An internet educational resource developed by
Christopher D. Green
York University, Toronto, Ontario
(Return to index)
Part 1 of 5
Ladies and Gentlemen: It is a new and somewhat embarrassing experience for me to appear as lecturer before students of the New World. I assume that I owe this honor to the association of my name with the theme of psychoanalysis, and consequently it is of psychoanalysis that I shall aim to speak. I shall attempt to give you in very brief form an historical survey of the origin and further development of this new method of research and cure.
Granted that it is a merit to have created psychoanalysis, it is not my merit. I was a student, busy with the passing of my last examinations, when another physician of Vienna, Dr. Joseph Breuer, made the first application of, this method to the case of an hysterical girl (1880-82). We must now examine the history of this case and its treatment, which can be found in detail in "Studien über Hysterie," later published by Dr. Breuer and myself.
But first one word. I have noticed, with considerable satisfaction, that the majority of my hearers do not belong to the medical profession. Now do not fear that a medical education is necessary to follow what I shall have to say. We shall now accompany the doctors a little way, but soon we shall take leave of them and follow Dr. Breuer on a way which is quite his own.
Dr. Breuer's patient was a girl of twenty-one, of a high degree of intelligence. She had developed in the course of her two years' illness a series of physical and mental disturbances which well deserved to be taken seriously. She had a severe paralysis of both right extremities, with anasthesia [sic], and at times the same affection of the members of the left side of the body; disturbance of eye-movements, and much impairment of vision; difficulty in maintaining the position of the head, an intense Tussis nervosa, nausea when she attempted to take nourishment, and at one time for several weeks a loss of the power to drink, in spite of tormenting thirst. Her power of speech was also diminished, and this progressed so far that she could neither speak nor understand her mother tongue; and, finally, she was subject to states of "absence," of confusion, delirium, alteration of her whole personality. These states will later claim our attention.
When one hears of such a case, one does not need to be a physician to incline to the opinion that we are concerned here with a serious injury, probably of the brain, for which there is little hope of cure and which will probably lead to the early death of the patient. The doctors will tell us, however, that in one type of cases with just as unfavorable symptoms, another, far more favorable, opinion is justified. When one finds such a series of symptoms in the case of a young girl, whose vital organs (heart, kidneys), are shown by objective tests to be normal, but who has suffered from strong emotional disturbances, and when the symptoms differ in certain finer characteristics from what one might logically expect, in a case like this the doctors are not too much disturbed. They consider that there is present no organic lesion of the brain, but that enigmatical state, known since the time of the Greek physicians as hysteria, which can simulate a whole series of symptoms of various diseases. They consider in such a case that the life of the patient is not in danger and that a restoration to health will probably come about of itself. The differentiation of such an hysteria from a severe organic lesion is not always very easy. But we do not need to know how a differential diagnosis of this kind is made; you may be sure that the case of Breuer's patient was such that no skillful physician could fail to diagnose an hysteria. We may also add a word here from the history of the case. The illness first appeared while the patient was caring for her father, whom she tenderly loved, during the severe illness which led to his death, a task which she was compelled to abandon because she herself fell ill.
So far it has seemed I best to go with the doctors, but we shall soon part company with them. You must not think that the outlook of a patient with regard to medical aid is essentially bettered when the diagnosis points to hysteria rather than to organic disease of the brain. Against the serious brain diseases medical skill is in most cases powerless, but also in the case of hysterical affections the doctor can do nothing. He must leave it to benign nature, when and how his hopeful prognosis will be realized. Accordingly, with the recognition of the disease as hysteria, little is changed in the situation of the patient, but there is a great change in the attitude of the doctor. We can observe that he acts quite differently toward hystericals than toward patients suffering from organic diseases. He will not bring the same interest to the former as to the latter, since their suffering is much less serious and yet seems to set up the claim to be valued just as seriously.
But there is another motive in this action. The physician, who through his studies has learned so much that is hidden from the laity, can realize in his thought the causes and alterations of the brain disorders in patients suffering from apoplexy or dementia, a representation which must be right up to a certain point, for by it he is enabled to understand the nature of each symptom. But before the details of hysterical symptoms, all his knowledge, his anatomical-physiological and pathological education, desert him. He cannot understand hysteria. He is in the same position before it as the layman. And that is not agreeable to any one, who is in the habit of setting such a high valuation upon his knowledge. Hystericals, accordingly, tend to lose his sympathy; he considers them persons who overstep the laws of his science, as the orthodox regard heretics; he ascribes to them all possible evils, blames them for exaggeration and intentional deceit, "simulation," and be punishes them by withdrawing his interest.
