eading Freud clear version in English

CHARCOT 53 his 'Lefons du mardi'. There he took up cases which were completely unknown to hirn; he exposed hirnself to all the chances of an exami- nation, a11 the errors of a first investigation; he would put aside his authority on occasion and admit-in one ca se that he could arrive at no diagnosis and in another that he had been deceived by appearances; and he never appeared greater to his audience than when, by giving the most detailed account of his processes of thought and by showing the greatest frankness about his doubts and hesitations, he had thus sought to narrow the gulf between teacher and pupil. The publication of these improvised lectures, given in the year 1887 and 1888, at first in French and now in German as weIl, has also immeasurably widened the circle of his admirers; and never before has a work on neuropathology had such a success with the medical public as this. At about the time at which the clinic was established and at which he gave up the Chair of Pathological Anatomy, a change occurred in the direction of Charcot's scientific pursuits, and to this we owe the finest ofhis work. He now pronounced that the theory of organic nervous illnesses was for the time being fairly complete, and he began to turn his attention almost exclusive!y to hysteria, which thus all at once be- ca me the focus of general interest. This, the most enigmatic of a1l nervous diseases, for the evaluation of which medicine had not yet found a serviceable angle of approach, had just then fallen into thorough discredit; and this discredit extended not only to the patients but to the physicians who concerned themselves with the neurosis. It was held that in hysteria anything was possible, and no credence was given to a hysteric about anything. The first thing that Charcot's work did was to restore its dignity to the topic. Little by little, people gave up the scomful smile with which the patient could at that time fee! certain of being met. She was no longer necessarily a malingerer, for Charcot had thrown the whole weight of his authority on the side of the genuineness and ob- jectivity of hysterical phenomena. * * * He treated hysteria as just another topic in neuropathology; he gave a complete description of its phenomena, demonstrated that these had their own laws and uniform- ities, and showed how to recognize the symptoms which enable a di- agnosis of hysteria to be made. The most painstaking investigations, initiated by himse!f and his pupils, extended over hysterical disturbances of sensibility in the skin and deeper tissues, over the behaviour of the sense organs, and over the peculiarities of hysterical contractures and paralyses, and of trophic disturbances and changes in metabolism. The many different forms ofhysterical attack were described, and a schematic plan was drawn up by depicting the typical configuration of the major hysterical attack ['grande hysterie'] as occurring in four stages, which made it possible to trace the commonly observed 'minor' attacks ['petite hysterie'] back to this same typical configuration. The localization and frequency of occurrence of the so-caIled 'hysterogenic zones' and their re!ationship to the attacks were also studied, and so on. Once a11 this

54 MAKlNG OF A PSYCHOANAL YST information about the manifestations of hysteria had been arrived at, a number of surprising discoveries were made. Hysteria in males, and especially in men of the working class, was found far more often than had been expected; it was convincingly shown that certain conditions which had been put down to alcoholic intoxication or lead-poisoning were of a hysterical nature; it was possible to subsurne under hysteria a whole number of affections which had hitherto not been understood and which had remained unclassified; and where the neurosis had be- come joined with other disorders to form complex pictures, it was pos- ;ible to separate out the part played by hysteria. Most far-reaching of all were the investigations into nervous illnesses which followed upon severe traumas-the 'traumatic neuroses'-views about which are still under discussion and in connection with which Charcot has successfully put forward the arguments in favour of hysteria. * * * The construction of this great edifice was naturally not achieved with- out violent opposition. But it was the sterile opposition of an old gen- eration who did not want to have their views changed. The younger among the neuropathologists, including those in Germany, accepted Charcot's teaching to a greater or lesser degree. Charcot hirnself was completely certain that his theories about hysteria would triumph. When it was objected that the four stages of hysteria, hysteria in men, and so on, were not observable outside France, he pointed out how long he hirnself had overlooked these things, and he said once more that hysteria was the same in all places and at every time. He was very sensitive about the accusation that the French were a far more neurotic nation than any other and that hysteria was a kind of national bad habit; and he was much pleased when a paper 'On a Ca se of Reflex Epilepsy', which dealt with a Prussian Grenadier, enabled hirn to make a long-range diagnosis of hysteria. At one point in his work Charcot rose to a level higher even than that of his usual treatment of hysteria. The step he took assured hirn far all time, too, the farne of having been the first to explain hysteria. While he was engaged in the study of hysterical paralyses arising after traumas, he had the idea of artificially reproducing those paralyses, which he had earlier differentiated with ca re from organic ones. For this purpose he made use of hysterical patients whom he put into astate of somnam- bulism by hypnotizing them. He succeeded in proving, by an unbroken chain of argument, that these paralyses were the result of ideas which had dominated the patient's brain at moments of a special disposition. In this way, the mechanism of a hysterical phenomenon was explained for the first time. This incomparably fine piece of clinical research was afterwards taken up by his own pupil, Pierre Janet, as weil as by Breuer and others, who developed from it a theory of neurosis which coincided

DRAFT B 55 with the mediaeval view-when once they had replaced the 'dem on' of clerical phantasy by a psychological formula. Charcot's concern with hypnotic phenomena in hysterical patients led to very great advances in this important field of hitherto neglected and despised facts, for the weight of his name put an end once and for all to any doubt about the reality of hypnotic manifestations. But the exdusively nosographical approach adopted at the School of the Sal- petriere was not suitable far a purely psychological subject. The restric- tion of the study of hypnosis to hysterical patients, the differentiation between major and minar hypnotism, the hypothesis of three stages of 'major hypnosis', and their characterization by somatic phenomena- all this sank in the estimation of Charcot's contemporaries when Li€:- beault' s pupil, Bernheim, set about constructing the theory of hypnotism on a mare comprehensive psychological foundation and making sug- gestion the central point of hypnosis. It is only the opponents of hyp- notism who, content to conceal their lack of personal experience behind an appeal to authority, still ding to Charcot's assertions and who like to take advantage of a pronouncement made by hirn in his last years, in which he denied to hypnosis any value as a therapeutic method. Furthermore, the aetiological theories supported by Charcot in his doctrine of the 'familIe nevropathique', which he made the basis of his whole concept of nervous disorders, will no doubt soon require sifting and emending. So greatly did Charcot overestimate heredity as a caus- ative agent that he left no room far the acquisition of nervous illness. To syphilis he merely allotted a modest place among the 'agents pro- vocateurs'; nor did he make a sufficiently sharp distinction between organic nervous affections and neuroses, either as regards their aetiology or in other respects. It is inevitable that the advance of our science, as it increases our knowledge, must at the same time lessen the value of a number of things that Charcot taught us; but neither changing times nor changing views can diminish the farne of the man whom-in France and elsewhere-we are mourning to-day. VIENNA, August 1893. Draft B Freud met Wilhelm Fliess (1858-1926), a reputable nose and throat spe- cialist from Berlin, in November 1887, and the two men soon became fast friends, sharing the most intimate personal and professional secrets. They remained friends until they quarreled irreparably in 1900 and, though their correspondence lingered on for several years, never saw one another again. The importance of Fliess for Freud cannot be overestimated: during the 1890s, the decade that Freud scouted out unknown terrains of the mind,

56 MAKING OF A PSYCHOANAL YST Fliess was Freud's reliable and imaginative supporter, critic, inspiration. In a rather loose sense, he acted as Freud's analyst; there was no one--no one--whom Freud trusted so completely and on whom he transferred more passionate feelings. Fliess was enamored of highly unconventional notions concerning the influence of the nose on other bodily organs, and propagated speculations about male and female cycles of twenty-three and twenty-eight days respectively, which, he thought, deterrnined moods, creativity, and the recurrence of ailments. For years, though, Freud was wholly uncritical of his friend from Berlin, met hirn at occasional \"congresses\" where the two men canvassed their latest discoveries, and sent hirn confidential letters and long exploratory memoranda in which he developed his burgeoning theories of mental functioning-and malfunctioning. The following draft, enclosed in a letter of February 8, 1893, is a good instance of such a memorandum. It shows Freud experimenting with ideas about what he would later call \"anxiety neurosis.\" It also shows the importance that sexuality had begun to assurne as a causative factor in \"neurasthenia.\" THE AETIOLOGY OF THE NEUROSES I am writing the whole thing down a second time, for you, my dear friend, and for the sake of our common labours. Y ou will of course keep the draft away from your young wife. 1. It may be taken as a recognized fact that neurasthenia is a frequent consequence of an abnormal sexuallife. The assertion, however, which I wish to make and to test by my observations is that neurasthenia is always only a sexual neurosis. I have adopted a similar point of view (along with Breuer) in regard to hysteria. Traumatic hysteria was weil known; what we asserted beyond this was that every hysteria that is not hereditary is traumatic. In the same way I am now asserting that every neurasthenia is sexual. We will for the moment leave on one side the question of whether hereditary disposition and, seeondarily, toxie influenees ean produce genuine neurasthenia, or whether what appears to be hereditary neur- asthenia in fact also goes back to early sexual exhaustion. If there is such a thing as hereditary neurasthenia, the questions arise of whether the status nervosus in the hereditary eases should not be distinguished from neurasthenia, what relation at all it has to the eorresponding symptoms in childhood, and so on. In the first instanee, therefore, my contention will be restricted to acquired neurasthenia. What I am asserting ean aeeordingly be for- mulated as folIows. In the aetiology of a nervous affection we must distinguish (1) the necessary precondition without whieh the state eannot eome ahout at all , and (2) the precipitating factors. The relation between these two can be pictured thus. Ifthe necessary preeondition has operated

DRAFI' B 57 sufficiently, the affection sets in as an inevitable consequence; if it has not operated sufficiently, the result of its operation is in the first place a disposition to the affection which ceases to be latent as soon as a sufficient amount of one of the secondary factors supervenes. Thus what is lacking for full effect in the first aetiology can be replaced by the aetiology of the second order. The aetiology of the second order can, however, be dispensed with, while that of the first order is indispensable. If this aetiological formula is applied to our present case, we arrive at this. Sexual exhaustion can by itself alone provoke neurasthenia. If it fails to achieve this by itself, it has such an effect on the disposition of the nervous system that physical illness, depressive affects and overwork (toxic inAuences) can no longer be tolerated without [leading toJ neur- asthenia. Without sexual exhaustion, however, all these factors are in- capable of generating neurasthenia. They bring about normal fatigue, normal sorrow, normal physical weakness, but they only continue to give evidence of how much 'of these detrimental inAuences anormal person can tolerate'. I will consider neurasthenia in men and in women separately. Neurasthenia in males is acquired at puberty and becomes manifest in the patient's twenties. Its source is masturbation, the frequency of which runs complet~ly parallel with the frequency of male neurasthenia. One can observe in the circle of one's acquaintances that (at all events in urban populations) those who have been seduced by women at an early age have escaped neurasthenia. When this noxa has operated long and intensely, it turns the person concerned into a sexual neurasthenic, whose potency, too, has been impaired; the intensity of the cause is paralleled by a life-long persistence of the condition. Further evidence of the causa I connection lies in the fact that a sexual neurasthenic is always a general neurasthenic at the same time. If the noxa has not been sufficiently intense, it will have (in accordance with the formula given above) an effect on the patient's disposition; so that later, if provoking factors supervene, it will produce neurasthenia, which those factors alone would not have produced. Intellectual work- cerebral neurasthenia; normal sexual activity-spinal neurasthenia, etc. In intermediate cases we find the neurasthenia of youth, which typ- ically begins and runs its course accompanied by dyspepsia, etc., and which terrninates at marriage. The second noxa, which affects men at a later age, makes its impact on a nervous system which is either intact or which has been disposed to neurasthenia through masturbation. The question is whether it can lead to detrimental results even in the former case; probably it can. Its effect is manifest in the second case, where it revives the neurasthenia of youth and creates new symptoms. This second noxa is onanismus conjugalis-incomplete coition in order to prevent conception. In the ca se of men all the methods of achieving this seem to fall into line: they

58 MAKING OF A PSYCHOANALYST operate with varying intensity aeeording to the subjeees earlier dispo- sition, but do not aetually differ qualitatively. Even normal eoition is not tolerated by those with a strong disposition or by ehronie neuras- thenies; and beyond this, intoleranee of the eondom, of extra-vaginal eoition and of eoitus interruptus take their toll. A healthy man will tolerate all of these for quite a long time, but even so not indefinitely. After a eertain time he behaves like the disposed subject. His only advantage over the masturbator is the privilege of a longer lateney or the fact that on every oeeasion he needs a provoking eause. Here eoitus interruptus proves to be the main noxa and produees its eharacteristic effect even in non-disposed subjeets. Neurasthenia in {emales. Normally, girls are sound and not neurasthenie; and this is true as weIl of young married women, in spite of aB the sexual traumas of this period of life. In eomparatively rare eases neur- asthenia appears in married women and in older unmarried ones in its pure form; it is then to be regarded as having arisen spontaneously and in the same manner [? as is men]. Far more often neurasthenia in a married woman is derived from neurasthenia in a man or is produeed simultaneously. In that ease there is almost always an admixture of hysteria and we have the common mixed neurosis of women. The mixed neurosis of women is derived from neurasthenia in men in aB those not infrequent cases in which the man, being a sexual neurasthenie, suffers from impaired poteney. The admixture of hysteria results direetly from the holding-back of the excitation of the aet. The poarer the man's poteney, the more the woman's hysteria predominates; so that in reality a sexually neurasthenie man makes his wife not so mueh neurasthenie as hysterieal. This neurosis arises, with neurasthenia in males, during the seeond on set of sexual noxae, whieh is of far the greater signifieance for a woman, assuming that she is sound. Thus we eome aeross far more neurotie men during the first deeade of puberty and far more neurotie women during the seeond. In the latter ease this is the result of the noxae due to the prevention of eoneeption. It is not easy to arrange them in order and in general none of them should be regarded as entirely innoeuous to women; so that even in the most favorable ease (a eondom) women, being the more exaeting partners, will searcely eseape slight neurasthenia. A great deal will obviously depend on the two dispositions: whether (1) she herself was neurasthenie before marriage or whether (2) she was made hysterieo-neurasthenic during the period of free inter- eourse [without preventives]. 11. Anxiety neurosis. Every case of neurasthenia is no doubt marked by a eertain lowering of self-eonfidence, by pessimistie expectation and an inelination to distressing antithetie ideas. But the question is whether

