Selected papers on hysteria and other psychoneuroses

by Sigmund Freud

III. Analysis of a Case of Chronic Paranoia.

For some length of time I entertained the idea that paranoia also—or the group of cases belonging to paranoia—is a defense psychosis, that is, like hysteria and obsessions it originates from the repression of painful reminiscences, and that the form of its symptoms is determined by the content of the repression. A special way or mechanism of repression must be peculiar to paranoia perhaps just as in hysteria which brings about the repression by way of conversion into bodily innervation, and perhaps like obsessions in which a substitution is accomplished (displacement along certain associative categories). I observed many cases which seemed to favor this interpretation, but I had not found any which demonstrated it until a few months ago when, through the kindness of Dr. J. Breuer, I subjected to psychoanalysis, with therapeutic aims, an intelligent woman of 32, whom no one will be able to refuse to designate as a chronic paranoiac. I report here some explanations gained in this work, because I have no prospects of studying paranoia except in very isolated examples, and because I think it possible that these observations may instigate a psychiatrist for whom conditions are more favorable, to give due justice to the moment of defense in the present animated discussion on the nature and psychic mechanism of paranoia. It is of course far from my thoughts to wish to show from the following single observation anything but that this case is a defense psychosis, and that in the group of “paranoia” there may be still others of a similar nature.

Mrs. P. thirty-two years old, married three years. She is the mother of a two-year-old child, and does not descend from nervous parents; but her sister and brother whom I know, are also neurotic. It was doubtful whether she was not transitorily depressed and mistaken in her judgment in the middle of her twentieth year. During the last years she was healthy and capacitated until she evinced the first symptoms of the present illness, six months after the birth of her child. She became secluded and suspicious, showing a disinclination towards social relations with the relatives of her husband, and complained that the neighbors in the little town now behaved towards her in a rather impolite and regardless manner. Gradually these complaints grew in intensity, she thought that there was something against her, though she had no notion what it could be. But there was no doubt that all the relatives and friends denied her respect, and did everything to aggravate her. She was trying very hard to find out whence this came but could not discover anything. Some time later she complained that she was watched, that her thoughts were guessed, and that everything that happened in her house was known. One afternoon she suddenly conceived the thought that she was watched during the evening while undressing. Since then she applied while undressing the most complicated precautionary measures. She slipped into her bed in the darkness and undressed only under cover. As she avoided all social relations, and took but little nourishment, and was very depressed, she was sent in the summer of 1895 to a hydrotherapeutic institute. There new symptoms appeared and reinforced those already existing. As early as the spring, while she was alone with the servant girl, she suddenly perceived a sensation in her lap, and thought that the servant girl then had an unseemly thought. This sensation became more frequent in the summer, it was almost continuous, and she felt her genitals “as if one feels a heavy hand.” She then began to see pictures which frightened her; they were hallucinations of female nakedness, especially an exposed woman’s lap with hair; occasionally she also saw male genitals. The picture of the hairy lap and the organic sensation in the lap usually came conjointly. The pictures became very aggravating, as she regularly perceived them when she was in the company of a woman, and the thought accompanying them was that she sees the woman in an indecent exposure, and that in the same moment the woman sees the same picture of her (!) Simultaneously with these visual hallucinations, which, after their first appearance in the asylum, disappeared again for many months, she began to be troubled with voices which she did not recognize and could not explain. When she was in the street she heard, “This is Mrs. P.—Here she goes.—Where does she go?”. Every one of her movements and actions were commented upon. Occasionally she heard threats and reproaches. All these symptoms became worse when she was in society, or even in the street; she therefore hesitated about going out; she also stated that she experienced nausea for food, and as a result she became reduced in vitality.

I obtained this from her when she came under my care in the winter of 1895. I present this case in detail in order to make the impression that we really deal here with a very frequent form of chronic paranoia, which diagnosis will agree with the details of the symptoms and their behavior to be mentioned later. At that time she either concealed from me the delusions for the interpretation of the hallucinations or they really had not as yet occurred. Her intelligence was undiminished. It was reported to me as peculiar that she had a number of rendezvous with her brother who lived in the neighborhood, in order to confide something to him, but this she never told him. She never spoke about her hallucinations, and towards the end she did not say much about the aggravations and persecutions from which she suffered. What I have to report about this patient concerns the etiology of the case and the mechanism of the hallucinations. I discovered the etiology by applying Breuer’s method exactly as in hysteria, for the investigation and removal of the hallucinations. I started with the presupposition that just as in the two other defense neuroses known to me this paranoia must contain unconscious thoughts and repressed reminiscences which have to be brought to consciousness, in the same manner as in the others, by overcoming a certain resistance. The patient immediately corroborated this expectation by behaving during the analysis exactly like a hysteric, and under attention to the pressure of my hand she reproduced thoughts which she could not remember having had, which she at first could not understand, and which contradicted her expectations. The occurrence of important unconscious ideas was therefore also demonstrated in a case of paranoia, and I could hope to reconduct the compulsion of paranoia to repression. It was only peculiar that the assertions which originated in the unconscious were usually heard inwardly or hallucinated by her as her voices.

Concerning the origin of the visual hallucinations, or at least the vivid pictures, I discovered the following: The picture of the female lap occurred almost always together with the organic sensation in the lap. The latter, however, was more constant and often occurred without the picture.

The first pictures of feminine laps appeared in the hydrotherapeutic institute a few hours after she had actually seen a number of women naked in the bath house. They were therefore only simple reproductions of a real impression. It may be assumed that these impressions repeated themselves because something of great interest was connected with them. She stated that she was at that time ashamed of these women, and that since she recalled it she is ashamed of having been seen naked. Having been obliged to look upon this shame as something compulsive, I concluded that according to the mechanism of defense an experience must have here been repressed in which she was not ashamed, and I requested her to allow those reminiscences to emerge which belonged to the theme of shame. She promptly reproduced a series of scenes from her seventeenth to her eighth year, during which while bathing before her mother, her sister, and her physician she was ashamed of her nakedness. This series, however, reached back to a scene in her sixth year when she undressed in the children’s room before going to sleep without feeling ashamed of her brother who was present. On questioning her it was found that there were a number of such scenes, and that for years the brothers and sisters were in the habit of showing themselves naked to one another before retiring. I now understood the significance of the sudden thought of being watched on going to sleep. It was an unchanged fragment of the old reproachful reminiscence, and she was now trying to make up in shame what she lost as a child.

The supposition that we dealt here with an amour of childhood so frequent in the etiology of hysteria was strengthened by the further progress of the analysis which also showed simultaneous solutions for individual frequently recurring details in the picture of paranoia. The beginning of her depression commenced at the time of a disagreement between her husband and her brother on account of which the latter no longer visited her. She was always much attached to this brother and missed him very much at this time. Besides this she spoke about a moment in the history of her disease during which for the first time “everything became clear,” that is, during which she became convinced that her assumption about being generally despised and intentionally annoyed was true. She gained this assurance during a visit of her sister-in-law, who in the course of conversation dropped the words, “If such a thing should happen to me I would not mind it.” Mrs. P. at first took this utterance unsuspectingly, but when her visitor left her it seemed to her that these words contained a reproach meaning that she was in the habit of taking serious matters lightly, and since that hour she was sure that she was a victim of common slander. On asking her why she felt justified in referring those words to herself she answered that the tone in which her sister-in-law spoke convinced her of it—to be sure subsequently—This is really a characteristic detail of paranoia. I now urged her to recall her sister-in-law’s conversation before the accusing utterance, and it was found that she related that in her father’s home there were all sorts of difficulties with the brothers, and added the wise remark, “In every family many things happen which one would rather keep under cover, and that if such a thing should happen to her she would take it lightly.” Mrs. P. had to acknowledge that her depression was connected with the sentences before the last utterance. As she repressed both sentences which could recall her relations with her brother, and retained only the last meaningless one, she was forced to connect with it the feeling of being reproached by her sister-in-law; but, inasmuch as the contents of this sentence offered absolutely no basis for such assumption she disregarded it and laid stress on the tone with which the words were pronounced. It is probably a typical illustration for the fact that the misinterpretations of paranoia depend on repression.

In a most surprising manner it also explains her peculiar behavior in making appointments with her brother and then refusing to tell him anything. Her explanation was that she thought that if she only looked at him he must understand her suffering, as he knew the cause of it. As this brother was really the only person who could know anything about the etiology of her disease it followed that she acted from a motive which, though she did not consciously understand, seemed perfectly justified as soon as a new sense was put on it from the unconscious.

I then succeeded in causing her to reproduce different scenes the culminating points of which were the sexual relations with her brother at least from her sixth to her tenth year. During this work of reproduction the organic sensation in the lap “joined in the discussion,” precisely as regularly observed in the analysis of memory remnants of hysterical patients. The picture of a naked female lap (but now reduced to childish proportions and without hair) immediately appeared or stayed away in accordance with the occurrence of the scene in question in full light or in darkness. The disgust for eating, too, was explained by a repulsive detail of these actions. After we had gone through this series, the hallucinatory sensations and pictures disappeared without having thus far returned.[^[52]]

I have thus learned that these hallucinations were nothing other than fragments from the content of the repressed experiences of childhood, that is, symptoms of the return of the repressed material.

I now turned to the analysis of the voices. Here it must before all be explained why such indifferent remarks as, “Here goes Mrs. P.—She now looks for apartments, etc.” could be so painfully perceived, and how these harmless sentences managed to become distinguished by hallucinatory enforcement. To begin with, it was clear that these “voices” could not be hallucinatory reproduced reminiscences like the pictures and sensations, but rather thoughts which “became loud.”

