VOL. I · Collected papers, Volume I

BY SIGM. FREUD, M.D., LL.D.

AUTHORIZED TRANSLATION UNDER THE SUPERVISION OF JOAN RIVIERE

THE INTERNATIONAL PSYCHO-ANALYTICAL PRESS NEW YORK LONDON VIENNA M C M X X I V

CONTENTS OF VOLUME I PAGE EDITORIAL PREFACE . . . . . . . . . . . . . . 3 EARLY PAPERS I Charcot (1893) . . . . . . . . . . . . 9 II On the psychical mechanism of hysterical pheno- mena (1893) . . . . . . . . . . . . . 24 III Some points in a comparative study of organic and hysterical paralysis (1893) . . . . . . 42 IV The defence neuro-psychoses (1894) . . . . . 59 V The justification for detaching from neurasthenia a particular syndrome: The anxiety-neurosis (1894) 76 VI A reply to criticisms on the anxiety-neurosis (1895) 107 VII Obsessions and phobias; their psychical mechanisms and their ætiology (1895) . . . . . . . . 128 VIII Heredity and the ætiology of the neuroses (1896) 138 IX Further remarks on the defence neuro-psychoses (1896) . . . . . . . . . . . . . . . 155 X The ætiology of hysteria (1896) . . . . . . 183 XI Sexuality in the ætiology of the neuroses (1898) 220 XII On psychotherapy (1904) . . . . . . . . . 249 XIII Freud's psycho-analytic method (1904) . . . . 264 XIV My views on the part played by sexuality in the ætiology of the neuroses (1905) . . . . . . 272 * ON THE HISTORY OF THE PSYCHO-ANALYTIC MOVEMENT (1914) . . . . . . . . . . . . . 287

EDITORIAL PREFACE {3}

To write a preface is often a perfunctory matter, but in the preface to this series of Collected Papers we wish to direct the reader's special attention to two cardinal considerations.

In the first place it should be said that these Collected Papers, of which the present is the first volume, constitute the real basis of Psycho-Analysis. All Professor Freud's other work and theories are essentially founded on the clinical investigations of which these papers are the only published record. It is unfortunate that the English-speaking public should for years have had access only to what may be called the superstructure of his work, the application of his psycho-analytic method to the study of dreams, sexuality, totemism, and so on, while the basis of it all remained buried in a foreign tongue. It is now proposed to fill this central lacuna in English psycho-analytical literature by publishing, in four or more volumes, a translation of the _Sammlung kleiner Schriften zur Neurosenlehre_. Incidentally it may be said that the papers in this series have been re-grouped, in co-operation with Professor Freud, so that they do not follow the same order as that of the German original.

This brings us to the second consideration. If the reader wishes to extract the greatest profit from these volumes, it is quite essential that he should constantly bear in mind the _date_ when each Paper was written. The only really satisfactory way of acquiring a knowledge of Professor Freud's writings is to follow the order of development of his work. It is hardly possible otherwise to obtain a coherent picture of the whole. To follow this development is not only a fascinating study in itself, disclosing as it does a beautiful example of the way in which ideas are gradually unfolded---and constantly extended and modified---under the pressure of widening and deepening experience. It also gives a conviction of the truly scientific nature of the author's work, for the tentative "feeling forward" here revealed---now in one direction, now in another, as occasion and opportunity present---is the very antithesis of the promulgation of an _a priori_ philosophic system such as has sometimes been ignorantly imputed to him. One inflexible determination has always guided him, and that was the {4} determination to keep ever in the closest contact with the actual material daily brought before his observation, and not to be tempted along side-tracks by speculations, however enticing these might appear. His path lay through a jungle hitherto completely unexplored. Rarely did his path follow a straight line for long: deviations, détours, fresh departures were often necessary, and occasionally even the retracing of his steps. No one will expect that in these circumstances of exploring an unknown territory the pioneer's trail would be orderly and regular in its progress, or that the path should be everywhere beaten equally smooth; but that the progress has been a real and inspiring one is attested by the host of workers now following in his steps.

In his preface to the first volume of the _Sammlung kleiner Schriften_ Professor Freud writes:---"Whoever is familiar with the development of human knowledge will hear without astonishment that I have passed beyond some part of the views here presented and have learnt to modify some others. Still I have been able to retain unchanged the greater part, and do not really need to withdraw anything as completely erroneous and quite worthless". He probably had in mind here particularly the view that underwent most modification subsequently, that concerning the importance of sexual traumas in infancy. Few episodes in the history of scientific research provide a more dramatic test of true genius than the occasion on which Professor Freud made the devastating discovery that many of these traumas to which he had been obliged to attach ætiological significance had never occurred outside the imagination of the patients. The realization---so modestly related in the last of the Early Papers (p. 276)---that an imagined event could in certain psychological circumstances produce an effect exactly equivalent to that of an actual event was one that only an investigator gifted with a supreme feeling for psychology could have achieved. Initial error led to a profound discovery. Most of Professor Freud's alleged "inconsistencies" will be found to carry a similar moral.

In the work of organizing the translations I have had the invaluable assistance of Mrs. Riviere; they have also been carefully revised by her as well as by myself. In this Frl. Anna Freud was very helpful, and we wish to express our indebtedness to her.

EARLY PAPERS {7}

I {9} CHARCOT[1] (1893)

In the person of J. M. Charcot whom, after a life of happiness and fame, a sudden death without suffering or illness took from us on the 16th of August the young science of neurology has lost its most active promoter, neurologists of all countries have been bereft of their teacher, and France has lost prematurely one of its leading men. He was only sixty-eight years of age; his bodily strength and mental vigour, together with the hopes he so frankly expressed, seemed to promise him that long life which has been granted to not a few of the thinkers of this century. The imposing nine volumes of his _Œuvres Complètes_, in which his pupils had collected his contributions to the science of medicine and of neuropathology, the _Leçons du Mardi_, the yearly reports of his clinic at the Salpêtrière, and other papers---all these publications, though they will remain precious to his pupils and to science, cannot take the place of the man who still had much to give and to teach, whose personality and whose work no one ever approached without learning from them.

He had a perfectly honest, human delight in his own great success and used to speak freely about his early days and the road that he had traversed. His scientific curiosity had been aroused early in life when he was but a young house-physician by the abundance of material, at that time utterly unintelligible, contained in the facts of {10} neuropathology. At that period in his life, whenever he made the rounds in the wards of the Salpêtrière (the asylum for women) with his chief, when he saw all the wilderness of paralyses, tremors and spasms for which no name or proper understanding existed forty years ago, he would say, '_Faudrait y retourner et y rester_', and he kept his word. As soon as he had become _médecin des hôpitaux_ (hospital physician) his goal was to get into the Salpêtrière, into one of the wards for nervous patients. Once there, he remained; instead of, as is the privilege of French physicians, transferring in regular order from hospital to hospital and from ward to ward, at the same time changing his speciality.

Thus his first impression and the resolution to which it led determined his whole future career. Having at his disposal a considerable number of patients afflicted with chronic nervous disease he was enabled to take full advantage of his peculiar talent. He was not much given to cogitation, was not of the reflective type, but he had an artistically gifted temperament---as he said himself, he was a '_visuel_', a seer. He himself told us the following about his method of working: he was accustomed to look again and again at things that were incomprehensible to him, to deepen his impression of them day by day, until suddenly understanding of them dawned upon him. Before his mind's eye, order then came into the chaos apparently presented by the constant repetition of the same symptoms; the new clinical pictures which were characterized by the constant combination of certain syndromes took shape; the complete and extreme cases, the 'types', were then distinguishable with the aid of a specific kind of schematic arrangement, and with these as a starting-point the eye could follow {11} down the long line of the less significant cases, the '_formes frustes_', showing some one or other peculiar feature of the type and fading into the indefinite. He called this kind of mental work, in which he had no equal, 'practising nosography' and he was proud of it. He was heard to say that the greatest satisfaction man can experience is to see something new, that is, to recognize it as new, and he constantly returned with repeated observations to the subject of the difficulties and the value of such 'seeing'. He wondered how it happened that in the practice of medicine men could only see what they had already been taught to see, he described how wonderful it was suddenly to see new things---new diseases---although they were probably as old as the human race; he said that he often had to admit that he could now see many a thing which for thirty years in his wards he had ignored. No physician will need to be reminded of the wealth of new outlines which the science of neuropathology gained through his efforts, and of the much greater keenness and accuracy in diagnosis which was made possible by the aid of his observations. But to his pupils, who made the rounds with him through the wards of the Salpêtrière---that museum of clinical facts for the greater part named and defined by him---he seemed a very Cuvier, as we see him in the statue in front of the Jardin des Plantes, surrounded by the various types of animal life which he had understood and described; or else he reminded them of the myth of Adam, who must have experienced in its most perfect form that intellectual delight so highly praised by Charcot, when the Lord led before him the creatures of Paradise to be named and grouped. {12}

Charcot never tired of defending the claims of the purely clinical task of seeing and classifying phenomena, as against the encroaches of theoretical medicine. One day a small group of foreign students brought up in the ways of German orthodox physiology annoyed him by raising objections to his clinical innovations. 'That cannot possibly be', one of us interrupted him, 'that contradicts the theory of Young-Helmholtz.' He did not reply, 'So much the worse for the theory, clinical facts rank first', and so forth. But he did say---leaving us deeply impressed '_La théorie, c'est bon, mais ça n'empêche pas d'exister_.'

For a long term of years Charcot held the chair of pathological anatomy in Paris, carrying on as a side-issue his neuropathological work and the lectures which rapidly made him famous abroad as well as at home. It was fortunate, however, for neuropathology that the same man could fulfil the functions of two incumbents; on the one hand he created the clinical pictures by observations, and on the other he proved that in the typical case as well as in the _forme fruste_ the same anatomical changes were the foundation of the disease. It is generally known how great the success of this anatomical-clinical method was in the sphere of organic nervous disease, with tabes, multiple sclerosis, amyotrophic lateral sclerosis, and so on. With these chronic, not immediately fatal diseases, patient years of waiting were often necessary before proof of the organic changes could be established, and only in a hospital for incurables like the Salpêtrière was it possible to keep and to watch the patients for such long periods. As it happened, Charcot made his first discovery in this field before he was in charge of a ward. During his student days chance brought him into contact with a charwoman who suffered from a {13} peculiar form of tremor and could not get work because of her awkwardness. Charcot recognized her condition to be 'choreiform paralysis', already described by Duchenne, of the origin of which, however, nothing was known. In spite of her costing him a small fortune in broken plates and platters, Charcot kept her for years in his service and, when at last she died, could prove in the autopsy that 'choreiform paralysis' was the clinical expression of multiple cerebro-spinal sclerosis.

Pathological anatomy has to serve neuropathology in two ways: first, to bring proof of morbid alterations, and secondly, to determine the localization of these changes; we all know that in the last two decades the second part of the task has aroused greater interest and has been more actively advanced. In this field also Charcot co-operated brilliantly, although the pioneer work was not done by him; he followed to begin with the footsteps of our countryman Türck, who is said to have lived and worked among us in comparative obscurity. Later, after the two important discoveries which inaugurated a new epoch in our knowledge of the 'localization of nervous diseases'---namely, the stimulation tests of Hitzig-Fritsch and Flechsig's work on the development of the spinal cord---his lectures on localization were the best and most significant aid towards co-ordinating the new theories with the clinical side and making them available for clinical purposes. As regards the relation of the muscular system to the motor area of the cerebrum, I should like to remind the reader how long the specific mode and topography of this connection was a matter of conjecture (common representation of both extremities in the same areas, representation of the upper extremity in the anterior, of the lower in the posterior central {14} convolution: that is, vertical disposition), until at last continued clinical investigations, with stimulation---as well as extirpation--- tests on human beings during surgical operations, decided the matter in favour of Charcot's and Pitres' view, namely, that the middle third of the central gyri mainly serves the representation of the arm, while the upper third and the mesial portion serve the representation of the leg; in other words, that the disposition in the motor areas is a horizontal one.

