For a long time I have entertained the suspicion that paranoia, or groups of cases belonging to it, is also a defence-psychosis; that is to say, that it results from the repression of painful memories, as do hysteria and obsessions, and that the form of the symptoms is determined by the content of the repressed memory. A special path or mechanism of repression, however, must be peculiar to paranoia; just as in hysteria the repression is effectively established by means of _conversion_ into bodily innervation, and in the obsessional neurosis by means of _substitution_ (displacement along certain associated channels). I observed several cases which favoured this view, but had {170} found none which proved it until I had the opportunity some months ago through the kindness of Dr. J. Breuer of undertaking psycho-analytic treatment of an intelligent woman, aged thirty-two, in whose case the diagnosis of chronic paranoia was undeniable. I am already here reporting a few of the points which it was possible to obtain light upon in the course of this piece of work, because I have no opportunity of studying paranoia except in very isolated cases, and because I consider it possible that these observations may induce a psychiatrist more favourably situated than I to bring the factor of 'defence' into its rightful place in the discussion, now so brisk, on the nature and psychical mechanism of paranoia. On the basis of a single observation I should naturally not think of going further than some such conclusion as this: this case is a defence-psychosis and in the category of paranoia there are probably others like it.

Frau P., thirty-two years of age, three years married and the mother of a two-year-old child, was born of parents who were not nervous; her brother and sister I knew, however, to be also neurotic. It is doubtful whether she was not temporarily depressed and confused in her judgement in her twenties; in later years she was healthy and active until six months after the birth of her child when she showed the first symptoms of her present illness. She became uncommunicative and distrustful, showed a disinclination to meet her husband's family and complained that the neighbours in the small town where she lived had changed towards her and were now rude and disagreeable. By degrees these complaints increased in intensity, though not in definiteness: people had something against her, although she had no notion what it could be; there was not the slightest doubt that everyone---relations {171} and friends---had ceased to respect her, and that they did all sorts of things to wound her; she racked her brains to find the reason for this, but could not discover it. Somewhat later she complained that she was being watched, that people read her thoughts, that they knew everything that went on in her house. One afternoon she suddenly got the idea that people watched her undressing at night. From that time onwards she employed the most complicated precautions when undressing, slipping into bed in the dark and undressing under the bedclothes. Since she cut herself off from the world, ate little, and was very depressed, she was sent in the summer of 1895 to a hydrotherapeutic institution. There new symptoms appeared and those she already had became exacerbated. In the previous spring when alone one day with a housemaid she had suddenly had a sensation in her genitals and the idea came into her mind that the girl had just then had an improper thought. This sensation became more frequent in the summer and was almost continuous, her genitals felt 'as if there was a heavy hand there'. Then she began to see images which horrified her---hallucinations of naked females, in particular an uncovered vulva with hair; occasionally male genitals as well. The vision of the hairy vulva and the physical sensation in the genital organs usually occurred simultaneously. These images were very tormenting to her, for they recurred regularly whenever she was in the company of a woman, and she supposed that she was seeing the woman in a state of most unseemly nakedness and that at the same moment the woman was having the same vision of her (!). Simultaneously with these visual hallucinations, which after their first appearance in the institution disappeared again for several months, voices which she did not {172} recognize and which she could not explain began to pester her; when she was in the street they said, 'That is Frau P. There she goes! Where's she going?' Some one commented on her every movement and action, occasionally she heard threats and reproaches. All these symptoms became worse if she was among several people or even when she was in the street; she therefore refused to go out and then declared that eating disgusted her, so that her condition became rapidly worse.

I gathered this from her when she came to Vienna in the winter of 1895 to be treated by me. I have described the case circumstantially in order to demonstrate that we are really dealing here with a quite frequent type of chronic paranoia; the details of the symptoms and of her conduct which will be adduced later will also support this conclusion. At the time she concealed from me any delusions concerning the meaning of the hallucinations or perhaps they had really not yet been formed; her intelligence was unimpaired; the only unusual thing I was informed of was that she had repeatedly made appointments with her brother, who lived in the neighbourhood, in order to tell him something important but had never actually told him anything. She never spoke about her hallucinations and towards the end said practically nothing about the grievances and persecutions which she suffered from.

What I have to report about this patient concerns the ætiology of the case and the mechanism of her hallucinations. I discovered the ætiology while I was applying Breuer's method, exactly as in a case of hysteria, for the investigation and removal of the hallucinations. I started from the assumption that there must be in this case of paranoia unconscious thoughts and repressed memories, as there were in {173} the two other defence neuroses which were known to me---unconscious thoughts and repressed memories which might be brought to consciousness as in the other cases by overcoming a certain resistance. The patient at once confirmed my expectation by behaving under analysis exactly like, for example, an hysteric; in a state of attention under the pressure of my hand[47] thoughts came into her mind which she did not remember ever to have had, which at first she did not understand and which were quite contrary to her expectations. The presence of significant unconscious ideas was thus demonstrated in a case of paranoia too, and I had hopes of tracing back the compulsion of the paranoia also to repression. The only peculiar thing was that the thoughts arising in the unconscious were usually heard inwardly or hallucinated in the same way as she had heard the voices.

About the origin of the visual hallucinations or at least of the vivid images I gathered the following: The vision of the female genitals came almost always in connection with the organic sensation in her own genitals; but the latter was much more constant and very often occurred without the vision.

The first of these images had appeared in the hydrotherapeutic establishment a few hours after she had actually seen a number of women naked in the bathing-room, and proved therefore to be a simple reproduction of a real impression. It was to be presumed that it had been repeated only because great interest had been taken in it. She then said she had at the time felt shame for those women; she had herself been ashamed to be seen naked as long as she could remember. I had to regard this shame as something obsessive and concluded that {174} according to the defence-mechanism an experience had been repressed for which she did _not_ feel shame; so I required her to let any memories come up relating to the topic of shame. She promptly reproduced a series of scenes from her seventeenth back to her eighth year in which she had been ashamed of her nakedness in the presence of her mother while bathing, her sister, or the family physician; the series, however, ended in a scene in her sixth year in which she undressed in the nursery on going to bed without feeling shame about her brother's presence. On being questioned she informed me that such scenes had often occurred and that the brother and sister had for years had the habit of showing themselves to each other naked before going to bed. I now understood the significance of the sudden idea that someone was watching her when she was going to bed. It was an unaltered fragment of the old memory evoking self-reproach and she was now making up for the shame which she had not felt as a child.

The conjecture that we were concerned with an affair between children, as so frequently also in the ætiology of hysteria, was strengthened by further progress in the analysis, which at the same time yielded solutions for several of the details frequently recurring in the clinical picture of paranoia. The beginning of her depression occurred at the time of a quarrel between her husband and her brother in consequence of which the latter no longer came to the house. She had always been very fond of this brother and missed him greatly when this happened. Further, she also referred to a certain period in her illness at which for the first time 'everything became clear to her'---that is to say, the time when she became convinced of the truth of her conjecture that she was generally scorned and deliberately {175} insulted. This certainty came upon her during a visit from a sister-in-law, who in the course of conversation remarked casually, 'If anything of that kind happened to me I should simply shrug my shoulders'. Frau P. at first received this remark with indifference, but later, after the visitor had left, it occurred to her that the words contained a reproach, as if _she_ was wont to make light of serious things; and from that moment she felt sure that she was the victim of universal slander. When I questioned her why she felt justified in applying these words to herself, she replied that it was the tone in which her sister-in-law had spoken which (although only later) had convinced her of it---a characteristically paranoiac detail. I now urged her to recollect the remarks which her sister-in-law had made _before_ the expression complained of, and I learnt that the sister-in-law had related that in her home there had been all sorts of difficulties with the _brothers_, and had added the wise comment: 'In every family things occur over which one would gladly draw a veil, but if anything of the kind happened to me I should think nothing of it'. Frau P. had now to admit that her depression was related to these sentences before the last remark. Since she had repressed both the two sentences which might have aroused the memory of her relations with her brother and had retained in memory only the insignificant last sentence, she had had to connect her idea that her sister-in-law was intending a reproach against her with this last sentence; and as its contents offered no support to this interpretation she turned from the contents to the _tone_ in which these words were spoken. Probably a typical piece of evidence that the misinterpretations of paranoia are based upon repression. {176}

Her singular conduct in fixing appointments with her brother in which she had nothing to say to him was explained in a surprising way. Her explanation was that she thought that if she could only look at him he would understand her suffering because he knew the cause of it. Now since this brother was actually the only person who could know of the ætiology of her illness, it became clear that she had been acting in accordance with a motive which she did not herself consciously understand, but which was seen to be completely justified as soon as a meaning from the unconscious was supplied.

I then succeeded in inducing her to reproduce the various scenes in which the sexual relations with her brother had culminated (they had lasted certainly not less than from her sixth to her tenth year). During this work of reproduction the organic feeling in the genitals 'joined in the discussion'---a regular occurrence during the analysis of the memory-fragments of hysterics. The vision of naked female genitals (now, however, of childish proportions and without hair) appeared or stayed away according to whether the scene in question had occurred in bright light or in the dark. Her disgust in regard to eating, too, was explained by a repulsive detail in these proceedings. After we had come to an end of these scenes the hallucinatory sensations and visions disappeared and, up to the present at least, have not returned.[48] {177}

I had discovered, therefore, that these hallucinations were nothing else but parts of the content of repressed experiences of childhood---symptoms of the return of the repressed.

I now directed my attention to the analysis of the voices. In the first place it had to be explained why such an indifferent content as 'Here comes Frau P.', 'She's looking for a house now', and the like, could be so distressing to her; then I turned to the question how these particular harmless sentences had come to be selected for hallucinatory reinforcement. From the first it was clear that these 'voices' could not be hallucinatory reproductions of memories like the images and sensations, but were rather thoughts that had been 'said aloud'.

The first time that she heard the voices occurred under the following circumstances: she had been reading O. Ludwig's novel, _Die Heiterethei_, finding it very thrilling, and had noticed that while reading thoughts kept creeping into her mind. Immediately afterwards she went a walk along a country road and suddenly the voices said to her as she walked past a peasant's cottage: 'That's what Heiterethei's house looked like! There's the spring and there's the shrubbery! How happy she was in spite of all her poverty!' Then the voices repeated to her whole paragraphs from the book she had just read; but it was {178} still quite unintelligible why the house, shrubbery and spring of Heiterethei, and just the most trifling and irrelevant parts of the novel should be forced on her attention with such pathological intensity. However, the solution of the puzzle was not difficult. The analysis showed that during her reading her mind had wandered and she had become excited by totally different passages in the book. Against this material---analogies between the couple in the novel and herself and her husband, memories of intimacies in her married life and family secrets---there arose a repressing resistance, because it was connected by easily demonstrable trains of thought with her sexual dread and finally amounted to an awakening of the old childhood-experience. In consequence of the censorship exercised by the repression the harmless and idyllic passages, which were connected with the proscribed ones by contrast and also by proximity, became strengthened in consciousness and were able to 'say themselves aloud'. The first of the repressed ideas, for instance, related to the gossip among the neighbours to which the heroine, who lived all alone, was exposed. She easily discovered the analogy with herself in this; she also lived in a small place, saw no one, and thought herself despised by her neighbours. This distrust of her neighbours had a foundation in real experience; for when she was first married she had at first been obliged to be content with a small dwelling, and the wall of the bedroom against which the bed of the young couple stood adjoined a room of the neighbours. Great sexual shyness first awoke in her at the time of her marriage---obviously by its rousing memories of the affair in her childhood when the two children played at man and wife; she was continually apprehensive lest the neighbours should distinguish words and noises through the intervening wall, and this {179} shame turned itself into suspicions of the neighbours in her mind.

The voices therefore owed their origin to the repression of thoughts which, if followed to their conclusion, really signified self-reproaches in regard to experiences which had a significance analogous to that of the trauma in childhood; they were accordingly symptoms of the return of the repressed, at the same time, however, a compromise between the resistance of the ego and the strength of the idea under repression, which in this case had brought about an absolutely unrecognizable distortion. In other instances where I had an opportunity to analyse the voices in Frau P.'s case the distortion was not so great; nevertheless, the words always had the character of diplomatic indefiniteness; the distressing allusion was usually closely hidden, the connection between the particular sentences being disguised by a strange tone of voice, unusual forms of speech, and the like---characteristics common to the auditory hallucinations of paranoiacs and in which I see traces of the compromise-distortion. The remark, 'There goes Frau P., she's looking for a house' signified, for example, a threat that she would never be well again, because I had promised her that after treatment she would be able to return to the small town where her husband's business was;---she had taken a lodging in Vienna for some months.

In isolated instances Frau P. was also aware of more definite threats, for example, as proceeding from her husband's relations, but they were always so mildly expressed as to be in marked contrast to the pain which they caused her. In view of what is known about paranoia I am inclined to believe that gradual weakening of the resistance which is designed to keep the self-reproaches under takes place; so that {180} finally the defence fails completely and the original reproach, the actual insulting word against which protection is being sought, returns in its original form. I do not know however whether this is a regular process, whether the censorship exerted over the reproaching speeches may not sometimes be absent from the beginning, or may not sometimes persist to the end.