She heard the voices for the first time under the following circumstances. With great tension she read the pretty story, “The Heiterethei” by O. Ludwig, and noticed that while reading she was preoccupied with incoming thoughts. Immediately after she took a walk on the highway and suddenly while passing a peasant’s cottage the voices told her, “That is how the house of the Heiterethei looked! Here is the well, and here is the bush! How happy she was in all her poverty!” The voices then repeated whole paragraphs of what she had just read, but it remained incomprehensible why house, bush, and well of the Heiterethei, and just such indifferent and most irrelevant passages of the romance should have obtruded themselves upon her attention with pathological strength. The analysis showed that while reading she at the same time entertained extraneous thoughts, and that she was excited by totally different passages of the book. Against this material analogy between the couple of the romance and herself and her husband, the reminiscence of intimate things of her married life and family secrets, against all these there arose a repressive resistance because they were connected with her sexual shyness by very simple and demonstrable streams of thought, and finally resulted in the awakening of old experiences of childhood. In consequence of the censorship exercised by the repression the harmless and idyllic passages connected with the objectionable ones by contrast and vicinity, became reinforced in consciousness, enabling them to become audible. For example, the first repressed thought referred to the slander to which the secluded heroine was subjected by her neighbors. She readily found in this an analogy to herself. She, too, lived in a small place, had no intercourse with anybody and considered herself despised by her neighbors. The suspicion against the neighbors was founded on the fact that in the beginning of her married life she was obliged to content herself with a small apartment. The wall of the bedroom, near which stood the nuptial bed of the young couple, adjoined the neighbors’ room. With the beginning of her marriage there awakened in her a great sexual shyness. This was apparently due to an unconscious awakening of some reminiscences of childhood of having played husband and wife. She was very careful lest the neighbors might hear through the adjacent wall either words or noises and this shyness changed into suspicion against the neighbors.

The voices therefore owed their origin to the repression of thoughts which in the last analysis really signified reproaches on the occasion of an experience analogous to the infantile trauma; they were accordingly symptoms of the return of the repression, but at the same time they were results of a comparison between the resistance of the ego and the force of the returning repression which in this case produce a distortion beyond recognition. On other occasions when analyzing voices in Mrs. P. the distortion was less marked, still the words heard always showed a character of diplomatic uncertainty. The annoying allusion was generally deeply hidden, the connection of the individual sentences was masked by a strange expression, unusual forms of speech, etc., characteristics generally common to the auditory hallucinations of paranoiacs, and in which I noticed the remnant of the compromise distortion. The expression, “There goes Mrs. P., she is looking for apartments in the street,” signified, for example, the threat that she will never recover, for I promised her that after the treatment she would be able to return to the little city where her husband was employed. She rented temporary quarters in Vienna for a few months.

On some occasions Mrs. P. also perceived more distinct threats, for example, concerning the relatives of her husband, the restrained expression of which still continued to contrast with the grief which such voices caused her. Considering all that we otherwise know of paranoiacs I am inclined to assume a gradual relaxation of that resistance which weakens the reproaches so that finally the defense fails completely and the original reproach, the insulting word, which one wanted to save himself returns in unchanged form. I do not, however, know whether this is a constant course, whether the censor of the expressions of reproach can not from the beginning stay away, or persist to the end.

It is left for me to utilize the explanations gained in this case of paranoia for the comparison of paranoia with compulsion neurosis. Here, as there, the repression was shown to be the nucleus of the psychic mechanism, and in both cases the repression is a sexual experience of childhood. The origin of every compulsion in this paranoia is in the repression, and the symptoms of paranoia allow a similar classification as the one found justified in compulsion neurosis. Some symptoms also originate from the primary defense among which are all delusions of distrust, suspicion and persecution by others. In the compulsion neurosis the initial reproach became repressed through the formation of the primary symptom of defense, self-distrust, moreover, the reproach was recognized as justified, and for the purpose of adjustment the validity acquired by the scrupulousness during the normal interval now guards against giving credence to the returning reproach in the form of an obsession. By the formation of the defense symptom of distrust in others, the reproach in paranoia is repressed in a way which may be designated as projection; the reproach is also deprived of recognition, and as a retaliation there is no protection against the returning reproaches contained in the delusions.

The other symptoms in my case of paranoia are therefore to be designated as symptoms of the return of the repression, and as in the compulsion neurosis they show the traces of the compromise which alone permits an entrance into consciousness. Such are the delusions of being observed while undressing, the visual hallucinations, the perceptual hallucinations and the hearing of voices. The memory content existing in the delusion mentioned is almost unchanged and appears only uncertain through utterance. The return of the repression into visual pictures comes nearer to the character of hysteria than to the character of compulsion neurosis; still, hysteria is wont to repeat its memory symbols without modification, whereas the paranoiac memory hallucination undergoes a distortion similar to those in compulsion neurosis. An analogous modern picture takes the place of the one repressed (instead of a child’s lap it was the lap of a woman upon which the hairs were particularly distinct because they were absent in the original impression). Quite peculiar to paranoia but no further elucidated in this comparison is the fact that the repressed reproaches return as loud thoughts, this must yield to a double distortion: (1) a censor, which either leads to a replacement through other associated thoughts or to a concealment by indefinite expressions, and (2) the reference to the modern which is merely analogous to the old.

The third group of symptoms found in compulsion neurosis, the symptoms of the secondary defense, cannot exist as such in paranoia, for no defense asserts itself against the returning symptoms which really find credence. As a substitute for this we find in paranoia another source of symptom formation; the delusions (symptoms of return) reaching consciousness through the compromise demand a great deal of the thinking work of the ego until they can be unconditionally accepted. As they themselves are not to be influenced the ego must adapt itself to them, and hence the combining delusional formation, the delusion of interpretation which results in the transformation of the ego, corresponds here to the symptoms of secondary defense of compulsion neurosis. In this respect my case was imperfect as it did not at that time show any attempt at interpretation, this only appeared later. I do not doubt, however that if psychoanalysis were also applied to that stage of paranoia, another important result would be established. It would probably be found that even the so called weakness of memory in paranoiacs is purposeful, that is, it depends on the repression and serves its purpose. Subsequently even those nonpathogenic memories which stand in opposition to the transformation of the ego become repressed and replaced; this the symptoms of return imperatively demand.

CHAPTER VIII.
On Psychotherapy.[^[53]]

Gentlemen:

It is almost eight years since, at the request of your deceased chairman, Prof. v. Reder, I had the pleasure of speaking in your midst on the subject of hysteria. Shortly before (1895) I had published the “Studien über Hysterie” together with Dr. J. Breuer, and on the basis of a new knowledge for which we are thankful to this investigator, I have attempted to introduce a new way of treating the neurosis. Fortunately, I can say that the endeavors of our “Studies” have met with success, and that the ideas which they advocate concerning the effects of psychic traumas through the restraint of affects and the conception of the hysterical symptom as a result of a displacement of excitement from the psychic to the physical—ideas for which we have created the terms “ab-reaction” and “conversion”—are today generally known and understood. At least in German-speaking countries there are no descriptions of hysteria which do not to a certain extent take cognizance of them, and no colleague who does not at least partially follow this theory. And yet as long as they were new these theories and these terms must have sounded strange enough!

I can not say the same thing about the therapeutic procedure which we have proposed to our colleagues together with our theory. It still struggles for recognition. This may have its special reasons. The technique of the procedure was at that time still rudimentary. I was unable to give those indications to the medical reader of the book which would enable him to perform such a treatment. But surely there were other causes of a general nature. To many physicians psychotherapy even today appears as a product of modern mysticism, and in comparison to our physico-chemical remedies the application of which is based on physiological insight, psychotherapy appears quite unscientific and unworthy of the interest of a natural philosopher. You will therefore allow me to present to you the subject of psychotherapy, and to point out to you what part of this verdict can be designated as unjust or erroneous.

In the first place let me remind you that psychotherapy is not a modern therapeutic procedure. On the contrary it is one of the oldest remedies used in medicine. In Lëwenfeld’s instructive work (Lehrbuch der gesamten Psychotherapie) you can find the methods employed in primitive and ancient medicine. Most of them were of a psychotherapeutic nature. In order to cure a patient he was transferred into a state of “credulous expectation” which acts in a similar manner even today. Even after the doctors found other remedial agents psychotherapeutic endeavors never disappeared from this or that branch of medicine.

Secondly, I call your attention to the fact that we doctors really can not abandon psychotherapy if only because another very much to be considered party in the treatment—namely the patient—has no intention of abandoning it. You know how much we owe to the Nancy school (Liébault, Bernheim) for these explanations. Without our intention, an independent factor from the patient’s psychic disposition enters into the activity of every remedial agent introduced by the doctor, acting mostly in a favorable sense but often also in an inhibiting sense. We have learned to apply to this factor the word “suggestion,” and Moebius taught us that the failures of some of our remedies are to be ascribed to the disturbing influences of this very powerful moment. You doctors, all of you, constantly practice psychotherapy, even when you do not know it, or do not intend it, but it has one disadvantage, you leave entirely to the patient the psychic factor of your influence. It then becomes uncontrollable, it can not be divided into doses and can not be increased. Is it not a justified endeavor of the doctor to become master of this factor, to make use of it intentionally, to direct and enforce it? It is nothing other than that, that scientific psychotherapy expects of you.

