of opinion that the best idea of my theory concerning the
ætiological significance of the sexual factor in neurosis is obtained by
examining its evolution. For I have no sort of wish to deny that this
theory has passed through a process of development and has undergone a
transformation during this process. My colleagues could regard this
admission as evidence that the doctrine is nothing but the result of
continued and constantly extended experience; for anything that arises
from speculation may very easily appear once for all complete in form
and then remain unalterable.
The theory originally applied merely to the morbid states embraced
under the term neurasthenia; among these, I noticed two which
occasionally appeared in a pure form and which I have named
'neurasthenia proper' and 'anxiety-neurosis'. It was indeed always a
matter of general knowledge that sexual factors may play a part in the
causation of these forms of disease, but neither were these factors
found to be regularly active nor was there any thought of allotting
them a preferential position among other ætiological influences. I was
surprised to begin with at the frequency of grave disturbances in the
_vita sexualis_ of nervous invalids; the more I enquired into such {273}
disturbances (bearing in mind that all men conceal the truth in these
matters) and the more adept I became at persisting in my
interrogations in spite of denials at the beginning, the more
regularly did pathogenic factors from sexual life disclose themselves,
until there seemed to me little to prevent an assumption of their
general occurrence. Nevertheless, it was necessary to be prepared at
the outset for a frequent incidence of sexual irregularities such as
this, in view of the pressure of present-day social conditions, and
one might still be doubtful what degree of deviation from normal
sexual functioning was to be regarded as pathogenic. I therefore could
attribute less importance to the regular, demonstrable appearance of
sexual noxiæ than to another observed phenomenon which seemed to me
less ambiguous in character. It appeared that each type of ailment,
whether neurasthenia or anxiety-neurosis, showed a constant relation
to the type of sexual noxia. In typical cases of neurasthenia evidence
of masturbation or frequent pollutions would come to light; in
anxiety-neurosis, factors such as coitus interruptus and 'frustrated
excitation' could be shown which appeared to contain one common
element, namely, an unsatisfying discharge of the libido aroused. Only
after this recognition, which was easily observed and could at will be
frequently confirmed, had I the courage to accord a preferential
position to sexual influences in the ætiology of the neuroses. In
addition, a combination of the ætiologies ascribed to these
manifestations was discoverable in the cases of combined neurasthenia
and anxiety-neurosis which often occur; and it appeared that such a
dualism in the manifestations of neurosis accorded well with the polar
character of sexuality, male and female. {274}
At the time that I attributed to sexuality this part in the creation of
simple neuroses[58] I still adhered as regards the psychoneuroses
(hysteria and obsessions) to a purely psychological doctrine in which
sexual factors had no more significance than other sources of emotion.
In conjunction with J. Breuer, and based upon observations made by him
at least a decade before on an hysterical patient, I had studied, by
means of awakening memories in hypnotic states, the mechanism of the
origin of hysterical symptoms. We had reached inferences which helped to
bridge the gap between Charcot's traumatic hysteria and the common,
non-traumatic hysteria.[59] We had arrived at the conception that the
symptoms of hysteria were lasting effects of psychic traumas, whose sum
of affect had by peculiar circumstances been prevented from being worked
off in consciousness and had therefore forced an abnormal outlet into
bodily innervation. The terms 'strangulated affect', 'conversion' and
'abreaction' embrace the distinctive points of this conception.
In view of the close relation of the psychoneuroses to the simple
neuroses, which can go so far that an unpractised physician often
finds it difficult to make a diagnostic distinction, it became
inevitable that the knowledge acquired in one field would throw light
as well on the other. Moreover, quite apart from such a correlation,
closer examination of the psychical mechanism of hysterical symptoms
led to the same result. For, as the psychical traumas which were the
starting-point of the hysterical symptoms were followed---by means of
the cathartic method initiated by Breuer and myself---further and
further back into the patient's past, experiences were finally reached {275}
which belonged to his infancy and concerned his sexual life; and this
was so even where an ordinary emotion, not of a sexual kind, had led
to the outbreak of the disease. Without taking into account these
sexual traumas of childhood it was impossible to explain the symptoms,
comprehend their determination, or prevent their return. After this,
the unique significance of sexual experiences in the ætiology of the
psychoneuroses seemed incontestably established; and this fact remains
to-day one of the cornerstones of the theory.
When this theory is described in the statement that the cause of a
life-long hysterical neurosis lies in sexual experiences of infancy,
usually commonplace in themselves, it may indeed sound strange enough.
Yet if allowance is made for the historical development of the theory,
if its main content be summarised in the thesis that hysteria is the
expression of a peculiar behaviour of the sexual function in the person
concerned and that this behaviour is already decisively determined by
the first impressive influences and experiences during infancy, we shall
indeed be the poorer by a paradox, yet the richer by a motive for
directing our attention to these most significant after-effects of
infantile impressions which have hitherto been so grossly neglected.
Reserving for a later, more detailed discussion the question whether
the ætiology of hysteria and the obsessional neurosis is to be
regarded as contained in the sexual experiences of childhood, I will
return to the form the theory assumed in some short preliminary papers
published in the years 1895 and 1896[60]. By emphasizing the
ætiological factors already inferred, it was possible at that time to
contrast the common neuroses, which had a current ætiology, with the {276}
psychoneuroses, the ætiology of which lay particularly in sexual
experiences of the remote past. The doctrine culminated in the
sentence: No neurosis is possible with a normal _vita sexualis_.
Although even to-day I do not regard these statements as incorrect, it
is surely not surprising that during ten years of constant work
towards elucidation of these problems I should have travelled some
distance beyond my previous point of view and now believe that further
more extensive experience has placed me in a position to correct the
incompleteness, the displacements and the misconceptions under which
the theory then laboured. It happened by chance that my earlier, not
very plentiful material contained a disproportionately large number of
cases in whose infantile history seduction by adults or other older
children had played the chief part. I overestimated the frequency of
these occurrences, which are otherwise quite authentic, and all the
more so since I was not at this period able to discriminate between
the deceptive memories of hysterics concerning their childhood and the
memory-traces of actual happenings. I have since learned to unravel
many a phantasy of seduction and found it to be an attempt at defence
against the memory of sexual activities practised by the child himself
(masturbation of children). This explanation deprived the 'traumatic'
element in the sexual experiences of childhood of their importance,
and there remained a recognition that the form of the infantile sexual
activity (whether spontaneous or provoked) determines the direction
taken by later sexual life after maturity. This same explanation, by
which I was able to correct the most momentous of my early errors,
necessitated a change in the conception of the mechanism of hysterical
symptoms. These now no longer appeared as direct derivations of {277}
repressed memories of sexual experiences in childhood; but, on the
contrary, it appeared that between the symptoms and the infantile
impressions were interpolated the patient's phantasies
(memory-romances), created mostly during the years of adolescence and
relating on one side to the infantile memories on which they were
founded, and on the other side to the symptoms into which they were
directly transformed. Only after the factor of the hysterical
phantasies had been introduced did the structure of the neurosis and
its relation to the patient's life become perspicuous; at the same
time a really surprising analogy came to light between these
unconscious phantasies of hysterics and the romances which become
conscious as delusions in paranoia.
After this correction, the 'infantile sexual traumas' were in a sense
supplanted by the 'infantilism' of the sexuality in these cases. It
was not a far step to a second modification of the original
theory. When the frequency of seduction in childhood was no longer
assumed, there vanished also the overemphasis on the 'accidental',
external influencing of the sexuality to which I had attributed the
chief part in the causation of the disease, without, however, denying
the existence of constitutional and hereditary elements. In connection
with the details of the various sexual experiences of childhood, I had
even hoped to solve the problem of the 'choice of neurosis', that is,
to ascertain what form of psychoneurosis would develop from each type
of experience; I believed at that time, though with some reservations,
that passivity in such experiences produced a specific predisposition
to hysteria, and activity to obsessional neurosis. These views I was
later compelled to abandon entirely, although many actual facts seem {278}
to suggest that the supposed correlation between passivity and
hysteria and activity and the obsessional neurosis should be retained
in some form or other. With the decline in importance of the
influences experienced accidentally the constitutional and hereditary
elements again won the upper hand; with this difference, however, from
prevailing opinion, that in my conception the 'sexual constitution'
took the place of a general neuropathic disposition. In my recently
published _Drei Abhandlungen zur Sexualtheorie_ (1905) I have
attempted to describe the many aspects and varieties of this sexual
constitution, as well as the composite nature of the sexual instinct
as a whole and its origin from various contributory sources in the
organism.
While still maintaining the modifications imposed by the altered
conception of the 'infantile sexual traumas', the theory now advanced
in a direction which had already been indicated in the publications of
the years 1894--96. Already at that time, and even before sexuality
had been accorded its proper position in the ætiology, I had put it
forward as a condition of the pathogenic effectiveness of a given
experience that it must seem to the ego intolerable and must evoke an
effort towards defence[61]. To this defence I had referred the mental
dissociation---or as it was then called, the dissociation of
consciousness---of hysteria. If the defence succeeded, then the
unbearable experience and its affective consequences were banished
from consciousness and from the memory of the ego; but under certain
conditions the banished material---now become unconscious---became
operative and returned into consciousness by way of the symptoms and
the affects attached to them, so that the outbreak of the disease
represented a failure of the defence. This conception had the merit of {279}
taking into account the interplay of the mental forces, thereby
bringing the mental processes of hysteria nearer to the normal,
instead of reducing the characteristic of the neurosis to a mysterious
disturbance incapable of further analysis.
Investigation into the mental life of normal persons then yielded the
unexpected discovery that their infantile history in regard to sexual
matters was not necessarily different in essentials from that of the
neurotic, and that seduction particularly had played the same part in
it; the result was that the accidental influences receded still further
into the background in favour of the influence of 'repression', as I had
begun to call what I had formerly termed 'defence'. The important thing,
therefore, was evidently not the sexual stimulation that the person had
experienced during childhood; what mattered was, above all, how he had
reacted to these experiences, whether he had responded to them with
'repression' or not. With regard to spontaneous sexual activity it
became evident that in the course of development it was often broken off
by an act of repression. Thus the sexually mature neurotic regularly
carried within him a fragment of 'sexual repression' from his childhood
days, which came to expression under the stress imposed upon him by real
life. And psycho-analysis of hysterics showed that their illness was the
result of a conflict between the libido and the sexual repression, their
symptoms being equivalent to compromises in the conflict between these
two mental currents.
I could not expound this part of my theory further without a detailed
discussion of my views on the subject of repression. It must suffice
to bring the reader's notice at this point to my _Drei Abhandlungen {280}
zur Sexualtheorie_, in which I have attempted to throw some light,
even if only a meagre ray, on the somatic processes in which the
essence of sexuality lies. I have there described how the
constitutional disposition of the child is by far more variegated than
we might have expected, how it deserves to be called 'polymorphously
perverse' and how what is called the normal sexual function develops
from this disposition through certain components of it becoming
repressed. The infantile characteristics of sexuality provided a clue
which enabled me to establish a simple correlation between health,
perversion, and neurosis. It appeared that normality developed as the
result of repression of certain component-instincts and components of
the infantile disposition, and of a subordination of the remainder
under the primacy of the genital zone in the service of the
reproductive function; perversions represented disturbances in this
process of coalescence caused by an excessive (obsessive, as it were)
development of certain of the component-instincts; and neurosis could
be traced back to unduly severe repression of libidinal
tendencies. Since almost all the perverse impulses comprising the
infantile disposition demonstrably constitute the symptom-forming
forces of neurosis, though in the latter they are in a state of
repression, I was able to designate neurosis as the 'negative' of
perversion.
I consider it worth emphasis that, in spite of all changes in them, my
views concerning the ætiology of the psychoneuroses have never yet
caused me to disavow or abandon two points of view: namely, the
importance of sexuality and of infantilism. In other respects,
constitutional factors have supplanted accidental influences; 'sexual
repression' has taken the place of the concept of 'defence' which was
intended purely psychologically. Now if anyone should enquire where he {281}
is to look for an incontestable proof of the ætiological importance of
sexual factors in the psychoneuroses---since these maladies are
observed to ensue after the most commonplace emotional, or even
somatic disturbances, and since a specific ætiology in the form of
particular infantile experiences is not forthcoming---then I would
indicate psycho-analytic investigation of neurotics as the source from
which the disputed conviction springs. When this irreplaceable method
of investigation is used one learns that the _symptoms represent the
patient's sexual activity_, either the whole of it or a part of it,
and are rooted in the normal or the perverse component-instincts of
sexuality. Not only does a considerable portion of hysterical
symptomatology spring directly from the manifestations of sexual
excitement; not only does a series of erotogenic zones assume the
importance of genital organs in the neurosis by intensification of
their infantile qualities; but even the most complicated symptoms
reveal themselves as 'converted' representations of phantasies which
have a sexual situation as their content. Whoever knows how to
interpret the language of hysteria can perceive that the neurosis
deals only with the patient's repressed sexuality. Only one must
conceive of the sexual function in its true range, as circumscribed by
the infantile disposition. Wherever a commonplace emotion must be
included among the causative factors of the illness, analysis will
regularly show that the pathogenic effect has been exercised by the
ever-present sexual element in the traumatic occurrence.
This has led us imperceptibly away from the question of the causation
of the psychoneuroses to the problem of their nature. On the basis of
the knowledge acquired by means of psycho-analysis one can only say {282}
that the nature of these maladies lies in disturbances of the sexual
processes, of those organic processes which determine the development
and form of expression of the sexual craving. One can scarcely avoid,
in the last analysis, picturing those processes as chemical, so that
we might recognize the so-called actual neuroses as the somatic
effects of disturbances in sexual metabolism, and the psychoneuroses
as, in addition, the psychical effects of these disturbances. The
similarity of the neuroses to the phenomena of intoxication and
abstinence following upon certain alkaloids, as well as to Graves' and
to Addison's diseases, is readily apparent on the clinical side; and,
just as we can no longer describe as 'nervous diseases' the two
maladies mentioned, so the 'actual neuroses' also, despite their name,
will probably soon have to be removed from this category.
Thus, whatever has a harmful effect on the processes serving the
sexual function belongs to the ætiology of the neuroses. In the first
place, accordingly, there are the noxiæ affecting the sexual function
itself, in so far as they are felt to be harmful by the sexual
constitution, which varies with social culture and education. In the
next place, there are all the other noxiæ and traumas which are
capable of injuring the sexual processes secondarily through general
injury to the whole organism. It should not, however, be forgotten
that the ætiological problem presented by the neuroses is at least as
complicated as the causative factors of any other disease. A single
pathogenic influence is scarcely ever adequate to cause disease; most
often a number of ætiological factors supporting one another are
necessary and these are consequently not to be opposed to one
another. This is the reason why a condition of neurotic invalidism is {283}
not sharply distinguished from that of normal health. The malady
results from a summation of causes, and the measure of the ætiological
conditions may be filled from various accessory sources. To seek the
ætiology of the neuroses exclusively in heredity or in the
constitution would be no less one-sided than to attempt to find this
ætiology only in the accidental modifications undergone by sexuality
during life, although investigations show that the nature of these
disorders consists only of a disturbance of the sexual processes
within the organism.
------------------------------------------------------------------------
ON THE HISTORY OF THE {285}
PSYCHO-ANALYTIC MOVEMENT
(1914)
------------------------------------------------------------------------
ON THE HISTORY OF THE PSYCHO- {287}
ANALYTIC MOVEMENT[62]
(1914)
I
_Fluctuat nec mergitur._
No one need be surprised to find a subjective element in the
contribution I propose to make here to the history of the
psycho-analytic movement, nor need anyone wonder at the part I play in
it. For psycho-analysis is my creation; I was for ten years the only
person who concerned himself with it, and all the dissatisfaction
which the new doctrine aroused in my contemporaries has been poured
forth in the form of criticisms on my head. Although it is long now
since I was the only psycho-analyst, I regard myself as justified in
maintaining that even to-day no one can know better than I what
psycho-analysis is, how it differs from other ways of investigating
the life of the mind, and precisely what should be called
psycho-analysis and what would better be described by some other
name. In thus rejecting what seems to me a cool act of usurpation, I
am indirectly informing the readers of this _Jahrbuch_ of the events
leading to the changes in editorship and in character that it has
undergone.