DRAFf B 59 the prominent emergence of this factor [anxiety], without the other symptoms being specially developed, should not be detached as an in- dependent 'anxiety neurosis', especially as this is to be met with no less frequently in hysteria than in neurasthenia. Anxiety neurosis appears in two forms: as a chronic state and as an attack of anxiety. The two may readily be combined: and an anxiety attack never occurs without chronic symptoms. Anxiety attacks are com- moner in the farms connected with hysteria-more frequent, therefore, in women. The chronic symptoms are commoner in neurasthenie men. The chronic symptoms are: (1) anxiety relating to the body (hypo- chondria); (2) anxiety relating to the functioning of the body (agorapho- bia, c1austrophobia, giddiness on heights); (3) anxiety relating to decisions and memory (folie du doute, obsessive brooding, etc.). So far, I have found no oeeasion far not treating these symptoms as equivalent. Again, the question is (1) to what extent this condition emerges in hereditary cases, without any sexual noxa, (2) whether it is released in hereditary cases by any chance sexual noxa, (3) whether it supervenes as an inten- sification in common neurasthenia. There is no question but that it is acquired, and specially by men and women in marriage, during the seeond period of sexual noxae, through coitus interruptus. I do not believe that disposition owing to earlier neurasthenia is necessary for this; but where disposition is lacking, latency is longer. The causal formula is the same as in neurasthenia. The rarer ca ses of anxiety neurosis outside marriage are met with especially in men. They turn out to be cases of congressus interruptus in whieh the man is strongly involved psychically with women whose well-being is a matter of concern to hirn. This procedure in these con- ditions is a greater noxa far a man than coitus interruptus in mar- riage, far this is often corrected, as it were, by normal coitus outside marriage. I must look upon periodie depression, an attack of anxiety lasting for weeks ar months, as a third form of anxiety neurosis. This, in contrast to melaneholia proper, almost always has an apparently rational con- nection with a psychical trauma. The latter is, however, only the pro- voking cause. Mareover, this periodie depression is without psychical [sexual] anaesthesia, which is characteristic of melancholia. I have been able to trace back a number of such cases to coitus interruptus; their onset was a late one, during marriage, after the birth of the last child. In a case of tormenting hypochondria which began at puberty, I was able to prove an assault in the eighth year of life. Another case from childhood turned out to be a hysterical reaction to a mastur- batory assault. Thus I cannot tell whether we have here truly hereditary forms without a sexual cause; and on the other hand I cannot tell whether coitus interruptus alone is to be blamed here, whether hereditary dis- position can always be dispensed with.

60 MAKING OF A PSYCHOANALYST I will omit occupational neuroses, since, as I have told you, changes in the muscular parts have been demonstrated in them. CONCLUSIONS It follows from what I have said that neuroses are entirely preventible as weil as entirely incurable. The physician' s task is wholly shifted on to prophylaxis. The first part of this task, the prevention of the sexual noxa of the first period, coincides with prophylaxis against syphilis and gonorrhoea, since they are the noxae which threaten anyone who gives up mastur- bation. The only alternative would be free sexual intercourse between young men and respectable girls; but this could only be adopted if there were innocuous methods of preventing conception. Otherwise, the al- ternatives are: masturbation, neurasthenia in the male, hystero-neuras- thenia in the female, or syphilis in the male, syphilis in the next generation, gonorrhoea in the male, gonorrhoea and sterility in the female. The same problem-an innocuous means of controlling conception- is set by the sexual trauma of the second period; since the condom provides neither a safe solution nor one acceptable to someone who is already neurasthenie. In the absence of such a solution, society appears doomed to fall a victim to incurable neuroses, which reduce the enjoyment of life to a minimum, destroy the marriage relation and bring hereditary ruin on the whole coming generation. The lower strata of society know nothing of Malthusianism, but they are in full pursuit, and in the course of things will reach the same point and fall victim to the same fatality. Thus the physician is faced by a problem whose solution is worthy of all his efforts. JOSEF BREUER Anna O. During the early 1890s, as Freud's intimacy with Fliess grew, his intimacy with his older friend Josef Breuer began to wane. Through the previous decade, the horne of Breuer, and of his wife Mathilde, had been a warm, hospitable, generous, and always interesting refuge for the still unknown, immensely ambitious Freud. When Freud's oldest child, a daughter, was born in October 1887, he named her after Frau Breuer as a matter of course. And it was during these congenial years that Breuer told Freud about a fascinating hysterie he had treated some time earlier, between 1880 and 1882. The case had its embarrassing aspects, notably Anna O.'s infatuation with her physician (Freud would later call this a case of\"transference love\"), but precisely these interested Freud, and he pressed Breuer again and again for more details. While Breuer refused to follow the implications of \"Anna

ANNA O. 61 0.,\" Freud had the courage of Breuer's discoveries. Many years later, in his \"Autobiographical Study,\" Freud would incorporate the essen ce of the case and be rather scathing about what he thought Breuer's genteel, non- sexual interpretation of Anna O.'s hysteria (see above, p. 13). Still, in a very real sense, Anna O. (really Bertha Pappenheim, later to become a prominent social worker and energetic leader in Jewish feminist causes) may claim the distinction of being the founding patient of psychoanalysis. That is why Freud more than once gave Breuer credit for originating psycho- analysis, and why this text, even if it is not by Freud, is essential to this anthology. In Studies on Hysteria, a collection of case histories and theo- retical papers that Breuer and Freud published jointly in 1895, Anna O. has pride of place. II CASE HISTORIES (BREUER AND FREuD) CASE I FRÄULEIN ANNA O. (Breuer) At the time of her falling ill (in 1880) Fräulein Anna O. was twenty- one years old. She may be regarded as having had a moderately severe neuropathie heredity, sinee some .psyehoses had oecurred among her more distant relatives. Her parents were normal in this respeet. She herself had hitherto been eonsistently healthy and had shown no signs of neurosis during her period of growth. She was markedly intelligent, with an astonishingly quiek grasp of things and penetrating intuition. She possessed a powerful intellect which would have been capable of digesting solid mental pabulum and which stood in need of it-though without receiving it after she had left schoo!. She had great poetic and imaginative gifts, which were under the control of a sharp and critical common sense. Owing to this latter quality she was completely unsug- gestible; she was only influenced by arguments, never by mere assertions. Her will-power was energetic, tenacious and persistent; sometimes it reached the pitch of an obstinacy which only gave way out of kindness and regard for other people. One of her essential character traits was sympathetic kindness. Even during her illness she herself was greatly assisted by being able to look after a number of poor, sick people, for she was thus able to satisfy a powerful instinet. Her states of feeling always tended to a slight exag- geration, alike of cheerfulness and gloom; hence she was sometimes

62 MAKING OF A PSYCHOANALYST subject to moods. The element of sexuality was astonishingly undevel- oped in her. The patient, whose life became known to me to an extent to which one person's life is seldom known to another, had never been in love; and in all the enormous number of hallucinations which oc- curred during her illness that element of mental life never emerged. This girl, who was bubbling over with intellectual vitality, led an extremely monotonous existence in her puritanically-minded family. She embellished her life in a manner which probably influenced her decisively in the direction of her illness, by indulging in systematic day- dreaming, which she described as her 'private theatre'. While everyone thought she was attending, she was living through fairy tales in her imagination; but she was always on the spot when she was spoken to, so that no one was aware of it. She pursued this activity almost contin- uously while she was engaged on her household duties, which she discharged unexceptionably. I shall presently have to describe the way in which this habitual day-dreaming while she was weil passed over into illness without a break. The course of the illness fell into several clearly separable phases: (A) Latent incubation. From the middle of July, 1880, till about Oecember 10. This phase of an illness is usually hidden from us; but in this case, owing to its peculiar character, it was completely accessible; and this in itself lends no sm all pathological interest to the history. I shall describe this phase presently. (B) The manifest illness. A psychosis of a peculiar kind, paraphasia, a convergent squint, severe disturbances of vision, paralyses (in the form of contractures), complete in the right upper and both lower extremities, partial in the left upper extremity, paresis of the neck muscles: A gradual reduction of the contracture to the right-hand extremities. Some im- provement, interrupted by a severe psychical trauma (the death of the patient's father) in April, after which there followed (C) Aperiod of persisting somnambulism, subsequently alternating with more normal states. A number of chronic symptoms persisted till Oecember, 1881. (D) Gradual cessation of the pathological states and symptoms up to June, 1882. In July, 1880, the patient's father, of whom she was passionately fond, fell ill of a peripleuritic abscess which failed to clear up and to which he succumbed in April, 1881. Ouring the first months of the illness Anna devoted her whole energy to nursing her father, and no one was much surprised when by degrees her own health greatly deteriorated. No one, perhaps not even the patient herself, knew what was happening to her; but eventually the state of weakness, anaemia and distaste far food became so bad that to her great sorrow she was no longer allowed to continue nursing the patient. The immediate cause of this was a very severe cough, on account of which I examined her far the first time. It

ANNA O. 63 was a typical tussis nervosa. She soon began to displaya marked craving for rest during the afternoon, followed in the evening by a sleep-like state and afterwards a highly excited condition. At the beginning of December a convergent squint appeared. An ophthalmic surgeon explained this (mistakenly) as being due to paresis of one abducens. On December 11 the patient took to her bed and remained there until April 1. There developed in rapid succession aseries of severe disturbances which were apparently quite new: left-sided occipital headache; con- vergent squint (diplopia), markedly increased by excitement; complaints that the walls of the room seemed to be falling over (affection of the obliquus); disturbances of vision which it was hard to analyse; paresis of the muscles of the front of the neck, so that finally the patient could only move her head by pressing it backwards between her raised shoulders and moving her whole back; contracture and anaesthesia of the right upper, and, after a time, of the right lower extremity. The latter was fully extended, adducted and rotated inwards. Later the same symptom appeared in the left lower extremity and finally in the left arm, of which, however, the fingers to some extent retained the power of movement. So, too, there was no complete rigidity in the shoulder-joints. The contracture reached its maximum in the muscles of the upper arms. In the same way, the region of the elbows turned out to be the most affected by anaesthesia when, at a later stage, it became possible to make a more careful test of this. At the beginning of the illness the anaesthesia could not be eH1ciently tested, owing to the patient's resistance arising from feelings of anxiety. It was while the patient was in this condition that I undertook her treatment, and I at on ce recognized the seriousness of the psychical disturbance with wh ich I had to deal. Two entirely distinct states of consciousness were present which alternated very frequently and without warning and which became more and more differentiated in the course of the illness. In one of these states she recognized her surroundings; she was melancholy and anxious, but relatively normal. In the other state she hallucinated and was 'naughty'-that is to say, she was abusive, used to throw the cushions at people, so far as the contractures at various times allowed, tore buttons off her bedclothes and !inen with those of her fingers which she could move, and so on. At this stage of her illness if something had been moved in the room or someone had entered or left it [during her other state of consciousness] she would complain of having 'lost' so me time and would remark upon the gap in her train of conscious thoughts. Since those about her tried to deny this and to soothe her when she complained that she was going mad, she would, after throwing the pillows about, accuse people of doing things to her and leaving her in a muddle, etc. These 'absences' had already been observed before she took to her bed; she used then to stop in the middle of a sentence, repeat her last words

64 MAKING OF A PSYCHOANALYST and after a short pause go on talking. These interruptions gradually increased till they reached the dimensions that have just been described; and during the dimax of the iIIness, when the contractures had extended to the left side of her body, it was only for a short time during the day that she was to any degree normal. But the disturbances invaded even her moments of relatively dear consciousness. There were extremely rapid changes of mood leading to excessive but quite temporary high spirits, and at other times severe anxiety, stubborn opposition to every therapeutic effort and frightening hallucinations of black snakes, which was how she saw her hair, ribbons and similar things. At the same time she kept on telling herself not to be so silly: what she was seeing was really only her hair, etc. At moments when her mind was quite dear she would complain of the profound darkness in her head, of not being able to think, of becoming blind and deaf, of having two selves, areal one and an evil one which forced her to behave badly, and so on. In the afternoons she would fall into a somnolent state which lasted till about an hour after sunset. She would then wake up and complain that something was tormenting her-or rather, she would keep repeating in the impersonal form 'tormenting, tormenting'. For alongside of the development of the contractures there appeared a deep-going functional disorganization of her speech. It first became noticeable that she was at a loss to find words, and this difficulty gradually increased. Later she lost her command of grammar and syntax; she no longer conjugated verbs, and eventually she used only infinitives, for the most part incor- rectly formed from weak past participles; and she omitted both the def- inite and indefinite artiele. In the process of time she became almost completely deprived of words. She put them together laboriously out of four or five languages and became almost unintelligible. When she tried to write (until her contractures entirely prevented her doing so) she employed the same jargon. For two weeks she became completely du mb and in spite of making great and continuous efforts to speak she was unable to say a syllable. And now for the first time the psychical mech- anism of the disorder became dear. As I knew, she had feit very much offended over something and had determined not to speak about it. When I guessed this and obliged her to talk about it, the inhibition, which had made any other kind of utterance impossible as weil, disappeared. This change coincided with areturn of the power of movement to the extremities of the left side of her body, in March, 1881. Her para- phasia receded; but thenceforward she spoke only in English-appar- ently, however, without knowing that she was doing so. She had disputes with her nurse who was, of course, unable to understand her. It was only some months later that I was able to convince her that she was talking English. Nevertheless, she herself could still understand the people about her who talked Cerman. Only in moments of extreme

