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Title: Selected papers on hysteria and other psychoneuroses
Author: Sigmund Freud
Translator: A. A. Brill
Release date: January 17, 2025 [eBook #75132]
Language: English
Original publication: United States: The Journal of Nervous and Mental Disease Publishing Company, 1909
Credits: Richard Tonsing and the Online Distributed Proofreading Team at https://www.pgdp.net (This file was produced from images generously made available by The Internet Archive)
*** START OF THE PROJECT GUTENBERG EBOOK SELECTED PAPERS ON HYSTERIA AND OTHER PSYCHONEUROSES ***
SELECTED PAPERS ON HYSTERIA
AND
OTHER PSYCHONEUROSES
BY
PROF. SIGMUND FREUD
VIENNA
AUTHORIZED TRANSLATION
BY
A. A. BRILL, PH.D., M.D.
CHIEF OF NERVOUS DISPENSARY, BETH ISRAEL HOSPITAL; CLINICAL ASSISTANT,
DEPARTMENT OF PSYCHIATRY AND NEUROLOGY, COLUMBIA UNIVERSITY; ASSISTANT
IN MENTAL AND NERVOUS DISEASES, O. P. D., BELLEVUE HOSPITAL; ASSISTANT
VISITING PHYSICIAN, HOSPITAL FOR NERVOUS DISEASES.
NEW YORK
THE JOURNAL OF NERVOUS AND MENTAL DISEASE
PUBLISHING COMPANY
1909
Copyright 1909, by
THE JOURNAL OF NERVOUS AND MENTAL DISEASE PUBLISHING COMPANY.
CONTENTS.
PAGE.
TRANSLATOR’S PREFACE iii
CHAPTER.
I. THE PSYCHIC MECHANISM OF HYSTERICAL PHENOMENA 1
II. THE CASE OF MISS LUCY R. 14
III. THE CASE OF MISS ELISABETH V. R. 31
IV. THE PSYCHOTHERAPY OF HYSTERIA 75
V. THE DEFENSE NEURO-PSYCHOSES. A Tentative Psychological
Theory of Acquired Hysteria, many Phobias and Obsessions,
and Certain Hallucinatory Psychoses 121
VI. ON THE RIGHT TO SEPARATE FROM NEURASTHENIA A DEFINITE
SYMPTOM-COMPLEX AS “ANXIETY NEUROSIS” 133
VII. FURTHER OBSERVATIONS ON THE DEFENSE NEUROPSYCHOSES 155
VIII. ON PSYCHOTHERAPY 175
IX. MY VIEWS ON THE RÔLE OF SEXUALITY IN THE ETIOLOGY OF THE
NEUROSES 186
X. HYSTERICAL FANCIES AND THEIR RELATIONS TO BISEXUALITY 194
TRANSLATOR’S PREFACE.
In the first place I wish to express my gratitude to Doctors Frederick
Peterson, William A. White, and Ernest Jones, for their many helpful
suggestions in the translation of this work. This does not, however,
imply that they are in any way responsible for the numerous barbarisms
found in the translation, for this I, alone, ask the reader’s
indulgence. For one thing, it must be borne in mind that, aside from the
subject-matter, Freud is not easy to read, even in the original. Indeed,
I feel quite certain that only those who have read the original will
best appreciate the task of the translator. But no matter how devoid of
literary excellencies this translation may be, it can at least claim one
merit, to wit, it is a faithful reproduction of the author’s thoughts.
This is really all that should be required of a translation.
The chapters contained in this book were taken from three different
volumes of the author’s works, published at different intervals within
the last fifteen years. Although the first four chapters appear in the
“Studien über Hysterie” which was published by Breuer and Freud,[1]
still only the first chapter, “The Psychic Mechanism of Hysterical
Phenomena,” was written conjointly by both authors. The authorship of
the other three chapters belongs exclusively to Freud. The remaining six
chapters of the book were taken from Freud’s Collection of Small
Articles.[2]
It was by no means an easy task to compile in a single limited volume
Freud’s theories of the actual- and psychoneuroses. Freud’s views are
not only new and revolutionary, being based on an entirely new
psychology, but unless one is thoroughly familiar with their development
one is apt to misunderstand them. To obviate this it was thought best to
collect those chapters from the author’s works which fully illustrate
his theories and at the same time show the gradual evolution of his
psychology.
That Freud’s views have undergone some changes, or rather modifications,
within the last fifteen years we readily admit; but who will blame the
surgeon for modifying or rejecting some technique of his operation, if
after years of careful work he feels justified in so doing? Surely such
an action merits applause rather than reproach. It was only after
carefully investigating for years that Freud saw fit to change some of
his views, yet nothing was really totally discarded.
It is quite unnecessary to discuss here the whys and wherefores of the
modifications in question, these are fully explained in the text. But it
will not be mal à propos to say a few words concerning the technique of
the treatment.
For reasons given in the book the author has abandoned hypnotism and
used the pressure procedure, but this in turn was given up because it
was cumbersome for both doctor and patient and proved to be utterly
needless.
The technique is as follows: The patient lies on his back on a lounge,
the physician sitting behind the patient’s head at the head of the
lounge. In this way the patient remains free from all external
influences and impressions. The object is to avoid all muscular exertion
and distraction, thus allowing thorough concentration of attention on
the patient’s own psychic activities. The patient is then asked to give
a detailed account of his troubles, after having been told before to
repeat everything that occurs to his mind, even such thoughts as may
cause him embarrassment or mortification. On listening to such a history
one invariably notices many memory gaps, both in reference to time and
causal relations. These the patient is urged to fill in by concentration
of attention on the subject in question, and by repeating all the
unintentional thoughts originating in this connection. This is the so
called method of “free association!” The patient is required to relate
all his thoughts in the order of their sequence even if they seem
irrelevant to him. He must do away with all critique and remain
perfectly passive. It is in this way that we fathom the original meaning
of the symptom. But as the thoughts which originate in this manner are
of a disagreeable and painful nature they are pushed back with the
greatest resistance. This is further enhanced by the fact that the
hysterical symptom is the symbolic expression of the realization of a
repressed wish, and serves as a gratification for the patient. He
strives very hard, unconsciously of course, to retain the symptom, as it
is the only thing left to him from his former unattainable conscious
wishes and strivings. The object of the psychanalytic treatment is to
overcome all these resistances, and to reconduct to the patient’s
consciousness the thoughts underlying the symptoms. Here lies the
greatest difficulty, for just as in the normal life and the dream, a
psychoneurotic symptom is merely a symbolic or cryptic expression of the
original repressed thoughts. Every hysterical symptom, every obsession,
and every phobia, has a definite meaning, and as was shown by
Bleuler,[3] Jung,[4] Riklin,[5] and others,[6] the same holds true for
the psychoses proper.
To discover the hidden mechanism, one must make use of the author’s
developed method of interpretation, that is, one must look for
symbolic actions, lapses in speech, memory, etc., and above all, one
must resort to the analysis of dreams, as they give the most direct
access to the unconscious. No one is really qualified to use or
judge Freud’s psychanalytic method who has not thoroughly mastered
the Traumdeutung,[7] the Psychopathologie des Alltagsleben,[8] and
the Drei Abhandlungen zur Sexualtheorie,[9] and has not had
considerable experience in analyzing his own and other’s dreams and
psychopathological actions. It is especially in the Traumdeutung
that Freud has fully developed his psychanalytic technique and a
perfect knowledge of which is the sine qua non in the treatment. It
is only by following Freud in this manner that one can hope to solve
the hitherto unsolved riddles of the psychoneuroses and psychoses.
This treatment is more difficult than one can describe in a preface. It
not only presupposes a thorough knowledge of Freud but an equal
knowledge of normal and abnormal psychology. Those who have not acquired
this knowledge by reason of time or otherwise may remember the words of
the younger Pliny: _Ut enim de pictore scalptore fictore nisi artifex
indicare, ita nisi sapiens non potest perspicere sapientem_.
A. A. BRILL.
CHAPTER I.
THE PSYCHIC MECHANISM OF HYSTERICAL PHENOMENA.[10]
(PRELIMINARY COMMUNICATION.)
I.
Instigated by a number of accidental observations we have investigated
for a number of years the different forms and symptoms of hysteria in
order to discover the cause and the process which provoked the phenomena
in question for the first time, in a great many cases years back. In the
great majority of cases we did not succeed in elucidating this starting
point from the mere history, no matter how detailed it might have been,
partly because we had to deal with experiences about which discussion
was disagreeable to the patients, but mainly because they really could
not recall them; often they had no inkling of the causal connection
between the occasioning process and the pathological phenomenon. It was
generally necessary to hypnotize the patients and reawaken the memory of
that time in which the symptom first appeared, and we thus succeeded in
exposing that connection in a most precise and convincing manner.
This method of examination in a great number of cases has furnished us
with results which seem to be of theoretical as well as of practical
value.
It is of theoretical value because it has shown to us that in the
determination of the pathology of hysteria the accidental moment plays a
much greater part than is generally known and recognized. It is quite
evident that in “traumatic” hysteria it is the accident which evokes the
syndrome. Moreover in hysterical crises, if patients state that they
hallucinate in each attack the same process which evoked the first
attack, here too, the causal connection seems quite clear. The state of
affairs is more obscure in the other phenomena.
Our experiences have shown us _that the most varied symptoms which pass
as spontaneous, or so to say idiopathic attainments of hysteria, stand
in just as stringent connection with the causal trauma as the
transparent phenomena mentioned_. To such causal moments we were able to
refer neuralgias as well as the different kinds of anesthesias often of
years duration, contractures and paralyses, hysterical attacks and
epileptiform convulsions which every observer has taken for real
epilepsy, petit mal and tic-like affections, persistent vomiting and
anorexia, even the refusal of nourishment, all kinds of visual
disturbances, constantly recurring visual hallucinations, and similar
affections. The disproportion between the hysterical symptom of years
duration and the former cause is the same as the one we are regularly
accustomed to see in the traumatic neurosis. Very often they are
experiences of childhood which have established more or less intensive
morbid phenomena for all succeeding years.
The connection is often so clear that it is perfectly manifest how the
causal event produced just this and no other phenomenon. It is quite
clearly determined by the cause. Thus let us take the most banal
example; if a painful affect originates while eating but is repressed,
it may produce nausea and vomiting and continue for months as a
hysterical symptom. A girl was anxiously distressed while watching at a
sick bed. She fell into a dreamy state and experienced a frightful
hallucination, and at the same time her right arm hanging over the back
of a chair became numb. This resulted in a paralysis, contracture, and
anesthesia of that arm. She wanted to pray but could find no words, but
finally succeeded in uttering an English prayer for children. Later, on
developing a very grave and most complicated hysteria, she spoke, wrote,
and understood only English, whereas her native tongue was
incomprehensible to her for a year and a half. A very sick child finally
falls asleep. The mother exerts all her will power to make no noise to
awaken it, but just because she resolved to do so she emits a clicking
sound with her tongue (“hysterical counter-will”). This was later
repeated on another occasion when she wished to be absolutely quiet,
developing into a tic which in the form of tongue clicking accompanied
every excitement for years. A very intelligent man was present while his
brother was anesthetized and his ankylosed hip stretched. At the moment
when the joint yielded and crackled he perceived severe pain in his own
hip which continued for almost a year.
In other cases the connection is not so simple, there being only as it
were a symbolic relation between the cause and the pathological
phenomenon, just as in the normal dream. Thus psychic pain may result in
neuralgia, or the affect of moral disgust may cause vomiting. We have
studied patients who were wont to make the most prolific use of such
symbolization. In still other cases such a determination is at first
sight incomprehensible, yet to this group belong the typical hysterical
symptoms such as hemianesthesia, contraction of visual field,
epileptiform convulsions and many others. The explanation of our views
on this group we have to reserve for the more detailed discussion of the
subject.
_Such observations seem to demonstrate the pathogenic analogy between
simple hysteria and traumatic neurosis and justify a broader conception
of “traumatic hysteria.”_ The active etiological factor in traumatic
neurosis is really not the insignificant bodily injury but the affect of
the fright, that is, the psychic trauma. In an analogous manner our
investigations show that the causes of many, if not of all, cases of
hysteria can be designated as psychic traumas. Every experience which
produces the painful affect of fear, anxiety, shame or of psychic pain
may act as a psychic trauma. Whether an experience becomes of traumatic
importance naturally depends on the person affected as well as on the
determination to be mentioned later. In ordinary hysteria instead of one
big trauma we not seldom find many partial traumas, grouped causes which
can be of traumatic significance only when summarized and which belong
together in so far as they form small fragments of the sorrowful tale.
In still other cases apparently indifferent circumstances gain traumatic
dignity through their connection with the real effective event or with a
period of time of special excitability which they then retain but which
otherwise would have no significance.
Nevertheless the causal connection between the provoking psychic trauma
and the hysterical phenomena does not perhaps resemble the trauma which
as the _agent provocateur_ would call forth the symptom which would
become independent and continue to exist. We have to claim still more,
namely, that the psychic trauma or the memory of the same acts like a
foreign body which even long after its penetration must continue to
influence like a new causative factor. The proof of this we see in a
most remarkable phenomenon which at the same time gives to our
discoveries a distinct practical interest.
We found, at first to our greatest surprise, _that the individual
hysterical symptoms immediately disappeared without returning if we
succeeded in thoroughly awakening the memories of the causal process
with its accompanying affect, and if the patient circumstantially
discussed the process giving free play to the affect_. Affectless
memories are almost utterly useless. The psychic process originally
rebuffed must be reproduced as vividly as possible so as to bring it
back into the _statum nascendi_ and then be thoroughly “talked over.” At
the same time if we deal with such exciting manifestations as
convulsions, neuralgias and hallucinations they appear once more with
their full intensity and then vanish forever. Functional attacks like
paralyses and anesthesias likewise disappear, but naturally without any
appreciable distinctness of their momentary aggravation.[11]
It is quite reasonable to suspect that one deals here with an
unintentional suggestion. The patient expects to be relieved of his
suffering and it is this expectation and not the discussion that is the
effectual factor. But this is not so. The first observation of this kind
in which a most complicated case of hysteria was analyzed and the
individual causal symptoms separately abrogated, occurred in the year
1881, that is in a “pre-suggestive” time. It was brought about through a
spontaneous autohypnosis of the patient and caused the examiner the
greatest surprise.
In reversing the sentence: _cessante causa cessat effectus_, we may
conclude from this observation that the causal process continues to act
in some way even after years, not indirectly by means of a chain of
causal connecting links but directly as a provoking cause, just perhaps
as in the awakened consciousness where the memory of a psychic pain may
later call forth tears. _The hysteric suffers mostly from
reminiscences._[12]
II.
It would seem at first rather surprising that long-forgotten experiences
should effect so intensively, and that their recollections should not be
subject to the decay into which all our memories merge. We will perhaps
gain some understanding of these facts by the following examinations.
The blurring or loss of an affect of memory depends on a great many
factors. In the first place it is of great consequence whether there was
an energetic reaction to the affectful experience or not. By reaction we
here understand a whole series of voluntary or involuntary reflexes,
from crying to an act of revenge, through which according to experience
affects are discharged. If the success of this reaction is of sufficient
strength it results in the disappearance of a great part of the affect.
Language attests this fact of daily observation, in such expressions as
“to give vent to one’s feeling,” to be “relieved by weeping,” etc.
If the reaction is suppressed the affect remains united with the memory.
An insult retaliated, be it only in words, is differently recalled than
one that had to be taken in silence. Language also recognizes this
distinction between the psychic and physical results and designates most
characteristically the silently endured suffering as “grievance.” The
reaction of the person injured to the trauma has really no perfect
“cathartic” effect unless it is an adequate reaction like revenge. But
man finds a substitute for this action in speech through which help the
affect can well nigh be ab-reacted[13] (“abreagirt”). In other cases
talking in the form of deploring and giving vent to the torments of the
secret (confession) is in itself an adequate reflex. If such reaction
does not result through deeds, words, or in the lightest case through
weeping, the memory of the occurrence retains above all the affective
accentuation.
The ab-reaction (abreagiren), however, is not the only form of discharge
at the disposal of the normal psychic mechanism of the healthy person
who has experienced a psychic trauma. The memory of the trauma even
where it has not been ab-reacted enters into the great complex of the
association. It joins the other experiences which are perhaps
antagonistic to it and thus undergoes correction through the other
ideas. For example, after an accident the memory of the danger and
(dimmed) repetition of the fright is accompanied by the recollection of
the further course, the rescue, and the consciousness of present
security. The memory of a grievance may be corrected by a rectification
of the state of affairs by reflecting upon one’s own dignity and similar
things. Thus the normal person is able to cause a disappearance of the
accompanying affect by means of association.
In addition there appears that general blurring of impressions, that
fading of memories which we call “forgetting,” and which above all wears
out the affective ideas no longer active.
It follows from our observations that those memories which become the
causes of hysterical phenomena have been preserved for a long time with
wonderful freshness and with their perfect emotional tone. As a further
striking and a later realizable fact we have to mention that the
patients do not perhaps have the same control of these as of their other
memories of life. On the contrary, _these experiences are either
completely lacking from the memory of the patients in their usual
psychic state or at most exist greatly abridged_. Only after the
patients are questioned in the hypnotic state do these memories appear
with the undiminished vividness of fresh occurrences. Thus one of our
patients in a hypnotic state reproduced with hallucinatory vividness
throughout half a year all that excited her during an acute hysteria on
the same days of the preceding year. Her mother’s diary which was
unknown to the patient proved the faultless accuracy of the
reproduction. Another patient, partly in hypnosis and partly in
spontaneous attacks, went through with a hallucinatory distinctness all
experiences of a hysterical psychosis which she passed through ten years
before and for the greatest part of which she was amnesic until its
reappearance. She also showed with surprising integrity and sentient
force some etiologically important memories of fifteen to twenty-five
years’ duration which on their return acted with the full affective
force of new experiences.
The reason for this we can only find in the fact that in all the
aforesaid relations these memories assume an exceptional position in
reference to disappearance. _It was really shown that these memories
correspond to traumas which were not sufficiently ab-reacted to_
(“abreagirt”). On closer investigation of the reasons for this
prevention we can find at least two series of determinants through which
the reaction to the trauma was discontinued.
To the first group we add those cases in which the patient has not
reacted to psychic traumas because the nature of the trauma precluded a
reaction as in the case of an irremediable loss of a beloved person or
because social relations made the reaction impossible, or because it
concerned things which the patient wished to forget and which he
therefore intentionally inhibited and repressed from his conscious
memory. It is just those painful things which in the hypnotic state are
found to be the basis of hysterical phenomena (hysterical delirium of
saints, nuns, abstinent women, and well-bred children).
The second series of determinants is not conditioned by the content of
the memories but by the psychic states with which the corresponding
experiences in the patient have united. As a cause of hysterical
symptoms one really finds in hypnosis presentations which are
insignificant in themselves but which owe their preservation to the fact
that they originated during a severe paralyzing affect like fright or
directly in abnormal psychic conditions, as in the semi-hypnotic dreamy
states of reveries, in autohypnosis and similar states. Here it is the
nature of these conditions which make a reaction to the incident
impossible.
To be sure both determinants may unite, and as a matter of fact they
often do. This is the case when a trauma in itself effective occurs in a
state of a powerful paralyzing affect or in a transformed consciousness.
But due to the psychic trauma it may also happen that in many persons
one of these abnormal states occurs which in turn makes a reaction
impossible.
What is common to both groups of determinants is the fact that those
psychic traumas which are not rectified by reaction are also prevented
from adjustment by associative elaboration. In the first group it is due
to the resolution of the patient who wishes to forget the painful
experiences and in this way, if possible, to exclude them from
association, and in the second group the associative elaboration does
not succeed because there is no productive associative relationship
between the normal and pathological state of consciousness in which
these presentations originated. We shall soon have occasion to discuss
more fully these relationships.
Hence we can say, _that the reason why the pathogenically formed
presentations retain their freshness and affective force is because they
are not subject to the normal waste through ab-reaction and reproduction
in conditions of uninhibited association_.
III.
When we discussed the conditions which, according to our experience, are
decisive in the development of hysterical phenomena from psychic
traumas, we were forced to speak of abnormal states of consciousness in
which such pathogenic presentations originate, and we had to emphasize
the fact that the recollection of the effective psychic trauma is not to
be found in the normal memory of the patient but in the hypnotized
memory. The more we occupied ourselves with these phenomena the more
certain became our convictions _that the splitting of consciousness, so
striking in the familiar classical cases of double consciousness, exists
rudimentarily in every hysteria, and that the tendency to this
dissociation, and with it the tendency towards the appearance of
abnormal states of consciousness which we comprehend as “hypnoid
states,” is the chief phenomenon of this neurosis_. In this view we
agree with Binet and with both the Janets about whose most remarkable
findings in anesthetics we have had no experience.
Hence, to the often cited axiom, “Hypnosis is artificial hysteria,” we
would like to add another: “The existence of hypnoid states is the basis
and determination of hysteria.” These hypnoid states in all their
diversities agree among themselves and with hypnosis in the fact that
their emerged presentations are very intensive but are excluded from the
associative relations of the rest of the content of consciousness. The
hypnoid states are associable among themselves, and their ideation may
thus attain various high degrees of psychic organization. In other
respects the nature of these states and the degree of their
exclusiveness differ from the rest of the conscious processes as do the
various states in hypnosis, which range from light somnolence to
somnambulism, and from perfect memory to absolute amnesia.
If such hypnoid states already exist before the manifested disease they
prepare the soil upon which the affect establishes the pathogenic
memories and their somatic resulting manifestations. This behavior
corresponds to the predisposed hysteria. But the results of our
observations show that a severe trauma (like that of a traumatic
neurosis) or a painful suppression (perhaps of a sexual affect) may
bring about a splitting of presentation groups even in persons otherwise
not predisposed. This would then be the mechanism of the psychically
acquired hysteria. Between the extremes of these two forms we have to
admit a series in which the facility of dissociation in the concerned
individuals and the magnitude of the affect of the trauma vary
inversely.
We are unable to give anything new concerning the formation of the
predisposed hypnoid states. We presume that they often develop from
“reveries” very common to the normal for which, for example, the
feminine handwork offers so much opportunity. The questions why “the
pathological associations” formed in such states are so firm and why
they exert a stronger influence on the somatic processes than other
presentations, all fall together with the problem of the effectivity of
hypnotic suggestions in general. Our experiences in this matter do not
show us anything new, on the other hand they throw light on the
contradiction between the sentence “Hysteria is a psychosis” and the
fact that among hysterics one may meet persons of the clearest
intellects, the strongest wills, greatest principles, and of the
subtlest minds. In these cases such characteristics are only true for
the waking thought of the person, for in his hypnotic state he is
alienated just as we are in the dream. Yet, whereas our dream psychoses
do not influence our waking state, the products of hypnotic states
project as hysterical phenomena into the waking state.
IV.
Almost the same assertions that we have advanced in reference to the
continuous hysterical symptoms we may also repeat concerning hysterical
crises. As is known we have Charcot’s schematic description of the
“major” hysterical attack which when complete shows four phases: (1) The
epileptoid, (2) the grand movements, (3) the emotional—_attitudes
passionnelles_ (hallucinatory phase), and (4) the delirious. By
shortening or prolonging the attack and by isolating the individual
phases Charcot caused a succession of all those forms of the hysterical
attack which are really observed more frequently than the complete
_grande attaque_.
Our attempted explanation refers to the third phase, that is the
_attitudes passionnelles_. Wherever it is prominent it contains the
hallucinatory reproduction of a memory which was significant for the
hysterical onset. It is the memory of a grand trauma, the so called κατ’
ἐξοχὴν of traumatic hysteria or of a series of connected partial traumas
found at the basis of the common hysteria. Finally the attack may bring
back that occurrence which on account of its meeting with a moment of
special predisposition was raised to a trauma.
There are also attacks which ostensibly consist only of motor phenomena
and lack the passionnelle phase. If it is possible during such an attack
of general twitching, cataleptic rigidity or an _attaque de sommeil_, to
put one’s self _en rapport_ with the patient, or still better, if one
succeeds in evoking the attack in a hypnotic state, it will then be
found that here, too, the root of it is the memory of a psychic trauma,
or of a series of traumas which make themselves otherwise prominent in
an hallucinatory phase. A little girl had suffered for years from
attacks of general convulsions which could be and were taken for
epileptic. She was hypnotized for purposes of differential diagnosis and
she immediately merged into one of her attacks. On being asked what she
saw she said, “The dog, the dog is coming,” and it was really found that
the first attack of this kind appeared after she was pursued by a mad
dog. The success of the therapy then verified our diagnosis.
An official who became hysterical as a result of ill treatment on the
part of his employer suffered from attacks, during which he fell to the
floor raging furiously without uttering a word or displaying any
hallucinations. The attack was provoked in a state of hypnosis and he
then stated that he lived through the scene during which his employer
insulted him in the street and struck him with a cane. A few days later
he came to me complaining that he had the same attack, but this time it
was shown in the hypnosis that he went through the scene which was
really connected with the onset of his disease; it was the scene in the
court room when he was unable to get satisfaction for the ill treatment
which he received, etc.
The memories which appear in hysterical attacks or which can be awakened
in them correspond in all other respects to the causes which we have
found as the basis of the continuous hysterical symptoms. Like these
they refer to psychic traumas which were prevented from alleviation by
ab-reaction or by associative elaboration, like these they lack entirely
or in their essential components the memory possibilities of normal
consciousness and appear to belong to the ideation of hypnoid states of
consciousness with limited associations. Finally they are also amenable
to therapeutic proof. Our observations have often taught us that a
memory which has always evoked attacks becomes incapacitated when in a
hypnotic state it is brought to reaction and associative correction.
The motor phenomena of the hysterical attack can partly be interpreted
as the memory of a general form of reaction of the accompanying affect,
or partly as a direct motor expression of this memory (like the
fidgeting of the whole body which even infants make use of), and partly,
like the hysterical stigmata—the continuous symptoms—they are
inexplainable on this assumption.
Of special significance for the hysterical attack is the aforementioned
theory, namely, that in hysteria there are presentation groups which
come to light in hypnoid states which are excluded from the rest of the
associative process but are associable among themselves, thus
representing a more or less highly organized rudimentary second
consciousness, a _condition seconde_. A persistent hysterical symptom
therefore corresponds to a projection of this second state into a bodily
innervation otherwise controlled by the normal consciousness. A
hysterical attack gives evidence of a higher organization of this second
state, and if of recent origin it signifies a moment in which this
hypnoid consciousness gained control of the whole existence, and hence
we have an acute hysteria, but if it is a recurrent attack containing a
memory we simply have a repetition of the same. Charcot has already
given utterance to the fact that the hysterical attack must be the
rudiment of a _condition seconde_. During the attack the control of the
whole bodily innervation is transferred to the hypnoid consciousness. As
familiar experiences show, the normal consciousness is not always
repressed, it may even perceive the motor phenomena of the attack while
the psychic processes of the same escape its cognizance.
The typical course of a grave hysteria, as everybody knows, is as
follows: At first an ideation is formed in the hypnoid state which after
sufficient development gains control in a period of “acute hysteria” of
the bodily innervation and the existence of the patient thus forming
persistent symptoms and attacks, and then with the exception of some
remnants there is a recovery. If the normal personality can regain the
upper hand, all that survived the hypnoid ideation then returns in
hysterical attacks and at times it reproduces, in the personality,
states which are again amenable to influences and capable of being
affected by traumas. Frequently a sort of equilibrium then results among
the psychic groups which are united in the same person; attack and
normal life go hand in hand without influencing each other. The attack
then comes spontaneously just as memories are wont to come, it may also
be provoked just as memories may be by the laws of association. The
provocation of the attack results either through stimulating a
hysterogenic zone or through a new experience which by similarity
recalls the pathogenic experience. We hope to be able to show that there
is no essential difference between the apparently two diverse
determinants, and that in both cases the hyperesthetic memory is
touched. In other cases there is a great lability of equilibrium, the
attack appears as a manifestation of the hypnoid remnant of
consciousness as often as the normal person becomes exhausted and
incapacitated. We cannot disregard the fact that in such cases the
attack becomes denuded of its original significance and may return as a
contentless motor reaction.
It remains a task for future investigation to discover what conditions
are decisive in determining whether a hysterical individuality should
manifest itself in attacks, in persistent symptoms, or in a mingling of
both.
V.
We can now understand in what manner the psychotherapeutic method
propounded by us exerts its curative effect. _It abrogates the efficacy
of the original not ab-reacted presentation of affording an outlet to
the strangulated affect through speech. It brings it to associative
correction by drawing it into normal consciousness (in mild hypnosis) or
it is done away with through the physician’s suggestion just as happens
in somnambulism with amnesia._
We maintain that the therapeutic gain obtained by applying this process
is quite significant. To be sure we do not cure the hysterical
predisposition as we do not block the way for the recurrence of hypnoid
states; moreover, in the productive stage of acute hysteria our
procedure is unable to prevent the replacement of the carefully
abrogated phenomena by new ones. But when this acute stage has run its
course and its remnants continue as persistent hysterical symptoms and
attacks, our radical method usually removes them forever, and herein it
seems to surpass the efficacy of direct suggestion as practiced at
present by psychotherapists.
If by disclosing the psychic mechanisms of hysterical phenomena we have
taken a step forward on the path so successfully started by Charcot with
his explanation and experimental imitation of hystero-traumatic
paralysis, we are well aware that in doing this we have only advanced
our knowledge in the mechanisms of hysterical symptoms and not in the
subjective causes of hysteria. We have but touched upon the etiology of
hysteria and could only throw light on the causes of the acquired forms,
the significance of the accidental moments in the neurosis.
CHAPTER II.
THE CASE OF MISS LUCY R.
Towards the end of 1892 a friendly colleague recommended to me a young
lady whom he had been treating for chronic recurrent purulent rhinitis.
It was later found that the obstinacy of her trouble was caused by a
caries of the ethmoid. She finally complained of new symptoms which this
experienced physician could no longer refer to local affections. She had
lost all perception of smell and was almost constantly bothered by one
or two subjective sensations of smell. This she found very irksome. In
addition to this she was depressed in spirits, weak, and complained of a
heavy head, loss of appetite, and an incapacity for work.
This young lady visited me from time to time during my office hours—she
was a governess in the family of a factory superintendent living in the
suburbs of Vienna. She was an English lady of rather delicate
constitution, anemic, and with the exception of her nasal trouble was in
good health. Her first statements concurred with those of her physician.
She suffered from depression and lassitude, and was tormented by
subjective sensations of smell. Of hysterical signs, she showed a quite
distinct general analgesia without tactile impairment, the fields of
vision showed no narrowing on coarse testing with the hand, the nasal
mucous membrane was totally analgesic and reflexless, tactile sensation
was absent, and the perception of this organ was abolished for specific
as well as for other stimuli, such as ammonia or acetic acid. The
purulent nasal catarrh was then in a state of improvement.
On first attempting to understand this case the subjective sensations of
smell had to be taken as recurrent hallucinations interpreting
persistent hysterical symptoms. The depression was perhaps the affect
belonging to the trauma and there must have been an episode during which
the present subjective sensations were objective. This episode must have
been the trauma, the symbols of which recurred in memory as sensations
of smell. Perhaps it would be more correct to consider the recurring
hallucinations of smell with the accompanying depression as equivalents
of hysterical attacks. The nature of recurrent hallucinations really
makes them unfit to take the part of continuous symptoms, and this
really did not occur in this rudimentarily developed case. On the other
hand it was absolutely to be expected that the subjective sensations of
smell would show such a specialization as to be able to correspond in
its origin to a very definite and real object.
This expectation was soon fulfilled, for on being asked what odor
troubled her most she stated that it was an odor of burned pastry. I
could then assume that the odor of burned pastry really occurred in the
traumatic event. It is quite unusual to select sensations of smell as
memory symbols of traumas, but it is quite obvious why these were here
selected. She was afflicted with purulent rhinitis, hence the nose and
its perceptions were in the foreground of her attention. All I knew
about the life of the patient was that she took care of two children
whose mother died a few years ago from a grave and acute disease.
As a starting point of the analysis I decided to use the “odor of burned
pastry.” I will now relate the history of this analysis. It could have
occurred under more favorable conditions, but as a matter of fact what
should have taken place in one session was extended over a number of
them. She could only visit me during my office hours, during which I
could devote to her but little of my time. One single conversation had
to be extended for over a week as her duties did not permit her to come
to me often from such a distance, so that the conversation was
frequently broken off and resumed at the next session.
On attempting to hypnotize Miss Lucy R. she did not merge into the
somnambulic state. I therefore was obliged to forego somnambulism and
the analysis was made while she was in a state not perhaps differing
much from the normal.
I feel obliged to express myself more fully about the point of the
technique of my procedure. While visiting the Nancy clinics in 1889 I
heard Dr. Liébeault, the old master of hypnotism, say, “Yes, if we had
the means to put everybody into the somnambulic state, hypnotism would
then be the most powerful therapeutic agent.” In Bernheim’s clinic it
almost seemed that such an art really existed and that it could be
learned from Bernheim. But as soon as I tried to practice it on my own
patients I noticed that at least my powers were quite limited in this
respect. Whenever a patient did not merge into the somnambulistic state
after one to three attempts I possessed no means to force him into it.
However, the percentage of somnambulists in my experience were far below
that claimed by Bernheim.
Thus I had my choice, either to forbear using the cathartic method in
most of the cases suitable for it, or to venture the attempt without
somnambulism by using hypnotic influence in light or even doubtful
cases. It made no difference of what degree (following the accepted
scales of hypnotism) the hypnotism was which did not correspond to
somnambulism, for every direction of suggestibility is independent of
the other and nothing is prejudicial towards the evocation of catalepsy,
automatic movements and similar phenomena for the purpose of
facilitating the awakening of forgotten recollections. I soon
relinquished the habit of deciding the degree of hypnotism, as in a
great number of cases it incited the patients’ resistance, and clouded
the confidence which I needed for the more important psychic work.
Moreover, in mild grades of hypnotism I soon tired of hearing, after the
assurance and command, “You will sleep, sleep now!” such protests as,
“But, Doctor, I am not sleeping.” I was then forced to bring in the very
delicate distinction, saying, “I do not mean the usual sleep, I mean the
hypnotic,—you see, you are hypnotized, you cannot open your eyes”; or,
“I really don’t want you to sleep.” I, myself, am convinced that many of
my colleagues using psychotherapy know how to get out of such
difficulties more skilfully than I; they can proceed differently. I,
however, believe that if through the use of a word one can so frequently
become embarrassed, it is better to avoid the word and the
embarrassment. Wherever the first attempt did not produce either
somnambulism or a degree of hypnotism with pronounced bodily changes, I
dropped the hypnosis and demanded only “concentration,” I ordered the
patient to lie on his back and close his eyes as a means of reaching
this “concentration.” With little effort I obtained as profound a degree
of hypnotism as was possible.
But inasmuch as I forbore using somnambulism, I perhaps robbed myself of
a preliminary stipulation without which the cathartic method seems
inapplicable. For it is based on the fact that in the altered state of
consciousness the patients have at their disposal such recollections and
recognize such connections which do not apparently exist in their normal
conscious state. Wherever the somnambulic broadening of consciousness
lacks there must also be an absence of the possibility of bringing about
a causal relation which the patient cannot give to the doctor as
something known to him, and it is just the pathogenic recollections
“which are lacking from the memory of the patients in their usual
psychic states or only exist in a most condensed state” (preliminary
communication).
My memory helped me out of this embarrassment. I, myself, saw Bernheim
adduce proof that the recollections of somnambulism are only manifestly
forgotten in the waking state and can be readily reproduced by slight
urging accompanied by hand pressure which is supposed to mark another
conscious state. He, for instance, imparted to a somnambulist the
negative hallucination that he was no more present, and then attempted
to make himself noticeable to her by the most manifold and regardless
attacks, but was unsuccessful. After the patient was awakened he asked
her what he did to her during the time that she thought he was not
there. She replied very much astonished, that she knew nothing, but he
did not give in, insisting that she would recall everything; and placed
his hand on her forehead so that she should recall things, and behold,
she finally related all that she did not apparently perceive in the
somnambulic state and about which she ostensibly knew nothing in the
waking state.
This astonishing and instructive experiment was my model. I decided to
proceed on the supposition that my patients knew everything that was of
any pathogenic significance, and that all that was necessary was to
force them to impart it. When I reached a point where to the question
“Since when have you this symptom?” or, “Where does it come from?” I
receive the answer, “I really don’t know this,” I proceeded as follows:
I placed my hand on the patient’s forehead or took her head between my
hands and said, “Under the pressure of my hand it will come into your
mind. In the moment that I stop the pressure you will see something
before you, or something will pass through your mind which you must
note. It is that which we are seeking. Well, what have you seen or what
came into your mind?”
On applying this method for the first time (it was not in the case of
Miss Lucy R.) I was surprised to find just what I wanted, and I may say
that it has since hardly ever failed me, it always showed me the way to
proceed in my investigations and enabled me to conclude all such
analyses without somnambulism. Gradually I became so bold that when a
patient would answer, “I see nothing,” or “Nothing came into my mind,” I
insisted that it was impossible. They probably had the right thought but
did not believe it and repudiated it. I would repeat the procedure as
often as they wished, and every time they saw the same thing. Indeed, I
was always right; the patients had not as yet learned to let their
criticism rest. They repudiated the emerging recollection or fancy
because they considered it as a useless intruding disturbance, but after
they imparted it, it was always shown that it was the right one.
Occasionally after forcing a communication by pressing the head three or
four times I got such answer as, “Yes, I was aware of it the first time,
but did not wish to say it,” or, “I hoped that it would not be this.”
By this method it was far more laborious to broaden the alleged narrowed
consciousness than by investigating in the somnambulic state, but it
made me independent of somnambulism and afforded me an insight into the
motives which are frequently decisive for the “forgetting” of
recollections. I am in position to assert that this forgetting is often
intentional and desired. It is always only manifestly successful.
It appeared to me even more remarkable that apparently long forgotten
numbers and dates can be reproduced by a similar process, thus proving
an unexpected faithfulness of memory.
The insignificant choice which one has in searching for numbers and
dates especially allows us to take to our aid the familiar axiom of the
theory of aphasia, namely, that recognition is a slighter accomplishment
of memory than spontaneous recollection.
Hence to a patient who is unable to recall in what year, month or day a
certain event took place, enumerate the years during which it might have
occurred as well as the names of the twelve months and the thirty-one
days of the month, and assure him that at the right number or name his
eyes will open themselves or that he will feel which number is the
correct one. In most cases the patients really decide on a definite date
and frequently enough (as in the case of Mrs. Cäcilie N.) it could be
ascertained from existing notes of that time that the date was correctly
recognized. At other times and in different patients it was shown from
the connection of the recollected facts that the dates thus found were
incontestable. A patient, for instance, after a date was found by
enumerating for her the dates, remarked, “This is my father’s birthday,”
and added “Of course I expected this episode [about which we spoke]
because it was my father’s birthday.”
I can only slightly touch upon this theme. The conclusion which I wished
to draw from all these experiences is that the pathogenic important
experiences with all their concomitant circumstances are faithfully
retained in memory, even where they seem forgotten, as when the patient
seems unable to recall them.[14]
After this long but unavoidable digression I now return to the history
of Miss Lucy R. As aforesaid, she did not merge into somnambulism when
an attempt was made to hypnotize her, but lay calmly in a degree of mild
suggestibility, her eyes constantly closed, the features immobile, the
limbs without motion. I asked her whether she remembered on what
occasion the smell perception of burned pastry originated.—“Oh, yes, I
know it well. It was about two months ago, two days before my birthday.
I was with the children (two girls) in the school room playing and
teaching them to cook, when a letter just left by the letter carrier was
brought in. From its postmark and handwriting I recognized it as one
sent to me by my mother from Glasgow and I wished to open it and read
it. The children then came running over, pulled the letter out of my
hand and exclaimed, ‘No you must not read it now, it is probably a
congratulatory letter for your birthday and we will keep it for you
until then.’ While the children were thus playing there was a sudden
diffusion of an intense odor. The children forgot the pastry which they
were cooking and it became burned. Since then I have been troubled by
this odor, it is really always present but is more marked during
excitement.”
“Do you see this scene distinctly before you?”—“As clearly as I
experienced it.”—“What was there in it that so excited you?”—“I was
touched by the affection which the children displayed towards me.”—“But
weren’t they always so affectionate?”—“Yes, but I just got the letter
from my mother.”—“I can’t understand in what way the affection of the
little ones and the letter from the mother contrasted, a thing which you
appear to intimate.”—“I had the intention of going to my mother and my
heart became heavy at the thought of leaving those dear children.”—“What
is the matter with your mother? Was she so lonesome that she wanted you,
or was she sick just then and you expected some news?”—“No, she is
delicate but not really sick, and has a companion with her.”—“Why then
were you obliged to leave the children?”—“This house had become
unbearable to me. The housekeeper, the cook, and the French maid seemed
to be under the impression that I was too proud for my position. They
united in intriguing against me and told the grandfather of the children
all sorts of things about me, and when I complained to both gentlemen I
did not receive the support which I expected. I then tendered my
resignation to the master (father of the children) but he was very
friendly, asking me to reconsider it for two weeks before taking any
definite steps. It was while I was in that state of indecision that the
incident occurred. I thought that I would leave the house but have
remained.”—“Aside from the attachment of the children is there anything
particular which attracts you to them?”—“Yes, my mother is distantly
related to their mother and when the latter was on her death bed I
promised her to do my utmost in caring for the children, that I would
not forsake them, and be a mother to them, and this promise I broke when
offering my resignation.”
The analysis of the subjective sensation of smell seemed completed. It
was once objective and intimately connected with an experience, a small
scene, in which contrary affects conflicted, sorrow at forsaking the
children, and the mortification which despite all urged her to this
decision. Her mother’s letter naturally recalled the motives of this
decision because she thought of returning to her mother. The conflict of
the affects raised this moment to a trauma and the sensation of smell
which was connected with it remained as its symbol. The only thing to be
explained was the fact that out of all the sensory perceptions of that
scene, the perception of smell was selected as the symbol, but I was
already prepared to use the chronic nasal affliction as an explanation.
On being directly questioned she stated that just at that time she
suffered from a severe coryza and could scarcely smell anything but in
her excitement she perceived the odor of burned pastry, it penetrated
the organically motived anosmia.
As plausible as this sounded it did not satisfy me; there seemed to be
something lacking. There was no acceptable reason wherefore this series
of excitements and this conflict of affects should have led to hysteria.
Why did it not all remain on a normal psychological basis? In other
words, what justified the conversion under discussion? Why did she not
recall the scenes themselves instead of the sensations connected with
them which she preferred as symbols for her recollection? Such questions
might seem superfluous and impertinent when dealing with old hysterias
in whom the mechanism of conversion was habitual, but this girl first
acquired hysteria through this trauma, or at least through this slight
distress.
From the analysis of similar cases I already knew that where hysteria is
to be newly acquired one psychic determinant is indispensible; namely,
that some presentation must intentionally be repressed from
consciousness and excluded from associative elaboration.
In this intentional repression I also find the reason for the conversion
of the sum of excitement, be it partial or total. The sum of excitement
which is not to enter into psychic association more readily finds the
wrong road to bodily innervation. The reason for the repression itself
could only be a disagreeable feeling, the incompatibility of one of the
repressible ideas with the ruling presentation-mass of the ego. The
repressed presentation then avenges itself by becoming pathogenic.
From this I concluded that Miss Lucy R. merged into that moment of
hysterical conversion, which must have been under the determinations of
that trauma which she intentionally left in the darkness and which she
took pains to forget. On considering her attachment for the children and
her sensitiveness towards the other persons of the household, there
remained but one interpretation which I was bold enough to impart to
her. I told her that I did not believe that all these things were simply
due to her affection for the children, but that I thought that she was
rather in love with her master, perhaps unwittingly, that she really
nurtured the hope of taking the place of the mother, and it was for that
reason that she became so sensitive towards the servants with whom she
had lived peacefully for years. She feared lest they would notice
something of her hope and scoff at her.
She answered in her laconic manner: “Yes, I believe it is so.”—“But if
you knew that you were in love with the master, why did you not tell me
so?”—“But I did not know it, or rather, I did not wish to know it. I
wished to crowd it out of my mind, never to think of it, and of late I
have been successful.”[15]
“Why did you not wish to admit it to yourself? Were you ashamed because
you loved a man?”—“O, no, I am not unreasonably prudish; one is
certainly not responsible for one’s own feelings. I only felt chagrined
because it was my employer in whose service I was and in whose house I
lived, and toward whom I could not feel as independent as towards
another. What is more, I am a poor girl and he is a rich man of a
prominent family, and if anybody should have had any inkling about my
feelings they would have ridiculed me.”
After this I encountered no resistances in elucidating the origin of
this affection. She told me that the first years of her life in that
house were passed uneventfully. She fulfilled her duties without
thinking about unrealizable wishes. One day, however, the serious, and
very busy and hitherto very reserved master, engaged her in conversation
about the exigencies of rearing the children. He became milder and more
cordial than usual, he told her how much he counted on her in the
bringing up of his orphaned children, and looked at her rather
peculiarly. It was in this moment that she began to love him, and gladly
occupied herself with the pleasing hopes which she conceived during that
conversation. However, as this was not followed by anything else, and
despite her waiting and persevering no other confidential heart-to-heart
talk followed, she decided to crowd it out of her mind. She quite agreed
with me that the look in connection with the conversation was probably
intended for the memory of his deceased wife. She was also perfectly
convinced that her love was hopeless.
After this conversation I expected a decided change in her condition but
for a time it did not take place. She continued depressed and moody—a
course of hydrotherapy which I ordered for her at the same time
refreshed her somewhat mornings. The odor of burned pastry did not
entirely disappear; though it became rarer and feebler it appeared only,
as she said, when she was very much excited.