In 1909, in the lecture-hall of an American university, I had my first
opportunity of speaking in public about psycho-analysis[63]; the
occasion was a momentous one for my work, and moved by this thought I {288}
then declared that it was not I who had brought psycho-analysis into
existence. The credit for this was due to another, to Josef Breuer,
whose work had been done at a time when I was still a student occupied
with my examinations (1880--82). Since I gave those lectures, however,
well-meaning friends have suggested to me a doubt whether my gratitude
should not have been expressed less extravagantly on that
occasion. According to them, I should have done as I had previously
been accustomed to do, and regarded Breuer's 'cathartic procedure' as
a forerunner of psycho-analysis, the latter beginning with my
discarding the hypnotic method and introducing that of free
association. It is of no great importance in any case whether the
history of psycho-analysis is reckoned as beginning with the cathartic
method or with my modification of it; I refer to this uninteresting
point merely because certain opponents of psycho-analysis have the
habit of recollecting occasionally that the art of psycho-analysis was
after all not invented by me, but by Breuer. This of course happens
only when for once in a way they are able to find something worthy of
attention in it; when they impose no such limits to their general
rejection of it, however, psycho-analysis is always without question
my work alone. I have never heard that Breuer's great share in
psycho-analysis has earned him a corresponding measure of criticism
and abuse; and as it is long ago now since I recognized that to stir
up contradiction and arouse bitterness is the inevitable fate of
psycho-analysis, I conclude that I must be the real originator of all
that is particularly characteristic in it. I am happy to be able to
add that none of the efforts to minimize my part in creating this
much-reviled analysis have ever come from Breuer himself or have {289}
met with any support from him.
Breuer's discovery has so often been described that I can dispense with
discussing it in detail here. The fundamental fact was that the symptoms
of hysterical patients are founded upon highly significant, but
forgotten, scenes in their past lives (traumas); the therapy founded
upon this consisted in causing them to remember and reproduce these
scenes in a state of hypnosis (catharsis); and the fragment of theory
inferred from this was that these symptoms represented an abnormal form
of discharge for quantities of excitation which had not been disposed of
otherwise (conversion). Whenever Breuer, in his theoretical contribution
to the _Studien über Hysterie_, referred to this process of conversion,
he always added my name in brackets after it, as though the priority for
this first attempt at theoretic evaluation belonged to me. I believe
that actually this distinction relates only to the name, and that the
conception was evolved by us simultaneously together.
It is known that after Breuer made his first discovery of the
cathartic method he let it rest for a number of years, and took it up
again only after I returned from studying with Charcot and induced him
to do so. He had a large consulting practice in medicine which made
great claims on him; I had only unwillingly taken up the profession of
medicine, but I had at that time a strong motive for helping nervous
persons or at least for wishing to understand something about nervous
states. I had already devoted myself to physical therapy, and had felt
absolutely helpless after the disappointing results I had experienced
with Erb's 'electrotherapy', which was so full of detailed
indications. If I did not at the time arrive on my own account at the {290}
conclusion which Möbius later established, that the successes of
electrical treatment in nervous patients are the effects of
suggestion, certainly only the total absence of these promised
successes was to blame. Treatment by suggestion during deep hypnosis,
which I learned from Liébeault's and Bernheim's highly impressive
demonstrations, then seemed to offer a satisfactory substitute for the
failure of electrical treatment. But the method of investigating
patients in a state of hypnosis, which I learned of from Breuer---with
its automatic effectiveness and the satisfaction it afforded to
scientific interest---was bound to be incomparably more attractive
than the monotonous, arbitrary prohibitions used in treatment by
suggestion, which stood in the way of all research.
We have lately received an admonition purporting to represent one of
the latest developments of psycho-analysis, to the effect that the
current conflict and the exciting cause of illness are to be brought
into the foreground in the analysis. Now this is exactly what Breuer
and I used to do at the beginning of our work with the cathartic
method. We led the patient's attention directly to the traumatic scene
in which the symptom had arisen, endeavoured to find the mental
conflict inherent in it and to release the suppressed affect. In the
course of this we discovered the mental process, so characteristic of
the neuroses, which I later named regression. The patient's
associations led back from the scene which one was trying to elucidate
to earlier experiences, and compelled the analysis, which had to
correct the present, to occupy itself with the past. This regression
led constantly further backwards; at first it seemed regularly to
bring us to puberty; later on, failures and points which still awaited
explanation beckoned the analytic work still further back into years {291}
of childhood which had hitherto been inaccessible to any kind of
exploration. This regressing trend became an important character of
analysis. It appeared that psycho-analysis could explain nothing
current without referring back to something past; more, that every
pathogenic experience implied a previous one which, though not in
itself pathogenic, had yet endowed the later one with its pathogenic
quality. The temptation to confine attention to the known actual
exciting cause was so strong, however, that even in later analyses I
gave way to it. In the analysis of the patient I named 'Dora', carried
out in 1899, I had knowledge of the event which occasioned the
outbreak of the actual illness. I tried innumerable times to analyse
this experience, but even direct demands always failed to produce from
her anything more than the same meagre and incomplete description of
it. Not until a long détour, leading back over her earliest childhood,
had been traversed, did a dream present itself which on analysis
brought to mind the hitherto forgotten details of this scene, so that
comprehension and a solution of the current conflict became finally
possible.
This one example shows how very misleading is the advice just now
referred to, and what a degree of scientific regression is represented
by the neglect of regression in analytic technique thus enjoined upon
us.
The first difference between Breuer and myself came to light in regard
to a question concerning the finer psychical mechanism of hysteria. He
gave preference to a theory which was still to some extent
physiological, as one might call it; he wished to explain the mental
dissociation of hysteria by the absence of communication between
various psychical states (states of consciousness, as we called them {292}
at that time), and he therefore constructed the theory of 'hypnoid'
states, the effects of which were supposed to penetrate into waking
consciousness like unassimilated foreign bodies. I had taken the
matter less academically; everywhere I seemed to discern motives and
tendencies analogous to those of everyday life, and I looked upon
mental dissociation itself as an effect of a process of rejection
which at that time I called _defence_, and later called
_repression_. I made a shortlived attempt to allow the two mechanisms
a separate existence side by side, but as observation showed me always
and only one thing, it was not long before my 'defence' doctrine took
up its stand opposite his 'hypnoid' theory.
I am quite sure, however, that this opposition between our views had
nothing to do with the severance of our relations which followed
shortly after. This severance had deeper causes, but it came about in
such a way that at first I did not understand it; it was only later
that I learnt from many sure indications how to account for it. It
will be remembered that Breuer said of his famous first patient that
the sexual element was amazingly undeveloped in her and had
contributed nothing to the very rich clinical picture of the case. I
have always wondered why the critics did not more often cite this
assurance of Breuer's as an argument against my contention of a sexual
ætiology in the neuroses, and even to-day I do not know whether I
should regard the omission as evidence of tact or of carelessness on
their part. Anyone who reads the history of Breuer's case now in the
light of the knowledge gained in the last twenty years will at once
perceive the symbolism in it---the snake, the stiffening, the
disabling of the arm---and, on taking into account the situation at
the bedside of the sick father, will easily guess the real {293}
interpretation of her symptom-formation; his opinion of the part
played by sexuality in the young woman's mental life will then be very
different from that of her physician. In his treatment of her case,
Breuer could make use of a very intense suggestible _rapport_ on the
part of the patient, which may serve us as a prototype of what we call
'transference' to-day. Now I have strong reasons for surmising that
after all her symptoms had been relieved Breuer must have discovered
from further indications the sexual motivation of this transference,
but that the universal nature of this unexpected phenomenon escaped
him, with the result that, as though confronted by an 'untoward
event', he broke off all further investigation. He never told me this
in so many words, but he gave me at various times indications enough
to justify this reconstruction of what happened. When I later began
more and more resolutely to put forward the significance of sexuality
in the ætiology of neurosis, he was the first to show that reaction of
distaste and repudiation which was later to become so familiar to me,
but which at that time I had not yet learnt to recognize as my
inevitable fate.
The fact of the transference appearing, although neither desired nor
induced by either physician or patient, in every neurotic who comes
under treatment, in its crude sexual, or affectionate, or hostile
form, has always seemed to me the most irrefragable proof that the
source of the propelling forces of neurosis lies in the sexual
life. This argument has never received anything approaching the degree
of attention that it merits, for if it had, there would really be no
choice but acceptance. In my own conviction of the truth it remains,
beside and above the more specific results of analytic work, the
decisive factor. {294}
There was some consolation for the bad reception accorded even among my
intimate friends to my contention of a sexual ætiology in the
neuroses---a vacuum rapidly formed itself about my person---in the
thought that I was taking up the fight for a new and original idea. But,
one day, certain memories collected in my mind which disturbed this
pleasing notion, and gave me instead a valuable insight into the
processes of human activity and the nature of human knowledge. The idea
for which I was being made responsible had by no means originated with
me. It had been imparted to me by no less than three people whose
opinion had commanded my deepest respect---by Breuer himself, by
Charcot, and by the gynæcologist of Vienna University, Chrobak, perhaps
the most eminent of all our Viennese physicians. These three men had all
communicated to me a piece of knowledge which, strictly speaking, they
themselves did not possess. Two of them later denied having done so when
I reminded them of the fact; the third (Charcot) would probably have
done the same if it had been granted to me to see him again. But these
three identical opinions, which I had heard without understanding, had
lain dormant in my mind for years until one day they awoke in the form
of an apparently original idea.
One day when I was a young house-physician I was walking with Breuer
through the town, when a man came up who evidently wished urgently to
speak to him. I fell back; as soon as Breuer was free, he told me in
his friendly instructive way that this man was the husband of a
patient and had brought him some news of her. The wife, he added, was
behaving in such an extraordinary way in society that she had been
brought to him for treatment as nervous. Then he concluded: 'These
things are always _secrets d'alcove!_' Astonished, I asked him what he {295}
meant, and he answered by telling me the meaning of the word _alcove_
(marriage-bed), for he did not realize how extraordinary his remark
had seemed to me.
Some years later, at one of Charcot's evening receptions, I happened to
be standing near the great teacher at a moment when he appeared to be
telling Brouardel some very interesting story from his day's work. I
hardly heard the beginning, but gradually my attention was seized by
what he was saying. A young married couple from the far East: the woman
a confirmed invalid: the man either impotent or exceedingly awkward.
'_Tâchez donc_, I heard Charcot repeating, _je vous assure, vous y
arriverez_.' Brouardel, who spoke less loudly, must have expressed his
astonishment that symptoms such as the wife's could have been produced
in such circumstances. For Charcot suddenly broke in with great
animation, '_Mais, dans des cas pareils c'est toujours la chose
génitale, toujours_ ... _toujours_... _toujours_'; and he crossed his
arms over his stomach, hugging himself and jumping up and down on his
toes several times in his own characteristic lively way. I know that for
one second I was almost paralyzed with amazement and said to myself,
'Well, but if he knows that, why does he never say so?' But the
impression was soon forgotten; brain anatomy and the experimental
induction of hysterical paralyses absorbed all available interest.
A year later, I had begun medical practice in Vienna as a
_Privatdozent_ for nervous diseases, and in everything relating to the
ætiology of the neuroses I was still as ignorant and innocent as one
could only expect of a promising student trained at a university. One
day I had a friendly message from Chrobak, asking me to take a patient {296}
of his to whom he could not give enough time, owing to his new
appointment as University lecturer. I arrived at the patient's house
before he did and found that she was suffering from attacks of
insensate anxiety, and could only be soothed by the most detailed
information about where her physician was at every moment of the
day. When Chrobak arrived he took me aside and told me that the
patient's anxiety was due to the fact that although she had been
married for eighteen years she was still _virgo intacta_. The husband
was absolutely impotent. In such cases, he said, there was nothing for
a medical man to do but to shield this domestic misfortune with his
own reputation, and put up with it if people shrugged their shoulders
and said of him, 'He is no good if he can't cure her after so many
years'. The sole prescription for such a malady, he added, is familiar
enough to us, but we cannot order it. It runs:
R. Penis normalis
dosim
repetatur!
I had never heard of such a prescription and would have liked to shake
my head over my kind friend's cynicism.
I have certainly not disclosed the illustrious parentage of this
scandalous idea in order to saddle others with the responsibility for
it. I am well aware that it is one thing once or twice, or even
oftener, to give words to an idea that comes in the form of a fleeting
inspiration, and quite another to intend it seriously, to take it
literally, to pursue it in spite of all difficulties into every detail
and to win it a place among accepted truths. It is the difference
between a casual flirtation and solemn matrimony with all its duties
and difficulties. 'To be wedded to an idea' is not an uncommon figure
of speech. {297}
Among the other new factors which were added to the cathartic procedure
as a result of my work, transforming it into psycho-analysis, I should
mention particularly: The doctrine of repression and resistance, the
recognition of infantile sexuality, and the interpreting and making use
of dreams as a source of knowledge of the unconscious.
The doctrine of repression quite certainly came to me independently of
any other source; I know of no outside impression which might have
suggested it to me, and for a long time I imagined it to be entirely my
own, until Otto Rank showed us the passage in Schopenhauer's _World as
Will and Idea_ in which the philosopher is trying to give an explanation
of insanity[64]. What he says there about the struggle against
acceptance of a painful part of reality fits my conception of repression
so completely that I am again indebted for having made a discovery to
not being a wide reader. And yet others have read the passage and passed
it by without making this discovery, and perhaps the same would have
happened to me if in my young days I had had more taste for reading
philosophical works. In later years I have denied myself the very great
pleasure of reading the works of Nietzsche from a deliberate resolve not
to be hampered in working out the impressions received in
psycho-analysis by any sort of expectation derived from without. I have
to be prepared, therefore---and am so, gladly---to forego all claim to
priority in the many instances in which laborious psycho-analytic
investigation can merely confirm the truths which this philosopher
recognized intuitively.
The doctrine of repression is the foundation-stone on which the whole
structure of psycho-analysis rests, the most essential part of it, and {298}
yet it is nothing but a theoretical formulation of a phenomenon which
may be observed to recur as often as one undertakes an analysis of a
neurotic without resorting to hypnosis. One notices a resistance then
making itself evident in opposition to the work of analysis and
inducing a failure to recall memories in order to frustrate it. The
use of hypnosis is bound to hide this resistance; the history of
psycho-analysis proper, therefore, begins with the new technique that
dispenses with hypnosis. Considered theoretically, the fact that this
resistance coincides with an amnesia leads inevitably to that view of
unconscious mental activity which is peculiar to psycho-analysis and
after all distinguishes it quite clearly from philosophical
speculations about the unconscious. It may thus be said that the
theory of psycho-analysis is an attempt to account for two observed
facts that strike one conspicuously and unexpectedly whenever an
attempt is made to trace the symptoms of a neurotic back to their
sources in his past life: the facts of transference and of resistance.
Any line of investigation, no matter what its direction, which
recognizes these two facts and takes them as the starting-point of its
work may call itself psycho-analysis, though it arrives at results
other than my own. But anyone who takes up other sides of the problem
while avoiding these two premisses will hardly escape the charge of
misappropriating by attempted impersonation, if he persists in calling
himself a psycho-analyst.
If anyone should seek to regard the theory of repression and of
resistance as assumptions instead of as results following from
psycho-analysis, I should oppose him most emphatically. Such
assumptions of a general psychological and biological nature do exist,
and it would be useful to consider them on some other occasion; but {299}
the doctrine of repression is the outcome of psycho-analytic
work, a theoretic inference legitimately drawn from innumerable
observations. The formulation of infantile sexuality is another of
these products, acquired, however, at a much later date; in the early
days of tentative investigation by analysis no such thing was thought
of. At first one merely remarked that the effect of current
experiences had to be traced back to something in the past. Only,
'enquirers often find more than they bargain for'. One was drawn
further and further back into the past; one hoped at last to be able
to halt at puberty, the period in which sexuality is traditionally
supposed to awake. But in vain; the tracks led on still further
backwards, into childhood and into its earliest years. On the way an
obstacle had to be overcome that was almost fatal to the young
science. Influenced by Charcot's view of the traumatic origin of
hysteria, one was readily inclined to accept as true and ætiologically
significant the statements made by patients in which they ascribed
their symptoms to passive sexual experiences in early childhood ---
broadly speaking, to seduction. When this ætiology broke down under
its own improbability and under contradiction in definitely
ascertainable circumstances, the result at first was helpless
bewilderment. Analysis had led by the right paths back to these sexual
traumas, and yet they were not true. Reality was lost from under one's
feet. At that time I would gladly have given up the whole thing, just
as my esteemed predecessor, Breuer, had done when he made his
unwelcome discovery. Perhaps I persevered only because I had no choice
and could not then begin again at anything else. At last came the
reflection that, after all, one has no right to despair because one
has been deceived in one's expectations; one must revise them. If {300}
hysterics trace back their symptoms to fictitious traumas, this new
fact signifies that they create such scenes in phantasy, and psychical
reality requires to be taken into account alongside actual
reality. This was soon followed by the recognition that these
phantasies were intended to cover up the auto-erotic activity of early
childhood, to gloss it over and raise it to a higher level; and then,
from behind the phantasies, the whole range of the child's sexual life
came to light.
