I. The “Specific” Etiology of Hysteria.
That the symptoms of hysteria become comprehensible only through a reduction to “traumatically” effective experiences, and that these psychic traumas refer to the sexual life has already been asserted by Breuer and me in former publications. What I have to add today as a uniform result of thirteen analyzed cases of hysteria concerns, on the one hand, the nature of these sexual traumas, and on the other, the period of life in which they occurred. An experience occurring at any period of life, touching in any way the sexual life, and then becoming pathogenic through the liberation and suppression of a painful affect is not sufficient for the causation of hysteria. It must on the contrary belong to the sexual traumas of early childhood (the period of life before puberty), and its content must consist in a real irritation of the genitals (coitus-like processes).
This specific determination of hysteria—sexual passivity in pre-sexual periods—I have found fulfilled in all analyzed cases of hysteria (among which were two men). To what extent the determination of the accidental etiological moment diminishes the requirement of the hereditary predisposition needs only be intimated. We can, moreover, understand the disproportionately greater frequency of hysteria in the female sex, as even in childhood this sex is more subject to sexual assaults.
The objection most frequently advanced against this result may be to the purport, that sexual assaults on little children occur too frequently to give an etiological value to its verification, or that such experiences must remain ineffectual just because they concern a sexually undeveloped being; and that one must moreover be careful not to obtrude upon the patient through the examination such alleged reminiscences or believe in the romances which they themselves fabricate. To the latter objections I hold out the request that no one should really judge with great certainty this obscure realm unless he has made use of the only method which can clear it up (the method of psychoanalysis for bringing to consciousness the hitherto unconscious[[48]]). The essential point in the first doubts is settled by the observation that it really is not the experiences themselves that act traumatically, but their revival as reminiscences after the individual has entered into sexual maturity.
My thirteen cases of hysteria were throughout of the graver kind, they were all of long duration, and some had undergone a lengthy and unsuccessful asylum treatment. Every one of the infantile traumas which the analysis revealed for these severe cases had to be designated as marked sexual injuries; some of them were indeed abominable. Among the persons who were guilty of such serious abuse we have in the first place nurses, governesses, and other servants to whom children are left much too carelessly, then in regrettable frequency come the teachers; but in seven of the thirteen cases we dealt with innocent childish offenders, mostly brothers who for years entertained sexual relations with their younger sisters. The course of events always resembled some of the cases which could with certainty be tracked, namely, that the boy had been abused by a person of the feminine sex, thus awakening in him prematurely the libido, and that after a few years he repeated in sexual aggression on his sister the same procedures to which he himself was subjected.
I must exclude active masturbation from the list of sexual injuries of early childhood as being pathogenic for hysteria. That it is so very frequently found associated with hysteria is due to the fact that masturbation in itself is more frequently the result of abuse or seduction than one supposes. It not seldom happens that both members of a childish pair later in life become afflicted by defense neuroses, the brother by obsessions and the sister by hysteria, which naturally gives the appearance of a familial neurotic predisposition. This pseudo-heredity is now and then solved in a surprising manner. I have had under observation a brother, sister, and a somewhat older cousin. The analysis which I have undertaken with the brother showed me that he suffered from reproaches for being the cause of his sister’s malady; he himself was corrupted by his cousin, concerning whom it was known in the family that he fell a victim to his nurse.
I can not definitely state up to what age sexual damage occurs in the etiology of hysteria, but I doubt whether sexual passivity can cause repression after the eighth and tenth year unless qualified for it by previous experiences. The lower limit reaches as far as memory in general, that is, to the delicate age of one and one half or two years! (two cases). In a number of my cases the sexual trauma (or the number of traumas) occurred during the third and fourth year of life. I myself would not lend credence to this peculiar discovery if it were not for the fact that the later development of the neurosis furnished it with full trustworthiness. In every case there are a number of morbid symptoms, habits and phobias which are only explainable by returning to those youthful experiences, and the logical structure of the neurotic manifestation makes it impossible to reject the faithfully retained memories of childhood. Except through psychoanalysis it is of no avail to ask a hysterical patient about these infantile traumas; their remains can only be found in the morbid symptoms and not in conscious memory.
All the experiences and excitements which prepare the way for, or occasion the outburst of, hysteria in the period of life after puberty evidently act through the fact that they awaken the memory remnants of those infantile traumas which do not become conscious but lead to the liberation of affect and repression. It is quite in harmony with this rôle of the later traumas not to be subject to the strict limitation of the infantile traumas, but that both in intensity and quality they can vary from an actual sexual assault to a mere approximation of the sexual, such as perceiving the sexual acts of others, or receiving information concerning sexual processes.[[49]]
In my first communication on the defense neuropsychoses I failed to explain how the exertion of a hitherto healthy individual to forget such traumatic happenings would result in the real intentional repression, and thus open the door for the defense neurosis. It can not depend on the nature of the experience, as other persons remain unaffected despite the same motives. Hysteria cannot therefore be fully explained by the effect of the trauma, and we are forced to admit that the capacity for hysteria already existed before the trauma.
This indefinite hysterical predisposition can now wholly or partially be substituted by the posthumous effect of the infantile sexual trauma. The “repression” of the memory of a painful sexual experience of maturer years can take place only in persons in whom this experience can bring into activity the memory remnants of an infantile trauma.[[50]]
The prerequisite of obsessions is also a sexual infantile experience, but of a different nature than that of hysteria. The etiology of both defense neuropsychoses now shows the following relation to the etiology of both simple neuroses, neurasthenia and anxiety neurosis. As I have shown above, both the latter neuroses are the direct results of the sexual noxas alone, while both defense neuroses are the direct results of sexual noxas which acted before the appearance of sexual maturity, that is, they are the results of the psychic memory remnants of these noxas. The actual causes producing neurasthenia and anxiety neurosis simultaneously play the rôle of inciting causes of the defense neuroses, and on the other hand, the specific causes of the defense neuroses, the infantile traumas, may simultaneously prepare the soil for the later developing neurasthenia. Finally it not seldom happens that the existence of a neurasthenia or anxiety neurosis is only preserved by continued recollection of an infantile trauma rather than by actual sexual injuries.