It only remains for me now to turn to account what has been learned from this case of paranoia in a comparison between paranoia and the obsessional neurosis. In each of them repression has proved to be the nucleus of the psychical mechanism, and in each of them the repressed content is a sexual experience in childhood. And in this case of paranoia, too, every compulsion comes from repression; the symptoms of paranoia may be classified in the same way that has proved justifiable in regard to the obsessional neurosis. Part of the symptoms again originate in a primary defence---namely, all the delusions of distrust, suspicion and persecution by others. In the obsessional neurosis the initial self-reproach has undergone repression by the formation of the primary symptom: _self-distrust_. The self-reproach is thereby recognized as justified and, in compensation, a recognition of the conscientiousness in the healthy interval serves as a protection against belief in the reproaches when they return in the form of obsessions. In paranoia the reproach is repressed in a manner which may be described as _projection_;[49] by the defence-symptom of _distrust directed against others_ being erected; in this way recognition of the reproach is withheld, and, as if in return, protection is lost against the self-reproaches which reappear in the delusions. {181}

Other symptoms of my case of paranoia are to be described as symptoms of the return of the repressed and bear traces, as do those of the obsessional neurosis also, of a compromise which alone makes its entry into consciousness possible. Such are, for instance, the delusion that she is being observed while undressing, the visions, the sensory hallucinations and the hearing of voices. In the delusion mentioned, almost unaltered memories are present, which are only indefinite because a part of their content is omitted. The return of the repressed in visual images approximates more to the character of hysteria than to that of obsessional neurosis; although hysteria is wont to repeat its memory-symbols without modification, whereas the paranoiac memory-hallucination undergoes a distortion similar to that of the obsessional neurosis---an analogous current image takes the place of the repressed one (the genitals of an adult woman instead of that of a child, the hair on the former being particularly prominent because it was lacking in the original impression). A circumstance quite peculiar to paranoia and one that cannot be cleared up in this comparison is that the repressed reproaches return as thoughts spoken aloud. They must thereby suffer a two-fold distortion, first, through a censorship, which leads to their substitution by other associated ideas or to a disguise by indefinite kinds of expressions, and secondly, through their relation to current experiences which are merely analogous to the original.

The third group of symptoms found in the obsessional neurosis, those of a secondary defence, cannot be present in paranoia as such; because the symptoms of the return of the repressed are not opposed by any defence---indeed, they find acceptance. Paranoia, on the other hand, {182} turns to another source in forming symptoms; the delusions which by means of a compromise succeed in becoming conscious (symptoms of the return of the repressed) absorb the thought-processes of the ego until they finally become accepted without contradiction. Since the delusions themselves are not to be influenced, the ego must accommodate itself to them; and thus the combinatory delusion-formations, such as _interpretation-delusions_ ending in a _change within the ego_, correspond to the secondary defence in the obsessional neurosis. My case was in this respect not fully developed; at that time there was no sign of the attempts at interpretation which appeared later. But I do not doubt that it will still be possible to arrive at further important results if psycho-analysis is applied also to this stage of paranoia. It might then be proved that the so-called _weakness of memory_ in paranoiacs is a tendencious manifestation, that is, that it is based upon repression and serves the ends of repression. Finally, even memories which are not in the least pathogenic, but which stand in contradiction to that change within the ego that the symptoms of the return of the repressed so tyrannically demand, become repressed and replaced.

X {183} THE ÆTIOLOGY OF HYSTERIA[50] (1896)

I

When we endeavour to form some opinion about the causation of a morbid condition such as that of hysteria we first of all adopt the method of anamnestic enquiry, examining the patient or his friends about the harmful influences to which they themselves trace the appearance of the particular neurotic symptoms. The value of what we discover in this way is, of course, impaired by all the various circumstances which commonly conceal from a patient the knowledge of his own condition---his lack of scientific understanding of ætiological influences, the fallacy _post hoc_, _ergo propter hoc_, the distress it causes him to think or speak of certain noxiæ and traumas. Hence, in making any such enquiry we adhere to the principle of not adopting the patients' belief without a thorough critical examination and not allowing them to lay down for us our scientific opinion upon the ætiology of the neurosis. Although on the one hand we acknowledge certain constantly recurring statements, as that the hysterical condition is a long-persisting effect of an emotional disturbance which once took place, we have on the other hand introduced into the ætiology of hysteria a factor which the patient himself never cites and only reluctantly admits---namely, the disposition inherited from {184} his parents. You know that in the opinion of the influential school of Charcot heredity alone is to be recognized as the real cause of hysteria, whilst all other harmful influences of the most varying kind and intensity only play the part of exciting causes, of '_agents provocateurs_'.

You will readily admit that it would be desirable to find another way of arriving at the ætiology of hysteria, one in which we should feel less dependent on the statements of the patients themselves. The dermatologist, for instance, is able to recognize the luetic character of a sore from the nature of its edges, of the crust upon it and from its shape, without being misled by the protestation of the patient who denies any source of infection. In forensic medicine, the physician can explain how an injury has been caused, even without any information from the injured person. Now in hysteria there exists a similar possibility of penetrating from the symptoms to knowledge of their causes. As for what concerns the relation which the method to be employed bears to the older method of anamnestic enquiry, I will put before you a simile taken from an advance which has in fact been made in another field of work.

Imagine that an explorer comes in his travels to a region of which but little is known and that there his interest is aroused by ruins showing remains of walls, fragments of pillars and of tablets with obliterated and illegible inscriptions. He may content himself with inspecting what lies there on the surface and with questioning the people who live near by, perhaps semi-barbaric natives, about what tradition tells of the history and meaning of these monumental remains, and taking notes of their statements---and then go his way. But he may proceed differently; he may have come equipped with {185} picks, shovels and spades, and may press the inhabitants into his service and arm them with these tools, make an onslaught on the ruins, clear away the rubbish and, starting from the visible remains, may bring to light what is buried. If his work is crowned with success, the discoveries explain themselves; the ruined walls are part of the ramparts of a palace or a treasure-house, from the ruined pillars a temple can be constructed, the many inscriptions, which by good luck may be bilingual, reveal an alphabet and a language, and when deciphered and translated may yield undreamed-of information about the events of the past, to commemorate which these monuments were built. _Saxa loquuntur!_

If one tries in something the same way to let the symptoms of a case of hysteria tell the tale of the development of the disease, we must start from the momentous discovery of J. Breuer: that the symptoms of hysteria (apart from stigmata) are determined by certain experiences of the patient's which operate traumatically and are reproduced in his psychic life as memory-symbols of these experiences. We must adopt Breuer's method---or one of a similar kind---in order to lead the patient's attention from the symptom back to the scene in and through which it originated; and having thus discovered it, we proceed when the traumatic scene is reproduced to correct the original psychical reaction to it and thus remove the symptom.

It is no part of my intention to-day to treat of the difficult technique of this therapeutic method or the psychological revelations it has achieved. I had to start from this point, simply because analyses conducted on Breuer's method seem at the same time to open up the way to the causes of hysteria. If we subject a large number of symptoms in many people to this analysis, we shall come to know of a {186} correspondingly large number of traumatically operative scenes. We have learnt to recognize in these experiences the efficient causes of hysteria; hence we may hope to discover from the study of these traumatic scenes by what influences and in what ways hysterical symptoms are produced.

That this expectation is justified follows from the fact that Breuer's theses, when put to the test in more numerous cases, prove to be actually correct. But the way from the symptoms of hysteria to its ætiology is longer and introduces us to all sorts of unexpected connections.

For let us be quite clear that tracing an hysterical symptom back to a traumatic scene assists our understanding only if the scene in question fulfils two conditions---if it possesses the required _determining quality_ and if we can credit it with the necessary _traumatic power_. Let me give an illustration instead of a mere explanation of terms. Suppose that the symptom in question is that of hysterical vomiting, we think we can apprehend its cause (or at any rate leave only a certain part unexplained) if analysis traces the symptom to an experience which justifiably gave rise to a high degree of disgust, for instance the sight of a decomposing corpse. Supposing, instead of this, analysis traces back the vomiting to some great shock, e.g. a railway accident, this explanation will be unsatisfactory and we shall have to ask ourselves how it is that the shock led to the particular symptom of vomiting. This derivation of the symptom lacks determining quality. We have another instance of an unsatisfactory explanation when the vomiting is said to have originated in eating a fruit which had a rotten spot in it. Then the vomiting is indeed determined by disgust, but we cannot understand how {187} the disgust in this case could be so powerful as to perpetuate itself in an hysterical symptom; the experience lacks traumatic power.

Now let us consider to what extent the traumatic scenes of hysteria which are revealed in analysis fulfil the two above requirements in a large number of symptoms and cases. Here we encounter our first great disappointment. It does sometimes happen that the traumatic scene in which the symptom originated really possesses both properties which we require in order to understand the symptom: determining quality and traumatic force. But far oftener---incomparably so---we find realized one of three other possibilities which are very difficult to understand: either the scene indicated by analysis in which the symptom first made its appearance seems to us not qualified to determine the symptom, for its content bears no relation to the form of that symptom; or the ostensibly traumatic experience whose content is so related proves to be a normally harmless impression, one which ordinarily would have no effect; or finally the 'traumatic scene' disconcerts us in both directions, appearing both harmless and altogether unrelated to the peculiar form of the hysterical symptom.

(Here I may remark in passing that Breuer's conception of the origin of hysterical symptoms is not affected by the discovery of traumatic scenes which represent experiences in themselves insignificant. For Breuer assumed---in agreement with Charcot---that even a harmless experience may acquire the significance of a trauma and may develop determining power when the subject is in a particular psychic condition, the so-called _hypnoid state_. I find, however, that often there are no grounds for presupposing such hypnoid states. What is {188} definite is that the theory of hypnoid states contributes nothing to the solution of the other difficulties, namely, that so often the traumatic scenes are lacking in determining quality.)

Moreover, this first disappointment in the practice of Breuer's method is followed immediately by another which must be specially grievous to a physician. Such derivations as these which do not contribute to our understanding of the case in respect of determining quality and traumatic force are also of no therapeutic advantage; the patient keeps his symptoms unaltered, in spite of the first result yielded by analysis. You will understand how great the temptation then is to go no further with work which, apart from this, is laborious.

But perhaps we only need a fresh inspiration to help us out of our dilemma and lead to valuable results. Here it is:---we know indeed through Breuer that hysterical symptoms may be resolved if, starting from them, we can find our way back to the memory of a traumatic experience. If the memory so revealed does not answer our expectations, possibly we must pursue the same path a little further; perhaps there is hidden behind the first traumatic scene the recollection of a second, which satisfies our requirements better and the reproduction of which has a better therapeutic result, so that the scene first discovered has only the significance of a link in the chain of association. And perhaps this situation repeats itself, inoperative scenes being in several places interpolated as necessary transitions in the reproduction, till finally, starting from the hysterical symptom, we arrive at the scene which really operates traumatically and is in every respect, from both the therapeutic and the analytic point of view, satisfactory. Well, this supposition is {189} correct. When the scene first revealed does not satisfy our requirements, we say to the patient that this experience does not explain anything, but that there must be hidden behind it an earlier and more significant experience, and, following the same technique, we direct his attention to that strand in the associations which unites both memories---that which we have found and that which we have still to find.[51] Continuation of the analysis then leads in every instance to the reproduction of new scenes of the kind we should expect; for example, to instance again the case of hysterical vomiting which I selected before and which was first referred by analysis to the shock of a railway accident. Now although this experience lacks the determining quality, I find on further analysis that this accident woke the memory of another which had happened previously, in which the patient had not, it is true, been himself involved, but which was the occasion of his seeing a corpse, a sight which aroused in him horror and disgust. It is as though the combined influence of these two scenes led to the fulfilment of our two postulates, the one experience supplying, in the shock, the traumatic force and the other, in its content, the determining influence. The other instance, where the vomiting was traced to eating an apple in which there was a rotten spot, is amplified through analysis somewhat as follows: the rotting apple roused the memory of a former experience of picking up fallen apples in a garden when the patient happened to come on the loathsome carcase of an animal. {190}

I will not again return to these examples, for I must admit that they are not taken from any case in my experience, but that I invented them, and most probably they are bad inventions; I myself regard such explanations of hysterical symptoms as impossible. But there were several reasons why I had to make up examples, and one reason I can state at once. The real examples are all of them far and away more complicated; to relate a single one of them in detail would occupy the whole of this lecture hour. The chain of associations has always more than two links; the traumatic scenes do not form simple rows like a pearl necklace, but they branch out and are interconnected like genealogical trees, a new experience being influenced by two or more earlier ones in the form of memories; in short, to give an account of the resolution of a single symptom is practically synonymous with the task of giving a complete history of a case.

But now I must not neglect to lay special emphasis on the one conclusion derived, quite unexpectedly, from analytic work by means of these chains of recollections. We have found out that no hysterical symptom can originate in one real experience alone, but that in every instance the memory roused by association co-operates with earlier experiences in causing the symptom. If this conclusion is (as I believe) _without exception_ correct, it indicates the foundation upon which a psychological theory of hysteria is to be built.

You might think that those rare instances in which analysis can trace the symptom immediately to a traumatic scene of satisfactory determining quality and traumatic force and, by so tracing it, at the same time remove it (as described in Breuer's history of the case of Anna O.) would surely constitute powerful objections to the general {191} validity of the conclusion just propounded. Certainly it looks as if that were so; but I can assure you I have the best of reasons for assuming that even in these cases there exists a chain of operative memories which stretches far back behind the traumatic scene, even though the reproduction of the latter alone may result in the removal of the symptom.

In my opinion it is really astonishing that hysterical symptoms should arise only where memories are at work, especially when we reflect that these memories, according to all the statements of the patients themselves, did not come into consciousness at the moment when the symptom first made its appearance. Here is food for much reflection, but for the present we must not let these problems deflect the course of our discussion of the ætiology of hysteria. Rather we must ask ourselves: where shall we get to if we follow the chain of associated memories revealed to us by analysis? How far do they go? Is there any point at which they come naturally to an end? Do they perhaps lead to experiences which are in any way similar, whether by relation of time or of content, so that in these universally similar factors we may discern that ætiology of hysteria for which we are seeking?