With this sexual activity during early childhood the inherited
constitution at last came into its own. Predisposition and experience
were here linked up in an indissoluble ætiological unity; impressions
which were entirely commonplace, and would otherwise have had no effect,
became exaggerated by the predisposition into traumas giving rise to
excitation and fixations; while experiences stimulated factors in the
disposition which, without them, might have remained long dormant and
perhaps never have awakened. The last word on the subject of traumatic
ætiology was spoken later by Abraham, when he pointed out that the
peculiarity of the sexual constitution in children is precisely
calculated to provoke sexual experiences of a certain kind, namely,
traumas.
In the beginning my formulations regarding infantile sexuality were
founded almost exclusively upon the results of analysis in adults,
leading as they did back into the past. I had no opportunity of direct
observations on children. It was therefore a very great triumph when
it became possible years later to confirm almost all my inferences by
direct observation and analysis of children, a triumph that lost some
of its magnitude as one gradually realized that the nature of the
discovery was such that one should really be ashamed of having to make {301}
it. The further one carried these observations on children, the more
self-evident the facts became, and the more astonishing was it too
that so much trouble was taken to overlook them.
Such a certain conviction of the existence and significance of infantile
sexuality can, it is true, only be obtained by the path of analysis,
pursuing the symptoms and peculiarities of neurotics back to their
ultimate sources, the discovery of which then explains whatever is
explicable in them and enables whatever is modifiable in them to be
changed. I can understand that one would arrive at different results if,
as C. G. Jung has recently done, one first forms a theoretical
conception of the nature of the sexual instinct and then seeks to
explain the life of children on this basis. A conception of this kind is
bound to be selected arbitrarily or in accordance with secondary
considerations, and runs the risk of not corresponding adequately to the
field in which it is applied. It is true that the road of analysis leads
also to certain final difficulties and obscurities in regard to
sexuality and its relation to the whole life of the individual: but
these problems cannot be dealt with by speculation; they must await
solution by other observations or by observations in other fields.
I need say little about the interpretation of dreams. It came as the
first-fruits of the new technique, when, following a dim presentiment,
I had decided to exchange hypnosis for free association. My desire for
knowledge had not been directed to start with towards understanding
dreams. I do not know of any outside influence which drew my interest
to them or inspired me with any helpful expectations. Before Breuer
and I ceased to meet there had only just been time for me to tell him
in one sentence that I now understood how to translate dreams. Since {302}
this was how the discovery came about, it followed that the symbolism
in the language of dreams was almost the last thing to become clear to
me, for the dreamer's associations help very little towards
understanding symbols. I have held fast to the habit of always
studying things themselves before looking for information about them
in books, and therefore I was able to establish the symbolism of
dreams for myself before I was led to it by Scherner's work on the
subject. It was only later that I came to appreciate to its full
extent this mode of expression in dreams---partly through the
influence of Stekel, who at first did such very creditable work but
afterwards went totally astray. The close connection between
psycho-analytic dream-interpretation and the art of interpreting
dreams as practised and held in such high esteem by the ancients only
became clear to me much later. I found the essential characteristic
and most significant part of my dream theory---the reduction of
dream-distortion to an inner conflict, a kind of inward
dishonesty---later in a writer who was familiar with philosophy though
not with medicine, the engineer J. Popper, who published his
_Phantasien eines Realisten_ under the name of Lynkeus.
The interpretation of dreams became a solace and a support to me in
those arduous first years of analysis, when I had to master the
technology, clinical phenomena and therapy of the neuroses all at the
same time; I was then completely isolated, and in the network of
problems and accumulation of difficulties often dreaded losing my way
and also my confidence. It was often a long time before the test of my
hypothesis, that a neurosis must become intelligible by analysis, was
realized in the patient; in their dreams, which might be regarded as
analogues of their symptoms, this hypothesis was confirmed almost {303}
without exception.
It was only my success in this direction that enabled me to persevere.
The result is that I have acquired the habit of gauging the measure of a
psychologist's understanding by his attitude to dream-interpretation;
and have observed with satisfaction that most of the opponents of
psycho-analysis avoid this question altogether or else display
remarkable clumsiness if they attempt to deal with it. I soon saw the
necessity of an analysis of myself and this I carried out with the help
of a series of my own dreams which led me back through all the events of
my childhood; I am still to-day of the opinion that this kind of
analysis may suffice for anyone who is a prolific dreamer and not too
abnormal.
I think that by narrating this history of its development I have shown
what psycho-analysis is better than by a systematic description of
it. I did not at first perceive the peculiar nature of what I had
discovered. Without thinking, I sacrificed at its inception my
popularity as a physician, and the growth of a large consulting
practice among nervous patients, by enquiries relating to the sexual
factors involved in the causation of their neuroses; this brought me a
great many new facts which definitively confirmed my conviction of the
practical importance of the sexual factor. Unsuspectingly, I spoke
before the Vienna Neurological Society, then under the presidency of
Krafft-Ebing, expecting to be compensated by the interest and
recognition of my colleagues for the material losses I had willingly
undergone. I treated my discoveries as ordinary contributions to
science and hoped to be met in the same spirit. But the silence with
which my addresses were received, the void which formed itself about
me, the insinuations that found their way to me, caused me gradually {304}
to realize that one cannot count upon views about the part played by
sexuality in the ætiology of the neuroses meeting with the same
reception as other communications. I understood that from now onwards
I belonged to those who have 'disturbed the sleep of the world', as
Hebbel says, and that I could not reckon upon objectivity and
tolerance. Since, however, my conviction of the general accuracy of my
observations and conclusions grew and grew, and as my confidence in my
own judgement was by no means slight, any more than my moral courage,
there could be no doubt about the outcome of the situation. I made up
my mind that it had been my fortune to discover particularly important
connections, and was prepared to accept the fate that sometimes
accompanies such discoveries.
I imagined the future somewhat as follows: I should probably succeed
in sustaining myself by means of the therapeutic success of the new
method, but science would ignore me entirely during my lifetime. Some
decades later, someone else would infallibly come upon the same
things---for which the time was not yet ripe---, would achieve
recognition for them and bring me to honour as a forerunner whose
failure had been inevitable. Meanwhile I settled down, like Robinson,
as comfortably as possible on my lonely island. When I look back to
those lonely years, away from the pressure and preoccupations of
to-day, it seems to me like a glorious 'heroic era'; my 'splendid
isolation' was not lacking in advantages and in charms. I had not to
read any publications, nor to listen to any ill-informed opponents; I
was not subject to influence from any quarter; no one attempted to
hurry me. I learnt to restrain speculative tendencies and to follow {305}
the unforgotten advice of my master, Charcot---to look at the same
things again and again until they themselves begin to speak. There was
no need for my writings, for which with some difficulty I found a
publisher, to keep pace with my knowledge; they could be postponed as
long as I pleased; there was no doubtful 'priority' to be
secured. _Die Traumdeutung_, for instance, was complete in all
essentials at the beginning of 1896; it was not written out until the
summer of 1899. The analysis of 'Dora' was over at the end of 1899;
the case was noted down in the next two weeks, but not published until
1905. All this time my writings were not reviewed in the medical
journals, or, if by an exception this happened, they were scouted with
contemptuous or pitying arrogance. Occasionally a colleague would make
some reference to me in one of his publications; it would be very
short and not at all flattering---such as 'eccentric', 'extreme',
'very peculiar ideas'. It happened once that an assistant at the
clinic in Vienna where I gave lectures asked me for permission to
attend one of the courses. He listened very attentively and said
nothing; after the last lecture was over he offered to accompany
me. As we walked, he told me that with the knowledge of his chief he
had written a book against my views, but regretted very much that he
had not first learnt more about them from my lectures, as in that case
he would have written very differently. He had indeed enquired at the
clinic whether he had not better first read the _Die Traumdeutung_;
but had been advised against it, as it was not worth the trouble. He
then himself compared the solidity of the structure of my doctrine
with that of the Catholic church. In the interests of his salvation I
take this as an expression of acknowledgement. But, he concluded {306}
by saying, it was too late to alter anything; his book was already
printed. Nor did this man think it necessary later on to make known
anything of the change in his opinion of psychoanalysis, but in his
capacity of reviewer for a medical journal chose rather to follow its
development with flippant comments.
Whatever personal sensitiveness I possessed was blunted in those
years, to my advantage. From embitterment I was saved, however, by one
circumstance that is not always present to help lonely
discoverers. Many a one is tormented by the need to account for the
lack of sympathy or the repudiation expressed by his contemporaries,
and feels their attitude painfully as a contradiction of his own
secure conviction. There was no need for me to feel so; for
psycho-analytical principles enabled me to understand this attitude in
my contemporaries and to see it as a necessary consequence of
fundamental analytic premisses. If it was true that the associated
connections I had discovered were kept from the knowledge of patients
by inward resistances of an affective kind, then these resistances
would be bound to appear in the healthy also, as soon as, from some
external source, they became confronted with what is repressed. It was
not surprising that they should be able to justify on intellectual
grounds this rejection of my ideas though it was actually affective in
nature. The same thing happened just as often in patients, and the
arguments they advanced were just the same and not precisely
brilliant---reasons are as plenty as blackberries, as Falstaff
says. The only difference was that with patients one was in a position
to bring pressure to bear on them, so as to induce them to realize
their resistances and overcome them, but had to do without this
advantage in dealing with those who were apparently healthy. How to {307}
compel these normal persons to examine the matter in a cool, objective
scientific spirit was an insoluble problem which was best left to time
to accomplish. In the history of science one can clearly see that
often the very proposition that at first called out nothing but
contradiction came later on to be accepted, although no new proofs in
support of it were forthcoming.
One would hardly, however, expect me, during those years when I alone
represented psycho-analysis, to have developed any particular respect
for the opinion of the world or any propensity to intellectual
compromise.
II
From the year 1902 onwards, a number of young medical men gathered round
me with the express intention of learning, practising, and spreading
knowledge of psycho-analysis. The stimulus came from a colleague who had
himself experienced the beneficial effect of analytic therapy. Regular
meetings were held on certain evenings at my house; discussions were
arranged according to certain rules; the guests endeavoured to orient
themselves in this new and strange field of research and to interest
others in it. One day a young man who had passed through the technical
training school introduced himself with a manuscript which showed very
unusual comprehension. We induced him to go through the _Gymnasium_ and
the University and to devote himself to the non-medical side of
psycho-analytic investigation. The little society acquired in him a
zealous and dependable secretary and I gained in Otto Rank a faithful
helper and co-worker.
The little circle soon expanded, and in the course of the next few
years often changed its composition. On the whole I could regard it as {308}
hardly inferior, in wealth and variety of talent, to the staff of any
clinical lecturer one could think of. It included from the beginning
those men who were later to play such a considerable, if not always an
agreeable, part in the history of the psycho-analytic movement. At
that time, however, one could not imagine these developments. I had
every reason to be satisfied, and I think I did everything possible to
impart to the others my own knowledge and experiences. There were only
two inauspicious circumstances which at last estranged me inwardly
from the group. I could not succeed in establishing among the members
those friendly relations that ought to obtain between men who are all
engaged upon the same difficult work, nor could I crush out the
disputes about priority for which there were many opportunities under
these conditions of work in common. The difficulties in the way of
instructing beginners in the practice of psycho-analysis, which are
quite particularly great and are responsible for much in the present
dissensions among us, were evident already in this private Vienna
Psycho-Analytical Society. I myself did not venture to put forward a
technique which was still incomplete, or a theory which was still in
the making, with that authority which, if I had, would perhaps have
spared the others many a pitfall and many a fatal error. The
self-reliance of intellectual workers, their early independence of
their teacher, is always gratifying psychologically; it is an
advantage scientifically only when the workers personally fulfil
certain conditions which are none too common. For psycho-analysis in
particular a long and severe discipline and training in
self-discipline was actually required. In view of the courage
displayed by devotion to a subject so despised and so poor in
prospects, I was disposed to tolerate much among the members to {309}
which I should otherwise have made objection. The circle also included
others besides medical men---cultured persons who had recognized
something important in psycho-analysis---writers, painters and so
on. _Die Traumdeutung_ and the book on wit (_Der Witz_), among others,
had shown from the beginning that the principles of psycho-analysis
cannot be limited to the medical field, but are capable of application
to various other mental sciences.
In 1907 the situation changed at one stroke, contrary to all
expectations. It appeared that psycho-analysis had unobtrusively
awakened interest and gained friends, and that even some scientific
workers existed who were ready to acknowledge an allegiance to it. A
communication from Bleuler had informed me before this that my works had
been studied and made use of in Burghölzli. In January 1907, a physician
of the Zurich clinic, Dr. Eitingon, came to Vienna for the first time
and other visits followed which led to an animated exchange of ideas.
Finally, on the invitation of C. G. Jung, at that time still assistant
physician at Burghölzli, a first meeting took place at Salzburg in the
spring of 1908 which included friends of psycho-analysis from Vienna,
Zurich and other places. One of the results of this first
psycho-analytical Congress was the founding of a periodical called the
_Jahrbuch für psycho-analytische und psychopathologische Forschungen_,
published by Bleuler and Freud, and edited by Jung, which first appeared
in the year 1909. A close community in the work of Vienna and Zurich
found expression in this publication.
I have repeatedly acknowledged with gratitude the great efforts made
towards the spread of psycho-analysis by the Zurich School of
Psychiatry, in particular by Bleuler and Jung, and I have no {310}
hesitation in doing so again, even in such altered circumstances. It
was not indeed the partisanship of the Zurich School which led the
attention of the scientific world to psycho-analysis at that time. The
latency period had expired and everywhere psycho-analysis was becoming
the object of ever-increasing interest. But in all other places this
accession of interest at first produced nothing but very emphatic
repudiation, mostly quite violent; whereas in Zurich, on the contrary,
agreement was on the whole the dominant note. Moreover, nowhere else
could such a compact little group of adherents be found, or a public
clinic be placed at the service of psycho-analytic researches, or was
there a clinical lecturer who embodied psycho-analytical principles as
an integral part in his psychiatric course. The Zurich group became as
it were the nucleus of the little band who were fighting for the
recognition of analysis. The only opportunity of learning the new art
and working at it in practice lay there. Most of my followers and
co-workers at the present time came to me by way of Zurich, even those
who were geographically much nearer to Vienna than to Switzerland.
For western Europe, which contains the great centres of culture, the
position of Vienna is an outlying one; and its prestige has for many
years been affected by strong prejudices. Representatives of all the
most important nations congregate in Switzerland where mental activity
is so great; an infective spot there was bound to be of great
importance for the spread of the 'psychical epidemic', as Hoche of
Freiburg has called it.
According to the evidence of a colleague who witnessed developments at
Burghölzli, it appears that psycho-analysis awakened interest there
very early. In Jung's work on occult phenomena, published in 1902, {311}
there was already an allusion to my book on dream-interpretation. From
1903 or 1904, says my informant, psycho-analysis was in the forefront
of interest. After personal relations between Vienna and Zurich had
been established in the middle of 1907, an informal society was also
started in Burghölzli where the problems of psycho-analysis were
discussed at regular meetings. In the alliance between the Vienna and
the Zurich schools the Swiss were by no means mere recipients. They
had already produced very creditable scientific work, the results of
which were of service to psycho-analysis. The association experiments
started by the Wundt School had been interpreted by them in a
psycho-analytic sense, and had proved applicable in unexpected
ways. By this means it had been possible to arrive at rapid
experimental confirmation of psycho-analytic observations and to
demonstrate to students certain connections which the analyst would
only have been able to describe to them. The first bridge linking up
experimental psychology with psycho-analysis had been constructed.
