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Further Remarks On The Neuro-Psychoses Of Defence

400

   My patient’s singular
conduct, too, in making appointments with her brother, and then
having nothing to tell him, was solved in a surprising fashion. Her
explanation was that she had thought that if she could only look at
him he would be bound to understand her sufferings, since he knew
the cause of them. Now, as this brother was in fact the only person
who could know about the aetiology of her illness, it was clear
that she had been acting in accordance with a motive which,
although she herself did not understand it consciously, could be
seen to be perfectly justified as soon as it was supplied with a
meaning derived from the unconscious.

   I then succeeded in getting her
to reproduce the various scenes in which her sexual relationship
with her brother (which had certainly lasted at least from her
sixth to her tenth year) had culminated. During this work of
reproduction, the physical sensation in her abdomen ‘joined
in the conversation’ as it were, as is regularly observed to
happen in the analysis of hysterical mnemic residues. The image of
the lower part of a woman’s naked abdomen (but now reduced to
childish proportions and without hair on it) appeared with the
sensation or stayed away, according as the scene in question had
occurred in full light or in the dark. Her disgust at eating, too,
found an explanation in a repulsive detail of these proceedings.
After we had gone through this series of scenes, the hallucinatory
sensations and images had disappeared, and (up to the present, at
any rate) they have not returned.¹

  
¹
Later on, when an exacerbation of her
illness undid the successful results of the treatment - which were
in any case meagre - the patient no longer saw the offensive images
of other people’s genitals but had the idea that other people
saw
her
genitals whenever they were
behind
her.

(
Added
1922) The fragmentary account of this analysis in the text above
was written while the patient was still undergoing treatment. Very
shortly after, her condition became so much more serious that the
treatment had to be broken off. She was transferred to an
institution and there went through a period of severe
hallucinations which had all the signs of dementia praecox.
Contrary to expectation, however, she recovered and returned home,
had another child which was quite healthy, and was able for a long
period (12 to 15 years) to carry out all her duties in a
satisfactory manner. The only sign of her earlier psychosis was
said to be that she avoided the company of all relatives, whether
of her own family or of her husband’s. At the end of this
period, affected by very adverse changes in her circumstances, she
again became ill. Her husband had become unable to work and the
relatives she had avoided were obliged to support the family. She
was again sent to an institution, and died there soon after, of a
pneumonia which rapidly supervened.

Further Remarks On The Neuro-Psychoses Of Defence

401

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

   I now turned to the analysis of
the voices. First and foremost what had to be explained was why
such an indifferent content as ‘Here comes Frau P.’,
‘She’s looking for a house now’, and so on, could
have been so distressing to her; next, how it was that precisely
these innocent phrases had managed to be marked out by
hallucinatory reinforcement. From the first it was clear that the
‘voices’ could not be
memories
that were being
produced in a hallucinatory way, like the images and sensations,
but were rather
thoughts
that were being ‘said
aloud’.

   The first time she heard the
voices was in the following circumstances. She had been reading
Otto Ludwig’s fine story,
Die Heiterethei
, with eager
interest, and she noticed that while she was reading, thoughts were
emerging which claimed her attention. Immediately afterwards, she
went for a walk along a country road, and, as she was passing a
small peasant’s house, the voices suddenly said to her
‘That’s what the Heiterethei’s cottage looked
like! There’s the spring and there are the bushes! How happy
she was in spite of all her poverty!’ The voices then
repeated to her whole paragraphs from what she had just been
reading. But it remained unintelligible why the Heiterethei’s
cottage and bushes and spring, and precisely the most trivial and
irrelevant passages of the story, should be forced on her attention
with pathological strength. However, the solution of the puzzle was
not difficult. Her analysis showed that while she was reading, she
had had other thoughts as well and that she had been excited by
quite different passages in the book. Against this material -
analogies between the couple in the story and herself and her
husband, memories of intimacies in her married life, and of family
secrets - against all this a repressing resistance had arisen
because it was connected, by easily demonstrable trains of thought,
with her aversion to sexuality and thus ultimately went back to the
awakening of her old childhood experience. In consequence of this
censorship exercised by the repression, the innocuous and idyllic
passages, which were connected with the proscribed ones by contrast
and also by propinquity, acquired the additional strength in their
relation to consciousness which made it possible for them to be
spoken aloud. The first of the repressed ideas, for instance,
related to the slander to which the heroine, who lived alone, was
exposed from her neighbours. My patient easily discovered the
analogy with her own self. She, too, lived in a small place, met no
one, and thought she was despised by her neighbours. This distrust
of her neighbours had a real foundation. She had been obliged at
first to be content with a small apartment, and the bedroom wall
against which the young couple’s double bed stood adjoined a
room belonging to their neighbours. With the beginning of her
marriage - obviously through an unconscious awakening of her
childhood affair, in which she and her brother had played at
husband and wife - she had developed a great aversion to sexuality.
She was constantly worried in case her neighbours might hear words
and noises through the party wall, and this shame turned into
suspiciousness towards the neighbours.

