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SELECTED PAPERS ON HYSTERIA
AND
OTHER PSYCHONEUROSES

BY

PROF. SIGMUND FREUD

VIENNA

AUTHORIZED TRANSLATION

BY

A. A. BRILL, Ph.D., M.D.

CHIEF OF NERVOUS DISPENSARY, BETH ISRAEL HOSPITAL; CLINICAL ASSISTANT, DEPARTMENT OF PSYCHIATRY AND NEUROLOGY, COLUMBIA UNIVERSITY; ASSISTANT IN MENTAL AND NERVOUS DISEASES, O. P. D., BELLEVUE HOSPITAL; ASSISTANT VISITING PHYSICIAN, HOSPITAL FOR NERVOUS DISEASES.

NEW YORK

THE JOURNAL OF NERVOUS AND MENTAL DISEASE

PUBLISHING COMPANY

1909

Copyright 1909, by

The Journal of Nervous and Mental Disease Publishing Company.

CONTENTS.

TRANSLATOR’S PREFACE.

In the first place I wish to express my gratitude to Doctors Frederick Peterson, William A. White, and Ernest Jones, for their many helpful suggestions in the translation of this work. This does not, however, imply that they are in any way responsible for the numerous barbarisms found in the translation, for this I, alone, ask the reader’s indulgence. For one thing, it must be borne in mind that, aside from the subject-matter, Freud is not easy to read, even in the original. Indeed, I feel quite certain that only those who have read the original will best appreciate the task of the translator. But no matter how devoid of literary excellencies this translation may be, it can at least claim one merit, to wit, it is a faithful reproduction of the author’s thoughts. This is really all that should be required of a translation.

The chapters contained in this book were taken from three different volumes of the author’s works, published at different intervals within the last fifteen years. Although the first four chapters appear in the “Studien über Hysterie” which was published by Breuer and Freud,[^[1]] still only the first chapter, “The Psychic Mechanism of Hysterical Phenomena,” was written conjointly by both authors. The authorship of the other three chapters belongs exclusively to Freud. The remaining six chapters of the book were taken from Freud’s Collection of Small Articles.[^[2]]

It was by no means an easy task to compile in a single limited volume Freud’s theories of the actual- and psychoneuroses. Freud’s views are not only new and revolutionary, being based on an entirely new psychology, but unless one is thoroughly familiar with their development one is apt to misunderstand them. To obviate this it was thought best to collect those chapters from the author’s works which fully illustrate his theories and at the same time show the gradual evolution of his psychology.

That Freud’s views have undergone some changes, or rather modifications, within the last fifteen years we readily admit; but who will blame the surgeon for modifying or rejecting some technique of his operation, if after years of careful work he feels justified in so doing? Surely such an action merits applause rather than reproach. It was only after carefully investigating for years that Freud saw fit to change some of his views, yet nothing was really totally discarded.

It is quite unnecessary to discuss here the whys and wherefores of the modifications in question, these are fully explained in the text. But it will not be mal à propos to say a few words concerning the technique of the treatment.

For reasons given in the book the author has abandoned hypnotism and used the pressure procedure, but this in turn was given up because it was cumbersome for both doctor and patient and proved to be utterly needless.

The technique is as follows: The patient lies on his back on a lounge, the physician sitting behind the patient’s head at the head of the lounge. In this way the patient remains free from all external influences and impressions. The object is to avoid all muscular exertion and distraction, thus allowing thorough concentration of attention on the patient’s own psychic activities. The patient is then asked to give a detailed account of his troubles, after having been told before to repeat everything that occurs to his mind, even such thoughts as may cause him embarrassment or mortification. On listening to such a history one invariably notices many memory gaps, both in reference to time and causal relations. These the patient is urged to fill in by concentration of attention on the subject in question, and by repeating all the unintentional thoughts originating in this connection. This is the so called method of “free association!” The patient is required to relate all his thoughts in the order of their sequence even if they seem irrelevant to him. He must do away with all critique and remain perfectly passive. It is in this way that we fathom the original meaning of the symptom. But as the thoughts which originate in this manner are of a disagreeable and painful nature they are pushed back with the greatest resistance. This is further enhanced by the fact that the hysterical symptom is the symbolic expression of the realization of a repressed wish, and serves as a gratification for the patient. He strives very hard, unconsciously of course, to retain the symptom, as it is the only thing left to him from his former unattainable conscious wishes and strivings. The object of the psychanalytic treatment is to overcome all these resistances, and to reconduct to the patient’s consciousness the thoughts underlying the symptoms. Here lies the greatest difficulty, for just as in the normal life and the dream, a psychoneurotic symptom is merely a symbolic or cryptic expression of the original repressed thoughts. Every hysterical symptom, every obsession, and every phobia, has a definite meaning, and as was shown by Bleuler,[^[3]] Jung,[^[4]] Riklin,[^[5]] and others,[^[6]] the same holds true for the psychoses proper.

To discover the hidden mechanism, one must make use of the author’s developed method of interpretation, that is, one must look for symbolic actions, lapses in speech, memory, etc., and above all, one must resort to the analysis of dreams, as they give the most direct access to the unconscious. No one is really qualified to use or judge Freud’s psychanalytic method who has not thoroughly mastered the Traumdeutung,[^[7]] the Psychopathologie des Alltagsleben,[^[8]] and the Drei Abhandlungen zur Sexualtheorie,[^[9]] and has not had considerable experience in analyzing his own and other’s dreams and psychopathological actions. It is especially in the Traumdeutung that Freud has fully developed his psychanalytic technique and a perfect knowledge of which is the sine qua non in the treatment. It is only by following Freud in this manner that one can hope to solve the hitherto unsolved riddles of the psychoneuroses and psychoses.

This treatment is more difficult than one can describe in a preface. It not only presupposes a thorough knowledge of Freud but an equal knowledge of normal and abnormal psychology. Those who have not acquired this knowledge by reason of time or otherwise may remember the words of the younger Pliny: Ut enim de pictore scalptore fictore nisi artifex indicare, ita nisi sapiens non potest perspicere sapientem.

A. A. Brill.

CHAPTER I.
The Psychic Mechanism of Hysterical Phenomena.[^[10]]
(Preliminary Communication.)

I.

Instigated by a number of accidental observations we have investigated for a number of years the different forms and symptoms of hysteria in order to discover the cause and the process which provoked the phenomena in question for the first time, in a great many cases years back. In the great majority of cases we did not succeed in elucidating this starting point from the mere history, no matter how detailed it might have been, partly because we had to deal with experiences about which discussion was disagreeable to the patients, but mainly because they really could not recall them; often they had no inkling of the causal connection between the occasioning process and the pathological phenomenon. It was generally necessary to hypnotize the patients and reawaken the memory of that time in which the symptom first appeared, and we thus succeeded in exposing that connection in a most precise and convincing manner.

This method of examination in a great number of cases has furnished us with results which seem to be of theoretical as well as of practical value.

It is of theoretical value because it has shown to us that in the determination of the pathology of hysteria the accidental moment plays a much greater part than is generally known and recognized. It is quite evident that in “traumatic” hysteria it is the accident which evokes the syndrome. Moreover in hysterical crises, if patients state that they hallucinate in each attack the same process which evoked the first attack, here too, the causal connection seems quite clear. The state of affairs is more obscure in the other phenomena.

Our experiences have shown us that the most varied symptoms which pass as spontaneous, or so to say idiopathic attainments of hysteria, stand in just as stringent connection with the causal trauma as the transparent phenomena mentioned. To such causal moments we were able to refer neuralgias as well as the different kinds of anesthesias often of years duration, contractures and paralyses, hysterical attacks and epileptiform convulsions which every observer has taken for real epilepsy, petit mal and tic-like affections, persistent vomiting and anorexia, even the refusal of nourishment, all kinds of visual disturbances, constantly recurring visual hallucinations, and similar affections. The disproportion between the hysterical symptom of years duration and the former cause is the same as the one we are regularly accustomed to see in the traumatic neurosis. Very often they are experiences of childhood which have established more or less intensive morbid phenomena for all succeeding years.

The connection is often so clear that it is perfectly manifest how the causal event produced just this and no other phenomenon. It is quite clearly determined by the cause. Thus let us take the most banal example; if a painful affect originates while eating but is repressed, it may produce nausea and vomiting and continue for months as a hysterical symptom. A girl was anxiously distressed while watching at a sick bed. She fell into a dreamy state and experienced a frightful hallucination, and at the same time her right arm hanging over the back of a chair became numb. This resulted in a paralysis, contracture, and anesthesia of that arm. She wanted to pray but could find no words, but finally succeeded in uttering an English prayer for children. Later, on developing a very grave and most complicated hysteria, she spoke, wrote, and understood only English, whereas her native tongue was incomprehensible to her for a year and a half. A very sick child finally falls asleep. The mother exerts all her will power to make no noise to awaken it, but just because she resolved to do so she emits a clicking sound with her tongue (“hysterical counter-will”). This was later repeated on another occasion when she wished to be absolutely quiet, developing into a tic which in the form of tongue clicking accompanied every excitement for years. A very intelligent man was present while his brother was anesthetized and his ankylosed hip stretched. At the moment when the joint yielded and crackled he perceived severe pain in his own hip which continued for almost a year.

In other cases the connection is not so simple, there being only as it were a symbolic relation between the cause and the pathological phenomenon, just as in the normal dream. Thus psychic pain may result in neuralgia, or the affect of moral disgust may cause vomiting. We have studied patients who were wont to make the most prolific use of such symbolization. In still other cases such a determination is at first sight incomprehensible, yet to this group belong the typical hysterical symptoms such as hemianesthesia, contraction of visual field, epileptiform convulsions and many others. The explanation of our views on this group we have to reserve for the more detailed discussion of the subject.

Such observations seem to demonstrate the pathogenic analogy between simple hysteria and traumatic neurosis and justify a broader conception of “traumatic hysteria.” The active etiological factor in traumatic neurosis is really not the insignificant bodily injury but the affect of the fright, that is, the psychic trauma. In an analogous manner our investigations show that the causes of many, if not of all, cases of hysteria can be designated as psychic traumas. Every experience which produces the painful affect of fear, anxiety, shame or of psychic pain may act as a psychic trauma. Whether an experience becomes of traumatic importance naturally depends on the person affected as well as on the determination to be mentioned later. In ordinary hysteria instead of one big trauma we not seldom find many partial traumas, grouped causes which can be of traumatic significance only when summarized and which belong together in so far as they form small fragments of the sorrowful tale. In still other cases apparently indifferent circumstances gain traumatic dignity through their connection with the real effective event or with a period of time of special excitability which they then retain but which otherwise would have no significance.

Nevertheless the causal connection between the provoking psychic trauma and the hysterical phenomena does not perhaps resemble the trauma which as the agent provocateur would call forth the symptom which would become independent and continue to exist. We have to claim still more, namely, that the psychic trauma or the memory of the same acts like a foreign body which even long after its penetration must continue to influence like a new causative factor. The proof of this we see in a most remarkable phenomenon which at the same time gives to our discoveries a distinct practical interest.

We found, at first to our greatest surprise, that the individual hysterical symptoms immediately disappeared without returning if we succeeded in thoroughly awakening the memories of the causal process with its accompanying affect, and if the patient circumstantially discussed the process giving free play to the affect. Affectless memories are almost utterly useless. The psychic process originally rebuffed must be reproduced as vividly as possible so as to bring it back into the statum nascendi and then be thoroughly “talked over.” At the same time if we deal with such exciting manifestations as convulsions, neuralgias and hallucinations they appear once more with their full intensity and then vanish forever. Functional attacks like paralyses and anesthesias likewise disappear, but naturally without any appreciable distinctness of their momentary aggravation.[^[11]]

It is quite reasonable to suspect that one deals here with an unintentional suggestion. The patient expects to be relieved of his suffering and it is this expectation and not the discussion that is the effectual factor. But this is not so. The first observation of this kind in which a most complicated case of hysteria was analyzed and the individual causal symptoms separately abrogated, occurred in the year 1881, that is in a “pre-suggestive” time. It was brought about through a spontaneous autohypnosis of the patient and caused the examiner the greatest surprise.

In reversing the sentence: cessante causa cessat effectus, we may conclude from this observation that the causal process continues to act in some way even after years, not indirectly by means of a chain of causal connecting links but directly as a provoking cause, just perhaps as in the awakened consciousness where the memory of a psychic pain may later call forth tears. The hysteric suffers mostly from reminiscences.[^[12]]

II.

It would seem at first rather surprising that long-forgotten experiences should effect so intensively, and that their recollections should not be subject to the decay into which all our memories merge. We will perhaps gain some understanding of these facts by the following examinations.

The blurring or loss of an affect of memory depends on a great many factors. In the first place it is of great consequence whether there was an energetic reaction to the affectful experience or not. By reaction we here understand a whole series of voluntary or involuntary reflexes, from crying to an act of revenge, through which according to experience affects are discharged. If the success of this reaction is of sufficient strength it results in the disappearance of a great part of the affect. Language attests this fact of daily observation, in such expressions as “to give vent to one’s feeling,” to be “relieved by weeping,” etc.

If the reaction is suppressed the affect remains united with the memory. An insult retaliated, be it only in words, is differently recalled than one that had to be taken in silence. Language also recognizes this distinction between the psychic and physical results and designates most characteristically the silently endured suffering as “grievance.” The reaction of the person injured to the trauma has really no perfect “cathartic” effect unless it is an adequate reaction like revenge. But man finds a substitute for this action in speech through which help the affect can well nigh be ab-reacted[^[13]] (“abreagirt”). In other cases talking in the form of deploring and giving vent to the torments of the secret (confession) is in itself an adequate reflex. If such reaction does not result through deeds, words, or in the lightest case through weeping, the memory of the occurrence retains above all the affective accentuation.

The ab-reaction (abreagiren), however, is not the only form of discharge at the disposal of the normal psychic mechanism of the healthy person who has experienced a psychic trauma. The memory of the trauma even where it has not been ab-reacted enters into the great complex of the association. It joins the other experiences which are perhaps antagonistic to it and thus undergoes correction through the other ideas. For example, after an accident the memory of the danger and (dimmed) repetition of the fright is accompanied by the recollection of the further course, the rescue, and the consciousness of present security. The memory of a grievance may be corrected by a rectification of the state of affairs by reflecting upon one’s own dignity and similar things. Thus the normal person is able to cause a disappearance of the accompanying affect by means of association.

In addition there appears that general blurring of impressions, that fading of memories which we call “forgetting,” and which above all wears out the affective ideas no longer active.

It follows from our observations that those memories which become the causes of hysterical phenomena have been preserved for a long time with wonderful freshness and with their perfect emotional tone. As a further striking and a later realizable fact we have to mention that the patients do not perhaps have the same control of these as of their other memories of life. On the contrary, these experiences are either completely lacking from the memory of the patients in their usual psychic state or at most exist greatly abridged. Only after the patients are questioned in the hypnotic state do these memories appear with the undiminished vividness of fresh occurrences. Thus one of our patients in a hypnotic state reproduced with hallucinatory vividness throughout half a year all that excited her during an acute hysteria on the same days of the preceding year. Her mother’s diary which was unknown to the patient proved the faultless accuracy of the reproduction. Another patient, partly in hypnosis and partly in spontaneous attacks, went through with a hallucinatory distinctness all experiences of a hysterical psychosis which she passed through ten years before and for the greatest part of which she was amnesic until its reappearance. She also showed with surprising integrity and sentient force some etiologically important memories of fifteen to twenty-five years’ duration which on their return acted with the full affective force of new experiences.

The reason for this we can only find in the fact that in all the aforesaid relations these memories assume an exceptional position in reference to disappearance. It was really shown that these memories correspond to traumas which were not sufficiently ab-reacted to (“abreagirt”). On closer investigation of the reasons for this prevention we can find at least two series of determinants through which the reaction to the trauma was discontinued.

To the first group we add those cases in which the patient has not reacted to psychic traumas because the nature of the trauma precluded a reaction as in the case of an irremediable loss of a beloved person or because social relations made the reaction impossible, or because it concerned things which the patient wished to forget and which he therefore intentionally inhibited and repressed from his conscious memory. It is just those painful things which in the hypnotic state are found to be the basis of hysterical phenomena (hysterical delirium of saints, nuns, abstinent women, and well-bred children).

The second series of determinants is not conditioned by the content of the memories but by the psychic states with which the corresponding experiences in the patient have united. As a cause of hysterical symptoms one really finds in hypnosis presentations which are insignificant in themselves but which owe their preservation to the fact that they originated during a severe paralyzing affect like fright or directly in abnormal psychic conditions, as in the semi-hypnotic dreamy states of reveries, in autohypnosis and similar states. Here it is the nature of these conditions which make a reaction to the incident impossible.

To be sure both determinants may unite, and as a matter of fact they often do. This is the case when a trauma in itself effective occurs in a state of a powerful paralyzing affect or in a transformed consciousness. But due to the psychic trauma it may also happen that in many persons one of these abnormal states occurs which in turn makes a reaction impossible.

What is common to both groups of determinants is the fact that those psychic traumas which are not rectified by reaction are also prevented from adjustment by associative elaboration. In the first group it is due to the resolution of the patient who wishes to forget the painful experiences and in this way, if possible, to exclude them from association, and in the second group the associative elaboration does not succeed because there is no productive associative relationship between the normal and pathological state of consciousness in which these presentations originated. We shall soon have occasion to discuss more fully these relationships.

Hence we can say, that the reason why the pathogenically formed presentations retain their freshness and affective force is because they are not subject to the normal waste through ab-reaction and reproduction in conditions of uninhibited association.

III.

When we discussed the conditions which, according to our experience, are decisive in the development of hysterical phenomena from psychic traumas, we were forced to speak of abnormal states of consciousness in which such pathogenic presentations originate, and we had to emphasize the fact that the recollection of the effective psychic trauma is not to be found in the normal memory of the patient but in the hypnotized memory. The more we occupied ourselves with these phenomena the more certain became our convictions that the splitting of consciousness, so striking in the familiar classical cases of double consciousness, exists rudimentarily in every hysteria, and that the tendency to this dissociation, and with it the tendency towards the appearance of abnormal states of consciousness which we comprehend as “hypnoid states,” is the chief phenomenon of this neurosis. In this view we agree with Binet and with both the Janets about whose most remarkable findings in anesthetics we have had no experience.

Hence, to the often cited axiom, “Hypnosis is artificial hysteria,” we would like to add another: “The existence of hypnoid states is the basis and determination of hysteria.” These hypnoid states in all their diversities agree among themselves and with hypnosis in the fact that their emerged presentations are very intensive but are excluded from the associative relations of the rest of the content of consciousness. The hypnoid states are associable among themselves, and their ideation may thus attain various high degrees of psychic organization. In other respects the nature of these states and the degree of their exclusiveness differ from the rest of the conscious processes as do the various states in hypnosis, which range from light somnolence to somnambulism, and from perfect memory to absolute amnesia.

If such hypnoid states already exist before the manifested disease they prepare the soil upon which the affect establishes the pathogenic memories and their somatic resulting manifestations. This behavior corresponds to the predisposed hysteria. But the results of our observations show that a severe trauma (like that of a traumatic neurosis) or a painful suppression (perhaps of a sexual affect) may bring about a splitting of presentation groups even in persons otherwise not predisposed. This would then be the mechanism of the psychically acquired hysteria. Between the extremes of these two forms we have to admit a series in which the facility of dissociation in the concerned individuals and the magnitude of the affect of the trauma vary inversely.

We are unable to give anything new concerning the formation of the predisposed hypnoid states. We presume that they often develop from “reveries” very common to the normal for which, for example, the feminine handwork offers so much opportunity. The questions why “the pathological associations” formed in such states are so firm and why they exert a stronger influence on the somatic processes than other presentations, all fall together with the problem of the effectivity of hypnotic suggestions in general. Our experiences in this matter do not show us anything new, on the other hand they throw light on the contradiction between the sentence “Hysteria is a psychosis” and the fact that among hysterics one may meet persons of the clearest intellects, the strongest wills, greatest principles, and of the subtlest minds. In these cases such characteristics are only true for the waking thought of the person, for in his hypnotic state he is alienated just as we are in the dream. Yet, whereas our dream psychoses do not influence our waking state, the products of hypnotic states project as hysterical phenomena into the waking state.

IV.

Almost the same assertions that we have advanced in reference to the continuous hysterical symptoms we may also repeat concerning hysterical crises. As is known we have Charcot’s schematic description of the “major” hysterical attack which when complete shows four phases: (1) The epileptoid, (2) the grand movements, (3) the emotional—attitudes passionnelles (hallucinatory phase), and (4) the delirious. By shortening or prolonging the attack and by isolating the individual phases Charcot caused a succession of all those forms of the hysterical attack which are really observed more frequently than the complete grande attaque.

Our attempted explanation refers to the third phase, that is the attitudes passionnelles. Wherever it is prominent it contains the hallucinatory reproduction of a memory which was significant for the hysterical onset. It is the memory of a grand trauma, the so called κατ’ ἐξοχὴν of traumatic hysteria or of a series of connected partial traumas found at the basis of the common hysteria. Finally the attack may bring back that occurrence which on account of its meeting with a moment of special predisposition was raised to a trauma.

There are also attacks which ostensibly consist only of motor phenomena and lack the passionnelle phase. If it is possible during such an attack of general twitching, cataleptic rigidity or an attaque de sommeil, to put one’s self en rapport with the patient, or still better, if one succeeds in evoking the attack in a hypnotic state, it will then be found that here, too, the root of it is the memory of a psychic trauma, or of a series of traumas which make themselves otherwise prominent in an hallucinatory phase. A little girl had suffered for years from attacks of general convulsions which could be and were taken for epileptic. She was hypnotized for purposes of differential diagnosis and she immediately merged into one of her attacks. On being asked what she saw she said, “The dog, the dog is coming,” and it was really found that the first attack of this kind appeared after she was pursued by a mad dog. The success of the therapy then verified our diagnosis.

An official who became hysterical as a result of ill treatment on the part of his employer suffered from attacks, during which he fell to the floor raging furiously without uttering a word or displaying any hallucinations. The attack was provoked in a state of hypnosis and he then stated that he lived through the scene during which his employer insulted him in the street and struck him with a cane. A few days later he came to me complaining that he had the same attack, but this time it was shown in the hypnosis that he went through the scene which was really connected with the onset of his disease; it was the scene in the court room when he was unable to get satisfaction for the ill treatment which he received, etc.

The memories which appear in hysterical attacks or which can be awakened in them correspond in all other respects to the causes which we have found as the basis of the continuous hysterical symptoms. Like these they refer to psychic traumas which were prevented from alleviation by ab-reaction or by associative elaboration, like these they lack entirely or in their essential components the memory possibilities of normal consciousness and appear to belong to the ideation of hypnoid states of consciousness with limited associations. Finally they are also amenable to therapeutic proof. Our observations have often taught us that a memory which has always evoked attacks becomes incapacitated when in a hypnotic state it is brought to reaction and associative correction.

The motor phenomena of the hysterical attack can partly be interpreted as the memory of a general form of reaction of the accompanying affect, or partly as a direct motor expression of this memory (like the fidgeting of the whole body which even infants make use of), and partly, like the hysterical stigmata—the continuous symptoms—they are inexplainable on this assumption.