ANNA O. 65 anxiety did her power of speech desert her entirely, or else she would use a mixture of all sorts of languages. At tim es when she was at her very best and most free, she talked French and ltalian. There was com- plete amnesia between these times and those at which she talked English. At this point, too, her squint began to diminish and made its appearance only at moments of great excitement. She was once again able to support her head. On the first of April she got up for the first time. On the fifth of April her adored father died. Ouring her illness she had seen hirn very rarely and for short periods. This was the most severe psychical trauma that she could possibly have experienced. A violent outburst of excitement was succeeded by profound stupor which lasted about two days and from which she emerged in a greatly changed state. At first she was far quieter and her feelings of anxiety were much di- minished. The contracture of her right arm and leg persisted as well as their anaesthesia, though this was not deep. There was a high degree of restriction of the field of vision: in a bunch of Bowers which gave her much pleasure she could only see one Bower at a time. She complained of not being able to recognize people. Normally, she said, she had been able to recognize faces without having to make any deliberate effort; now she was obliged to do laborious 'recognizing work'l and had to say to herself 'this person's nose is such-and-such, his hair is such-and-such, so he must be so-and-so'. All the people she saw seemed like wax figures without any connection with her. She found the presence of some of her dose relatives very distressing and this negative attitude grew con- tinually stronger. If someone whom she was ordinarily pleased to see came into the room, she would recognize hirn and would be aware of things for a short time, but would soon sink back into her own broodings and her visitor was biotted out. I was the only person whom she always recognized when I came in; so long as I was talking to her she was always in contact with things and lively, except for the sudden inter- ruptions caused by one of her hallucinatory 'absences'. She now spoke only English and could not understand what was said to her in German. Those about her were obliged to talk to her in English; even the nurse learned to make herself to so me extent understood in this way. She was, however, able to read French and ltalian. If she had to read one of these aloud, what she produced, with extraordinary Buency, was an admirable extempore English translation. She began writing again, but in a peculiar fashion. She wrote with her left hand, the less stiff one, and she used Roman printed letters, copying the alphabet from her edition of Shakespeare. She had eaten extremely little previously, but now she refused nour- ishment altogether. However, she allowed me to feed her, so that she very soon began to take more food. But she never consented to eat bread. 1. [In English in the original. I

66 MAKING OF A PSYCHOANALYST After her meal she invariably rinsed out her mouth and even did so if, for any reason, she had not eaten anything-which shows how absent- minded she was about such things. Her somnolent states in the afternoon and her deep sleep after sunset persisted. If, after this, she had talked herself out (I shall have to explain what is meant by this later) she was c1ear in mind, calm and cheerful. This comparatively tolerable state did not last long. Some ten days after her father's death a consuItant was brought in, whom, like all strangers, she completely ignored while I demonstrated all her pecul- iarities to hirn. 'That's like an examination,'2 she said, laughing, when I got her to read a French text aloud in English. The other physician intervened in the conversation and tried to attract her attention, but in vain. It was a genuine 'negative hallucination' of the kind which has since so often been produced experimentally. In the end he succeeded in breaking through it by blowing smoke in her face. She suddenly saw a stranger before her, rushed to the door to take away the key and fell unconscious to the ground. There followed a short fit of anger and then a severe attack of anxiety which I had great difficulty in calming down. Unluckily I had to leave Vienna that evening, and when I came back several days later I found the patient much worse. She had gone entirely without food the whole time, was full of anxiety and her hallucinatory absences were filled with terrifying figures, death's heads and skeletons. Since she acted these things through as though she was experiencing them and in part put them into words, the people around her becarne aware to a great extent of the content of these hallucinations. The regular order of things was: the somnolent state in the afternoon, followed after sunset by the deep hypnosis for which she invented the technical name of 'c1ouds'. 3 If during this she was able to narrate the hallucinations she had had in the course of the day, she would wake up c1ear in mind, calm and cheerful. She would sit down to work and write or draw far into the night quite rationally. At about four she would go to bed. Next day the whole series of events would be repeated. It was a truly remarkable contrast: in the day-time the irresponsible patient pursued by hallucinations, and at night the girI with her mind completely deaL In spite of her euphoria at night, her psychical condition deteriorated steadily. Strong suicidal impulses appeared which made it seem inad- visable for her to continue living on the third Roor. Against her will, therefore, she was transferred to a country house in the neighbourhood ofVienna (on June 7, 1881). I had neverthreatened her with this removal from her horne, which she regarded with horror, but she herself had, without saying so, expected and dreaded it. This event made it dear once more how much the affect of anxiety dominated her psychical disorder. Just as after her father's death a calmer condition had set in, 2. [In English in the original. J 3. [In English in the original. J

ANNA O. 67 so now, when wh at she feared had actually taken place, she once more became calmer. Nevertheless, the move was immediately followed by three days and nights completely without sleep or nourishment, by numerous attempts at suicide (though, so long as she was in a garden, these were not dangerous), by smashing windows and so on, and by hallucinations unaccompanied by absences-which she was able to dis- tinguish easily from her other hallucinations. After this she grew quieter, let the nurse feed her and even took chloral at night. Before continuing my account of the case, I must go back once more and describe one of its peculiarities which I have hitherto mentioned only in passing. I have already said that throughout the illness up to this point the patient fell into a somnolent state every afternoon and that after sunset this period passed into a deeper sleep-'clouds'. (It seems plausible to attribute this regular sequence of events merely to her ex- perience while she was nursing her father, which she had had to do for several months. During the nights she had watched by the patient's bedside or had been awake anxiously listening till the morning; in the afternoons she had lain down for a short rest, as is the usual habit of nurses. This pattern of waking at night and sleeping in the afternoons seems to have been carried over into her own illness and to have persisted long after the sleep had been replaced by a hypnotic state.) After the deep sleep had lasted about an hour she grew restless, tossed to and fro and kept repeating 'tormenting, tormenting', with her eyes shut all the time. It was also noticed how, during her absences in day-time she was obviously creating some situation or episode to which she gave a clue with a few muttered words. It happened then-to begin with accidentally but later intentionally-that someone near her repeated one of these phrases of hers while she was complaining about the 'tormenting'. She at on ce joined in and began to paint some situation or tell some story, hesitatingly at first and in her paraphasie jargon; but the longer she went on the more fluent she became, till at last she was speaking quite correct German. (This applies to the early period before she began talking English only.) The stories were always sad and some of them very charming, in the style of Hans Andersen's Picture-book without Pictures, and, indeed, they were probably constructed on that model. As a rule their starting-point or central situation was of a girl anxiously sitting by a sick-bed. But she also built up her stories on quite other topics.-A few moments after she had finished her narrative she would wake up, obviously calmed down, or, as she called it, 'gehäglich'.4 During the night she would again become restless, and in the morning, after a couple of hours' sleep, she was visibly involved in some other set of ideas.-If for any reason she was unable to tell me the story during her evening hypnosis she failed to calm down afterwards, and on the fol- 4. [She used this made-up word instead of the regular German 'beIwglich,' meaning 'comfortable.']

68 MAKING OF A PSYCHOANALYST lowing day she had to tell 'me two stories in order for this to happen. The essential features of this phenomenon-the mounting up and intensification of her absences into her auto-hypnosis in the evening, the effect of the products of her imagination as psychical stimuli and the easing and removal of her state of stimulation when she gave utter- ance to them in her hypnosis--remained constant throughout the whole eighteen months during which she was under observation. The stories naturally became still more tragic after her father's death. It was not, however, until the deterioration of her mental condition, which followed when her state of somnambulism was forcibly broken into in the way already described, that her evening narratives ceased to have the character of more or less freely-created poetical compositions and changed into a string of frightful and terrifying hallucinations. (It was already possible to arrive at these from the patient' s behaviour during the day.) I have already described how completely her mind was relieved when, shaking with fear and horror, she had reproduced these frightful images and given verbal utterance to them. While she was in the country, when I was unable to pay her daily visits, the situation developed as folIows. I used to visit her in the evening, when I knew I should find her in her hypnosis, and I then relieved her of the whole stock of imaginative products which she had accumulated since my last visit. It was essential that this should be effected completely if good results were to follow. When this was done she became perfectly calm, and next day she would be agreeable, easy to manage, industrious and even cheerful; but on the second day she would be increasingly moody, contrary and unpleasant, and this would become still more marked on the third day. When she was like this it was not always easy to get her to talk, even in her hypnosis. She aptly described this pro- cedure, speaking seriously, as a 'talking cure', while she referred to it jokingly as 'chimney-sweeping'. 5 She knew that after she had given utterance to her hallucinations she would lose all her obstinacy and what she described as her 'energy'; and when, after some eomparatively long interval, she was in a bad temper, she would refuse to talk, and I was obliged to overcome her unwillingness by urging and pleading and using devices such as repeating a formula with which she was in the habit of introducing her stories. But she would never begin to talk until she had satisfied herself of my identity by carefully feeling my hands. On those nights on which she had not been calmed by verbal utterance it was neeessary to fall back upon chloral. I had tried it on a few earlier occasions, but I was obliged to give her 5 grammes, and sleep was preceded by astate of intoxication which lasted for some hours. When I was present this state was euphorie, but in my absence it was highly disagreeable and characterized by anxiety as weil as excitement. (It may 5. [These !wo phrases are in English in the original. J

ANNA O. 69 be remarked incidentally that this severe state of intoxication made no difference to her constractures.) I had been able to avoid the use of narcotics, since the verbal utterance of her hallucinations calmed her even though it might not induce sleep; but when she was in the country the nights on which she had not obtained hypnotic relief were so un- bearable that in spite of everything it was necessary to have recourse to chloral. But it became possible gradually to reduce the dose. The persisting somnambulism did not return. But on the other hand the alternation between two states of consciousness persisted. She used to hallucinate in the middle of a conversation, run off, start climbing up a tree, etc. If one caught hold of her, she would very quickly take up her interrupted sentence without knowing anything about what had happened in the interval. All these hallucinations, however, came up and were reported on in her hypnosis. Her condition improved on the whole. She took nourishment without difficulty and allowed the nurse to feed her; except that she asked for bread but rejected it the moment it touched her lips. The paralytic contracture of the leg diminished greatly. There was also an improve- ment in her power of judgement and she became much attached to my friend Dr. B., the physician who visited her. She derived much benefit from a Newfoundland dog which was given to her and of which she was passionately fond. On one occasion, though, her pet made an attack on a cat, and it was splendid to see the way in which the frai! girl seized a whip in her left hand and beat off the huge beast with it to rescue his victim. Later, she looked after some poor, sick people, and this helped her greatly. It was after I returned from a holiday trip which lasted several weeks that I received the most convincing evidence of the pathogenic and exciting effect brought about by the ideational complexes which were produced during her absences, or condition seconde, and of the fact that these complexes were disposed ofby being given verbal expression during hypnosis. During this interval no 'talking cure' had been carried out, for it was impossible to persuade her to confide what she had to say to anyone but me-not even to Dr. B. to whom she had in other respects become devoted. I found her in a wretched moral state, inert, un- amenable, ilI-tempered, even malicious. It became plain from her eve- ning stories that her imaginative and poetic vein was drying up. What she reported was more and more concerned with her hallucinations and, for instance, the things that had annoyed her during the past days. These were clothed in imaginative shape, but were merely formulated in ster- eotyped images rather than elaborated into poetic productions. But the situation only became tolerable after I had arranged for the patient to be brought back to Vienna for a week and evening after evening made her tell me three to five stories. When I had accomplished this, every- thing that had accumulated during the weeks of my absence had been worked off. It was only now that the former rhythm was re-established:

70 MA1a:NG OF A PSYCHOANALYST on the day after her giving verbal utterance to her phantasies she was amiable and cheerful, on the second day she was more irritable and less agreeable and on the third positively 'nasty'. Her moral state was a function of the time that had elapsed since her last utterance. This was because every one of the spontaneous products of her imagination and every event which had been assimilated by the pathological part of her mind persisted as a psychical stimulus until it had been narrated in her hypnosis, after which it completely ceased to operate. When, in the autumn, the patient retumed to Vienna (though to a different house from the one in which she had fallen ill), her condition was bearable, both physically and mentaIly; for very few of her experi- ences--in fact only her more striking ones--were made into psychical stimuli in a pathological manner. I was hoping for a continuous and increasing improvement, provided that the permanent burdening of her mind with fresh stimuli could be prevented by her giving regular verbal expression to them. But to begin with I was disappointed. In December there was a marked deterioration of her psychical condition. She once more became excited, gloomy and irritable. She had no more 'really good days' even when it was impossible to detect anything that was remaining 'stuck' inside her. Towards the end ofDecember, at Christmas time, she was particularly restless, and for a whole week in the evenings she told me nothing new but only the imaginative products which she had elaborated under the stress of great anxiety and emotion during the Christrnas of 1880 [a year earlier J. When the scenes had been completed she was greatly relieved. A year had now passed since she had been separated from her father and had taken to her bed, and from this time on her condition became dearer and was systematized in a very peculiar manner. Her alternating states of consciousness, wh ich were characterized by the fact that, from morning onwards, her absences (that is to say, the emergence of her condition seconde) always became more frequent as the day advanced and took entire possession by the evening-these alternating states had differed from each other previously in that one (the first) was normal and the second alienated; now, however, they differed further in that in the first she lived, like the rest of us, in the winter of 1881-2, whereas in the second she lived in the winter of 1880-1, and had completely forgotten all the subsequent events. The one thing that nevertheless seemed to remain conscious most of the time was the fact that her father had died. She was carried back to the previous year with such intensity that in the new house she hallucinated her old room, so that when she wanted to go to the door she knocked up against the stove which stood in the same relation to the window as the door did in the old room. The change-over from one state to another occurred spontaneously but could also be very easily brought about by any sense-impression which vividly recalled the previous year. One had only to hold up an orange before her eyes (oranges were what she had chieRy lived on du ring the

ANNA O. 71 first part of her illness) in order to carry her over from the year 1882 to the year 1881. But this transfer into the past did not take place in a general or indefinite mann er; she lived through the previous winter day by day. I should only have been able to suspect that this was happening, had it not been that every evening during the hypnosis she talked through whatever it was that had excited her on the same day in 1881, and had it not been that a private diary kept by her mother in 1881 confirmed beyond a doubt the occurrence of the underlying events. This re-living of the previous year continued till the illness came to its final close in June, 1882. It was interesting here, too, to observe the way in which these revived psychical stimuli belonging to her secondary state made their way over into her first, more normal one. It happened, for instance, that one morning the patient said to me laughingly that she had no idea what was the matter but she was angry with me. Thanks to the diary I knew what was happening; and, sure enough, this was gone through again in the evening hypnosis: I had annoyed the patient very much on the same evening in 1881. Or another time she told me there was something the matter with her eyes; she was seeing colours wrong. She knew she was wearing a brown dress but she saw it as a blue one. We so on found that she could distinguish all the colours of the visual test-sheets correctly and clearly, and that the disturbance only related to the dress-material. The reason was that during the same period in 1881 she had been very busy with a dressing-gown for her father, which was made with the same material as her present dress, but was blue instead ofbrown. Incidentally, it was often to be seen that these emergent memories showed their effect in advance; the disturbance of her normal state would occur earlier on, and the memory would only gradually be awakened in her condition seconde. Her evening hypnosis was thus heavily burdened, for we had to talk off not only her contemporary imaginative products but also the events and 'vexations'6 of 1881. (Fortunately I had already relieved her at the time of the imaginative products of that year.) But in addition to all this the work that had to be done by the patient and her physician was immensely increased by a third group of separate disturbances which had to be disposed of in the same manner. These were the psychical events involved in the period of incubation of the illness between July and December, 1880; it was they that had produced the whole of the hysterical phenomena, and when they were brought to verbal utterance the symptoms disappeared. When this happened for the first time-when, as a result of an ac- ci dental and spontaneous utterance of this kind, during the evening hypnosis, a disturbance which had persisted for a considerable time vanished-I was greatly surprised. It was in the summer during aperiod 6. [In English in the original.]