Further Remarks On The Neuro-Psychoses Of Defence

402

   Thus the voices owed their origin
to the repression of thoughts which, in the last analysis, were in
fact self-reproaches about experiences that were analogous to her
childhood trauma. The voices were accordingly symptoms of the
return of the repressed. But they were at the same time
consequences of a compromise between the resistance of the ego and
the power of the returning repressed - a compromise which in this
instance had brought about a distortion that went beyond
recognition. In other instances in which I had occasion to analyse
Frau P.’s voices, the distortion was less great.
Nevertheless, the words she heard always had a quality of
diplomatic indefiniteness: the insulting allusion was generally
deeply hidden; the connection between the separate sentences was
disguised by a strange mode of expression, unusual forms of speech
and so on - characteristics which are common to the auditory
hallucinations of paranoics in general and in which I see the
traces of distortion through compromise. For instance, the remark,
’there goes Frau P.; she’s looking for a house in the
street’, meant a threat that she would never recover; for I
had promised her that after her treatment she would be able to go
back to the small town in which her husband worked.(She had
provisionally taken rooms in Vienna for a few months.)

   In isolated instances Frau P.
also received more definite threats - for example, in regard to her
husband’s relatives; yet there was still a contrast between
the reserved manner in which they were expressed and the torment
which the voices caused her. In view of what is known of paranoia
apart from this, I am inclined to suppose that there is a gradual
impairment of the resistances which weaken the self-reproaches; so
that finally the defence fails altogether and the original
self-reproach, the actual term of abuse, from which the subject was
trying to spare himself, returns in its unaltered form. I do not
know, however, whether this course of events is a constant one, or
whether the censorship of the words involving the self-reproach may
be absent from the beginning or may persist to the end.

Further Remarks On The Neuro-Psychoses Of Defence

403

   It only remains for me now to
employ what has been learned from this case of paranoia for making
a comparison between paranoia and obsessional neurosis. In each of
them, repression has been shown to be the nucleus of the psychical
mechanism, and in each what has been repressed is a sexual
experience in childhood. In this case of paranoia, too, every
obsession sprang from repression; the symptoms of paranoia allow of
a classification similar to the one which has proved justified for
obsessional neurosis. Part of the symptoms, once again, arise from
primary defence - namely, all the delusional ideas which are
characterized by distrust and suspicion and which are concerned
with ideas of being persecuted by others. In obsessional neurosis
the initial self-reproach has been repressed by the formation of
the primary symptom of defence:
self-distrust
. With this,
the self-reproach is acknowledged as justified; and, to weigh
against this, the conscientiousness which the subject has acquired
during his healthy interval now protects him from giving credence
to the self-reproaches which return in the form of obsessional
ideas. In paranoia, the self-reproach is repressed in a manner
which may be described as
projection
. It is repressed by
erecting the defensive symptom of
distrust of other people
.
In this way the subject withdraws his acknowledgement of the
self-reproach; and, as if to make up for this, he is deprived of a
protection against the self-reproaches which return in his
delusional ideas.

   Other symptoms of my case of
paranoia are to be described as symptoms of the return of the
repressed, and they, too, like those of obsessional neurosis, bear
the traces of the compromise which alone allows them to enter
consciousness. Such are, for instance, my patient’s
delusional idea of being watched while she was undressing, her
visual hallucinations, her hallucinations of sensation and her
hearing of voices. In the delusional idea which I have just
mentioned there is a mnemic content which is almost unaltered and
has only been made indefinite through omission. The return of the
repressed in visual images approaches the character of hysteria
rather than of obsessional neurosis; but hysteria is in the habit
of repeating its mnemic symbols without modification, whereas
mnemic hallucinations in paranoia undergo a distortion similar to
that in obsessional neurosis: an analogous modern image takes the
place of the repressed one. (E. g., the abdomen of an adult woman
appears instead of a child’s, and an abdomen on which the
hairs are especially distinct, because they were absent in the
original impression.) A thing which is quite peculiar to paranoia
and on which no further light can be shed by this comparison, is
that the repressed self-reproaches return in the form of thoughts
spoken aloud. In the course of this process, they are obliged to
submit to twofold distortion: they are subjected to a censorship,
which leads to their being replaced by other, associated, thoughts
or to their being concealed by an indefinite mode of expression,
and they are referred to recent experiences which are no more than
analogous to the old ones.