Of special significance for the hysterical attack is the aforementioned theory, namely, that in hysteria there are presentation groups which come to light in hypnoid states which are excluded from the rest of the associative process but are associable among themselves, thus representing a more or less highly organized rudimentary second consciousness, a condition seconde. A persistent hysterical symptom therefore corresponds to a projection of this second state into a bodily innervation otherwise controlled by the normal consciousness. A hysterical attack gives evidence of a higher organization of this second state, and if of recent origin it signifies a moment in which this hypnoid consciousness gained control of the whole existence, and hence we have an acute hysteria, but if it is a recurrent attack containing a memory we simply have a repetition of the same. Charcot has already given utterance to the fact that the hysterical attack must be the rudiment of a condition seconde. During the attack the control of the whole bodily innervation is transferred to the hypnoid consciousness. As familiar experiences show, the normal consciousness is not always repressed, it may even perceive the motor phenomena of the attack while the psychic processes of the same escape its cognizance.

The typical course of a grave hysteria, as everybody knows, is as follows: At first an ideation is formed in the hypnoid state which after sufficient development gains control in a period of “acute hysteria” of the bodily innervation and the existence of the patient thus forming persistent symptoms and attacks, and then with the exception of some remnants there is a recovery. If the normal personality can regain the upper hand, all that survived the hypnoid ideation then returns in hysterical attacks and at times it reproduces, in the personality, states which are again amenable to influences and capable of being affected by traumas. Frequently a sort of equilibrium then results among the psychic groups which are united in the same person; attack and normal life go hand in hand without influencing each other. The attack then comes spontaneously just as memories are wont to come, it may also be provoked just as memories may be by the laws of association. The provocation of the attack results either through stimulating a hysterogenic zone or through a new experience which by similarity recalls the pathogenic experience. We hope to be able to show that there is no essential difference between the apparently two diverse determinants, and that in both cases the hyperesthetic memory is touched. In other cases there is a great lability of equilibrium, the attack appears as a manifestation of the hypnoid remnant of consciousness as often as the normal person becomes exhausted and incapacitated. We cannot disregard the fact that in such cases the attack becomes denuded of its original significance and may return as a contentless motor reaction.

It remains a task for future investigation to discover what conditions are decisive in determining whether a hysterical individuality should manifest itself in attacks, in persistent symptoms, or in a mingling of both.

V.

We can now understand in what manner the psychotherapeutic method propounded by us exerts its curative effect. It abrogates the efficacy of the original not ab-reacted presentation of affording an outlet to the strangulated affect through speech. It brings it to associative correction by drawing it into normal consciousness (in mild hypnosis) or it is done away with through the physician’s suggestion just as happens in somnambulism with amnesia.

We maintain that the therapeutic gain obtained by applying this process is quite significant. To be sure we do not cure the hysterical predisposition as we do not block the way for the recurrence of hypnoid states; moreover, in the productive stage of acute hysteria our procedure is unable to prevent the replacement of the carefully abrogated phenomena by new ones. But when this acute stage has run its course and its remnants continue as persistent hysterical symptoms and attacks, our radical method usually removes them forever, and herein it seems to surpass the efficacy of direct suggestion as practiced at present by psychotherapists.

If by disclosing the psychic mechanisms of hysterical phenomena we have taken a step forward on the path so successfully started by Charcot with his explanation and experimental imitation of hystero-traumatic paralysis, we are well aware that in doing this we have only advanced our knowledge in the mechanisms of hysterical symptoms and not in the subjective causes of hysteria. We have but touched upon the etiology of hysteria and could only throw light on the causes of the acquired forms, the significance of the accidental moments in the neurosis.

CHAPTER II.
The Case of Miss Lucy R.

Towards the end of 1892 a friendly colleague recommended to me a young lady whom he had been treating for chronic recurrent purulent rhinitis. It was later found that the obstinacy of her trouble was caused by a caries of the ethmoid. She finally complained of new symptoms which this experienced physician could no longer refer to local affections. She had lost all perception of smell and was almost constantly bothered by one or two subjective sensations of smell. This she found very irksome. In addition to this she was depressed in spirits, weak, and complained of a heavy head, loss of appetite, and an incapacity for work.

This young lady visited me from time to time during my office hours—she was a governess in the family of a factory superintendent living in the suburbs of Vienna. She was an English lady of rather delicate constitution, anemic, and with the exception of her nasal trouble was in good health. Her first statements concurred with those of her physician. She suffered from depression and lassitude, and was tormented by subjective sensations of smell. Of hysterical signs, she showed a quite distinct general analgesia without tactile impairment, the fields of vision showed no narrowing on coarse testing with the hand, the nasal mucous membrane was totally analgesic and reflexless, tactile sensation was absent, and the perception of this organ was abolished for specific as well as for other stimuli, such as ammonia or acetic acid. The purulent nasal catarrh was then in a state of improvement.

On first attempting to understand this case the subjective sensations of smell had to be taken as recurrent hallucinations interpreting persistent hysterical symptoms. The depression was perhaps the affect belonging to the trauma and there must have been an episode during which the present subjective sensations were objective. This episode must have been the trauma, the symbols of which recurred in memory as sensations of smell. Perhaps it would be more correct to consider the recurring hallucinations of smell with the accompanying depression as equivalents of hysterical attacks. The nature of recurrent hallucinations really makes them unfit to take the part of continuous symptoms, and this really did not occur in this rudimentarily developed case. On the other hand it was absolutely to be expected that the subjective sensations of smell would show such a specialization as to be able to correspond in its origin to a very definite and real object.

This expectation was soon fulfilled, for on being asked what odor troubled her most she stated that it was an odor of burned pastry. I could then assume that the odor of burned pastry really occurred in the traumatic event. It is quite unusual to select sensations of smell as memory symbols of traumas, but it is quite obvious why these were here selected. She was afflicted with purulent rhinitis, hence the nose and its perceptions were in the foreground of her attention. All I knew about the life of the patient was that she took care of two children whose mother died a few years ago from a grave and acute disease.

As a starting point of the analysis I decided to use the “odor of burned pastry.” I will now relate the history of this analysis. It could have occurred under more favorable conditions, but as a matter of fact what should have taken place in one session was extended over a number of them. She could only visit me during my office hours, during which I could devote to her but little of my time. One single conversation had to be extended for over a week as her duties did not permit her to come to me often from such a distance, so that the conversation was frequently broken off and resumed at the next session.

On attempting to hypnotize Miss Lucy R. she did not merge into the somnambulic state. I therefore was obliged to forego somnambulism and the analysis was made while she was in a state not perhaps differing much from the normal.

I feel obliged to express myself more fully about the point of the technique of my procedure. While visiting the Nancy clinics in 1889 I heard Dr. Liébeault, the old master of hypnotism, say, “Yes, if we had the means to put everybody into the somnambulic state, hypnotism would then be the most powerful therapeutic agent.” In Bernheim’s clinic it almost seemed that such an art really existed and that it could be learned from Bernheim. But as soon as I tried to practice it on my own patients I noticed that at least my powers were quite limited in this respect. Whenever a patient did not merge into the somnambulistic state after one to three attempts I possessed no means to force him into it. However, the percentage of somnambulists in my experience were far below that claimed by Bernheim.

Thus I had my choice, either to forbear using the cathartic method in most of the cases suitable for it, or to venture the attempt without somnambulism by using hypnotic influence in light or even doubtful cases. It made no difference of what degree (following the accepted scales of hypnotism) the hypnotism was which did not correspond to somnambulism, for every direction of suggestibility is independent of the other and nothing is prejudicial towards the evocation of catalepsy, automatic movements and similar phenomena for the purpose of facilitating the awakening of forgotten recollections. I soon relinquished the habit of deciding the degree of hypnotism, as in a great number of cases it incited the patients’ resistance, and clouded the confidence which I needed for the more important psychic work. Moreover, in mild grades of hypnotism I soon tired of hearing, after the assurance and command, “You will sleep, sleep now!” such protests as, “But, Doctor, I am not sleeping.” I was then forced to bring in the very delicate distinction, saying, “I do not mean the usual sleep, I mean the hypnotic,—you see, you are hypnotized, you cannot open your eyes”; or, “I really don’t want you to sleep.” I, myself, am convinced that many of my colleagues using psychotherapy know how to get out of such difficulties more skilfully than I; they can proceed differently. I, however, believe that if through the use of a word one can so frequently become embarrassed, it is better to avoid the word and the embarrassment. Wherever the first attempt did not produce either somnambulism or a degree of hypnotism with pronounced bodily changes, I dropped the hypnosis and demanded only “concentration,” I ordered the patient to lie on his back and close his eyes as a means of reaching this “concentration.” With little effort I obtained as profound a degree of hypnotism as was possible.

But inasmuch as I forbore using somnambulism, I perhaps robbed myself of a preliminary stipulation without which the cathartic method seems inapplicable. For it is based on the fact that in the altered state of consciousness the patients have at their disposal such recollections and recognize such connections which do not apparently exist in their normal conscious state. Wherever the somnambulic broadening of consciousness lacks there must also be an absence of the possibility of bringing about a causal relation which the patient cannot give to the doctor as something known to him, and it is just the pathogenic recollections “which are lacking from the memory of the patients in their usual psychic states or only exist in a most condensed state” (preliminary communication).

My memory helped me out of this embarrassment. I, myself, saw Bernheim adduce proof that the recollections of somnambulism are only manifestly forgotten in the waking state and can be readily reproduced by slight urging accompanied by hand pressure which is supposed to mark another conscious state. He, for instance, imparted to a somnambulist the negative hallucination that he was no more present, and then attempted to make himself noticeable to her by the most manifold and regardless attacks, but was unsuccessful. After the patient was awakened he asked her what he did to her during the time that she thought he was not there. She replied very much astonished, that she knew nothing, but he did not give in, insisting that she would recall everything; and placed his hand on her forehead so that she should recall things, and behold, she finally related all that she did not apparently perceive in the somnambulic state and about which she ostensibly knew nothing in the waking state.

This astonishing and instructive experiment was my model. I decided to proceed on the supposition that my patients knew everything that was of any pathogenic significance, and that all that was necessary was to force them to impart it. When I reached a point where to the question “Since when have you this symptom?” or, “Where does it come from?” I receive the answer, “I really don’t know this,” I proceeded as follows: I placed my hand on the patient’s forehead or took her head between my hands and said, “Under the pressure of my hand it will come into your mind. In the moment that I stop the pressure you will see something before you, or something will pass through your mind which you must note. It is that which we are seeking. Well, what have you seen or what came into your mind?”

On applying this method for the first time (it was not in the case of Miss Lucy R.) I was surprised to find just what I wanted, and I may say that it has since hardly ever failed me, it always showed me the way to proceed in my investigations and enabled me to conclude all such analyses without somnambulism. Gradually I became so bold that when a patient would answer, “I see nothing,” or “Nothing came into my mind,” I insisted that it was impossible. They probably had the right thought but did not believe it and repudiated it. I would repeat the procedure as often as they wished, and every time they saw the same thing. Indeed, I was always right; the patients had not as yet learned to let their criticism rest. They repudiated the emerging recollection or fancy because they considered it as a useless intruding disturbance, but after they imparted it, it was always shown that it was the right one. Occasionally after forcing a communication by pressing the head three or four times I got such answer as, “Yes, I was aware of it the first time, but did not wish to say it,” or, “I hoped that it would not be this.”

By this method it was far more laborious to broaden the alleged narrowed consciousness than by investigating in the somnambulic state, but it made me independent of somnambulism and afforded me an insight into the motives which are frequently decisive for the “forgetting” of recollections. I am in position to assert that this forgetting is often intentional and desired. It is always only manifestly successful.

It appeared to me even more remarkable that apparently long forgotten numbers and dates can be reproduced by a similar process, thus proving an unexpected faithfulness of memory.

The insignificant choice which one has in searching for numbers and dates especially allows us to take to our aid the familiar axiom of the theory of aphasia, namely, that recognition is a slighter accomplishment of memory than spontaneous recollection.

Hence to a patient who is unable to recall in what year, month or day a certain event took place, enumerate the years during which it might have occurred as well as the names of the twelve months and the thirty-one days of the month, and assure him that at the right number or name his eyes will open themselves or that he will feel which number is the correct one. In most cases the patients really decide on a definite date and frequently enough (as in the case of Mrs. Cäcilie N.) it could be ascertained from existing notes of that time that the date was correctly recognized. At other times and in different patients it was shown from the connection of the recollected facts that the dates thus found were incontestable. A patient, for instance, after a date was found by enumerating for her the dates, remarked, “This is my father’s birthday,” and added “Of course I expected this episode [about which we spoke] because it was my father’s birthday.”

I can only slightly touch upon this theme. The conclusion which I wished to draw from all these experiences is that the pathogenic important experiences with all their concomitant circumstances are faithfully retained in memory, even where they seem forgotten, as when the patient seems unable to recall them.[^[14]]

After this long but unavoidable digression I now return to the history of Miss Lucy R. As aforesaid, she did not merge into somnambulism when an attempt was made to hypnotize her, but lay calmly in a degree of mild suggestibility, her eyes constantly closed, the features immobile, the limbs without motion. I asked her whether she remembered on what occasion the smell perception of burned pastry originated.—“Oh, yes, I know it well. It was about two months ago, two days before my birthday. I was with the children (two girls) in the school room playing and teaching them to cook, when a letter just left by the letter carrier was brought in. From its postmark and handwriting I recognized it as one sent to me by my mother from Glasgow and I wished to open it and read it. The children then came running over, pulled the letter out of my hand and exclaimed, ‘No you must not read it now, it is probably a congratulatory letter for your birthday and we will keep it for you until then.’ While the children were thus playing there was a sudden diffusion of an intense odor. The children forgot the pastry which they were cooking and it became burned. Since then I have been troubled by this odor, it is really always present but is more marked during excitement.”

“Do you see this scene distinctly before you?”—“As clearly as I experienced it.”—“What was there in it that so excited you?”—“I was touched by the affection which the children displayed towards me.”—“But weren’t they always so affectionate?”—“Yes, but I just got the letter from my mother.”—“I can’t understand in what way the affection of the little ones and the letter from the mother contrasted, a thing which you appear to intimate.”—“I had the intention of going to my mother and my heart became heavy at the thought of leaving those dear children.”—“What is the matter with your mother? Was she so lonesome that she wanted you, or was she sick just then and you expected some news?”—“No, she is delicate but not really sick, and has a companion with her.”—“Why then were you obliged to leave the children?”—“This house had become unbearable to me. The housekeeper, the cook, and the French maid seemed to be under the impression that I was too proud for my position. They united in intriguing against me and told the grandfather of the children all sorts of things about me, and when I complained to both gentlemen I did not receive the support which I expected. I then tendered my resignation to the master (father of the children) but he was very friendly, asking me to reconsider it for two weeks before taking any definite steps. It was while I was in that state of indecision that the incident occurred. I thought that I would leave the house but have remained.”—“Aside from the attachment of the children is there anything particular which attracts you to them?”—“Yes, my mother is distantly related to their mother and when the latter was on her death bed I promised her to do my utmost in caring for the children, that I would not forsake them, and be a mother to them, and this promise I broke when offering my resignation.”

The analysis of the subjective sensation of smell seemed completed. It was once objective and intimately connected with an experience, a small scene, in which contrary affects conflicted, sorrow at forsaking the children, and the mortification which despite all urged her to this decision. Her mother’s letter naturally recalled the motives of this decision because she thought of returning to her mother. The conflict of the affects raised this moment to a trauma and the sensation of smell which was connected with it remained as its symbol. The only thing to be explained was the fact that out of all the sensory perceptions of that scene, the perception of smell was selected as the symbol, but I was already prepared to use the chronic nasal affliction as an explanation. On being directly questioned she stated that just at that time she suffered from a severe coryza and could scarcely smell anything but in her excitement she perceived the odor of burned pastry, it penetrated the organically motived anosmia.

As plausible as this sounded it did not satisfy me; there seemed to be something lacking. There was no acceptable reason wherefore this series of excitements and this conflict of affects should have led to hysteria. Why did it not all remain on a normal psychological basis? In other words, what justified the conversion under discussion? Why did she not recall the scenes themselves instead of the sensations connected with them which she preferred as symbols for her recollection? Such questions might seem superfluous and impertinent when dealing with old hysterias in whom the mechanism of conversion was habitual, but this girl first acquired hysteria through this trauma, or at least through this slight distress.

From the analysis of similar cases I already knew that where hysteria is to be newly acquired one psychic determinant is indispensible; namely, that some presentation must intentionally be repressed from consciousness and excluded from associative elaboration.

In this intentional repression I also find the reason for the conversion of the sum of excitement, be it partial or total. The sum of excitement which is not to enter into psychic association more readily finds the wrong road to bodily innervation. The reason for the repression itself could only be a disagreeable feeling, the incompatibility of one of the repressible ideas with the ruling presentation-mass of the ego. The repressed presentation then avenges itself by becoming pathogenic.

From this I concluded that Miss Lucy R. merged into that moment of hysterical conversion, which must have been under the determinations of that trauma which she intentionally left in the darkness and which she took pains to forget. On considering her attachment for the children and her sensitiveness towards the other persons of the household, there remained but one interpretation which I was bold enough to impart to her. I told her that I did not believe that all these things were simply due to her affection for the children, but that I thought that she was rather in love with her master, perhaps unwittingly, that she really nurtured the hope of taking the place of the mother, and it was for that reason that she became so sensitive towards the servants with whom she had lived peacefully for years. She feared lest they would notice something of her hope and scoff at her.

She answered in her laconic manner: “Yes, I believe it is so.”—“But if you knew that you were in love with the master, why did you not tell me so?”—“But I did not know it, or rather, I did not wish to know it. I wished to crowd it out of my mind, never to think of it, and of late I have been successful.”[^[15]]

“Why did you not wish to admit it to yourself? Were you ashamed because you loved a man?”—“O, no, I am not unreasonably prudish; one is certainly not responsible for one’s own feelings. I only felt chagrined because it was my employer in whose service I was and in whose house I lived, and toward whom I could not feel as independent as towards another. What is more, I am a poor girl and he is a rich man of a prominent family, and if anybody should have had any inkling about my feelings they would have ridiculed me.”

After this I encountered no resistances in elucidating the origin of this affection. She told me that the first years of her life in that house were passed uneventfully. She fulfilled her duties without thinking about unrealizable wishes. One day, however, the serious, and very busy and hitherto very reserved master, engaged her in conversation about the exigencies of rearing the children. He became milder and more cordial than usual, he told her how much he counted on her in the bringing up of his orphaned children, and looked at her rather peculiarly. It was in this moment that she began to love him, and gladly occupied herself with the pleasing hopes which she conceived during that conversation. However, as this was not followed by anything else, and despite her waiting and persevering no other confidential heart-to-heart talk followed, she decided to crowd it out of her mind. She quite agreed with me that the look in connection with the conversation was probably intended for the memory of his deceased wife. She was also perfectly convinced that her love was hopeless.

After this conversation I expected a decided change in her condition but for a time it did not take place. She continued depressed and moody—a course of hydrotherapy which I ordered for her at the same time refreshed her somewhat mornings. The odor of burned pastry did not entirely disappear; though it became rarer and feebler it appeared only, as she said, when she was very much excited.

The continuation of this memory symbol led me to believe that besides the principal scene it represented many smaller side traumas and I therefore investigated everything that might have been in any way connected with the scene of the burned pastry. We thus passed through the theme of family friction, the behavior of the grandfather and others, and with that the sensation of burned odor gradually disappeared. Just then there was a lengthy interruption occasioned by a new nasal affliction which led to the discovery of the caries of the ethmoid.

On her return she informed me that she received many Christmas presents from both gentlemen as well as from the household servants, as if they were trying to appease her and wipe away the recollection of the conflicts of the last months. These frank advances made no impression on her.

On questioning her on another occasion about the odor of burned pastry she stated that it had entirely disappeared, but instead she was now bothered by another and similar odor like the smoke of a cigar. This odor really existed before; it was only concealed by the odor of the pastry but now appeared by itself.

I was not very much pleased with the success of my treatment. What occurred here is what a mere symptomatic treatment is generally blamed for, namely, that it removes one symptom only to make room for another. Nevertheless, I immediately set forth to remove this new memory symbol by analysis.

This time I did not know whence this subjective sensation of smell originated, nor on what important occasion it was objective. On being questioned she said, “They constantly smoke at home, I really don’t know whether the smell which I feel has any particular significance.” I then proposed that she should try to recall things under the pressure of my hands. I have already mentioned that her recollections were plastically vivid, that she was a “visual.” Indeed under the pressure of my hands a picture came into her mind—at first only slowly and fragmentarily. It was the dining room of the house in which she waited with the children for the arrival of the gentlemen from the factory for dinner.—“Now we are all at the table, the gentlemen, the French maid, the housekeeper, the children and I. It is the same as usual.”—“Just keep on looking at that picture. It will soon become developed and specialized.”—“Yes, there is a guest, the chief accountant, an old gentleman who loves the children like his own grandchildren, but he dines with us so frequently that it is nothing unusual.”—“Just have patience, keep on looking at the picture, something will certainly happen.”—“Nothing happens. We leave the table, the children take leave and go with us up to the second floor as usual.”—“Well?”—“It really is something unusual, I now recognize the scene. As the children take leave the chief accountant attempts to kiss them, but my master jumps up and shouts at him, ‘Don’t kiss the children!’ I then experienced a stitch in the heart, and as the gentlemen were smoking, this odor remained in my memory.”

This, therefore, was the second, deeper seated scene causing the trauma and leaving the memory symbol. But why was this scene so effective? I then asked her which scene happened first, this one or the one with the burned pastry?—“The last scene happened first by almost two months.”—“Why did you feel the stitch at the father’s interference? The reproof was not meant for you.”—“It was really not right to rebuke an old gentleman in such manner who was a dear friend and a guest, it could have been said quietly.”—“Then you were really affected by your master’s impetuosity? Were you perhaps ashamed of him, or have you thought, ‘If he could become so impetuous to an old friend guest over such a trifle, how would he act towards me if I were his wife?’”—“No, that is not it.”—“But still it was about his impetuosity?”—“Yes, about the kissing of the children, he never liked that.” Under the pressure of my hands there emerged a still older scene which was the real effective trauma and which bestowed on the scene with the chief accountant the traumatic effectivity.

A few months before a lady friend visited the house and on leaving kissed both children on the lips. The father, who was present, controlled himself and said nothing to the lady, but when she left he was very angry at the unfortunate governess. He said that he held her responsible for this kissing; that it was her duty not to tolerate it; that she was neglecting her duties in allowing such things, and that if it ever happened again he would entrust the education of his children to some one else. This occurred while she believed herself loved and waited for a repetition of that serious and friendly talk. This episode shattered all her hopes. She thought: “If he can upbraid and threaten me on account of such a trifle, of which I am entirely innocent, I must have been mistaken, he never entertained any tenderer feelings towards me, else he would have been considerate.”—It was evidently this painful scene that came to her as the father reprimanded the chief accountant for attempting to kiss the children.