It would not be possible to demonstrate Charcot's importance to the science of neuropathology by enumerating particular achievements, for during the last two decades there have been few questions of any significance to the formulation and discussion of which the 'school of the Salpêtrière' has not made contributions of signal importance. The 'school of the Salpêtrière' was, of course, Charcot himself; his wealth of experience, his power of plastic description, his transparent clearness of diction was easily recognizable in the papers of every one of his pupils. Some members of this circle of young men whom he gathered about him and made his partners in his work had attained to consciousness of their own individuality, and won celebrity on their own account, and one or other of them would now and then advance an opinion that seemed to the master clever rather than correct; this he would attack sarcastically enough in conversation and in his lectures without, however, in any way injuring his affectionate relation with the pupil. Charcot does indeed leave behind him a group of pupils whose intellectual qualifications and whose work are pledges that the practice of neuropathology in Paris will not readily descend form the high level to which it was brought by him. {15}

In Vienna we have repeatedly found that an academic teacher of intellectual importance is not also as a matter of course gifted with that close personal influence on his students which expresses itself in the formation of a numerous and important 'school'. If Charcot was more favoured in this respect we must attribute it to his personal qualities as a man, to the magic of his aspect and his voice, to the gracious frankness of his manner after the first strangeness of a new relation had worn off, to the readiness with which he placed everything at the disposal of his pupils, and to his life-long loyalty to them. The hours he spent in his wards were hours of fellowship and interchange of ideas with his whole medical staff. He never shut himself off from them; the youngest assistant had an opportunity of seeing him at work and might interrupt him, and the same privilege was granted to the foreigners who were never absent from his rounds in later years. Finally, his pupils and assistants were regarded as part of his family in welcoming the guests on the evenings when Madame Charcot---assisted by a highly gifted daughter, not unlike her father---received a distinguished company in her hospitable house.

In the year 1882 or 1883 the circumstances of Charcot's life and work took on their final form. The idea had come to be generally realized that the activity of this man was part of the national '_gloire_', to be guarded all the more jealously since the unsuccessful war of 1870--1871. The government, headed by Charcot's old friend, Gambetta, created for him a chair of neuropathology at the Faculty of Medicine, which permitted him to give up his course in pathological anatomy, and, in addition, founded for him a clinic with auxiliary scientific departments at the Salpêtrière. '_Le service de M. Charcot_' now {16} embraced (with the old wards of the chronic patients) several clinical halls where men also were received, a large out-patient department---the _consultation externe_---an histological laboratory, a museum, an electro-therapeutic department, an eye-and-ear department, and a special photographic studio. Each of these institutions offered opportunities for attaching former assistants and pupils permanently to the clinic in good positions. The two-storey-high, weather-beaten buildings and the courts they enclosed reminded the foreigner extraordinarily of our Allgemeines Krankenhaus in Vienna, but the resemblance did not go very far. 'It is perhaps not beautiful here', Charcot would say as he showed the visitor about his domain, 'but you can find room for everything you want to do.'

Charcot stood at the zenith of his career when this abundance of material for teaching and investigating was placed at his disposal. He was an indefatigable worker, always the most industrious of the whole group. His private practice, crowded with patients 'from Samarcand and from the Antilles', could not divert him from his activities as a teacher and investigator. This throng was assuredly not attracted merely by the famous scientist, but as much or more by the great physician, and by the sympathetic nature of the man, who always knew how to give counsel, and could surmise and guess in those cases where the present status of science did not permit him to know. He has often been reproached on account of his therapeuty, which with its multiplicity of prescriptions could not but offend a rationalistic conscience: he simply continued the current and local methods customary at that time and place, without deceiving himself much about their effectiveness. Incidentally, he was not pessimistic in regard to {17} therapeutic results and was ever willing to encourage at his clinic experiments with new methods of treatment, which had but a short-lived success, as others were quick to point out. As a teacher, Charcot was positively fascinating; each of his lectures was a little masterpiece in construction and composition, perfect in style, and so impressive that the words spoken resounded in one's ears and the subject demonstrated remained before one's eyes for the rest of the day. He rarely made a demonstration with a single patient, but was accustomed to present a whole group or a number of contrasting types which he then compared with one another. In the hall in which he gave his lectures hung a picture of the 'citizen' Pinel, causing the poor insane of the Salpêtrière to be relieved of their chains; for after having been the scene of so many horrors during the French Revolution, the Salpêtrière had also witnessed this most humane innovation. Maître Charcot himself made a strange impression during these lectures; usually bubbling over with vivacity and cheerfulness, with witticisms always on his lips, he would appear at such moments solemn and serious, nay, even aged in his velvet cap; his voice seemed muffled, and we almost understood how malicious strangers could accuse the whole performance of theatricality. Those who expressed themselves in this manner were probably accustomed to the lack of form in German clinical lectures or else they forgot that Charcot, who gave only one lecture a week, could prepare it carefully.

Charcot was very probably following a tradition of long standing with this ceremonious lecture, in which everything was prepared and had to happen as planned; nevertheless he felt the need of displaying his {18} activity to his pupils in a less artificial setting. For this purpose he made use of the out-patient department which he took charge of personally in the so-called _Leçons du mardi_. There he examined cases quite unknown to him, risked all the chance occurrences of an interrogation, laid his authority aside and confessed at times that in one case diagnosis was impossible, and that in another appearances had deceived him. Never did he appear greater to his students than on these occasions, when he thus did his best to lessen the distance between teacher and pupils by giving them a complete and faithful account of his own train of thought, by stating his doubts and misgivings with the utmost frankness. The publication, at first in French, now also in German of these improvised lectures of the years 1887 and 1888 has extended the circle of his admirers indefinitely; nor has any other neuropathological work ever achieved greater success among the medical public.

About the time that the clinic was instituted and the course in pathological anatomy given up, there occurred a change in Charcot's scientific interests to which we owe the best part of his work. He explained that the theory of organic nervous diseases was for the present fairly complete, and he began to turn his attention almost exclusively to hysteria, thus suddenly focussing general attention on this subject. This most enigmatic of all nervous diseases---no workable point of view having yet been found from which physicians could regard it---had just at this time come very much into discredit, and this ill-repute related not only to the patients but was extended to the physicians who treated this neurosis. The general opinion was that anything may happen in hysteria; hysterics found no credit whatsoever. First of all Charcot's work restored dignity to the subject; gradually the sneering attitude, which the hysteric could {19} reckon on meeting when she told her story, was given up; she was no longer a malingerer, since Charcot had thrown the whole weight of his authority on the side of the reality and objectivity of hysterical phenomena. Charcot had repeated on a small scale the act of liberation commemorated in the picture of Pinel which adorned the lecture hall of the Salpêtrière. Now that the blind fear of being fooled by the poor patient which had stood in the way of a serious study of the neurosis was overcome, the question arose which mode of procedure would most speedily lead to the solution of the problem. The wholly unprejudiced observer might have found an opening in the following reflection: If I find a person in a condition bearing all the marks of a painful affect, crying, screaming, raving, I am led to surmise that a mental process is going on in him of which these bodily phenomena are the adequate expression. In such a case the normal person is capable of telling us what is troubling him, but the hysteric would answer that he did not know; and the problem at once arises: How comes it that the hysteric is subject to an affect of the causes of which he claims to know nothing? If we adhere to the conclusion that there must exist a corresponding psychic process, and at the same time believe the patient's assertion when he denies its existence, if we assemble all the manifold signs which indicate that the patient nevertheless behaves as though he knows the cause, if we search into the patient's life and find therein a cause---a trauma---likely to create such an affective expression---then indeed the solution is forced upon us that the patient is in a peculiar mental condition in which his impressions or memories are no longer all linked up one with the other, and in {20} which it is possible for one memory to express its affect by means of bodily phenomena without the other mental processes---the ego---knowing about it or being able to interfere; and the recollection of the well-known psychological difference between sleep and the waking state might have lessened the strangeness of such an hypothesis. Let no one object that the theory of dissociation of consciousness as a solution of the enigma of hysteria is too far-fetched to suggest itself to the untrained and unprejudiced observer. In fact the Middle Ages had chosen this very solution, in declaring possession by a demon to be the cause of hysterical manifestations; all that would have been required was to replace the religious terminology of those dark and superstitious times by the scientific one of to-day.

Charcot did not choose this path in his explanation of hysteria, though he drew plentifully from existing records of witchcraft trials and of possession in order to show that the manifestations of neurosis were the same then as they are now. He treated hysteria like any other theme of neuropathology, gave the complete description of its manifestations, showed that these had their own laws, and taught his pupils to recognize the symptoms which make the diagnosis of hysteria possible. He and his pupils occupied themselves in most careful tests with the disturbances of sensibility caused by hysteria on the skin and the deeper tissues, with the behaviour of the sense organs, peculiarities of hysterical contractures and paralyses, trophic disturbances and alterations of metabolism. The manifold forms of the hysterical attack were described and a scheme drawn up which represented the typical configuration of the attack of '_grande hystérie_' in four stages, and permitted the correlation of the commonly observed attacks of '_petite hystérie_' with the type. They {21} also investigated the localization and frequency of the so-called hysterogenic zones and their relation to the attacks, and so on. Equipped with all this information about the manifestations of hysteria it was possible to make a number of surprising discoveries; it was found that hysteria was far commoner among men than had been suspected, especially among working-men, and that certain conditions which had been ascribed to alcoholic or lead poisoning were hysterical. It was possible to include a large number of hitherto unintelligible, unclassified affections under the head of hysteria, and to distinguish the part played by hysteria in cases where the neurosis was combined with other diseases, forming a complex clinical picture. Most far-reaching in its influence was probably that research work concerning the nervous diseases following upon traumas---the traumatic neuroses---the conception of which is still under discussion to-day; in all these affections Charcot successfully presented the case for hysteria.

Since the latest extensions of the conception of hysteria had so frequently led to a rejection of any ætiological diagnosis, the need arose to investigate the ætiology of hysteria. Charcot laid down a simple formula for this: heredity is the unique originating cause of hysteria, which is therefore a form of degeneration, a member of the '_famille névropathique_', all other ætiological factors playing the part of precipitating causes, of '_agents provocateurs_'.

The building up of this great structure of doctrine was not, of course, achieved without violent opposition. This was, however, nothing but the barren objection of an older generation which disliked making any change in its views. The younger group of neuropathologists, in Germany as well, accepted Charcot's theories to a greater or lesser extent. Charcot himself was quite convinced of {22} the success of his teaching in regard to hysteria; if objections were raised that the four stages of the attack, or that hysteria among men, etc., were not observable outside France, he pointed out that he had himself overlooked these things for a long time, and reasserted that hysteria was the same everywhere and at all times. He disliked to hear the French accused of being a far more nervous nation than other peoples, and hysteria spoken of as their national foible; he was delighted when a paper on a case of 'reflex epilepsy' in a German grenadier could be diagnosed by him at a distance as one of hysteria.

At one point Charcot's work rose above the level of his general treatment of hysteria and took a step which gives him for all time the glory of being the first to elucidate hysteria. While he was occupied with the study of hysterical paralyses appearing after traumas, the idea occurred to him to reproduce by artificial means such paralyses as he had previously carefully differentiated from organic disturbances; for this purpose he took hysterical patients and placed them in a state of somnambulism by hypnotism. He succeeded in producing a faultless demonstration and proved thereby that these paralyses were the result of specific ideas holding sway in the brain of the patient at moments of special disposition. With this the mechanism of an hysterical phenomenon was for the first time disclosed, and on this incomparably fine piece of clinical research his own pupil Janet, and also Breuer and others, based their theories of the neurosis which, while agreeing with the mediæval view, replaces the 'demon' of priestly imagination by a psychological formula.