In the third place, gentlemen, I wish to refer you to the well known experience, namely, that certain maladies and particularly the psychoneuroses, are more accessible to psychic influences than to any other medications. It is no modern talk but a dictum of old physicians that these diseases are not cured by the drug, but by the doctor, to wit, by the personality of the physician in so far as it exerts a psychic influence. I am well aware, gentlemen, that you like very much the idea which the aesthete Vischer, in his parody on Faust (Faust, der Tragödie, III Teil) endowed with a classical expression: “I know that the physical often acts on the moral.”

But would it not be more adequate and frequently more correct to influence the moral part of the person with the moral, that is, with psychic means?

There are many ways and means of psychotherapy. All methods are good which produce the aim of the therapy. Our usual consolation, “You will soon be well again,” with which we are so generous to our patients, corresponds to one of the psychotherapeutic methods, only that on gaining a profounder insight into the neuroses we are not forced to limit ourselves to this consolation alone. We have developed the technique of hypnotic suggestion, of psychotherapy through diversion, through practice, and through the evocation of serviceable affects. I do not disdain any of them, and would practice them all under suitable conditions. That I have in reality restricted myself to a single therapeutic procedure, to the method called by Breuer “cathartic,” which I prefer to call “analytic,” is simply due to subjective motives which guided me. Having participated in the elaboration of this therapy I feel it a personal duty to devote myself to its investigation, and to the final development of its technique. I maintain that the analytic method of psychotherapy is one which acts most penetratingly, and carries farthest; through it one can produce the most prolific changes in the patient. If I relinquish for a moment the therapeutic point of view, I can assert that it is the most interesting, and that it alone teaches us something concerning the origin and the connection of the morbid manifestations. Owing to insights which it opens for us into the mechanism of the psychic malady, it can even lead us beyond itself, and show us the way to still other kinds of therapeutic influences.

Allow me now to correct some errors, and furnish some explanations concerning this cathartic or analytic method of psychotherapy.

(a) I notice that this method is often mistaken for the hypnotic suggestive treatment. I notice this by the fact that quite frequently colleagues whose confidant I am not by any means, send patients to me, refractory patients of course, with the request that I should hypnotize them. Now, for eight years I have not practiced hypnotism (individual cases excluded) as a therapeutic aim, and hence I used to return the patients with the advice that he who relies on hypnosis should do it himself. In truth, the greatest possible contrast exists between the suggestive and the analytic technique, that contrast which the great Leonardo da Vinci has expressed for the arts in the formulæ per via di porre and per via di levare. Said Leonardo, “the art of painting works per via di levare, that is to say, places little heaps of paint where they have not been before on the uncolored canvas; sculpturing, on the other hand, goes per via di levare, that is to say, it takes away from the stone as much as covers the surface of the statue therein contained.” Quite similarly, gentlemen, the suggestive technique acts per via di porre, it does not concern itself about the origin, force, and significance of the morbid symptoms, but puts on something, to wit, the suggestion which it expects will be strong enough to prevent the pathogenic idea from expression. On the other hand the analytic therapy does not wish to put on anything, or introduce anything new, but to take away, and extract, and for this purpose it concerns itself with the genesis of the morbid symptoms, and the psychic connection of the pathogenic idea the removal of which is its aim. This manner of investigation has considerably furthered our understanding. I have so early given up the technique of suggestion, and with it hypnosis, because I despaired of making the suggestion as strong and persistent as would be necessary for a lasting cure. In all grave cases I noticed that the suggestions which were put on crumbled off again, and then the disease, or one replacing it, reappeared. Besides, I charge this technique with concealing from us the psychic play of forces, for example, it does not permit us to recognize the resistance with which the patients adhere to their malady, with which they also strive against the recovery, and which alone can give us an understanding of their behavior in life.

(b) It seems to me that a very widespread mistake among my colleagues is the idea that the technique of the investigation for the causes of the disease and the removal of the manifestations by this investigation is easy and self-evident. I concluded this from the fact that of the many who interest themselves in my therapy and express a definite opinion on the same, no one has yet asked me how I do it. There can only be one reason for it, they believe there is nothing to ask, that it is a matter of course. I occasionally also hear with surprise that in this or that division of the hospital a young interne is requested by his chief to undertake a “psychoanalysis” with a hysterical woman. I am convinced that he would not entrust him with the examination of an extirpated tumor without previously assuring himself that he is acquainted with the histological technique. Likewise I am informed that this or that colleague has made appointments with a patient for psychic treatment, whereas I am certain that he does not know the technique of such a treatment. He must, therefore, expect that the patient will bring him her secrets, or he seeks salvation in some kind of a confession or confidence. I should not wonder if the patient thus treated would rather be harmed than benefited. The mental instrument is really not at all easy to play. On such occasions I can not help but think of the speech of a world-renowned neurotic, who really never came under a doctor’s treatment, and only lived in the fancy of the poet. I mean Prince Hamlet of Denmark. The king has sent the two courtiers, Rosencrantz and Guildenstern, to investigate him and rob him of his secret. While he defended himself, pipes were brought on the stage. Hamlet took a pipe and requested one of his tormentors to play on it, saying that it is as easy to play as lying. The courtier hesitated because he knew no touch of it, and as he could not be moved to attempt to play the pipe, Hamlet finally burst forth: “Why, look you now, how unworthy a thing you make of me! You would play upon me; you would seem to know my stops; you would pluck out the heart of my mystery; you would sound me from my lowest note to the top of my compass; and there is much music, excellent voice, in this little organ, yet you cannot make it speak. ’Sblood! do you think I am easier to be played on than a pipe? Call me what instrument you will, though you can fret me, you cannot play upon me.” (Act III, Scene 2.)

(c) You will have surmised from some of my observations that the analytic cure contains qualities which keep it away from the ideal of a therapy. Tuto, cito, iucunde; the investigation and examination does not really mean rapidity of success, and the allusion to the resistance has prepared you for the expectation of inconveniences. Certainly the psychoanalytic method lays high claims on the patient as well as the physician. From the first it requires the sacrifice of perfect candor, it takes up much of his time, and is therefore also expensive; for the physician it also means the loss of much time, and due to the technique which he has to learn and practice, it is quite laborious. I even find it quite justified to employ more suitable remedies as long as there is a prospect to achieve something with them. It comes to this point only: if we gain by the more laborious and cumbersome procedure considerably more than by the short and easy one, the first is justified despite everything. Just think, gentlemen, by how much the Finsen therapy of lupus is more inconvenient and expensive than the formerly used cauterization and scraping, and yet it means a great progress, merely because it achieves more, it actually cures the lupus radically. I do not really wish to carry through the comparison, but psychoanalysis can claim for itself a similar privilege. In reality I could develop and test my therapeutic method in grave and in the gravest of cases only; my material at first consisted of patients who tried everything unsuccessfully, and had spent years in asylums. I hardly gained enough experience to be able to tell you how my therapy behaves in those lighter, episodically appearing diseases which we see cured under the most diverse influences, and also spontaneously. The psychoanalytic method was created for patients who are permanently incapacitated, and its triumph is to make a gratifying number of such, permanently capacitated. Against this success all expense is insignificant. We can not conceal from ourselves what we were wont to disavow to the patient, namely, that the significance of a grave neurosis for the individual subjected to it is not less than any cachexia or any of the generally feared maladies.

(d) In view of the many practical limitations which I have encountered in my work, I can hardly definitely enumerate the indications and contraindications of this treatment. However, I will attempt to discuss with you a few points:

1. The former value of the person should not be overlooked in the disease, and you should refuse a patient who does not possess a certain degree of education, and whose character is not in a measure reliable. We must not forget that there are also healthy persons who are good for nothing, and that if they only show a mere touch of the neurosis, one is only too much inclined to blame the disease for incapacitating such inferior persons. I maintain that the neurosis does not in any way stamp its bearer as a dégéneré, but that frequently enough it is found in the same individual associated with the manifestations of degeneration. The analytic psychotherapy is therefore no procedure for the treatment of neuropathic degeneration, on the contrary it is limited by it. It is also not to be applied in persons who are not prompted by their own suffering to seek the treatment, but subject themselves to it by order of their relatives. The characteristic feature upon which the usefulness of the psychoanalytic treatment depends, the educability, we will still have to consider from another point of view.

2. If one wishes to take a safe course he should limit his selection to persons of a normal state, for, in psychoanalytic procedures, it is from the normal that we seize upon the morbid. Psychoses, confusional states, and marked (I might say toxic) depressions, are unsuitable for analysis, at least as it is practiced today. I do not think it at all impossible that with the proper changes in the procedure it will be possible to disregard this contraindication, and thus claim a psychotherapy for the psychoses.

3. The age of the patient also plays a part in the selection for the psychoanalytic treatment. Persons near or over the age of fifty lack, on the one hand, the plasticity of the psychic processes upon which the therapy depends—old people are no longer educable—and on the other hand, the material which has to be elaborated, and the duration of the treatment is immensely increased. The earliest age limit is to be individually determined; youthful persons, even before puberty, are excellent subjects for influence.

4. One should not attempt psychoanalysis when it is a question of rapidly removing a threatening manifestation, as, for example, in the case of an hysterical anorexia.

You have now gained the impression that the sphere of application of the analytic psychotherapy is a very limited one, for you really heard me enumerate nothing but contraindications. Nevertheless, there remain sufficient cases and morbid states, such as all chronic forms of hysteria with remnant manifestations, the extensive realms of compulsive states, abulias, etc., on which this therapy can be tried.