My experience up till now enables me already to answer these questions. Taking a case which presents several symptoms, from whatever symptom we start we arrive by means of analysis at a series of experiences the memories of which are linked together by association. At first the memory-chains are distinct from one another as they lead backwards, but, as we said before, they branch out; from a single scene two or more memories may be reached at the same time, and from these again there issue side-chains the single links of which {192} may in their turn be joined by association to links of the main chain. The metaphor of a family tree of which the members have also intermarried is really not a bad one. Other complications in the linking up of the chains arise from the circumstance that a single scene in the same chain may be several times recalled to memory, so that it is related in more than one way to a later scene, and may prove both to be directly connected with it and also to be joined by means of intermediate links. In short, the connection is by no means a simple one, and the fact that the scenes are discovered in reverse chronological order (the very feature which justifies our comparison with the excavation of ruins) certainly does not contribute to a more rapid understanding of the process.

New complications are met if the analysis is pursued further. The chains of associations for the separate symptoms then begin to enter into relation with one another; the family trees intertwine. When we come to a certain experience in the memory-chain which has reference, for instance, to the symptom of vomiting, besides the backward-leading links in this chain, there is revived a memory which belongs to another chain and which is the basis of another symptom, perhaps that of headaches. So that experience belongs to both series and thus constitutes a _nodal point_, several of which are to be found in every analysis. Its clinical correlation may perhaps be that from a certain time on the two symptoms occur together, symbiotically, really without any inner mutual dependence. Still further back we find nodal points of another sort. There the chains of associations converge; we find experiences in which two or more symptoms have originated. One chain {193} has attached itself to one detail of the scene and a second chain to another detail.

But the most important result arrived at by such a consistent pursuit of analysis is this: whatever case and whatever symptom we take as our starting-point, _in the end we infallibly come to the realm of sexual experience_. So here for the first time we would seem to have discovered an ætiological condition of hysterical symptoms.

From previous experience I can foresee that it is just against this conclusion or against its universal validity that your opposition will be directed. Perhaps it would be more correct to say: your inclination to opposition, for probably none of you can refer to investigations which, if the same method had been employed, would have yielded a different result. On the actual matter in dispute I will only remark that in my case at least there was no preconceived opinion which led me to single out the sexual factor in the ætiology of hysteria. The two investigators as whose pupil I began my work on the subject, Charcot and Breuer, emphatically had no such presupposition, in fact they had a personal disinclination to it which I originally shared. Only the most laborious and detailed investigations have converted me, and that slowly enough, to the opinion which I defend to-day. If you subject to the closest scrutiny my assertion that the ætiology of hysteria is to be sought in the sexual life, it amounts to the statement that I can assure you that, in some eighteen cases of hysteria, I was able to recognize this connection to hold for every single symptom and, when circumstances permitted, to confirm the fact by therapeutic success. You may of course object that the nineteenth and twentieth analyses would perhaps show that hysterical symptoms can {194} be derived from other sources also, and that thus the validity of the sexual ætiology would not be universal but would be reduced to 80 per cent. By all means let us wait and see, but since those eighteen cases are at the same time _all_ those which I was able to analyse, and since nobody picked them out to please me, you will understand that I do not share any such expectation, but am prepared to let my belief outrun the evidential force of my discoveries up to the present time. Besides, I am influenced by yet another motive, which for the moment is of merely subjective value. In the single attempt to explain the physiological and psychical mechanism of hysteria that I have made for the purpose of embracing the results of my observations, I have found the participation of sexual impulses an indispensable hypothesis.

So, the memory-chains having converged, we come at last to sexual things and to some few experiences which for the most part occur at the same period of life, namely, the age of puberty. In these experiences we are to find the ætiology of hysteria and through them learn to understand how hysterical symptoms originate. But here we meet with a fresh disappointment and a grave one. It is true that these experiences which have been discovered and extracted from the whole mass of memories with such difficulty and seemed to be the ultimate traumata, have two characteristics in common: they are sexual and they occur at the time of puberty, but otherwise they are very different in kind and unequal in importance. In some cases it was a matter of experiences which must be recognized as serious traumata---an attempt at rape, revealing at one blow to the immature girl the whole brutality of sexual desire; or the involuntary witnessing of sexual acts on the part of the parents, which at one and {195} the same time reveals unsuspected ugliness and wounds both the childish and the moral sensibility; and so forth. In other cases these experiences are astonishingly trivial. The experience on which the neurosis of one of my patients was shown to be based was that a boy friend had stroked her hand caressingly and on another occasion had pressed his leg against her dress as they sat side by side at table, his expression at the same time leading her to guess that this was something forbidden. With another young lady, hearing a riddle which suggested an obscene answer actually sufficed to call forth the first anxiety-attack with which the illness began. Clearly, discoveries such as these are not favourable to an understanding of the cause of hysterical symptoms. If both serious and trifling occurrences, experiences undergone by the patient in person as well as visual impressions and verbal communications may be recognized as the ultimate traumata of hysteria, we may perhaps put forward the explanation that hysterics are peculiarly constituted human beings---probably on account of some hereditary disposition or process of degeneration---in whom the shrinking from sexuality which normally plays a certain part at the age of puberty is developed to a pathological extent and is permanently retained; so to speak, persons who are not adequate mentally to the demands of sexuality. It is true that in this statement we pass over hysteria in men; but, even without such an obvious objection, it would scarcely be a very great temptation to halt at this solution. We are only too conscious intellectually that we have here something only half understood, something obscure and unsatisfactory.

Luckily for our explanation, certain of these sexual experiences at puberty display a further inadequacy likely to stimulate us to {196} continue our analytic work. For we find that these experiences may also too lack the determining quality, though this is much rarer than in the traumatic scenes of later life. So, for example, the two patients whom I spoke of above as cases in which the experiences of puberty were actually harmless began, in consequence of those experiences, to suffer from peculiar painful sensations in the genital organs. These sensations had persisted as main symptoms of the neurosis, but it could not be shown that they were determined either by the scenes at puberty or by later ones; certainly they were neither normal organic sensations nor manifestations of sexual excitation. Does it not then seem obvious to say that we must look for the determining quality of these symptoms in yet other experiences, dating from an even earlier period; that here, for the second time, we must follow that saving inspiration which led us before from the first traumatic scenes to the memory-chains? To be sure, by so doing, we get back to the time of earliest childhood, the time before the sexual life developed, and this would seem to involve abandoning our sexual ætiology. But have we no right to assume that even the age of childhood is not without delicate sexual excitations, more, that perhaps the later sexual development is decisively influenced by childish experiences? Injuries sustained by an organ as yet immature, or a function in process of development, do indeed so often cause graver and more lasting effects than can ensue in riper years. Perhaps the abnormal reaction to sexual impressions which surprises us in hysterics at puberty is always due to such sexual experiences in childhood, experiences which might then prove to be significant and similar in kind? We should then come to the view that certain {197} things must be regarded as having been acquired in early life which hitherto have been laid to the charge of some by no means clearly understood hereditary predisposition. And, since infantile experiences of a sexual nature can surely manifest a psychic influence only through their memory-traces, would not this view bear out in a gratifying manner the result reached in analysis---namely, that the influence of memories is essential for the production of hysterical symptoms?

II

You will doubtless have suspected that I should not have developed this last train of thought at such length, if I had not wished to prepare you for the idea that this path alone, after our many delays, can lead us to the goal. For now we really stand at the end of our lengthy and laborious analytic work and find fulfilled here all that we have so far maintained and expected. When we are persevering enough to carry our analysis back into early childhood, to the very furthest point which human memory can reach, we thereby in every instance cause the patient to reproduce the experiences which, on account both of their special features and of their relation to subsequent morbid symptoms, must be regarded as the ætiology for which we are looking. These _infantile_ experiences are once more _sexual_ in content, but are far more uniform in kind than was the case in the scenes of puberty which we had lately discovered; it is now no longer a question of sexual thoughts being awakened by any chance sensory impression, but of sexual experiences undergone by the patient personally, of sexual intercourse (in a wide sense). You will admit that the importance of such scenes needs no further argument; to this {198} you may now add that in the details of this scene you can invariably discover the determining factors which were perhaps still lacking in those other scenes that had taken place later and were reproduced earlier.

I put forward the proposition, therefore, that at the bottom of every case of hysteria will be found one or more experiences of premature sexual experience, belonging to the first years of childhood, experiences which may be reproduced by analytic work though whole decades have intervened. I believe this to be a momentous revelation, the discovery of a _caput Nili_ of neuropathology, but I hardly know from what point to continue the discussion of the situation. Shall I set out before you the actual material I have obtained from the analyses I have conducted, or ought I not rather first of all to try to meet the mass of objections and doubts which I am probably right in supposing to be at this moment absorbing your attention? I choose the latter course; perhaps we shall then be able to dwell on the facts with a more objective mind.

(_a_) Anyone who is altogether opposed to the psychological conception of hysteria, who is unwilling to give up the hope of one day tracing its symptoms to 'finer anatomical changes' and has rejected the view that the material foundations of hysterical changes must necessarily be similar in kind to those of our normal mental processes---anyone who adopts this attitude will naturally put no faith in the results of our analyses; but the difference in principle between his premisses and ours absolves us from any obligation to convince him on single points.

But someone else, less determined to reject psychological theories of hysteria, will when considering our analytical results be tempted to {199} ask what degree of certainty the application of psycho-analysis involves; whether it is not very possible either that the physician forces such scenes upon the docile patient, alleging them to be recollections, or that the patient tells him things which he has purposely invented or spontaneous phantasies which the physician accepts as genuine facts. Well, my answer is that the general misgiving about the reliability of the psycho-analytic method can be appraised and removed only when a complete presentation of its technique and results is available; doubts about the genuine nature of the infantile sexual scenes, however, can be deprived of their force here and now by more than one argument. In the first place, the behaviour of the patients who reproduce these infantile experiences is in every respect incompatible with the assumption that the scenes are anything but a most distressing reality which is recalled with the utmost reluctance. Before they are analysed, the patients know nothing of these scenes; they are generally indignant if we tell them that something of the sort is now coming to light; they can be induced only under the very strongest compulsion of the treatment to engage in reproducing the scenes; whilst calling these infantile experiences into consciousness they experience the most violent sensations, of which they are ashamed and which they endeavour to hide, and they still try, even after going through them again in so convincing a fashion, to withhold belief by emphasizing the fact that they have no feeling of recollecting these scenes as they had in the case of other forgotten material.

Now this last attitude on their part seems absolutely decisive. Why should patients assure me so emphatically of their unbelief, if from any motive they had invented the very things that they wish to {200} discredit?

It is less easy to refute the charge that the physician forces reminiscences of this sort upon the patient and influences him by suggestion to imagine and recount them; nevertheless I think this position is just as untenable. I have never yet succeeded in forcing on a patient a scene that I expected to find in such a way that he appeared to live through it again with all the appropriate emotions; perhaps others are more successful.

There is however a whole series of further evidence which vouches for the reality of the infantile sexual scenes. First, they display just the uniformity in certain details that would necessarily follow from the identically-recurring conditions of the existence of these experiences; otherwise we should have to believe in a secret conspiracy between the individual patients. And again, patients often describe them as if they were harmless events, the significance of which they obviously do not perceive, for if they did they would be shocked; or they mention details to which they attach no importance but which only someone with experience of life knows of and can appreciate as subtle indications of reality.

Such occurrences strengthen the impression that patients must actually have experienced what they reproduce under the compulsion of analysis as scenes from childhood, and we have yet another and even more convincing proof when we examine the relation of the infantile scenes to the content of the whole subsequent history of the illness. Just as when putting together children's picture-puzzles, we finally after many attempts become absolutely certain which piece belongs to the gap not yet filled---because only that particular piece at the same time completes the picture and can be fitted in with its irregular edges to {201} the edges of the other pieces in such a way as neither to leave a space nor to overlap---so the content of the infantile scenes proves to be an inevitable completion of the associative and logical structure of the neurosis; and only after they have been inserted does its origin become evident---one might often say, self-evident.

Without wishing to lay special stress on the fact, I will add that in a number of cases the therapeutic test also speaks for the genuine nature of the infantile scenes. There are cases in which a complete or partial cure can be achieved without going down as far as the infantile experiences; others in which there is no success at all until the analysis comes to its natural end with the discovery of the earliest traumata. I think that in the former cases we are not secure against relapses; my belief is that a complete psycho-analysis implies the radical cure of a case of hysteria. However, do not let us here anticipate what experience will show.

There would be yet one more proof, one which is really unassailable, of the genuineness of the childish sexual experiences---namely, the confirmation of the statements of the person analysed by the account of someone else who is, or is not, under treatment. These two persons must have taken part in the same experience in their childhood, perhaps had stood in a sexual relation to one another. Such relations between children are, as you will hear in a moment, by no means rare; moreover, it quite often happens that both persons concerned suffer subsequently from neuroses; and yet I regard it as a fortunate accident that I have had objective confirmation of this kind in two out of my eighteen cases. In one instance, the brother, who had not fallen ill, of his own accord confirmed for me not, it is true, the {202} earliest sexual experiences with his sister, the patient, but at least scenes of this kind from their later childhood and the fact of sexual relations dating further back. Another time it happened that two women whom I was treating had as children had sexual intercourse with the same man, when certain scenes had occurred in which all three took part. A particular symptom which could be traced to these childish experiences had been developed in both cases and bore witness to this common experience.