72 MAKING OF A PSYCHOANAL YST of extreme heat, and the patient was suffering very badly from thirst; for, without being able to account for it in any way, she suddenly found it impossible to drink. She would take up the glass of water she longed for, but as soon as it touched her lips she would push it away like someone suffering from hydrophobia. As she did this, she was obviously in an absence for a couple of seconds. She lived only on fruit, such as melons, etc., so as to lessen her tormenting thirst. This had lasted for some six weeks, when one day during hypnosis she grumbled about her English lady-companion whom she did not care for, and went on to describe, with every sign of disgust, how she had once gone into that lady's room and how her Iittle dog-horrid creature!-had drunk out of a glass there. The patient had said nothing, as she had wanted to be polite. After giving further energetic expression to the anger she had held back, she asked for something to drink, drank a large quantity of water without any difficulty and woke from her hypnosis with the gl ass at her lips; and thereupon the disturbance vanished, never to return. A number of extremely obstinate whims were similarly removed after she had described the experiences which had given rise to them. She took a great step forward when the first of her chronic symptoms disappeared in the same way-the contracture of her right leg, which, it is true, had already diminished a great deal. These findings-that in the ca se of this patient the hysterical phenomena disappeared as soon as the event which had given rise to them was reproduced in her hypnosis-made it possible to arrive at a therapeutic technical procedure which left nothing to be desired in its logical consistency and systematic application. Each in- dividual symptom in this complicated case was taken separately in hand; all the occasions on which it had appeared were described in reverse order, starting before the time when the patient became bed-ridden and going back to the event which had led to its first appearance. When this had been described the symptom was permanently removed. In this way her paralytic contractures and anaesthesias, disorders of vision and hearing of every sort, neuralgias, coughing, tremors, etc., and finally her disturbances of speech were 'talked away'. Amongst the disorders of vision, the following, for instance, were disposed of sepa- rately: the convergent squint with diplopia; deviation of both eyes to the right, so that when her hand reached out for something it always went to the left of the object; restriction of the visual field; central amblyopia; macropsia; seeing a death's head instead of her father; inability to read. Only a few scattered phenomena (such, for instance, as the extension of the paralytic contractures to the left side of her body) which had developed while she was confined to bed, were untouched by this process of analysis, and it is probable, indeed, that they had in fact no immediate psychical cause. It turned out to be quite impracticable to shorten the work by trying to e1icit in her memory straight away the first provoking cause of her symptoms. She was unable to find it, grew confused, and things pro-

ANNA O. 73 ceeded even more slowly than if she was allowed quietly and steadily to follow back the thread of memories on which she had embarked. Since the latter method, however, took too long in the evening hypnosis, owing to her being over-strained and distraught by 'talking out' the two other sets of experiences-and owing, too, to the reminiscences needing time before they could attain sufficient vividness-we evolved the following procedure. I used to visit her in the morning and hypnotize her. (Yery simple methods of doing this were arrived at empirically.) I would next ask her to concentrate her thoughts on the symptom we were treating at the moment and to tell me the occasions on which it had appeared. The patient would proceed to describe in rapid succession and under brief headings the external events concerned and these I would jot down. During her subsequent evening hypnosis she would then, with the help of my notes, give me a fairly detailed account of these circumstances. An example will show the exhaustive manner in which she accom- plished this. It was our regular experience that the patient did not hear when she was spoken to. It was possible to differentiate this passing habit of not hearing as folIows: (a) Not hearing when someone came in, while her thoughts were abstracted. 108 separate detailed instances of this, mentioning the per- sons and circumstances, often with dates. First instance: not hearing her father come in. (b) Not understanding when several people were talking. 27 instances. First instance: her father, once more, and an acquaintance. (c) Not hearing when she was alone and directly addressed. 50 in- stances. Origin: her father having vainly asked her for some wine. (d) Deafness brought on by being shaken (in a carriage, etc.). 15 instances. Origin: having been shaken angrily by her young brother when he caught her one night listening at the sickroom door. (e) Deafness brought on by fright at a noise. 37 instances. Origin: a choking fit of her father's, caused by swallowing the wrong way. (f) Deafness during deep absence. 12 instances. (g) Deafness brought on by listening hard for a long time, so that when she was spoken to she failed to hear. 54 instances. Of course all these episodes were to a great extent identical in so far as they could be traced back to states of abstraction or absences or to fright. But in the patient's memory they were so clearly differentiated, that if she happened to make amistake in their sequence she would be obliged to correct herself and put them in the right order; if this was not done her report came to a standstill. The events she described were so lacking in interest and significance and were told in such detail that there could be no suspicion of their having been invented. Many of these incidents consisted of purely internal experiences and so could not be verified; others ofthem (or circumstances attending them) were within the recollection of people in her environment. This example, too, exhibited a feature that was always observable

74 MAKING OF A PSYCHOANALYST when a symptom was being 'talked away': the partieular symptom emerged with greater force while she was diseussing it. Thus during the analysis of her not being able to hear she was so deaf that for part of the time I was obliged to eommunieate with her in writing. The first provoking eause was habitually a fright of some kind, experieneed while she was nursing her father-some oversight on her part, for instance. The work of remembering was not always an easy matter and some- times the patient had to make great efforts. On one oeeasion our whole progress was obstructed for some time beeause a reeolleetion refused to emerge. It was a question of a partieularly terrifying hallueination. While she was nursing her father she had seen hirn with a death's head. She and the people with her rem em bered that onee, while she still appeared to be in good health, she had paid a visit to one of her relatives. She had opened the door and all at onee fallen down uneonseious. In order to get over the obstruetion to our progress she visited the same pI ace again and, on entering the room, again fell to the ground uneonseious. During her subsequent evening hypnosis the obstacle was surmounted. As she eame into the room, she had seen her pale face refleeted in a mirror hanging opposite the door; but it was not herself that she saw but her father with a death's head.-We often notieed that her dread of a memory, as in the present instanee, inhibited its emergenee, and this had to be brought about foreibly by the patient or physieian. The following ineident, among others, illustrates the high degree of logieal eonsisteney of her states. During this period, as has already been explained, the patient was always in her condition seconde--that is, in the year 1881-at night. On one oeeasion she woke up during the night, declaring that she had been taken away from horne on ce again, and beeame so seriously exeited that the whole household was alarmed. The reason was simple. During the previous evening the talking 'eure had cleared up her disorder of vision, and this applied also to her condition seconde. Thus when she woke up in the night she found herself in a strange room, for her family had moved house in the spring of 188l. Disagreeable events of this kind were avoided by my always (at her request) shutting her eyes in the evening and giving her a suggestion that she would not be able to open them till I did so myself on the following morning. The disturbanee was only repeated onee, when the patient eried in a dream and opened her eyes on waking up from it. Sinee this laborious analysis for her symptoms dealt with the summer months of 1880, whieh was the preparatory period of her iIlness, I obtained eomplete insight into the ineubation and pathogenesis of this ease of hysteria, and I will now deseribe them briefly. In July, 1880, while he was in the eountry, her father fell seriously iIl of a sub-pleural abseess. Anna shared the duties of nursing hirn with her mother. She onee woke up during the night in great anxiety about t~e patient, who was in a high fever; and she was under the strain of expeeting the arrival of a surgeon from Vienna who was to operate. Her

ANNA O. 75 mother had gone away far a short time and Anna was sitting at the bedside with her right arm over the back of her chair. She fell into a waking dream and saw a black snake coming towards the siek man from the wall to bite hirn. (It is most likely that there were in fact snakes in the field behind the house and that these had previously given the girl a fright; they would thus have provided the material far her hallucina- tion.) She tried to keep the snake off, but it was as though she was paralysed. Her right arm, over the back of the chair, had gone to sleep and had become anaesthetic and paretic; and when she looked at it the fingers turned into little snakes with death's heads (the nails). (It seems probable that she had tried to use her paralysed right arm to drive off the snake and that its anaesthesia and paralysis had consequently become associated with the hallucination of the snake.) When the snake van- ished, in her terror she tried to pray. But language failed her: she could find no tongue in which to speak, till at last she thought of so me children's verses in English and then found herself able to think and pray in that language. The whistle of the train that was bringing the doctor whom she expected broke the speil. Next day, in the course of agame, she threw a quoit into some bushes; and when she went to pick it out, a bent branch revived her hallucination of the snake, and simultaneously her right arm became rigidly extended. Thenceforward the same thing invariably occurred whenever the hal- lucination was recalled by some object with a more or less snake-like appearance. This hallucination, however, as weil as the contracture only appeared during the short absences which became mare and mare fre- quent from that night onwards. (The contracture did not become sta- bilized until December, when the patient broke down completely and took to her bed permanently.) As a result of some particular event which I cannot find recorded in my notes and which I no longer recall, the contracture of the right leg was added to that of the right arm. Her tendency to auto-hypnotic absences was from now on established. On the morning after the night I have described, while she was waiting for the surgeon's arrival, she fell into such a fit of abstraction that he 'finally arrived in the room without her having heard his approach. Her persistent anxiety interfered with her eating and gradually led to intense feelings of nausea. Apart from this, indeed, each ofher hysterical symp- toms arose during an affect. It is not quite certain whether in every ca se a momentary state of absence was involved, but this seems probable in view of the fact that in her waking state the patient was totally unaware of wh at had been going on. * * I cannot feel much regret that the incompleteness of my notes makes it impossible for me to enumerate all the occasions on which her various hysterical symptoms appeared. She herself told me them in every single case, with the one exception I have mentioned; and, as I have already

76 MAKING OF A PSYCHOANALYST said, each symptom disappeared after she had described its first occur- rence. In this way, too, the whole illness was brought to a dose. The patient herself had formed a strong determination that the whole treatment should be finished by the anniversary of the day on which she was moved into the country [June 7]. At the beginning of June, accordingly, she entered into the 'talking cure' with the greatest energy. On the last day- by the help of re-arranging the room so as to resemble her father's sickroom-she reproduced the terrifying hallucination which I have described above and which constituted the root of her whole illness. During the original scene she had only been able to think and pray in English; but immediately after its reproduction she was able to speak German. She was moreover free from the innumerable disturbances 7 which she had previously exhibited. After this she left Vienna and travelled for a while; but it was a considerable time before she regained her mental balance entirely. Since then she has enjoyed complete health. * * * There were two psychical characteristics present in the girl while she ~as still completely healthy which acted as predisposing causes for her subsequent hysterical illness: (1) Her monotonous family life and the absence of adequate intel- lectual occupation left her with an unemployed surplus of mental live- liness and energy, and this found an outlet in the constant activity of her imagination. (2) This led to ahabit of day-dreaming (her 'private theatre'), which laid the foundations for a dissociation of her mental personality. Never- theless a dissociation ofthis degree is still within the bounds of normality. Reveries and reflections during a more or less mechanical occupation do not in themselves imply a pathological splitting of consciousness, since if they are interrupted-if, for instance, the subject is spoken to -the normal unity of consciousness is restored; nor, presumably, is any amnesia present. In the case of Anna 0., however, this habit prepared the ground upon which the affect of anxiety and dread was able to establish itself in the way I have described, when once that affect had transformed the patient's habitual day-dreaming into a hallucinatory 7. [At this point (so Freud once told the present Breuer had said good-bye to his patient, about to editor (James Strachey}, with his finger on an open go off on a trip with his wife who had become copy of the book) there is a hiatus in the text. What iealous ofher husband's interesting patient, he was he had in mi nd and went on to describe was the suddenly called back that very evening to disco ver occurrence which marked the end of Anna O.'s thatshe was in the throes of a hysterical pregnancy, treatment.. [IJt is enough to say here that, when c1aiming to be carrying Breuers child.} Jt was this the treatment had apparently reached a successful occurrence, Freud believed, that caused Breuer to end, the patient suddenly made manifest to Breuer hold back the publication of the oase history for the presence of a strong unanalyzed positive trans- so many years and that led ultimately to his aban- ference of an unmistakably sexual nature. {Behind donment of .11 further collaboration in Freud's these technical terms lies a dramatic story: after researches. ]

ANNA O. 77 absence. lt is remarkable how completely the earliest manifestation of her illness in its beginnings already exhibited its main characteristics, which afterwards remained unchanged for almost two years. * * * * * The question now arises how far the patient's statements are to be trusted and whether the occasions and mode of origin of the phenomena were really as she represented them. So far as the more important and fundamental events are concerned, the trustworthiness of her account seems to me to be beyond question. As regards the symptoms disap- pearing after being 'talked away', I cannot use this as evidence; it may very weil be explained by suggestion. But I always found the patient entirely truthful and trustworthy. The things she told me were intimately bound up with wh at was most sacred to her. Whatever could be checked by other people was fully confirmed. Even the most highly gifted girl would be incapable of concocting a tissue of data with such a degree of internal consistency as was exhibited in the history of this case. It cannot be disputed, however, that precisely her consistency may have led her (in perfectly good faith) to assign to some ofher symptoms a precipitating cause which they did not in fact possess. But this suspicion, too, I consider unjustified. The very insignificance of so many of those causes, the irrational character of so many of the connections involved, argue in favour of their reality. The patient could not understand how it was that dance music made her cough; such a construction is too meaningless to have been deliberate. (It seemed very likely to me, incidentally, that each of her twinges of conscience brought on one of her regular spasms of the glottis and that the motor impulses which she felt-for she was very fond of dancing-transformed the spasm into a tussis nervosa.) Accordingly, in my view the patient's statements were entirely trust- worthy and corresponded to the facts. * * * * * * Every one of her hypnoses in the evening afforded evidence that the patient was entirely clear and well-ordered in her mind and normal as regards her feeling and volition so long as none of the products ofher secondary state was acting as a stimulus 'in the unconscious'. The extremely marked psychosis wh ich appeared whenever there was any considerable interval in this unburdening process showed the degree to which those products influenced the psychical events of her 'normal' state. lt is hard to avoid expressing the situation by saying that the patient was split into two personalities of which one was mentally normal and the other insane. The sharp division between the two states in the present patient only exhibits more clearly, in my opinion, what has given rise to a number ofunexplained problems in many other hysterical patients. It was especially noticeable in Anna O. how much the products of her 'bad self, as she herself called it, affected her moral habit of mind. If

