THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES GIFT OF DR. ROY VAN WART Nervous and Mental Disease Monograph Series No. 17 Freud's Theories of the Neuroses By DR. EDUARDiHITSCHMANN of Vienna New York 1913 ANNOUNCEMENT 3E Nervous and Mental Disease Monograph Series will consist of short monographs, translations and minor text-books, on subjects related to these speciaLIes It is purposed to issue them from time to time as the material becomes available. The editors will be pleased to consider the avail- ability of manuscripts for the series. Nervous and Mental Disease Monograph Series Editors SMITH ELY JBLLIFFE, M.D. WM. A. WHITE, M.D. No. 1. Outlines cf Psychiatry. (Fourth Edition, 1913.) Price, $3.00 By WM. A. WHITS, M.D. No. 2. Studies in Paranoia. (Out of Print.) No. 3. Psychology of Dementia Praecox. (Out of Print.) No. 4. Selected Papers on Hysteria and Other Psycho- neuroses. (Second Edition, 1912.) Price, $2.50 By PROF. SIGMUND FREUD, M.D, No. 5. 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EITSCHMANN Address all communications to JOURNAL OF NERVOUS AND MENTAL DISEASE DISEASE, 64 West Fifty-Sixth Street, New York. NERVOUS AND MENTAL DISEASE MONOGRAPH SERIES, No. 17 FREUD'S THEORIES OF THE NEUROSES BY DR. EDUARD H1TSCHMANN of Vienna Authorized Translation by DR. C. R. PAYNE Westport, N. Y. With an Introduction by Ernest Jones, M.D., M.R.C.P., of London NEW YORK THE JOURNAL OF NERVOUS AND MENTAL DISEASE PUBLISHING COMPANY NERVOUS AND MENTAL DISEASE MONOGRAPH SERIES Edited by Drs. SUITE ELY JELLIFFE and WM. A. WHITE Numbers Issued 1. Outlines of Psychiatry. (4th Edition.) $3.00. By Dr. William A. White. 2. Studies in Paranoia. By Drs. N. Gierlich and M. Friedman. 3 . The Psychology of Dementia Praecoz. ( Out of Print. ) By Dr. C.G.Jung. 4. Selected Papers on Hysteria and other Psy chone ur oses . (3d Edition.) $2.50. By Prof . Sigmund Freud. 5. TheWassermannSerumDiagnosisinPsychiatry. $2.00. By Dr. FelixPlaut. 6. Epidemic Poliomyelitis. New York, 1907. (Outof Print.) 7. Three Contributions to Sexual Theory. $2.00. By Prof. Sigmund Freud. 8. Mental Mechanisms. $2.00. By Dr. Wm. A. White. 9. Studies in Psychiatry. $2.00. New York Psychiatrical Society, zo. Handbook of Mental Examination Methods. $2.00. By Shepherd Ivory Franz. 11. The Theory of Schizophrenic Negativism. $0.60. By Professor E. Blenler- 12. Cerebellar Functions. $3.00. By Dr. Andre-Thomas. 13. History of Prison Psychoses. $1.25. By Drs. P. Nitsche and K. Wilmanns. 14. General Paresis. $3.00. By Prof. E. Kraepelin. 15. Dreams and Myths. f i.oo. By Dr. Karl Abraham. 16. Poliomyelitis. $3.00. Dr. I. Wickmann 17. Frued's Theories of the Neuroses. $2.00. Dr. E. Hitschmann. Copyright, 1913, by THE JOURNAL OF NERVOUS AND MENTAL DISEASE PUBLISHING COMPANY, NEW YORK PRESS or THE NEW ERA PRINTING COMPANY LANCASTER. PA. no Ht>: 1113 INTRODUCTION BY ERNEST JONES, M.D. (London), M.R.C.P. (London), ASSOCIATE PROFESSOR OF PSYCHIATRY, UNIVERSITY OF TORONTO; SECRETARY OF THE AMERICAN PSYCHO-ANALYTIC ASSOCIATION Dr. Hitschmann has in this volume undertaken an important task, namely, a synthetic presentation of the Freudian theory. It will on all sides be acknowledged that the need for this has long been felt, the reason being that it is exceedingly difficult properly to grasp the significance of the theory from the reading only of disconnected fragments, which taken in themselves often present an appearance that is far from convincing. The especial difficulty inherent in any attempt to render a connected description as is here given lies in the fact that the Freudian theory represents not a fixed philosophic doctrine but a growing body of science. Strangely enough this has sometimes been made a source of reproach to Professor Freud, as indicating a fluctuating change and lack of stability in his conclusions. It is certainly true that during the gradual evolution of his methods and conclusions, an evolution which is still in progress, he has been led to introduce various modifications into his earlier views. These have always been, however, of the nature of amplifications rather than of retractions, increasing experience having shown him that some of his earlier views were, though correct so far as they went, yet incomplete and at times imperfectly oriented. This very evolution is surely evidence in itself that the conclu- sions reached are based on definite data of experience, and repre- sent no subjective opinions of the author; a theory of such novel and intricate matters as unconscious mental processes should, on the contrary, arouse a justifiable suspicion were it promulgated as being complete and perfect from its inception. The further consideration has to be weighed that the field of Professor Freud's investigations has undergone a remarkable widening in the course of years. Confined at first to the study of the neuroses, it became iii IV INTRODUCTION extended first to the subject of normal dream life, of the processes underlying the production of wit, and the development and varia- tion of the instinct of sex. In the past eight years it has been further extended so as to comprise on the one hand various devi- ations from the normal, such as criminality, certain psychoses, failures in mental functioning with healthy people, the nature and origin of sexual perversions, and on the other hand an increasing number of more normal manifestations, such as the source of literary and artistic inspiration, the evolution of language, the structure and meaning of religious, mythological and superstitious beliefs, and the sources of many other human interests and activi- ties, encroaching thus in ever widening circles on the domain of normal psychology. These last named extensions, Dr. Hitsch- mann has here for the first time given a connected account of, one which no doubt would have been less brief had not the main purpose of the book been a medical one ; those who are interested in these important aspects of psycho-analysis may be referred to a special journal, Imago, which is devoted to the non-medical applications of the subject. When one works systematically over the apparently disconnected fields here mentioned, one realizes more and more both the breadth and the unity of the fundamental conceptions that follow from psycho-analytic investigations. They constitute an organic whole, and it would seem that the time is now ripe for a presentation of them as such. In carrying out this task, Dr. Hitschmann has been singularly successful. Being in near personal touch with Professor Freud himself and also having at his disposal an extensive psycho- analytic experience, he is in a position to render an especially faithful presentation of both the theory and the practice of the subject. He has subordinated his personal views and striven to reproduce Professor Freud's own as exactly as possible, making indeed lengthy quotations from the latter's writings so as to fur- nish an additional safeguard against any deflections. The book should therefore be invaluable to those who contemplate making a serious study of this important subject, and should serve as a useful introduction to more detailed and special publications. When Dr. Hitschmann asked me to suggest the name of a translator for his book, I must confess that I felt at a considerable loss, for it was clear to me that the task would be no easy one. INTRODUCTION V German is a harder language to translate from than French, and as most of the sentences have to be entirely reconstructed, the translator must have a thorough knowledge both of German and of the subject-matter, especially so in such a book as the present one where so much material is tightly packed into a relatively small space. Further, not only had English equivalents to be found for the new terms that inevitably accompany new ideas, but so much of the thought was novel and strange that in order to make the translation intelligible especial care had to be taken in couching the language in an unambiguous, lucid and accurately grammatical form, a responsibility not always realized by trans- lators of scientific works. I had the good fortune, however, of being able to enlist the energies of Dr. Payne, who has, as I know from a personal acquaintance with his work, a thorough knowl- edge and understanding of psycho-analysis and whose care in rendering the precise meaning of the original combined with a rare happiness of expression will commend itself to all his readers. Dr. Payne has further enriched the book with a number of foot- notes that elucidate particularly difficult passages in the text, and has added bibliographical references to some of the rapidly accu- mulating literature in English. May his translation win the success it is justly entitled to. ERNEST JONES. PREFACE The motives that led me to believe there is a need for a sum- mary of the Freudian investigations have only been strengthened during its preparation. The book is intended to serve as an introduction as well as an incentive to the study of Freud's works and the application of the psycho-analytic methods ; it aims at separating from the ranks of the indifferent and antagonistic those whose position is due to insufficient or erroneous information; finally it is desired that this book by pointing out the unsolved problems of the theory may further their solution. Later editions will have to take into consideration the progress or modifications as well as the new views arising from them. I am greatly indebted to Professor Freud for his revision and many suggestions and to Dr. O. Rank for his collaboration in prepar- ing the book. DR. EDUARD HITSCHMANN. VIENNA, Autumn, 1910. vn TABLE OF CONTENTS INTRODUCTION TO THE ENGLISH EDITION BY DR. ERNEST JONES iii INTRODUCTION I Aim and Scope of the Book. Adherents and Opponents. Ob- jections. Objections to the Theory. Attempt at Refutation and Explanation of Them. CHAPTER I GENERAL THEORY OF THE NEUROSES 7 Freud's Field of Work. General Pathology. Classification of the Neuroses. Course of Development of Freud's Theory of the Neuroses. General Etiology. Role of Sexuality and Heredity. The Psycho-Sexual Constitution. Cultural Sexual Morality. Reference to the Therapy. CHAPTER II THE TRUE NEUROSES 15 A. Neurasthenia. Clinical Picture. Etiology. Prophylaxis and Therapy. B. Anxiety-Neurosis. Symptomatology. Etiology. Theory. C. Refutation of the Objections to the Sexual Etiology of the True Neuroses. CHAPTER III THE SEXUAL INSTINCT 31 Existence and Significance of Sexuality in Children. Opposi- tion to the Acceptance of this Discovery. The Sexual Theory: A. Infantile Sexuality: I. Sexuality of the Suckling. 2. Sexuality in Children. 3. Changes at Puberty. B. Deviations of the Sexual Instinct: Inversion, Perversion, Fetichism, Sadism, Masochism, Exhibitionism, etc. C. Sexuality of Neurotics. Confirmation of the Theory by Analysis of Neuroses of Children. Infantile Sexual Theories. Nuclear Complex of the Neuroses. CHAPTER IV THE UNCONSCIOUS 50 Consciousness and the Unconscious. Common Meaning of Unconscious. Hypnosis and Double Consciousness. The Uncon- scious in Hysteria. Resistance and Repression. Genesis and Con- tent of the Real Unconscious. The Complex. The Free Asso- ciation. The Association Experiment. Determinism of All Mental Processes. The Phenomena of the Unconscious in the Psychopathology of Everyday Life. The Unconscious in Wit and Dream Formation. IX X CONTENTS CHAPTER V THE DREAM 60 Chief Characteristics of the Dream: Wish-fulfillment, Sexual Erotic Content. The Dream Sources. The Dream Distortion (manifest and latent content). The Dream-Making. Interpreta- tion Technique: (a) by Symbolism, (&) by Associations. Tech- nical Rules. Typical Dreams. CHAPTER VI HYSTERIA 75 Freud's Position in the Theory of Hysteria. Repression and Conversion. Sexuality and Infantilism. The Hysterical Mind. The Hysterical Symptom: Its Somatic and Psychic Foundations. The Hysterical Phantasies. The Hysterical Attack. Nervous Dis- turbances. Neurotic Anxiety (Anxiety-Dream, Anxiety-Hysteria, Phobia). Concerning the Psychoses. CHAPTER VII THE OBSESSIONAL NEUROSIS 100 Relation to Hysteria. Substitution Instead of Conversion. Characteristic Obsession. Nature and Mechanism of the Obses- sional Neurosis (1896). Remarks on a Case of Obsessional Neurosis (1909). Significance of the Instinct in Life (Sadism). Love and Hate; Obsession and Doubt. Mechanism of Distor- tion. Some Mental Peculiarities of the Obsessed. CHAPTER VIII PSYCHO-ANALYTIC METHOD OF INVESTIGATION AND TREATMENT 114 Its Peculiarity (Specific Therapy). History of the Develop- ment of This Method. General Technique. Art of Interpreta- tion. Indications and Contra-indications. The Transference. Refutation of the Objections to the Method. CHAPTER IX GENERAL PROPHYLAXIS OF THE NEUROSES 135 Cultural Sexual Morality. Sexual Education. Sexual En- lightenment CHAPTER X APPLICATION OF PSYCHO-ANALYSIS 142 Significance of Psycho-analysis for Medicine. Significance for the Psychology of Normal Individuals and for Normal Psy- chology (Unconscious, Dream, Wit). Psychopathology of Every- day Life. Elucidation of the Psychology of Psychopaths, Crimi- nals, Artists, Poets, Geniuses (Characterology). Significance for the History of Culture and Folk Psychology. CHRONOLOGICAL REVIEW OF THE FREUDIAN WRITINGS 150 REFERENCES TO THE PUBLICATIONS IN ENGLISH 153 FREUD'S THEORY OF THE NEUROSES INTRODUCTION Aim and Scope of the Book. Adherents and Opponents. Objections and Opposition to the Theory. Attempt at Refutation or Explanation of Them. The following condensed presentation of the present status of Freud's theory of the neuroses is justified in the first place by the difficulty of the subject, the constantly increasing extent of the publications dealing with it and the fact that the lack of a systematic arrangement of Freud's writings has made the first perusal and study of them a hard task. Freud has never pre- tended to offer a completely elaborated theory of the neuroses; indeed he could not have done so, since he proceeded from prac- tical experience which of necessity could only develop and deepen by degrees. A theory, complete and well rounded at the begin- ning, could only be the product of speculation, which might indeed be suitable for a philosophical system but not for a medical study. Nevertheless, the foundation and framework of the theory are already erected so that it is time to attempt a provisional review of the whole. It is obvious that this synthetic presentation avoids either filling in or concealing the necessary gaps ; on the contrary, it will call attention to them and thus point out the problems still to be solved. The book is meant to be purely a review ; it there- fore uses many of Freud's own words and has especially endeav- ored to place the empirical foundations of his investigations in the foreground. It has in view the arousing of interest in the study and examination of this important method among distant circles of medical men both in the clinic and in private practice, and hopes in this way to be able to show the general validity of it. Where, but a short time ago only a small band of zealous col- leagues were gathered around Freud, now in recent years the Freudian doctrine has found, especially in foreign countries, an 2 FREUD'S THEORY OF THE NEUROSES echo of agreement and a group of influential adherents. 1 Still, wide circles of the medical profession either remain indifferent or are led astray and alarmed by the extreme attacks of certain fanatical opponents. It is imperative, therefore, to begin by exposing the motives which lie at the bottom of so much of the opposition to an unprejudiced examination of these new and original conceptions, at the same time refuting some objections which often enough arise from only an incomplete understanding of the theories which they oppose. Naturally, one can only do justice to the Freudian doctrines, which have in no way been evolved from theories but slowly de- veloped from painfully acquired experience, when he has tried out in practice the method of mental investigation (psycho-analysis) derived from them. The difficulty which is experienced in attempting this has many causes. In the first place, it may be explained by the fact that for the present generation of physicians educated in the chemico-anatomico-pathological school it is almost impossible to allow a proper place to psychic causes of disease. It is customary to be satisfied with the hereditary and constitu- tional theories of the neuroses. By far the greatest and most universal opposition raised against the Freudian doctrines has been because of the disclosure of an unfailing sexual agency in the causation of neurotic manifestations. Here the resistance, a normal one, lies in the nature of the thing itself, since healthy and slightly neurotic individuals are inclined for intelligible reasons to deny the paramount importance of sexuality: the healthy, because it constitutes no problem for them; the others because of their unconsious need to spread a veil over their own weaknesses. Unfortunately, physicians in their personal relation to the ques- tion of sexual life have not been given any preference over the rest of the children of men and many of them stand under the ban of that combination of prudery and lust which governs the atti- tude of most cultivated people in sexual matters. Even those whose medical experience will not allow them to escape from the 1 This applies especially to the Swiss school with Bleuler and Jung at its head. Compare the important works of this school in the bibli- ography of the Jahrbuch fur psychoanalytische und psychopathologische Forschungen, published under the supervision of Bleuler and Freud and edited by Jung, Vol. II, 1910. INTRODUCTION 3 observation that sexuality plays an important role in the neuroses deny the universal application of this experience and dispute the conclusion that in every case the exciting or decisive causes must be of a sexual nature. Against this attitude is Freud's assertion that his experience of many years has as yet shown no exception to this rule. It will thus be necessary to wait and see if in the use of the method of investigation developed by Freud any excep- tions may be proven. 2 In strange contrast to this reproach of unjustified generaliza- tions is brought forward from another side the assertion that Freud's teaching brings forth absolutely nothing new, but merely reiterates the old naive folk-opinion which brought the affections into close connection with nervous and mental diseases. While Freud has acknowledged with satisfaction these supporters who are in no way to be despised, still it must be kept clearly in mind what a distance separates his exact scientific methods and demon- strations from these primitive and naive folk-beliefs. This applies especially to the question of whether or not dreams can be inter- preted; that dreams are susceptible of a genuine scientific inves- tigation the scholastics deny ; against this learned opinion, Freud's splendid work has produced the proof that dreams have a real meaning in the sense of the primitive folk-belief. Whoever con- descends to interpret his own or another's dreams according to the Freudian principles will soon bow respectfully before this, perhaps the most important of Freud's contributions, and arrive at identical results. 3 On the other hand, the common sentiment of all people in favor of free-will in mental processes is in direct opposition to the recognition by the Freudian theory of a strict de- terminism of every psychic process ; likewise, the ignorance of sym- bolism which is indispensable for dream and symptom interpreta- tion creates a doubt of its reality and justification. 4 Finally, much opposition has been manifested against the numerous observations which Freud has reported concerning the early sexual expressions 'One may compare with this the course of development of the etio- logical views regarding tabes dorsalis where now syphilis is considered an invariable antecedent. 'Compare for example Eberhard Buchner. "Traum und Traumde- tung," in Frankfurter Zeitung of Jan. 30, 1910. 4 Both of these objections which arise from the nature of things will be made intelligible and refuted in the course of the presentation. 4 FREUD'S THEORY OF THE NEUROSES of children which until now were quoted by others merely as odd or as frightful examples of precocious depravity. Here again anyone who has made similar observations can be convinced of the universality of these occurrences ; indeed one should not spare himself the trouble of directing his attention to such unpleas- ant signs. A part of the antagonism is explained by the fact that Freud is compelled by his investigations to use the word sexuality in a broader sense than usual, giving it about the same meaning as the word " love " in the German language, thus asserting the under- lying unity of all love from the grossly sensual sexual intercourse to the most unassuming exhibition of affection. The use of the term sexuality in the Freudian sense is justified psychologically and brings forward a most fruitful point of view. It is also obvious that not only the actual activities of the sexual life but also its phantasies are to be considered. Freud refuses to counte- nance the narrow and degraded use of the word sexuality on which a part of the antagonism rests. A condition which has hitherto really hindered to a certain degree the diffusion and confirmation of Freud's views regarding the neuroses is the fact that so far there is no systematic and complete exposition of the method of the analysis; in medicine, one is usually accustomed to acquire the method and thus be in a position to test it at first hand. Further, a practical demonstra- tion of the method, a public psycho-analysis as it were, is impos- sible. Of course, it is always possible for those really interested to acquire the technique by personal contact with Freud and by their own subsequent exertions which as a matter of fact many have succeeded in doing. On the other hand, the technical diffi- culties in the way of reproducing the analyses render learning from examples a hard task. Freud's relatively few published analyses 5 are only put forth in fragmentary form because their complete reproduction would take an enormous space and bring the physician into conflict with his duty of discretion. On the other hand, individual details torn from their context lose the 'Freud, "Bruchstiick einer Hysterieanalyse " (Literature index No. 21), "Analyse der Phobic eines ftinfjahrigen Knaben" (Jahrb. I), " Be- merkungen uber einen Fall von Zwangsneurose " (ebenda). Further, compare L. Binswanger, " Versuch einer Hysterieanalyse" (ebenda) as well as other articles in the Jahrbuch with brief analyses. INTRODUCTION 5 greatest part of their power to convince. For these reasons, the present exposition cannot cite case records. For the rest, one could not by innumerable examples or brochures convince those who will not allow themselves to be convinced, while those who have already gained a conviction of the objective reality of the unconscious pathogenic material already possess in their own experience the means of confirming the progress in the realm of the Freudian theory of the neuroses. They will also be in the best position to oppose those all too numerous individuals who will always repeat the assertion that much of the pathogenic sexual material which the analysis uncovers in the patients examined has been suggested to them. He who has listened to such a patient calmly and without prejudice for hours at a time will be easily convinced that every neurotic is full of the subject and is only waiting to confide to an appreciative listener the secrets carefully guarded from others, even from those nearest him. Only by the way of psycho-analysis can the therapeutic results be attained which are in no way connected with the personality and authority of an individual as many sceptically assert, but lie in the correct conception and utilization of the method and its technique. . In the attempt to justify by plausible objections the untenable antipathy against this new-fashioned and in no way easily acquired system, the reproach has been raised against Freud's conclusions that they are not trustworthy because in the course of years they have undergone more than one modification. It is really scarcely necessary to defend against this reproach an investigator who has carried through so revolutionary a life work, many years without aid or encouragement from his colleagues. Freud himself has dismissed it with these words : " Whoever believes in the develop- ment of human intelligence will hear without surprise that I have learned to discard a part of the opinions once put forth, to modify another part. Still, I have been able to hold the greatest part unchanged and need retract absolutely nothing as entirely wrong and quite worthless." For the intelligent, the gradual evolution of the Freudian doctrines is rather the proof of a remarkable con- ception in the beginning, which remains essentially unchanged and only undergoes a more detailed elaboration in certain parts. This progressive development gives the best assurance for the belief that this theory is nothing else than the accumulation of continued 6 FREUD S THEORY OF THE NEUROSES and deepening experience. It should in no way be denied that there are still to-day many points in the Freudian field of work in part unexplained, in part not sufficiently verified and that it will require not less than a generation of strenuous labor to carry the system to its full completion. It may be foreseen that the contents of the Freudian philosophy will then be an indispensable part of medical education and that the science of psycho-analysis in the hands of the next generation of physicians will succeed to an indispensable practical importance. CHAPTER I GENERAL THEORY OF THE NEUROSES Freud's Field of Work. General Pathology. Classification of the Neuroses. Course of Development of Freud's Theory of the Neuroses. General Etiology. Role of Sexuality and of Heredity. The Psycho- sexual Constitution. The Cultural Sexual Morality. Reference to the Therapy. The field of Freud's work comprises the neuroses in the nar- rower sense as well as certain closely related psychoses, such as paranoia, acute hallucinatory confusion, etc. Formerly, numerous clinical pictures were included in the term neuroses from which many have been separated by the progress of the study of the blood-forming organs, for example, Basedow's disease and tetany, while on the other hand, others have been classified as infections, for example, chorea. Thus, the term neuroses has now been limited to neurasthenia, hysteria and the compulsion or obsessional neurosis (Zwangsneurose). According to Freud's opinion, the neuroses deserve the name sexual-neuroses, since for these clinical pictures the chief etiological factors may be proven to lie in the psychosexual sphere. In the field of neurasthenia, the Freudian investigation has yielded a classification of great theoretical importance and practical significance. In a classical study, 6 Freud has separated from the vague term neurasthenia the "anxiety-neurosis "and further sharply marked off a symptom- complex as real or true neurasthenia. He calls these two clinical pictures true neuroses because their cause lies in the present abnormal condition of the sexual function of the individual and in opposition to these he calls hysteria and the obsessional neurosis, psychoneuroses. 7 In these latter, the real causative factors in contrast to those of the true neuroses belong not to the actual sexual life but to a long past period of life in early childhood. 6 "t)ber die Berechtigung, von der Neurasthenic einen bestimmten Symptomenkomplex als ' Angstneurose ' abzutrennen," Lit. No. 4. T In the following presentation, neurasthenia and hysteria will be used as the best known examples of their kind. 7 8 FREUD'S THEORY OF THE NEUROSES Further, these infantile experiences and impressions which only later become actively pathogenic turn out to belong without excep- tion to the erotic life which is generally though erroneously believed to be completely negligible in the child. Thus in every case of neurosis, a sexual etiology was revealed ; in neurasthenia, the agencies were of a physical nature, in the psychoneuroses, of an infantile nature. A second essential difference between these two groups of nervous maladies is to be sought in the fact that in the true neuroses the disturbances (symptoms) may find expres- sion in physical or mental manifestations which seem to be of a toxic nature ; they are similar to the phenomena accompanying an excess or deficiency of certain nerve poisons. These neuroses, formerly grouped mostly under neurasthenia, can be produced by certain injurious influences of the sexual life without any neces- sary hereditary predisposition; indeed the form of the malady corresponds to the kind of injurious influence so that frequently one can infer the special sexual etiology merely from the clinical picture presented. With the psychoneuroses on the other hand, the influence of heredity is more important, the original cause less evident. A special method of investigation which will be described later as psycho-analysis has, however, allowed the fact to be recog- nized that the symptoms of the disorders (hysteria, obsessional neurosis, etc.) are psychogenic, depending on the activity of uncon- scious (repressed) idea-complexes. This same method has also recognized these complexes and shown them to be universally of a sexual erotic content ; they arise from the sexual needs of indi- viduals ungratified in the broadest sense of the word and afford them a kind of substitute gratification. The value of the theoretical distinction between the toxic (true) neuroses and the psychogenic neuroses is not diminished by the fact that in most nervous persons disturbances due to both sources may be observed. Such mixed cases are very frequent ; thus, the obsessional neurosis is often associated with neuras- thenia, anxiety-neurosis with hysteria (compare later "anxiety- hysteria"). In all these cases, a mixed and combined etiology in the sense explained later is found without exception. While it was just now stated that those two great groups of diseases were the original field of Freud's work, it must be empha- sized that for about fifteen years Freud has not had opportunity GENERAL THEORY OF THE NEUROSES 9 to continue his investigation of the true neuroses, hence this part of the theory has not experienced a further expansion. The im- portant progress which the comprehension of the nature of the psychoneurotic troubles has made in the meantime will place their relation to the true neuroses in a somewhat different light and it will probably necessitate a revision in this field in the near future. The more limited field of Freud's work is constituted by the psychoneurotic forms, especially hysteria and the obsessional neurosis, and it is exceedingly instructive to follow the steps in the development of the nucleus of the Freudian doctrine if one wishes to appreciate the full extent and value of his theory of the etiolog- ical significance of the psychosexual agencies for the neuroses. As a pupil of Charcot in Paris in 1885-1886, Freud received important incentives to investigation. 8 Prominent among these was the step by which Charcot surpassed the level of his original conception of hysteria and assured himself the fame of being the first to explain this enigmatical malady, a fact of great significance for the further investigations in this field. While Charcot was engaged in the study of the hysterical paralyses which follow dreams the idea came to him to reproduce these paralyses artifi- cially and to this end he made use of hysterical patients whom he brought into the somnambulistic state by hypnosis. He succeeded in proving that these paralyses may be the result of ideas which have gained the mastery of the patient's brain in moments of special disposition. Thus was the mechanism of an hysterical symptom elucidated for the first time and this incomparably beauti- ful piece of clinical investigation enabled Charcot's pupil, P. Janet, to pave the way for a deeper penetration into the peculiar psychic processes of hysteria. This example was followed by Breuer and Freud who succeeded in sketching a psychological theory of hysteria in their jointly published " Studies in Hysteria" (1895 ) . In the years 1880-1882, Breuer had observed a noteworthy case of hys- 8 Compare Freud's obituary notice on Charcot, Lit. No. 23. While lecturer in Vienna University, Freud translated into German the most important works of his French master, J. M. Charcot, " Poliklinische Vortrage," School-year 1887-88. " Neue Vorlesungen iiber die Krank- heiten des Nervensystems, indesondere iiber Hysteric." H. Bernheim, " Die Suggestion und ihre Heilwirkung." " Neue Studien iiber Hypno- tismus, Suggestion, und Psychotherapie." Collected by the press of F. Deuticke, Vienna and Leipzic. io FREUD'S THEORY OF THE NEUROSES teria which, in so-called hypnoidal states, revealed to the attending physician those psychic-traumatic experiences which had brought about the individual hysterical symptom. Thereby appeared the entirely new and surprising fact that the individual hysterical symptoms disappear when the memory of the event which caused them is successfully brought to clear consciousness, at the same time arousing its accompanying affect and having the patient describe the event in all possible detail and give the affect expres- sion in words. Following this classical observation of Breuer's, as you might say the first psycho-analysis, Freud applied the cathartic method to a series of cases with success. Breuer and Freud arrived at conclusions which permitted of bridging the gap between the traumatic hysteria of Charcot and the general non- traumatic variety. Their conception was that the hysterical symptoms are the continued activities of mental traumas, the accompanying affects of which have been separated by special conditions from the conscious mental processes and are accord- ingly in a position to attain an abnormal path to bodily innervation (conversion). The terms "pent-up affect," "conversion," "to abreact " sum up the characteristics of this view. It showed these painful experiences " repressed into the unconscious," the affects of the original idea not abreacted as " pent-up " ; only by the com- plete expression of this idea in words could the pathogenic activity of the old memory be broken. If the requisite conditions for conversion are not at hand in a person, then the idea separated from its affect may remain separated from all associations in con- sciousness; the emotion thus set free may become attached to other not unbearable ideas and these from this false association become obsessions in the broader sense of the term (substitution). Hysteria and obsessional neurosis are thus both to be considered as cases of unsuccessful defence. In the further investigation of the psychoneuroses to which Freud now devoted himself exclusively, he found upon a more detailed study of the causative psychic traumas from which the hysterical symptoms were supposed to be derived that these orig- inal scenes which had appeared to possess etiological importance must sometimes be absolved from being the determining factor and the traumatic force which occasioned the disease. The " trau- matic experience" thus lost its supreme importance and Freud GENERAL THEORY OF THE NEUROSES I I found through continued analytic work in the associated memories of the patient that no symptom of an hysteric could arise solely from an actual experience, but that in every case a memory awakened by association of an earlier traumatic experience usually belonging to the time of puberty, which had not at that time caused trouble, cooperated in the causation of the symptom. A further result of this later analytic work was the discovery that from whatever case or whatever symptom one wished to start, he finally came without exception to the field of sexual experience. Here- with was revealed for the first time an etiological condition of an hysterical symptom. But experiences recovered with so much trouble, extracted from the mass of old memories, seemingly the final traumatic events, although they had the two characteristics of sexuality and puberty in common, proved themselves to be very disparate and of different value so that further investigation was demanded. It was finally revealed that behind these sexual erotic events of puberty are still more far-reaching experiences of infantile life, which are also of sexual content but of far more uniform kind than the previously revealed scenes occurring at puberty. These infantile experiences evince their effect in only the slightest degree at the time when they happen; far more important is the later effect, which finds expression only in later periods of maturity. Since these infantile experiences of sexual content can produce a psychic effect only by the aid of the memory, here is revealed the insight that hysterical symptoms never arise without the cooperation of the memory. Hysterical patients suffer from "reminiscences." At the bottom of every case of hysteria are found one or more events of premature sexual experience which belong to earliest youth ; these may be reproduced in memory by persevering analytic work even after decades have intervened. At that time, these traumatic experiences were erroneously limited to neurotics ; it soon became evident, however, that such experi- ences were often consciously remembered by individuals who re- mained perfectly healthy afterwards, hence the specific etiological agent in the causation of the neurotic symptoms could not lie in this circumstance. By a penetrating investigation of the sexual life of the first years of childhood this noteworthy and very instructive error was 12 FREUD'S THEORY OF THE NEUROSES exposed and by a deepened insight into the constitutional factors, overcome. Freud had previously revealed in the " Drei Abhand- lungen zur Sexualtheorie " 9 the whole polymorphous fulness of the normal infantile sexual life with its germs of disease and abnormality. Thereby infantilism of sexuality took the place of the originally over-rated infantile sexual traumas. And as the sexual experiences of childhood reported by patients turned out repeatedly to be the products of later-formed phantasies from the eroticism of puberty concerning earlier childhood, the importance of the preponderating erotic phantasy-life for the breaking out oT a neurosis came to the foreground. When Freud had finally suc- ceeded in analyzing a child-neurosis in state of formation there was revealed the decisive influence of the family constellation on the content and intensity of the child's affections as well as for the later possibilities of development. The nature and degree of the psychic fixation of the growing child on the parents and brothers and sisters, as well as on the related problems of birth and procreation, disclose themselves more and more clearly as the essential nuclear complex of the neuroses. To the formation of a neurosis from this nuclear complex, which is also present in normal individuals, belong in exquisite fashion, besides quantitative transgressions, a hereditary predisposition which Freud has de- scribed in a narrower sense as the psychosexual constitution. In this decisive importance of the instinctive life and its psycho- sexually conditioned disharmonies there has been attained a pro- visional ultimate source for the later formation of the neurosis. When Freud appeared on the scene, heredity constituted the most important presupposition of the neurosis. He could thus with justice apply himself at first to the exciting agencies; in this connection, he has not overlooked but repeatedly called attention to the fact that besides the agencies in the psychosexual field, the etiology of the neuroses may be conditioned both by inherit- ance and by a special constitution and that the neuroses, like all other diseases, have complex causes. Though more recently the theory of an hereditary predisposition has undergone a certain abridgment, still there is no doubt that there are neuropathic "Translation by Brill in Monograph Series of Journal of Nervous and Mental Disease. GENERAL THEORY OF THE NEUROSES 13 families in which an hereditary taint can be clearly traced. 