The continuation of this memory symbol led me to believe that besides
the principal scene it represented many smaller side traumas and I
therefore investigated everything that might have been in any way
connected with the scene of the burned pastry. We thus passed through
the theme of family friction, the behavior of the grandfather and
others, and with that the sensation of burned odor gradually
disappeared. Just then there was a lengthy interruption occasioned by a
new nasal affliction which led to the discovery of the caries of the
ethmoid.
On her return she informed me that she received many Christmas presents
from both gentlemen as well as from the household servants, as if they
were trying to appease her and wipe away the recollection of the
conflicts of the last months. These frank advances made no impression on
her.
On questioning her on another occasion about the odor of burned pastry
she stated that it had entirely disappeared, but instead she was now
bothered by another and similar odor like the smoke of a cigar. This
odor really existed before; it was only concealed by the odor of the
pastry but now appeared by itself.
I was not very much pleased with the success of my treatment. What
occurred here is what a mere symptomatic treatment is generally blamed
for, namely, that it removes one symptom only to make room for another.
Nevertheless, I immediately set forth to remove this new memory symbol
by analysis.
This time I did not know whence this subjective sensation of smell
originated, nor on what important occasion it was objective. On being
questioned she said, “They constantly smoke at home, I really don’t know
whether the smell which I feel has any particular significance.” I then
proposed that she should try to recall things under the pressure of my
hands. I have already mentioned that her recollections were plastically
vivid, that she was a “visual.” Indeed under the pressure of my hands a
picture came into her mind—at first only slowly and fragmentarily. It
was the dining room of the house in which she waited with the children
for the arrival of the gentlemen from the factory for dinner.—“Now we
are all at the table, the gentlemen, the French maid, the housekeeper,
the children and I. It is the same as usual.”—“Just keep on looking at
that picture. It will soon become developed and specialized.”—“Yes,
there is a guest, the chief accountant, an old gentleman who loves the
children like his own grandchildren, but he dines with us so frequently
that it is nothing unusual.”—“Just have patience, keep on looking at the
picture, something will certainly happen.”—“Nothing happens. We leave
the table, the children take leave and go with us up to the second floor
as usual.”—“Well?”—“It really is something unusual, I now recognize the
scene. As the children take leave the chief accountant attempts to kiss
them, but my master jumps up and shouts at him, ‘Don’t kiss the
children!’ I then experienced a stitch in the heart, and as the
gentlemen were smoking, this odor remained in my memory.”
This, therefore, was the second, deeper seated scene causing the trauma
and leaving the memory symbol. But why was this scene so effective? I
then asked her which scene happened first, this one or the one with the
burned pastry?—“The last scene happened first by almost two
months.”—“Why did you feel the stitch at the father’s interference? The
reproof was not meant for you.”—“It was really not right to rebuke an
old gentleman in such manner who was a dear friend and a guest, it could
have been said quietly.”—“Then you were really affected by your master’s
impetuosity? Were you perhaps ashamed of him, or have you thought, ‘If
he could become so impetuous to an old friend guest over such a trifle,
how would he act towards me if I were his wife?’”—“No, that is not
it.”—“But still it was about his impetuosity?”—“Yes, about the kissing
of the children, he never liked that.” Under the pressure of my hands
there emerged a still older scene which was the real effective trauma
and which bestowed on the scene with the chief accountant the traumatic
effectivity.
A few months before a lady friend visited the house and on leaving
kissed both children on the lips. The father, who was present,
controlled himself and said nothing to the lady, but when she left he
was very angry at the unfortunate governess. He said that he held her
responsible for this kissing; that it was her duty not to tolerate it;
that she was neglecting her duties in allowing such things, and that if
it ever happened again he would entrust the education of his children to
some one else. This occurred while she believed herself loved and waited
for a repetition of that serious and friendly talk. This episode
shattered all her hopes. She thought: “If he can upbraid and threaten me
on account of such a trifle, of which I am entirely innocent, I must
have been mistaken, he never entertained any tenderer feelings towards
me, else he would have been considerate.”—It was evidently this painful
scene that came to her as the father reprimanded the chief accountant
for attempting to kiss the children.
On being visited by Miss Lucy R. two days after the last analysis I had
to ask her what pleasant things happened to her. She looked as though
transformed, she smiled and held her head aloft. For a moment I thought
that after all I probably mistook the conditions and that the governess
of the children had now become the bride of the master. But she soon
dissipated all my suppositions, saying, “Nothing new happened. You
really do not know me. You have always seen me while I was sick and
depressed. I am otherwise always cheerful. On awaking yesterday morning
my burden was gone and since then I feel well.”—“What do you think of
your chances in the house?”—“I am perfectly clear about that. I know
that I have none, and I am not going to be unhappy about it.”—“Will you
now be able to get along with the others in the house?”—“I believe so,
because most of the trouble was due to my sensitiveness.”—“Do you still
love the master?”—“Certainly I love him, but that does not bother me
much. One can think and feel as one wishes.”
I now examined her nose and found that the pain and the reflex
sensations had almost completely reappeared. She could distinguish
odors, but she was uncertain when they were very intense. What part the
nasal trouble played in the anosmia I must leave undecided.
The whole treatment extended over a period of nine weeks. Four months
later I accidentally met the patient at one of our summer resorts—she
was cheerful and stated that her health continued to be good.
EPICRISIS.
I would not underestimate the aforesaid case even though it only
represents a young and light hysteria presenting but few symptoms.
Moreover, it seems to me instructive that even such a slight neurotic
affliction requires so many psychic determinants, and on a more
exhaustive consideration of this history I am tempted to put it down as
an illustration of that form of hysteria which even persons not burdened
by heredity may acquire if their experiences favor it. It should be well
noted that I do not speak of a hysteria which may be independent of all
predisposition; such form does not probably exist, but we speak of such
a predisposition only after the person became hysterical, as nothing
pointed to it before this. A neuropathic disposition as commonly
understood is something different. It is determined even before the
disease by a number of hereditary burdens, or a sum of individual
psychic abnormalities. As far as I know none of these moments could be
demonstrated in the case of Miss Lucy R. Her hysteria could therefore be
called acquired and presupposes nothing except probably a very marked
susceptibility to acquire hysteria, a characteristic about which we know
hardly anything. The chief importance in such cases lies in the nature
of the trauma, to be sure in connection with the reaction of the person
to the trauma. It is an indispensable condition for the acquirement of
hysteria that there should arise a relation of incompatibility between
the ego and some of its approaching presentations. I hope to be able to
show in another place how a variety of neurotic disturbances originate
from the different procedures which the “ego” pursues in order to free
itself from that incompatibility. The hysterical form of defence, for
which a special adaptation is required, consists in converting the
excitement into physical innervation. The gain brought about by this
process is the crowding out of the unbearable presentation from the ego
consciousness, which then contains instead the physical reminiscences
produced by conversion—in our case the subjective sensation of smell—and
suffers from the affect which is more or less distinctly adherent to
these reminiscences. The situation thus produced is no longer
changeable, for changing and conversion annihilate the conflict which
helped towards the adjustment of the affect. Thus the mechanism
producing hysteria corresponds on the one hand to an act of moral faint
heartedness, on the other hand it presents itself as a protective
arrangement at the command of the ego. There are many cases in which it
must be admitted that the defense of the increased excitement through
the production of hysteria may actually have been most expedient, but
more frequently one will naturally come to the conclusion that a greater
measure of moral courage would have been an advantage to the individual.
Accordingly the real traumatic moment is that, in which the conflict
thrusts itself upon the ego and the latter decides to banish it. Such
banishment does not annihilate the opposing presentation but merely
crowds it into the unconscious. This process, occurring for the first
time, forms a nucleus and point of crystallization for the formation of
a new psychic group separated from the ego, around which, in the course
of time, everything collects in accord with the opposing presentation.
The splitting of consciousness in such cases of acquired hysteria is
thus a desired and intentional one, and is often initiated by at least
one arbitrary act. But literally, something different happens than the
individual expects, he would wish to eliminate a presentation as though
it never came to pass but only succeeds in isolating it psychically.
The traumatic moment in the history of our patient corresponds to the
scene created by the master on account of the kissing of the children.
For the time being this scene remained without any palpable effects,
perhaps it initiated the depression and sensitiveness, but I leave this
open;—the hysterical symptoms, however, commenced later in moments which
can be designated as “auxiliary,” and which may be characterized by the
fact that in them there is a simultaneous flowing together of both
separated groups just as in the broadened somnambulic consciousness. The
first of these moments in which the conversion took place in Miss Lucy
R., was the scene at the table when the chief accountant attempted to
kiss the children. The traumatic memory helped along, and she acted as
though she had not entirely banished her attachment for her master. In
other cases we find that these different moments come together and the
conversion occurs directly under the influence of the trauma.
The second auxiliary moment repeated almost precisely the mechanism of
the first. A strong impression transitorily reestablished the unity of
consciousness and the conversion takes the same route opened to it in
the first. It is interesting to note that the symptom occurring second
concealed the first so that it could not be distinctly perceived until
the second was eliminated. The reversal of the succession of events to
which also the analysis must be adapted seems to me quite remarkable. In
a whole series of cases I found that the symptoms which came later
covered the first, and only the last thing in the analysis contained the
key to the whole.
The therapy here consisted in forcing the union of the dissociated
psychic groups with the ego consciousness. It is remarkable that the
success did not run parallel with the accomplished work, the cure
resulted suddenly only after the last part was accomplished.
CHAPTER III.
THE CASE OF MISS ELISABETH V. R.
In the fall of 1892 I was requested by a friendly colleague to examine a
young lady who had suffered from pains in her legs for over two years
and who walked badly. He also added that he diagnosed the case as
hysteria, though none of the usual symptoms of the neurosis could be
found. He stated that he knew something of the family and that the last
few years had brought them much misfortune and little pleasure. At first
the father of the patient died, then the mother underwent a serious
operation for the eyes, and soon thereafter a married sister succumbed
to a chronic cardiac affection after childbirth. Our patient had taken
an active part in all the afflictions and in all the nursings of the
sick. I made no further progress into the case after I had seen the
twenty-four-year-old patient for the first time. She seemed intelligent
and psychically normal and her affliction, which interfered with her
social relations and pleasure, she bore with a happy mien, thus vividly
recalling the “belle indifference” of hysterics. She walked with the
upper part of her body bent forward, but without any support; her gait
did not correspond to any known pathological gait and it was in no way
strikingly bad. She complained of severe pains on walking, of early
fatigue in walking as well as standing, and after a brief period she
would seek rest in which the pains became diminished but they by no
means disappeared. The pain was of an indefinite nature—one could assume
it to be a painful fatigue. The seat of the pain was given as a quite
extensive but indefinitely circumscribed location on the superficial
surface of the right thigh. It was from this area that the pains
radiated and where they were of the greatest intensity. Here, too, the
skin and muscles were especially sensitive to pressure and pinching,
while needle pricks were rather indifferently perceived. The same
hyperalgesia of the skin and muscles was demonstrable, not only in this
area, but over almost the entire surface of both legs. The muscles were
perhaps more painful than the skin, but both kinds of pains were
unmistakably most pronounced over the thighs. The motor power of the
legs was not diminished, the reflexes were of average intensity and all
other symptoms were lacking, so that there was no basis for the
assumption of a serious organic affection. The disease developed
gradually during two years and changed considerably in its intensity.
I did not find it easy to determine the diagnosis, but for two reasons I
concluded to agree with my colleague. First, because it was rather
peculiar that such a highly intelligent patient should not be able to
give anything definite about the character of her pains. A patient
suffering from an organic pain, if it is not accompanied by any
nervousness will be able to describe it definitely and calmly; it may
perhaps be lancinating, appearing at certain intervals, extending from
this to that location, and in his opinion it may be evoked by this or
that influence. The neurasthenic describing his pain gives the
impression of being occupied with some difficult mental problem reaching
far beyond his powers. His features are tense and distorted as though
under the domination of a painful affect, his voice becomes shriller, he
struggles for expression, he rejects all designations that the physician
makes for his pains, even though they are undoubtedly afterwards found
as appropriate. He is ostensibly of the opinion that language is too
poor to give expression to his feelings. His sensations are something
unique, they never existed before so that they can not be exhaustively
described. He never tires of constantly adding new details and when he
has to stop he is surely controlled by the impression that he was
unsuccessful in making himself understood to the physician. All this is
due to the fact that his pains absorb his whole attention. In the case
of Miss v. R. we had just the opposite behavior and we had to conclude
from this that she attributed sufficient significance to the pain, but
that her attention was concentrated on something else of which the pains
were the accompanying phenomena, perhaps on thoughts and sensations
which were connected with the pain.
A still greater determination for the conception of the pain must
however, be found in a second moment. If we irritate a painful area in a
patient suffering from an organic disease or neurasthenia his
physiognomy will show a definite expression of discomfort or of physical
pain. Furthermore, the patient winces, refuses to be examined and
assumes a defensive attitude. With Miss v. R. when the hyperalgesic skin
or muscles of her legs were pinched or pressed her face assumed a
peculiar expression approaching nearer pleasure than pain, she cried out
and—I had to think of a pleasurable tickling—her face reddened, she
threw her head backward, closed her eyes, and her body bent backward;
all this was not very distinct but sufficiently marked so that it could
only agree with the conception that her affliction was a hysteria and
that the irritation touched a hysterogenic zone.
Her mien was not in accord with the pain which the pinching of the
muscles and skin were supposed to excite. It probably harmonized better
with the content of the thoughts which were behind the pain and which
were evoked in the patient by irritating that part of the body
associated with them. I have repeatedly observed similar significant
expressions on irritating hyperalgesic zones in unmistakable cases of
hysteria. The other gestures evidently corresponded to the slightest
indications of a hysterical attack.
We could not at that time find any explanation for the unusual
localization of the hysterogenic zone. That the hyperalgesia chiefly
concerned the muscles gave material for reflection. The most frequent
affliction causing the diffuse and local pressure sensitiveness of the
muscles is the rheumatic infiltration of the same, the common chronic
muscular rheumatism about which aptitude to mask nervous affections I
have already spoken. The consistency of the painful muscles in Miss v.
R. did not contradict this assumption, as there were many hard cords in
the muscle masses which seemed to be especially sensitive. There was
probably also an organic change in the muscles, in the assumed sense,
upon which the neurosis rested and which significance was markedly
exaggerated by the neurosis.
The therapy followed out was based on a supposition of a mixed
affection. We recommended the continuation of a systematic massage and
faradization of the sensitive muscles without regard to the pain
produced, and in order to remain in communication with the patient I
undertook the treatment of her legs by means of strong Franklin’s
sparks. To her question whether she should force herself to walk we
answered decidedly in the affirmative.
We thus attained a slight improvement. She particularly liked the
painful shocks of the influence machine and the stronger they were the
more they seemed to suppress her pains. My colleague meanwhile prepared
the soil for the psychic treatment, and when after four weeks of sham
treatment I proposed the same and gave the patient some explanations
concerning the procedures and its effects I found a ready understanding
and only slight resistances.
The work which then began became eventually the most arduous that ever
befell my lot, and the difficulty of giving an account of this work
ranks well with the obstacles that had to be overcome. For a long time,
too, I did not understand the connection between the history of the
disease and the affliction, a thing which should really have been caused
and determined by this row of events.
When one undertakes a cathartic treatment he at first asks himself
whether the patient understands the origin and cause of her suffering.
If that is so one does not need any special technique to cause her to
reproduce the history of her ailment. The interest shown in her, the
understanding which we foreshadow, the hope of recovery extended to her,
all these will induce the patient to give up her secrets. With Miss
Elisabeth it seemed probable to me right from the very beginning that
she was conscious of the reasons for her suffering, that she had only a
secret but no foreign body in consciousness. On looking at her one had
to think of the poet’s words,
“That mask indicates a hidden meaning.”[16]
At first I could thus forego hypnosis, reserving it, however, for future
use if in the course of the confession conditions should arise for which
explanation the memory would not perhaps suffice. Thus in this first
complete analysis of a hysteria which I had undertaken, I reached a
process of treatment which later I raised into a method and employed it
consciously in the process of removing by strata the pathogenic psychic
material which we used to compare with the technique of excavating a
buried city. I at first allowed the patient to relate to me what was
known to her, paying careful attention wherever a connection remained
enigmatical or where a link in the chain of causation seemed to be
lacking. Later I penetrated into the deeper strata of memory by using
for those locations hypnotic investigation or a similar technique. The
presupposition of the whole work was naturally the expectation that a
perfect and sufficient determination could be demonstrated. The means of
the deeper investigation will soon be discussed.
The history which Miss Elisabeth gave was very dull and was woven of
manifold painful experiences. During this recital she was not in a
hypnotic state; I merely asked her to lie down and keep her eyes closed.
I however made no objection if she from time to time opened her eyes,
changed her position or sat up. Whenever she entered more deeply into a
part of her history she seemed to merge spontaneously into a condition
resembling a hypnotic state. She then remained motionless and kept her
eyes firmly closed.
I shall now reproduce the results of the superficial strata of her
memory. As the youngest of three daughters she spent her youth with her
parents, to whom she was devotedly attached, on their estate in Hungary.
Her mother’s health was frequently disturbed by an affliction of her
eyes and also by nervous conditions. It thus happened that she became
especially and devotedly attached to her jovial and broadminded father
who was wont to say that this daughter took the place of both a son and
friend with whom he could exchange his thoughts. As much as the girl
gained in mental stimulation in consequence of this intercourse it did
not escape the father that her psychic constitution deviated from that
ideal which one so much desires to see in a girl. Jocosely he called her
pert and disputatious. He warned her against being too confident in her
judgments, against her tendencies to tell the truth regardlessly to
everybody, and expressed his opinion that she would find it difficult to
get a husband. As a matter of fact she was very discontented with her
girlhood; she was filled with ambitious plans, wishing to study or
obtain a musical education, and revolted at the thought of being forced
to give up her inclination to sacrifice her freedom of judgment on
account of marriage. Meanwhile she was proud of her father, of the
regard and social position of her family, and jealously guarded
everything connected with these matters. The indifference with which she
treated her mother and older sisters, as will be shown, was considered
by her parents to be due to the blunter side of her character.
The age of the girls impelled the family to move into the metropolis,
where for a time Elisabeth enjoyed the richer and gayer life. But then
came the calamity which destroyed the happiness of the home. The father
either concealed or overlooked a chronic cardiac affection, and one day
he was brought home in an unconscious state after the first attack of
edema of the lungs. This was followed by an illness of one and a half
years, during which Elisabeth took the most prominent part in nursing
him. She slept in her father’s room, awoke at night at his call, watched
over him faithfully during the day, and forced herself to appear
cheerful while he went through a hopeless condition with amiable
resignation. The beginning of her affection must have been connected
with this time of her nursing, for she could recall that during the last
half year of this care she had to remain in bed on one occasion for a
day and a half on account of severe pain in the leg. She maintained,
however, that these pains soon passed away and excited neither worry nor
attention. As a matter of fact it was two years after the death of her
father that she began to feel sick and became unable to walk on account
of pain.
The gap which the father left in the life of this family consisting of
four women, the social solitude, the cessation of so many relations
which promised stimulation and pleasure, the increased infirmity of the
mother, all these clouded the mood of our patient, but simultaneously
stimulated a warm desire that the family might soon find a substitute
for the lost happiness and urged her to concentrate her entire devotion
and care on the surviving mother. At the end of the mourning year the
eldest sister married a talented and ambitious man of notable position,
who by his mental capacity seemed to be destined for a great future, but
who, however, very soon developed a morbid sensitiveness and egotistic
perseveration of moods, and dared to show his disregard for the old lady
in the family circle. That was more than Elisabeth could endure. She
felt herself called upon to take up the fight against her brother-in-law
whenever he gave occasion for it, while the other women took lightly the
outburst of his excited temperament. To her it was a painful
disillusionment to find that the reconstruction of the old family
happiness experienced such a disturbance. She could not forgive her
married sister because with feminine docility she strove to avoid
espousing her cause. Thus a whole series of scenes remained in
Elisabeth’s memory to which were attached a number of partially uttered
grievances against her first brother-in-law. But what she reproached him
most for was the fact that for the sake of a promotion in view he moved
with his small family to a distant city in Austria and thus increased
the lonesomeness of her mother. On this occasion Elisabeth distinctly
felt her inability and helplessness to afford her mother a substitute
for the lost happiness, and the impossibility of following out the
resolution made at the death of her father.
The marriage of the second sister seemed to promise more for the future
of the family. The second brother-in-law, although not of the same
mental calibre as the first, was a man after the heart of delicate
ladies, and his behavior reconciled Elisabeth to the matrimonial
institution and to the thought of the sacrifice connected with it. What
is more the second couple remained near her mother, and the child of
this brother-in-law and the second sister became Elisabeth’s pet.
Unfortunately the year during which the child was born was clouded by
another event. The visual affliction of the mother demanded many weeks’
treatment in a dark room, in which Elisabeth participated. Following
this an operation proved necessary and the excitement connected with
this occurred at the same time that the first brother-in-law made
preparations to move. Finally the operation, skilfully performed, proved
successful, and the three families met at a summer resort. There
Elisabeth, exhausted by the worries of the past months, had the first
opportunity to recuperate from the effects of the suffering and anxiety
that the family had undergone since the death of her father.
But during the time spent at this resort Elisabeth was attacked by the
pain and weakness. Afterwards, the pains, which had become noticeable
for a short while some time previously, manifested themselves severely
for the first time after taking a warm bath at a small watering place.
In connection with this it was thought that a long walk, really a walk
of half a day, a few days, previously, had some connection with the
onset of the pains. This readily produced the impression that Elisabeth
at first became “fatigued” and then “caught cold.”
From this time on Elisabeth became the patient in the family. Following
the advice of the physician she spent the rest of the summer in the
watering place at Gastein, whither she went with her mother, but not
without having a new worriment to think about. The second sister was
again pregnant and information as to her condition was quite
unfavorable, so that Elisabeth could hardly decide to take the journey
to Gastein. After barely two weeks at Gastein both mother and sister
were recalled as the patient at home did not feel well.
An agonizing journey, which for Elisabeth was a mixture of pain and
anxious expectations, was followed by certain signs at the home railroad
station which forebode the worst, and then on entering the chamber of
the patient they were confronted with the reality—that they arrived too
late to take leave of the dying one.
Elisabeth not only suffered from the loss of this sister whom she dearly
loved but was also grieved by the thoughts caused by her death and the
changes which it caused. The sister had succumbed to heart trouble which
was aggravated by the pregnancy.
She then conceived the thought that the heart trouble was the paternal
inheritance. It was then recalled that in her early childhood the
deceased went through an attack of chorea with a slight heart affection.
The family then blamed themselves and the physicians for permitting the
marriage. They could not spare reproaches to the unfortunate widower for
impairing the health of his wife by two successive pregnancies without
any pause. The sad thought that this happiness should terminate thus,
after the rare conditions for a happy marriage had been found,
thereafter constantly occupied Elisabeth’s mind. Moreover, she again saw
everything fail that she had planned for her mother. The widowed
brother-in-law was inconsolable and withdrew from his wife’s family. It
seemed that his own family from whom he was estranged during his short
and happy married life took advantage of the opportunity to again draw
him into their own circle. There was no way of maintaining the former
union; to live together with the mother-in-law was improper out of
regard for the unmarried sister-in-law, and inasmuch as he refused to
relinquish the child, the only legacy of the deceased, to the two
ladies, he for the first time gave them the opportunity of accusing him
of heartlessness. Finally, and that was not the least painful thing,
Elisabeth received some indefinite information concerning a disagreement
between the two brothers-in-law, the occasion for which she could only
surmise. It seemed as if the widower made some requests concerning
financial matters which the other brother-in-law considered
unjustifiable, and thought, that in view of the recent sorrow of his
mother, it was nothing but an evil extortion. This then was the history
of the young woman of ambitious and loving disposition. Resentful of her
fate, embittered over the failures of her little plans to restore the
lustre of the home; of her beloved ones, some being dead, some away, and
some estranged— without any inclination to seek refuge in the love of a
strange man, she lived thus for a year and a half nursing her mother and
her pains, separated from almost, all social intercourse.
If we forget the greater sufferings and place ourselves in this girl’s
position, we can but extend to Miss Elisabeth our hearty sympathy. But
what is the physician’s interest in this sorrowful tale; what is its
relation to her painful and her weak gait; what outlook is there for
explaining and curing this case by the knowledge which we perhaps
obtained from these psychic traumas?
For the physician this confession of the patient signified at first a
great disappointment, for to be sure it was a history composed of banal
mental shocks from which we could neither explain why the patient became
afflicted with hysteria nor how the hysteria assumed the form of the
painful abasia. It explained neither the causation nor the determination
of the hysteria in question. We could perhaps assume that the patient
had formed an association between her psychically painful impressions
and bodily pains which she accidentally perceived simultaneously, and
that now she made use in her memory of the physical sensation as a
symbol for the psychic. What motive she had for this substitution and in
what moment this came about remained unexplained. To be sure, these were
questions whose nature was not familiar to the physicians. For it was
customary to content one’s self with the information and to assume that
the patient was constitutionally hysterical and that under the intensive
pressure of any kind of excitement hysterical symptoms could develop.
Even less than for the explanation did this confession offer for the
treatment of the case. One could not conceive what beneficial influence
Miss Elisabeth could derive from recounting sad familiar family
experiences of the past years to a stranger who could give her in return
only moderate sympathy, nor could we perceive any improvement after the
confession. During the first period of the treatment the patient never
failed to repeat to her physician: “I continue to feel ill, I have the
same pains as before,” and when she accompanied this by a crafty and
malicious glance, I could perhaps recall the words which old Mr. v. R.
was wont to utter concerning his favorite daughter: “She is frequently
pert and disputatious,” but after all I had to confess that she was
right.
Had I given up the patient at this stage of the psychic treatment the
case of Miss Elisabeth v. R. would have been quite unimportant for the
theory of hysteria. Nevertheless, I continued my analysis because I felt
sure that an understanding of the causation as well as the determination
of the hysterical symptoms could be gained from the deeper strata of
consciousness.
I therefore decided to put the direct question to the broadened
consciousness of the patient, in order to find out with what psychic
impression the origin of the pain in the legs was connected.
For this purpose the patient should have been put in deep hypnosis. But
unhappily I had to realize that all my procedures in that direction
could put the patient in no other state of consciousness than that in
which she gave me her confession. Still I was very pleased that this
time she abstained from triumphantly remonstrating with the words: “You
see, I really do not sleep, I cannot be hypnotized.” In such despair I
conceived the idea of making use of the trick of pressing the head, the
origin of which I have thoroughly discussed in the preceding
contribution concerning Miss Lucy. This was done by requesting the
patient to unfailingly inform me of what came before her mind’s eye or
passed through her memory at the moment of the pressure. For a long time
she was silent, and then admitted that on my pressure she thought of an
evening in which a young man had accompanied her home from some social
affair. She also thought of the conversation that passed between them,
and her feelings on returning home to nurse her father.
With this first mention of the young man a new shaft was opened, the
content of which I now gradually brought out. We dealt here rather with
a secret, for with the exception of a mutual friend, no one knew
anything of the relation and the hopes connected with it. It concerned
the son of an old friend who was formerly one of their neighbors. The
young man having become an orphan attached himself with great devotion
to her father; he was guided in his career by his advice, and this
veneration for the father was extended to the ladies of the family.
Numerous reminiscences of repeated joint readings, exchange of thoughts
and utterances on his side marked the gradual growth of her conviction
that he loved and understood her and that a marriage with him would not
impose the sacrifice that she feared. Unhappily he was but little older
than she and as yet was far from being independent. She however firmly
resolved to wait for him.
With the serious illness of her father, and the necessity of her nursing
him their relations became less frequent. The evening which she at first
recalled marked the height of her feeling, but even then there was no
exchange of ideas between them on the subject. It was only at the urging
of her family that she consented to leave the sick bed that evening and
go to an affair where she was to meet him. She wished to hasten home
early but was forced to remain, only yielding on his promising to
accompany her home. At no time had she entertained such a tender regard
for him as during this walk, but after returning home at a late hour in
this blissful state and finding the condition of her father aggravated
she bitterly reproached herself for having sacrificed so much time for
her own amusement. It was the last time that she left her sick father
for a whole evening; her friend she saw but seldom after this. After the
death of her father he seemed to hold himself aloof out of respect for
her sorrow and then business affairs drew him into other spheres.
Gradually she came to the realization that his interest in her was
suppressed by other feelings and that he was lost to her. This failure
of her first love pained her as often as she thought of it.
In this relationship and in the scene caused by it, I was to seek the
causation of the first hysterical pain. A conflict, or a state of
incompatibility arose through the contrast between the happiness which
she had not at that time denied herself and the sad condition in which
she found her father upon her arrival home. As a result of this conflict
the erotic presentations were repressed from the associations, and the
affect connected with them was made use of in aggravating or reviving a
simultaneously (or somewhat previously) existing physical pain. It was
therefore the mechanism of a conversion for the purpose of defense as I
have shown circumstantially in another place.[17]
To be sure, we have room here for all kinds of observations. I must
assert that I was unsuccessful in demonstrating from her memory that the
conversion took place in the moment of her returning home. I therefore
investigated for similar experiences which might have occurred while she
was nursing her father, and I evoked a number of scenes, among which was
one during which she had to jump out of bed with bare feet in a cold
room to respond to the repeated calls of her father. I was inclined to
attribute to this moment a certain significance, for in addition to
complaining of pain in her legs she also complained of tormenting
sensations of coldness. Nevertheless, here, too I could not with
certainty lay hold of the scene which could be indicated as the scene of
conversion. This led me to admit that there was here some gap, when I
recalled the fact that the hysterical pains in the legs were really not
present at the time she nursed her father. From her memory she recalled
only a single attack of pain lasting a few days to which at that time
she paid no attention. I then directed my attention to the first
appearance of the pains. In this respect I was successful in awakening a
perfect memory. They came on just at the time of a relative’s visit whom
she could not receive because she was ill in bed, and who had the
misfortune to find her ill in bed on another occasion two years later.
But the search for the psychic motive of these first pains failed as
often as repeated. I believed that I could assume that these first pains
were due to a slight rheumatic attack and really had no psychic basis,
and I also discovered that this organic trouble was the model for the
later hysterical imitation, at all events that it occurred before the
scene of being accompanied home. That these mild organic pains could
continue for some time without her paying much attention to them is
quite possible when we consider the nature of the disease. The obscurity
resulting from this, namely, that the analysis pointed to a conversion
of psychic excitement into bodily pain at a time when such pain was
certainly not perceived and not recalled—this problem I hope to be able
to solve in later considerations and by other examples.[18]
With the discovery of the motive for the first conversion we began a
second more fruitful period of the treatment. In the first place very
soon afterward the patient surprised me with the statement that she now
knew why the pains always radiated from that definite location on the
right thigh and were most painful there. This is really the place upon
which her father’s leg rested every morning while she changed the
bandages of his badly swollen leg. That occurred hundreds of times, and
strange to say she did not think of this connection until today. She
thus gave me the desired explanation of the origin of an atypical
hysterogenic zone. Furthermore during our analysis her painful legs
always commenced to “join in the discussion.” I mean the following
remarkable state of affairs: The patient was as a rule free from pain
when we began our work, but as soon as I evoked some recollection by
question or by pressure of the head she at first reported some pain
usually of a very vivid nature, and then winced and placed her hand on
the painful area. This awakened pain remained constant as long as the
patient was controlled by the recollection, reaching its height when she
was about to utter the essential and critical part of her communication,
and disappearing with the last words of the statement. I gradually
learned to use this awakened pain as a compass. Whenever she was moody
or claimed to have pains I knew that she had not told me everything, and
urged a continuation of the confession until the pain was “spoken away.”
Then only did I awaken a new recollection.
During this period of ab-reaction, the patient’s condition showed such a
striking improvement both somatically and psychically that I used to
remark half jokingly that during each treatment I carried away a certain
number of pain motives, and that when I had cleaned them all out she
would be well. She soon reached a stage during which she had no pain
much of the time; she consented to walk a great deal and to give up her
hitherto condition of isolation. During the analysis I followed up now
the spontaneous fluctuations of her condition and now some fragments of
her sorrowful tale which in my opinion I had not sufficiently exhausted.
In this work I made some interesting discoveries the principles of which
I could later verify in other patients.
In the first place it was found that the spontaneous fluctuations never
occurred unless provoked associatively by the events of the day. On one
occasion she heard of an illness in the circle of her acquaintances
which recalled to her a detail in the illness of her father. On another
occasion the child of her deceased sister visited her and its
resemblance to its mother recalled many painful incidents. On still
another occasion it was a letter from her absent sister showing
distinctly the influence of the inconsiderate brother-in-law, and this
awakened a pain causing the reproduction of a family scene heretofore
not reported.
As she never reproduced the same pain motives twice we were justified in
the expectation that the stock would in time become exhausted. I never
prevented her from merging into a situation tending to evoke new
memories which had not as yet come to the surface. Thus for example I
sent her to the grave of her sister, or I urged her to go in society
where she was apt to meet her youthful friend who happened to be in the
city.
In this manner I obtained an insight into the mode of origin of a
hysteria which could be designated as monosymptomatic. I found, for
example, that the right leg became painful during our hypnosis when we
dealt with memories relating to the nursing of her father, to her young
friend, and to other memories occurring during the first period of the
pathogenic term; while the pain in the left leg came on as soon as I
evoked the memory of her lost sister, of both brothers-in-law, in brief
of any impression relating to the second half of the history. My
attention having been called to that by this constant behavior I went
further in my investigations and gained the impression that perhaps
detailization went still further and that every new psychic cause of
painful feeling might have some connection with a differently located
painful area in the legs. The original painful location on the right
thigh referred to the nursing of her father, and as the result of new
traumas the painful area then grew by apposition so that strictly
speaking we had here not one single physical symptom connected with a
multiform psychic memory complex but a multiplicity of similar symptoms
which on superficial examination seemed to be fused into one. To be sure
I have not followed out the demarcations of the individual psychic
causes corresponding to the pain zones for I found that the patient’s
attention was turned away from these relations.
Notwithstanding this I directed further interest to the mode of
construction of the whole symptom-complex of the abasia upon this
painful zone, and with this view in mind I asked such questions as this:
“What is the origin of the pains in walking and standing, or on lying?”
She answered these questions partially uninfluenced, partially under the
pressure of my hand. We thus obtained two results. In the first place
she grouped all scenes connected with painful impressions according to
their occurrence, sitting, standing, etc. Thus, for example, she stood
at the door when her father was brought home with his cardiac attack and
in her fright remained as though rooted to the spot. To this first
quotation “fright while standing” she connected more recollections up to
the overwhelming scene when she again stood as if pinned near the death
bed of her sister. The whole chain of reminiscences should justify the
connection of the pain with standing up, and could also serve as an
association proof, only one had to bear in mind the fact that in all
these occasions we must demonstrate another moment which had served to
direct the attention—and as a further result the conversion—just on the
standing, walking, sitting, etc. The explanation for this direction of
attention could hardly be sought in other connections than in the fact
that walking, standing, and lying are connected with capabilities and
conditions of those members which here bore the painful zones; namely,
the legs. We could then easily understand the connection between the
astasia-abasia and the first scene of conversion in this history.
Among the scenes which in consequence of this review had made the
walking painful one which referred to a walk she had taken in company,
at the watering place, which apparently lasted too long, stood out most
prominently. The deeper circumstances of this occurrence revealed
themselves only hesitatingly and left many a riddle unsolved. She was in
an especially good humor and gladly joined the circle of friendly
persons; it was a lovely day, not too warm, her mother remained at home;
her older sister had already departed, the younger one felt indisposed
but did not wish to mar her pleasure. The husband of the second sister
at first declared that he would remain at home with his wife, but
finally went along for her (Elisabeth’s) sake. This scene seemed to have
a great deal to do with the first appearance of the pains, for she
recalled that she returned home from the walk very fatigued and with
severe pains, she could not however say definitely whether she had
perceived the pains before this. I took for granted that if she had
suffered any pain she would have hardly resolved to enter upon this long
walk. On being questioned whence the pains originated on this walk she
answered rather indefinitely saying that the contrast between her
solitude and the married happiness of her sick sister, of which she was
constantly reminded by the behavior of her brother-in-law, was painful
to her.
Another closely related scene played a part in the connection of the
pain with sitting. It was a few days later, her sister and
brother-in-law had already departed and she found herself in an
excitable longing mood. She arose in the morning and ascended a small
hill which they were wont to visit together and which afforded the only
pretty view. There she sat down on a stone bench giving free play to her
thoughts. Her thoughts again concerned her lonesomeness, the fate of her
family, and she now frankly admitted that she entertained the eager wish
to become as happy as her sister. After this morning’s meditation she
returned home with severe pains. In the evening of the same day she took
the bath, after which the pains definitely appeared and continued
persistently.
We could further ascertain with great certainty that the pains on
walking and standing diminished in the beginning on lying down. Only
after hearing of her sister’s illness and on leaving Gastein in the
evening, spending a sleepless night in the sleeping car, and being
tormented simultaneously by the worries concerning her sister and
violent pains, it was only then that the pains appeared for the first
time while she was lying down, and throughout that time lying down was
even more painful than walking or standing.
Thus the painful sphere grew by apposition first because every new
pathogenically affecting theme occupied a new region of the legs,
second, every one of the impressionable scenes left a trace because it
produced a lasting, always more cumulative, “occupation” of the
different functions of the legs, thus connecting these functions with
the sensations of pain. There was unmistakably, however, still a third
mechanism which furthered the production of astasia-abasia. When the
patient finished the recitation of a whole series of events with the
plaint that she then perceived pain in “standing alone,” and when in
another series referring to the unfortunate attempt of bringing about
new conditions in the family she was not tired of repeating that the
painful in that was the feeling of her helplessness, the sensation that
she “could make no headway,” I had to admit that her reflections
influenced the formation of the abasia, and had to assume that she
directly sought a symbolic expression for her painfully accentuated
thoughts and had found it in the aggravation of her pains. That somatic
symptoms of hysteria could originate through such symbolization we have
already asserted in our Preliminary Communication, and in the epicrisis
to this history. I will give some examples of conclusive evidence. In
Miss Elisabeth v. R. the psychic mechanism of the symbolization was not
in the foreground, it had not produced the abasia, but everything
pointed to the fact that the already existing abasia had in this way
undergone a considerable reinforcement. Accordingly this abasia as I met
it in the stage of development was not only to be compared to a
psychically associative paralysis of function but also to a symbolic
paralysis of function.
Before I continue with the history of my patient I will add something
about her behavior during the second period of the treatment. Throughout
this whole analysis I made use of the method of evoking pictures and
ideas by pressing the head, a method therefore, which would be
inapplicable without the full cooperation and voluntary attention of the
patient. At times it was really surprising how promptly and how
infallibly the individual scenes belonging to one theme succeeded each
other in chronological order. It was as if she read from a long picture
book the pages of which passed in review before her eyes. At other times
there seemed to be inhibitions, of what kind I could not at that time
surmise. When I exerted some pressure she maintained that nothing came
into her mind. I repeated the pressure and told her to wait, but still
nothing would come. At first when such obstinacy manifested itself I
determined to discontinue the work and to try again, as the day seemed
unpropitious. Two observations, however, caused me to change my
procedure. Firstly, because such failure of this method only occurred
when I found Elisabeth cheerful and free from pain and never when she
had a bad day; secondly, because she frequently made assertions of
seeing nothing after the lapse of a long pause during which her tense
and occupied mind betrayed to me some psychic process within. I
therefore decided to assume that the method had never failed, that under
the pressure of my hands Elisabeth had each time perceived some idea or
had seen some picture but that she was not always ready to inform me of
it and attempted to repress the thing evoked. I could think of two
motives for such concealment; either Elisabeth subjected the idea that
came to her mind to a criticism to which she was not entitled, thinking
it not sufficiently important and unfit as an answer to the question, or
she feared to say it because that statement was too disagreeable to her.
I therefore proceeded as if I were perfectly convinced of the
reliability of my technique. Whenever she asserted that nothing came
into her mind, I did not let that pass. I assured her that something
must have come to her but that perhaps she was not attentive enough,
that I was quite willing to repeat the pressure. I also told her not to
entertain any doubts concerning the correctness of the idea presenting
itself to her mind, that that was not any of her concern; that it was
her duty to remain perfectly objective and to tell whatever came into
her mind, be it suitable or not, and I ended by saying that I knew well
that something did come which she concealed from me and that as long as
she would continue to do so she would not get rid of her pains. After
such urging I found that there was really no pressure that remained
unsuccessful. I then had to assume that I correctly recognized the state
of affairs, and indeed I won through this analysis perfect confidence in
my technique. It often happened that only after the third pressure did
she make a statement then added “Why I could have told you that the
first time”—“Indeed why did you not say it”—“I thought that it was not
correct:” or “I thought that I could avoid it, but it recurred each
time.” During this difficult work I began to attach a profounder
significance to the resistance which the patient showed in the
reproduction of her recollections, and I carefully compared those
occasions in which it was especially striking.
I now come to the description of the third period of our treatment. The
patient felt better, she was psychically unburdened and more capable,
but the pains were manifestly not removed, reappearing from time to time
with the old severity. The imperfect cure went hand in hand with the
imperfect analysis, as yet I did not know in what moment and through
what mechanisms the pains originated. During the reproduction of the
most manifold scenes of the second period and the observation of the
patient’s resistance towards the reproduction, I formed a definite
suspicion which I did not then dare to use as a basis for my action. An
accidental observation turned the issue. While working with the patient
one day I heard the steps of a man in the adjacent room and a rather
pleasant voice asking some questions. My patient immediately arose
requesting me to discontinue the treatment for the day because she heard
her brother-in-law who just arrived asking for her. Before this
disturbance she was free from pains, but thereafter she betrayed by her
mien and gait the sudden appearance of violent pains. This strengthened
my suspicion and I decided to elicit the decisive explanation.
I questioned her concerning the circumstances and causes of the first
appearance of the pains. Her thoughts were directed to the summer resort
in that watering place where she had been before taking the journey to
Gastein. A number of scenes were reproduced which had already been
treated less exhaustively. They recalled her frame of mind at that time,
the exhaustion following the worriment about her mother’s vision and the
nursing of her mother during the time of the operation and her final
despair at being unable as a lonesome girl to enjoy life or to
accomplish anything in life. Until then she felt strong enough to
dispense with the help of a man, but now she was controlled by a feeling
of her womanly weakness, a yearning for love in which, to put it in her
own words, “her obdurate self began to soften.” In such humor the happy
marriage of her younger sister made the profoundest impression on her.
She thought how affectionately he cared for her, how they understood
each other with a mere glance, and how sure they seemed to be of each
other. It was truly regrettable that the second pregnancy followed so
quickly the first and her sister knew that this was the cause of her
suffering but how willingly she endured it and all because he was the
cause of it. The brother-in-law did not at first wish to participate in
the walk which was so intimately connected with Elisabeth’s pain; he
preferred to remain home with his sick wife, but the latter urged him
with a glance to go because she thought that would give Elisabeth
pleasure. Elisabeth remained with him throughout the whole walk; they
spoke about the most varied and intimate things; she found herself in
thorough accord with all he said, and she became overwhelmed with the
desire to possess a man like him. This was followed by a scene a few
days later, when, on the morning after their departure, she visited the
point commanding the beautiful view which had been their favorite walk.
There she seated herself upon a stone and again dreamed of her sister’s
happiness and of a man like her brother-in-law who could engage her
affections. When she arose she had pains which again disappeared, and
only in the afternoon after having taken the warm bath did they
reappear, remaining ever since. I attempted to investigate the thoughts
which occupied her mind while taking the bath, but all I could obtain
was that the bath house recalled her absent sister because she had lived
in the same house.
For some time the state of affairs was clear to me. Absorbed in
painfully sweet recollections she was wholly unconscious of the drift of
her thoughts and continued to reproduce her reminiscences, the time in
Gastein, the worry connected with the expectations of the letter,
finally the information of her sister’s illness, the long wait until the
evening when she could first leave Gastein, the journey with its
tormenting uncertainties during a sleepless night—all these moments were
accompanied by a violent aggravation of the pain. I asked her if during
the journey she thought of the sad possibility which she afterward found
realized. She answered that she carefully avoided the thought but that
in her opinion her mother expected the worst from the very beginning.
This was followed by the reminiscences of her arrival in Vienna—the
impressions which she received from the relatives at the station, the
short journey from Vienna to the neighboring summer resort where her
sister lived, the arrival in the evening, the hasty walk through the
garden to the door of the little garden pavilion—a silence in the house,
the oppressive darkness, the fact of not having been received by the
brother-in-law. She then recalled standing before the bed seeing the
deceased, and in the moment of the awful certainty that the beloved
sister had died without having taken leave of them and without having
her last days eased through their nursing—in that very moment another
thought flashed through Elisabeth’s brain which now peremptorily
repeated itself. The thought which flashed like dazzling lightning
through the darkness was, “Now he is free again, and I can become his
wife.”
Of course, now everything was clear. The analyzer’s effort was richly
repaid. The ideas of the “defense” (abwehr) against an unbearable
presentation, the origin of hysterical symptoms through conversion of
psychic into physical excitement, the formation of a separate psychic
group by an arbitrary act, leading to the defense—all these were in that
moment palpably presented before my eyes. Thus and thus alone did things
happen here. This girl entertained an affectionate regard for her
brother-in-law against the acceptance of which into her consciousness
her whole moral being struggled. She succeeded in sparing herself the
painful consciousness that she was in love with her sister’s husband by
creating for herself instead bodily pains, and in the moment when this
certainty wished to thrust itself into her consciousness (while she
walked with him, during that morning reverie, in the bath, and before
her sister’s bed) her pains originated by means of a successful
conversion into the somatic. When she came under my care there was
already a complete isolation from her consciousness of the presentation
group referring to this love, else, I believe that she would never have
agreed to such a treatment. The resistance which she repeatedly brought
forth during the reproduction of traumatically produced scenes really
corresponded to the energy with which the unbearable presentation had
been crowded out from the association.