Charcot's application of the phenomena of hypnosis to hysteria enabled a very great advance to be made in this important sphere of hitherto {23} neglected and despised facts, because the weight of his reputation put an end once for all to doubts of the reality of hypnotic manifestations. But this exclusively nosographic approach was not suited to a purely psychological subject. Limiting the study of hypnosis to hysterical patients, distinguishing between greater and lesser hypnotism, establishing three stages of 'greater' hypnosis distinguished by somatic signs---all these practices sank in the estimation of contemporaries when Liébeault's pupil, Bernheim, undertook the task of basing the theory of hypnotism on a broader psychological foundation and of making suggestion the nucleus of hypnosis. Only the opponents of hypnotism who content themselves with hiding their own lack of experience behind some recognized authority still cling to Charcot's pronouncements, and like to quote an expression uttered in his last years denying that hypnosis has any therapeutic efficacy whatever.

As for the ætiological theories which Charcot defended in his doctrine of the '_famille névropathique_' and made the cornerstone of his whole conception of nervous diseases, they too will probably soon need to be probed into and corrected. So greatly did Charcot over-estimate heredity as a cause that no loophole was left by which nervous disease could be acquired; to syphilis he allotted only a modest place among the '_agents provocateurs_'; nor did he, in ætiology or elsewhere, differentiate sharply enough between the organic nervous affections and the neuroses. The progress our science has made in additions to its knowledge will inevitably diminish the value of much that Charcot has taught us, but neither the passing of time nor the changing of ideas will diminish the glory of the man whom we---in France and elsewhere---are mourning to-day.

II {24}

ON THE PSYCHICAL MECHANISM OF HYSTERICAL PHENOMENA[2]

(In collaboration with Dr. Joseph Breuer, 1892)

Stimulated by a chance observation, we have for a number of years been investigating the most varied types and symptoms of hysteria with reference to the exciting cause, the event which evoked the phenomenon in question for the first time, often many years before. In the great majority of cases it is impossible to discover this starting-point by straightforward interrogation of the patient, be it ever so thorough; partly because it is often a matter of experiences which the patient finds it disagreeable to discuss, but chiefly because he really does not remember and has no idea of the causal connection between the exciting occurrence and the pathological phenomenon. As a rule it is necessary to hypnotise the patient and under hypnosis to arouse recollections relating to the time when the symptom first appeared; one can then succeed in revealing this connection in the clearest and most convincing manner.

In a great number of cases this method of examination has yielded results which appear to be valuable theoretically as well as practically. From the theoretical point of view the results are valuable because, for the pathology of hysteria, the accidental factor is decisive to a far greater extent than is known or acknowledged. In {25} regard to traumatic hysteria it is obviously the accident which has evoked the syndrome; and when we learn from the utterances of patients in hysterical attacks that they invariably hallucinate in every attack a repetition of the original occurrence which evoked the first, the causal connection then also becomes perfectly clear here. The question is more obscure in the case of other phenomena.

Our experience has shown us, however, that the most varied symptoms, usually regarded as spontaneous and, so to speak, idiopathic products of hysteria, have just as strict a connection with the exciting trauma as those mentioned above in which the relation of the two sets of facts to one another is transparent. To exciting causes of this kind we have been able to trace anæsthesias as well as neuralgias of the most varied kind, often of many years duration, contractures and paralyses, hysterical attacks and epileptoid convulsions which all observers had taken for genuine epilepsy, _petit-mal_, symptoms of the nature of tics, chronic vomiting and anorexia carried to the point of refusal of food, the most varied disturbances of vision, constantly recurring visual hallucinations---and the like. The disproportion between the many years duration of an hysterical symptom and the single occurrence which evoked it is similar to that which we are accustomed to see regularly in traumatic neurosis; it was quite frequently in childhood that the events occurred producing a more or less grave symptom which persisted from that time onwards.

The connection is often so clear that it is quite evident how the exciting event has happened to produce just this and no other manifestation; the phenomenon is determined in a perfectly clear manner by the cause; to take the most ordinary example, a painful {26} affect, which was originally excited while eating but was suppressed, produces nausea and vomiting, and this continues for months as hysterical vomiting. A girl watching in harrowing anxiety at the bedside of a sick person falls into a twilight state and has a terrifying hallucination while her right arm which is hanging over the back of the chair 'goes to sleep'; from this develops a paresis of that arm with contracture and anæsthesia. She wants to pray but can find no words; finally she succeeds in repeating an English prayer which she learnt in childhood. Then later a severe and highly complicated hysteria develops in which she can speak, write and understand only English, while for a year and a half her mother-tongue remains unintelligible to her.---A child who is very ill at last falls asleep, and its mother tries her utmost to keep quiet and not to wake it; but just in consequence of this resolution (hysterical counterwill) she makes a clucking noise with her tongue. On another occasion when she wishes to keep absolutely quiet this happens again, and so a tic in the form of tongue-clicking develops which for a number of years accompanies every excitement.---A highly intelligent man assists while his brother's ankylosed hip is straightened under an anæsthetic. At the instant when the joint gives way with a crack he feels a violent pain in his own hip-joint which lasts for almost a year; and so on.

In other cases the connection is not so simple; there exists only what may be called a symbolic relation between the cause and the pathological manifestation, such as normal people also fashion in dreams; for example, a neuralgia links itself on to some mental distress, or vomiting accompanies a feeling of moral disgust. We have had under observation patients who habitually made extensive use of {27} such symbolism. In yet other cases a determination of this kind is not at the first glance clearly intelligible; to these belong precisely the typical hysterical symptoms---hemianæsthesia, contraction of the field of vision, epileptiform convulsions and the like. The exposition of our theories concerning this group must be reserved for a more detailed consideration of the subject.

Such observations seem to us to prove the pathogenic analogy between ordinary hysteria and traumatic neurosis and to justify an extension of the concept of traumatic hysteria. In traumatic neurosis the active cause of illness is not the trifling bodily injury but the affect of fright---the psychic trauma. Similarly, our investigations of many, if not of the majority, of hysterical symptoms have revealed causes which must be described as psychic traumas. Any experience which rouses the distressing affects of fright, apprehension, shame, or psychical pain can have this effect and it obviously depends on the sensitiveness of the person concerned (as well as on a further condition which we will refer to later) whether the experience acquires the importance of a trauma. We not infrequently find in ordinary hysteria several partial traumas instead of one grand trauma---a group of causes---which can only achieve traumatic effectiveness by accumulation and which belong together only in so far as they form parts of a whole painful experience. In still other cases circumstances in themselves apparently indifferent have attained an otherwise unexpected importance as traumas, either on account of their conjunction with really effective experiences or because they occurred at a moment of special susceptibility. This importance they then retain henceforward. {28}

But the causal connection between the exciting psychical trauma and the hysterical symptom is not of such a kind that the trauma (like an _agent provocateur_) sets going a symptom which then becomes independent and persists on its own account. On the contrary, we are of opinion that the psychical trauma, or the memory of it, acts as a kind of foreign body constituting an effective agent in the present even long after it first penetrated; and we see the proof of this in a highly remarkable phenomenon which also lends an important practical interest to these results of our observations.

The discovery that we made, at first to our own great surprise, was that when we had succeeded in bringing the exciting event to clear recollection, and had also succeeded in arousing with it the accompanying affect, and when the patient had related the occurrence in as detailed a manner as possible and had expressed his feeling in regard to it in words, the various hysterical symptoms disappeared at once, never to return. Recollection without affect is nearly always quite ineffective; the original psychical process must be repeated as vividly as possible, brought into _statum nascendi_ and then 'talked out'. In the case of excitation phenomena---contractures, neuralgias, and hallucinations---the symptoms appear again during this repetition in full intensity and then disappear for ever. Defects in functioning, paralyses and anæsthesias disappear in the same way, the transitory exacerbation not being of course perceptible in those cases.[3] {29}

One may be inclined to suspect that the explanation lies in unintentional suggestion; the patient expects to be rid of his suffering as a result of the treatment, and this expectation might be the effective factor, not the 'talking out'. But this is not the fact; the first observation of this kind was a highly complicated case of hysteria having symptoms with distinct causes which were separately dispersed, and was analysed on these lines in the year 1881, that is, in the 'pre-suggestion' era. It was made possible by spontaneous auto-hypnosis on the part of the patient, and it occasioned the observer the greatest surprise.

Inverting the phrase '_cessante causa cessat effectus_', we may well conclude from these observations that the exciting experience continues in some way to be effective even years after, not indirectly by means of a chain of causes linking up with one another, but directly as the actual exciting cause---just as, for instance, the recollection of mental distress in full consciousness at some later period may stimulate tears; we thus conclude that _hysterical patients suffer principally from reminiscences_.[4]

It may at first appear strange that experiences long since past should operate with such intensity, and that the memory of them should not {30} succumb to the fate which we see overtaking all our memories; perhaps these facts may become rather more comprehensible in the light of the following considerations.

The fading of a memory or of its affect depends on several factors. First and foremost it depends on whether an energetic reaction (discharge of feeling) supervened on the affective experience or not. By _reaction_ we here mean the whole range of voluntary and involuntary reflexes, by which according to experience the affects are habitually worked off---from weeping up to an actual act of revenge. If this reaction occurs with sufficient intensity a great part of the affect disappears; common speech bears witness to these facts of every-day observation in the expressions 'to cry oneself out', 'to storm oneself out (_sich austoben_)'. If the reaction is suppressed the affect remains attached to the memory. An insult which is returned, if only in words, is remembered differently from one which had to be endured in silence. Common speech also recognizes this difference in the psychical and bodily consequences, and most characteristically designates silently endured suffering as a _Kränkung_,[5] wound, injury, mortification. The reaction of an injured person to the trauma has a really complete 'cathartic' effect only if it takes the form of a fully adequate reaction, such as an act of revenge. But man finds a surrogate for such an act in speech, by the help of which the affect may be almost as effectually 'abreacted'. In other cases talking is itself sufficient as a reflex, for example, complaining or relieving the burden of a secret (the confessional!). If a reaction of this kind by word or deed, or in the {31} mildest cases by tears, does not ensue, the memory of the occurrence retains for a time its affective tone.

'Abreaction' is, however, not the only kind of solution at the disposal of the normal psychical mechanism in a healthy person who has met with a psychical trauma. Even if the memory is not abreacted it becomes merged in the great complex of associations, and is then ranged alongside of other experiences which perhaps contradict it; thus it undergoes correction by means of other ideas. After an accident, for example, the remembrance of the danger and the subsequent (weakened) reproduction of the terror is accompanied by the memory of the sequel, of the rescue and the consciousness of present security. The memory of an injury to the feelings is corrected by an objective evaluation of the facts, consideration of one's actual worth and the like, and thus the normal man succeeds by means of associations in dissipating the accompanying affect.

In addition to this there is also that general effacing of impressions, that fading of recollection called 'forgetting', which tends more than anything else to absorb ideas which have lost their affective tone.

Our observations have shown that those memories which give rise to hysterical phenomena are retained with wonderful freshness and with full affective tone for a long period. But we must mention as a further striking fact, to be turned to account later, that these recollections are not at the disposal of the patient in the way that his more commonplace memories are. On the contrary, when the patient is in his usual psychical condition these experiences are completely absent from his memory or are present to it only in the most summary manner. Only when patients are questioned under hypnosis do these {32} memories recur with the undiminished vividness of recent events.

Thus for six months one of our patients under hypnosis reproduced with hallucinatory vividness everything which had excited her on the corresponding day of the previous year (during an acute hysteria); her mother's diary, of which she knew nothing, attested the perfect accuracy of the reproduction. Another patient lived through with hallucinatory clearness---partly in hypnosis, partly in spontaneous attacks---all the experiences of an hysterical psychosis which she had suffered from ten years before, and in regard to which amnesia had been almost complete until the moment of the re-emergence. Several ætiologically important recollections dating back fifteen to twenty-five years were of astonishing integrity, and intensity of feeling; on reproduction their effect had the full force of new experiences.