10 Freud thus assumes that the heredity finds expression in a pecu- liar psychosexual constitution of the individual which asserts itself in an abnormally strong and many-sided instinctive life and a consequent sexual precocity. This renders difficult the later desirable subjection of the sexual instinct to the higher mental powers, its adaptation to the prevailing cultural demands and strengthens the obsessional character which the psychic repre- sensation of this instinct lays claim to. This early and excessive development of the sexual instinct brought about by constitutional conditions can only be counteracted by an abnormal amount of efferent repressive effort (sexual repression) ; the psychological analysis shows further how to solve the contradictory mysterious- ness of hysteria by the perception of two opposing forces, a too severe sexual abstinence and an excessive sexual need. The occa- sion for the onset of the disease in the hysterically disposed person arises when, on account of the progressive internal matur- ing process or of external events, the real sexual demands earnestly assert themselves. Between the compulsion of the instinct and the opposing force of sexual denial, the way is prepared for the malady, which does not solve the conflict but seeks to escape it by changing the libidinous strivings into symptoms. The mani- fold varieties and the different possibilities of development of such an abnormal psychosexual constitution Freud has explained in detail in his " Drei Abhandlungen zur Sexualtheorie." Added to the hereditary and constitutional prerequisite conditions of the neurosis, there are many premature sexual experiences and activi- ties which act as agencies favoring its outbreak; the importance of these could have been so long overlooked only because so much more attention has been directed to that long past period of the lifetimes of the ancestors, namely heredity, than to that long past period in the history of the individual, namely, early childhood. Freud has done a great service in calling attention to the early seduction of children by other children or adults and the abnormal 10 Freud has emphatically pointed out more than once that in more than half of his cases of severe hysteria, obsessional neurosis etc., treated by psychotherapy, syphilis in the father before marriage was to be proven. Not that the later neurotic children bore physical signs of hereditary lues but that in these cases the abnormal psycho-sexual constitution could be observed as the last offshoot of luetic inheritance. 14 FREUD'S THEORY OF THE NEUROSES reaction to these experiences as a result of an especial suscepti- bility to these impressions. " The greatest effect will be produced by the neurosis when constitution and experience combine toward the same end. 11 An outspoken constitution may be able to escape by the impressions of life, a sufficient shock in life may bring about the neurosis in an average constitution." 12 Besides the admitted share of true heredity, Freud has revealed a pseudo-heredity in the influence of an environment of nervous people, namely the nervous parents, and has shown that there is a nearer way than heredity for nervous parents to transmit their disturbances to their children. " It is one of the surest signs of a later neurosis when a child shows itself insatiable in its demands for caresses from the parents and, on the other hand, it is just the neuropathic parents who tend to exhibit unbounded affection and by their fondling predispose the disposition of the child to a neurotic out- break at the earliest possible moment." 12 Thus upon more care- ful analysis, what appears to be hereditary transmission resolves itself into the effect of powerful infantile influences. From a higher point of view, it is observed that our present-day cultural standard of sexual morality, which imposes so many injuries and restrictions on a natural life, is an important factor in the causa- tion of nervous diseases, especially the true neuroses. Cultural, indeed still more frequently, material agencies often place insur- mountable obstacles in the way of a normal sexual life, which is necessary as a protection against neurasthenic and anxiety- neurotic troubles, for in this connection it is found that nothing else is necessary for a cure except the correction of the inadequate sexual gratification. Much more difficult is the treatment of the psychoneuroses ; for the healing of these a very complicated psy- chological technique has been perfected, which will be explained later ; in certain particulars this is still undergoing deepening and refinement. "The admission that there may be such a combination of different causes instead of the assertion of one set of causes is a peculiarity of the Freudian theory of the neuroses which never fails to emphasize the variety of causes and in no way conducts itself in a one-sided dogmatic fashion as it is reproached with doing. "Lit. No. 20. CHAPTER II i THE TRUE NEUROSES A. Neurasthenia: Clinical Picture; Etiology; Prophylaxis and Therapy. B. Anxiety-Neurosis: Symptomatology; Etiology; Theory. C. Refutation of the Objections to the Sexual Etiology of the True Neuroses. A. TRUE NEURASTHENIA As already related, while Freud was following the causative sexual injuries in detail, he succeeded in showing that neuras- thenia as it had been described by the earlier authors resolved itself into two typical clinical pictures: into so-called "true neurasthenia" and into anxiety-neurosis, which forms not only have a specific etiology but can also be sharply differentiated clin- ically. Under neurasthenia, Freud understands those frequent symptom-complexes of pressure in the head, spinal irritation, dyspepsia with flatulency and constipation, paresthesias, dimin- ished potency, as well as a prevailing emotional depression. According to Freud's views, this clinical picture corresponds to the specific cause of excessive masturbation or frequent pollutions or better expressed: neurasthenia may in every case be traced back to a condition of the nervous system which has been acquired through excessive masturbation or arisen spontaneously from frequent pollutions. 13 This picture of neurasthenia is a fairly uniform one, hence the various pseudo-neurasthenias (as the nervous disturbances of cachexia and arterio-sclerosis, the early conditions of progressive paralysis and of many of the psychoses, etc.) may be more sharply differentiated from true neurasthenia than formerly. Further, according to Moebius's proposal many a status nervosi of hereditary degenerates can be placed at one side and one will also find reasons for classifying many neuroses which are to-day called neurasthenia, especially those of inter- mittent or periodical nature, more properly as melancholia (cyclo- thymia). The neurasthenia of the authors really includes much more, but also much that is ill-defined. The place of hypochondria a Lit. No. 23. 1 6 FREUD'S THEORY OF THE NEUROSES remains for the present unexplained, though certain forms seem to correspond to a third form of true neurosis. To make easier the comprehension of true neurasthenia, the course of development of a typical case may be briefly sketched. A boy who practices onanism excessively 14 at puberty usually re- mains without control until, warned by companions or one of those dangerous popular scientific books, he is changed into an hypo- chondriac who interprets the symptoms of his neurasthenia as the premonitory signs of a softening of the brain and spinal tubercu- losis resulting from his self -pollution. Falling into anxiety and depression, he suddenly gives up his masturbation and often begins to suffer from frequent pollutions. The outlet provided for the discharge of the sexual product by the act of masturbation does not correspond to the complicated spinal reflex act with its psychic preliminaries as provided by normal coitus. From this abuse arises also the widespread symptom of ejaculatio prsecox, which betrays years afterward the youth who had been greatly given to onanism with phantasies. 15 Such men are usually not in condition to give the woman the normal outlet for her excitement and gratification of coitus, a condition which, as will later be explained in detail, leads to anxiety-neurosis in the woman. It is obvious that it is the duty of the physician to forbid the excess- ive onanist his manner of sexual gratification. But it is recom- mended that this be done without dire predictions of the terrible results of continuing this vice, in contrast to the pseudo-scientific articles ; rather it should be done by advising a gradual giving up of the practice and seeking to strengthen the patient by dietetic and hydrotherapeutic measures. If frequent pollutions still con- tinue then a strict avoidance of all incentives to sexual excitement seems indicated as well as a regulation of the digestion. If the patient is not helped by these measures then it becomes necessary to recommend a normal method of gratifying the sexual appetite. For the sexual need once aroused and long gratified no longer permits itself to be silenced, but only transferred to another object. "Light forms of neurasthenia because of corresponding conditions may be found in childhood. "The so-called "mental onanism" (phantasies leading to ejaculation), further the protracted masturbation which puts off the ejaculation, finally the " masturbatio interrupta " which prevents the ejaculation seem to be especially injurious (Stekel). THE TRUE NEUROSES I/ A therapeutic interference of that kind is also best suited to con- vince the practical physician of the correctness of the specific etiology of neurasthenia here described; for a cure follows the removal of the sexual injury. That the former therapeutic meas- ures, such as sanitarium treatment, travel and water cures, etc., now and then show results is explainable by the fact that unin- tentionally they also change the patient's sexual relations, which, according to recent investigations, are regularly the cause of such apparent results. These improvements are therefore often only transitory and especially unreliable. The chief service which the wise physician can render to the neurasthenic lies in the prophylaxis. If excessive masturbation in youth is the cause of neurasthenia, then the prevention of the same in both sexes deserves more attention than it has yet received. Until now, the weighty question of masturbation could, however, receive no decisive answer because, on the one hand, the existence of masturbation in the suckling and child has not been sufficiently recognized and, on the other hand, no agreement has been reached between the disparate medical views regarding the onanism of puberty and later life. The purely autoerotic masturbation in the littlest children may seldom and only in excessive cases demand the interference of the tutor, not to mention the physician. Childish onanism around the third to fourth or fifth years must within certain limits be considered a normal phenomenon. 16 Further, this is normally soon replaced by the so-called latent period. If this does not occur or if the practice becomes excess- ive, then it must be checked. Nevertheless, terrifying and gruff prohibition is to be avoided ; much more can be accomplished by gentler methods. Often in the neurosis which breaks out later there appears the anxious hallucination of parental prohibitions; through the quite customary threat of cutting off the penis, a further psychic trauma may be inflicted which is frequently fol- lowed by lasting and pernicious results. Far more important is the problem of the onanism of puberty and later life, over which the most opposite experiences are "Among the patients suffering from impotence, are a relatively large number who have never practiced onanism at all, and there seems to exist a connection between the neglect of the act of masturbation which pre- supposes a certain activity and the sexual weakness. 1 8 FREUD'S THEORY OF THE NEUROSES reported and the most contradictory views held. It must be emphasized at the beginning that this onanism can not be entirely avoided, because in our civilized social organization too great an interval has been interposed between the awakening of the sexual instinct and the possibility of its regular gratification. There is thus the necessity of allowing this mode of gratification up to a certain degree, that is within moderate limits and with quieting explanations; it can then be observed that this happens without real injury. The injuriousness of a precocious or later excessive onanism is only in small part conditioned by the very nature of masturbation. There is, however, a special sexual constitution which causes certain people to become ill as a result of masturba- tion while others bear their onanism of puberty, which is nothing more than the revival of the masturbation of earliest childhood, without noticeable injury. In general, the injuriousness especially of excessive masturbation is not to be doubted in the least, even if a part of the medical profession is not inclined to share the hypochondriacal exaggerations of many nervous patients who would trace back all evil to their self -gratification. The injurious- ness begins in the somatic field in that onanism gives occasion to excessive sexual activity, does not take into consideration all the psychological sources of excitement, affords inadequate relief and diminishes potency. 17 More important are the injuries in the mental field. These come to light both in the demands of the sexual life and also in those of the social life. For the former, a serious result is a lasting inability to endure abstinence or coitus interruptus. Further, there comes about a sort of turning away from reality, from the female sexual object, which is later dis- closed in an intolerance of the necessary imperfections in the same. As one of the chief mental injuries of onanism, must finally be asserted the fact that it favors in every relation the fixation of an infantile condition which furnishes the proper foundation for the psychoneurotic illness. The injuries which the onanist experiences for his social life are numerous. The easy attainability of the goal of gratification in masturbation weakens the individual according to the Freudian principle of psycho- sexual parallelism, that is the typicalness of the sexual life for his 1T The stomachache of onanists should also be mentioned. (Compare Lit. No. 34-) THE TRUE NEUROSES 1 9 behavior in other relations of life for the strife of life which can no longer be undertaken with the necessary display of energy. Through his turning away from society, the masturbator becomes antisocial and betrays the result of his vain strife against passion in a number of other characteristics, as weak will power, doubt of the possibility of accomplishment and similar self-reproaches. Thus, there seems to be a kind of mental type for him who has misused onanism. From these considerations, the theory of neurasthenia should undergo a revision. B. THE ANXiETY-NEUROsis 18 Especially valuable for medicine has been Freud's sharp differ- entiation of the symptom-complex of the anxiety-neurosis 19 from the previously described clinical picture of true neurasthenia. The name anxiety-neurosis arises from the fact that the various components of this symptom-complex are grouped around the cardinal symptom of anxiety to which each individual symptom shows a definite relationship. I. Clinical Symptomatology of Anxiety-Neurosis. The clin- ical picture of the anxiety-neurosis comprises the following symptoms : 1. General irritability and irritation. A special point of value is the expression of this heightened irritability through an hyperes- thesia for visual impressions but especially through an hyperes- thesia for sounds, hypersensitiveness to noises. This is also fre- quently the cause of sleeplessness, of which more than one form belongs to the anxiety-neurosis. 2. Anxious expectation, a condition which can be best illus- trated by example. A lady, for example, who is suffering from anxious expectation, thinks of pneumonia every time her hus- band, who has catarrh, has an attack of coughing and sees in her mind his funeral passing by. If, on her way home, she sees two persons standing together in front of the door, she cannot help "Abbreviated repetition of Freud's work. Lit. No. 4. Attention should here be called to the fact that the English has no exact equivalent for the German word " Angst " which connotes apprehension, dread, fear, etc., in addition to anxiety, which is the nearest English word and the one which will be used throughout this translation. Trans. 19 As a forerunner of the Freudian view may be mentioned the work of E. Hecker, " t)ber larvierte und abortive Angstzustande bei Neuras- thenic" (Zentralblatt filr Nervenheilkunde, Dez., 1893). 2O FREUD S THEORY OF THE NEUROSES thinking that one of her children may have fallen out of the window; when she hears the bell ring, someone is bringing bad news, etc., while in all these cases, there is no especial occasion to strengthen such a mere possibility. For one form of anxious expectation, that in respect to the person's own health, one can- not avoid the old name, hypochondria. A further expression of anxious expectation is the frequent tendency to anxiety for certainty found in persons of great moral scrupulousness, which likewise varies from the normal up to skepticism. The anxious expectation is the nuclear symptom of the neu- rosis ; in it may plainly be seen a part of the theory of the same. It can be said that there is here a quantity of free-floating fear (Angst) at hand which in the expectation rules the choice of ideas and is always ready to attach itself to any passing idea. 3. The anxiousness which is constantly present can, however, also break through into consciousness suddenly, without being awakened by the course of ideas, thus causing an attack of anxiety. Such an anxiety attack may consist of either an anxious feeling without any associated idea or of the idea of impending death, of a stroke, of threatening insanity, or some paresthesia may be mixed with the anxious feeling (like the hysterical aura), or finally, with the feeling of anxiety may come a disturbance of one or more of the bodily functions, the respiration, circulation, vaso- motor innervation, glandular functions, etc. Out of this combina- tion, the patient emphasizes now one, now another factor, he com- plains of heart cramp, dyspnea, sweating, ravenous appetite, etc., and in his representation the anxious feeling frequently becomes obscured or becomes really unrecognizable and described as a " bad feeling " of indefinite discomfort. 4. There are therefore rudimentary attacks of anxiety and equivalents of the anxiety attack of which Freud has prepared the following list : (a) Disturbances of the heart's action, palpitation with brief arrhythmia, with longer attacks of tachycardia up to severe condi- tions of cardiac weakness, the differentiation of which from organic affections of the heart is not always easy ; pseudo-angina pectoris, 20 a delicate diagnostic field. * Compare M. Herz, "Die sexuelle psychogene Herzneurose (Phreno- kardie)," Braumuller, Vienna and Leipzic, 1909. THE TRUE NEUROSES 21 (&) Disturbances of respiration, many forms of nervous dyspnea, 21 asthmatic attacks, etc. These attacks, however, are not always accompanied by recognizable anxiety. (c) Attacks of sweating, often nocturnal. (d} Attacks of shaking and trembling, which may only too easily be taken for hysterical. (e) Attacks of ravenous appetite often accompanied by vertigo. (/) Diarrhea in form of attacks. (g) Attacks of locomotor vertigo. 22 (/&) Attacks of so-called congestions, about everything which has been called vasomotor neurasthenia. Here may be mentioned the vasomotor edemas, the sudden dying of a finger, an arm or foot (angina pectoris vasomotoria). 23 (t) Attacks of paresthesias (these, however, seldom without anxiety or a similar feeling of discomfort). 5. Nothing but a variety of anxiety attack are the frequent night terrors (pavor nocturnus of adults), commonly accom- panied by anxiety, dyspnea, sweating, 24 etc. This disturbance occasions a second form of sleeplessness in the framework of the anxiety-neurosis. In addition, the pavor nocturnus of children shows a form which undoubtedly belongs to anxiety-neurosis. It frequently has an hysterical touch which makes it appear as something special and brings it into closer connection with the anxiety-hysteria which will be discussed later. 6. A prominent place in the symptomatology of the anxiety- neurosis is occupied by vertigo which, in its lightest forms, is better designated as giddiness, in its severer types as "attack of vertigo" with or without anxiety, which belongs to the severest 21 Compare M. Herz, " t)ber eine Form der falschen Dyspnoe (' Seuf- zerkrampf ')," Wiener Klin. Wochenschrift, 1909, No. 39. Both articles of Herz give superfluous new names to partial phenomena of the anxiety- neurosis. 22 The vertigo can become a foundation for a locomotor phobia such as agoraphobia. 28 Compare Curschmann (Mainz), "t)ber Angina pectoris vasa- motoria," III. Jahresversammlung d. Gesellsch. Deutscher Nervenarzte, Vienna, 1909. "Concerning the characteristic dreams, compare the latter part of chapter on hysteria. 22 FREUD S THEORY OF THE NEUROSES symptoms of the neurosis. This vertigo never leads to complete loss of equilibrium. On the other hand, it seems possible for such an attack of vertigo to be replaced by an attack of profound weakness. 25 Other fatigue conditions of the anxiety-neurosis appear to depend on a heart collapse. Dizziness at heights, on mountains and precipices likewise frequently accompanies anxiety- neurosis. 7. On a basis of a chronic anxiousness (anxious expectation) on the one hand, and a tendency to attacks of vertigo on the other, two groups of typical phobias develop, the first in regard to gen- eral physiological menaces, the other in regard to locomotion. To the first group belong the anxiety over snakes, thunder, darkness, vermin and the like as well as the typical moral overscrupulous- ness. 26 Forms of skepticism; here the unattached anxiety is plainly applied to the strengthening of doubts which are instinc- tively implanted in every person. The other group embraces agoraphobia with all its varieties collectively characterized by its relation to locomotion. 27 A pre- ceding attack of anxiety is here frequently the foundation of the phobia. 8. The digestion in anxiety-neurosis undergoes only a few but characteristic disturbances. Sensations like a tendency to nausea and vomiting are not rare and the symptom of ravenous appetite either alone or with other congestions can give something of a rudimentary attack of anxiety; as a chronic change, analogous to the anxious expectation, is found a tendency to diarrhea which has given occasion for the strangest diagnostic errors. The diarrhea is the analogue of the frequent micturition of the anxiety- neurosis. 9. The paresthesias which may accompany the vertigo or attack of anxiety are of interest because of the fact that they are associated in a regular sequence like the sensations of the hys- terical aura. Nevertheless, these associated feelings, in contrast 25 Occasionally a sudden unexpected feeling of fatigue precedes it. Stekel, " Nervose Angstzustande und ihre Behandlung." Urban und Schwarzenberg, Vienna and Berlin, 1908. "An intensive sexual feeling of guilt, which can already be cultivated by children, always depends on the suppression of excessive libido. * For this, the complete psychoneurotic mechanism is necessary (com- pare later). THE TRUE NEUROSES 23 to the hysterical, are atypical and changeable. A large number of so-called rheumatic patients really suffer from anxiety- neurosis. 28 In addition, many cases of anxiety-neurosis show a tendency to hallucinations ; these cannot be considered hysterical. 10. Many of the so-called symptoms which accompany or re- place the anxiety-neurosis appear in chronic form. This applies especially to the diarrhea, vertigo and the paresthesias. 11. Occurrence and Etiology of the Anxiety-Neurosis. As already explained, the morphology of this malady is the corollary of a typical etiology which makes it preferable to consider men and women separately. Anxiety-neurosis occurs in females classi- fied according to their age and positions in life in the following cases : (a) As anxiety of virgins or adolescents. A number of indis- putable observations have shown that a first experience with the sexual problem, a rather sudden revelation of what up to that time had been veiled, for example by the sight of the sexual act or of the male genitals, by a lecture, printed or pictorial representation, can cause an anxiety-neurosis in a maturing girl which is com- bined with hysteria in an almost typical manner ; 29 (&) As anxiety of the newly married. Young women who have remained anesthetic during the first co-habitations often develop an anxiety neurosis which disappears again after the anesthesia has given way to a normal feeling. Total anesthesia is not meant here, but that of those women who are excitable up to a certain degree but are incompletely gratified ; (c} As anxiety of women whose husbands exhibit ejaculatio praecox or a very diminished potency. (d) Anxiety of women whose husbands practice coitus inter- ruptus or reservatus. These last two cases belong together, for it is easily proven from the analysis of a great number of cases that the occurrence depends on whether or not the woman is gratified during coitus. In the latter case, the ground is prepared for the outbreak of an anxiety-neurosis. On the other hand, if the husband can gratify the woman either through a better per- 28 Compare F. Pineles, " Zur Klinik und Pathogenese der sogenannten ' Harnsaureschmerzen,' " Wiener Klin. Wochenschr., 1909, No. 21. "According to the present status of the theory, this is more properly classed as anxiety-hysteria (Angsthystefie). 24 FREUD S THEORY OF THE NEUROSES formance of the act or by preventing ejaculation at the beginning of the act, she remains free from anxiety-neurosis. The con- gressus reservatus by means of a condom exposes the woman to no injury if she is very easily excited or the man very potent; in other cases, this kind of conception-preventing intercourse is not less injurious than the other forms ; (e) As anxiety of widows and intentional abstainers, often in typical combination with obsessions ; (/) As anxiety in the climacteric, during the last great climax of the sexual appetite. Classes c, d, e embrace the conditions under which the anxiety- neurosis begins most frequently in the female sex and earliest, independent of hereditary disposition. For the conditions of the anxiety-neurosis in men, Freud has formulated the following groups analogous to those found in women : (a) Anxiety of intentional abstainers, frequently combined with symptoms of defence (obsessions, hysteria). () Anxiety of men as a result of unsatisfied excitement (dur- ing the engagement period), further of persons who through fear of the results of sexual intercourse content themselves with fond- ling and looking at the woman. This group of conditions (which is also transferable unchanged to the other sex), engagement, relations with sexual forebearance, afford the purest cases of the neurosis. (c) Anxiety of men who practice coitus interruptus, therewith delaying the ejaculation until the woman is gratified. This form of anxiety-neurosis in men is usually mixed with neurasthenia. (d) Anxiety of men in the senium. There are men who show 30 a climacteric like that of women and at the time of their diminishing potency and increasing libido, develop anxiety- neurosis. For both sexes, the two following classes apply : (e) Neurasthenics as a result of masturbation fall into anxiety-neurosis as soon as they forego their method of sexual gratification. These persons have rendered themselves especially unable to stand abstinence. It is here important for the understanding of the anxiety- * > Compare F. Pineles, /. c. THE TRUE NEUROSES 2$ neurosis to notice that a very serious case of this condition occurs only in men who remain potent and in women not entirely anesthetic. (/) Anxiety-neurosis arises in both sexes occasionally from overwork, exhausting exertion, for example, night watching, nursing the sick and after severe illness. 31 In addition to the results of his observations, Freud has sought to give a theoretical interpretation of the pathogenesis of anxiety- neurosis in which he takes into account the observation that many cases of anxiety-neurosis accompany an appreciable lessening of the libido or psychic pleasure. In the points adduced thus far concerning the anxiety-neurosis there are sufficient stopping points from which to gain a view of the mechanism of this neurosis. One gains the impression that it has to do with an accumulation of excitement; that the anxiety which corresponds to this accumulated excitement as psychic anxiety which finds no outlet is of somatic origin ; and further that the accumulated excitement is of a sexual nature. These hints favor the expectation that the mechanism of the anxiety-neurosis is to be sought in the diversion of the somatic sexual excitement from the psychic and in the abnormal application of this diverted excitement caused thereby. This idea of the mechanism of the anxiety-neurosis can be made clearer by a consideration of the normal sexual process, at first only as it occurs in men. The normal sexual act may be sketched as follows : First there is an accumulation of somatic excitation ; this increases to a point where it occasions a psychic irritation, creating the libido ; finally this is discharged by a complicated spinal reflex act which must also carry off the psychic excitement simultaneously. Such a psychic discharge is only possible by the way which Freud has called ade- quate or specific action. The etiology of true neurasthenia and anxiety-neurosis finds its place in the outline of this representation of the sexual process, which in essentials is also applicable to the woman. Neurasthenia ensues every time the adequate discharge is replaced by an inadequate one, as when normal coitus under favorable conditions is replaced by masturbation or spontaneous 81 Compare in this connection the remarks on the sexual mechanism in distinction from sexual etiology (later in this chapter). 26 FREUD'S THEORY OF THE NEUROSES pollution ; all agencies, however, which hinder the psychic utiliza- tion of the somatic excitement conduce to anxiety-neurosis. The previously described etiological conditions of anxiety- neurosis disclose the common characteristic of accumulation of excitement. Intentional abstinence constitutes the first etiological factor for the man in that it prevents the specific action which should follow the libido. The somatic excitement is thus accumu- lated and is discharged in other ways. In this way, abstinence leads to anxiety-neurosis. Abstinence is also the real factor in the second etiological group, that of frustrated excitement. The third class, that of coitus with precautions (reservatus), acts injuriously by disturbing the psychic preparation for the sexual discharge since it interposes another diverting psychic task before allowing the completion of the sexual act. Anxiety in the senium (climacteric of men) demands another explanation. There is here, as in the climacteric of women, such an increase in the production of somatic excitement that the mind proves relatively inefficient to care for the same. The etiological conditions in the woman may without difficulty be viewed from the same standpoints. In addition, the disa- greement between the somatic and the psychic in the course of the sexual excitement can occur earlier in the woman and is more difficult to remove than in the man. Thus, the Freudian view considers the symptoms of the anxiety-neurosis as substitutes in a way for the omitted specific action which should follow the sexual excitement. As a further corroboration of this view, it should be remembered that also in normal coitus the excitement is accompanied by acceleration of the respiration, palpitation, sweating, congestion, etc. In the cor- responding attack of anxiety of our neurosis, there is the dyspnea, palpitation, etc., of coitus isolated and exaggerated. In those exceptional cases which do not arise from specific causes but from other banal injuries, such as nursing the sick, overwork, etc., the sexual etiology is indeed absent but the illness is established on the foundation of a sexual mechanism, since general exhaustion renders the mind unable to care for the somatic excitement which continually makes demands on it. This reference to the exceptional causes of the anxiety-neurosis is always overlooked by the critics who, in opposition to Freud, THE TRUE NEUROSES 2/ think they have found anxiety-neuroses without sexual injury. This explanation of a sexual mechanism replacing a sexual etiol- ogy is, however, a very important one, and it is easy to make the same one for those very similar cases of neurasthenia not of sexual etiology, for example, those occurring with arterio-scle- rosis. In these conditions, the disease may also arise from indi- rect disturbances of the elaboration of sexual products like the primary disturbances of other organic processes. By the substi- tution of a sexual mechanism for the sexual accidents, there may result a progress in the comprehension of the true neuroses similar to that which the theory of the psychoneuroses experienced when the importance of the sexual traumas was replaced by infantilism of sexuality. C. REFUTATION OF THE OBJECTIONS BROUGHT AGAINST THE SEXUAL ETIOLOGY OF THE TRUE NEUROSES As already mentioned, the formerly much greater field of the neuroses has been lessened by the diseases of the blood-forming glands. Neurasthenia and anxiety-neurosis constitute the transi- tion from the sexual neuroses to such exquisite toxic diseases of the nervous system. They are caused by disturbances of sexual processes in the organism which we must call chemical. Further, they actually show a great similarity to the phenomena of intoxi- cation and abstinence ; the similarity to Basedow's and Addison's diseases is obvious. Freud, in his assertions regarding the etiology of the true neuroses, knew that in bringing forward the sexual etiology he adduced nothing completely new, for the undercurrents in medical literature which took this fact into account have never disappeared. Indeed, in many of these undercurrents, the cure of " sexual diffi- culties " and " nervous weakness " has been united in a common promise. Further, the official medicine of the schools has really noticed these relations, although it has acted as if it knew nothing of them. It may easily be perceived that a dim perception of the predominating importance of sexual agencies in the production of nervousness such as Freud has recently sought to establish scien- tifically has never been absent from the consciousness of the laity, as many of the naive but fundamentally correct expressions of patients concerning the cause of their troubles indicate. 28 FREUD'S THEORY OF THE NEUROSES The chief objection to Freud's assertion of a sexual etiology of the anxiety-neurosis concerns the fact that abnormal relations of the sexual life are so exceedingly frequent that they must always be at hand whenever sought. Thus, the existence of these in cases of anxiety-neurosis cited does not prove that the etiology of the neurosis lies therein. Further, the number who practice coitus interruptus and the like must be incomparably greater than the number afflicted with anxiety-neurosis. In reply to this, it may be asserted that in the recognized tremendous frequency of the neuroses and of anxiety-neurosis in particular, one ought not to expect to find a rare etiological agent ; further, that a postulate of pathology is actually fulfilled in this case, namely, that in the investigation of etiology, the etiological agent must be proved more frequent than its result, since for the latter other conditions (as disposition, total of specific etiologies, other banal injuries) may be required ; finally, that the detailed analysis of suitable cases of anxiety-neurosis proves the significance of the sexual agency beyond dispute. Perhaps many a one who is entirely ready to take into account the sexual etiology of the nervous malady will still repudiate it as one-sided because he is not requested to direct his attention also to the other agencies commonly mentioned by the authors. It is far from Freud's intention to substitute the sexual etiology of the neuroses for every other, hence he would explain that the efficiency of these remains. Freud means rather that in addition to all the known and probably rightly recognized etiological agencies of the authorities are added the sexual, which have not been sufficiently appreciated. It should not be forgotten that the etiological prob- lem of the neuroses is at least as complicated as that of other diseases. A single pathogenic influence is almost never sufficient ; for most, a combination of etiological agencies is necessary, which aid one another and which cannot be brought into opposition to one another. The sexual agencies in the etiology of the neuroses deserve, however, according to Freud's estimate, to be assigned a prominent place in the etiological series. For only these will be found missing in no case, these alone are able to produce the neurosis without other assistance, so that the other agencies seem reduced to the role of predisposing or supplementary causes ; these alone enable the physician to recognize certain relations between THE TRUE NEUROSES 29 the variety and multitude of clinical pictures. Heredity, which is so strongly emphasized by most authors, is undoubtedly an im- portant factor where it is found ; it permits a severe case of illness to result where otherwise only a very mild one would have ensued. Heredity alone is inaccessible to the physician's efforts, while the sexual causes are just those which offer him a good opportunity for his therapeutic activity. The agency of overwork, which physicians so gladly tell their patients is the cause of their neurosis, is subjected to excessive abuse. The physicians will have to accustom themselves to explaining to the official who has " over- taxed" himself in his office or the housewife whose household duties have been " too hard " that they are not sick because they have sought to perform duties really easy for a civilized brain but because they have in the meantime grossly neglected and stifled their sexual life. Whoever approaches the cases from this side will find the proof of how valuable for the anamnesis are these points of view. Naturally, he who would convince himself from his patients whether or not their neuroses are really connected with their sexual life, cannot avoid making express inquiries regarding their sexual life and giving a truthful explanation of the same without being diverted from this medical duty by ethic- ally colored arguments. It would facilitate his task if the patients might know with what certainty the trained physician can now detect the meaning of their neurotic difficulties and the inference from these to the real sexual etiology. The semblance of negative cases without sexual etiology, which might be given by a negative result of the examination, is explained by the fact that behind such cases is an hysteria (anxiety-hysteria) or obsessional neurosis which the actual neurosis merely imitates. Such hysterias in the form of neurasthenia are not at all rare; a more penetrating in- vestigation by means of psycho-analysis invariably unmasks them. For the very frequent mixed forms of true and psycho-neuroses, it is recommended in many cases to overlook at first the psycho- neurotic component in the clinical picture and to combat thera- peutically the true neurosis ; in this way one can sometimes succeed in becoming master also of the separated psychoneurosis. The anxiety-neurosis is such a widespread malady that it is daily encountered in practice. Its prevention would be a weighty social task; still, the elimination of certain injuries is dependent 30 FREUD'S THEORY OF THE NEUROSES on so many material and social factors that an ideal accomplish- ment of the task under present civilized conditions is not to be thought of. This much can be said, that only an individual who has no great sexual appetite can endure abstinence and that the entire abstinence before marriage is not to be generally recom- mended, let alone demanded, since it can lead in many cases to deficient capacity for work and indeed directly to a neurosis. Still, complete abstinence is repeatedly harmless just as frustrated excitement or methods of imperfect gratification are. Finally, if it is necessary for a married couple to go without children, harm- less measures for the prevention of conception must be employed which are suited to the tolerance of the individuals participating. That from this standpoint a liberal legislation in relation to the introduction of artificial abortion may be favored is conceivable. 