(_b_) Sexual experiences in childhood consisting of stimulation of the genitals, coitus-like activities, etc. are therefore in the final analysis to be recognized as the traumata from which proceed hysterical reactions against experiences at puberty and hysterical symptoms themselves. Two objections which contradict each other are sure to be raised from different quarters against this statement. Some will say that such sexual abuses, practised on children or by children on one another, happen too seldom to be regarded as conditioning so common a neurosis as hysteria; others will perhaps maintain that such experiences are, on the contrary, very frequent, far too frequent for us to ascribe ætiological significance to them where their existence is proved. Further, it will be urged that it is easy enough on enquiry to find people who remember scenes of sexual seduction and abuse in their childhood, but yet have never suffered from hysteria; finally, as a weighty argument, that in the lower strata of the population hysteria certainly does not appear more frequently than in the highest, while surely everything goes to show that the rule of keeping a child from everything sexual is transgressed far more commonly among the proletariat. {203}

Let us begin our defence with the easier part of our task. It seems to me certain that our children are far oftener exposed to sexual aggressions than we should suppose, judging by the scanty precautions taken by parents in this matter. When I first made enquiries about what was known on the subject, I learnt from colleagues that there are several publications by children's physicians in which the frequency of sexual practices by nurses and attendants with their charges, even with infants, is complained of and in the last few weeks I have come across a study by Dr. Stekel of Vienna on 'Coitus in Childhood.'[52] I have not had time to collect other published evidence, but even if only isolated testimony were forthcoming, we might expect that increased attention to this subject would confirm the great frequency of sexual experiences and sexual activity in childhood.

Lastly, the results of my analysis may speak for themselves. In all the eighteen cases (of pure hysteria and hysteria combined with obsessions: six men and twelve women) I have, as I said, discovered such sexual experiences in childhood. I may divide my cases into three groups, according to the source of the sexual excitation. In the first group it was a question of assaults---single or at any rate isolated instances of abuse by grown-up strangers (who took care to avoid gross mechanical injury) where consent by the children did not enter into the matter and the first and preponderating result of the experience was terror. A second group consists of those far more numerous cases in which some adult attendant of the child---a maid, nurse, governess, teacher, unhappily only too often a near relation---initiated the child into sexual intercourse and maintained a regular love-relation {204} with him, often for years, which had its mental counterpart. To the third group belong finally the real child-relations, sexual relations between two children of different sex, mostly between brother and sister, which are often continued past the age of puberty and have far-reaching consequences for the two concerned. In most of my cases I could trace the combined influences of two or more such ætiologies; in certain instances the accumulation of sexual experiences from different quarters was really amazing. You will understand this peculiarity in my observations more easily when you consider that the cases were all of severe forms of neurosis involving almost complete incapacity for life.

Where there had been a relation between two children I was sometimes able to prove that the boy---who played the aggressive part---had previously been seduced by a woman, and that then, urged on by his prematurely aroused libido and in consequence of the obsessive memory, he tried to repeat with the little girl exactly the same practices as he had learnt from the adult, without attempting any independent modification in the form of the sexual activity.

So I am inclined to assume that without previous seduction children cannot find the way to acts of sexual aggression. The foundation of the neurosis would accordingly have been laid in childhood by adults, and the children themselves have transmitted to one another the disposition to suffer later from hysteria. I ask you to pause for a moment upon the special frequency of sexual relations in childhood between brothers and sisters, or cousins, due to the opportunity afforded by their being constantly together; now suppose that ten or fifteen years later several of the younger generation of the same {205} family are found to be ill, and then ask yourselves whether this familial type of neurotic manifestation would not naturally lead us to assume an hereditary disposition, where there is actually only _pseudo-heredity_, a transmission or infection having taken place in childhood.

Now let us turn to the other objection which is based upon the very frequency---freely admitted---of infantile sexual experiences and the fact that many people who have not developed hysteria remember such scenes.

We shall reply in the first place that excessive frequency in an ætiological factor cannot possibly be used as an objection to its ætiological significance. Is not the tubercle bacillus ubiquitous, inhaled by many more human beings than suffer from tuberculosis? And is its ætiological significance impaired by the fact that it clearly needs the concurrence of other factors to produce the disease that is its specific effect? It is enough to establish it as the specific cause that tuberculosis is never found where the bacillus is not active. The same is probably true of our problem also. It makes no difference that many people go through infantile sexual experiences without developing hysteria, so long as all those who do become hysterics have had such experiences. The radius of an ætiological factor may be wider, but not less wide than its effect. Not everyone who touches or comes near a smallpox patient develops smallpox, and yet infection from an actual case of it is almost the only known ætiology of the disease.

Of course if infantile sexual activity were an almost universal occurrence, it would prove nothing to find it in every case. But first, such a statement would be a grave exaggeration, and secondly, the ætiological pretensions of infantile scenes rest not only on their {206} constant appearance in the anamnesis of hysterics, but above all on the evidence of the associative and logical connections between these scenes and the hysterical symptoms, connections which would be as clear as daylight to you if you had the complete history of the illness.

What are the other factors that are necessary to the 'specific ætiology' of hysteria in order actually to produce the neurosis? Now this is really a theme in itself, one which I do not propose to discuss; today I need only indicate the point of contact at which the sides of the question---the specific and the subsidiary ætiology---fit into one another. Probably a considerable number of factors will have to be considered: inherited and personal constitution; the importance of the infantile sexual experiences in themselves and particularly their number---a short relation with a boy outside the patient's family to whom she later becomes indifferent will not have so powerful an effect as intimate sexual relations with a brother lasting for several years. In the ætiology of the neurosis quantitative conditions are just as important as qualitative; there are thresholds which have to be crossed if the illness is to manifest itself. Moreover, I myself do not regard the ætiological series mentioned above as complete, nor do I think it solves the problem why hysteria is not more common in the lower classes. (You will remember, by the way, how surprisingly frequent Charcot declared it to be in the _men_ of the working classes.) But I may also remind you that I myself a few years ago indicated a factor hitherto but little remarked, to which I ascribe the leading part in the production of hysteria _after_ puberty. At that time I put forward the view that the outbreak of hysteria may almost invariably be traced to a _psychic conflict_, {207} arising through an unbearable idea having called up the _defences_ of the ego and demanding repression. In what circumstances this attempt at defence has the pathological effect of actually thrusting into the unconscious a memory painful to the ego and creating an hysterical symptom in its place I could not at that time say. I can complete my statement to-day: The defence achieves its purpose of thrusting the unbearable idea out of consciousness, if in the (hitherto normal) person concerned infantile sexual scenes exist in the form of unconscious memories and if the idea to be repressed can be brought into logical or associative connection with any such infantile experience.

Since the ego's attempt at defence depends on the whole moral and intellectual development of the person concerned, the fact that hysteria is so much rarer in the lower classes than would follow from its specific ætiology is no longer entirely incomprehensible.

Let us go back once more to the last group of objections, the answer to which has led us so far afield. We have heard and acknowledged that there are many people who have a very clear recollection of infantile sexual experiences and yet do not suffer from hysteria. This objection has really no weight at all, but it provides an occasion for a valuable comment. People of this type _should_ not (according to our understanding of neurosis) be hysterical at all, at least not in consequence of scenes which they consciously remember. In our patients these memories are never conscious; we cure their hysteria, however, by converting their unconscious memories of infantile scenes into conscious recollection. We could not in any way alter the fact that they had such memories nor need we. From this you perceive that it is {208} not merely a question of the existence of the infantile sexual experiences, but that a certain psychological condition enters into the case. These scenes must exist as _unconscious memories_; only so long and in so far as they are unconscious can they produce and maintain hysterical symptoms. But upon what the consciousness or unconsciousness of these memories depends, whether it be conditioned by their content, or by the time at which they occur, or by some later influences, is a fresh problem which we will take care to avoid. Let me just remind you that the first result of analysis is embodied in the conclusion: hysterical symptoms are derivatives of memories operating unconsciously.

(_c_) If we hold fast to the assumption that infantile sexual experiences are the fundamental condition of hysteria---constitute, if I may say so, the _disposition_ to that disease---they yet do not produce hysterical symptoms directly, for in the first instance they have no effect and exercise a pathogenic influence only later when they are roused after puberty in the form of unconscious memories---then we have to deal with the numerous observations which prove that hysterical illness may already make its appearance in childhood and before puberty. But this difficulty is solved when we examine more closely the particulars gathered in analysis about the period when these infantile sexual experiences took place. We then find that in our severe cases the formation of hysterical symptoms begins, not exceptionally but regularly, with the eighth year, and that those sexual experiences which show no direct result invariably date further back, to the third and fourth or even the second year. Since in no single instance does the chain of effective experiences break off with the eighth year, I must assume that this {209} time of life, the period of growth in which the second dentition occurs, forms a boundary line for hysteria, which cannot be caused when once this line is passed. Anyone who has not had sexual experiences before this cannot be disposed to hysteria after this; anyone who has had them is ready to develop hysterical symptoms. The isolated instances of the occurrence of hysteria on the other side of the dividing line of age (before eight years) may be interpreted as evidence of premature development. The existence of this dividing line has probably some connection with processes of development in the sexual system. Premature sexual development on the physical side may often be observed and we may even suppose that it may in general be promoted by premature sexual excitation.

So we have an indication that a certain infantile condition of the psychic functions, as of the sexual system, is necessary in order that a sexual experience occurring within this period should subsequently, in the form of a memory, exercise a pathogenic influence. Still I do not as yet venture to make any more precise statement about the nature of this psychic infantilism and its temporal limits.

(_d_) Another of our critics might possibly take exception to the idea that the memory of infantile sexual experiences should have so tremendous a pathogenic effect, while the experience itself had none. True, we are not accustomed to find that a memory-picture has a power that the real impression lacked. Here, however, we note, by the way, with what consistency the proposition that symptoms can only proceed from memories is borne out in hysteria. All the later scenes at which the symptoms begin are not the causative ones: those which really are causative do not at first have any effect. But here we are confronted {210} by a problem which we may justifiably keep separate from our main theme. We feel indeed that synthesis is required of us when we reflect upon the number of remarkable conditions we have come to recognize: that in order to form an hysterical symptom there must be an effort of defence against a painful idea; that this idea must be shown to have an associative and logical connection with an unconscious memory, many or few links being present, all of which remain unconscious too for the time being; that the content of the unconscious memory must be sexual; that that content is an experience which occurred at a certain infantile period of life; and we cannot help asking how it comes about that this memory of an experience which was harmless at the time can subsequently have the abnormal effect of conducting to a pathological issue a psychic process like that of defence, while itself remaining all the time unconscious.

But one must say to oneself that this is a purely psychological problem, the solution of which may perhaps require certain assumptions about normal psychic processes and the part played in them by consciousness; for the time, however, it may remain unsolved without robbing of its value the insight so far acquired into the ætiology of hysterical phenomena.

III

The problem I have just formulated concerns the _mechanism_ of hysterical symptom-formation. But I have to present the causation of these symptoms without taking this mechanism into consideration, and the conclusions are consequently bound to forfeit something in clearness and completeness. Let us go back to the part played by the {211} infantile sexual scenes. I am afraid that I may have misled you in the direction of over-estimating their power to form symptoms. So I will again emphasize the fact that every case of hysteria displays symptoms which are determined not by infantile, but by later, often by recent experiences. Other symptoms, of course, date from the very earliest experiences, have, so to speak, the longest pedigree. Such are especially the numerous and manifold sensations and paræsthesias of the genital organs and other parts of the body, sensations which simply correspond to those belonging to the infantile scenes, reproduced in hallucinatory fashion and often intensified to a painful degree.

Another series of exceedingly common hysterical phenomena---painful bladder pressure, painful sensations in defecation, intestinal disturbances, choking and vomiting, indigestion and nausea---could similarly be recognized in my analyses (and that with surprising regularity) as derivatives of the same childhood-experiences and were explained without difficulty by certain invariable features of these episodes. Now the feeling of a sexually normal human being recoils from the idea of these infantile sexual scenes, containing, as they do, all the abuses known to libertines and impotent persons, whose sexual practices include the improper use of the mouth and the rectum. The physician's astonishment at this soon gives place to complete understanding. We cannot expect that people who do not scruple to gratify their sexual desires upon children will be repelled by any lack of refinement in the manner of that gratification, and the natural sexual impotence of childhood inevitably impels towards those surrogate activities to which the adult degrades himself in the case {212} of acquired sexual impotence. All the peculiar circumstances in which the ill-matched pair carry on their love-relation: the adult---who cannot escape his share in the mutual dependence inherent in a sexual relation and yet is endued with complete authority and the right of punishment, and can exchange the one rôle for the other in unbridled gratification of his moods; the child---helpless victim of this capriciousness, prematurely awakened to every kind of sensation and exposed to every kind of disappointment, often interrupted in the practice of the sexual activities assigned to him by his imperfect control of his natural needs---all these grotesque, yet tragic, incongruities become stamped upon the further development of the person concerned and his neurosis, manifesting themselves in innumerable lasting consequences which deserve to be carefully traced out. Where the relation is one between two children, the character of the sexual scenes is still repulsive, since every relation of the sort between children postulates a previous seduction of one of them by an adult. The psychic consequences of such a childhood-relation are quite extraordinarily far-reaching; the two persons remain all their lives united by an invisible bond.

Sometimes it is the accidental circumstances of these infantile sexual scenes which in later years exercise a determining influence upon the symptoms of the neurosis. Thus in one of my cases the circumstance that the child was required to stimulate the genitals of an adult woman with his foot sufficed for years to fix neurotic attention on the legs and their functions and finally to produce an hysterical paraplegia. In another case a patient suffering from anxiety-attacks which tended to come on at certain hours of the day could not be calmed unless one particular sister remained at her side. It would {213} have remained a problem why she would not allow this one of her many sisters to leave her, had not analysis revealed that formerly the man who seduced the patient used to ask every time he came whether this sister, from whom he anticipated an interruption, was at home.