On being visited by Miss Lucy R. two days after the last analysis I had to ask her what pleasant things happened to her. She looked as though transformed, she smiled and held her head aloft. For a moment I thought that after all I probably mistook the conditions and that the governess of the children had now become the bride of the master. But she soon dissipated all my suppositions, saying, “Nothing new happened. You really do not know me. You have always seen me while I was sick and depressed. I am otherwise always cheerful. On awaking yesterday morning my burden was gone and since then I feel well.”—“What do you think of your chances in the house?”—“I am perfectly clear about that. I know that I have none, and I am not going to be unhappy about it.”—“Will you now be able to get along with the others in the house?”—“I believe so, because most of the trouble was due to my sensitiveness.”—“Do you still love the master?”—“Certainly I love him, but that does not bother me much. One can think and feel as one wishes.”

I now examined her nose and found that the pain and the reflex sensations had almost completely reappeared. She could distinguish odors, but she was uncertain when they were very intense. What part the nasal trouble played in the anosmia I must leave undecided.

The whole treatment extended over a period of nine weeks. Four months later I accidentally met the patient at one of our summer resorts—she was cheerful and stated that her health continued to be good.

Epicrisis.

I would not underestimate the aforesaid case even though it only represents a young and light hysteria presenting but few symptoms. Moreover, it seems to me instructive that even such a slight neurotic affliction requires so many psychic determinants, and on a more exhaustive consideration of this history I am tempted to put it down as an illustration of that form of hysteria which even persons not burdened by heredity may acquire if their experiences favor it. It should be well noted that I do not speak of a hysteria which may be independent of all predisposition; such form does not probably exist, but we speak of such a predisposition only after the person became hysterical, as nothing pointed to it before this. A neuropathic disposition as commonly understood is something different. It is determined even before the disease by a number of hereditary burdens, or a sum of individual psychic abnormalities. As far as I know none of these moments could be demonstrated in the case of Miss Lucy R. Her hysteria could therefore be called acquired and presupposes nothing except probably a very marked susceptibility to acquire hysteria, a characteristic about which we know hardly anything. The chief importance in such cases lies in the nature of the trauma, to be sure in connection with the reaction of the person to the trauma. It is an indispensable condition for the acquirement of hysteria that there should arise a relation of incompatibility between the ego and some of its approaching presentations. I hope to be able to show in another place how a variety of neurotic disturbances originate from the different procedures which the “ego” pursues in order to free itself from that incompatibility. The hysterical form of defence, for which a special adaptation is required, consists in converting the excitement into physical innervation. The gain brought about by this process is the crowding out of the unbearable presentation from the ego consciousness, which then contains instead the physical reminiscences produced by conversion—in our case the subjective sensation of smell—and suffers from the affect which is more or less distinctly adherent to these reminiscences. The situation thus produced is no longer changeable, for changing and conversion annihilate the conflict which helped towards the adjustment of the affect. Thus the mechanism producing hysteria corresponds on the one hand to an act of moral faint heartedness, on the other hand it presents itself as a protective arrangement at the command of the ego. There are many cases in which it must be admitted that the defense of the increased excitement through the production of hysteria may actually have been most expedient, but more frequently one will naturally come to the conclusion that a greater measure of moral courage would have been an advantage to the individual.

Accordingly the real traumatic moment is that, in which the conflict thrusts itself upon the ego and the latter decides to banish it. Such banishment does not annihilate the opposing presentation but merely crowds it into the unconscious. This process, occurring for the first time, forms a nucleus and point of crystallization for the formation of a new psychic group separated from the ego, around which, in the course of time, everything collects in accord with the opposing presentation. The splitting of consciousness in such cases of acquired hysteria is thus a desired and intentional one, and is often initiated by at least one arbitrary act. But literally, something different happens than the individual expects, he would wish to eliminate a presentation as though it never came to pass but only succeeds in isolating it psychically.

The traumatic moment in the history of our patient corresponds to the scene created by the master on account of the kissing of the children. For the time being this scene remained without any palpable effects, perhaps it initiated the depression and sensitiveness, but I leave this open;—the hysterical symptoms, however, commenced later in moments which can be designated as “auxiliary,” and which may be characterized by the fact that in them there is a simultaneous flowing together of both separated groups just as in the broadened somnambulic consciousness. The first of these moments in which the conversion took place in Miss Lucy R., was the scene at the table when the chief accountant attempted to kiss the children. The traumatic memory helped along, and she acted as though she had not entirely banished her attachment for her master. In other cases we find that these different moments come together and the conversion occurs directly under the influence of the trauma.

The second auxiliary moment repeated almost precisely the mechanism of the first. A strong impression transitorily reestablished the unity of consciousness and the conversion takes the same route opened to it in the first. It is interesting to note that the symptom occurring second concealed the first so that it could not be distinctly perceived until the second was eliminated. The reversal of the succession of events to which also the analysis must be adapted seems to me quite remarkable. In a whole series of cases I found that the symptoms which came later covered the first, and only the last thing in the analysis contained the key to the whole.

The therapy here consisted in forcing the union of the dissociated psychic groups with the ego consciousness. It is remarkable that the success did not run parallel with the accomplished work, the cure resulted suddenly only after the last part was accomplished.

CHAPTER III.
The Case of Miss Elisabeth v. R.

In the fall of 1892 I was requested by a friendly colleague to examine a young lady who had suffered from pains in her legs for over two years and who walked badly. He also added that he diagnosed the case as hysteria, though none of the usual symptoms of the neurosis could be found. He stated that he knew something of the family and that the last few years had brought them much misfortune and little pleasure. At first the father of the patient died, then the mother underwent a serious operation for the eyes, and soon thereafter a married sister succumbed to a chronic cardiac affection after childbirth. Our patient had taken an active part in all the afflictions and in all the nursings of the sick. I made no further progress into the case after I had seen the twenty-four-year-old patient for the first time. She seemed intelligent and psychically normal and her affliction, which interfered with her social relations and pleasure, she bore with a happy mien, thus vividly recalling the “belle indifference” of hysterics. She walked with the upper part of her body bent forward, but without any support; her gait did not correspond to any known pathological gait and it was in no way strikingly bad. She complained of severe pains on walking, of early fatigue in walking as well as standing, and after a brief period she would seek rest in which the pains became diminished but they by no means disappeared. The pain was of an indefinite nature—one could assume it to be a painful fatigue. The seat of the pain was given as a quite extensive but indefinitely circumscribed location on the superficial surface of the right thigh. It was from this area that the pains radiated and where they were of the greatest intensity. Here, too, the skin and muscles were especially sensitive to pressure and pinching, while needle pricks were rather indifferently perceived. The same hyperalgesia of the skin and muscles was demonstrable, not only in this area, but over almost the entire surface of both legs. The muscles were perhaps more painful than the skin, but both kinds of pains were unmistakably most pronounced over the thighs. The motor power of the legs was not diminished, the reflexes were of average intensity and all other symptoms were lacking, so that there was no basis for the assumption of a serious organic affection. The disease developed gradually during two years and changed considerably in its intensity.

I did not find it easy to determine the diagnosis, but for two reasons I concluded to agree with my colleague. First, because it was rather peculiar that such a highly intelligent patient should not be able to give anything definite about the character of her pains. A patient suffering from an organic pain, if it is not accompanied by any nervousness will be able to describe it definitely and calmly; it may perhaps be lancinating, appearing at certain intervals, extending from this to that location, and in his opinion it may be evoked by this or that influence. The neurasthenic describing his pain gives the impression of being occupied with some difficult mental problem reaching far beyond his powers. His features are tense and distorted as though under the domination of a painful affect, his voice becomes shriller, he struggles for expression, he rejects all designations that the physician makes for his pains, even though they are undoubtedly afterwards found as appropriate. He is ostensibly of the opinion that language is too poor to give expression to his feelings. His sensations are something unique, they never existed before so that they can not be exhaustively described. He never tires of constantly adding new details and when he has to stop he is surely controlled by the impression that he was unsuccessful in making himself understood to the physician. All this is due to the fact that his pains absorb his whole attention. In the case of Miss v. R. we had just the opposite behavior and we had to conclude from this that she attributed sufficient significance to the pain, but that her attention was concentrated on something else of which the pains were the accompanying phenomena, perhaps on thoughts and sensations which were connected with the pain.

A still greater determination for the conception of the pain must however, be found in a second moment. If we irritate a painful area in a patient suffering from an organic disease or neurasthenia his physiognomy will show a definite expression of discomfort or of physical pain. Furthermore, the patient winces, refuses to be examined and assumes a defensive attitude. With Miss v. R. when the hyperalgesic skin or muscles of her legs were pinched or pressed her face assumed a peculiar expression approaching nearer pleasure than pain, she cried out and—I had to think of a pleasurable tickling—her face reddened, she threw her head backward, closed her eyes, and her body bent backward; all this was not very distinct but sufficiently marked so that it could only agree with the conception that her affliction was a hysteria and that the irritation touched a hysterogenic zone.

Her mien was not in accord with the pain which the pinching of the muscles and skin were supposed to excite. It probably harmonized better with the content of the thoughts which were behind the pain and which were evoked in the patient by irritating that part of the body associated with them. I have repeatedly observed similar significant expressions on irritating hyperalgesic zones in unmistakable cases of hysteria. The other gestures evidently corresponded to the slightest indications of a hysterical attack.

We could not at that time find any explanation for the unusual localization of the hysterogenic zone. That the hyperalgesia chiefly concerned the muscles gave material for reflection. The most frequent affliction causing the diffuse and local pressure sensitiveness of the muscles is the rheumatic infiltration of the same, the common chronic muscular rheumatism about which aptitude to mask nervous affections I have already spoken. The consistency of the painful muscles in Miss v. R. did not contradict this assumption, as there were many hard cords in the muscle masses which seemed to be especially sensitive. There was probably also an organic change in the muscles, in the assumed sense, upon which the neurosis rested and which significance was markedly exaggerated by the neurosis.

The therapy followed out was based on a supposition of a mixed affection. We recommended the continuation of a systematic massage and faradization of the sensitive muscles without regard to the pain produced, and in order to remain in communication with the patient I undertook the treatment of her legs by means of strong Franklin’s sparks. To her question whether she should force herself to walk we answered decidedly in the affirmative.

We thus attained a slight improvement. She particularly liked the painful shocks of the influence machine and the stronger they were the more they seemed to suppress her pains. My colleague meanwhile prepared the soil for the psychic treatment, and when after four weeks of sham treatment I proposed the same and gave the patient some explanations concerning the procedures and its effects I found a ready understanding and only slight resistances.

The work which then began became eventually the most arduous that ever befell my lot, and the difficulty of giving an account of this work ranks well with the obstacles that had to be overcome. For a long time, too, I did not understand the connection between the history of the disease and the affliction, a thing which should really have been caused and determined by this row of events.

When one undertakes a cathartic treatment he at first asks himself whether the patient understands the origin and cause of her suffering. If that is so one does not need any special technique to cause her to reproduce the history of her ailment. The interest shown in her, the understanding which we foreshadow, the hope of recovery extended to her, all these will induce the patient to give up her secrets. With Miss Elisabeth it seemed probable to me right from the very beginning that she was conscious of the reasons for her suffering, that she had only a secret but no foreign body in consciousness. On looking at her one had to think of the poet’s words,

“That mask indicates a hidden meaning.”[^[16]]

At first I could thus forego hypnosis, reserving it, however, for future use if in the course of the confession conditions should arise for which explanation the memory would not perhaps suffice. Thus in this first complete analysis of a hysteria which I had undertaken, I reached a process of treatment which later I raised into a method and employed it consciously in the process of removing by strata the pathogenic psychic material which we used to compare with the technique of excavating a buried city. I at first allowed the patient to relate to me what was known to her, paying careful attention wherever a connection remained enigmatical or where a link in the chain of causation seemed to be lacking. Later I penetrated into the deeper strata of memory by using for those locations hypnotic investigation or a similar technique. The presupposition of the whole work was naturally the expectation that a perfect and sufficient determination could be demonstrated. The means of the deeper investigation will soon be discussed.

The history which Miss Elisabeth gave was very dull and was woven of manifold painful experiences. During this recital she was not in a hypnotic state; I merely asked her to lie down and keep her eyes closed. I however made no objection if she from time to time opened her eyes, changed her position or sat up. Whenever she entered more deeply into a part of her history she seemed to merge spontaneously into a condition resembling a hypnotic state. She then remained motionless and kept her eyes firmly closed.

I shall now reproduce the results of the superficial strata of her memory. As the youngest of three daughters she spent her youth with her parents, to whom she was devotedly attached, on their estate in Hungary. Her mother’s health was frequently disturbed by an affliction of her eyes and also by nervous conditions. It thus happened that she became especially and devotedly attached to her jovial and broadminded father who was wont to say that this daughter took the place of both a son and friend with whom he could exchange his thoughts. As much as the girl gained in mental stimulation in consequence of this intercourse it did not escape the father that her psychic constitution deviated from that ideal which one so much desires to see in a girl. Jocosely he called her pert and disputatious. He warned her against being too confident in her judgments, against her tendencies to tell the truth regardlessly to everybody, and expressed his opinion that she would find it difficult to get a husband. As a matter of fact she was very discontented with her girlhood; she was filled with ambitious plans, wishing to study or obtain a musical education, and revolted at the thought of being forced to give up her inclination to sacrifice her freedom of judgment on account of marriage. Meanwhile she was proud of her father, of the regard and social position of her family, and jealously guarded everything connected with these matters. The indifference with which she treated her mother and older sisters, as will be shown, was considered by her parents to be due to the blunter side of her character.

The age of the girls impelled the family to move into the metropolis, where for a time Elisabeth enjoyed the richer and gayer life. But then came the calamity which destroyed the happiness of the home. The father either concealed or overlooked a chronic cardiac affection, and one day he was brought home in an unconscious state after the first attack of edema of the lungs. This was followed by an illness of one and a half years, during which Elisabeth took the most prominent part in nursing him. She slept in her father’s room, awoke at night at his call, watched over him faithfully during the day, and forced herself to appear cheerful while he went through a hopeless condition with amiable resignation. The beginning of her affection must have been connected with this time of her nursing, for she could recall that during the last half year of this care she had to remain in bed on one occasion for a day and a half on account of severe pain in the leg. She maintained, however, that these pains soon passed away and excited neither worry nor attention. As a matter of fact it was two years after the death of her father that she began to feel sick and became unable to walk on account of pain.

The gap which the father left in the life of this family consisting of four women, the social solitude, the cessation of so many relations which promised stimulation and pleasure, the increased infirmity of the mother, all these clouded the mood of our patient, but simultaneously stimulated a warm desire that the family might soon find a substitute for the lost happiness and urged her to concentrate her entire devotion and care on the surviving mother. At the end of the mourning year the eldest sister married a talented and ambitious man of notable position, who by his mental capacity seemed to be destined for a great future, but who, however, very soon developed a morbid sensitiveness and egotistic perseveration of moods, and dared to show his disregard for the old lady in the family circle. That was more than Elisabeth could endure. She felt herself called upon to take up the fight against her brother-in-law whenever he gave occasion for it, while the other women took lightly the outburst of his excited temperament. To her it was a painful disillusionment to find that the reconstruction of the old family happiness experienced such a disturbance. She could not forgive her married sister because with feminine docility she strove to avoid espousing her cause. Thus a whole series of scenes remained in Elisabeth’s memory to which were attached a number of partially uttered grievances against her first brother-in-law. But what she reproached him most for was the fact that for the sake of a promotion in view he moved with his small family to a distant city in Austria and thus increased the lonesomeness of her mother. On this occasion Elisabeth distinctly felt her inability and helplessness to afford her mother a substitute for the lost happiness, and the impossibility of following out the resolution made at the death of her father.

The marriage of the second sister seemed to promise more for the future of the family. The second brother-in-law, although not of the same mental calibre as the first, was a man after the heart of delicate ladies, and his behavior reconciled Elisabeth to the matrimonial institution and to the thought of the sacrifice connected with it. What is more the second couple remained near her mother, and the child of this brother-in-law and the second sister became Elisabeth’s pet. Unfortunately the year during which the child was born was clouded by another event. The visual affliction of the mother demanded many weeks’ treatment in a dark room, in which Elisabeth participated. Following this an operation proved necessary and the excitement connected with this occurred at the same time that the first brother-in-law made preparations to move. Finally the operation, skilfully performed, proved successful, and the three families met at a summer resort. There Elisabeth, exhausted by the worries of the past months, had the first opportunity to recuperate from the effects of the suffering and anxiety that the family had undergone since the death of her father.

But during the time spent at this resort Elisabeth was attacked by the pain and weakness. Afterwards, the pains, which had become noticeable for a short while some time previously, manifested themselves severely for the first time after taking a warm bath at a small watering place. In connection with this it was thought that a long walk, really a walk of half a day, a few days, previously, had some connection with the onset of the pains. This readily produced the impression that Elisabeth at first became “fatigued” and then “caught cold.”

From this time on Elisabeth became the patient in the family. Following the advice of the physician she spent the rest of the summer in the watering place at Gastein, whither she went with her mother, but not without having a new worriment to think about. The second sister was again pregnant and information as to her condition was quite unfavorable, so that Elisabeth could hardly decide to take the journey to Gastein. After barely two weeks at Gastein both mother and sister were recalled as the patient at home did not feel well.

An agonizing journey, which for Elisabeth was a mixture of pain and anxious expectations, was followed by certain signs at the home railroad station which forebode the worst, and then on entering the chamber of the patient they were confronted with the reality—that they arrived too late to take leave of the dying one.

Elisabeth not only suffered from the loss of this sister whom she dearly loved but was also grieved by the thoughts caused by her death and the changes which it caused. The sister had succumbed to heart trouble which was aggravated by the pregnancy.

She then conceived the thought that the heart trouble was the paternal inheritance. It was then recalled that in her early childhood the deceased went through an attack of chorea with a slight heart affection. The family then blamed themselves and the physicians for permitting the marriage. They could not spare reproaches to the unfortunate widower for impairing the health of his wife by two successive pregnancies without any pause. The sad thought that this happiness should terminate thus, after the rare conditions for a happy marriage had been found, thereafter constantly occupied Elisabeth’s mind. Moreover, she again saw everything fail that she had planned for her mother. The widowed brother-in-law was inconsolable and withdrew from his wife’s family. It seemed that his own family from whom he was estranged during his short and happy married life took advantage of the opportunity to again draw him into their own circle. There was no way of maintaining the former union; to live together with the mother-in-law was improper out of regard for the unmarried sister-in-law, and inasmuch as he refused to relinquish the child, the only legacy of the deceased, to the two ladies, he for the first time gave them the opportunity of accusing him of heartlessness. Finally, and that was not the least painful thing, Elisabeth received some indefinite information concerning a disagreement between the two brothers-in-law, the occasion for which she could only surmise. It seemed as if the widower made some requests concerning financial matters which the other brother-in-law considered unjustifiable, and thought, that in view of the recent sorrow of his mother, it was nothing but an evil extortion. This then was the history of the young woman of ambitious and loving disposition. Resentful of her fate, embittered over the failures of her little plans to restore the lustre of the home; of her beloved ones, some being dead, some away, and some estranged— without any inclination to seek refuge in the love of a strange man, she lived thus for a year and a half nursing her mother and her pains, separated from almost, all social intercourse.

If we forget the greater sufferings and place ourselves in this girl’s position, we can but extend to Miss Elisabeth our hearty sympathy. But what is the physician’s interest in this sorrowful tale; what is its relation to her painful and her weak gait; what outlook is there for explaining and curing this case by the knowledge which we perhaps obtained from these psychic traumas?

For the physician this confession of the patient signified at first a great disappointment, for to be sure it was a history composed of banal mental shocks from which we could neither explain why the patient became afflicted with hysteria nor how the hysteria assumed the form of the painful abasia. It explained neither the causation nor the determination of the hysteria in question. We could perhaps assume that the patient had formed an association between her psychically painful impressions and bodily pains which she accidentally perceived simultaneously, and that now she made use in her memory of the physical sensation as a symbol for the psychic. What motive she had for this substitution and in what moment this came about remained unexplained. To be sure, these were questions whose nature was not familiar to the physicians. For it was customary to content one’s self with the information and to assume that the patient was constitutionally hysterical and that under the intensive pressure of any kind of excitement hysterical symptoms could develop.

Even less than for the explanation did this confession offer for the treatment of the case. One could not conceive what beneficial influence Miss Elisabeth could derive from recounting sad familiar family experiences of the past years to a stranger who could give her in return only moderate sympathy, nor could we perceive any improvement after the confession. During the first period of the treatment the patient never failed to repeat to her physician: “I continue to feel ill, I have the same pains as before,” and when she accompanied this by a crafty and malicious glance, I could perhaps recall the words which old Mr. v. R. was wont to utter concerning his favorite daughter: “She is frequently pert and disputatious,” but after all I had to confess that she was right.

Had I given up the patient at this stage of the psychic treatment the case of Miss Elisabeth v. R. would have been quite unimportant for the theory of hysteria. Nevertheless, I continued my analysis because I felt sure that an understanding of the causation as well as the determination of the hysterical symptoms could be gained from the deeper strata of consciousness.

I therefore decided to put the direct question to the broadened consciousness of the patient, in order to find out with what psychic impression the origin of the pain in the legs was connected.

For this purpose the patient should have been put in deep hypnosis. But unhappily I had to realize that all my procedures in that direction could put the patient in no other state of consciousness than that in which she gave me her confession. Still I was very pleased that this time she abstained from triumphantly remonstrating with the words: “You see, I really do not sleep, I cannot be hypnotized.” In such despair I conceived the idea of making use of the trick of pressing the head, the origin of which I have thoroughly discussed in the preceding contribution concerning Miss Lucy. This was done by requesting the patient to unfailingly inform me of what came before her mind’s eye or passed through her memory at the moment of the pressure. For a long time she was silent, and then admitted that on my pressure she thought of an evening in which a young man had accompanied her home from some social affair. She also thought of the conversation that passed between them, and her feelings on returning home to nurse her father.

With this first mention of the young man a new shaft was opened, the content of which I now gradually brought out. We dealt here rather with a secret, for with the exception of a mutual friend, no one knew anything of the relation and the hopes connected with it. It concerned the son of an old friend who was formerly one of their neighbors. The young man having become an orphan attached himself with great devotion to her father; he was guided in his career by his advice, and this veneration for the father was extended to the ladies of the family. Numerous reminiscences of repeated joint readings, exchange of thoughts and utterances on his side marked the gradual growth of her conviction that he loved and understood her and that a marriage with him would not impose the sacrifice that she feared. Unhappily he was but little older than she and as yet was far from being independent. She however firmly resolved to wait for him.

With the serious illness of her father, and the necessity of her nursing him their relations became less frequent. The evening which she at first recalled marked the height of her feeling, but even then there was no exchange of ideas between them on the subject. It was only at the urging of her family that she consented to leave the sick bed that evening and go to an affair where she was to meet him. She wished to hasten home early but was forced to remain, only yielding on his promising to accompany her home. At no time had she entertained such a tender regard for him as during this walk, but after returning home at a late hour in this blissful state and finding the condition of her father aggravated she bitterly reproached herself for having sacrificed so much time for her own amusement. It was the last time that she left her sick father for a whole evening; her friend she saw but seldom after this. After the death of her father he seemed to hold himself aloof out of respect for her sorrow and then business affairs drew him into other spheres. Gradually she came to the realization that his interest in her was suppressed by other feelings and that he was lost to her. This failure of her first love pained her as often as she thought of it.

