Freud - Complete Works (75 page)

   The nature of the subject treated
here called at many points for a closer investigation of the
delimitation between the physiological and the psychological
approach. Meynert’s and Wernicke’s views on the
localization of ideas in nervous elements have had to be rejected
and Meynert’s account of a representation of the body in the
cerebral cortex has required revision. Two facts of cerebral
anatomy, namely (1) that the masses of fibres entering the spinal
cord are constantly diminished on passing upwards, owing to the
interposition of grey matter, and (2) that there are no direct
paths from the periphery of the body to the cortex - these two
facts lead to the conclusion that a really complete representation
of the body is present only in the grey matter of the cord (as a
‘projection’), whereas in the cortex the periphery of
the body is only ‘represented’ in less detail through
selected fibres arranged according to function.

XX

  
Clinical Studies of the
Unilateral Cerebral Palsies of Children
.

   (In collaboration with Dr. O.
Rie.)

   (No. III of
Beiträge zur
Kinderheilkunde
edited by Dr. M. Kassowitz.)

   A monograph describing this
affection, based on studies of material in the First Public
Institute for Children’s Diseases in Vienna, directed by
Kassowitz. In ten sections it deals with (1) the history and
literature of the cerebral palsies of children;(2) 35 observations
of the authors’ own, which are then summarized in tabular
form and described individually; (3) the analysis of the individual
symptoms of the clinical picture; (4) the pathological anatomy; (5)
the relations of cerebral palsy to epilepsy and, (6) to infantile
poliomyelitis; (7) differential diagnosis and (8) therapy. A
‘choreatic paresis’ is described by the authors for the
first time; it is distinguished by peculiar characteristics in its
onset and course, and in it the unilateral paresis is from the
beginning represented by hemichorea. There is further an account of
the findings of an autopsy (lobar sclerosis as a result of an
embolism of the middle cerebral artery) on a woman patient
described in the
Iconographie de la
Saltpêtrière
. Emphasis is laid on the close
relations between epilepsy and the cerebral palsies of children, in
consequence of which some cases of apparent epilepsy might deserve
to be described as ‘cerebral palsy without palsy’. In
connection with the much discussed question as to the existence of
a
polioencephalitis acuta
, which is supposed to constitute
the anatomical basis of unilateral cerebral palsy and to offer a
complete analogy with
poliomyelitis infantilis
, the authors
argue against this hypothesis of Strümpell’s; but they
hold firmly to the expectation that a modified view of
poliomyelitis acuta infantilis
will allow of its being
equated with cerebral palsy on another basis. In the therapeutic
section are collected the hitherto published reports on the
intervention by brain surgeons directed to the cure of genuine or
traumatic epilepsy.

Abstracts Of The Scientific Writings Of Dr. Sigm. Freud 1877-1897

443

XXI

   ‘A case of successful
treatment by hypnotism with some remarks on the origin of
hysterical symptoms through "counter will".’

   A young woman after the birth of
her first child was compelled to give up breast-feeding it owing to
a complex of hysterical symptoms (loss of appetite, sleeplessness,
pains in her breasts, failure of milk-secretion, agitation). When,
after the birth of a second child, these obstacles recurred, deep
hypnosis on two occasions, accompanied by counter-suggestions,
succeeded in removing the obstacles, so that the patient became an
excellent nursing mother. The same result was brought about a year
later in similar circumstances after two more hypnoses. Some
remarks are appended on the fact that it is possible in hysterical
patients for distressing antithetic or anxious ideas to be realized
which normal people are able to inhibit; several observations of
tic
are traced back to this mechanism of
‘counter-will’.

XXII

   ‘Charcot.’

   An obituary of the master of
neuropathology who died in 1893 and among whose pupils the present
writer numbers himself.

XXIII

   ‘On a symptom which often
accompanies
enuresis nocturna
in children.’