It may happen that the determining power of the infantile scenes disguises itself so effectually that it would certainly be overlooked in a superficial analysis. We imagine that we have found the explanation of a certain symptom in the content of one of the later scenes, but in the course of the analysis we come upon the same content in one of the infantile scenes, so that finally we have to admit that after all the later scene owes its power of determining the symptoms only to its agreement with the earlier one. I do not wish for this reason to represent the later scene as of no importance; if my task were to discuss the laws of hysterical symptom-formation, I should have to recognize as one of these laws that the idea chosen as the basis of a symptom will be one which various factors combine to arouse and which is stirred up from several directions simultaneously;---a state of affairs I have elsewhere tried to formulate by saying that _hysterical symptoms are over-determined_.

One thing more. It is true that so far I have set aside the relation between recent and infantile ætiology as a theme apart; nevertheless I cannot leave the subject without making at least one remark on this point. You will admit that there is one fact in particular which is apt to mislead us in the understanding of the psychology of hysterical phenomena, which so often seem to warn us not to judge by the same standard psychic acts in hysterics and in normal people. I refer to {214} the discrepancy between psychic excitation and psychic reaction which we observe in hysterics and for which we try to account by assuming in them a general abnormal sensibility to stimulation; we often attempt to explain it in terms of physiology, as though in such patients certain organs of the brain which serve to transmit stimuli were in a peculiar morbid state (something like the spinal centres of a frog which has been injected with strychnine) or else had withdrawn from the influence of the higher, inhibiting centres, as in animals experimented upon in vivisection. Here and there either of these conceptions may be a perfectly valid explanation of hysterical phenomena: I do not deny it. But the most important part of the phenomenon, that is, of the abnormal, exaggerated, hysterical reaction to psychic stimuli admits of another explanation, supported by countless instances taken from the analyses of patients. This explanation is as follows: the reaction of hysterics only appears exaggerated; it is bound to appear so to us, because we know only a small part of the motive forces behind it.

In reality, this reaction is proportionate to the exciting stimulus, and therefore normal and psychologically intelligible. We immediately perceive this when analysis has added to the manifest causes of which the patient is conscious those other causes which have contributed to the result, though the patient knows nothing about them and is therefore unable to tell us anything.

I could spend hours demonstrating the validity of this important assertion for the whole range of psychic activity in hysterics, but here I must confine myself to a few examples. You will remember the mental 'hypersensitiveness' so common in hysterics, which leads them {215} to react to the least suggestion of depreciation as to a deadly insult. Now what would you think if you observed such a readiness to take offence in two normal people, for instance husband and wife? You would certainly infer that the conjugal scene you witnessed was not simply the result of the present trifling occasion, but that, for a long time, inflammable material had been accumulating and that the whole mass had now been brought to an explosion by this last shock.

Now apply this train of thought to hysterics. It is not the last, in itself infinitesimal, mortification which produces the fit of crying, the outbreak of despair, the attempted suicide---regardless of the axiom that effect must be proportioned to cause, but this trivial actual mortification has roused and set working the memories of so many, far more intense, previous mortifications, behind all of which lies the memory of a serious one in childhood, one which the patient never got over. Or, when a young girl reproaches herself most bitterly for allowing a boy secretly to caress her hand, and from that moment is the victim of neurosis, you can of course explain it by pronouncing her to be an abnormal, eccentric, hypersensitive person; but you will take a different view when analysis shows that the touch reminded her of a similar one felt in very early youth, which was part of a less harmless story, so that really the reproaches belong to that former occasion. Finally, the problem of hysterogenic areas is another of the same kind; if you touch one particular spot, you do something you did not intend: i.e. you wake a memory which may bring on an hysterical attack, and since you know nothing of the psychic connecting link you refer the attack directly to your touch. The patients are equally ignorant and therefore fall into similar errors; {216} they constantly establish 'false connections' between the last recent cause of which they are conscious and the effect which depends on so many intermediate links. But if the physician succeeds in linking up the unconscious and the conscious determinants of an hysterical reaction, he nearly always has to recognize that this seemingly exaggerated reaction is appropriate and is abnormal only in form.

You may now rightly object to this justification of the hysterical reaction to psychic stimuli that it is none the less abnormal, for why do healthy people behave differently? Why do not all the long-past excitations in them also combine afresh to operate when there is a real new excitation? We do indeed get the impression that in hysterics all the former experiences, to which there has so often already been such a violent reaction, retain their power of producing an effect, as though these people were incapable of discharging psychic stimuli. That is so; we must indeed assume something of the sort. Do not, however, forget that the former experiences of hysterics become operative on some actual occasion, in the form of _unconscious memories_. It seems as though the difficulty of discharge, the impossibility of transforming an actual impression into a powerless memory, was related to the nature of the unconscious part of the mind. You see that the rest of the problem is again psychology, a psychology too for which philosophers have done little to prepare the way.

To this psychology, which has yet to be constructed to meet our requirements---the future _pathopsychology_---I must also refer you when in conclusion I tell you something which at first will make you apprehensive lest it should confuse our dawning understanding of the ætiology of hysteria. For I must state that the ætiological rôle of {217} infantile sexual experiences is not confined to hysteria, but holds good equally for the remarkable obsessional neurosis and perhaps even for the different forms of chronic paranoia and other functional psychoses. I express myself on this point less definitely, because I have analysed far fewer cases of obsessional neurosis than of hysteria; I have actually only a single full analysis and several fragmentary ones of cases of paranoia to which to refer. But what I discovered in these cases seemed to me reliable evidence and gave me confident expectations for future cases. You will perhaps remember that I had already placed both hysteria and obsessions under the single heading of 'defence neuroses', even before I knew of common features in the infantile ætiology of both. Now I must add---though this is a thing which of course need not be of general occurrence---that every one of my cases of obsessional neurosis revealed a substratum of hysterical symptoms, mainly sensations and pains, which were traced to those earliest experiences of childhood. What then determines whether the subsequent developments of the infantile sexual scenes shall take the form of hysteria or obsessional neurosis, or even paranoia, when the other pathogenic factors supervene? These additions to our knowledge would seem to diminish the ætiological significance of these scenes, for the ætiological relation would lose its specific character.

I am not yet able to give a positive answer to this question. The number of cases I have analysed is not large enough, nor have the conditioning factors been sufficiently various. So far I have noted that obsessional ideas can regularly be shown by analysis to be disguised and transformed self-reproaches for sexual aggressions in childhood, that they are therefore more frequently met with in men {218} than in women, and that men develop them more often. From this I might conclude that the character of the infantile scenes---whether the experience was pleasurable or was merely passively submitted to---has a determining influence upon the choice of the subsequent neurosis, but again I do not wish to underestimate the significance of the age at which these childish activities take place, and of certain other factors. On these points we need discussion of further analyses to guide us to a conclusion; but when it becomes clear which are the decisive factors in the choice between the possible forms of defence neurosis, the mechanism by which that particular form develops will once more be a purely psychological problem.

I have now come to the end of my subject for today's discussion. I am prepared for contradiction and unbelief, and will therefore say one thing more in support of my position. Whatever you may think of my conclusions, I have the right to ask you not to look upon them as the fruit of idle speculation. They are based on laborious individual examination of patients, which in most cases has taken a hundred hours and more of work. Even more important to me than your estimation of my results is the direction of your attention to the method I have used, which is novel, difficult to handle and yet irreplaceable for scientific and therapeutic purposes. I am sure you will realize that one cannot gainsay the conclusions reached by the use of this modification of Breuer's original method if one neglects that method and uses only the ordinary one of questioning the patient. To do so would be like trying to refute the discoveries of histological technique by the aid of macroscopic investigations. Since the new method of research gives access to a new element in psychic processes, {219} namely, to that which remains unconscious or, to use Breuer's expression, is _incapable of entering consciousness_, it beckons to us with the hope of a new and better understanding of all functional mental disturbances. I cannot believe that psychiatry will long hold back from this new path to knowledge.

XI {220} SEXUALITY IN THE ÆTIOLOGY OF THE NEUROSES[53] (1898)

Detailed investigations during the last few years have led me to the conviction that factors arising in sexual life represent the nearest and practically the most momentous causes of every single case of nervous illness. This theory is not entirely novel; a certain amount of ætiological importance has always been allowed to sexual factors by all writers on the subject. Many of the side-currents of medicine assure us of a cure for 'sexual complaints' and for 'nervous debility' in one and the same breath. Once its validity is no longer denied, it will not be hard, therefore, to dispute the originality of the theory.

In several short papers which have appeared in the last few years in the _Neurologisches Zentralblatt_, the _Revue Neurologique_ and the _Wiener klinische Rundschau_, I have endeavoured to give some account of the material and the points of view which offer scientific support to the doctrine of the 'sexual ætiology of the neuroses'. Detailed presentation of them, however, has not yet been undertaken, mainly because, while attempting to explain the observed actual interrelations between the phenomena, new problems arise, for the solution of which the necessary preliminary researches are lacking. It does not seem to me, however, at all premature to attempt to direct the attention of practitioners to the circumstances that, as I {221} maintain, exist, so that they may convince themselves of the accuracy of my conclusions and at the same time of the benefits to be derived in medical practice by a knowledge of them.

I know that efforts will be made, based upon arguments of an ethical nature, to prevent physicians from pursuing this topic further. Anyone who wishes to assure himself whether or not his patients' neuroses are really connected with their sexual life cannot avoid the necessity of questioning them about it and demanding a truthful account from them. But in this, it is asserted, lies the danger, both for the individual and for society. I hear it said that a physician has no right to intrude upon his patients' privacy in sexual matters, or to wound their modesty (especially that of his women patients) so grossly as such an interrogation would do. His clumsy hand would only ruin family happiness, and with youthful patients destroy innocence and undermine the authority of parents; with adults he would become the uncomfortable possessor of disquieting knowledge and his relations with his patients would suffer in consequence. It is therefore his ethical duty to hold himself aloof from the whole question of their sexual life.

One may well reply to this that it is nothing but prudery, concealing scanty justification behind very weak arguments, and is unworthy of a medical man. If factors arising in sexual life are definitely recognizable as causes of disease, then investigation and discussion of them come on this ground alone without further ado into the range of a physician's professional duty. The offence against modesty which he thereby commits is no different and no worse, I imagine, than when {222} he insists on examining a woman's genital organs in order to treat a local affection---a demand which his training itself binds him to make. Even to-day one hears that older women whose youth was spent in country places often become reduced by excessive genital hæmorrhages to a state of severe prostration, because they cannot make up their minds to permit a physician to see them uncovered. As a result of the educative influence exercised in the course of a single generation by the medical world upon the general public, an objection of this kind is only in the rarest cases exhibited by young women at the present time. Whenever it does occur it is condemned as unreasonable prudishness---modesty out of place---and the husband might well ask: 'Are we living in Turkey, where a sick wife may only show her arm to a doctor through a hole in the wall?'

It is not true that interrogation and communications referring to sexual matters give the physician a dangerous power over his patient. The same objection might with more justification have been alleged in earlier days against the use of anæsthetics, which deprive the patient of consciousness and will-power and leave it to the physician to decide when and whether they are to return. And yet we cannot do without anæsthetics to-day, because they enable the physician to render help better than anything else; he has taken over the responsibility for them along with his other weighty professional duties.

A physician can always do harm if he is clumsy or unscrupulous, no more and no less in probing into the sexual life of his patients than in other directions. Naturally, if anyone discovers by a meritorious endeavour to arrive at self-knowledge that he is deficient in the tact, seriousness and discretion necessary for interrogating neurotic {223} patients, if anyone knows that revelations of a sexual character will evoke in himself only lewd thoughts instead of scientific interest, he will do right to keep away from the subject of the ætiology of the neuroses. We only ask in addition that he should avoid treatment of nervous patients altogether.

Neither is it true that patients themselves raise insuperable objections to an investigation of their sexual life. After some slight hesitation, grown-up persons usually adjust themselves to the situation by saying: 'I am at the doctor's; I can say anything to him.' Numerous women who find it difficult enough to go through life with the task of concealing their sexual feelings are relieved to find that to the physician their recovery is the paramount issue, and are grateful to him for allowing them for once to behave quite naturally in regard to sexual matters. A dim comprehension of the overwhelming importance of sexual factors in producing neurosis (a recognition which I am trying to formulate anew for medical science) seems actually never to have quite passed out of the consciousness of the laity. How often do scenes like this take place: A married couple comes for consultation, one of the two suffering from neurosis. After some introductory remarks and explanations to the effect that no conventional barriers should be allowed to interfere when a physician wishes to help in such a case, and so forth, one tells them one's surmise that the origin of the malady will be found to lie in an unnatural and harmful form of sexual intercourse, which they have probably been practising since the wife's last confinement. Physicians are not in the habit of concerning themselves with these matters, but this attitude on their part is ill-advised, not withstanding the fact that patients don't wish to discuss these things; and so forth. Then {224} one partner nudges the other and says, 'You see, I told you all along it would make me ill', and the other partner answers, 'Well, I know, I thought so too, but what is one to do?'

In certain other circumstances, such as, for instance, with young girls who are systematically trained to conceal their sexual life, the physician will have to content himself with a very modest measure of sincerity in the patient's admissions. But an important consideration that has to be taken into account on the other side is that an experienced physician does not meet his patients unprepared and as a rule asks of them not elucidation but merely confirmation of his surmises. Anyone who will follow these indications of mine, in the matter of how the morphology of the neuroses is to be regarded and translated into ætiological terms, will require but little more in the way of confessions from his patients; in the very description of their symptoms, which they volunteer only too readily, they will usually have acquainted him with the sexual factors hidden behind.