In this relationship and in the scene caused by it, I was to seek the causation of the first hysterical pain. A conflict, or a state of incompatibility arose through the contrast between the happiness which she had not at that time denied herself and the sad condition in which she found her father upon her arrival home. As a result of this conflict the erotic presentations were repressed from the associations, and the affect connected with them was made use of in aggravating or reviving a simultaneously (or somewhat previously) existing physical pain. It was therefore the mechanism of a conversion for the purpose of defense as I have shown circumstantially in another place.[^[17]]

To be sure, we have room here for all kinds of observations. I must assert that I was unsuccessful in demonstrating from her memory that the conversion took place in the moment of her returning home. I therefore investigated for similar experiences which might have occurred while she was nursing her father, and I evoked a number of scenes, among which was one during which she had to jump out of bed with bare feet in a cold room to respond to the repeated calls of her father. I was inclined to attribute to this moment a certain significance, for in addition to complaining of pain in her legs she also complained of tormenting sensations of coldness. Nevertheless, here, too I could not with certainty lay hold of the scene which could be indicated as the scene of conversion. This led me to admit that there was here some gap, when I recalled the fact that the hysterical pains in the legs were really not present at the time she nursed her father. From her memory she recalled only a single attack of pain lasting a few days to which at that time she paid no attention. I then directed my attention to the first appearance of the pains. In this respect I was successful in awakening a perfect memory. They came on just at the time of a relative’s visit whom she could not receive because she was ill in bed, and who had the misfortune to find her ill in bed on another occasion two years later. But the search for the psychic motive of these first pains failed as often as repeated. I believed that I could assume that these first pains were due to a slight rheumatic attack and really had no psychic basis, and I also discovered that this organic trouble was the model for the later hysterical imitation, at all events that it occurred before the scene of being accompanied home. That these mild organic pains could continue for some time without her paying much attention to them is quite possible when we consider the nature of the disease. The obscurity resulting from this, namely, that the analysis pointed to a conversion of psychic excitement into bodily pain at a time when such pain was certainly not perceived and not recalled—this problem I hope to be able to solve in later considerations and by other examples.[^[18]]

With the discovery of the motive for the first conversion we began a second more fruitful period of the treatment. In the first place very soon afterward the patient surprised me with the statement that she now knew why the pains always radiated from that definite location on the right thigh and were most painful there. This is really the place upon which her father’s leg rested every morning while she changed the bandages of his badly swollen leg. That occurred hundreds of times, and strange to say she did not think of this connection until today. She thus gave me the desired explanation of the origin of an atypical hysterogenic zone. Furthermore during our analysis her painful legs always commenced to “join in the discussion.” I mean the following remarkable state of affairs: The patient was as a rule free from pain when we began our work, but as soon as I evoked some recollection by question or by pressure of the head she at first reported some pain usually of a very vivid nature, and then winced and placed her hand on the painful area. This awakened pain remained constant as long as the patient was controlled by the recollection, reaching its height when she was about to utter the essential and critical part of her communication, and disappearing with the last words of the statement. I gradually learned to use this awakened pain as a compass. Whenever she was moody or claimed to have pains I knew that she had not told me everything, and urged a continuation of the confession until the pain was “spoken away.” Then only did I awaken a new recollection.

During this period of ab-reaction, the patient’s condition showed such a striking improvement both somatically and psychically that I used to remark half jokingly that during each treatment I carried away a certain number of pain motives, and that when I had cleaned them all out she would be well. She soon reached a stage during which she had no pain much of the time; she consented to walk a great deal and to give up her hitherto condition of isolation. During the analysis I followed up now the spontaneous fluctuations of her condition and now some fragments of her sorrowful tale which in my opinion I had not sufficiently exhausted. In this work I made some interesting discoveries the principles of which I could later verify in other patients.

In the first place it was found that the spontaneous fluctuations never occurred unless provoked associatively by the events of the day. On one occasion she heard of an illness in the circle of her acquaintances which recalled to her a detail in the illness of her father. On another occasion the child of her deceased sister visited her and its resemblance to its mother recalled many painful incidents. On still another occasion it was a letter from her absent sister showing distinctly the influence of the inconsiderate brother-in-law, and this awakened a pain causing the reproduction of a family scene heretofore not reported.

As she never reproduced the same pain motives twice we were justified in the expectation that the stock would in time become exhausted. I never prevented her from merging into a situation tending to evoke new memories which had not as yet come to the surface. Thus for example I sent her to the grave of her sister, or I urged her to go in society where she was apt to meet her youthful friend who happened to be in the city.

In this manner I obtained an insight into the mode of origin of a hysteria which could be designated as monosymptomatic. I found, for example, that the right leg became painful during our hypnosis when we dealt with memories relating to the nursing of her father, to her young friend, and to other memories occurring during the first period of the pathogenic term; while the pain in the left leg came on as soon as I evoked the memory of her lost sister, of both brothers-in-law, in brief of any impression relating to the second half of the history. My attention having been called to that by this constant behavior I went further in my investigations and gained the impression that perhaps detailization went still further and that every new psychic cause of painful feeling might have some connection with a differently located painful area in the legs. The original painful location on the right thigh referred to the nursing of her father, and as the result of new traumas the painful area then grew by apposition so that strictly speaking we had here not one single physical symptom connected with a multiform psychic memory complex but a multiplicity of similar symptoms which on superficial examination seemed to be fused into one. To be sure I have not followed out the demarcations of the individual psychic causes corresponding to the pain zones for I found that the patient’s attention was turned away from these relations.

Notwithstanding this I directed further interest to the mode of construction of the whole symptom-complex of the abasia upon this painful zone, and with this view in mind I asked such questions as this: “What is the origin of the pains in walking and standing, or on lying?” She answered these questions partially uninfluenced, partially under the pressure of my hand. We thus obtained two results. In the first place she grouped all scenes connected with painful impressions according to their occurrence, sitting, standing, etc. Thus, for example, she stood at the door when her father was brought home with his cardiac attack and in her fright remained as though rooted to the spot. To this first quotation “fright while standing” she connected more recollections up to the overwhelming scene when she again stood as if pinned near the death bed of her sister. The whole chain of reminiscences should justify the connection of the pain with standing up, and could also serve as an association proof, only one had to bear in mind the fact that in all these occasions we must demonstrate another moment which had served to direct the attention—and as a further result the conversion—just on the standing, walking, sitting, etc. The explanation for this direction of attention could hardly be sought in other connections than in the fact that walking, standing, and lying are connected with capabilities and conditions of those members which here bore the painful zones; namely, the legs. We could then easily understand the connection between the astasia-abasia and the first scene of conversion in this history.

Among the scenes which in consequence of this review had made the walking painful one which referred to a walk she had taken in company, at the watering place, which apparently lasted too long, stood out most prominently. The deeper circumstances of this occurrence revealed themselves only hesitatingly and left many a riddle unsolved. She was in an especially good humor and gladly joined the circle of friendly persons; it was a lovely day, not too warm, her mother remained at home; her older sister had already departed, the younger one felt indisposed but did not wish to mar her pleasure. The husband of the second sister at first declared that he would remain at home with his wife, but finally went along for her (Elisabeth’s) sake. This scene seemed to have a great deal to do with the first appearance of the pains, for she recalled that she returned home from the walk very fatigued and with severe pains, she could not however say definitely whether she had perceived the pains before this. I took for granted that if she had suffered any pain she would have hardly resolved to enter upon this long walk. On being questioned whence the pains originated on this walk she answered rather indefinitely saying that the contrast between her solitude and the married happiness of her sick sister, of which she was constantly reminded by the behavior of her brother-in-law, was painful to her.

Another closely related scene played a part in the connection of the pain with sitting. It was a few days later, her sister and brother-in-law had already departed and she found herself in an excitable longing mood. She arose in the morning and ascended a small hill which they were wont to visit together and which afforded the only pretty view. There she sat down on a stone bench giving free play to her thoughts. Her thoughts again concerned her lonesomeness, the fate of her family, and she now frankly admitted that she entertained the eager wish to become as happy as her sister. After this morning’s meditation she returned home with severe pains. In the evening of the same day she took the bath, after which the pains definitely appeared and continued persistently.

We could further ascertain with great certainty that the pains on walking and standing diminished in the beginning on lying down. Only after hearing of her sister’s illness and on leaving Gastein in the evening, spending a sleepless night in the sleeping car, and being tormented simultaneously by the worries concerning her sister and violent pains, it was only then that the pains appeared for the first time while she was lying down, and throughout that time lying down was even more painful than walking or standing.

Thus the painful sphere grew by apposition first because every new pathogenically affecting theme occupied a new region of the legs, second, every one of the impressionable scenes left a trace because it produced a lasting, always more cumulative, “occupation” of the different functions of the legs, thus connecting these functions with the sensations of pain. There was unmistakably, however, still a third mechanism which furthered the production of astasia-abasia. When the patient finished the recitation of a whole series of events with the plaint that she then perceived pain in “standing alone,” and when in another series referring to the unfortunate attempt of bringing about new conditions in the family she was not tired of repeating that the painful in that was the feeling of her helplessness, the sensation that she “could make no headway,” I had to admit that her reflections influenced the formation of the abasia, and had to assume that she directly sought a symbolic expression for her painfully accentuated thoughts and had found it in the aggravation of her pains. That somatic symptoms of hysteria could originate through such symbolization we have already asserted in our Preliminary Communication, and in the epicrisis to this history. I will give some examples of conclusive evidence. In Miss Elisabeth v. R. the psychic mechanism of the symbolization was not in the foreground, it had not produced the abasia, but everything pointed to the fact that the already existing abasia had in this way undergone a considerable reinforcement. Accordingly this abasia as I met it in the stage of development was not only to be compared to a psychically associative paralysis of function but also to a symbolic paralysis of function.

Before I continue with the history of my patient I will add something about her behavior during the second period of the treatment. Throughout this whole analysis I made use of the method of evoking pictures and ideas by pressing the head, a method therefore, which would be inapplicable without the full cooperation and voluntary attention of the patient. At times it was really surprising how promptly and how infallibly the individual scenes belonging to one theme succeeded each other in chronological order. It was as if she read from a long picture book the pages of which passed in review before her eyes. At other times there seemed to be inhibitions, of what kind I could not at that time surmise. When I exerted some pressure she maintained that nothing came into her mind. I repeated the pressure and told her to wait, but still nothing would come. At first when such obstinacy manifested itself I determined to discontinue the work and to try again, as the day seemed unpropitious. Two observations, however, caused me to change my procedure. Firstly, because such failure of this method only occurred when I found Elisabeth cheerful and free from pain and never when she had a bad day; secondly, because she frequently made assertions of seeing nothing after the lapse of a long pause during which her tense and occupied mind betrayed to me some psychic process within. I therefore decided to assume that the method had never failed, that under the pressure of my hands Elisabeth had each time perceived some idea or had seen some picture but that she was not always ready to inform me of it and attempted to repress the thing evoked. I could think of two motives for such concealment; either Elisabeth subjected the idea that came to her mind to a criticism to which she was not entitled, thinking it not sufficiently important and unfit as an answer to the question, or she feared to say it because that statement was too disagreeable to her. I therefore proceeded as if I were perfectly convinced of the reliability of my technique. Whenever she asserted that nothing came into her mind, I did not let that pass. I assured her that something must have come to her but that perhaps she was not attentive enough, that I was quite willing to repeat the pressure. I also told her not to entertain any doubts concerning the correctness of the idea presenting itself to her mind, that that was not any of her concern; that it was her duty to remain perfectly objective and to tell whatever came into her mind, be it suitable or not, and I ended by saying that I knew well that something did come which she concealed from me and that as long as she would continue to do so she would not get rid of her pains. After such urging I found that there was really no pressure that remained unsuccessful. I then had to assume that I correctly recognized the state of affairs, and indeed I won through this analysis perfect confidence in my technique. It often happened that only after the third pressure did she make a statement then added “Why I could have told you that the first time”—“Indeed why did you not say it”—“I thought that it was not correct:” or “I thought that I could avoid it, but it recurred each time.” During this difficult work I began to attach a profounder significance to the resistance which the patient showed in the reproduction of her recollections, and I carefully compared those occasions in which it was especially striking.

I now come to the description of the third period of our treatment. The patient felt better, she was psychically unburdened and more capable, but the pains were manifestly not removed, reappearing from time to time with the old severity. The imperfect cure went hand in hand with the imperfect analysis, as yet I did not know in what moment and through what mechanisms the pains originated. During the reproduction of the most manifold scenes of the second period and the observation of the patient’s resistance towards the reproduction, I formed a definite suspicion which I did not then dare to use as a basis for my action. An accidental observation turned the issue. While working with the patient one day I heard the steps of a man in the adjacent room and a rather pleasant voice asking some questions. My patient immediately arose requesting me to discontinue the treatment for the day because she heard her brother-in-law who just arrived asking for her. Before this disturbance she was free from pains, but thereafter she betrayed by her mien and gait the sudden appearance of violent pains. This strengthened my suspicion and I decided to elicit the decisive explanation.

I questioned her concerning the circumstances and causes of the first appearance of the pains. Her thoughts were directed to the summer resort in that watering place where she had been before taking the journey to Gastein. A number of scenes were reproduced which had already been treated less exhaustively. They recalled her frame of mind at that time, the exhaustion following the worriment about her mother’s vision and the nursing of her mother during the time of the operation and her final despair at being unable as a lonesome girl to enjoy life or to accomplish anything in life. Until then she felt strong enough to dispense with the help of a man, but now she was controlled by a feeling of her womanly weakness, a yearning for love in which, to put it in her own words, “her obdurate self began to soften.” In such humor the happy marriage of her younger sister made the profoundest impression on her. She thought how affectionately he cared for her, how they understood each other with a mere glance, and how sure they seemed to be of each other. It was truly regrettable that the second pregnancy followed so quickly the first and her sister knew that this was the cause of her suffering but how willingly she endured it and all because he was the cause of it. The brother-in-law did not at first wish to participate in the walk which was so intimately connected with Elisabeth’s pain; he preferred to remain home with his sick wife, but the latter urged him with a glance to go because she thought that would give Elisabeth pleasure. Elisabeth remained with him throughout the whole walk; they spoke about the most varied and intimate things; she found herself in thorough accord with all he said, and she became overwhelmed with the desire to possess a man like him. This was followed by a scene a few days later, when, on the morning after their departure, she visited the point commanding the beautiful view which had been their favorite walk. There she seated herself upon a stone and again dreamed of her sister’s happiness and of a man like her brother-in-law who could engage her affections. When she arose she had pains which again disappeared, and only in the afternoon after having taken the warm bath did they reappear, remaining ever since. I attempted to investigate the thoughts which occupied her mind while taking the bath, but all I could obtain was that the bath house recalled her absent sister because she had lived in the same house.

For some time the state of affairs was clear to me. Absorbed in painfully sweet recollections she was wholly unconscious of the drift of her thoughts and continued to reproduce her reminiscences, the time in Gastein, the worry connected with the expectations of the letter, finally the information of her sister’s illness, the long wait until the evening when she could first leave Gastein, the journey with its tormenting uncertainties during a sleepless night—all these moments were accompanied by a violent aggravation of the pain. I asked her if during the journey she thought of the sad possibility which she afterward found realized. She answered that she carefully avoided the thought but that in her opinion her mother expected the worst from the very beginning. This was followed by the reminiscences of her arrival in Vienna—the impressions which she received from the relatives at the station, the short journey from Vienna to the neighboring summer resort where her sister lived, the arrival in the evening, the hasty walk through the garden to the door of the little garden pavilion—a silence in the house, the oppressive darkness, the fact of not having been received by the brother-in-law. She then recalled standing before the bed seeing the deceased, and in the moment of the awful certainty that the beloved sister had died without having taken leave of them and without having her last days eased through their nursing—in that very moment another thought flashed through Elisabeth’s brain which now peremptorily repeated itself. The thought which flashed like dazzling lightning through the darkness was, “Now he is free again, and I can become his wife.”

Of course, now everything was clear. The analyzer’s effort was richly repaid. The ideas of the “defense” (abwehr) against an unbearable presentation, the origin of hysterical symptoms through conversion of psychic into physical excitement, the formation of a separate psychic group by an arbitrary act, leading to the defense—all these were in that moment palpably presented before my eyes. Thus and thus alone did things happen here. This girl entertained an affectionate regard for her brother-in-law against the acceptance of which into her consciousness her whole moral being struggled. She succeeded in sparing herself the painful consciousness that she was in love with her sister’s husband by creating for herself instead bodily pains, and in the moment when this certainty wished to thrust itself into her consciousness (while she walked with him, during that morning reverie, in the bath, and before her sister’s bed) her pains originated by means of a successful conversion into the somatic. When she came under my care there was already a complete isolation from her consciousness of the presentation group referring to this love, else, I believe that she would never have agreed to such a treatment. The resistance which she repeatedly brought forth during the reproduction of traumatically produced scenes really corresponded to the energy with which the unbearable presentation had been crowded out from the association.

For the therapeutist there now came a sorry time. The effect of the resumption of that repressed presentation was a crushing one for the poor child. When I summed up the whole situation with these prosaic words: “you were really for a long time in love with your brother-in-law,” she complained of the most horrible pains at that moment; she made another despairing effort to reject the explanation, saying that it was not true, that I suggested it to her, it could not be, she was incapable of such baseness, and that she would never forgive herself for it. It was quite easy to prove to her that her own information allowed no other interpretation, but it took a long time before the two reasons that I offered for consolation, namely, that one is not responsible for one’s feelings and that her behavior, her sickness under those circumstances was sufficient proof of her moral nature—I say it took a long time before these consolations made an impression on her. I was now forced to pursue more than one course in order to calm the patient. In the first place I wished to give her the opportunity to rid herself by ab-reaction of the material long since accumulated. We investigated the first impressions of the relations with her brother-in-law, the beginning of those unconsciously kept affectionate regards. We found here all those little indications and forebodings which on a retrospective view showed a fully developed passion. On his first visit to the house he mistook her for his destined bride and greeted her before he greeted her older and homely sister. One evening they entertained each other so vivaciously and seemed to understand each other so well that the bride interrupted them with this half serious remark: “You two, indeed, would have suited each other very nicely.” On another occasion while in a gathering who were ignorant of the engagement the conversation drifted to the young man, and a young lady indiscreetly remarked about a blemish in his shape, a juvenile joint affliction. The bride herself remained calm while Elisabeth flew into a passion, and with an ardor which even she herself could not afterward understand she defended the straight form of her future brother-in-law. While we worked our way through these reminiscences it became clear to Elisabeth that her affection for her brother-in-law had slumbered in her for a long time, perhaps since the beginning of their relations, and had concealed itself so long under the mask of a mere kinsmanlike affection as only her very delicate family feeling would allow.

This ab-reaction benefited her much but I was able to give her still more relief by taking a friendly interest in her present state of affairs. With this object in view I sought an interview with Mrs. v. R. whom I found to be an intelligent and refined lady whose courage to face life, however, was somewhat lessened through the last misfortune. From her I learned that the accusation of rude extortion which the older brother-in-law had brought against the widower, and which was so painful to Elisabeth, had to be retracted on closer investigation. The character of the young man remained untarnished, it was merely a misunderstanding, an easily conceived difference of opinion concerning the valuation of money that could arise between the merchant, to whom money is only a working tool, and the official—that is all there was to this seemingly so painful incident. I begged the mother to give Elisabeth all explanations that she might hereafter need, and to offer her in the future that opportunity for unburdening her mind to which I had accustomed her.

Naturally I was also anxious to know what chance there was for the fulfilment of the girl’s present conscious wish. Here things were less favorable! The mother stated that for some time she had had an inkling of Elisabeth’s affection for her brother-in-law, of course she did not know that it existed during the lifetime of her sister. Whoever saw them both in friendly intercourse—of late, to be sure, only seldom—could entertain no doubt of the girl’s anxiety to please him. However, neither she, her mother, nor the advisers of the family showed any particular inclination to bring about a matrimonial union between the two. The health of the young man had not been very good and had received a setback through the death of his beloved wife, and it was not at all certain that he had sufficiently recovered from the shock to enter into a new matrimony. It was quite probable that this was the reason for his reserve, perhaps also because he was not sure of his position, and wished to avoid all obvious gossip. With such a reserve on both sides the solution for which Elisabeth was yearning was likely to fail.

I informed the girl of everything that I had heard from her mother and had the satisfaction of seeing her benefited by the explanation concerning the money affair. On the other hand, I expected her to bear calmly the uncertainties of her future which could not be set aside. The advancing summer compelled us to bring the treatment to an end. She now felt better, and since we had discussed the causes to which the pain could be traced she no longer complained of pain. We both felt that the work was done, although I thought that the ab-reaction of the suppressed love was really not as complete as it should have been. I regarded her as cured and urged her to continue independently the solution after the way had been cleared, to which she agreed. She left with her mother for a summer resort where they were to join the older sister and her family.

I still have something more to report about the further course of Miss Elisabeth v. R.’s disease. A few weeks after our parting I received a despairing letter from her mother informing me that at the first attempt to draw Elisabeth into a conversation about her love affairs she became very excited and refused to talk, and since then had suffered from violent pains. She was very indignant at my having betrayed her confidence and was perfectly inaccessible so that the treatment seemed a complete failure. She wished to know what was to be done, for of me she would hear nothing. I made no reply. It was to be expected that after she was relieved from my discipline she would make another attempt to reject her mother’s interference and return to her inaccessibility. I was, however, quite certain that everything would adjust itself and that my efforts had not been in vain. Two months later they returned to Vienna and the colleague to whom I was grateful for the case informed me that Elisabeth was perfectly well, and that her behavior was normal although occasionally she had slight pains. Since then she has repeatedly sent me similar messages, each time promising to visit me, which she has never done. This is quite characteristic of the personal relationship formed during such treatment. My colleague then assured me that she could be considered cured. The relation of the brother-in-law to the family underwent no change.

In the spring of 1894 I was informed that she would be present at a private ball to which I could gain access. I did not let the opportunity escape me and saw my former patient gliding along in a rapid dance. Since then, following her own inclination, she has married a stranger.

Epicrisis.

I was not always a psychotherapist but like other neuropathologists I was educated to the use of focal diagnosis and electrical prognosis so that even I myself am struck by the fact that the histories of the diseases which I write read like novels and, as it were, dispense with the serious features of the scientific character. Yet I must console myself with the fact that the nature of the subject is apparently more responsible for this issue than my own predilection. Focal diagnosis and electrical reactions are really not important in the study of hysteria, whereas a detailed discussion of the psychic processes, as one is wont to receive it from the poet, and the application of a few psychological formulæ, allows one to gain an insight into the course of events of hysteria. Such histories should be considered like psychiatrical ones, but they have the advantage over the latter in the fact that they give the intimate connection between the history of the disease and the morbid symptoms, a thing for which we still look in vain in the biographies of other psychoses.

With the description of the treatment I endeavored to interweave the explanations which I gave about the case of Miss Elisabeth v. R. and it will perhaps be superfluous to summarize here the essential features. I have discussed the character of the patient and the features which repeat themselves in so many hysterics, and which we really can not consider as degenerative. I mentioned the talent, the ambition, the moral sensitiveness, the immense yearning for love which found its gratification in the family, the independence of her nature reaching beyond the womanly ideal which manifested itself largely by obstinacy, readiness for fight, and inaccessibility. According to the information of my colleague no hereditary taints could be shown on either side of the family. Her mother, to be sure, suffered for years from some indefinite neurotic depression, but her brothers and sisters, her father and his family belonged to the even-tempered and not to the nervous. There was no serious case of neuropsychosis in the nearest relatives.