In psycho-analytic treatment association-experiments enable a
provisional, qualitative analysis of the case to be made, but they
furnish no essential contribution to the technique and can be
dispensed with in carrying out analyses. More important, however, was
another achievement by the Zurich school, or its leaders, Bleuler and
Jung. The former showed that light could be thrown on a large number
of purely psychiatric cases by reference to the same processes as have
been recognized through psycho-analysis to obtain in dreams and
neuroses (Freudian mechanisms); and Jung successfully applied the
analytic method of interpretation to the most alien and obscure
phenomena of dementia præcox, so that their sources in the life and {312}
interests of the patient came clearly to light. After this it was
impossible for psychiatrists to ignore psycho-analysis any longer.
Bleuler's great work on schizophrenia (1911), in which the
psycho-analytical point of view was placed on an equal footing with
the systematic clinical one, completed this success.
I will not omit to point out a divergence which was already at that time
noticeable in the direction taken by the work of the two schools. I had
published as early as 1897 the analysis of a case of schizophrenia,
which however took a paranoid form, so that the solution of it could not
have anticipated the results of Jung's analyses. But to me the important
point had been, not so much the possibility of interpreting the
symptoms, as the psychical mechanism of the disease, and above all the
similarity of this mechanism with that of hysteria which was already
known. At that time no light had yet been thrown on the differences
between the two disorders. I was in fact already aiming at a libido
theory of the neuroses, which should explain all neurotic and psychotic
manifestations as abnormal directions taken by libido, that is, as
deviations of it from its normal course. This point of view was
overlooked by the Swiss investigators. As far as I know, Bleuler
maintains the view even to-day that the various forms of dementia præcox
have an organic causation; and Jung, whose book on this disease appeared
in 1907, at the Congress at Salzburg in 1908 supported the toxic theory
of its causation which takes no account of the libido theory, although
it is true that it does not exclude it. Later on (1912) he came to grief
on this point, by making too much of what he had previously ignored.
There is a third contribution made by the Swiss School, and probably
to be ascribed entirely to Jung, which I do not value so highly as {313}
others do whose concern with these matters is more remote. I mean the
theory of 'complexes' which grew out of the _Diagnostische
Assoziationsstudien_ (1906 to 1910). It has neither produced a
psychological theory in itself, nor has it proved capable of easy
incorporation into the context of psycho-analytical theory. The word
'complex', on the other hand, has become naturalized, so to speak, in
psycho-analytic language; it is a convenient and often indispensable
term for summing up descriptively a psychological state. None of the
other terms coined by psycho-analysis for its own needs has achieved
such widespread popularity, or been so misapplied to the detriment of
formulating clear concepts. Analysts began to speak among themselves
of a 'return of a complex' where they meant a 'return of the
repressed'; or got into the habit of saying 'I have a complex against
him', where correctly they could only have said 'a resistance against
him'.
In the years following 1907 when the schools of Vienna and Zurich were
united, psycho-analysis made that extraordinary plunge forward, the
momentum of which is felt even to-day; this is shown both by the
spread of psycho-analytic literature and by the constant increase in
the number of medical men who are practising or studying it, and also
by the frequency of the attacks upon it made at Congresses and in
learned societies. It has penetrated into the most distant lands and
everywhere has not merely startled psychiatrists but has commanded the
attention of the cultured public and of scientific workers in other
fields. Havelock Ellis, who has followed its development with sympathy
without ever calling himself an adherent, wrote in 1911 in a report
for the Australasian Medical Congress: 'Freud's psycho-analysis is now {314}
championed and carried out not only in Austria and in Switzerland, but
in the United States, in England, in India, in Canada, and, I doubt
not, in Australasia[65].' A physician from Chile (probably a German)
spoke at the International Congress at Buenos Ayres in 1910 in support
of the existence of infantile sexuality and commended highly the
effects of psycho-analytic therapy for obsessional symptoms[66]. An
English neurologist in Central India informed me, through a
distinguished colleague who was coming to Europe, that the analyses of
Mohammedan Indians which he had carried out showed the same ætiology
of neuroses in them as we find in our European patients.
The introduction of psycho-analysis into North America took place with
very special marks of honour. In the autumn of 1909, Stanley Hall, the
President of Clark University, Worcester, Massachusetts, invited Jung
and myself to take part in the celebration of the twentieth
anniversary of the foundation of the University by giving addresses in
the German language. To our great surprise, we found the members of
that small but highly respected University for the study of pedagogy
and philosophy so unprejudiced that they were acquainted with all the
literature of psycho-analysis and had given it a place in their
lectures to students. In prudish America it was possible, at least in
academic circles, to discuss freely and scientifically everything that
in ordinary life is regarded as objectionable. The five lectures which
I improvised in Worcester appeared in English in the American Journal
of Psychology, and were shortly after published in German under the
title _Über Psychoanalyse_. Jung read a paper on 'Diagnostic {315}
Association-experiments' and one on 'Conflicts in the Mind of the
Child'. We were rewarded with the honorary degree of Doctor of
Laws. In that week at Worcester, psycho-analysis was represented by
five persons; besides Jung and myself, there was Ferenczi, who had
joined me as travelling companion, Ernest Jones, then at the
University of Toronto (Canada), now returned to London, and
A. A. Brill, who was already practising psycho-analysis in New York.
The most important personal relationship which arose from the meeting at
Worcester was that with James J. Putnam, Professor of Neuropathology at
Harvard University. Some years before, he had expressed an unfavourable
opinion of psycho-analysis, but now he rapidly reconciled himself to it
and recommended it to his countrymen and his colleagues in a series of
lectures which were as rich in content as they were brilliant in form.
The esteem he enjoyed throughout America on account of his high moral
character and unflinching love of truth was of great service to
psycho-analysis and protected it against the denunciations which might
otherwise have early overwhelmed it. Later on, yielding too much to the
strong ethical and philosophical bent of his nature, Putnam made what
seems to me an impossible demand---he expected psycho-analysis to place
itself in the service of a particular moral-philosophical conception of
the Universe---but he remains the chief pillar of the psycho-analytic
movement in his native land.
For the further spread of this movement Brill and Jones deserve the
greatest credit; they achieved this by repeatedly with self-denying
assiduity bringing to the notice of their countrymen in their writings
the easily observable fundamental facts of everyday life, of dreams {316}
and neurosis. Brill has contributed still further to this effect by
medical practice and by his translations of my works, and Jones by
erudite lectures and by his skill in debate at congresses in
America.[67] The absence of any deep-rooted scientific tradition in
America and the much less stringent rule of official authority there
have been decidedly advantageous to the movement which Stanley Hall
started. It was characteristic of that country that from the beginning
both professors and superintendents of mental hospitals as well as
independent practitioners were all equally interested in analysis. But
it is clear that precisely for this reason the centres of ancient
culture, where the greatest resistance has been displayed, must be the
scene of the final decisive battle for psycho-analysis.
Among European countries France has hitherto shown itself the least
disposed to welcome psycho-analysis, although useful work in French by
A. Maeder of Zurich has provided easy access to its doctrines. The
first indications of allegiance came from the provinces;
Morichau-Beauchant (Poitiers) was the first Frenchman to subscribe
publicly to psycho-analysis. Régis and Hesnard (Bordeaux) have
recently (1913) attempted to disperse the prejudices of their
countrymen against the new ideas by an exhaustive and intelligent
presentation which takes exception only to symbolism. In Paris itself,
a conviction still seems to reign (to which Janet himself gave
eloquent expression at the Congress in London in 1913) that everything
good in psycho-analysis is a repetition of Janet's views with {317}
insignificant modifications, and that everything else in it is bad. At
this congress, indeed, Janet had to submit to a number of corrections
by Ernest Jones, who was able to point out to him his insufficient
knowledge of the subject. Even though we deny his claims, however, we
cannot forget the value of his work on the psychology of the neuroses.
In Italy, after several promising starts, no real interest was
forthcoming. In Holland, analysis found an early hearing by way of
personal relationships; Van Emden, Van Ophuijsen, Van Renterghem (_Freud
en zijn School_) and the two Stärckes are actively occupied with it both
practically and theoretically.[68] In scientific circles in England
interest in analysis has developed very slowly, but there is reason to
expect that the sense for the practical and the passionate love of
justice in the English will ensure it a brilliant future there.
In Sweden, P. Bjerre, who succeeded to Wetterstrand's practice, gave
up hypnotic suggestion, at least for the time, in favour of analytic
treatment. R. Vogt (Christiania) had already in 1907 appreciated
psycho-analysis in his book _Psykiatrien's grundtraek_, so that the
first text-book of psychiatry to refer to psycho-analysis was a
Norwegian one. In Russia, psycho-analysis has become generally known
and has spread widely; almost all my writings, as well as those of
other adherents of analysis, have been translated into Russian. But a
really penetrating comprehension of analytical principles has not yet
been evinced in Russia; so that the contributions of Russian
physicians are at present not very notable. The only skilled analyst {318}
there is M. Wulff who practises in Odessa. It is principally due to
L. Jekels that psycho-analysis has been introduced to Polish
scientific and literary circles. Hungary, so near geographically to
Austria, and so far from it scientifically, has produced only one
collaborator, S. Ferenczi, but one that indeed outweighs a whole
society.
The position of psycho-analysis in Germany can only be described by
saying that it forms the centre-point of scientific discussions and
evokes the most emphatic repudiation from both medical men and laity;
these controversies, however, have come to no conclusion, but are
continually being revived and intensified. No official seat of
learning there has up to the present recognized psycho-analysis;
successful practitioners who employ it are very few; only a few
institutions, such as Binswanger's in Kreuzlingen (on Swiss soil) and
Marcinowski's in Holstein, have introduced it. One of the most
prominent representatives of analysis, Karl Abraham, at one time an
assistant of Bleuler's, maintains himself in the critical atmosphere
of Berlin. One might wonder that this state of things should continue
unaltered for several years if one did not know that it is merely a
superficial appearance. Too much significance should not be attributed
to rejection by the official representatives of science and heads of
institutions, together with their dependents and followers. It is
natural that opponents should raise a clamour while intimidated
adherents preserve silence. Some of the latter, after producing
contributions to analysis which raised considerable expectations,
later withdrew from the movement under the pressure of
circumstances. The movement itself advances surely though silently,
wins new adherents continually among psychiatrists and laity, brings
in a constant stream of new readers for psycho-analytical literature {319}
and so compels its opponents to ever more vehement defensive
measures. At least a dozen times in recent years, in reports of the
proceedings of certain Congresses and scientific assemblies or in
reviews of certain publications, I have read 'Psycho-Analysis is dead,
at last defeated and finally abolished!' The answer to all this might
be like that of Mark Twain in his telegram to the newspapers which
falsely reported his death: Report of my death grossly
exaggerated. After these announcements psycho-analysis always gained
new adherents and co-operators or acquired new means of advancing
itself. After all, to be hailed as a corpse is an advance on being
received in dead silence.
Hand in hand with this geographical extension of psycho-analysis went
an expansion in its content; its application was pushed forward from
the field of the neuroses and psychiatry to other fields of
knowledge. I shall not treat this aspect of the development of our
discipline in much detail, since this has been done with great success
by Rank and Sachs in a volume (one of Löwenfeld's _Grenzfragen_) which
deals exhaustively with this side of analytical research. Moreover,
this branch is still in its infancy; it has been little worked at,
consists mostly of attempts and to a certain extent of work which as
yet has only been planned. No reasonable person will see any grounds
for a reproach in this. An enormous mass of work confronts our little
group of workers, most of whom have their main occupation elsewhere
and can bring only the qualifications of an amateur to the technical
problems of these unfamiliar fields of science. These workers who
belong really to psycho-analysis make no secret of their lack of
special training; they intend merely to point a way, and to occupy the
places of the specialists to whom they recommend analytic technique {320}
and principles only until the latter are ready to take up the work
themselves. That the results achieved are nevertheless not
inconsiderable is due partly to the fruitfulness of the analytic
method, and partly to the circumstance that already there are a few
investigators who, without being medical men, have taken up the
application of psycho-analysis to the mental sciences as their
profession in life.
As is natural, most of these branches of study owe their origin to
remarks in my earlier analytic writings. Analytic examination of
neurotic persons and the neurotic manifestations observable in normal
people necessitated conclusions in regard to psychological connections
which could not possibly be limited to the field in which they had
been discovered. In this way analysis has provided us not only with
the explanation of pathological phenomena, but has revealed their
connection with normal mental life and disclosed undreamt-of
relationships between psychiatry and the most various other sciences
dealing with products of the mind. Certain typical dreams, for
instance, have yielded an explanation of many myths and
fairy-tales. Riklin and Abraham followed this hint and initiated those
researches into myths which have found their completion, in a manner
complying with all expert demands, in Rank's works on
mythology. Further investigation into dream-symbolism led to the heart
of the problems of mythology, folklore (Jones and Storfer), and the
abstractions of religion. A deep impression was made on all hearers at
one of the psycho-analytical Congresses when a pupil of Jung
demonstrated the correspondence of schizophrenic phantasy-formations
with the cosmogonies of primitive times and races. Mythological
material later on received further elaboration, no longer free from {321}
objection and yet very interesting, at the hands of Jung, in works
attempting to correlate the various neurotic, religious and
mythological phantasies.
Another path led from the investigation of dreams to the analysis of
works of imagination and of their creators---poets and artists
themselves. The first step was taken by the recognition that dreams
invented by writers will often yield to analysis in the same way as
genuine ones (Gradiva). The conception of an unconscious mental
activity made it possible to form a preliminary idea of the nature of
poetic creative work; and the realization, gained in the study of
neurotics, of the part played by the instincts enabled us to perceive
the sources of artistic production and confronted us with two
problems: how the artist reacts to these stimuli and what means he
employs to disguise these reactions[69]. Most analysts with wide
general interests have contributed something to the solution of these
problems, which are among the most fascinating in the whole
application of psycho-analysis. Naturally, opposition in this
direction also was not lacking on the part of those who know nothing
of analysis; it took the same form as it did in the original field of
psycho-analytic research---the same misconceptions and vehement
rejections. It was only to be expected from the beginning that,
whatever regions psycho-analysis might penetrate into, it would
inevitably experience the same struggles with the occupants in
possession. These little invasions, however, have not yet all aroused
in some fields the attention that awaits them in the future. Among
the strictly scientific applications of analysis to literature, Rank's {322}
exhaustive work on the theme of incest easily takes the first place;
its subject will ensure it the greatest unpopularity. Up to the
present, little work based on psychoanalysis has been done in the
sciences of language and history. I myself ventured the first approach
to the problems of the psychology of religion, in 1910, by drawing a
parallel between religious ritual and the ceremonials of
neurotics. Dr. Pfister, a clergyman in Zurich, has traced the origin
of religious fanaticism back to perverse erotism in his book on the
piety of Count von Zinzendorf (as well as in other contributions). In
the latest works of the Zurich school we find analysis permeated with
religious ideas rather than the opposite, as is intended.
In the four essays called _Totem und Tabu_ I have made an attempt to
deal with the problems of race-psychology in the light of analysis; this
line of investigation leads direct to the origins of the most important
institutions of our civilization, of state organization, morality and
religion, and, moreover, of the prohibition against incest and of the
conscience. How far the connections which have come to light in this
matter will withstand criticism is probably not ascertainable at the
present time.
The first example of an application of the analytic mode of thought to
the problems of æsthetics was contained in my book on
_Wit_. Everything beyond this is still awaiting workers, who may
expect a particularly rich harvest in this field. We are entirely
without the co-operation of specialists in all these branches, and in
order to attract them Hanns Sachs founded in 1912 the periodical
_Imago_ which is edited by him and Rank. A beginning has been made by
Hitschmann and von Winterstein in illuminating philosophical systems
and personalities by analysis, and here both more extended and deeper {323}
investigation is much needed.