As a reason for this we can only conjecture that these recollections have met with an exceptional fate in reference to all the ordinary processes of effacement discussed above, for we find that they relate to traumas which have not been sufficiently abreacted; closer investigation of the reasons which have prevented the operation of the latter then shows us at least two groups of conditions under which reaction to the trauma does not ensue.

In the first group we reckon those cases in which the patient has not reacted to the psychical trauma because its nature excluded the possibility of any such reaction, as in the case of the apparently irretrievable loss of a loved person, or when social conditions made a reaction impossible, or when the trauma concerned something which the patient wished to forget and therefore deliberately repressed[6] and {33} excluded from his conscious thoughts. Under hypnosis we discover painful ideas of precisely this character underlying the hysterical phenomena (e.g. in the hysterical deliria of saints and nuns, of abstinent women and well-brought-up children).

The second group of conditions is not determined by the content of the recollection, but by the mental condition of the patient at the moment when the given experience occurred. That is to say, among the exciting factors of hysterical symptoms we also discover under hypnosis ideas which though not in themselves significant owe their preservation to the circumstance that they happen to coincide with a seriously disabling affect, for example, terror, or with a directly abnormal mental condition, such as the half-hypnotic twilight state of day-dreaming, auto-hypnosis, and the like. In these cases it is the nature of these conditions which made a reaction to the experience impossible.

Naturally both determinants may and often do occur together. This happens when a trauma effective enough in itself occurs during a state of seriously disabling affect or of altered consciousness; but it seems that in many persons an abnormal state of this kind is produced as the result of a psychic trauma which then in its turn makes a reaction impossible.

Both groups of determining conditions have this in common: that the psychical traumas which are not resolved by reaction will also fail of solution by means of associative absorption. In the first group the patient's intention to do so causes him to forget the painful {34} experiences and consequently to exclude them from association as far as possible. In the second group the associative absorption does not succeed because sufficient associative connection does not exist between the normal state of consciousness and the pathological state in which these ideas originally arose. We shall have immediate occasion to go more closely into these conditions.

Thus it may be said that the ideas which have become pathogenic are preserved with such freshness and affective force because the normal process of absorption by abreaction and by reproduction in a state of unrestrained association is denied them.

III

In describing the conditions which according to our experience are decisive for the development of hysterical phenomena from psychical traumas, we mentioned the abnormal states of consciousness in which such pathological ideas arise; and we laid stress on the fact that the recollection of the effective psychical trauma is not to be found in the normal memory of the patient, but in his memory under hypnosis. Indeed, the more we occupied ourselves with these phenomena the more certain did our conviction become that that splitting of consciousness, which is so striking in the well-known classical cases of _double conscience_, exists in a rudimentary fashion in every hysteria and that the tendency to this dissociation---and therewith to the production of abnormal states of consciousness, which may be included under the term '_hypnoid_'---is a fundamental manifestation of this neurosis. This view is in agreement with those of Binet and the two Janets; we have not had the opportunity, however, to confirm their highly remarkable discoveries in reference to anæsthetic {35} patients.

We should like therefore to supplement the often-quoted phrase 'hypnosis is an artificial hysteria' with another---namely, 'the existence of hypnoid states forms the foundation and condition of hysteria'. There is one thing common to all these hypnoid states and to hypnosis, in spite of all their differences---namely, that the ideas which emerge in them are marked by great intensity of feeling but are cut off from associative connection with the rest of the content of consciousness. These hypnoid states are capable of association among themselves and the ideas belonging to them may in this way attain different degrees of psychical organization. Incidentally, however, the nature of these states and the degree of their inaccessibility to the rest of conscious processes would very probably vary in a fashion similar to that of hypnosis, which ranges from light sleepiness to somnambulism, from complete recollection to absolute amnesia.

If such hypnoid states exist before the manifest illness, they provide a foothold upon which the affect establishes itself with its pathogenic recollection and its subsequent somatic manifestations. This situation corresponds to dispositional hysteria. But our observations show that a severe trauma (such as that in a traumatic neurosis) or a troublesome suppression (for instance, of sexual affect) can effect a splitting of groups of ideas in people previously free from it, and this would constitute the mechanism of psychically acquired hysteria. Between the extremes of these two forms we must recognize a series within which the readiness to dissociation in the persons concerned and the volume of affect roused by the trauma varies inversely. {36}

We have nothing new to say concerning the origin of dispositional hypnoid states. They often develop, we believe, from the 'day-dreams' so frequently met with also in healthy people, great opportunity for which is provided, for instance, in the feminine occupation of needlework. The question why the 'pathological associations' formed in such states are so strong and why they influence somatic processes so much more strongly than ideas habitually do is part of the problem of the operation of hypnotic suggestion in general. Our experiences teach us nothing new on this point; they do, however, illuminate the contradiction between the statement 'hysteria is a psychosis' and the fact that one finds among hysterics people with the clearest and most critical intellects, of great strength of character and will-power. These characteristics in such people are valid for their waking thoughts; in the hypnoid state they become alienated from their conscious personalities as we all are in dreams. But whereas our dream-psychoses do not influence our waking existence the products of hypnoid states intrude as hysterical phenomena into waking life.

Almost the same conclusions that we have just formed concerning hysterical symptoms of long duration may be repeated concerning hysterical attacks. As is well known, we possess a schematic description of the '_grande attaque_', worked out by Charcot, according to which four phases may be recognized in a complete attack: (1) the epileptoid, (2) that of violent movements, (3) that of '_attitudes passionnelles_' (the hallucinatory phase), and (4) that of the concluding delirium. According to Charcot, all the various forms of an hysterical attack (which as a matter of fact are more frequently {37} observed than the full _grande attaque_) are derived from a shortening, lengthening, omission or isolation of these separate phases.

Our attempt at explanation has to do with the third phase, the _attitudes passionnelles_. When this is well-marked it will reveal itself as an hallucinatory reproduction of a memory important for the outbreak of the hysteria, i.e. the memory of the one grand trauma in what is called _κατ' ἐξοχήν_ traumatic hysteria, or of a series of inter-related partial traumas which lie at the root of ordinary hysteria. The remaining alternative is that the attack will reproduce those experiences which were raised to importance by happening to occur at a time of special sensitivity to traumas.

But there are also attacks which seems to consist of nothing but motor symptoms and in which the _phase passionnelle_ is lacking. If we can succeed in establishing a _rapport_ with the patient during such general clonic attacks, during tonic catalepsy, or during an _attaque de sommeil_, or, better still, if we succeed in summoning up an attack while the patient is under hypnosis, we find that these attacks too are based on the memory of a psychic trauma or series of traumas which usually finds expression in an hallucinatory phase. For instance, a little girl has suffered for years from attacks of general convulsions which might have been epilepsy and had in fact been taken for it. To establish a differential diagnosis she was hypnotised and was promptly seized by an attack. When asked: 'What do you see now?' she answered: 'The dog, the dog is coming!' Further enquiry revealed that the first attack of the kind had appeared after she had been chased by a mad dog. Therapeutic success later confirmed the diagnosis of a psychogenic malady.---A clerk who had become hysterical in consequence {38} of being assaulted by his superior suffered from attacks during which he fell to the ground in a frenzy of rage, but without uttering a word or betraying any signs of an hallucination. An attempt to produce the attack under hypnosis proved successful, and the patient revealed that he was again living through the situation in which his superior had openly insulted him in the street and thrashed him with a stick. A few days afterwards he returned complaining that the same attack had occurred again, and this time he revealed under hypnosis that he had been living through the situation which provoked the actual outbreak of the disease, i.e. the trial in court where he failed to obtain compensation for the injury.

The memories which come to the fore in hysterical attacks, or can be wakened during them, correspond also in all other respects with the exciting occurrences which we have found at the root of hysterical symptoms of long duration. Like these, they relate to psychic traumas which have remained unresolved by abreaction or by associative mental operations; and like these, they---or at least their essential constituents---are absent from the store of memories of which normal consciousness is made up; they belong to the ideational content of hypnoid states of consciousness with their narrow fields of association. Finally, they also admit of the therapeutic test. Our observations have often demonstrated that a memory of this kind which had hitherto provoked such attacks lost this power as soon as it was brought during hypnosis to a reaction or to associative readjustment.

The motor phenomena of hysterical attacks are to be explained partly as a general mode of reaction to the affect which accompanies the memory, and may be compared, for example, with the beating movements {39} of all the limbs which even an infant makes use of for this purpose; and partly as signifying direct emotional expressions of this memory; although they also elude this explanation to some extent as do the hysterical stigmata in chronic symptoms.

There is yet another aspect of the hysterical attack which reveals itself in the light of the theory we have just indicated: that in hysteria there are present ideational groups (arising in hypnoid states) which, cut off from associative relations with the remainder but associable _inter se_, establish a more or less highly organized nucleus of a second consciousness, a _condition seconde_. An hysterical symptom of long duration then corresponds to an intrusion of this _condition seconde_ into the somatic innervations usually controlled by normal consciousness; an hysterical attack, however, gives evidence of a higher organization of this _condition seconde_ and, when of recent origin, signifies the moment at which this hypnoid consciousness takes possession of the subject's whole personality (i.e. an acute hysteria); but recurring attacks which contain a memory signify a recurrence of this moment. Charcot has already suggested that the hysterical attack is probably the nucleus of a _condition seconde_. During the attack, control of the entire somatic innervation has passed to the hypnoid consciousness. Experience shows that in these cases normal consciousness is not always completely superseded; it may even perceive the motor phenomena of the attack while the psychic processes of the latter escape its notice.

The typical course of a severe hysteria is, as is well known, that first an ideational content is formed in hypnoid states, which then, when sufficiently developed, takes possession during a period of 'acute hysteria' of the somatic innervation and personality of the {40} patient, creates chronic symptoms and attacks, and then recedes until mere vestiges of it are left. If therefore the normal personality can regain control, what remains of the hypnoid ideational contents then returns in hysterical attacks and again temporarily produces in the patient similar states, which are again susceptible themselves and predisposing to the influence of traumas. A sort of equilibrium between the psychical groups united in the same personality is then frequently established; attacks and normal life exist side by side without affecting one another. The attacks then arise spontaneously, as memories commonly do; but they may also be provoked, just as any memory may be aroused according to the laws of association. Provocation of an attack occurs either by stimulation of an hysterogenic zone or by a new experience resembling the pathogenic experience. We hope to be able to show that no essential difference exists between the two conditions, apparently so distinct; that in both cases a hyperæsthetic memory has been stirred. In other cases this equilibrium is very unstable; the attack appears as an expression of the vestiges of hypnoid consciousness whenever the normal personality is exhausted and powerless. It is not impossible that in such cases the attack may be divested of its original significance and may return as a motor reaction without content.

It remains a task for further enquiry to discover what are the conditions determining whether in any given patient an hysteria will take the form of attacks, or chronic symptoms, or a combination of both.

It is now clear how the method of psychotherapy which we have just described leads to recovery. By providing an opportunity for the pent-up affect to discharge itself in words the therapy deprives of {41} its effective power the idea which was not originally abreacted; by conducting it into normal consciousness (in light hypnosis) it brings it into associative readjustment or else dispels it by means of the physicians' suggestion, as happens in cases of somnambulism combined with amnesia.

We regard the therapeutic effect achieved by employing this procedure as important. We naturally cannot cure that element in hysteria which is dispositional; we can do nothing against the return of hypnoid states. Even during the productive state of an acute hysteria our procedure cannot prevent the phenomena which have just been removed with such difficulty being forthwith replaced by new ones. But when the acute stage has passed off and its vestiges remain in the form of chronic hysterical symptoms and attacks our method will frequently remove them in turn, and the results are permanent because radical. It therefore appears to us that in this respect it far surpasses the effect of removal by direct suggestion which is now practised by psychotherapeutists.