For the therapeutist there now came a sorry time. The effect of the
resumption of that repressed presentation was a crushing one for the
poor child. When I summed up the whole situation with these prosaic
words: “you were really for a long time in love with your
brother-in-law,” she complained of the most horrible pains at that
moment; she made another despairing effort to reject the explanation,
saying that it was not true, that I suggested it to her, it could not
be, she was incapable of such baseness, and that she would never forgive
herself for it. It was quite easy to prove to her that her own
information allowed no other interpretation, but it took a long time
before the two reasons that I offered for consolation, namely, that one
is not responsible for one’s feelings and that her behavior, her
sickness under those circumstances was sufficient proof of her moral
nature—I say it took a long time before these consolations made an
impression on her. I was now forced to pursue more than one course in
order to calm the patient. In the first place I wished to give her the
opportunity to rid herself by ab-reaction of the material long since
accumulated. We investigated the first impressions of the relations with
her brother-in-law, the beginning of those unconsciously kept
affectionate regards. We found here all those little indications and
forebodings which on a retrospective view showed a fully developed
passion. On his first visit to the house he mistook her for his destined
bride and greeted her before he greeted her older and homely sister. One
evening they entertained each other so vivaciously and seemed to
understand each other so well that the bride interrupted them with this
half serious remark: “You two, indeed, would have suited each other very
nicely.” On another occasion while in a gathering who were ignorant of
the engagement the conversation drifted to the young man, and a young
lady indiscreetly remarked about a blemish in his shape, a juvenile
joint affliction. The bride herself remained calm while Elisabeth flew
into a passion, and with an ardor which even she herself could not
afterward understand she defended the straight form of her future
brother-in-law. While we worked our way through these reminiscences it
became clear to Elisabeth that her affection for her brother-in-law had
slumbered in her for a long time, perhaps since the beginning of their
relations, and had concealed itself so long under the mask of a mere
kinsmanlike affection as only her very delicate family feeling would
allow.
This ab-reaction benefited her much but I was able to give her still
more relief by taking a friendly interest in her present state of
affairs. With this object in view I sought an interview with Mrs. v. R.
whom I found to be an intelligent and refined lady whose courage to face
life, however, was somewhat lessened through the last misfortune. From
her I learned that the accusation of rude extortion which the older
brother-in-law had brought against the widower, and which was so painful
to Elisabeth, had to be retracted on closer investigation. The character
of the young man remained untarnished, it was merely a misunderstanding,
an easily conceived difference of opinion concerning the valuation of
money that could arise between the merchant, to whom money is only a
working tool, and the official—that is all there was to this seemingly
so painful incident. I begged the mother to give Elisabeth all
explanations that she might hereafter need, and to offer her in the
future that opportunity for unburdening her mind to which I had
accustomed her.
Naturally I was also anxious to know what chance there was for the
fulfilment of the girl’s present conscious wish. Here things were less
favorable! The mother stated that for some time she had had an inkling
of Elisabeth’s affection for her brother-in-law, of course she did not
know that it existed during the lifetime of her sister. Whoever saw them
both in friendly intercourse—of late, to be sure, only seldom—could
entertain no doubt of the girl’s anxiety to please him. However, neither
she, her mother, nor the advisers of the family showed any particular
inclination to bring about a matrimonial union between the two. The
health of the young man had not been very good and had received a
setback through the death of his beloved wife, and it was not at all
certain that he had sufficiently recovered from the shock to enter into
a new matrimony. It was quite probable that this was the reason for his
reserve, perhaps also because he was not sure of his position, and
wished to avoid all obvious gossip. With such a reserve on both sides
the solution for which Elisabeth was yearning was likely to fail.
I informed the girl of everything that I had heard from her mother and
had the satisfaction of seeing her benefited by the explanation
concerning the money affair. On the other hand, I expected her to bear
calmly the uncertainties of her future which could not be set aside. The
advancing summer compelled us to bring the treatment to an end. She now
felt better, and since we had discussed the causes to which the pain
could be traced she no longer complained of pain. We both felt that the
work was done, although I thought that the ab-reaction of the suppressed
love was really not as complete as it should have been. I regarded her
as cured and urged her to continue independently the solution after the
way had been cleared, to which she agreed. She left with her mother for
a summer resort where they were to join the older sister and her family.
I still have something more to report about the further course of Miss
Elisabeth v. R.’s disease. A few weeks after our parting I received a
despairing letter from her mother informing me that at the first attempt
to draw Elisabeth into a conversation about her love affairs she became
very excited and refused to talk, and since then had suffered from
violent pains. She was very indignant at my having betrayed her
confidence and was perfectly inaccessible so that the treatment seemed a
complete failure. She wished to know what was to be done, for of me she
would hear nothing. I made no reply. It was to be expected that after
she was relieved from my discipline she would make another attempt to
reject her mother’s interference and return to her inaccessibility. I
was, however, quite certain that everything would adjust itself and that
my efforts had not been in vain. Two months later they returned to
Vienna and the colleague to whom I was grateful for the case informed me
that Elisabeth was perfectly well, and that her behavior was normal
although occasionally she had slight pains. Since then she has
repeatedly sent me similar messages, each time promising to visit me,
which she has never done. This is quite characteristic of the personal
relationship formed during such treatment. My colleague then assured me
that she could be considered cured. The relation of the brother-in-law
to the family underwent no change.
In the spring of 1894 I was informed that she would be present at a
private ball to which I could gain access. I did not let the opportunity
escape me and saw my former patient gliding along in a rapid dance.
Since then, following her own inclination, she has married a stranger.
EPICRISIS.
I was not always a psychotherapist but like other neuropathologists I
was educated to the use of focal diagnosis and electrical prognosis so
that even I myself am struck by the fact that the histories of the
diseases which I write read like novels and, as it were, dispense with
the serious features of the scientific character. Yet I must console
myself with the fact that the nature of the subject is apparently more
responsible for this issue than my own predilection. Focal diagnosis and
electrical reactions are really not important in the study of hysteria,
whereas a detailed discussion of the psychic processes, as one is wont
to receive it from the poet, and the application of a few psychological
formulæ, allows one to gain an insight into the course of events of
hysteria. Such histories should be considered like psychiatrical ones,
but they have the advantage over the latter in the fact that they give
the intimate connection between the history of the disease and the
morbid symptoms, a thing for which we still look in vain in the
biographies of other psychoses.
With the description of the treatment I endeavored to interweave the
explanations which I gave about the case of Miss Elisabeth v. R. and it
will perhaps be superfluous to summarize here the essential features. I
have discussed the character of the patient and the features which
repeat themselves in so many hysterics, and which we really can not
consider as degenerative. I mentioned the talent, the ambition, the
moral sensitiveness, the immense yearning for love which found its
gratification in the family, the independence of her nature reaching
beyond the womanly ideal which manifested itself largely by obstinacy,
readiness for fight, and inaccessibility. According to the information
of my colleague no hereditary taints could be shown on either side of
the family. Her mother, to be sure, suffered for years from some
indefinite neurotic depression, but her brothers and sisters, her father
and his family belonged to the even-tempered and not to the nervous.
There was no serious case of neuropsychosis in the nearest relatives.
This nature was acted upon by painful emotions, the foremost of which
was the debilitating influence of a long attendance upon her beloved
sick father.
That nursing of the sick plays such a significant rôle in the histories
of hysterias has its good reasons. A number of effective moments which
are found here are quite obvious, namely, the disturbance of the
physical health through interrupted sleep, neglect of nourishment, and
the reaction of a constantly gnawing worriment on the vegetative
functions; but the most important factor, however, is, in my estimation,
to be found elsewhere. He whose mind is occupied with the hundred
different tasks of nursing which succeed each other continuously for
weeks and months, becomes accustomed, on the one hand, to suppress all
signs of his own emotions, and on the other, his attention is soon
turned away from his own impressions because he has neither the time nor
strength to do them justice. Thus the nurse accumulates for himself an
over abundance of affective impressions which he barely perceived
clearly enough, at any rate they were not weakened by ab-reaction, that
is, he creates for himself the material for a retention hysteria. If the
patient recovers these impressions naturally become reduced in value,
but if he dies and the period of mourning comes during which only that
which refers to the deceased seems of value, the impressions waiting for
discharge appear in turn, and after a brief pause of exhaustion the
hysteria, the germ of which originated during the nursing, bursts forth.
The same subsequent discharge of traumas accumulated during nursing is
occasionally encountered where the general impression of the disease
does not ensue, and yet the mechanism of hysteria can be noticed. Thus,
I know a highly gifted but slightly nervous lady whose whole personality
suggests the hysteric though she never became a burden to the doctor and
was never obliged to interrupt the exercise of her duties. This lady had
nursed three or four of her beloved ones until their death, causing her
each time complete physical exhaustion, yet these sad duties never made
her ill. However, shortly after the death of the patient she began the
work of reproduction, bringing again to her view the scenes of the
disease and death. Each day—one might say at her leisure—she went over
again every impression, crying and consoling herself. Such adjustment
she passed through daily in conjunction with her usual duties, without,
however confusing the two activities. Everything passed before her
chronologically. Whether the memory work of one day precisely
corresponded to a day of the past I am unable to say. I presume that it
depended on the leisure which was allowed to her by the current affairs
of the household.
Aside from this “subsequent tear” which attached itself to these deaths
at short intervals, this lady periodically observed annual anniversaries
representing the time of the various catastrophes, and here her vivid
visual reproduction and her affective manifestations followed faithfully
the date. Thus, for example, I found her in tears, and on sympathetic
inquiry as to what occurred that day, she half irritably remarked,
“Nothing on that day except that Professor N. was again here and gave us
to understand that things were hopeless—at that time I had no time to
cry.” She referred to the last illness of her husband who died three
years before. It would have been very interesting to know whether she
always repeated the same scenes on these recurring anniversaries, or
whether as I suppose in the interest of my theory other details
presented themselves each time for ab-reaction. I was however, unable to
find anything definite about that; the wise and courageous woman was
ashamed of the intensity with which those reminiscences acted upon
her.[19]
I again repeat that this woman was not sick, that subsequent
ab-reaction, despite all resemblance, is still not a hysterical process;
one may ask why, after one nursing there results a hysteria and after
another none. It cannot lie in personal predisposition for the lady that
I have in mind showed it very remarkably.
I now return to Miss Elisabeth v. R. While nursing her father there
occurred for the first time an hysterical symptom in the form of a pain
in a definite location on the right thigh. The mechanism of this symptom
is fully explained on an analytical basis. It occurred in a moment
during which the ideas of her duties towards her sick father came into
conflict with the content of her erotic yearning which she then
entertained. Under vivid self reproach she decided in favor of the
former and created for herself the hysterical pain. According to the
conception explained by the theory of conversion in hysteria, the
process could be described as follows: She repressed the erotic idea
from her consciousness and changed the sum of the affect into somatic
sensations of pain. Whether this first conflict occurred only once, or
repeated itself is not clear. The latter is more probable. Quite a
similar conflict—of a higher moral significance, and even better
demonstrated by the analysis—repeated itself after years and led to the
aggravation of the same pain and to its dissemination beyond its
original limits. Again, it was an erotic idea which came into conflict
with all her moral conceptions, for her affection for her
brother-in-law, both during the life and after the death of her sister,
and the thought that she should yearn just for this man, was to her very
disagreeable. This analysis gives detailed information about this
conflict which represents the pivotal point in the history of her
malady. The patient’s affection for her brother-in-law might have begun
to germinate long ago, but in favor of its development was the physical
exhaustion through the recent nursing, and her moral exhaustion through
years of disillusionment which then began to break down her reserve and
she confessed to herself the need of the love of a man. During a
friendly intercourse continuing for weeks (in the summer resort) this
erotic inclination reached its full development simultaneously with the
pain. The analysis shows a special psychic condition of the patient at
that time, which in connection with her inclination and the pain, seems
to afford an understanding of the process in the sense of the conversion
theory.
I place reliance on the opinion that the patient’s affection for her
brother-in-law, intensive as it was, was not clearly known to her except
on certain rare occasions and then only momentarily. If that were not so
she would have become conscious of the inconsistency between this
fondness and her moral ideas and would have had to endure the same
mental agony which I saw her suffer after the analysis. Her
reminiscences gave us no information concerning such suffering. These
she spared herself and as a result the love itself did not become clear
to her. At that time, as well as during the analysis, her love for her
brother-in-law existed in the form of a foreign body in her
consciousness without entering into any relationship with her other
ideation. In reference to this love there existed the peculiar condition
of knowing and simultaneously not knowing, it was the condition of the
split off psychic group. When we assert that this love was not “clearly
known” to her we mean exactly what we say. We do not mean a lower
quality or a lesser degree of consciousness, but a separation of the
free associative thinking process from the rest of ideation.
How does it come about that such an intensively accentuated presentation
group should be kept so isolated? As a rule the rôle played by an idea
in the association really increases with the sum of its affect.
This question can be answered if we bear in mind two facts which we can
make use of as a safeguard: (1) That the hysterical pains originated
simultaneously with the formation of these separate psychic groups, (2)
that the patient exerted great resistance against the attempt to bring
about the association between the separate psychic groups and the rest
of the content of consciousness, and when the union was finally effected
she perceived excessive psychic pain. Our conception of hysteria brings
together these two moments with the fact of the splitting of
consciousness, for (2) contains the indication for the motive for the
splitting of consciousness while (1) shows the mechanism of the same.
The motive was that of defense, it was the striving of the whole ego to
agree with this presentation group and the mechanism was that of
conversion, that is, instead of psychic pains which she spared herself
there appeared physical pains. Thus a transformation occurred through
which gain the patient had escaped an unbearable psychic state, though
it was at the cost of a psychic anomaly in the form of a splitting of
consciousness and a physical suffering, pains, upon which an
astasia-abasia was constructed.
To be sure I can give no instruction as to how one can bring about such
a conversion. It is not apparently done as one intentionally does an
arbitrary action, it is a process which is executed in the individual
under the impulse of the motive of defense if an adaptation for it
exists in his organization or is brought about by temporary
modification.
One has the right to attack the theory more closely by asking what it is
that is transformed into physical pains. The cautious reply will be
something out of which psychic pains could have and should have been
formed. If we wish to venture further and attempt a kind of algebraic
formulation of the presentation mechanism we may attribute to the
presentation complex of this unconsciously remaining love a certain
amount of affect and designate the latter quantity as the thing
converted. Direct deduction of this conception would be the fact that
the “unconscious love” has through such conversion forfeited so much of
its intensity that it was reduced to a weak idea. Its existence as a
separate psychic group would only be made possible through such
weakening. Yet this present case is not suitable to afford us any
clearness in this delicate matter. It probably corresponds to an
imperfect conversion only. From other cases it seems quite probable that
perfect conversions also occur and that in these the unbearable idea
actually becomes repressed as only an idea of very little intensity
could be repressed. After an associative union has been consummated the
patients assure us that since the origin of the hysterical symptoms
their unbearable thoughts never occupied their minds.
I have stated above that on certain occasions, though only transitorily,
the patient consciously recognized the love for her brother-in-law. Such
a moment occurred when for example, at the death bed of her sister the
thought flashed through her mind, “Now he is free and I can become his
wife.” I must discuss the significance of these moments for the
conception of the whole neurosis. However, I think that the assumption
of a defense hysteria (abwehr hysterie) includes the requisite that at
least one such moment has already occurred. For consciousness does not
know in advance when such an unbearable idea will present itself. The
unbearable idea which with its appendix is later excluded for the
formation of a separate psychic group must have been originally in the
mind, otherwise no conflict would have resulted leading to its
exclusion.[20] Just such moments should be designated as “traumatic.” It
is in them that the conversion takes place which results in the
splitting of consciousness and the hysterical symptoms. Everything tends
to show that in Miss Elisabeth v. R. there were a number of such moments
(the scenes of the walking, morning meditation, bath, and at the bed of
her sister) and perhaps new moments of this kind occurred during the
treatment. The multiplicity of such traumatic moments is made possible
by the fact that an experience similar to the one which at first
initiated the unbearable idea, introduces new emotions to the separated
psychic groups and thus transitorily abolishes the success of the
conversion. The ego is forced to occupy itself with this suddenly
enforced and lighted-up idea, and then to restore the former state by
means of new conversions. Miss Elisabeth who was in constant relation
with her brother-in-law must have been particularly exposed to the
appearance of new traumas.
I must now occupy myself with the point which I have designated as a
difficulty for the understanding of the afore mentioned history. On the
analytical basis I assume that the first conversion took place in the
patient while she nursed her father, at the time when her duties as
nurse came into conflict with her erotic yearnings, and that this
process was the prototype for the later ones which led to the outbreak
of the disease in the Alpine watering place. But then we have it from
the patient’s statement that at the time of nursing and the period
following which I designated as the “first period” she had not suffered
at all from the pains and weakness. To be sure, during the illness of
her father she was once bedridden for a few days with pains in her legs,
but it is doubtful whether this attack already belonged to the hysteria.
A causal relation between these first pains and any psychic impressions
could not be demonstrated by analysis; it is possible, even probable,
that at that time we dealt with a common rheumatic muscular pain. Even
if we should assume that this first attack of pain was the result of a
hysterical conversion in consequence of the rejection of the erotic
thoughts then existing, the fact nevertheless remains that the pains
disappeared after a few days so that the patient actually behaved
differently than she did during the analysis. During the reproduction of
the so called first period all her statements concerning the illness and
death of her father, the impressions relating to her first
brother-in-law, etc., all these were accompanied by manifestations of
pain, while at the time she really experienced these impressions she
perceived no pains. Is this not a contradiction tending to considerably
diminish the confidence in the explanatory value of such an analysis?
I believe that I can explain the contradiction by assuming that the
pains—the product of the conversion—did not originate while the patient
experienced the impressions during the first period, but subsequently,
that is in the second period when the patient reproduced these
impressions in her mind. The conversion did not follow the fresh
impressions but the memories of them. I even believe that such a process
is not at all unusual in hysteria and regularly participates in creating
hysterical symptoms. Nevertheless, as such an assertion does not seem
plausible I shall attempt to make it more credible by citing other
experiences.
It once happened to me during a similar analysis that a new hysterical
symptom was formed during the treatment so that I could attempt its
removal on the day after its origin.
I will describe the essential features of the history of this patient.
They are simple but not without interest.
Miss Rosalia H., twenty-three years old, who for a number of years made
great effort to educate herself as a singer, complained that her
beautiful voice did not obey her in certain notes. There appeared
choking and tightening sensations in the throat so that the tones
sounded strained, and her teacher could therefore not allow her to
appear in public. Although this imperfection affected only her middle
notes it could not be explained to be due to a defect of her vocal
organs, for at times this disturbance was absent and her teacher was
very pleased with her, but at other times the slightest excitement,
seemingly without any provocation, evoked the choking sensation, and
prevented free expansion of the voice. It was not difficult to recognize
in this annoying sensation an hysterical conversion. Whether there
really appeared a contracture of certain muscles of the vocal chords I
have not verified.[21] In the hypnotic analysis which I undertook with
this girl I found out the following concerning her vicissitudes and her
ailments occasioned through them. She became an orphan at an early age
and was brought up at the house of an aunt who had many children of her
own, and she thus shared the life of a most unfortunate family. The
husband of this aunt, seemingly a pathological personality, abused his
wife and children in the most brutal manner and especially pained her by
his sexual preference for the servant girl in the house. This became
even more obnoxious as the children grew older. When the aunt died
Rosalia became the protectress of the orphaned children who were
harassed by their father. She took her duties seriously, fought through
all conflicts and had to exert her greatest efforts to suppress the
manifestations of her contempt for her uncle. It was then that the
choking sensation in her throat originated. Whenever she was compelled
to swallow an affront, whenever she had to remain silent on hearing a
provoking accusation she perceived a scratching in her throat, the
tightening and failure of her voice, in brief she had all the localized
sensations in her larynx and pharynx which now disturbed her in singing.
It was conceivable that she sought the possibility of making herself
independent in order to escape the excitement and painful impressions
which were daily occurrences in her uncle’s house. An efficient music
teacher took an unselfish interest in her, assuring her that her voice
entitled her to choose the profession of singing. She began secretly to
take lessons of him and because she often went for her lessons with the
choking sensation in her throat following some violent scene in the
house, a connection was formed between the singing and the hysterical
paresthesia for which a way was prepared by the sensitiveness of the
organ during singing. The apparatus of which she should have had free
control was filled with the remnants of innervation after those numerous
scenes of repressed excitement. Since then she has left the house of her
uncle, having moved to another city so as to be away from the family,
but her ailments were not benefited by it. No other hysterical symptoms
were discovered in this pretty and unusually bright girl.
I endeavored to cure this “retention hysteria” by a reproduction of all
the exciting impressions and by subsequent ab-reaction. I afforded her
the opportunity of railing against her uncle in long speeches and of
telling him the bare truth to his face, etc. The treatment benefited
her, but unfortunately she lived here under quite unfavorable
conditions. She had no luck with her relatives. She was the guest of
another uncle who treated her with friendliness, but just for that
reason she incurred the displeasure of her aunt. The latter believed
that her husband evinced too marked an interest in his niece and made it
a point of opposing the girl’s stay in Vienna. She herself in her youth
was obliged to relinquish a desire of becoming an artist and was now
jealous of her niece because she had the opportunity to develop her
talent not considering that it was not mere desire but a wish to become
independent which led her niece to take this step. Rosalia felt so
uncomfortable in the house that she for instance, did not dare to sing
or play the piano when her aunt was within hearing distance, and
carefully avoided either singing or playing anything for her aged
uncle—brother of her mother—whenever her aunt was home. While I was
endeavoring to efface the traces of the old excitements, new ones
originated through these relations with her host and finally interfered
with the success of my treatment and prematurely interrupted the cure.
One day the patient came to me with a new symptom hardly twenty-four
hours old. She complained of a disagreeable prickling sensation in the
fingertips which had manifested itself every few hours since the day
before and forced her to make very peculiar jerky movements with the
fingers. I could not see the attack, otherwise I would have guessed its
meaning on seeing the finger movements but I immediately endeavored to
trace through hypnotic analysis the causation of this symptom (it was
really a minor hysterical attack). As the whole thing only existed for a
short time I hoped to be able to explain it and quickly remove it. To my
surprise without any hesitation she reproduced in chronological order a
whole row of scenes beginning in her early childhood. All these had
perhaps the same characteristics in the fact that she had suffered an
injustice without defense, something which could make her fingers jerk,
for example, scenes like the one of being forced to hold out her hand in
school while her teacher struck it with a ruler. But they were all banal
causes the right of which to enter into the etiology of an hysterical
symptom I have already opposed. It was different, however, with one
scene of her early girlhood which was connected with the others. The bad
uncle who suffered from rheumatism asked her to massage his back. She
did not dare refuse him. He was in bed while she was doing it and
suddenly threw off the covers, jumped up, attempting to get hold of her
and throw her down. Naturally she stopped the massage and in a moment
escaped and locked herself within her own room. She evidently did not
like to recall this experience and could not say whether she had seen
anything when the man suddenly exposed himself. The sensations of the
fingers could be explained as due to the suppressed impulse to punish
him, or it might simply have originated from the fact that she was at
that time massaging him. Only after this scene did she begin to talk
about the one experienced yesterday after which the sensitiveness and
jerkiness of the fingers appeared as a recurring memory symbol. The
uncle with whom she now lived begged her to play something for him. She
sat at the piano and accompanied herself singing, believing that her
aunt was out. Suddenly she appeared in the doorway, Rosalie jumped up,
closed the piano, and flung away the sheet of music. We can guess what
memories came to her mind, and the train of thought which she tried to
ward off at that moment, for the exasperation brought on by the unjust
accusation should have really urged her to leave the house, but on
account of her illness she was forced to remain in Vienna and had no
other shelter. The movement of the fingers which I saw during the
reproduction of this scene resembled a continuous jerking as if one
literally and figuratively would reject something like throwing away a
sheet of music or rejecting an unreasonable demand.
She was quite positive in her assurance that she did not perceive the
symptom before, that it was not caused by the scenes previously related.
Was there anything else to be assumed except that the scene experienced
yesterday had in the first place awakened the recollection of a former
similar content and that then the formation of a memory symbol for the
whole group of recollections took place? The conversion was on the one
hand furnished with newly experienced affects, on the other with
recollected affects.
When we consider this state of affairs we must admit that in the origin
of hysterical symptoms such a process is the rule rather than the
exception. Whenever I seek for the determinants of such states I
frequently find not a single but a group of similar traumatic motives.
In some cases it could be ascertained that this particular symptom had
already existed for a short time after the first trauma and then
subsided, but reappeared after the next trauma and become fixed. Yet no
real distinction can be made between the temporary appearance and the
latency after the first motives. In a large majority of cases it was
also found that the first traumas had left no symptoms, while a later
trauma of the same kind produced a symptom for the origin of which the
cooperation of the former motives could not be dispensed with and for
the solution of which it really required a consideration of all the
motives. Translating this into the language of the conversion theory we
will say that this undeniable fact of the summation of the traumas and
the erstwhile latency of the symptoms simply means that the conversion
can be brought about from a fresh as well as from a remembered affect,
and this assumption fully explains the contradiction which seems to
exist in the history and analysis of Miss Elisabeth v. R.
There is no question that normal persons carry in their consciousness in
considerable numbers the continuation of ideas with unadjusted affects.
The theory which I just asserted merely approximates the behavior of
hysteria to the normal. It is apparently reduced to a quantitative
moment; it is simply a question of how many such affective strains an
organization can endure. Even a hysterical person will be able to retain
a certain amount in an unadjusted state, but if through a summation of
similar motives it increases beyond the individual’s endurance, the
impetus for conversion is formed. It is therefore no singular theory but
almost a postulate to say that the formation of hysterical symptoms may
also be brought about at the cost of recollected affects.
I have now occupied myself with the motive and mechanism of this case of
hysteria, it still remains to discuss the determination of the
hysterical symptoms. Why should just the pains in the legs be selected
to represent the psychic pains? The circumstances of the case point to
the fact that this somatic pain was not created by the neurosis but was
merely utilized, aggravated, and retained by it. I will add that in most
of the cases of hysterical algias into which I have been able to gain an
insight the conditions were similar, that is, there was to begin with
always a real organically founded pain. It is always the most common,
the most widespread pains of humanity that seem to be most frequently
called upon to play a part in hysteria. Among the most common are the
periosteal and neuralgic pains of the teeth, headaches which originate
from so many different sources, and not in a lesser degree the so often
mistaken rheumatic pains of the muscles. The first attack of pain which
Miss Elisabeth v. R. had while she nursed her father, I consider to have
been organically determined, for I received no information when I
investigated for its psychic motive, and I admit that I am inclined to
attribute differential diagnostic significance to my methods of evoking
hidden memories if they are carefully applied. This original rheumatic
pain[22] became in the patient the memory symbol for her painful psychic
emotions, and as far as I can see, for more than one reason. First and
principally because it existed in consciousness almost simultaneously
with the other excitements, and second because it was or could be
connected in many ways with the ideation of that time. At all events it
was perhaps a remote consequence of the nursing, of her want of
exercise, and the poor nutrition entailed by her duties as nurse. But
this hardly became clear to the patient and what is more important is
the fact that she had to perceive it during significant moments of the
nursing, as for example, when she jumped out of bed in the cold room to
respond to her father’s call. Even more decisive for the direction taken
by the conversion must have been the other manner of associative
connection, namely, the fact that for many days one of her painful legs
came in contact with the swollen leg of her father during the changing
of bandages. The location on the right leg distinguished by this contact
remained henceforth the focus and starting point of the pains, an
artificial hysterogenic zone the origin of which can be plainly seen in
this case.
If any one should be surprised at the associative connection between
physical pain and psychic affect, thinking it to be too manifold and
artificial, I should answer that such surprise is just as unfair as to
be surprised over the fact “that just the richest in the world possess
most money.” Where prolific connections do not exist there is naturally
no formation of hysterical symptoms, and conversion does not find its
way. I can also state that in reference to determinations the case of
Miss Elisabeth v. R. belongs to the simpler ones. In the case of Mrs.
Cäcilie M.[23] particularly, I had to solve the most intricate knots of
this kind.
I have already discussed in the history of the case how the
astasia-abasia of our patient was built up on those pains after the
conversion had taken definite direction. But there, too, I have
expressed the opinion that the patient has created or aggravated the
disturbance of function through symbolization. For her dependence and
helplessness to change anything in the circumstances she found a somatic
expression in the astasia-abasia, and the expressions “to make no
headway,” “to have no support,” etc., formed the bridge for this new act
of conversion. I will endeavor to support this conception by other
examples.
Conversion on the basis of coincidence in otherwise existing associative
connections seems to exert the slightest claims on the hysterical
predisposition; on the other hand conversion through symbolization seems
to require a higher grade of hysterical modification, a fact also
demonstrated in Miss Elisabeth in the later stages of her hysteria. The
prettiest examples of symbolization I have observed in Mrs. Cäcilie
M.,[24] whom I can call my most difficult and most instructive case. I
have already mentioned that this history does not unfortunately lend
itself to detailed reproduction.
Among other things Mrs. Cäcilie also suffered from a most violent facial
neuralgia which appeared suddenly two or three times during the year and
persisted for from five to ten days, resisting every remedy, and ceased
as if cut off. It limited itself to the second and third branches of the
trigeminus, and as there was undoubtedly an excess of urates in the
urine, and as a not very “clear acute rheumatism” played a certain part
in the patient’s history it was reasonable to assume that we dealt with
a gouty neuralgia. This opinion was also shared by the consulting
physicians who saw every attack. The neuralgia was treated with the
methods in vogue, such as electric pencilling, alkaline waters and
purgatives, but it always remained uninfluenced until it was convenient
to make room for another symptom. In former years—the neuralgia was
fifteen years old—the teeth were accused of preserving it and were
condemned to extraction, and one fine morning under narcosis the
execution of seven of the culprits took place. That did not run so
smoothly as the teeth were so firm that most of the roots were left
behind. This cruel operation was followed by neither temporary nor
permanent relief. At that time the neuralgia raged for months. Even
while under my care whenever she had neuralgia the dentist was called
and he always declared he found diseased roots. He commenced to get
ready for such work but usually he was soon interrupted, for the
neuralgia suddenly ceased and with it the desire for the dentist. During
the intervals the teeth did not ache at all. One day just while another
attack was raging I put the patient into a hypnotic condition and placed
an energetic interdiction on the pains, and from that moment they
ceased. I then began to doubt the genuineness of this neuralgia.
About a year after this hypnotic remedial success the condition of Mrs.
Cäcilie M. took a new and surprising turn. There suddenly appeared other
states than those that had been characteristic of the last years, but
after some reflection the patient declared that all these conditions had
existed in her before and were really scattered over the long period of
her disease (thirty years). Indeed a surprising abundance of hysterical
incidents were unrolled which the patient was able to localize correctly
in the past and soon the frequently very entangled thought connections
which determined the sequence of these incidents became recognizable. It
was like a series of pictures with an explanatory text. Pitres, on
describing his délire ecmnésique must have had in mind a similar case.
The way such a hysterical condition belonging to the past was reproduced
was most remarkable. In the first place while the patient was in the
best of condition there appeared a pathological mood of special coloring
which was regularly mistaken by the patient and was referred to a banal
occurrence of the last hours. This increasing obnubilation of
consciousness was followed by hysterical symptoms, such as
hallucinations, pains, convulsions, and long declamations, and finally
an event of the past attached itself to this hallucinatory manifestation
which could explain the initial mood and determine the occasional
symptoms. With this last part of the attack lucidity returned, the
ailments disappeared as if by magic and good health again existed—until
the next attack which was half a day later. Usually I was called at the
height of this condition. I produced hypnosis, evoked a reproduction of
the traumatic events, and by artificial aid I curtailed the attack.
Having gone through with the patient many hundreds of such cycles, I
obtained the most instructive explanations concerning the determinants
of hysterical symptoms. The joint observation with Breuer of this
remarkable case was also the chief motive for the publication of our
“Preliminary Communication.”
In this connection it finally came to the reproduction of the facial
neuralgia which I myself had still treated as actual attacks. I was
desirous of knowing whether we would find here a psychic causation. When
I attempted to evoke the traumatic scene, the patient soon imagined
herself in a period during which she felt marked psychic sensitiveness
against her husband. She related a conversation with him and a remark
that he made which aggravated her very much. She then suddenly grasped
her cheek, crying aloud with pain, and said, “That was like a slap in
the face”—with this both the attack and the pain came to an end. There
is no doubt that here, too, we dealt with a symbolization. She had felt
as if she really received a slap in the face. Now everybody will ask how
the sensation of “a slap in the face” can lead to the manifestations of
a trigeminal neuralgia, to its limiting itself to the second and third
branch, and to its being aggravated on opening the mouth and mastication
(not by talking!).
The following day the neuralgia reappeared, but this time it could be
solved by the reproduction of another scene the content of which equally
showed a supposed insult. This process continued for nine days; from the
result it seemed that for years, aggravations, especially through words,
produced new attacks of this facial neuralgia by way of symbolization.
But finally we also succeeded in reproducing the first attack of the
neuralgia which occurred more than fifteen years before. Here there was
no symbolization but a conversion through coincidence. It was a painful
sight which recalled to her mind a reproach and this caused her to
repress another series of thoughts. We have here, then, a case of
conflict and defense, and the origin of the neuralgia in this moment
could not be explained if we do not wish to assume that she then
suffered from slight toothache or facial pains, a thing not improbable,
as she was then in the first months of pregnancy.
The result of the explanation showed that this neuralgia became the mark
of a definite psychic excitement through the usual road of conversion
but that afterward it could be awakened through associative
reminiscences of thoughts and symbolic conversions. It was really the
same procedure as encountered in Miss Elisabeth v. R.
I will now introduce another example which will illustrate the efficacy
of symbolization under other determinants. On one occasion Mrs. Cäcilie
M. was tormented by a violent pain in her right heel, experiencing
stinging sensations which made walking impossible. The analysis
conducted us to a time when the patient was in a foreign institution.
For eight days she lay in her room, and for the first time the house
physician was to take her to the dining room. The pain came on while the
patient took the physician’s arm on leaving the room. It disappeared
during the reproduction of this scene while she remarked that at that
time she feared lest she would not make the “proper impression” on this
strange society[25] (“rechte Auftreten”).
This seems a striking, almost comical example for the origin of
hysterical symptoms through symbolization by means of an expression of
speech. But a closer investigation of the circumstances of that moment
will favor another conception. The patient at that time suffered from
pain in her feet on account of which she remained in bed, and we can
only assume that the fear which obsessed her on taking the first steps
produced from the simultaneously existing pains the one symbolically
appropriate symptom in the right heel so as to form it into a psychic
algia and to particularly fit it for long duration.
Notwithstanding the fact that the mechanism of symbolization in these
examples seems to be crowded to second rank, that which certainly
corresponds to the rule, I have still other examples at my disposal
which seem to demonstrate the origin of hysterical symptoms through
symbolization only. One of the best is the following example which again
refers to Mrs. Cäcilie M. At the age of fifteen she once lay in bed
watched by her austere grandmother. The girl suddenly cried out
complaining of having perceived a pain in the forehead between the eyes
which thereafter continued for weeks. On analyzing this pain, which was
reproduced after almost thirty years, she stated that her grandmother
gazed at her so “piercingly” that it seemed as if her look penetrated
deeply into her brain. She was really afraid of being looked upon
suspiciously by this old lady. On reproducing this thought she burst
into loud laughter and the pain ceased. Here I find nothing other than
the mechanism of symbolization which in a way stands midway between the
mechanism of auto-suggestion and that of conversion.
The study of Mrs. Cäcilie M. gave me the opportunity to gather a
collection of such symbolizations. A whole series of physical sensations
which were otherwise looked upon as organically determined were of a
psychic origin, or at least furnished with a psychic interpretation. A
certain number of her experiences were accompanied by a piercing
sensation in the region of the heart (“I felt a stitch in my heart”).
The piercing headache of hysteria was undoubtedly, in her case, to be
interpreted as thought pains (“something sticks in my head”), and it
disappeared each time when the problem in question was solved. The
sensation of the hysterical aura in the throat, when it manifested
itself during an aggravation, ran parallel with the thought, “I have to
swallow that.” There was a whole series of parallel running sensations
and ideas in which it was now the sensation evoking the idea as an
interpretation and now the idea which produced the sensation by
symbolization, and not seldom it remained obscure which was the primary
element of the two.
In no other patient was I able to find such a prolific application of
symbolization. To be sure, Mrs. Cäcilie M. was a person of quite unusual
and of a special artistic temperament whose highly developed sense for
form manifested itself in very beautiful poems. I maintain, however,
that if a hysteria creates through symbolization a somatic sensation for
the emotionally accentuated presentation, it is due less to individual
and arbitrary things than one supposes. When during an offending
harangue she takes literally such phrases as “stitch in the heart” or
“slap in the face,” and perceives them as real occurrences she practices
no facetious misuse but only revives the sensations to which this phrase
thanks its existence. For how does it happen that in speaking of an
aggrieved person we use such expressions as “he experienced a ‘stitch in
his heart,’” if the mortification was not actually accompanied by a
precordial sensation that could be so interpreted and recognized? Is it
not probable that the phrase “to swallow something” applied to an
unreturned insult really originates from the sensation of innervation
appearing in the pharynx when one forces back his speech thus preventing
a reaction to the insult? All these sensations and innervations belong
to the “expression of the emotions,” which as Darwin taught us,
originally consisted of sensible and expedient actions; at present most
of them may be so weakened that their expression in speech seems to us
like a figurative transformation, but very probably all this was once
meant literally, and hysteria is justified in reconstructing the
original literal sense for its stronger innervation. Indeed, perhaps it
is improper to say that it creates such sensations through
symbolization, perhaps it has not taken the usage of speech as a model,
but both originated from a common source.[26]
CHAPTER IV.
THE PSYCHOTHERAPY OF HYSTERIA.
In our “Preliminary Communication” we have stated that while
investigating the etiology of hysterical symptoms we have also
discovered a therapeutic method which we consider of practical
significance. “We found, at first to our very greatest surprise, that
the individual hysterical symptoms immediately disappeared without
returning if we succeeded in thoroughly awakening the memories of the
causal process with its accompanying affect, and if the patient
circumstantially discussed the process giving free play to the affect”
(p. 4).
We furthermore attempted to explain how our psychotherapeutic method
acts. “It does away with the effects of the original not ab-reacted to
ideas by affording an outlet to the suppressed affect through speech. It
brings it into associative correction by drawing it into normal
consciousness (in mild hypnosis), or it is done away with through the
physician’s suggestion just as happens in somnambulism with amnesia” (p.
13).
Although the essential features of this method have been enumerated in
the preceding pages, a repetition is unavoidable, and I shall now
attempt to show connectedly how far reaching this method is, its
superiority over others, its technique, and its difficulties.
I.
I, for my part, may state that I can adhere to the “Preliminary
Communication,” but I must confess that after continuous occupation for
years with the problems therein touched, I was confronted with new
views, as a result of which the former material underwent at least a
partial change in grouping and conception. It would be unjust to impute
too much of the responsibility for this development to my honored
friend, J. Breuer. I therefore take the weight of responsibility upon
myself.
In attempting to use Breuer’s method of treating hysterical symptoms in
a great number of patients by investigation and ab-reaction in hypnosis,
I encountered two obstacles, the pursuit of which led me to change the
technique as well as the conception. (1) Not all persons were
hypnotizable who undoubtedly showed hysterical symptoms, and in whom
there most probably existed the same psychic mechanism. (2) I had to
question what essentially characterizes hysteria, and in what it differs
from other neuroses.
How I overcame the first difficulty, and what it taught me, I will show
later. I will first state what position I have taken in my daily
practice towards the second problem. It is very difficult to examine a
case of neurosis before it has been subjected to a thorough analysis,
such as would result only through the application of Breuer’s method.
But before we have such a thorough knowledge we are obliged to decide
upon the diagnosis and kind of treatment. Hence the only thing remaining
for me was to select such cases for the cathartic method which could,
for the time being, be diagnosed as hysteria, and which showed some or
many stigmata, or the characteristic symptoms of hysteria. Yet it
sometimes happened that in spite of the diagnosis of hysteria the
therapeutic results were very poor, and even the analysis revealed
nothing of importance. At other times I attempted to treat cases which
no one took for hysteria by Breuer’s method, and I found that I could
influence them, and even cure them. Such, for example, was my experience
with obsessions, the real obsessions of Westphal’s type, cases which did
not show a single feature of hysteria. Thus the psychic mechanism
revealed in the “Preliminary Communication” could not be pathognomonic
of hysteria. Nor could I for the sake of this mechanism throw so many
neuroses into the same pot with hysteria. From all the investigated
doubts I finally seized upon a plan to treat all the other neuroses in
question just like hysteria, to investigate the etiology and the form of
psychic mechanisms, and to leave the diagnosis of hysteria to be
dependent upon the result of this investigation.
It thus happened that, proceeding from Breuer’s methods, I occupied
myself mostly with the etiology and the mechanism of the neuroses. After
a relatively brief period I was fortunate in obtaining useful results. I
then became cognizant of the fact that if we may speak of a reason for
the acquirement of neuroses the etiology must be sought for in the
sexual moments. This agrees with the fact that, generally speaking,
various sexual moments may also produce various pictures of neurotic
disease. Similarly we now venture to employ the etiology for the
characteristics of the neuroses, and build up a sharp line of
demarcation between the morbid pictures of the neuroses. If the
etiological characters constantly agreed with the clinical ones, this
was justified.
In this way it was found that neurasthenia really corresponds to a
monotonous morbid picture in which, as shown by the analysis, “psychic
mechanisms” play no part. From neurasthenia we sharply distinguished the
compulsion neurosis (Zwangsneurose), [obsessions, doubts, impulses], the
neurosis of the genuine obsessions, in which we can recognize a
complicated psychic mechanism, an etiology resembling the one of
hysteria, and a far reaching possibility of an involution by
psychotherapy. On the other hand it seemed to me undoubtedly imperative
to separate from neurasthenia a neurotic symptom-complex which depends
on a totally divergent, strictly speaking, on a contrary etiology. The
partial symptoms of this complex have been recognized by E. Hecker[27]
as having a common character. They are either symptoms, or equivalents,
or rudiments of anxiety manifestations, and it is for that reason that
this complex, so different from neurasthenia, was called by me anxiety
neurosis. I maintain that it originates from an accumulation of physical
tension which is in turn of a sexual origin. This neurosis, too, has no
psychic mechanism, but regularly influences the psychic life, so that
among its regular manifestations we have anxious expectation, phobias,
hyperesthesias to pain, and other symptoms. This anxiety neurosis, as I
take it, certainly corresponds in part to the neurosis called
hypochondria, which in some features resembles hysteria and
neurasthenia. Yet in none of the earlier works can I consider the
demarcation of this neurosis as correct, and moreover, I find that the
usefulness of the name hypochondria is impaired by its close relation to
the symptom of “nosophobia.”
After I had thus constructed for myself the simple picture of
neurasthenia, anxiety neuroses, and obsessions, I turned my attention to
the commonly occurring cases of neuroses which enter into the diagnosis
of hysteria. I now said to myself that it would not do to mark a
neurosis as hysterical on the whole, merely because its symptom complex
evinced some hysterical signs. I could readily explain this practice by
the fact that hysteria is the oldest, the most familiar, and the most
striking neurosis under consideration, but still it was an abuse which
allowed the placing of many features of perversion and degeneration
under the caption of hysteria. Whenever a hysterical symptom, such as
anesthesia or a characteristic attack, could be discovered in a
complicated case of psychic degeneration, the whole thing was called
“hysteria,” and hence one could naturally find united under this same
trade mark the worst and most contradictory features. As certain as this
diagnosis was incorrect it is also certain that our classification must
be made from the neurotic standpoint, and as we know neurasthenia,
anxiety neurosis, and similar conditions in the pure state, there is no
need of overlooking them in combination.
It seemed therefore that the following conception was more warrantable.
The neuroses usually occurring are generally to be designated as
“mixed.” Neurasthenia and anxiety neurosis can be found without effort
in pure forms, and most frequently in young persons. Pure cases of
hysteria and compulsion neurosis “Zwangsneurose” (obsessions, doubts,
impulses) are rare, they are usually combined with an anxiety neurosis.
This frequent occurrence of mixed neuroses is due to the fact that their
etiological moments are frequently mixed, now only accidentally, and now
in consequence of a causal relation between the processes which give
rise to the etiological moments of the neuroses. This can be sustained
and proven in the individual cases without any difficulty. But it
follows from this that it is hardly possible to take hysteria out of
connection with the sexual neuroses, that hysteria as a rule presents
only one side, one aspect of the complicated neurotic case, and that
only, as it were, in the borderline case can it be found and treated as
an isolated neurosis. In a series of cases we can perhaps say a potiori
fit denominatio.
I shall now examine the cases reported to see whether they speak in
favor of my conception of the clinical dependence of hysteria. Breuer’s
patient, Anna O.,[28] seems to contradict this and exemplifies a pure
hysterical disease. Yet this case which became so fruitful for the
knowledge of hysteria was never considered by its observer under the
guise of a sexual neurosis, and hence cannot at present be utilized as
such. When I began to analyze the second patient, Mrs. Emmy v. N., the
idea of a sexual neurosis on a hysterical basis was far from my mind. I
had just returned from the Charcot school, and considered the connection
of hysteria with the sexual theme as a sort of insult—just as my
patients were wont to do. But when I today review my notes on this case
there is absolutely no doubt that I have to consider it as a severe case
of anxiety neurosis with anxious expectations and phobias, which was due
to sexual abstinence and was combined with hysteria.