The revolutionary discoveries of psycho-analysis in regard to the mental
life of children---the part played in it by sexual impulses (von
Hug-Hellmuth), and the final fate of those components of sexuality which
cannot be taken up into the function of reproduction---were bound to
direct attention early to pedagogics and to stimulate an attempt to
bring the analytic point of view into the foreground in this field of
work. Recognition is due to the Rev. Dr. Pfister for having, with
sincere enthusiasm, initiated the application of psycho-analysis in this
direction and brought it to the notice of ministers of religion and
persons concerned with education.[70] He has succeeded in gaining the
sympathy and participation of a number of Swiss pedagogues in this
matter. Certain members of his own profession are said to share his
views but to have elected nevertheless to remain cautiously in the
background. In retreating from psycho-analysis, a section of Vienna
analysts seems to have alighted upon a kind of medical pedagogy.[71]
With these indications, which are far from complete, I have attempted
to give some idea of the innumerable connections, not even yet
exhausted, which have evinced themselves between medical
psycho-analysis and other fields of science. There is material for a
generation of investigators to work at, and I do not doubt that the
work will be carried out as soon as the resistances against
psycho-analysis are overcome in the field in which it originally
appeared.[72] {324}
To write the story of these resistances would be, in my opinion, both
fruitless and inopportune at the present time. The story is not very
creditable to the scientific men of our time. But to this I will
immediately add that it has never occurred to me to pour contempt upon
the opponents of psycho-analysis merely because they were opponents,
apart from the few paltry creatures, swindlers and adventurers, who are
always found on both sides in time of war. I knew very well how to
account for the behaviour of these opponents and, moreover, I had learnt
that psycho-analysis always brings to the surface the worst that is in a
man. But I made up my mind not to answer my opponents and, so far as my
influence went, to restrain others from controversy. Under the peculiar
conditions of the altercation about psycho-analysis it seemed to me very
doubtful whether either spoken or written debates would avail anything;
it was certain which way the majority at congresses and meetings would
go, and my faith in the reasonableness and nobility of the gentlemen who
opposed me was not at any time great. Experience shows that only very
few persons are capable of preserving courtesy in a scientific dispute,
to say nothing of keeping to the point, and an altercation about a
scientific matter had always been odious to me. Perhaps this attitude on
my part has been misunderstood; perhaps I have been thought so
good-natured or so easily intimidated that no further notice need be
taken of me. This was a mistake; I can rave and revile as well as
anybody, but I do not find it so easy to give expression in a manner
suitable for publication to the emotions involved and therefore I
abstain entirely from the attempt.
Perhaps in many respects it would have been better if I had given free
rein to my own feelings and to those of others round me. We have all {325}
heard of the interesting attempt to explain psycho-analysis as a
product of the peculiar character of Vienna as a city; as recently as
1913 Janet did not disdain to employ this argument, although he
himself is undoubtedly proud of being a Parisian. This inspiration
runs as follows: psycho-analysis, so far as it consists of the
assertion that the neuroses are traceable to disturbances in the
sexual life, could only have come to birth in a town like Vienna---in
an atmosphere of sensuality and immorality foreign to other
cities---and it simply contains a reflection, a projection into
theory, as it were, of these peculiar Viennese conditions. Now
honestly I am no local patriot; but this theory about psycho-analysis
always seems to me quite exceptionally stupid, so stupid, in fact,
that I have sometimes been inclined to suppose that the reproach of
being a citizen of Vienna is only a euphemistic substitute for another
reproach which no one would care to put forward openly. If the
premisses on which the argument rests were the opposite of what they
are, then it might be worth a hearing. Given a town in which the
inhabitants imposed exceptional restrictions upon themselves in regard
to sexual gratification, and at the same time exhibited a marked
tendency to severe neurotic disorders, that town might certainly give
rise in the mind of an observer to the idea that these two
circumstances had some connection with each other, and to lead to the
inference that one was contingent upon the other. But neither of these
assumptions is true of Vienna. The Viennese are no more abstinent and
no more nervous than dwellers in other large cities. There is rather
less embarrassment---less prudery---in regard to sexual relationships
than in the cities of the West and North which are so proud of their
chastity. These peculiar characteristics of Vienna would be more {326}
likely to mislead the supposed observer in regard to the causation of
neurosis than to throw any light on it.
Vienna has done everything possible, however, to deny her share in the
origin of psycho-analysis. In no other place is the hostile indifference
of the learned and cultivated section of the population so evident to
the analyst as in Vienna.
It may be that my policy of avoiding wide publicity is to some extent
responsible for this. If I had permitted or given an opportunity for the
medical societies of Vienna to busy themselves with psycho-analysis in
stormy debates, where violent feelings could come to the surface, and
the accusations and abuse which everyone had in his heart could be
freely expressed, perhaps the ban on psycho-analysis would have been
overcome by now and it would no longer be a stranger in its native city.
As it is---the poet may be right when he makes his Wallenstein say:
But this the Viennese will not forgive me
That I deprived them of a spectacle.
The task to which I was not equal---that of demonstrating _suaviter in
modo_ to the opponents of psycho-analysis their injustice and
arbitrary attitude---was undertaken and carried out most efficiently
by Bleuler in 1911 in his essay _Die Psychanalyse Freuds: Verteidigung
und Kritische Bemerkungen_. It would be so natural for me to praise
this work which criticizes both sides that I will hasten to say what I
deprecate in it. It seems to me in spite of all not truly impartial,
too lenient to the faults of the opponents of psycho-analysis and too
severe on the shortcomings of its adherents. This trait in it may
possibly explain why the opinion of a psychiatrist of such high
repute, such undoubted ability and independence, has not had more {327}
effect upon his colleagues. The author of _Affektivität_ (1906) will
not be surprised that the effect of a book is determined not by the
strength of its arguments but by the note of feeling in it. Another
aspect of the effect of this book---that on the followers of
psycho-analysis---was destroyed later on by Bleuler himself, when in
1913 he showed the reverse side of his attitude to psycho-analysis in
his _Kritik der Freudschen Theorie_. In this book he demolishes so
much of the structure of psycho-analytical theory that our opponents
may well be glad of the assistance this champion of psycho-analysis
renders them. No new arguments or better observations have served him
as a guide to these pronouncements; he takes his stand simply on his
own judgement and no longer himself admits, as he did in earlier
works, the inadequacy of this ground. It seemed therefore that an
almost irreparable loss threatened psycho-analysis here. But in his
last publication, _Die Kritiken der Schizophrenie_, 1914, Bleuler
summons up all his forces in the face of the attacks made upon him for
introducing psycho-analysis into his book on schizophrenia and makes
what he himself calls a 'presumptuous claim'. 'But now I will make a
presumptuous claim: I consider that up to the present the various
kinds of psychology have contributed precious little towards an
explanation of the underlying connections in psychogenic symptoms and
diseases, but that the psychology of the depths offers something
towards a psychology which still awaits creation and which physicians
are in need of in order to understand their patients and to cure them
rationally; and I even believe that in my _Schizophrenie_ I have taken
a very short step towards the required understanding. The first two
assertions are certainly correct; the last may be an error.' {328}
Since by 'psychology of the depths' he means nothing else but
psycho-analysis we may for the present be content with this admission.
III
_Mach es kurz!_
_Am Jüngsten Tag ist's nur ein Furz!
Goethe.
Two years after the first, the second private Congress of
psycho-analysts took place at Nuremberg, in March, 1910. In the
interval between them, influenced partly by the favourable reception
in America, the increasing hostility in German-speaking countries, and
by the unforeseen acquisition of support from Zurich, I had conceived
a project which with the help of my friend Ferenczi I carried out at
this second Congress. What I had in mind was to organize the
psycho-analytical movement, to transfer its centre to Zurich and to
give it a leader who would look after its future career. As this
scheme has met with much opposition among the adherents of
psycho-analysis, I will set out my reasons for it in some detail. I
hope that they will justify my action, even though it turns out that
it was not a very wise one.
I judged that its association with Vienna was no recommendation but
rather a handicap to the new movement. A place in the heart of Europe
like Zurich, at which an academic instructor had adopted
psycho-analysis in his institution, seemed to me much more
promising. I supposed too that my own person constituted a second
handicap; all estimates of my personality were vitiated by the liking
or dislike of the different factions; I was either compared with
Darwin and Kepler or was hooted at as a general paralytic. I wished to
withdraw myself into the background, therefore, as well as the city {329}
where psycho-analysis first saw the light. Moreover, I was no longer
young; I saw that there was a long road ahead, and I felt oppressed by
the thought that the responsibilities of a leader should fall to me at
my time of life. Yet I felt that there must be a leader. I knew only
too well the pitfalls lying in wait for anyone who undertakes
analysis, and hoped that many of them might be avoided if someone
prepared to instruct and admonish could be established in a position
of authority. This position had at first been occupied by myself,
owing to my fifteen years' start in experience which nothing could
make up. I felt the need of transferring this authority to a younger
man, who would then as a matter of course take my place after my
death. This man could only be C. G. Jung, since Bleuler was my
contemporary in age; in favour of Jung were his exceptional talents,
the contributions he had already made to psycho-analysis, his
independent position and the impression of energy and assurance which
his personality conveyed. In addition to this, he seemed ready to
enter into a friendly relationship with me and for my sake to give up
certain prejudices in regard to race which he had previously permitted
himself. I had no inkling at that time that in spite of all these
advantages the choice was a most unfortunate one, that I had lighted
upon a person who was incapable of tolerating the authority of
another, who was still less fitted himself to wield it, and whose
energies were ruthlessly devoted to the furtherance of his own
interests.
I considered it necessary to form an official association because I
feared the abuses to which psycho-analysis would be subjected as soon
as it became popular. There should be some headquarters whose duty it
would be to announce: 'All this nonsense is nothing to do with {330}
psycho-analysis; this is not analysis.' The meetings of the branch
societies (which together would form the international association)
would provide opportunities for learning and studying psycho-analysis
and for the training of medical men, whose work would then have a kind
of guarantee upon it. Moreover, it seemed to me desirable, since
official science had pronounced its solemn ban upon psycho-analysis
and had declared a boycott against medical men and institutions
practising it, that the adherents of psycho-analysis should come
together for friendly communication with one another and mutual
support.
This and nothing else was what I hoped to achieve by founding the
International Psycho-Analytical Association. It was probably more than
could be attained. Just as my opponents were to discover that it was
not possible to stem the tide of the new movement, so I was to find
that it would not proceed in the direction I wished to mark out for
it. The proposals made by Ferenczi in Nuremberg were adopted, it is
true; Jung was elected President and made Riklin his secretary; the
publication of a correspondence bulletin which should link the Central
Executive with the branch Societies was resolved upon. The objects of
the Association were declared to be 'to foster and further the science
of psycho-analysis founded by Freud, both as a pure discipline of
psychology and in its application to medicine and the mental sciences;
and to promote mutual support among the members in all endeavours to
acquire and to spread psycho-analytical knowledge.' The scheme,
unfortunately, was very violently opposed by the Vienna group. Adler,
in great excitement, expressed the fear that 'censorship and
restrictions of scientific freedom' were intended. Finally the
Viennese gave in, after having secured that not Zurich, but the place {331}
of residence of the President, should be the centre of the Association
and that he should be elected for two years.
At this Congress three local branch societies were inaugurated: one in
Berlin, under the chairmanship of Abraham; one in Zurich, whose head
became President of the Association; and one in Vienna, the chairmanship
of which I made over to Adler. A fourth group, in Budapest, could not be
formed until later. Bleuler had not attended the Congress on account of
illness, and later he evinced hesitation about joining the Association
on grounds of principle; he let himself be persuaded to do so, it is
true, after a personal conversation with me, but resigned again shortly
after on account of disagreements at Zurich. This severed the connection
between the Zurich group and the Burghölzli institution.
One of the results of the Nuremberg Congress was the founding of the
_Zentralblatt für Psychoanalyse_, for which purpose Adler and Stekel
joined forces. It had obviously been designed originally as an
instrument of opposition, to win back for Vienna the hegemony threatened
by the election of Jung. But when the two founders of the journal,
labouring under the difficulties of finding a publisher, assured me of
their friendly intentions and as a guarantee of their sincerity gave me
a right of veto, I accepted the direction of it and worked energetically
for this new organ; its first number appeared in September, 1910.
I will now continue the story of the psycho-analytical Congresses. The
third Congress took place in September, 1911, in Weimar, and surpassed
the previous ones in spirit and scientific fervour. J. J. Putnam, who
was present on this occasion, declared afterwards in America how much {332}
pleasure it had given him and expressed his respect for 'the mental
attitude' of those present, quoting some words I was said to have used
in reference to them, 'They have learnt to endure a bit of the truth.'
It is a fact that no one who had attended scientific congresses could
have failed to carry away a favourable impression of the
Psycho-Analytical Association. I myself had conducted the first two
Congresses and I had allowed every speaker time for his paper and left
discussions to take place in private afterwards among the
members. Jung, as President, took over the direction at Weimar and
instituted the practice of discussing each paper at the time, which,
however, gave rise to no difficulties on that occasion.
A very different picture was presented by the fourth Congress in Munich
two years later in September, 1913; it is still clear in the memory of
all who were present. It was conducted in a disagreeable and incorrect
manner by Jung; the speakers were greatly restricted in time and the
discussions overwhelmed the papers. By a stroke of malice on the part of
chance it happened that that evil genius, Hoche, had settled in the very
house in which the meetings were held. Hoche might easily have convinced
himself how ridiculous his notion was of the adherents of
psycho-analysis as a fanatical sect blindly submissive to their leader.
The fatiguing and unedifying proceedings ended in the re-election of
Jung to the Presidency of the International Psycho-Analytical
Association, which he accepted, although two-fifths of those present
refused their support. We dispersed without any desire to meet again.
About the time of this third Congress the position of the
International Psycho-Analytical Association was as follows. The branch
societies in Vienna, Berlin and Zurich had been formed at the Congress {333}
in Nuremberg as early as 1910. In May, 1911, a branch at Munich under
the chairmanship of Dr. L. Seif was incorporated. In the same year the
first American branch society was formed under the chairmanship of
A. A. Brill, with the name 'The New York Psycho-Analytic Society'. At
the Congress in Weimar the foundation of a second American Society was
sanctioned; it came into existence during the following year under the
name of 'The American Psycho-Analytic Association', and included
members in Canada and the whole of America; Putnam was elected
President and Ernest Jones secretary. Shortly before the Congress in
Munich in 1913, the Budapest branch society was formed under the
chairmanship of S. Ferenczi. Soon after this the first English group
was formed by Ernest Jones, who had returned to London. The membership
of these branch societies, of which there were now eight, naturally
gives no measure of the number of unorganized students and adherents
of psycho-analysis.
The development of the periodicals devoted to psycho-analysis also
deserves mention. The first of these was a series of monographs
entitled _Schriften zur angewandten Seelenkunde_ which have appeared
irregularly since 1907 and now number fifteen volumes. (The publisher
was at first H. Heller in Vienna and later F. Deuticke.) They comprise
works by Freud (1 and 7), Riklin, Jung, Abraham (4 and 11), Rank (5
and 13), Sadger, Pfister, M. Graf, Jones (10 and 14), Storfer and
v. Hug-Hellmuth. When the journal _Imago_, which will be referred to
later, was founded this form of publication ceased to have quite the
same value. After the meeting in Salzburg in 1908, the _Jahrbuch für
psychoanalytische und psychopathologische Forschungen_ was founded,
which appeared for five years under Jung's editorship and has now been {334}
re-issued, under new editorship and with a slight change in the title,
as the _Jahrbuch der Psychoanalyse_. It is no longer intended, as
formerly, as an archive for collecting valuable work on
psycho-analysis, but its editorial activity is aimed at recording all
work done and advances made in psycho-analysis during the year. The
_Zentralblatt für Psychoanalyse_, which was set on foot by Adler and
Stekel, as already stated, after the foundation of the International
Psycho-Analytical Association in Nuremberg, 1910, has in quite a short
time had a very unsettled career. As early as the tenth number of the
first volume an announcement appeared on the title-page that, on
account of scientific differences of opinion with the direction,
Dr. Alfred Adler had resolved to withdraw voluntarily from
editorship. After this Dr. Stekel remained the sole editor (summer of
1911). At the Congress in Weimar the _Zentralblatt_ was raised to the
position of official organ of the International Association and made
available to all members by increasing the annual subscription. From
the third number of the second year (winter, 1912) Stekel alone was
responsible for its contents. His behaviour, which is not easy to
describe, compelled me to resign the direction and hurriedly to
establish a new organ for psycho-analysis in the _Internationale
Zeitschrift für ärztliche Psychoanalyse_. The combined efforts of
almost all our workers and of H. Heller, the new publisher, resulted
in the appearance of the first number in January, 1913, whereupon it
took the place of the _Zentralblatt_ as official organ of the
International Psycho-Analytical Association.