Although, by thus disclosing the psychical mechanism of hysterical phenomena, we have now made a further step along the path which Charcot first opened up so successfully with his explanations and experimental imitations of hystero-traumatic paralyses, we nevertheless do not conceal from ourselves that it is only the mechanism of the hysterical symptom that has been brought within our grasp and not the inner causes of hysteria. We have but touched upon the ætiology of hysteria and have really only been able to throw light on the causes of its acquired forms---the significance of the accidental factor for this neurosis.

III {42} SOME POINTS IN A COMPARATIVE STUDY OF ORGANIC AND HYSTERICAL PARALYSES[7] (1893)

In 1885 and 1886, when I was his pupil, Charcot was good enough to entrust me with the task of making a comparative study of organic and hysterical motor paralyses, based upon observations at the Salpêtrière, which might serve to discover some of the common characteristics of neuroses and lead to a conception of their nature. Accidental and personal reasons prevented me from following his suggestion for a long time; even now I only intend to give an account of some of the results of my work, omitting the details needed for a complete demonstration of my views.

I must begin with some remarks on the nature of organic paralyses, which incidentally represent generally accepted conclusions. Clinical neurology recognizes two forms of motor paralyses: periphero-spinal (or bulbar) and cerebral. This distinction is entirely in harmony with the facts of the nervous system, which show that there are only two segments in the course of the motor fibres: one extending from the periphery to the anterior horn cells of the spinal cord, and a second which proceeds from here to the cerebral cortex. Modern neuro-histology, based upon the work of Golgi, Ramón y Cajal, Kölliker, etc., formulates these facts as follows: The path of fibres conducting motor impulses consists of two neurones (a {43} neuro-histological unit composed of a cell and its fibres) which meet in intimate relation at the so-called motor cells of the anterior horn. The essential clinical difference between these two types of paralysis is the following: _Periphero-spinal paralysis is a paralysis of individual elements while cerebral paralysis is a paralysis en masse_. Types of the former are the facial palsy of Bell, the paralysis in infantile anterior poliomyelitis, etc. Now in these diseases each muscle, we might say each muscle fibre, may be paralysed individually and in isolation. It depends only upon the site and extent of the nerve lesion; there is, moreover, no definite rule according to which one peripheral element escapes paralysis while another is permanently subject to it.

Cerebral paralysis, on the other hand, is always a disease affecting a considerable portion of the periphery, an extremity, a segment of it, or a complicated motor apparatus. It never affects one muscle alone, as for example, the biceps brachii or the tibialis; in any apparent exceptions to this rule (cortical ptosis, for example) it is evident that the muscles concerned are of the kind which in themselves fulfil a particular function---in which they are the sole agents.

It may be noted that in cerebral paralyses affecting the extremities distal segments always suffer more than proximal ones; the hand, for example, is more paralysed than the shoulder. As far as I know, there is no isolated cerebral paralysis of the shoulder in which the hand retains its motor power, while the reverse is the rule in incomplete paralyses.

In a critical study of aphasia, published in 1891 (_Zur Auffassung der Aphasien_, _Wien_, _1891_), I attempted to show that the cause of this important difference between periphero-spinal and cerebral paralysis was to be sought in the structure of the nervous system. Each element {44} in the periphery corresponds to one in the grey substance, which is, as Charcot expresses it, its neural terminus; the periphery is then, so to say, projected on to the grey substance of the spinal cord, point by point, element for element. I have proposed that the particularized periphero-spinal paralysis should be named 'projection paralysis'. The relation between the elements of the spinal cord and those of the cortex is, however, different. The number of conducting fibres would no longer suffice for a second projection of the periphery, to the cortex. We must suppose that the fibres coming from the spinal cord to the cortex no longer represent single peripheral elements, but rather a group of them; on the other hand, a peripheral element may correspond to several spino-cortical fibres. The change in arrangement occurs at the point where the two segments of the motor system meet.

Therefore I would say that the reproduction of the periphery in the cortex is no longer an accurate one, point for point; it is not a true projection. The relation is established so to say by representative fibres, and I propose therefore to name the cerebral form of paralysis 'representation paralysis'.

Naturally, when a projection paralysis is total and very extensive, it too becomes a paralysis _en masse_ and its striking distinctive characteristic disappears. Cortical paralysis, on the other hand, which is differentiated from the other cerebral paralyses by a greater tendency to dissociation, nevertheless invariably presents the character of a representation paralysis.

The other differences between projection paralysis and representation paralysis are well known. Among them I may mention the preservation of nutrition and of electrical reaction in the latter. Although {45} clinically very important, these signs have not the theoretical significance that is to be ascribed to the first differential trait mentioned, i.e., whether the paralysis be one of individual elements or _en masse_.

Hysteria has often been credited with the faculty of simulating the most varied kinds of organic nervous diseases. The question arises whether it can simulate accurately the characteristics of both types of organic paralysis, whether there are hysterical projection paralyses and hysterical representation paralyses, as in the organic symptomatology. An important fact at once confronts us here. Hysteria never simulates the periphero-spinal or projection paralyses; hysterical paralyses show the characteristics of organic representation paralyses only. This is indeed a very interesting fact, since Bell's palsy, musculo-spinal paralysis, etc., are among the most common diseases of the nervous system.

It should be noted in this connection, in order to avoid all confusion, that I am dealing only with flaccid hysterical paralyses and not with hysterical contractures. It seems to me impossible to apply the same rules to both hysterical paralyses and hysterical contractures. The contention that the paralysis never affects an isolated muscle (unless such a muscle be the sole agent of a function), that the paralysis is always _en masse_, agreeing in this respect with an organic cerebral representation paralysis, can only be maintained in respect of flaccid hysterical paralyses. Further, in regard to the nutrition and electrical reactions of the paralysed part hysterical paralysis shows the same characteristics as organic cerebral paralysis.

But although hysterical paralysis may be related in this way to cerebral and especially to cortical paralysis, which exhibits a {46} greater aptitude for dissociation, important distinctive traits are not lacking between them. In the first place, it is not subject to the constant fixed rule of organic cerebral paralyses, namely, that the distal segment is always more extensively affected than the proximal one. In hysteria, the shoulder or the thigh may be more seriously paralysed than the hand or the foot. Movements may occur in the fingers while the proximal part is still absolutely motionless. There is not the least difficulty in producing artificially an isolated paralysis of the thigh, of the leg, etc., and clinically we quite frequently meet with these isolated paralyses which do not conform to the rules of organic cerebral paralyses.

In this important respect hysterical paralysis is, so to speak, intermediate in type between projection paralysis and representation paralysis. On the one hand it does not possess all the characteristics of dissociation and isolation proper to the former; on the other hand it is by no means subject to the rules which strictly govern the latter. With these reservations we may say that hysterical paralysis also is a representation paralysis, but one possessing a special manner of representation which remains to be discovered.[8]

As a step in this direction I propose to study the other traits which differentiate hysterical paralysis from the most perfect form of {47} cerebral organic paralysis---namely, cortical paralysis. The first of these distinguishing characteristics has been mentioned, the fact that hysterical paralysis may be much more dissociated and systematised than cerebral paralysis. The symptoms of organic paralysis appear in hysteria as if apportioned. Hysteria reproduces the common organic hemiplegia (paralysis of the upper and lower extremities and of the lower half of the face) only to the extent of imitating the paralysis of the limbs; frequently it even splits off the paralysis of the arm from that of the leg, exhibiting with the greatest ease paralysis in the form of a monoplegia. It reproduces in an isolated form the motor aphasia seen in the syndrome of organic aphasia and, as I have observed in some unpublished cases, it can create a total aphasia (motor and sensory) for a given language, without affecting in the least the ability to understand and to speak another, a phenomenon unheard-of in organic aphasia. This power of dissociation is again manifested in those isolated paralyses in which one segment of a limb is affected while other portions of the same limb are entirely intact, and again, when one function is completely abolished (abasia astasia) while another function performed by the same organ is unaffected. The more complex the function in question, the more striking is this dissociation. In organic disease, whenever several functions are impaired in different degrees, it is always the most complex function, the one most recently acquired, that is most extensively affected by the paralysis.

In addition to the above, hysterical paralysis presents another characteristic, which is, as it were, the hall-mark of the neurosis. Indeed, as I heard Charcot say, hysteria is a malady with extravagant manifestations, with a tendency to produce its symptoms in the {48} severest possible degree. This characteristic is not met with only in the paralyses but also in the contractures and anæsthesias. The degree of distortion that may be produced by hysterical contractures is well known and is hardly equalled in organic symptomatology. We also know how frequently hysteria exhibits the absolute, profound anæsthesias, of which the organic lesions only reproduce a faint sketch. The same is true of the paralyses; they are often as complete as is possible. The hysterical aphasic does not utter a word, while the organic aphasic almost always retains a few syllables, 'yes', 'no', an oath, etc.; the paralysed arm is absolutely inert, and so on. This characteristic is too well known to dwell on it at length. On the other hand, it is known that in organic paralysis partial paresis is always more common than complete paralysis.

Hysterical paralysis, then, shows an _exact delimitation_ and an _excessive intensity_. It possesses these two qualities simultaneously, and it is in this respect that it contrasts most strongly with organic cerebral paralysis, in which these two characteristics are never associated. Monoplegias do exist in organic symptomatology also, but they are almost always monoplegias _a potiori_ and not sharply delimited. If an arm is paralysed in consequence of a cortical lesion, there is almost always a minor concomitant affection of the face and leg; and if this complication is no longer visible at a given period, it existed nevertheless at the beginning of the disease. Cortical monoplegia is indeed always a hemiplegia, of which one part or another has been more or less effaced but still remains recognizable. To go further, let us suppose that the paralysis has affected the arm alone, that it is a pure cortical {49} monoplegia; in such a case we shall see that the paralysis is one of moderate degree. As this monoplegia increases in degree, and as soon as it becomes a total paralysis, it at once loses its characteristic of being a pure monoplegia and will be accompanied by motor disturbances in the leg or the face. _It cannot become a complete paralysis and at the same time remain restricted in area_.

This is the very condition, however, that hysterical paralysis can easily accomplish, as we may see daily in clinical work. For example, it may affect the arm exclusively without showing a trace in the leg or the face. Further, in the arm it is as complete as a paralysis can possibly be, and this forms a striking contrast to organic paralysis, a difference that gives occasion for serious reflection.

There are, of course, cases of hysterical paralysis in which the degree of paralysis is not excessive and in which the dissociation offers nothing remarkable. Such cases are recognized by other traits; but they are cases that do not bear the typical stamp of neurosis and, since they cannot teach us anything about the nature of the latter, are of no interest for our present purpose.

Let me add a few remarks of minor importance, though they overstep the limits of my subject.

To begin with, I may recall the fact that hysterical paralyses are much more frequently accompanied by sensory disturbances than are organic paralyses; such disturbances are altogether more profound and frequent in neurosis than in organic disease. Nothing is more common than hysterical anæsthesia or analgesia. Recollect, in contrast to this, how obstinately sensation persists in cases of organic lesion. If a peripheral nerve is cut, the anæsthesia will be less extensive and intense than might be expected. When an inflammatory {50} process attacks the spinal nerves or the spinal cord centres the result always is that motility suffers in the first instance, while sensibility remains or is merely diminished; for some part of the nervous elements which have not been completely destroyed always persists. With cerebral lesions the frequency and the permanency of motor hemiplegia is well known, while the accompanying hemianæsthesia is vague and transitory, and is not always present. Only a few special localizations can produce a marked and lasting sensory disturbance (_carrefour sensitif_), and even this fact is not free from doubt.