   In perhaps half the cases of
children suffering from enuresis we find a hypertonia of the lower
extremities the significance and implications of which are
unexplained.

XXIV

   ‘On the psychical mechanism
of hysterical phenomena.’

   (Preliminary communication in
collaboration with Dr. J. Breuer.)

   The mechanism to which Charcot
traced back hystero-traumatic paralyses, and the assumption of
which enabled him to provoke them deliberately in hypnotized
hysterical patients, can also be made responsible for numerous
symptoms of what is described as non-traumatic hysteria. If we put
the hysteric under hypnosis and lead his thoughts back to the time
at which the symptom in question first appeared, a memory of a
psychical trauma (or series of traumas) belonging to that time
awakens in him with hallucinatory vividness, the symptom having
persisted as a mnemic symbol of the trauma. Thus hysterics suffer
mainly from reminiscences. If the traumatic scene which has been
arrived at in this way is reproduced vividly, accompanied by a
generation of affect, the symptom which has hitherto been
obstinately maintained disappears. We must therefore suppose that
the forgotten memory has been acting like a foreign body in the
mind, with the removal of which the irritating phenomena cease.
This discovery, first made by Breuer in 1881, can be made the basis
of a therapy of hysterical phenomena which deserves to be described
as ‘cathartic’.

   The memories which are revealed
as ‘pathogenic’, as the roots of hysterical symptoms,
are regularly ‘unconscious’ to the patient. It seems
that by thus remaining unconscious they escape the wearing-away
process to which psychical material is normally subject. A
wearing-away of this sort is brought about by the method of
‘abreaction’. Pathogenic memories avoid being dealt
with by abreaction either because the experiences concerned have
occurred in special psychical states to which hysterical persons
are inherently inclined, or because those experiences have been
accompanied by an affect which brings about a special psychical
state in hysterical persons. A tendency to a ‘splitting of
consciousness’ is accordingly the basic psychical phenomenon
in cases of hysteria.

Abstracts Of The Scientific Writings Of Dr. Sigm. Freud 1877-1897

444

XXV

  
An Account of the Cerebral
Diplegias of Childhood (in Connection with Little’s
Disease
.)

   (No. III, New Series, of
Beiträge zur Kinderheilkunde
edited by Dr. M.
Kassowitz.)

   A supplement to the
Clinical
Study of the Unilateral Cerebral Palsies of Children
summarized
under XX above.The history, pathological anatomy and physiology of
the affection are treated here in the same order as in the earlier
monograph, and the relevant clinical pictures are illustrated by 53
observations made by the author himself. It was, however, necessary
in addition to take into account the range of forms that must be
described as ‘cerebral diplegias’ and to point out
their clinical similarity. In face of the differences of opinion
that prevail in the literature of these disorders, the author has
adopted the standpoint of an earlier authority, Little, and has
thus arrived at the erection of four principal types, which are
described as general spasticity, paraplegic spasticity, general
chorea and bilateral athetosis, and bilateral spastic hemiplegia
(spastic diplegia).

   General spasticity includes the
forms which are usually referred to as ‘Little’s
disease’. Paraplegic spasticity is the name given to what was
earlier regarded as a spinal affection,
tabes spastica
infantilis
. The spastic diplegias correspond most easily to a
doubling of unilateral cerebral palsies, but are characterized by a
superfluity of symptoms which finds its explanation in the
bilateral nature of the cerebral affection. The justification for
including general chorea and bilateral athetosis among these types
is provided by numerous characteristics of the clinical picture and
by the existence of many mixed and transitional forms which link
all these types together.