78 MAKING OF A PSYCHOANALYST these produets had 110t been eontinually disposed of, we should have been faeed by a hysterie of the malieious type-refraetory, lazy, dis- agreeable and ill-natured; but, as it was, after the removal of those stimuli her true eharacter, whieh was the opposite of a11 these, always reappeared at onee. * * The final eure of the hysteria deserves a few more words. It was aeeompanied, as I have already said, by eonsiderable disturbanees and a deterioration in the patient's mental eondition. I had a very strong impression that the numerous produets ofher seeondary state whieh had been quieseent were now foreing their way into eonseiousness; and though in the first instanee they were being rem em bered only in her seeondary state, they were nevertheless burdening and disturbing her normal one. It remains to be seen whether it may not be that the same origin is to be traeed in other eases in whieh a ehronie hysteria terminates in a psyehosis. 8 Katharina There were a total of five extended ease histories in Breuer and Freud's Studies on Hysteria: Breuer's ep6ch-making report on Anna O. (just above), and four cases by Freud. These patients--and others, like \"Cäcilie M.,\" mentioned in passing-were Freud's highly appreciated instructors in what was rapidly beeoming psychoanalytic teehnique. \"Emmy von N.,\" a wealthy middle-aged widow whom Freud treated in 1889 and 1890 with Breuer's hypnoanalytic method for her ties and terrifying hallucinations, instructed Freud in the virtue of patience: rather crossly she told hirn as he kept interrupting that he should let her finish and tell her story in her own way. \"Fräulein Elisabeth von R. ,\" whom Freud hypnotized only briefly during her treatment in 1892, taught hirn the value of free association, of letting the patient's thoughts and speech ramble without rational contro!, and of working through symptoms over and over. \"Miss Lucy R.,\" whom Freud treated late that same year, an English govemess suffering from bizarre and apparently trivial symptoms--she was haunted by such olfactory halluci- nations as the smell of bumt pudding-made Freud see (as he was already suspecting) that every symptom is meaningful, none is wholly arbitrary or absurd. Moreover, she confirrned in her treatment the lesson that Elisabetll von R. had already inculcated: the value of free association. In comparison, the case of\"Katharina\" appears almost like an anecdote. It illustrates Freud's early excessive self-confidence; he was later compelled by his clinical ex- perience to abandon any hope that a single \"session\" might wholly cure a hysteria. It also dramatizes (see the concluding footnote) the tension between 8. {It remains 10 be said that Anna O.'s eure was still frequently subject to the loss of her Gennan by no means so complete as this concluding par- language. It was only after a time thai most of her agraph ofBreuers intimates. She had 10 spend time symptoms abated and she began to lead an active, in a sanatorium, still addicted to morphine and highly productive life.}

KATHARINA 79 the physician's need to respect his patient's privacy and to publicize his ca ses in the interest of science. CASE 4 KATHARINA--(Freud) In the summer vacation of the year 189- I made an excursion into the 1 Hohe Tauern so that for a while I might forget medicine and more particularly the neuroses. I had almost succeeded in this when one day I turned aside from the main road to climb mountain which lay some- what apart and which was renowned for its views and for its weil-run refuge hut. I reached the top after a strenuous climb and, feeling re- freshed and rested, was sitting deep in contemplation of the charm of the distant prospect. I was so lost in thought that at first I did not connect it with myself when these words reached my ears: 'Are you a doctor, sir?' But the question was addressed to me, and by the rather sulky- looking girl of perhaps eighteen who had served my meal and had been spoken to by the land lady as 'Katharina'. To judge by her dress and bearing, she could not be a servant, but must no doubt be a daughter or relative of the landlady's. Coming to myselfI replied: 'Yes, I'm a doctor: but how did you know that?' 'Y ou wrote your name in the Vi si tors' Book, sir. And I thought if you had a few moments to spare ... The truth is, sir, my nerves are bad. I went to see a doctor in 1..-- about them and he gave me something for them; but I'm not well yet.' So there I was with the neuroses once again-for nothing else could very weil be the matter with this strong, well-built girl with her unhappy look. I was interested to find that neuroses could flourish in this way at a height of over 6,000 feet; I questioned her further therefore. Ireport the conversation that followed between us just as it is impressed on my memory. * * * 'Weil, what is it you suffer from?' 'I get so out of breath. Not always. But sometimes it catches me so that I think I shall suffocate.' This did not, at first sight, sound like a nervous symptom. But soon it occurred to me that probably it was only adescription that stood for an anxiety attack: she was choosing shortness ofbreath out of the complex of sensations arising from anxiety and laying undue stress on that single factor. 'Sit down here. What is it like when you get \"out of breath\"?' 'It comes over me all at once. First of all it's like something pressing I. [One of the highes! ranges in the Eastem Alps.]

80 MAKING OF A PSYCHOANAL YST on my eyes. My head gets so heavy, there's a dreadful buzzing, and 1 fee! so giddy that I almost fall over. Then there's something crushing my ehest so that I can't get my breath.' 'And you don't notice anything in your throat?' 'My throat's squeezed together as though I were going to choke.' 'Ooes anything e!se happen in your head?' 'Yes, there's a hammering, enough to burst it.' 'And don't you fee! at all frightened while this is going on?' '1 always think I'm going to die. I'm brave as a rule and go about everywhere by myse!f-into the cellar and all over the mountain. But on a day when that happens I don't dare to go anywhere; I think all the time someone's standing behind me and going to catch hold of me all at once.' So it was in fact an anxiety attack, and introduced by the signs of a hysterical 'aura'2~r, more correctly, it was a hysterical attack the con- tent of which was anxiety. Might there not probably be some other content as weil? 'When you have an attack do you think of something? and always the same thing? or do you see something in front of you?' 'Yes. I always see an awful face that looks at me in a dreadful way, so that I'm frightened.' Perhaps this might offer a quick means of getting to the heart of the matter. '00 you recognize the face? I mean, is it a face that you've really seen some time?' 'No.' '00 you know what your attacks come from?' 'No.' 'When did you first have them?' 'Two years ago, while I was still living on the other mountain with my au nt. (She used to run arefuge hut there, and we moved here eighteen months ago.) But they keep on happening.' Was I to make an attempt at an analysis? I could not venture to transplant hypnosis to these altitudes, but perhaps I might succeed with a simple talk. 1 should have to try a lucky guess. 1 had found often enough that in girls anxiety was a consequence of the horror by which a virginal mind is overcome when it is faced for the first time with the world of sexuality. 3 So I said: 'lf you don't know, I'll tell you how I think you got your 2. [The premonitory sensations preceding an epi- mained firm. When we had co me to know eaeh leptie or hysterieal attaek] other better she suddenly said to me one day: Tll 3. I will quote here the ease in whieh I first ree- tell you now how I came by my atlacks of anxiety ognized this causa} connect1on. I was treating a when I was a girL At that time I used to sleep in yaung married wornan who was suffering from a a roarn next to ruy parents'; the doOf was Jeft open complicated neurosis and. . was unable to admit and a night-light used to bum on the !able. So that her illness arose from her married life. She more than onee I saw my father get inta bed with objected that while she was still a girl she had had my mother and heard sounds that greatly excited attacks of anxiety, ending in fainting fits. I re- me. It was then that my attacks carne on.'

KATHARINA 81 attacks. At that time, two years ago, you must have seen or heard something that very much embarrassed you, and that you'd much rather not have seen.' 'Heavens, yes!' she replied, 'that was when I caught my uncle with the girl, with Franziska, my cousin.' 'What's this story about a girl? Won't you tell me all about it?' 'You can say anything to a doctor, I suppose. Weil, at that time, you know, my uncle-the husband of the aunt you've seen here-kept the inn on the--kogel. Now they're divorced, and it's my fault they were divorced, because it was through me that it ca me out that he was carrying on with Franziska.' 'And how did you discover it?' 'This way. One day two years ago some gentlemen had climbed the mountain and asked for something to eat. My aunt wasn't at horne, and Franziska, who always did the cooking, was nowhere to be found. And my uncle was not to be found either. We looked everywhere, and at last Alois, the little boy, my cousin, said: \"Why, Franziska must be in Father's room!\" And we both laughed; but we weren't thinking anything bad. Then we went to my uncle' s room but found it locked. That seemed strange to me. Then Alois said: \"There's a window in the passage where you can look into the room.\" W e went into the passage; but Alois wouldn't go to the window and said he was afraid. So I said: \"You silly boy! 1'11 go. I'm not a bit afraid.\" And I had nothing bad in my mind. 1 looked in. The room was rather dark, but 1 saw my uncle and Franziska; he was Iying on her.' 'Weil?' 'I came away from the window at once, and leant up against the wall and couldn't get my breath-just what happens to me since. Everything went blank, my eyelids were forced together and there was a hammering and buzzing in my head.' 'Did you tell yom aunt that very same day?' 'Oh no, I said nothing.' 'Then why were you so frightened when you found them together? Did you understand it? Did you know what was going on?' 'Oh no. 1 didn't understand anything at that time. I was only sixteen. I don't know what I was frightened about.' 'Fräulein Katharina, if you could remember now what was happening in you at that time, when you had yom first attack, what you thought about it-it would help you.' 'Yes, if I could. But I was so frightened that I've forgotten everything.' * * * 'Tell me, Fräulein. Can it be that the head that you always see when you lose yom breath is Franziska's head, as you saw it then?' 'Oh no, she didn't look so awful. Besides, it's a man's head.' 'Or perhaps yom uncle's?'

82 MAKING OF A PSYCHOANALYST 'I didn't see his face as dearly as that. lt was too dark in the wom. And why should he have been making such a dreadful face just then?' 'You're quite right.' (The wad suddenly seemed blocked. Perhaps something might turn up in the rest of her story.) 'And what happened then?' 'Weil, those two must have heard a noise, because they came out soon afterwards. 1 feit very bad the whole time. 1 always kept thinking about it. Then two days later it was a Sunday and there was a great deal to do and 1 worked all day long. And on the Monday moming 1 feit giddy again and was siek, and 1 stopped in bed and was siek without stopping for three days.' We [Breuer and I] had often compared the symptomatology ofhysteria with a pictographic script which has be co me intelligible after the dis- covery of a few bilingual inscriptions. In that alphabet being siek means disgust. So I said: 'If you were siek three days later, I believe that means that when you looked into the room you feit disgusted.' 'Yes, I'm sure I feit digusted,' she said reflectively, 'but disgusted at what?' 'Perhaps you saw something naked? What sort of state were they in?' 'lt was too dark to see anything; besides they both of them had their dothes on. Oh, if only I knew what it was I feit disgustedat!' I had no idea either. But I told her to go on and tell me whatever occurred to her, in the confident expectation that she would think of precisely what I needed to explain the case. WeIl, she went on to describe how at last she reported her discovery to her aunt, who found that she was changed and suspected her of concealing some secret. There followed some very disagreeable seen es between her unde and aunt, in the course of which the children came to hear a number of things which opened their eyes in many ways and which it would have been better for them not to have heard. At last her aunt decided to move with her children and niece and take over the present inn, leaving her unde alone with Franziska, who had meanwhile become pregnant. After this, however, to my astonishment she dropped these threads and began to tell me two sets of older stories, which went back two or three years earlier than the traumatic moment. The first set related to occasions on which the same unde had made sexual advances to her herself, when she was only fourteen years old. She described how she had once gone with hirn on an expedition down into the valley in the winter and had spent the night in the inn there. He sat in the bar drinking and playing cards, but she feit sleepy and went up to bed early in the room they were to share on the upper floor. She was not quite asleep when he ca me up; then she fell asleep again and woke up suddenly 'feeling his body' in the bed. She jumped up and remonstrated with hirn: 'Wh at are you up to, Unde? Why don't you stay in your own bed?' He tried to pacify her: 'Go on, you silly girl, keep still. You don't

KATHARINA 83 know how nice it iso '-'I don't like your \"nice\" things; you don't even let one sleep in peace.' She remained standing by the door, ready to take refuge outside in the passage, till at last he gave up and went to sleep hirnself. Then she went back to her own bed and slept till morning. From the way in which she reported having defended herself it seems to follow that she did not clearly recognize the attack as' a sexual one. When I asked her if she knew what he was trying to do to her, she replied: 'Not at the time.' lt had become dear to her much later on, she said; she had resisted because it was unpleasant to be disturbed in one's sleep and 'because it wasn't nice'. I have been obliged to relate this in detail, because of its great im- portance for understanding everything that followed.-She went on to tell me of yet other experiences of somewhat later date: how she had once again had to defend herself against hirn in an inn when he was completely drunk, and similar stories. In answer to a question as to whether on these occasions she had feit anything resembling her later loss of breath, she answered with decision that she had every time feit the pressure on her eyes and ehest, but with nothing like the strength that had characterized the scene of discovery. Immediately she had finished this set of memories she began to tell me a second set, which dealt with occasions on which she had noticed something between her unde and Franziska. Once the wh oie family had spent the night in their dothes in a hay loft and she was woken up suddenly by a noise; she thought she noticed that her unde, who had been lying between her and Franziska, was turning away, and that Franziska was just lying down. Another time they were stopping the night at an inn at the village of N--; she and her unde were in one room and Franziska in an adjoining one. She woke up suddenly in the night and saw a tal! white figure by the door, on the point of turning the handle: 'Goodness, is that you, Unde? What are you doing at the door?'-'Keep quiet. I was only looking for something.'-'But the way oufs by the other door,'-Td just made amistake' ... and so on. I asked her if she had been suspicious at that time. 'No, I didn't think anything about it; I only just noticed it and thought no more about it.' When I enquired whether she had been frightened on these occasions too, she replied that she thought so, but she was not so sure of it this time. At the end of these two sets of memories she came to a stop. She was like someone transformed. The sulky, unhappy face had grown lively, her eyes were bright, she was lightened and exalted. Meanwhile the understanding of her ca se had become dear to me. The later part of what she had told me, in an apparently aimless fashion, provided an admirable explanation of her behaviour at the scene of the discovery. At that time she had carried about with her two sets of experiences which she remembered but did not understand, and from which she drew no inferences. When she caught sight of the couple in intercourse, she at