This difference in the nature of the sensory disturbances in organic lesions and in hysteria is scarcely explicable with our present knowledge. The solution of this problem would probably reveal the core of the whole matter.

Another point that seems to me worthy of mention is that there are some forms of cerebral paralysis which, just like the periphero-spinal projection paralyses, are not found in hysteria. Paralysis of the lower half of the face, the most frequent manifestation of organic brain disease, should be mentioned first in this connection, and, if I may be permitted to enter the field of sensorial disturbances, homonymus lateral hemianopsia. I know that I run a risk in stating that a given symptom does not exist in hysteria when the researches of Charcot and his pupils are almost daily discovering new and hitherto unsuspected symptoms. But I must take things as they are at the moment. The existence of an hysterical facial paralysis is seriously contested by Charcot, and, even if we believe those who vouch for it, it is a very rare phenomenon. Hemianopsia has not as yet been seen in hysteria, and I believe it never will be. {51}

Now how is it that hysterical paralyses closely simulate cortical ones and yet differ from them in the distinctive characteristics that I have attempted to enumerate, and what is the special type of representation to which they conform? The answer to this question would embody a large and important part of the theory of this neurosis.

III

Not the least doubt exists about the conditions controlling the symptomatology of cerebral paralysis. They are the facts of anatomy---the structure of the nervous system, the distribution of its vessels and the inter-relation between these two sets of facts and the nature of the lesion. We have said that the basis of the difference between the projection paralysis and the representation paralysis lies in the smaller number of fibres proceeding from the spinal cord to the cortex in comparison with the number proceeding from the periphery to the spinal cord. Again, every clinical detail of a representation paralysis finds its explanation in some detail of cerebral anatomy and, _vice versa_, we can deduce the structure of the brain from the clinical characteristics of the paralyses. We believe that a perfect parallel exists between these two series of facts.

Thus if cerebral paralysis does not show any great tendency to dissociation, it is because the fibres conducting motor impulses run too close together for a great part of their intra-cerebral course for them to be injured individually. If cortical paralysis shows a greater tendency to monoplegias, it is because the diameter of the conducting bundle, brachial, crural, etc., goes on increasing up to the cortex. If paralysis of the hand is the most complete of all the cortical ones, it is, I believe, because the contralateral relation between hemisphere and periphery is more nearly complete for the hand {52} than for any other part of the body. If the distal segment of an extremity suffers a greater degree of paralysis than a proximal segment, it may be assumed that the representative fibres of the distal segment are more numerous than those of the proximal one, so that the influence of the cortex is more important for the former than for the latter. If moderate-sized lesions of the cortex do not succeed in producing pure monoplegias, we infer from this that the motor centres of the cortex are not cleanly separated from one another by indifferent areas, or that there are factors operating at a distance (_Fernwirkungen_) which nullify the effect of an exact separation of the centres.

Similarly, if disturbances of various functions are always found in a mixed form in organic aphasia, this is explained by the fact that branches of the same artery nourish all the speech centres, or, if the view expressed in my critical study of aphasia is accepted, it is because we are dealing, not with separate centres, but with a continuous association area. In any event, there is always some reason to be found in anatomy for these things.

The remarkable combinations which are so often observed in the symptomatology of cortical paralyses (motor aphasia and right hemiplegia, alexia and right hemianopsia) are explained by the proximity of the injured centres. Hemianopsia itself, a symptom that seems curious and strange to the unscientific mind, is only explicable by the crossing of the fibres of the optic nerve at the chiasma; like all the details of cerebral paralyses it is the clinical expression of an anatomical fact.

Since there cannot be more than one authentic cerebral anatomy, and since that one is expressed in the clinical characteristics of {53} cerebral paralyses, it is evidently impossible for that anatomy to explain the distinctive traits of hysterical paralyses. For this reason we should not draw conclusions about cerebral anatomy based upon the symptomatology of these paralyses.

We must certainly turn our attention to the nature of the lesion to find this difficult explanation. In organic paralyses the nature of the lesion plays a secondary part, it is rather the extent and localization of it that, under the given conditions of the structure of the nervous system, produce the characteristics of organic paralysis we have mentioned above. What can be the nature of the lesion in hysterical paralysis which alone dominates the situation, independent of localization, of extent, and of the anatomy of the nervous system?

Charcot constantly taught us that it is a cortical lesion, but one of a purely dynamic or functional kind.

It is easy to understand the negative side of this proposition. It is equivalent to affirming that no appreciable tissue changes will be found _post mortem_; but regarded from a positive stand-point, it is far from being devoid of ambiguity. After all, what is a dynamic lesion? I am sure that many who read the works of Charcot think that dynamic lesion is indeed a lesion, but a lesion of which no trace is found after death, like œdema, anæmia, active hyperæmia. But the latter, although they do not necessarily persist after death, are true organic lesions, however insignificant and transitory. Paralyses produced by lesions of this type partake, necessarily, of all the characteristics of organic paralyses. Œdema and anæmia could no more produce the dissociation and intensity of an hysterical paralysis than could hæmorrhage and softening. The only difference would be that a {54} paralysis produced by œdema, by vascular constriction etc., would be less lasting than a paralysis caused by the destruction of nervous tissue. All the other conditions are common to both, and the anatomy of the nervous system will determine the characteristics of a paralysis in a case of transitory anæmia no less than in a case of permanent anæmia.

I do not think that these remarks are wholly uncalled-for. Reading 'there must be an hysterical lesion' in a given centre (the same centre an organic lesion of which would produce the corresponding organic syndrome) and recollecting that it is customary to localize the dynamic hysterical lesion in the same way as the organic lesion, we are led to believe that there lurks behind the expression 'dynamic lesion' the idea of a lesion like œdema and anæmia, which are in fact transitory organic affections. I maintain on the contrary that the lesion in hysterical paralyses must be entirely independent of the anatomy of the nervous system, since _hysteria behaves in its paralyses and other manifestations as if anatomy were non-existent, or as if it had no knowledge of it_.

Indeed, a good number of the features of hysterical paralyses justify this statement. Hysteria is ignorant of the distribution of the nerves and for this reason does not simulate the periphero-spinal or projection paralyses; it is not acquainted with the optic chiasma and consequently does not produce a hemianopsia. It regards the organs according to the common popular meaning of their names: the leg is the leg up to its insertion into the hip, the arm is the upper extremity as mapped out by our clothing. It would see no reason for combining a facial paralysis to a brachial one. An hysterical patient who loses the power of speech has no motive for forgetting the meaning of {55} language, since motor aphasia and word-deafness are not related in the popular mind. On this point I must agree completely with the views expressed by Janet in the latest numbers of the _Archives de Neurologie_; hysterical paralyses demonstrate their truth just as well as anæsthesias and psychic symptoms do.

I shall now try finally to suggest what might be the lesion that causes hysterical paralyses. I do not claim that I shall demonstrate what it actually is; it is merely a matter of pointing out a line of thought that may lead to a concept not in contradiction with the features of hysterical paralysis, in so far as this differs from organic cerebral paralysis.

I will take the word 'functional or dynamic lesion' in its proper sense: 'alteration in function or mechanism', alteration in a functional attribute. Such an alteration, for example, would be a diminution in excitability or in a physiological quality which in the normal state remains constant or varies within fixed limits.

But it will be said that a functional alteration is only an organic one considered from a different aspect. Let us suppose that nervous tissue is in a state of transitory anæmia, its excitability will be diminished by that circumstance; it is not possible by this means to avoid considering organic lesions.

I will try to show that a functional alteration may exist without an accompanying organic lesion, at least without a lesion capable of detection even by means of the most delicate methods. In other words, I will give an appropriate example of a primary functional change; to do so, I only ask permission to pass over into the field of psychology, which cannot be ignored in dealing with hysteria. {56}

With Janet I maintain that it is the common, popular idea of the organs and of the body in general that is at work in hysterical paralyses as well as in anæsthesias, etc. This idea is based, not upon a profound knowledge of neuro-anatomy, but upon our tactile and, above all, our visual perceptions. If it determines the characteristics of hysterical paralysis the latter must prove to be ignorant and independent of any idea of the anatomy of the nervous system. The lesion of hysterical paralysis will be an alteration of the concept, of the idea 'arm', for example. But what kind of alteration in regard to the concept is capable of producing a paralysis?

Psychologically considered, the paralysis of the arm is embodied in the fact that the concept 'arm' cannot enter into association with those other ideas that make up the ego, of which the body of the individual is an important part. The lesion, then, would consist in the abolition of the accessibility of the concept 'arm' in association. The arm acts as if it did not exist in the interplay of associations. Of course, if the physical conditions corresponding with the concept 'arm' are profoundly changed then the concept will also be lost, but I must show that it may be inaccessible without being destroyed and without its physical substratum (the nervous tissue of the corresponding cortical area) being damaged.

I will commence with examples taken from ordinary life. A comic story is told of a loyal subject who would no longer wash his hand because his sovereign had touched it. The relation of this hand to the idea 'king' seems to be so important for the psychic life of this person that he refused to let it enter into other relations. We obey the same impulse when we break the glass in which we have drunk the health of a newly-married couple. Ancient savage tribes, in burning the horse, the {57} weapons, and even the wives of a deceased chief together with his body, followed a similar idea that no one should touch them after him. The motive for all these acts is clear. The affective value which attaches to the first association is reluctant to let the object enter into a new association with another object and consequently renders the idea inaccessible to association.

If we now pass on to the field of the psychology of concepts we find that this is not a simple comparison but an almost identical situation. If the concept 'arm' is attached to an association of great affective value it will be inaccessible to the free play of other associations. The arm will be paralysed in proportion to the persistence of that affective value or to the diminution in the latter effected by suitable psychic measures. This is the solution of the problem that we have raised; for in every case of hysterical paralysis we find that the paralysed organ or the abolished function is engaged in a subconscious association endowed with great affective value, and it may be demonstrated that the arm becomes free as soon as this affective value is removed. The concept 'arm' exists, then, in the physical substratum; but it is not accessible to conscious associations and volition because its entire associative affinity, so to speak, is saturated by a subconscious association with the recollection of the event, of the trauma, that produced the paralysis.

Charcot was the first to teach us that we must turn to psychology for the explanation of the hysterical neurosis. Breuer and I have followed his example in a preliminary paper.[9] In this paper we show that the permanent symptoms of so-called non-traumatic hysteria (the stigmata excepted) may be explained by the same mechanism that Charcot {58} recognized in traumatic paralyses. But we also give the reasons why these symptoms persist and why they can be cured by a special form of hypnotic psychotherapy. Every occurrence, every psychic impression is supplied with a certain affective value (_Affektbetrag_), of which the ego rids itself either by means of a motor reaction or by a process of mental association. If the person cannot or will not free himself of this excess, the memory of the impression acquires the importance of a trauma and becomes the cause of the permanent symptoms of hysteria. When the impression remains subconscious its elimination is impossible. We have called this theory: _Das Abreagieren der Reizzuwächse_ (the abreaction of an accumulation of stimuli).

To sum up, I think that it is quite in harmony with our general conception of hysteria, formed from the teachings of Charcot, to state that the lesion in hysterical paralyses consists of nothing but the inaccessibility of the concept of the organ or function to the associations of the conscious ego; that this purely functional change (the concept itself being intact) is caused by the fixation of that concept in subconscious association with the memory of the trauma; and that this concept cannot become free or accessible as long as the affective value of the psychic trauma has not been eliminated by an adequate motor reaction or a conscious psychic process. Even if this mechanism does not take place, if a direct auto-suggestive idea is always necessary in an hysterical paralysis, as in the traumatic cases of Charcot, we have succeeded in showing what the nature of the lesion, or rather of the change, in hysterical paralysis may be, so as to explain the differences between it and organic cerebral paralysis.