It is pleasing that particularly the worthiest and highest developed persons can thus be most helped. Where the analytic psychotherapy has accomplished but little one can cheerfully assert that any other treatment would have certainly resulted in nothing.

(e) You will surely wish to ask me about the possibility of doing harm through the application of psychoanalysis. To this I will reply that if you will judge justly you will meet this procedure with the same critical good-feeling as you have met our other therapeutic methods, and doing this you will have to agree with me that a rationally executed analytic treatment entails no dangers for the patient. One who, like a layman, is accustomed to ascribe to the treatment everything occurring during the disease, will probably judge differently. It is really not so long since our hydrotherapeutic asylums met with similar opposition. Thus one who was advised to go to such an asylum became thoughtful because he had an acquaintance who entered the asylum as nervous and there become insane. As you surmise we deal with cases of initial general paresis who in the first stages could still be sent to hydrotherapeutic asylums, and who there merged into the irresistible course leading to manifest insanity. For the layman the water was the cause and author of this sad transformation. Where it is a question of unfamiliar influences, even doctors are not free from such mistaken judgment. I recall having once attempted to treat a woman by psychotherapy who passed a great part of her existence by alternating between mania and melancholia. I began to treat her at the end of a melancholia and everything seemed to go well for two weeks, but in the third week she was again merging into a mania. It was surely a spontaneous alteration of the morbid picture, for two weeks is no time in which anything can be accomplished by psychotherapy, but the prominent—now deceased—physician who saw the case with me could not refrain from remarking that this decline must have been due to the psychotherapy. I am quite convinced that he would have been more critical under different conditions.

(f) In conclusion, gentlemen, I must say to myself that it will not do to lay claim to your attention so long in favor of the analytic psychotherapy without telling you of what this treatment consists, and on what it is based. To be sure I can only indicate it as I have to be brief. This therapy is founded on the understanding that unconscious ideas—or rather the unconsciousness of certain psychic processes—are the main causes of a morbid symptom. We share this conviction with the French school (Janet) which moreover by gross schematization reduces the hysterical symptom to an unconscious idée fixe. Do not fear now that we will thus merge too far into the obscurest philosophy. Our unconscious is not quite the same as that of the philosophers and what is more, most philosophers wish to know nothing of the “psychical unconscious.” But if you will put yourselves in our position, you will understand that the interpretation of this unconscious, in patients’ psychic life, into the conscious, must result in a correction of their deviation from the normal, and in an abrogation of the compulsion controlling their psychic life. For the conscious will reaches as far as the conscious psychic processes and every psychic compulsion is substantiated by the unconscious. You need never fear that the patient will be harmed by the emotion produced in the entrance of his unconscious into consciousness, for you can theoretically readily understand that the somatic and affective activity of the emotion which became conscious can never become as great as those of the unconscious. For we only control all our emotions by directing upon them our highest psychic activities which are connected with consciousness.

We can still choose another point of view for the understanding of the psychoanalytic treatment. The revealing and interpreting of the unconscious takes place under constant resistance on the part of the patient. The emerging of the unconscious is connected with displeasure and owing to this displeasure it is continuously repulsed by the patient. It is upon this conflict in the patient’s psychic life that you encroach, and if you succeed in prevailing upon him to accept something, for motives of better insight, which he has thus far repulsed (repressed) on account of the automatic adjustment of displeasure, you have achieved in him a piece of educational work. For it is really an education if you can induce a person to leave his bed early in the morning despite his unwillingness to do so. As such an after training for the overcoming of inner resistances you can conceive the psychoanalytic treatment in quite a general manner. But in no sphere of the nervous patients is such an after training so essential as in the psychic elements of their sexual life. For nowhere have culture and education produced as much harm as here, and it is here, as experience will show you, that the controlling etiologies of the neuroses are found. The other etiological element, the constitutional contribution, is really given to us as something immutable. But this gives rise to an important demand on the doctor. Not only must he be of unblemished character—“morality is really a matter of course” as the principal person in Th. Vischer’s “Auch Einer” used to say—but he must have overcome in his own personality the mixture of lewdness and prudishness with which so many others are wont to meet the sexual problems.

This is perhaps the place for another observation. I know that the emphasis which I laid on the sexual rôle in the origin of the psychoneuroses has become widely known. But I also know that restriction and nearer determinations are of little use with the great public; the multitude has little room in its memory, and generally retains from a statement the bare nucleus, thus creating for itself an easily remembered extreme. The same might also have happened to some physicians when the faint notion that they have of my theory is that I trace back the neurosis in the last place to sexual privation. Of such there is surely no dearth under the vital conditions of our society. But if that supposition were true would it not seem obvious that in order to avoid the roundabout way of the psychic treatment and tend directly towards the cure, we should directly recommend sexual participation as the remedy? I really do not know what could induce me to suppress these conclusions if they were justified. But the state of affairs is different. The sexual need or privation is merely one of the factors playing a part in the mechanism of the neurosis, and if it alone existed the result would not be a disease but a dissipation. The other equally indispensable factor, which one is only too ready to forget, is the sexual repugnance of neurotics, their inability to love; it is that psychic feature which I have designated as “repression.” It is only from the conflict between the two strivings that the neurotic malady originates, and it is for this reason that the advice for sexual participation in the psychoneuroses can really only seldom be designated as good.

Allow me to conclude with this guarded remark. Let us hope that with an interest for psychotherapy, purified of all hostile prejudice, you will help us to do some good in the treatment of the severe cases of psychoneuroses.

CHAPTER IX.
My Views on the Rôle of Sexuality in the Etiology of the Neuroses.[^[54]]

I am of the opinion that my theory on the etiological significance of the sexual moment in the neuroses can be best appreciated by following its development. I will by no means make any effort to deny that it passed through an evolution during which it underwent a change. My colleagues can find the assurance in this admission that this theory is nothing other than the result of continued and painstaking experiences. In contradistinction to this whatever originates from speculation can certainly appear complete at one go and continue unchanged.

Originally the theory had reference only to the morbid pictures comprehended as “neurasthenia,” among which I found two types which occasionally appeared pure, and which I described as “actual neurasthenia” and “anxiety neurosis.” For it was always known that sexual moments could play a part in the causation of these forms, but they were found neither regularly effective, nor did one think of conceding to them a precedence over other etiological influences. I was above all surprised at the frequency of coarse disturbances in the vita sexualis of nervous patients. The more I was in quest of such disturbances, during which I remembered that all men conceal the truth in things sexual, and the more skilful I became in continuing the examination despite the incipient negation, the more regularly such disease-forming moments were discovered in the sexual life, until it seemed to me that they were but little short of universal. But one must from the first be prepared for similar frequent occurrences of sexual irregularities under the stress of the social relations of our society, and one could therefore remain in doubt as to what part of the deviation from the normal sexual function is to be considered as a morbid cause. I could therefore only place less value on the regular demonstration of sexual noxas than on other experiences which appeared to me to be less equivocal. It was found that the form of the malady, be it neurasthenia or anxiety neurosis, shows a constant relation to the form of the sexual injury. In the typical cases of neurasthenia we could always demonstrate masturbation or accumulated pollutions, while in anxiety neurosis we could find such factors as coitus interruptus, “frustrated excitement,” etc. The moment of insufficient discharge of the generated libido seemed to be common to both. Only after this experience, which is easy to gain and very often confirmed, had I the courage to claim for the sexual influences a prominent place in the etiology of the neurosis. It also happened that the mixed forms of neurasthenia and anxiety neurosis occurring so often, showed the admixture of the etiologies accepted for both, and that such a bipartition in the form of the manifestations of the neurosis seemed to accord well with the polar characters of sexuality (male and female).

At the same time, while I assigned to sexuality this significance in the origin of the simple neurosis, I still professed for the psychoneuroses (hysteria and obsessions) a purely psychological theory in which the sexual moment was no differently considered than any other emotional sources. Together with J. Breuer, and in addition to observations which he has made on his hysterical patients fully a decade before, I have studied the mechanism of the origin of hysterical symptoms by the awakening of memories in hypnotic states. We obtained information which permitted us to cross the bridge from Charcot’s traumatic hysteria to the common non-traumatic hysteria. We reached the conception that the hysterical symptoms are permanent results of psychic traumas, and that the amount of affect belonging to them was pushed away from conscious elaboration by special determinations, thus forcing an abnormal road into bodily innervation. The terms “strangulated affect,” “conversion,” and “ab-reaction,” comprise the distinctive characteristics of this conception.

In the close relations of the psychoneuroses to the simple neuroses, which can go so far that the diagnostic distinction is not always easy for the unpracticed, it could happen that the cognition gained from one sphere has also taken effect in the other. Leaving such influences out of the question, the deep study of the psychic traumas also leads to the same results. If by the “analytic” method we continue to trace the psychic traumas from which the hysterical symptoms are derived, we finally reach to experiences which belong to the patient’s childhood, and concern his sexual life. This can be found even in such cases where a banal emotion of a non-sexual nature has occasioned the outburst of the disease. Without taking into account these sexual traumas of childhood we could neither explain the symptoms, find their determination intelligible, nor guard against their recurrence. The incomparable significance of sexual experiences in the etiology of the psychoneuroses seems therefore firmly established, and this fact remains until today one of the main supports of the theory.

If we represent this theory by saying that the course of the life long hysterical neurosis lies in the sexual experiences of early childhood which are usually trivial in themselves, it surely would sound strange enough. But if we take cognizance of the historical development of the theory, and transfer the main content of the same into the sentence: hysteria is the expression of a special behavior of the sexual function of the individual, and that this behavior was already decisively determined by the first effective influences and experiences of childhood, we will perhaps be poorer in a paradox but richer in a motive for directing our attention to a hitherto very neglected and most significant aftereffect of infantile impressions in general.