This nature was acted upon by painful emotions, the foremost of which was the debilitating influence of a long attendance upon her beloved sick father.

That nursing of the sick plays such a significant rôle in the histories of hysterias has its good reasons. A number of effective moments which are found here are quite obvious, namely, the disturbance of the physical health through interrupted sleep, neglect of nourishment, and the reaction of a constantly gnawing worriment on the vegetative functions; but the most important factor, however, is, in my estimation, to be found elsewhere. He whose mind is occupied with the hundred different tasks of nursing which succeed each other continuously for weeks and months, becomes accustomed, on the one hand, to suppress all signs of his own emotions, and on the other, his attention is soon turned away from his own impressions because he has neither the time nor strength to do them justice. Thus the nurse accumulates for himself an over abundance of affective impressions which he barely perceived clearly enough, at any rate they were not weakened by ab-reaction, that is, he creates for himself the material for a retention hysteria. If the patient recovers these impressions naturally become reduced in value, but if he dies and the period of mourning comes during which only that which refers to the deceased seems of value, the impressions waiting for discharge appear in turn, and after a brief pause of exhaustion the hysteria, the germ of which originated during the nursing, bursts forth.

The same subsequent discharge of traumas accumulated during nursing is occasionally encountered where the general impression of the disease does not ensue, and yet the mechanism of hysteria can be noticed. Thus, I know a highly gifted but slightly nervous lady whose whole personality suggests the hysteric though she never became a burden to the doctor and was never obliged to interrupt the exercise of her duties. This lady had nursed three or four of her beloved ones until their death, causing her each time complete physical exhaustion, yet these sad duties never made her ill. However, shortly after the death of the patient she began the work of reproduction, bringing again to her view the scenes of the disease and death. Each day—one might say at her leisure—she went over again every impression, crying and consoling herself. Such adjustment she passed through daily in conjunction with her usual duties, without, however confusing the two activities. Everything passed before her chronologically. Whether the memory work of one day precisely corresponded to a day of the past I am unable to say. I presume that it depended on the leisure which was allowed to her by the current affairs of the household.

Aside from this “subsequent tear” which attached itself to these deaths at short intervals, this lady periodically observed annual anniversaries representing the time of the various catastrophes, and here her vivid visual reproduction and her affective manifestations followed faithfully the date. Thus, for example, I found her in tears, and on sympathetic inquiry as to what occurred that day, she half irritably remarked, “Nothing on that day except that Professor N. was again here and gave us to understand that things were hopeless—at that time I had no time to cry.” She referred to the last illness of her husband who died three years before. It would have been very interesting to know whether she always repeated the same scenes on these recurring anniversaries, or whether as I suppose in the interest of my theory other details presented themselves each time for ab-reaction. I was however, unable to find anything definite about that; the wise and courageous woman was ashamed of the intensity with which those reminiscences acted upon her.[^[19]]

I again repeat that this woman was not sick, that subsequent ab-reaction, despite all resemblance, is still not a hysterical process; one may ask why, after one nursing there results a hysteria and after another none. It cannot lie in personal predisposition for the lady that I have in mind showed it very remarkably.

I now return to Miss Elisabeth v. R. While nursing her father there occurred for the first time an hysterical symptom in the form of a pain in a definite location on the right thigh. The mechanism of this symptom is fully explained on an analytical basis. It occurred in a moment during which the ideas of her duties towards her sick father came into conflict with the content of her erotic yearning which she then entertained. Under vivid self reproach she decided in favor of the former and created for herself the hysterical pain. According to the conception explained by the theory of conversion in hysteria, the process could be described as follows: She repressed the erotic idea from her consciousness and changed the sum of the affect into somatic sensations of pain. Whether this first conflict occurred only once, or repeated itself is not clear. The latter is more probable. Quite a similar conflict—of a higher moral significance, and even better demonstrated by the analysis—repeated itself after years and led to the aggravation of the same pain and to its dissemination beyond its original limits. Again, it was an erotic idea which came into conflict with all her moral conceptions, for her affection for her brother-in-law, both during the life and after the death of her sister, and the thought that she should yearn just for this man, was to her very disagreeable. This analysis gives detailed information about this conflict which represents the pivotal point in the history of her malady. The patient’s affection for her brother-in-law might have begun to germinate long ago, but in favor of its development was the physical exhaustion through the recent nursing, and her moral exhaustion through years of disillusionment which then began to break down her reserve and she confessed to herself the need of the love of a man. During a friendly intercourse continuing for weeks (in the summer resort) this erotic inclination reached its full development simultaneously with the pain. The analysis shows a special psychic condition of the patient at that time, which in connection with her inclination and the pain, seems to afford an understanding of the process in the sense of the conversion theory.

I place reliance on the opinion that the patient’s affection for her brother-in-law, intensive as it was, was not clearly known to her except on certain rare occasions and then only momentarily. If that were not so she would have become conscious of the inconsistency between this fondness and her moral ideas and would have had to endure the same mental agony which I saw her suffer after the analysis. Her reminiscences gave us no information concerning such suffering. These she spared herself and as a result the love itself did not become clear to her. At that time, as well as during the analysis, her love for her brother-in-law existed in the form of a foreign body in her consciousness without entering into any relationship with her other ideation. In reference to this love there existed the peculiar condition of knowing and simultaneously not knowing, it was the condition of the split off psychic group. When we assert that this love was not “clearly known” to her we mean exactly what we say. We do not mean a lower quality or a lesser degree of consciousness, but a separation of the free associative thinking process from the rest of ideation.

How does it come about that such an intensively accentuated presentation group should be kept so isolated? As a rule the rôle played by an idea in the association really increases with the sum of its affect.

This question can be answered if we bear in mind two facts which we can make use of as a safeguard: (1) That the hysterical pains originated simultaneously with the formation of these separate psychic groups, (2) that the patient exerted great resistance against the attempt to bring about the association between the separate psychic groups and the rest of the content of consciousness, and when the union was finally effected she perceived excessive psychic pain. Our conception of hysteria brings together these two moments with the fact of the splitting of consciousness, for (2) contains the indication for the motive for the splitting of consciousness while (1) shows the mechanism of the same. The motive was that of defense, it was the striving of the whole ego to agree with this presentation group and the mechanism was that of conversion, that is, instead of psychic pains which she spared herself there appeared physical pains. Thus a transformation occurred through which gain the patient had escaped an unbearable psychic state, though it was at the cost of a psychic anomaly in the form of a splitting of consciousness and a physical suffering, pains, upon which an astasia-abasia was constructed.

To be sure I can give no instruction as to how one can bring about such a conversion. It is not apparently done as one intentionally does an arbitrary action, it is a process which is executed in the individual under the impulse of the motive of defense if an adaptation for it exists in his organization or is brought about by temporary modification.

One has the right to attack the theory more closely by asking what it is that is transformed into physical pains. The cautious reply will be something out of which psychic pains could have and should have been formed. If we wish to venture further and attempt a kind of algebraic formulation of the presentation mechanism we may attribute to the presentation complex of this unconsciously remaining love a certain amount of affect and designate the latter quantity as the thing converted. Direct deduction of this conception would be the fact that the “unconscious love” has through such conversion forfeited so much of its intensity that it was reduced to a weak idea. Its existence as a separate psychic group would only be made possible through such weakening. Yet this present case is not suitable to afford us any clearness in this delicate matter. It probably corresponds to an imperfect conversion only. From other cases it seems quite probable that perfect conversions also occur and that in these the unbearable idea actually becomes repressed as only an idea of very little intensity could be repressed. After an associative union has been consummated the patients assure us that since the origin of the hysterical symptoms their unbearable thoughts never occupied their minds.

I have stated above that on certain occasions, though only transitorily, the patient consciously recognized the love for her brother-in-law. Such a moment occurred when for example, at the death bed of her sister the thought flashed through her mind, “Now he is free and I can become his wife.” I must discuss the significance of these moments for the conception of the whole neurosis. However, I think that the assumption of a defense hysteria (abwehr hysterie) includes the requisite that at least one such moment has already occurred. For consciousness does not know in advance when such an unbearable idea will present itself. The unbearable idea which with its appendix is later excluded for the formation of a separate psychic group must have been originally in the mind, otherwise no conflict would have resulted leading to its exclusion.[^[20]] Just such moments should be designated as “traumatic.” It is in them that the conversion takes place which results in the splitting of consciousness and the hysterical symptoms. Everything tends to show that in Miss Elisabeth v. R. there were a number of such moments (the scenes of the walking, morning meditation, bath, and at the bed of her sister) and perhaps new moments of this kind occurred during the treatment. The multiplicity of such traumatic moments is made possible by the fact that an experience similar to the one which at first initiated the unbearable idea, introduces new emotions to the separated psychic groups and thus transitorily abolishes the success of the conversion. The ego is forced to occupy itself with this suddenly enforced and lighted-up idea, and then to restore the former state by means of new conversions. Miss Elisabeth who was in constant relation with her brother-in-law must have been particularly exposed to the appearance of new traumas.

I must now occupy myself with the point which I have designated as a difficulty for the understanding of the afore mentioned history. On the analytical basis I assume that the first conversion took place in the patient while she nursed her father, at the time when her duties as nurse came into conflict with her erotic yearnings, and that this process was the prototype for the later ones which led to the outbreak of the disease in the Alpine watering place. But then we have it from the patient’s statement that at the time of nursing and the period following which I designated as the “first period” she had not suffered at all from the pains and weakness. To be sure, during the illness of her father she was once bedridden for a few days with pains in her legs, but it is doubtful whether this attack already belonged to the hysteria. A causal relation between these first pains and any psychic impressions could not be demonstrated by analysis; it is possible, even probable, that at that time we dealt with a common rheumatic muscular pain. Even if we should assume that this first attack of pain was the result of a hysterical conversion in consequence of the rejection of the erotic thoughts then existing, the fact nevertheless remains that the pains disappeared after a few days so that the patient actually behaved differently than she did during the analysis. During the reproduction of the so called first period all her statements concerning the illness and death of her father, the impressions relating to her first brother-in-law, etc., all these were accompanied by manifestations of pain, while at the time she really experienced these impressions she perceived no pains. Is this not a contradiction tending to considerably diminish the confidence in the explanatory value of such an analysis?

I believe that I can explain the contradiction by assuming that the pains—the product of the conversion—did not originate while the patient experienced the impressions during the first period, but subsequently, that is in the second period when the patient reproduced these impressions in her mind. The conversion did not follow the fresh impressions but the memories of them. I even believe that such a process is not at all unusual in hysteria and regularly participates in creating hysterical symptoms. Nevertheless, as such an assertion does not seem plausible I shall attempt to make it more credible by citing other experiences.

It once happened to me during a similar analysis that a new hysterical symptom was formed during the treatment so that I could attempt its removal on the day after its origin.

I will describe the essential features of the history of this patient. They are simple but not without interest.

Miss Rosalia H., twenty-three years old, who for a number of years made great effort to educate herself as a singer, complained that her beautiful voice did not obey her in certain notes. There appeared choking and tightening sensations in the throat so that the tones sounded strained, and her teacher could therefore not allow her to appear in public. Although this imperfection affected only her middle notes it could not be explained to be due to a defect of her vocal organs, for at times this disturbance was absent and her teacher was very pleased with her, but at other times the slightest excitement, seemingly without any provocation, evoked the choking sensation, and prevented free expansion of the voice. It was not difficult to recognize in this annoying sensation an hysterical conversion. Whether there really appeared a contracture of certain muscles of the vocal chords I have not verified.[^[21]] In the hypnotic analysis which I undertook with this girl I found out the following concerning her vicissitudes and her ailments occasioned through them. She became an orphan at an early age and was brought up at the house of an aunt who had many children of her own, and she thus shared the life of a most unfortunate family. The husband of this aunt, seemingly a pathological personality, abused his wife and children in the most brutal manner and especially pained her by his sexual preference for the servant girl in the house. This became even more obnoxious as the children grew older. When the aunt died Rosalia became the protectress of the orphaned children who were harassed by their father. She took her duties seriously, fought through all conflicts and had to exert her greatest efforts to suppress the manifestations of her contempt for her uncle. It was then that the choking sensation in her throat originated. Whenever she was compelled to swallow an affront, whenever she had to remain silent on hearing a provoking accusation she perceived a scratching in her throat, the tightening and failure of her voice, in brief she had all the localized sensations in her larynx and pharynx which now disturbed her in singing. It was conceivable that she sought the possibility of making herself independent in order to escape the excitement and painful impressions which were daily occurrences in her uncle’s house. An efficient music teacher took an unselfish interest in her, assuring her that her voice entitled her to choose the profession of singing. She began secretly to take lessons of him and because she often went for her lessons with the choking sensation in her throat following some violent scene in the house, a connection was formed between the singing and the hysterical paresthesia for which a way was prepared by the sensitiveness of the organ during singing. The apparatus of which she should have had free control was filled with the remnants of innervation after those numerous scenes of repressed excitement. Since then she has left the house of her uncle, having moved to another city so as to be away from the family, but her ailments were not benefited by it. No other hysterical symptoms were discovered in this pretty and unusually bright girl.

I endeavored to cure this “retention hysteria” by a reproduction of all the exciting impressions and by subsequent ab-reaction. I afforded her the opportunity of railing against her uncle in long speeches and of telling him the bare truth to his face, etc. The treatment benefited her, but unfortunately she lived here under quite unfavorable conditions. She had no luck with her relatives. She was the guest of another uncle who treated her with friendliness, but just for that reason she incurred the displeasure of her aunt. The latter believed that her husband evinced too marked an interest in his niece and made it a point of opposing the girl’s stay in Vienna. She herself in her youth was obliged to relinquish a desire of becoming an artist and was now jealous of her niece because she had the opportunity to develop her talent not considering that it was not mere desire but a wish to become independent which led her niece to take this step. Rosalia felt so uncomfortable in the house that she for instance, did not dare to sing or play the piano when her aunt was within hearing distance, and carefully avoided either singing or playing anything for her aged uncle—brother of her mother—whenever her aunt was home. While I was endeavoring to efface the traces of the old excitements, new ones originated through these relations with her host and finally interfered with the success of my treatment and prematurely interrupted the cure.

One day the patient came to me with a new symptom hardly twenty-four hours old. She complained of a disagreeable prickling sensation in the fingertips which had manifested itself every few hours since the day before and forced her to make very peculiar jerky movements with the fingers. I could not see the attack, otherwise I would have guessed its meaning on seeing the finger movements but I immediately endeavored to trace through hypnotic analysis the causation of this symptom (it was really a minor hysterical attack). As the whole thing only existed for a short time I hoped to be able to explain it and quickly remove it. To my surprise without any hesitation she reproduced in chronological order a whole row of scenes beginning in her early childhood. All these had perhaps the same characteristics in the fact that she had suffered an injustice without defense, something which could make her fingers jerk, for example, scenes like the one of being forced to hold out her hand in school while her teacher struck it with a ruler. But they were all banal causes the right of which to enter into the etiology of an hysterical symptom I have already opposed. It was different, however, with one scene of her early girlhood which was connected with the others. The bad uncle who suffered from rheumatism asked her to massage his back. She did not dare refuse him. He was in bed while she was doing it and suddenly threw off the covers, jumped up, attempting to get hold of her and throw her down. Naturally she stopped the massage and in a moment escaped and locked herself within her own room. She evidently did not like to recall this experience and could not say whether she had seen anything when the man suddenly exposed himself. The sensations of the fingers could be explained as due to the suppressed impulse to punish him, or it might simply have originated from the fact that she was at that time massaging him. Only after this scene did she begin to talk about the one experienced yesterday after which the sensitiveness and jerkiness of the fingers appeared as a recurring memory symbol. The uncle with whom she now lived begged her to play something for him. She sat at the piano and accompanied herself singing, believing that her aunt was out. Suddenly she appeared in the doorway, Rosalie jumped up, closed the piano, and flung away the sheet of music. We can guess what memories came to her mind, and the train of thought which she tried to ward off at that moment, for the exasperation brought on by the unjust accusation should have really urged her to leave the house, but on account of her illness she was forced to remain in Vienna and had no other shelter. The movement of the fingers which I saw during the reproduction of this scene resembled a continuous jerking as if one literally and figuratively would reject something like throwing away a sheet of music or rejecting an unreasonable demand.

She was quite positive in her assurance that she did not perceive the symptom before, that it was not caused by the scenes previously related. Was there anything else to be assumed except that the scene experienced yesterday had in the first place awakened the recollection of a former similar content and that then the formation of a memory symbol for the whole group of recollections took place? The conversion was on the one hand furnished with newly experienced affects, on the other with recollected affects.

When we consider this state of affairs we must admit that in the origin of hysterical symptoms such a process is the rule rather than the exception. Whenever I seek for the determinants of such states I frequently find not a single but a group of similar traumatic motives. In some cases it could be ascertained that this particular symptom had already existed for a short time after the first trauma and then subsided, but reappeared after the next trauma and become fixed. Yet no real distinction can be made between the temporary appearance and the latency after the first motives. In a large majority of cases it was also found that the first traumas had left no symptoms, while a later trauma of the same kind produced a symptom for the origin of which the cooperation of the former motives could not be dispensed with and for the solution of which it really required a consideration of all the motives. Translating this into the language of the conversion theory we will say that this undeniable fact of the summation of the traumas and the erstwhile latency of the symptoms simply means that the conversion can be brought about from a fresh as well as from a remembered affect, and this assumption fully explains the contradiction which seems to exist in the history and analysis of Miss Elisabeth v. R.

There is no question that normal persons carry in their consciousness in considerable numbers the continuation of ideas with unadjusted affects. The theory which I just asserted merely approximates the behavior of hysteria to the normal. It is apparently reduced to a quantitative moment; it is simply a question of how many such affective strains an organization can endure. Even a hysterical person will be able to retain a certain amount in an unadjusted state, but if through a summation of similar motives it increases beyond the individual’s endurance, the impetus for conversion is formed. It is therefore no singular theory but almost a postulate to say that the formation of hysterical symptoms may also be brought about at the cost of recollected affects.

I have now occupied myself with the motive and mechanism of this case of hysteria, it still remains to discuss the determination of the hysterical symptoms. Why should just the pains in the legs be selected to represent the psychic pains? The circumstances of the case point to the fact that this somatic pain was not created by the neurosis but was merely utilized, aggravated, and retained by it. I will add that in most of the cases of hysterical algias into which I have been able to gain an insight the conditions were similar, that is, there was to begin with always a real organically founded pain. It is always the most common, the most widespread pains of humanity that seem to be most frequently called upon to play a part in hysteria. Among the most common are the periosteal and neuralgic pains of the teeth, headaches which originate from so many different sources, and not in a lesser degree the so often mistaken rheumatic pains of the muscles. The first attack of pain which Miss Elisabeth v. R. had while she nursed her father, I consider to have been organically determined, for I received no information when I investigated for its psychic motive, and I admit that I am inclined to attribute differential diagnostic significance to my methods of evoking hidden memories if they are carefully applied. This original rheumatic pain[^[22]] became in the patient the memory symbol for her painful psychic emotions, and as far as I can see, for more than one reason. First and principally because it existed in consciousness almost simultaneously with the other excitements, and second because it was or could be connected in many ways with the ideation of that time. At all events it was perhaps a remote consequence of the nursing, of her want of exercise, and the poor nutrition entailed by her duties as nurse. But this hardly became clear to the patient and what is more important is the fact that she had to perceive it during significant moments of the nursing, as for example, when she jumped out of bed in the cold room to respond to her father’s call. Even more decisive for the direction taken by the conversion must have been the other manner of associative connection, namely, the fact that for many days one of her painful legs came in contact with the swollen leg of her father during the changing of bandages. The location on the right leg distinguished by this contact remained henceforth the focus and starting point of the pains, an artificial hysterogenic zone the origin of which can be plainly seen in this case.

If any one should be surprised at the associative connection between physical pain and psychic affect, thinking it to be too manifold and artificial, I should answer that such surprise is just as unfair as to be surprised over the fact “that just the richest in the world possess most money.” Where prolific connections do not exist there is naturally no formation of hysterical symptoms, and conversion does not find its way. I can also state that in reference to determinations the case of Miss Elisabeth v. R. belongs to the simpler ones. In the case of Mrs. Cäcilie M.[^[23]] particularly, I had to solve the most intricate knots of this kind.

I have already discussed in the history of the case how the astasia-abasia of our patient was built up on those pains after the conversion had taken definite direction. But there, too, I have expressed the opinion that the patient has created or aggravated the disturbance of function through symbolization. For her dependence and helplessness to change anything in the circumstances she found a somatic expression in the astasia-abasia, and the expressions “to make no headway,” “to have no support,” etc., formed the bridge for this new act of conversion. I will endeavor to support this conception by other examples.

Conversion on the basis of coincidence in otherwise existing associative connections seems to exert the slightest claims on the hysterical predisposition; on the other hand conversion through symbolization seems to require a higher grade of hysterical modification, a fact also demonstrated in Miss Elisabeth in the later stages of her hysteria. The prettiest examples of symbolization I have observed in Mrs. Cäcilie M.,[^[24]] whom I can call my most difficult and most instructive case. I have already mentioned that this history does not unfortunately lend itself to detailed reproduction.

Among other things Mrs. Cäcilie also suffered from a most violent facial neuralgia which appeared suddenly two or three times during the year and persisted for from five to ten days, resisting every remedy, and ceased as if cut off. It limited itself to the second and third branches of the trigeminus, and as there was undoubtedly an excess of urates in the urine, and as a not very “clear acute rheumatism” played a certain part in the patient’s history it was reasonable to assume that we dealt with a gouty neuralgia. This opinion was also shared by the consulting physicians who saw every attack. The neuralgia was treated with the methods in vogue, such as electric pencilling, alkaline waters and purgatives, but it always remained uninfluenced until it was convenient to make room for another symptom. In former years—the neuralgia was fifteen years old—the teeth were accused of preserving it and were condemned to extraction, and one fine morning under narcosis the execution of seven of the culprits took place. That did not run so smoothly as the teeth were so firm that most of the roots were left behind. This cruel operation was followed by neither temporary nor permanent relief. At that time the neuralgia raged for months. Even while under my care whenever she had neuralgia the dentist was called and he always declared he found diseased roots. He commenced to get ready for such work but usually he was soon interrupted, for the neuralgia suddenly ceased and with it the desire for the dentist. During the intervals the teeth did not ache at all. One day just while another attack was raging I put the patient into a hypnotic condition and placed an energetic interdiction on the pains, and from that moment they ceased. I then began to doubt the genuineness of this neuralgia.