Further Remarks On The Neuro-Psychoses Of Defence

404

   The third group of symptoms that
are found in obsessional neurosis, the symptoms of secondary
defence, cannot be present as such in paranoia, because no defence
can avail against the returning symptoms to which, as we know,
belief is attached. In place of this, we find in paranoia another
source for the formation of symptoms. The delusional ideas which
have arrived in consciousness by means of a compromise (the
symptoms of the return) make demands on the thought-activity of the
ego until they can be accepted without contradiction. Since they
are not themselves open to influence, the ego must adapt itself to
them; and thus what corresponds here to the symptoms of secondary
defence in obsessional neurosis is a combinatory delusional
formation -
interpretative delusions
which end in an
alteration of the ego
. In this respect, the case under
discussion was not complete; at that time my patient did not as yet
exhibit any signs of the attempts at interpretation which appeared
later. But I have no doubt that if we apply psycho-analysis to this
stage of paranoia as well, we shall be able to arrive at a further
important result. It should then turn out that the so-called
weakness of memory
of paranoics is also a tendentious one -
that is to say, that it is based on repression and serves the ends
of repression. A subsequent repression and replacement takes place
of memories which are not in the least pathogenic, but which are in
contradiction to the alteration of the ego which the symptoms of
the return of the repressed so insistently demand.

405

THE AETIOLOGY OF HYSTERIA

(1896)

406

Intentionally left blank

407

THE AETIOLOGY OF HYSTERIA

GENTLEMEN
, - When we set out to form
an opinion about the causation of a pathological state such as
hysteria, we begin by adopting the method of anamnestic
investigation: we question the patient or those about him in order
to find out to what harmful influences they themselves attribute
his having fallen ill and developed these neurotic symptoms. What
we discover in this way is, of course, falsified by all the factors
which commonly hide the knowledge of his own state from a patient -
by his lack of scientific understanding of aetiological influences,
by the fallacy of
post hoc, propter hoc
, by his reluctance
to think about or mention certain noxae and traumas. Thus in making
an anamnestic investigation of this sort, we keep to the principle
of not adopting the patients’ belief without a thorough
critical examination, of not allowing them to lay down our
scientific opinion for us on the aetiology of the neurosis.
Although we do, on the one hand, acknowledge the truth of certain
constantly repeated assertions, such as that the hysterical state
is a long-persisting after-effect of an emotion experienced in the
past, we have, on the other hand, introduced into the aetiology of
hysteria a factor which the patient himself never brings forward
and whose validity he only reluctantly admits - namely, the
hereditary disposition derived from his progenitors. As you know,
in the view of the influential school of Charcot heredity alone
deserves to be recognized as the true cause of hysteria, while all
other noxae of the most various nature and intensity only play the
part of incidental causes, of ‘
agents
provocateurs
’.

The Aetiology Of Hysteria

408

   You will readily admit that it
would be a good thing to have a second method of arriving at the
aetiology of hysteria, one in which we should feel less dependent
on the assertions of the patients themselves. A dermatologist, for
instance, is able to recognize a sore as luetic from the character
of its margins, or the crust on it and of its shape, without being
misled by the protestations of his patient, who denies any source
of infection for it; and a forensic physician can arrive at the
cause of an injury, even if he has to do without any information
from the injured person. In hysteria, too, there exists a similar
possibility of penetrating from the symptoms to a knowledge of
their causes. But in order to explain the relationship between the
method which we have to employ for this purpose and the older
method of anamnestic enquiry, I should like to bring before you an
analogy taken from an advance that has in fact been made in another
field of work.