Meanwhile, early in 1912 a new Journal _Imago_ (published by Heller),
designed exclusively for the application of psycho-analysis to the
mental sciences, was founded by Dr. Hanns Sachs and Dr. Otto {335}
Rank. _Imago_ is now in the middle of its third year and enjoys the
patronage of a continually increasing number of readers, many of whom
have no concern with medical psycho-analysis.
Apart from these four periodical publications (_Schriften zur
angewandten Seelenkunde_, _Jahrbuch_, _Zeitschrift_, and _Imago_) there
are other German and foreign journals publishing works which may claim a
place in the literature of psycho-analysis. _The Journal of Abnormal
Psychology_, directed by Morton Prince, usually contains so many good
analytic contributions that it may be regarded as the principal
representative of analytic literature in America. In the winter of 1913,
White and Jelliffe in New York started a new journal, probably in view
of the fact that most medical men in America who are interested in
analysis find the German language a great difficulty; it is called the
_Psycho-Analytic Review_ and is devoted exclusively to
psycho-analysis.[73]
------------------------------------------------------------------------
I now have to consider two secessions which have taken place among the
adherents of psycho-analysis; the first occurred between the founding
of the Association in 1910 and the Congress at Weimar in 1911; the
second took place after this and disclosed itself at Munich in
1913. The disappointment that they caused me might have been averted {336}
if I had considered more thoughtfully the reactions of patients
undergoing analytic treatment. I knew very well of course that anyone
may take to flight on a first approach to the unwelcome truths of
psycho-analysis; I had always myself asserted that everyone's
understanding will be limited by his own repressions (rather, by the
resistances which sustain them) so that he cannot go beyond a certain
point in his relation to analysis. But I had not expected that anyone
who had reached a certain depth in his comprehension of analysis could
discard it again, or ever lose it. And yet everyday experience with
patients had shown that total rejection of all analytical knowledge
may ensue whenever a strong resistance arises at any deep level in the
mind; one may have succeeded in laboriously bringing a patient to
grasp some parts of analytical knowledge and to handle them like
possessions of his own, and yet may see him, in the power of the very
next resistance, throw all he has learnt to the winds and defend
himself against it as in the first days of his treatment. I had to
learn that just the same thing can happen with psycho-analysts as with
patients under analysis.
It is no easy or enviable task to write the history of these two
defections, partly because I am devoid of any strong personal motive
to do so---I had not expected gratitude nor am I revengeful in any
active degree---and partly because I know that by so doing I lay
myself open to the contumely of not very scrupulous opponents and
offer to the enemies of analysis the spectacle they have so warmly
desired---of seeing the psycho-analysts tearing one another to bits. I
had to exercise so much restraint to keep myself from entering the
lists with opponents outside analysis; and now I see myself compelled
to take up arms against former followers of it or those who would {337}
still like to be called followers. I have no choice in the matter,
however; only convenience or cowardice could prompt one to keep
silence and this would do more harm than a frank revelation of the
existing evils. Anyone who has followed the growth of other scientific
movements will know that the same upheavals and dissensions have
commonly occurred in them too. It may be that with them they were
more carefully concealed; but psycho-analysis, which repudiates so
many conventional ideals, is more honest in these matters also.
Another very disagreeable circumstance is that I cannot altogether
avoid some analysis in explanation of these two opposition
movements. Analysis is not suited, however, to be used in controversy;
it presupposes the consent of the analysed; the situation of analysis
involves a superior and a subordinate. Anyone who presses analysis
into the service of polemics must therefore expect the person analysed
to use the weapon upon him in turn, so that the discussion will reach
a state which entirely excludes the possibility of convincing any
impartial third person. I shall therefore restrict my use of analytic
knowledge, and with it, of indiscreet and provocative statements, as
far as is possible; and in addition I will state that no criticism in
regard to scientific aspects are based on these grounds. I do not
propose to deal with the possible truth in the substance of the
theories rejected nor shall I attempt to refute them. This task is
left to other able workers in psycho-analysis and has already been
performed in part. I merely intend to show that these theories
controvert the fundamental principles of analysis (and on what points
they controvert them) and that for this reason they should not be
known under this name. So I shall only avail myself of analysis in {338}
order to explain how these departures from analysis could arise among
analysts. At the points of departure, it is true, I must defend the
just rights of psycho-analysis by purely critical remarks.
The first task confronting psycho-analysis was to explain the
neuroses; it took the two facts of resistance and transference as
starting-points, and, giving due weight to the third fact of amnesia,
accounts for them with its theories of repression, the sexual
propelling forces in neurosis and the unconscious. Psycho-analysis has
never claimed to provide a complete theory of human mentality as a
whole, but only expected that what it offered should be applied to
supplement and correct the knowledge acquired by other means. Now
Alfred Adler's theory goes far beyond this point; it seeks at one
stroke to explain the behaviour and character of human beings as well
as the neurotic and psychotic manifestations in them. It is actually
more suited to any other field than that of neurosis, although from
motives connected with the history of its development it still places
this in the foreground. For many years I had opportunities of
studying Dr. Adler and have never refused to recognize his unusual
ability, combined with a particularly speculative disposition. As an
instance of the 'persecution' that he maintains he has suffered at my
hands, I can point to the fact that after the Association was founded
I made over to him the leadership of the Vienna society. Not until
urgent demands were put forward by all the members of the society was
I induced to take the chair again at its scientific meetings. When I
had perceived how little gift Adler had in particular for appreciating
the importance of unconscious material my view changed to an
expectation that he would apply himself to the connections of {339}
psycho-analysis with psychology and to discovering the biological
foundations of instinctual processes; this idea was justified in a
certain sense by his valuable work on the inferiority of organs. He
did actually do something of the kind, but his work conveys an
impression _as if_---to speak in his own jargon---it intended to prove
that psycho-analysis was wrong in everything and that the sexual
propelling forces had only been given so much significance by
psycho-analysts in consequence of an undue credulity towards the
statements of neurotics. Of the personal motive of his work I may also
speak publicly, since he himself declared it in the presence of a
small circle of members of the Vienna Society. 'Do you think it is
much pleasure for me to stand all my life long in your shadow?' To be
sure, I see nothing reprehensible in a younger man freely admitting
the ambition which in any case one would surmise to be an incentive of
his work. But even though a man is dominated by a motive of this kind
he should know how to avoid being what the English, with their fine
social tact, call 'unfair'---a word which can only be expressed in
German by something much coarser. How little Adler was capable of this
is shown by the profusion of petty outbursts of malice which disfigure
his writings and by the indications they contain of an irrepressible
mania on the question of priority. At the Vienna Psycho-analytical
Society we once actually heard him claim priority in regard to the
'unity of the neuroses' and the 'dynamic conception' of neurosis. This
caused me great astonishment, since I had always believed I had voiced
these two principles before I had ever known Adler.
This craving of Adler's for a place in the sun has, however, had one
result which is bound to be beneficial to psycho-analysis. When, after {340}
irreconcilable scientific disagreements had come to light, I was
obliged to bring about Adler's resignation from the editorial staff of
the _Zentralblatt_, he left the Vienna society also and founded a new
one, which at first adopted the charming title of 'The Society for
Free Psycho-Analysis'. Unfortunately, however, the outside world
unconnected with analysis is clearly as incapable of appreciating the
differences between the views of two psycho-analysts as we Europeans
are of detecting shades of difference in the faces of two Chinamen.
'Free' psycho-analysis remained under the shadow of 'official',
'orthodox' psycho-analysis and was treated as an appendage of the
latter. Then Adler took a step for which we are thankful and severed
all connection with psycho-analysis, designating his theory
'Individual Psychology'. There is room enough on God's earth, and
anybody who can is fully entitled to cut any capers he likes on it
without interference; but it is not a good thing for people who no
longer understand one another and no longer agree together to remain
under the same roof together. Adler's 'Individual Psychology' is now
one of the many psychological movements adverse to psycho-analysis,
and its further development is no concern of ours.
The Adlerian theory was from the very beginning a 'system', which
psycho-analysis was careful to avoid becoming. It is also a remarkably
good example of 'secondary elaboration', such as occurs, for instance,
in the process which dream-material undergoes by the action of waking
thought. In Adler's case the place of dream-material is taken by the
new material obtained through psycho-analytic study; this is then
regarded exclusively from the standpoint of the ego, reduced to terms
with which the ego is familiar, translated, twisted, and misunderstood {341}
exactly as happens in dream-formation. Moreover, the Adlerian theory
is characterized less by what it asserts than by what it denies, so
that it consists of three elements of quite dissimilar value: the
useful contributions to the psychology of the ego, the superfluous but
admissible introduction of a new jargon to describe analytical facts,
and the distortions and perversions of these facts when they do not
comply with presuppositions in regard to the ego. The first element
has never been ginored by psycho-analysis, although it was not one
that demanded special attention; psycho-analysis was more concerned to
show that all the ego-trends contain libidinal components. The
Adlerian theory emphasizes the opposite view, the egoistic constituent
in all libidinal tendencies. This would have been an obvious gain if
Adler did not misuse this conclusion by throughout denying the
libidinal trends in favour of the egoistic component in them. His
theory does what all patients do and what our waking thought in
general does---namely, makes use of a _rationalization_, as Jones has
called it, in order to conceal unconscious motives. Adler carries his
theory to such lengths that he regards the ambition to mastery of the
woman, to being _above_, as positively the strongest motive in the
sexual act itself. I do not know if he has given vent to these
monstrous ideas in his writings.
Psycho-analysis recognized early that every neurotic symptom owes its
existence to a compromise. Every symptom must therefore in some way
comply with the demands of the ego which regulates repression, must
offer some advantage, admit of some profitable utilization, or it
would undergo the same fate as the original impulse itself which is
being kept in check. The expression 'advantage by illness' represents
this state of things; one is even justified in differentiating the {342}
'paranosic' gain to the ego, which is operative at the start, from an
'epinosic' aspect of it, which supervenes and relates to other
purposes of the ego, when the symptom is required to be permanently
maintained. It has also long been known that the withdrawal of this
advantage by illness, or a disappearance of it in consequence of some
change in external circumstances (reality), constitutes one of the
mechanisms of a cure of the symptom. In the Adlerian doctrine the main
emphasis falls on these easily verifiable and clearly intelligible
connections, while it is altogether overlooked that on innumerable
occasions the ego is merely making a virtue of necessity in
submitting, because of the use it can make of it, to the very
disagreeable symptom which is forced upon it---for instance, in
accepting anxiety as a means to security. The ego is here playing the
part of the clown in a circus who tries to convince the audience by
his gestures that every figure of the _manège_ is performed at his
command. But only the youngest among the spectators are deceived by
it.
The second constituent of the Adlerian theory psycho-analysis must
claim as its own. It is actually nothing else but psycho-analytic
knowledge, which the author extracted from all the sources open to him
during ten years of work in common and has now labelled as his own by
changing the terminology of it. 'Insurance' (_Sicherung_), for
instance, I myself consider a better word than 'protective measure'
(_Schutzmassregel_) which I employ, but I cannot find any difference
in their meaning. Again, a host of familiar features come to light in
Adler's propositions when one restores the original 'phantasized' and
'phantasy' in place of 'manufactured (_fingiert_), fictive, and
fiction'. This identity would be emphasized by psycho-analysis even if {343}
the author had not for many years taken part in our common work.
The third element in the Adlerian theory, the distortions and
misinterpretations put upon the disagreeable facts of analysis,
constitutes that which henceforth definitely separates 'Individual
Psychology' from psycho-analysis. As is known, the principle of
Adler's system is that the governing motive of self-preservation in
the individual, his 'will to power', expresses itself pre-eminently in
the form of a 'masculine protest' in the conduct of life, in
character-formation and in neurosis. This 'masculine protest', the
motive-force at work, according to Adler's theory, is however nothing
else but repression detached from its psychological mechanism and,
moreover, sexualized in addition---which accords very badly with his
vaunted ejection of sexuality from its place in mental life. The
'masculine protest' undoubtedly exists, but in making it the motor of
mental life one is treating the observed fact like a spring-board
which is left behind as one raises oneself from it. Let us consider
one of the fundamental situations in which desire is felt in infancy,
that of a child observing the sexual act between adults. When the
life-story of those persons who later come into the physician's hands
is subjected to analysis it is found that at that moment two currents
of feeling took possession of the immature spectator; in the case of a
boy, one is the impulse to put himself in the place of the active man,
and the other, the opposing feeling, is to identify himself with the
suffering woman. Between them these two impulses exhaust the
pleasurable possibilities of the situation. The first alone can come
under the head of the masculine protest, if this conception is to
retain any meaning at all. The second, however, the further course of {344}
which Adler either disregards or knows nothing about, is the one that
assumes greater significance in the neurosis later. Adler has so
merged himself in the jealous narrowness of the ego that he takes
account only of those tendencies that are agreeable to the ego and are
fostered by it; the situation of neurosis, in which these impulses
rise up against the ego, is the very one that lies outside his
horizon.
In the attempt---one which psycho-analysis has made necessary---to
correlate the fundamental principle of his theory with the mental life
of the child, Adler exhibits the most serious departures from actual
observation and the most fundamental confusion of concepts. The
biological, social and psychological meanings of 'masculine' and
'feminine' are here hopelessly mixed in an inextricable
combination. It is quite impossible to suppose---and demonstrably so
by observation---that the child---male or female---founds the plan of
its life on an original depreciation of the female sex and takes the
wish 'to be a real man' as its guiding principle. Children have, to
begin with, no idea of the significance of a difference between the
sexes; on the contrary, they start with the assumption that the same
genital organ (the male) belongs to both sexes; they do not begin
their enquiries into sexual problems with the question of sexual
differences, while the social underestimation of the female sex is
completely foreign to them. There are women in whose neurosis the
wish to be a man has played no part. Whatever of the masculine protest
can be shown to exist is easily traceable to a disturbance in the
primary narcissism due to threats of castration or to early
interference with sexual activities. All disputes about the
psychogenesis of the neuroses must eventually be decided on the field {345}
of the neuroses of childhood. Careful dissection of a neurosis in
early childhood puts an end to all misapprehensions about the ætiology
of the neuroses and to all doubts about the part played by the sexual
impulses in them. That is why, in his criticism of Jung's work
'Conflicts in the Mind of the Child',[74] Adler had to resort to the
imputation that the material of the case had been arranged in
conformity with some tendency, 'probably by the father'.
I will not dwell any longer on the biological aspect of the Adlerian
theory nor discuss whether either actual inferiority of organs or a
subjective feeling of it---one does not know which---is really capable
of carrying the weight of Adler's system. I will merely interpolate
the remark that if it were so neurosis would be a by-product of
general decrepitude, whereas observation shows that an impressive
majority of ugly, misshapen, helpless and miserable creatures fail to
react to their defects by neurosis. Nor will I deal with the very
interesting proposition by which inferiority is referred back to
feelings of childishness. It shows the disguise in which the factor of
infantilism, so strongly emphasized by psycho-analysis, recurs in
'Individual Psychology'. On the other hand, I must point out how all
the psychological acquisitions of psycho-analysis have been thrown to
the winds by Adler. In his book _Der nervöse Charakter_ the
unconscious is still mentioned as a psychological peculiarity, without
however, any relation to the system. Later on he quite logically
declared that it was a matter of indifference to him whether an idea
was conscious or unconscious. Adler never from the beginning evinced
any understanding of repression. In abstracting a paper read at the {346}
Vienna Society (February, 1911) he writes: 'On the evidence of a case
it must be pointed out that the patient had never repressed his
libido, against which he was continually securing himself.'[75] Soon
after, in a discussion at the Vienna Society, he said: 'If you ask
where repression comes from, you are told "From civilization"; and if
you ask where civilization comes from, you are told "From
repression". You can see therefore it is nothing but playing with
words.' A tithe of the acuteness and ingenuity with which Adler has
unmasked the defensive devices of the 'nervous character' would have
sufficed to show him the way out of this pettifogging kind of
reasoning. What it means is simply that civilization is based upon the
repressions effected by former generations, and that each fresh
generation is required to maintain this civilization by effectuating
the same repressions. I once heard of a child that thought people were
laughing at it, and began to cry, because when it asked 'Where do eggs
come from?' they told it 'From hens', and then when it went on to
enquire where hens came from, they said 'From eggs'. But they were not
playing with words; on the contrary, they were telling it the truth.