About a year after this hypnotic remedial success the condition of Mrs. Cäcilie M. took a new and surprising turn. There suddenly appeared other states than those that had been characteristic of the last years, but after some reflection the patient declared that all these conditions had existed in her before and were really scattered over the long period of her disease (thirty years). Indeed a surprising abundance of hysterical incidents were unrolled which the patient was able to localize correctly in the past and soon the frequently very entangled thought connections which determined the sequence of these incidents became recognizable. It was like a series of pictures with an explanatory text. Pitres, on describing his délire ecmnésique must have had in mind a similar case. The way such a hysterical condition belonging to the past was reproduced was most remarkable. In the first place while the patient was in the best of condition there appeared a pathological mood of special coloring which was regularly mistaken by the patient and was referred to a banal occurrence of the last hours. This increasing obnubilation of consciousness was followed by hysterical symptoms, such as hallucinations, pains, convulsions, and long declamations, and finally an event of the past attached itself to this hallucinatory manifestation which could explain the initial mood and determine the occasional symptoms. With this last part of the attack lucidity returned, the ailments disappeared as if by magic and good health again existed—until the next attack which was half a day later. Usually I was called at the height of this condition. I produced hypnosis, evoked a reproduction of the traumatic events, and by artificial aid I curtailed the attack. Having gone through with the patient many hundreds of such cycles, I obtained the most instructive explanations concerning the determinants of hysterical symptoms. The joint observation with Breuer of this remarkable case was also the chief motive for the publication of our “Preliminary Communication.”

In this connection it finally came to the reproduction of the facial neuralgia which I myself had still treated as actual attacks. I was desirous of knowing whether we would find here a psychic causation. When I attempted to evoke the traumatic scene, the patient soon imagined herself in a period during which she felt marked psychic sensitiveness against her husband. She related a conversation with him and a remark that he made which aggravated her very much. She then suddenly grasped her cheek, crying aloud with pain, and said, “That was like a slap in the face”—with this both the attack and the pain came to an end. There is no doubt that here, too, we dealt with a symbolization. She had felt as if she really received a slap in the face. Now everybody will ask how the sensation of “a slap in the face” can lead to the manifestations of a trigeminal neuralgia, to its limiting itself to the second and third branch, and to its being aggravated on opening the mouth and mastication (not by talking!).

The following day the neuralgia reappeared, but this time it could be solved by the reproduction of another scene the content of which equally showed a supposed insult. This process continued for nine days; from the result it seemed that for years, aggravations, especially through words, produced new attacks of this facial neuralgia by way of symbolization.

But finally we also succeeded in reproducing the first attack of the neuralgia which occurred more than fifteen years before. Here there was no symbolization but a conversion through coincidence. It was a painful sight which recalled to her mind a reproach and this caused her to repress another series of thoughts. We have here, then, a case of conflict and defense, and the origin of the neuralgia in this moment could not be explained if we do not wish to assume that she then suffered from slight toothache or facial pains, a thing not improbable, as she was then in the first months of pregnancy.

The result of the explanation showed that this neuralgia became the mark of a definite psychic excitement through the usual road of conversion but that afterward it could be awakened through associative reminiscences of thoughts and symbolic conversions. It was really the same procedure as encountered in Miss Elisabeth v. R.

I will now introduce another example which will illustrate the efficacy of symbolization under other determinants. On one occasion Mrs. Cäcilie M. was tormented by a violent pain in her right heel, experiencing stinging sensations which made walking impossible. The analysis conducted us to a time when the patient was in a foreign institution. For eight days she lay in her room, and for the first time the house physician was to take her to the dining room. The pain came on while the patient took the physician’s arm on leaving the room. It disappeared during the reproduction of this scene while she remarked that at that time she feared lest she would not make the “proper impression” on this strange society[^[25]] (“rechte Auftreten”).

This seems a striking, almost comical example for the origin of hysterical symptoms through symbolization by means of an expression of speech. But a closer investigation of the circumstances of that moment will favor another conception. The patient at that time suffered from pain in her feet on account of which she remained in bed, and we can only assume that the fear which obsessed her on taking the first steps produced from the simultaneously existing pains the one symbolically appropriate symptom in the right heel so as to form it into a psychic algia and to particularly fit it for long duration.

Notwithstanding the fact that the mechanism of symbolization in these examples seems to be crowded to second rank, that which certainly corresponds to the rule, I have still other examples at my disposal which seem to demonstrate the origin of hysterical symptoms through symbolization only. One of the best is the following example which again refers to Mrs. Cäcilie M. At the age of fifteen she once lay in bed watched by her austere grandmother. The girl suddenly cried out complaining of having perceived a pain in the forehead between the eyes which thereafter continued for weeks. On analyzing this pain, which was reproduced after almost thirty years, she stated that her grandmother gazed at her so “piercingly” that it seemed as if her look penetrated deeply into her brain. She was really afraid of being looked upon suspiciously by this old lady. On reproducing this thought she burst into loud laughter and the pain ceased. Here I find nothing other than the mechanism of symbolization which in a way stands midway between the mechanism of auto-suggestion and that of conversion.

The study of Mrs. Cäcilie M. gave me the opportunity to gather a collection of such symbolizations. A whole series of physical sensations which were otherwise looked upon as organically determined were of a psychic origin, or at least furnished with a psychic interpretation. A certain number of her experiences were accompanied by a piercing sensation in the region of the heart (“I felt a stitch in my heart”). The piercing headache of hysteria was undoubtedly, in her case, to be interpreted as thought pains (“something sticks in my head”), and it disappeared each time when the problem in question was solved. The sensation of the hysterical aura in the throat, when it manifested itself during an aggravation, ran parallel with the thought, “I have to swallow that.” There was a whole series of parallel running sensations and ideas in which it was now the sensation evoking the idea as an interpretation and now the idea which produced the sensation by symbolization, and not seldom it remained obscure which was the primary element of the two.

In no other patient was I able to find such a prolific application of symbolization. To be sure, Mrs. Cäcilie M. was a person of quite unusual and of a special artistic temperament whose highly developed sense for form manifested itself in very beautiful poems. I maintain, however, that if a hysteria creates through symbolization a somatic sensation for the emotionally accentuated presentation, it is due less to individual and arbitrary things than one supposes. When during an offending harangue she takes literally such phrases as “stitch in the heart” or “slap in the face,” and perceives them as real occurrences she practices no facetious misuse but only revives the sensations to which this phrase thanks its existence. For how does it happen that in speaking of an aggrieved person we use such expressions as “he experienced a ‘stitch in his heart,’” if the mortification was not actually accompanied by a precordial sensation that could be so interpreted and recognized? Is it not probable that the phrase “to swallow something” applied to an unreturned insult really originates from the sensation of innervation appearing in the pharynx when one forces back his speech thus preventing a reaction to the insult? All these sensations and innervations belong to the “expression of the emotions,” which as Darwin taught us, originally consisted of sensible and expedient actions; at present most of them may be so weakened that their expression in speech seems to us like a figurative transformation, but very probably all this was once meant literally, and hysteria is justified in reconstructing the original literal sense for its stronger innervation. Indeed, perhaps it is improper to say that it creates such sensations through symbolization, perhaps it has not taken the usage of speech as a model, but both originated from a common source.[^[26]]

CHAPTER IV.
The Psychotherapy of Hysteria.

In our “Preliminary Communication” we have stated that while investigating the etiology of hysterical symptoms we have also discovered a therapeutic method which we consider of practical significance. “We found, at first to our very greatest surprise, that the individual hysterical symptoms immediately disappeared without returning if we succeeded in thoroughly awakening the memories of the causal process with its accompanying affect, and if the patient circumstantially discussed the process giving free play to the affect” (p. [4]).

We furthermore attempted to explain how our psychotherapeutic method acts. “It does away with the effects of the original not ab-reacted to ideas by affording an outlet to the suppressed affect through speech. It brings it into associative correction by drawing it into normal consciousness (in mild hypnosis), or it is done away with through the physician’s suggestion just as happens in somnambulism with amnesia” (p. [13]).

Although the essential features of this method have been enumerated in the preceding pages, a repetition is unavoidable, and I shall now attempt to show connectedly how far reaching this method is, its superiority over others, its technique, and its difficulties.

I.

I, for my part, may state that I can adhere to the “Preliminary Communication,” but I must confess that after continuous occupation for years with the problems therein touched, I was confronted with new views, as a result of which the former material underwent at least a partial change in grouping and conception. It would be unjust to impute too much of the responsibility for this development to my honored friend, J. Breuer. I therefore take the weight of responsibility upon myself.

In attempting to use Breuer’s method of treating hysterical symptoms in a great number of patients by investigation and ab-reaction in hypnosis, I encountered two obstacles, the pursuit of which led me to change the technique as well as the conception. (1) Not all persons were hypnotizable who undoubtedly showed hysterical symptoms, and in whom there most probably existed the same psychic mechanism. (2) I had to question what essentially characterizes hysteria, and in what it differs from other neuroses.

How I overcame the first difficulty, and what it taught me, I will show later. I will first state what position I have taken in my daily practice towards the second problem. It is very difficult to examine a case of neurosis before it has been subjected to a thorough analysis, such as would result only through the application of Breuer’s method. But before we have such a thorough knowledge we are obliged to decide upon the diagnosis and kind of treatment. Hence the only thing remaining for me was to select such cases for the cathartic method which could, for the time being, be diagnosed as hysteria, and which showed some or many stigmata, or the characteristic symptoms of hysteria. Yet it sometimes happened that in spite of the diagnosis of hysteria the therapeutic results were very poor, and even the analysis revealed nothing of importance. At other times I attempted to treat cases which no one took for hysteria by Breuer’s method, and I found that I could influence them, and even cure them. Such, for example, was my experience with obsessions, the real obsessions of Westphal’s type, cases which did not show a single feature of hysteria. Thus the psychic mechanism revealed in the “Preliminary Communication” could not be pathognomonic of hysteria. Nor could I for the sake of this mechanism throw so many neuroses into the same pot with hysteria. From all the investigated doubts I finally seized upon a plan to treat all the other neuroses in question just like hysteria, to investigate the etiology and the form of psychic mechanisms, and to leave the diagnosis of hysteria to be dependent upon the result of this investigation.

It thus happened that, proceeding from Breuer’s methods, I occupied myself mostly with the etiology and the mechanism of the neuroses. After a relatively brief period I was fortunate in obtaining useful results. I then became cognizant of the fact that if we may speak of a reason for the acquirement of neuroses the etiology must be sought for in the sexual moments. This agrees with the fact that, generally speaking, various sexual moments may also produce various pictures of neurotic disease. Similarly we now venture to employ the etiology for the characteristics of the neuroses, and build up a sharp line of demarcation between the morbid pictures of the neuroses. If the etiological characters constantly agreed with the clinical ones, this was justified.

In this way it was found that neurasthenia really corresponds to a monotonous morbid picture in which, as shown by the analysis, “psychic mechanisms” play no part. From neurasthenia we sharply distinguished the compulsion neurosis (Zwangsneurose), [obsessions, doubts, impulses], the neurosis of the genuine obsessions, in which we can recognize a complicated psychic mechanism, an etiology resembling the one of hysteria, and a far reaching possibility of an involution by psychotherapy. On the other hand it seemed to me undoubtedly imperative to separate from neurasthenia a neurotic symptom-complex which depends on a totally divergent, strictly speaking, on a contrary etiology. The partial symptoms of this complex have been recognized by E. Hecker[^[27]] as having a common character. They are either symptoms, or equivalents, or rudiments of anxiety manifestations, and it is for that reason that this complex, so different from neurasthenia, was called by me anxiety neurosis. I maintain that it originates from an accumulation of physical tension which is in turn of a sexual origin. This neurosis, too, has no psychic mechanism, but regularly influences the psychic life, so that among its regular manifestations we have anxious expectation, phobias, hyperesthesias to pain, and other symptoms. This anxiety neurosis, as I take it, certainly corresponds in part to the neurosis called hypochondria, which in some features resembles hysteria and neurasthenia. Yet in none of the earlier works can I consider the demarcation of this neurosis as correct, and moreover, I find that the usefulness of the name hypochondria is impaired by its close relation to the symptom of “nosophobia.”

After I had thus constructed for myself the simple picture of neurasthenia, anxiety neuroses, and obsessions, I turned my attention to the commonly occurring cases of neuroses which enter into the diagnosis of hysteria. I now said to myself that it would not do to mark a neurosis as hysterical on the whole, merely because its symptom complex evinced some hysterical signs. I could readily explain this practice by the fact that hysteria is the oldest, the most familiar, and the most striking neurosis under consideration, but still it was an abuse which allowed the placing of many features of perversion and degeneration under the caption of hysteria. Whenever a hysterical symptom, such as anesthesia or a characteristic attack, could be discovered in a complicated case of psychic degeneration, the whole thing was called “hysteria,” and hence one could naturally find united under this same trade mark the worst and most contradictory features. As certain as this diagnosis was incorrect it is also certain that our classification must be made from the neurotic standpoint, and as we know neurasthenia, anxiety neurosis, and similar conditions in the pure state, there is no need of overlooking them in combination.

It seemed therefore that the following conception was more warrantable. The neuroses usually occurring are generally to be designated as “mixed.” Neurasthenia and anxiety neurosis can be found without effort in pure forms, and most frequently in young persons. Pure cases of hysteria and compulsion neurosis “Zwangsneurose” (obsessions, doubts, impulses) are rare, they are usually combined with an anxiety neurosis. This frequent occurrence of mixed neuroses is due to the fact that their etiological moments are frequently mixed, now only accidentally, and now in consequence of a causal relation between the processes which give rise to the etiological moments of the neuroses. This can be sustained and proven in the individual cases without any difficulty. But it follows from this that it is hardly possible to take hysteria out of connection with the sexual neuroses, that hysteria as a rule presents only one side, one aspect of the complicated neurotic case, and that only, as it were, in the borderline case can it be found and treated as an isolated neurosis. In a series of cases we can perhaps say a potiori fit denominatio.

I shall now examine the cases reported to see whether they speak in favor of my conception of the clinical dependence of hysteria. Breuer’s patient, Anna O.,[^[28]] seems to contradict this and exemplifies a pure hysterical disease. Yet this case which became so fruitful for the knowledge of hysteria was never considered by its observer under the guise of a sexual neurosis, and hence cannot at present be utilized as such. When I began to analyze the second patient, Mrs. Emmy v. N., the idea of a sexual neurosis on a hysterical basis was far from my mind. I had just returned from the Charcot school, and considered the connection of hysteria with the sexual theme as a sort of insult—just as my patients were wont to do. But when I today review my notes on this case there is absolutely no doubt that I have to consider it as a severe case of anxiety neurosis with anxious expectations and phobias, which was due to sexual abstinence and was combined with hysteria.

The third case, Miss Lucy R., could perhaps be called the first borderline case of pure hysteria. It is a short episodic hysteria based on an unmistakably sexual etiology. It corresponds to an anxiety neurosis in an over-ripe, amorous girl, whose love was too rapidly awakened through a misunderstanding. Yet the anxiety neurosis could either not be demonstrated or had escaped me. Case IV, Katharina,[^[29]] is really a model of what I have called virginal anxiety; it is a combination of an anxiety neurosis and hysteria, the former produces the symptoms, while the latter repeats them and works with them. At all events, it is a typical case of many juvenile neuroses called “hysteria.” Case V, Miss Elisabeth v. R., was again not investigated as a sexual neurosis. I could only suspect that there was a spinal neurasthenia at its basis but I could not confirm it. I must, however, add that since then pure hysterias have become still rarer in my experience. That in grouping together these four cases of hysteria I could disregard in the discussion the decisive factors of sexual neuroses was due to the fact that they were older cases in which I had not as yet carried out the purposed and urgent investigation for the neurotic sexual subsoil. Moreover the reason for my reporting four instead of twelve cases of hysteria, the analysis of which would have confirmed our claims of psychic mechanism for hysterical phenomena, is due to one circumstance, namely that the analysis of these cases would have simultaneously revealed them as sexual neuroses, though surely no diagnostician would have denied them the name “hysteria.” However, the discussion of such sexual neuroses would have overstepped the limits of our joint publication.

I do not wish to be misunderstood and give the impression that I refuse to accept hysteria as an independent neurotic affection, that I conceive it only as a psychic manifestation of the anxiety neurosis, that I ascribe to it “ideogenous” symptoms only, and that I attribute the somatic symptoms, like hysterogenic points and anesthesias, to the anxiety neurosis. None of these statements are true. I believe that hysteria, purified of all admixtures, can be treated independently in every respect except in therapy. For in the treatment we deal with a practical purpose, namely, we have to do away with the whole diseased state, and even if the hysteria occurs in most cases as a component of a mixed neurosis, the case merely resembles a mixed infection where the task is to preserve life, and not merely to combat the effect of one inciting cause of the disease.

I, therefore, find it important to separate the hysterical part in the pictures of the mixed neuroses from neurasthenia, anxiety neurosis, etc., for after this separation I can express concisely the therapeutic value of the cathartic method. I would venture to assert that—principally—it can readily dispose of any hysterical symptom, whereas, as can be easily understood, it is perfectly powerless in the presence of neurasthenic phenomena, and can only seldom, and through detours, influence the psychic results of the anxiety neurosis. Its therapeutic efficacy in the individual case will depend on whether or not the hysterical components of the morbid picture can claim a practical and significant position in comparison to the other neurotic components.

Another limitation placed on the efficacy of the cathartic method we have already mentioned in our “Preliminary Communication.” It does not influence the causal determinations of hysteria, and hence it can not prevent the origin of new symptoms in the place of those removed. Hence, on the whole, I must claim a prominent place for our therapeutic method in the realm of the therapy of neuroses, but I would caution against attaching any importance to it, or putting it into practice outside of this connection. As I am unable to give here a “Therapy of Neuroses” as would be required by the practicing physician, the preceding statements are put on a level with the deferred reference to a later communication; still, for purposes of discussion and elucidation, I can add the following remarks:

1. I do not claim that I have actually removed all the hysterical symptoms which I have undertaken to influence by the cathartic method, but I believe that the obstacles were due to the personal circumstances of the cases, and not to the general principles. In passing sentence, these cases of failure may be left out of consideration, just as the surgeon puts aside all cases who die as a result of narcosis, hemorrhage, accidental sepsis, etc., when deciding upon a new technique. I will again consider the failures of such origin in my later discussions on the difficulties and drawbacks of this method.

2. The cathartic method does not become valueless simply because it is symptomatic and not causal. For a causal therapy is really in most cases only prophylactic; it stops the further progress of the injury, but it does not necessarily remove the products which have already resulted from it. To do this it requires, as a rule, a second agent, and in cases of hysteria the cathartic method is really unsurpassable for such purposes.

3. Where the period of hysterical production, or the acute hysterical paroxysm, has subsided, and the only remnant manifestations left are hysterical symptoms, the cathartic method fulfills all indications, and achieves a full and lasting success. Such a favorable constellation for the therapy does not seldom result on the basis of the sexual life, in consequence of the marked fluctuations in the intensity of the sexual desire and the complications of the required determination for a sexual trauma. Here the cathartic method accomplishes all that is required of it, for the physician can not resolve to change a hysterical constitution. He must rest content if he can remove the disease for which such a constitution shows a tendency, and which can arise through the assistance of external determinants. He must be satisfied if the patient will again become capacitated. Moreover, he can have some hopes for the future, if the possibility of a relapse be considered, for he knows the main character of the etiology of the neuroses, namely, that their origin is mostly over-determined, and that many moments must unite to produce this result. He can hope that this union will not take place very soon, if individual etiological moments remain in force.

It may be argued that in such subsided cases of hysteria the remaining symptoms would spontaneously disappear without anything else, but this can be answered by the fact that such spontaneous cures very often terminate neither rapidly nor fully, and that the cure will be extraordinarily advanced by the treatment. Whether the cathartic treatment cures only that which is capable of spontaneous recovery, or incidentally also, that which would not cease spontaneously, that question may surely be left open for the present.

4. Where we encounter an acute hysteria during the most acute production of hysterical symptoms, and the consecutive overwhelming of the ego by the morbid products (hysterical psychosis), even the cathartic method will change little the expression and course of the disease. One finds himself in the same position to the neurosis as the doctor to an acute infectious disease. For some time past, now beyond the reach of influence, the etiological moments exerted a sufficient amount of effect, which becomes manifest after overcoming the interval of incubation. The affection can not be warded off, it has to run its course, but meanwhile one must bring about the most favorable conditions for the patient. If during such an acute period one can remove the morbid products, the newly formed hysterical symptoms, it may be expected that their places will be taken by new ones. The physician will not be spared the depressing impression of fruitless effort, the enormous expenditure of exertion, and the disappointment of the relatives, to whom the idea of the necessary duration of time of an acute neurosis is hardly as familiar as in the analogous case of an acute infectious disease; these, and many other things, will probably make most impossible the consequent application of the cathartic method in the assumed case. Nevertheless, it still remains to be considered whether, even in an acute hysteria, the frequent removal of the morbid products does not exercise a curative influence by supporting the normal ego which is occupied with the defense, and thus preventing it from merging into a psychosis or into ultimate confusion.

That the cathartic method can accomplish something, even in an acute hysteria, and that it can even reduce the new productions of the morbid symptoms quite practically and noticeably, is undoubtedly evident from the case of Anna O., in which Breuer first learned to exercise this process.[^[30]]

5. Where we deal with chronic progressive hysterias with moderate or continued productions of hysterical symptoms, we learn to regret the lack of a causally effective therapy, but we also learn to value the indications of the cathartic method as a symptomatic remedy. We then deal with an injury produced by an etiology which continues to act chronically. We have to strengthen the capacity for resistance of the nervous system of our patient, and we must bear in mind that the existence of an hysterical symptom signifies a weakening of resistance of the nervous system, and represents a predisposing moment. From the mechanism of monosymptomatic hysteria we know that a new hysterical symptom generally originates as an addition to and as an analogy of one already in existence. The location once penetrated represents the weak spot which can be penetrated again. The split off psychic group plays the part of the provoking crystal from which a formerly omitted crystallization emerges with great facility. To remove the already existing symptoms, to do away with the psychic alterations lying at their basis, is the return to the patients the full measure of their resistance capacity, with which they are successfully able to resist the noxious influences. One can do a great deal for the patient by such long continued watchfulness and occasional “chimney-sweeping.”

6. I still have to mention the apparent contradiction arising between the admission that not all hysterical symptoms are psychogenic, and the assertion that they can all be removed by psychotherapeutic procedures. The solution lies in the fact that some of these non-psychogenic symptoms, though they represent morbid symptoms, as, for instance, the stigmata, should nevertheless not be designated as affections, and hence it cannot be practically noticed even if they remain after the treatment is finished. Other symptoms of a similar nature seem to be taken along indirectly by the psychogenic symptoms, for indirectly they really depend on some psychic causation.