The third case, Miss Lucy R., could perhaps be called the first
borderline case of pure hysteria. It is a short episodic hysteria based
on an unmistakably sexual etiology. It corresponds to an anxiety
neurosis in an over-ripe, amorous girl, whose love was too rapidly
awakened through a misunderstanding. Yet the anxiety neurosis could
either not be demonstrated or had escaped me. Case IV, Katharina,[29] is
really a model of what I have called virginal anxiety; it is a
combination of an anxiety neurosis and hysteria, the former produces the
symptoms, while the latter repeats them and works with them. At all
events, it is a typical case of many juvenile neuroses called
“hysteria.” Case V, Miss Elisabeth v. R., was again not investigated as
a sexual neurosis. I could only suspect that there was a spinal
neurasthenia at its basis but I could not confirm it. I must, however,
add that since then pure hysterias have become still rarer in my
experience. That in grouping together these four cases of hysteria I
could disregard in the discussion the decisive factors of sexual
neuroses was due to the fact that they were older cases in which I had
not as yet carried out the purposed and urgent investigation for the
neurotic sexual subsoil. Moreover the reason for my reporting four
instead of twelve cases of hysteria, the analysis of which would have
confirmed our claims of psychic mechanism for hysterical phenomena, is
due to one circumstance, namely that the analysis of these cases would
have simultaneously revealed them as sexual neuroses, though surely no
diagnostician would have denied them the name “hysteria.” However, the
discussion of such sexual neuroses would have overstepped the limits of
our joint publication.
I do not wish to be misunderstood and give the impression that I refuse
to accept hysteria as an independent neurotic affection, that I conceive
it only as a psychic manifestation of the anxiety neurosis, that I
ascribe to it “ideogenous” symptoms only, and that I attribute the
somatic symptoms, like hysterogenic points and anesthesias, to the
anxiety neurosis. None of these statements are true. I believe that
hysteria, purified of all admixtures, can be treated independently in
every respect except in therapy. For in the treatment we deal with a
practical purpose, namely, we have to do away with the whole diseased
state, and even if the hysteria occurs in most cases as a component of a
mixed neurosis, the case merely resembles a mixed infection where the
task is to preserve life, and not merely to combat the effect of one
inciting cause of the disease.
I, therefore, find it important to separate the hysterical part in the
pictures of the mixed neuroses from neurasthenia, anxiety neurosis,
etc., for after this separation I can express concisely the therapeutic
value of the cathartic method. I would venture to assert
that—principally—it can readily dispose of any hysterical symptom,
whereas, as can be easily understood, it is perfectly powerless in the
presence of neurasthenic phenomena, and can only seldom, and through
detours, influence the psychic results of the anxiety neurosis. Its
therapeutic efficacy in the individual case will depend on whether or
not the hysterical components of the morbid picture can claim a
practical and significant position in comparison to the other neurotic
components.
Another limitation placed on the efficacy of the cathartic method we
have already mentioned in our “Preliminary Communication.” It does not
influence the causal determinations of hysteria, and hence it can not
prevent the origin of new symptoms in the place of those removed. Hence,
on the whole, I must claim a prominent place for our therapeutic method
in the realm of the therapy of neuroses, but I would caution against
attaching any importance to it, or putting it into practice outside of
this connection. As I am unable to give here a “Therapy of Neuroses” as
would be required by the practicing physician, the preceding statements
are put on a level with the deferred reference to a later communication;
still, for purposes of discussion and elucidation, I can add the
following remarks:
1. I do not claim that I have actually removed all the hysterical
symptoms which I have undertaken to influence by the cathartic method,
but I believe that the obstacles were due to the personal circumstances
of the cases, and not to the general principles. In passing sentence,
these cases of failure may be left out of consideration, just as the
surgeon puts aside all cases who die as a result of narcosis,
hemorrhage, accidental sepsis, etc., when deciding upon a new technique.
I will again consider the failures of such origin in my later
discussions on the difficulties and drawbacks of this method.
2. The cathartic method does not become valueless simply because it is
symptomatic and not causal. For a causal therapy is really in most cases
only prophylactic; it stops the further progress of the injury, but it
does not necessarily remove the products which have already resulted
from it. To do this it requires, as a rule, a second agent, and in cases
of hysteria the cathartic method is really unsurpassable for such
purposes.
3. Where the period of hysterical production, or the acute hysterical
paroxysm, has subsided, and the only remnant manifestations left are
hysterical symptoms, the cathartic method fulfills all indications, and
achieves a full and lasting success. Such a favorable constellation for
the therapy does not seldom result on the basis of the sexual life, in
consequence of the marked fluctuations in the intensity of the sexual
desire and the complications of the required determination for a sexual
trauma. Here the cathartic method accomplishes all that is required of
it, for the physician can not resolve to change a hysterical
constitution. He must rest content if he can remove the disease for
which such a constitution shows a tendency, and which can arise through
the assistance of external determinants. He must be satisfied if the
patient will again become capacitated. Moreover, he can have some hopes
for the future, if the possibility of a relapse be considered, for he
knows the main character of the etiology of the neuroses, namely, that
their origin is mostly over-determined, and that many moments must unite
to produce this result. He can hope that this union will not take place
very soon, if individual etiological moments remain in force.
It may be argued that in such subsided cases of hysteria the remaining
symptoms would spontaneously disappear without anything else, but this
can be answered by the fact that such spontaneous cures very often
terminate neither rapidly nor fully, and that the cure will be
extraordinarily advanced by the treatment. Whether the cathartic
treatment cures only that which is capable of spontaneous recovery, or
incidentally also, that which would not cease spontaneously, that
question may surely be left open for the present.
4. Where we encounter an acute hysteria during the most acute production
of hysterical symptoms, and the consecutive overwhelming of the ego by
the morbid products (hysterical psychosis), even the cathartic method
will change little the expression and course of the disease. One finds
himself in the same position to the neurosis as the doctor to an acute
infectious disease. For some time past, now beyond the reach of
influence, the etiological moments exerted a sufficient amount of
effect, which becomes manifest after overcoming the interval of
incubation. The affection can not be warded off, it has to run its
course, but meanwhile one must bring about the most favorable conditions
for the patient. If during such an acute period one can remove the
morbid products, the newly formed hysterical symptoms, it may be
expected that their places will be taken by new ones. The physician will
not be spared the depressing impression of fruitless effort, the
enormous expenditure of exertion, and the disappointment of the
relatives, to whom the idea of the necessary duration of time of an
acute neurosis is hardly as familiar as in the analogous case of an
acute infectious disease; these, and many other things, will probably
make most impossible the consequent application of the cathartic method
in the assumed case. Nevertheless, it still remains to be considered
whether, even in an acute hysteria, the frequent removal of the morbid
products does not exercise a curative influence by supporting the normal
ego which is occupied with the defense, and thus preventing it from
merging into a psychosis or into ultimate confusion.
That the cathartic method can accomplish something, even in an acute
hysteria, and that it can even reduce the new productions of the morbid
symptoms quite practically and noticeably, is undoubtedly evident from
the case of Anna O., in which Breuer first learned to exercise this
process.[30]
5. Where we deal with chronic progressive hysterias with moderate or
continued productions of hysterical symptoms, we learn to regret the
lack of a causally effective therapy, but we also learn to value the
indications of the cathartic method as a symptomatic remedy. We then
deal with an injury produced by an etiology which continues to act
chronically. We have to strengthen the capacity for resistance of the
nervous system of our patient, and we must bear in mind that the
existence of an hysterical symptom signifies a weakening of resistance
of the nervous system, and represents a predisposing moment. From the
mechanism of monosymptomatic hysteria we know that a new hysterical
symptom generally originates as an addition to and as an analogy of one
already in existence. The location once penetrated represents the weak
spot which can be penetrated again. The split off psychic group plays
the part of the provoking crystal from which a formerly omitted
crystallization emerges with great facility. To remove the already
existing symptoms, to do away with the psychic alterations lying at
their basis, is the return to the patients the full measure of their
resistance capacity, with which they are successfully able to resist the
noxious influences. One can do a great deal for the patient by such long
continued watchfulness and occasional “chimney-sweeping.”
6. I still have to mention the apparent contradiction arising between
the admission that not all hysterical symptoms are psychogenic, and the
assertion that they can all be removed by psychotherapeutic procedures.
The solution lies in the fact that some of these non-psychogenic
symptoms, though they represent morbid symptoms, as, for instance, the
stigmata, should nevertheless not be designated as affections, and hence
it cannot be practically noticed even if they remain after the treatment
is finished. Other symptoms of a similar nature seem to be taken along
indirectly by the psychogenic symptoms, for indirectly they really
depend on some psychic causation.
I shall now mention those difficulties and inconveniences of our
therapeutic method which are not evident from the preceding histories,
or from the following remarks concerning the technique of the method.—I
will rather enumerate and indicate than carry them out. The process is
toilsome and wearisome for the physician, it presupposes a profound
interest for psychological incidents, as well as a personal sympathy for
the patient. I could not conceive myself entering deeply into the
psychic mechanism of a hysteria in a person who appeared to me common
and disagreeable, and who would not, on closer acquaintanceship, be able
to awaken in me human sympathy; whereas I can well treat a tabetic or a
rheumatic patient regardless of such personal liking. Not less are the
requisites on the patient’s side. The process is especially inapplicable
below a certain niveau of intelligence. It is rendered extremely
difficult wherever there is any tinge of weakmindedness. It requires the
full consent and the attention of the patients, but, above all, their
confidence, for the analysis regularly leads to the inmost and most
secretly guarded psychic processes. A large proportion of the patients
suitable for such treatment withdraw from the physician as soon as they
become cognizant whither his investigations tend; to them the physician
remains a stranger. In others who have determined to give themselves up
to the physician and bestow their confidence upon him, something usually
voluntarily given but never demanded, in all those, I say, it is hardly
avoidable that the personal relation to the physician should not become
unduly prominent, at least for some time. Indeed, it seems as if such an
influence exerted by the physician is a condition under which alone a
solution of the problem is made possible. I do not believe that it makes
any essential difference in this condition whether we make use of
hypnosis or have to avoid or substitute it. Yet fairness demands that we
emphasize the fact that although these inconveniences are inseparable
from our method, they, nevertheless, cannot be charged to it. It is much
more evident that they are formed in the preliminary states of the
neurosis to be cured, and that they then attach themselves to every
medical activity which intensively concerns itself with the patient, and
produce in him a psychic change. I could see no harm or danger in the
application of hypnosis even in those cases where it was used
excessively. The causes for the harm produced lay elsewhere and deeper.
When I review the therapeutic efforts of those years since the
communications of my honored teacher and friend, J. Breuer, gave me the
cathartic method, I believe that I have more often produced good than
harm, and brought about some things which could not have been produced
by any other therapeutic means. On the whole it was, as expressed in the
“Preliminary Communication,” “a distinct therapeutic gain.”
I must mention still another gain in the application of this method. No
severe case of complicated neurosis, with either an excessive or slight
tinge of hysteria can better be explained than by subjecting it to an
analysis by Breuer’s method. In making this analysis I find that
whatever shows the hysterical mechanism disappears first, while the rest
of the manifestations I meanwhile learn to interpret and refer to their
etiology. I thereby gained the essential factors indicated by the
instrument of the therapy of the neurosis in question. When I think of
the usual differences between my opinion of a case of neurosis before
and after such an analysis, I am almost tempted to maintain that the
analysis is indispensable for the knowledge of a neurotic disease. I
have furthermore made it a practice of applying the cathartic
psychotherapy in conjunction with a rest cure, which when required is
changed to a full Weir-Mitchell treatment. This advantage lies in the
fact that, on the one side I avoid the very disturbing intrusion of new
psychic impressions produced during psychotherapy; on the other hand, I
exclude the monotony of the Weir-Mitchell treatment, during which the
patient not seldom merges into harmful reveries. One might expect that
the very considerable psychic labor often imposed upon the patient
during the cathartic cure, and the excitement resulting from the
reproduction of traumatic events, would run counter to the sense of the
Weir-Mitchell rest cure, and would prevent the successes which one is
wont to obtain from it. But the contrary happens; through the
combination of the Breuer and the Weir-Mitchell therapy, we obtain all
the physical improvements which we expect from the latter, and such
marked psychic improvement as never occurs in the rest cure without
psychotherapy.
II.
I will now add to my former observations that in attempting to use
Breuer’s method in greater latitude I met this difficulty—although the
diagnosis was hysteria, and the probabilities spoke in favor of the
prevalence of the psychic mechanism described by us, yet a number of
patients could not be put into the hypnotic state. The hypnosis was
necessary to broaden consciousness so as to find the pathogenic
reminiscences which do not exist in the ordinary consciousness. I,
therefore, was forced to either give up such patients, or to bring about
this broadening by other means.
The reason why one person is hypnotizable and another not I could no
more explain than others, and hence I could not start on a causal way
towards the removal of the difficulties. I also observed that in some
patients the obstacle was still more marked, as they even refused to
submit to hypnosis. The idea then occurred to me that both cases might
be identical, and that in both it might merely be an unwillingness.
Those who entertain a psychic inhibition against hypnotism are not
hypnotizable, it makes no difference whether they utter their
unwillingness or not. It is not fully clear to me whether I can firmly
adhere to this conception or not.
It was, therefore, important to avoid hypnotism and yet to obtain the
pathogenic reminiscences. This I attained in the following manner:
On asking my patients during our first interview whether they remembered
the first motive for the symptom in question, some said that they knew
nothing, while others thought of something which they designated as an
indistinct recollection, yet were unable to pursue it. I then followed
Bernheim’s example of awakening the apparently forgotten impressions
obtained during somnambulism (see the case of Miss Lucy). I urged them
by assuring them that they did know it, and that they will recall it,
etc., and thus some thought of something, while in others the
recollections went further. I became still more pressing, I ordered the
patient to lie down and voluntarily shut his eyes so as to “concentrate”
his mind, causing thereby at least a certain similarity to hypnosis, and
I then discovered that without any hypnosis there emerged new and
retrospective reminiscences which probably belonged to our theme.
Through such experiences I gained the impression that through urging
alone it would really be possible to bring to light the definitely
existing pathogenic series of ideas; and as this urging necessitated
much exertion on my part, and showed me that I had to overcome a
resistance, I, therefore, formulated this whole state of affairs into
the following theory: _Through my psychic work I had to overcome a
psychic force in the patient which opposed the pathogenic idea from
becoming conscious_ (remembered). It then became clear to me that this
must really be the same psychic force which assisted in the origin of
the hysterical symptom, and at that time prevented the pathogenic idea
from becoming conscious. What kind of effective force could here be
assumed, and what motive could have brought it into activity? I could
easily formulate an opinion, for I already had some complete analyses at
my disposal in which I found examples of pathogenic, forgotten, and
repressed ideas. From these I could judge the general character of such
ideas. They were altogether of a painful nature, adapted to provoke the
affects of shame, reproach, of psychic pain, and the feeling of injury;
they were altogether of that kind which one would not like to experience
and prefers to forget.
From all these the thought of defense resulted as if simultaneously.
Indeed, it is generally admitted by all psychologists that the
assumption of a new idea (assumption in the sense of belief, judgment of
reality), depends on the mode and drift of the ideas already united in
the ego. For the process of the censor, to which the newly formed ideas
are subjected, special technical names have been created. An idea
entered into the ego of the patient which proved to be unbearable and
evoked a power of repulsion on the part of the ego, the purpose of which
was a defense against this unbearable idea. This defense actually
succeeded, and the idea concerned was crowded out of consciousness and
out of the memory, so that its psychic trace could not apparently be
found. Yet this trace must have existed. When I made the effort to
direct the attention to it, I perceived as a resistance the same force
which showed itself as repulsion in the genesis of the symptom. If I
could now make it probable that the idea became pathogenic in
consequence of the exclusion and repression, the chain would seem
complete. In many epicrises of our histories, and in a small work
concerning the defense neuropsychoses (1894), I have attempted to
indicate the psychological hypotheses with the help of which this
connection also—the fact of conversion—can be made clear.
Hence, a psychic force, the repugnance of the ego, has originally
crowded the pathogenic idea from the association, and now opposes its
return into the memory. The not knowing of the hysterics was really
a—more or less conscious—not willing to know, and the task of the
therapeutist was to overpower this resistance of association by psychic
labor. Such accomplishment is, above all, brought about by “urging,”
that is, by applying a psychic force in order to direct the attention of
the patient on the desired traces of ideas. It does not, however, stop
here, but as I will show, it assumes new forms in the course of the
analysis, and calls to aid more psychic forces.
I shall, above all, still linger at “the urging.” One cannot go very far
with such simple assurances as, “You do know it, just say it,” or “It
will soon come to your mind.” After a few sentences the thread breaks,
even in the patient who is in a state of concentration. We must not,
however, forget that we deal everywhere here with a quantitative
comparison, with the struggle between motives of diverse force and
intensity. The urging of the strange and inexperienced physician does
not suffice for the “association resistance” in a grave hysteria. One
must resort to more forceful means.
In the first place I make use of a small technical artifice. I inform
the patient that I will in the next moment exert pressure on his
forehead, I assure him that during this pressure he will see some
reminiscence in the form of a picture, or some thought will occur to
him, and I oblige him to communicate to me this picture or this thought,
no matter what it may be. He is not supposed to hold it back because he
may perhaps think that it is not the desired or the right thing, or
because it is too disagreeable to say. There should be neither criticism
nor reserve on account of affect or disregard. Only thus could we find
the things desired, and only thus have we unfailingly found them. I then
exert pressure for a few seconds on the forehead of the patient lying in
front of me, and after stopping the pressure, I ask in a calm tone, as
if any disappointment is out of the question, “What have you seen?” or,
“What occurred to your mind?”
This method[31] taught me a great deal and led me to the goal every
time. Of course I know that I can substitute this pressure on the
forehead by any other sign, or any other physical influence, but as the
patient lies before me the pressure on the forehead, or the grasping of
his head between my two hands, is the most suggestive and most
convenient thing that I could undertake for this end. To explain the
efficacy of this artifice, I may perhaps say that it corresponds to a
“momentary reinforced hypnosis”; but the mechanism of hypnosis is so
enigmatical to me that I would not like to refer to it as an
explanation. I rather think that the advantage of the process lies in
the fact that through it I dissociate the attention of the patient from
his conscious quest and reflection, in brief, from everything upon which
his will can manifest itself. This resembles the process of staring at a
crystal globe, etc. The fact, that under the pressure of my hand there
always appears that which I am looking for, teaches that the supposedly
forgotten pathogenic ideas always lie ready, “close by,” being
attainable through easily approachable associations, and all that is
necessary is to clear away some obstacle. This obstacle again seems to
be the person’s will, and different persons learn to discard their
premeditations, and to assume a perfectly objective attitude toward the
psychic processes within them.
It is not always a “forgotten” reminiscence which comes to the surface
under the pressure of the hand; in the rarest cases the real pathogenic
reminiscences can be superficially discovered. More frequently an idea
comes to the surface which is a link between the starting idea and the
desired pathogenic one of the association chain, or it is an idea
forming the starting point of a new series of thoughts and
reminiscences, at the end of which the pathogenic idea exists. The
pressure, therefore, has really not revealed the pathogenic idea, which,
if torn from its connections without any preparation, would be
incomprehensible; but it has shown the way to it, and indicated the
direction towards which the investigation must proceed. The idea which
is at first awakened through the pressure may correspond to a familiar
reminiscence which was never repressed. If the connection becomes torn
on the road to the pathogenic idea, all that is necessary for the
reproduction of a new orientation and connection is a repetition of the
procedure, that is, of the pressure.
In still other cases the pressure of the hand awakens a reminiscence
well known to the patient, which appearance, however, causes him
surprise because he had forgotten its relation to the starting idea. In
the further course of the analysis this relation becomes clear. From all
these results of the pressure one receives a delusive impression of a
superior intelligence external to the patient’s consciousness, which
systematically holds a large psychic material for definite purposes, and
has provided an ingenious arrangement for its return into consciousness.
I presume, however, that this unconscious second intelligence is really
only apparent.
In every complicated analysis one works repeatedly, nay continuously,
with the help of this procedure (pressure on the forehead), which leads
us from the place where the patient’s conscious reconductions become
interrupted, showing us the way over reminiscences which remained known,
and calling our attention to connections which have merged into
forgetfulness. It also evokes and connects memories which have for years
been withdrawn from the association, but can still be recognized as
memories; and finally, as the highest performance of reproduction, it
causes the appearance of thoughts which the patient never wishes to
recognize as his own, which he does not remember, although he admits
that they are inexorably demanded by the connection, and is convinced
that just these ideas cause the termination of the analysis and the
cessation of the symptoms.
I will now attempt to give a series of examples showing the excellent
achievements of this procedure. I treated a young lady who suffered for
six years from an intolerable and protracted nervous cough, which
apparently was nurtured by every common catarrh, but must have had its
strong psychic motives. Every other remedy had long since shown itself
to be powerless, and I therefore attempted to remove the symptom by
psychoanalysis. All that she could remember was that the nervous cough
began at the age of fourteen while she boarded with her aunt. She
remembered absolutely no psychic excitement during that time, and did
not believe that there was a motive for her suffering. Under the
pressure of my hand, she at first recalled a large dog. She then
recognized the memory picture; it was her aunt’s dog which was attached
to her, and used to accompany her everywhere, and without any further
aid it occurred to her that this dog died and that the children buried
it solemnly; and on the return from this funeral her cough appeared. I
asked her why she began to cough, and after helping her with the
pressure, the following thought occurred to her: “Now I am all alone in
this world; no one loves me here; this animal was my only friend, and
now I have lost it.” She then continued her story. “The cough
disappeared when I left my aunt, but reappeared a year and a half
later.”—“What was the reason for it?”—“I do not know.”—I again exerted
some pressure on the forehead, and she recalled the news of her uncle’s
death during which the cough again manifested itself, and also recalled
a train of thought similar to the former. The uncle was apparently the
only one in the family who sympathized with and loved her. That was,
therefore, the pathogenic idea: “People do not love her; everybody else
is preferred; she really does not deserve to be loved,” etc. To the idea
of love there clung something which caused a marked resistance to the
communication. The analysis was interrupted before this explanation.
Some time ago I attempted to relieve an elderly lady of her anxiety
attacks, which considering their characteristic qualities, were hardly
adapted to such influence. Since her menopause she had become extremely
religious, and always received me as if I were the Devil. She was always
armed with a small ivory crucifix which she hid in her hand. Her attacks
of anxiety, which bore the hysterical character, could be traced to her
early girlhood, and were supposed to have originated from the
application of an iodine preparation used to reduce a moderate swelling
of the thyroid. I naturally repudiated this origin, and sought to
substitute it by another which was in better harmony with my views
concerning the etiology of neurotic symptoms. To the first question for
an impression of her youth which would stand in causal connection to the
attacks of anxiety, there appeared under the pressure of my hand the
reminiscence of reading a so called devotional book wherein piously
enough there was some mention of the sexual processes. The passage in
question made an impression on this girl, which was contrary to the
intention of the author. She burst into tears and flung the book away.
That was before the first attack of anxiety. A second pressure on the
forehead of the patient evoked the next reminiscence, it referred to her
brother’s teacher who showed her great respect, and for whom she
entertained a warmer feeling. This reminiscence culminated in the
reproduction of an evening in her parents’ home, during which they all
sat around the table with the young man, and delightfully enjoyed
themselves in a lively conversation. During the night following this
evening she was awakened by the first attack of anxiety which surely had
more to do with some resistance against a sensual feeling than perhaps
with the coincidently used iodine. In what other way could I have
succeeded in revealing in this obstinate patient, prejudiced against me
and every worldly remedy, such a connection contrary to her own opinion
and assertion?
On another occasion I had to deal with a young happily married woman,
who as early as in the first years of her girlhood, was found every
morning for some time in a state of lethargy, with rigid members, opened
mouth, and protruding tongue. Similar attacks, though not so marked,
recurred at the present time on awakening. A deep hypnosis could not be
produced, so that I began my investigation in a state of concentration,
and assured her during the first pressure that she would see something
that would be directly connected with the cause of her condition during
her childhood. She acted calmly and willingly, she again saw the
residence in which she had passed her early girlhood, her room, the
position of her bed, the grandmother who lived with them at the time,
and one of her governesses whom she dearly loved. There was then a
succession of small, quite indifferent scenes, in these rooms, and among
these persons, the conclusion of which was the leave taking of the
governess who married from the home. I did not know what to start with
these reminiscences; I could not bring about any connection between them
and the etiology of the attacks. To be sure the various circumstances
were recognized as having occurred at the same time at which the attacks
first appeared.
Before I could continue the analysis, I had occasion to talk to a
colleague, who, in former years, was my patient’s family physician. From
him I obtained the following explanation: At the time that he treated
the mature and physically very well developed girl for these first
attacks, he was struck by the excessive affection in the relations
between her and her governess. He became suspicious and caused the
grandmother to watch these relations. After a short while the old lady
informed him that the governess was wont to pay nightly visits to the
child’s bed, and that quite regularly after such visits the child was
found in the morning in an attack. She did not hesitate to bring about
the quiet removal of this corruptress of youth. The children, as well as
the mother, were made to believe that the governess left the house in
order to get married.
The treatment, which was above all successful, consisted in informing
the young woman of the explanations given to me.
Occasionally the explanations, which one obtains by the pressure
procedure, follow in very remarkable form, and under circumstances which
make the assumption of an unconscious intelligence appear even more
alluring. Thus I recall a lady who suffered for years from obsessions
and phobias, and who referred the origin of her trouble to her
childhood, but could mention nothing to which it could have been
attributed. She was frank and intelligent, and evinced only a very
slight conscious resistance. I will add here that the psychic mechanism
of obsessions is very closely related to that of hysterical symptoms,
and that the technique of the analysis in both is the same.
On asking the lady whether she had seen or recalled anything under the
pressure of my hand, she answered, “Neither, but a word suddenly
occurred to me.”—“A single word?”—“Yes, but it is too foolish.”—“Just
tell it.”—“Teacher.”—“Nothing more?”—“No.” I exerted pressure a second
time, and again a single word flashed through her mind: “Shirt.”—I now
observed that we have dealt with a new mode of replying, and by repeated
pressure I evoked the following apparently senseless series of words:
Teacher—shirt—bed—city—wagon. I asked, “What does all that mean?” She
reflected for a moment, and it then occurred to her that “it can only
refer to this one incident which now comes to my mind. When I was ten
years old my older sister of twelve had an attack of frenzy one night,
and had to be bound, put in a wagon and taken to the city. I remember
distinctly that it was the teacher who overpowered her and accompanied
her to the asylum.”—We then continued this manner of investigation, and
received from our oracle another series of words which, though we could
not altogether interpret, could nevertheless be used as a continuation
of this story, and as an appendix to a second. The significance of this
reminiscence was soon clear. The reason why her sister’s illness made
such an impression on her was because they both shared a common secret.
They slept in the same room, and one night they both submitted to a
sexual assault by a certain man. In discovering this sexual trauma of
early youth, we revealed not only the origin of the first obsession but
also the trauma which later acted pathogenically.—The peculiarity of
this case lies only in the appearance of single catch words which we had
to elaborate into sentences, for the irrelevance and incoherence found
in these oracle like uttered words adhere to all ideas and scenes which
generally occur as a result of pressure. On further investigation it is
regularly found that the seemingly disconnected reminiscences are
connected by close streams of thought, and that they lead quite directly
to the desired pathogenic moment.
With pleasure do I therefore recall a case of analysis in which my
confidence in the results of pressure was splendidly justified. A very
intelligent, and apparently very happy, young woman consulted me for
persistent pain in her abdomen which yielded to no treatment. I found
that the pain was situated in the abdominal wall and was due to palpable
muscular hardening, and I ordered local treatment.
After months I again saw the patient who said that “the former pain
disappeared after following the treatment and remained away a long time,
but now it has reappeared as a nervous pain. I recognize it by the fact
that I do not perceive it now on motion as before, but only during
certain hours, as for example, in the morning on awakening, and during
certain excitements.” The patient’s diagnosis was quite correct. It was
now important to discover the cause of this pain, but in this she could
not assist me in her uninfluenced state. When, in a state of
concentration and under the pressure of my hand, I asked her whether
anything occurred to her, or whether she saw anything, she began to
describe her visual pictures. She saw something like a sun with rays,
which I naturally had to assume to be a phosphene produced by pressure
on the eyes. I expected that the useful pictures would follow, but she
continued to see stars of a peculiar pale blue light, like moonlight,
etc., and I believed that she merely saw glittering, shining, and
twinkling spots before the eyes. I was already prepared to add this
attempt to the failures, and I was thinking how I could quietly withdraw
from this affair, when my attention was called to one of the
manifestations which she described. She saw a big black cross which was
inclined, the edges of which were surrounded by a subdued moonlike light
in which all the pictures thus far seen were shining, and upon the arm
there flickered a little flame that was apparently no longer a
phosphene. I continued to listen. She saw numerous pictures in the same
light, peculiar signs resembling somewhat sanscrit. She also saw figures
like triangles, among which there was one big triangle, and again the
cross. I now thought of an allegorical interpretation, and asked, “What
does this cross mean?”—“It is probably meant to interpret pain,” she
answered. I argued, saying, that “by cross one usually understands a
moral burden,” and asked her what was hidden behind that pain. She could
not explain that and continued looking. She saw a sun with golden rays
which she interpreted as God, the primitive force; she then saw a
gigantic lizard which she examined quizzically but without fear; then a
heap of snakes, then another sun but with mild silvery rays, and in
front of it, between her own person and this source of light, there was
a barrier which concealed from her the center of the sun.
I knew for some time that we dealt here with allegories, and I
immediately asked for an explanation of the last picture. Without
reflecting she answered: “The sun is perfection, the ideal, and the
barrier represents my weaknesses and failings which stand between me and
the ideal.”—“Indeed, do you reproach yourself? Are you dissatisfied with
yourself?”—“Yes.”—“Since when?”—“Since I became a member of the
Theosophical Society and read the writings edited by it. I have always
had a poor opinion of myself.” “What was it that made the last strongest
impression upon you?”—“A translation from the sanscrit which now appears
in serial numbers.” A minute later I was initiated into her mental
conflicts, and into her self reproaches. She related a slight incident
which gave occasion for a reproach, and in which, as a result of an
inciting conversion, the former organic pain at first appeared.—The
pictures which I had at first taken for phosphenes were symbols of
occultistic streams of thought, perhaps plain emblems from the title
pages of occultistic books.
I have thus far so warmly praised the achievements of the pressure
procedure, and have so entirely neglected the aspect of the defense or
the resistance, that I certainly must have given the impression that by
means of this small artifice one is placed in position to become master
of the psychic resistances against the cathartic cure. But to believe
this would be a gross mistake. Such advantages do not exist in the
treatment so far as I can see; here, as everywhere else, great change
requires much effort. The pressure procedure is nothing but a trick
serving to surprise for awhile the defensive ego, which in all graver
cases recalls its intentions and continues its resistance.
I need only recall the various forms in which this resistance manifested
itself. In the first place, the pressure experiment usually fails the
first or second time. The patient then expresses himself disappointed,
saying, “I believed that some idea would occur to me, but I only thought
so; as attentive as I was nothing came.” Such attitudes assumed by the
patient are not yet to be counted as a resistance; we usually answer to
that, “You were really too anxious, the second time things will come.”
And they really come. It is remarkable how completely the patients—even
the most tractable and the most intelligent—can forget the agreement
which they have previously entered into. They have promised to tell
everything that occurs to them under the pressure of the hand, be it
closely related to them or not, and whether it is agreeable to them to
say it or not; that is, they are to tell everything without any choice,
or influence by critique or affect. Yet they do not keep their promise,
it is apparently beyond their powers. The work repeatedly stops, they
continue to assert that this time nothing came to their mind. One needs
not believe them, and one must always assume, and also say, that they
hold back something because they believe it to be unimportant, or
perceive it as painful. One must insist, repeat the pressure, and assume
an assured attitude until one really hears something. The patient then
adds, “I could have told you that the first time.”—“Why did you not say
it?”—“I could not believe that that could be it. Only after it returned
repeatedly have I decided to tell it;” or, “I had hoped that it would
not be just that, that I could spare myself from saying it, but only
after it could not be repressed have I noticed that I could not avoid
it.”—Thus the patient subsequently betrays the motives of a resistance
which he did not at first wish to admit. He apparently could not help
offering resistances.
It is remarkable under what subterfuges these resistances are frequently
hidden. “I am distracted today”; “the clock or the piano playing in the
next room disturbs me,” they say. I became accustomed to answer to that,
“Not at all, you simply struck against something that you do not
willingly wish to say. That does not help you at all. Just stick to
it.”—The longer the pause between the pressure of my hand and the
utterance of the patient, the more suspicious I become, and the more is
it to be feared that the patient arranges what comes to his mind, and
distorts it in the reproduction. The most important explanations are
frequently ushered in as superfluous accessories, just as the princes of
the opera who are dressed as beggars. “Something now occurred to me, but
it has nothing to do with it. I only tell it to you because you wish to
know everything.” With this introduction we usually obtain the long
desired solution. I always listen when I hear a patient talk so lightly
of an idea. That the pathogenic idea should appear of so little
importance on its reappearance is a sign of the successful defense. One
can infer from this of what the process of defense consisted. Its object
was to make a weak out of a strong idea, that is, to rob it of its
affect.
Among other signs the pathogenic memories can also be recognized by the
fact that they are designated by the patient as unessential, and yet are
only uttered with resistance. There are also cases where the patient
seeks to disavow the recollections, even while they are being
reproduced, with such remarks as these: “Now something occurred to me,
but apparently you talked it into me;” or, “I know what you expect to
this question, you surely think that I thought of this and that.” An
especially clever way of shifting is found in the following expression:
“Now something really occurred to me, but it seems to me as if I added
it, and that it is not a reproduced thought.”—In all these cases I
remain inflexibly firm, I admit none of these distinctions, but explain
to the patient that these are only forms and subterfuges of the
resistance against the reproduction of a recollection which in spite of
all we are forced to recognize.
One generally experiences less trouble in the reproduction of pictures
than thoughts. Hysterical patients who are usually visual are easier to
manage than patients suffering from obsessions. Once the picture emerges
from the memory we can hear the patient state that as he proceeds to
describe it, it proportionately fades away and becomes indistinct; the
patient wears it out, so to speak, by transforming, it into words. We
then orient ourselves through the memory picture itself in order to find
the direction towards which the work should be continued. We say to the
patient, “Just look again at the picture, has it disappeared?”—“As a
whole, yes, but I still see this detail.”—“Then this must have some
meaning, you will either see something new, or this remnant will remind
you of something.” When the work is finished the visual field becomes
free again, and a new picture can be called forth; but at other times
such a picture, in spite of its having been described, remains
persistently before the inner eye of the patient, and I take this as a
sign that he still has something important to tell me concerning its
theme. As soon as this has been accomplished, the picture disappears
like a wandering spirit returning to rest.
It is naturally of great value for the progress of the analysis to carry
our point with the patient, otherwise we have to depend on what he
thinks is proper to impart. It, therefore, will be pleasant to hear that
the pressure procedure never failed except in a single case which I
shall discuss later, but which I can now characterize by the fact that
there was a special motive for the resistance. To be sure, it may happen
under certain conditions that the procedure may be applied without
bringing anything to light; as, for example, we may ask for the further
etiology of a symptom when the same has already been exhausted; or, we
may investigate for the psychic genealogy of a symptom, perhaps a pain,
which really was of somatic origin. In these cases the patient equally
insists that nothing occurred to him, and he is right. We should strive
to avoid doing an injustice to the patient by making it a general rule
not to lose sight of his features while he calmly lies before us during
the analysis. One can then learn to distinguish, without any difficulty,
the psychic calm in the real non appearance of a reminiscence from the
tension and emotional signs under which the patient labors in trying to
disavow the emerging reminiscences for the purpose of defense. The
differential diagnostic application of the pressure procedure is really
based on such experiences.
We can see, therefore, that even with the help of the pressure procedure
the task is not an easy one. The only advantage gained is the fact that
we have learned from the results of this method in what direction to
investigate, and what things we have to force upon the patient. For some
cases that suffices, for the question is really to find the secret, and
tell it to the patient, so that he is usually then forced to relinquish
his resistance. In other cases more is necessary; here the surviving
resistance of the patient manifests itself by the fact that the
connections become torn, the solutions do not appear, and the recalled
pictures come indistinctly and incompletely. On reviewing, at a later
period, the earlier results of an analysis, we are often surprised at
the distorted aspects of all the occurrences and scenes which we have
snatched from the patient by the pressure procedure. It usually lacks
the essential part, the relations to the person or to the theme, and for
that reason the picture remained incomprehensible. I will now give one
or two examples showing the effects of such a censoring during the first
appearance of the pathogenic memories. The patient sees the upper part
of a female body on which a loose covering fits carelessly, only much
later he adds to this torso the head, and thereby betrays a person and a
relationship. Or, he relates a reminiscence of his childhood about two
boys whose forms are very indistinct, and to whom a certain
mischievousness was attributed. It required many months and considerable
progress in the course of the analysis before he again saw this
reminiscence and recognized one of the children as himself and the other
as his brother. What means have we now at our disposal to overcome this
continued resistance?
We have but few, yet we have almost all those by which one person exerts
a psychic influence on the other. In the first place we must remember
that psychic resistance, especially of long continuance, can only be
broken slowly, gradually, and with much patience. We can also count on
the intellectual interest which manifests itself in the patient after a
brief period of the analysis. On explaining and imparting to him the
knowledge of the marvelous world of psychic processes, which we have
gained only through such analysis, we obtain his collaboration, causing
him to view himself with the objective interest of the investigator, and
we thus drive back the resistance which rests on an affective basis. But
finally—and this remains the strongest motive force—after the motives
for the defense have been discovered, we must make the attempt to reduce
or even substitute them by stronger ones. Here the possibility of
expressing the therapeutic activity in formulæ ceases. One does as well
as he can as an explainer where ignorance has produced timorousness, as
a teacher, as a representative of a freer and more superior
world-conception, and as confessor, who through the continuance of his
sympathy and his respect, imparts, so to say, absolution after the
confession. One endeavors to do something humane for the patient in so
far as the range of one’s own personality and the measure of sympathy
which one can set apart for the case allows. It is an indispensable
prerequisite for such psychic activities to have approximately
discovered the nature of the case and the motives of the defense here
effective. Fortunately the technique of the urging and the pressure
procedure take us just so far. The more we have solved such enigmas the
easier will we discover new ones, and the earlier will we be able to
manage the actual curative psychic work. For it is well to bear in mind
that although the patient can rid himself of an hysterical symptom only
after reproducing and uttering under emotion its causal pathogenic
impressions, yet the therapeutic task merely consists in inducing him to
do it, and once the task has been accomplished there remains nothing for
the doctor to correct or abolish. All the contrary suggestions necessary
have already been employed during the struggle carried on against the
resistance. The case may be compared to the unlocking of a closed door,
where, as soon as the door knob has been pressed downward, no other
difficulties are encountered in opening the door.
Among the intellectual motives employed for the overcoming of the
resistance one can hardly dispense with one affective moment, that is,
the personal equation of the doctor, and in a number of cases, this
alone will be able to break the resistance. The conditions here do not
differ from those found in any other branch of medicine, and one should
not expect any therapeutic method to fully disclaim the assistance of
this personal moment.
III.
In view of the discussions in the preceding section concerning the
difficulty of my technique, which I have unreservedly exposed,—I have
really collected them from my most difficult cases, though it will often
be easier work—in view then of this state of affairs everybody will wish
to ask whether it would not be more suitable, instead of all these
tortures, to apply oneself more energetically to hypnosis, or to limit
the application of the cathartic method to only such cases as can be
placed in deep hypnosis. To the latter proposition I should have to
answer that the number of patients available for my skill would shrink
considerably; but to the former advice I will advance the supposition
that even where hypnosis could be produced the resistance would not be
very much lessened. My experiences in this respect are not particularly
extensive, so that I am unable to go beyond this supposition, but
wherever I achieved a cathartic cure in the hypnotic state I found that
the work devolved upon me was not less than in the state of
concentration. I have only recently finished such a treatment during
which course I caused the disappearance of a hysterical paralysis of the
legs. The patient merged into a state, psychically very different from
the conscious, and somatically distinguished by the fact that she was
unable to open her eyes or rise without my ordering her to do so; and
still I never had a case showing greater resistance than this one. I
placed no value on these physical signs, and toward the end of the ten
months’ treatment they really became imperceptible. The condition of the
patient during our work has therefore lost nothing of its psychic
peculiarities, such as the ability to recall the unconscious and its
very peculiar relation to the person of the physician. To be sure, in
the history of Mrs. Emmy v. N. I have described an example of a
cathartic cure accomplished in a profound somnambulism in which the
resistance played almost no part. But nothing that I obtained from this
woman would have required any special effort; I obtained nothing that
she could not have told me in her waking state after a longer
acquaintanceship and some esteem. The real causes of her disease, which
were surely identical with the causes of her relapses after my
treatment, I have never found—it was my first attempt in this
therapy—and when I once asked her accidentally for a reminiscence which
contained a fragment of the erotic, I found her just as resistant and
unreliable in her statements as any one of my later non-somnambulic
patients. This patient’s resistance, even in the somnambulic state,
against other requirements and exactions I have already discussed in her
history. Since I have witnessed cases who, even in deep somnambulism
were absolutely refractory therapeutically despite their obedience in
everything else, I really became skeptical as to the value of hypnosis
for the facilitation of the cathartic treatment. A case of this kind I
have reported in brief,[32] and could still add others.
In our discussion thus far, the idea of resistance has thrust itself to
the foreground. I have shown how, in the therapeutic work, one is led to
the conception that hysteria originates through the repression of an
unbearable idea from a motive of defense, that the repressed idea
remains as a weak (mildly intensive) reminiscence, and that the affect
snatched from it is used for a somatic innervation, that is, conversion
of the excitement. By virtue of its repression the idea becomes the
cause of morbid symptoms, that is pathogenic. A hysteria showing this
psychic mechanism may be designated by the name of “defense hysteria,”
but both Breuer and myself have repeatedly spoken of two other kinds of
hysterias which we have named hypnoid and retention hysteria. The first
to reveal itself to us was really the hypnoid-hysteria, for which I can
mention no better example than Breuer’s case of Miss Anna O.[33] For
this form of hysteria Breuer gives an essentially different psychic
mechanism than for the form which is characterized by conversion. Here
the idea becomes pathogenic through the fact that it is conceived in a
peculiar psychic state, having remained from the very beginning external
to the ego. It therefore needs no psychic force to keep it away from the
ego, and it need not awaken any resistance when, with the help of the
somnambulic psychic authority, it is initiated into the ego. The history
of Anna O. really shows no such resistance.
I held this distinction as so essential that it has readily induced me
to adhere to the formation of the hypnoid-hysteria. It is however
remarkable that in my own experience I encountered no genuine
hypnoid-hysteria, whatever I treated changed itself into a defense
hysteria. Not that I have never dealt with symptoms which manifestly
originated in separated conscious states, and therefore were excluded
from being accepted into the ego. I found this also in my own cases, but
I could show that the so called hypnoid state owed its separation to the
fact that a split off psychic group originated before, through defense.
In brief, I cannot suppress the suspicion that hypnoid and defense
hysteria meet somewhere at their roots, and that the defense is the
primary thing; but I know nothing about it.
Equally uncertain is at present my opinion concerning the retention
hysteria in which the therapeutic work is also supposed to follow
without any resistance. I had a case which I took for a typical
retention hysteria, and I was pleased over the anticipation of an easy
and certain success; but this success did not come as easy as the work
really was. I therefore presume, and again with all caution appropriate
to ignorance, that in retention hysteria, too, we can find at its basis
a fragment of defense which has thrust the whole process into hysteria.
Let us hope that new experiences will soon decide whether I am running
into the danger of one-sidedness and error in my tendency to spread the
conception of defense for the whole of hysteria.
Thus far I have dealt with the difficulties and technique of the
cathartic method, I would now like to add a few indications showing how
one makes an analysis with technique. For me this is a very interesting
theme, but I do not expect that it will excite similar interest in
others who have not practiced such analyses. Properly speaking we shall
again deal with the technique, but this time with those difficulties
concerning which the patient cannot be held responsible, and which must
in part be the same in a hypnoid and a retention hysteria as well as in
the defense hysteria which I have in mind as a model. I start on this
last fragment of discussion with the expectation that the psychic
peculiarities revealed here might sometime attain a certain value as raw
material for an intellectual dynamics.
The first and strongest impression which one gains through such an
analysis is surely the fact that the pathogenic psychic material,
apparently forgotten and not at the disposal of the ego, playing no rôle
in the association and in memory, still lies ready in some manner and in
proper and good order. All that is necessary is to remove the
resistances blocking the way. Barring that, everything is known as we
know anything else, the proper connections of the individual ideas among
themselves and with the nonpathogenic are frequently recalled and are
present; they have been produced in their time and retained in memory.
The pathogenic psychic material appears as the property of an
intelligence which is not necessarily inferior to the normal ego. The
semblance of a second personality is often most delusively produced.
Whether this impression is justified, whether the arrangements of the
psychic material resulting after the adjustment is not transferred back
into the time of the disease, these are questions which I do not like to
consider in this place. One cannot easily and intuitively describe the
experiences resulting from these analyses as if he placed himself in the
position, which one can only take a survey of after their disappearance.