As I reserve the question whether the etiology of hysteria (and compulsion neurosis) is to be found in the sexual infantile experiences for a later more thorough discussion, I now return to the construction of the theory expressed in some small preliminary publications in the years 1895–1896.[^[55]] The bringing into prominence of the assumed etiological moments permitted us at the time to contrast the common neuroses which are maladies with an actual etiology, with the psychoneuroses which etiology was in the first place to be sought in the sexual experiences of remote times. The theory culminates in the sentence: In a normal vita sexualis no neurosis is possible.

If I still consider today this sentence as correct it is really not surprising that after ten years labor on the knowledge of these relations I passed a good way beyond my former point of view, and that I now think myself in a position to correct by detailed experience the imperfections, the displacements, and the misconceptions, from which this theory then suffered. By chance my former rather meagre material furnished me with a great number of cases in which infantile histories, sexual seduction by grown-up persons or older children, played the main rôle. I overestimated the frequency of these (otherwise not to be doubted) occurrences, the more so because I was then in no position to distinguish definitely the deceptive memories of hysterical patients concerning their childhood, from the traces of the real processes, whereas, I have since then learned to explain many a seduction fancy as an attempt at defense against the reminiscence of their own sexual activity (infantile masturbation). The emphasis laid on the “traumatic” element of the infantile sexual experience disappeared with this explanation, and it remained obvious that the infantile sexual activities (be they spontaneous or provoked) dictate the course of the later sexual life after maturity. The same explanation which really corrects the most significant of my original errors perforce also changed the conception of the mechanism of the hysterical symptoms. These no longer appeared as direct descendants of repressed memories of sexual infantile experiences, but between the symptoms and the infantile impressions there slipped in the fancies (confabulations of memory) of the patients which were mostly produced during the years of puberty and which on the one hand, are raised from and over the infantile memories, and on the other, are immediately transformed into symptoms. Only after the introduction of the element of hysterical fancies did the structure of the neurosis and its relation to the life of the patient become transparent. It also resulted in a veritable surprising analogy between these unconscious hysterical fancies and the romances which became conscious as delusions in paranoia.

After this correction the “infantile sexual traumas” were in a sense supplanted by the “infantilism of sexuality.” A second modification of the original theory was not remote. With the accepted frequency of seduction in childhood there also disappeared the enormous emphasis of the accidental influences of sexuality to which I wished to shift the main rôle in the causation of the disease without, however, denying constitutional and hereditary moments. I even hoped to solve thereby the problem of the selection of the neurosis, that is, to decide by the details of the sexual infantile experience, the form of the psychoneurosis into which the patient may merge. Though with reserve I thought at that time that passive behavior during these scenes results in the specific predisposition for hysteria, while active behavior results in compulsion neurosis. This conception I was later obliged to disclaim completely though some facts of the supposed connection between passivity and hysteria, and activity and compulsion neurosis, can be maintained to some extent. With the disappearance of the accidental influences of experiences, the elements of constitution and heredity had to regain the upper hand, but differing from the view generally in vogue I placed the “sexual constitution” in place of the general neuropathic predisposition. In my recent work, “Three Contributions to the Sexual Theory.”[^[56]] I have attempted to discuss the varieties of this sexual constitution, the components of the sexual impulse in general, and its origin from the contributory sources of the organism.

Still in connection with the changed conception of the “sexual infantile traumas,” the theory continued to develop in a course which was already indicated in the publications of 1894–1896. Even before sexuality was installed in its proper place in the etiology, I had already stated as a condition for the pathogenic efficaciousness of an experience that the latter must appear to the ego as unbearable and thus evoke an exertion for defense. To this defense I have traced the psychic splitting—or as it was then called the splitting of consciousness—of hysteria. If the defense succeeded, the unbearable experience with its resulting affect was expelled from consciousness and memory; but under certain conditions the thing expelled which was now unconscious, developed its activity, and with the aid of the symptoms and their adhering affect it returned into consciousness, so that the disease corresponded to a failure of the defense. This conception had the merit of entering into the play of the psychic forces, and hence approximate the psychic processes of hysteria to the normal instead of shifting the characteristic of the neurosis into an enigmatic and no further analyzable disturbance.

Further inquiries among persons who remained normal furnished the unexpected result, that the sexual histories of their childhood need not differ essentially from the infantile life of neurotics, and that especially the rôle of seduction is the same in the former, so the accidental influences receded still more in comparison to the moments of “repression” (which I began to use instead of “defense”). It really does not depend on the sexual excitements which an individual experiences in his childhood but above all on his reactions towards these experiences, and whether these impressions responded with “repression” or not. It could be shown that spontaneous sexual manifestations of childhood were frequently interrupted in the course of development by an act of repression. The sexual maturity of neurotic individuals thus regularly brings with it a fragment of “sexual repression” from childhood which manifests itself in the requirements of real life. Psychoanalyses of hysterical individuals show that the malady is the result of the conflict between the libido and the sexual repression, and that their symptoms have the value of a compromise between both psychic streams.

Without a comprehensive discussion of my conception of repression I could not explain any further this part of the theory. It suffices to refer here to my “Three Contributions to the Sexual Theory,” where I have made an attempt to throw some light on the somatic processes in which the essence of sexuality is to be sought. I have stated there that the constitutional sexual predisposition of the child is more irregularly multifarious than one would expect, that it deserves to be called “polymorphous-perverse,” and that from this predisposition the so called normal behavior of the sexual functions results through a repression of certain components. By referring to the infantile character of sexuality, I could form a simple connection among normal, perversions, and neurosis. The normal resulted through the repression of certain partial impulses and components of the infantile predisposition, and through the subordination of the rest under the primacy of the genital zones for the service of the function of procreation. The perversions corresponded to disturbances of this connection due to a superior compulsive like development of some of the partial impulses, while the neurosis could be traced to a marked repression of the libidinous strivings. As almost all perversive impulses of the infantile predisposition are demonstrable as forces of symptom formation in the neurosis, in which, however, they exist in a state of repression, I could designate the neurosis as the “negative” of the perversion.

I think it worth emphasizing that with all changes my ideas on the etiology of the psychoneuroses still never disavowed or abandoned two points of view, to wit, the estimation of sexuality and infantilism. In other respects we have in place of the accidental influences the constitutional moments, and instead of the pure psychologically intended defense we have the organic “sexual repression.” Should anybody ask where a cogent proof can be found for the asserted etiological significance of sexual factors in the psychoneuroses, and argue that since an outburst of these diseases can result from the most banal emotions, and even from somatic causes, a specific etiology in the form of special experiences of childhood must therefore be disavowed; I mention as an answer for all these arguments the psychoanalytic investigation of neurotics as the source from which the disputed conviction emanates. If one only makes use of this method of investigation he will discover that the symptoms represent the whole or a partial sexual manifestation of the patient from the sources of the normal or perverse partial impulses of sexuality. Not only does a good part of the hysterical symptomatology originate directly from the manifestations of the sexual excitement, not only are a series of erogenous zones in strengthening infantile attributes raised in the neurosis to the importance of genitals, but even the most complicated symptoms become revealed as the converted representations of fancies having a sexual situation as a content. He who can interpret the language of hysteria can understand that the neurosis only deals with the repressed sexuality. One should, however, understand the sexual function in its proper sphere as circumscribed by the infantile predisposition. Where a banal emotion has to be added to the causation of the disease, the analysis regularly shows that the sexual components of the traumatic experience, which are never missing, have exercised the pathogenic effect.

We have unexpectedly advanced from the question of the causation of the psychoneuroses to the problem of its essence. If we wish to take cognizance of what we discovered by psychoanalysis we can only say that the essence of these maladies lies in disturbances of the sexual processes, in those processes in the organism which determine the formation and utilization of the sexual libido. We can hardly avoid perceiving these processes in the last place as chemical, so that we can recognize in the so called actual neuroses the somatic effects of disturbances in the sexual metabolism, while in the psychoneuroses we recognize besides the psychic effects of the same disturbances. The resemblance of the neuroses to the manifestations of intoxication and abstinence following certain alkaloids, and to Basedow’s and Addison’s diseases, obtrudes itself clinically without any further ado, and just as these two diseases should no more be described as “nervous diseases,” so will the genuine “neuroses” soon have to be removed from this class despite their nomenclature.

Everything that can exert harmful influences in the processes serving the sexual function therefore belongs to the etiology of the neurosis. In the first place we have the noxas directly affecting the sexual functions insofar as they are accepted as injuries by the sexual constitution which is changeable through culture and breeding. In the second place, we have all the different noxas and traumas which may also injure the sexual processes by injuring the organism as a whole. But we must not forget that the etiological problem in the neuroses is at least as complicated as in the causation of any other disease. One single pathogenic influence almost never suffices, it mostly requires a multiplicity of etiological moments reinforcing one another, and which can not be brought in contrast to one another. It is for that reason that the state of neurotic illness is not sharply separated from the normal. The disease is the result of a summation, and the measure of the etiological determinations can be completed from any one part. To seek the etiology of the neurosis exclusively in heredity or in the constitution would be no less one sided than to attempt to raise to the etiology the accidental influences of sexuality alone, even though the explanations show that the essence of this malady lies only in a disturbance of the sexual processes of the organism.