84 MAKING OF A PSYCHOANALYST once established a connection between the new impression and these two sets of recollections, she began to understand them and at the same time to fend them off. There then followed a short period of working- out, of 'incubation', after which the symptoms of conversion set in, the vomiting as a substitute for moral and physical disgust. This solved the riddle. She had not been disgusted by the sight of the two people but by the memory which that sight had stirred up in her. And, taking everything into ac count, this could only be the memory of the attempt on her at night when she had 'feit her uncle's body'. So when she had finished her confession I said to her: 'I know now what it was you thought when you looked into the room. You thought: \"Now he's doing with her what he wanted to do with me that night and those other times. \" That was what you were disgusted at, because you rem em bered the feeling when you woke up in the night and feit his body.' 'It may weIl be,' she replied, 'that that was what I was disgusted at and that that was what I thought.' Tell me just one thing more. You're a grown-up girl now and know all sorts of things . . .' 'Yes, now I am.' Tell me just one thing. What part of his body was it that you feIt that night?' But she gave me no more definite answer. She smiled in an embar- rassed way, as though she had been found out, like someone who is obliged to admit that a fundamental position has been reached where there is not much more to be said. I could imagine what the tactile sensation was wh ich she had later learnt to interpret. Her facial expres- sion seemed to me to be saying that she supposed that I was right in my conjecture. But I could not penetrate further, and in any ca se I owed her a debt of gratitude for having made it so much easier for me to talk to her than to the prudish ladies of my city practice, who regard whatever is natural as shameful. Thus the ca se was cleared up.-But stop amoment! What about the recurrent hallucination of the head, which appeared during her attacks and struck terror into her? Where did it come from? I proceeded to ask her about it, and, as though her knowledge, too, had been extended by our conversation, she promptly replied: 'Yes, I know now. The head is my uncle's head-I recognize it now-but not from that time. Later, when all the disputes had broken out, my uncle gave way to a senseless rage against me. He kept saying that it was all my fault: if I hadn't chattered, it would never have come to a divorce. He kept threatening he would do something to me; and if he caught sight of me at a distance his face would get distorted with rage and he would make for me with his hand raised. I always ran away from hirn, and always feit terrified that he would catch me some time unawares. The face I always see now is his face when he was in arage.'

KATHARINA 85 This information reminded me that her first hysterical symptom, the vomiting, had passed away; the anxiety attack remained and acquired a fresh content. Accordingly, what we were dealing with was a hysteria which had to a considerable extent been abreacted. And in fact she had reported her discovery to her aunt soon after it happened. 'Did you tell your aunt the other stories-about his making advances to you?' 'Yes. Not at once, but later on, when there was already talk of a divorce. My aunt said: \"We'l1 keep that in reserve. If he causes trouble in the Court, we'll say that too.\" , I can well understand that it should have been precisely this last period-when there were more and more agitating scenes in the house and when her own state ceased to interest her aunt, who was entirely occupied with the dispute-that it should have been this period of ac- cumulation and retention that left her the legacy of the mnemic symbol [of the hallucinated face). I hope this girl, whose sexual sensibility had been injured at such an early age, derived some benefit from our conversation. I have not seen her since. DrscussrON If someone were to assert that the present ca se history is not so much an analysed case of hysteria as a case solved by guessing, I should have nothing to say against hirn. It is true that the patient agreed that what I interpolated into her story was probably true; but she was not in a position to recognize it as something she had experienced. I believe it would have required hypnosis to bring that about. Assuming that my guesses were correct, I will now attempt to fit the case into the schematic picture of an 'acquired' hysteria on the lines suggested by Case 3. It seems plausible, then, to compare the two sets of erotic experiences with 'traumatic' moments and the scene of discovering the couple with an 'auxiliary' moment. The similarity lies in the fact that in the former experiences an element of consciousness was created which was excluded from the thought-activity of the ego and remained, as it were, in storage, while in the latter scene a new impression forcibly brought about an associative connection between this separated group and the ego. On the other hand there are dissimilarities which cannot be overlooked. The cause of the isolation was not, as in Ca se 3, an act of will on the part of the ego but ignorance on the part of the ego, which was not yet capable of coping with sexual experiences. In this respect the ca se of Katharina is typical. In every analysis of a ca se of hysteria based on sexual traumas we find that impressions from the pre-sexual period wh ich produced no effect on the child attain traumatic power at a later date as memories, when the girl or married woman has acquired an under- standing of sexual life. The splitting-off of psychical groups may be said

86 MAKING OF A PSYCHOANALYST to be a nonnal process in adolescent development; and it is easy to see that their later reception into the ego affords frequent opportunities for psychical disturbances. Moreover, I should like at this point to express a doubt as to whether a splitting of consciousness due to ignorance is really different from one due to conscious rejection, and whether even adolescents do not possess sexual knowledge far oftener than is supposed or than they themselves believe. A further distinction in the psychical mechanism of this case lies in the fact that the scene of discovery, which we have described as 'aux- iliary', deserves equally to be called 'traumatic'. It was operative on account of its own content and not merely as something that revived previous traumatic experiences. It combined the characteristics of an 'auxiliary' and a 'traumatic' moment. There seems no reason, however, why this coincidence should lead us to abandon a conceptual separation which in other ca ses corresponds also to a separation in time. Another peculiarity of Katharina's case, which, incidentally, has long been fa- miliar to us, is seen in the circumstance that the conversion, the pro- duction of the hysterical phenomena, did not occur immediately after the trauma but after an interval of incubation. Charcot liked to describe this interval as the 'period of psychical working-out' (elaboration]. The anxiety from which Katharina suffered in her attacks was a hys- terical one; that is, it was a reproduction of the anxiety which had appeared in connection with each of the sexual traumas. I shall not here comment on the fact which I have found regularly present in a very large number of cases--namely that a mere suspicion of sexual relations calls up the affect of anxiety in virginal individuals. 4 Project für a Scientific Psychülügy From the spring of 1895 on, Freud was working intensely on what he called, to Fliess, his \"psychology for neurologists.\" He had two aims in view: to discover and describe \"a kind of economics of nervous force,\" and to utilize his experience with psychopathology in constructing a general theory of mind. Even then, and increasingly after, Freud saw neuroses as on a con- tinuum of mental functioning, and neurotics as displaying in exaggerated (and hence extremely instructive) form the traits and troubles of \"normal\" humans. In September 1895, after a \"congress\" with Fliess in Berlin, Freud set to work rapidly, starting on the train, to draft his project. It owes much to the researches he had conducted in previous years, but it is also a way station to his turn away from the neurological, physiological view of mi nd then dominant, and toward his psychology for psychologists. He never /in- 4. (Footnote added 1924:) I venture after the lapsc I introduced in the present instance should be al- of so many years to lift the veil of discretion and together avoided in a case history. From the point revea! the fact that Katharina was not the niece of view of understanding the case, a distortion of hut the daughter of the landlady. The girl fen ilI, this kind is not, of course, a matter of such indif- therefore, as a result of sexual attempts on the part ference as would be shifting the scene from one of her own father. Distortions like the one which mountain to another.

PRüJECT FüR A SCIENTIFIC PSYCHüLOGY 87 ished, or published, his draft, but the editors of the Standard Edition of Freud's psychological writings are correct to say that \"the Pro;ect, in spite of being ostensibly a neurological document, contains within itself the nu- cleus of a great part of Freud's later psychological theories .... The Pro;ect, or rather its invisible ghost, haunts the whole series of Freud's theoretical writings to the very end\" (SE I, 290). The short extract here reproduced should give an inkling of Freud's scientific style in 1895, on the verge of his breakthrough to what he would call the following year, for the first time, \"psychoanalysis. \" [PART I] GENERAL SCHEME Introduction The intention is to furnish a psychology that shall be a natural science: that is, to represent psychical processes as quantitatively deterrninate states of specifiable material particles, thus making those processes per- spicuous and free from contradiction. Two principal ideas are involved: [1] What distinguishes activity from rest is to be regarded as Q, subject 1 to the general laws of motion. (2) The neurones are to be taken as the material particles. * * * [1] (a) First Principal Theorem The Quantitative Conception This is derived directly from pathological clinical observation espe- cially where excessively intense ideas were concerned-in hysteria and obsessions, in which, as we shall see, the quantitative characteristic emerges more plainly than in the normal. Processes such as stimulus, substitution, conversion and discharge, which had to be described there [in connection with those disorders], directly suggested the conception of neuronal excitation as quantity in astate of flow. It seemed legitimate to attempt to generalize what was recognized there. Starting from this consideration, it was possible to lay down a basic principle of neuronal activity in relation to Q, which promised to be highly enlightening, since it appeared to comprise the entire function. This is the principle of neuronal inertia: that neurones tend to divest themselves of Q. On 1. [The term 'neurone' , as adescription of the histological researches had led hirn towaros the ultimate unit of the nervous system, had been in- same finding.] troduced by W. Waldeyer in 1891. Freud's own

88 MAKING OF A PSYCHOANALYST this basis the structure and development as weil as the functions [of neurones) are to be understood. 2 In the first place, the principle of inertia explains the structural di- chotomy [of neurones) into motor and sensory as a contrivance for neutralizing the reception of QfJ by giving it off. Reflex movement is now intelligible as an established form of this giving-off: the principle provides the motive for reflex movement. If we go further back from here, we can in the first instance link the nervous system, as inheritor of the general irritability of protoplasm, with the irritable extemal surface [of an organism), which is interrupted by considerable stretch es of non- irritable surface. A primary nervous system makes use of this QfJ which it has thus acquired, by giving it off through a connecting path to the muscular mechanisms, and in that way keeps itself free from stimulus. This discharge represents the primary function of the nervous system. Here is room for the development of a secondary function. For among the paths of discharge those are preferred and retained which involve a cessation of the stimulus: (light {rom the stimulus. Here in general there is aproportion between the Q of excitation and the effort necessary for the flight from the stimulus, so that the principle of inertia is not upset by this. The principle of inertia is, however, broken through from the first owing to another circumstance. With an [increasing] complexity of the interior [of the organismJ, the nervous system receives stimuli from the somatic element itself~ndogenous stimuli-which have equally to be discharged. These have their origin in the cells of the body and give rise to the major needs: hunger, respiration, sexuality. From these the organism cannot withdraw as it does from extemal stimuli; it cannot employ their Q for flight from the stimulus. They only cease subject to particular conditions, which must be realized in the external world. (Cf., for instance, the need for nourishment.) In order to accomplish such an action (which deserves to be named 'specific'), an effort is required which is independent of endogenous QfJ and in general greater, since the individual is being subjected to conditions which may be described as the exigencies of life. In consequence, the nervous system is obliged to abandon its original trend to inertia (that is, to bringing the level [of QfJ) to zero). It must put up with [maintaining] a store of QfJ sufficient to meet the demand for a specific action. Nevertheless, the manner in which it does this shows that the same trend persists, modified into an endeavour at least to keep the QfJ as low as possible and to guard against any increase of it-that is, to keep it constant. All the functions of the nervous system can be comprised either under the aspect of the primary function or of the secondary one imposed by the exigencies of life. 2. [. . this is whal was laler known as the 'principle of conslancy' .nd attribuled by Freud 10 {the German philosopher .nd physicisl Guslav Theoder} Fechner {1801-87}.]

DRAFf K 89 [2] [b] Second Principal Theorem The Neurone Theory Theidea of combining with this Qi] theory the knowledge of the neurones arrived at by recent histology is the second pillar of this thesis. The main substance of these new discoveries is that the nervous system consists of distinct and similarly constructed neurones, which have con- tact with one another through the medium of a foreign substance, which terminate upon one another as they do upon portions of foreign tissue, land] in which certain lines of conduction are laid down in so far as they [the neuron es] receive [excitations] through cell-processes [den- drites] and [give them off] through an axis-cylinder [axon]. They have in addition numerous ramifications of varying calibre. If we combine this account of the neurones with the conception of the Qi] theory, we arrive at the idea of a cathected neuro ne filled with a certain Qi] while at other times it may be empty.3 The principle of inertia [po 296] finds its expression in the hypothesis of a CUTTent passing from the cell's paths of conduction or processes [dendrites] to the axis- cylinder. A single neurone is thus a model of the whole nervous system with its dichotomy of structure, the axis-cylinder being the organ of discharge. The secondary function [of the nervous system], however, which calls for the accumulation of Qi] [po 297], is made possible by the assumption of resistances wh ich oppose discharge; and the structure of neurones makes it probable that the resistances are all to be located in the contacts [between one neuro ne and another], which in this way assume the value of barriers. The hypothesis of contact-barriers is fruitful in many directions. * * * Draft K Here is another memorandum Freud enclosed in a letter to Fliess (January 1, 1896). It was certainly, as Freud indicates by calling it a \"Christmas Fairy Tale,\" written the week before. Draft K deals with the vexed question of \"choice of neurosis,\" to which Freud retumed again and again, and it utilizes in preliminary but recognizable form such fundamental psychoanalytic ideas as defensive activity (particularly repression) and the nature of symptoms as compromises. Freud indicates in describing \"the course taken by the illness in neuroses of repression\" that he thinks their origins go back to traumatic sexual experiences. He later feit compelled to complicate, indeed largely 3. [The notion of'cathexis' (\"Besetzung') had been charge (.s in electrical charge) would be \"interest.\" used by Freud already, but not much earlier, in In general, Freud used common rather than tech· Studies on Hysteria.] {It is worth adding that Freud nical terms, • habit that his English Iransl.tors only hirnself thought a good translation for his \"Beset· imperfectly respected.} zung,\" which means occupation (as by Iroops) or