I shall now mention those difficulties and inconveniences of our therapeutic method which are not evident from the preceding histories, or from the following remarks concerning the technique of the method.—I will rather enumerate and indicate than carry them out. The process is toilsome and wearisome for the physician, it presupposes a profound interest for psychological incidents, as well as a personal sympathy for the patient. I could not conceive myself entering deeply into the psychic mechanism of a hysteria in a person who appeared to me common and disagreeable, and who would not, on closer acquaintanceship, be able to awaken in me human sympathy; whereas I can well treat a tabetic or a rheumatic patient regardless of such personal liking. Not less are the requisites on the patient’s side. The process is especially inapplicable below a certain niveau of intelligence. It is rendered extremely difficult wherever there is any tinge of weakmindedness. It requires the full consent and the attention of the patients, but, above all, their confidence, for the analysis regularly leads to the inmost and most secretly guarded psychic processes. A large proportion of the patients suitable for such treatment withdraw from the physician as soon as they become cognizant whither his investigations tend; to them the physician remains a stranger. In others who have determined to give themselves up to the physician and bestow their confidence upon him, something usually voluntarily given but never demanded, in all those, I say, it is hardly avoidable that the personal relation to the physician should not become unduly prominent, at least for some time. Indeed, it seems as if such an influence exerted by the physician is a condition under which alone a solution of the problem is made possible. I do not believe that it makes any essential difference in this condition whether we make use of hypnosis or have to avoid or substitute it. Yet fairness demands that we emphasize the fact that although these inconveniences are inseparable from our method, they, nevertheless, cannot be charged to it. It is much more evident that they are formed in the preliminary states of the neurosis to be cured, and that they then attach themselves to every medical activity which intensively concerns itself with the patient, and produce in him a psychic change. I could see no harm or danger in the application of hypnosis even in those cases where it was used excessively. The causes for the harm produced lay elsewhere and deeper. When I review the therapeutic efforts of those years since the communications of my honored teacher and friend, J. Breuer, gave me the cathartic method, I believe that I have more often produced good than harm, and brought about some things which could not have been produced by any other therapeutic means. On the whole it was, as expressed in the “Preliminary Communication,” “a distinct therapeutic gain.”

I must mention still another gain in the application of this method. No severe case of complicated neurosis, with either an excessive or slight tinge of hysteria can better be explained than by subjecting it to an analysis by Breuer’s method. In making this analysis I find that whatever shows the hysterical mechanism disappears first, while the rest of the manifestations I meanwhile learn to interpret and refer to their etiology. I thereby gained the essential factors indicated by the instrument of the therapy of the neurosis in question. When I think of the usual differences between my opinion of a case of neurosis before and after such an analysis, I am almost tempted to maintain that the analysis is indispensable for the knowledge of a neurotic disease. I have furthermore made it a practice of applying the cathartic psychotherapy in conjunction with a rest cure, which when required is changed to a full Weir-Mitchell treatment. This advantage lies in the fact that, on the one side I avoid the very disturbing intrusion of new psychic impressions produced during psychotherapy; on the other hand, I exclude the monotony of the Weir-Mitchell treatment, during which the patient not seldom merges into harmful reveries. One might expect that the very considerable psychic labor often imposed upon the patient during the cathartic cure, and the excitement resulting from the reproduction of traumatic events, would run counter to the sense of the Weir-Mitchell rest cure, and would prevent the successes which one is wont to obtain from it. But the contrary happens; through the combination of the Breuer and the Weir-Mitchell therapy, we obtain all the physical improvements which we expect from the latter, and such marked psychic improvement as never occurs in the rest cure without psychotherapy.

II.

I will now add to my former observations that in attempting to use Breuer’s method in greater latitude I met this difficulty—although the diagnosis was hysteria, and the probabilities spoke in favor of the prevalence of the psychic mechanism described by us, yet a number of patients could not be put into the hypnotic state. The hypnosis was necessary to broaden consciousness so as to find the pathogenic reminiscences which do not exist in the ordinary consciousness. I, therefore, was forced to either give up such patients, or to bring about this broadening by other means.

The reason why one person is hypnotizable and another not I could no more explain than others, and hence I could not start on a causal way towards the removal of the difficulties. I also observed that in some patients the obstacle was still more marked, as they even refused to submit to hypnosis. The idea then occurred to me that both cases might be identical, and that in both it might merely be an unwillingness. Those who entertain a psychic inhibition against hypnotism are not hypnotizable, it makes no difference whether they utter their unwillingness or not. It is not fully clear to me whether I can firmly adhere to this conception or not.

It was, therefore, important to avoid hypnotism and yet to obtain the pathogenic reminiscences. This I attained in the following manner:

On asking my patients during our first interview whether they remembered the first motive for the symptom in question, some said that they knew nothing, while others thought of something which they designated as an indistinct recollection, yet were unable to pursue it. I then followed Bernheim’s example of awakening the apparently forgotten impressions obtained during somnambulism (see the case of Miss Lucy). I urged them by assuring them that they did know it, and that they will recall it, etc., and thus some thought of something, while in others the recollections went further. I became still more pressing, I ordered the patient to lie down and voluntarily shut his eyes so as to “concentrate” his mind, causing thereby at least a certain similarity to hypnosis, and I then discovered that without any hypnosis there emerged new and retrospective reminiscences which probably belonged to our theme. Through such experiences I gained the impression that through urging alone it would really be possible to bring to light the definitely existing pathogenic series of ideas; and as this urging necessitated much exertion on my part, and showed me that I had to overcome a resistance, I, therefore, formulated this whole state of affairs into the following theory: Through my psychic work I had to overcome a psychic force in the patient which opposed the pathogenic idea from becoming conscious (remembered). It then became clear to me that this must really be the same psychic force which assisted in the origin of the hysterical symptom, and at that time prevented the pathogenic idea from becoming conscious. What kind of effective force could here be assumed, and what motive could have brought it into activity? I could easily formulate an opinion, for I already had some complete analyses at my disposal in which I found examples of pathogenic, forgotten, and repressed ideas. From these I could judge the general character of such ideas. They were altogether of a painful nature, adapted to provoke the affects of shame, reproach, of psychic pain, and the feeling of injury; they were altogether of that kind which one would not like to experience and prefers to forget.

From all these the thought of defense resulted as if simultaneously. Indeed, it is generally admitted by all psychologists that the assumption of a new idea (assumption in the sense of belief, judgment of reality), depends on the mode and drift of the ideas already united in the ego. For the process of the censor, to which the newly formed ideas are subjected, special technical names have been created. An idea entered into the ego of the patient which proved to be unbearable and evoked a power of repulsion on the part of the ego, the purpose of which was a defense against this unbearable idea. This defense actually succeeded, and the idea concerned was crowded out of consciousness and out of the memory, so that its psychic trace could not apparently be found. Yet this trace must have existed. When I made the effort to direct the attention to it, I perceived as a resistance the same force which showed itself as repulsion in the genesis of the symptom. If I could now make it probable that the idea became pathogenic in consequence of the exclusion and repression, the chain would seem complete. In many epicrises of our histories, and in a small work concerning the defense neuropsychoses (1894), I have attempted to indicate the psychological hypotheses with the help of which this connection also—the fact of conversion—can be made clear.

Hence, a psychic force, the repugnance of the ego, has originally crowded the pathogenic idea from the association, and now opposes its return into the memory. The not knowing of the hysterics was really a—more or less conscious—not willing to know, and the task of the therapeutist was to overpower this resistance of association by psychic labor. Such accomplishment is, above all, brought about by “urging,” that is, by applying a psychic force in order to direct the attention of the patient on the desired traces of ideas. It does not, however, stop here, but as I will show, it assumes new forms in the course of the analysis, and calls to aid more psychic forces.

I shall, above all, still linger at “the urging.” One cannot go very far with such simple assurances as, “You do know it, just say it,” or “It will soon come to your mind.” After a few sentences the thread breaks, even in the patient who is in a state of concentration. We must not, however, forget that we deal everywhere here with a quantitative comparison, with the struggle between motives of diverse force and intensity. The urging of the strange and inexperienced physician does not suffice for the “association resistance” in a grave hysteria. One must resort to more forceful means.

In the first place I make use of a small technical artifice. I inform the patient that I will in the next moment exert pressure on his forehead, I assure him that during this pressure he will see some reminiscence in the form of a picture, or some thought will occur to him, and I oblige him to communicate to me this picture or this thought, no matter what it may be. He is not supposed to hold it back because he may perhaps think that it is not the desired or the right thing, or because it is too disagreeable to say. There should be neither criticism nor reserve on account of affect or disregard. Only thus could we find the things desired, and only thus have we unfailingly found them. I then exert pressure for a few seconds on the forehead of the patient lying in front of me, and after stopping the pressure, I ask in a calm tone, as if any disappointment is out of the question, “What have you seen?” or, “What occurred to your mind?”

This method[^[31]] taught me a great deal and led me to the goal every time. Of course I know that I can substitute this pressure on the forehead by any other sign, or any other physical influence, but as the patient lies before me the pressure on the forehead, or the grasping of his head between my two hands, is the most suggestive and most convenient thing that I could undertake for this end. To explain the efficacy of this artifice, I may perhaps say that it corresponds to a “momentary reinforced hypnosis”; but the mechanism of hypnosis is so enigmatical to me that I would not like to refer to it as an explanation. I rather think that the advantage of the process lies in the fact that through it I dissociate the attention of the patient from his conscious quest and reflection, in brief, from everything upon which his will can manifest itself. This resembles the process of staring at a crystal globe, etc. The fact, that under the pressure of my hand there always appears that which I am looking for, teaches that the supposedly forgotten pathogenic ideas always lie ready, “close by,” being attainable through easily approachable associations, and all that is necessary is to clear away some obstacle. This obstacle again seems to be the person’s will, and different persons learn to discard their premeditations, and to assume a perfectly objective attitude toward the psychic processes within them.

It is not always a “forgotten” reminiscence which comes to the surface under the pressure of the hand; in the rarest cases the real pathogenic reminiscences can be superficially discovered. More frequently an idea comes to the surface which is a link between the starting idea and the desired pathogenic one of the association chain, or it is an idea forming the starting point of a new series of thoughts and reminiscences, at the end of which the pathogenic idea exists. The pressure, therefore, has really not revealed the pathogenic idea, which, if torn from its connections without any preparation, would be incomprehensible; but it has shown the way to it, and indicated the direction towards which the investigation must proceed. The idea which is at first awakened through the pressure may correspond to a familiar reminiscence which was never repressed. If the connection becomes torn on the road to the pathogenic idea, all that is necessary for the reproduction of a new orientation and connection is a repetition of the procedure, that is, of the pressure.

In still other cases the pressure of the hand awakens a reminiscence well known to the patient, which appearance, however, causes him surprise because he had forgotten its relation to the starting idea. In the further course of the analysis this relation becomes clear. From all these results of the pressure one receives a delusive impression of a superior intelligence external to the patient’s consciousness, which systematically holds a large psychic material for definite purposes, and has provided an ingenious arrangement for its return into consciousness. I presume, however, that this unconscious second intelligence is really only apparent.

In every complicated analysis one works repeatedly, nay continuously, with the help of this procedure (pressure on the forehead), which leads us from the place where the patient’s conscious reconductions become interrupted, showing us the way over reminiscences which remained known, and calling our attention to connections which have merged into forgetfulness. It also evokes and connects memories which have for years been withdrawn from the association, but can still be recognized as memories; and finally, as the highest performance of reproduction, it causes the appearance of thoughts which the patient never wishes to recognize as his own, which he does not remember, although he admits that they are inexorably demanded by the connection, and is convinced that just these ideas cause the termination of the analysis and the cessation of the symptoms.

I will now attempt to give a series of examples showing the excellent achievements of this procedure. I treated a young lady who suffered for six years from an intolerable and protracted nervous cough, which apparently was nurtured by every common catarrh, but must have had its strong psychic motives. Every other remedy had long since shown itself to be powerless, and I therefore attempted to remove the symptom by psychoanalysis. All that she could remember was that the nervous cough began at the age of fourteen while she boarded with her aunt. She remembered absolutely no psychic excitement during that time, and did not believe that there was a motive for her suffering. Under the pressure of my hand, she at first recalled a large dog. She then recognized the memory picture; it was her aunt’s dog which was attached to her, and used to accompany her everywhere, and without any further aid it occurred to her that this dog died and that the children buried it solemnly; and on the return from this funeral her cough appeared. I asked her why she began to cough, and after helping her with the pressure, the following thought occurred to her: “Now I am all alone in this world; no one loves me here; this animal was my only friend, and now I have lost it.” She then continued her story. “The cough disappeared when I left my aunt, but reappeared a year and a half later.”—“What was the reason for it?”—“I do not know.”—I again exerted some pressure on the forehead, and she recalled the news of her uncle’s death during which the cough again manifested itself, and also recalled a train of thought similar to the former. The uncle was apparently the only one in the family who sympathized with and loved her. That was, therefore, the pathogenic idea: “People do not love her; everybody else is preferred; she really does not deserve to be loved,” etc. To the idea of love there clung something which caused a marked resistance to the communication. The analysis was interrupted before this explanation.

Some time ago I attempted to relieve an elderly lady of her anxiety attacks, which considering their characteristic qualities, were hardly adapted to such influence. Since her menopause she had become extremely religious, and always received me as if I were the Devil. She was always armed with a small ivory crucifix which she hid in her hand. Her attacks of anxiety, which bore the hysterical character, could be traced to her early girlhood, and were supposed to have originated from the application of an iodine preparation used to reduce a moderate swelling of the thyroid. I naturally repudiated this origin, and sought to substitute it by another which was in better harmony with my views concerning the etiology of neurotic symptoms. To the first question for an impression of her youth which would stand in causal connection to the attacks of anxiety, there appeared under the pressure of my hand the reminiscence of reading a so called devotional book wherein piously enough there was some mention of the sexual processes. The passage in question made an impression on this girl, which was contrary to the intention of the author. She burst into tears and flung the book away. That was before the first attack of anxiety. A second pressure on the forehead of the patient evoked the next reminiscence, it referred to her brother’s teacher who showed her great respect, and for whom she entertained a warmer feeling. This reminiscence culminated in the reproduction of an evening in her parents’ home, during which they all sat around the table with the young man, and delightfully enjoyed themselves in a lively conversation. During the night following this evening she was awakened by the first attack of anxiety which surely had more to do with some resistance against a sensual feeling than perhaps with the coincidently used iodine. In what other way could I have succeeded in revealing in this obstinate patient, prejudiced against me and every worldly remedy, such a connection contrary to her own opinion and assertion?

On another occasion I had to deal with a young happily married woman, who as early as in the first years of her girlhood, was found every morning for some time in a state of lethargy, with rigid members, opened mouth, and protruding tongue. Similar attacks, though not so marked, recurred at the present time on awakening. A deep hypnosis could not be produced, so that I began my investigation in a state of concentration, and assured her during the first pressure that she would see something that would be directly connected with the cause of her condition during her childhood. She acted calmly and willingly, she again saw the residence in which she had passed her early girlhood, her room, the position of her bed, the grandmother who lived with them at the time, and one of her governesses whom she dearly loved. There was then a succession of small, quite indifferent scenes, in these rooms, and among these persons, the conclusion of which was the leave taking of the governess who married from the home. I did not know what to start with these reminiscences; I could not bring about any connection between them and the etiology of the attacks. To be sure the various circumstances were recognized as having occurred at the same time at which the attacks first appeared.

Before I could continue the analysis, I had occasion to talk to a colleague, who, in former years, was my patient’s family physician. From him I obtained the following explanation: At the time that he treated the mature and physically very well developed girl for these first attacks, he was struck by the excessive affection in the relations between her and her governess. He became suspicious and caused the grandmother to watch these relations. After a short while the old lady informed him that the governess was wont to pay nightly visits to the child’s bed, and that quite regularly after such visits the child was found in the morning in an attack. She did not hesitate to bring about the quiet removal of this corruptress of youth. The children, as well as the mother, were made to believe that the governess left the house in order to get married.

The treatment, which was above all successful, consisted in informing the young woman of the explanations given to me.

Occasionally the explanations, which one obtains by the pressure procedure, follow in very remarkable form, and under circumstances which make the assumption of an unconscious intelligence appear even more alluring. Thus I recall a lady who suffered for years from obsessions and phobias, and who referred the origin of her trouble to her childhood, but could mention nothing to which it could have been attributed. She was frank and intelligent, and evinced only a very slight conscious resistance. I will add here that the psychic mechanism of obsessions is very closely related to that of hysterical symptoms, and that the technique of the analysis in both is the same.

On asking the lady whether she had seen or recalled anything under the pressure of my hand, she answered, “Neither, but a word suddenly occurred to me.”—“A single word?”—“Yes, but it is too foolish.”—“Just tell it.”—“Teacher.”—“Nothing more?”—“No.” I exerted pressure a second time, and again a single word flashed through her mind: “Shirt.”—I now observed that we have dealt with a new mode of replying, and by repeated pressure I evoked the following apparently senseless series of words: Teacher—shirt—bed—city—wagon. I asked, “What does all that mean?” She reflected for a moment, and it then occurred to her that “it can only refer to this one incident which now comes to my mind. When I was ten years old my older sister of twelve had an attack of frenzy one night, and had to be bound, put in a wagon and taken to the city. I remember distinctly that it was the teacher who overpowered her and accompanied her to the asylum.”—We then continued this manner of investigation, and received from our oracle another series of words which, though we could not altogether interpret, could nevertheless be used as a continuation of this story, and as an appendix to a second. The significance of this reminiscence was soon clear. The reason why her sister’s illness made such an impression on her was because they both shared a common secret. They slept in the same room, and one night they both submitted to a sexual assault by a certain man. In discovering this sexual trauma of early youth, we revealed not only the origin of the first obsession but also the trauma which later acted pathogenically.—The peculiarity of this case lies only in the appearance of single catch words which we had to elaborate into sentences, for the irrelevance and incoherence found in these oracle like uttered words adhere to all ideas and scenes which generally occur as a result of pressure. On further investigation it is regularly found that the seemingly disconnected reminiscences are connected by close streams of thought, and that they lead quite directly to the desired pathogenic moment.

With pleasure do I therefore recall a case of analysis in which my confidence in the results of pressure was splendidly justified. A very intelligent, and apparently very happy, young woman consulted me for persistent pain in her abdomen which yielded to no treatment. I found that the pain was situated in the abdominal wall and was due to palpable muscular hardening, and I ordered local treatment.

After months I again saw the patient who said that “the former pain disappeared after following the treatment and remained away a long time, but now it has reappeared as a nervous pain. I recognize it by the fact that I do not perceive it now on motion as before, but only during certain hours, as for example, in the morning on awakening, and during certain excitements.” The patient’s diagnosis was quite correct. It was now important to discover the cause of this pain, but in this she could not assist me in her uninfluenced state. When, in a state of concentration and under the pressure of my hand, I asked her whether anything occurred to her, or whether she saw anything, she began to describe her visual pictures. She saw something like a sun with rays, which I naturally had to assume to be a phosphene produced by pressure on the eyes. I expected that the useful pictures would follow, but she continued to see stars of a peculiar pale blue light, like moonlight, etc., and I believed that she merely saw glittering, shining, and twinkling spots before the eyes. I was already prepared to add this attempt to the failures, and I was thinking how I could quietly withdraw from this affair, when my attention was called to one of the manifestations which she described. She saw a big black cross which was inclined, the edges of which were surrounded by a subdued moonlike light in which all the pictures thus far seen were shining, and upon the arm there flickered a little flame that was apparently no longer a phosphene. I continued to listen. She saw numerous pictures in the same light, peculiar signs resembling somewhat sanscrit. She also saw figures like triangles, among which there was one big triangle, and again the cross. I now thought of an allegorical interpretation, and asked, “What does this cross mean?”—“It is probably meant to interpret pain,” she answered. I argued, saying, that “by cross one usually understands a moral burden,” and asked her what was hidden behind that pain. She could not explain that and continued looking. She saw a sun with golden rays which she interpreted as God, the primitive force; she then saw a gigantic lizard which she examined quizzically but without fear; then a heap of snakes, then another sun but with mild silvery rays, and in front of it, between her own person and this source of light, there was a barrier which concealed from her the center of the sun.

I knew for some time that we dealt here with allegories, and I immediately asked for an explanation of the last picture. Without reflecting she answered: “The sun is perfection, the ideal, and the barrier represents my weaknesses and failings which stand between me and the ideal.”—“Indeed, do you reproach yourself? Are you dissatisfied with yourself?”—“Yes.”—“Since when?”—“Since I became a member of the Theosophical Society and read the writings edited by it. I have always had a poor opinion of myself.” “What was it that made the last strongest impression upon you?”—“A translation from the sanscrit which now appears in serial numbers.” A minute later I was initiated into her mental conflicts, and into her self reproaches. She related a slight incident which gave occasion for a reproach, and in which, as a result of an inciting conversion, the former organic pain at first appeared.—The pictures which I had at first taken for phosphenes were symbols of occultistic streams of thought, perhaps plain emblems from the title pages of occultistic books.

I have thus far so warmly praised the achievements of the pressure procedure, and have so entirely neglected the aspect of the defense or the resistance, that I certainly must have given the impression that by means of this small artifice one is placed in position to become master of the psychic resistances against the cathartic cure. But to believe this would be a gross mistake. Such advantages do not exist in the treatment so far as I can see; here, as everywhere else, great change requires much effort. The pressure procedure is nothing but a trick serving to surprise for awhile the defensive ego, which in all graver cases recalls its intentions and continues its resistance.

I need only recall the various forms in which this resistance manifested itself. In the first place, the pressure experiment usually fails the first or second time. The patient then expresses himself disappointed, saying, “I believed that some idea would occur to me, but I only thought so; as attentive as I was nothing came.” Such attitudes assumed by the patient are not yet to be counted as a resistance; we usually answer to that, “You were really too anxious, the second time things will come.” And they really come. It is remarkable how completely the patients—even the most tractable and the most intelligent—can forget the agreement which they have previously entered into. They have promised to tell everything that occurs to them under the pressure of the hand, be it closely related to them or not, and whether it is agreeable to them to say it or not; that is, they are to tell everything without any choice, or influence by critique or affect. Yet they do not keep their promise, it is apparently beyond their powers. The work repeatedly stops, they continue to assert that this time nothing came to their mind. One needs not believe them, and one must always assume, and also say, that they hold back something because they believe it to be unimportant, or perceive it as painful. One must insist, repeat the pressure, and assume an assured attitude until one really hears something. The patient then adds, “I could have told you that the first time.”—“Why did you not say it?”—“I could not believe that that could be it. Only after it returned repeatedly have I decided to tell it;” or, “I had hoped that it would not be just that, that I could spare myself from saying it, but only after it could not be repressed have I noticed that I could not avoid it.”—Thus the patient subsequently betrays the motives of a resistance which he did not at first wish to admit. He apparently could not help offering resistances.

It is remarkable under what subterfuges these resistances are frequently hidden. “I am distracted today”; “the clock or the piano playing in the next room disturbs me,” they say. I became accustomed to answer to that, “Not at all, you simply struck against something that you do not willingly wish to say. That does not help you at all. Just stick to it.”—The longer the pause between the pressure of my hand and the utterance of the patient, the more suspicious I become, and the more is it to be feared that the patient arranges what comes to his mind, and distorts it in the reproduction. The most important explanations are frequently ushered in as superfluous accessories, just as the princes of the opera who are dressed as beggars. “Something now occurred to me, but it has nothing to do with it. I only tell it to you because you wish to know everything.” With this introduction we usually obtain the long desired solution. I always listen when I hear a patient talk so lightly of an idea. That the pathogenic idea should appear of so little importance on its reappearance is a sign of the successful defense. One can infer from this of what the process of defense consisted. Its object was to make a weak out of a strong idea, that is, to rob it of its affect.

Among other signs the pathogenic memories can also be recognized by the fact that they are designated by the patient as unessential, and yet are only uttered with resistance. There are also cases where the patient seeks to disavow the recollections, even while they are being reproduced, with such remarks as these: “Now something occurred to me, but apparently you talked it into me;” or, “I know what you expect to this question, you surely think that I thought of this and that.” An especially clever way of shifting is found in the following expression: “Now something really occurred to me, but it seems to me as if I added it, and that it is not a reproduced thought.”—In all these cases I remain inflexibly firm, I admit none of these distinctions, but explain to the patient that these are only forms and subterfuges of the resistance against the reproduction of a recollection which in spite of all we are forced to recognize.