CHAPTER X.
Hysterical Fancies and their Relations to Bisexuality.[^[57]]

The delusional formations of paranoiacs containing the greatness and sufferings of their own ego, which manifest themselves quite typically in almost monotonous forms are universally familiar. Furthermore, through numerous communications we became acquainted with the peculiar organizations by means of which certain perverts put into operation their sexual gratifications, be it in fancy or reality. On the other hand it may sound rather novel to some to hear that quite analogous psychic formations regularly appear in all psychoneuroses, especially in hysteria, and that these so called hysterical fancies show important relations to the causation of the neurotic symptoms.

Of the same source and of the normal prototype are all these fantastic creations, so called reveries of youth, which have already gained a certain consideration in the literature, though not a sufficient one.[^[58]] They are perhaps equally frequent in both sexes; in girls and women they seem to be wholly of an erotic nature, while in men they are of an erotic or ambitious nature. Yet even in men the significance of the erotic moment is not to be put in the second place, for on examining more closely the reveries of men we generally learn that all these heroic acts are accomplished, that all these successes are acquired in order to please a woman and to be preferred to other men.[^[59]] These fancies are wish gratifications which emanate from privation and longing. They are justly named “day dreams” for they give the key for the understanding of night dreams in which the nucleus of the dream formation is produced by just such complicated, disfigured day fancies which are misunderstood by the conscious psychic judgment.[^[60]]

These day dreams are garnished with great interest, are cautiously nurtured, and coyly guarded, as if they were numbered among the most intimate estates of personality. On the street, however, the day dreamer can be readily recognized by a sudden, as if absent minded smile, by talking to himself, or by a running-like acceleration of his gait wherein he designates the acme of the imaginary situation.

All hysterical attacks which I have been thus far able to examine proved to be such involuntary incursions of day dreams. Observation leaves no doubt that such fancies may exist as unconscious or conscious and whenever they become unconscious they may also become pathogenic, that is, they may express themselves in symptoms and attacks. Under favorable conditions it is possible for consciousness to seize such unconscious fancies. One of my patients whose attention I have called to her fancies narrated that once while in the street she suddenly found herself in tears, and rapidly reflecting over the cause of her weeping the fancy became clear to her. She fancied herself in delicate relationship with a piano virtuoso familiar in the city, but whom she did not know personally. In her fancy she bore him a child (she was childless), and he then deserted her, leaving her and her child in misery. At this passage of the romance she burst into tears.

The unconscious fancies are either from the first unconscious, having been formed in the unconscious, or what is more frequently the case they were once conscious fancies, day dreams, and were then intentionally forgotten, merging into the unconscious by “repression.” Their content then either remained the same or underwent a transformation, so that the present unconscious fancy represents a descendant of the once conscious one. The unconscious fancy stands in a very important relation to the sexual life of the person, it is really identical with that fancy which helped it towards sexual gratification during a period of masturbation. The masturbating act (in the broader sense the onanistic) then consisted of two parts, the evocation of the fancy, and the active performance of self gratification at the height of the same. This combination is familiarly in itself a soldering.[^[61]] Originally this action was a purely auto-erotic undertaking for the pleasure obtained from a certain so called erogenous part of the body. Later this action blended with a wish presentation from the sphere of the object loved, and served for a partial realization of the situation in which this fancy culminated. If, then, the person forgoes in this manner the masturbo-fantastic gratification, the action remains undone, the fancy, however, changes from a conscious to an unconscious one. If no other manner of sexual gratification occurs, if the person remains abstinent and does not succeed in sublimating his libido, that is, in diverting the sexual excitement to a higher aim, we then have the conditions for the refreshment of the unconscious fancy; it grows exuberantly and with all the force of the desire for love at least a fragment of its content becomes a morbid symptom.

The unconscious fancies are then the nearest psychical first steps of a whole series of hysterical symptoms. The hysterical symptoms are nothing other than unconscious fancies brought to light by “conversion,” and insofar as they are somatic symptoms they are frequently enough taken from the spheres of the sexual feelings and motor innervations which originally accompanied the former still conscious fancies. In this way the disuse of onanism is really made retrograde, and the final aim of the whole pathological process, the restoration of the primary sexual gratification, though it never becomes perfect, in a manner always achieves a certain approximation.

The interest of him who studies hysteria turns directly from the symptoms to the fancies from which the former originate. The technique of psychoanalysis gives the means of finding out from the symptoms the unconscious fancies, and then of bringing them back to the patient’s consciousness. In this way it was found that the unconscious fancies of hysterics perfectly correspond in content to the consciously performed gratification situations of perverts. Those who lack examples of such nature need only recall the historical managements of the Roman Caesars whose frenzies were naturally only conditioned by the unrestricted fullness of the fancy creators. The delusional formations of paranoiacs are of the same nature, they are fancies which directly become conscious, and which are borne by the masochistic-sadistic components of the sexual impulse. Complete counterparts of these can also be found in certain unconscious fancies of hysterics. It is a familiar, practically significant fact that hysterics express their fancies not as symptoms but in conscious realization, and in this way they feign and commit murders, assaults, and sexual aggressions.

All that can be found out about the sexuality of the psychoneurotic can be ascertained by the psychoanalytic examination which leads from the obtrusive symptoms to the hidden unconscious fancies; herein, too, is the fact, the communication of which will be put in the foreground of this short preliminary publication.

Probably in view of the difficulties which prevent the effort of the unconscious fancies from expressing themselves, the relation between the fancies to the symptoms is not simple but rather manifoldly complicated.[^[62]] As a rule, that is, in a fully developed and a long standing neurosis, a symptom does not correspond to an individual unconscious fancy, but to a number of such, and indeed it is not arbitrary but in lawful combination. To be sure in the beginning of the disease all these complications are not developed.

For the sake of general interest I pass over the connection of this communication and insert a series of formulæ which strive to progressively exhaust the nature of hysteria. They do not contradict one another but correspond partly to more complete and sharper conceptions, and partly to the use of different points of view.

1. The hysterical symptom is the memory symbol of certain efficacious (traumatic) impressions and experiences.

2. The hysterical symptom is the compensation by conversion for the associative return of the traumatic experience.

3. The hysterical symptom—like all other psychic formations—is the expression of a wish realization.

4. The hysterical symptom is the realization of an unconscious fancy serving as a wish fulfilment.

5. The hysterical symptom serves as a sexual gratification, and represents a part of the sexual life of the individual (corresponding to one of the components of his sexual impulse).

6. The hysterical symptom, in a fashion, corresponds to the return of the sexual gratification which was real in infantile life but had been repressed since then.

7. The hysterical symptom results as a compromise between two opposing affects or impulse incitements, one of which strives to bring to realization a partial impulse, or a component of the sexual constitution, while the other strives to suppress the same.

8. The hysterical symptom may undertake the representation of diverse unconscious non-sexual incitements, but can not lack the sexual significance.

It is the seventh among these determinations which expresses most exhaustively the essence of the hysterical symptom as a realization of an unconscious fancy, and it is the eighth which properly designates the significance of the sexual moment. Some of the preceding formulæ are contained as first steps in this formula.

In view of these relations between symptoms and fancies one can readily reach from the psychoanalysis of the symptoms to the knowledge of the components of the sexual impulse controlling the individual, just as I have shown in the “Three Contributions to the Sexual Theory.” But in some cases this examination gives rather unexpected results. It shows that many symptoms can not be solved by one unconscious sexual fancy or by a series of fancies in which the most significant and most primitive is of a sexual nature, but in order to solve the symptom two sexual fancies are required, one of the masculine and one of the feminine character, so that one of these fancies arises from a homosexual impulse. The axiom pronounced in formula seven is in no way effected by this novelty, so that a hysterical symptom necessarily corresponds to a compromise between a libidinous and a repressed emotion, but besides that, it can correspond to a union of two libidinous fancies of contrary sex characters.

I refrain from giving examples for this axiom. Experience has taught me that short analyses compressed into the form of an abstract can never make the demonstrable impression for which they were intended. The communication of fully analyzed cases must be reserved for another place.

I therefore content myself in formulating the axiom and in elucidating its significance:

9. An hysterical symptom is the expression, on the one hand, of a masculine, and on the other hand of a feminine unconscious sexual fancy.

I expressly observe that I am unable to adjudge to this axiom the similar general validity that I claimed for the other formulæ. As far as I can see it is met neither in all symptoms of a single case, nor in all cases. On the contrary it is not difficult to find cases in which the contrary sexual emotions have found separate symptomatic expression, so that the symptoms of hetero- and homosexuality can be as sharply distinguished from each other as the fancies hidden behind them. Nevertheless, the relation claimed in the ninth formula occurs frequently enough, and wherever it is found it is of sufficient significance to merit a special formulation. It seems to me to signify the highest stage of complexity to which the determination of hysterical symptoms can reach, and can only be expected in a long standing neurosis and where a great amount of organization has occurred.[^[63]]

The demonstrable bisexual significance of hysterical symptoms occurring in many cases is indeed an interesting proof for the assertion formulated by me that the supposed bisexual predisposition of man can be especially recognized in psychoneurotics by means of psychoanalysis.[^[64]] Quite an analogous process from the same sphere is that in which the masturbator in his conscious fancies attempts to live through in his imagination the fancied situations of both the man and the woman. Other counterparts are found in certain hysterical crises in which the patients play both rôles lying at the basis of sexual fancies; thus, for example, one of the cases under my observation presses his garments to his body with one arm (as woman), and with the other arm he attempts to tear them off (as man). This contradictory simultaneity determines most of the incomprehensibility of the situation otherwise so plastically represented in the attack, and is excellently suited for the concealment of the effective unconscious fancy.