32 Thus, here again, just as in the prophylaxis of neurasthenia, it is shown that these neuroses are rooted in a true sense in our whole present-day sexual morality and that only a thorough change of our entire social and economic organization can bring humanity the solution of the old inherited evil of nervousness. "Compare Wittels, "Die sexuelle Not." C. W. Stern, Vienna and Leipzic, 1909. CHAPTER III THE SEXUAL INSTINCT Existence and Significance of Sexuality in Children ; Opposition to the Acceptance of This Discovery. The Sexual Theory: A. Infantile Sexu- ality: I. Sexuality of the Suckling. 2. Sexuality in Children. 3. Changes at Puberty. B. The Deviations of the Sexual Instinct: Inversion, Per- version, Fetichism, Sadism, Masochism, Exhibitionism, etc. C. Sexuality of Neurotics. Confirmation of the Theory by Analysis of Neuroses of Children. Infantile " Sexual Theories." Nuclear-Complex of the Neuroses. Freud has discovered by way of psycho-analysis the existence of a sexual life in children and has described the phenomena in detail in his classic, " Drei Abhandlungen zur Sexualtheorie." The entirely new conception that the pure, innocent child could have a sexual life met much opposition. Besides this sentimental oppo- sition, there is the infantile amnesia which veils 33 the first years of childhood for most people up to the sixth or eighth year and hinders their acknowledging the fact of infantile sexuality. And still we know that our memory can be fully reviewed and repro- duced at no time of life ; on the other hand, psycho-analysis has shown that the very impressions which we have forgotten leave behind the deepest traces in our mental life and have become determining for our whole later development. Thus, there can be no real forgetting of childhood impressions, but only an amnesia like that which we observe in neurotics for their later experiences, the essential feature of which is a mere detention of consciousness (repression). This is the first amnesia which appears in the life of an individual and it seems probable that no hysterical amnesia would be possible without this infantile amnesia. It is the same with the observations of sexual expressions in "This amnesia for the first years of childhood is not a complete one but is broken through by entirely isolated childhood memories of indif- ferent and secondary content behind which, however, is hidden a weighty and important content which may be shown by psycho-analysis. Freud has called these " cover-memories " because they serve as substitutes for the really important impressions, the direct reproduction of which meets a resistance. (Compare Lit. No. 13.) 3* 32 FREUD'S THEORY OF THE NEUROSES childhood as with many other observations, they only really im- press one when they are examined and described collectively. The physicians who have once directed their attention to this side of the child's mental life will find 34 in every case traces of a sexual instinct early expressing itself; hence Freud can assert without injustice that the time will soon come when one will publish as rare exceptions cases which in no way betray expressions of sex- uality in the first years of life. A. THE INFANTILE SEXUALITY i. Sexuality in the Suckling. Freud has emphasized the fact that the child brings with it into the world the germ of sexuality and enjoys in the taking of nourishment sexual pleasure which it ever after seeks to procure by sucking, independent of the taking of food. The Hungarian pediatrist, Dr. Lindner, has devoted a penetrating study to the sucking or pleasure-sucking of children. 35 The sucking which appears in the suckling and if it becomes fixed as a childish fault can be continued even up to the years of maturity, consists in a rhythmically repeated sucking movement with the mouth (lips) in which the object of taking nourishment is excluded. One part of the lips or any other skin surface which can be reached, perhaps the big toe, is taken as the object on which the sucking is carried out. Therewith appears a complete absorp- tion of the attention and the "pleasure-sucking" ends in falling asleep or even in a kind of orgasm. 86 Often, there is combined with the pleasure-sucking a rubbing of certain sensitive parts of the body, the breast, the external genitals, etc. In this way, many children proceed from sucking to masturbation. There is no doubt that we are here dealing with a sexual condition which pre- sents, however, many difficulties to its comprehension, since the instinct is not directed toward other persons but is gratified on the child's own body in a manner called by H. Ellis, " autoerotic." In this connection, the mouth and lips are revealed as erogenous "* Compare for example Bleuler's work on " Sexuelle Abnormitaten der Kinder" (Jahrbuch d. schweiz. Ges f. Schulgesundheitspflege, IX, 1908). "Jahrbuch fur Kinderheilkunde, N. F., XIV, 1879. "Here is already shown something which is applicable to the whole of life, namely, that sexual gratification is the best hypnotic. Most cases of nervous insomnia go back to lack of sexual gratification. THE SEXUAL INSTINCT 33 zones, a significance which they retain in later normal life in the kiss. For many, it may occasion surprise to learn that sucking is exhibited independently of its relation to the hunger instinct. It is, however, plain that the mouth zone is at first concerned only with the gratifying of the hunger instinct; later, the desire for a repetition of pleasurable experiences gained in this way is separated from the need of taking nourishment, thereby trans- forming this mucous surface into an erogenous zone. It is to be assumed that even those children who later remain normal had the childish fault of sucking in whom the erogenous importance of the lip zone was constitutionally strengthened. If this accentuation persists, these children as adults become passionately fond of kiss- ing, tend to perverse kissing or if men show a strong tendency to smoking and drinking. If the repression intervenes, however, then there is produced an aversion for eating and hysterical vomit- ing. Because of these different functions of the lip-zone, the repression is carried over to the hunger instinct. All later hyster- icals with disturbances of eating, globus, snoring in the throat and vomiting have during childhood been energetic suckers. Both the essential characteristics of infantile sexual expres- sion which the sucking displays, namely, autoeroticism and the domination of the erogenous zones, exhibit also the other activities of the infantile sexual instinct. Thus, in particular, the mastur- bation of the suckling which scarcely an individual escapes and which is plainly appointed to fix the future primacy of the genital zone for the later sexual functions. The action which allays the irritation and furnishes the gratification consists of a rubbing fric- tion with the hand or a pressure of the tightly approximated thighs. To one who is little acquainted with neurotics and who has not encountered these phenomena in adult patients in their full im- portance, Freud's disclosure that the anal zone of the child may afford pleasurable sensations seems at first hardly conceivable. 37 Nevertheless, one can occasionally observe in little children that they refuse to empty the bowels when they are placed on the closet because they obtain pleasure from defecation when the retained stool by its accumulation excites strong muscular contractions and in the passage through the anus produces a strong irritation of the mucosa. Therewith, the pleasurable sensation must be realized r Remains of continued " analeroticism " are often found in adults. 34 FREUD'S THEORY OF THE NEUROSES besides the painful one. The frequent intestinal catarrhs of child- hood afford occasion for intense excitement of these erogenous zones. Intestinal catarrh in the youngest years makes the patients " nervous " as it is called. In later neurotic maladies, these exert a determining influence on the symptomatology of the neurosis, placing at its disposal the whole range of intestinal disturbances. Thus, the original masturbationary irritation of the anal zone which is often practiced by older children and adult neurotics with the aid of the fingers is one of the roots of the constipation so frequently found in neuropaths. The great importance of the anal zone is reflected in the fact that one finds only few neurotics who have not their special skatalogical customs, ceremonials, etc. It is just these coprophiliacs, that is, those who associated pleasur- able emotions with the excements in childhood, who are most profoundly perplexed by the repression; Freud has shown the important part which these instinctive impulses destined to be sup- pressed play in the later character formation. Psycho-analysis of neurotics revealed the fact, purely empiric, that individuals who have successfully repressed an anal eroticism, which was originally intense, regularly show certain traits of character in unmistakable form: orderliness, frugality, and stubbornness. 38 Also entirely new is the Freudian discovery that the neck of the bladder can serve as an erogenous zone. Pollution in the child lacking a sexual secretion seems to take the form of an excretion of urine and may lie at the bottom of many cases of eneuresis. Further, in later life, especially in neurotics there occurs simul- taneously with the sexual excitement a desire to micturate and urination very frequently appears in dreams as the symbol of the sexual act. 89 The bed-wetting which plays a great role in the previous histories of neurotics is repeatedly closely connected with masturbation. The sources of all these sexual excitements lie in part in in- ternal processes, in part are brought about through peripheral irritation of these zones (anal, genital) by the cleansing as well as by caressing of parents and nurses. * For the attempt at a psychological explanation of the connection, compare Freud, " Charakter und Analerotik," Lit. No. 29. ** The biological problems connected with the theory of the erogenous zones are treated in a valuable " Studie fiber Minderwertigkeit von Organen," by Dr. Alf. Adler (Urban & Schwarzenberg, Vienna and Ber- lin, 1907). THE SEXUAL INSTINCT 35 These germs of sexual excitement in the new born develop for a time, then undergo a progressive suppression in a " latent period " which is normally interrupted about the third or fourth year, During this period of complete or merely partial latency, as a result of organic processes (organic repression) 40 and the indis- pensable help of the education, the mental forces are formed which appear later as inhibitions to the sexual instinct and narrow its course like dams: the disgust, the feeling of shame, the esthetic and moral standards of ideas. During the latent period, another part of these sexual energies is separated from the sexual aim and applied to cultural and social ends, a process which Freud has designated by the name sublimation as important for culture, his- tory and the individual. The possibility of certain components of the sexual instinct being diverted from the original goal to a higher and no longer sexual aim furnishes in later life additional energies to our mental powers; to these, we probably owe our highest cultural attainments. From this point of view, the often expressed skepticism regard- ing the specific virulence of the sexual etiology loses its justifica- tion. No instinct so important and necessary for the furtherance of culture is limited and suppressed like the sexual instinct, from childhood on, chiefly in its perverse manifestations. The afflic- tions known as neuroses are to be traced back to the manifold forms of misfortune which may befall this transformation process of the components of the sexual instinct. 2. Sexuality in Children. The sexuality of the suckling re- turns in the years of childhood, although a fixed time for this can- not be named. This reappearance of sexual activity is determined by internal causes and external conditions. At the head, stands the influence of seduction, which treats the child prematurely as sexual object. Recent investigations have shown that the child now and then very prematurely, at the age of three to five years, is capable of a choice of an object accompanied by affects and not merely of a series of autoerotic gratifications. This premature sexual appetite is directed at first toward the parents and nurses, a choice of object which springs from the dependency of the child. 40 The nature of this process which corresponds in a way to an organic developmental tendency is still unexplained; its importance for the origin of the psychoneuroses is pointed out in the chapter on hysteria. 36 FREUD'S THEORY OF THE NEUROSES One can also observe without trouble that the apparently most harmless love affairs of little children are not without an erotic tinge. 41 It is obvious that seduction is not necessary to awaken the sexual life of the child in this second period and that such awak- ening can also occur spontaneously from internal causes. It is now instructive to observe that the child under the influence of occasional seduction can become polymorphous-perverse, that is to say, can be seduced to all possible transgressions; this shows that it brings along within its own person the possibility for this condition. It brings with it the tendency to all perversions and as a result of its bisexual nature also the tendency toward inversion (homosexuality) ; its development either into a neurosis or nor- mality is conditioned on the special emphasis of certain instincts and zones as well as on the experiences of childhood. All the peculiarities of this second infantile sexual activity lie behind the deepest impressions in the (unconscious) memory of the indi- viduals and condition the development of their characters if they remain healthy, of the symptomatology of their neuroses if they become afflicted with one after puberty. In the latter case, one finds this sexual period forgotten and the conscious memories formed of it displaced. Freud, however, also brings the normal infantile amnesia into connection with this infantile sexual activ- ity. Through psycho-analytic investigation, it has been possible to render this forgotten material conscious and thereby overcome an obsession which came from the unconscious psychic material. The perversions contained in the polymorphous-perverse tend- encies may be traced back to a series of partial or component instincts which in themselves, however, are not primary. Besides an instinct not itself sexual arising from motor impulse sources, one distinguishes in these a contribution from an irritation of the receptive organ (skin, mucosa, sense organ) of the erogenous zones, the excitation of which lends to the instinct the sexual character; as such partial or component instincts, Freud has revealed exhibi- tionism, the peeping tendency, active and passive algolagnia (sadism and masochism) and others. The undisguised pleasure of the little child in the undressing of its body and in particular tt Compare the interesting work of Sanford Bell, " A preliminary study of the emotion of love between the sexes" (Anter. Jour. Psych., 1902). THE SEXUAL INSTINCT 37 of its genital parts shows the exhibitionistic tendency. The coun- terpart of this in later life as a perverse tendency is the curiosity to see the genitals of other persons (Schaulust, peeping tendency) which under suitable influence can attain a great importance for the sexual life of the child. Looking at and handling the genitals of playmates is not rare and such children become voyeurs (peep- ers), ardent observers of the micturition and defecation of others. The roots of sadism are easily detected in normal individuals in the aggression which the sexuality of most male individuals exhibits, the biological importance of which may lie in the neces- sity of overcoming the resistance of the sexual object otherwise than by the act of courtship. Thus, sadism corresponds to an aggressive component of the sexual instinct which has become independent and exaggerated through having been moved by dis- placement to a preponderating influence. Nevertheless, the com- plete psychological analysis of the sadistic instinct has not yet succeeded. Also for masochism, a normal root cannot be denied in the sexual overvaluation (compare later). As a further root of masochism, the painful irritation of the skin of the buttocks in spanking is to be emphasized. The study of the component instincts revealed the important discovery that the sexual instinct itself is not a unit but a com- posite structure of many components which are again set free in the perversions. For the origin of sexual excitation in this second period of sexuality in childhood, we go back to the following: (a) To an imitation of a gratification experienced in connection with other organic processes (for example, sucking) ; (6) to suitable periph- eral irritation of erogenous zones; (c) to the expression of some instinct, the origin of which is not entirely plain to us as yet, as the peeping tendency (Schautrieb) and the tendency to cruelty. Rhythmical mechanical movements of the body likewise cause pleasurable sensations ; hence, swinging, being tossed, rocking, as well as railroad and carriage journeys are so much liked by children. 42 That the muscular activity set up by scuffling and 43 Freud thinks that we may assume that these influences which in mild intensity are sources of sexual excitement may have, when connected by fright with violent mechanical shaking, an etiological significance for hysteriform traumatic neurosis. He has, however, not yet taken trau- matic hysteria into the scope of his investigation. 38 FREUD'S THEORY OF THE NEUROSES wrestling with playmates can serve as a sexual excitation is also recognized. Fear and anxiety can likewise call forth sexual excita- tion, in connection with which the feelings of irritation caused by anxiety in school children which can then lead to onanism and pollution may be particularly mentioned. Finally, it is undeniable that the concentration of the attention on an intellectual task in young or mature persons may result in a coincident sexual excita- tion; this is probably the only just ground for attributing nervous disturbances to intellectual overwork, a cause formerly assigned but always doubtful. 3. The Changes at Puberty. The latent period lasts, apart from the interruptions mentioned, up to the changes at puberty in which the heretofore autoerotic character of the sexual activity is lost and the instinct finds its object. Until now, this was com- posed of separate instincts and derived from erogenous zones which sought independently of one another a certain pleasure as the only sexual goal. The new sexual aim which is created by the changes of puberty and is characterized by an amalgamation of all instinctive tendencies which proceed from the erogenous zones consists in the man in the discharge of the sexual product ; for the accomplishment of this, there must be a subordination of all the erogenous zones to the primacy of the genital zone, which is facili- tated by the development of the genital organs and the elaboration of the seminal secretion. To the conditions which first appear at puberty, there is also added that "pleasure of gratification" (Befriedigungslust) of sexuality which ends the normal sexual act: the end-pleasure (Endlust). The pleasure derived previously from the excitation of the erogenous zones needs a name for itself and is called in contrast by Freud, the fore-pleasure (Vorlust). 43 The finding of an object is influenced by the infantile inclination of the child towards its parents and nurses which is revived at puberty and similarly directed by the incest barriers against these persons which have been erected in the meantime. Both these essential changes at puberty, the primacy of the genital zone and the finding of an object, are indispensable for the establishment of a normal sexual life. If, on account of patho- * Later material on the mechanism of the fore-pleasure as well as on the nature of pleasure in general is found in Freud's work " Der Witz und seine Beziehung zum Unbewussten" (Lit. No. 19). THE SEXUAL INSTINCT 39 logical heredity and accidental experiences, this amalgamation of the excitations springing from various sources and its application to the sexual object does not occur, then there results the patho- logical deviations of the sexual instinct, determined in part by earlier processes, such as a preservation of a definite part of the original polymorphous-perverse tendency. The perversions are thus developed from seeds which are present in the undifferen- tiated tendencies of the child and constitute in adults a condition of arrested development. Puberty is also the period in which the development of the two sexes widely diverges in respect to the new sexual aim. That of the male is of the more far reaching influence, while in the female, a kind of retrograde process sets in. The autoerotic activity of both sexes has been the same, and in respect to the manifestation of masturbation in the genital zone one could make the statement that the sexuality of the little girl has throughout a masculine character. The chief erogenous zone in the female child is situated in the clitoris, the homologue of the glans of the male penis. This excitability of the clitoris, however, at puberty, which brings a great influx of libido to the boy, under- goes a new repression. Thus, it is a characteristic of male sexual life which the repression thereby destroys. The transference of the excitability of the clitoris to the vaginal entrance often takes a certain time for its accomplishment during which the young woman is often anesthetic for coitus. If the clitoris zone attempts to retain the great activity which it had in childhood and refuses to give up its excitability, then the anesthesia becomes permanent. In this vicissitude of the chief erogenous zone as well as in the new increase of repression at puberty lie the chief conditions for the predisposition of the woman for a neurosis, especially hysteria. If one would give a definite meaning to the terms masculine and feminine, he could make the assertion that libido is regularly and lawfully a masculine attribute whether it occurs in man or woman and not taking its object into account which may be either man or woman. B. DEVIATIONS OF THE SEXUAL INSTINCT By the aid of the analytic investigation of the sexual instinct in the neurotic, Freud has been able to interpret exhaustively the 4O FREUD S THEORY OF THE NEUROSES pathological deviations of the instinct of sex and to indicate its relation to the normal. These deviations are not to be considered a priori pathological, but only in their exclusiveness and fixation lies the justification for considering the so-called perversions symptoms of disease. Freud has greatly illuminated this extended field of phenomena, in doing which he divides the perversions into two groups, according as the deviation concerns the sexual object or the sexual aim. i. Deviations in Respect to the Sexual Object. Among these, inversion, as Freud calls homosexuality, shows the greatest diver- sity and therefore the most difficult problems. The persons hav- ing this perversion are either (a) absolutely inverted, that is, their sexual object can belong only to the same sex; (&) amphi- genously inverted (psycho-sexual hermaphrodites), that is, their sexual object can belong to the same sex or to the opposite sex; (c) occasionally inverted. A satisfactory explanation of inversion is afforded only by the perception that there is in everyone an original bisexual tendency which is also established anatomically. Normal development leads from bisexuality to the primacy of the heterosexual instinct ; thus, inversion corresponds to a disturbance of development. In this perception, the inadequate question of whether it is inborn or acquired disappears. It arises undoubtedly in earliest childhood and has as a foundation, disturbances which the sexual instinct encounters in its development. In every case, it is absolutely inadmissible to differentiate a special homosexual instinct; it is not a peculiarity of the instinctive life but of the choice of an object which constitutes the homosexual. The prob- lem of homosexuality is a very involved one and embraces quite different types of sexual activity and development. One should expressly distinguish whether the inversion has inverted the sexual character of the object or that of the subject. The sexual object of the male invert is frequently not of the same sex in his essential characteristic but a union of the characteristics of both sexes with the fixed condition of masculinity of body (genitals). The analysis of the phobia of a five year old boy brought Freud the explanation of this condition. One finds among homosexuals in later life, who according to Freud's and Sadger's 44 observations ** J. Sadger : " Fragment der Psychoanalyse eines Homosexuellen " (Jahrb. f. sex. Zwischenstufen, 1908). Same, "Zur Atiologie der kon- THE SEXUAL INSTINCT 4! pass through in childhood an amphigenous stage, the same infantile overvaluation of the genitals, especially of the penis as distin- guished this little patient. This premature preponderance of the masculine organ determines the fate of the homosexual. They choose the woman as the sexual object in their childhood so long as they presuppose in woman the existence of that part of the body which is apparently indispensable to them ; with the convic- tion that the woman has deceived them in this point, the woman ceases to be acceptable as sexual object. They cannot do without the penis on the person who should stimulate them to sexual inter- course and in favorable cases fax their libido upon the " woman with the penis," the youth of effeminate appearance. The homo- sexuals have thus remained fixed during the course of develop- ment from autoeroticism to love of an object in a position nearer autoeroticism. The presupposition of a penis on the woman is one of those frequent infantile sexual theories developed by the still unenlightened child whose sexual curiosity is already awakened. Although psycho-analysis has as yet furnished no complete explanation of the origin of inversion, still it can disclose the psychic mechanism in certain cases and enrich the discussion con- cerning this. In the cases thus far investigated, it can be asserted that those who later become inverted pass through during the first years of childhood a phase of very intense but short-lived fixation on the woman (usually the mother), after the conclusion of which they identify themselves with the woman and take themselves for the sexual object, that is, proceeding from narcism, they seek young men like their own person whom they wish to love as the mother loved them. In this connection, it has been discovered that the supposed inverted were in no way insusceptible to the stimulus of the woman but the excitement called forth by the woman is continually transposed to a male object. Thus they repeat during their whole life the mechanism by which their inversion was occa- sioned. Their obsessional striving after the man shows itself as conditioned by their restless flight from the woman. Meanwhile, it is to be noticed that thus far psycho-analysis has undertaken to analyze only a few types of inversion : persons with generally traren Sexualempfindung " (Mediz. Klinik, 1909). Same, "1st die kon- trare Sexualempfindung heilbar?" (Zeitschr. f. Sexualwissenschaft, 1908). 42 FREUD'S THEORY OF THE NEUROSES restricted sexual activity whose sexuality is exhibited as inversion. The development of homosexuality seems further to be favored for both sexes by purely feminine surroundings during the period of growth. Exceptionally, sexually immature persons and animals may also be taken as sexual objects, thus throwing a light on the nature of the sexual instinct which in contrast to hunger permits of so many kinds of variations and such a degradation of its object. 2. The deviations in respect to the sexual aim which are de- scribed as perversions Freud divides into (a) anatomic trans- gressions of the portions of the body appointed for the sexual union; (&) lingering over the intermediary relations to the sexual object which should normally be passed through quickly on the way to the final sexual goal. In the most normal sexual process, those steps are already discernible, the development of which leads to the deviations which are called perversions. (a) The psychic valuation which the sexual object shares as the wish-goal of the sexual instinct is limited in the rarest cases to the genitals but usually encroaches on the whole body and radiates to the psychic field. It is this psychic " sexual overvalua- tion " which endures so badly the limitation of the sexual aim and helps to bring other parts of the body to serve as sexual goals. In the elaboration of these most varied anatomical transgressions, a need for variation is unmistakable. The importance of the agency of sexual overvaluation may be best studied in the man whose sexual life is open to investigation while that of the woman in part because of cultural limitation, in part through conventional concealment and insincerity is hidden in darkness. The application of the lip and mouth mucosa to the normal kiss is generally practiced among most peoples. On the contrary, against the union of the lip-mouth-zone with the sexual organ of the other sex there are various strong feelings of disgust. In this disgust, Freud sees one of the forces which have brought about the limitation of the sexual aim. As a rule, these stop short of the genitals. However, if the genitals become the object of the disgust (sexual refusal) this is to be considered a characteristic sign of hysteria (especially among females). In connection with this, it may be noted that with hystericals, certain other portions of the body, as mouth and anal mucosa, may assume as it were the significance and role of genitals. THE SEXUAL INSTINCT 43 Freud brings into connection with the sexual overvaluation the common abnormality of fetichism. The fetichistic substitute for the sexual object is in general a part of the body only slightly adapted to the sexual purpose (foot, hair) or an inanimate object which stands in near relation to the sexual person (pieces of clothing, linen, shoes, etc.). A certain degree of fetichism is always peculiar to normal love. This first becomes pathological when the striving after the fetich becomes fixed and takes the place *of the normal goal. Further, when the fetich becomes sepa- rated from the definite person and becomes the sole sexual object. A certain diminution in the desire for the normal sexual goal seems to be a presupposition for all cases (executive weakness of the sexual apparatus). In the choice of the fetich, there is shown, as Binet first asserted and as was later affirmed by numerous proofs, the persisting influence of a sexual impression usually received in early childhood. In other cases, it is a symbolic asso- ciation of thoughts usually not conscious to the individual which has influenced the substitution of the object by the fetich. Psycho- analysis could recently fill out the previous gaps in the understand- ing of fetichism by pointing out the significance of a pleasure derived from smell (Riechlust) for the choice of the fetich which has been lost through repression. Feet and hair are peculiarly odoriferous objects which after the renunciation of the pleasure derived from the smell and corresponding idealization are raised to fetiches. 45 In the perversion corresponding to the foot- fetichism, the bad-smelling foot is accordingly the original sexual object. Another contribution to the explanation of fetichistic preference for the foot is revealed in the infantile sexual theories to be discussed later ; the foot represents the greatly missed penis of the woman. 46 (&) Fixations of temporary sexual goals. All external and internal conditions which render difficult the attainment of the normal sexual aim or long defer it (impotence, costliness of the sexual object, dangers of the sexual act) strengthen the tendency 45 This conception is confirmed by an investigation by Abraham on a case of shoe and corset fetichism (Jahrbuch, 1910). For pleasure in smelling, compare Jahrbuch, I, 2, page 420. 48 The foot is an ancient symbol of the penis long used in myths and corresponding to the shoe or slipper symbol of the female genitals. Com- pare Aigremont, " Schuh- and Fuss-Fetichismus und Erotik," Leipzic, 1909. 44 FREUD S THEORY OF THE NEUROSES to prolong the preparatory acts and form new sexual goals from these which may replace the normal. Closer investigation always shows that the apparently most strange of these new purposes are already hinted at in the normal sexual process and provided by the intimacies which serve for the excitement of themselves and the opposite party. In this respect, the fondling of the sexual object plays the greatest role. A certain amount of fondling and a prolongation of the intermediary sexual goal of sexually toned looking at is present in a certain degree in most normal men. The pleasure of looking (Schaulust) becomes a perversion (a) when it is limited exclusively to the genitals, (&) when it is joined with the overcoming of the disgust (voyeurs, peepers), onlookers at the excretory functions, (c) when it represses the normal sexual goal instead of preparing for it. The latter is shown most clearly in the case of the exhibitionists who display their genitals. In this perversion there stands forth most distinctly a curious trait which is also sometimes present in other perversions. The sexual goal is really present here in double form, in active and passive form. Thus, these instincts appear in contrasting pairs. The same is the case in one of the most frequent and important of the perver- sions, in the instinct to inflict pain on the sexual object (sadism) and its opposite (masochism) also called active and passive algolagnia. C. THE SEXUAL INSTINCT OF NEUROTICS The results which have come to Freud from the conditions described are intimately connected with the starting point of his theory, since they have afforded an important point of view for understanding the sexual instinct of neurotics. Neurotics are really persons with strongly formed impulses which have in the course of development been repressed and unconsciously become perverse. Their sexual instinct displays, therefore, all the devia- tions which we have studied as variations of the normal and as expressions of the pathological sexual life and their unconscious phantasies show during the process of rendering these conscious by analysis the same content as the fixed acts of the perverts. (a) In the unconscious mental life of all neurotics without exception, are found impulses to inversion, 47 fixation of the libido 47 Compare Alf . Adler, " Der psychische Hermaphroditismus im Leben und in der Neurose," Fortschritte d. Medizin, 1910. THE SEXUAL INSTINCT 45 on persons of the same sex, a discovery which is of especial im- portance for the elucidation of hysteria in males. (&) Among the psychoneurotics may be detected all the tend- encies to the anatomic transgressions existing in the unconscious as symptom-creators; among such occurring with especial fre- quency and intensity are those which convert the oral and anal mucosa to the role of genitals. (c) A most important role among the symptom-creators of the psychoneuroses is played by the component instincts which were discussed as creators of the new sexual goal; these appear mostly in contrasting pairs, the peeping tendency and the exhibi- tionistic tendency, the active and passive tendency to cruelty. The contribution of the latter is indispensable to the comprehension of the painful nature of the symptoms and almost invariably controls a part of the social relations of the patients. Where such an in- stinct which is capable of being paired with an opposite is found in the unconscious, the second part may regularly be detected as acting. Every active perversion is thus accompanied by its pass- ive counterpart. For example, whoever has difficulty in following the repression of sadistic impulses, finds another entrance to the symptoms by way of the masochistic tendency. The complete agree- ment with the conduct of the corresponding positive perversions is certainly very noteworthy. In the clinical picture, however, one or the other of the contrasting tendencies plays the paramount role. In a clear case of psychoneurosis, there is seldom only one of these perverse tendencies present, usually a large number of them and as a rule traces of all. The sexuality of neurotics discloses one kind of repression of the instinctive life which exceeds the normal amount. The symp- toms of the neurotic malady are the expression of the sexual activity of the patients taken in the broadest, polymorphous- perverse sense. Thus they originate not, as a mistaken conception of the Freudian doctrine insists, only at the expense of the so- called normal sexual instinct, but represent the converted expres- sion of instincts which one must call perverse (in the broadest sense). 48 The neurotics have, in a certain sense, kept the infantile ** Compare W. Strohmayer, "Zur Analyse und Prognose psychoneu- rotischer Symptome," Zeitschr. f. Psychotherapie u. med. Psychologic, II, 2, 1910. 46 FREUD'S THEORY OF THE NEUROSES attitude toward sexuality or would go back to it, but with the difference that with neurotics the sexual instinct is not expressed consciously and actively but exists in repression, thus acting in the unconscious and there finding expression only in the form of inhibitions. The neurosis may thus be called the negative of the perversion. With such a conception naturally disappears the con- tradiction that there may be persons whose sexual life has ceased who may yet contract a neurosis ; one should not forget that there may be a number of perverse emotions, the deficient gratification of which leads to a neurosis in the end. The sexual instinct of the neurotic expresses itself before everything else in a spontaneous sexual precocity which shows itself in the interruption, shortening or abolition of the infantile latent period. This precocity renders difficult the later control of the sexual instinct and confers upon it a certain amount of obses- sional character. It leads further to an excessive development of the sexual instinct against which, on the other hand, the abnormal (failed) repression stands opposed. Between the pressure of the instinct and the counter pressure of the sexual denial, the malady then makes its appearance as a way out which does not solve the conflict but seeks to escape it by changing the libidinous tendencies into symptoms. These were the results which Freud had gained from psycho- analytic investigation of adults and some isolated cases of observa- tions of children. In an especially favorable and because of its youthful age most suitable case, he succeeded later in confirming directly this insight into the nature of child sexuality which had been established retrospectively. Since the neuroses of adults were to be traced back in every case to the same basic complexes as those the child showed in complete distinctness and elaboration, Freud could claim for this child-neurosis a typical significance. This child analysis showed positively that the picture of the child's mental life as it was presented from the observation of the little patient by his parents was in complete accord with the description which Freud had sketched in his sexual theory from psycho- analytic investigations of adults and at that time only occasional observations on children. In the boy's relation to his father and mother, this case confirmed in every detail everything which Freud THE SEXUAL INSTINCT 47 had asserted concerning the sexual relations of children to their parents. The boy is a little CEdipus who would have the father out of the way in order that he might be alone with the beloved mother and sleep with her. Besides this typical QEdipus-complex 49 of sensuous love for the mother with antipathy against the father and wishes for his removal, the greatest influence on the psycho- sexual development of the patient was exerted by the birth of a sister when he was three and a half years old. This event had intensified his relations to the parents, placed insoluble problems in his thoughts and the observation of the nursing of the new- born child revived the memory traces of his own earliest pleasur- able experiences. This influence is also a typical one; in an unexpectedly large number of life- and clinical histories, one must consider this flaming up of sexual pleasure and curiosity which is connected with the birth of the next child as the starting point of the understanding. The desire for knowledge in children does not in general awaken spontaneously but under the instigation of the instinct of jealousy, when at about the end of the second year they are met by the arrival of a new child. The justly feared ending of the parental care has an awakening influence on the emotional life of the child and stimulates his powers of thought. 