One generally experiences less trouble in the reproduction of pictures than thoughts. Hysterical patients who are usually visual are easier to manage than patients suffering from obsessions. Once the picture emerges from the memory we can hear the patient state that as he proceeds to describe it, it proportionately fades away and becomes indistinct; the patient wears it out, so to speak, by transforming, it into words. We then orient ourselves through the memory picture itself in order to find the direction towards which the work should be continued. We say to the patient, “Just look again at the picture, has it disappeared?”—“As a whole, yes, but I still see this detail.”—“Then this must have some meaning, you will either see something new, or this remnant will remind you of something.” When the work is finished the visual field becomes free again, and a new picture can be called forth; but at other times such a picture, in spite of its having been described, remains persistently before the inner eye of the patient, and I take this as a sign that he still has something important to tell me concerning its theme. As soon as this has been accomplished, the picture disappears like a wandering spirit returning to rest.

It is naturally of great value for the progress of the analysis to carry our point with the patient, otherwise we have to depend on what he thinks is proper to impart. It, therefore, will be pleasant to hear that the pressure procedure never failed except in a single case which I shall discuss later, but which I can now characterize by the fact that there was a special motive for the resistance. To be sure, it may happen under certain conditions that the procedure may be applied without bringing anything to light; as, for example, we may ask for the further etiology of a symptom when the same has already been exhausted; or, we may investigate for the psychic genealogy of a symptom, perhaps a pain, which really was of somatic origin. In these cases the patient equally insists that nothing occurred to him, and he is right. We should strive to avoid doing an injustice to the patient by making it a general rule not to lose sight of his features while he calmly lies before us during the analysis. One can then learn to distinguish, without any difficulty, the psychic calm in the real non appearance of a reminiscence from the tension and emotional signs under which the patient labors in trying to disavow the emerging reminiscences for the purpose of defense. The differential diagnostic application of the pressure procedure is really based on such experiences.

We can see, therefore, that even with the help of the pressure procedure the task is not an easy one. The only advantage gained is the fact that we have learned from the results of this method in what direction to investigate, and what things we have to force upon the patient. For some cases that suffices, for the question is really to find the secret, and tell it to the patient, so that he is usually then forced to relinquish his resistance. In other cases more is necessary; here the surviving resistance of the patient manifests itself by the fact that the connections become torn, the solutions do not appear, and the recalled pictures come indistinctly and incompletely. On reviewing, at a later period, the earlier results of an analysis, we are often surprised at the distorted aspects of all the occurrences and scenes which we have snatched from the patient by the pressure procedure. It usually lacks the essential part, the relations to the person or to the theme, and for that reason the picture remained incomprehensible. I will now give one or two examples showing the effects of such a censoring during the first appearance of the pathogenic memories. The patient sees the upper part of a female body on which a loose covering fits carelessly, only much later he adds to this torso the head, and thereby betrays a person and a relationship. Or, he relates a reminiscence of his childhood about two boys whose forms are very indistinct, and to whom a certain mischievousness was attributed. It required many months and considerable progress in the course of the analysis before he again saw this reminiscence and recognized one of the children as himself and the other as his brother. What means have we now at our disposal to overcome this continued resistance?

We have but few, yet we have almost all those by which one person exerts a psychic influence on the other. In the first place we must remember that psychic resistance, especially of long continuance, can only be broken slowly, gradually, and with much patience. We can also count on the intellectual interest which manifests itself in the patient after a brief period of the analysis. On explaining and imparting to him the knowledge of the marvelous world of psychic processes, which we have gained only through such analysis, we obtain his collaboration, causing him to view himself with the objective interest of the investigator, and we thus drive back the resistance which rests on an affective basis. But finally—and this remains the strongest motive force—after the motives for the defense have been discovered, we must make the attempt to reduce or even substitute them by stronger ones. Here the possibility of expressing the therapeutic activity in formulæ ceases. One does as well as he can as an explainer where ignorance has produced timorousness, as a teacher, as a representative of a freer and more superior world-conception, and as confessor, who through the continuance of his sympathy and his respect, imparts, so to say, absolution after the confession. One endeavors to do something humane for the patient in so far as the range of one’s own personality and the measure of sympathy which one can set apart for the case allows. It is an indispensable prerequisite for such psychic activities to have approximately discovered the nature of the case and the motives of the defense here effective. Fortunately the technique of the urging and the pressure procedure take us just so far. The more we have solved such enigmas the easier will we discover new ones, and the earlier will we be able to manage the actual curative psychic work. For it is well to bear in mind that although the patient can rid himself of an hysterical symptom only after reproducing and uttering under emotion its causal pathogenic impressions, yet the therapeutic task merely consists in inducing him to do it, and once the task has been accomplished there remains nothing for the doctor to correct or abolish. All the contrary suggestions necessary have already been employed during the struggle carried on against the resistance. The case may be compared to the unlocking of a closed door, where, as soon as the door knob has been pressed downward, no other difficulties are encountered in opening the door.

Among the intellectual motives employed for the overcoming of the resistance one can hardly dispense with one affective moment, that is, the personal equation of the doctor, and in a number of cases, this alone will be able to break the resistance. The conditions here do not differ from those found in any other branch of medicine, and one should not expect any therapeutic method to fully disclaim the assistance of this personal moment.

III.

In view of the discussions in the preceding section concerning the difficulty of my technique, which I have unreservedly exposed,—I have really collected them from my most difficult cases, though it will often be easier work—in view then of this state of affairs everybody will wish to ask whether it would not be more suitable, instead of all these tortures, to apply oneself more energetically to hypnosis, or to limit the application of the cathartic method to only such cases as can be placed in deep hypnosis. To the latter proposition I should have to answer that the number of patients available for my skill would shrink considerably; but to the former advice I will advance the supposition that even where hypnosis could be produced the resistance would not be very much lessened. My experiences in this respect are not particularly extensive, so that I am unable to go beyond this supposition, but wherever I achieved a cathartic cure in the hypnotic state I found that the work devolved upon me was not less than in the state of concentration. I have only recently finished such a treatment during which course I caused the disappearance of a hysterical paralysis of the legs. The patient merged into a state, psychically very different from the conscious, and somatically distinguished by the fact that she was unable to open her eyes or rise without my ordering her to do so; and still I never had a case showing greater resistance than this one. I placed no value on these physical signs, and toward the end of the ten months’ treatment they really became imperceptible. The condition of the patient during our work has therefore lost nothing of its psychic peculiarities, such as the ability to recall the unconscious and its very peculiar relation to the person of the physician. To be sure, in the history of Mrs. Emmy v. N. I have described an example of a cathartic cure accomplished in a profound somnambulism in which the resistance played almost no part. But nothing that I obtained from this woman would have required any special effort; I obtained nothing that she could not have told me in her waking state after a longer acquaintanceship and some esteem. The real causes of her disease, which were surely identical with the causes of her relapses after my treatment, I have never found—it was my first attempt in this therapy—and when I once asked her accidentally for a reminiscence which contained a fragment of the erotic, I found her just as resistant and unreliable in her statements as any one of my later non-somnambulic patients. This patient’s resistance, even in the somnambulic state, against other requirements and exactions I have already discussed in her history. Since I have witnessed cases who, even in deep somnambulism were absolutely refractory therapeutically despite their obedience in everything else, I really became skeptical as to the value of hypnosis for the facilitation of the cathartic treatment. A case of this kind I have reported in brief,[^[32]] and could still add others.

In our discussion thus far, the idea of resistance has thrust itself to the foreground. I have shown how, in the therapeutic work, one is led to the conception that hysteria originates through the repression of an unbearable idea from a motive of defense, that the repressed idea remains as a weak (mildly intensive) reminiscence, and that the affect snatched from it is used for a somatic innervation, that is, conversion of the excitement. By virtue of its repression the idea becomes the cause of morbid symptoms, that is pathogenic. A hysteria showing this psychic mechanism may be designated by the name of “defense hysteria,” but both Breuer and myself have repeatedly spoken of two other kinds of hysterias which we have named hypnoid and retention hysteria. The first to reveal itself to us was really the hypnoid-hysteria, for which I can mention no better example than Breuer’s case of Miss Anna O.[^[33]] For this form of hysteria Breuer gives an essentially different psychic mechanism than for the form which is characterized by conversion. Here the idea becomes pathogenic through the fact that it is conceived in a peculiar psychic state, having remained from the very beginning external to the ego. It therefore needs no psychic force to keep it away from the ego, and it need not awaken any resistance when, with the help of the somnambulic psychic authority, it is initiated into the ego. The history of Anna O. really shows no such resistance.

I held this distinction as so essential that it has readily induced me to adhere to the formation of the hypnoid-hysteria. It is however remarkable that in my own experience I encountered no genuine hypnoid-hysteria, whatever I treated changed itself into a defense hysteria. Not that I have never dealt with symptoms which manifestly originated in separated conscious states, and therefore were excluded from being accepted into the ego. I found this also in my own cases, but I could show that the so called hypnoid state owed its separation to the fact that a split off psychic group originated before, through defense. In brief, I cannot suppress the suspicion that hypnoid and defense hysteria meet somewhere at their roots, and that the defense is the primary thing; but I know nothing about it.

Equally uncertain is at present my opinion concerning the retention hysteria in which the therapeutic work is also supposed to follow without any resistance. I had a case which I took for a typical retention hysteria, and I was pleased over the anticipation of an easy and certain success; but this success did not come as easy as the work really was. I therefore presume, and again with all caution appropriate to ignorance, that in retention hysteria, too, we can find at its basis a fragment of defense which has thrust the whole process into hysteria. Let us hope that new experiences will soon decide whether I am running into the danger of one-sidedness and error in my tendency to spread the conception of defense for the whole of hysteria.

Thus far I have dealt with the difficulties and technique of the cathartic method, I would now like to add a few indications showing how one makes an analysis with technique. For me this is a very interesting theme, but I do not expect that it will excite similar interest in others who have not practiced such analyses. Properly speaking we shall again deal with the technique, but this time with those difficulties concerning which the patient cannot be held responsible, and which must in part be the same in a hypnoid and a retention hysteria as well as in the defense hysteria which I have in mind as a model. I start on this last fragment of discussion with the expectation that the psychic peculiarities revealed here might sometime attain a certain value as raw material for an intellectual dynamics.

The first and strongest impression which one gains through such an analysis is surely the fact that the pathogenic psychic material, apparently forgotten and not at the disposal of the ego, playing no rôle in the association and in memory, still lies ready in some manner and in proper and good order. All that is necessary is to remove the resistances blocking the way. Barring that, everything is known as we know anything else, the proper connections of the individual ideas among themselves and with the nonpathogenic are frequently recalled and are present; they have been produced in their time and retained in memory. The pathogenic psychic material appears as the property of an intelligence which is not necessarily inferior to the normal ego. The semblance of a second personality is often most delusively produced. Whether this impression is justified, whether the arrangements of the psychic material resulting after the adjustment is not transferred back into the time of the disease, these are questions which I do not like to consider in this place. One cannot easily and intuitively describe the experiences resulting from these analyses as if he placed himself in the position, which one can only take a survey of after their disappearance.

The condition is usually not so simple as one represents it in special cases, as, for example, in a single case in which a symptom originates through a serious trauma. We frequently deal not with a single hysterical symptom but with a number of the same which are partially independent of one another and partially connected. We must not expect a single traumatic reminiscence whose nucleus is a single pathogenic idea, but we must be ready to assume a series of partial traumas and a concatenation of pathogenic streams of thought. The monosymptomatic traumatic hysteria is, as it were, an elementary organism, it is a single being in comparison to the complicated structure of a grave hysterical neurosis as is generally encountered.

The psychic material of such hysteria presents itself as a multidimensional formation of at least triple stratification. I hope to be able to soon justify this figurative expression. First of all there is a nucleus of such reminiscences (either experiences or streams of thought) in which the traumatic moment culminated, or in which the pathogenic idea has found its purest formation. Around this nucleus we often find an incredibly rich mass of other memory material which we have to elaborate by the analysis in the triple arrangement mentioned before. In the first place, there is an unmistakable linear chronological arrangement which takes place within every individual theme. As an example of this I can only cite the arrangements in Breuer’s analysis of Anna O. The theme is that of becoming deaf, of not hearing,[^[34]] which then becomes differentiated according to seven determinants, and under each heading there were from ten to one hundred single reminiscences in chronological order. It was as if one should take up an orderly kept record. In the analysis of my patient, Emmy v. N., there were similar if not so many memory sub-divisions; they formed quite a general event in every analysis. They always occurred in a chronological order which was as definitely reliable as the serial sequences of the days of the week or the names of the months in psychically normal individuals. They increased the work of the analysis through the peculiarity of reversing the series of their origin in the reproduction; the freshest and the most recent occurrence of the accumulation occurred first as a “wrapper,” and that with which the series really began gave the impression of the conclusion.

The grouping of similar reminiscences in a multiplicity of linear stratifications, as represented in a bundle of documents, in a package, etc., I have designated as the formation of a theme. These themes now show a second form of arrangement. I cannot express it differently than by saying that they are concentrically stratified around the pathogenic nucleus. It is not difficult to say what determines these strata, and according to what decreasing or increasing magnitude this arrangement follows. They are layers of equal resistance tending towards the nucleus, accompanied by zones of similar alteration of consciousness into which the individual themes extend. The most peripheral layers contain those reminiscences (or fascicles) of the different themes which can readily be recalled and were always perfectly conscious. The deeper one penetrates the more difficult it becomes to recognize the emerging reminiscences until one strikes those near the nucleus which the patient disavows, even at the reproduction.

As we shall hear later it is the peculiarity of the concentric stratification of the pathogenic psychic material which gives to the course of such an analysis its characteristic features. We must now mention the third and most essential arrangement concerning which a general statement can hardly be made. It is the arrangement according to the content of thought, the connection through the logical thread reaching to the nucleus which might in each case correspond to a special, irregular, and manifoldly devious road. This arrangement has a dynamic character in contradistinction to both morphological stratifications mentioned before. Whereas, in a spacially formed scheme the latter would be represented by rigid, arched, and straight lines, the course of the logical concatenation would have to be followed with a wand, over the most tortuous route, from the superficial into the deep layers and back, generally, however, progressing from the peripheral to the central nucleus, and touching thereby all stations; that is, its movement is similar to the zigzag movement of the knight in the solution of a chess problem.

I will still adhere for a moment to the last comparison in order to call attention to a point in which it does not do justice to the qualities of the thing compared. The logical connection corresponds not only to a zigzag-like devious line, but rather to a ramifying and especially to a converging system of lines. It has a junction in which two or more threads meet only to proceed thence united, and, as a rule, many threads running independently, or here and there connected by by-paths, open into the nucleus. To put it in different words, it is very remarkable how frequently a symptom is manifoldly determined, that is, over-determined.

I will introduce one more complication, and then my effort to illustrate the organization of the pathogenic psychic material will be achieved. It can happen that we may deal with more than one single nucleus in the pathogenic material, as, for example, when we have to analyze a second hysterical outbreak having its own etiology but which is still connected with the first outbreak of an acute hysteria which has been overcome years before. It can readily be imagined what strata and streams of thought must be added in order to produce a connection between the two pathogenic nuclei.

I will still add a few observations to the picture obtained of the organization of the pathogenic material. We have said of this material that it behaves like a foreign body, and that the therapy also acts like the removal of a foreign body from the living tissues. We are now in position to consider the shortcomings of this comparison. A foreign body does not enter into any connection with the layers of tissue surrounding it, although it changes them and produces in them a reactive inflammation. On the other hand, our pathogenic psychic group does not allow itself to be cleanly shelled out from the ego, its outer layers radiate in all directions into the parts of the normal ego, and really belong to the latter as much as to the pathogenic organization. The boundaries between both become purely conventional in the analysis, being placed now here, now there, and in certain locations no demarcation is possible. The inner layers become more and more estranged from the ego without showing a visible beginning of the pathogenic boundaries. The pathogenic organization really does not behave like a foreign body, but rather like an infiltration. The infiltrate must, in this comparison, be assumed to be the resistance. Indeed, the therapy does not consist in extirpating something—psychotherapy cannot do that at present—but it causes a melting of the resistance, and thus opens the way for the circulation into a hitherto closed territory.

(I make use here of a series of comparisons all of which have only a very limited resemblance to my theme, and do not even agree among themselves. I am aware of that, and I am not in danger of over-estimating their value; but, as it is my intention to illustrate the many sides of a most complicated and not as yet depicted idea, I therefore take the liberty of dealing also in the following pages with comparisons which are not altogether free from objections.)

If, after a thorough adjustment, one could show to a third party the pathogenic material in its present recognized, complicated and multidimensional organization, he would justly propound the question, “How could such a camel go through the needle’s eye?” Indeed, one does not speak unjustly of a “narrowing of consciousness.” The term gains in sense and freshness for the physician who accomplishes such an analysis. Only one single reminiscence can enter into the ego consciousness; the patient occupied in working his way through this one sees nothing of that which follows, and forgets everything that has already wedged its way through. If the conquest of this one pathogenic reminiscence strikes against impediments, as for example, if the patient does not yield the resistance against it, but wishes to repress or distort it, the strait is, so to speak, blocked; the work comes to a standstill, it cannot advance, and the one reminiscence in the breach confronts the patient until he takes it up into the breadth of his ego. The whole spacially extended mass of the pathogenic material is thus drawn through a narrow fissure and reaches consciousness as if disjointed into fragments or strips, and it is the task of the psychotherapist to recompose it into the conjectured organization. He who desires still more comparisons may think here of a Chinese puzzle.

If one is about to begin an analysis in which one may expect such an organization of the pathogenic material, the following results of experience may be useful: It is perfectly hopeless to attempt to make any direct headway towards the nucleus of the pathogenic organization. Even if it could be guessed the patient would still not know what to start with the explanation given to him, nor would it change him psychically.

There is nothing left to do but follow up the periphery of the pathogenic psychic formation. One begins by allowing the patient to relate and recall what he knows, during which one can already direct his attention, and through the application of the pressure procedure slight resistances may be overcome. Whenever a new way is opened through pressure it can be expected that the patient will continue it for some distance without any new resistance.

After having worked for a while in such manner a coöperating activity is usually manifested in the patient. A number of reminiscences now occur to him without any need of questioning or setting him a task. A way has thus been opened into an inner strata, within which the patient now spontaneously disposes of the material of equal resistance. It is well to allow him to reproduce for a while without being influenced; of course, he is unable to reveal important connections, but he may be allowed to clear things within the same stratum. The things which he thus reproduces often seem disconnected, but they give up the material which is later revived by the recognized connections.

One has to guard here in general against two things. If the patient is checked in the reproduction of the inflowing ideas, something is apt to be “buried” which must be uncovered later with great effort. On the other hand one must not overestimate his “unconscious intelligence,” and one must not allow it to direct the whole work. If I should wish to schematize the mode of labor, I could perhaps say that one should himself undertake the opening of the inner strata and the advancement in the radial direction, while the patient should take care of the peripheral extension.

The advancement is brought about by the fact that the resistance is overcome in the manner indicated above. As a rule, however, one must at first solve another problem. One must obtain a piece of a logical thread by which direction alone one can hope to penetrate into the interior. One should not expect that the voluntary information of the patient, the material which is mostly in the superficial strata, will make it easy for the analyzer to recognize the locations where it enters into the deep, and to which points the desired connections of thought are attached. On the contrary, just this is cautiously concealed, the assertion of the patient sounds perfect and fixed in itself. One is at first confronted, as it were, by a wall which shuts off every view, and gives no suggestion of anything hidden behind it.

If, however, one views with a critical eye the assertion obtained from the patient without much effort and resistance, one will unmistakably discover in it gaps and injuries. Here the connection is manifestly interrupted and is scantily completed by the patient by an expression conveying quite insufficient information. Here one strikes against a motive which in a normal person would be designated as flimsy. The patient refuses to recognize these gaps when his attention is called to them. The physician, however, does well to seek under these weak points access to the material of the deeper layers and to hope to discover just here the threads of the connections which he traces by the pressure procedure. One, therefore, tells the patient, “You are mistaken, what you assert can have nothing to do with the thing in question; here we will have to strike against something which will occur to you under the pressure of my hand.”

The hysterical stream of thought, even if it reaches into the unconscious, may be expected to show the same logical connections and sufficient causations as those that would be formed in a normal individual. A looseness of these relationships does not lie within the sphere of influence of the neurosis. If the association of ideas of neurotics, and especially of hysterics, makes a different impression, if the relation of the intensities of different ideas does not seem to be explainable here on psychological determinants alone, we know that such manifestations are due to the existence of concealed unconscious motives. Such secret motives may be expected wherever such a deviation in the connection, or a transgression from the normally justified causations can be demonstrated.

To be sure one must free himself from the theoretical prejudice that one has to deal with abnormal brains of dégénerés and deséquilibrés, in whom the freedom of overthrowing the common psychological laws of the association of ideas is a stigma, or in whom a preferred idea without any motive may grow intensively excessive, and another without psychological motives may remain indestructible. Experience shows the contrary in hysteria; as soon as the hidden—often unconsciously remaining—motives have been revealed and brought to account there remains nothing in the hysterical thought connection that is enigmatical and anomalous.

Thus by tracing the breaches in the first statements of the patient, which are often hidden by “false connections,” one gets hold of a part of the logical thread at the periphery, and thereafter continues the route by the pressure procedure.

Very seldom do we succeed in working our way into the inner strata by the same thread, usually it breaks on the way when the pressure fails, giving up either no experience, or one which cannot be explained or be continued despite all efforts. In such a case we soon learn how to protect ourselves from the obvious confusion. The expression of the patient must decide whether one really reached an end or encountered a case needing no psychic explanation, or whether it is the enormous resistance that halts the work. If the latter cannot soon be overcome, it may be assumed that the thread has been followed into a strata which is as yet impenetrable. One lets it fall in order to grasp another thread which may, perhaps, be followed up just as far. If one has followed all the threads into this strata, if the knottings have been reached through which no single isolated thread can be followed, it is well to think of seizing anew the resistances on hand.

One can readily imagine how complicated such a work may become. By constantly overcoming the resistance, one pushes his way into the inner strata, gaining knowledge concerning the accumulative themes and passing threads found in this layer; one examines as far as he can advance with the means at hand, and by means of the pressure procedure he gains first information concerning the content of the next strata.

The threads are dropped, taken up again, and followed up until they reach the juncture; they are always retrieved, and by following a memory fascicle one reaches some by-way which finally opens again. In this manner it is possible to leave the work, layer by layer, and advance directly on the main road to the nucleus of the pathogenic organization. Thus the fight is won but not finished. One has to follow up the other threads and exhaust the material; but now the patient helps again energetically, for his resistance has mostly been broken.

In these later stages of the work it is of advantage if one can surmise the connection and tell it to the patient before it has been revealed. If the conjecture is correct the course of the analysis is accelerated, but even an incorrect hypothesis helps, for it urges the patient to participate and elicits from him energetic refutation, thus revealing that he surely knows better.