Now Dr. Breuer did not deserve this reproach in this case; he gave his patient sympathy and interest, although at first be did not understand how to help her. Probably this was easier for him on account of those superior qualities of the patient's mind and character, to which he bears witness in his account of the case.
His sympathetic observation soon found the means which made the first help possible. It had been noticed that the patient, in her states of "absence," of psychic alteration, usually mumbled over several words to herself. These seemed to spring from associations with which her thoughts were busy. The doctor, who was able to get these words, put her in a sort of hypnosis and repeated them to her over and over, in order to bring up any associations that they might have. The patient yielded to his suggestion and reproduced for him those psychic creations which controlled her thoughts during her "absences," and which betrayed themselves in these single spoken words. These were fancies, deeply sad, often poetically beautiful, day dreams, we might call them, which commonly took as their starting point the situation of a girl beside the sick-bed of her father. Whenever she had related a number of such fancies, she was, as it were, freed and restored to her normal mental life. This state of health would last for several hours, and then give place on the next day to a new "absence," which was removed in the same way by relating the newly-created fancies. It was impossible not to get the impression that the psychic alteration which was expressed in the "absence" was a consequence of the excitations originating from these intensely emotional fancy-images. The patient herself, who at this time of her illness strangely enough understood and spoke only English, gave this new kind of treatment the name "talking cure," or jokingly designated it as "chimney sweeping."
The doctor soon hit upon the fact that through such cleansing of the soul more could be accomplished than a temporary removal of the constantly recurring mental "clouds." Symptoms of the disease would disappear when in hypnosis the patient could be made to remember the situation and the associative connections under which they first appeared, provided free vent was given to the emotions which they aroused. "There was in the summer a time of intense heat, and the patient had suffered very much from thirst; for, without any apparent reason, she had suddenly become unable to drink. She would take a glass of water in her hand, but as soon as it touched her lips she would push it away as though suffering from hydrophobia. Obviously for these few seconds she was in her absent state. She ate only fruit, melons and the like, in order to relieve this tormenting thirst. When this had been going on about six weeks, she was talking one day in hypnosis about her English governess, whom she disliked, and finally told, with every sign of disgust, how she had come into the room of the governess, and how that lady's little dog, that she abhorred, had drunk out of a glass. Out of respect for the conventions the patient had remained silent. Now, after she had given energetic expression to her restrained anger, she asked for a drink, drank a large quantity of water without trouble, and woke from hypnosis with the glass at her lips. The symptom thereupon vanished permanently.
Permit me to dwell for a moment on this experience. No one had ever cured an hysterical symptom by such means before, or had come so near understanding its cause. This would be a pregnant discovery if the expectation could be confirmed that still other, perhaps the majority of symptoms, originated in this way and could be removed by the same method. Breuer spared no pains to convince himself of this and investigated the pathogenesis of the other more serious symptoms in a more orderly way. Such was indeed the case; almost all the symptoms originated in exactly this way, as remnants, as precipitates, if you like, of affectively-toned experiences, which for that reason we later called "psychic traumata." The nature of the symptoms became clear through their relation to the scene which caused them. They were, to use the technical term, "determined" (determiniert) by the scene whose memory traces they embodied, and so could no longer be described as arbitrary or enigmatical functions of the neurosis.
Only one variation from what might be expected must be mentioned. It was not always a single experience which occasioned the symptom, but usually several, perhaps many similar, repeated traumata cooperated in this effect. It was necessary to repeat the whole series of pathogenic memories in chronological sequence, and of course in reverse order, the last first and the first last. It was quite impossible to reach the first and often most essential trauma directly, without first clearing away those coming later.
You will of course want to hear me speak of other examples of the causation of hysterical symptoms beside this of inability to drink on account of the disgust caused by the dog drinking from the glass. I must, however, if I hold to my programme, limit myself to very few examples. Breuer relates, for instance, that his patient's visual disturbances could be traced back to external causes, in the following way. "The patient, with tears in her eyes, was sitting by the sick-bed when her father suddenly asked her what time it was. She could not see distinctly, strained her eyes to see, brought the watch near her eyes so that the dial seemed very large (macropia and strabismus conv.), or else she tried hard to suppress her tears, so that the sick man might not see them."