Equally empty and unproductive is all that Adler has to offer about
dreams, the shibboleth of psycho-analysis. First he regarded dreams as
a turning from the masculine to the feminine side, which is simply a
translation of the wish-fulfilment theory of dreams into terms of the
'masculine protest'. Later on he found that the essence of dreams lies
in enabling man to realize unconsciously things that consciously he
has to go without. Adler must also be credited with priority in
confounding the dream itself with the latent dream-thoughts, which {347}
leads to the discovery of a 'prospective tendency' in them; Maeder
followed his lead in this later. In this he overlooks only too readily
that every interpretation of a dream that is on the surface entirely
incomprehensible is based on the very method of dream-interpretation
the assumptions and conclusions of which he disputes. In regard to
resistance, Adler informs us that it serves the purposes of the
patient's opposition to the physician. This is certainly true; it is
as much as to say that it serves the purposes of the resistance. Where
it comes from, however, or how it happens that its manifestations are
at the disposal of the patient in this way is not enquired into, being
a point of no interest to the ego. The detailed mechanism of symptoms
and the manifestations of disease, the foundations of the manifold
variety of diseases and their forms of expression, are disregarded _in
toto_; for everything is pressed equally into the service of the
masculine protest, self-assertion and the aggrandizement of
personality. The system is complete; to produce it an enormous amount
of labour in shuffling interpretations has been expended, while it has
not furnished a single new observation. I imagine I have made it clear
that it has nothing to do with psycho-analysis.
The view of life which is reflected in the Adlerian system is founded
exclusively on the aggressive impulse; there is no room in it for love.
It might surprise one that such a cheerless view of life should meet
with any attention at all; but we must not forget that, weighed down by
the burden of its sexual desires, humanity is ready to accept anything
when tempted with 'ascendancy over sexuality' as a bait.
Adler's defection took place before the Congress at Weimar in 1911;
after this date the Swiss began theirs. The first signs of it, {348}
curiously enough, were some remarks of Riklin's in popular articles in
Swiss publications, by which the general public learned earlier than
the closest colleagues in the work that psycho-analysis had got the
better of some regrettable errors which had previously discredited
it. In 1912 Jung boasted, in a letter from America, that his
modifications of psycho-analysis had overcome the resistances of many
people who had hitherto refused to have anything to do with it. I
replied that that was nothing to boast of; the more he sacrificed of
the hard-won truths of psycho-analysis the quicker would he see
resistances vanishing. This modification which the Swiss were so proud
of introducing was again nothing else but a theoretical suppression of
the sexual factor. I confess that from the beginning I regarded this
'advance' as too far-reaching an adjustment to the demands of reality.
These two reactionary movements veering away from psycho-analysis,
which I must now compare with each other, show another point in
common, in that they both court popular favour by means of certain
lofty ideas, as if they were _sub specie æternitatis_. With Adler, the
relativity of all knowledge and the right of the personality
artificially to construe the substance of knowledge in an individual
manner plays this part; by Jung the appeal is made to the age-old
right of youth to throw off the fetters in which tyrannical age with
its hidebound views would bind it. A few remarks must be devoted to
exposing the fallacy of these ideas. The relativity of our knowledge
is a consideration which may be used against every other science just
as well as against psycho-analysis. Its use is prompted by well-known
reactionary currents of present-day feeling, which are hostile to
science, and it sets up an appearance of superiority to which no one {349}
is entitled. No one among us can guess what the ultimate judgement of
mankind about our tentative theories will be. There are instances in
which rejection by the next three generations has been corrected by
the succeeding one and changed into recognition. After he has listened
carefully to the voice of criticism in himself and has paid some
attention to the criticisms of his opponents, there is nothing for the
individual worker to do but to stand fast for his own convictions
which are based on experience. One must be content to behave honestly
in this matter, not assuming the office of judge which is one reserved
to the remote future. It is going very far wrong to stress the
question of personal and arbitrary views in a scientific matter; it is
clearly an attempt to rob psycho-analysis of its position as a
science, after it has indeed already been depreciated by the previous
consideration. Anyone who values highly the scientific mode of thought
will rather seek all possible means and methods of circumscribing the
influence of the personal arbitrary factor wherever it plays too great
a part. It must be borne in mind, too, that all eagerness to defend is
out of place. These arguments of Adler's are not intended seriously;
they are intended only for use against opponents; when confronted with
his own theories they keep at a respectful distance. Nor have they
hindered his own followers from hailing him as the Messiah for whose
appearance expectant humanity has been prepared by any number of
forerunners. The Messiah is certainly no longer a relative phenomenon.
Jung's _ad captandam benevolentiam_ argument rests on the unduly
optimistic assumption that the progress of the human race, of culture
and knowledge, has unrolled itself in an unbroken line; as if there
had been no epigones, reactions and restorations after every {350}
revolution, no generations who have taken a backward step and foregone
the gains of their forefathers. Its approximation to the demands of
the multitude, its abandonment of an innovation which proved
unwelcome, makes it improbable from the start that Jung's revised
version of psycho-analysis can justly claim to be a liberation for
youth. In the last resort it is not the years of the doer that
determine this but the character of the deed.
Of the two movements under discussion Adler's is indubitably the more
significant; while radically false, it is marked by consistence and
coherence. It is, moreover, in spite of all, founded upon a theory of
the instincts. Jung's modification, on the other hand, disconnects the
phenomena from their relation with impulse-life; and further, as its
critics (Abraham, Ferenczi, Jones) have pointed out, it is so
unintelligible, obscure, and confused that it is difficult to take up
any standpoint in regard to it. Wherever one lays hold of anything, one
must be prepared to hear that one has misunderstood it, and it is
impossible to know how to arrive at a correct understanding of it. It is
put forward too in a peculiarly vacillating manner, one moment as 'quite
a minor deviation which does not justify the fuss that has been made
about it' (Jung), and the next as a new message of salvation which is to
begin a new epoch in psycho-analysis, in fact, reveal a new aspect of
the universe for everything else.
When one thinks of the disagreement displayed in the various public
and private expressions of Jung's views, one is bound to ask oneself
how much of this is due to his own lack of clearness and how much to
lack of sincerity. It must be admitted, however, that the exponents of
the new doctrine find themselves in a difficult position. They are now {351}
disputing things which formerly they themselves upheld, and not,
moreover, on the ground of fresh observations by which they might have
been taught something further, but in consequence of different
interpretations of the same observations which make the things they
see look different to them now from what they did before. For this
reason they are unwilling to give up their connection with
psycho-analysis, through which they became known to the world, and
prefer to proclaim that psycho-analysis has changed. At the Congress
in Munich I saw that I must clear up this confusion, and did so by
declaring that I did not admit the innovations of the Swiss to be
legitimate continuations and further developments of the
psycho-analysis that originated with me. Outside critics (like
Furtmüller) had already before this perceived the state of things, and
Abraham truly says that Jung is in full retreat from
psycho-analysis. I am naturally perfectly ready to allow that anyone
has a right to think and to write what he likes; but he has no right
to put it forward as something which it really is not.
Just as Adler's investigation brought something new to
psycho-analysis---a contribution to the psychology of the ego---and
then tried to recoup itself all too dearly for this liberality by
throwing over all the fundamental analytic doctrines, so in the same
way a new contribution formed the base of operations in the campaign
started by Jung and his followers against psycho-analysis. They traced
in detail (as Pfister did before them) the way in which the material
of sexual ideas belonging to the family-complexes and the incestuous
object-choice is made use of in representing the highest ethical and
religious interests of man---that is, they have explained an important {352}
instance of sublimation of the erotic instinctual forces and of their
transformation into trends which can no longer be called erotic. This
was in complete harmony with all the expectations of psycho-analysis,
and would have agreed very well with the view that in dreams and
neurosis a regressive dissolution of this, as of all other
sublimations, becomes visible. But unfortunately, the world would have
risen in indignation and protested that they were sexualizing ethics
and religion! Now I cannot refrain from thinking teleologically for
once and concluding that these discoverers were not equal to meeting
the storm of righteous wrath they saw ahead. Perhaps it even began to
rage in their own bosoms. The importance of theological tradition in
the former history of so many Swiss is no less significant for their
attitude to psycho-analysis than is the socialistic element in that of
Adler for the line of development taken by his psychology. One is
reminded of Mark Twain's famous story of the vicissitudes his watch
underwent and of the remark with which he ends it: 'And he used to
wonder what became of all the unsuccessful tinkers, and gunsmiths, and
shoemakers, and blacksmiths; but nobody could ever tell him.'
I will now digress into the region of parables: Suppose that in a
certain district there lived an upstart who boasted of ancient descent
from a noble family living far off. It was proved to him, however,
that his parents lived somewhere in the neighbourhood and were quite
simple people. There was only one way out of the difficulty and he
seized upon it. He could not any longer repudiate his parentage, so he
asserted that they themselves were of an ancient noble strain, but
that their fortunes had declined; and he proceeded to procure from
some obliging office a document showing their descent. I think the
Swiss must have behaved in much the same way. If ethics and religion {353}
must not be sexualized, but had been something 'higher' from the
start, and yet the descent of the ideas they contain from the family
and Œdipus complex appeared undeniable, there could be only one thing
to do---these complexes themselves could not from the beginning have
had the significance that they seemed to express, but instead must
have that higher 'anagogic' meaning (as Silberer terms it) which
adapts them for incorporation into the abstract trains of thought of
ethics and religious mysticism.
I am quite resigned to being told again that I have misunderstood the
substance and tendency of the New-Zurich doctrines; but I must protest
from the start against this contradiction of my interpretation of
these doctrines (which is formed from the publications of this school)
being laid to my door, instead of theirs. In no other way can I make
intelligible to myself the whole range of Jung's innovations and grasp
all its implications. All the changes that Jung has wrought in
psycho-analysis flow from the ambition to eliminate all that is
disagreeable in the family complexes, so that it may not evidence
itself again in ethics and religion. For sexual libido an abstract
term has been substituted, of which one may safely say that it remains
mystifying and incomprehensible to fools and wise alike. The Œdipus
complex was intended merely as something 'symbolic'; the mother in it
means the unattainable, which one must renounce in the interests of
civilization; the father who is killed in the Œdipus myth is the
'inner' father, from whom one must become free in order to be
independent. Other details of the material of sexual ideas will
undoubtedly undergo similar reinterpretation in the course of time. In
the place of a conflict between erotic trends obnoxious to the ego and {354}
the self-maintenance tendency of the ego there appears the conflict
between the life-task and 'psychic inertia'; the neurotic's sense of
guilt corresponds to the reproach of not properly fulfilling his
'life-task'. Thus a new religious-ethical system was created, which,
just like the Adlerian system, must necessarily lead to new
interpretations of the actual results of analysis, or else distort or
ignore them. In truth this signifies but that a few of Culture's
harmonics in the symphony of life have sounded again, while the
dæmonic forces of the instinct-melody have once more passed unheard.
In order to preserve this 'system' intact it was necessary to turn
entirely away from observations and from the technique of
psycho-analysis. Occasionally enthusiasm for the sacred cause even
required a disregard for scientific logic, as when Jung finds the
Œdipus complex not 'specific' enough for the causation of neurosis and
attributes a specific character to 'inertia', the most universal
characteristic of all matter, animate or inanimate! It is to be noted,
by the way, that the 'Œdipus complex' represents only the content of
the strivings of mental forces in the individual, and is not in itself
a force, like 'psychic inertia'. The study of any individual human
being has shown and always will show that the sexual complexes in
their original sense are active in him. For this reason the
investigation of individuals has been neglected and replaced by
conclusions arrived at from points arising from study of the race. In
the early childhood of every human being there is the greatest risk of
coming upon the original, undisguised meaning of these misinterpreted
complexes; consequently in therapy the precaution of dwelling as
little as possible on this past history has been developed, and the {355}
main emphasis is laid on reverting to the current conflict, in which,
moreover, not the individual, personal element is the essential thing,
but a general feature---'non-fulfilment of the life-task'. We know,
however, that the current conflict of a neurotic becomes
comprehensible and admits of solution only when it is referred back to
the patient's previous history, when one goes back along the path that
his libido took in his illness.
How the New-Zurich therapy shapes itself in accordance with these
tendencies can best be conveyed in the words of a patient who had to
experience it in his own person: 'This time not an atom of
consideration was expended on the past or on transference. Wherever I
believed I recognized the latter it was explained as a pure
libido-symbol. The moral teaching was very fine and I followed it
faithfully, but I did not advance a step. It was more annoying for me
than for him, but how could I help it? ... Instead of freedom through
analysis, every day brought fresh terrific demands on me, which had to
be fulfilled if the neurosis were to be conquered---for instance,
inward concentration by means of introversion, religious meditation,
resuming life with my wife in loving devotion, etc. It was almost
beyond one's strength; it went beyond a radical transformation of
one's whole inner nature. I left the analysis as a poor sinner with
intense feelings of contrition and the best resolutions, but at the
same time in utter discouragement. Any clergyman would have advised
what he recommended, but where was I to find the strength?' The
patient did in fact mention that he had heard that analysis of the
past and of transference must be gone through first. He was told that
he had already had enough of that. Since it had not helped him
sufficiently, the conclusion seems justified that the patient had _not {356}
had enough_ of the first kind of analysis. Certainly the subsequent
treatment, which no longer has any claim to be called psycho-analysis,
did not improve matters. It is remarkable that the men of Zurich
should have taken the long road round by Vienna in order to arrive at
last at Berne which is so near, where Dubois cures neuroses by ethical
encouragement in a less painful manner.[76]
The total incompatibility of this new movement with psycho-analysis also
of course shows itself, first, in the treatment of repression, which is
hardly mentioned nowadays in Jung's writings; again in the
misapprehension in regard to dreams, which, in complete disregard of
dream-psychology, like Adler, he confounds with the latent
dream-thoughts; and in a loss of all understanding of the
unconscious---in short, in all the essential points I should choose as
characteristic of psycho-analysis. When Jung tells us that the
incest-complex is merely 'symbolic', that it has no 'real' existence,
that a savage feels no desire towards an old gammer but prefers a young
and pretty woman, one is tempted to conclude that 'symbolic' and
'without real existence' simply mean what, in virtue of its power of
expression and pathogenic effects, is described by psycho-analysis as
'existing unconsciously'---a description that disposes of the apparent
contradictions.
When one remembers that the dream itself is something different from
the latent dream-thoughts which it elaborates, something more, there {357}
is nothing surprising in patients dreaming of things with which their
minds have been filled during the treatment, whether it be the
'life-task', or 'being above or below'. The dreams of people being
analysed are undoubtedly open to influence, in the same way as by
stimuli produced for experimental purposes. One can determine a part
of the material which appears in a dream; nothing in the essence or
mechanism of dreams is altered by this. Nor do I believe that
'biographical' dreams, as they are called, occur outside analysis. If
one analyses dreams which occurred before treatment, or if one
considers the dreamer's own additions to what has been suggested to
him in the cure, or if one avoids giving him any such instructions,
then one may convince oneself how far removed it is from the purpose
of a dream to produce attempted solutions of the life-task. Dreams are
nothing but a form of thinking; one can never understand this form by
reference to the content of the thoughts; only an appreciation of the
work of dream-making will lead to it.
It is not difficult to find an effective refutation of Jung's
misconceptions of psycho-analysis and deviations from it. Every
analysis conducted in a proper manner, and in particular any analysis
of a child, strengthens the convictions upon which the theory of
psycho-analysis is founded, and shows the fallacy of the
misinterpretations in both Jung's and Adler's systems. In the days
before he became so enlightened Jung himself carried out and published
such an analysis of a child; it remains to be seen whether he will
undertake a new interpretation of its results with the help of a
different 'uniform trend of the facts', to use an expression that
Adler employs in this connection. {358}
The view that the sexual representation of 'higher' thoughts in dreams
and neurosis is nothing but an archaic mode of expression is naturally
irreconcilable with the fact that in neurosis these sexual complexes
prove to be the channels of such quantities of libido as are withdrawn
from utilization in real life. If they were nothing more than a jargon
of sexual terms, the distribution of the libido could not have been
affected in any way through them. Jung still admits this himself in his
_Darstellung der psychoanalytischen Theorie_ and formulates the task of
therapy as detachment of these complexes from their libido-cathexis.