50 Under the excitation of these emotions and troubles, the child comes into contact with the first great problem of life and raises the question whence come the children, which is usually couched in the form: whence comes this particular disturbing child. If the child, after his unavailing and unsatisfactory investigation, turns to adults for information, he receives either no answer or no sufficient answer or a rebuke for his unseemly curiosity or he will be put off with the mythologically 51 important information that the stork brings the children out of the water. As a rule, the children give this stork fable no credence, since the pregnancy of the mother seldom escapes their sharp observation. On the contrary, they build false theories 52 of the generation and birth of "Concerning the expression of this complex in the dream, compare Chapter V. "The elder child often expresses his enmity against the new arrival quite openly. 81 See Rank, "Der Mythus von der Geburt des Helden" (Schriften z. angewandten Seelenkunde, Part 5, F. Deuticke, Vienna and Leipzic, 1909). "Compare Freud: "Uber infantile Sexualtheorien," Lit. No. 32. 48 FREUD'S THEORY OF THE NEUROSES this child which plainly grew in the body of the mother. Ignor- ance of the female genitals enables a boy to form a theory whereby the fetus is expelled as an excrement from the anus (cloacal- theory) ; others suppose it comes out through the navel, to which they can assign no other function. These theories naturally allow the possibility, for they overlook the peculiarities of the female genitals, of both sexes bearing children, which idea really plays a great role in childish phantasy-life. In general, the still incom- plete recognition of or disbelief in two different sexual appa- ratuses furnishes the child a weighty problem for childish thinking and investigation and is solved at first by the assumption that the female sex possess a penis. The grievous later results of this sexual theory have already been mentioned under homosexuality. To- this misunderstanding concerning the external genitals is joined a comprehensive generation phantasy, for example, the maiden's phantasy that generation is accomplished by a mere kiss. The children also often think of the condition of wedlock in a childish naive manner as a pleasure-giving affair which pays little attention to shame and disgust, most frequently in the form that the man and woman unceremoniously urinate before each other or show their posterior parts. Exceedingly often, the children arrive at a sadistic conception of coitus and the boys usually con- sider it a row to which the overhearing of the noisy accomplish- ment of the act by adults, mostly the parents, with its loud breath- ing, misleads them. It must be asserted that all these childish theories are of still greater value within the neuroses themselves and exert a determining influence on the formation of the symptoms. Thus, the content of the child's psycho-sexuality consists in the autoerotic activity of the predominating sexual components, in traces of love of an object and in the formation of that complex which Freud has called the nuclear-complex of the neuroses which embraces the first affectionate as well as hostile emotions toward the parents 53 and brothers and sisters. From the uniformity of "The way in which the persons in authority in the family serve as models for the whole character development and determination of the fate of healthy as well as neurotic individuals can not be discussed in detail here. Reference can only be made to the important works of Jung, " Die Bedeutung des Vaters fur das Schicksal des Einzelnen," and Abraham, " Die Stellung der Verwandtenehe in der Psychologic der Neurosen " (both in Jahrbuch, I, 1909). THE SEXUAL INSTINCT 49 this content and the constancy of the influences which later modify it, the statement may be made that in general the same phantasies concerning childhood are always formed. Thus, the neurotics are not to be sharply differentiated from the normal and especially in childhood are not always to be distinguished from those who re- main healthy. On the contrary, it is one of the most valuable results of psycho-analytic investigations that the neuroses are shown to have no special characteristic mental content peculiar to themselves, but that the neurotics, as Jung expresses it, are inca- pacitated by the same complexes with which the healthy struggle. The difference is that the healthy know how to control these com- plexes without gross visible injuries while for the neurotics, the suppression of these complexes is accomplished only at the price of costly substitute structures, thus practically failing. In still another respect was the case of that five-year-old patient interesting. Namely, he showed in all distinctness what Freud had then found and announced in a case of obsessional neurosis, 5 * that a completely formed psychoneurosis can be met with at an early age, about five or six years. The neurosis of the little fellow showed itself as an anxiety-hysteria of the kind prop- erly, classified as a phobia. These anxiety-hysterias are, according to Freud's experience, not only the most frequent of all psycho- neurotic maladies in general, but also the first to appear in life, indeed the neuroses of childhood. Unfortunately, the finer mechanism of this important malady is still insufficiently studied. Doubtless now that attention has once been called to the neuroses of children, the publication of similar cases will follow 55 which will confirm the former results and lead to a deeper understand- ing of this so important and interesting pathological manifestation. "Lit No. 36. " Compare Jung, " Uber Konflicte der kindlichen Seek," Jahrb., II, I, 1910. CHAPTER IV THE UNCONSCIOUS Consciousness and the Unconscious. Common Meaning of Uncon- scious. Hypnosis and Double-Consciousness. The Unconscious in Hys- teria. Resistance and Repression. Genesis and Content of the Real Unconscious. The Complex. The Free Association. The Association Experiment. Determination of All Mental Processes. Phenomena of the Unconscious in the Psychopathology of Everyday Life. The Unconscious in Wit and Dream Formation. The basic presupposition for an intelligent penetration into the secrets of hysteria is the recognition of the nature and activity of unconscious mental life. As an obstacle to appreciating this, stands preeminently the conception of the prevailing school- psychology for which everything psychic is a priori only conscious, hence the speaking of unconscious mental processes constitutes an absolute absurdity. 56 The observations of the psycho-analysts, however, compel the recognition of the existence of unconscious mental processes. The physician educated in psycho-analysis can not do otherwise than reject the dogma of the psychologists that consciousness is the indispensable characteristic of mental life and hold fast to his conviction based on impressions gained from his observations on patients. The results of psycho-analysis really prove with every certainty possible in the field of psychology an unconscious of wide scope and great intensity. Right here it should be emphasized that this unconscious, as psycho-analysis has revealed it, has nothing to do with the term unconscious as em- ployed in ordinary speech usage. This conventional "uncon- scious " signifies as much as " unintentional," " involuntary " or it indicates psychic elements of which one has not just thought, which, however, are accessible to consciousness and by the concen- 68 This brusque opposition is really only the result of an erroneous use of the word " conscious " for psychic, two terms whose meaning is not identical. 5 THE UNCONSCIOUS $1 tration of the attention can every time be reproduced. 57 Uncon- scious, in the Freudian sense, on the contrary, means something which one does not really know, while one is compelled in the analysis by conclusive inferences to recognize it. As already mentioned, it is chiefly the investigations on neurotics which convince the analyst of the existence of the unconscious. Nevertheless, there are certain other phenomena closely related to the neuroses suited to demonstrate in a much easier way the activity of the unconscious mental forces. Observ- ers must recognize that there may be in one and the same indi- vidual many mental groupings which can remain fairly independ- ent of one another, knowing nothing of one another and alternately splitting consciousness. Cases of this kind, which are called double personality or multiple personality, occasionally come to observation in patients spontaneously. If in such a splitting of personality the consciousness remains constantly joined to one of the two conditions, then this is called the conscious mental condi- tion, the one separated from it, the unconscious. In the recog- nized phenomenon of the so-called post-hypnotic suggestion, in which a command given in the hypnotic state is later obeyed in the normal condition, one has an excellent picture of the influences which the conscious condition can experience from processes unconscious to it; taking this as a pattern, one may classify the experiences of hysteria. Freud made use of hypnotism in the treatment of hysteria only at the beginning of his work with the neuroses; since he soon discovered that only a portion of his patients could be hypnotized, he decided to work with the normal condition. Proceeding from the free associations of the patients, he came, like Breuer in. his noted case by hypnoidal conditions, to the discovery that those impressions which had been the occasion of hysterical phenomena had remained in wonderful freshness and with their full affect-tone for a long period of time without the patient's being cognizant of these as he was of other affairs of his life. On the contrary, these events are completely missing in the memory of the patient in his ordinary mental state or are present at most only in outline. By the aid of the Freudian psycho- analytic technique, it soon appeared that the splitting of con- 57 Compare Bleuler, " Bewusstsein und Assoziation." Diagnostische Assoziationsstudien, ed. by Jung, Vol. I, No. 5, Leipzic, 1906, J. A. Earth. 52 FREUD'S THEORY OF THE NEUROSES sciousness which is so frequent in the recognized classical cases as double consciousness may appear in every case of hysteria in the form of a mental dissociation. Thus resulted the necessity of localizing somewhere else these ideas which were not present in consciousness in the customary figurative language employed in the description of mental processes. Freud has, therefore, in accordance with Lipps, 58 accepted the name " unconscious." We speak here only of the narrower meaning of unconscious, as we might say the Freudian unconscious or the unconscious of the neurosis. The meaning of the same can only become clear when one has recognized in what way the sum of its content was sepa- rated from the conscious mental processes. The patient betrays these pathogenic unconscious mental impulses only under great resistance ; a force prevents their becoming conscious and compels them to remain unconscious. One can only really appreciate the existence of this force when one seeks in opposition to it to bring the unconscious impulses of the patient into consciousness. On this idea of "resistance" (Widerstand) Freud has founded his conception of the mental processes of hysteria. The same forces which to-day oppose as resistance the making conscious of the unconscious, purposely forgotten, must at one time have accom- plished this forgetting and forced the offending pathogenic experi- ence out of consciousness. Freud named this process, which he supposed dynamic, repression (Verdrangung), and considered it as demonstrated by the undeniable existence of the resistance (Widerstand). 59 The repression came about by a psychic trau- matic experience of special intensity and entire disagreement with the mental character of the individual or, as appeared later, even a similarly established wish (instinct) impulse becoming engaged in a kind of struggle for existence with the ethical and esthetic attributes of the personality and being thrust out of the con- scious mental structure as you might say by an act of the will. 60 84 " Der Begriff des Unbewussten in der Psychologic." Article at 3d International Congress for Psychology, Munich, 1897. "Compare Freud, "Uber Psychoanlyse," Lit No. 37. "A similar active process probably lies at the bottom of many appar- ently purely automatic forgettings. Freud rightly asserts that it is not so much the condition of memory in the earliest childhood which needs explanation as it is the forgetting of all experiences of a time when the child is perfectly capable of remembering. Compare in this connection THE UNCONSCIOUS 53 There had been a short previous conflict, the end of which was the repression of the unbearable idea. In the field of logic, something like the rejection of judgment would correspond to this process. The acceptance of the unbearable wish-impulse or a prolonged duration of the conflict would have called forth a higher degree of discomfort; this discomfort would be avoided by the repression which acts as a kind of protective mechanism of the mental per- sonality, as an expression of the instinct of self-preservation of the psychic ego. The dissociation of the mind into conscious and unconscious is explained not as an inborn weakness (Janet) but as a dynamic result of the conflict of contending mental forces. It may be mentioned here in advance that the repression tending to form a neurosis is one which has failed in so far that the re- pressed wish-impulse continues to exist in the unconscious and waits, as it were, only for the opportunity to become active in the form of a distorted and unrecognizable substitute formation for the material repressed into the unconscious : the hysterical symp- tom (compare Chapters VI and VII). The hysterical repression has its prototype in that previously mentioned organic repression 61 of the first instinctive impulses in the child which normally brings to a close the earliest period of polymorphous-perverse sexual activity. In this there occurs the submersion into the unconscious not only of individual experi- ences but of a whole period of development. The continuation of certain instinctive impulses which were originally accompanied by pleasure is brought by the necessary subordination to cultural requirements into opposition to the goal ideas of the secondary thought processes and now causes discomfort or pain instead of pleasure. Just this change of affect constitutes the essence of repression. 82 The material in repressed instincts, sexual activities, wish-impulses and erotic phantasies forms the foundation, as you what has been said on infantile amnesia and cover-memories. On the purpose of forgetting in general, compare Freud's paper on the psychic mechanism of forgetting (Lit. No. 12), where he shows that a part of forgetting occurs automatically but that frequently automatism and tend- ency (or purpose) work together. 91 An explanation of the relation of this organic repression to the psychological repression is still lacking. 63 More recent treatment of this is found in Freud's " Traumdeutung," 2d ed., page 375, also Brill's translation. 54 FREUD'S THEORY OF THE NEUROSES might say the oldest and deepest layers in the structure, of the unconscious. A second part of the repressed material comes from repressions in later life. This repression of later years comes about through the attraction of the old nucleus of the unconscious, while from the other side the repelling forces of consciousness again seek to reject this definite material. These forces acting from both sides aid the act of repression which when successful is a normal psychological process. Through the domination of the unconscious it can, however, easily fail; although for the indi- vidual the repression succeeds here also since the repressed material now expresses its pathogenic activity from the un- conscious. That sum of primary instinctive impulses which are killed by the original repression, the real unconscious in the Freudian sense, which furnish the stream both of the neurosis and the dream, is to be distinctly differentiated from that popular " unconscious " men- tioned in the beginning, the combination of automatic, half- forgotten, unintentional mental processes. The psycho-analytic " unconscious," on the contrary, contains nothing except repressed instinctive impulses in the widest sense of the word, as well as those psychic formations which appear as offspring of these repressed impulses. Thus, the nucleus of this contains the sup- pressed component instincts in so far as they were overcome and discarded in childhood. The sexual disinclination of the hyster- ically disposed individual causes all later sexual and erotic experi- ences to sink into the unconscious and join the early originally repressed material. The fundamental characteristic of the uncon- scious is thus its sexual character, sexual taken in its broadest sense. Only one who has completely comprehended the theory of the neuroses is capable of understanding the whole life power and indestructibility of the unconscious. The force of this is shown most clearly in the eternally recurring dreams and pathologically in the lasting productivity of the neurosis. The whole content of the unconscious is, since it is indestructible, reproducible in full vividness under appropriate conditions (psycho-analysis) ; in fact, some prehistoric event of early childhood, long gone from con- scious thought, occasionally appears so unchanged and undimin- ished in intensity that one must characterize it as eternal. The THE UNCONSCIOUS 55 task of psycho-analysis is to find the entrance to the unconscious, which is also the only way to make conscious the unconscious. The difficulty of representing what is included under the term " unconscious " is especially conspicuous in the fact that when we speak of the unconscious of a patient, we understand other things besides the infantile unconscious. In reality, the later repressed psycho-sexual material, as one encounters it in the patient, is not to be sharply distinguished from the infantile unconscious mate- rial. The more remote descendants of the original repressed impulses may no longer lie at the bottom of the mass of repressed material and can often crop up suddenly in consciousness. These descendants constitute what might be called flitting transitions from conscious to unconscious and would be about the material which Freud calls " fore-conscious," something which the patient either knows or wishes to know only momentarily, which with a little effort, however, can be brought to memory. It has proved expedient to call such groups of related elementary ideas possessed of an affect, complexes, following the example of the Zurich school (Bleuler, Jung and others). A definite complex is in every case the occasion and content of the neurosis; it is the ruling power in the diseased mind and from whatever point one examines the patient, he comes upon derivatives which have be- come conscious, the conscious substitute ideas of the repressed complex, hence regularly upon the repressed material, since he is controlled by the goal idea- of the treatment that the apparently most innocent and arbitrary thing reported has some relation to the pathological condition. Proceeding from this presupposition, the analyst has merely to pay attention to the free associations of the patient coming as it were from the psychic surface to reach the repressed pathogenic complex. If it seems to a critic arbitrary to consider the results obtained from such unguided associations as at all valuable, attention must be emphatically called to the empirically discovered phenomenon which is of fundamental importance for the whole psycho-analytic technique, namely, that there is no accidental course of association, that there are no " free " associations, that in general, in mental life, as elsewhere in nature, there is nothing accidental, arbitrary, not related to a cause, but that every thought, every association, every mental occurrence stands in relation to its cause, thus is 56 FREUD'S THEORY OF THE NEUROSES determined, or more exactly, as the dream investigation shows, is determined from several sides, thus is over-determined. This causal connection science has never denied; Freud's service con- sists in having confirmed it by psycho-analysis. The Zurich school later furnished 63 experimental proof of this truth discovered by Freud, in the association experiments. The association experi- ment inaugurated by the Wundt school for formal experimental psychological investigations, which consists in calling out to the person being examined test words and registering his involun- tary answers (reaction words), was elaborated by the Swiss school (Jung and others) in manner of application and utilized in the sense of the psycho-analytic investigations, so that now both meaning and content of the reactions are considered in relation to the test word and to each other. From this resulted, besides other interesting details, the fact that all reaction words which the person being tested gives to happily chosen test words stand in a close relation to one another and belong, especially in neurotics, to the prevailing thought and emotional complex. This complex manifests itself by quite definite tokens, while the reactions dis- close it by the following peculiarities : lengthened reaction times, false reactions, disturbances of reproduction in the repetition of the experiment, accompanying motor phenomena, apparent con- tradiction, incoherence between test word and reaction, etc. These disturbances which the complex causes in the association experiment are nothing else than the Freudian " resistances " of the psycho-analysis. 6 * It is even possible to carry out in this field a physical control by the combination of the association experiment with a mensuration of the fluctuation of an electric current corresponding to the affect shown. 65 The association experiment has thus confirmed the existence of the unconscious, the activity of the complex, the specific con- ** Compare " Diagnostische Assoziationsstudien," ed. by Jung, Vol. I, 1906, and Vol. II, 1910. Jung gives a comprehensive survey of the results of the association investigation in the Apr. number of Amer. Journal of Psychology, 1910. ** Compare Jung, " Assoziation, Traum und hyst. Symptom." Diag. Assoziationsstudien, Vol. II, No. 8, 1910. " Compare L. Binswanger, " Uber das Verhalten des psychogalvanischen Phanomens beim Assoziationsexperiment." Diag. Assoz. Stud., Vol. II, No. II. THE UNCONSCIOUS 57 tent of the etiological complex in the neuroses and likewise brings experimental proof for the determinism of the apparently free associations which had been previously asserted by Freud. This comprehensive and demonstrable determinism in all mental occur- rences is one of the most important basic principles of the Freud- ian psychology. It seems conceivable that there may be an uni- versal human, as you might say normal, resistance against this limitation of free will which may lead to a resistance against the whole Freudian theory. The psycho-analytic investigations aided by the association experiment have shown with absolute certainty that in mental phenomena there is nothing little, nothing arbitrary, nothing acci- dental. In his book " Zur Psychopathologie des Alltagslebens " 68 ( Psychopathology of Everyday Life) Freud has turned his in- vestigations in this direction, namely, to certain mistakes, such as forgetting, errors of speech, writing and action and the like, and could point out that these insufficiencies of our mental perform- ances as well as certain apparently aimless performances (symp- tomatic acts) are regularly well motivated and determined by motives unknown to consciousness; this is corroborated when one subjects these unjustly neglected minor affairs to a pene- trating psychological consideration. The reason that the motives for such unintentional acts are hidden in the unconscious and can only be revealed by psycho-analysis is to be sought in the fact that these phenomena go back to motives of which consciousness will know nothing, hence were crowded into the unconscious, without, however, having been deprived of every possibility of expressing themselves. These mistakes, in which an omission has the same value as an error of commission, are thus the disguised expres- sion of a mental impulse which has remained unconscious and thus has a meaning that appears only in a kind of indirect representa- tion. In similar manner, Freud could regularly point out behind the wit 67 which has a purpose, thought processes which make use of this characteristic method of expression in order to half con- ceal, half reveal impulses remaining unconscious. The most imposing evidence and far-reaching explanations of the unconscious psychic processes in man are afforded by the "Lit. No. 16. * " Der Witz und seine Beziehung zum Unbewussten," Lit. No. 19. 58 FREUD'S THEORY OF THE NEUROSES penetrating study of the dream in the art of dream interpretation elaborated by Freud. The scientific dream interpretation inaugu- rated by the help of psycho-analytic methods produces the proof of the unexpected fulness of unconscious activity and thought formation in the mind and shows that all mental processes both of simplest and most complicated character can go on uncon- sciously. Everything conscious has an unconscious preliminary stage; the unconscious mental circle appears as the greater one which includes the lesser one of consciousness (Lipps). The speech of the unconscious is rich in means of expression which are full of oddities for one who becomes acquainted with them for the first time : dream, symptomatic act, wit, the peculiar manners of reaction in the association experiment, the enigmatical neurotic symptoms and finally the seemingly free association which seems the more harmless and distorted the farther it is separated from the repressed complex. All these phenomena owe their complication or difficulty of interpretation to the circum- stance that the unconscious can express itself only in a form which has been censored by consciousness. Consciousness allows no direct representation of the scandalous and since the indirect (censored) representation contains so much that is novel, para- doxical and curious for the uninitiated, so an intelligible resist- ance is directed against psycho-analysis which unmasks this secret speech. The resistance against this strange method of expression of the unconscious gladly clothes itself in an intellectual denial of the whole Freudian theory and is to be overcome only by repeated experiences which convince one of the entire regularity of the speech of the unconscious. Whoever brings the good intention to take this explanation of his resistance succeeds best in the study of his own dreams according to Freud's directions; he can thus convince himself of the presence and power of his unconscious mental impulses and thus succeeds in the best way in becoming a psycho-analyst. Dreams are really the first member in the series of abnormal psychic structures, the other members of which, the hysterical phobia, the obsessional and delusional idea, occupy the physician for practical reasons. Freud may thus rightly insist that he who does not know how to elucidate the origin of the dream picture will work in vain for a comprehension of the obses- sional and delusional idea. Our nocturnal dream products are THE UNCONSCIOUS 59 indeed compatible with full health of waking life but have also the greatest external similarity and internal relationship to the creations of the insanities. Thus the dream stands in the center not only of the Freudian theory but also of the psycho-analytic technique, and because of its fundamental importance will be treated in the next chapter in detail as an introduction to the theory of the psychoneuroses and analytic therapy. CHAPTER V THE DREAM Chief Characteristics of the Dream: Wish Fulfillment, Sexual Erotic Content. Dream Sources. Dream Distortion (Manifest and Latent Con- tent). The Dream Making. Interpretation Technique: (a) by Symbo- lism; (&) by Associations. Technical Rules. Typical Dreams. Freud came to take up the scientific study of dreams in an empirical way since neurotics who were undergoing psycho- analytic treatment often related to him spontaneously dreams which were still intensively occupying them by day. A closer examination of the content of these dreams revealed the fact that they stood in close relation to the agencies which caused the malady and that here again the infantile sexual roots were exhib- ited. In this way, Freud came to create the technique for the interpretation of dreams corresponding in its main features to the psycho-analytic method of investigation ; this has become an indis- pensable part of the psycho-analytic therapy. The unconscious which lies at the bottom of the neurosis betrays itself in the dream, not undisguised to be sure, but in decipherable manner, so that the dream becomes the chief entrance, you might say the " via regia " to the patient's unconscious. How great significance the solution of the ancient dream problem has for psychology cannot here be gone into in detail ; our interest here is only in the practical value of dream interpretation for the treatment of the neuroses. All mechanisms which enter into the origin of neurotic symptoms have also a share in the formation of the dream. The incomprehensibility of the dream is therefore the same as that of neurotic symptoms ; they are both the substitute expression for the sexual material which has become unconscious through repres- sion. In both cases, we have to deal with incompletely repressed infantile sexual impulses and later sexual material which has joined these. Besides the infantile and sexual matters which fur- nish the real dream sources, there also come into consideration as such sources, the unnoticed daily happenings (" Tagesreste ") 60 THE DREAM 6 1 with their numerous apparently indifferent details; to superficial observation, these frequently seem to control the dream picture. Somatic stimuli and external irritations should not be overesti- mated as dream instigators ; they can indeed instigate the dream, but always serve merely to clothe the unconscious wishes like all other recent material. After profound investigation of his own dreams and those of neurotics, Freud, in the year 1900, could give in his "Traum- deutung" a detailed account of the characteristics of the dream. The most important discovery was that the dream regularly rep- resents a wish-fulfillment, that is, it brings to representation in dramatic form an unconscious wish of the dreamer represented as fulfilled. In this an infantile wish is readily combined with an actual one. The wish characteristic may be easily recognized in isolated dreams if it is not apparent in the majority of the dreams of adults. On the contrary, the dreams of healthy chil- dren show as fulfilled their naive simple wishes which have been active by day and remained unfulfilled. Numerous other dreams, especially such as anxiety and fear dreams, seem at first to be an argument against the universal validity of the wish theory. Naturally Freud could not escape this, but he has pointed out that the anxiety dream after being subjected to penetrating inter- pretation likewise shows itself to be the representation of a sup- pressed (repressed) sexual wish, the disguise of which has failed. To prove this position, Freud has undertaken in his work the analysis of a number of anxiety-dreams and shown the sexual material in the dream thoughts. From these it was made evident that the anxiety which we feel in the dream is only apparently explained by the content of the dream ; it is only attached to the accompanying idea and arises from other sources. Thus, the anxiety-dreams not only exhibit a new side of the dream prob- lem but are also important for the comprehension of neurotic anxiety in general. The anxiety-dream belongs, therefore, to the anxiety problem and will be further discussed in the cfhapter on hysteria. One must not represent the interpretation and arrangement of the dream in the mental life of the individual as too simple. What we remember in the morning ("the manifest content") is mostly a highly phantastic, sometimes paradoxical, thought pic- 62 FREUD'S THEORY OF THE NEUROSES ture which even where it seems logically composed does not betray the real meaning of the dream (" the latent content"). Only the interpretation work which will be discussed in detail later can show the "latent" thought content hidden behind this manifest dream content, that is to say, the particular unconscious wish. One must not be led astray by the fact that the dream is joined in many ways to the events and impressions of the preceding day or evening. These connections are only superficial and have only loose, unimportant relations to the real dream-forming complexes. The true foundation of the dream is furnished by the wishes of childhood which have become unattainable and stored away in the unconscious ; these have normally disappeared into the uncon- scious because of psycho-sexual development. The particular dream- forming wishes which are fulfilled in the dream and can be disclosed only by the interpretation work show, in contrast to the manifest content, a logical and intelligible as well as affectively well-motived train of thought which is organically connected with the rest of the mental life. The manifest dream remembered in the morning, on the contrary, is often without affect, discon- nected, unintelligible, as strange to the waking consciousness as the delusions of the insane are to the normal consciousness. Thus one comes upon the fact that the dream is the expression of those old instinctive wishes later felt as painful (repressed), now re- turned to life again distorted by a complicated mechanism. Freud assumes that consciousness in the service of the repressing activ- ity of the ego continues working in the dream as a kind of psychic censor, not allowing those forbidden impulses to pass in full dis- tinctness but only when disguised in speech and form. By this cultural limitation the appearance of painful emotions which would accompany the becoming fully conscious of the unconscious is avoided as a rule (compare on the contrary the failure of this dream tendency in the anxiety-dream) and undisturbed peaceful sleep is protected. Thus, the dream proves just the opposite of the common opinion the real protector of sleep, against which the fact that it does not always accomplish this task (anxiety- dreams) in no way militates. This tendency shows plainest in a group of dreams which have always been cited in support of the common theory that the dream pictures owe their origin merely to certain physical irritations. In the sense of the Freudian concep- THE DREAM 63 tion, a series of these dreams, the so-called satisfaction-dreams, afford the best proof of two dream characteristics declared by Freud to be universal, since these dreams represent a bodily need which appears in sleep (for example thirst) as gratified and thus serve to guard sleep. These dreams, like children's dreams, also plainly show the wish-fulfilling characteristic. It is nevertheless quite otherwise with that by far the greatest group of dreams of adults, especially of neurotics, for the illumi- nation of which a painstaking and complicated interpretation work is necessary ; after this has been done, however, these dreams also show the same characteristics. Now arises the question, what are the mental processes which have transformed the dream thoughts discovered by painstaking interpretation into the dream form so incomprehensible to us at first. From the comparison of the remembered manifest content of the dream with the discovered latent content comes the term "dream-making" (Traumarbeit) which has occasioned the dream distortion (Traumentstellung). If one proceeds to get a closer view of the many-sided and peculiar dream-making process, one is at once struck by a phe- nomenon already recognized externally. The dream thoughts discovered by analysis tremendously exceed in extent the remem- bered dream content. This circumstance points to a great conden- sation of the dream thoughts. Each element of the dream con- tent really traces its source not to a single element of the latent dream thoughts but to a series of such elements; on the other hand, however, it is also a rule that a dream thought may be rep- resented by more than one dream element in the dream. Thus, the threads of association do not simply converge from dream thoughts to dream content but criss cross and interweave promis- cuously on the way. In this condensation process, certain like- nesses which originally existed among the dream thoughts or have been elaborated by the dream-making in a very keen and ingenious, witty manner play the greatest role. Besides the condensation, there is a second process suited to add to our misunderstanding of the dream picture a strangeness concerning the mental value of the same, while the complete inter- pretation shows us well-ordered and ingenious trains of thought which lie at the bottom of the dream in their proper mental accen- tuation; almost always in the dream, something of secondary 64 FREUD'S THEORY OF THE NEUROSES importance and insignificance is exhibited with a disproportionate amount of affect. This displacement (Verschiebung) of the mental values from important to insignificant serves mostly to conceal the meaning of the dream and to render irrecognizable the connection between the dream content and the dream thoughts. 