IV {59} THE DEFENCE NEURO-PSYCHOSES[10]

An endeavour to provide a psycho- logical theory of acquired hysteria, many phobias and obsessions, and certain hallucinatory psychoses.

(1894)

After a close study of several patients suffering from phobias and obsessions a tentative explanation of these symptoms forced itself upon me; and as it later enabled me successfully to divine the origin of similar pathological ideas in other cases, I consider it worthy of publication and of further tests. Along with this 'psychological theory of phobias and obsessions', observation of these patients has resulted in a contribution to the theory of hysteria, or rather an alteration in it, which appears to account for an important characteristic common both to hysteria and to the neuroses mentioned above. Further, I had opportunities of gaining some insight into the psychological mechanism of a form of disease that is undoubtedly of mental origin, and then found that the tentative point of view I had adopted established an intelligible connection between these psychoses and the two neuroses mentioned. At the end of this essay I shall bring forward an hypothesis which I have employed in all three cases.

Let me begin with the alteration that in my view we are called upon to make in the theory of the hysterical neurosis. {60}

Since the publication of the fine work carried out by P. Janet, J. Breuer and others, it may be taken as generally acknowledged that the syndrome of hysteria, in so far as it permits of understanding up to the present, justifies the concept of a splitting of consciousness, with the formation of separate psychical groups; opinions are less definite, however, concerning the origin of this splitting of consciousness and the part which this character plays in the structure of the hysterical neurosis.

According to Janet's theory[11] the splitting of consciousness is a primary feature of the hysterical change. It is dependent on an inborn weakness in the capacity for psychical synthesis, on the narrowness of the 'field of consciousness' (_champ du conscience_) which in the form of a psychic stigma is evidence of the degeneration of hysterical persons.

In contradistinction to Janet's view, which seems to me to admit of many and various objections, we have that advocated by J. Breuer in our joint publication[12]. According to Breuer, the 'foundation and condition' of hysteria is the occurrence of peculiar dream-like states of consciousness with diminished capacity for association, for which he suggests the name 'hypnoid states'. The splitting of consciousness is then secondary and acquired; it occurs because the ideas which emerge in hypnoid states are cut off from associative connection with the remaining contents of consciousness.

I can now bring forward evidence of two other more extreme forms of hysteria in which it is impossible to regard the splitting of consciousness as primary in Janet's sense. In the first of these forms I repeatedly succeeded in demonstrating that the splitting of the {61} contents of consciousness is the consequence of a voluntary act on the part of the patient; that is to say, it is instituted by an effort of will, the motive of which is discoverable. By this I do not of course mean that the patient intends to produce a splitting of his consciousness; the patient's aim is a different one, but instead of attaining its end it produces a splitting of consciousness.

In the third form of hysteria, as shown by the mental analysis of intelligent patients, the splitting of consciousness plays an insignificant part, or perhaps none at all. These are the cases in which all that had happened was that the reaction to traumatic stimuli had failed to occur, so that they are accordingly dissolved and cured by 'abreaction'[13]---they are the pure 'retention' hysterias.

In connection with what I have to say about phobias and obsessions I shall here deal only with the second form of hysteria, which for reasons that will soon be evident I shall designate as _defence hysteria_, and distinguish by this name from _hypnoid_ and _retention hysteria_. I may also provisionally represent my cases of defence hysteria as cases of 'acquired hysteria', because there was in them no question either of grave hereditary taint or of individual atrophic degeneration.

These patients whom I analysed had enjoyed good mental health up to the time at which an intolerable idea presented itself within the content of their ideational life; that is to say, until their ego was confronted by an experience, an idea, a feeling, arousing an affect so painful that the person resolved to forget it, since he had no confidence in his power to resolve the incompatibility between the {62} unbearable idea and his ego by the processes of thought.

Such unbearable ideas develop in women chiefly in connection with sexual experiences and sensations, and the patients can recollect with the most satisfactory minuteness their efforts at defence---their resolution to 'push the thing out', not to think of it, to suppress it. I will give from my experience some examples which I could easily multiply: A young girl who disapproved of herself because while nursing her sick father she had let her mind dwell on the thought of a young man who had made a slight erotic impression on her; a governess who had fallen in love with her employer and had resolved to thrust this affection from her mind because it appeared to her incompatible with her pride; and so on.[14]

I do not of course assert that an effort of will to thrust such things out of the mind is a pathological act, nor am I able to say whether and in what manner intentional forgetting is successful in people who remain healthy, although subject to similar mental impressions. I only know that this kind of 'forgetting' did not succeed with the patients whom I analysed, but led to various pathological reactions, giving rise either to hysteria, or to an obsession, or to an hallucinatory psychosis. The ability to bring about by an effort of will one of these states, which are all of them associated with splitting of consciousness, is to be regarded as the manifestation of a pathological disposition---which, however, is not necessarily identical with personal or hereditary 'degeneration'.

In regard to the intermediate processes between the patient's effort of will and the onset of the neurotic symptom, I have formed an opinion which may be expressed in the customary psychological {63} abstractions somewhat as follows: The task which the ego undertakes in defence---of treating the unbearable idea as '_non arrivée_'---is absolutely insoluble; both the memory-trace and the affect attached to the idea are there once and for all, and it is no longer possible to extirpate them. But it amounts to an approximate fulfilment of this task if the ego succeeds in transforming a strong idea into a weak one, in depriving it of its affect---the quantity of excitation with which the idea is charged. The weak idea will then make practically no demands on the work of association; the quantity of excitation, however, which is then detached from the idea, must be utilized in another direction.

Up to this point the processes are the same in hysteria and in phobias and obsessions; from now onwards their ways diverge. In hysteria the unbearable idea is rendered innocuous by the quantity of excitation attached to it being transmuted into some bodily form of expression, a process for which I should like to propose the name of _conversion_.

The conversion may be either total or partial, and it proceeds along the line of the motor or sensory innervation that is more or less intimately related to the traumatic experience. Thus the ego succeeds in resolving the incompatibility within itself; but instead it has burdened itself with a memory-symbol, which dwells in consciousness, like a sort of parasite, either in the form of a persistent motor innervation or else as a constantly recurring hallucinatory sensation, and remains until a reversion takes place in the opposite direction. The memory-trace of the repressed idea is not, however, annihilated by this process; on the contrary, from now onwards it forms the nucleus of a secondary psychical group. {64}

I will only add a few more words to this conception of the psycho-physical processes in hysteria. When once such a nucleus of an hysterical splitting has been formed owing to a 'traumatic' factor it will be developed by the influence of other factors (which might be called 'auxiliary traumatic' factors) as soon as an impression of a similar kind, subsequently experienced, succeeds in breaking through the barriers erected by the will, in furnishing the weakened idea with fresh affect and in re-establishing for a time an associative connection between the two psychical groups---until a further conversion creates a defence against it. The distribution of excitation thus brought about in hysteria proves as a rule an unstable one; the excitation which is directed into a wrong channel (into somatic innervation) now and then finds its way back to the idea from which it was detached, and then compels the subject either to undertake the work of associative absorption or else to discharge it by the way of hysterical attacks---a conclusion which is supported by the familiar opposition between the hysterical attack and chronic symptoms. Breuer's cathartic method achieves its results by deliberately effecting such a re-transmutation of the excitation from the somatic into the mental field, in order then to enforce a resolution of the opposed elements by a process of thought and a discharge of the excitation in speech.

The conclusion that the splitting of consciousness in acquired hysteria is based on an act of will also explains with surprising simplicity the remarkable fact that hypnosis regularly widens the narrowed consciousness of the hysteric and makes the psychical group which has been split off accessible. Indeed, we know it to be a peculiarity of all sleep-like conditions that they abrogate that distribution of excitation upon which the 'will' of the conscious {65} personality depends.

Thus we can see that the characteristic factor in hysteria is not to be found in the splitting of consciousness but in the _capacity for conversion_, and we may assume that the psycho-physical capacity to transmute such large quantities of excitation into somatic innervation is an important element of the disposition to hysteria, which in other respects is still unknown.

This capacity does not in itself preclude mental health and leads to hysteria only where there is some mental incompatibility or an accumulation of excitation. With this new turn in the theory Breuer and I approach Oppenheim's[15] and Strümpell's[16] well-known definition of hysteria, and recede from Janet[17] who assigns too great importance to the splitting of consciousness as a characteristic of hysteria. The presentation here given may claim to have rendered the relation between conversion and the hysterical splitting of consciousness intelligible.

If the capacity for conversion does not exist in a person predisposed to hysteria and yet the separation of its affect from an unbearable idea is nevertheless undertaken as a defence against the latter, then {66} this affect must persist in the psychical sphere. Thus weakened, the idea remains present in consciousness, detached from all associations; but its affect, now freed from it, attaches itself to other ideas which are not in themselves unbearable, but which through this 'false connection' grow to be obsessions. This is shortly the psychological theory of obsessions and phobias which I mentioned to start with.

I will now enumerate the various elements necessary to the structure of this theory that admit of direct proof, and then describe those that I have myself supplied. Apart from the final result of the process, that is, the obsession, it is possible in the first place to demonstrate the ultimate source of the affect which is now falsely attached to some other idea. In all the cases I have analysed it was in the sexual life that a painful affect---of precisely the same quality as that attaching to the obsession---had originated. On theoretical grounds it is not impossible that this affect may at times arise in other spheres; I have merely to state that hitherto I have not discovered any other origin of it. Incidentally, it is easy to see that it is precisely in regard to the sexual life that unbearable ideas most frequently arise.

Further, we have the most unequivocal utterances on the part of patients in proof of the effort of will, the attempt at defence, upon which the theory lays emphasis; and in at least a number of cases the patients themselves will inform us of the fact that the phobia or obsession first made its appearance after this effort of will had apparently succeeded in its aim. 'Once something very disagreeable happened to me, and I did my utmost to thrust it out of my mind, to think no more about it. Finally I succeeded, but then I got this, which since then I have never been rid of.' With these words a patient {67} confirmed the chief points of the theory I have developed here.

Not all those who suffer from obsessions are themselves so clear about the origin of them. As a rule, when one draws these patients' attention to the original idea of a sexual nature, the answer is, 'It can't come from that; indeed, I thought very little about that. For a moment I was scared, but I turned my mind to something else and since then it hasn't troubled me.' In this frequent objection we have a proof that the obsession represents a substitute or surrogate for the unbearable sexual idea, and has taken its place in consciousness.

Between the patient's effort of will which successfully represses the intolerable sexual idea, and the appearance of the obsessional idea, which though having little intensity in itself is now endowed with incomprehensibly strong affect, there lies a gap which the theory here developed aims at filling in. The detachment of the sexual idea from its affect and the connection of the latter with another idea, suited to it but not intolerable, are processes which occur outside consciousness---they may be presumed but they cannot be proved by any clinical-psychological analysis. Perhaps it would be more correct to say: These processes are not of a psychical nature at all, but are physical processes the psychical consequences of which are so represented as if what is expressed by the words 'detachment of the idea from its affect and false connection of the latter' had really happened.

Alongside the cases which show the unbearable sexual idea followed subsequently by the obsession, there is another series in which obsessions and painful sexual ideas are present simultaneously. We cannot very well call the latter 'sexual obsessions', for _one_ essential feature of obsessions is missing from them; they are fully {68} justified, whereas the painfulness of the ordinary obsession constitutes a problem for both physician and patient. So far as I have been able to see in cases of this kind, it appears that in them a perpetual defence is going on against sexual ideas continually arising anew; that is, we are here concerned with an operation that has not yet been completed.

As long as they are conscious of the sexual origin of their obsessions, the patients often keep them concealed. When they complain about them, they as a rule express their astonishment that they are subject to the affect in question---that they feel anxious, or that they have such and such an impulse, and so on. To the experienced physician this affect appears, on the contrary, to be justified and comprehensible; he only finds it surprising that an affect of that kind should be associated with an inappropriate idea. The affect of the obsession appears to him, in other words, to be _dislocated_ or _transposed_, and if he is proceeding on the assumptions here laid down he can in a great number of cases attempt its re-translation into the sexual.