90 MAKING OF A PSYCHOANALYST abandon, this etiology (see below, pp. 111-13), but the sequence of events leading to neurosis he proposes in this draft remained largely intact in his thought. The memorandum also makes it apparent that after years of con- centrating on dinical work with hysterics, Freud is now tuming to obses- sional neuroses, though he does not neglect hysteria. His indusion of paranoia among the neuroses of defense is also of interest. THE NEUROSES OF DEFENCE (A ehristmas Fairy Tale) There are four types of these and many forms. I can only make a comparison between hysteria, obsessional neurosis and one form of par- anoia. They have various things in common. They are pathological aberrations of normal psychical affective states: of confliet (hysteria), of self-reproaeh (obsessional neurosis), of morti{ieation (paranoia), of mouming (acute hallucinatory amentia). They differ from these affects in that they do not lead to anything being settled but to permanent damage to the ego. They come about subject to the same precipitating causes as their affective prototypes, provided that the cause fulfils two more preconditions-that it is of a sexual kind and that it occurs during the period before sexual maturity (the preconditions of sexuality and infantilism). About preconditions applying to the individual concerned I have no fresh knowledge. In general I should say that heredity is a further precondition, in that it facilitates and increases the pathological affect-the precondition, that is, which mainly makes possible the gra- dations between the normal and the extreme case. I do not be!ieve that heredity determines the choice of the particular defensive neurosis. There is a normal trend towards defence-that is, an aversion to direction psychical energy in such a way that unpleasure results. This trend, which is linked to the most fundamental conditions of the psychi- cal mechanism (the law of constancy), cannot be employed against perceptions, for these are able to compe! attention (as is evidenced by their consciousness); it only comes in question against memories and thoughts. It is innocuous where it is a matter of ideas to whieh unpleasure was at one time attached but which are unable to acquire any contem- porary unpleasure (other than remembered unpleasure), and in such ca ses too it can be over-ridden by psychical interest. The trend towards defence becomes detrimental, however, if it is directed against ideas which are also able, in the form of memories, to release fresh unpleasure-as is the case with sexual ideas. Here, indeed, the one possibility is realized of a memory having a greater releasing power subsequently than had been produced by the experience corre-

DRAFf K 91 sponding to it. Only one thing is necessary for this: that puberty should be interpolated between the experience and its repetition in memory- an event which so greatly increases the effect of the revival. The psychical mechanism seems unprepared for this exception, and it is for that reason a necessary precondition of freedom from neuro ses of defence that no considerable sexual irritation should occur before puberty, though it is true that the effect of such an experience must be increased by hereditary disposition before it can reach a pitch capable of causing illness. (Here a subsidiary problem branches off: how does it come about that under analogous conditions, perversion or simple immorality emerges instead of neurosis?) We shall be plunged deep into psychological riddles if we enquire into the origin of the unpleasure which seems to be released by premature sexual stimulation and without which, after all, arepression cannot be explained. ·The most plausible answer will appeal to the fact that shame and morality are the repressing forces and that the neighbourhood in which the sexualorgans are naturally placed must inevitably arouse disgust along with sexual experiences. Where there is no shame (as in a male person), or where no morality comes about (as in the lower classes of society), or where disgust is blunted by the conditions of life (as in the country), there too no repression and therefore no neurosis will result from sexual stimulation in infancy. I fear, nevertheless, that this expla- nation will not stand up to deeper testing. I do not think that the release of unpleasure during sexual experiences is the consequence ofthe chance admixture of certain unpleasurable factors. Everyday experience teaches us that if libido reaches a sufficient height disgust is not feit and morality is over-ridden; and I believe that the generation of shame is connected with sexual experience by deeper links. In my opinion there must be an independent source for the release of unpleasure in sexual life: once that source is present, it can activate sensations of disgust, lend force to morality, and so on. I hold to the model of anxiety neurosis in adults, where a quantity deriving from sexuallife similarly causes a disturbance in the psychical sphere, though it would ordinarily have found another use in the sexual process. So long as there is no correct theory of the sexual process, the question of the origin of the unpleasure operating in repression remains unanswered. The course taken by the illness in neuroses of repression is in general always the same: (I) the sexual experience (or series of experiences) which is traumatic and premature and is to be repressed. (2) Its repression on some later occasion which arouses a memory of it; at the same time the formation of a primary symptom. (3) A stage of successful defence, which is equivalent to health except for the existence of the primary symptom. (4) The stage in which the repressed ideas return, and in which, during the struggle between them and the ego, new symptoms are formed which are those of the illness proper: that is, a stage of adjustrnent, of being overwhelmed, or of recovery with a malformation.

92 MARING OF A PSYCHOANALYST The main differences between the various neuroses are shown in the way in which the repressed ideas return; others are seen in the mann er in wh ich the symptoms are formed and in the course taken by the illness. But the specific character of a particular neurosis lies in the fashion in which the repression is accomplished. The course of events in obsessional neurosis is wh at is cIearest to me, because I have come to know it the best. ÜBSESSIONAL NEUROSIS Here the primary experience has been accompanied by pleasure. Whether an active one (in boys) or a passive one (in girls), it was without pain or any admixture of disgust; and this in the case of girls implies a comparatively high age in general (about 8 years). When this experience is remembered later, it gives rise to a release of unpleasure; and, in particular, there first emerges a self-reproach, which is conscious. It seems, indeed, as though the whole psychical complex-memory and self-reproach-is conscious to start with. Later, both of them, without anything fresh supervening, are repressed and in their pI ace an antithetic symptom, some nuance of conscientiousness, is formed in consciousness. The repression may come about owing to the memory of the pleasure itself releasing unpleasure when it is reproduced in later years; this should be explicable by a theory of sexuality. But things may happen differently as weiL In all my cases of obsessional neurosis, at a very early age, years before the experience of pleasure, there had been a purely passive ex- perience; and this can hardly be accidental. If so, we may suppose that it is the later convergence of this passive experience with the experience of pleasure that adds the unpleasure to the pleasurable memory and makes repression possible. So that it would be a necessary cIinical pre- condition of obsessional neurosis that the passive experience should happen early enough not to be able to prevent the spontaneous occur- rence of the experience of pleasure. The formula would therefore run: Unpleasure-Pleasure-Repression. The determining factor would be the chronological relations of the two experiences to each other and to the date of sexual maturity. At the stage of the return of the repressed, it turns out that the self- reproach returns unaltered, but rarely in such a way as to draw attention to itself; for a while, therefore, it emerges as a pure sense of guilt without any content. It usually becomes linked with a content which is distorted in two ways--in time and in content: the former in so far as it relates to a contemporary or future action, and the latter in so far as it signifies not the real event but a surrogate chosen from the category of what is analogous--a substitution. An obsessional idea is accordingly a product of compromise, correct as regards affect and category but false owing to chronological displacement and substitution by analogy.

DRAFT K 93 The affect of the self-reproach may be transformed by various psychical processes into other affects, which then enter consciousness more clearly than the affect itself: for instance, into anxiety (fear of the consequences of the action to which the self-reproach applies), hypochondria (fear of its bodily effects), delusions of persecution (fear of its social effects), shame (fear of other people knowing about it), and so on. The conscious ego regards the obsession as something alien to itself: it withholds belief from it, by the help, it seems, of the antithetic idea of conscientiousness, formed long before. But at this stage it may at times happen that the ego is overwhelmed by the obsession-for instance, if the ego is affected by an episodic melancholia. Apart from this, the stage of illness is occupied by the defensive struggle of the ego against the obsession; and this may itself produce new symptoms--those of the secondary defence. The obsessional idea, like any other, is attacked by logic, though its compulsive force is unshakable. The secondary symp- toms are an intensification of conscientiousness, and a compulsion to examine things and to hoard them. Other secondary symptoms arise if the compulsion is transferred to motor impulses against the obsession- for instance, to brooding, drinking (dipsomania), protective ceremonials, folie du doute. Here, then, we arrive at the formation of three species of symptoms: (a) the primary symptom of defence--conscientiousness, (b) the compromise symptoms of the illness--obsessional ideas or obsessional affects, (c) the secondary symptoms of defence--obsessional brooding, obses- sional hoarding, dipsomania, obsessional ceremonials. Those cases in which the content of the memory has not become admissible to consciousness through substitution, but in which the affect of self-reproach has become admissible through transformation, give one the impression of a displacement having occurred along a chain of inferences: Ireproach myself on account of an event-I am afraid other people know about it-therefore I feel ashamed in front of other people. As soon as the first link in this chain is repressed, the obsession jumps on to the second or third link, and leads to two forms of delusions of reference, which, however, are in fact part of the obsessional nemosis. The defensive struggle terminates in general doubting mania or in the development of the life of an eccentric with an indefinite number of secondary defensive symptoms--that is, if such a termination is reached at all. It further remains an open question whether the repressed ideas return of their own accord, without the assistance of any contemporary psychical force, or whether they need this kind of assistance at every fresh wave of their return. My experiences indicate the latter alternative. States of contemporary unsatisfied libido, it seems, are what employ the force of their unpleasme to arouse the repressed self-reproach. Once this arousal has occmred and symptoms have arisen through the impact of the re-

94 MAKING OF A PSYCHOANALYST pressed on the ego, then, no doubt the repressed ideational material continues to operate on its own account; but in the oscillations of its quantitative power it always remains dependent on the quota of libidinal tension present at the moment. Sexual tension which, owing to being satisfied, has no time to turn into unpleasure remains harmless. Ob- sessional neurotics are people who are subject to the danger that even- tually the whole of the sexual tension genera ted in them daily may turn into self-reproach or rather into the symptoms resulting from it, although at the present time they would not recognize the primary self-reproach afresh. Obsessional neurosis can be cured if we undo all the substitutions and affective transformations that have taken place, till the primary self- reproach and the experience belonging to it can be laid bare and placed before the conscious ego for judging anew. In doing this we have to work through an incredible number of intermediate or compromise ideas which become obsessional ideas temporarily. We gain the liveliest con- viction that it is impossible for the ego to direct on to the repressed material the part of the psychical energy to which conscious thought is Iinked. The repressed ideas-so we must believe-are present in and enter without inhibition into the most rational trains of thought; and the memory of them is aroused too by the merest allusions. The suspicion that 'morality' is put forward as the repressing force only as apretext is confirmed by the experience that resistance during the therapeutic work avails itself of every possible motive of defence. PARANOIA The c1inical determinants and chronological relations of pleasure and unpleasure in the primary experience are still unknown to me. What I have distinguished is the fact of repression, the primary symptom and the stage of iIIness as determined by the return of the repressed ideas. The primary experience seems to be of a similar nature to that in )bsessional neurosis; repression occurs after the memory of it has released unpleasure-it is unknown how. No self-reproach, however, is formed and afterwards repressed; but the unpleasure generated is referred to the patient's fellow-men in accordance with the psychical formula of pro- jection. The primary symptom formed is distrust (sensitiveness to other people). In this, belief has been withheld from a self-reproach. We may suspect the existence of different forms, according to whether only the affect is repressed by projection or the content of the experience too, along with it. So, again, what returns may be merely the distressing affect or the' memory as weil. In the second case, which is the only one I am c10sely acquainted with, the content of the experience returns as a thought that occurs to the patient or as a visual or sensory hallucination. The repressed affect seems invariably to return in hallucinations of voices.

DRAFI' K 95 The returning portions of the memory are distorted by being replaced by analogous images from the present day-that is, they are simply distorted by a chronological replacement and not by the formation of a surrogate. The voices, too, bring back the self-reproach as a compromise symptom and they do so, firstly, distorted in its wording to the pitch of being indefinite and changed into a threat; and, secondly, related not to the primary experience but precisely to the distrust-that is, to the primary symptom. Since belief has been withheld from the primary self-reproach, it is at the unrestricted command of the compromise symptoms. The ego does not regard them as alien to itself but is incited by them to make attempts at explaining them which may be described as assimilatory delusions. At this point, with the return of the repressed in distorted form, the defence has at once failed; and the assimilatory delusions cannot be interpreted as a symptom of secondary defence but as the beginning of an alteration of the ego, an expression of its having been overwhelmed. The process reaches its conclusion either in melancholia (a sense of the ego's littleness), which, in a secondary manner, attaches to the distortions the belief which has been withheld from the pimary self-reproach, or- what is more frequent and more serious-in protective delusions (meg- alomania), till the ego has been completely remodelIed. The determining element of paranoia is the mechanism of projection involving the refusal of belief in the self-reproach. Hence the common characteristic features of the neurosis: the significance of the voices as the means by which other people affect us, and also of gestures, which reveal other people's mental life to us; and the importance of the tone of remarks and allusions in them-since a direct reference from the content of remarks to the repressed memory is inadmissible to con- SClOusness. In paranoia repression takes place after a complicated conscious pro- cess of thought (the withholding of belief). This may perhaps be an indication that it first sets in at a later age than in obsessional neurosis and hysteria. The preconditions of repression are no doubt the same. It remains a completely open question whether the mechanism of projec- tion is entirely a matter of individual disposition or whether it is selected by particular temporal and accidental fadors. Four species of symptoms: (a) primary symptoms of defence, (b) compromise symptoms of the return, (c) secondary symptoms of defence, (d) symptoms of the overwhelming of the ego.