68 Besides the condensation and displacement, the two most im- portant and for the dream-making most characteristic processes, the attempt to present the material in dramatic form (Rucksicht auf Darstellbarkeit) drives the dream, at first in verbal expression, to very strange performances in order that the dream thoughts may be presented in visible form ; to this aim, manifold distortions and modifications must be brought about. The dream thoughts which by the attempt to present them in dramatic form and by the dream distortion practiced by the censor have become irrecognizable and incomprehensible are finally sub- jected to a final external arrangement which is carried out more or less carefully in different dreams to give the dream, pictures which were originally intelligible but have become meaningless through the dream-making, at least externally the appearance of sense and connection. This procedure of the dream-making which Freud has called "secondary elaboration" ("sekundare Bear- beitung"), which really represents a concession to conscious thinking, also serves on the other hand to further the aims of the censor, since conscious attention, which in badly elaborated dreams is diverted by the judgment : " foolish " or " dreams are nonsense," in dreams with well-composed facades is reassured by this super- ficial meaning whereby a penetration into the deeper meaning of the dream is avoided. The next most important fact concerning dreams after the wish characteristic is the basic principle that the majority of dreams of adults deal with sexual material and give expression to erotic wishes. It is obvious that one can form an opinion on this only when one considers not merely the manifest content but w Condensation and displacement find expression not only in thought- making, but also in the dramatization of details. Thus, objects, words and persons can be made irrecognizable by combination; a person at first apparently unknown to the dreamer is regularly a composite person. THE DREAM 65 understands how to penetrate to the latent dream thoughts. The explanation of the ubiquity of sexual erotic material in dreams is to be sought in the fact that no other instinct has undergone so much suppression from childhood on, as the sexual instinct in its numerous components. Thus, the erotic wish-fulfillment forms the essential content of the dream ; still, it has never occurred to Freud to make this characteristic of the dream exclusive, as is best shown by his comprehensive book on dream interpretation where justice is done to selfish and ambitious wishes. The assertion that the majority of the dreams of adults betray in their ultimate analysis a sexual content seems at first just like the wish- fulfillment theory unproven, since the wording and pictures of the dream, aside from the exquisite sexual (pollution) dreams, seldom deal with sexual scenes, lascivious allusions and the like but are mostly thrown together in a harmless, often poet- ical manner from nature, family, society, travels, etc., forming living pictures corresponding to the real family, vocational and amusement life. At first it seems arbitrary to wish to read out of this boundless picture gallery comprising the whole life in all its phases a single definite tendency which would serve only one instinct. Since we are dealing with an instinct of which everyone is more or less ashamed and which he does not like to acknowl- edge himself too much possessed by, it was this part of the dream theory which aroused universal surprise and contradiction. Never- theless, Freud has proven that the theme of sexuality does not appear undisguised in dreams but is represented in a definite, typical, regularly found symbolic manner of expression analogous to pantomime. 69 To a layman, who came across this theory for the first time, it might seem grossly arbitrary to consider quite innocent and apparently accidental pictures, objects, persons, activities, plays on words, etc., in sexual and shocking sense. But he who has learned to understand the speech of the neurosis released from the repression will be easily convinced that the dream as well as the pantomime of the neurosis can not disclose "In a dream in two parts of a healthy person, the second part of which an undisguised pollution-dream disclosed the apparently harm- less symbolically clothed and sublimated introductory dream as grossly sexual, Rank was able to substantiate the fundamental principles of the Freudian dream theory as it were by the dream itself. Compare " Ein Traum der sich selbst deutet," Jahrb., II, 2, 1910. 6 66 FREUD'S THEORY OF THE NEUROSES its real meaning undisguised. Where the manifest content of the dream is accidently harmless, confused or indistinct (which is frequently coupled with anxiety) one should always suspect behind it an especially abundant repression of something valuable. It is the censor which compels dreams to adopt the mystic lan- guage of symbolism to secure the possibility of dramatization of sexual material in dreams. If one has convinced himself of the wide use of symbolism for the dramatization of sexual material in dreams, he must have been struck by the question whether or not many of these symbols appear like the characters of stenog- raphy with a fixed meaning for all cases. In this connection, it is to be noticed that this symbolism belongs not only to dreams but also to the unconscious folk ideas and is found as completely in folk-lore, myths, saga, 70 sayings, maxims and in the current wit of a people as in dreams. 71 Among the symbols so used are really many which regularly or almost regularly mean the same thing; upon this, in greatest part, the general understanding and far- reaching activity of these creations of the folk-mind depend. 72 Still, one must always bear in mind the possibility that occasion- ally an element in the dream content is not to be interpreted sym- bolically but in its real sense; in other cases, the dreamer may claim the right to anything possible out of special remembered material as an individual sexual symbol which is not generally so employed. Further, the customary sexual symbols are not in every case limited to the one meaning. After giving these limitations and precautions, Freud intro- duces a series of typical sexual symbols: emperor and empress (king and queen) usually stand for the parents of the dreamer, prince or princess for the dreamer himself. All long objects such 70 Compare Riklin, " Wunscherf iillung und Symbolik im Marchen." Further, Abraham, " Traum und Mythus" and the works cited there by Kleinpaul and others ; also Rank, " Der Mythus von der Geburt des Helden." They all appear in Schriften z. angew. Seelenkunde. "In regard to the skepticism which the symbolic interpretation en- counters from so many, it is characteristic that the same men while listening to the cynical tune at the Kneipe or the cabaret or reading the humorous paper are suddenly sufficiently disposed to understand sexual symbolism ! "Symbolism was already familiar in part to the old authors (Arte- midorus) and also to the newer ones (Schemer, Volkelt and others). THE DREAM 6/ as canes, limbs of trees, snakes, umbrellas (because when put up they resemble an erection!) indicate the penis. A 1 frequent, not readily understood symbol of the same is the nail file (because of the rubbing and scraping?). Small boxes, band-boxes, caskets, closets, ovens, wagons correspond to the female body. Rooms in dreams are mostly ladies' rooms, the representation of the en- trances and exits will not be misunderstood in this connection. The dream of going through a series of rooms is a brothel or harem dream. Tables, tables that are set and boards are likewise women probably because of the contrast which here preserves the body arches. Since board and bed make the marriage, in dreams, the first is often placed for the last and so far as it applies, the sexual idea-complex is transported to the eating complex. All complicated machines and apparatus in dreams are with great probability genitals, in the describing of which, dream symbolism shows itself as untiring as wit-making. Landscapes often signify female genitals ; the locality " in which one was once before " may symbolize the mother's genitals. Children in dreams also often signify the genitals as men and women are occasionally disposed to call their genitals their " little one." Stekel, who has devoted himself especially to tracing out dream symbolism, 73 continues further that left and right often mean wrong and " right " or are then used in transferred sense for sensuous (sinnlich) and moral (sittlich), normal and abnormal, male and female, etc.; further, that death and thoughts of death in dreams are often to be taken as repressed counterparts for life and riotous living. It is to be expected that the scientific proof for the wide range and folk- psychological basis of symbolism will soon be fully produced by mythologists, linguists and students of folk-lore 74 and that thus its paradox will be lost. He who does not understand the lan- guage of dream symbolism will never completely interpret a dream and can never carry through a completely successful psycho- analysis. The symbolism is the first and most important tech- 73 " Beitrage zur Traumdeutung " (Jahrb., I, page 458) and further in the discussion of the " Angstzustande." Interesting data on dream symbol- ism are also found in Maeder, " Essai d'interpretation des quelques reves " (Archives de Psychologic, 1907, No. 24). 74 Compare " Anthropophyteia," ed. by F. S. Krauss, Leipzic, Deut. Ver. Akgt. 68 FREUD'S THEORY OF THE NEUROSES nical aid to psycho-analytic dream interpretation. Therefore, a knowledge of it is indispensable to the psycho-analyst because this symbolism, so widespread in the history of races and forming such a sure postulate for those living under the same cultural condi- tions, still in isolated cases, especially in neurotics, may be an unconscious one and therefore brings no associations to the dreamer when he relates his dream. It is the task of the analyst to bring the same into use and just where an element, through the absence of associations, makes itself suspicious as a symbol. Thorough familiarity with symbolism enables the physician to disclose the deepest strata of the unconscious dream thoughts with a high degree of certainty; still, the discovery of the recent experiences and the dream thoughts springing from actual con- flicts can only be accomplished by the aid of free associations. In this way only is it possible to arrange the special dream in its proper psychic connection. This particular kind of analysis brings to light some material which is not unconscious in the strict sense of the word but may be called fore-conscious because it is not directly inaccessible to consciousness but rather may be rendered conscious without any especial difficulty. Here, the technique of dream interpretation does not proceed from symbolism but from the particular associations and spon- taneous connections of the dreamer, the relation of which to the sought-for thought complex may be proven by the already men- tioned association experiment. If one wishes to interpret a dream according to the method here described, it is best to analyze the dream elements separately, according to the dream text noted down from the fresh remembrance in the morning without any attention to its eventual external connection (secondary elabora- tion). If one devotes himself now to the free associations from each of these elements taken at random out of its context of ideas and memories, then he soon succeeds in apprehending a lot of ideas and memories which not only possess an internal rela- tionship to the dream content but also arrange themselves in a connected and intelligible whole. The associations, whether free or from test words, are distinguished in many ways by a super- ficial connection, by clang association, plays on meanings of words, temporal conjunctions, inner sense relations, in short by all the THE DREAM 69 association ways which we are accustomed 75 to observe in wit and puns. No connection is too loose, no witticism too far-fetched to have formed the bridge from one thought to another. The serious and important utilization of these associations becomes plausible, however, when one knows that every time a psychic element is joined to another by a shocking and superficial association, a cor- rect and deeper attachment exists between the two, which because of the underlying resistance of the censor must be concealed be- hind that superficial connection. The beginner who can hardly make up his mind to adopt this rule will also not hear without resistance that occasionally a part of a dream only becomes intel- ligible after one has inverted 76 individual elements either in con- tent or temporal relationship. The inversion, change to the con- trary, 77 is one of the favorite means of dramatization in the dream- making and capable of manifold application. It serves first of all to furnish meaning for the wish- fulfillment in respect to a defi- nite element. " Would that it had been different " is often the best expression for the relation of the ego concerning a painful bit of memory. The inversion becomes very valuable in the serv- ice of the censor since it brings about a measure of distortion of the material being dramatized which immediately interferes with the understanding of the dream. Therefore, when a dream obsti- nately refuses to yield its meaning to interpretation, one may every time venture to try the inversion of the special parts of its manifest content and often all becomes clear. Besides the inver- sion of content, the inversion of time is also not to be overlooked. 78 Whoever wishes to take up the scientific interpretation of dreams, must continually study the " Traumdeutung " of Freud's. Here 75 That the ancients had a knowledge of such mechanisms which must in general be considered as forerunners of psychological dream inter- pretation is shown by the following example: Alexander while despairing of the capture of the city of Tyre which he had besieged had his dream of a Satyr dancing in triumph on a shield interpreted by the dream- interpreter as being good fortune since ^Hif. nf hysffrjfli '" furfrfft- ^"'y -p-7 u t"f : ^1? "*"tn rnr hnn nized that the hysterical fulfills an unconscious wish with_ his < malady which should f^xempt him frpm th<* ;n1iiti'nn nf hTT \ momentous erotic conflict. OIL this point, there is a certain ex- ternal similarity between Freud's conception and tne common view to the extent that a rP| * ^p^;^/^ oi c hysterical notoriously ill. Later inv^, ( itijyatinn T howYer, 5.ho ws these rece^fjexge:^pnrpg ^ hp.. rpprniarly Conflicts of the eroticism (a disappointment in love, a compulsory or renounced"*^ ment, a sexual assault, a sudden sexual enlightenment), ^id when to^superficial observation, there jeern tojje other motives (nursing the sick, death oT a Telative. etc.^. a^more penetrating investiga- tion regularly reveals tmconscioufiflttrr 11 ^^ hptw fffl these banal patients suffer from rerninjagfiaCfiS- Tl^e fj^^tion of certain menta portant and practically significant characffrj'it 1 ' />c The reaction to the recent experiences seems inappropria when one does not take into consideration as motives the real reminiscences in the unconscious. Thus are explained the over- powering or exclusive reactions to sexual excitations with feel- ings of discomfort in which Freud sees a sure sign of hysteria whether the person shows a somatic symptom or not. Doubtless this peculiarity has the closest relationship as to content with the previously mentioned abnormal constitutional forces of instinct and the combative tendencies of these and further an historical connection with the earlier repressions. Further, the hysterical . traits_of_ being suggestible and easily hypnotized seem to have foundlheliitrrerto laCKlng explanationln believes that the essence of hypnosis is to be found in the unconscious libidinous fixation on the person of the hypnotizer and Ferenczi, in his study, " Introjektion und HYSTERIA 79 Ubertragung " (Jahrb. I), has sought the proof of this phenomenon at the bottom of the " parent complex." If this peculiar nature of hystericals may thus be understood as coming from a special psycho-sexual basis, the origin of the mysterious symptoms of hysteria must be correspondingly eluci- dated. The theory of the pathogenesis of the hysterical symptoms forms, as we have cursorily shown in the history of the develop- ment of the Freudian theory of the neuroses (Chapter II), the starting point for Freud's investigation of the psychoneuroses. The disc^ry y^ "Ri-^n^ ^A^ ; teiia that somewhat analogously to the traumatic hysteria, the ^ordinary hysteria owes its symptoms to dream-like mental ns. was the ..starting point of the theory of hvsteri^Jlateg . eTaborateijtvy Frenrl. The_ xual traumatic experiences, since th^ * ideas which accompanied these had power ful__affects (sum of excitation ^ which had not been abreacted by the normal reactjo: mijjht b e c nmf tbp rfju.se o^^o^^j^^L panying affect, separated from the unbearable idea, was appliqd to me formation of a physical symptom. 89 In part, these "pent-j up" affects remain as lasting burdens of the mental life and! sources of constant excitation to the same; in part, they accom-l plish a transformation into uncommon physical innervations andjl inhibitions which manifest themselves as the physical symptoms \\ of the case. Breuer and Freud coined for the last process the name " conversion." For the comprehension of this term, the reference to the " expression of the emotions " which normally betrays our mental excitement is of service; this the hysterical conversion exaggerates as well as leads into collateral channels. The psycho-physical tendency to conversion represents a part of the hysterical disposition. Though the nature of conversion, the transformation of psychic excitation into physical innervation is still a problem, Ei^ud has, neverthplpss^^irQugh his jecei\Limsti- I J ) *j gation been able to make important contributions concerning the directiorl Wnich if 1 ^ mrp^ ^ tov^g m individual cases, now caus- ing the paralysis of some particular part of the body, again an 84 Experience shows that the conversion does not follow immediately the causative event but that a long interval may intervene before the establishment of the symptom. 8o FREUD'S THEORY OF THE NEUROSES grical cough or vomiting, etc. 80 If his discoveries in the . psychological fe'lUL'lUHS aiid^ determinations to be discussed "later is to DC considered as Freud's greatest work, still, / failed to emphasize distinct " ^ not" only a psychic origin but also a somatic, basis and V-S %* Vi n to expres nn wheji n rrrtrr ^ ; " "r*- Q r'"' Q r1nri'i" ("somatis- ches Entgegenkommen ") is at hand; this is provided by a normal or pathological process in or on an organ of the body. This somatic preparedness consists of numerous conditions: first is the way already prepared by physical conditions of irritation of these organs, for example, the establishment of an hysterical cough from an acute catarrh. A much more important condition of somatic preparedness is when the affected organ represents an erogenous zone. In this connection, Freud has.jQoint^ n"t that just as in children the erogenous peculiarity can be moved to any favorite body zone so an analogous moyability returns in the Symptomatology of hysteria. 91 In this neurosis, the repjession concerns the actual ''gemtaTs for the most part; these give their irntaDTiity to the other zones which ordinarily possess little such function and these latter then behave exactly like genitals. Thus for example, an hysterical vomiting might arise in an individual for whom the mouth zone was preeminently emphasized in child- hood and yielded a pleasure (sucking) ; the later repression of this pleasurable sucking, because of the close connection of the mouth zone with the instinct of hunger, might encroach on the latter. All of Freud's patients with disturbances of Beating, hys- terical ^Tobu$ r snorjpp- in th< thrnat ^r|d vomiting had Kfpn^npr- getic suckers in childhood. Iji this, fashion, all hysterical abulias come about,, smceTnyorgans or systems these two instincts when they deny the erogenous function also refuse to serve in their other junction, inus arises, for example, an hysterical disturbance of the gait (abasia) if the motor move- ment in a phase of childhood had received strong erogenous em- * Concerning conversion into anxiety, compare "anxiety-hysteria" in latter part of this chapter. "With the typical symptoms, the so-called stigmata, formerly greatly overvalued as signs of hysteria, Freud has not dealt closer than occasion- ally to point out that the movability of the erogenous zones has also here the greatest significance: erogenous and hysterogenous zones show the same characteristics HYSTERIA 8 1 phasis which later became repressed. 92 That the disturbance can turn to different organs rests on the fact that corresponding to the component instincts and the perversions connected with them, besides their regular organic functions, these organs also serve in childhood the most diverse erogenous functions. The mouth serves for kissing as well as for eating and the speech function (hysterical vomiting, mutism) ; the eyes receive stimuli in order to perceive not only the changes in the external world important for the preservation of life but also the peculiarities of objects by which these are raised to objects to be loved (hysterical disturb- ances of vision). According to Freud, for the establishment of an hysterical symptom, the displacement of sexual feeling also plays a role. Thus, nausea may arise in a girl who perceives a genital sensation on the occasion of a kiss ; by displacement, this sensation is per- ceived as a feeling of discomfort in the mouth and digestive zone. The same girl suffers from an hysterical pain in the breast since, during an embrace, she felt the pressure of an erect penis against her thigh. Thus, here we have to deal with the displacement to the breast of a tactile impression on the thigh converted into an hysterical pain. More important than the reference to the somatic conditions of the symptom and Freud's particular masterpiece, is the dis- covery of the symptom's psychic roots. The psychic determina- tion" ar^ TIP* simple Hut rnntf rnrnpJirafpH Determination plays -vlC^ an important role through a comprehensive and widespread sym- ' fP^ bolism analogous to that of dream life. Thus, for example, in a \& iemale patient, thf ^ iinfrmsrirmg phantasy of the erect male organ mayserve as model for a stiff arm ; at the same time, however, this symptom was the punishment for an intended sexual aggres- sion With the"Tiand As a rule, the hysterical symptom does not have merely a single meaning but several meanings at the same time (overdetermination) ; these, it does not possess from the beginning but rather gains from the thoughts striving to find ex- pression. Since the origination of a symptom is difficult and joined to a series of favoring somatic conditions, it is evident that an hysterical symptom, once formed, is retained to give alternate express ^^^U^tSfiJBfiSLfliflfi 8 - ** Compare also the agoraphobia later in chapter. 7 82 FREUD'S THEORY OF THE NEUROSES Just as certain presuppositions are necessary for the establish- ment of the symptom, so later circumstances appear in this con- nection which at the beginning of the malady were not present and had no share in the symptom formation; only upon the later appearance of these is the disease fully established : jjiese circum- stances are the motives for the malady. Wherever a tram of thought finds it convenient to use a symptom, this becomes a secondary function and appears fixed in the mental life.fThe pur- pose of the disease is often to gain affection, indulgence or other advantage from the surroundings ; frequently a desire for revenge is one of the strongest unconscious motives for the further estab- lishment of the symptom and naturally a great hindrance to the treatment. Nevertheless, there are also cases with purely internal motives such as, for example, self-punishment, repentance and penitengajl According to the original view, it was only the sexual trau- matic experiences which by their intensity and unbearableness gave occasion to the repression; deeper psycho-analytic investigation has disclosed the fact that it is much more the phantasies (inven- tions of memory) of the patients, intensively elaborated mostly in the years around puberty which interpose themselves between the infantile processes and the symptoms, the content of which can, under certain conditions, join the infantile repression of instinct and be withdrawn into the unconscious. Sojpng as these rQns.iii we .call them da-dram bility for b^ing re.pr^ssfA th^ir becoming unconscious rests on me ose relation JLQ the sexual '. Hm. quesilllii.- The phantasy, after it has become unconscious, is really Identical^ with the (conscious) phantasy which the person has indulged in for sexual gratification during a period of masturbation. The act of masturbation (in widest sense, t. e., onanistic act) is com- posed at that time of two parts, the production of the phantasy and the active performance of the self-gratification. This com- bination displays, however, a line of cleavage : originally the action was a purely autoerotic attempt to gain pleasure from a definite erogenous zone. Later this action blended with the wish idea from the circle of lovable objects and served as a partial realiza- tion of the situation to which this phantasy pointed. If then, the person renounced this kind of masturbation-phantasy-gratification, HYSTERIA 83 the action would be stopped but the phantasy would pass from a conscious to an unconscious one. If no other kind of sexual gratification took its place, the person remained in abstinence and was unable to sublimate his libido, that is, divert the sexual excita- tion to higher aims, the condition was just right for the uncon- scious phantasy to come to life, grow luxuriantly and constitute itself with the whole force of the sexual appetite at least in one part of its content as a disease symptom. For a whole series of hysterical symptoms, unconscious phantasies of this kind are the nearest psychic prototypes. The hysterical symptoms are nothing else than unconscious phantasies brought to representation through conversion and in so far as they are somatic symptoms they were often enough borrowed from the circle of real sexual feelings and motor innervations which originally accompanied them when they were still conscious phantasies. In this way, the giving up of onanism becomes really retrograde and thereby the final ulti- mate aim of the whole pathological process, the recovery of the sexual gratification at that time primary, is never attained but always approximated. The interest of the student of hysteria soon turns from the symptoms themselves to the phantasies from which these were first derived. The psycho-analytic method has made it possible to investigate these ultimate unconscious disease- producing phantasies of people and in Freud's analysis of a child neurosis (see lit. No. 35) these could be directly pointed out in statu nascendi. In this analysis, it was revealed that these phantasies which intensively occupy the dreamy, neurotically pre- disposed child choose for their objects at first the parents and the immediate surroundings of the child, that in this connection, pregnancy- and birth-phantasies as well as infantile sexual theories 93 which the unenlightened child elaborates for the expla- nation of these mysterious processes, play an important role. Since at this time the activity of the normal sexual zone does not yet stand in the foreground, the child being thus still poly- morphous-perverse, these phantasies serve the most diverse erotic desires and as the difference in sex is still also a problem for the child, these phantasies are also bisexual. The fact that in general the same phantasies concerning childhood are always formed without regard to how much or how little actual material real life "Lit. No. 32. 84 FREUD'S THEORY OF THE NEUROSES has added to them, is explained by the uniformity of the child's sexual life and the later modifying influences. 9 * Psycho-analytic investigations of neurotics plainly reveal the fact that the growing individual seeks to efface in his phantasy- formations concerning his earliest childhood the memory of his autoerotic activity, at the same time raising his reminiscences to the stage of love-of-an-object. Hence, the superabundance of seductions and outrages in these phantasies, where often enough the reality is limited to autoerotic activity, 95 a distinction which in forensic cases must occasion the judge the greatest difficulties. The correct distinction between the phantasies, afterwards sexual- ized, and the actual, as a rule banal events of childhood, is ren- dered very difficult by the fact that in the neurosis, thought-reality and not actual reality has value. Freud has enunciated 96 a series of formulae which attempt to treat exhaustively and progressively the nature of the hysterical symptom. These do not contradict one another but correspond in part to more complete and sharper delineations, in part to the use of different points of view: 1. The hysterical symptom is the memory-symbol of certain actual (traumatic) impressions and experiences. 2. The hysterical symptom is the substitute created by con- version for the associative return of these traumatic experiences. 3. The hysterical symptom is like other psychic formations the expression of a wish-fulfillment. 4. The hysterical symptom is the realization of an unconscious phantasy which serves the wish-fulfillment. 5. The hysterical symptom serves the end of sexual gratifica- tion and represents a part of the sexual life of the person (corre- sponding to one of the components of his sexual instinct). **In individuals especially constituted by their heredity, hysteria may break out in childhood from these conditions, usually in the form of anxiety-hysteria. "It must be constantly borne in mind that the hystericals are in- clined in their phantasy-life to produce injurious dreams and to conceal them because of the accompanying pleasure gained. Abraham, " Das Erleiden infantiler Sexualtraumen als Form der infantilen Sexualbetati- gung," Zentralblatt f. Nervenh. u. Psych., 1907. A series of dreams com- ing to light in the analysis may, nevertheless, be traced back to a later phantastic elaboration of autoerotic sexual experiences. Jahrb., I, page 393- "Lit. No. 28. HYSTERIA 85 6. The hysterical symptom corresponds to the return to a kind of sexual gratification which was real in infantile life but has since been repressed. 7. The hysterical symptom arises from a compromise between two opposed affective and instinctive impulses by which the one brings a partial instinct or component of the sexual constitution to expression, the other seeks to suppress the same. 8. The hysterical symptom can become the representative of different unconscious non-sexual impulses but cannot be without a sexual meaning. Among these definitions, it is the seventh which most exhaust- ively expresses the nature of the hysterical symptom, as realiza- tion of an unconscious phantasy. When one in this manner, by means of psycho-analysis, succeeds in recognizing the component of the sexual instinct which is controlling the individual, one comes upon the unexpected discovery that for many symptoms the solution by the original unconscious sexual phantasy is not sufficient, but that one needs for the solution of the symptom two sexual phantasies, of which one has a masculine character, the other a feminine, so that one of these phantasies arises from an homosexual impulse. Thus, 9. An hysterical symptom is the expression, on the one hand of a masculine, on the other hand, of a feminine unconscious sexual phantasy. Freud believes, however, that no universal application can be made of this occurrence of two opposite sexual tendencies in one symptom as in the other formulae, important though it is theoret- ically and also not to be underestimated in practice. A counter- part of this hermaphrodism of the hysterical symptom is shown by certain hysterical attacks in which the patient plays both roles at the same time in the underlying sexual phantasy. This contra- dictory synchronism conditions in large part the incomprehensi- bility of the situation otherwise so plastically represented in the attack and is thus suited for disguising the actual unconscious phantasy. Freud has really shown that the attack, 97 this most imposing symptom of hysteria, is also nothing else than a phantasy trans- lated into motor phenomena, projected into motor activity, 97 Lit. No. 33- 86 FREUD'S THEORY OF THE NEUROSES represented in pantomime and that by witnessing this, it is pos- sible to recognize the phantasy dramatized in the attack; this procedure alone succeeds only rarely. As a rule, the pantomimic representation of the phantasy has undergone under the influence of the censor, distortions quite analogous to the hallucinatory ones of the dream, so that both alike have become incomprehensible for the patient's consciousness and for that of the observer as well. The hysterical attack may thus undergo the same important elaboration that we see in nocturnal dreams. Thereby, one is easily convinced that not only the forces from which the distor- tion proceeds and the purpose of this distortion are the same but also the technique is the same as that which we have recognized in the interpretation of dreams. The hysterical attack is rendered incomprehensible, indistinct, distorted and misleading : 1. By condensation of several simultaneous phantasies, for example, a recent wish and the revival of an infantile impression. 2. By multiple identification when the patient undertakes to carry out the activities of both persons appearing in the phantasy. 3. By the antagonistic conversion of the innervation which is analogous to the change of an element to its opposite practiced in the dream-making, for example, if in the attack, an embrace would be represented, the arms would be drawn backwards con- vulsively. As far as possible, the recognized " arc de cercle "of the great hysterical attack is nothing else than such an energetic denial through antagonistic innervation of a position of the body suitable for sexual intercourse. 4. By the inversion of the time sequence in the phantasy rep- resented, which again finds its counterpart in many dreams which begin with the end of the action in order to conclude with its beginning. The outbreak of the hysterical attack follows easily understandable laws. Since the repressed complex consists of libido and content of ideas (phantasy), the attack can be occa- sioned by : ( i ) Associations, when the complex ( sufficiently deep rooted) is touched upon by something of conscious life; (2) organically, when from somatic causes and from psychic influ- ences from without, the amount of libido is increased beyond a certain measure; (3) in the service of the primary tendency, as expression of "the flight into sickness" when reality becomes HYSTERIA / painful or dreaded, thus, for consolation; (4) in service of the secondary tendencies with which the disease has united so that by the production of an attack, an advantage to the patient is gained. The investigation of the childhood history of hystericals teaches that the hysterical attack is also used as a substitute for autoerotic gratification once practiced and since renounced. In a great number of cases, this gratification (masturbation by rubbing or pressing the thighs together, sucking the tongue, etc.) also returns in the attack during a relaxation of consciousness. The involuntary micturition should certainly not be considered inconsistent with the diagnosis of hysterical attacks ; it can repeat the infantile form of impetuous pollution. Further, one can also encounter the biting of the tongue in undoubted hysteria. The loss of consciousness, 98 the "absence" of the hysterical attack proceeds from those transitory but unmistakable failures of consciousness which are to be detected at the height of every intense sexual gratification (also in the autoerotic forms). In the origination of the hysterical " absences " from pollution- attacks of young female individuals, this development may be fol- lowed most clearly. The arrangement which opens the way for the repressed libido to find an outlet is that already present reflex mechanism of coitus present in every man and also in women which we see become manifest in its unrestricted devotion to sexuality. The ancients used to say " coitus is a little epilepsy." We may alter this to " the hysterical convulsive attack is a coitus equivalent." In conclusion of the symptoms of hysteria, the so-called " nervous disturbances," which play a great role in practice, may also be discussed. If one overlooks the ill-defined classes of "being nervous," the nervous disturbances according to Freud belong in the field of sexual neuroses. The description of the true neuroses included already a wide array of psychic and somatic nervous disturbances for which a toxic cause is assumed : nervous anxiety, irritability, nervous palpitation, headache, stomachache, sweating, trembling, diarrhea, vertigo and many others. ** Compare Abraham, "Uber hysterische Traumzustande," Jahrb., II, I, 1910. 88 FREUD'S THEORY OF THE NEUROSES Opposed to these neuroses of the heart, intestine, " vasomotor neuroses," etc., or associated with them are very often in indi- vidual cases psychogenic symptoms which, when isolated, appear as mono-symptomatic hysteria. Thus, for example, a nervous nausea, nervous vomiting, dyspepsia ("stomach neurosis") has the same mechanism of origin as the same symptoms in the course of an hysteria." When a nervous vomiting seems apparently to be determined by a recent event and a somatic preparedness (Entgegenkommen), indeed if occasionally a cure by abreaction of recent experiences seems to have been effected, nevertheless, behind this, a determination from childhood is to be discovered under which in the ultimate analysis lies an erogenous strengthen- ing of the mouth-digestive zone. The same applies to psychic impotence in which, often a recent experience, a single failure, seems to inhibit later results by anxiety, while in reality the hindrance comes from unconscious infantile complexes, such as the family-complex (unconscious fixation of the libido upon mother or sister) which prevents the transference of the libido to the later sexual object. Of course an organic weakness of the sexual system or a true neurosis may share in this as Steiner and Ferenczi could show. 100 Although the psycho-analytic treatment is effective in psychic impotence, still the share of the actual conditions is likewise to be taken into consideration. 101 In women, the condition corresponding to this is sexual anesthesia which very frequently accompanies hysteria but is also otherwise so enormously widespread that one must connect it with our all too Puritanical system of female education. Freud was able to trace this sexual anesthesia back to the following condition: after the irritation of the clitoris by masturbation which occurred in childhood, the normally occurring transference **Here belong the disturbances of appetite in children which are so important in practice and often last for months. Idiosyncrasies against certain foods are likewise often of psychogenic origin. 100 Steiner, " Die f unktionelle Impotenz des Mannes und ihre Behand- lung," Wiener Med. Presse, 1907, No. 42. Ferenczi, "Analyt. Deutung und Behandlung der psychosexuellen Impotenz beim Manne," Psychiatr.- Neurolog. Wochenschr., No. 35, 1908. 101 A cure attained by other means, as suggestion, cannot be considered as an argument against a complicated psychogenesis. HYSTERIA 89 of the excitability of the clitoris to the adjoining female parts (vagina), as is necessary for the sensibility in the normal sexual act, is retarded or is prevented altogether. Further, this trans- ference normally demands a certain length of time, during which the young woman is anesthetic. It is recognized that this anes- thesia of women is frequently only an apparent and local one. They are anesthetic at the vaginal entrance but in no way unex- citable at the clitoris itself or in other zones. To these erogenous causes of the anesthesia, are added the psychic ones likewise con- ditioned by the repression. The psychogenic part is removable by psycho-analysis during the first years of married life. The nervous disturbances have an eminently practical impor- tance for general medicine and, according to Freud's conception, are very productive for the most diverse specialties outside of neurology, for example, internal medicine, eye, ear, etc., which employ so often the term " nervous." It is evident that no physi- cian can do without a knowledge of psycho-analysis and especially the viewpoint of psychogenesis and sexuality for the differential diagnosis. The most diverse neuralgias, tics, dyspepsias, cases of nervous asthma, vaginismus, many cases of hyperemesis gravi- darum, etc., seem to be psychically conditioned and subject to psycho-analytic influence. There are already works on these dis- eases which point to the psychogenic etiology (compare Drey- fuss, 102 Walthard, 103 H. E. Miiller) 10 * while TreupeP 05 and Wegele 106 lay more stress on the agencies of the true neuroses. In this field, there must come about a decision or rather a compromise between the standpoint represented by the internists of all kinds that for example, bronchial asthma (nervous) is an intoxication corresponding to an exudative diathesis and the psycho-analytic disclosure of its psychological connections. Thus, cases of bronchial asthma and conditions like migraine, vaso- motor edema and others which can occasionally stand for it, are 102 " tJber nervose Dyspepsie," G. Fischer, Jena, 1908. 