Any idea which is either suited by nature to be associated with an affect of this quality or else bears a certain relation to the unbearable idea---in consequence of which it appears practicable to employ it as a surrogate for the latter---may be made use of in secondary connection with the detached affect. Thus for example, an unattached anxiety, the sexual origin of which the patient is unable to recall, will seize upon the common primary phobias of mankind in regard to animals, thunderstorms, darkness and the like, or upon things which are manifestly associated with the sexual in some way or other, such as urination, defæcation, defilement and contagion generally. {69}

The ego gains considerably less advantage by choosing the method of _transposition_ of affect as a measure of defence than it does by the hysterical conversion of psychical excitation into somatic innervation. The affect which the ego had to endure remains unchanged and undiminished, just as before---the only difference being that the unbearable idea is suppressed and cut off from recollection. The repressed ideas then form again the nucleus of a second psychical group, which, as it seems to me, is accessible even without the aid of hypnosis. If in phobias and obsessions the striking symptoms which in hysteria accompany the formation of an independent psychical group fail to appear, this is probably because in the former the whole transformation takes place within the psychical sphere---the relation between psychical excitation and somatic innervation has undergone no change.

To illustrate what has been said concerning obsessions I will give a few examples, which are probably typical:

1. A young girl suffered from obsessive reproaches. If she read in the papers about counterfeiting coinage the thought occurred to her that she also had forged coins; if an unknown criminal had committed a murder she asked herself anxiously whether she had not done the deed. At the same time she was quite conscious of the absurdity of these obsessive reproaches. This sense of guilt gained for a time such an influence over her that her critical faculty was stifled, so that she accused herself to her relations and her physician of having really committed all these crimes (psychosis through simple intensification---overwhelming-psychosis---_Überwältigungspsychose_). A close examination then revealed the source in which her sense of guilt arose: Accidentally stimulated by a voluptuous sensation, she had {70} allowed herself to be led astray by a friend into masturbation and had practised it for years, with full knowledge of her wrong-doing and accompanied by most intense self-reproaches, which as usual were of no avail. An excessive indulgence after attending a ball had evoked the intensification leading to the psychosis. After a few months of treatment and close watching the patient was cured.

2. Another young girl had suffered from the dread of being forced to pass water and wet herself ever since the time when an impulse of this kind had really obliged her to leave a concert during a performance. This phobia had gradually made her completely unable to enjoy herself or to go into society. She only felt well if there was a closet near at hand to which she could have access without arousing attention. Any organic complaint justifying this lack of confidence in her control of the bladder was excluded; at home under quiet conditions and at night the urgency did not arise. A penetrating enquiry showed that the urgency had appeared for the first time in the following circumstances: A gentleman to whom she was not indifferent had been sitting not far from her at the concert; she began to think about him and to imagine how she would sit beside him as his wife. During this erotic reverie she had that bodily sensation which is to be compared with erection in men and which in her case---I do not know if it is always so---ended with a slight desire to micturate. She became greatly frightened by the sexual sensation, to which she was otherwise quite accustomed, because she had resolved within herself to overcome her affection for this man as well as for all others, and the next moment the affect transferred itself to the accompanying desire to micturate and compelled her to leave the hall after a very painful {71} struggle. In her life she was so prudish that she positively shuddered at anything sexual and could not even contemplate the thought of marrying; on the other hand, she was sexually so hyperæsthetic that during every erotic reverie, which she willingly indulged in, that pleasurable sensation appeared. The erection was always accompanied by the desire to micturate which, up to the time of the scene at the concert, had made no impression on her. Treatment led to a nearly complete mastery of the phobia.

3. A young woman who in five years of married life had had only one child complained to me of an obsessive impulse to throw herself from the window or balcony, and also of the fear of stabbing her child which seized her at the sight of a sharp knife. She confessed that marital relations seldom occurred, and only with precautions against conception; but she added that this was no privation to her as she was not of a sensual nature. I ventured to tell her that at the sight of a man she had erotic ideas and that she had therefore lost confidence in herself and regarded herself as a depraved person, capable of anything. The re-translation of the obsession into the sexual was successful; in tears she confessed at once to her long-concealed misery in her marriage and later on related in addition some painful thoughts of an unchanged sexual nature, such as the often-recurring sensation of something forcing itself under her skirts.

I have turned experiences of this kind to therapeutic advantage by re-directing the attention of patients with phobias and obsessions, in spite of all their protestations, back to the repressed sexual ideas and, where feasible, in blocking the source whence they arose. I {72} naturally cannot assert that _all_ phobias and obsessions arise in the manner here described; for, first, my experience of them embraces only a limited number as compared with the relative frequency of these neuroses, and secondly, I myself know that these 'psychasthenic' symptoms, as Janet terms them, are not all to be estimated alike.[18] There are, for example, pure hysterical phobias. I believe, however, that the mechanism of transposition of affect will be found to exist in the great majority of phobias and obsessions; and I would therefore urge that these neuroses, which are as often found in an isolated form as combined with hysteria or neurasthenia, should not be loosely classified together with ordinary neurasthenia, in which there is absolutely no ground for assuming a psychical mechanism of the principal symptoms.

III

In both the cases described above defence against an unbearable idea was effected by detachment of its affect from it; the idea itself remained in consciousness, although weakened and isolated. Now there exists a very much more energetic and successful kind of defence, which takes the following form: the ego rejects the unbearable idea together with its associated affect and behaves as if the idea had never occurred to the person at all. But, as soon as this process has been successfully carried through, the person in question will have developed a psychosis, and his state can only be described as one of 'hallucinatory confusion'. A single example will serve to illustrate {73} this.

A young girl gave her first impulsive affection to a man and firmly believed in the return of her love. As a matter of fact she was mistaken; the young man had another motive for visiting the house. Disappointments were not spared her; first of all she defended herself against her experiences by means of hysterical conversion, thus preserving her belief that he would one day come and seek her hand; but at the same time she felt unhappy and ill on account of incomplete conversion and of the perpetual experience of fresh painful impressions. Finally on a certain day, the day of a family festival, she waited for him in a state of intense excitement. The day wore on without his coming; after all the trains by which he could arrive had gone by, her condition passed into one of hallucinatory confusion. He _is come_, she hears his voice in the garden, hastens downstairs in her night-dress to receive him. From that time she lived for two months in a happy dream, of which the content was that he is there, ever by her side, everything is as it was a little while ago (before the time of the disappointment against which she had so strenuously defended herself). The hysteria and the depression of spirits were both overcome; nothing of the latter period of doubt and suffering was alluded to during her illness; she was happy as long as she was left undisturbed, and only raved when some circumstance of her surroundings prevented her from carrying out the logical promptings of her blissful dream. This psychosis, which at the time of its occurrence had been unintelligible, was explained ten years later with the aid of an hypnotic analysis.

The fact to which I now wish to call attention is that the content of such an hallucinatory psychosis consists precisely in the accentuation {74} of the very idea which was first threatened by the experience occasioning the outbreak of the illness. One is therefore justified in saying that the ego has averted the unbearable idea by a flight into psychosis; and the process by which this result is obtained again withdraws itself out of range of self-perception as well as of psychological-clinical analysis. It is to be regarded as the expression of a high degree of pathological predisposition and may perhaps be described somewhat as follows: The ego has broken away from the unbearable idea; but, the latter being inseparably bound up with a part of reality, in so far as the ego achieves this result it has also cut itself loose from reality, totally or in part. In my opinion, this is the condition under which certain ideas acquire hallucinatory vividness, and consequently when this form of defence is successfully carried through the person finds himself in a state of hallucinatory confusion.

I have very few analyses of psychoses of this kind at my disposal; but I think we must here be concerned with a type of psychical illness that is very frequently developed, for in no insane asylum are analogous examples wanting---for instance, the mother who, falling ill after the loss of her baby, is to be seen incessantly rocking a log of wood in her arms, or the jilted bride arrayed in all her finery who has for years been awaiting her betrothed.

It is perhaps not superfluous to point out that the three modes of defence here described, together with the three forms of illness to which they lead, may all be combined in the same person. The simultaneous appearance of phobias and hysterical symptoms, observed so often in practice, is one of those factors which render it difficult to distinguish hysteria in a clear-cut manner from other {75} neuroses, and make it necessary to set up the category of 'mixed neuroses'. To be sure, hallucinatory confusion is not often compatible with a continuance of hysteria, nor of obsessions, as a rule. On the other hand, it is not rare for a defence psychosis to break out episodically in the course of an hysterical or mixed neurosis.

I should like finally to dwell for a moment on the hypothesis which I have made use of in the exposition of the defence neuroses. I mean the conception that among the psychic functions there is something which should be differentiated (an amount of affect, a sum of excitation), something having all the attributes of a quantity---although we possess no means of measuring it---a something which is capable of increase, decrease, displacement and discharge, and which extends itself over the memory-traces of an idea like an electric charge over the surface of the body. We can apply this hypothesis, which by the way already underlies our theory of 'abreaction',[19] in the same sense as the physicist employs the conception of a fluid electric current. For the present it is justified by its utility in correlating and explaining diverse psychical conditions.

V {76} THE JUSTIFICATION FOR DETACHING FROM NEURASTHENIA A PARTICULAR SYNDROME: THE ANXIETY-NEUROSIS[20] (1894)

It is difficult to say anything of general validity concerning neurasthenia so long as we allow this name to cover all that Beard included under the term. In my opinion, nothing but gain to neuropathology can result if we make an attempt to distinguish from neurasthenia proper all those neurotic disturbances of which the symptoms, on the one hand, are more closely related to one another than to the typical symptoms of neurasthenia (headache, spinal irritation, and dyspepsia with flatulence and constipation) and, on the other hand, show in their ætiology and their mechanism essential differences from typical neurasthenia. If we accept this plan we shall soon obtain a more or less uniform picture of neurasthenia; and shall then be in a position to differentiate more sharply than had hitherto been possible between neurasthenia proper and various kinds of pseudo-neurasthenia, such as the clinical picture of the organically determined nasal reflex neurosis, the nervous disorders of the cachexias and arterio-sclerosis, the early stages of general paralysis of the insane and of the psychoses. Further, it will be possible---as Möbius proposed---to eliminate many of the nervous conditions of the hereditarily degenerate; and we shall also find good reason to include {77} under melancholia many neuroses (especially intermittent and periodic types) which are to-day called neurasthenia. But the most decisive change of all will be introduced if we decide to distinguish from neurasthenia the syndrome I here propose to describe, which fulfils with unusual completeness the conditions set forth above. The symptoms of this syndrome are clinically much more closely related to one another than to those of neurasthenia proper (that is, they frequently appear together and replace each other during the course of the illness), while the ætiology and mechanism of this neurosis are essentially different from what remains of true neurasthenia after this subtraction has been made from it.

I call this syndrome 'Anxiety-Neurosis', because all its component elements can be grouped round the central symptom of 'morbid anxiety' and because individually they each have a definite connection with this. I believed that this conception of the symptoms of the anxiety-neurosis had originated with myself until an interesting paper by E. Hecker[21] came into my hands, in which I found the same idea expounded with the most satisfying clearness and completeness. Although Hecker recognizes certain symptoms as equivalents or incomplete manifestations of an anxiety-attack, he does not separate them from neurasthenia as I propose to do; this is evidently due to his not having taken into account the difference in the ætiological conditions of the two forms of disease. When this last difference between them is fully recognized, we have no longer {78} any motive for designating anxiety symptoms by the same term as those of neurasthenia proper; for the purpose served by giving a name, however arbitrary it may be in other respects, is above all that of enabling us more easily to form generalizations.