In psychoanalytical treatment it is very important to be prepared for the bisexual significance of a symptom. It should not be at all surprising or misleading when a symptom remains apparently undiminished in spite of the fact that one of its sexual determinants is already solved. Perhaps it is still supported by the unsuspected contrary sexual. Furthermore, during the treatment of such cases we can observe how the patient makes use of this convenience. During the analysis of the one sexual significance he continually switches his thoughts into the sphere of the contrary significance just as if onto a neighboring track.

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[1]. Studien über Hysterie von Jos. Breuer und Sigm. Freud. Leipzig und Wien, Franz Deuticke, 1895. 2nd ed., 1909.

[2]. Sammlung kleiner Schriften zur Neurosenlehre, Vols. I. and II. Leipzig und Wien, Deuticke, 1906, and 1909.

[3]. Bleuler, Freudsche Mechanismen in der Symptomatologie der Psychosen, Psychiatrisch-Neurolog. Wochenschrift, 1906, Nrs. 35 and 36.

[4]. Jung, The Psychology of Dementia Præcox, Nervous and Mental Disease Monograph Series, Nr. 3.

[5]. Riklin, Psychiatrisch-Neurolog. Wochenschrift, 1905, Nr. 46.

[6]. Brill, Psychological Factors in Dementia Præcox, Journal of Abnormal Psychology, Vol. III, Nr. 4, and A Case of Schizophrenia, American Journal of Insanity, Vol. LXVI, No. 1.

[7]. Freud, Deuticke, 1909.

[8]. Freud, Karger, 1907.

[9]. Freud, Deuticke, 1905.

[10]. Written in collaboration with Dr. Joseph Breuer.

[11]. The possibility of such a therapy was clearly recognized by Delboeuf and Binet, as is shown by the accompanying quotations: Delboeuf, Le magnétisme animal, Paris, 1889: “On s’expliquerait des lors comment le magnétiseur aide à guérison. Il remet le sujet dans l’état où le mal s’est manifesté et combat par la parole le même mal, mais renaissant.” (Binet, Les altérations de la personnalité, 1892, p. 243): “... peut-être verra-t-on qu’en reportant le malade par un artifice mental, au moment même ou le symptome a apparu pour la premiere fois, on rend ce malade plus docile a une suggestion curative.” In the interesting book of Janet, L’Automatism Psychologique, Paris, 1889, we find the description of a cure brought about in a hysterical girl by a process similar to our method.

[12]. We are unable to distinguish in this preliminary contribution what there is new in this content and what can be found in such other authors as Moebius and Strümpel who present similar views on hysteria. The greatest similarity to our theoretical and therapeutical accomplishments we accidentally found in some published observations of Benedict which we shall discuss hereafter.

[13]. The German abreagiren has no exact English equivalent. It will therefore be rendered throughout the text by “ab-react,” the literal meaning is to react away from or to react off. It has different shades of meaning, from defense reaction to emotional catharsis, which can be discerned from the context.

[14]. As an example of the technique mentioned above, that is, of investigating in a non-somnambulic state or where consciousness is not broadened, I will relate a case which I analyzed recently. I treated a woman of thirty-eight who suffered from an anxiety neurosis (agoraphobia, fear of death, etc.). Like many patients of that type she had a disinclination to admit that she acquired this disease in her married state and was quite desirous of referring it back to early youth. She informed me that at the age of seventeen when she was in the street of her small city she had the first attack of vertigo, anxiety, and faintness, and that these attacks recurred at times up to a few years ago when they were replaced by her present disease. I thought that the first attacks of vertigo, in which the anxiety was only blurred, were hysterical and decided to analyze the same. All she knows is that she had the first attack when she went out to make purchases in the main street of her city.—“What purchases did you wish to make?”—“Various things, I believe it was for a ball to which I was invited.”—“When was the ball to take place?”—“I believe two days later.”—“Something must have happened a few days before this which excited you, and which made an impression on you.”—“But I don’t know, it is now twenty-one years.”—“That does not matter, you will recall it. I will exert some pressure on your head and when I stop it you will either think of or see something which I want you to tell me.” I went through this procedure, but she remained quiet.—“Well, has nothing come into your mind?”—“I thought of something, but that can have no connection with it.”—“Just say it.”—“I thought of a young girl who is dead, but she died when I was eighteen, that is, a year later.”—“Let us adhere to this. What was the matter with your friend?”—“Her death affected me very much, because I was very friendly with her. A few weeks before another young girl died, which attracted a great deal of attention in our city, but then I was only seventeen years old.”—“You see, I told you that the thought obtained under the pressure of the hands can be relied upon. Well now, can you recall the thought that you had when you became dizzy in the street?”—“There was no thought, it was vertigo.”—“That is quite impossible, such conditions are never without accompanying ideas. I will press your head again and you will think of it. Well, what came to your mind?”—“I thought, ‘now I am the third.’”—“What do you mean?”—“When I became dizzy I must have thought, now I will die like the other two.”—“That was then the idea, during the attack you thought of your friend, her death must have made a great impression on you.”—“Yes, indeed, I recall now that I felt dreadful when I heard of her death, to think that I should go to a ball while she lay dead, but I anticipated so much pleasure at the ball and was so occupied with the invitation that I did not wish to think of this sad event.” (Notice here the intentional repression from consciousness which caused the reminiscences of her friend to become pathogenic.)

The attack was now in a measure explained, but I still needed the occasional moment which just then provoked this recollection, and accidentally I formed a happy supposition about it.—“Can you recall through which street you passed at that time?”—“Surely, the main street with its old houses, I can see it now.”—“And where did your friend live?”—“In the same street. I had just passed her house and was two houses farther when I was seized with the attack.”—“Then it was the house which you passed that recalled your dead friend, and the contrast which you then did not wish to think about that again took possession of you.”

Still I was not satisfied, perhaps there was something else which provoked or strengthened the hysterical disposition in a hitherto normal girl. My suppositions were directed to the menstrual indisposition as an appropriate moment, and I asked, “Do you know when during that month you had your menses?”—She became indignant: “Do you expect me to know that? I only know that I had them then very rarely and irregularly. When I was seventeen I only had them once.”—“Well let us enumerate the days, months, etc., so as to find when it occurred.”—She with certainty decided on a month and wavered between two days preceding a date which accompanied a fixed holiday.—Does that in any way correspond with the time of the ball?—She answered quietly: “The ball was on this holiday. And now I recall that I was impressed by the fact that the only menses which I had had during the year occurred just when I had to go to the ball. It was the first invitation to a ball that I had received.”

The combination of the events can now be readily constructed and the mechanism of this hysterical attack readily viewed. To be sure the result was gained after painstaking labor. It necessitated on my side full confidence in the technique and individual directing ideas in order to reawaken such details of forgotten experiences after twenty-one years in a sceptical and awakened patient. But then everything agreed.

[15]. A better description of this peculiar state in which one knows something and at the same time does not know it, I could never obtain. It can apparently be understood only if one has found himself in such a state. I have at my disposal a very striking recollection of this kind which I can vividly see. If I make the effort to recall what passed through my mind at that time my output seems very poor. I saw at that time something which was not at all appropriate to my expectations, and what I saw did not in the least divert me from my definite purpose, whereas this perception ought to have done away with my purpose. I did not become conscious of this contradiction nor did I remark the affect of the repulsion to which it was undoubtedly due that this perception did not attain any psychic validity. I was struck with that form of blindness in seeing eyes, which one admires so much in mothers towards their daughters, in husbands towards their wives, and in rulers towards their favorites.

[16]. It will be shown that, notwithstanding, I erred.

[17]. Die Abwehr-Neuropsychosen, Neurologisches Centralblatt, 1 June, 1894.

[18]. I can neither exclude nor prove that this pain, especially of the thighs, was of a neurasthenic nature.

[19]. To my surprise I once discovered that such subsequent ab-reaction—through other impressions than nursing—may form the content of an otherwise enigmatic neurosis. It was the case of a pretty girl of nineteen, Miss Matilda H. whom I first saw with an incomplete paralysis of the legs, and months afterward I was again called because her character had changed. She was depressed and tired of living, entertaining lack of consideration for her mother, and was irritable and inapproachable. The whole picture of the patient did not seem to me to be that of an ordinary melancholia. She could easily be put into a somnambulic state, and I made use of this peculiarity to impart to her each time commands and suggestions to which she listened in her profound sleep and responded with profuse tears, but which, however, caused but little change in her condition. One day while hypnotized she became talkative and informed me that the reason for her depression was the breaking of her betrothal many months before. She stated that on closer acquaintance with her fiance the things displeasing to her and her mother became more and more evident. On the other hand, the material advantages of the engagement were too tangible to make the decision of a rupture easy, thus, both of them hesitated for a long time. She then merged into a condition of indecision in which she allowed everything to pass apathetically, and finally her mother pronounced for her the decisive “no.” Shortly after, she awoke as from a dream and began to occupy herself fervently with the thoughts about the broken betrothal, she began to weigh the pros and cons, a process which she continued for some time. At present she continues to live in that time of doubt, and entertains daily the moods and the thoughts which would have been appropriate for that day. The irritability against her mother could only be explained if we took into consideration the circumstances that existed on that decisive day. Next to this thought activity she found her present life a mere phantom just like a dream. I did not again succeed in getting the girl to talk—I continued my exhortations during deep somnambulism. I saw her each time burst into tears without however receiving any answer from her. But one day, it was near the anniversary of the engagement, the whole state of depression disappeared. This was attributed to my great hypnotic cure.