108 " Die psychogene Atiologie und die Psychotherapie des Vaginis- mus," Miinchn. mediz. Wachenschr., 1909, p. 1998. 104 " Beitrage zur Kenntnis der Hyperemesis gravidarum," Psychiatr.- Neurolog. Wochenschr., loth year. 106 "t}ber Herzneurosen," Miinchn. mediz. Wochenschr., 1909. io < Uber den Zusammenhang zwischen Affektionen der Genitalorgane mit Storungen der Magen- und Darmverdauung," Med. Klinik, 1910. 90 FREUD'S THEORY OF THE NEUROSES often plainly psychically conditioned. Asthma is an important symptom of anxiety-hysteria and for the anxiety-neurosis as well. In the works of Stekel, 107 Stegmann, 108 and others there appear valuable disclosures concerning its psycho-sexual nature and its relief by psychic means, both of the individual attack and the dis- ease in general. One thing is certain, the toxic conditions are especially well suited for psychogenic complications. Still, there is the difficult question as to how the organic, toxic and psycho- genie share in the causation of the symptoms as well as the sharp differentiation of the still confused terms " hysterical," " psycho- genic" and " (toxic) -neurotic." In this connection, Freud has pointed out in a recent article 109 on the elucidation of "psychogenic visual disturbances" certain disturbances which have an organic-toxic foundation besides the psychogenic. When an organ which serves both fundamental instincts, the ego- and the sexual-, increases its sexual role, it is generally to be expected that this will not disappear without changes in the excitability and innervation. When we see that an organ which otherwise serves the sense perception, for example, the organ of vision, by the raising of its erogenous value, immediately takes on the function of a genital organ, we will also not consider toxic changes in it improbable. For both classes of functional disturbances resulting from strengthened erogenous significance both of psychological and toxic origin, Freud would, for want of a better term, retain the old unsuitable name neurotic and call them sexual-neurotic disturbances. i In the framework of an attempt at a comprehensive represen- tation of hysteria, the treatment of the anxiety problem also has a place. Anxiety as the cardinal symptom of a true neurosis we have already encountered in the presentation of the anxiety- neurosis, where according to Freud it was explained that the mechanism of the anxiety-neurosis is to be sought in the sepa- ration of the somatic sexual excitement from the psychic which 101 " Nervose Angstzustande." 108 Stegmann, " Zur Atiologie des Asthmas bei Kindern," Med. Klinik, 1908, 29. Same, " Psychotherapie bei Asthma bronchiale," Miinchn. med. Wochenschr., 1908. Compare also Sanger, Briigelmann, Goldscheider. " Lit. No. 38. HYSTERIA 9 1 causes an abnormal employment of this excitement. We have here to deal with an anxiety which does not have a psychic deri- vation. Clinically, the cases of anxiety-neurosis are often seen mixed with anxiety derived from psychic sources. .This brought about the creation by Freud of the term "anxiety-hysteria," a clinical phenomenon to which Stekel has devoted the greatest part of his book on anxiety conditions and their treatment, which is especially important for the practitioner. In these cases, the anxiety arises not only from somatic sources but from a part of the ungratified libido which embraces unconscious complexes and through the repression of these gives rise to neurotic anxiety. As the mind normally reacts to impending danger from without by anxiety, so one might say that in neurotic anxiety, the ego is defending itself against internal enemies. In these cases, we have a psychic mechanism which is identical with that of hysteria ex- cept that it does not lead to conversion into physical symptoms but into the development of anxiety. Anxiety is likewise the only symptom into which the psychic excitement is converted in this case. In cases as they occur in practice, this anxiety-hysteria may be mixed in any degree with the conversion-hysteria: there may be conversion-hysteria without any anxiety as well as pure anxiety-hysteria which expresses itself in feelings of anxiety and phobias. Freud has already in his work on anxiety-neurosis pointed out the frequent combination of hysteria with anxiety- neurosis. This is explained by the fact that very often besides the somatic diversion of the libido, a part of the same may strike back to the unconscious complexes and bring these to life again. It is, therefore, not chance when hysteria and anxiety-neurosis so frequently combine, and experience shows that in many cases which look exactly like anxiety-neurosis one finds a bit of hysteria as well. In this sense, Freud says anxiety-neurosis may be called the somatic partner of hysteria. Here as there, is an accumula- tion of excitation in which perhaps the similarity of the symptoms is founded. Here as there, a psychic insufficiency which comes into existence in consequence of abnormal somatic processes. a diversion of the jthe distinction lies mgrplv i" the fact that the excitation, in the displacement ot wmch ^^""""^^^.-^^ . the jieurosis nnds Mpiessiuu, lj, in 4he^HBrictr^te anger mat \\// -t-'-L'j.' V \ * / 94 FREUD'S THEORY OF THE NEUROSES from the repression of libidinous impulses, the anxiety-dream, an almost universal experience, which is also a frequent symptom of the neurosis, cannot be understood. The theory of the anxiety dream does not belong to the problem of the normal dream but to the anxiety problem. The anxiety-dream seems at first to con- tradict the dream-theory that every dream represents a wish ful- filled. When one has clearly shown, however, what lurks behind the manifest dream content of the anxiety-dream and penetrated to the latent psychic content, the objection to the wish theory falls to pieces. The interpretation work shows that the anxiety which we feel in dreams is only apparently explained by the content of the dream. The anxiety is, as already remarked, only attached to the accompanying idea and springs from other sources. The interpretation of such dreams regularly reveals their true content to be a repressed sexual wish, the distortion of which in the dream has failed. To the breaking through of the sexual in the dream which is also apt to awaken the sleeper, the dreamer can only react like the neurotic in waking life, namely, by anxiety. In this sense, the representation of the unconscious in the anxiety-dream would be an especially successful one. The anxiety in these dreams is thus mostly a psychoneurotic one arising from psycho- sexual impulses whereby the anxiety corresponds to repressed libido. Then, this anxiety has, like the whole anxiety-dream, the significance of a neurotic symptom and we stand on the boundary where the wish- fulfilling tendency of the dream fails. 112 Anxiety-dreams are of frequent occurrence in anxiety-neurosis and anxiety-hysteria, where they show the following character- istic content. 113 The dream picture accompanied by anxiety rep- resents the patient (usually female) oppressed by a great and dangerous beast which threatens to throw itself on the dreamer; characteristically, it is often a stallion or a bull, thus, animals which have ever stood as symbols of the potent strength of animal masculinity. It is easy to see in these animal figures the symbol- ized givers of sexual gratification forbidden by conscious thinking. ""In other anxiety-dreams, the feeling of anxiety is somatically caused, as for example, in lung and heart diseases and is then made use of to bring to fulfillment in the dream of suppressed wishes in individuals whose dreams had already had anxiety from psychic motives. 118 Compare in this connection Ferenczi, " The Psycho-analysis of Dreams," Amer. Jour. Psychology, Apr., 1910, as well as Stekel's cited work. HYSTERIA 95 A still plainer symbolism aiming at this end appears in dreams of burglars who, armed with revolvers, daggers or similar instru- ments, press in upon the dreaming lady. The starting up from sleep because of such anxiety-dreams, 114 one finds frequently in widows and ungratified women as a characteristic kind of dis- turbance of sleep. Stekel 115 especially emphasizes the dream of the death of the child who stands in the way of breaking the mar- riage or prevents the divorce; in general, dreams of death and funerals, especially of near relatives, are typical for the anxiety- neuroses. For want of clinical material, Freud had relatively little oppor- tunity to deal with the outspoken psychoses; still, he considered these within the scope of his investigations. The few cases to which he himself has applied the insight gained from the psycho- neuroses have yielded highly important disclosures and really incited the Zurich clinic to splendid work. Through the dogma, insanities are brain diseases, and through scientific work chiefly devoted to nosography, the psychological way to the understanding of the psychoses was little used. Freud joined Griesinger who ascribed to the psychic causes the predominant role in the causa- tion of the psychoses. Freud divided the cases analyzed by him- self into "overpowering psychoses" and "defence-psychoses." Under the former, he classed those cases in which the unconscious had completely and violently overcome the conscious. Freud re- ported one such case, met with in the course of an hysteria, of an hallucinatory confusion (of which he had seen a few) in which the person (in sense of Griesinger) represented the fulfillment of her repressed wishes in hallucinatory manner, while she awaited in vain an appointed day with her lover, suddenly had hallucina- tions, hastened to meet him, greeted him and for two months lived in the happy dream that he was there, always near her, etc. Thus, the patient has warded off the unbearable idea of remaining away from a longed-for lover in energetic and in a certain sense, U4 Recently Ernest Jones has sought to elucidate the nightmare from Freudian standpoint, " On the Nightmare," Amer. Jour. Insanity, Jan., 1910. UB This repressed wish can express itself as an obsessional impulse to injure or kill the child. Compare Lit. No. 6. g6 FREUD'S THEORY OF THE NEUROSES successful manner, while the ego rejects the unbearable idea together with its affect and behaves as if the idea had never occurred to it. But in the moment in which this succeeded, the person is already in a psychosis which one can classify only as hallucinatory confusion. Thus, the ego tears itself loose from the unbearable idea; this is inseparably connected with a piece of reality however, and while the ego accomplishes this task, it has separated itself in whole or in part, from reality. According to Freud, this is the condition in which hallucinatory vivacity, amid its own ideas, is to be judged. In contrast to this overcoming en masse, the analogy to hysteria in the defence-psychoses (paranoia, dementia paranoides) is complete so that in the initial stages of these cases, they often cannot be sharply differentiated from hysteria and other neuroses. In these cases of defence-psychosis, the whole previous history, course of development, genesis, complexes and infantile repres- sion are the same as in cases of hysteria. It seems that the differ- ent clinical pictures of the defence-psychoses are characterized only by different repression mechanisms which come into play later, concerning which, however, nothing definite is known. The libido may have suffered a quite special fate in this. Thus, in dementia praecox, there seems to be a characteristic withdrawal of the libido the term taken in its broadest sense from the objects of the external world. Therein, lies an exquisite contrast to hysteria to which Abraham has referred. 118 While in hysteria there is much free floating libido for the use of the object, in cer- tain cases of the psychosis it seems to be fastened to the ego complex and thus leads to ideas of grandeur. Thus is also explained the inner connection between persecution mania and delusions of grandeur in the paranoiad forms. Freud has described in detail a case of hallucinatory para- noia 117 analyzed by him, in which he shows that a group of cases which belong to paranoia arise just like hysteria and the obses- sional neurosis from the repression of painful memories and that the symptoms of these are determined in form by the content of the repressed material. Further, in this case, the repressed n * " Die psychosexuellen Differenzen zwischen Hysteric und Dementia praecox," Zentralblatt f. Psych, u. Neural., July, 1908. UT Perhaps more correctly called dementia paranoides. Lit. No. 3. HYSTERIA 97 material was revealed as a sexual experience of childhood (phantasy), the content of which, however, does not have to be recovered by the tedious way of analytic interpretation work but which the patient, as in all cases of paranoia, expressed quite undisguised. In paranoia, much pushes into consciousness which we proved to exist in the unconscious of normal and neurotic individuals only by psycho-analysis. Thus, the phantasies of hystericals which have to be made conscious by analysis hide themselves from sexual and cruel maltreatment, for example, occasionally as far as in individual cases the complaint of para- noiacs, " persecuted." It is worthy of note, but not incomprehen- sible in the light of the Freudian sexual theory, that the identical content meets us as reality in the arrangements of perverts for the gratification of their appetites. For the periodic melancholia, Freud asserts that these cases appear to dissolve in unexpected frequency into obsessional ideas and obsessional affects, a perception which is not of indifferent importance therapeutically. The individual attack of ill humor may be favorably influenced psycho-analytically even if further attacks may not always be prevented. In this relatively small casuistry Freud has been able to show that sense and logic may be demonstrated in delusions, as also in the peculiar variety of unconscious thinking, and has, thereby, brought the cause and content of mental disturbances into psycho- analytic investigation. The Zurich school, with Jung at its head, has busied itself according to the clinical material at its command, with especial attention to dementia prsecox. Jung's painstaking labors in the analysis of every expression of a very averse dement succeeded in showing the same psychic mechanisms which Freud had found in the neuroses also present here in demonstrable form, so that no more doubt can exist that at the bottom of dementia praecox lies a repressed erotic complex. 118 The dulling of the affect is only apparent and, according to Jung, explained by its absorption by the ruling complex. 119 The psycho-analytic study of these conditions has yielded still more. It showed that the 118 Jung, "Uber die Psychologic der Dementia praecox." K. Marhold, Halle, 1907. 119 Compare also Bleuler-Jung, " Komplexe als Krankheitsursachen bei Dementia praecox," Zentralb. f. Nervenheilkunde u. Psychiatric, 1908. 8 98 FREUD'S THEORY OF THE NEUROSES apparently absurd symptoms of dementia prsecox prove on analytic investigation to be symbolic figures of intelligible and, in the mental life of the person, highly important trains of thought and impulses. 120 Abraham has brought out, beside the article already mentioned on the withdrawal of the libido from the external world which is so especially characteristic of dementia praecox, also another article on the significance of dreams of youth for the symptomatology of dementia praecox ; 121 Maeder 122 has dealt in detail with the delusional structures of the paranoiad conditions. Riklin published a " contribution to the psychology of cataleptic conditions in catatonia." 123 Freudian mechanisms could also be shown in various other psychoses. Thus Bleuler, 124 in his work on " Freudian mechanisms in the symptomatology of the psychoses," furnished a series of interesting examples. Otto Gross considered "the Freudian idiogenesis agency and its sig- nificance in manic depressive insanity of Kraepelin" (Leipzig, 1907). In this work appears also a reference to the psycho- genesis of kleptomania. 125 Finally, there follows a short reference to some published works of Jung: "A Case of Hysterical Stupor in a Prisoner Under Trial," further " Concerning Simulation of Insanity." 126 On the psychology of hysterical twilight states, Riklin 127 and Schwarzwald 128 have published contributions. " On Obsessional Psychoses " Warda 128 has written. Stekel has under- 139 Jung, "Der Inhalt der Psychose," Schr. z. angew. Seelenkunde, 3, 1908. 121 Zentralblatt fur Nervenheilkunde und Psychiatric, 1907. 122 " Psychologische Untersuchungen an Dementia praecox-Kranken." Jahrb., II, i, 1910. 123 Riklin, " Beitrag zur Psychologic der kataleptischen Zustande bei Katatonie," Psychiatr.-Neurol. Wochenschr., 1906, No. 32. "* Bleuler, " Freudsche Mechanismen in der Symptomatologie der Psy- chosen," Psychiatr.-Neurolog. Wochenschr., 1906, Nos. 35-36. 125 Compare also Stekel, " Die sexuelle Wurzel der Kleptomanie," Zeit- schrift f. Sexualwissenschaft, 1st year. 136 Jung, " Ein Fall von hysterischen Stupor bei einem Untersuchungs- gef angenen," and " t)ber Simulation von Geistesstorung," Journal f. Psy- chologie u. Neurologic, 1902 and 1905. ""Psychiatr.-Neurolog. Wochenschrift, 1904. 128 Journal /. Psychologic u. Neurologic, 1909. 129 Warda, " t)ber Zwangsvorstellungspsychosen," Monatsschr. f. Psy- chiatrie und Neurologic, 1902. HYSTERIA 99 taken an analysis of a case of melancholia. 130 Jones reports on a case of hypomania, 131 Maeder 132 on a psycho-analysis of a melan- cholic depression and Riklin 133 on prison psychoses. From this enumeration, which does not pretend to be complete, it may be recognized how much promise for psychiatry is held out by the Freudian theory of the neuroses. 130 Compare " Die Angstzustande." 1 " Psycho-analytic notes on a case of hypomania," Amer. Jour. In- sanity, 1910. 32 " Eine Psychoanalyse bei einer melancholischen Depression," Zentral- blatt f. Neurologic u. Psychiatric, 1910, page 50. 133 Uber Gefangnispsychosen," Psychiatri.-Neurol. Wochenschr., 1909. CHAPTER VII THE OBSESSIONAL NEUROSIS Relation to Hysteria. Substitution Instead of Conversion. Charac- teristic Obsession. " Nature and Mechanism of the Obsessional Neu- rosis" (1896). "Remarks on a Case of Obsessional Neurosis" (1909). Significance of Instinct in Life (Sadism). Love and Hate; Obsession and Doubt. Mechanism of Distortion. Some Mental Peculiarities of the Obsessed. As a result of Freud's work, the obsessional neurosis has received an important elucidation and the treatment of this afflic- tion, which is often so severe as to undermine every happiness of life, seems to warrant a much better prognosis. To be sure, those suffering from this neurosis, the symptoms of which often appear in childhood, must come under treatment early. The explanation of this complicated clinical picture is accompanied by much greater difficulties than the interpretation of hysteria, and Freud himself admits that even he has not yet succeeded in completely elucidating a case of obsessional neurosis ; still, there has recently appeared a most illuminating work by Freud which utilizes the results of his investigations during the past years, especially regarding the nuclear-complex and instinctive life, in explaining a case of obsessional neurosis. In the exposition of the theory of the psychoneuroses, the fact has already been repeatedly mentioned and emphasized that the presuppositions of the obsessional neurosis are in part the same as in hysteria and that their origin likewise rests on the unsuccessful repression of psycho-sexual factors. The differ- ences are due to the fact that here a different repression mechan- ism and, because of the breaking through of repressed material, a different kind of symptom formation conies into existence. The affect of the painful idea does not become transformed into physical symptoms as in hysteria (conversion), but affixes itself to other ideas, not in themselves unbearable, thus producing by this false relationship, obsessions (substitution). Characteristic of obsessive ideas and, in a broader sense, of obsessive mental 100 THE OBSESSIONAL NEUROSIS IOI processes in general, is that paradoxical feeling of compulsion or obsessiveness (Zwang) in which absurd or quite harmless ideas stand in the foreground of consciousness and resist dislodgment by logic, even proving completely refractory to it. This arises from the fact that the contents of these obsessive mental processes are only false labels, carriers of affects which do not really belong to them. Conscious logical effort exerts itself in vain inasmuch as it only reaches a sphere of mental activity where it can accom- plish no useful end. The displacement of the affect onto the sub- stituted idea thus attains the end of making the real connection unrecognizable and the work of logic fruitless. Only when by the aid of psycho-analysis the true relation of the obsessive ideas to the infantile material is made conscious can the obsession be removed. The analytic therapy proceeds, therefore, upon the following assumption, which is also demonstrable elsewhere in mental life: where there occurs a mesalliance between an idea and an affect, hence between the intensity of a self-reproach, for example, and the occasion for the reproach, the laity would say that the affect is too strong for the occasion, hence excessive and the deduction drawn from the reproach is therefore false. The psycho-analyst, on the contrary, has to say: no, the affect is justi- fied, the consciousness of guilt is not to be criticized; it belongs to another, unknown (unconscious) content which must be uncovered. -4s already mentioned, infantilism and sexuality possess a fun- damental etiological significance for the obsessional neurosis as well as for hysteria, although in the obsessional condition these exhibit certain peculiarities. The sexual activities of childhood are manifested in a particularly active manner; without exception, these are children who even in early life betray very intense aggressiveness. In contrast to hysteria, this characteristic of precocious sexual activity is absent in no case of obsessional neurosis. With this difference is connected another, namely, that in this neurosis the male sex seems to have the preference. In general, the obsessional neurosis shows much more clearly than hysteria that the agents causing the neurosis are to be sought, not in the actual but in the infantile sexual life. The necessary infantile basis of the obsessional neurosis, in distinction to that of hysteria, is not always completely lost in amnesia ; in particular, IO2 FREUD S THEORY OF THE NEUROSES the idea which is separated from its affect is frequently present and treated as of no consequence by the patient's consciousness. Etiologically, these two neuroses stand close together and fre- quently appear in combination. At the bottom of an obsessional neurosis, the analysis often reveals a bit of hysteria. The first detailed work of Freud's on the obsessions 13 * con- tains the most important features of the analysis of this clinical picture but was later found by Freud himself to require improve- ment in certain particulars. Nevertheless, for the student, this work, because of its schematic presentation of this clinical picture with its most complicated psychology, is an especially good guide. According to Freud's original exposition, the typical course of a case of obsessional neurosis would be something as follows : In a first period period of childish immorality the events con- taining the seed of the later neurosis occur. In earliest childhood, the acts of sexual aggression take place against the other sex which later appear in actions symbolizing reproach. This period is brought to an end by the appearance of sexual maturity, often self-induced. Now a reproach becomes joined to the memory of those sensual acts, this is repressed and replaced by a primary defence symptom. Scrupulousness, shame, self-distrust are such symptoms, with which the third period, that of apparent health but really successful defence, begins. The next stage, that of actual sickness, is characterized by the return of the repressed material, that is, by the failure of the defence. The revived impulses and memories as well as the reproaches formed from them penetrate consciousness but never in unchanged form, always as obsessive idea and obsessive affect and the pathogenic memory substituted for the conscious life; thus are formed compromise formations between the repressed and repressing ideas, so that the repressing material may again be identified in the symptoms alongside some of the repressed. In the further course of the development of the neurosis two forms of the disease can be differentiated according as only the memory content of the act symbolizing reproach forces an 1M " Weitere Bemerkungen uber die Abwehr-Neuropsychosen " (1896), Lit. No. 8. Earlier compare under "Die Abwehrneuropsychosen " (1894), Lit. No. 53. "Obsessions et phobies; leur mecanisme psychique et leur etiologie" (1895), Lit. No. 6. THE OBSESSIONAL NEUROSIS 1 03 entrance into consciousness or is accompanied by the reproach- affect. The first case is that of the typical obsession in which the content attracts the patient's attention accompanied by only an indefinite feeling of discomfort as affect, whereas only the affect of reproach would be suitable for the content of the obsessive idea. In the second form of obsessional neurosis the reproach-affect can, by a psychic addition, change itself into any other unpleasant affect; if this has happened, then nothing more stands in the way of the substituted affect's becoming conscious. Thus the reproach (of having carried out some sexual acts in childhood) is easily changed into shame (if another becomes aware of it), into hypo- chondriacal anxiety (because of the injurious physical conse- quences of those reproachful acts), into social anxiety (fearing punishment by society for that offense), into religious anxiety, into the delusion of being observed ( fear of betraying those acts to others), into fear of being tempted (justified distrust in their own power of resistance) and so on. Therewith, the memory content of the act symbolizing reproach can be present in con- sciousness or entirely absent, which greatly complicates the diagnostic difficulties. Many cases which a superficial examina- tion calls general (neurasthenic) hypochondria belong to this group of obsessive affects; especially do the so-called "periodic neurasthenia" or "periodic melancholia" (cyclothymia) seem in unexpected frequency to resolve into obsessive affects or obsessive ideas, a perception which is not of slight therapeutic importance. Besides these compromise symptoms which signify the return of the repressed material and thereby a failure of the originally achieved defence, the obsessional neurosis forms a series of other symptoms of a totally different origin. The ego seeks to defend itself against those descendants of the initial repressed memory, and in this conflict produces symptoms which Freud has grouped together under the name " secondary defence." These are without exception protective measures which have performed good service in the struggle against the obsessions and obsessive affects. If these aids in the defence process really succeed in repressing aeew the symptoms of the return of the memories originally repressed by the ego, then the obsession is transferred to the protective measures themselves and produces a third form of obsessional neurosis, the obsessive acts. These seem to be seldom primary; IO4 FREUD'S THEORY OF THE NEUROSES they never contain anything except a defence, never an aggres- sion. Psycho-analysis demonstrates that in spite of their peculi- arity and diversity, these acts in every case may be fully explained in this manner. It is found that these obsessive acts, which often seem so silly and senseless, have a meaning in all of their pecu- liarities without exception ; they serve the most vital interests of the personality and bring to expression 185 experiences which are still active as well as thoughts tinged with affects from the latter ; this is effected by direct or symbolic representation. The obses- sive acts are, therefore, to be interpreted either as historical or symbolic. The secondary defence of the obsessions can be accomplished by a strange diversion to other thoughts of possibly contrary con- tent ; hence in case of success, the obsessive reasoning is regularly concerned with abstract and transcendental subjects, because the repressed ideas always occupied themselves with sensuality. Or the patient attempts to become master of each individual obsessive idea by force of logic and appeal to his conscious memories ; this leads to obsessive thinking, obsessive testing and doubting mania. In these testing measures, the superior power of the obsessive idea over the actual memory at first impels the patient and later com- pels him to collect and preserve all objects with which he comes in contact. The frequently grotesque and quite unintelligible content of the obsessions is made clear by the explanation that these ideas, in contrast to the content of obsessional acts of child- hood, are distorted in a twofold manner: (i) An actual occur- rence is put in the place of a past experience; (2) something sexual is replaced by something analogous non-sexual, both processes due to the ever-present tendency to repression. This displacement onto another idea goes forward only gradually as the idea becomes little by little more disparate and unrecognizable. The obsession finally appears, devoid of motive and senseless, quite like the wording of our nocturnal dreams, and the first task which it imposes is to give them meaning and position in the mental life of the individual, so that they may become intelligible and indeed even obvious. 185 According to a later statement of Freud's, the unconscious model for certain obsessive acts which is always imitated in the course of the disease may be the original sexual act which was later repressed. Lit. No. 36. THE OBSESSIONAL NEUROSIS IO$ The secondary defence against the obsessive affects develops a still longer series of protective measures, which are readily changeable into obsessive acts. These can be grouped according to their tendencies : penitential measures, irksome ceremonials, observation of numbers, measures of protection (all kinds of phobias, superstitions, pedantry, aggravation of primary symp- toms of scrupulousness), fear of betrayal (paper-collecting, diffidence), narcotization (dipsomania). Among these obsessive acts and impulses, the phobias play the greatest role in restricting the life activities of the patient. The phobias which appear in the course of an obsessional neurosis are the expression, not of fears but of prohibitions. To give a systematic and well-rounded exposition of the obses- sional neurosis on the basis of Freud's works is impossible ; only recently, his first publication has been succeeded by a second which brings out much that is entirely new and valuable, though only devoted to the exposition of a single case of severe obsessional neurosis without pretending to have elaborated an exhaustive or universally applicable theory of the subject. For a presentation which is intended to be merely a summary, the long interval between the two works as well as the differences in their content are well suited to illustrate the important progress and growing depth of the Freudian doctrines. These " Remarks on a Case of Obsessional Neurosis" 136 (1910) give extracts from a detailed analysis of a common type of severe obsessional neurosis and, in accordance with the modern status of the theory, trace the etiol- ogy in widest measure to infantile sexual life and instinct, at the same time showing in particular the connection of the obsessional neurosis to the sadistic component of the sexual instinct. In addi- tion, the new work contains statements on the genesis and finer mental mechanism of obsessive thought in general, communica- tions which, since they bear on the exposition of the psycho- genesis of the obsessions thus far given, will be reviewed first. In his first work, Freud had defined obsessions in the broadest sense collectively in the following words: they are in every case transformed reproaches which have escaped from the repression and are always connected with some pleasurably accomplished " Lit. No. 36. 106 FREUD'S THEORY OF THE NEUROSES sexual act of childhood. This definition is not discarded in the later work but the greatest accent is placed on the word " trans- formed." Freud's most recent work now goes into the manner and mechanism of this transformation in exhaustive and detailed fashion with special attention to the psychological refinements in the formation of the neurosis. Freud starts by asserting that it is more correct to speak of obsessive thinking than of obsessive ideas (obsessions), at the same time emphasizing the fact that the obses- sional structure may have the value of the most diverse kinds of mental processes. They may be felt as wishes, temptations, im- pulses, reflexions, doubts, commands and prohibitions. The patients, however, strive in general to weaken this definiteness and to consider the thought-content robbed of its affect-index only as a mental process, as an obsession. When a psycho-analyst comes into opposition to a person suffering from such an obses- sional neurosis, there appears as already mentioned the paradox- ical emotion of obsessive force attached to a very indifferent content and it is only after much effort that he succeeds in pene- trating to the original content to which this affect rightly belongs. The mechanism and distortion which the patient has brought into use in this defence conflict are not so simple as originally thought. The value of the correctly recognized distinction between primary and secondary defence conflict becomes limited in an unexpected manner by the discovery that the patients for the most part do not know the wording of their obsessions and only in the psycho- analytic treatment become aware of their true meaning, especially by the aid of dreams. During the analytic investigation of the patient's history, the conviction is forced upon one that the obses- sions which appear successively, although not expressed in iden- tical language, are at bottom one and the same. The obsession which has been happily gotten rid of once now returns again in a more distorted form. The original form is the correct one, which often allows its meaning to be clearly recognized. After one has patiently worked out an unintelligible obsessive idea, he often hears the patient say that such a temptation, idea or wish really did appear at one time before the obsessive idea, but did not remain. The typical characteristic obsession carries thus in its distortion against its original wording traces of the primary defence conflict. The distortion allows them to find expression THE OBSESSIONAL NEUROSIS IO/ by compelling consciousness to misunderstand them, just as the dream content, which is likewise a compromise and distortion product, is misunderstood by the waking consciousness. 137 The distortion makes use of various mechanisms. The sim- plest is the distortion through ellipse, which finds such special application in wit, 138 but also does duty in the neurosis as a means of protection against the correct recognition of the obsessive idea. One of the favorite obsessive ideas of the patient whom Freud took as paradigma in his publication is expressed as follows : " If I marry Madame X misfortune will befall my father (in the other world)." If we insert the connecting links which are omitted in this expression and only brought to consciousness by the analysis, the train of thought takes a more intelligible form : " If my father were alive, he would become greatly enraged over my intention of marrying Madame X, just as he did that time he flogged me as a child, and I would again be angry at him and wish him all evil, which the omnipotent power of my wishes cannot help bringing to fulfillment upon him." This elliptical distortion technique seems to be typical for the obsessional neurosis. Alongside the distor- tion which the obsessive thought has undergone before becoming conscious, there is seldom lacking a separation of the individual obsessive idea from the occasion of its origin in which in spite of the distortion it would be most easily accessible to the understand- ing. In furtherance of this purpose, an interval is interposed between the pathogenic occasion and the resulting obsessional idea which leads consciousness astray in its search for a cause and correspondingly disturbs the interpretation of the obsessional idea when it is again attempted to ascertain its temporal relation- ship to the event in the experience of the patient by discovering when the individual obsessive idea first appeared and under what external circumstances it usually reappears. In addition to this temporal displacement, the content of the obsessive idea is almost regularly freed from its special relations by generalization. In this connection, Freud brings forward, as an example, a patient who had the obsessive prohibition of wearing any jewelry what- 1IT This misunderstanding by consciousness is observable not only in the obsessive idea itself but also in the products of the secondary defence conflict, for example, in the protective measures. 