It would be a great advantage if patients could know the extent to which physicians will henceforth be able to interpret their neurotic complaints with certainty, and to infer from them the sexual ætiology at work; it would undoubtedly stimulate them, from the moment they have made up their minds to seek relief for their troubles, to throw off their secretiveness. Moreover, it is to the interest of us all that a higher measure of sincerity in sexual matters should obtain among us than is demanded at the present time. Sexual morality can only gain by this; in matters of sexuality at present we are all, every one of us, hypocrites, whether we be ill or well. It will only {225} be advantageous if a certain amount of tolerance in sexual matters results from more widespread honesty in this regard.

Medical practitioners have usually very little interest in many of the questions discussed among neuropathologists with regard to the neuroses: for instance, whether it is justifiable to differentiate strictly between hysteria and neurasthenia, whether a hystero-neurasthenia may also be distinguished beside these forms, whether obsessional ideas should be classified with neurasthenia or recognized as a special form of neurosis, and so on. In actual life such distinctions may well be a matter of indifference if nothing further results from the decision---no deeper insight, no landmark pointing out a direction for therapeutic efforts---so long, too, as the patient is invariably sent off to a hydrotherapeutic establishment---or told that there is nothing the matter with him! It would be otherwise, however, if the point of view advanced here about the causative relations between sexuality and the neuroses were adopted; fresh interest is then aroused by the symptomatology of the various neurotic ailments, and an ability to analyse the complicated picture correctly into its component parts and to classify these correctly becomes of practical importance. For the morphology of neurosis may be translated into its ætiology with very little difficulty, and with a knowledge of the latter new therapeutic indications spring to life as a matter of course.

Now it is always possible, in every instance, by careful consideration of the symptoms to reach a decision which is important, namely, whether the case bears the characteristic marks of neurasthenia or of some form of psychoneurosis (hysteria, obsessions). (Very frequently composite-formations occur, in which signs of neurasthenia are {226} intermingled with those of a psychoneurosis; we will, however, leave consideration of them till later.) Only in the various forms of neurasthenia does interrogation result in disclosing the ætiological factors belonging to sexual life; these factors are naturally known to the patient and belong to the present, or more properly, to the period since maturity (although this limitation in time does not cover all cases). With cases of psychoneurosis an interrogation of this kind has little result, though it may perhaps gain for us a knowledge of factors which must be recognized as exciting or contributory and may or may not be related to sexual life. When they are so related they manifest themselves as of the same type as the ætiological factors of neurasthenia, that is, they entirely lack any specific relation to the cause of the psychoneurosis. And yet the ætiology of the psychoneuroses, too, in every instance lies in the patient's sexual life. By a curious by-path, which will be considered later, it is possible to arrive at a knowledge of this ætiology and to understand why the patient could not tell us anything about it; for the events and influences which lie at the root of every psychoneurosis belong not to the present time, but to a long-past period, to a prehistoric period of life, so to say---to early childhood, and that is why the patient knows nothing of them. He has---but only in a certain sense---forgotten them.

Thus we have a sexual ætiology in all cases of neurosis; in neurasthenia, however, this is of present-day origin, whereas in the psychoneuroses the factors belong to infancy; this is the first important contrast in the ætiology of the neuroses. A second contrast appears when we take account of a distinction in the symptomatology of neurasthenia itself. On the one hand, we find cases in which definite {227} symptoms characteristic of neurasthenia are conspicuous: cranial pressure, tendency to fatigue, dyspepsia, constipation, irritation of the spine, and so forth. On the other hand, in certain cases these indications are of minor importance and the syndrome is composed of other symptoms which all show a relation to one main symptom, to 'anxiety' (free-floating anxiety, restlessness, expectant anxiety, complete, rudimentary or supplementary anxiety-attacks, locomotor vertigo, agoraphobia, sleeplessness, exacerbation of pains, etc.). I have left to the former type of neurasthenia its designation, but have distinguished the second as 'anxiety-neurosis' and have justified this separation elsewhere, there also taking into account the fact that both neuroses commonly appear together. For the present purpose it is sufficient to emphasize that a distinction in the ætiology runs parallel with a symptomatic differentiation in the two forms. Neurasthenia may always be traced back to a condition of the nervous system such as is induced by excessive masturbation, or may arise spontaneously on account of frequent emissions. In the anxiety-neurosis there may regularly be found conditions relating to the sexual life which all have in common the element of abstinence or of incomplete satisfaction: such as coitus interruptus, abstinence with strong libido, so-called frustrated excitation, and so forth. In the short paper intended to introduce the anxiety-neurosis I put forward the view that anxiety actually was libido diverted from its usual course.

Wherever symptoms of neurasthenia are mingled in any one case with those of anxiety-neurosis, that is, where a composite-formation appears, the thesis (which has been empirically arrived at) may be adopted that a combination of neuroses represents the co-operation of {228} several ætiological factors; in every instance this expectation is confirmed. It would be well worth while to discuss in detail how often these ætiological factors are closely interwoven organically by the interrelation of sexual processes, as, for instance, coitus interruptus or insufficient potency of the husband with masturbation.

Having accurately diagnosed a case of neurasthenic neurosis under observation, and correctly classified its symptoms, one may proceed to transpose into ætiology the symptomatological knowledge so gained and may fearlessly require the patient's confirmation of one's surmises. Denial at the beginning should not mislead the physician; every resistance is finally overcome by firmly insisting on what has been inferred, and by emphasizing the unshakable nature of one's convictions. In this manner one learns all kinds of things about the sexual life of men and women which might well fill a useful and instructive volume; we learn, too, to regret from every point of view that scientific knowledge of sexual matters is still regarded as opprobrious. Since minor digressions from the normal _vita sexualis_ are much too frequent for the discovery of them to constitute a factor of much importance, only serious and long-continued abnormality in the sexual life of neurotic patients will be allowed to weigh as an explanatory agent; and, also, it may safely be regarded as an imaginary danger that a patient who is psychically normal could be induced by a physician's persistence to accuse himself falsely of sexual misdemeanours.

If we proceed in this manner with our patients we also gain the conviction that no cases of neurasthenia are negative in respect to a sexual ætiology. In my mind, at least, the conviction has become so {229} fixed that I have turned to account the negative result of an interrogation in making a diagnosis; that is, I have concluded that such negative cases could not be neurasthenia. In this way I arrived in several instances at a diagnosis of general paralysis instead of neurasthenia, because it was not possible to demonstrate the frequent masturbation required according to my theory; and the further course of these cases confirmed my judgement as correct. In another instance when the patient, in the absence of any apparent organic lesions, complained of cranial pressure, headache and dyspepsia and met my suspicions regarding his sexual life with honesty and serene certainty, it occurred to me to suspect a latent suppuration in one of the nasal sinuses, and a specialist colleague of mine confirmed this conclusion---which I had arrived at through the negative results of the interrogation on the sexual life---by relieving the patient of his ailment through the removal of putrid matter from the antrum.

The illusion that negative cases do exist, in spite of all this, can arise in other ways as well. Sometimes interrogation reveals a normal sexual life in persons whose neurosis, superficially viewed, really resembles neurasthenia or anxiety-neurosis very closely. More penetrating investigation, however, regularly reveals the true state of affairs. Behind such cases, which have been taken for neurasthenia, there lies a psychoneurosis: an hysteria or obsessional neurosis. Hysteria in particular, which apes so many organic affections, can with ease assume the appearance of one of the forms of actual neurosis by giving hysterical value to the symptoms of the latter. Such forms of hysteria coming under the guise of neurasthenia are not even very infrequent. To fall back on a psychoneurosis wherever neurasthenia {230} shows a negative result sexually is, however, not a cheap way out of the difficulty, and the proof that it is so lies in the only process which unmasks hysteria completely---namely, in the method of psycho-analysis, which will be discussed later.

There may, however, be many who are quite willing to take the sexual ætiology into account with their neurasthenic patients, but who will yet regard it as going too far if they are not required to consider as well the other factors which are always mentioned by medical writers as the causes of neurasthenia. Now it would never occur to me to suggest that we should substitute a sexual ætiology in the neuroses for all the others and thereby declare the latter entirely inoperative. That would be a misunderstanding of my attitude. What I mean is simply that the sexual factors, which have hitherto not been properly estimated, are to be taken into account in addition to all the well-known ætiological factors mentioned by the medical authors, which have probably been quite correctly recognized as such. These sexual factors, however, according to my view of them, deserve a special position in the series of ætiological factors. For they alone are never absent in any case of neurasthenia; they alone are capable of producing neurosis without other contributory factors, so that these other factors seem to be reduced to the position of a supplementary or auxiliary ætiology; they alone permit the physician to recognize the constant interrelation between the manifold forms in which they appear and the many varieties of clinical pictures. When, on the other hand, I review the cases in which neurasthenia has apparently developed because of over-work or emotional excitement, or as the after-effect of typhoid fever and similar diseases, the various {231} symptoms they show appear to have nothing in common; I am not able to form any expectation about the symptoms from the special character of the ætiology, nor can I derive anything about the ætiology at work from the clinical picture presented.

The sexual factors are also those which most readily lend themselves as starting-points for therapeutic efforts. Heredity is doubtless a momentous factor when it is present; it can enable a serious morbid effect to develop where otherwise only an insignificant one would have appeared. But heredity is not amenable to the influence of the physician; every human being has his own hereditary morbid tendencies from birth; we cannot alter anything in them. Nor should we forget that, precisely in the ætiology of neurasthenia, we are bound of necessity to forego the first place to the influences of heredity; neurasthenia, both forms of it, is among those diseases which anyone may readily acquire without being hampered by heredity. If it were otherwise, the prodigious increase in neurasthenia of which all writers on medical subjects complain would be inconceivable. As far as civilization is concerned, too, it is possible that these authorities may be judging correctly in so often reckoning the causation of neurasthenia in the list of its crimes (although this probably comes about in a very different way from that which they suppose); yet the state of our civilization again is unalterable for the individual. Incidentally, this factor, being as it is of the same importance for all the members of one community, can in no way explain the fact of selection in the incidence of the disease. The physician himself actually lives, unaffected by neurasthenia, under the same conditions in this apparently morbific civilization as the {232} neurasthenic patient whom he is to treat.---The significance of exhausting influences remains intact, after allowing for the limitation mentioned above. But the factor of 'over-work', which physicians are so fond of allowing their patients to regard as the cause of their neuroses, is unduly misused. It is quite true that anyone who has become disposed to neurasthenia through an injurious mode of sexual life tolerates intellectual work and the emotional stress of existence very badly, but it never happens that work or excitement alone makes anyone neurotic. Intellectual effort is rather a protection against neurasthenic illness; the most unremitting of intellectual workers are precisely the people who remain untouched by neurasthenia, and what neurasthenics call 'dangerous over-work' does not as a rule deserve the name of 'brain work' at all, regarded either qualitatively or quantitatively. Physicians will have to accustom themselves to explain to an official who has been 'over-done' at the office, or to a housewife whose duties in her home have become too much for her, that they have fallen ill not because they have tried to fulfil tasks which for the brain of a civilized person are really quite easy, but because all the time they have sorely neglected and played havoc with their sexual life.

Further, the sexual ætiology alone makes it possible to comprehend all the details of the clinical history of neurasthenics, the mysterious improvement in the course of the illness and the equally incomprehensible relapses, both of which are usually referred by physicians and patients to the therapy that has been undertaken. In my records, embracing the histories of more than two hundred cases, there is, for example, the story of a man who, when the treatment prescribed by the family physician had failed, had recourse to Father Kneipp and, {233} beginning with this therapy, showed an extraordinary improvement in the very middle of his illness. A year later, however, the troublesome symptoms grew worse and he again sought relief at Wörishofen, but the second treatment failed to bring any improvement. A glance into the history of this patient's family affairs solved the double riddle. Six and a half months after his first return from Wörishofen the patient's wife gave birth to a child (in fact, without knowing it, he had left her at the beginning of a pregnancy) and after his return he was able to have normal intercourse with her. At the close of this period, which was beneficial to his neurosis, his ailment was rekindled by recourse to coitus interruptus again, so that the second treatment was bound to show negative results, for the pregnancy mentioned above was the last that occurred.

Another case in which a similar unexpected influence of treatment called for explanation took an even more instructive form; for a strange alternation in the symptoms of the neurosis showed itself. A young neurotic patient had been sent by his physician for a typical neurasthenia to a well-conducted hydrotherapeutic establishment. In this establishment his condition at first improved so much that he was justifiably expected soon to depart as a grateful convert to hydrotherapeutic methods. In the sixth week a sudden change occurred; the patient 'couldn't stand the water any longer', became more and more nervous, and finally left the establishment after two more weeks, dissatisfied and unrelieved of his trouble. When he complained to me about the deceptive action of the therapy, I asked him a few questions about the symptoms which had set in during it. Strange to say, there had been a complete change in them. He had come to the sanatorium {234} complaining of cranial pressure, lassitude and dyspepsia; the disturbances in the course of the treatment had been excitement, attacks of dyspnœa, locomotor vertigo and troubled sleep. Now I was able to tell the patient: 'You are not fair to hydrotherapy. You fell ill, as you know yourself, on account of long-continued masturbation. In the sanatorium you gave up this form of gratification and therefore improved rapidly. But when you felt well you unwisely sought the company of a lady, let us say one of your fellow-patients, and started a relationship with her which without normal satisfaction could only lead to excitement. The beautiful walks in the neighbourhood of the institution gave you many opportunities. Your relapse is due to this relationship, and not to a sudden inability to tolerate hydrotherapy. From your present condition I should conclude, by the way, that you are continuing this relationship here in town as well.' I can assure the reader that the patient confirmed my supposition point for point.