The condition is usually not so simple as one represents it in special
cases, as, for example, in a single case in which a symptom originates
through a serious trauma. We frequently deal not with a single
hysterical symptom but with a number of the same which are partially
independent of one another and partially connected. We must not expect a
single traumatic reminiscence whose nucleus is a single pathogenic idea,
but we must be ready to assume a series of partial traumas and a
concatenation of pathogenic streams of thought. The monosymptomatic
traumatic hysteria is, as it were, an elementary organism, it is a
single being in comparison to the complicated structure of a grave
hysterical neurosis as is generally encountered.
The psychic material of such hysteria presents itself as a
multidimensional formation of at least triple stratification. I hope to
be able to soon justify this figurative expression. First of all there
is a nucleus of such reminiscences (either experiences or streams of
thought) in which the traumatic moment culminated, or in which the
pathogenic idea has found its purest formation. Around this nucleus we
often find an incredibly rich mass of other memory material which we
have to elaborate by the analysis in the triple arrangement mentioned
before. In the first place, there is an unmistakable linear
chronological arrangement which takes place within every individual
theme. As an example of this I can only cite the arrangements in
Breuer’s analysis of Anna O. The theme is that of becoming deaf, of not
hearing,[34] which then becomes differentiated according to seven
determinants, and under each heading there were from ten to one hundred
single reminiscences in chronological order. It was as if one should
take up an orderly kept record. In the analysis of my patient, Emmy v.
N., there were similar if not so many memory sub-divisions; they formed
quite a general event in every analysis. They always occurred in a
chronological order which was as definitely reliable as the serial
sequences of the days of the week or the names of the months in
psychically normal individuals. They increased the work of the analysis
through the peculiarity of reversing the series of their origin in the
reproduction; the freshest and the most recent occurrence of the
accumulation occurred first as a “wrapper,” and that with which the
series really began gave the impression of the conclusion.
The grouping of similar reminiscences in a multiplicity of linear
stratifications, as represented in a bundle of documents, in a package,
etc., I have designated as the formation of a theme. These themes now
show a second form of arrangement. I cannot express it differently than
by saying that they are concentrically stratified around the pathogenic
nucleus. It is not difficult to say what determines these strata, and
according to what decreasing or increasing magnitude this arrangement
follows. They are layers of equal resistance tending towards the
nucleus, accompanied by zones of similar alteration of consciousness
into which the individual themes extend. The most peripheral layers
contain those reminiscences (or fascicles) of the different themes which
can readily be recalled and were always perfectly conscious. The deeper
one penetrates the more difficult it becomes to recognize the emerging
reminiscences until one strikes those near the nucleus which the patient
disavows, even at the reproduction.
As we shall hear later it is the peculiarity of the concentric
stratification of the pathogenic psychic material which gives to the
course of such an analysis its characteristic features. We must now
mention the third and most essential arrangement concerning which a
general statement can hardly be made. It is the arrangement according to
the content of thought, the connection through the logical thread
reaching to the nucleus which might in each case correspond to a
special, irregular, and manifoldly devious road. This arrangement has a
dynamic character in contradistinction to both morphological
stratifications mentioned before. Whereas, in a spacially formed scheme
the latter would be represented by rigid, arched, and straight lines,
the course of the logical concatenation would have to be followed with a
wand, over the most tortuous route, from the superficial into the deep
layers and back, generally, however, progressing from the peripheral to
the central nucleus, and touching thereby all stations; that is, its
movement is similar to the zigzag movement of the knight in the solution
of a chess problem.
I will still adhere for a moment to the last comparison in order to call
attention to a point in which it does not do justice to the qualities of
the thing compared. The logical connection corresponds not only to a
zigzag-like devious line, but rather to a ramifying and especially to a
converging system of lines. It has a junction in which two or more
threads meet only to proceed thence united, and, as a rule, many threads
running independently, or here and there connected by by-paths, open
into the nucleus. To put it in different words, it is very remarkable
how frequently a symptom is manifoldly determined, that is,
over-determined.
I will introduce one more complication, and then my effort to illustrate
the organization of the pathogenic psychic material will be achieved. It
can happen that we may deal with more than one single nucleus in the
pathogenic material, as, for example, when we have to analyze a second
hysterical outbreak having its own etiology but which is still connected
with the first outbreak of an acute hysteria which has been overcome
years before. It can readily be imagined what strata and streams of
thought must be added in order to produce a connection between the two
pathogenic nuclei.
I will still add a few observations to the picture obtained of the
organization of the pathogenic material. We have said of this material
that it behaves like a foreign body, and that the therapy also acts like
the removal of a foreign body from the living tissues. We are now in
position to consider the shortcomings of this comparison. A foreign body
does not enter into any connection with the layers of tissue surrounding
it, although it changes them and produces in them a reactive
inflammation. On the other hand, our pathogenic psychic group does not
allow itself to be cleanly shelled out from the ego, its outer layers
radiate in all directions into the parts of the normal ego, and really
belong to the latter as much as to the pathogenic organization. The
boundaries between both become purely conventional in the analysis,
being placed now here, now there, and in certain locations no
demarcation is possible. The inner layers become more and more estranged
from the ego without showing a visible beginning of the pathogenic
boundaries. The pathogenic organization really does not behave like a
foreign body, but rather like an infiltration. The infiltrate must, in
this comparison, be assumed to be the resistance. Indeed, the therapy
does not consist in extirpating something—psychotherapy cannot do that
at present—but it causes a melting of the resistance, and thus opens the
way for the circulation into a hitherto closed territory.
(I make use here of a series of comparisons all of which have only a
very limited resemblance to my theme, and do not even agree among
themselves. I am aware of that, and I am not in danger of
over-estimating their value; but, as it is my intention to illustrate
the many sides of a most complicated and not as yet depicted idea, I
therefore take the liberty of dealing also in the following pages with
comparisons which are not altogether free from objections.)
If, after a thorough adjustment, one could show to a third party the
pathogenic material in its present recognized, complicated and
multidimensional organization, he would justly propound the question,
“How could such a camel go through the needle’s eye?” Indeed, one does
not speak unjustly of a “narrowing of consciousness.” The term gains in
sense and freshness for the physician who accomplishes such an analysis.
Only one single reminiscence can enter into the ego consciousness; the
patient occupied in working his way through this one sees nothing of
that which follows, and forgets everything that has already wedged its
way through. If the conquest of this one pathogenic reminiscence strikes
against impediments, as for example, if the patient does not yield the
resistance against it, but wishes to repress or distort it, the strait
is, so to speak, blocked; the work comes to a standstill, it cannot
advance, and the one reminiscence in the breach confronts the patient
until he takes it up into the breadth of his ego. The whole spacially
extended mass of the pathogenic material is thus drawn through a narrow
fissure and reaches consciousness as if disjointed into fragments or
strips, and it is the task of the psychotherapist to recompose it into
the conjectured organization. He who desires still more comparisons may
think here of a Chinese puzzle.
If one is about to begin an analysis in which one may expect such an
organization of the pathogenic material, the following results of
experience may be useful: _It is perfectly hopeless to attempt to make
any direct headway towards the nucleus of the pathogenic organization._
Even if it could be guessed the patient would still not know what to
start with the explanation given to him, nor would it change him
psychically.
There is nothing left to do but follow up the periphery of the
pathogenic psychic formation. One begins by allowing the patient to
relate and recall what he knows, during which one can already direct his
attention, and through the application of the pressure procedure slight
resistances may be overcome. Whenever a new way is opened through
pressure it can be expected that the patient will continue it for some
distance without any new resistance.
After having worked for a while in such manner a coöperating activity is
usually manifested in the patient. A number of reminiscences now occur
to him without any need of questioning or setting him a task. A way has
thus been opened into an inner strata, within which the patient now
spontaneously disposes of the material of equal resistance. It is well
to allow him to reproduce for a while without being influenced; of
course, he is unable to reveal important connections, but he may be
allowed to clear things within the same stratum. The things which he
thus reproduces often seem disconnected, but they give up the material
which is later revived by the recognized connections.
One has to guard here in general against two things. If the patient is
checked in the reproduction of the inflowing ideas, something is apt to
be “buried” which must be uncovered later with great effort. On the
other hand one must not overestimate his “unconscious intelligence,” and
one must not allow it to direct the whole work. If I should wish to
schematize the mode of labor, I could perhaps say that one should
himself undertake the opening of the inner strata and the advancement in
the radial direction, while the patient should take care of the
peripheral extension.
The advancement is brought about by the fact that the resistance is
overcome in the manner indicated above. As a rule, however, one must at
first solve another problem. One must obtain a piece of a logical thread
by which direction alone one can hope to penetrate into the interior.
One should not expect that the voluntary information of the patient, the
material which is mostly in the superficial strata, will make it easy
for the analyzer to recognize the locations where it enters into the
deep, and to which points the desired connections of thought are
attached. On the contrary, just this is cautiously concealed, the
assertion of the patient sounds perfect and fixed in itself. One is at
first confronted, as it were, by a wall which shuts off every view, and
gives no suggestion of anything hidden behind it.
If, however, one views with a critical eye the assertion obtained from
the patient without much effort and resistance, one will unmistakably
discover in it gaps and injuries. Here the connection is manifestly
interrupted and is scantily completed by the patient by an expression
conveying quite insufficient information. Here one strikes against a
motive which in a normal person would be designated as flimsy. The
patient refuses to recognize these gaps when his attention is called to
them. The physician, however, does well to seek under these weak points
access to the material of the deeper layers and to hope to discover just
here the threads of the connections which he traces by the pressure
procedure. One, therefore, tells the patient, “You are mistaken, what
you assert can have nothing to do with the thing in question; here we
will have to strike against something which will occur to you under the
pressure of my hand.”
The hysterical stream of thought, even if it reaches into the
unconscious, may be expected to show the same logical connections and
sufficient causations as those that would be formed in a normal
individual. A looseness of these relationships does not lie within the
sphere of influence of the neurosis. If the association of ideas of
neurotics, and especially of hysterics, makes a different impression, if
the relation of the intensities of different ideas does not seem to be
explainable here on psychological determinants alone, we know that such
manifestations are due to the existence of concealed unconscious
motives. Such secret motives may be expected wherever such a deviation
in the connection, or a transgression from the normally justified
causations can be demonstrated.
To be sure one must free himself from the theoretical prejudice that one
has to deal with abnormal brains of dégénerés and deséquilibrés, in whom
the freedom of overthrowing the common psychological laws of the
association of ideas is a stigma, or in whom a preferred idea without
any motive may grow intensively excessive, and another without
psychological motives may remain indestructible. Experience shows the
contrary in hysteria; as soon as the hidden—often unconsciously
remaining—motives have been revealed and brought to account there
remains nothing in the hysterical thought connection that is enigmatical
and anomalous.
Thus by tracing the breaches in the first statements of the patient,
which are often hidden by “false connections,” one gets hold of a part
of the logical thread at the periphery, and thereafter continues the
route by the pressure procedure.
Very seldom do we succeed in working our way into the inner strata by
the same thread, usually it breaks on the way when the pressure fails,
giving up either no experience, or one which cannot be explained or be
continued despite all efforts. In such a case we soon learn how to
protect ourselves from the obvious confusion. The expression of the
patient must decide whether one really reached an end or encountered a
case needing no psychic explanation, or whether it is the enormous
resistance that halts the work. If the latter cannot soon be overcome,
it may be assumed that the thread has been followed into a strata which
is as yet impenetrable. One lets it fall in order to grasp another
thread which may, perhaps, be followed up just as far. If one has
followed all the threads into this strata, if the knottings have been
reached through which no single isolated thread can be followed, it is
well to think of seizing anew the resistances on hand.
One can readily imagine how complicated such a work may become. By
constantly overcoming the resistance, one pushes his way into the inner
strata, gaining knowledge concerning the accumulative themes and passing
threads found in this layer; one examines as far as he can advance with
the means at hand, and by means of the pressure procedure he gains first
information concerning the content of the next strata.
The threads are dropped, taken up again, and followed up until they
reach the juncture; they are always retrieved, and by following a memory
fascicle one reaches some by-way which finally opens again. In this
manner it is possible to leave the work, layer by layer, and advance
directly on the main road to the nucleus of the pathogenic organization.
Thus the fight is won but not finished. One has to follow up the other
threads and exhaust the material; but now the patient helps again
energetically, for his resistance has mostly been broken.
In these later stages of the work it is of advantage if one can surmise
the connection and tell it to the patient before it has been revealed.
If the conjecture is correct the course of the analysis is accelerated,
but even an incorrect hypothesis helps, for it urges the patient to
participate and elicits from him energetic refutation, thus revealing
that he surely knows better.
One, thereby, becomes astonishingly convinced, _that it is not possible
to press upon the patient things which he apparently does not know, or
to influence the results of the analysis by exciting his expectations_.
I have not succeeded a single time in altering or falsifying the
reproductions of memory or the connections of events by my predictions;
had I succeeded it surely would have been revealed in the end by a
contradiction in the construction. If anything occurred as I predicted,
the correctness of my conjecture was always attested by numerous
trustworthy reminiscences. Hence, one must not fear to express his
opinion to the patient concerning the connections which are to follow;
it does no harm.
Another manifestation which can be repeatedly observed refers to the
patient’s independent reproductions. It can be asserted that not a
single reminiscence comes to the surface during such an analysis which
has no significance. An interposition of irrelevant memory pictures
having no connection with the important associations does not really
occur. An exception not contrary to the rule may be postulated for those
reminiscences which, though in themselves unimportant, are indispensable
as intercalations, since the associations between two related
reminiscences passed through them only.—As mentioned above, the period
during which a reminiscence abides in the pass of the patient’s
consciousness is directly proportionate to its significance. A picture
which does not disappear requires further consideration; a thought which
cannot be abolished must be followed further. A reminiscence never
recurs if it has been adjusted, a picture spoken away cannot be seen
again. However, if that does happen it can be definitely expected that
the second time the picture will be joined by a new content of thought,
that the idea will contain a new inference which will show that no
perfect adjustment has taken place. On the other hand, a recurrence of
different intensities, at first vaguely then quite plainly, often
occurs, but it does not, however, contradict the assertion just
advanced.
If the object of the analysis is to remove a symptom (pains, symptoms
like vomiting, sensations and contractures) which is capable of
aggravation or recurrence, the symptom shows during the work the
interesting and not undesirable phenomenon of “joining in the
discussion.” The symptom in question reappears, or appears with greater
intensity, as soon as one penetrates into the region of the pathogenic
organization containing the etiology of this symptom, and it continues
to accompany the work with characteristic and instructive fluctuations.
The intensity of the same (let us say of a nausea) increases the deeper
one penetrates into its pathogenic reminiscence; it reaches its height
shortly before the latter has been expressed, and suddenly subsides or
disappears completely for a while after it has been fully expressed. If
through resistance the patient delays the expression, the tension of the
sensation of nausea becomes unbearable, and, if the expression cannot be
forced, vomiting actually sets in. One thus gains a plastic impression
of the fact that the vomiting takes the place of a psychic action (here
that of speaking) just as was asserted in the conversion theory of
hysteria.
The fluctuation of intensity on the part of the hysterical symptom
recurs as often as one of its new and pathogenic reminiscences is
attacked; the symptom remains, as it were, all the time the order of the
day. If it is necessary to drop for awhile the thread upon which this
symptom hangs, the symptom, too, merges into obscurity in order to
emerge again at a later period of the analysis. This play continues
until, through the completion of the pathogenic material, there occurs a
definite adjustment of this symptom.
Strictly speaking the hysterical symptom does not behave here
differently than a memory picture or a reproduced thought which is
evoked by the pressure of the hand. Here, as there, the adjustment
necessitates the same obsessing obstinacy of recurrence in the memory of
the patient. The difference lies only in the apparent spontaneous
appearance of the hysterical symptom, whereas one readily recalls having
himself provoked the scenes and ideas. But in reality the memory symbols
run in an uninterrupted series from the unchanged memory remnants of
affectful experiences and thinking-acts to the hysterical symptoms.
The phenomenon of “joining in the discussion” of the hysterical symptom
during the analysis carries with it a practical inconvenience to which
the patient should be reconciled. It is quite impossible to undertake
the analysis of a symptom in one stretch or to divide the pauses in the
work in such a manner as to precisely coincide with the resting point in
the adjustment. Furthermore, the interruption which is categorically
dictated by the accessory circumstances of the treatment, like the late
hour, etc., often occurs in the most awkward locations, just when some
critical point could be approached or when a new theme comes to light.
These are the same inconveniences which every newspaper reader
experiences in reading the daily fragments of his newspaper romance,
when, immediately after the decisive speech of the heroine, or after the
report of a shot, etc., he reads, “To be continued.” In our case the
raked-up but unabolished theme, the at first strengthened but not yet
explained symptom, remains in the patient’s psyche, and troubles him
perhaps more than before.
But the patient must understand this as it cannot be differently
arranged. Indeed, there are patients who during such an analysis are
unable to get rid of the theme once touched; they are obsessed by it
even during the interval between the two treatments, and as they are
unable to advance alone with the adjustment, they suffer more than
before. Such patients, too, finally learn to wait for the doctor,
postponing all interest which they have in the adjustment of the
pathogenic material for the hours of the treatment, and they then begin
to feel freer during the intervals.
The general condition of the patient during such an analysis seems also
worthy of consideration. For a while it remains uninfluenced by the
treatment expressing the former effective factors. But then a moment
comes in which the patient is seized, and his interest chained and from
that time his general condition becomes more and more dependent on the
condition of the work. Whenever a new explanation is gained and an
important contribution in the chain of the analysis is reached, the
patient feels relieved and experiences a presentiment of the approaching
deliverance; but at each standstill of the work, at each threatening
entanglement, the psychic burden which oppresses him grows, and the
unhappy sensation of his incapacity increases. To be sure, both
conditions are only temporary, for the analysis continues disdaining to
boast of a moment of wellbeing, and continues regardlessly over the
period of gloominess. One is generally pleased if it is possible to
substitute the spontaneous fluctuations in the condition of the patient
by such as one himself provokes and understands, just as one prefers to
see in place of the spontaneous discharge of the symptoms that order of
the day which corresponds to the condition of the analysis.
Usually the deeper one penetrates into the above described layers of the
psychic structure the more obscure and difficult the work will at first
become. But once the nucleus is reached light ensues, and there is no
more fear that a marked gloom will be cast over the condition of the
patient. However, the reward of the labor, the cessation of the symptoms
of the disease can only be expected when the full analysis of every
individual symptom has been accomplished; indeed where the individual
symptoms are connected through many junctures one is not even encouraged
by partial successes during the work. By virtue of the great number of
existing causal connections every unadjusted pathogenic idea acts as a
motive for the complete creation of the neurosis, and only with the last
word of the analysis does the whole picture of the disease disappear,
just as happens in the behavior of the individual reproduced
reminiscence.
If a pathogenic reminiscence or a pathogenic connection which was
previously withdrawn from the ego consciousness is revealed by the work
of the analysis and inserted into the ego, one can observe in the
psychic personality which was thus enriched the many ways in which it
gives utterance to its gain. Especially does it frequently happen that
after the patients have been painstakingly forced to a certain
knowledge, they say: “Why I have known that all the time, I could have
told you that before.” Those who have more insight recognize this
afterwards as a self deception and accuse themselves of ungratefulness.
In general the position that the ego takes towards the new acquisition
depends upon the strata of the analysis from which the latter
originates. Whatever belongs to the outermost layers is recognized
without any difficulty, for it always remained in the possession of the
ego, and the only thing that was new to the ego was its connection with
the deeper layers of the pathogenic material. Whatever is brought to
light from these deeper layers also finds appreciation and recognition,
but frequently only after long hesitation and reflection. Of course,
visual memory pictures are here more difficult to deny than
reminiscences of mere streams of thought. Not very seldom the patient
will at first say, “It is possible that I thought of that, but I cannot
recall it,” and only after a longer familiarity with this supposition
recognition will appear. He then recalls and even verifies by sight
associations that he once really had this thought. During the analysis I
make it a point of holding the value of an emerging reminiscence
independent of the patient’s recognition. I am not tired of repeating
that we are obliged to accept everything that we bring to light with our
means. Should there be anything unreal or incorrect in the material thus
revealed, the connection will later teach us to separate it. I may add
that I rarely ever have occasion to subsequently withdraw the
recognition from a reminiscence which I had preliminarily admitted. In
spite of the deceptive appearance of an urgent contradiction, whatever
came to the surface finally proved itself correct.
Those ideas which originate in the deepest layer, and from the nucleus
of the pathogenic organization, are only with the greatest difficulty
recognized by the patient as reminiscences. Even after everything is
accomplished, when the patients are overcome by the logical force and
are convinced of the curative effect accompanying the emerging of this
idea—I say even if the patients themselves assume that they have thought
“so” and “so” they often add, “but to recall, that I have thought so, I
cannot.” One readily comes to an understanding with them by saying that
these were unconscious thoughts. But how should we note this state of
affairs in our own psychological views? Should we pay no heed to the
patient’s demurring recognition which has no motive after the work has
been completed; should we assume that it was really a question of
thoughts which never occurred, and for which there is only a possibility
of existence so that the therapy would consist in the consummation of a
psychic act which at that time never took place? It is obviously
impossible to state anything about it, that is, to state anything
concerning the condition of the pathogenic material previous to the
analysis, before one has thoroughly explained his psychological views
especially concerning the essence of consciousness. It is a fact worthy
of reflection that in such analyses one can follow a stream of thought
from the conscious into the unconscious (that is, absolutely not
recognized as a reminiscence) thence draw it for some distance through
the consciousness, and again see it end in the unconscious; and still
this variation of the psychic elucidation would change nothing in it, in
its logicalness, and in a single part of its connection. Should I then
have this stream of thought freely before me, I could not conjecture
what part was, and what part was not recognized by the patient as a
reminiscence. In a measure I see only the points of the stream of
thought merging into the unconscious, just the reverse of that which has
been claimed for our normal psychic processes.
I still have another theme to treat which plays an undesirably great
part in the work of such a cathartic analysis. I have already admitted
the possibility that the pressure procedure may fail and despite all
assurance and urging it may evoke no reminiscences. I also stated that
two possibilities are to be considered, there is really nothing to evoke
in the place where we investigate—that can be recognized by the
perfectly calm expression of the patient—or, we have struck against a
resistance to be overcome only at some future time. We are confronted
with a new layer into which we cannot as yet penetrate, and this can
again be read from the drawn and psychic exertion of the patient’s
expression. A third cause may be possible which also indicates an
obstacle, not as to the purport, but externally. This cause occurs when
the relation of the patient to the physician is disturbed, and signifies
the worst obstacle that can be encountered. One may consider that in
every more serious analysis.
I have already alluded to the important rôle falling to the personality
of the physician in the creation of motives which are to overcome the
psychic force of the resistance. In not a few cases, especially in women
and where we deal with the explanation of erotic streams of thought, the
cooperation of the patient becomes a personal sacrifice which must be
recompensed by some kind of a substitute of love. The great effort and
the patient friendliness for the physician suffice as such substitutes.
If this relation of the patient to the physician is disturbed the
readiness of the patient fails; if the physician desires information
concerning the next pathogenic idea, the patient is confronted by the
consciousness of the unpleasantness which has accumulated in her against
the physician. As far as I have discovered this obstacle occurs in three
principal cases:
1. In personal estrangement, if the patient believes herself slighted,
disparaged and insulted, or if she hears unfavorable accounts concerning
the physician and his methods of treatment. This is the least serious
case. The obstacle can readily be overcome by discussion and
explanation, although the sensitiveness and the suspicion of hysterics
can occasionally manifest itself in unsuspected dimensions.
2. If the patient is seized with the fear that she becomes too
accustomed to her physician, that in his presence she loses her
independence and could even become sexually dependent upon him; this
case is more significant because it is less determined individually. The
occasion for this obstacle lies in the nature of the therapeutic
distress. The patient has now a new motive to resist which manifests
itself, not only in a certain reminiscence but at each attempt of the
treatment. Whenever the pressure procedure is started the patient
usually complains of headache. Her new motive for the resistance remains
to her for the most part unconscious, and she manifests it by a newly
created hysterical symptom. The headache signifies the aversion towards
being influenced.
3. If the patient fears lest the painful ideas emerging from the content
of the analysis would be transferred to the physician. This happens
frequently, and, indeed, in many analyses it is a regular occurrence.
The transference to the physician occurs through false connections.[35]
I must here give an example. The origin of a certain hysterical symptom
in one of my hysterical patients was the wish she entertained years ago
which was immediately banished into the unconscious, that the man with
whom she at that time conversed would heartily grasp her and force a
kiss on her. After the ending of a session such a wish occurred to the
patient in reference to me. She was horrified and spent a sleepless
night, and at the next session, although she did not refuse the
treatment she was totally unfit for the work. After I had discovered the
obstacle and removed it, the work continued. The wish that so frightened
the patient appeared as the next pathogenic reminiscence, that is, as
the one now required by the logical connection. It came about in the
following manner: The content of the wish at first appeared in the
patient’s consciousness without the recollection of the accessory
circumstances which would have transferred this wish into the past. By
the associative force prevailing in consciousness the existing wish
became connected with my own person, with which the patient could
naturally occupy herself, and in this mesalliance—which I call a false
connection—the same affect became reawakened which originally urged the
patient to banish this clandestine wish. As soon as I discovered this I
could presuppose every similar claim on my personality to be another
transference and false connection. It is remarkable how the patient
falls a victim to deception on every new occasion.
No analysis can be brought to an end if one does not know how to meet
the resistances resulting from the causes mentioned. The way can be
found if one bears in mind that the new symptom produced after the old
model should be treated like the old symptoms. In the first place it is
necessary to make the patient conscious of the obstacle. In one of my
patients, in whom the pressure symptoms suddenly failed and I had cause
to assume an unconscious idea like the one mentioned in 2, I met it for
the first time with an unexpected attack. I told her that there must
have originated some obstacle against the continuation of the treatment
and that the pressure procedure has at least the power to show her the
obstacle, and then pressed her head. She then said, surprisingly, “I see
you sitting here on the chair, but that is nonsense, what can that
mean?”—But now I could explain it.
In another patient the obstacle did not usually show itself directly on
pressure, but I could always demonstrate it by taking the patient back
to the moment in which it originated. The pressure procedure never
failed to bring back this moment. By discovering and demonstrating the
obstacle, the first difficulty was removed, but a greater one still
remained. The difficulty lay in inducing the patient to give information
where there was an obvious personal relation and where the third person
coincided with the physician. At first I was very much annoyed about the
increase of this psychic work until I had learned to see the lawful part
of this whole process, and I then also noticed that such a transference
does not cause any considerable increase in the work. The work of the
patient remained the same, she perhaps had to overcome the painful
affect of having entertained such a wish, and it seemed to be the same
for the success whether she took this psychic repulsion as a theme of
the work in the historical case or in the recent case with me. The
patients also gradually learned to see that in such transferences to the
person of the physician they generally dealt with a force or a deception
which disappeared when the analysis was accomplished. I believe,
however, that if I should have delayed in making clear to them the
nature of the obstacle, I would have given them a new, though a milder,
hysterical symptom for another spontaneously developed.
I now believe that I have sufficiently indicated how such analyses
should be executed, and the experiences connected with them. They
perhaps make some things appear more complicated than they are, for many
things really result by themselves during such work. I have not
enumerated the difficulties of the work in order to give the impression
that in view of such requirements it pays for the physician and patient
to undertake a cathartic analysis only in the rarest cases. I allow my
medical activities to be inflected by the contrary suppositions.—To be
sure I am unable to formulate the most definite indications for the
application of the here discussed therapeutic method without entering
into the valuation of the more significant and more comprehensive theme
of the therapy of the neuroses in general. I have often compared the
cathartic psychotherapy to surgical measures, and designated my cures as
psychotherapeutic operations; the analogies follow the opening of a pus
pocket, the curetting of a carious location, etc. Such an analogy finds
its justification, not so much in the removal of the morbid as in the
production of better curative conditions for the issue of the process.
When I promised my patients help and relief through the cathartic
method, I was often obliged to hear the following objections: “You say,
yourself, that my suffering has probably to do with my own relation and
destinies. You cannot change any of that. In what manner, then, can you
help me?” To this I could always answer: “I do not doubt at all that it
would be easier for destiny than for me to remove your sufferings, but
you will be convinced that much will be gained if we succeed in
transforming your hysterical misery into everyday unhappiness, against
which you will be better able to defend yourself with a restored nervous
system.”
CHAPTER V.
THE DEFENSE NEURO-PSYCHOSES.
A TENTATIVE PSYCHOLOGICAL THEORY OF ACQUIRED HYSTERIA, MANY PHOBIAS AND
OBSESSIONS, AND CERTAIN HALLUCINATORY PSYCHOSES.
After an exhaustive study of many nervous patients afflicted with
phobias and obsessions a tentative explanation of these symptoms urged
itself upon me. This helped me afterwards happily to divine the origin
of such morbid ideas in new and other cases, and I therefore believe it
worthy of reporting and further examination. Simultaneously with this
“psychological theory of phobias and obsessions,” the examination of
these patients resulted in a contribution to the theory of hysteria, or
rather in an alteration of the same, which seems to imply an important
and common character to hysteria as well as the mentioned neuroses.
Furthermore, I had the opportunity to look into the psychological
mechanism of a form of indubitable psychic disease and found that my
attempted observation shows an intelligible connection between these
psychoses and the two neuroses mentioned. At the conclusion of this
theme I will describe the supporting hypothesis which I have used in all
three cases.
I.
I am beginning with that alteration which seems to be necessary for the
theory of the hysterical neuroses.
That the symptom-complex of hysteria as far as it can be understood,
justifies the assumption of a splitting of consciousness with the
formation of separate psychic groups, has attained general recognition
since P. Janet, J. Breuer, and others have given out their interesting
work. Less understood are the opinions concerning the origin of this
splitting of consciousness and concerning the rôle played by this
character in the structure of the hysterical neuroses.
According to Janet’s[36] theory, the splitting of consciousness is a
primary feature of the hysterical alteration. It is due to a congenital
weakness of the capacity for psychic synthesis, and to a narrowing of
the “field of consciousness” (champ du conscience) which as a psychic
stigma proves the degeneration of hysterical individuals.
In contradistinction to Janet’s views, which in my opinion admit the
most manifold objections, are those advocated by J. Breuer in our joint
communication. According to Breuer, the “basis and determination” of
hysteria is the occurrence of peculiar dream-like conscious states with
a narrowed association capacity, for which he proposes the name “hypnoid
states.” The splitting of consciousness is secondary and acquired, and
originates because the ideas emerging in the hypnoid states are isolated
from associative communication with the rest of consciousness.
I can now demonstrate two other extreme forms of hysteria in which it is
impossible to show that the splitting of consciousness is primary in the
sense of Janet. In the first of these forms I could repeatedly show that
the splitting of the content of consciousness was an arbitrary act of
the patient, that is, it was initiated through an exertion of the will
which motive can be stated. I naturally do not maintain that the patient
intended to produce a splitting of his consciousness; the patient’s
intention was different, but instead of attaining its aim it provoked a
splitting of consciousness.
In the third form of hysteria, as we have demonstrated by
psychic-analysis of intelligent patients, the splitting of consciousness
plays only an insignificant and perhaps really no rôle. This includes
those cases in which there had been no reaction to the traumatic
stimulus and which were then adjusted and cured by ab-reaction. They are
the pure retention hysterias.
In connection with the phobias and obsessions I have only to deal here
with the second form of hysteria which for reasons to be presently
explained I will designate as defense hysteria and thus distinguish it
from the hypnoid and retention hysterias. Preliminarily I am able to
call my cases of defense hysteria “acquired” hysterias for they show
neither marked hereditary taints nor any degenerative disfigurements.
In those patients whom I have analyzed there existed psychic health
until the moment in which a case of incompatibility occurred in their
ideation, that is, until there appeared an experience, idea, or feeling
which evoked such a painful affect that the person decided to forget it
because he did not trust his own ability to remove the resistance
between the unbearable ideas and his ego.
Such incompatible ideas originate in the feminine sex on the basis of
sexual experiences and feelings. With all desired precision the patients
recall their efforts of defense, their intention “to push it away,” not
to think of it, to repress it. As appropriate examples I can easily cite
the following cases from my own experience: A young lady reproached
herself because, while nursing her sick father, she thought of a young
man who made a slight erotic impression on her; a governess fell in love
with her employer and decided to crowd it out of her mind because it was
incompatible with her pride, etc.
I am unable to maintain that the exertion of the will, in crowding such
thoughts out of one’s mind, is a pathological act, nor am I able to
state whether and how, the intentional forgetting succeeds in those
persons who remain well under the same psychic influences. I only know
that in the patients whom I analyzed such “forgetting” was unsuccessful
and led to either a hysteria, obsession, or a hallucinatory psychosis.
The ability to produce, by the exertion of the will one of these states
all of which are connected with the splitting of consciousness, is to be
considered as the expression of a pathological disposition, but it need
not necessarily be identified with personal or hereditary
“degeneration.”
Over the road leading from the patient’s exertion of the will to the
origin of a neurotic symptom I formed a conception which in the current
psychological abstractions may be thus expressed: The task assumed by
the defensive ego to treat the incompatible idea as “non arrivée” can
not be directly accomplished. The memory trace as well as the affect
adhering to the idea are here and can not be exterminated. The task can
however, be brought to an approximate solution if it is possible to
change the strong idea into a weak one and to take away the affect or
sum of excitement which adheres to it. The weak idea will then exert
almost no claims on the association work; but the separated sum of
excitement must be utilized in another direction.
Thus far the processes are the same in hysteria, in phobias and
obsessions, but from now on their ways part. The unbearable idea in
hysteria is rendered harmless because the sum of excitement is
transformed into physical manifestations, a process for which I would
like to propose the term conversion.
The conversion may be total or partial, and follows that motor or
sensory innervation which is either ultimately or more loosely connected
with the traumatic experience. In this way the ego succeeds in freeing
itself from opposition but instead it becomes burdened with a memory
symbol which remains in consciousness as an unadjusted motor
innervation, or as a constantly recurring hallucinatory sensation
similar to a parasite. It thus remains fixed until a conversion takes
place in the opposite direction. The memory symbol of the repressed idea
does not perish, but from now on forms the nucleus for a second psychic
group.
I will follow up this view of the psycho-physical processes in hysteria
with a few more words. If such a nucleus for an hysterical splitting is
once formed in a “traumatic moment” it then increases in other moments
which might be designated as “auxiliary traumatic” as soon as a newly
formed similar impression succeeds in breaking through the barrier
formed by the will and in adding new affects to the weakened idea, and
in forcing for a while the associative union of both psychic groups
until a new conversion produces defense. The condition thus attained in
hysteria in regard to the distribution of the excitement, proves to be
unstable in most cases. As shown by the familiar contrast of the attacks
and the persistent symptoms, the excitement which was pushed on a false
path (in the bodily innervation) now and then returns to the idea from
which it was discharged and forces the person to associative elaboration
or to adjustment in hysterical attacks. The effect of Breuer’s cathartic
method consists in the fact that it consciously reconducts the
excitement from the physical into the psychic spheres and then forces an
adjustment of the contradiction through intellectual work, and a
discharge of the excitement through speech.
If the splitting of consciousness in acquired hysteria is due to an act
of volition we can explain with surprising simplicity the remarkable
fact that hypnosis regularly broadens the narrowed consciousness of
hysteria, and causes the split off psychic groups to become accessible.
For we know that it is peculiar to all sleep-like states to remove that
distribution of excitement which depends on the “will” of the conscious
personality.
We accordingly recognize that the characteristic moment of hysteria is
not the splitting of consciousness but the ability of conversion, and as
an important part of the hitherto unknown disposition of hysteria we can
mention the psycho-physical adaptation for the transference of a great
sum of excitement into bodily innervation.
The adaptation does not in itself exclude psychic health, and leads to
hysteria only in event of a psychic incompatibility or accumulation of
excitement. With this turn, we—Breuer and I—come near to the familiar
definitions of hysteria of Oppenheim[37] and Strümpel,[38] and deviate
from Janet,[39] who assigns to the splitting of consciousness too great
a rôle in the characteristics of hysteria. The description here given
can lay claim to the fact that it explains the connection between the
conversion and the hysterical splitting of consciousness.
II
In a predisposed person if there is no adaptation for conversion, and
still for the purpose of defense a separation of the unbearable idea
from its affect is undertaken, the affect must then remain in the
psychic sphere. The weakened idea remains apart from all association in
consciousness, but its freed affect attaches itself to other not in
themselves unbearable ideas, which on account of this “false” connection
become obsessions. This is in brief the psychological theory of the
obsessions and phobias concerning which I have spoken above.
I will now state what parts demanded in this theory can be directly
demonstrated and what parts I have supplemented. Besides the end product
of the process, the obsession, we can in the first place directly
demonstrate the source from which the affect in the false connection
originates. In all cases that I have analyzed it was the sexual life
that has furnished a painful affect of precisely the same character as
the one attached to the obsession. It is not theoretically excluded that
this affect could not occasionally originate in other spheres, but I
must say that thus far I have found no other origin. Moreover, one can
readily understand that it is precisely the sexual life which furnishes
the most manifold occasions for the appearance of unbearable ideas.
Moreover, the exertion of the will, the attempt at defence, upon which
this theory lays stress is demonstrated by the most unequivocal
utterances of the patients. At least in a number of cases the patients
themselves inform us that the phobia or obsession appeared only after
the exertion of the will manifestly gained its point. “Something very
disagreeable happened to me once and I have exerted all my power to push
it away, not to think of it. When I have finally succeeded I have gotten
the other thing instead, which I have not lost since.” With these words
a patient verified the main points of the theory here developed.
Not all who suffer from obsessions are so clear concerning the origin of
the same. As a rule when we call the patient’s attention to the original
idea of a sexual nature we receive the following answer: “It could not
have come from that. Why I have not thought much about it. For a moment
I was frightened, then I distracted myself and since then it has not
bothered me.” In this, so frequent objection, we have the proof that the
obsession represents a compensation or substitute for the unbearable
sexual idea, and that it has taken its place in consciousness.
Between the patient’s exertion of the will which succeeds in repressing
the unacceptable sexual idea and the appearance of the obsession, which
though in itself of little intensity, is here furnished with
inconceivably strong affect, there is a yawning gap which the theory
here developed will fill. The separation of the sexual idea from its
affect and the connection of the latter with another suitable but not
unbearable idea—these are processes which take place unconsciously which
we can only presume but not prove by any clinico-psychological analysis.
Perhaps it would be more correct to say that these are not really
processes of a psychic nature but physical processes of which the
psychic result so presents itself that the expressions “separation of
the idea from its affect and false connection of the latter,” seem
actual occurrences.
Besides the cases evincing in turn the sexual unbearable idea and the
obsession we find a series of others in which there are simultaneously
obsessions and painfully accentuated sexual ideas. It will not do very
well to call the latter “sexual obsessions”; they lack the essential
character of obsessions in proving themselves fully justified, whereas
the painfulness of the ordinary obsession is a problem for the doctor as
well as the patient. From the amount of insight that could be obtained
in such cases, it seems that we deal here with a continued defense
against sexual ideas which are constantly renewed, a work heretofore not
accomplished.
As long as the patients are aware of the sexual origin of their
obsessions they often conceal them. If they complain they generally
express surprise that this affect underlies the symptoms, at being
afraid, and at having certain impulses, etc. To the experienced
physician, however, the affect appears justified and intelligible; he
finds the striking part only in the connection of such an affect with an
idea unworthy of it. In other words the affect of the obsession appears
to him as one dislocated or transposed, and if he has accepted the
observations here laid down he can in a great many cases of obsessions
attempt a retranslation into the sexual.
Any idea which either through its character may be combinable with an
affect of such quality or which bears a certain relation to the
unbearable by virtue of which it seems fit as a substitute for the same,
may be used for the secondary connection of the freed affect. Thus, for
example, freed anxiety, the sexual origin of which can not be recalled,
attaches itself to the common primary phobias of man for animals,
thunderstorms, darkness, etc., or to things which are unmistakably in
some way associated with the sexual, such as urination, defecation,
pollutions and infections.
The advantage gained by the ego in the transposition of the affect for
the purpose of defense is considerably less than in the hysterical
conversion of psychic excitement into somatic innervation. The affect
under which the ego has suffered remains now as ever unchanged and
undiminished, but the unbearable idea is suppressed and excluded from
memory. The repressed ideas again form the nucleus of a second psychic
group which I believe can be accessible without having recourse to
hypnotism. That in the phobias and obsessions there appear none of the
striking symptoms which in hysteria accompany the formation of an
independent psychic group, is due to the fact that in the former case
the whole transformation remains in the psychic sphere and the somatic
innervation experiences no change.
What I have here said concerning obsessions I will explain by some
examples which are probably of a typical nature:
1. A young girl suffers from obsessive reproaches. If she reads anything
in the journal about false coiners she conceives the thought that she
too, made counterfeit money; if a murder was anywhere committed by an
unknown assassin she anxiously asked herself whether she had not
committed this crime. At the same time she is perfectly aware of the
absurdity of these obsessive reproaches. For a time the consciousness of
her guilt gained such a power over her that her judgment was suppressed,
and she accused herself before her relatives and physician of having
really committed all these crimes (Psychosis through simple
aggravation—overwhelming psychosis—Uberwältigungspsychose). A thorough
examination revealed the source of the origin of this guilty conscience.
Accidentally incited by a sensual feeling she allowed herself to be
allured by a friend to masturbate. She practiced it for years with the
full consciousness of her wrong doing, and under the most violent but
useless self reproaches.—The girl was cured after a few months’
treatment and strict watching.
2. Another girl suffered from the fear of getting sudden desires of
micturition and of being forced to wet herself. This began after such a
desire had really forced her to leave a concert hall during the
performance. This phobia had gradually caused her to become quite
incapable of any enjoyment and social relationship. She felt secure only
when she knew that there was a toilet in the neighborhood to which she
could repair unobserved. An organic suffering which might have justified
this lack of confidence of the control of the bladder was excluded. At
home among quiet surroundings and during the night there was no such
desire to micturate. Detailed examination showed that the desire to
micturate appeared for the first time under the following conditions: A
gentleman to whom she was not indifferent took a seat in the concert
hall not far from her. She began to think and to picture to herself how
she would sit near him as his wife. In this erotic revery she
experienced that physical feeling which must be compared to erection in
the man, and which in her—I do not know whether it is general—ended in a
slight desire to micturate. She now became extremely frightened over her
otherwise accustomed sexual sensation because she had determined to
overcome this as well as every desire, and in the next moment the affect
transposed itself to the accompanying desire to micturate and forced her
to leave the hall after a very painful struggle. In her life she was so
prudish that she experienced an intensive horror for all things sexual,
and could not conceive the thought of ever marrying; on the other hand
she was sexually so hyperesthetic that during every erotic revery, which
she gladly allowed herself, there appeared sensual feeling. The erection
was always accompanied by the desire to micturate, and up to the time of
the scene in the concert hall it had made no impression on her. The
treatment led to an almost complete control of the phobia.
3. A young woman who had only one child after five years of married life
complained of obsessive impulses to throw herself from the window or
balcony, and of fears lest at the sight of a sharp knife she might kill
her child. She admitted that the marriage relations were seldom
practised and then only with caution against conception; but she added
that she did not miss this as she was not of a sensual nature. I then
ventured to tell her that at the sight of a man she conceives erotic
ideas, and that she therefore lost confidence in herself and imagined
herself a depraved person fit for anything. The retranslation of the
obsession into the sexual was successful; weeping, she soon admitted her
long concealed marital misery, and then mentioned painful ideas of an
unchanged sexual character such as the often recurring sensation of
something forcing itself under her skirts.
I have made use of such experiences in the therapy of phobias and
obsessions, and despite the patient’s resistances I have redirected the
attention to the repressed sexual ideas, and wherever feasible I have
blocked the sources from which the same originated. To be sure I cannot
maintain that all phobias and obsessions originate in the manner here
revealed; first, my experience, in proportion to the abundance of these
neuroses, embraces only a limited amount, and second, I, myself, know
that these “psychasthenic” symptoms (according to Janet’s designation)
are not all of the same value.[40] Thus, for instance, there are pure
hysterical phobias. But I believe that the mechanism of the
transposition of the affect will be demonstrated in the greater part of
the phobias and obsessions, and I must assert that these neuroses, which
are found just as often isolated as combined with hysteria and
neurasthenia, are not to be thrown together with the ordinary
neurasthenia for which fundamental symptom a psychic mechanism is not
all to be assumed.
III.
In both cases thus far considered the defense of the unbearable idea was
brought about by the separation of the same from its affect; the idea
though weakened and isolated remained in consciousness. There exists,
however, a far more energetic and more successful form of defense
wherein the ego misplaces the unbearable idea with its affect, and
behaves as though the unbearable idea had never approached the ego. But
at the moment when this is brought about the person suffers from a
psychosis which can only be classified as an “hallucinatory confusion.”
A single example will explain this assertion. A young girl gives her
first impulsive love to a man who she firmly believed reciprocated her
love. As a matter of fact she was mistaken; the young man had other
motives for visiting her. It was not long before she was disappointed;
at first she defended herself against it by converting hysterically the
corresponding experience, and thus came to believe that he would come
some day to ask her in marriage; but in consequence of the imperfect
conversion and the constant pressure of new painful impressions, she
felt unhappy and ill. She finally expects him with the greatest tension
on a definite day, it is the day of a family reunion. The day passes but
he does not come. After all the trains on which he could have come have
passed she suddenly merged into an hallucinatory confusion. She thought
that he did come, she heard his voice in the garden, and hastened down
in her night gown to receive him. For two months after she lived in a
happy dream, the content of which was that he was there, that he was
always with her, and that everything was as before (before the time of
the painfully defended disappointment). The hysteria and depression were
thus conquered; during her sickness she never mentioned anything about
the last period of doubt and suffering; she was happy as long as she was
left undisturbed, and frenzied only when a regulation of her environment
prevented her from accomplishing something which she thought quite
natural as a result of her blissful dream. This psychosis,
unintelligible as it was in its time, was revealed ten years later
through hypnotic analysis.