[20]. It is different in a hypnoid-hysteria. Here the content of the separate psychic groups may never have been in the ego consciousness.

[21]. I had under my observation another case in which a contracture of the masseters made it impossible for the artist to sing. The young lady in question through painful experiences in the family was forced to go on the stage. While in Rome rehearsing, in great excitement she suddenly perceived the sensation of being unable to close her opened mouth and sank fainting to the floor. The physician who was called closed her jaws forcibly, but the patient since that time was unable to open her jaws more than a finger’s breadth and had to give up her newly chosen profession. When she came under my care many years later, the motives for that excitement were apparently over for some time, for massage in a light hypnosis sufficed to open her mouth widely. The lady has since sung in public.

[22]. But perhaps spinal neurasthenic?

[23]. See Studien über Hysterie, p. 57, footnote.

[24]. l. c.

[25]. The literal translation of Auftreten is to press down by treading.

[26]. In conditions of profounder psychic changes we apparently find a symbolic stamp (mark) of the more artificial usage of language in the form of emblematic pictures and sensations. There was a time in Mrs. Cäcilie M. during which every thought was changed into an hallucination, and which solution frequently afforded great humor. She at that time complained to me of being troubled by the hallucination that both her physicians, Breuer and I, were hanged in the garden on two nearby trees. The hallucination disappeared after the analysis revealed the following origin: The evening before Breuer refused her request for a certain drug. She then placed her hopes on me but found me just as inflexible. She was angry at both of us, and in her affect she thought, “They are worthy of each other, the one is a pendant of the other!”

[27]. E. Hecker, Centralblatt für Nervenheilkunde, Dec., 1893.

[28]. See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und Wien, 1895, p. 15.

[29]. See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und Wien, 1895, p. 106.

[30]. See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und Wien, 1895, p. 15.

[31]. As mentioned in the preface the author has long since discarded this pressure procedure.—Translator’s note.

[32]. See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und Wien, 1895, p. 85.

[33]. l. c., p. 15.

[34]. See Breuer und Freud, Studien über Hysterie. Deuticke, Wien und Leipzig, 1895, p. 28.

[35]. See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und Wien, 1895, p. 55.

[36]. État mental des hystériques, Paris, 1893 and 1894. Quelques définitions récentes de l’hystérie, Arch. de Neurol., 1893, XXXV-VI.

[37]. Oppenheim: Hysteria is an exaggerated expression of emotion. But the “expression of emotion” represents that amount of psychic excitement which normally experiences conversion.

[38]. Strümpel: The disturbance of hysteria lies in the psycho-physical, there where the physical and psychical are connected with each other.

[39]. Janet, in the second chapter of his spirited essay “Quelques definitions,” etc., has treated the objection that the splitting of consciousness belongs also to the psychoses and the so called psychaesthenia, but in my opinion he has not satisfactorily solved it. It is essentially this objection which urged him to call hysteria a form of degeneration. But through no characteristic is he able to separate sufficiently the hysterical splitting of consciousness from the psychopathic, etc.

[40]. The group of typical phobias, for which agoraphobia is a prototype, cannot be reduced to the psychic mechanisms here developed. Furthermore the mechanism of agoraphobia deviates in one decisive point from that of the real obsessions and from phobias based on such. Here there is no repressed idea from which the affect of fear has been separated. The fear of this phobia has another origin.

[41]. E. Hecker, Über larvierte und abortive Angstzustände bei Neurasthenie, Centralblatt für Nervenheilkunde, December, 1893.—Anxiety is made particularly prominent among the chief symptoms of neurasthenia by Kaan, Der neurasthenische Angstaffekt bei Zwangsvorstellungen und der primordiale Grübelzwang, Wien, 1893.

[42]. Die Abwehr-Neuropsychosen, Neurol. Centralbl., 1894, Nr. 10 u. 11.

[43]. Obsession et phobies, Révue neurologique, 1895.

[44]. Moebius, Neuropathologische Beiträge, 1894, 2. Heft.

[45]. Peyer, Die nervösen Affektionen des Darmes, Wiener Klinik, Jänner, 1893.

[46]. Freud, Abwehr-Neuropsychosen.

[47]. Neurologisches Centralblatt, 1896, Nr. 10.

[48]. I myself surmise that the so frequently fabricated assaults of hysterical persons are obsessional confabulations emanating from the memory traces of infantile traumas.

[49]. In an article on the anxiety neurosis (Neurologisches Centralblatt, 1895, Nr. 2) I stated that “an anxiety neurosis which can almost typically be combined with hysteria can be evoked in maturing girls at the first encounter with the sexual problem.” I know today that the occasion in which such virginal anxiety breaks out does not really correspond to the first encounter with sexuality, but that in such persons there was in childhood a precedent experience of sexual passivity which memory was awakened at the “first encounter.”

[50]. A psychological theory of the repression ought also to inform us why only ideas of a sexual content can be repressed. It may be formulated as follows: It is known that ideas of a sexual content produce exciting processes in the genitals resembling the actual sexual experience. It may be assumed that this somatic excitement becomes transformed into psychic. As a rule the activity referred to is much stronger at the time of the occurrence than at the recollection of the same. But if the sexual experience takes place during the time of sexual immaturity and the recollection of the same is awakened during or after maturity, the recollection then acts disproportionately more exciting than the previous experience, for puberty has in the mean time incomparably increased the reactive capacity of the sexual apparatus. But such an inverse proportion seems to contain the psychological determination of repression. Through the retardation of the pubescent maturity in comparison with the psychic function, the sexual life offers the only existing possibility for that inversion of the relative efficacy. The infantile traumas subsequently act like fresh experiences, but they are then unconscious. Deeper psychological discussions I will have to postpone for another time. I moreover call attention to the fact that the here considered time of “sexual maturity” does not coincide with puberty, but occurs before the same (eight to ten years).

[51]. One example instead of many: An eleven-year-old boy has obsessively arranged for himself the following ceremonial before going to bed: He could not fall asleep unless he related to his mother most minutely all experiences of the day; not the smallest scrap of paper or any other rubbish was allowed in the evening on the carpet of his bedroom. The bed had to be moved close to the wall, three chairs had to stand in front of it, and the pillows had to lie in just such a position. In order to fall asleep he had to kick with both legs a number of times, and then had to lie on the side. This was explained as follows: Years before while putting this pretty boy to sleep, the servant girl made use of this opportunity to lay over him and assault him sexually. When this reminiscence was later awakened by a recent experience it made itself known to consciousness by the compulsion in the above mentioned ceremonial which sense could really be surmised and the details verified by psychoanalysis. The chairs before the bed which was close to the wall—so that no one could have access to it; the arrangement of the pillows in a definite manner—so that they should be differently arranged than they were on that evening; the motion with the legs—to kick away the person lying on him; sleeping on the side—because during that scene he lay on his back; the detailed confession to his mother—because in consequence of the prohibition of his seductress he concealed from his mother this and other sexual experiences; finally, keeping the floor of his bedroom clean—because this was the main reproach which he had to hear from his mother up to that time.

[52]. When the meagre success of this treatment was later removed by an exacerbation, she did not again see the offensive pictures of strange genitals, but she had the idea that strangers saw her genitals as soon as they were behind her.

[53]. Lecture delivered before the Vienna Medic. Doktorenkollegium, on December 12, 1904.

[54]. From Löwenfeld, “Sexualleben und Nervenleiden,” IV ed., 1906.

[55]. See Chapter VII, and Zur Aetiologie der Hysterie, Wiener, Klinische Rundschau, 1896.

[56]. An English translation in preparation.

[57]. Zeitschrift für Sexualwissenschaft, herausgegeben von Hirschfeld, I, 1908.

[58]. Compare Breuer and Freud Studien über Hysterie, 1895. P. Janet, Névroses et ideés fixes, I (Les rêveries subconscientes), 1898. Havelock Ellis, Sexual Impulse and Modesty (German by Kötscher), 1900. Freud, Traumdeutung, 1906, 2d ed., 1909. A. Pick, Über pathologische Träumerei und ihre Beziehungen zur Hysteria, Jahrbuch für Psychiatrie und Neurologie, XIV, 1896.

[59]. H. Ellis similarly expresses himself, l. c., p. 185.

[60]. Compare Freud, Traumdeutung, 2d ed., p. 302.

[61]. Compare Freud, Three Contributions to the Sexual Theory, 1895.

[62]. The same thing holds true for the relation between the “latent” thoughts of the dream and the elements of the manifest content of the dream. See the Chapter on the “Work of the Dream” in the author’s Traumdeutung.

[63]. Indeed J. Sadger, who recently discovered this sentence in question, independently by psychoanalysis, claims for it a general validity (Die Bedeutung der psychoanalytische Methode nach Freud, Centralbl. f. Nerv. u. Psych., Nr. 229.)

[64]. Three Contributions to the Sexual Theory.

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TRANSCRIBER’S NOTES

Page	Changed from	Changed to
[10]	the so called χατ’ εξοχὴν of traumatic hysteria or of a series of	the so called κατ’ ἐξοχὴν of traumatic hysteria or of a series of
[65]	scenes like the one of being forced to hold our her hand in	scenes like the one of being forced to hold out her hand in
[123]	be identified with personel or hereditary “degeneration.”	be identified with personal or hereditary “degeneration.”

• Typos fixed; non-standard spelling and dialect retained.
• Used numbers for footnotes, placing them all at the end of the last chapter.