The present treatment of neurasthenia, carried out perhaps most successfully in hydrotherapeutic establishments, aims at amelioration of the nervous condition by means of two factors, rest and recuperation. I know of nothing against this therapy, except that it does not take into account the circumstances of the patient's sexual life. According to my experience, it would be highly desirable for the medical directors of such establishments to become fully aware that they are dealing not with victims of civilization or of heredity, but---_sit venia verbo_---with persons disabled by their sexuality. They would then, on the one hand, more readily find explanations both for their successes as well as their failures, and {235} on the other hand, achieve new results, which are now dependent upon chance or upon the patient's undirected course of action. If a neurasthenic woman suffering from anxiety is taken away from home and sent to a hydrotherapeutic establishment, freed from all duties, able to bathe, to take gymnastic exercise and plenty of food, one is naturally inclined to give the credit for the splendid improvement which often sets in within a few weeks or months to the quiet life which the patient has been enjoying and to the invigoration which hydrotherapy has brought about. That may be so: but it is apt to be overlooked, that with the separation from home there is also an interruption in marital relations and that it is precisely this temporary removal of the originating cause of the ailment which makes it possible for her to recuperate under the influence of favourable treatment. Neglect of this point of view in regard to the ætiology avenges itself, too, when the apparently satisfactory cure proves to be a very transitory one. Soon after the patient has returned to her ordinary way of life, the symptoms of the trouble reappear and force her from time to time to spend a part of her existence unproductively in establishments of this kind, or else to turn in another direction for hope of recovery. It is therefore clear that in neurasthenia the therapy must take its starting-point within the radius of the patient's ordinary existence, and not in sanatoria.

This ætiological theory will also explain the source of failures which medical superintendents of sanatoria would greatly like to prevent---failures of the treatment within the establishment itself. Masturbation among grown-up girls and adult men is far more frequent than is commonly supposed and has a harmful effect not only by {236} producing neurasthenic symptoms, but also because the patient is kept under the oppression of a secret which he feels to be shameful. Physicians who are not accustomed to translate neurasthenia into masturbation account for the diseased condition by referring it back to some catchword like anæmia, over-work, and so on, and then expect the patient to recover after undergoing a therapy devised to remedy such things. To their astonishment, however, periods of improvement alternate with periods in which all the symptoms grow worse and are accompanied by severe depression. The outcome of such a therapy is generally doubtful. If the physician knew that all the time the patient was struggling with this bad habit and is in despair because he has once again been overcome by it, if he understood how to relieve the patient of his secret, to diminish its importance in the patient's eyes and to support him in his fight against the habit, the success of the therapeutic efforts might well be assured.

To induce the patient to abandon the habit of masturbation is only one of the new therapeutic tasks which confronts the physician upon consideration of a sexual ætiology, and this one seems, in common with every other attempt to wean people from some form of indulgence, practicable only in an institution under medical supervision. Left to himself, whenever things are at all depressing the masturbator usually turns to the gratification that he finds so easy and comforting. Medical treatment can then only set itself the goal of leading the neurasthenic who has recovered his health back to normal forms of sexual satisfaction; for, once it has been aroused and satisfied for any length of time, sexual need is not to be silenced again but can only be transferred to another object. Incidentally, the {237} same thing applies to all abstinence-treatments, which will succeed only superficially as long as physicians content themselves with removing the narcotic from the patient without troubling about the source of this imperative need for the drug. 'Habit' is merely an empty phrase without any explanatory significance; not everybody who has occasion to take morphine, cocaine, chloral-hydrate and the like for a space of time thereby acquires a craving for them. More searching examination generally shows that these narcotics are intended as substitutes (directly or indirectly) for the missing sexual gratification, and wherever normal sexual life cannot be re-established a patient who has been weaned from his habit may be expected quite certainly to slide back into it.

The other task set the physician by this ætiology refers to the anxiety-neurosis; it consists in bringing the patient to abandon all injurious varieties of sexual intercourse and to enter into normal sexual relations. As will be readily understood, this duty falls to the lot of the patient's confidential adviser, that is, the family physician, who is seriously at fault in his duty to the patient if he considers it beneath his dignity to meddle in such matters.

Since he has most often to deal with married couples in these instances, he at once finds his efforts confronted by the current malthusian tendencies to limit the offspring of marriage. I have not the least doubt that these principles are gaining ground more and more among our middle classes; I have come across couples who began to practise the prevention of conception as soon as the first child was born, and others who intended that sexual intercourse should accord with these principles from the wedding-night itself. The problem of malthusianism is a far-reaching and complicated one; I have no {238} intention of treating it here in the exhaustive manner which would really be necessary for the therapy of the neuroses. I shall only discuss how a physician who recognizes the importance of sexual ætiology in the neuroses can best face this problem.

Obviously, the worst thing he can do is to ignore it, no matter under what pretence. A thing that is necessary cannot be beneath my professional dignity, and it is necessary to give the assistance of medical advice to a married couple who are planning to limit their offspring, if you wish to prevent one or both of the partners being exposed to a neurosis. It cannot be denied that contraceptive measures become a necessity in married life at some time or other, and theoretically it would be one of the greatest triumphs of mankind, one of the most tangible liberations from the bondage of nature to which we are subject, were it possible to raise the responsible act of procreation to the level of a voluntary and intentional act, and to free it from its entanglement with an indispensable satisfaction of a natural desire.

A clear-sighted physician will therefore take it upon himself to decide under what conditions the use of contraceptive measures is justified, and will require to distinguish between the harmful and the harmless forms among these measures. Everything is harmful that hinders the fulfilment of gratification; it is well-known, however, that at present we possess no method of preventing conception which satisfies all the requirements which may properly be asked of it, that is, which is certain, convenient, does not diminish pleasurable sensation during coitus, nor wound feminine sensibilities. This is a practical problem which physicians might well apply their energy to {239} solve; they would thereby reap great gratitude. Anyone who could fill this gap in our medical technique would be the means of preserving the joy of living and good health for countless men and women, though it is true he would at the same time have initiated a profound change in our social conditions.

This does not exhaust the list of the sources of inspiration which lie in a recognition of the sexual ætiology of the neuroses. The main benefit which we obtain from it for neurasthenia falls in the sphere of prophylaxis. If masturbation is the cause of neurasthenia in youth, and later on also has its ætiological significance in the anxiety-neurosis by its action in reducing potency, then the prevention of masturbation in both sexes is a task that deserves more attention than it has received up to the present time. On considering both the slight and the serious disabilities that have their root in neurasthenia, which is apparently growing more and more prevalent, it becomes evident that it is positively to the public interest _that men should enter upon sexual relations with full potency_. In matters of prophylaxis, however, the individual is almost helpless. The whole community must take an interest in the matter and give its assent to the construction of measures valid for all. At present we are still far removed from a state of things holding out such hope of relief, so that the increase in neurasthenia may quite rightly be accounted to our civilization. There is a great deal which must be changed. The opposition of a generation of physicians who can no longer remember their own youth must be broken down, the pride of fathers who are unwilling to descend to the level of common humanity in the eyes of their children will have to be overcome, the unreasonable prudery of {240} mothers, who at present quite generally regard it as an incomprehensible and also undeserved stroke of fate that 'just their children should be nervous', would have to be met. Above all, popular opinion would have to make room for the discussion of problems of sexual life; it must become possible to speak of such things without being stamped as a disturber of the peace or as a person whose aim is to arouse the lower instincts. And so there still remains plenty of work in this direction for the next century---in which our civilization will have to learn to become compatible with the claims of our sexuality!

The value of a correct diagnostic differentiation between the psychoneuroses and neurasthenia is also shown by the fact that the former need to be regarded differently in practice and require special therapeutic measures. Psychoneuroses appear under two kinds of conditions, either independently or in the wake of actual neuroses (neurasthenia and anxiety-neurosis). In these latter cases we are dealing with a new type, incidentally very frequent, of mixed neurosis. The ætiology of the actual neuroses has become a supplementary ætiology of the psychoneuroses, and a clinical picture results in which, for example, anxiety-neurosis predominates, but which in other respects shows features of real neurasthenia, of hysteria and of the obsessional neurosis. Even when faced with such a combination, it is not profitable to abandon the distinctions between the various single clinical pictures of neuroses, since it is really not so very difficult to analyse the result into the following constituents: The predominance of the anxiety-neurosis shows that the morbid condition has arisen under the influence of an actual sexual noxia. The person concerned was, however, besides this, predisposed by {241} a particular ætiology to one or more forms of psychoneurosis, and would have developed a psychoneurosis at some time or other, either spontaneously or under the influence of some other weakening cause. Thus the still lacking supplementary ætiology of the psychoneurosis has been supplied by the current ætiology of the anxiety-neurosis.

For such cases it has quite correctly come to be a therapeutic practice to disregard the psychoneurotic components in the clinical picture and to treat exclusively the 'actual' neurosis. In very many cases it is possible to overcome the accompanying neurosis if the neurasthenic condition is handled in the right manner. A different estimate is required in those cases of psychoneurosis which appear either spontaneously or at the close of a long illness composed of neurasthenia and psychoneurosis, and remain as an independent condition. When I speak of the 'spontaneous' appearance of a psychoneurosis, I do not mean, for example, that every ætiological element is lacking after anamnestic research. Though that may well be so, it may also be that attention is drawn to some more commonplace factor, for instance, an emotional crisis, an enfeebled condition after organic illness and the like. It must, however, be remembered with all these cases that the real ætiology of the psychoneuroses does not rest upon these factors, but remains outside the reach of ordinary anamnestic examination.

As is well known, this is the gap that some have attempted to bridge by the assumption of a special neuropathic temperament which, if it existed, would indeed not leave much hope for the success of any therapy with these morbid conditions. The neuropathic disposition itself is conceived of as a sign of general degeneration and then this {242} convenient term is levelled broadcast against the poor sufferers whom medical men are quite powerless to aid. Fortunately, this is not at all the true state of affairs. Although the neuropathic temperament doubtless exists, I deny that it is adequate alone to produce a psychoneurosis. Moreover, I must further deny that a neuropathic temperament in conjunction with the contributory causes exciting an outbreak of illness in adult life together represent a sufficiently adequate ætiology of psychoneurosis. In referring the fate of an individual who shows a morbid condition back to the experiences of his ancestors we have gone too far; we have forgotten that between conception and maturity there lies a long and important period in the life of a man---childhood---in which the seeds of later disease may be acquired. That is what in fact happens with the psychoneuroses. Their real ætiology is to be found in experiences during childhood, and again---exclusively, too---in those impressions which have to do with sexual matters. We do wrong entirely to ignore the sexual life of children; in my experience children are capable of all the mental and many of the physical activities. Just as the whole sexual apparatus of man is not comprised in the external genital organs and the two reproductive glands, so his sexual life does not begin only with the onset of puberty, as to casual observation it may appear to do. It is true, however, that the organization and evolution of the species man strives to prevent extensive sexual activity during childhood; apparently the sexual instincts of the human animal are to be stored up in order that at the time of their release at puberty they may serve important cultural ends (W. Fliess). It is perhaps possible to understand, through considerations of this kind, why sexual {243} experiences in childhood are bound to have a pathogenic effect. This effect, however, displays itself only in the slightest degree at the actual time of their occurrence; far more important is their subsequent effect, which can show itself only in later periods of maturity. This subsequent effect can only originate in the mental traces which have been left behind by the infantile sexual experiences. In the interval between the occurrence of these experiences and their reproduction (we ought rather to say the later intensification of the libidinous impulses aroused by them) not only the physical sexual but also the mental apparatus has undergone an important development, and therefore an abnormal mental reaction now follows upon the effect produced by these earlier sexual experiences; that is, psychopathological formations appear.

In these introductory remarks I can only mention the main elements on which the theory of the psychoneuroses is based: the subsequence of the effect, the infantile condition of the sexual apparatus and of the mental organism. In order to attain full comprehension of the mechanism by which the psychoneuroses come into being, more detailed exposition would be necessary; above all, it would be indispensable to regard as credible certain assumptions concerning the composition of the mental instrument and the way in which it works, which seem to me to be novel. In a book on the interpretation of dreams at which I am now working, I shall find occasion to touch upon these principles of a psychology of the neuroses. For dreams belong to the same category of psychopathological formations as the _idée fixe_ of hysteria, obsessions and delusions.

Since the manifestations of the psychoneuroses arise through the subsequent action of unconscious mental traces, they are amenable to {244} psychotherapy, which, however, must seek other methods than the only one followed so far, that of suggestion with or without hypnosis. In recent years I have worked out almost completely a therapeutic procedure, based on the 'cathartic' method initiated by J. Breuer, which I intend to call the 'psycho-analytic' method; I owe countless successes to it and may reasonably hope to increase its effectiveness considerably yet. The first account of this method---its technique and applicability---was given in the _Studien über Hysterie_ written in conjunction with J. Breuer and published in 1895. Much of it, I may say, has since then been altered for the better. Whereas at that time we modestly declared that we could undertake to remove only the symptoms of hysteria and not the disease itself, I have since perceived that this distinction is without significance, so that the prospect of an effectual cure of hysteria and obsessions lies ahead. I have therefore been most interested to read statements like the following in the writings of my colleagues: 'In this case the ingenious method devised by Breuer and Freud has failed', or 'The method has not fulfilled the promise it seemed originally to hold out'. On these occasions I have had something of the sensations of a man who comes across an obituary notice of himself in the newspapers, but ventures to feel reassured by his better knowledge of the situation. For the method is so difficult that serious study of it is indispensable, and I cannot remember that any one of my critics expressed any wish to learn it from me; nor do I believe that they have applied themselves to the matter, as I have done, with sufficient intensity to come upon it of their own accord. The remarks in the _Studien über Hysterie_ are totally inadequate to give the reader a mastery of this technique, nor are they in any way intended to {245} furnish complete instruction in it.