The fact to which I call attention is this: That the content of such an
hallucinatory psychosis consists in directly bringing into prominence
that idea which was threatened by the motive of the disease. One is
therefore justified in saying that through its flight into the psychosis
the ego defended the unbearable idea; the process through which this has
been brought about withdraws itself from self perception as well as from
the psychological-clinical analysis. It is to be considered as the
expression of a higher grade of pathological disposition, and can
perhaps be explained as follows: The ego tears itself away from the
unbearable idea, but as it hangs inseparably together with a part of
reality, the ego while accomplishing this performance also detaches
itself wholly or partially from reality. The latter is, in my opinion
the condition under which hallucinatory vividness is decreed to
particular ideas, and hence after very successful defense the person
finds himself in a hallucinatory confusion.
I have but very few analyses of such psychoses at my disposal; but I
believe that we deal with a very frequently employed type of psychic
illness. For analogous examples such as the mother who becoming sick
after the loss of her child continues to rock in her arms a piece of
wood, or the jilted bride who in full dress expects her bridegroom, can
be seen in every insane asylum.
It will perhaps not be superfluous to mention that the three forms of
defense here considered, and hence the three forms of disease to which
this defense leads may be united in the same person. The simultaneous
occurrence of phobias and hysterical symptoms, so frequently observed in
praxis, really belongs to those moments which impede a pure separation
of hysteria from other neuroses and urge the formation of the “mixed
neuroses.” To be sure the hallucinatory confusion is not frequently
compatible with the continuation of hysteria and not as a rule with
obsessions; but on the other hand it is not rare that a defense
psychosis should episodically break through the course of a hysteria or
mixed neurosis.
In conclusion I will mention in few words the subsidiary idea of which I
have made use in this discussion of the defense neuroses. It is the idea
that there is something to distinguish in all psychic functions (amount
of affect, sum of excitement), that all qualities have a quantity though
we have no means to measure the same—it is something that can be
increased, diminished, displaced, and discharged, and that extends over
the memory traces of the ideas perhaps like an electric charge over the
surface of the body.
This hypothesis, which also underlies our theory of “ab-reaction”
(“Preliminary Communication”), can be used in the same sense as the
physicist uses the assumption of the current of electric fluid. It is
preliminarily justified through its usefulness in the comprehension and
elucidation of diverse psychic states.
CHAPTER VI.
ON THE RIGHT TO SEPARATE FROM NEURASTHENIA A DEFINITE SYMPTOM-COMPLEX AS
“ANXIETY NEUROSIS”
(ANGSTNEUROSE).
It is difficult to assert anything of general validity concerning
neurasthenia as long as this term is allowed to express all that for
which Beard used it. I believe that neuropathology can only gain by an
attempt to separate from the actual neurosis all those neurotic
disturbances the symptoms of which are on the one hand more firmly
connected among themselves than to the typical neurasthenic symptoms,
such as headache, spinal irritation, dyspepsia with flatulence and
constipation, and which on the other hand show essential differences
from the typical neurasthenic neurosis in their etiology and mechanism.
If we accept this plan we will soon gain quite a uniform picture of
neurasthenia. We will soon be able to differentiate—sharper than we have
hitherto succeeded—from the real neurasthenia the different
pseudoneurasthenias, such as the organically determined nasal reflex
neurosis, the neurotic disturbances of cachexias and arteriosclerosis,
the early stages of progressive paralysis, and of some psychoses.
Furthermore, following the proposition of Moebius, some status nervosi
of hereditary degenerates will be set aside and we will also find
reasons for ascribing some of the neuroses which are now called
neurasthenia to melancholia, especially those of an intermittent or
periodic nature. But we force the way into the most marked changes if we
decide to separate from neurasthenia that symptom-complex which I shall
hereafter describe and which especially fulfills the conditions
formulated above. The symptoms of this complex are clinically more
related to one another than to the real neurasthenic symptoms, that is,
they frequently appear together and substitute one another in the course
of the disease, and both the etiology as well as the mechanism of this
neurosis differs basically from the etiology and the mechanism of the
real neurasthenia which remains after such a separation.
I call this symptom-complex “anxiety neurosis” (Angstneurose) because
the sum of its components can be grouped around the main symptom of
anxiety, because each individual symptom shows a definite relation to
anxiety. I believed that I was original in this conception of the
symptoms of anxiety neurosis until an interesting lecture by E.
Hecker[41] fell into my hands. In this lecture I found the description
of the same interpretation with all the desired clearness and
completeness. To be sure, Hecker does not separate the equivalents or
rudiments of the attack of anxiety from neurasthenia as I intend to do;
but this is apparently due to the fact that neither here nor there has
he taken into account the diversity of the etiological determinants.
With the knowledge of the latter difference every obligation to
designate the anxiety neurosis by the same name as the real neurasthenia
disappears, for the only object of arbitrary naming is to facilitate the
formulation of general assertions.
I. CLINICAL SYMPTOMATOLOGY OF ANXIETY NEUROSIS.
What I call “anxiety neurosis” can be observed in complete or
rudimentary development, either isolated or in combination with other
neuroses. The cases which are in a measure complete, and at the same
time isolated, are naturally those which especially corroborate the
impression that the anxiety neurosis possesses clinical independence. In
other cases we are confronted with the task of selecting and separating
from a symptom-complex which corresponds to a “mixed neurosis,” all
those symptoms which do not belong to neurasthenia, hysteria, etc., but
to the anxiety neurosis.
The clinical picture of the anxiety neurosis comprises the following
symptoms:
1. _General Irritability._—This is a frequent nervous symptom, common as
such to many nervous states. I mention it here because it constantly
occurs in the anxiety neurosis and is of theoretical significance. For
increased irritability always points to an accumulation of excitement or
to an inability to bear accumulation, hence to an absolute or relative
accumulation of excitement. The expression of this increased
irritability through an auditory hyperesthesia is especially worth
mentioning; it is an over sensitiveness for noises, which symptom is
certainly to be explained by the congenital intimate relationship
between auditory impressions and fright. Auditory hyperesthesia is
frequently found as a cause of insomnia, of which more than one form
belongs to anxiety neurosis.
2. _Anxious Expectation._—I can not better explain the condition that I
have in mind, than by this name and by some appended examples. A woman,
for example, who suffers from anxious expectation thinks of
influenza-pneumonia whenever her husband who is afflicted with a
catarrhal condition has a coughing spell; and in her mind she sees a
passing funeral procession. If on her way home she sees two persons
standing together in front of her house she can not refrain from the
thought that one of her children fell out of the window; if she hears
the bell ring she thinks that someone is bringing her mournful tidings,
etc.; yet in none of these cases is there any special reason for
exaggerating a mere possibility.
The anxious expectation naturally reflects itself constantly in the
normal, and embraces all that is designated as “uneasiness and a
tendency to a pessimistic conception of things,” but as often as
possible it goes beyond such a plausible uneasiness, and it is
frequently recognized as a part of constraint even by the patient
himself. For one form of anxious expectation, namely, that which refers
to one’s own health, we can reserve the old name of hypochondria.
Hypochondria does not always run parallel with the height of the general
anxious expectation; as a preliminary stipulation it requires the
existence of paresthesias and annoying somatic sensations. Hypochondria
is thus the form preferred by the genuine neurasthenics whenever they
merge into the anxiety neurosis, a thing which frequently happens.
As a further manifestation of anxious expectation we may mention the
frequent tendency observed in morally sensitive persons to pangs of
conscience, scrupulosity, and pedantry, which varies as it were, from
the normal to its aggravation as doubting mania.
Anxious expectation is the most essential symptom of the neurosis; it
also clearly shows a part of its theory. It can perhaps be said that we
have here a quantum of freely floating anxiety which controls the choice
of ideas by expectation and is forever ready to unite itself with any
suitable ideation.
3. This is not the only way in which the anxiousness, usually latent but
constantly lurking in consciousness, can manifest itself. On the
contrary it can also suddenly break into consciousness without being
aroused by the issue of an idea, and thus provoke an attack of anxiety.
Such an attack of anxiety consists of either the anxious feeling alone
without any associated idea, or of the nearest interpretation of the
termination of life, such as the idea of “sudden death” or threatening
insanity; or the feeling of anxiety becomes mixed with some paresthesia
(similar to the hysterical aura); or finally the anxious feeling may be
combined with a disturbance of one or many somatic functions, such as
respiration, cardiac activity, the vasomotor innervation, and the
glandular activity. From this combination the patient renders especially
prominent now this and now the other moment. He complains of
“heartspasms,” “heavy breathing,” “profuse perspiration,” “inordinate
appetite,” etc., and in his description the feeling of anxiety is put to
the background or it is rather vaguely described as “feeling badly,”
“uncomfortably,” etc.
4. What is interesting and of diagnostic significance is the fact that
the amount of admixture of these elements in the attack of anxiety
varies extraordinarily, and that almost any accompanying symptom can
alone constitute the attack as well as the anxiety itself. Accordingly
there are rudimentary attacks of anxiety, and equivalents for the attack
of anxiety, probably all of equal significance in showing a profuse and
hitherto little appreciated richness in forms. A more thorough study of
these larvated states of anxiety (Hecker) and their diagnostic division
from other attacks ought soon to become the necessary work for the
neuropathologist.
I now add a list of those forms of attacks of anxiety with which I am
acquainted. There are attacks:
(_a_) With disturbances of heart action, such as palpitation with
transitory arrythmia, with longer continued tachycardia up to grave
states of heart weakness, the differentiation of which from organic
heart affection is not always easy; among such we have the pseudo-angina
pectoris, a delicate diagnostic sphere!
(_b_) With disturbances of respiration, many forms of nervous dyspnoea,
asthma-like attacks, etc. I assert that even these attacks are not
always accompanied by conscious anxiety;
(_c_) Of profuse perspiration, often nocturnal;
(_d_) Of trembling and shaking which may readily be mistaken for
hysterical attacks;
(_e_) Of inordinate appetite, often combined with dizziness;
(_f_) Of attack-like appearing diarrhoea;
(_g_) Of locomotor dizziness;
(_h_) Of so called congestions, embracing all that was called vasomotor
neurasthenia; and,
(_i_) Of paresthesias (These are seldom without anxiety or a similar
discomfort).
5. Very frequently the nocturnal frights (pavor nocturnus of adults)
usually combined with anxiety, dyspnoea, perspiration, etc., is nothing
other than a variety of the attack of anxiety. This disturbance
determines a second form of insomnia in the sphere of the anxiety
neurosis. Moreover I became convinced that even the pavor nocturnus of
children evinces a form belonging to the anxiety neurosis. The
hysterical tinge and the connection of the fear with the reproduction of
appropriate experience or dream, makes the pavor nocturnus of children
appear as something peculiar, but it also occurs alone without a dream
or a recurring hallucination.
6. “_Vertigo._”—This in its lightest forms is better designated as
“dizziness,” assumes a prominent place in the group of symptoms of
anxiety neurosis. In its severer forms the “attack of vertigo,” with or
without fear, belongs to the gravest symptoms of the neurosis. The
vertigo of the anxiety neurosis is neither a rotatory dizziness nor is
it confined to certain planes or lines like Menier’s vertigo. It belongs
to the locomotor or coordinating vertigo, like the vertigo in paralysis
of the ocular muscles; it consists in a specific feeling of discomfort
which is accompanied by sensations of a heaving ground, sinking legs, of
the impossibility to continue in an upright position, and at the same
time there is a feeling that the legs are as heavy as lead, they shake,
or give way. This vertigo never leads to falling. On the other hand, I
would like to state that such an attack of vertigo may also be
substituted by a profound attack of syncope. Other fainting-like states
in the anxiety neurosis seem to depend on a cardiac collapse.
The vertigo attack is frequently accompanied by the worst kind of
anxiety and is often combined with cardiac and respiratory disturbances.
Vertigo of elevations, mountains and precipices, can also be frequently
observed in anxiety neurosis; moreover, I do not know whether we are
still justified in recognizing a vertigo “a stomacho laeso.”
7. On the basis of the chronic anxiousness (anxious expectation) on the
one hand, and the tendency to vertiginous attacks of anxiety on the
other, there develop two groups of typical phobias; the first refers to
the general physiological menaces, while the second refers to
locomotion. To the first group belong the fear for snakes,
thunderstorms, darkness, vermin, etc., as well as the typical moral
overscrupulousness, and the forms of doubting mania. Here the available
fear is merely used to strengthen those aversions which are
instinctively implanted in every man. But usually a compulsively acting
phobia is formed only after a reminiscence is added to an experience in
which this fear could manifest itself; as, for example, after the
patient has experienced a storm in the open air. To attempt to explain
such cases as mere continuations of strong impressions is incorrect.
What makes these experiences significant and their reminiscences durable
is after all only the fear which could at that time appear and can also
appear today. In other words such impressions remain forceful only in
persons with “anxious expectations.”
The other group contains agoraphobia with all its accessory forms, all
of which are characterized by their relation to locomotion. As a
determination of the phobia we frequently find a precedent attack of
vertigo; I do not think that it can always be postulated. Occasionally,
after a first attack of vertigo without fear, we see that though
locomotion is always accompanied by the sensation of vertigo, it remains
possible without any restrictions, but as soon as fear attaches itself
to the attack of vertigo, locomotion fails, under the conditions of
being alone, narrow streets, etc.
The relation of these phobias to the phobias of obsessions, which
mechanism I discussed above,[42] is as follows: The agreement lies in
the fact that here as there, an idea becomes obsessive through its
connection with an available affect. The mechanism of transposition of
the affect therefore holds true for both kinds of phobias. But in
phobias of the anxiety neurosis this affect is (1) a monotonous one, it
is always one of anxiety; (2) it does not originate from a repressed
idea, and on psychological analysis it proves itself not further
reducible, nor can it be attacked through psychotherapy. The mechanism
of substitution does not therefore hold true for the phobias of anxiety
neurosis.
Both kinds of phobias (or obsessions) often occur side by side, though
the atypical phobias which depend on obsessions need not necessarily
develop on the basis of anxiety neurosis. A very frequent, ostensibly
complicated mechanism appears if the content of an original simple
phobia of anxiety neurosis is substituted by another idea, the
substitution is then subsequently added to the phobia. The “protective
measures” originally employed in combatting the phobia are most
frequently used as substitutions. Thus, for example, from the effort to
provide oneself with counter evidence that one is not crazy, contrary to
the assertion of the hypochondriacal phobia, there results a reasoning
mania. The hesitations, doubts, and the many repetitions of the folie du
doute originate from the justified doubt concerning the certainty of
one’s own stream of thoughts, for, through the compulsive like idea one
is surely conscious of so obstinate a disturbance, etc. It may therefore
be claimed that many syndromes of compulsion neurosis, like folie du
doute and similar ones, can clinically, if not notionally be attributed
to anxiety neurosis.[43]
8. The digestive functions in anxiety neurosis are subject to very few
but characteristic disturbances. Sensations like nausea and sickly
feeling are not rare, and the symptom of inordinate appetite alone or
with other congestions, may serve as a rudimentary attack of anxiety. As
a chronic alteration analogous to the anxious expectations one finds a
tendency to diarrhea which has occasioned the queerest diagnostic
mistakes. If I am not mistaken it is this diarrhea to which Moebius[44]
has recently called attention in a small article. I believe, moreover,
that Peyer’s[45] reflex diarrhea which he attributes to a disease of the
prostate is nothing other than the diarrhea of anxiety neurosis. The
deceptive reflex relation is due to the fact that the same factors which
are active in the origin of such prostatic affections also come into
play in the etiology of anxiety neurosis.
The behavior of the gastro-intestinal function in anxiety neurosis shows
a sharp contrast to the influence of this same function in neurasthenia.
Mixed cases often show the familiar “fluctuations between diarrhea and
constipation.” The desire to urinate in anxiety neurosis is analogous to
the diarrhea.
9. The paresthesias which accompany the attack of vertigo or anxiety are
interesting because they associate themselves into a firm sequence,
similar to the sensations of the hysterical aura. But in contrast to the
hysterical aura I find these associated sensations atypical and
changeable. Another similarity to hysteria is shown by the fact that in
anxiety neurosis a kind of conversion[46] into bodily sensations, as for
example into rheumatic muscles, takes place which otherwise can be
overlooked at one’s pleasure. A large number of so called rheumatics,
who are moreover demonstrable as such, really suffer from an anxiety
neurosis. Besides this aggravation of the sensation of pain I have
observed in a number of cases of anxiety neurosis a tendency towards
hallucinations which could not be explained as hysterical.
10. Many of the so called symptoms which accompany or substitute the
attack of anxiety also appear in a chronic manner. They are then still
less discernible, for the anxious feeling accompanying them appears more
indistinct than in the attack of anxiety. This especially holds true for
the diarrhea, vertigo, and paresthesias. Just as the attack of vertigo
can be substituted by an attack of syncope, so can the chronic vertigo
be substituted by the continuous feeling of feebleness, lassitude, etc.
II. THE OCCURRENCE AND ETIOLOGY OF ANXIETY NEUROSIS.
In some cases of anxiety neurosis no etiology can readily be
ascertained. It is noteworthy that in such cases it is seldom difficult
to demonstrate a marked hereditary taint.
Where we have reason to assume that the neurosis is acquired we can find
by careful and laborious examination that the etiologically effective
moments are based on a series of injuries and influences from the sexual
life. These at first appear to be of a varied nature but easily display
the common character which explains their homogeneous effect on the
nervous system. They are found either alone or with other banal injuries
to which a reinforcing effect can be attributed. This sexual etiology of
anxiety neurosis can be demonstrated so preponderately often that I
venture for the purpose of this brief communication to set aside all
cases of a doubtful or different etiology.
For the more precise description of the etiological determinations under
which anxiety neurosis occurs, it will be advisable to treat separately
those occurring in men and those occurring in women. Anxiety neurosis
appears in women—disregarding their predisposition—in the following
cases:
(_a_) As virginal fear or anxiety in adults. A number of unequivocal
observations showed me that an anxiety neurosis, which is almost
typically combined with hysteria, can be evoked in maturing girls, at
the first encounter with the sexual problem, that is at the sudden
revelation of the things hitherto veiled, by either seeing the sexual
act, or by hearing or reading something of that nature;
(_b_) As fear in the newly married. Young women who remain anesthetic
during the first cohabitation not seldom merge into an anxiety neurosis
which disappears after the anesthesia is displaced by the normal
sensation. As most young women remain undisturbed through such a
beginning anesthesia, the production of this fear requires determinants
which I will mention;
(_c_) As fear in women whose husbands suffer from ejaculatio precox or
from diminished potency; and,
(_d_) In those whose husbands practice coitus interruptus or reservatus.
These cases go together, for on analyzing a large number of examples one
can easily be convinced that they only depend on whether the woman
attained gratification during coitus or not. In the latter case one
finds the determinant for the origin of anxiety neurosis. On the other
hand the woman is spared from the neurosis if the husband afflicted by
ejaculatio precox can repeat the congress with better results
immediately thereafter. The congressus reservatus by means of the condom
is not injurious to the woman if she is quickly excited and the husband
is very potent; in other cases the noxiousness of this kind of
preventive measure is not inferior to the others. Coitus interruptus is
almost regularly injurious; but for the woman it is injurious only if
the husband practices it regardlessly, that is, if he interrupt coitus
as soon as he comes near ejaculating without concerning himself about
the determination of the excitement of his wife. On the other hand if
the husband waits until his wife is gratified, the coitus has the same
significance for the latter as a normal one; but then the husband
becomes afflicted with an anxiety neurosis. I have collected and
analyzed a number of cases which furnished the material for the above
statements.
(_e_) As fear in widows and intentional abstainers, not seldom in
typical combination with obsessions; and,
(_f_) As fear in the climacterium during the last marked enhancement of
the sexual desire.
The cases (_c_), (_d_), and (_e_), contain the determinants under which
the anxiety neurosis originates in the female sex, most frequently and
most independently, of hereditary predisposition. I will endeavor to
demonstrate in these—curable, acquired—cases of anxiety neurosis that
the discovered sexual injuries really represent the etiological moments
of the neurosis. But before proceeding I will mention the sexual
determinants of anxiety neurosis in men. I would like to formulate the
following groups, every one of which finds its analogy in women:
(_a_) Fear of the intentional abstainers; this is frequently combined
with symptoms of defense (obsessions, hysteria). The motives which are
decisive for intentional abstinence carry along with them the fact that
a number of hereditarily burdened eccentrics, etc., belong to this
category.
(_b_) Fear in men with frustrated excitement (during the engagement
period), persons who out of fear for the consequences of sexual
relations satisfy themselves with handling or looking at the woman. This
group of determinants which can moreover be transferred to the other
sex—engagement periods, relations with sexual forbearance—furnish the
purest cases of the neurosis.
(_c_) Fear in men who practice coitus interruptus. As observed above,
coitus interruptus injures the woman if it is practiced regardless of
the woman’s gratification; it becomes injurious to the man, if in order
to bring about the gratification in the woman be voluntarily controls
the coitus by delaying the ejaculation. In this manner we can understand
why it is that in couples who practice coitus interruptus it is usually
only one of them who becomes afflicted. Moreover the coitus interruptus
only rarely produces in man a pure anxiety neurosis, usually it is a
mixture of the same with neurasthenia.
(_d_) Fear in men in the senium. There are men who show a climacterium
like women, and merge into an anxiety neurosis at the time when their
potency diminishes and their libido increases.
Finally I must add two more cases holding true for both sexes:
(_e_) Neurasthenics merge into anxiety neurosis in consequence of
masturbation as soon as they refrain from this manner of sexual
gratification. These persons have especially made themselves unfit to
bear abstinence.
What is important for the understanding of the anxiety neurosis is the
fact that any noteworthy development of the same occurs only in men who
remain potent, and in non-anesthetic women. In neurasthenics, who on
account of masturbation have markedly injured their potency, anxiety
neurosis as a result of abstinence occurs but rarely and limits itself
usually to hypochondria and light chronic dizziness. The majority of
women are really to be considered as “potent”; a real impotent, that is,
a real anesthetic woman, is also inaccessible to anxiety neurosis, and
bears strikingly well the injuries cited.
How far we are perhaps justified in assuming constant relations between
individual etiological moments and individual symptoms from the complex
of anxiety neurosis, I do not care to discuss here.
(_f_) The last of the etiological determinants to be mentioned seems, in
the first place, really not to be of a sexual nature. Anxiety neurosis
originates in both sexes through the moment of overwork, exhaustive
exertion, as for instance, after sleepless nights, nursing the sick, and
even after serious illnesses.
The main objection against my formulation of a sexual etiology of the
anxiety neurosis will probably be to the purport that such abnormal
relations of the sexual life can be found so very often that wherever
one will look for them they will be found near at hand. Their
occurrence, therefore, in the cases cited of anxiety neurosis does not
prove that the etiology of the neurosis was revealed in them. Moreover,
the number of persons practicing coitus interruptus, etc., is
incomparably greater than the number of those who are burdened with
anxiety neurosis, and the overwhelming number of the first are quite
well in spite of this injury.
To this I can answer that we certainly ought not to expect a rarely
occurring etiological moment in the conceded enormous frequency of the
neurosis, and especially anxiety neurosis; furthermore, that it really
fulfills a postulate of pathology if on examining an etiology the
etiological moments can be more frequently demonstrated than their
effects, for, for the latter still other determinants (predisposition,
summation of the specific etiology, reinforcement through other banal
injuries) could be demanded; and furthermore, that the detailed analysis
of suitable cases of anxiety neurosis show quite unequivocally the
significance of the sexual moment. I shall, however, here confine myself
to the etiological moment of coitus interruptus, and I will render
prominent obvious individual experiences.
1. As long as the anxiety neurosis in young women is not yet constituted
but appears in fragments which again spontaneously disappear, it can be
shown that every such turn of the neurosis depends on a coitus with lack
of gratification. Two days after this influence, and in persons of
little resistance the day after, there regularly appears the attack of
anxiety or vertigo to which all the other symptoms of the neurosis
attach themselves, only to separate again on rarer marriage relations.
An unexpected journey of the husband, a sojourn in the mountains causing
a separation of the married couple, does good; the benefit from a course
of gynecological treatment is due to the fact that during its
continuation the marriage relations are stopped. It is noteworthy that
the success of a local treatment is only transitory, the neurosis
reappears while in the mountains if the husband joins his wife for his
own vacation, etc. If, in a not as yet constituted neurosis, a physician
aware of this etiology causes a substitution of the coitus interruptus
by normal relations there results a therapeutic proof of the assertion
here formulated. The anxiety is removed and does not return unless there
be a new or similar cause.
2. In the anamnesis of many cases of anxiety neurosis we find in both
men and women a striking fluctuation in the intensity of the appearances
in both the coming and going of the whole condition. This year was
almost wholly good, the following was terrible, etc.; on one occasion
the improvement occurred after a definite treatment which, however,
failed to produce a response at the next attack. If we inform ourselves
about the number and the sequence of the children, and compare this
marriage chronicle with the peculiar course of the neurosis, the result
of the simple solution shows that the periods of improvement or well
being corresponded with the pregnancies of the woman during which,
naturally, the occasions for preventive relations were unnecessary. The
treatment which benefited the husband, be it Father Kneip’s or the
hydrotherapeutic institute, was the one which he has taken after he
found his wife was pregnant.
3. From the anamnesis of the patients we often find that the symptoms of
the anxiety neurosis are relieved at a certain time by another neurosis,
perhaps a neurasthenia which has supplanted it. It can then be regularly
demonstrated that shortly before this change of the picture there
occurred a corresponding change in the form of a sexual injury.
Whereas such experiences, which can be augmented at pleasure, plainly
obtrude upon the physician the sexual etiology for a certain category of
cases, other cases which would have otherwise remained incomprehensible
can at least without gainsaying be solved and classified by the key of
the sexual etiology. We refer to those numerous cases in which
everything exists that has been found in the former category, such as
the appearance of anxiety neurosis on the one hand, and the specific
moment of the coitus interruptus on the other, but yet something else
slips in, namely, a long interval between the assumed etiology and its
effect, and perhaps other etiological moments of a non-sexual nature. We
have here, for example, a man who was seized with an attack of
palpitation on hearing of his father’s death, and who since that time
suffered from an anxiety neurosis. The case cannot be understood, for up
to that time this man was not nervous. The death of the father, well
advanced in years, did not occur under any peculiar circumstances, and
it must be admitted that the natural expected death of an aged father
does not belong to those experiences which are wont to make a healthy
adult sick. The etiological analysis will perhaps seem clearer if I add
that out of regard for his wife this man practiced coitus interruptus
for eleven years. At all events the manifestations are precisely the
same as those appearing in other persons after a short sexual injury of
this nature, and without the intervention of another trauma. The same
judgment may be pronounced in the case of a woman who merges into an
anxiety neurosis after the death of her child, or in the case of the
student who becomes disturbed by an anxiety neurosis while preparing for
his final state examination. I find that here, as there, the effect is
not explained by the reported etiology. One must not necessarily
“overwork” himself studying, and a healthy mother is wont to react to
the death of her child with normal grief. But, above all, I would expect
that the overworked student would acquire a cephalasthenia, and the
mother in our example a hysteria. That both became afflicted with
anxiety neurosis causes me to attach importance to the fact that the
mother lived for eight year in marital coitus interruptus, and that the
student entertained for three years a warm love affair with a
“respectable” girl whom he was not allowed to impregnate.
These examples tend to show that where the specific sexual injury of the
coitus interruptus is in itself unable to provoke an anxiety neurosis it
at least predisposes to its acquisition. The anxiety neurosis then comes
to light as soon as the effect of another banal injury enters into the
latent effect of the specific moment. The former can quantitatively
substitute the specific moment but not supplant it qualitatively. The
specific moment always remains that which determines the form of
neurosis. I hope to be able to prove to a greater extent this
proposition for the etiology of the neurosis.
Furthermore, the last discussions contain the, not in itself, improbable
assumption that a sexual injury like coitus interruptus asserts itself
through summation. The time required before the effect of this summation
becomes visible depends upon the predisposition of the individual and
the former burdening of his nervous system. The individuals who bear
coitus interruptus manifestly without disadvantage really become
predisposed by it to the disturbance—anxiety neurosis—which can at any
time burst forth spontaneously or after a banal, otherwise inadequate,
trauma, just as the chronic alcoholic finally develops a cirrhosis or
another disease by summation, or under the influence of a fever he
merges into a delirium.
III. ADDENDA TO THE THEORY OF ANXIETY NEUROSIS.
The following discussions claim nothing but the value of a first
tentative experiment, which judgment should not influence the acceptance
of the facts mentioned above. The estimation of this “Theory of Anxiety
Neurosis” is rendered still more difficult by the fact that it merely
corresponds to a fragment of a more comprehensive representation of the
neuroses.
The facts hitherto expressed concerning the anxiety neurosis already
contain some starting points for an insight into the mechanism of this
neurosis. In the first place it contains the assumption that we deal
with an accumulation of excitement, and then the very important fact
that the anxiety underlying the manifestations of the neurosis is not of
psychic derivation. Such, for example, would exist if we found as a
basis for the anxiety neurosis a justified fright happening once or
repeatedly which has since supplied the source of the preparedness for
the anxiety neurosis. But this is not the case; a former fright can
perhaps cause a hysteria or a traumatic neurosis but never an anxiety
neurosis. As the coitus interruptus is rendered so prominent among the
causes of anxiety neurosis I have thought at first that the source of
the continuous anxiety was perhaps the repeated fear during the sexual
act lest the technique will fail and conception follow. But I have found
that this state of mind of the man or woman during the coitus
interruptus plays no part in the origin of anxiety neurosis, that the
women who are really indifferent to the possibilities of conception are
just as exposed to the neurosis as those who are trembling at the
possibility of it, it all depends on which person suffers the loss of
sexual gratification.
Another starting point presents itself in the as yet unmentioned
observation that in a whole series of cases the anxiety neurosis goes
along with the most distinct diminution of the sexual libido or the
psychic desire, so that on revealing to the patients that their
affliction depends on “insufficient gratification,” they regularly reply
that this is impossible as just now their whole desire is extinguished.
The indications that we deal with an accumulation of excitement, that
the anxiety which probably corresponds to such accumulated excitement is
of somatic origin, so that somatic excitement becomes accumulated, and
furthermore, that this somatic excitement is of a sexual nature, and
that it is accompanied by a decreased psychic participation in the
sexual processes—all these indications, I say, favor the expectation
that the mechanism of the anxiety neurosis is to be found in the
deviation of the somatic sexual excitement from the psychic, and in the
abnormal utilization of this excitement occasioned by the former.
This conception of the mechanism of anxiety neurosis will become clearer
if one accepts the following view concerning the sexual process in man.
In the sexually mature male organism, the somatic sexual excitement
is—probably continuously—produced, and this becomes a periodic stimulus
for the psychic life. To make our conceptions clearer we will add that
this somatic sexual excitement manifests itself as a pressure on the
wall of the seminal vesicle which is provided with nerve endings. This
visceral excitement thus becomes continuously increased, but not before
attaining a certain height is it able to overcome the resistances of the
intercalated conduction as far as the cortex, and manifest itself as
psychic excitement. Then the group of sexual ideas existing in the
psyche becomes endowed with energy and results in a psychic state of
libidinous tension which is accompanied by an impulse to remove this
tension. Such psychic unburdening is possible only in one way which I
wish to designate as specific or adequate action. This adequate action
for the male sexual impulse consists of a complicated spinal reflex-act
which results in the unburdening of those nerve endings, and of all
psychically formed preparations for the liberation of this reflex.
Anything else except the adequate action would be of no avail, for after
the somatic sexual excitement has once reached the liminal value, it
continuously changes into psychic excitement; that must by all means
occur which frees the nerve endings from their heavy pressure, and thus
abolish the whole somatic excitement existing at the time and allow the
subcortical conduction to reestablish its resistance.
I will desist from presenting in a similar manner more complicated cases
of the sexual process. I will merely formulate the statement that this
scheme can essentially be transferred to the woman despite the problem
of the perplexity, artificial retardation, and stunting of the female
sexual impulse. In the woman, too, it can be assumed that there is a
somatic sexual excitement and a state in which this excitement becomes
psychic, evoking libido and the impulse to specific action which is
accompanied by the sensual feeling. But we are unable to state what
analogy there may be in the woman to the unburdening of the seminal
vesicles.
We can bring into the bounds of this representation of the sexual
process the etiology of actual neurasthenia as well as of the anxiety
neurosis. Neurasthenia always originates whenever the adequate (action)
unburdening is replaced by a less adequate one, like the normal coitus
under the most favorable conditions, by a masturbation or spontaneous
pollution; while anxiety neurosis is produced by all moments which
impede the psychic elaboration of the somatic sexual excitement. The
manifestations of anxiety neurosis are brought about by the fact that
the somatic sexual excitement diverted from the psyche expends itself
subcortically in not at all adequate reactions.
I will now attempt to test the etiological determinants suggested before
in order to see whether they show the common character formulated by me.
As the first etiological moment for the man, I have mentioned
intentional abstinence. Abstinence consists in foregoing the specific
action which results from the libido. Such foregoing may have two
consequences, namely that the somatic excitement accumulates, and then,
what is more important, is the fact that it becomes diverted to another
route where there is more chance for discharge than through the psyche.
It will then finally diminish the libido and the excitement will
manifest itself subcortically as anxiety. Where the libido does not
become diminished, or the somatic excitement is expended in pollutions,
or where it really becomes exhausted in consequence of repulsion,
everything else except anxiety neurosis is formed. In this manner
abstinence leads to anxiety neurosis. But abstinence is also the active
process in the second etiological group of frustrated excitement. The
third case, that of the considerate coitus reservatus, acts through the
fact that it disturbs the psychic preparedness for the sexual discharge
by establishing beside the subjugation of the sexual affect, another
distracting psychic task. Through this psychic distraction, too, the
libido gradually disappears and the further course is then the same as
in the case of abstinence. The anxiety in old age (climacterium of men)
requires another explanation. Here the libido does not diminish, but
just as in the climacterium of women, such an increase takes place in
the somatic excitement that the psyche shows itself relatively
insufficient for the subjugation of the same.
The subsummation of the etiological determinants in the woman, under the
aspect mentioned, does not afford any greater difficulties. The case of
the virginal fear is especially clear. Here the group of ideas with
which the somatic sexual excitement should combine are not as yet
sufficiently developed. In anesthetically newly married the anxiety
appears only if the first cohabitations awakened a sufficient amount of
somatic excitement. Where the local signs of such excitability (like
spontaneous feelings of excitement, desire to micturate, etc.) are
lacking, the anxiety, too, stays away. The case of ejaculatio precox or
coitus interruptus is explained similarly to that in the man by the fact
that the libido gradually disappears in the psychically ungratified act,
whereas the excitement thereby evoked is subcortically expended. The
formation of an estrangement between the somatic and psychic in the
discharge of the sexual excitement succeeds quicker in the woman than in
the man and is more difficult to remove. The case of widowhood or
voluntary abstinence, as well as the case of climacterium adjusts itself
in the woman as in the man, but in the case of abstinence there surely
is in addition the intentional repression of the sexual ideas, for an
abstinent woman struggling with temptation must often decide to suppress
it. The abhorrence perceived by an elderly woman during her menopause
against the immensely increased libido can have a similar effect.
The two etiological determinants mentioned last can also be classified
without any difficulty.
The tendency to anxiety of the masturbator who becomes neurasthenic is
explained by the fact that these persons so easily merge into the state
of abstinence after they have for long been accustomed to afford a
discharge, to be sure an incorrect one, for every little quantity of
somatic excitement. Finally the last case, the origin of anxiety
neurosis through a severe illness, overwork, exhaustive nursing, etc.,
in addition to the efficacy of coitus interruptus readily permits a free
interpretation. Through deviation the psyche becomes here insufficient
for the subjugation of the somatic sexual excitement, a task which
continuously devolves upon it. We know how deeply the libido can sink
under the same conditions, and we have here a nice example of a neurosis
which although not of a sexual etiology still evinces a sexual
mechanism.
The conception here developed represents the symptoms of anxiety
neurosis in a measure as a substitute for the omitted specific action to
the sexual excitement. As a further corroboration of this I recall that
also in normal coitus the excitement expends itself in respiratory
acceleration, palpitation, perspiration, congestion, etc. In the
corresponding attack of anxiety of our neurosis we have before us the
dyspnoea, the palpitation, etc., of the coitus in an isolated and
aggravated manner.
It can still be asked why the nervous system merges into a peculiar
affective state of anxiety under the circumstances of psychic inadequacy
for the subjugation of the sexual excitement? A hint to the answer is as
follows: The psyche merges into the affect of fear when it perceives
itself unable to adjust an externally approaching task (danger) by
corresponding reaction; it merges into the neurosis of anxiety when it
finds itself unable to equalize the endogenously originated (sexual)
excitement. The psyche, therefore, behaves as if projecting this
excitement externally. The affect and the neurosis corresponding to it
stand in close relationship to each other; the first is the reaction to
an exogenous, the latter the reaction to an analogous endogenous
excitement. The affect is a rapidly passing state, the neurosis is
chronic because the exogenous excitement acts like a stroke happening
but once, while the endogenous acts like a constant force. The nervous
system reacts in the neurosis against an inner source of excitement just
as it does in the corresponding affect against an analogous external
one.
IV. THE RELATIONS TO OTHER NEUROSES.
A few observations still remain to be mentioned on the relations of the
anxiety neurosis to the other neuroses in reference to occurrence and
inner relationship.
The purest cases of anxiety neurosis are also usually the most
pronounced. They are found in potent young individuals with a uniform
etiology, and where the disease is not of long standing.
To be sure, the symptoms of anxiety are found more frequently as a
simultaneous and common occurrence with those of neurasthenia, hysteria,
compulsive ideas, and melancholia. If on account of such clinical
mixtures one hesitates in recognizing anxiety neurosis as an independent
unity, he will also have to abandon the laboriously acquired separation
of hysteria and neurasthenia.
For the analysis of the “mixed neuroses” I can advocate the following
proposition: Where a mixed neurosis exists, an involvement of many
specific etiologies can be demonstrated.
Such a multiplicity of etiological moments determining a mixed neurosis
can only come about accidentally, if the activities of a newly formed
injury are added to those already existing. Thus, for example, a woman
who was at all times a hysteric begins to practice coitus reservatus at
a certain period of her married life, and adds an anxiety neurosis to
her hysteria; a man who had masturbated and become neurasthenic, becomes
engaged and excites himself with his fiancée so that a fresh anxiety
neurosis allies itself to his neurasthenia.
The multiplicity of etiological moments in other cases is not
accidental, one of them has brought the other into activity. Thus a
woman, with whom her husband practices coitus reservatus without regard
to her gratification, finds herself forced to finish the tormenting
excitement following such an act with masturbation, as a result of which
she shows an anxiety neurosis with symptoms of neurasthenia. Under the
same noxiousness another woman has to contend with lewd pictures against
which she wishes to defend herself, and in this way the coitus
interruptus will cause her to acquire obsessions along with the anxiety
neurosis. Finally a third woman, as a result of coitus interruptus loses
her affection for her husband and forms another which she secretly
guards, and as a result she evinces a mixture of hysteria and anxiety
neurosis.
In a third category of mixed neuroses the connection of the symptoms is
of a still more intimate nature, as the same etiological determinants
regularly and simultaneously evoke both neuroses. Thus, for example, the
sudden sexual explanation which we have found in virginal fear always
produces hysteria, too; most causes of intentional abstinence connect
themselves in the beginning with actual obsessions; and it seems to me
that the coitus interruptus of men can never provoke a pure anxiety
neurosis, but always a mixture of the same with neurasthenia, etc.
It follows from this discussion that the etiological determinants of the
occurrence must moreover be distinguished from the specific etiological
moments of neurasthenia. The first moments, as for example the coitus
interruptus, masturbation, and abstinence, are still ambiguous, and can
each produce different neuroses; and it is only the etiological moments
abstracted from them, like the inadequate unburdening, psychic
insufficiency, and defense with substitution, that have an unambiguous
and specific relation to the etiology of the individual great neuroses.
In its intrinsic property, anxiety neurosis shows the most interesting
agreements and differences when compared with the other great neuroses,
particularly when compared with neurasthenia and hysteria. With
neurasthenia it shares one main character, namely, that the source of
excitement, the cause of the disturbance, lies in the somatic rather
than in the psychic sphere as in the case of hysteria and compulsion
neurosis. For the rest we can recognize a kind of contrast between the
symptoms of neurasthenia and anxiety neurosis, which can be expressed in
the catchwords, accumulation and impoverishment of excitement. This
contrast does not hinder the two neuroses from combining with each
other, but shows itself in the fact that the most extreme forms in both
cases are also the purest.
When compared with hysteria anxiety neurosis shows in the first place a
number of agreements in the symptomatology the valuation of which is
still unsettled. The appearance of the manifestations as persistent
symptoms or attacks, the aura-like grouped paresthesias, the
hyperesthesias and pressure points can be found in certain substitutes
for the anxiety attack, as in dyspnoea and palpitation, the aggravation
of the perhaps organically determined pains (by conversion)—these and
other joint features lead to the supposition that some things which are
ascribed to hysteria can with full authority be fastened to anxiety
neurosis. But if we enter into the mechanism of both neuroses, as far as
it can at present be penetrated, we find aspects which make it appear
that the anxiety neurosis is really the somatic counterpart to hysteria.
Here as there we have accumulation and excitement—on which is perhaps
based the similarity of the aforementioned symptoms—; here as there we
have a psychic insufficiency which results from abnormal somatic
processes; and here as there we have instead of a psychic elaboration a
deviation of the excitement into the somatic. The difference only lies
in the fact that the excitement, in which displacement the neurosis
manifests itself, is purely somatic (somatic sexual excitement) in
anxiety neurosis, while in hysteria it is psychic (evoked through a
conflict). Hence it is not surprising that hysteria and anxiety neurosis
lawfully combine with each other, as in the “virginal fear” or in the
“sexual hysteria,” and that hysteria simply borrows a number of symptoms
from anxiety neurosis, etc. This intimate relationship between anxiety
neurosis and hysteria furnishes us with a new argument for demanding the
separation of anxiety neurosis from hysteria, for if this be denied, one
will also be unable to maintain the so painstakingly acquired
distinction between neurasthenia and hysteria, so indispensable for the
theory of the neuroses.
CHAPTER VII.
FURTHER OBSERVATIONS ON THE DEFENSE NEUROPSYCHOSES.
Under the caption of “Defense Neuropsychoses” I have comprised hysteria,
obsessions, as well as certain cases of acute hallucinatory
confusion.[47] All these affections evince one common aspect in the fact
that their symptoms originated through the psychic mechanism of
(unconscious) defense, that is, through the attempt to repress an
unbearable idea which appeared in painful contrast to the ego of the
patient. I was also able to explain and exemplify by cases reported in
the preceding chapters in what sense this psychic process of “defense”
or “repression” is to be understood. I have also discussed the laborious
but perfectly reliable method of psychoanalysis of which I make use in
my examinations, and which at the same time serves as a therapy.
My experiences during the last two years have strengthened my
predilection for making the defense the essential point in the psychic
mechanism of the mentioned neuroses, and on the other hand have
permitted me to give a clinical foundation to the psychological theory.
To my surprise I have discovered some simple but sharply circumscribed
solutions for the problem of the neuroses which I shall provisionally
briefly report in the following pages. It would be inconsistent with
this manner of reporting to add to the assertions the required proofs,
but I hope to be able to fulfill this obligation in a comprehensive
discussion.
I. THE “SPECIFIC” ETIOLOGY OF HYSTERIA.
That the symptoms of hysteria become comprehensible only through a
reduction to “traumatically” effective experiences, and that these
psychic traumas refer to the sexual life has already been asserted by
Breuer and me in former publications. What I have to add today as a
uniform result of thirteen analyzed cases of hysteria concerns, on the
one hand, the nature of these sexual traumas, and on the other, the
period of life in which they occurred. An experience occurring at any
period of life, touching in any way the sexual life, and then becoming
pathogenic through the liberation and suppression of a painful affect is
not sufficient for the causation of hysteria. It must on the contrary
belong to the sexual traumas of early childhood (the period of life
before puberty), and its content must consist in a real irritation of
the genitals (coitus-like processes).
This specific determination of hysteria—sexual passivity in pre-sexual
periods—I have found fulfilled in all analyzed cases of hysteria (among
which were two men). To what extent the determination of the accidental
etiological moment diminishes the requirement of the hereditary
predisposition needs only be intimated. We can, moreover, understand the
disproportionately greater frequency of hysteria in the female sex, as
even in childhood this sex is more subject to sexual assaults.
The objection most frequently advanced against this result may be to the
purport, that sexual assaults on little children occur too frequently to
give an etiological value to its verification, or that such experiences
must remain ineffectual just because they concern a sexually undeveloped
being; and that one must moreover be careful not to obtrude upon the
patient through the examination such alleged reminiscences or believe in
the romances which they themselves fabricate. To the latter objections I
hold out the request that no one should really judge with great
certainty this obscure realm unless he has made use of the only method
which can clear it up (the method of psychoanalysis for bringing to
consciousness the hitherto unconscious[48]). The essential point in the
first doubts is settled by the observation that it really is not the
experiences themselves that act traumatically, but their revival as
reminiscences after the individual has entered into sexual maturity.