118 Compare Freud's " Der Witz, etc.," Lit. No. 19. io8 FREUD'S THEORY OF THE NEUROSES ever, although the occasion for the prohibition went back to a particular piece of jewelry which she had envied her mother and which she hoped would one day come to her by inheritance. A further frequent characteristic of the mental processes of the obsessional neurosis is the mechanism of displacement which Freud first discovered in the dream formation and later proved to be also an essential factor of the technique of wit. Especially in the obsessive acts is it most evident how by a displacement from the thing of real importance onto a substitute of little im- portance, the symbolism and detail of the process (the cere- monial) come to expression. It is this tendency to displacement which is constantly changing the clinical picture of the disease and finally succeeds in making the apparently most trivial things seem the weightiest and most urgent. Finally, one can separate from the distorted content the am- biguous and indefinite wording which serves as a protection of the obsessive idea against the conscious attempt to solve it. The further amplifications or replacements by the obsessive force become joined to this misunderstood wording instead of to the correct context. These processes, in contrast to the distortion technique of the content, belong to the secondary defence conflict, the symptomatology of which receives a new increase from the so-called deliria, under which term Freud places mixed conditions between purely rational considerations and the obsessive thought processes to which these are opposed ; and indeed these thoughts do incorporate some of the presuppositions of the obsession which they combat and by the aid of reason take their place in the pathological thought. Into these deliria also enter the previously mentioned misunderstandings; still, it can be observed that the deliria are always striving to gain new relations to the content and expression of the obsession which are not appreciated by con- sciousness. In the recent description of the secondary defence conflict, Freud also points out the genesis of the so-called pro- tective obsession which signifies nothing else than the reaction, repentance and penitence, to an opposite impulse. The obsessive acts often show an alternating course in which the first tempo is set in opposite to the second. We do not exactly understand this second part of the obsessive act if we consider it only as a critical aversion to the pathological act which he would THE OBSESSIONAL NEUROSIS 1 09 like to give up. The obsessive acts represent the conflict of two impulses of opposite but equal value, chiefly the opposition between love and hate, which plays a great role in the genesis of the obsessional neurosis and also finds expression in its symptoms. These alternating obsessive acts claim an especial theoretical interest because they disclose a new type of symptom formation. Instead of finding a compromise, as regularly happens in hysteria, which satisfies both opposing forces in one representation, the two opposing forces are here satisfied individually, first one, then the other, naturally not without the attempt being made to produce between these two hostile forces a kind of logical union, often with the destruction of all logic. The most important thing in the new work of Freud's on the obsessional neurosis is, as mentioned, the proof of the funda- mental significance of original instinct. Characteristic of a later obsessional neurosis is the appearance of a special aggression and activity in childhood which expresses itself chiefly in an intensive activity of the impulse to peek (Schautrieb) and to know (Wiss- trieb). Instinct has been especially abundant and powerful in childhood and succeeds in being of extraordinary significance in the genesis of the obsessional neurosis through the most intensive elaboration of the emotions of affection and hostility toward the parents, 139 brothers and sisters which, in conjunction with infantile sexual curiosity regarding sex and birth processes, forms the nuclear-complex of the neurosis. We find, however, in the symp- tomatology of the obsessional neurosis a continual conflict be- tween love and hate, a chronic existence side by side of these two feelings toward the same person and indeed both emotions in highest intensity, a phenomenon which is calculated to astonish us when we always find it in these patients. Such a continuance of contrasts is possible only under peculiar psychological condi- tions and through the cooperation of the unconscious condition. Love has not extinguished hate but only succeeded in repressing it into the unconscious, where, protected from elimination through the aid of consciousness, it can exist and even grow. Under these conditions, conscious love attempts by way of reaction to expand to an especially high intensity in order that it may meet the con- stantly imposed task of holding its opponent in repression. A 138 Compare the already mentioned " Odipuscomplex." no FREUD'S THEORY OF THE NEUROSES very early separation of these two opposing feelings occurring in the earliest years of childhood, with the repression of one of them, commonly hate, seems to be the foundation of this strange constel- lation of the life of love. Although the connection between the negative factor of love to the sadistic component of the sexual instinct is not explained, Freud believes that he can give out the provisional opinion that in these cases of unconscious hate, the sadistic component of love may have been especially strongly developed constitutionally and have received a premature and all too profound suppression; thus, the phenomena of the neurosis are derived, on the one hand, from conscious affection highly developed as a reaction, on the other hand, from the sadism con- tinually active in the unconscious. 140 This sort of constitutional hate component is accidentally supported by the traumata received from prohibitions imposed mostly by the parents (father) which attain a great significance in the genesis of the obsessional neu- rosis. Thus, a vigorous punishment on account of sexual activity or childhood fault in connection with this, becomes a strong sup- porting measure of the hate which originally sprang from the parent-complex. The occasion for such punishment soon arises for a definite type of patient who is later afflicted with an obses- sional neurosis, shows even in childhood voluptuous wishes to which, of course, uncomfortable expectations and tendencies to protective acts are joined. Thus, a conflict is present in the men- tal life of these little voluptuaries; beside the obsessional wish stands an obsessional fear intimately connected with the wish. Thus, a sexual instinct and a rebellion against it, a wish (not yet obsessive) and fear (already obsessive) striving against it, a pain- ful affect and the compulsion toward protective acts, the inventory of the neurosis is complete. This infantile preliminary stage of the neurosis is regularly present and often becomes manifest in the child as disease. 14 * The next result of this noteworthy connection between love and hate which is demonstrable in every case of obsessional neu- 140 This connection also explains the frequent and enigmatical obses- sional laughing on occasions of sorrow which betrays the unconscious joy at the suffering or downfall of the unconsciously hated person. " Thus beside the anxiety-hysteria, the obsessional neurosis is a second type of neurosis of childhood. THE OBSESSIONAL NEUROSIS III rosis, is a partial weakening of the will, an incapacity for resolu- tion in all actions for which love should be the compelling motive. The irresolution, however, does not long remain limited to this group of acts, but, by means of the already mentioned mechanism of displacement, gradually spreads over the whole range of the person's activity. Thereby is created the sway of obsession and doubt as it is exhibited in the mental life of the obsessional patients. The doubt corresponds to the inner appreciation of the irresolution which as a result of the inhibition of love by hate takes possession of every voluntary act of the patient and can spread further to all acts, those already completed, those not yet related to the love-hate complex and to the whole past. This is really the doubt of the power to love which should be subjec- tively the greatest certainty. It is the same doubt which, in pro- tective measures, leads to uncertainty and continual repetition which finally makes these protective acts become as impossible of attainment as the original inhibited love resolution. The uncer- tainty of the patients finds expression also, for example, in their prayers imploring the sparing of the life of another which uncon- scious phantasies incessantly interrupt; these phantasies contain for the most part the impulse which is in direct contradiction to the petition voiced in the prayer. The obsession becomes now a " search for the compensation for the doubt " and for a correction of the unbearable states of inhibi- tion to which the doubt refers. If the patient, by the aid of the displacement, has succeeded in bringing any one of the inhibited intentions to a decision, this demands immediate execution; it is indeed no longer the original energy belonging to the intention but the pent-up energy which now finds occasion to escape by the substitute act. It thus finds expression in commands and prohi- bitions according as it is now the affectionate, now the hostile impulse which gains the way of escape. By a kind of regression, further preparatory acts take the place of the final resolution, thought replaces action and some sort of mental preparation for the act is carried out by obsessive force instead of the substitute act itself. 'According as this regres- sion from motor function to ideational is more or less complete, the case of obsessional neurosis assumes the character of obsessive thinking (obsession) or obsessive act in the narrower sense. The H2 FREUD'S THEORY OF THE NEUROSES point in question is in what stage of the continual progress of the defence conflict the breaking through of the repressed instinct takes place and which impulse is in control. This acceptance of a thought as a substitute for an impulsive act makes possible the following formula for the psychological characteristic which gives the products of the disease its obsessional attribute: those processes tend to become obsessions which, on account of an opposing inhibition at the motor end of the nervous system, have taken to themselves a fund of energy of a quality and quantity otherwise used only for motor functions, that is to say, thoughts which necessarily represent regressive acts. This displacement of the accent from the motor process to the thought process shows the obsessional neurosis to be in general a misuse of thinking. The pathological exaggerations of the obses- sonal neurosis, if investigated more closely, might afford great profit for the understanding of the intellectual life in general. In this way, Freud was able to derive something typical from the mental peculiarities of his case. Thus, the peculiar relation to superstition, death and reality, which is different in those suffer- ing from obsessional neurosis. These peculiarities have their ultimate foundation for the most part in instinct. Especially does the strange conduct toward the subject of death and the intensive occupation with this problem attract the attention of the physician. Those obsessed often sympathize warmly in all cases of death and piously take part in the funerals. This strange characteristic of the patients rests on the fact that as children they came into con- tact with the problem of death through their evil, vengeful wishes; as compensation for this, there then appears their intellectual and emotional occupation with this subject, thus this complex is also a root of their phantasies of the future life (superstition). Their superstitious tendencies have for the most part absolutely no other content and in general have perhaps no other origin. Before all, however, and here we touch on one of the motives for the illness, they need the possibility of death as a solution of the mental con- flicts which they find insoluble by themselves. Their essential characteristic is indeed that they are incapable of decision, espe- cially in matters of love. Thus, in every life conflict, they look for the death of one who is important to them, usually of a loved one, it may be a parent, a rival or a lover, between whom their affection wavers. THE OBSESSIONAL NEUROSIS 113 Through the overvaluation of the product of their mental processes, for example, the possibility of causing death by their thoughts (wishes), such obsessed patients gradually come to believe in the omnipotence of their thoughts. On the one hand, there is also in this belief a piece of the old childish delusion of grandeur. Another mental need which has a certain relationship to the one already mentioned is that of uncertainty in life or doubt. The bringing about of uncertainty is one of the methods which the neurosis adopts to draw the patient away from reality, to isolate him from the world, which is indeed the tendency of every psycho- neurotic disturbance. The predilection of the patients for uncer- tainty and doubt becomes a motive for them to fasten their thoughts chiefly on those subjects where uncertainty is common to all the race and where our knowledge or our judgment must necessarily remain exposed to doubt. Such subjects in particular as paternal parentage, duration of life, life after death and the reliability of memory. An especially strange trait of a patient with obsessional neurosis who has otherwise a fairly high degree of intelligence, is the above mentioned superstitiousness. This belongs to their sufferings but not to their personality; it does not indeed permeate all their thought. The patient may be superstitious during the illness but otherwise enlightened and a freethinker. In this connection, they often have two opposed convictions, not one incomplete opinion. Between these two convictions, they oscillate in the most obvious proportion to their suffering. This superstition is thus no real conviction with the patients but has an obsessive character. From the analysis of cases of obsessional neurosis, a deep insight into the psychology of superstition may be gained; it can here be recognized that superstition springs from suppressed hostile and cruel impulses. Superstition is in great part expectation of mis- fortune, and he who has frequently wished another evil, but on account of being trained to kindness has repressed such wishes into the unconscious, will find it especially easy to anticipate mis- fortune threatening him from without as punishment for such unconscious wickedness. CHAPTER VIII i PSYCHO-ANALYTIC METHOD OF INVESTIGATION AND TREATMENT Its Peculiarity (Specific Therapy). History of the Development of the Method. General Technique. Art of Interpretation. Indications and Contraindications. The Transference. Refutation of the Objections to the Method. Freud has expressed himself repeatedly both orally and in writing concerning his psycho-analytic technique, which has com- pletely replaced the original cathartic and hypnotic methods; nevertheless, there is still lacking a detailed and systematic rep- resentation especially of the technical rules and devices founded on painstaking empiric procedure. In spite of this, a number of students and adherents, who in great part are in close touch with Professor Freud, practice the therapy according to his directions and their own auto-didactic studies and experiments. In the hands of a physician not sufficiently versed in the subject, the therapy can easily work harm. Psychotherapy of other kinds has nothing in common with psycho-analysis, which differs from hypnosis as well as every kind of suggestion and utilizes the associations as well as the dreams of the patient to lay bare his unconscious. Psycho-analysis proceeds from the "psychic sur- face" and seeks from there in narrative-like penetration to set free the repressed complexes and thereby the instinctive impulses. The superiority of this over the methods of treatment previously used in the treatment of nervous disorders shows best in the fact that while acting as a specific, it reveals the etiology of the case. Thus it is to be considered as theoretically the ideal psychotherapy of psychogenic maladies. Freud does not mean at all that it is always and in all cases and under all conditions the only possible or necessary therapy and has never asserted that all cases of neurosis are therapeutically accessible or that all can be cured. The psycho-analytic therapy is, however, shown by experience to work the most impressively, carry the farthest and accomplish 114 METHOD OF INVESTIGATION AND TREATMENT the most intense changes in the patients. Quite apart from the therapeutic view-point, we are indebted to this irreplacable method for such unexpected enlightenment on the theory of the neuroses as more than compensates for the only occasional bad result which no therapy escapes. In any case, psycho-analysis is the most interesting of all psychotherapies because it alone teaches us something of the origin and relations of the disease manifesta- tions. As a result of the insight into the mental mechanism of mental diseases which it opens to us, it alone is in a position to lead us on and show us the way to still other kinds of thera- peutic influences. The particular method of psychotherapy 142 which Freud prac- tices and calls psycho-analysis has come from the so-called cathartic method on which he at one time collaborated with J. Breuer in a book " Studien iiber Hysteric." The cathartic therapy was a discovery of Breuer's by the aid of which he had, about a decade previously, restored an hysterical patient to health, thereby gaining an insight into the pathogenesis of her symptoms. At the personal suggestion of Breuer, Freud then took up the method and tested it on a large number of patients. The cathartic method presupposed that the patient is hypno- tizable and rested on the extension of consciousness which ap- peared in hypnosis. He set up as a goal the removal of the dis- ease symptom and attained this by transferring the patient back to the mental state in which the symptom first appeared. Then there came to the hypnotized patient memories, thoughts and impulses which had previously escaped from consciousness and if he communicated these mental processes under intense expres- sions of affect to the physician, the symptom was overcome and its return prevented. This apparently regularly recurring experi- ence the two authors explained in their book by the fact that the symptoms stood in place of suppressed psychic processes which could not appear in consciousness, thus represented a change ("conversion") of the latter. The therapeutic efficacy of their method they explained as a discharge of an affect dammed up, 142 The following review of " Freudsche psychoanalytische Methode" is in some points an enlarged repetition of the article of Freud's by the same name. Lit. No. 18. n6 FREUD'S THEORY OF THE NEUROSES as it were, which had remained from the suppressed mental processes (abreaction, Abreagieren). This simple scheme of therapeutic attack was complicated nearly all the time, however, by the fact that not a single " traumatic " impression but usually a complex series of such impressions shared in the origin of the symptom. The chief characteristic of the cathartic method, which puts it in contrast to all other methods of psychotherapy, lies in the fact that in this procedure the therapeutic efficiency does not depend on a suggestive command of the physician. It anticipates rather that the symptoms will disappear if the attempt, which appeals to certain presuppositions concerning the mental mechanism, succeeds in bringing the mental processes into different channels than they have previously followed in the formation of symptoms. The modifications of the cathartic method undertaken were at first changes in the technique; these brought new results and have necessitated a different though not contradictory conception of the therapeutic work. As the cathartic method had already abandoned suggestion, so Freud took the further step of also giving up hypnosis. Since the hypnotization, in spite of every skill of the physician, interferes, as is known, with the free will of the patient and a great number of neurotic persons cannot be hypnotized by any method, thus through the abandonment of hypnosis, the applicability of the method was extended to an unlimited number of patients. On the other hand, the extension of consciousness was omitted which had furnished the physician just that psychic material in memories and ideas by the help of which the transposition of the symptoms and the freeing of the affect was accomplished If no substitute were to be provided for this deficiency there could be no such thing as therapeutic influence. Such an entirely sufficient substitute, Freud found in the associations of the patient, that is, in the involuntary thoughts which are mostly perceived as disturbing ones and therefore under ordinary circumstances disregarded; these involuntarily press to the psychic surface in the " recital " of the patient to the physician and betray the disease complex. 143 Thus, at that time the work 118 The experimental confirmation of this presupposition of the Freu- dian method of treatment has, as already mentioned, been afforded by the METHOD OF INVESTIGATION AND TREATMENT proceeded from the symptoms and set up the solution of the same serially as a goal ; Freud has since given up this method because he found it entirely unsuited to the finer structure of the neurosis. He now allows the patient himself to determine the theme of the daily work and by this means proceeds from the complex which is present in the foreground of the patient's mind. Thus, one receives all kinds of material which belongs to a solution of the symptom, broken into fragments, interwoven in different connec- tions and distributed over widely separated periods of time; in spite of this apparent disadvantage the new technique far sur- passes the old. In order to strengthen these associations, Freud uses the fol- lowing outside means of assistance. He has the patient recline comfortably on a couch while he sits on a chair behind and out of his line of vision. He does not insist upon the eyes being closed and avoids any touch as well as every other procedure which might lead to hypnosis. Such a seance goes along like a conver- sation between two similarly awake persons of whom one is relieved of every muscular tension and every distracting sense impression which might disturb the concentration of the attention upon his own mental affairs. Before he proceeds to details, he urges them often for several sessions to sketch a general picture of their whole illness and most intimate family and life surround- ings, 144 to tell him everything which comes into their heads whether they think it important, irrelevant or nonsensical. With special emphasis, it is asked of them that no thought or association be omitted from the communication because this telling might be shameful or painful. In taking pains to collect 145 this material from associations which would otherwise have been pushed aside, Freud now made the observations which have become determin- association experiments undertaken by the Zurich school which many psycho-analysts use to gain associations from patients. "* It is not recommended that the psycho-analyst undertake an investi- gation of the somatic conditions himself but where possible to have this done by a specialist in that line. 145 Freud warns expressly against taking up the time of the treatment itself with making notes of the conversation of the patient because this would awaken a mistrust on the patient's part and confuse the physician in the appreciation of the material produced. Notes made afterwards are nevertheless indispensable. n8 FREUD'S THEORY OF THE NEUROSES ing for his whole conception. Already in this narration of the patient's history, there appear defects of memory; perhaps actual occurrences are forgotten or temporal relations twisted or causal relations distorted so that incomprehensible effects result. No neurotic clinical history is free from amnesia of some kind. The psycho-analyst can only wonder how the smooth and exact clin- ical histories of hysterical cases are produced by other authors. Only in the course of the treatment does the patient bring forth what he has held back or what has not occurred to him, although he has always known it. When one urges the narrator to fill in these breaks in his memory by concentrated attention, one dis- covers that the interrupted associations are held back from him by all the means of critique until the patient finally feels direct discomfort if the memory has really stopped. From this experi- ence, Freud concluded that the amnesias are the result of the process which he has described as repression (Verdrangung). The psychic forces which have caused this repression are to be detected in the resistance which sets itself against the revival of the memories. To seek out and overcome these resistances is the most important part of the therapeutic work. The agency of the resistance has become one of the funda- mentals of the Freudian theory. He considers the associations side-tracked under all sorts of pretexts, as descendants of the repressed psychic structures (thoughts and emotions), as dis- tortions of the same by the opposition of the resistance against their reproduction. Further, the associations of the patient are quasi-symptoms, new, artificial and ephemeral substitutions for the repressed material but already so much distorted that they have only the remotest resemblance to the repressed material. If the resistance is not too intense, it may be possible to guess from the association the desired concealed material. The greater the resistance, the more pronounced the distortion. In this relation of the undirected associations to the repressed psychic material, rests its value for the therapeutic technique. If one possesses a method which renders it possible to discover the repressed mate- rial from the associations, the things distorted from the original, then one can, without hypnosis, make attainable to consciousness the earlier unconscious material in the mental life. In this regard, Freud has elaborated an interpretation tech- METHOD OF INVESTIGATION AND TREATMENT nique. that accomplishes this task; this might be described as recovering from the ore of unguided associations the metal con- tent of repressed thoughts. The objects of this interpretation technique are not merely the associations of the patient but also his dreams which afford 146 the most direct entrance to the uncon- scious, his unintentional acts such as aimless acts (symptomatic acts) and the mistakes 147 of his performances in everyday life (misstatements, misunderstandings, etc.). According to Freud, there is a series of empiric rules which enable the analyst to con- struct the unconscious material from the associations of the patient; instructions concerning what one is to understand if the associations of the patient contradict and examples of the most important typical resistances which appear in the course of such a treatment. Although as yet Freud has published no collected representa- tion 148 of the details of this interpretation and translation tech- nique, still there are in his " Bruchstiick einer Hysterieanalyse " 149 some preliminary references to the overcoming of certain difficul- ties which appear regularly in every psycho-analytic treatment; these may be removed only by an exact knowledge of their psychic motives and the communication of this to the patient. If it would seem at first that one might rely on the flow of associations, on the interpretation of which the treatment depends, even a short investigation teaches every time that, as it lies in the nature of the whole method of treatment and its presuppositions, the analysis is often interrupted by the resistances combating the laying bare of the repressions. The removal, that is, the exposing li6 Freud shows the value of the technique of dream interpretation in the psycho-analytic treatment in a book entitled " Bruchstiick einer Hys- terieanalyse " (Lit. No. 31). One must not expect that every dream right at the beginning of the treatment may be completely interpreted before one is oriented in relation to the most important complexes of the patient. 10 The interpretation technique of mistakes is in " Psychopathologie des Alltagslebens," Lit. No. 16. ""The comprehensive work on dream interpretation ("Traumdeu- tung") is to be considered a precursor to such an introduction to the technique. 149 Those of the following rules which are not derived from this analysis are taken from Freud's lectures on " Methodik der Psycho- therapie" delivered in the winter semester 1908, the publication of which is in preparation. I2O FREUD'S THEORY OF THE NEUROSES of these resistances, is the chief task of the technique; after this has been accomplished, the material necessary for the uncovering of the complexes reveals itself. The physician must be prepared for these resistances which clothe themselves in the most varied forms and lead to pauses in the associations of the patient. The pauses have, as experience gained from numerous analyses shows, certain typical and, for the skillful physician, readily transparent causes. Thus, a gross sexual memory, the communication of which to the physician may be withheld contrary to the conditions of the treatment, keeps constantly recurring to the patient against his will and regularly leads to such a break in the associations. Similarly, works a disturbance of the relation to the physician : it may be the feeling of an especially intense antipathy or sympathy which will not be betrayed by the patient. Further, the material side of the treatment, an impatience over a relatively long dura- tion of the treatment can interrupt the flow of associations. The resistance also frequently expresses itself in the fact that the otherwise copious dream reports stop or flow in such fulness and extent that the placing of them in the framework of the treatment becomes impossible. The skillful psycho-analyst will explain to the patient how the resistance stands in the way and the motive for his denial of associations from case to case whereby the anal- ysis can almost always proceed more rapidly since every time, through the elimination of the resistance, the entrance to new unconscious material becomes free which this resistance really only serves to conceal. As already described, besides the associations and dreams of the patient, the so-called symptomatic acts have great importance for the explanation of the unconscious mental life. Under this term Freud understands those actions which a person carries out as they say " automatically, unconsciously, without thinking about them, as if playing," to which they would deny any significance and if questioned about them explain as indifferent and accidental. Careful observation shows that such acts, of which consciousness knows nothing or wishes to know nothing, give expression to unconscious thoughts and impulses which are valuable and illumi- nating as unpermitted expressions of the unconscious. Besides the unlimited number of possibilities for individual and specific METHOD OF INVESTIGATION AND TREATMENT 121 symptomatic acts 150 certain typical forms regularly take a hand fn the psycho-analysis. Thus, the patient's tardiness in coming to the treatment often indicates a secret resistance against his com- ing on this day; still more clearly does the remaining entirely away from the appointment speak for an ordinarily very weakly motivated ground for the prevailing powerful resistance. Just as important as symptomatic acts are all those first communications of the patient especially at the beginning of the treatment and also the first expressions sometimes made at the beginning of each consultation hour. In similar indirect manner as the patient com- municates to the physician by means of symptomatic acts, the direct expression of which is not possible or painful to him, so also the next dream may bring to expression the same material in veiled terms. Besides these aphoristic communications of a general nature, Freud has given in their practical application, in his published pamphlet on an analysis of a case of hysteria, some of the rules of interpretation gained empirically. Especially in some illumi- nating references to reactions of the patient to certain instruc- tions or communications of the physician which reveal uncon- scious processes. Among these reactions of the patient, the one called by Freud the " unconscious yes " is especially to be noticed ; under this term, Freud understands associations which contain something corresponding to the assertion of the physician but not directly confirmatory. A further indirect confirmation that the veiled unconscious material has become manifest to conscious perception is an accidental laughing by the patient in the treat- ment which occurs when the content of disclosed material in no way justifies it. Other forms of affirmation are a failure to under- stand things which come from the unconscious; in general, there is no " unconscious no." From this standpoint, " no " which one is accustomed to hear from the patient after one has first laid bare the unconscious thoughts to his conscious perception, is to be received only as a continuation of the repression ; its resoluteness likewise lacks the strength of the same. If one considers this "no" not as the expression of an impartial judgment, of which the patient is not capable, but passes lightly over it and continues 350 Examples of these may be found in " Bruchstuck einer Hysteric- analyse " as well as in the " Psychopathologie des Alltagslebens." 122 FREUD S THEORY OF THE NEUROSES the work, the first evidence soon appears that " no " in such a case has the significance of the expected yes. In a similar sense is also to be considered the very frequent manner of the patient in seeking to reject some information which has come up out of the repressed by replying to a hint of the physician concerning this with " I knew you would say that ! " A further rule which has been derived empirically from psycho-analytic technique is that an inner but still hidden connection is indicated by the con- tiguity, the temporal relationship of the associations, just as a and b in script placed beside each other mean that the syllable ab should be formed. A further experience teaches that in cases where the narrator is doubtful in expressing an opinion, one should entirely overlook this uncertainty and consider the opinion in the affirmative sense. Between the two forms of a wavering presentation one should consider the first given as the correct one, the second as a product of the repression. Based on this experi- ence is the device of the interpreter of dreams of having a dream related a second time and beginning the work of interpretation at the places which have been changed as the least assured. From this highly incomplete and unsystematized information concerning the technique of the psycho-analytic method, one might conclude that the originator of the system had caused him- self an excessive amount of trouble and done wrong in giving up the less complicated hypnotic methods. But on the one hand, the technique of psycho-analysis is much easier to practice, once it has been learned, than a description of it would indicate; on the other hand, no other way leads to the goal, hence the round- about way is the shortest. Hypnosis is to be rejected because it covers the resistance and thereby obstructs the physician's view of the play of mental forces. It does not remove the resistance, but only evades it, gives incomplete information and only tem- porary results. The task which the psycho-analytic method is called upon to solve may be expressed in different formulae which are, however, essentially equivalent. It may be said, the object of the treat- ment is to abolish the amnesias. If all the gaps in the memory are filled out, all enigmatical effects of the mental life explained, a continuance, indeed a recurrence of the suffering is rendered impossible. The condition may be put differently : to trace back METHOD OF INVESTIGATION AND TREATMENT 123 all repressions; the mental condition is then the same as that in which all amnesias are filled. Far more important is another con- ception: to make the unconscious attainable to consciousness, which comes about through the overcoming of the resistances. Thereby a piece of educational work is accomplished and for such a reeducation for the overcoming of the deviations of child- hood, one can conceive a very general application for the psycho- analytic treatment. One must not forget, however, that such an ideal condition does not exist among normal people and that only seldom does one have the opportunity to conduct the treatment so far. Just as health and sickness are not separate entities but are only divided by practical definite boundaries, so one will never set up as a goal for the treatment anything but the practical heal- ing of the sick, the restoration of their power to work and love. In an incomplete treatment or incomplete results of the same, one gains especially an important improvement of the general mental condition while one or another symptom, but with diminished sig- nificance for the patient, can continue without branding him as an invalid. Aside from certain modifications which the representation of a special therapy demands, the therapeutic method remains the same for all the clinical pictures of the many varieties of hysteria as well as for all manifestations of the obsessional neurosis. Of the unlimited applicability of the same, there is no question. The nature of the psycho-analytic method imposes indications and contraindications both in regard to the persons to be treated and also to the clinical picture. Most favorable for psycho-analysis are the chronic cases of psychoneuroses with few violent or dan- gerous symptoms; thus, all kinds of obsessional neurosis, obses- sional thinking or obsessional acts and cases of hysteria in which phobias and abulias play the chief roles ; further also all somatic expressions of hysteria except those, such as anorexia, where a rapid amelioration of the symptoms is the chief task of the physi- cian. In acute cases of hysteria, one must await the appearance of a quiet state; in all cases in which nervous exhaustion is the prominent symptom, one should avoid a method which itself demands an effort, makes only slow progress and for a long time can pay no regard to a continuation of the symptoms. Concerning the persons on whom psycho-analysis can be 124 FREUD'S THEORY OF THE NEUROSES undertaken with profit, there are several conditions to be observed. First of all, they must possess a normal mental condition from which the pathological material can be gained ; in times of mental confusion or melancholic depression, though of hysterical type, nothing can be accomplished. Further, a certain degree of natural intelligence and ethical development is necessary; with worthless persons, the interest of the physician which strengthens him for delving into the mental life of the patient soon wanes. Outspoken defects of character, traits of actual constitutional degeneration exhibit themselves in the treatment as sources of resistances which can scarcely be overcome. In general, the constitution sets a limit for the effectiveness of psychotherapy. A too mature age, in the neighborhood of the fifth decade, imposes unfavorable condi- tions for psycho-analysis. The mass of psychic material is then no longer amenable to change, the time required for a cure becomes too long and the possibility of making psychic processes attain- able begins to diminish. In spite of all these limitations, the number of persons suited to psycho-analysis is extraordinarily large and the increase of our therapeutic power by this method is very considerable. Freud demands a long period of time, from a half to three years, for an effective treatment ; he says, however, that so far he has applied his treatment, because of circumstances easily guessed, to very severe cases, persons with maladies of many years duration and complete incapacity for work, who having tried all treatments came to his new and much disputed treatment as a last resort. In cases of less severity, the duration of the treatment might be correspondingly shortened and an extraordinary gain be made for prevention in the future. This applies especially to the neuroses of children, the frequency and importance of which is not yet sufficiently appreciated; according to the results obtained so far, they are very favorable cases for psycho-analysis. For the treat- ment of these, it is recommended that besides the personal obser- vation of the child, his involuntary expressions be observed by a trustworthy and suitable person (preferably when possible, the parents) who can keep him under observation the whole time. As a means of combating the insanities, the method is not yet correspondingly elaborated and modified; still, isolated cases of investigation undertaken by the Zurich school seem to justify the METHOD OF INVESTIGATION AND TREATMENT 125 expectation that the psycho-analytic method may prove thera- peutically effective up to a certain point in some forms of insanity, such as dementia praecox and paranoia. The art of psycho-analytic treatment as described, which places the greater share of work on the patient, might awaken the idea that we are dealing with a technique easily learned and applied. If it be granted that its practice by a skilled physician suited to it, with sufficient time to give to it, offers no difficulties, still, the acquirement of the technique demands great perseverance and patience especially from beginners. First of all, the patient's associations, which are the foundation of the treatment, do not always flow as freely, fully and in the desired clearness as is nec- essary for a perceptible progress of the treatment. The very nature of the neurotic malady and the processes of repression at work causing it makes certain that the different psychic inhibi- tions can be removed only under a resistance, the size of which corresponds to the forces which had shared in the repression. The patient, because of the malady, applies all the means of the censor, concealment, disguise, symbolism, to render inaccessible the object of the search, the repressed unconscious sexual root. Thus, the treatment progresses under a constant struggle against the ever-appearing resistance. The disclosure of the uncon- scious mental life is of necessity accompanied by discomfort and hence always retarded by the patient. One can estimate the difficulties of the process by considering that the treatment only approaches its end when all the strata of the mental life have been penetrated and all gaps in memory (amnesias) of the patient, even to the earliest childhood, have been filled out. The great abundance of experiences which after decades of sickness finally become inexhaustible as well as the necessary resistances under which the actual rendering conscious of the unconscious proceeds are the circumstances which sorely try the patience of patient and physician and can protract the treatment many months and even years. This demand on the patience of the patient diminishes in contrast to the patience which the continuance of the pathological phenomena requires of him. In the end, it is the content of infantile repression which con- tains the pathogenic material which cannot be at all clearly 126 FREUD'S THEORY OF THE NEUROSES obtained from the patient but must be in part guessed by the physician on the ground of his previous experience and arranged so that the patient's consciousness will perceive his unconscious wish-impulses. We attain this by bringing before his conscious- ness in our own language the unconscious complexes which he has given hints of possessing and which the art of interpretation has assisted in revealing. The similarity between what he has heard and what he seeks will penetrate consciousness in spite of all resist- ance and put him in a position to find the unconscious. The physician is a little ahead in comprehension, the patient follows in his own way until both reach the goal aimed at. Beginners in psycho-analysis seek to change these two points and to consider the time, at which they recognized an unconscious complex of the patient, the same as that at which the patient perceived it. They expect too much if they would heal the patient by communicating this knowledge, for he can only use the communication as an aid in finding the unconscious complex in his unconscious where it is fixed. With this part of the analysis, that purely expectant atti- tude of the physician which was formerly laid down as a condition of the treatment finds a limitation. It is important here that the skillful physician should not leave his patient unprepared and as a rule he has to ask from him not enlightenment but merely con- firmation of his suspicions. The psycho-analysis of a patient is no aimless scientific investigation but a therapeutic procedure ; it wishes to prove nothing, merely to change something. Every time in the analysis, the physician gives the patient the conscious ideas expected, by the help of which he will be in position to recognize and comprehend the unconscious. What the physician communi- cates to the patient comes from other analytic experiences and it is really proof enough if by the aid of this medical intervention the connection and solution of the pathogenic material is attained. The best way to introduce these expected ideas is by giving the patient on suitable occasion a view of the meaning and procedure of psycho-analytic therapy as well as its psychological presupposi- tions, for example, by explaining to him the importance of the psychological distinction between conscious and unconscious, con- cerning infantilism, etc., and wherever possible allowing him to find and comprehend it from his own material. 