The psycho-analytic method is not at present applicable to all cases; I recognize the following limitations in regard to it: it demands a certain measure of clearsightedness and maturity in the patient and is therefore not suited for youthful persons or for adults who are feeble-minded or uneducated. With persons who are too far advanced in years it fails because, owing to the accumulation of material, so much time would be required that the end of the cure would be reached at a period of life in which much importance is no longer attached to nervous health. And finally it is possible only if the patient is capable of a normal mental condition from the vantage-point of which he may overlook the pathological material. During an hysterical confusion or interpolated mania or melancholia nothing can be effected by psycho-analytic means. Such cases can, nevertheless, be subjected to the treatment after the violent manifestations have yielded to the customary methods. In practice, the chronic cases of psychoneuroses are altogether more tractable by this method than cases with acute crises, in which the greatest weight is naturally laid on the speed with which the latter can be subdued. Hysterical phobias and the different forms of obsessional neurosis are consequently the most favourable field of work for this new therapy.

That the method is restricted by these limitations is to a great extent explicable by the conditions under which I had to work it out. My material does in fact consist of chronic nervous cases recruited from the more cultivated classes. I consider it very probable that supplementary methods may be arrived at for treating young persons and for those who seek relief in hospitals. I should {246} also mention that up to the present I have tried my treatment exclusively on severe cases of hysteria and obsessional neurosis; I cannot tell how it would react on those slight cases which appear to be cured in a few months by some neutral kind of treatment. It will readily be understood that a new therapy which requires many sacrifices can reckon on only such patients as have already tried the generally accepted methods without success, or by those whose condition justified the inference that they could expect nothing from these apparently more convenient and shorter therapeutic methods. I was obliged to attack at once the hardest tasks with imperfect instruments; the test has therefore proved all the more convincing.

The essential difficulties which still stand in the way of the psycho-analytic method of cure are due, not to its own character, but rather to the lack of comprehension among laymen and physicians in regard to the real character of the psychoneuroses. It is only an inevitable corollary of this complete ignorance that physicians should consider themselves justified in consoling the patient or in persuading him to try various therapeutic measures with the most flimsy assurances, 'Come to my sanatorium for six weeks and you will get rid of your symptoms (phobias, obsessions and the like).' Sanatoria are, as a matter of fact, indispensable for subduing acute conditions arising in the course of a psychoneurosis and effect this by means of diversion, care and rest; towards removing chronic conditions they achieve nothing, and this is as true of the distinguished sanatoria which are supposed to be scientifically conducted as of ordinary hydrotherapeutic establishments.

It would be more dignified as well as more helpful to the patient (who after all has somehow to reconcile himself to his ailments) if {247} physicians would tell the truth as they see it day by day: the psychoneuroses as a genus are by no means slight illnesses. When hysteria has once begun no one can foretell when it will end. One mostly seeks in vain to comfort oneself with the prophecy, 'Some day it will suddenly come to an end.' Often enough recovery proves to be a mere compromise, a condition of mutual toleration between the sound and the unsound elements in the patient, or comes about by way of the transformation of the symptom into a phobia. An hysteria in a young girl, which has with difficulty been relieved, will be resuscitated, after a short interruption due to a new-found happiness, in the hysteria of the wife; with one difference, that this time another person, the husband, will be impelled by his own interests to keep silent about the illness. Even if no manifest incapacity for life results, there almost always follows a loss of power to make free use of the energies of the mind. Obsessions recur again and again during the patient's whole life; phobias and other restrictions of will-power have hitherto proved inaccessible to every kind of treatment. All these facts are kept from the knowledge of the public, so that the father of an hysterical girl is horrified when he is told that he ought to consent to a year's treatment for his daughter, though the illness may perhaps be of only a few months' duration. The layman is deeply convinced inwardly of the unnecessariness, so to speak, of all these psychoneuroses, and therefore regards the course of the disease with little patience and is unwilling to make sacrifices for the treatment. He behaves more reasonably with a case of typhoid lasting three weeks, or a fracture which requires six months to heal, or he regards it as proper that orthopædic treatment should be undergone for several years when his child shows the first signs of curvature {248} of the spine; and the difference in his behaviour is due to the better understanding shown by physicians in these matters, about which they honestly impart their knowledge to the lay public. Sincerity on the part of physicians and tractability in the public will be achieved in regard to the psychoneuroses also, when once insight into the essential character of these complaints becomes the common property of medicine. A thorough psychotherapeutic treatment of these ailments will no doubt always require a special training and will be incompatible with other kinds of medical practice. As a compensation, this group of physicians, which in the future will doubtless be a large one, has before it the prospect of noteworthy achievements and of a gratifying insight into the mental life of mankind.

XII {249} ON PSYCHOTHERAPY[54] (1904)

About eight years have passed since I had the opportunity, on the invitation of your lamented chairman, Professor von Reder, of speaking here on the subject of hysteria. Shortly before that occasion I had published, in 1895, in collaboration with Dr. Joseph Breuer, the _Studien über Hysterie_ in which, on the basis of the new knowledge which we owe to this investigator, an attempt was made to introduce a novel therapy for the neuroses. Fortunately, I may say, the efforts of our 'Studies' have been successful; the ideas expressed in them concerning the action of psychical traumas through retention of affect, as well as the conception of hysterical symptoms which explains them as the result of an emotion transposed from the realm of the mental to the physical---ideas for which we created the terms 'abreaction' and 'conversion'---are to-day generally known and understood. There is, at least in German-speaking countries, no presentation of hysteria to-day that does not to some extent take them into account, and we have no colleagues who do not follow at least for a short distance the road pointed out by us. And yet, while they were still new, these propositions and the terms for them must have sounded not a little strange! {250}

I cannot say the same of the therapeutic method which was introduced to our colleagues at the same time as our theory; it is still struggling for recognition. There may be special reasons for this. At that time the technique of the process was as yet undeveloped; it was impossible for me to give medical readers of the book the directions necessary to enable them to carry through this method of treatment completely. But causes of a general nature have certainly also played a part. To many physicians, even to-day, psychotherapy seems to be the offspring of modern mysticism and, compared with our physico-chemical specifics which are applied on the basis of physiological knowledge, appears quite unscientific and unworthy of the attention of a serious investigator. Allow me, therefore, to defend the cause of psychotherapy before you, and to point out to you what may be described as unjust or mistaken in this condemnation of it.

In the first place, let me remind you that psychotherapy is in no way a modern method of healing. On the contrary, it is the most ancient form of therapy in medicine. In Löwenfeld's instructive work (_Lehrbuch der gesamten Psychotherapie_) many of the methods of primitive and ancient medical science are described. The majority of them must be classed under the head of psychotherapy; in order to effect a cure a condition of 'expectant faith' was induced in sick persons, the same condition which answers a similar purpose for us to-day. Even since physicians have come upon other therapeutic agents, psychotherapeutic endeavours of one kind or another have never completely disappeared from medicine.

Secondly, let me draw your attention to the fact that we physicians cannot discard psychotherapy altogether, simply because the other person so intimately concerned in the process of recovery---the {251} patient---has no intention of giving it up. You will know of the increase in knowledge on this subject that we owe to the Nancy school, to Liébeault and Bernheim. An element dependent on the psychical disposition of the patient enters as an accompanying factor, without any such intention on our part, into the effect of every therapeutic process initiated by a physician; most frequently it is favourable to recovery, but often it acts as an inhibition. We have learned to use the word 'suggestion' for this phenomenon, and Möbius has taught us that the unreliability which we deplore in so many of our therapeutic measures may be traced back actually to the disturbing influence of this very powerful factor. All physicians, therefore, yourselves included, are continually practising psychotherapy, even when you have no intention of doing so and are not aware of it; it is disadvantageous, however, to leave entirely in the hands of the patient what the mental factor in your treatment of him shall be. In this way it is uncontrollable; it can neither be measured nor intensified. Is it not then a justifiable endeavour on the part of a physician to seek to control this factor, to use it with a purpose, and to direct and strengthen it? This and nothing else is what scientific psychotherapy proposes.

And, in the third place, I would remind you of the well-known experience that certain diseases, in particular the psychoneuroses, are far more readily accessible to mental influences than to any other form of medication. It is not a modern dictum but an old saying of physicians that these diseases are not cured by the drug but by the physician, that is by the personality of the physician, inasmuch as through it he exerts a mental influence. I am well aware that you {252} favour the view which Vischer, the professor of æsthetics, expressed so well in his parody of Faust:

> "Ich weiß, das Physikalische\ > Wirkt öfters aufs Moralische"[55].

But is it not more reasonable and more likely to happen that moral, that is, mental means can influence the moral side of a human being?

There are many ways and means of practising psychotherapy. All that lead to recovery are good. Our usual word of comfort, which we dispense very liberally to our patients---'Never fear, you will soon be all right again'---corresponds to one of these psychotherapeutic methods; only, now that deeper insight has been won into the neuroses, we are no longer forced to confine ourselves to the word of comfort. We have developed the technique of hypnotic suggestion, and psychotherapy by diversion of attention, by exercise, and by eliciting suitable affects. I despise none of these methods and would use them all under proper conditions. If I have actually come to confine myself to one form of treatment, to the method that Breuer called _cathartic_, which I myself prefer to call 'analytic', it is because I have allowed myself to be influenced by purely subjective motives. Because of the part I have played in founding this therapy, I feel a personal obligation to devote myself to closer investigation of it and to the development of its technique. And I may say that the analytic method of psychotherapy is the one that penetrates most deeply, and carries farthest, the one by means of which the most extensive transformations can be wrought in patients. Putting aside for a moment the therapeutic point of view, I may also say of it that {253} it is the most interesting method, the only one which informs us at all about the origin and interrelation of morbid manifestations. Owing to the insight which we gain into mental illness by this method, it alone should be capable of leading us beyond its own limits and of pointing out the way to other forms of therapeutic influence.

Permit me now to correct several mistakes that have been made in regard to this cathartic or analytic method of psychotherapy, and give a few explanations on the subject.

(_a_) I have observed that this method is very often confounded with hypnotic treatment by suggestion; I have noticed this because it happens comparatively often that colleagues who do not ordinarily confide their cases to me send me patients---refractory patients, of course---with a request that I should hypnotise them. Now I have not used hypnosis for therapeutic purposes for the last eight years (except for a few special experiments) so that I habitually send back these cases with the recommendation that anyone who relies upon hypnosis may perform it himself. There is, actually, the greatest possible antithesis between suggestive and analytic technique---the same antithesis that in regard to the fine arts the great Leonardo da Vinci summed up in the formulas: _Per via di porre_ and _per via di levare_. Painting, says Leonardo, works _per via di porre_, for it applies a substance---particles of colour---where there was nothing before, on the colourless canvas; sculpture, however, proceeds _per via di levare_, since it takes away from the rough stone all that hides the surface of the statue contained in it. The technique of suggestion aims in a similar way at proceeding _per via di porre_; it is not concerned with the origin, strength and meaning of the morbid {254} symptoms, but instead, it superimposes something---a suggestion---and expects this to be strong enough to restrain the pathogenic idea from coming to expression. Analytic therapy, on the other hand, does not seek to add or to introduce anything new, but to take away something, to bring out something; and to this end concerns itself with the genesis of the morbid symptoms and the psychical context of the pathogenic idea which it seeks to remove. It is by the use of this mode of investigation that analytic therapy has increased our knowledge so notably. I gave up the suggestive technique, and with it hypnosis, so early in my practice because I despaired of making suggestion powerful and enduring enough to effect permanent cures. In all severe cases I saw the suggestions which had been applied crumble away again; and then the disease or some substitute for it returned. Besides all this I have another reproach against this method, namely, that it conceals from us all insight into the play of mental forces; it does not permit us, for example, to recognize the _resistance_ with which the patient clings to his disease and thus even fights against his own recovery; yet it is this phenomenon of resistance which alone makes it possible to comprehend his behaviour in daily life.

(_b_) It seems to me that among my colleagues there is a widespread and erroneous impression that this technique of searching for the origins of the symptoms and removing the manifestations by means of this investigation is a easy one which can be practised off-hand, as it were. I conclude this from the fact that not one of all those who show an interest in my therapy and pass definite judgements upon it has ever asked me how I actually go about it. There can be but one {255} reason for this, namely, that they think there is nothing to enquire about, that the thing is perfectly obvious. Again, I am now and then astonished to hear that in this or that ward of a hospital a young assistant has received an order from his chief to undertake a 'psycho-analysis' of an hysterical patient. I am sure he would not be allowed to examine an extirpated tumour until he had convinced his chiefs that he was conversant with histological technique. Similarly, a report reaches my ears that this or that colleague has arranged appointments with a patient in order to undertake a mental treatment of the case, though I am certain that he knows nothing of the technique of any such therapy. His expectation must be therefore that the patient will offer him his secrets as a present, as it were, or perhaps he looks for salvation in some sort of confession or confidence. I should not be surprised if an invalid were injured rather than benefited by being treated in such a fashion. For it is not so easy to play upon the instrument of the soul. I am reminded at this point of a world-famed neurotic, although certainly he was never treated by a physician but existed only in a poet's imagination: I mean Hamlet, Prince of Denmark. The King appointed the two courtiers, Rosenkranz and Guildenstern, to follow him, to question him and drag from him the secret of his depression. He wards them off; then flutes are brought on the stage and Hamlet, taking one of them, begs one of his torturers to play upon it, telling him that it is as easy as lying. The courtier excuses himself for he knows no touch of the instrument, and when he cannot be persuaded to try it, Hamlet finally breaks out with these words: 'Why, look you now, how unworthy a thing you make of me, you would play upon me.---You would pluck out the {256} heart of my mystery; you would sound me from my lowest note to the top of my compass; and there is much music, excellent voice, in this little organ; yet you cannot make it speak. '_Sblood, do you think I am easier to be played on than a pipe? Call me what instrument you will, though you can fret me you cannot play upon me._' (Act III,