My thirteen cases of hysteria were throughout of the graver kind, they
were all of long duration, and some had undergone a lengthy and
unsuccessful asylum treatment. Every one of the infantile traumas which
the analysis revealed for these severe cases had to be designated as
marked sexual injuries; some of them were indeed abominable. Among the
persons who were guilty of such serious abuse we have in the first place
nurses, governesses, and other servants to whom children are left much
too carelessly, then in regrettable frequency come the teachers; but in
seven of the thirteen cases we dealt with innocent childish offenders,
mostly brothers who for years entertained sexual relations with their
younger sisters. The course of events always resembled some of the cases
which could with certainty be tracked, namely, that the boy had been
abused by a person of the feminine sex, thus awakening in him
prematurely the libido, and that after a few years he repeated in sexual
aggression on his sister the same procedures to which he himself was
subjected.
I must exclude active masturbation from the list of sexual injuries of
early childhood as being pathogenic for hysteria. That it is so very
frequently found associated with hysteria is due to the fact that
masturbation in itself is more frequently the result of abuse or
seduction than one supposes. It not seldom happens that both members of
a childish pair later in life become afflicted by defense neuroses, the
brother by obsessions and the sister by hysteria, which naturally gives
the appearance of a familial neurotic predisposition. This
pseudo-heredity is now and then solved in a surprising manner. I have
had under observation a brother, sister, and a somewhat older cousin.
The analysis which I have undertaken with the brother showed me that he
suffered from reproaches for being the cause of his sister’s malady; he
himself was corrupted by his cousin, concerning whom it was known in the
family that he fell a victim to his nurse.
I can not definitely state up to what age sexual damage occurs in the
etiology of hysteria, but I doubt whether sexual passivity can cause
repression after the eighth and tenth year unless qualified for it by
previous experiences. The lower limit reaches as far as memory in
general, that is, to the delicate age of one and one half or two years!
(two cases). In a number of my cases the sexual trauma (or the number of
traumas) occurred during the third and fourth year of life. I myself
would not lend credence to this peculiar discovery if it were not for
the fact that the later development of the neurosis furnished it with
full trustworthiness. In every case there are a number of morbid
symptoms, habits and phobias which are only explainable by returning to
those youthful experiences, and the logical structure of the neurotic
manifestation makes it impossible to reject the faithfully retained
memories of childhood. Except through psychoanalysis it is of no avail
to ask a hysterical patient about these infantile traumas; their remains
can only be found in the morbid symptoms and not in conscious memory.
All the experiences and excitements which prepare the way for, or
occasion the outburst of, hysteria in the period of life after puberty
evidently act through the fact that they awaken the memory remnants of
those infantile traumas which do not become conscious but lead to the
liberation of affect and repression. It is quite in harmony with this
rôle of the later traumas not to be subject to the strict limitation of
the infantile traumas, but that both in intensity and quality they can
vary from an actual sexual assault to a mere approximation of the
sexual, such as perceiving the sexual acts of others, or receiving
information concerning sexual processes.[49]
In my first communication on the defense neuropsychoses I failed to
explain how the exertion of a hitherto healthy individual to forget such
traumatic happenings would result in the real intentional repression,
and thus open the door for the defense neurosis. It can not depend on
the nature of the experience, as other persons remain unaffected despite
the same motives. Hysteria cannot therefore be fully explained by the
effect of the trauma, and we are forced to admit that the capacity for
hysteria already existed before the trauma.
This indefinite hysterical predisposition can now wholly or partially be
substituted by the posthumous effect of the infantile sexual trauma. The
“repression” of the memory of a painful sexual experience of maturer
years can take place only in persons in whom this experience can bring
into activity the memory remnants of an infantile trauma.[50]
The prerequisite of obsessions is also a sexual infantile experience,
but of a different nature than that of hysteria. The etiology of both
defense neuropsychoses now shows the following relation to the etiology
of both simple neuroses, neurasthenia and anxiety neurosis. As I have
shown above, both the latter neuroses are the direct results of the
sexual noxas alone, while both defense neuroses are the direct results
of sexual noxas which acted before the appearance of sexual maturity,
that is, they are the results of the psychic memory remnants of these
noxas. The actual causes producing neurasthenia and anxiety neurosis
simultaneously play the rôle of inciting causes of the defense neuroses,
and on the other hand, the specific causes of the defense neuroses, the
infantile traumas, may simultaneously prepare the soil for the later
developing neurasthenia. Finally it not seldom happens that the
existence of a neurasthenia or anxiety neurosis is only preserved by
continued recollection of an infantile trauma rather than by actual
sexual injuries.
II. THE ESSENCE AND MECHANISM OF COMPULSION NEUROSIS.
Sexual experiences of early childhood have the same significance in the
etiology of the compulsion neurosis as in hysteria, still we no longer
deal here with sexual passivity but with pleasurably accomplished
aggressions, and with pleasurably experienced participation in sexual
acts, that is, we deal here with sexual activity. It is due to this
difference in the etiological relations that the masculine sex seems to
be preferred in the compulsion neurosis.
In all my cases of compulsion neurosis I have found besides a subsoil of
hysterical symptoms which could be traced to a pleasurable action of
sexual passivity from a precedent scene. I presume that this coincidence
is a lawful one, and that premature sexual aggression always presupposes
an experience of seduction. But I am unable to present as yet a complete
description of the etiology of the compulsion neurosis. I only believe
that the final determination as to whether a hysteria or compulsion
neurosis should originate on the basis of infantile traumas depends on
the temporal relation of the development of the libido.
The essence of the compulsion neurosis may be expressed in the following
simple formula: Obsessions are always transformed _reproaches_ returning
from consciousness which always refer to a pleasurably accomplished
sexual action of childhood. In order to elucidate this sentence it will
be necessary to describe the typical course of compulsion neurosis.
In a first period—period of childish immorality—the events containing
the seeds of the later neurosis take place. In the earliest childhood
there appear at first the experiences of sexual seduction which later
makes the repression possible, and this is followed by the actions of
sexual aggressions against the other sex which later manifest themselves
as actions of reproach.
This period is brought to an end by the appearance of the—often self
ripened—sexual “maturity.” A reproach then attaches itself to the memory
of that pleasurable action, and the connection with the initial
experience of passivity makes it possible—often only after conscious and
recollected effort—to repress it and replace it by a primary symptom of
defense. The third period, that of apparent healthiness but really of
successful defense, begins with the symptoms of scrupulousness, shame
and diffidence.
The next period, the disease is characterized by the return of the
repressed reminiscences, hence, by the failure of the defense; but it
remains undecided whether the awakening of the same is more frequently
accidental and spontaneous, or whether it appears in consequence of
actual sexual disturbances, that is, as additional influences of the
same. But the revived reminiscences and the reproaches formed from them
never enter into consciousness unchanged, but what becomes conscious as
an obsession and obsessive affect and substitutes the pathogenic memory
in the conscious life, are compromise formations between the repressed
and the repressing ideas.
In order to describe clearly and probably convincingly the processes of
repression, the return of the repression, and the formation of the
pathological ideas of compromise, we would have to decide upon very
definite hypotheses concerning the substratum of the psychic occurrence
and consciousness. As long as we wish to avoid it we will have to rest
content with the following rather figuratively understood observations.
Depending on whether the memory content of the reproachful action alone
forces an entrance into consciousness or whether it takes with it the
accompanying reproachful affect, we have two forms of compulsion
neurosis. The first represents the typical obsessions, the content of
which attracts the patient’s attention; only an indefinite displeasure
is perceived as an affect, whereas, for the content of the obsession the
only suitable affect would be one of reproach. The content of the
obsession is doubly distorted when compared to the content of the
infantile compulsive act. First, something actual replaces the past
experience, and second, the sexual is substituted by an analogous
non-sexual experience. These two changes are the results of the constant
tendency to repression still in force which we will attribute to the
“ego.” The influence of the revived pathogenic memory is shown by the
fact that the content of the obsession is still partially identical with
the repressed, or can be traced to it by a correct stream of thought.
If, with the help of the psychoanalytic method, we reconstruct the
origin of one individual obsession we find that one actual impression
instigated two diverse streams of thought, and that the one which passed
over the repressed memory, though incapable of consciousness and
correction, proves to be just as correctly formed logically as the
other. If the results of the two psychic operations disagree, the
contradiction between the two may never be brought to logical
adjustment, but as a compromise between the resistance and the
pathological result of thought an apparently absurd obsession enters
into consciousness beside the normal result of the thought. If both
streams of thought yield the same result, they reinforce each other so
that the normally gained result of thought now behaves psychically like
an obsession. Wherever neurotic compulsion manifests itself psychically
it originates from repression. The obsessions have, as it were, a
psychical course of compulsion which is due, not to their own validity,
but to the source from which they originate, or to the source which
furnishes a part of their validity.
A second form of compulsion neurosis results if the repressed reproach
and not the repressed content of memory forces a replacement in the
conscious psychic life. Through a psychic admixture, the affect of the
reproach can change itself into any other affect of displeasure, and if
this occurs there is nothing to hinder the substituting affect from
becoming conscious. Thus, the reproach (of having performed in childhood
some sexual actions) may be easily transformed into shame (if some one
else becomes aware of it), into hypochondriacal anxiety (because of the
physical harmful consequences of those reproachful acts), into social
anxiety (fearing punishment from others), into religious anxiety, into
delusions of observation (fear of betraying those actions to others),
into fear of temptations (justified distrust in one’s own moral ability
of resistance), etc. Besides, the memory content of the reproachful
action may also be represented in consciousness, or it may be altogether
concealed, which makes the diagnosis very difficult. Many cases which on
superficial examination are taken as ordinary (neurasthenic)
hypochondria often belong to this group of compulsive affects; the very
frequently so called “periodic neurasthenia” or “periodic melancholia”
especially seem to be explained by compulsive affects or obsessions, a
recognition not unimportant therapeutically.
Beside these compromise symptoms which signify the return of the
repression and hence a failure of the originally achieved defense, the
compulsion neurosis forms a series of other symptoms of a totally
different origin. The ego really tries to defend itself against those
descendants of the initial repressed reminiscence, and in this conflict
of defense it produces symptoms which may be comprehended as “secondary
defense.” These are throughout “protective measures” which have
performed good service in the struggle carried on against the obsessions
and the obsessing affects. If these helps in the conflict of the defense
really succeed in repressing anew the symptoms of return obtruding
themselves on the ego, the compulsion then transmits itself on the
protective measures themselves and produces a third form of the
“compulsion neurosis,” the compulsive action. These are never primary,
they never contain anything else but a defense, never an aggression.
Psychic analysis shows that despite their peculiarity they can always be
fully explained by reduction to the compulsive reminiscence which they
oppose.[51]
The secondary defense of the obsessions can be brought about by a
forcible deviation to other thoughts of possibly contrary content;
hence, in case of success there is a compulsive reasoning, regularly
concerning abstract and transcendental subjects, because the repressed
ideas always occupied themselves with the sensuous. Or the patient tries
to become master of every compulsive idea through logical labor and by
appealing to his conscious memory; this leads to compulsive thinking and
examination and to doubting mania. The priority of the perception before
the memory in these examinations at first induce and then force the
patient to collect and preserve all objects with which he comes in
contact. The secondary defense against the compulsive affects results in
a greater number of defensive measures which are capable of being
transformed into compulsive actions. These can be grouped according to
their tendency. We may have measures of penitence (irksome ceremonial
and observation of numbers), of prevention (diverse phobias,
superstition, pedantry, aggravation of the primary symptom of
scrupulousness), measures of fear of betrayal (collecting papers and
shyness), and measures of becoming unconscious (dipsomania). Among these
compulsive acts and impulses the phobias play the greatest part as
limitations of the patient’s existence.
There are cases in which we can observe how the compulsion becomes
transferred from the idea or affect to the measure, and other cases in
which the compulsion oscillates between the returning symptoms of
secondary defense. But there are also cases in which no obsessions are
really formed, but the repressed reminiscence immediately becomes
replaced by the apparent primary defensive measure. Here that stage is
attained at a bound which otherwise ends the course of the compulsion
neurosis only after the conflict of the defense. Grave cases of this
affection end either with a fixation of ceremonial actions, general
doubting mania, or in an existence of eccentricity conditioned by
phobias.
That the obsessions and everything derived from them are not believed is
probably due to the fact that the defense symptom of scrupulousness was
formed during the first repression and gained compulsive validity. The
certainty of having lived morally throughout the whole period of the
successful defense makes it impossible to give credence to the reproach
which the obsession really involves. Only transitorily during the
appearance of a new obsession, and now and then in melancholic
exhaustive states of the ego do the morbid symptoms of the return also
enforce the belief. The “compulsion” of the psychic formations here
described has in general nothing to do with the recognition through
belief, and is not to be mistaken for that moment which is designated as
“strength” or “intensity” of an idea. Its main characteristic lies in
its inexplicableness through psychic activities of conscious ability,
and this character undergoes no change whether the idea to which the
compulsion is attached is stronger or weaker, more or less intensively
“elucidated,” “supplied with energy,” etc.
The reason for the unassailableness of the obsession or its derivative
is due only to its connection with the repressed memory of early
childhood, for as soon as we succeed in making it conscious, for which
the psychotherapeutic methods already seem quite sufficient, the
compulsion, too, becomes detached.
III. ANALYSIS OF A CASE OF CHRONIC PARANOIA.
For some length of time I entertained the idea that paranoia also—or the
group of cases belonging to paranoia—is a defense psychosis, that is,
like hysteria and obsessions it originates from the repression of
painful reminiscences, and that the form of its symptoms is determined
by the content of the repression. A special way or mechanism of
repression must be peculiar to paranoia perhaps just as in hysteria
which brings about the repression by way of conversion into bodily
innervation, and perhaps like obsessions in which a substitution is
accomplished (displacement along certain associative categories). I
observed many cases which seemed to favor this interpretation, but I had
not found any which demonstrated it until a few months ago when, through
the kindness of Dr. J. Breuer, I subjected to psychoanalysis, with
therapeutic aims, an intelligent woman of 32, whom no one will be able
to refuse to designate as a chronic paranoiac. I report here some
explanations gained in this work, because I have no prospects of
studying paranoia except in very isolated examples, and because I think
it possible that these observations may instigate a psychiatrist for
whom conditions are more favorable, to give due justice to the moment of
defense in the present animated discussion on the nature and psychic
mechanism of paranoia. It is of course far from my thoughts to wish to
show from the following single observation anything but that this case
is a defense psychosis, and that in the group of “paranoia” there may be
still others of a similar nature.
Mrs. P. thirty-two years old, married three years. She is the mother of
a two-year-old child, and does not descend from nervous parents; but her
sister and brother whom I know, are also neurotic. It was doubtful
whether she was not transitorily depressed and mistaken in her judgment
in the middle of her twentieth year. During the last years she was
healthy and capacitated until she evinced the first symptoms of the
present illness, six months after the birth of her child. She became
secluded and suspicious, showing a disinclination towards social
relations with the relatives of her husband, and complained that the
neighbors in the little town now behaved towards her in a rather
impolite and regardless manner. Gradually these complaints grew in
intensity, she thought that there was something against her, though she
had no notion what it could be. But there was no doubt that all the
relatives and friends denied her respect, and did everything to
aggravate her. She was trying very hard to find out whence this came but
could not discover anything. Some time later she complained that she was
watched, that her thoughts were guessed, and that everything that
happened in her house was known. One afternoon she suddenly conceived
the thought that she was watched during the evening while undressing.
Since then she applied while undressing the most complicated
precautionary measures. She slipped into her bed in the darkness and
undressed only under cover. As she avoided all social relations, and
took but little nourishment, and was very depressed, she was sent in the
summer of 1895 to a hydrotherapeutic institute. There new symptoms
appeared and reinforced those already existing. As early as the spring,
while she was alone with the servant girl, she suddenly perceived a
sensation in her lap, and thought that the servant girl then had an
unseemly thought. This sensation became more frequent in the summer, it
was almost continuous, and she felt her genitals “as if one feels a
heavy hand.” She then began to see pictures which frightened her; they
were hallucinations of female nakedness, especially an exposed woman’s
lap with hair; occasionally she also saw male genitals. The picture of
the hairy lap and the organic sensation in the lap usually came
conjointly. The pictures became very aggravating, as she regularly
perceived them when she was in the company of a woman, and the thought
accompanying them was that she sees the woman in an indecent exposure,
and that in the same moment the woman sees the same picture of her (!)
Simultaneously with these visual hallucinations, which, after their
first appearance in the asylum, disappeared again for many months, she
began to be troubled with voices which she did not recognize and could
not explain. When she was in the street she heard, “This is Mrs. P.—Here
she goes.—Where does she go?”. Every one of her movements and actions
were commented upon. Occasionally she heard threats and reproaches. All
these symptoms became worse when she was in society, or even in the
street; she therefore hesitated about going out; she also stated that
she experienced nausea for food, and as a result she became reduced in
vitality.
I obtained this from her when she came under my care in the winter of
1895. I present this case in detail in order to make the impression that
we really deal here with a very frequent form of chronic paranoia, which
diagnosis will agree with the details of the symptoms and their behavior
to be mentioned later. At that time she either concealed from me the
delusions for the interpretation of the hallucinations or they really
had not as yet occurred. Her intelligence was undiminished. It was
reported to me as peculiar that she had a number of rendezvous with her
brother who lived in the neighborhood, in order to confide something to
him, but this she never told him. She never spoke about her
hallucinations, and towards the end she did not say much about the
aggravations and persecutions from which she suffered. What I have to
report about this patient concerns the etiology of the case and the
mechanism of the hallucinations. I discovered the etiology by applying
Breuer’s method exactly as in hysteria, for the investigation and
removal of the hallucinations. I started with the presupposition that
just as in the two other defense neuroses known to me this paranoia must
contain unconscious thoughts and repressed reminiscences which have to
be brought to consciousness, in the same manner as in the others, by
overcoming a certain resistance. The patient immediately corroborated
this expectation by behaving during the analysis exactly like a
hysteric, and under attention to the pressure of my hand she reproduced
thoughts which she could not remember having had, which she at first
could not understand, and which contradicted her expectations. The
occurrence of important unconscious ideas was therefore also
demonstrated in a case of paranoia, and I could hope to reconduct the
compulsion of paranoia to repression. It was only peculiar that the
assertions which originated in the unconscious were usually heard
inwardly or hallucinated by her as her voices.
Concerning the origin of the visual hallucinations, or at least the
vivid pictures, I discovered the following: The picture of the female
lap occurred almost always together with the organic sensation in the
lap. The latter, however, was more constant and often occurred without
the picture.
The first pictures of feminine laps appeared in the hydrotherapeutic
institute a few hours after she had actually seen a number of women
naked in the bath house. They were therefore only simple reproductions
of a real impression. It may be assumed that these impressions repeated
themselves because something of great interest was connected with them.
She stated that she was at that time ashamed of these women, and that
since she recalled it she is ashamed of having been seen naked. Having
been obliged to look upon this shame as something compulsive, I
concluded that according to the mechanism of defense an experience must
have here been repressed in which she was not ashamed, and I requested
her to allow those reminiscences to emerge which belonged to the theme
of shame. She promptly reproduced a series of scenes from her
seventeenth to her eighth year, during which while bathing before her
mother, her sister, and her physician she was ashamed of her nakedness.
This series, however, reached back to a scene in her sixth year when she
undressed in the children’s room before going to sleep without feeling
ashamed of her brother who was present. On questioning her it was found
that there were a number of such scenes, and that for years the brothers
and sisters were in the habit of showing themselves naked to one another
before retiring. I now understood the significance of the sudden thought
of being watched on going to sleep. It was an unchanged fragment of the
old reproachful reminiscence, and she was now trying to make up in shame
what she lost as a child.
The supposition that we dealt here with an amour of childhood so
frequent in the etiology of hysteria was strengthened by the further
progress of the analysis which also showed simultaneous solutions for
individual frequently recurring details in the picture of paranoia. The
beginning of her depression commenced at the time of a disagreement
between her husband and her brother on account of which the latter no
longer visited her. She was always much attached to this brother and
missed him very much at this time. Besides this she spoke about a moment
in the history of her disease during which for the first time
“everything became clear,” that is, during which she became convinced
that her assumption about being generally despised and intentionally
annoyed was true. She gained this assurance during a visit of her
sister-in-law, who in the course of conversation dropped the words, “If
such a thing should happen to me I would not mind it.” Mrs. P. at first
took this utterance unsuspectingly, but when her visitor left her it
seemed to her that these words contained a reproach meaning that she was
in the habit of taking serious matters lightly, and since that hour she
was sure that she was a victim of common slander. On asking her why she
felt justified in referring those words to herself she answered that the
tone in which her sister-in-law spoke convinced her of it—to be sure
subsequently—This is really a characteristic detail of paranoia. I now
urged her to recall her sister-in-law’s conversation before the accusing
utterance, and it was found that she related that in her father’s home
there were all sorts of difficulties with the brothers, and added the
wise remark, “In every family many things happen which one would rather
keep under cover, and that if such a thing should happen to her she
would take it lightly.” Mrs. P. had to acknowledge that her depression
was connected with the sentences before the last utterance. As she
repressed both sentences which could recall her relations with her
brother, and retained only the last meaningless one, she was forced to
connect with it the feeling of being reproached by her sister-in-law;
but, inasmuch as the contents of this sentence offered absolutely no
basis for such assumption she disregarded it and laid stress on the tone
with which the words were pronounced. It is probably a typical
illustration for the fact that the misinterpretations of paranoia depend
on repression.
In a most surprising manner it also explains her peculiar behavior in
making appointments with her brother and then refusing to tell him
anything. Her explanation was that she thought that if she only looked
at him he must understand her suffering, as he knew the cause of it. As
this brother was really the only person who could know anything about
the etiology of her disease it followed that she acted from a motive
which, though she did not consciously understand, seemed perfectly
justified as soon as a new sense was put on it from the unconscious.
I then succeeded in causing her to reproduce different scenes the
culminating points of which were the sexual relations with her brother
at least from her sixth to her tenth year. During this work of
reproduction the organic sensation in the lap “joined in the
discussion,” precisely as regularly observed in the analysis of memory
remnants of hysterical patients. The picture of a naked female lap (but
now reduced to childish proportions and without hair) immediately
appeared or stayed away in accordance with the occurrence of the scene
in question in full light or in darkness. The disgust for eating, too,
was explained by a repulsive detail of these actions. After we had gone
through this series, the hallucinatory sensations and pictures
disappeared without having thus far returned.[52]
I have thus learned that these hallucinations were nothing other than
fragments from the content of the repressed experiences of childhood,
that is, symptoms of the return of the repressed material.
I now turned to the analysis of the voices. Here it must before all be
explained why such indifferent remarks as, “Here goes Mrs. P.—She now
looks for apartments, etc.” could be so painfully perceived, and how
these harmless sentences managed to become distinguished by
hallucinatory enforcement. To begin with, it was clear that these
“voices” could not be hallucinatory reproduced reminiscences like the
pictures and sensations, but rather thoughts which “became loud.”
She heard the voices for the first time under the following
circumstances. With great tension she read the pretty story, “The
Heiterethei” by O. Ludwig, and noticed that while reading she was
preoccupied with incoming thoughts. Immediately after she took a walk on
the highway and suddenly while passing a peasant’s cottage the voices
told her, “That is how the house of the Heiterethei looked! Here is the
well, and here is the bush! How happy she was in all her poverty!” The
voices then repeated whole paragraphs of what she had just read, but it
remained incomprehensible why house, bush, and well of the Heiterethei,
and just such indifferent and most irrelevant passages of the romance
should have obtruded themselves upon her attention with pathological
strength. The analysis showed that while reading she at the same time
entertained extraneous thoughts, and that she was excited by totally
different passages of the book. Against this material analogy between
the couple of the romance and herself and her husband, the reminiscence
of intimate things of her married life and family secrets, against all
these there arose a repressive resistance because they were connected
with her sexual shyness by very simple and demonstrable streams of
thought, and finally resulted in the awakening of old experiences of
childhood. In consequence of the censorship exercised by the repression
the harmless and idyllic passages connected with the objectionable ones
by contrast and vicinity, became reinforced in consciousness, enabling
them to become audible. For example, the first repressed thought
referred to the slander to which the secluded heroine was subjected by
her neighbors. She readily found in this an analogy to herself. She,
too, lived in a small place, had no intercourse with anybody and
considered herself despised by her neighbors. The suspicion against the
neighbors was founded on the fact that in the beginning of her married
life she was obliged to content herself with a small apartment. The wall
of the bedroom, near which stood the nuptial bed of the young couple,
adjoined the neighbors’ room. With the beginning of her marriage there
awakened in her a great sexual shyness. This was apparently due to an
unconscious awakening of some reminiscences of childhood of having
played husband and wife. She was very careful lest the neighbors might
hear through the adjacent wall either words or noises and this shyness
changed into suspicion against the neighbors.
The voices therefore owed their origin to the repression of thoughts
which in the last analysis really signified reproaches on the occasion
of an experience analogous to the infantile trauma; they were
accordingly symptoms of the return of the repression, but at the same
time they were results of a comparison between the resistance of the ego
and the force of the returning repression which in this case produce a
distortion beyond recognition. On other occasions when analyzing voices
in Mrs. P. the distortion was less marked, still the words heard always
showed a character of diplomatic uncertainty. The annoying allusion was
generally deeply hidden, the connection of the individual sentences was
masked by a strange expression, unusual forms of speech, etc.,
characteristics generally common to the auditory hallucinations of
paranoiacs, and in which I noticed the remnant of the compromise
distortion. The expression, “There goes Mrs. P., she is looking for
apartments in the street,” signified, for example, the threat that she
will never recover, for I promised her that after the treatment she
would be able to return to the little city where her husband was
employed. She rented temporary quarters in Vienna for a few months.
On some occasions Mrs. P. also perceived more distinct threats, for
example, concerning the relatives of her husband, the restrained
expression of which still continued to contrast with the grief which
such voices caused her. Considering all that we otherwise know of
paranoiacs I am inclined to assume a gradual relaxation of that
resistance which weakens the reproaches so that finally the defense
fails completely and the original reproach, the insulting word, which
one wanted to save himself returns in unchanged form. I do not, however,
know whether this is a constant course, whether the censor of the
expressions of reproach can not from the beginning stay away, or persist
to the end.
It is left for me to utilize the explanations gained in this case of
paranoia for the comparison of paranoia with compulsion neurosis. Here,
as there, the repression was shown to be the nucleus of the psychic
mechanism, and in both cases the repression is a sexual experience of
childhood. The origin of every compulsion in this paranoia is in the
repression, and the symptoms of paranoia allow a similar classification
as the one found justified in compulsion neurosis. Some symptoms also
originate from the primary defense among which are all delusions of
distrust, suspicion and persecution by others. In the compulsion
neurosis the initial reproach became repressed through the formation of
the primary symptom of defense, self-distrust, moreover, the reproach
was recognized as justified, and for the purpose of adjustment the
validity acquired by the scrupulousness during the normal interval now
guards against giving credence to the returning reproach in the form of
an obsession. By the formation of the defense symptom of distrust in
others, the reproach in paranoia is repressed in a way which may be
designated as projection; the reproach is also deprived of recognition,
and as a retaliation there is no protection against the returning
reproaches contained in the delusions.
The other symptoms in my case of paranoia are therefore to be designated
as symptoms of the return of the repression, and as in the compulsion
neurosis they show the traces of the compromise which alone permits an
entrance into consciousness. Such are the delusions of being observed
while undressing, the visual hallucinations, the perceptual
hallucinations and the hearing of voices. The memory content existing in
the delusion mentioned is almost unchanged and appears only uncertain
through utterance. The return of the repression into visual pictures
comes nearer to the character of hysteria than to the character of
compulsion neurosis; still, hysteria is wont to repeat its memory
symbols without modification, whereas the paranoiac memory hallucination
undergoes a distortion similar to those in compulsion neurosis. An
analogous modern picture takes the place of the one repressed (instead
of a child’s lap it was the lap of a woman upon which the hairs were
particularly distinct because they were absent in the original
impression). Quite peculiar to paranoia but no further elucidated in
this comparison is the fact that the repressed reproaches return as loud
thoughts, this must yield to a double distortion: (1) a censor, which
either leads to a replacement through other associated thoughts or to a
concealment by indefinite expressions, and (2) the reference to the
modern which is merely analogous to the old.
The third group of symptoms found in compulsion neurosis, the symptoms
of the secondary defense, cannot exist as such in paranoia, for no
defense asserts itself against the returning symptoms which really find
credence. As a substitute for this we find in paranoia another source of
symptom formation; the delusions (symptoms of return) reaching
consciousness through the compromise demand a great deal of the thinking
work of the ego until they can be unconditionally accepted. As they
themselves are not to be influenced the ego must adapt itself to them,
and hence the combining delusional formation, the delusion of
interpretation which results in the transformation of the ego,
corresponds here to the symptoms of secondary defense of compulsion
neurosis. In this respect my case was imperfect as it did not at that
time show any attempt at interpretation, this only appeared later. I do
not doubt, however that if psychoanalysis were also applied to that
stage of paranoia, another important result would be established. It
would probably be found that even the so called weakness of memory in
paranoiacs is purposeful, that is, it depends on the repression and
serves its purpose. Subsequently even those nonpathogenic memories which
stand in opposition to the transformation of the ego become repressed
and replaced; this the symptoms of return imperatively demand.
CHAPTER VIII.
ON PSYCHOTHERAPY.[53]
_Gentlemen_:
It is almost eight years since, at the request of your deceased
chairman, Prof. v. Reder, I had the pleasure of speaking in your midst
on the subject of hysteria. Shortly before (1895) I had published the
“Studien über Hysterie” together with Dr. J. Breuer, and on the basis of
a new knowledge for which we are thankful to this investigator, I have
attempted to introduce a new way of treating the neurosis. Fortunately,
I can say that the endeavors of our “Studies” have met with success, and
that the ideas which they advocate concerning the effects of psychic
traumas through the restraint of affects and the conception of the
hysterical symptom as a result of a displacement of excitement from the
psychic to the physical—ideas for which we have created the terms
“ab-reaction” and “conversion”—are today generally known and understood.
At least in German-speaking countries there are no descriptions of
hysteria which do not to a certain extent take cognizance of them, and
no colleague who does not at least partially follow this theory. And yet
as long as they were new these theories and these terms must have
sounded strange enough!
I can not say the same thing about the therapeutic procedure which we
have proposed to our colleagues together with our theory. It still
struggles for recognition. This may have its special reasons. The
technique of the procedure was at that time still rudimentary. I was
unable to give those indications to the medical reader of the book which
would enable him to perform such a treatment. But surely there were
other causes of a general nature. To many physicians psychotherapy even
today appears as a product of modern mysticism, and in comparison to our
physico-chemical remedies the application of which is based on
physiological insight, psychotherapy appears quite unscientific and
unworthy of the interest of a natural philosopher. You will therefore
allow me to present to you the subject of psychotherapy, and to point
out to you what part of this verdict can be designated as unjust or
erroneous.
In the first place let me remind you that psychotherapy is not a modern
therapeutic procedure. On the contrary it is one of the oldest remedies
used in medicine. In Lëwenfeld’s instructive work (Lehrbuch der gesamten
Psychotherapie) you can find the methods employed in primitive and
ancient medicine. Most of them were of a psychotherapeutic nature. In
order to cure a patient he was transferred into a state of “credulous
expectation” which acts in a similar manner even today. Even after the
doctors found other remedial agents psychotherapeutic endeavors never
disappeared from this or that branch of medicine.
Secondly, I call your attention to the fact that we doctors really can
not abandon psychotherapy if only because another very much to be
considered party in the treatment—namely the patient—has no intention of
abandoning it. You know how much we owe to the Nancy school (Liébault,
Bernheim) for these explanations. Without our intention, an independent
factor from the patient’s psychic disposition enters into the activity
of every remedial agent introduced by the doctor, acting mostly in a
favorable sense but often also in an inhibiting sense. We have learned
to apply to this factor the word “suggestion,” and Moebius taught us
that the failures of some of our remedies are to be ascribed to the
disturbing influences of this very powerful moment. You doctors, all of
you, constantly practice psychotherapy, even when you do not know it, or
do not intend it, but it has one disadvantage, you leave entirely to the
patient the psychic factor of your influence. It then becomes
uncontrollable, it can not be divided into doses and can not be
increased. Is it not a justified endeavor of the doctor to become master
of this factor, to make use of it intentionally, to direct and enforce
it? It is nothing other than that, that scientific psychotherapy expects
of you.
In the third place, gentlemen, I wish to refer you to the well known
experience, namely, that certain maladies and particularly the
psychoneuroses, are more accessible to psychic influences than to any
other medications. It is no modern talk but a dictum of old physicians
that these diseases are not cured by the drug, but by the doctor, to
wit, by the personality of the physician in so far as it exerts a
psychic influence. I am well aware, gentlemen, that you like very much
the idea which the aesthete Vischer, in his parody on Faust (Faust, der
Tragödie, III Teil) endowed with a classical expression: “I know that
the physical often acts on the moral.”
But would it not be more adequate and frequently more correct to
influence the moral part of the person with the moral, that is, with
psychic means?
There are many ways and means of psychotherapy. All methods are good
which produce the aim of the therapy. Our usual consolation, “You will
soon be well again,” with which we are so generous to our patients,
corresponds to one of the psychotherapeutic methods, only that on
gaining a profounder insight into the neuroses we are not forced to
limit ourselves to this consolation alone. We have developed the
technique of hypnotic suggestion, of psychotherapy through diversion,
through practice, and through the evocation of serviceable affects. I do
not disdain any of them, and would practice them all under suitable
conditions. That I have in reality restricted myself to a single
therapeutic procedure, to the method called by Breuer “cathartic,” which
I prefer to call “analytic,” is simply due to subjective motives which
guided me. Having participated in the elaboration of this therapy I feel
it a personal duty to devote myself to its investigation, and to the
final development of its technique. I maintain that the analytic method
of psychotherapy is one which acts most penetratingly, and carries
farthest; through it one can produce the most prolific changes in the
patient. If I relinquish for a moment the therapeutic point of view, I
can assert that it is the most interesting, and that it alone teaches us
something concerning the origin and the connection of the morbid
manifestations. Owing to insights which it opens for us into the
mechanism of the psychic malady, it can even lead us beyond itself, and
show us the way to still other kinds of therapeutic influences.
Allow me now to correct some errors, and furnish some explanations
concerning this cathartic or analytic method of psychotherapy.
(_a_) I notice that this method is often mistaken for the hypnotic
suggestive treatment. I notice this by the fact that quite frequently
colleagues whose confidant I am not by any means, send patients to me,
refractory patients of course, with the request that I should hypnotize
them. Now, for eight years I have not practiced hypnotism (individual
cases excluded) as a therapeutic aim, and hence I used to return the
patients with the advice that he who relies on hypnosis should do it
himself. In truth, the greatest possible contrast exists between the
suggestive and the analytic technique, that contrast which the great
Leonardo da Vinci has expressed for the arts in the formulæ per via di
porre and per via di levare. Said Leonardo, “the art of painting works
per via di levare, that is to say, places little heaps of paint where
they have not been before on the uncolored canvas; sculpturing, on the
other hand, goes per via di levare, that is to say, it takes away from
the stone as much as covers the surface of the statue therein
contained.” Quite similarly, gentlemen, the suggestive technique acts
per via di porre, it does not concern itself about the origin, force,
and significance of the morbid symptoms, but puts on something, to wit,
the suggestion which it expects will be strong enough to prevent the
pathogenic idea from expression. On the other hand the analytic therapy
does not wish to put on anything, or introduce anything new, but to take
away, and extract, and for this purpose it concerns itself with the
genesis of the morbid symptoms, and the psychic connection of the
pathogenic idea the removal of which is its aim. This manner of
investigation has considerably furthered our understanding. I have so
early given up the technique of suggestion, and with it hypnosis,
because I despaired of making the suggestion as strong and persistent as
would be necessary for a lasting cure. In all grave cases I noticed that
the suggestions which were put on crumbled off again, and then the
disease, or one replacing it, reappeared. Besides, I charge this
technique with concealing from us the psychic play of forces, for
example, it does not permit us to recognize the resistance with which
the patients adhere to their malady, with which they also strive against
the recovery, and which alone can give us an understanding of their
behavior in life.
(_b_) It seems to me that a very widespread mistake among my colleagues
is the idea that the technique of the investigation for the causes of
the disease and the removal of the manifestations by this investigation
is easy and self-evident. I concluded this from the fact that of the
many who interest themselves in my therapy and express a definite
opinion on the same, no one has yet asked me how I do it. There can only
be one reason for it, they believe there is nothing to ask, that it is a
matter of course. I occasionally also hear with surprise that in this or
that division of the hospital a young interne is requested by his chief
to undertake a “psychoanalysis” with a hysterical woman. I am convinced
that he would not entrust him with the examination of an extirpated
tumor without previously assuring himself that he is acquainted with the
histological technique. Likewise I am informed that this or that
colleague has made appointments with a patient for psychic treatment,
whereas I am certain that he does not know the technique of such a
treatment. He must, therefore, expect that the patient will bring him
her secrets, or he seeks salvation in some kind of a confession or
confidence. I should not wonder if the patient thus treated would rather
be harmed than benefited. The mental instrument is really not at all
easy to play. On such occasions I can not help but think of the speech
of a world-renowned neurotic, who really never came under a doctor’s
treatment, and only lived in the fancy of the poet. I mean Prince Hamlet
of Denmark. The king has sent the two courtiers, Rosencrantz and
Guildenstern, to investigate him and rob him of his secret. While he
defended himself, pipes were brought on the stage. Hamlet took a pipe
and requested one of his tormentors to play on it, saying that it is as
easy to play as lying. The courtier hesitated because he knew no touch
of it, and as he could not be moved to attempt to play the pipe, Hamlet
finally burst forth: “Why, look you now, how unworthy a thing you make
of me! You would play upon me; you would seem to know my stops; you
would pluck out the heart of my mystery; you would sound me from my
lowest note to the top of my compass; and there is much music, excellent
voice, in this little organ, yet you cannot make it speak. ’Sblood! do
you think I am easier to be played on than a pipe? Call me what
instrument you will, though you can fret me, you cannot play upon me.”
(Act III, Scene 2.)
(_c_) You will have surmised from some of my observations that the
analytic cure contains qualities which keep it away from the ideal of a
therapy. Tuto, cito, iucunde; the investigation and examination does not
really mean rapidity of success, and the allusion to the resistance has
prepared you for the expectation of inconveniences. Certainly the
psychoanalytic method lays high claims on the patient as well as the
physician. From the first it requires the sacrifice of perfect candor,
it takes up much of his time, and is therefore also expensive; for the
physician it also means the loss of much time, and due to the technique
which he has to learn and practice, it is quite laborious. I even find
it quite justified to employ more suitable remedies as long as there is
a prospect to achieve something with them. It comes to this point only:
if we gain by the more laborious and cumbersome procedure considerably
more than by the short and easy one, the first is justified despite
everything. Just think, gentlemen, by how much the Finsen therapy of
lupus is more inconvenient and expensive than the formerly used
cauterization and scraping, and yet it means a great progress, merely
because it achieves more, it actually cures the lupus radically. I do
not really wish to carry through the comparison, but psychoanalysis can
claim for itself a similar privilege. In reality I could develop and
test my therapeutic method in grave and in the gravest of cases only; my
material at first consisted of patients who tried everything
unsuccessfully, and had spent years in asylums. I hardly gained enough
experience to be able to tell you how my therapy behaves in those
lighter, episodically appearing diseases which we see cured under the
most diverse influences, and also spontaneously. The psychoanalytic
method was created for patients who are permanently incapacitated, and
its triumph is to make a gratifying number of such, permanently
capacitated. Against this success all expense is insignificant. We can
not conceal from ourselves what we were wont to disavow to the patient,
namely, that the significance of a grave neurosis for the individual
subjected to it is not less than any cachexia or any of the generally
feared maladies.
(_d_) In view of the many practical limitations which I have encountered
in my work, I can hardly definitely enumerate the indications and
contraindications of this treatment. However, I will attempt to discuss
with you a few points:
1. The former value of the person should not be overlooked in the
disease, and you should refuse a patient who does not possess a certain
degree of education, and whose character is not in a measure reliable.
We must not forget that there are also healthy persons who are good for
nothing, and that if they only show a mere touch of the neurosis, one is
only too much inclined to blame the disease for incapacitating such
inferior persons. I maintain that the neurosis does not in any way stamp
its bearer as a dégéneré, but that frequently enough it is found in the
same individual associated with the manifestations of degeneration. The
analytic psychotherapy is therefore no procedure for the treatment of
neuropathic degeneration, on the contrary it is limited by it. It is
also not to be applied in persons who are not prompted by their own
suffering to seek the treatment, but subject themselves to it by order
of their relatives. The characteristic feature upon which the usefulness
of the psychoanalytic treatment depends, the educability, we will still
have to consider from another point of view.
2. If one wishes to take a safe course he should limit his selection to
persons of a normal state, for, in psychoanalytic procedures, it is from
the normal that we seize upon the morbid. Psychoses, confusional states,
and marked (I might say toxic) depressions, are unsuitable for analysis,
at least as it is practiced today. I do not think it at all impossible
that with the proper changes in the procedure it will be possible to
disregard this contraindication, and thus claim a psychotherapy for the
psychoses.
3. The age of the patient also plays a part in the selection for the
psychoanalytic treatment. Persons near or over the age of fifty lack, on
the one hand, the plasticity of the psychic processes upon which the
therapy depends—old people are no longer educable—and on the other hand,
the material which has to be elaborated, and the duration of the
treatment is immensely increased. The earliest age limit is to be
individually determined; youthful persons, even before puberty, are
excellent subjects for influence.
4. One should not attempt psychoanalysis when it is a question of
rapidly removing a threatening manifestation, as, for example, in the
case of an hysterical anorexia.
You have now gained the impression that the sphere of application of the
analytic psychotherapy is a very limited one, for you really heard me
enumerate nothing but contraindications. Nevertheless, there remain
sufficient cases and morbid states, such as all chronic forms of
hysteria with remnant manifestations, the extensive realms of compulsive
states, abulias, etc., on which this therapy can be tried.
It is pleasing that particularly the worthiest and highest developed
persons can thus be most helped. Where the analytic psychotherapy has
accomplished but little one can cheerfully assert that any other
treatment would have certainly resulted in nothing.
(_e_) You will surely wish to ask me about the possibility of doing harm
through the application of psychoanalysis. To this I will reply that if
you will judge justly you will meet this procedure with the same
critical good-feeling as you have met our other therapeutic methods, and
doing this you will have to agree with me that a rationally executed
analytic treatment entails no dangers for the patient. One who, like a
layman, is accustomed to ascribe to the treatment everything occurring
during the disease, will probably judge differently. It is really not so
long since our hydrotherapeutic asylums met with similar opposition.
Thus one who was advised to go to such an asylum became thoughtful
because he had an acquaintance who entered the asylum as nervous and
there become insane. As you surmise we deal with cases of initial
general paresis who in the first stages could still be sent to
hydrotherapeutic asylums, and who there merged into the irresistible
course leading to manifest insanity. For the layman the water was the
cause and author of this sad transformation. Where it is a question of
unfamiliar influences, even doctors are not free from such mistaken
judgment. I recall having once attempted to treat a woman by
psychotherapy who passed a great part of her existence by alternating
between mania and melancholia. I began to treat her at the end of a
melancholia and everything seemed to go well for two weeks, but in the
third week she was again merging into a mania. It was surely a
spontaneous alteration of the morbid picture, for two weeks is no time
in which anything can be accomplished by psychotherapy, but the
prominent—now deceased—physician who saw the case with me could not
refrain from remarking that this decline must have been due to the
psychotherapy. I am quite convinced that he would have been more
critical under different conditions.
(_f_) In conclusion, gentlemen, I must say to myself that it will not do
to lay claim to your attention so long in favor of the analytic
psychotherapy without telling you of what this treatment consists, and
on what it is based. To be sure I can only indicate it as I have to be
brief. This therapy is founded on the understanding that unconscious
ideas—or rather the unconsciousness of certain psychic processes—are the
main causes of a morbid symptom. We share this conviction with the
French school (Janet) which moreover by gross schematization reduces the
hysterical symptom to an unconscious idée fixe. Do not fear now that we
will thus merge too far into the obscurest philosophy. Our unconscious
is not quite the same as that of the philosophers and what is more, most
philosophers wish to know nothing of the “psychical unconscious.” But if
you will put yourselves in our position, you will understand that the
interpretation of this unconscious, in patients’ psychic life, into the
conscious, must result in a correction of their deviation from the
normal, and in an abrogation of the compulsion controlling their psychic
life. For the conscious will reaches as far as the conscious psychic
processes and every psychic compulsion is substantiated by the
unconscious. You need never fear that the patient will be harmed by the
emotion produced in the entrance of his unconscious into consciousness,
for you can theoretically readily understand that the somatic and
affective activity of the emotion which became conscious can never
become as great as those of the unconscious. For we only control all our
emotions by directing upon them our highest psychic activities which are
connected with consciousness.