All the pathogenic impressions sprang from the time when she shared in the care of her sick father. "Once she was watching at night in the greatest anxiety for the patient, who was in a high fever, and in suspense, for a surgeon was expected from Vienna, to operate on the patient. Her mother had gone out for a little while, and Anna sat by the sick-bed, her right arm hanging over the back of her chair. She fell into a revery [sic] and saw a black snake emerge, as it were, from the wall and approach the sick man as though to bite him. (It is very probable that several snakes had actually been seen in the meadow behind the house, that she had already been frightened by them, and that these former experiences furnished the material for the hallucination.) She tried to drive off the creature, but was as though paralyzed. Her right arm, which was hanging over the back of the chair, had 'gone to sleep,' become anasthetic [sic] and paretic, and as she was looking at it, the fingers changed into little snakes with deaths-heads. (The nails.) Probably she attempted to drive away the snake with her paralyzed right hand, and so the anasthesia [sic] and paralysis of this member formed associations with the snake hallucination. When this had vanished, she tried in her anguish to speak, but could not. She could not express herself in any language, until finally she thought of the words of an English nursery song, and thereafter she could think and speak only in this language." When the memory of this scene was revived in hypnosis the paralysis of .the right arm, which had existed since the beginning of the illness, was cured and the treatment ended.
When, a number of years later, I began to use Breuer's researches and treatment on my own patients, my experiences completely coincided with his. In the case of a woman of about forty, there was a tic, a peculiar smacking noise which manifested itself whenever she was laboring under any excitement, without any obvious cause. It had its origin in two experiences which had this common element, that she attempted to make no noise, but that by a sort of counter-will this noise broke the stillness. On the first occasion, she had finally after much trouble put her sick child to sleep, and she tried to be very quiet so as not to awaken it. On the second occasion, during a ride with both her children in a thunderstorm the horses took fright, and she carefully avoided any noise for fear of frightening them still more. I give this example instead of many others which are cited in the "Studien über Hysterie."
Ladies and gentlemen, if you will permit me to generalize, as is indispensable in so brief a presentation, we may express our results up to this point in the formula: Our hysterical patients suffer from reminiscences. Their symptoms are the remnants and the memory symbols of certain (traumatic) experiences.
A comparison with other memory symbols from other sources will perhaps enable us better to understand this symbolism. The memorials and monuments with which we adorn our great cities, are also such memory symbols. If you walk through London you will find before one of the greatest railway stations of the city a richly decorated Gothic pillar -- "Charing Cross." One of the old Plantagenet kings, in the thirteenth century, caused the body of his beloved queen Eleanor to be borne to Westminster, and had Gothic crosses erected at each of the stations where the coffin was set down. Charing Cross is the last of these monuments, which preserve the memory of this sad journey. In another part of the city, you will see a high pillar of more modern construction, which is merely called "the monument." This is in memory of the great fire which broke out in the neighborhood in the year 1666, and destroyed a great part of the city. These monuments are memory symbols like the hysterical symptoms; so far the comparison seems justified. But what would you say to a Londoner who to-day stood sadly before the monument to the funeral of Queen Eleanor, instead of going about his business with the haste engendered by modern industrial conditions, or rejoicing with the young queen of his own heart? Or to another, who before the "Monument" bemoaned the burning of his loved native city, which long since has arisen again so much more splendid than before?
Now hystericals and all neurotics behave like these two unpractical Londoners, not only in that they remember the painful experiences of the distant past, but because they are still strongly affected by them. They cannot escape from the past and neglect present reality in its favor. This fixation of the mental life on the pathogenic traumata is an essential, and practically a most significant characteristic of the neurosis. I will willingly concede the objection which you are probably formulating, as you think over the history of Breuer's patient. All her traumata originated at the time when she was caring for her sick father, and her symptoms could only be regarded as memory symbols of his sickness and death. They corresponded to mourning, and a fixation on thoughts of the dead so short a time after death is certainly not pathological, but rather corresponds to normal emotional behavior. I concede this: there is nothing abnormal in the fixation of feeling on the trauma shown by Breuer's patient. But in other cases, like that of the tic that I have mentioned, the occasions for which lay ten and fifteen years back, the characteristic of this abnormal clinging to the past is very clear, and Breuer's patient would probably have developed it, if she had not come under the "cathartic treatment" such a short time after the traumatic experiences and the beginning of the disease.