151 Nevertheless, 151 The reading of published articles by the patient is not advantageous to the treatment. METHOD OF INVESTIGATION AND TREATMENT 127 it should never be the aim of such discussions to convince. They should introduce the repressed complexes to consciousness, insti- gate the strife with them on the floor of conscious mental activity and render easier the appearance of new material from the uncon- scious. Conviction comes only after the material won from the unconscious has been elaborated by the patient, and so long as he is wavering one must consider the material as not exhausted. Without having won an intellectual conviction, however, the patients indulge in that peculiar cessation of authoritative belief and of the need of instruction from the physician and on the con- trary show an emotional interest in these things and through this to gradually participate intellectually in the theory. We come here upon a highly important agency of the psycho-analytic treat- ment, namely, the condition of "transference" ("t)bertra- gung") 152 as Freud has called that peculiar psychic dependence and respectful sympathy which the neurotic brings to the physician whom he trusts, and without the appearance of which, as occa- sionally happens because of uncongenial personalities, the treat- ment terminates spontaneously soon after its beginning. 153 This so-called transference is at bottom nothing else than what occurs in every psychic influencing, indeed one can say that in general no medical treatment is possible without a certain degree of confiding sympathy from the sufferer. According to Freud's experience, it is especially certain that, for example, the sanitarium treatment also depends only on such a subordination of sympathetic emo- tions to the authority of the esteemed physician. Now, neurotics are really much richer in free movable craving for love (libido), the quantity of which is constantly increased by the analytic breaking down .of inhibitions, so that it is no wonder that this sympathetic relation to the physician becomes more intense and emotionally toned than in patients with organic disease. What is more obvious than that this free floating libido (in widest extent of eroticism) freed from the repression in the way of sublimated 1S2 A comprehensive presentation of the "transference" is deferred until the title " general therapy " is reached. As preliminary, compare Freud (Lit. No. 21) as well as Ferenczi, " Intro jektion und t)bertragung " (Jahrb., I, page 422). 353 Striking results right at the beginning of the psycho-analytic treat- ment rest merely on transference and are mostly only temporary apparent results. 128 FREUD'S THEORY OF THE NEUROSES homo- or heterosexuality should be transferred to the attending physician whose intimate and prolonged dealing with the mental life of patients is the most favorable soil for such seeds. Thus, transference is not a specific result of psycho-analytic therapy but it appears here most clearly because of the conditions under which the treatment is carried out. Sentimental critics need not, how- ever, get angry at the thought that the physician could use or abuse this relation in any way. On the contrary, the real effect- iveness of this most important aid in the psycho-analytic treat- ment consists just in the fact that one has to continually release the patient from his transference by explaining to him that his whole intense interest in the person of the physician is only a transference of previous emotional impulses originally directed toward other persons. The productivity of the neurosis is really not interrupted during the psycho-analytic treatment, although the new formation of symptoms ceases, but busies itself in the creation of a special kind of thought formations, mostly uncon- scious, to which the name transference is given for the reason that they are new editions, later expressions of impulses or phan- tasies which have been awakened during the progress of the anal- ysis and should be made conscious. These transference-phantasies show themselves by a characteristic replacement of an earlier person by the person of the physician. To put it differently: A whole series of earlier psychic events becomes active again, not as something which has happened, but as an actual relation to the physician. To use Ferenczi's apt comparison from chemistry, the physician plays the role of a catalytic ferment, which in the process of setting free affects, draws them to itself. There are transferences which in their contents are to be distinguished from their prototype in absolutely nothing. Thus, they are special reprints, unchanged new editions. Others are artfully created and have undergone a toning down of their content, a sublima- tion, and thus resemble new works. The transference is a neces- sary part of every psycho-analytic treatment and one can easily convince himself in practice that it is in no way to be avoided and that this last phenomenon of the malady has to be combated like all the earlier ones. This part of the work is by far the hardest because one must guess the transference, independently, without any help from the patient, in insignificant stopping points and METHOD OF INVESTIGATION AND TREATMENT without making himself guilty of arbitrariness. To avoid it, how- ever, is impossible, since it is applied for the origination of all the obstructions which render the material inaccessible. One will be inclined to consider it a great disadvantage of a method otherwise inconvenient that it still increases the work of the physician through the creation of a new kind of pathological psychic product, indeed perhaps may work injury to the patient by the analytic treatment through the existence of the transfer- ence. Both would be erroneous. The work of the physician is not increased by the transference; it may be indifferent to him whether the resurrected impulse of the patient has to be overcome while it is attached to himself or to another person. Further, the transference in the treatment imposes no new task upon the patient which he would not otherwise have performed. If recov- eries from the neuroses also come about through other influences, still, it is possible only because of such a latent working transfer- ence. The difference is on?.y that the patient ordinarily merely produces affectionate and friendly transference in his recovery. In the psycho-analysis, on the contrary, all impulses corresponding to a change in motivation, even hostile ones (negative transfer- ence), are awakened, transferred to the physician and by being made conscious aid the treatment ; thus the transference is always destroyed for good. The transference which is destined to become the greatest hindrance to psycho-analysis is the mightiest means of help when one succeeds in detecting it immediately and translating it to the patient. One should not conclude that the transference is a sort of lasting attachment of the patient to the physician, as, for example, has been the reproach of hypnotic therapy. On the contrary, it has already been asserted that the patient must be constantly informed of it and that the physician should meet the patient with a certain cool aloofness and must really endeavor 154 at the close of the analysis to leave him as much a stranger to the patient as he was before the treatment began; in this way, not only the genuine cure of the patient but also his own independence is attained The one or another symptom which still persists often disappears entirely and for good only after the complete dissolution of the transference-relation. a " A similar transference on the part of the physician (reversed trans- ference) is to be avoided by self-analysis. 10 I3O FREUD S THEORY OF THE NEUROSES Against this method of Freud's loud dissenting voices have repeatedly been raised, characteristically though only by those who have never used the method at all or only with unsatisfactory results. For everyone who has gained by continued contact with neurotics an intimate insight into the hysterical mind must have been thereby convinced of the effectiveness of the Freudian therapy. No one can escape the convincing evidence of the erotic complexes always active in the foreground nor the accompanying powerful resistances against these becoming conscious. The justice of these empiric impressions is suited to banish the last doubt of the existence of the unconscious and its specific content. The objections of the critics arise not so much from intimate knowledge as from a priori dislike of the subject of sexuality which must inevitably be dealt with in the etiology of these patho- logical conditions. These same opponents are also quite unjustly indignant over the therapy in respect to the fear that it may accom- plish the seduction of the patient and by dealing with sexual themes and a subjectivmus which can only injure them. This kind of pretended suggestion is, however, nowhere so impossible as in psycho-analysis itself, where the free-flowing associations of the patient show the way for the progress of the treatment. On the contrary, the psycho-analyst knows that the analytic work stops immediately the moment the physician seeks to suggest a wrong or forced solution. The skillful psycho-analyst will in general limit himself as far as possible to the passive role of listener. Then the neurotic patient himself often brings forward his sexual and erotic phantasies and one needs only once to see the feeling of relief on the patient's part who has for the first time accused himself before a judge who understands, in order to be certain that there can be no question of suggestion. Freud has never insisted, as some superficial reviewers believe, upon forcing a free indulgence of the sexual appetite. He asserts, rather, that the recommendation of sexual activity to psychoneurotics is mostly to be considered bad counsel, because in the mechanism of the neurosis not merely the sexual need and deprivation come into play. The other just as important and indispensable factor which is all too readily forgotten is the sexual disinclination of neurotics, their incapacity for love, that psychic trait on which the repres- sion rests; it is from the conflict between these two tendencies that METHOD OF INVESTIGATION AND TREATMENT I$I the neurotic malady develops. The psycho-analytic treatment aims not at all at freeing the instincts from the repression, so that they may be indulged unhampered, but has in view the bring- ing of the patients to the point where they can control the same, partly by conscious mental forces, partly by conducting it to a higher and therefore unobjectionable goal (sublimation). The fear occasionally expressed that the unchaining of the suppressed evil instincts may bring injury becomes groundless through the experience that the psychic and somatic power of such instinctive impulses is only weakened by bringing them into consciousness. If it is further objected that there is a danger to the indi- vidual as well as to society in discussing the sexual theme in its widest extent and in all detail during the psycho-analytic treat- ment, that the physician has no right to penetrate into the sexual secrets of his patients, that he may wound their modesty espe- cially of the women through such gross examination, that his awkward hand may disturb family peace, that he may destroy the innocence of young persons and encroach upon parental authority, acquire disturbing knowledge of private affairs of adults and dis- turb his own relation to the patients, it may be answered : This is the language of an unworthy prudery of the physician which imperfectly covers his incompetency with bad arguments. If agencies from the sexual life are recognized as really causing disease, then the development and discussion of these agencies hereby falls without further thought into the duty of the physi- cian. The wounding of modesty of which he may be guilty is no different and no worse than he would inflict if in order to heal a local affection of the female genitals he made a digital or visual examination which the school imposes upon him as a duty. Occasionally one also hears the objection to the psycho- analytic treatment, which must be classed as almost malevolent, that the psycho-analytic treatment oftener than any other injures the patient, indeed may occasion suicide. So far as it is not direct personal hostility which dictates this reproach, it is the resistance against something new which forgets that hydrotherapy and other therapeutic methods sometimes treat as a neurosis, conditions which are really beginning psychoses. Also, one will judge other- wise if one has got in the habit of charging to the treatment everything which happens during the treatment of a case of dis- 132 FREUD'S THEORY OF THE NEUROSES ease. Occasionally, apparent retrogressions in the neurotic patho- logical condition will appear through acute conditions in no way chargeable to the treatment but which are in most cases necessary and healthful eruptions of the unconscious, strong reaction phenomena, under which the deviation from the normal is cor- rected, the mental obsession is broken. In general, the state of health during the treatment is no standard of measure for the final results. The resistance against this novel and not easily acquired method of treatment manifests itself also in a certain mischievous joy which is shown when occasionally results are not immediately forthcoming or are absent altogether. Now it happens often as related that the result does not follow immediately on the termina- tion of the treatment but that the condition of the patient only first approaches health some time after the end of the analysis and indeed from the time at which the relations to the physician are completely and smoothly dissolved. The delay in the cure or improvement seems in general to be essentially conditioned on the earlier described transference-relation. Moreover, the results in the treatment of the neuroses are often shattered by affairs in the external life of the patients, the healthful changing of which lies beyond the power of the physician. Against the recovery, stand many kinds of unconscious motives, since the patients fled to the neurosis and thus many a symptom, in spite of an analysis which has progressed far, is not to be got rid of because of this obstinacy of such a "secondary function" in mental life which nourishes such a mental disturbance. He who wishes to make the patient well stumbles to his astonishment upon a great resistance which teaches him that the patient is not sincere in wanting to get rid of his suffering. In the battle of these disease motives, as Freud calls them, lies quite generally the weakness of any therapy and also of the psycho-analytic. Thus, for example, when a neglected wife, or one who feels herself neglected, knows how to gain through sickness sympathy, attention and love from her husband which she lacked, by the relinquishment of which, the previous dull married life would begin again. In general, it is a pre- requisite of every possibility of cure that the patient suffers from his symptoms or better said suffers more than what he gains from his sickness. An homosexualist, a fetichist, a pervert will as a METHOD OF INVESTIGATION AND TREATMENT 133 rule absolutely refuse to give up his pathological tendencies. Whether this case occurs from external or internal causes, how- ever, taking into consideration the least influenced cases as well as the most favorably influenced, one must still consider the psycho-analytic therapy the method of choice in such abnormal conditions. It should be expressly mentioned that a psycho- analytic treatment, though incomplete, may show relatively good results by making the patient cheerful and capable of work and play. And even if the patient is not completely restored to health, still he has usually learned to partially diminish his symptoms by self-interpretation and to control his unconscious. From all this, one sees that the method of psycho-analysis makes high demands both on the patient and the physician ; from the former, it demands the offering of complete sincerity, a con- siderable amount of time and hence a good deal of expense; from the physician, it also demands much time and therefore makes desirable, as well as because of the tediously learned and difficult technique, a specialization in this field. It is therefore intelligible that one might prefer methods which promised cure more con- veniently and in shorter time. At first there came into the hands of the psycho-analyst mostly patients who had already sought all other methods in vain and had spent years in sanitaria. These patients, however, are in about the condition of sufferers from tuberculosis who have cavities in their lungs; treated as light catarrh of the apices, they would have yielded dazzling results. It should not be said that psycho-analysis cannot heal severe cases of neurosis the technique has been founded and proven on just such cases nevertheless, these cases must come at the right time into the hands of suitable psycho-analysts. There is still lacking and will be for a long time a sufficiently widespread recognition of the nature and significance of psychoneurotic maladies, both among medical circles and the laity, and herein lie the essential difficulties which now oppose the psycho-analytic method and not, as is still always supposed, in the thing itself. The psychoneuroses as a class are not at all mild diseases, as in greatest part the physi- cians and more yet the laity suppose ; the latter is firmly convinced of the superfluousness of all these disease phenomena and there- fore neither brings a patience for the course of the disease nor a special readiness to sacrifice to the therapy. The sincerity of the 134 FREUD'S THEORY OF THE NEUROSES physicians and the accommodation of the laity will be established for the psychoneuroses when it shall be known that a severe neurosis, in its importance for the afflicted individual, is not one whit behind any of the feared general diseases and that the resto- ration from years of incapacitating sufferings, corresponding in degree to their energies, is not to be expected in a few weeks nor from a treatment which causes no inconvenience. The psycho- analytic therapy has the triumph of having made permanently capable of existence a gratifying number of all the severest cases, and against these results all objection is insignificant. Hence it is obvious that the analytic treatment in the mild periodically appear- ing maladies or in the initial stages of severer cases can obtain brilliant and often surprisingly rapid and lasting results; it is only a question of time and of the increasing knowledge of these maladies when psycho-analysis will be able to prove its great cultural and social importance as a real prophylactic method (education, enlightenment). CHAPTER IX GENERAL PROPHYLAXIS OF THE NEUROSES Cultural Sexual-Morality. Sexual Education. Sexual Enlightenment. Physicians are accustomed to being unsatisfied with the mere curing of a disease and to seek the ideal condition in its preven- tion. This important point must be discussed : How do the new facts concerning the etiology of the neuroses affect their prophy- laxis? Freud has expressed himself in detail on some of these points in his article " Die kulturelle Sexualmoral und die moderne Nervositat " 155 (Cultural Sexual-morality and Modern Nervous- ness) and come there to the consoling opinion that the frequency of nervous maladies in our time is not due to the progress of civilization and the acquisitions of technical science nor to the complex and rushing manner of life of civilized men, as has been generally held. It is not so much that this widespread view is erroneous as that it is inadequate to explain the peculiarities of the phenomena of the nervous disturbances and leaves out of account the most important of etiological factors. If one looks away from the more indefinite kinds of "being nervous" and limits his attention to the genuine forms of nervous maladies, he finds the injurious influence of civilization really narrowed down to the injurious suppression of the sexual life of civilized people (or classes) through the prevailing cultural sexual morality. The Freudian investigations have shown that culture has been quite generally built upon the suppression of the instincts. Experience teaches, however, that for most people there is a limit beyond which their constitution cannot follow cultural demands. It is one of the most manifest social injustices that the cultural standard should demand of all persons the same conduct of the sexual life which is possible for some on account of their organization with- out trouble, while on others it imposes the greatest mental hard- ship. Really, in this way, the relatively large number of perverts is occasioned. Many idealistic reformers would even sharpen still 158 Lit. No. 30. 135 136 FREUD'S THEORY OF THE NEUROSES more the sexual morality by demanding from individuals of both sexes abstinence before marriage and lifelong abstinence for all who cannot enter into a legitimate marriage. To such an one, we may answer in opposition that the task of conquering such a mighty impulse as the normal sexual instinct can take all the strength of a man. The conquering through sublimation, the transference of the forces of the sexual instinct from sexual ends to higher cultural aims, succeeds in only a minority ; most of the others either become neurotic or come to other injury. Experi- ence shows that the majority of persons composing our society are not constitutionally adapted to endure abstinence. Those who would become ill under a more liberal sexual limitation become sick just so much earlier and so much more intensely because of the demands of our present-day cultural sexual moral- ity, for against the menace of a normal sexual impulse through bad heredity and disorders of development, we know no better secur- ity than sexual gratification itself. The more anyone is predis- posed to a neurosis, the worse he bears abstinence. The dammed-up libido is really placed in a condition to hunt out any weak place which is seldom lacking in the sexual life, there to break through into neurotic substitute gratification in the form of symptoms. He who knows how to penetrate into the conditions of nervous maladies soon becomes convinced that the increase of nervous diseases in our society arises from the increase of sexual limita- tions. In the vast majority of cases, the struggle against sen- suality saps the available energy of character, and this just at a time when the young man needs all of his powers to win his lot and place in society. On the other hand there is the onanism, often continued into the adult years, and when treating the question of abstinence, one distinguishes much too little two forms of the latter: the refraining from all sexual activity and the refraining from sexual intercourse with the opposite sex. Many persons who boast of abstinence from the other sex have accomplished this only by the aid of masturbation. Further, this corresponds in no way to the ideal demands of cultural sexual morality and therefore drives the young man into the same con- flict with the educational ideal which he would escape through abstinence. It further ruins the character in more ways than one, chiefly however, because the sexual activity of a man is a GENERAL PROPHYLAXIS OF THE NEUROSES model for his whole way of reacting in the world (psycho-sexual parallelism). To one who has energetically won his sexual object, we give credit for similar reckless energy in the pursuit of other goals. On the other hand, he who for various reasons renounces the gratification of his strong sexual instinct will also be rather conciliatory and resigned than energetic in other affairs of life. Even as complete an abstinence as possible during adolescence is not a young man's best preparation for marriage. The suppres- sion of everything sexual, this applies especially to the strict edu- cational rules for girls, as Freud has expressed it, is frequently so well accomplished and carried so far that the sexual instinct, after being released, seems to have suffered lasting injury. Further, the sexual intercourse in legitimate wedlock offers no full indemnity for the limitations before marriage, chiefly because that very frequently from cultural and material reasons, the marriage must be satisfied with a limited number of concep- tions, hence after a few years, the marital intercourse is limited by all those measures directed at the prevention of pregnancy, the sexual satisfaction is spoiled, the finer sensibilities of both parties disturbed or where an intolerance against these measures exists, the health suffers. It is especially the woman who, under such marriage conditions, may become most severely ill and endure for life the saddening neurosis. Marriage has thus, under present cultural conditions, long ceased to be a panacea for the nervous diseases of women; and if we physicians still always recommend it in such cases, we know that on the contrary, a girl must be really healthy to stand marriage and strongly advise our men patients against marrying a girl who has been " nervous " before marriage. For it is also a grievous discovery for the man to get a constantly anesthetic woman in marriage, a very frequent result of the present generally approved strict and over-moral education of girls. The undersensitive wife and the husband, because of chastity and masturbation of little potency and especially fre- quently suffering from ejaculatio praecox, make a picture of a modern " nervous " marriage where the incomplete sexual gratifi- cation brings on that nervousness and irritability which destroys the family life. The neurotic wife, ungratified by her husband, is as a mother overaffectionate and overanxious toward the child to whom she transfers her craving for love, thereby awakening 138 FREUD'S THEORY OF THE NEUROSES in him sexual precocity. The bad agreement between the parents excites the emotional life of the child and causes it in its tenderest years to feel intensely love, hate and jealousy. The strict edu- cation which tolerates no kind of expression of the early awakened sexual life assists the suppressing power and the conflict at this age contains everything necessary for the causation of a lifelong nervous invalidism. Individual prophylaxis must be instituted in earliest childhood as the whole etiology of the neuroses teaches ; according to Freud, this is a self-evident fact. The child cannot be too carefully guarded from every evil influence from other children as well as from adults, especially nurses, who are often guilty of abuse and seduction of little children. A constant oversight of the child and an environment in no way precarious must be most emphat- ically recommended. That the parents themselves in their igno- rance, by excessive affection, 156 boisterous caresses, all too fre- quent taking the child into bed with themselves, prematurely awaken his instincts and thereby bring injury upon him may be again asserted. That excessive masturbation must be combated at the right time has already been emphasized. 167 This should, however, not convey the impression that the avoidance of sexual experiences which finally bring enlightenment can by itself pre- vent the formation of neuroses. It must much rather be expressly emphasized that it is of decisive importance for the prophylaxis that no too rigorous demands for repression be imposed on the children, especially on those with bad heredity. For the relaxa- tion of the repression at the right time corresponding to the demands of life renders continuance in health possible. In this sense, Freud is a supporter of a systematic enlightenment of children. 168 The necessity for this lies in the fact that children often show great interest and understanding in the affairs and problems of the sexual life. This finds expression not only in the instinct for sexual investigation of children which leads to the already mentioned, sometimes very disastrous birth and creation phantasies but also in masked form in their untiring questioning, ""Compare A. Adler, "Das Zartlichkeitsbediirfnis des Kindes," Mo- natshefte f. Padagogik u. Schulpolitik, 1908. 1ST Compare the detailed discussion of the problem of onanism under neurasthenia (Chapter II). "Lit. No. 26. GENERAL PROPHYLAXIS OF THE NEUROSES 139 which education has to satisfy intelligently. The fear that the child may be enlightened prematurely is entirely ungrounded; for when the child once begins to inquire, it has already busied itself a long time most intimately with the sexual problem ; experi- ence teaches that it is injudicious either to wish to silence or lead into false channels this interest of the child once it is awakened. To wish to hold back the sexual instinct of the child through such concealment could only lead to his later learning to condemn everything sexual as something vulgar and abhorrent. If one seeks to deceive them through false information as the stork legend, etc., then when they penetrate behind this untruth fulness of the parents or teacher, they lose trust and respect for them and can often receive mistrust as a character trait for their whole lives. The manner of sexual enlightenment Freud has repre- sented as a gradually progressive and really uninterrupted instruc- tion for which, in place of the parents who are as yet unqualified for such a task, the school must take the initiative. The most important point in this is that the children should never get the idea that one wishes to make the affairs of the sexual life any more of a secret for them than anything else which is not yet comprehensible to their understanding. That there is opportunity for the public teacher and indeed for the clergy to make use of the Freudian knowledge for the good of their adherents is shown by the publications of the Zurich pastor Pfister. 159 Unfortunately, the parents as well as the teachers of to-day still lack the neces- sary knowledge of sexual matters, especially in relation to neurotic disturbances. Especially do our parents and educators lack the candor to discuss the sexual problem from which they in great part openly suffer with the children; consequently they lack the possibility of guarding the latter against sexual injuries and of explaining to them in sufficient manner all allied themes. A child ""Oskar Pfister, " Psychoanalytische Seelsorge und experimentellc Moralpadagogik," Protestantische Monatshefte, I3th year, part I, M. Heeksius, Leipzic, 1909. Same, "Ein Fall von psychoanalytischer Seel- sorge und Seelenheilung," Monatschrift " Evangelische Freiheit," pth year, Tubingen, J. C. B. Mohr, 1909. Same, "Die Psychoanalyse als wissen- schaftliches Prinzip und seelsorgerliche Methode," Ebenda, loth year, 1910. Dr. A. Muthmann also sought to interest the clergy in an article " Psychiatr.-theolog. Grenzfragen," Halle a. d. Saale, Karl Marhold, 1907. 140 FREUD'S THEORY OF THE NEUROSES who is ignorant of sexual matters will have quite a different fate from one who has been instructed in these things. We perceive therefore, that the education in the affairs of sex is of great importance not only in the prevention of the neuroses but also for the whole character development of the child. Therefore, sexual education 180 is essentially the fundamental problem of education and cannot be separated from the question of sexual enlightenment. How the education should begin or how to avoid injurious results which have already occurred is a subject on which Freud has not expressed himself in detail, since he con- sidered his field to be rather investigation and therapeutics than pedagogy and reformation. The three following chief view points for sexual education in general may be deduced from Freud's works : In a first period, the education should vigorously aid the suppression of the normally occurring instinctive impulses and the repression of wrong (perverse) impulses of the growing child, thus preventing wrong tendencies and disturbances of de- velopment ; in a later period, it would have to interfere positively and educate the child chiefly through love ; in a third period, the grown up child would with the aid of his own parents free him- self from their authority and establish his psychic and social individuality. If the prophylaxis, however, is to become effective and far- reaching, wider circles must be interested in the problem. For in affairs of prophylaxis, the individual is almost powerless. The whole body of citizens must acquire an interest in the subject and give their consent to the creation of generally observed regula- tions. At present, we are far removed, however, from a condition which would promise a remedy and can therefore justly make our civilization and cultural morality answerable for the spread of the neuroses. There must be a great change of mind. The opposition of a generation of physicians who no longer recall their youth must be broken. The haughtiness of the fathers who do not gladly descend to the level of ordinary mortals in the eyes of their children must be overcome, the foolish bash fulness of the mothers must be combated, for whom it now seems like an inscrutable and undeserved decree of fate that their children have become nerv- 160 Compare A. Adler, " Das sexuelle Problem in der Erziehung," Die neue Gesellschaft, 1905. GENERAL PROPHYLAXIS OF THE NEUROSES cms. " Before everything else, however, there must be opened in the general thought a chance for the discussion of the sexual problem ; one must be able to speak of these things without being pronounced a disturber of the peace or a delver in the vulgar instinct. And there remains enough work here for a century in which our civilization must learn to live according to the demands of our sexuality." 161 10 Lit. No. ii. CHAPTER X APPLICATION OF PSYCHO-ANALYSIS Importance of Psycho-Analysis for Medicine. Importance for the Psychology of Normal Individuals and for Normal Psychology (Uncon- scious, Dream, Wit). Psychopathology of Everyday Life. Elucidation of the Psychology of Psychopaths, Criminals, Artists, Poets and Geniuses (Characterology). Importance for the History of Culture and Folk- Psychology. It is an indisputable service of Freud's to have elaborated psycho-analysis to a method which is not only able to disclose the pathogenesis and content of mental disorders but is also valuable for their treatment. It cannot be rejected as Utopian to believe that when the fundamental principles of the neuroses as revealed by Freud shall have become for the general good a part of medical knowledge and thereby indirectly a part of universal knowledge, the frequency of the neuroses may be lessened. 162 The psycho- analytic recognition of the nature of these maladies, of their psycho-sexual root as well as the means of prophylaxis to which they point, will likewise work together to allow the neuroses to appear only in plain form. Individuals of neurotic disposition will have to renounce the representation of their symptoms after the origin and symbolism of these shall have become trans- parent. 183 Perhaps indeed, psycho-analysis may succeed in destroying the germ of the neurosis in childhood when the teacher, entrusted with the chief points of the theory, aids in the prevention. Psycho-analysis is not, however, merely a method for investigating disordered minds but seems to be destined to become perhaps the most influential method of mental investiga- tion in general. Psycho-analysis yields such far-reaching expla- nations of the mechanism of mental functioning that in contrast to a certain stagnation in the official psychology of the universities, 1. Mental Mechanisms. $2.00. By Dr. Wm. A. White. 9. Studies in Psychiatrv. $2.00. New York Psychiatrical Society, xo. Handbook of Mental Examination Methods. $2.00. By Shepherd Ivory Fra cz rx. The Theory of Schizophrenic Negativism. $0.60. By Professor E. Bleuler. IT.. Ceubellar Functions. $3.00. By Pr. Andre-Thomas. 13. History of Prison Psychoses. $1.25. By Drs. P. Nitsche and K. Wilmanns. 14. General Paresis. $3.00. By Prof. E. Kraepelin. 15. Dreams and Myths. 41.00. By Dr. Karl Abraham. 16. Poliomyelitis. $3.00. Dr. I. Wickmann 17. Prued's Theories of the Neuroses. $2.00. Dr. E. Hitschrnasn. UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles on toe la * date stamped below. OCT23J985 RECTO 3 1158 00347 0852