We can still choose another point of view for the understanding of the
psychoanalytic treatment. The revealing and interpreting of the
unconscious takes place under constant resistance on the part of the
patient. The emerging of the unconscious is connected with displeasure
and owing to this displeasure it is continuously repulsed by the
patient. It is upon this conflict in the patient’s psychic life that you
encroach, and if you succeed in prevailing upon him to accept something,
for motives of better insight, which he has thus far repulsed
(repressed) on account of the automatic adjustment of displeasure, you
have achieved in him a piece of educational work. For it is really an
education if you can induce a person to leave his bed early in the
morning despite his unwillingness to do so. As such an after training
for the overcoming of inner resistances you can conceive the
psychoanalytic treatment in quite a general manner. But in no sphere of
the nervous patients is such an after training so essential as in the
psychic elements of their sexual life. For nowhere have culture and
education produced as much harm as here, and it is here, as experience
will show you, that the controlling etiologies of the neuroses are
found. The other etiological element, the constitutional contribution,
is really given to us as something immutable. But this gives rise to an
important demand on the doctor. Not only must he be of unblemished
character—“morality is really a matter of course” as the principal
person in Th. Vischer’s “Auch Einer” used to say—but he must have
overcome in his own personality the mixture of lewdness and prudishness
with which so many others are wont to meet the sexual problems.
This is perhaps the place for another observation. I know that the
emphasis which I laid on the sexual rôle in the origin of the
psychoneuroses has become widely known. But I also know that restriction
and nearer determinations are of little use with the great public; the
multitude has little room in its memory, and generally retains from a
statement the bare nucleus, thus creating for itself an easily
remembered extreme. The same might also have happened to some physicians
when the faint notion that they have of my theory is that I trace back
the neurosis in the last place to sexual privation. Of such there is
surely no dearth under the vital conditions of our society. But if that
supposition were true would it not seem obvious that in order to avoid
the roundabout way of the psychic treatment and tend directly towards
the cure, we should directly recommend sexual participation as the
remedy? I really do not know what could induce me to suppress these
conclusions if they were justified. But the state of affairs is
different. The sexual need or privation is merely one of the factors
playing a part in the mechanism of the neurosis, and if it alone existed
the result would not be a disease but a dissipation. The other equally
indispensable factor, which one is only too ready to forget, is the
sexual repugnance of neurotics, their inability to love; it is that
psychic feature which I have designated as “repression.” It is only from
the conflict between the two strivings that the neurotic malady
originates, and it is for this reason that the advice for sexual
participation in the psychoneuroses can really only seldom be designated
as good.
Allow me to conclude with this guarded remark. Let us hope that with an
interest for psychotherapy, purified of all hostile prejudice, you will
help us to do some good in the treatment of the severe cases of
psychoneuroses.
CHAPTER IX.
MY VIEWS ON THE RÔLE OF SEXUALITY IN THE ETIOLOGY OF THE NEUROSES.[54]
I am of the opinion that my theory on the etiological significance of
the sexual moment in the neuroses can be best appreciated by following
its development. I will by no means make any effort to deny that it
passed through an evolution during which it underwent a change. My
colleagues can find the assurance in this admission that this theory is
nothing other than the result of continued and painstaking experiences.
In contradistinction to this whatever originates from speculation can
certainly appear complete at one go and continue unchanged.
Originally the theory had reference only to the morbid pictures
comprehended as “neurasthenia,” among which I found two types which
occasionally appeared pure, and which I described as “actual
neurasthenia” and “anxiety neurosis.” For it was always known that
sexual moments could play a part in the causation of these forms, but
they were found neither regularly effective, nor did one think of
conceding to them a precedence over other etiological influences. I was
above all surprised at the frequency of coarse disturbances in the vita
sexualis of nervous patients. The more I was in quest of such
disturbances, during which I remembered that all men conceal the truth
in things sexual, and the more skilful I became in continuing the
examination despite the incipient negation, the more regularly such
disease-forming moments were discovered in the sexual life, until it
seemed to me that they were but little short of universal. But one must
from the first be prepared for similar frequent occurrences of sexual
irregularities under the stress of the social relations of our society,
and one could therefore remain in doubt as to what part of the deviation
from the normal sexual function is to be considered as a morbid cause. I
could therefore only place less value on the regular demonstration of
sexual noxas than on other experiences which appeared to me to be less
equivocal. It was found that the form of the malady, be it neurasthenia
or anxiety neurosis, shows a constant relation to the form of the sexual
injury. In the typical cases of neurasthenia we could always demonstrate
masturbation or accumulated pollutions, while in anxiety neurosis we
could find such factors as coitus interruptus, “frustrated excitement,”
etc. The moment of insufficient discharge of the generated libido seemed
to be common to both. Only after this experience, which is easy to gain
and very often confirmed, had I the courage to claim for the sexual
influences a prominent place in the etiology of the neurosis. It also
happened that the mixed forms of neurasthenia and anxiety neurosis
occurring so often, showed the admixture of the etiologies accepted for
both, and that such a bipartition in the form of the manifestations of
the neurosis seemed to accord well with the polar characters of
sexuality (male and female).
At the same time, while I assigned to sexuality this significance in the
origin of the simple neurosis, I still professed for the psychoneuroses
(hysteria and obsessions) a purely psychological theory in which the
sexual moment was no differently considered than any other emotional
sources. Together with J. Breuer, and in addition to observations which
he has made on his hysterical patients fully a decade before, I have
studied the mechanism of the origin of hysterical symptoms by the
awakening of memories in hypnotic states. We obtained information which
permitted us to cross the bridge from Charcot’s traumatic hysteria to
the common non-traumatic hysteria. We reached the conception that the
hysterical symptoms are permanent results of psychic traumas, and that
the amount of affect belonging to them was pushed away from conscious
elaboration by special determinations, thus forcing an abnormal road
into bodily innervation. The terms “strangulated affect,” “conversion,”
and “ab-reaction,” comprise the distinctive characteristics of this
conception.
In the close relations of the psychoneuroses to the simple neuroses,
which can go so far that the diagnostic distinction is not always easy
for the unpracticed, it could happen that the cognition gained from one
sphere has also taken effect in the other. Leaving such influences out
of the question, the deep study of the psychic traumas also leads to the
same results. If by the “analytic” method we continue to trace the
psychic traumas from which the hysterical symptoms are derived, we
finally reach to experiences which belong to the patient’s childhood,
and concern his sexual life. This can be found even in such cases where
a banal emotion of a non-sexual nature has occasioned the outburst of
the disease. Without taking into account these sexual traumas of
childhood we could neither explain the symptoms, find their
determination intelligible, nor guard against their recurrence. The
incomparable significance of sexual experiences in the etiology of the
psychoneuroses seems therefore firmly established, and this fact remains
until today one of the main supports of the theory.
If we represent this theory by saying that the course of the life long
hysterical neurosis lies in the sexual experiences of early childhood
which are usually trivial in themselves, it surely would sound strange
enough. But if we take cognizance of the historical development of the
theory, and transfer the main content of the same into the sentence:
hysteria is the expression of a special behavior of the sexual function
of the individual, and that this behavior was already decisively
determined by the first effective influences and experiences of
childhood, we will perhaps be poorer in a paradox but richer in a motive
for directing our attention to a hitherto very neglected and most
significant aftereffect of infantile impressions in general.
As I reserve the question whether the etiology of hysteria (and
compulsion neurosis) is to be found in the sexual infantile experiences
for a later more thorough discussion, I now return to the construction
of the theory expressed in some small preliminary publications in the
years 1895–1896.[55] The bringing into prominence of the assumed
etiological moments permitted us at the time to contrast the common
neuroses which are maladies with an actual etiology, with the
psychoneuroses which etiology was in the first place to be sought in the
sexual experiences of remote times. The theory culminates in the
sentence: In a normal vita sexualis no neurosis is possible.
If I still consider today this sentence as correct it is really not
surprising that after ten years labor on the knowledge of these
relations I passed a good way beyond my former point of view, and that I
now think myself in a position to correct by detailed experience the
imperfections, the displacements, and the misconceptions, from which
this theory then suffered. By chance my former rather meagre material
furnished me with a great number of cases in which infantile histories,
sexual seduction by grown-up persons or older children, played the main
rôle. I overestimated the frequency of these (otherwise not to be
doubted) occurrences, the more so because I was then in no position to
distinguish definitely the deceptive memories of hysterical patients
concerning their childhood, from the traces of the real processes,
whereas, I have since then learned to explain many a seduction fancy as
an attempt at defense against the reminiscence of their own sexual
activity (infantile masturbation). The emphasis laid on the “traumatic”
element of the infantile sexual experience disappeared with this
explanation, and it remained obvious that the infantile sexual
activities (be they spontaneous or provoked) dictate the course of the
later sexual life after maturity. The same explanation which really
corrects the most significant of my original errors perforce also
changed the conception of the mechanism of the hysterical symptoms.
These no longer appeared as direct descendants of repressed memories of
sexual infantile experiences, but between the symptoms and the infantile
impressions there slipped in the fancies (confabulations of memory) of
the patients which were mostly produced during the years of puberty and
which on the one hand, are raised from and over the infantile memories,
and on the other, are immediately transformed into symptoms. Only after
the introduction of the element of hysterical fancies did the structure
of the neurosis and its relation to the life of the patient become
transparent. It also resulted in a veritable surprising analogy between
these unconscious hysterical fancies and the romances which became
conscious as delusions in paranoia.
After this correction the “infantile sexual traumas” were in a sense
supplanted by the “infantilism of sexuality.” A second modification of
the original theory was not remote. With the accepted frequency of
seduction in childhood there also disappeared the enormous emphasis of
the accidental influences of sexuality to which I wished to shift the
main rôle in the causation of the disease without, however, denying
constitutional and hereditary moments. I even hoped to solve thereby the
problem of the selection of the neurosis, that is, to decide by the
details of the sexual infantile experience, the form of the
psychoneurosis into which the patient may merge. Though with reserve I
thought at that time that passive behavior during these scenes results
in the specific predisposition for hysteria, while active behavior
results in compulsion neurosis. This conception I was later obliged to
disclaim completely though some facts of the supposed connection between
passivity and hysteria, and activity and compulsion neurosis, can be
maintained to some extent. With the disappearance of the accidental
influences of experiences, the elements of constitution and heredity had
to regain the upper hand, but differing from the view generally in vogue
I placed the “sexual constitution” in place of the general neuropathic
predisposition. In my recent work, “Three Contributions to the Sexual
Theory.”[56] I have attempted to discuss the varieties of this sexual
constitution, the components of the sexual impulse in general, and its
origin from the contributory sources of the organism.
Still in connection with the changed conception of the “sexual infantile
traumas,” the theory continued to develop in a course which was already
indicated in the publications of 1894–1896. Even before sexuality was
installed in its proper place in the etiology, I had already stated as a
condition for the pathogenic efficaciousness of an experience that the
latter must appear to the ego as unbearable and thus evoke an exertion
for defense. To this defense I have traced the psychic splitting—or as
it was then called the splitting of consciousness—of hysteria. If the
defense succeeded, the unbearable experience with its resulting affect
was expelled from consciousness and memory; but under certain conditions
the thing expelled which was now unconscious, developed its activity,
and with the aid of the symptoms and their adhering affect it returned
into consciousness, so that the disease corresponded to a failure of the
defense. This conception had the merit of entering into the play of the
psychic forces, and hence approximate the psychic processes of hysteria
to the normal instead of shifting the characteristic of the neurosis
into an enigmatic and no further analyzable disturbance.
Further inquiries among persons who remained normal furnished the
unexpected result, that the sexual histories of their childhood need not
differ essentially from the infantile life of neurotics, and that
especially the rôle of seduction is the same in the former, so the
accidental influences receded still more in comparison to the moments of
“repression” (which I began to use instead of “defense”). It really does
not depend on the sexual excitements which an individual experiences in
his childhood but above all on his reactions towards these experiences,
and whether these impressions responded with “repression” or not. It
could be shown that spontaneous sexual manifestations of childhood were
frequently interrupted in the course of development by an act of
repression. The sexual maturity of neurotic individuals thus regularly
brings with it a fragment of “sexual repression” from childhood which
manifests itself in the requirements of real life. Psychoanalyses of
hysterical individuals show that the malady is the result of the
conflict between the libido and the sexual repression, and that their
symptoms have the value of a compromise between both psychic streams.
Without a comprehensive discussion of my conception of repression I
could not explain any further this part of the theory. It suffices to
refer here to my “Three Contributions to the Sexual Theory,” where I
have made an attempt to throw some light on the somatic processes in
which the essence of sexuality is to be sought. I have stated there that
the constitutional sexual predisposition of the child is more
irregularly multifarious than one would expect, that it deserves to be
called “polymorphous-perverse,” and that from this predisposition the so
called normal behavior of the sexual functions results through a
repression of certain components. By referring to the infantile
character of sexuality, I could form a simple connection among normal,
perversions, and neurosis. The normal resulted through the repression of
certain partial impulses and components of the infantile predisposition,
and through the subordination of the rest under the primacy of the
genital zones for the service of the function of procreation. The
perversions corresponded to disturbances of this connection due to a
superior compulsive like development of some of the partial impulses,
while the neurosis could be traced to a marked repression of the
libidinous strivings. As almost all perversive impulses of the infantile
predisposition are demonstrable as forces of symptom formation in the
neurosis, in which, however, they exist in a state of repression, I
could designate the neurosis as the “negative” of the perversion.
I think it worth emphasizing that with all changes my ideas on the
etiology of the psychoneuroses still never disavowed or abandoned two
points of view, to wit, the estimation of sexuality and infantilism. In
other respects we have in place of the accidental influences the
constitutional moments, and instead of the pure psychologically intended
defense we have the organic “sexual repression.” Should anybody ask
where a cogent proof can be found for the asserted etiological
significance of sexual factors in the psychoneuroses, and argue that
since an outburst of these diseases can result from the most banal
emotions, and even from somatic causes, a specific etiology in the form
of special experiences of childhood must therefore be disavowed; I
mention as an answer for all these arguments the psychoanalytic
investigation of neurotics as the source from which the disputed
conviction emanates. If one only makes use of this method of
investigation he will discover that the symptoms represent the whole or
a partial sexual manifestation of the patient from the sources of the
normal or perverse partial impulses of sexuality. Not only does a good
part of the hysterical symptomatology originate directly from the
manifestations of the sexual excitement, not only are a series of
erogenous zones in strengthening infantile attributes raised in the
neurosis to the importance of genitals, but even the most complicated
symptoms become revealed as the converted representations of fancies
having a sexual situation as a content. He who can interpret the
language of hysteria can understand that the neurosis only deals with
the repressed sexuality. One should, however, understand the sexual
function in its proper sphere as circumscribed by the infantile
predisposition. Where a banal emotion has to be added to the causation
of the disease, the analysis regularly shows that the sexual components
of the traumatic experience, which are never missing, have exercised the
pathogenic effect.
We have unexpectedly advanced from the question of the causation of the
psychoneuroses to the problem of its essence. If we wish to take
cognizance of what we discovered by psychoanalysis we can only say that
the essence of these maladies lies in disturbances of the sexual
processes, in those processes in the organism which determine the
formation and utilization of the sexual libido. We can hardly avoid
perceiving these processes in the last place as chemical, so that we can
recognize in the so called actual neuroses the somatic effects of
disturbances in the sexual metabolism, while in the psychoneuroses we
recognize besides the psychic effects of the same disturbances. The
resemblance of the neuroses to the manifestations of intoxication and
abstinence following certain alkaloids, and to Basedow’s and Addison’s
diseases, obtrudes itself clinically without any further ado, and just
as these two diseases should no more be described as “nervous diseases,”
so will the genuine “neuroses” soon have to be removed from this class
despite their nomenclature.
Everything that can exert harmful influences in the processes serving
the sexual function therefore belongs to the etiology of the neurosis.
In the first place we have the noxas directly affecting the sexual
functions insofar as they are accepted as injuries by the sexual
constitution which is changeable through culture and breeding. In the
second place, we have all the different noxas and traumas which may also
injure the sexual processes by injuring the organism as a whole. But we
must not forget that the etiological problem in the neuroses is at least
as complicated as in the causation of any other disease. One single
pathogenic influence almost never suffices, it mostly requires a
multiplicity of etiological moments reinforcing one another, and which
can not be brought in contrast to one another. It is for that reason
that the state of neurotic illness is not sharply separated from the
normal. The disease is the result of a summation, and the measure of the
etiological determinations can be completed from any one part. To seek
the etiology of the neurosis exclusively in heredity or in the
constitution would be no less one sided than to attempt to raise to the
etiology the accidental influences of sexuality alone, even though the
explanations show that the essence of this malady lies only in a
disturbance of the sexual processes of the organism.
CHAPTER X.
HYSTERICAL FANCIES AND THEIR RELATIONS TO BISEXUALITY.[57]
The delusional formations of paranoiacs containing the greatness and
sufferings of their own ego, which manifest themselves quite typically
in almost monotonous forms are universally familiar. Furthermore,
through numerous communications we became acquainted with the peculiar
organizations by means of which certain perverts put into operation
their sexual gratifications, be it in fancy or reality. On the other
hand it may sound rather novel to some to hear that quite analogous
psychic formations regularly appear in all psychoneuroses, especially in
hysteria, and that these so called hysterical fancies show important
relations to the causation of the neurotic symptoms.
Of the same source and of the normal prototype are all these fantastic
creations, so called reveries of youth, which have already gained a
certain consideration in the literature, though not a sufficient
one.[58] They are perhaps equally frequent in both sexes; in girls and
women they seem to be wholly of an erotic nature, while in men they are
of an erotic or ambitious nature. Yet even in men the significance of
the erotic moment is not to be put in the second place, for on examining
more closely the reveries of men we generally learn that all these
heroic acts are accomplished, that all these successes are acquired in
order to please a woman and to be preferred to other men.[59] These
fancies are wish gratifications which emanate from privation and
longing. They are justly named “day dreams” for they give the key for
the understanding of night dreams in which the nucleus of the dream
formation is produced by just such complicated, disfigured day fancies
which are misunderstood by the conscious psychic judgment.[60]
These day dreams are garnished with great interest, are cautiously
nurtured, and coyly guarded, as if they were numbered among the most
intimate estates of personality. On the street, however, the day dreamer
can be readily recognized by a sudden, as if absent minded smile, by
talking to himself, or by a running-like acceleration of his gait
wherein he designates the acme of the imaginary situation.
All hysterical attacks which I have been thus far able to examine proved
to be such involuntary incursions of day dreams. Observation leaves no
doubt that such fancies may exist as unconscious or conscious and
whenever they become unconscious they may also become pathogenic, that
is, they may express themselves in symptoms and attacks. Under favorable
conditions it is possible for consciousness to seize such unconscious
fancies. One of my patients whose attention I have called to her fancies
narrated that once while in the street she suddenly found herself in
tears, and rapidly reflecting over the cause of her weeping the fancy
became clear to her. She fancied herself in delicate relationship with a
piano virtuoso familiar in the city, but whom she did not know
personally. In her fancy she bore him a child (she was childless), and
he then deserted her, leaving her and her child in misery. At this
passage of the romance she burst into tears.
The unconscious fancies are either from the first unconscious, having
been formed in the unconscious, or what is more frequently the case they
were once conscious fancies, day dreams, and were then intentionally
forgotten, merging into the unconscious by “repression.” Their content
then either remained the same or underwent a transformation, so that the
present unconscious fancy represents a descendant of the once conscious
one. The unconscious fancy stands in a very important relation to the
sexual life of the person, it is really identical with that fancy which
helped it towards sexual gratification during a period of masturbation.
The masturbating act (in the broader sense the onanistic) then consisted
of two parts, the evocation of the fancy, and the active performance of
self gratification at the height of the same. This combination is
familiarly in itself a soldering.[61] Originally this action was a
purely auto-erotic undertaking for the pleasure obtained from a certain
so called erogenous part of the body. Later this action blended with a
wish presentation from the sphere of the object loved, and served for a
partial realization of the situation in which this fancy culminated. If,
then, the person forgoes in this manner the masturbo-fantastic
gratification, the action remains undone, the fancy, however, changes
from a conscious to an unconscious one. If no other manner of sexual
gratification occurs, if the person remains abstinent and does not
succeed in sublimating his libido, that is, in diverting the sexual
excitement to a higher aim, we then have the conditions for the
refreshment of the unconscious fancy; it grows exuberantly and with all
the force of the desire for love at least a fragment of its content
becomes a morbid symptom.
The unconscious fancies are then the nearest psychical first steps of a
whole series of hysterical symptoms. The hysterical symptoms are nothing
other than unconscious fancies brought to light by “conversion,” and
insofar as they are somatic symptoms they are frequently enough taken
from the spheres of the sexual feelings and motor innervations which
originally accompanied the former still conscious fancies. In this way
the disuse of onanism is really made retrograde, and the final aim of
the whole pathological process, the restoration of the primary sexual
gratification, though it never becomes perfect, in a manner always
achieves a certain approximation.
The interest of him who studies hysteria turns directly from the
symptoms to the fancies from which the former originate. The technique
of psychoanalysis gives the means of finding out from the symptoms the
unconscious fancies, and then of bringing them back to the patient’s
consciousness. In this way it was found that the unconscious fancies of
hysterics perfectly correspond in content to the consciously performed
gratification situations of perverts. Those who lack examples of such
nature need only recall the historical managements of the Roman Caesars
whose frenzies were naturally only conditioned by the unrestricted
fullness of the fancy creators. The delusional formations of paranoiacs
are of the same nature, they are fancies which directly become
conscious, and which are borne by the masochistic-sadistic components of
the sexual impulse. Complete counterparts of these can also be found in
certain unconscious fancies of hysterics. It is a familiar, practically
significant fact that hysterics express their fancies not as symptoms
but in conscious realization, and in this way they feign and commit
murders, assaults, and sexual aggressions.
All that can be found out about the sexuality of the psychoneurotic can
be ascertained by the psychoanalytic examination which leads from the
obtrusive symptoms to the hidden unconscious fancies; herein, too, is
the fact, the communication of which will be put in the foreground of
this short preliminary publication.
Probably in view of the difficulties which prevent the effort of the
unconscious fancies from expressing themselves, the relation between the
fancies to the symptoms is not simple but rather manifoldly
complicated.[62] As a rule, that is, in a fully developed and a long
standing neurosis, a symptom does not correspond to an individual
unconscious fancy, but to a number of such, and indeed it is not
arbitrary but in lawful combination. To be sure in the beginning of the
disease all these complications are not developed.
For the sake of general interest I pass over the connection of this
communication and insert a series of formulæ which strive to
progressively exhaust the nature of hysteria. They do not contradict one
another but correspond partly to more complete and sharper conceptions,
and partly to the use of different points of view.
1. The hysterical symptom is the memory symbol of certain efficacious
(traumatic) impressions and experiences.
2. The hysterical symptom is the compensation by conversion for the
associative return of the traumatic experience.
3. The hysterical symptom—like all other psychic formations—is the
expression of a wish realization.
4. The hysterical symptom is the realization of an unconscious fancy
serving as a wish fulfilment.
5. The hysterical symptom serves as a sexual gratification, and
represents a part of the sexual life of the individual (corresponding to
one of the components of his sexual impulse).
6. The hysterical symptom, in a fashion, corresponds to the return of
the sexual gratification which was real in infantile life but had been
repressed since then.
7. The hysterical symptom results as a compromise between two opposing
affects or impulse incitements, one of which strives to bring to
realization a partial impulse, or a component of the sexual
constitution, while the other strives to suppress the same.
8. The hysterical symptom may undertake the representation of diverse
unconscious non-sexual incitements, but can not lack the sexual
significance.
It is the seventh among these determinations which expresses most
exhaustively the essence of the hysterical symptom as a realization of
an unconscious fancy, and it is the eighth which properly designates the
significance of the sexual moment. Some of the preceding formulæ are
contained as first steps in this formula.
In view of these relations between symptoms and fancies one can readily
reach from the psychoanalysis of the symptoms to the knowledge of the
components of the sexual impulse controlling the individual, just as I
have shown in the “Three Contributions to the Sexual Theory.” But in
some cases this examination gives rather unexpected results. It shows
that many symptoms can not be solved by one unconscious sexual fancy or
by a series of fancies in which the most significant and most primitive
is of a sexual nature, but in order to solve the symptom two sexual
fancies are required, one of the masculine and one of the feminine
character, so that one of these fancies arises from a homosexual
impulse. The axiom pronounced in formula seven is in no way effected by
this novelty, so that a hysterical symptom necessarily corresponds to a
compromise between a libidinous and a repressed emotion, but besides
that, it can correspond to a union of two libidinous fancies of contrary
sex characters.
I refrain from giving examples for this axiom. Experience has taught me
that short analyses compressed into the form of an abstract can never
make the demonstrable impression for which they were intended. The
communication of fully analyzed cases must be reserved for another
place.
I therefore content myself in formulating the axiom and in elucidating
its significance:
9. An hysterical symptom is the expression, on the one hand, of a
masculine, and on the other hand of a feminine unconscious sexual fancy.
I expressly observe that I am unable to adjudge to this axiom the
similar general validity that I claimed for the other formulæ. As far as
I can see it is met neither in all symptoms of a single case, nor in all
cases. On the contrary it is not difficult to find cases in which the
contrary sexual emotions have found separate symptomatic expression, so
that the symptoms of hetero- and homosexuality can be as sharply
distinguished from each other as the fancies hidden behind them.
Nevertheless, the relation claimed in the ninth formula occurs
frequently enough, and wherever it is found it is of sufficient
significance to merit a special formulation. It seems to me to signify
the highest stage of complexity to which the determination of hysterical
symptoms can reach, and can only be expected in a long standing neurosis
and where a great amount of organization has occurred.[63]
The demonstrable bisexual significance of hysterical symptoms occurring
in many cases is indeed an interesting proof for the assertion
formulated by me that the supposed bisexual predisposition of man can be
especially recognized in psychoneurotics by means of psychoanalysis.[64]
Quite an analogous process from the same sphere is that in which the
masturbator in his conscious fancies attempts to live through in his
imagination the fancied situations of both the man and the woman. Other
counterparts are found in certain hysterical crises in which the
patients play both rôles lying at the basis of sexual fancies; thus, for
example, one of the cases under my observation presses his garments to
his body with one arm (as woman), and with the other arm he attempts to
tear them off (as man). This contradictory simultaneity determines most
of the incomprehensibility of the situation otherwise so plastically
represented in the attack, and is excellently suited for the concealment
of the effective unconscious fancy.
In psychoanalytical treatment it is very important to be prepared for
the bisexual significance of a symptom. It should not be at all
surprising or misleading when a symptom remains apparently undiminished
in spite of the fact that one of its sexual determinants is already
solved. Perhaps it is still supported by the unsuspected contrary
sexual. Furthermore, during the treatment of such cases we can observe
how the patient makes use of this convenience. During the analysis of
the one sexual significance he continually switches his thoughts into
the sphere of the contrary significance just as if onto a neighboring
track.
-----
Footnote 1:
Studien über Hysterie von Jos. Breuer und Sigm. Freud. Leipzig und
Wien, Franz Deuticke, 1895. 2nd ed., 1909.
Footnote 2:
Sammlung kleiner Schriften zur Neurosenlehre, Vols. I. and II. Leipzig
und Wien, Deuticke, 1906, and 1909.
Footnote 3:
Bleuler, Freudsche Mechanismen in der Symptomatologie der Psychosen,
Psychiatrisch-Neurolog. Wochenschrift, 1906, Nrs. 35 and 36.
Footnote 4:
Jung, The Psychology of Dementia Præcox, Nervous and Mental Disease
Monograph Series, Nr. 3.
Footnote 5:
Riklin, Psychiatrisch-Neurolog. Wochenschrift, 1905, Nr. 46.
Footnote 6:
Brill, Psychological Factors in Dementia Præcox, Journal of Abnormal
Psychology, Vol. III, Nr. 4, and A Case of Schizophrenia, American
Journal of Insanity, Vol. LXVI, No. 1.
Footnote 7:
Freud, Deuticke, 1909.
Footnote 8:
Freud, Karger, 1907.
Footnote 9:
Freud, Deuticke, 1905.
Footnote 10:
Written in collaboration with Dr. Joseph Breuer.
Footnote 11:
The possibility of such a therapy was clearly recognized by Delboeuf
and Binet, as is shown by the accompanying quotations: Delboeuf, Le
magnétisme animal, Paris, 1889: “On s’expliquerait des lors comment le
magnétiseur aide à guérison. Il remet le sujet dans l’état où le mal
s’est manifesté et combat par la parole le même mal, mais renaissant.”
(Binet, Les altérations de la personnalité, 1892, p. 243): “...
peut-être verra-t-on qu’en reportant le malade par un artifice mental,
au moment même ou le symptome a apparu pour la premiere fois, on rend
ce malade plus docile a une suggestion curative.” In the interesting
book of Janet, L’Automatism Psychologique, Paris, 1889, we find the
description of a cure brought about in a hysterical girl by a process
similar to our method.
Footnote 12:
We are unable to distinguish in this preliminary contribution what
there is new in this content and what can be found in such other
authors as Moebius and Strümpel who present similar views on hysteria.
The greatest similarity to our theoretical and therapeutical
accomplishments we accidentally found in some published observations
of Benedict which we shall discuss hereafter.
Footnote 13:
The German abreagiren has no exact English equivalent. It will
therefore be rendered throughout the text by “ab-react,” the literal
meaning is to react away from or to react off. It has different shades
of meaning, from defense reaction to emotional catharsis, which can be
discerned from the context.
Footnote 14:
As an example of the technique mentioned above, that is, of
investigating in a non-somnambulic state or where consciousness is not
broadened, I will relate a case which I analyzed recently. I treated a
woman of thirty-eight who suffered from an anxiety neurosis
(agoraphobia, fear of death, etc.). Like many patients of that type
she had a disinclination to admit that she acquired this disease in
her married state and was quite desirous of referring it back to early
youth. She informed me that at the age of seventeen when she was in
the street of her small city she had the first attack of vertigo,
anxiety, and faintness, and that these attacks recurred at times up to
a few years ago when they were replaced by her present disease. I
thought that the first attacks of vertigo, in which the anxiety was
only blurred, were hysterical and decided to analyze the same. All she
knows is that she had the first attack when she went out to make
purchases in the main street of her city.—“What purchases did you wish
to make?”—“Various things, I believe it was for a ball to which I was
invited.”—“When was the ball to take place?”—“I believe two days
later.”—“Something must have happened a few days before this which
excited you, and which made an impression on you.”—“But I don’t know,
it is now twenty-one years.”—“That does not matter, you will recall
it. I will exert some pressure on your head and when I stop it you
will either think of or see something which I want you to tell me.” I
went through this procedure, but she remained quiet.—“Well, has
nothing come into your mind?”—“I thought of something, but that can
have no connection with it.”—“Just say it.”—“I thought of a young girl
who is dead, but she died when I was eighteen, that is, a year
later.”—“Let us adhere to this. What was the matter with your
friend?”—“Her death affected me very much, because I was very friendly
with her. A few weeks before another young girl died, which attracted
a great deal of attention in our city, but then I was only seventeen
years old.”—“You see, I told you that the thought obtained under the
pressure of the hands can be relied upon. Well now, can you recall the
thought that you had when you became dizzy in the street?”—“There was
no thought, it was vertigo.”—“That is quite impossible, such
conditions are never without accompanying ideas. I will press your
head again and you will think of it. Well, what came to your mind?”—“I
thought, ‘now I am the third.’”—“What do you mean?”—“When I became
dizzy I must have thought, now I will die like the other two.”—“That
was then the idea, during the attack you thought of your friend, her
death must have made a great impression on you.”—“Yes, indeed, I
recall now that I felt dreadful when I heard of her death, to think
that I should go to a ball while she lay dead, but I anticipated so
much pleasure at the ball and was so occupied with the invitation that
I did not wish to think of this sad event.” (Notice here the
intentional repression from consciousness which caused the
reminiscences of her friend to become pathogenic.)
The attack was now in a measure explained, but I still needed the
occasional moment which just then provoked this recollection, and
accidentally I formed a happy supposition about it.—“Can you recall
through which street you passed at that time?”—“Surely, the main
street with its old houses, I can see it now.”—“And where did your
friend live?”—“In the same street. I had just passed her house and was
two houses farther when I was seized with the attack.”—“Then it was
the house which you passed that recalled your dead friend, and the
contrast which you then did not wish to think about that again took
possession of you.”
Still I was not satisfied, perhaps there was something else which
provoked or strengthened the hysterical disposition in a hitherto
normal girl. My suppositions were directed to the menstrual
indisposition as an appropriate moment, and I asked, “Do you know when
during that month you had your menses?”—She became indignant: “Do you
expect me to know that? I only know that I had them then very rarely
and irregularly. When I was seventeen I only had them once.”—“Well let
us enumerate the days, months, etc., so as to find when it
occurred.”—She with certainty decided on a month and wavered between
two days preceding a date which accompanied a fixed holiday.—Does that
in any way correspond with the time of the ball?—She answered quietly:
“The ball was on this holiday. And now I recall that I was impressed
by the fact that the only menses which I had had during the year
occurred just when I had to go to the ball. It was the first
invitation to a ball that I had received.”
The combination of the events can now be readily constructed and the
mechanism of this hysterical attack readily viewed. To be sure the
result was gained after painstaking labor. It necessitated on my side
full confidence in the technique and individual directing ideas in
order to reawaken such details of forgotten experiences after
twenty-one years in a sceptical and awakened patient. But then
everything agreed.
Footnote 15:
A better description of this peculiar state in which one knows
something and at the same time does not know it, I could never obtain.
It can apparently be understood only if one has found himself in such
a state. I have at my disposal a very striking recollection of this
kind which I can vividly see. If I make the effort to recall what
passed through my mind at that time my output seems very poor. I saw
at that time something which was not at all appropriate to my
expectations, and what I saw did not in the least divert me from my
definite purpose, whereas this perception ought to have done away with
my purpose. I did not become conscious of this contradiction nor did I
remark the affect of the repulsion to which it was undoubtedly due
that this perception did not attain any psychic validity. I was struck
with that form of blindness in seeing eyes, which one admires so much
in mothers towards their daughters, in husbands towards their wives,
and in rulers towards their favorites.
Footnote 16:
It will be shown that, notwithstanding, I erred.
Footnote 17:
Die Abwehr-Neuropsychosen, Neurologisches Centralblatt, 1 June, 1894.
Footnote 18:
I can neither exclude nor prove that this pain, especially of the
thighs, was of a neurasthenic nature.
Footnote 19:
To my surprise I once discovered that such subsequent
ab-reaction—through other impressions than nursing—may form the
content of an otherwise enigmatic neurosis. It was the case of a
pretty girl of nineteen, Miss Matilda H. whom I first saw with an
incomplete paralysis of the legs, and months afterward I was again
called because her character had changed. She was depressed and tired
of living, entertaining lack of consideration for her mother, and was
irritable and inapproachable. The whole picture of the patient did not
seem to me to be that of an ordinary melancholia. She could easily be
put into a somnambulic state, and I made use of this peculiarity to
impart to her each time commands and suggestions to which she listened
in her profound sleep and responded with profuse tears, but which,
however, caused but little change in her condition. One day while
hypnotized she became talkative and informed me that the reason for
her depression was the breaking of her betrothal many months before.
She stated that on closer acquaintance with her fiance the things
displeasing to her and her mother became more and more evident. On the
other hand, the material advantages of the engagement were too
tangible to make the decision of a rupture easy, thus, both of them
hesitated for a long time. She then merged into a condition of
indecision in which she allowed everything to pass apathetically, and
finally her mother pronounced for her the decisive “no.” Shortly
after, she awoke as from a dream and began to occupy herself fervently
with the thoughts about the broken betrothal, she began to weigh the
pros and cons, a process which she continued for some time. At present
she continues to live in that time of doubt, and entertains daily the
moods and the thoughts which would have been appropriate for that day.
The irritability against her mother could only be explained if we took
into consideration the circumstances that existed on that decisive
day. Next to this thought activity she found her present life a mere
phantom just like a dream. I did not again succeed in getting the girl
to talk—I continued my exhortations during deep somnambulism. I saw
her each time burst into tears without however receiving any answer
from her. But one day, it was near the anniversary of the engagement,
the whole state of depression disappeared. This was attributed to my
great hypnotic cure.
Footnote 20:
It is different in a hypnoid-hysteria. Here the content of the
separate psychic groups may never have been in the ego consciousness.
Footnote 21:
I had under my observation another case in which a contracture of the
masseters made it impossible for the artist to sing. The young lady in
question through painful experiences in the family was forced to go on
the stage. While in Rome rehearsing, in great excitement she suddenly
perceived the sensation of being unable to close her opened mouth and
sank fainting to the floor. The physician who was called closed her
jaws forcibly, but the patient since that time was unable to open her
jaws more than a finger’s breadth and had to give up her newly chosen
profession. When she came under my care many years later, the motives
for that excitement were apparently over for some time, for massage in
a light hypnosis sufficed to open her mouth widely. The lady has since
sung in public.
Footnote 22:
But perhaps spinal neurasthenic?
Footnote 23:
See Studien über Hysterie, p. 57, footnote.
Footnote 24:
l. c.
Footnote 25:
The literal translation of Auftreten is to press down by treading.
Footnote 26:
In conditions of profounder psychic changes we apparently find a
symbolic stamp (mark) of the more artificial usage of language in the
form of emblematic pictures and sensations. There was a time in Mrs.
Cäcilie M. during which every thought was changed into an
hallucination, and which solution frequently afforded great humor. She
at that time complained to me of being troubled by the hallucination
that both her physicians, Breuer and I, were hanged in the garden on
two nearby trees. The hallucination disappeared after the analysis
revealed the following origin: The evening before Breuer refused her
request for a certain drug. She then placed her hopes on me but found
me just as inflexible. She was angry at both of us, and in her affect
she thought, “They are worthy of each other, the one is a pendant of
the other!”
Footnote 27:
E. Hecker, Centralblatt für Nervenheilkunde, Dec., 1893.
Footnote 28:
See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und
Wien, 1895, p. 15.
Footnote 29:
See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und
Wien, 1895, p. 106.
Footnote 30:
See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und
Wien, 1895, p. 15.
Footnote 31:
As mentioned in the preface the author has long since discarded this
pressure procedure.—Translator’s note.
Footnote 32:
See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und
Wien, 1895, p. 85.
Footnote 33:
l. c., p. 15.
Footnote 34:
See Breuer und Freud, Studien über Hysterie. Deuticke, Wien und
Leipzig, 1895, p. 28.
Footnote 35:
See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und
Wien, 1895, p. 55.
Footnote 36:
État mental des hystériques, Paris, 1893 and 1894. Quelques
définitions récentes de l’hystérie, Arch. de Neurol., 1893, XXXV-VI.
Footnote 37:
Oppenheim: Hysteria is an exaggerated expression of emotion. But the
“expression of emotion” represents that amount of psychic excitement
which normally experiences conversion.
Footnote 38:
Strümpel: The disturbance of hysteria lies in the psycho-physical,
there where the physical and psychical are connected with each other.
Footnote 39:
Janet, in the second chapter of his spirited essay “Quelques
definitions,” etc., has treated the objection that the splitting of
consciousness belongs also to the psychoses and the so called
psychaesthenia, but in my opinion he has not satisfactorily solved it.
It is essentially this objection which urged him to call hysteria a
form of degeneration. But through no characteristic is he able to
separate sufficiently the hysterical splitting of consciousness from
the psychopathic, etc.
Footnote 40:
The group of typical phobias, for which agoraphobia is a prototype,
cannot be reduced to the psychic mechanisms here developed.
Furthermore the mechanism of agoraphobia deviates in one decisive
point from that of the real obsessions and from phobias based on such.
Here there is no repressed idea from which the affect of fear has been
separated. The fear of this phobia has another origin.
Footnote 41:
E. Hecker, Über larvierte und abortive Angstzustände bei Neurasthenie,
Centralblatt für Nervenheilkunde, December, 1893.—Anxiety is made
particularly prominent among the chief symptoms of neurasthenia by
Kaan, Der neurasthenische Angstaffekt bei Zwangsvorstellungen und der
primordiale Grübelzwang, Wien, 1893.
Footnote 42:
Die Abwehr-Neuropsychosen, Neurol. Centralbl., 1894, Nr. 10 u. 11.
Footnote 43:
Obsession et phobies, Révue neurologique, 1895.
Footnote 44:
Moebius, Neuropathologische Beiträge, 1894, 2. Heft.
Footnote 45:
Peyer, Die nervösen Affektionen des Darmes, Wiener Klinik, Jänner,
1893.
Footnote 46:
Freud, Abwehr-Neuropsychosen.
Footnote 47:
Neurologisches Centralblatt, 1896, Nr. 10.
Footnote 48:
I myself surmise that the so frequently fabricated assaults of
hysterical persons are obsessional confabulations emanating from the
memory traces of infantile traumas.
Footnote 49:
In an article on the anxiety neurosis (Neurologisches Centralblatt,
1895, Nr. 2) I stated that “an anxiety neurosis which can almost
typically be combined with hysteria can be evoked in maturing girls at
the first encounter with the sexual problem.” I know today that the
occasion in which such virginal anxiety breaks out does not really
correspond to the first encounter with sexuality, but that in such
persons there was in childhood a precedent experience of sexual
passivity which memory was awakened at the “first encounter.”
Footnote 50:
A psychological theory of the repression ought also to inform us why
only ideas of a sexual content can be repressed. It may be formulated
as follows: It is known that ideas of a sexual content produce
exciting processes in the genitals resembling the actual sexual
experience. It may be assumed that this somatic excitement becomes
transformed into psychic. As a rule the activity referred to is much
stronger at the time of the occurrence than at the recollection of the
same. But if the sexual experience takes place during the time of
sexual immaturity and the recollection of the same is awakened during
or after maturity, the recollection then acts disproportionately more
exciting than the previous experience, for puberty has in the mean
time incomparably increased the reactive capacity of the sexual
apparatus. But such an inverse proportion seems to contain the
psychological determination of repression. Through the retardation of
the pubescent maturity in comparison with the psychic function, the
sexual life offers the only existing possibility for that inversion of
the relative efficacy. The infantile traumas subsequently act like
fresh experiences, but they are then unconscious. Deeper psychological
discussions I will have to postpone for another time. I moreover call
attention to the fact that the here considered time of “sexual
maturity” does not coincide with puberty, but occurs before the same
(eight to ten years).
Footnote 51:
One example instead of many: An eleven-year-old boy has obsessively
arranged for himself the following ceremonial before going to bed: He
could not fall asleep unless he related to his mother most minutely
all experiences of the day; not the smallest scrap of paper or any
other rubbish was allowed in the evening on the carpet of his bedroom.
The bed had to be moved close to the wall, three chairs had to stand
in front of it, and the pillows had to lie in just such a position. In
order to fall asleep he had to kick with both legs a number of times,
and then had to lie on the side. This was explained as follows: Years
before while putting this pretty boy to sleep, the servant girl made
use of this opportunity to lay over him and assault him sexually. When
this reminiscence was later awakened by a recent experience it made
itself known to consciousness by the compulsion in the above mentioned
ceremonial which sense could really be surmised and the details
verified by psychoanalysis. The chairs before the bed which was close
to the wall—so that no one could have access to it; the arrangement of
the pillows in a definite manner—so that they should be differently
arranged than they were on that evening; the motion with the legs—to
kick away the person lying on him; sleeping on the side—because during
that scene he lay on his back; the detailed confession to his
mother—because in consequence of the prohibition of his seductress he
concealed from his mother this and other sexual experiences; finally,
keeping the floor of his bedroom clean—because this was the main
reproach which he had to hear from his mother up to that time.
Footnote 52:
When the meagre success of this treatment was later removed by an
exacerbation, she did not again see the offensive pictures of strange
genitals, but she had the idea that strangers saw her genitals as soon
as they were behind her.
Footnote 53:
Lecture delivered before the Vienna Medic. Doktorenkollegium, on
December 12, 1904.
Footnote 54:
From Löwenfeld, “Sexualleben und Nervenleiden,” IV ed., 1906.
Footnote 55:
See Chapter VII, and Zur Aetiologie der Hysterie, Wiener, Klinische
Rundschau, 1896.
Footnote 56:
An English translation in preparation.
Footnote 57:
Zeitschrift für Sexualwissenschaft, herausgegeben von Hirschfeld, I,
1908.
Footnote 58:
Compare Breuer and Freud Studien über Hysterie, 1895. P. Janet,
Névroses et ideés fixes, I (Les rêveries subconscientes), 1898.
Havelock Ellis, Sexual Impulse and Modesty (German by Kötscher), 1900.
Freud, Traumdeutung, 1906, 2d ed., 1909. A. Pick, Über pathologische
Träumerei und ihre Beziehungen zur Hysteria, Jahrbuch für Psychiatrie
und Neurologie, XIV, 1896.
Footnote 59:
H. Ellis similarly expresses himself, l. c., p. 185.
Footnote 60:
Compare Freud, Traumdeutung, 2d ed., p. 302.
Footnote 61:
Compare Freud, Three Contributions to the Sexual Theory, 1895.
Footnote 62:
The same thing holds true for the relation between the “latent”
thoughts of the dream and the elements of the manifest content of the
dream. See the Chapter on the “Work of the Dream” in the author’s
Traumdeutung.
Footnote 63:
Indeed J. Sadger, who recently discovered this sentence in question,
independently by psychoanalysis, claims for it a general validity (Die
Bedeutung der psychoanalytische Methode nach Freud, Centralbl. f.
Nerv. u. Psych., Nr. 229.)
Footnote 64:
Three Contributions to the Sexual Theory.
------------------------------------------------------------------------
TRANSCRIBER’S NOTES
Page Changed from Changed to
10 the so called χατ’ εξοχὴν of the so called κατ’ ἐξοχὴν of
traumatic hysteria or of a traumatic hysteria or of a
series of series of
65 scenes like the one of being scenes like the one of being
forced to hold our her hand in forced to hold out her hand in
123 be identified with personel or be identified with personal or
hereditary “degeneration.” hereditary “degeneration.”
● Typos fixed; non-standard spelling and dialect retained.
● Used numbers for footnotes, placing them all at the end of the last
chapter.
● Enclosed italics font in _underscores_.
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