We have so far only explained the relation of the hysterical symptoms to the life history of the patient; now by considering two further moments which Breuer observed, we may get a hint as to the processes of the beginning of the illness and those of the cure. With regard to the first, it is especially to be noted that Breuer's patient in almost all pathogenic situations had to suppress a strong excitement, instead of giving vent to it by appropriate words and deeds. In the little experience with her governess' dog, she suppressed, through regard for the conventions, all manifestations of her very intense disgust. While she was seated by her father's sick bed, she was careful to betray nothing of her anxiety and her painful depression to the patient. When, later, she reproduced the same scene before the physician, the emotion which she had suppressed on the occurrence of the scene burst out with especial strength, as though it had been pent up all along. The symptom which had been caused by that scene reached its greatest intensity while the doctor was striving to revive the memory of the scene, and vanished after it had been fully laid bare. On the other hand, experience shows that if the patient is reproducing the traumatic scene to the physician, the process bas no curative effect if, by some peculiar chance, there is no development of emotion. It is apparently these emotional processes upon which the illness of the patient and the restoration to health are dependent. We feel justified in regarding "emotion" as a quantity which may become increased, derived and displaced. So we are forced to the conclusion that the patient fell ill because the emotion developed in the pathogenic situation was prevented from escaping normally, and that the essence of the sickness lies in the fact that these "imprisoned" (dingeklemmt) emotions undergo a series of abnormal changes. In part they are preserved as a lasting charge and as a source of constant disturbance in psycbical life; in part they undergo a change into unusual bodily innervations [sic] and inhibitions, which present themselves as the physical symptoms of the case. We have coined the name "hysterical conversion " for the latter process. Part of our mental energy is, under normal conditions, conducted off by way of physical innervation [sic] and gives what we call "the expression of emotions." Hysterical conversion exaggerates this part of the course of a mental process which is emotionally colored; it corresponds to a far more intense emotional expression, which finds outlet by new paths. If a stream flows in two channels, an overflow of one will take place as soon as the current in the other meets with an obstacle.
You see that we are in a fair way to arrive at a purely psychological theory of hysteria, in which we assign the first rank to the affective processes. A second observation of Breuer compels us to ascribe to the altered condition of consciousness a great part in determining the characteristics of the disease. His patient showed many sorts of mental states, conditions of "absence," confusion and alteration of character, besides her normal state. In her normal state she was entirely ignorant of the pathogenic scenes and of their connection with her symptoms. She had forgotten those scenes, or at any rate had dissociated them from their pathogenic connection. When the patient was hypnotized, it was possible, after considerable difficulty, to recall those scenes to her memory, and by this means of recall the symptoms were removed. It would have been extremely perplexing to know how to interpret this fact, if hypnotic practice and experiments had not pointed out the way. Through the study of hypnotic phenomena, the conception, strange though it was at first, has become familiar, that in one and the same individual several mental groupings are possible, which may remain relatively independent of each other, "know nothing" of each other, and which may cause a splitting of consciousness along lines which they lay down. Cases of such a sort, known as "double personality" ("double conscience"), occasionally appear spontaneously. If in such a division of personality consciousness remains constantly bound up with one of the two states, this is called the conscious mental state, and the other the unconscious. In the well-known phenomena of so-called post hypnotic suggestion, in which a command given in hypnosis is later executed in the normal state as though by an imperative suggestion, we have an excellent basis for understanding how the unconscious state can influence the conscious, although the latter is ignorant of the existence of the former. In the same way it is quite possible to explain the facts in hysterical cases. Breuer came to the conclusion that the hysterical symptoms originated in such peculiar mental states, which he called "hypnoidal states." (hypnoide Zustände.) Experiences of an emotional nature, which occur during such hypnoidal states easily become pathogenic, since such states do not present the conditions for a normal draining off of the emotion of the exciting processes. And as a result there arises a peculiar product of this exciting process, that is, the symptom, and this is projected like a foreign body into the normal state. The latter has, then, no conception of the significance of the hypnoidal pathogenic situation. Where a symptom arises, we also find an amnesia, a memory gap, and the filling of this gap includes the removal of the conditions under which the symptom originated.
I am afraid that this portion of my treatment will not seem very clear, but you must remember that we are dealing here with new and difficult views, which perhaps could not be made much clearer. This all goes to show that our knowledge in this field is not yet very far advanced. Breuer's idea of the hypnoidal states has, moreover, been shown to be superfluous and a hindrance to further investigation, and has been dropped from present conceptions of psychoanalysis. Later I shall at least suggest what other influences and processes have been disclosed besides that of the hypnoidal states, to which Breuer limited the causal moment.
You have probably also felt, and rightly, that Breuer's investigations gave you only a very incomplete theory and insufficient explanation of the phenomena which we have observed. But complete theories do not fall from Heaven, and you would have had still greater reason to be distrustful, had any one offered you at the beginning of his observations a well-rounded theory, without any gaps; such a theory could only be the child of his speculations and not the fruit of an unprejudiced investigation of the facts.