96 MAKING OF A PSYCHOANALYST HYSTERIA Hysteria necessarily presupposes a primary experience of unpleasure- that is, of a passive nature. The natural sexual passivity of women explains their being more inclined to hysteria. Where I have found hysteria in men, I have been able to prove the presence of abundant sexual passivity in their anamneses. A further condition of hysteria is that the primary experience of unpleasure shall not occur at too early a time, at which the release of unpleasure is still too slight and at which, of course, pleasurable events may still follow independently. Otherwise what will follow will be only the formation of obsessions. For this reason we often find in men a combination of the two neuroses or the replace- ment of an initial hysteria by a later obsessional neurosis. Hysteria begins with the ovewhelming of the ego, which is what paranoia leads to. The raising of tension at the primary experience of unpleasure is so great that the ego does not res ist it and forms no psychical symptom but is obliged to allow a manifestation of discharge-usually an excessive expression of excitation. This first stage of hysteria may be described as 'fright hysteria'; its primary symptom is the manifestation of fright ac- companied by a gap in the psyche. It is still unknown up to how late an age this first hysterical overwhelming of the ego can occur. Repression and the formation of defensive symptoms only occur sub- sequently, in connection with the memory; and thenceforward defence and overwhelming (that is, the formation of symptoms and the outbreak of attacks) may be combined to any extent in hysteria. Repression does not take place by the construction of an excessively strong antithetic idea but by the intensification of a boundary idea, which thereafter represents the repressed memory in the passage of thought. It may be called a boundary idea because on the one hand it belongs to the ego and on the other hand forms an undistorted portion of the traumatic memory. So, once again, it is the result of a compromise; this, however, is not manifested in areplacement on the basis of some category of subject-matter, but by a displacement of attention along a series of ideas linked by temporal simultaneity. If the traumatic event found an outlet for itself in a motor manifestation, it will be this that becomes the boundary idea and the first symbol of the repressed material. There is thus no need to assurne that some idea is being suppressed at each repetition of the primary attack; it is a question in the first instance of a gap in the psyche. The Aetiology of Hysteria This is the much-discussed paper that Freud read to the Viennese Soeiety for Psyehiatry and Neurology in late April 1896. It is at onee elegant and eloquent, but it advoeates an untenable theory-that neuroses are almost

THE AETIOLOGY OF HYSTERlA 97 invariably caused by sexual aggression of adults against children, whether subtle seduction or rude rape. Richard Freiherr von Kraffi-Ebing (1840- 1902), the celebrated neurologist who specialized in sexual pathology (and who in general thought weil enough of Freud to advance his career through the maze of the Austrian bureaucracy), dismissed the talk as \"a scientific fairy tale.\" Before long, Freud would think so, too, but the lecture is a splendid instance of his forensie skill. [I] Gentlemen,-When we set out to form an opinion about the causation of a pathological state such as hysteria, we begin by adopting the method of anamnestic investigation: we question the patient or those about hirn in order to find out to what harmful influences they themselves attribute his having fallen ill and developed these neurotic symptoms. What we discover in this way is, of course, falsified by all the factors which commonly hide the knowledge of his own state from a patient-by his lack of scientific understanding of aetiological influences, by the fallacy of post hoc, {Jropter hoc, by his reluctance to think about or mention certain noxae and traumas. Thus in making an anamnestic investigation of this sort, we keep to the principle of not adopting the patients' belief without a thorough critical examination, of not allowing them to lay down our scientific opinion for us on the aetiology of the neurosis. Although we do, on the one hand, acknowledge the truth of certain constantly repeated assertions, such as that the hysterical state is a long- persisting after-elfect of an emotion experienced in the past, we have, on the other hand, introduced into the aetiology of hysteria a factor which the patient himself never brings forward and whose validity he only reluctantly admits--namely, the hereditary disposition derived from his progenitors. As you know, in the view of the influential school of Charcot heredity alone deserves to be recognized as the true cause of hysteria, while all other noxae of the most various nature and intensity only play the part of incidental causes, of 'agents {Jrovocateurs'. Y ou will readily admit that it would be a good thing to have a second method of arriving at the aetiology of hysteria, one in which we should feelless dependent on the assertions of the patients themselves. * * * Imagine that an explorer arrives in a little-known region where his interest is aroused by an expanse of ruins, with remains of walls, frag- ments of columns, and tablets with half-elfaced and unreadable inscrip- tions. He may content hirnself with inspecting what lies exposed to view, with questioning the inhabitants--perhaps semi-barbaric people-who live in the vicinity, about what tradition teils them of the history and meaning of these archaeological remains, and with noting down what they tell him-and he may then proceed on his journey. But he may act differently. He may have brought picks, shovels and spades with

98 MAKING OF A PSYCHOANALYST hirn, and he may set the inhabitants to work with these implements. Together with them he may start upon the ruins, clear away the rubbish, and, beginning from the visible remains, uncover what is buried. If his work is crowned with success, the discoveries are self-explanatory: the ruined walls are part of the ramparts of a pa la ce or a treasure-house; the fragments of columns can be fiIIed out into atempie; the numerous inscriptions, which, by good luck, may be bilingual, reveal an alphabet and a language, and, when they have been deciphered and translated, yield undreamed-of information about the events of the remote past, to commemorate which the monuments were built. Saxa loquuntur! {Stones talk!} If we try, in an approximately similar way, to induce the symptoms of a hysteria to make themselves heard as witnesses to the history of the origin of the ilIness, we must take our start from Josef Breuer's mo- mentous discovery: the symptoms of hysteria (apart from the stigmata) are determined by certain experiences of the patient' s wh ich have opera ted in a traumatic fashion and which are being reproduced in his psychical life in the form of mnemic symbols. What we have to do is to apply Breuer's method-{)r one which is essentiaIly the same-so as to lead the patient's attention back from his symptom to the scene in which and through which that symptom arose; and, having thus located the scene, we remove the symptom by bringing about, during the repro- duction of the traumatic scene, a subsequent correction of the psychical course of events which took place at the time. It is no part of my intention to-day to discuss the difficult technique of this therapeutic procedure or the psychological discoveries which have been obtained by its means. I have been obliged to start from this point only because the analyses conducted on Breuer's lines see m at the same time to open up the path to the causes of hysteria. If we subject a fairly large number of symptoms in a great number of subjects to such an analysis, we shaIl, of course, arrive at a knowledge of a correspondingly large number of traumaticaIly operative scenes. It was in these experi- ences that the efficient causes of hysteria came into action. Hence we may hope to discover from the study of these traumatic scenes what the influences are which produce hysterical symptoms and in what way they do so. This expectation proves true; and it cannot fail to, since Breuer's theses, when put to the test in a considerable number of cases, have turned out to be correct. But the path from the symptoms of hysteria to its aetiology is more laborious and leads through other connections than one would have imagined. For let us be clear on this point. Tracing a hysterical symptom back to a traumatic scene assists our understanding only if the scene satisfies two conditions; if it possesses the relevant suitability to serve as a de- terminant and if it recognizably possesses the necessary traumatic force. Instead of a verbal explanation, here is an example. Let us suppose that

THE AETIOLOGY OF HYSTERIA 99 the symptom under consideration is hysterical vomiting; in that case we shall fee! that we have been able to understand its causation (except for a certain residue) if the analysis traces the symptom back to an experience which ;usti{iably produced a high amount of disgust-for instance, the sight of a decomposing dead body. But if, instead of this, the analysis shows us that the vomiting arose from a great fright, e.g. from a railway accident, we shall fee! dissatisfied and will have to ask ourselves how it is that the fright has led to the particular symptom of vomiting. This derivation lacks suitability as a detenninant. We shall have another instance of an insufficient explanation if the vomiting is supposed to have arisen from, let us say, eating a fruit which had partly gone bad. Here, it is true, the vomiting is determined by disgust, but we cannot understand how, in this instance, the disgust could have become so powerful as to be perpetuated in a hysterical symptom; the experience lacks traumatic force. Let us now consider how far the traumatic scenes of hysteria which are uncovered by analysis fulfil, in a fairly large number of symptoms and cases, the two requirements which I have named. Here we meet with our first great disappointment. It is true, indeed, that the traumatic scene in which the symptom originated does in fact occasionally possess both the qualities-suitability as a determinant and traumatic force- which we require for an understanding of the symptom. But far more frequently, incomparably more frequently, we find one of the three other possibilities realized, which are so unfavourable to an understand- ing. Either the scene to which we are led by analysis and in which the symptom first appeared seems to us unsuited for determining the symp- tom, in that its content bears no relation to the nature of the symptom; or the allegedly traumatic experience, though it does have a relation to the symptom, proves to be an impression which is normally innocuous and incapable as a rule of producing any effect; or, lastly, the 'traumatic scene' leaves us in the lurch in both respects, appearing at once innoc- uous and unrelated to the character of the hysterical symptom. * * Moreover, Gentlemen, this first disappointrnent we meet with in following Breuer's method is immediately succeeded by another, and one that must be especially painful to us as physicians. When our procedure leads, as in the cases described above, to findings which are insufficient as an explanation both in respect to their suitability as de- terminants and to their traumatic effectiveness, we also fail to sec ure any therapeutic gain; the patient retains his symptoms unaltered, in spite of the initial result yielded by the analysis. Y ou can understand how great the temptation is at this point to proceed no further with what is in any case a laborious piece of work. But perhaps all we need is a new idea in order to help us out of our dilemma and lead to valuable results. The idea is this. As we know from

100 MAKING OF A PSYCHOANALYST Breuer, hysterical symptoms can be resolved if, startihg from them, we are able to find the path back to the memory of a traumatic exp~rience. If the memory which we have uncovered does not answer our expec- tations, it may be that we ought to pursue the same path a little further; perhaps behind the first traumatic scene there may be concealed the memory of a second, which satisfies our requirements better and whose reproduction has a greater therapeutic effect; so that the scene that was first discovered only has the significance of a connecting link in the chain of associations. And perhaps this situation may repeat itself; in- operative scenes may be interpolated more than once, as necessary tran- sitions in the process of reproduction, until we finally make our way from the hysterical symptom to the scene which is really operative trau- matically and which is satisfactory in every respect, both therapeutically and analytically. Weil, Gentlemen, this supposition is correet. If the first-discovered scene is unsatisfactory, we tell our patient that this ex- perience explains nothing, but that behind it there must be hidden a more significant, earlier, experience; and we direct his attention by the same technique to the associative thread which connects the two mem- ories-the one that has been discovered and the one that has still to be discovered. A continuation of the analysis then leads in every instance to the reproduetion of new scenes of the character we expect. * * * But we must not fail to lay special emphasis on one conclusion to which analytic work along these chains of memory has unexpectedly led. We have learned that no hysterical symptom can arise from areal experience alone, but that in every case the memory of earlier experiences awakened in association to it plays a part in causing the symptom. If- as I believe-this proposition holds good without exception, it further- more shows us the basis on which a psychological theory of hysteria must be built. * * But the most important finding that is arrived at if an analysis is thus consistently pursued is this. Whatever case and whatever symptom we take as our point of departure, in the end we infallibly come to the field of sexual experience. So here for the first time we see m to have discovered an aetiological precondition for hysterical symptoms. From previous experience I can foresee that it is precisely against this assertion or against its universal validity that your contradiction, Gentle- men, will be directed. Perhaps it would be better to say, your inclination to contradict; for none of you, no doubt, have as yet any investigations at your disposal which, based upon the same procedure, might have yielded a different result. As regards the controversial matter itself, I will only remark that the singling out of the sexual factor in the aetiology of hysteria springs at least from no preconceived opinion on my part. The two investigators as whose pupil I began my studies of hysteria, Charcot and Breuer, were far from having any such presupposition; in fact they

THE AETlOLOGY OF HYSTERIA 101 had a personal disinclination to it which I originally shared. Only the most laborious and detailed investigations have converted me, and that slowly enough, to the view I hold to-day. If you submit my assertion that the aetiology ofhysteria lies in sexuallife to the strictest examination, you will find that it is supported by the fact that in some eighteen ca ses of hysteria I have been able to discover this connection in every single symptom, and, where the circumstances allowed, to confirm it by ther- apeutic success. * * * Eventually, then, after the chains of memories have converged, we come to the field of sexuality and to a small number of experiences which occur for the most part at the same period of life-namely, at puberty. It is in these experiences, it seems, that we are to look for the aetiology ofhysteria, and through them that we are to learn to understand the origin of hysterical symptoms. But here we meet with a fresh dis- appointrnent and a very serious one. lt is true that these experiences, which have been discovered with so much trouble and extracted out of aB the mnemic material, and which seemed to be the ultimate traumatic experiences, have in common the two characteristics of being sexual and of occurring at puberty; but in every other respect they are very different from each other both in kind and in importance. In some cases, no doubt, we are concerned with experiences which must be regarded as severe traumas-an attempted rape, perhaps, which reveals to the immature girl at a blowall the brutality of sexual desire, or the invol- untary witnessing of sexual acts between parents, which at one and the same time uncovers unsuspected ugliness and wounds childish and moral sensibilities alike, and so on. But in other cases the experiences are astonishingly trivial. In one of my women patients it tumed out that her neurosis was based on the experience of a boy of her acquaintance stroking her hand tenderly and, at another time, pressing his knee against her dress as they sat side by side at table, while his expression let her see that he was doing something forbidden. For another young lady, simply hearing ariddIe which suggested an obscene answer had been enough to provoke the first anxiety attack and with it to start the illness. Such findings are clearly not favourable to an understanding of the causation of hysterical symptoms. If serious and trifling events alike, and if not only experiences affecting the subjecl's own body but visual impres- sions too and information received through the ears are to be recognized as the ultimate traumas of hysteria, then we may be tempted to hazard the explanation that hysterics are peculiarly constituted creatures-prob- ably on account of so me hereditary disposition or degenerative atrophy- in whom a shrinking from sexuality, which normally plays some part at puberty, is raised to a pathological pitch and is permanently retained; that they are, as it were, people who are psychically inadequate to meeting the demands of sexuality. This view, of course, leaves hysteria in men out of account. But even without blatant objections such as that, we should scarcely be tempted to be satisfied with this solution. We are

102 MAKING OF A PSYCHOANALYST only too distinctly conscious of an intellectual sense of something half- understood, unclear and insufficient. Luckily for our explanation, so me of these sexual experiences at pu- berty exhibit a further inadequacy, which is calculated to stimulate us into continuing our analytic work. For it sometimes happens that they, too, lack suitability as determinants-although this is much more rarely so than with the traumatic scenes belonging to later life. Thus, for instance, let us take the two women patients whom I have just spoken of as ca ses in which the experiences at puberty were actually innocent ones. As a result of those experiences the patients had become subject to peculiar painful sensations in the genitals which had established them- selves as the main symptoms of the neurosis. I was unable to find indications that they had been determined either by the scenes at puberty or by later scenes; but they were certainly not normal organic sensations nor signs of sexual excitement. It seemed an obvious thing, then, to say to ourselves that we must look for the determinants of these symptoms in yet other experiences, in experiences which went still further back- and that we must, for the second time, follow the saving notion which had earlier led us from the first traumatic scenes to the chains of mem- ories behind them. In doing so, to be sure, we arrive at the period of earliest childhood, aperiod before the development of sexual life; and this would seem to involve the abandon me nt of a sexual aetiology. But have we not a right to assurne that even the age of childhood is not wanting in slight sexual excitations, that later sexual development may perhaps be decisively influenced by childhood experiences? Injuries sus- tained by an organ which is as yet immature, or by a function which is in process of developing, often cause more severe and lasting eifects than they could do in maturer years. Perhaps the abnormal reaction to sexual impressions which surprises us in hysterical subjects at the age of puberty is quite generally based on sexual experiences of this sort in childhood, in which ca se those experiences must be of a similar nature to one another, and must be of an important kind. If this is so, the prospect is opened up that wh at has hitherto had to be laid at the door of a still unexplained hereditary predisposition may be accounted for as having been acquired at an early age. And since infantile experiences with a sexual content could after all only exert a psychical eifect through their memory-traces, would not this view be a welcome amplification of the finding of psycho-analysis which teIls us that hysterical symptoms can only arise with the co-operation of memories? II * * * If we have the perseverance to press on with the analysis into early childhood, as far back as a human memory is capable of reaching, we invariably bring the patient to reproduce experiences which, on account both of their peculiar features and of their relations to the