This can never be achieved, however, by turning one's back upon them and
urging the patient to sublimate, but only by exhaustive examination of
them, so that they may be made fully and completely conscious. The first
piece of reality which the patient must deal with is his illness.
Efforts to spare him this task point to the physician's incapacity to
help him to overcome the resistances, or else to the physician's dread
of the results of his own work.
In conclusion I will say that by his 'modification' of psycho-analysis
Jung has given us a counterpart to Lichtenberg's famous knife. He has
changed the hilt and put a new blade into it; because the same name is
scratched on it we are to regard this instrument as the former one.
I think I have made clear, on the contrary, that the new teaching
which aims at replacing psycho-analysis signifies abandonment of
analysis and defection from it. Some may perhaps be inclined to fear
that this defection must have more serious consequences for analysis
than if it had originated with persons who had been less closely
connected with the movement and had done less to advance it. I do not
share this apprehension. {359}
Men are strong as long as they represent a strong idea; they become
powerless when they oppose it. Psycho-Analysis will survive this loss
and gain new adherents in place of these others. I can only conclude
with the wish that fate may grant an untroubled ascension to all who
have been discommoded by their sojourn in the underworld of
psycho-analysis. May it be vouchsafed to the others to carry their
work in the depths peacefully to an end.
February, 1914.
------------------------------------------------------------------------
NOTES
[1]: First published in the _Wiener Medizinische Wochenschrift_, 1893,
No. 37. [Translated by J. Bernays.]
[2]: First published in the _Neurologisches Zentralblatt_, 1893,
Nos. 1 and 2. [Translated by John Rickman.]
[3]: Delbœuf and Binet have clearly recognised the possibility of such
a therapy, as the following quotations show. Delbœuf: _Le
Magnétisme animal_, Paris, 1889: 'Since then it has been possible
to understand how the magnetist helps in bringing about
recovery. He restores the patient to the condition in which the
illness established itself and then with his words he attacks the
illness, now _in statu nascendi_.' --- Binet: _Les Altérations de
la personnalité_, 1892, p. 243: '... Perhaps we shall see that by
bringing back the patient by a mental device to the moment when
the symptom appeared for the first time we make him more
susceptible to suggestive therapy'.---In P. Janet's interesting
book _L'Automatisme psychologique_, Paris, 1889, there is a
description of a cure obtained in an hysterical girl by the
employment of a method analogous to ours.
[4]: In the text it is not possible to separate what is new in the
content of this provisional communication from what is also to be
found in other authors, e.g. Möbius and Strümpell, who have put
forward similar views on hysteria. The nearest approach to our
theoretical and therapeutic deductions is found in a few recently
published remarks of Benedikt's which we propose to consider
elsewhere.
[5]: [There is no satisfactory translation of this highly expressive
German word, which is obviously allied to _krank_ = ill.---Ed.]
[6]: [This is the first occasion on which this term was used. Later it
became the author's technical term for the _unconscious_ process
by which thoughts are excluded from consciousness.---Ed.]
[7]: First published in _Archives de Neurologie_, No. 77, 1893.
[Translated by M. Meyer.]
[8]: I will state by the way that that important feature of hysterical
paralyses of the leg emphasized by Charcot, following
Todd---namely, that an hysteric drags his leg like a dead mass
instead of performing the circumduction of the hip commonly
carried out in hemiplegia---is easily explained by a
characteristic of the neurosis already mentioned. In organic
hemiplegia, the proximal part of the extremity is always more or
less intact; the patient can move the hip and uses it to perform
the circumduction movement that carries the leg forward. In
hysteria, the proximal part (the hip) does not enjoy that
privilege; the paralysis is as complete as in the distal part,
and as a result the leg must be dragged _en masse_.
[9]: See No. II of this volume, above, p. 24.
[10]: First published in the _Neurologisches Zentralblatt_, 1894, Nos.
10 and 11. [Translated by John Rickman.]
[11]: _Etat mental des hystériques_, Paris, 1893 and 1894. ---
Quelques définitions récentes de l'hystérie, _Archives de
Neurologie_, 1893, XXXV---XXXVI.
[12]: See No. II of this volume, above, p. 24.
[13]: See No. II of this volume, above, p. 24.
[14]: These examples are more fully described in _Studien über
Hysterie_, Breuer and Freud. 1895.
[15]: Oppenheim: Hysteria is an intensified expression of emotion. The
'expression of emotion', however, represents that quantity of
the psychical excitation which normally undergoes conversion.
[16]: Strümpell: In hysteria the disturbance lies in the
psycho-physical sphere, where body and mind have their
connection with each other.
[17]: In the second edition of his ingenious paper, '_Quelques
definitions, etc._', Janet has himself dealt with the objection
that splitting of consciousness occurs also in the psychoses and
in psychasthenia, so-called, but in my judgement he has not
solved the difficulty satisfactorily. It is essentially this
objection that has forced him to regard hysteria as a form of
degeneration. He cannot, however, adequately distinguish the
hysterical splitting of consciousness from the psychotic and
other such forms by any characterization.
[18]: The group of typical phobias, of which agoraphobia is a model,
cannot be traced back to the psychical mechanism mentioned
above; on the contrary, the mechanism of agoraphobia differs
from that of true obsessions, and of the phobias derived from
them, in _one_ decisive particular---there is here no repressed
idea from which the affect of anxiety would be detached. The
anxiety of these phobias has another origin.
[19]: See No. II of this volume, above, p. 24.
[20]: First published in the _Neurologisches Zentralblatt_, 1895, Nr.
2. [Translated by John Rickman.]
[21]: E. Hecker: Über larvierte und abortive Angstzustände bei
Neurasthenie. _Zentralblatt für Nervenheilkunde_,
Dec. 1893. Morbid anxiety is actually quoted as one of the
principal symptoms of neurasthenia in a paper by Kaan: Der
neurasthenische Angstaffekt bei Zwangsvorstellungen und der
primordiale Grübelzwang. Wien, 1893.
[22]: See No. IV of this volume, above, p. 59.
[23]: See No. VII of this volume, p. 128.
[24]: Möbius: _Neuropathologische Beiträge_, Heft 2, 1894.
[25]: Peyer: Die nervösen Affektionen des Darmes. _Wiener Klinik_,
January, 1893.
[26]: See No. IV of this volume, above, p. 59.
[27]: [This term is here used in its original sense of conscious
sexual feeling; it was only later employed by the author as a
technical term in his theory of mental dynamics.---Ed.]
[28]: First published in the _Wiener Klinische Rundschau_, 1895.
[Translated by John Rickman.]
[29]: See No. V of this volume, above, p. 76.
[30]: E. Hecker: Über larvierte und abortive Angstzustände bei
Neurasthenie, _Zentralblatt für Nervenheilkunde_, Dec., 1893.
[31]: First published in the _Revue Neurologique_, 1895, t. III.
[Translated by M. Meyer.]
[32]: I am very glad to find that the authors of the most recent work
on this subject express opinions very similar to
mine. Cf. Gélineau, _Des peurs maladives ou phobies_, 1894, and
Hack Tuke, On Imperative Ideas, _Brain_, 1894.
[33]: Cf. the popular German song:
Auf jedes weiße Blatt Papier möcht' ich es schreiben:
Dein ist mein Herz und soll es ewig, ewig bleiben.
[34]: See. No. II of this volume, p. 24.
[35]: See No. V of this volume, p. 76.
[36]: First published in the _Revue Neurologique_, 1896, t. IV
[Translated by M. Meyer.]
[37]: See No. V of this volume, above, p. 76.
[38]: For the symptomatology and ætiology of the anxiety-neurosis see
my paper cited above, No. V of this volume, p. 76.
[39]: [The first use of this term by the author to designate his
technique.---Ed.]
[40]: See J. Breuer and Sigmund Freud. _Studien über Hysterie_. 1895.
[41]: First published in the _Neurologisches Zentralblatt_, Oct.,
1896, No. 10. [Translated by John Rickman.]
[42]: See No. IV of this volume, above, p. 59.
[43]: I myself am inclined to think that the tales of outrage which
hysterics so frequently relate may be obsessive fictions which
arise in the memory-trace of the trauma that occurred in
childhood.
[44]: In a paper on the Anxiety-Neurosis (see No. V of this volume,
p. 87) I mentioned that 'anxiety-neurosis can be evoked in
maturing girls by their first meeting with the sexual problem;
in these cases it is typically combined with hysteria'. I now
know that the occasion on which such 'virginal anxiety' breaks
out in young girls does not indeed represent their _first_
encounter with sexuality; but that an experience of a sexually
passive nature had previously occurred in their childhood, the
memory of which is awakened by the 'first encounter'.
[45]: A psychological theory of repression should also throw light on
the question why it is only ideas with a sexual content that can
be repressed. The following hints may assist us: The formation
of ideas with a sexual content produces, as is well-known,
excitation-processes in the genital organs similar to sexual
experience itself. We may suppose that this somatic excitation
transposes itself into the psychical sphere. As a rule this kind
of effect is much stronger during actual experiences than during
the recollection of them. But if the sexual experience occurs at
a time of sexual immaturity and the memory of it is aroused
during or after maturity, then the exciting effect of the
recollection will be very much stronger than that of the
experience itself; because in the meantime puberty has increased
to an incomparable degree the capacity of the sexual apparatus
for response. An inverted relation of this kind between real
experience and memory appears to be the psychological condition
of repression. Through the delay in the maturing of the sexual
functions in comparison with that of the psychical functions,
sexual life affords a unique possibility for this inversion of
relative effectiveness. _The traumas of childhood act
subsequently as fresh experiences_---_then, however,
unconsciously_. I must postpone psychological discussions of
wider range until another time. Let me say, however, that the
period of 'sexual maturity' here referred to does not coincide
with puberty, but comes earlier (eighth to tenth year).
[46]: See No. V of this volume, above, p. 76.
[47]: Cf. _Studien über Hysterie_.
[48]: A subsequent exacerbation removed the success of the treatment,
which was in any case not very great, and at this later stage
she no longer saw the offensive images of strange genitals, but
had the idea that strangers saw _her_ genitals as soon as they
were _behind_ her.
_Subsequent note by the Author for this Translation_. 1922.
The fragmentary account of this analysis in the text above was
written while the patient was still undergoing treatment. Very
shortly after, her condition became so much more serious that
the treatment had to be broken off. She was transferred to an
institution and there went through a period of severe
hallucinations having all the signs of dementia præcox. [The
original footnote applies to this period.] Contrary to
expectation, however, she recovered and returned home, had
another child which was quite healthy, and was able for a long
period (12 to 15 years) to carry out all her duties in a
satisfactory manner. The only sign of her previous psychosis was
said to be that she avoided the company of all relatives,
whether of her own family or of her husband's. At the end of
this period, affected by very adverse changes in her
circumstances, she again became ill. Her husband had become
unable to work and the relatives she had avoided were obliged to
support the family. She was again sent to an institution and
died there soon after, of a pneumonia which rapidly supervened.
[49]: [The first use of this technical term.---Ed.]
[50]: First published in the _Wiener klinische Rundschau_, 1896,
Nr. 22 to 26. Amplification of a lecture delivered at the
Society of Psychiatry and Neurology in Vienna, May 2,
1896. [Translated by Cecil M. Baines.]
[51]: We purposely refrain from discussing what type of association
unites the two memories (whether their relation is temporal,
causal or that of similarity of content, etc.) and from asking
what psychological character (conscious or unconscious) is to be
attributed to these 'memories'.
[52]: _Wiener Medizinische Blätter_. 18. April 1896.
[53]: First published in the _Wiener klinische Rundschau_, 1898, Nos.
2, 4, 5, and 7. [Translated by J. Bernays.]
[54]: First published in the _Wiener Medizinische Presse_, 1905,
No. 1. Lecture delivered before the College of Physicians, in
Vienna, December 12, 1904. [Translated by J. Bernays.]
[55]: [I know that the physical Often influences the moral.]
[56]: From Löwenfeld: _Psychische Zwangserscheinungen_. 1904. [This
chapter was written at Dr. Löwenfeld's request as a part of the
section on psychotherapy in the latter's book.---Translated by
J. Bernays.]
[57]: First published in Löwenfeld's _Sexualleben und Nervenleiden_,
IV te Auflage, 1906. [Translated by J. Bernays.]
[58]: See No. V of this volume, p. 76.
[59]: See _Studien über Hysterie_, 1895.
[60]: See Nos. VIII and IX of this volume, pp. 138 and 155.
[61]: See No. IV of this volume, p. 59.
[62]: First published in the _Jahrbuch der Psychoanalyse_, Bd. VI.
1914. [Translated by Joan Riviere.]
[63]: _Über Psychoanalyse_. Fünf Vorlesungen. Dritte Auflage, 1916.
Appeared simultaneously in English in the _American Journal of
Psychology_, March, 1910; translated into Dutch, Hungarian,
Polish, Russian and Italian.
[64]: _Zentralblatt für Psychoanalyse_, Bd. I, S. 69.
[65]: Havelock Ellis: The Doctrines of the Freud School.
[66]: G. Greve: Sobre Psicologia y Psicoterapia de ciertos Estados
angustiosos. _Zentralblatt für Psychoanalyse_, Bd. I, S. 594.
[67]: The publications of both authors have appeared in a collected
form. A. A. Brill: _Psychoanalysis, its Theories and practical
Applications_, 1912. (Third edition, 1922; Saunders,
Philadelphia.) Ernest Jones: _Papers on Psycho-Analysis_,
1912. (Third edition, 1923; Baillière, Tindall & Cox, London.)
[68]: The first _official_ recognition of dream-interpretation and
psychoanalysis in Europe was extended to them by the
psychiatrist Jelgersma, Rector of the University of Leiden, in
his official address on February 9, 1914.
[69]: Rank: _Der Künstler_; analyses of poets by Sadger, Reik and
others; my little monograph _Eine Kindheitserinnerung des
Leonardo da Vinci_; Abraham's analysis of Segantini.
[70]: _Die psychoanalytische Methode_. 1913. Vol. I of Meumann and
Messmer's Pedagogium.
[71]: Adler und Furtmüller: _Heilen und Bilden_. 1913.
[72]: See my two articles, entitled _Das Interesse an der
Psychoanalyse_, in _Scientia_. XIV. 1913.
[73]: [Since this was written, in 1914, there have been further
changes, notably the founding of the Internationaler
Psychoanalytischer Verlag in Vienna, which took over publication
of the four official periodicals mentioned in the text, and the
founding of an English branch of it, The International
Psycho-Analytical Press, now in London. One of the objects for
which the latter was constituted was to publish the second
official organ of the International Psycho-Analytical
Association instituted for English-speaking countries in 1920,
with the title of _The International Journal of
Psycho-Analysis_, directed by Prof. Freud and edited by Ernest
Jones. Another object was the publication of the International
Psycho-Analytical Library, of which the present volume forms
No. 7.---Ed.]
[74]: _Zentralblatt für Psychoanalyse_, Bd. I, S. 122. See also
_Analytical Psychology_, by C. G. Jung. 1917. Chap. II.
(Translation.)
[75]: _Korrespondenzblatt_, Nr. 5. Zürich, April 1911.
[76]: I know the objections there are to making use of a patient's
statements, and I will therefore expressly state that my
informant is a trustworthy person, very well capable of forming
a judgement. He gave me this information quite voluntarily and
I make use of his communication without asking his consent,
because I cannot admit that a psycho-analytic technique should
claim the protection of secrecy.
------------------------------------------------------------------------
Transcriber’s Note
The following typos in the original text have been corrected.
p. 25
- accustomed to see egularly
+ accustomed to see regularly
p. 46
- remains to be dicovered
+ remains to be discovered
p. 76
- general paralysis of the insance
+ general paralysis of the insane
p. 120
- is not yet clearly eludicated
+ is not yet clearly elucidated
p. 177
- analysis of the voices In the first place
+ analysis of the voices. In the first place
p. 229
- I have conluded that such negative cases
+ I have concluded that such negative cases
p. 234
- attacks of dypsnœa
+ attacks of dyspnœa
p. 260
- I am quite conviced
+ I am quite convinced
p. 357
- Nor do I belive that
+ Nor do I believe that
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