   Imagine that an explorer arrives
in a little-known region where his interest is aroused by an
expanse of ruins, with remains of walls, fragments of columns, and
tablets with half effaced and unreadable inscriptions. He may
content himself with inspecting what lies exposed to view, with
questioning the inhabitants - perhaps semi-barbaric people - who
live in the vicinity, about what tradition tells them of the
history and meaning of these archaeological remains, and with
noting down what they tell him - and he may then proceed on his
journey. But he may act differently. He may have brought picks,
shovels and spades with him, and he may set the inhabitants to work
with these implements. Together with them he may start upon the
ruins, clear away the rubbish, and, beginning from the visible
remains, uncover what is buried. If his work is crowned with
success, the discoveries are self-explanatory; the ruined walls are
part of the ramparts of a palace or a treasure house; the fragments
of columns can be filled out into a temple; the numerous
inscriptions, which, by good luck, may be bilingual, reveal an
alphabet and a language, and, when they have been deciphered and
translated, yield undreamed-of information about the events of the
remote past, to commemorate which the monuments were built.
Saxa
loquuntur!

   If we try, in an approximately
similar way, to induce the symptoms of a hysteria to make
themselves heard as witnesses to the history of the origin of the
illness, we must take our start from Josef Breuer’s momentous
discovery:
the symptoms of hysteria
(apart from the
stigmata)
are determined by certain
experiences of the
patient’s which have operated in a traumatic fashion and
which are being reproduced in his psychical life in the form of
mnemic symbols
. What we have to do is to apply Breuer’s
method - or one which is essentially the same - so as to lead the
patient’s attention back from his symptom to the scene in
which and through which that symptom arose; and, having thus
located the scene, we remove the symptom by bringing about, during
the reproduction of the traumatic scene, a subsequent correction of
the psychical course of events which took place at the time.

The Aetiology Of Hysteria

409

   It is no part of my intention
to-day to discuss the difficult technique of this therapeutic
procedure or the psychological discoveries which have been obtained
by its means. I have been obliged to start from this point only
because the analyses conducted on Breuer’s lines seem at the
same time to open up the path to the causes of hysteria. If we
subject a fairly large number of symptoms in a great number of
subjects to such an analysis, we shall, of course, arrive at a
knowledge of a correspondingly large number of traumatically
operative scenes. It was in these experiences that the efficient
causes of hysteria came into action. Hence we may hope to discover
from the study of these traumatic scenes what the influences are
which produce hysterical symptoms and in what way they do so.

   This expectation proves true; and
it cannot fail to, since Breuer’s theses, when put to the
test in a considerable number of cases, have turned out to be
correct. But the path from the symptoms of hysteria to its
aetiology is far more laborious and leads through other connections
than one would have imagined.

   For let us be clear on this
point. Tracing a hysterical symptom back to a traumatic scene
assists our understanding only if the scene satisfies two
conditions; if it possesses the relevant
suitability to serve as
a determinant
and if it recognizably possesses the necessary
traumatic force
. Instead of a verbal explanation, here is an
example. Let us suppose that the symptom under consideration is
hysterical vomiting;  in that case we shall feel that we have
been able to understand its causation (except for a certain
residue) if the analysis traces the symptom back to an experience
which
justifiably produced a high amount of disgust
- for
instance, the sight of a decomposing dead body. But if, instead of
this, the analysis shows us that the vomiting arose from a great
fright, e.g. from a railway accident, we shall feel dissatisfied
and will have to ask ourselves how it is that the fright has led to
the particular symptom of vomiting. This derivation lacks
suitability as a determinant
. We shall have another instance
of an insufficient explanation if the vomiting is supposed to have
arisen from, let us say, eating a fruit which had partly gone bad.
Here, it is true, the vomiting
is
determined by disgust, but
we cannot understand how, in this instance, the disgust could have
become so powerful as to be perpetuated in a hysterical symptom;
the experience lacks
traumatic force
.

The Aetiology Of Hysteria

410

   Let us now consider how far the
traumatic scenes of hysteria which are uncovered by analysis
fulfil, in a fairly large number of symptoms and cases, the two
requirements which I have named. Here we meet with our first great
disappointment. It is true, indeed, that the traumatic scene in
which the symptom originated does in fact occasionally possess both
the qualities - suitability as a determinant and traumatic force -
which we require for an understanding of the symptom. But far more
frequently, incomparably more frequently, we find one of the three
other possibilities realized, which are so unfavourable to an
understanding. Either the scene to which we are led by analysis and
in which the symptom first appeared seems to us unsuited for
determining the symptom, in that its content bears no relation to
the nature of the symptom; or the allegedly traumatic experience,
though it does have a relation to the symptom, proves to be an
impression which is normally innocuous and incapable as a rule of
producing any effect; or, lastly, the ‘traumatic scene’
leaves us in the lurch in both respects, appearing at once
innocuous and unrelated to the character of the hysterical
symptom.