   A discussion follows of the
relations of these clinical types to the aetiological factors which
are here assumed to be operative and to the insufficient number of
post-mortem findings that have been reported. The following
conclusions are reached:

   Cerebral diplegias can be divided
according to their origin into (
a
) those congenitally
determined, (
b
) those arising at the time of birth and
(
c
) those acquired after birth. But it is extremely rarely
that this distinction can be drawn from the clinical peculiarities
of the case, and not always possible from the anamnesis. All the
aetiological factors of the diplegias are enumerated: prenatal
(trauma, illness, or shock affecting the mother, place of the child
in the family); operative at the time of birth (the factors
stressed by Little, namely premature birth, difficult labour,
asphyxia); and after birth (infectious diseases, trauma or shock
affecting the child). Convulsions cannot be regarded as causes but
only as symptoms of the affection. The aetiological part played by
inherited syphilis is recognized as important. There is no
exclusive relation between any one of these aetiologies and any one
type of cerebral diplegia, but preferential relations are often
apparent. The view that cerebral diplegias are affections with a
single aetiology is untenable.

   The pathological findings in the
diplegias are of many kinds, and in general the same as in the
hemiplegias; for the most part they are in the nature of end
stages, from which it is not invariably possible to infer back to
the initial lesions. They do not as a rule allow of a decision as
to the aetiological category to which a case is to be referred. Nor
is it usually possible to deduce the clinical picture from the
post-mortem findings; so that the assumption that there are
intimate and exclusive relations between clinical types and
anatomical changes must also be rejected.

   The pathological physiology of
cerebral diplegias has an essential connection with the two
characteristics by which both general and paraplegic spasticity are
distinguished from other manifestations of organic disease of the
cerebrum. For in both these clinical forms contracture predominates
over paralysis and the lower extremities are affected more severely
than the upper ones. The discussion in this paper reaches the
conclusion that the more intense affection of the lower extremities
in general and paraplegic spasticity must be connected with the
localization of the lesion (meningeal haemorrhage along the median
fissure) and the preponderance of contracture with the
superficiality of the lesion. The strabismus of diplegic children,
which is particularly common in paraplegic spasticity and where
premature birth is the aetiology, is traceable to the retinal
haemorrhages in new-born children described by Königstein.

   A special section directs
attention to the numerous instances of the familial and hereditary
occurrence of children’s diseases which show a clinical
affinity with cerebral diplegias.

Abstracts Of The Scientific Writings Of Dr. Sigm. Freud 1877-1897

445

XXVI

   ‘On familial forms of
cerebral diplegias.’

   An observation of two brothers,
one six and a half and the other five years old, whose parents were
blood relations, and who present a complicated clinical picture
which has gradually developed, in the one case since birth and in
the other since the second year. The symptoms of this familial
disorder (lateral nystagmus, atrophy of the optic nerve,
alternating convergent strabismus, monotonous and, as it were,
scanning speech, intention tremor of the arms, spastic weakness of
the legs, accompanied by high intelligence) give grounds for
constructing a new affection which is to be regarded as a spastic
counterpart to Friedreich’s disease. Emphasis is laid on the
far-reaching similarity of these cases to those described as
multiple sclerosis by Pelizaeus in 1885.

XXVII

   ‘The cerebral diplegias of
children.’

   A summary of the findings in the
monograph abstracted above, No. XXV.

XXVIII

   ‘Some points for a
comparative study of organic and hysterical motor
paralyses.’

   A comparison between organic and
hysterical paralyses made under the influence of Charcot in order
to arrive at a line of approach to the nature of hysteria. Organic
paralysis is either periphero-spinal or cerebral. On the basis of
discussions in my critical study on the aphasias, the former is
described as
projection
paralysis and is paralysis
en
détail
, and the latter is described as
representation
paralysis and is paralysis
en masse
.
Hysteria imitates only the latter category of paralyses but has
freedom to specialize which makes it resemble projection paralysis;
it can dissociate the areas of paralysis which regularly occur in
cerebral affections. Hysterical paralysis has a tendency to
excessive development; it can be extremely in tense and yet
strictly confined to a small area, while cortical paralysis
regularly increases its extent with an increase in its intensity.
Sensibility behaves in a directly contrary manner in the two kinds
of paralysis.