   (Here I may remark in passing
that Breuer’s view of the origin of hysterical symptoms is
not shaken by the discovery of traumatic scenes which correspond to
experiences that are insignificant in themselves. For Breuer
assumed - following Charcot - that even an innocuous experience can
be heightened into a trauma and can develop determining force if it
happens to the subject when he is in a special psychical condition
- in what is described as a
hypnoid state
. I find, however,
that there are often no grounds whatever for presupposing the
presence of such hypnoid states. What remains decisive is that the
theory of hypnoid states contributes nothing to the solution of the
other difficulties, namely that the traumatic scenes so often lack
suitability as determinants.)

   Moreover, Gentlemen, this first
disappointment we meet with in following Breuer’s method is
immediately succeeded by another, and one that must be especially
painful to us as physicians. When our procedure leads, as in the
cases described above, to findings which are insufficient as an
explanation both in respect to their suitability as determinants
and to their traumatic effectiveness, we also fail to secure any
therapeutic gain; the patient retains his symptoms unaltered, in
spite of the initial result yielded by the analysis. You can
understand how great the temptation is at this point to proceed no
further with what is in any case a laborious piece of work.

The Aetiology Of Hysteria

411

   But perhaps all we need is a new
idea in order to help us out of our dilemma and lead to valuable
results. The idea is this. As we know from Breuer, hysterical
symptoms can be resolved if, starting from them, we are able to
find the path back to the memory of a traumatic experience. If the
memory which we have uncovered does not answer our expectations, it
may be that we ought to pursue the same path a little further;
perhaps behind the first traumatic scene there may be concealed the
memory of a second, which satisfies our requirements better and
whose reproduction has a greater therapeutic effect; so that the
scene that was first discovered only has the significance of a
connecting link in the chain of associations. And perhaps this
situation may repeat itself; inoperative scenes may be interpolated
more than once, as necessary transitions in the process of
reproduction, until we finally make our way from the hysterical
symptom to the scene which is really operative traumatically and
which is satisfactory in every respect, both therapeutically and
analytically. Well, Gentlemen, this supposition is correct. If the
first-discovered scene is unsatisfactory, we tell our patient that
this experience explains nothing, but that behind it there must be
hidden a more significant, earlier, experience; and we direct his
attention by the same technique to the associative thread which
connects the two memories - the one that has been discovered and
the one that has still to be discovered.¹ A continuation of
the analysis then leads in every instance to the reproduction of
new scenes of the character we expect. For example, let us take
once again the case of hysterical vomiting which I selected before,
and in which the analysis first led back to a fright from a railway
accident - a scene which lacked suitability as a determinant.
Further analysis showed that this accident had aroused in the
patient the memory of another, earlier accident, which, it is true,
he had not himself experienced but which had been the occasion of
his having a ghastly and revolting sight of a dead body. It is as
though the combined operation of the two scenes made the fulfilment
of our postulates possible, the one experience supplying, through
fright, the traumatic force and the other, from its content, the
determining effect. The other case, in which the vomiting was
traced back to eating an apple which had partly gone bad, was
amplified by the analysis somewhat in the following way. The bad
apple reminded the patient of an earlier experience: while he was
picking up windfalls in an orchard he had accidentally come upon a
dead animal in a revolting state.

   I shall not return any further to
these examples, for I have to confess that they are not derived
from any case in my experience but are inventions of mine. Most
probably, too, they are bad inventions. I even regard such
solutions of hysterical symptoms as impossible. But I was obliged
to make up fictitious examples for several reasons, one of which I
can state at once. The real examples are all incomparably more
complicated: to relate a single one of them in detail would occupy
the whole period of this lecture. The chain of associations always
has more than two links; and the traumatic scenes do not form a
simple row, like a string of pearls, but ramify and are
interconnected like genealogical trees, so that in any new
experience two or more earlier ones come into operation as
memories. In short, giving an account of the resolution of a single
symptom would in fact amount to the task of relating an entire case
history.