Further remarks on the neuro-psychoses of defence 3 страница

Let us now consider how far the traumatic scenes of hysteria which are uncovered by analysis fulfil, in a fairly large number of symptoms and cases, the two requirements which I have named. Here we meet with our first great disappointment. It is true, indeed, that the traumatic scene in which the symptom originated does in fact occasionally possess both the qualities - suitability as a determinant and traumatic force - which we require for an understanding of the symptom. But far more frequently, incomparably more frequently, we find one of the three other possibilities realized, which are so unfavourable to an understanding. Either the scene to which we are led by analysis and in which the symptom first appeared seems to us unsuited for determining the symptom, in that its content bears no relation to the nature of the symptom; or the allegedly traumatic experience, though it does have a relation to the symptom, proves to be an impression which is normally innocuous and incapable as a rule of producing any effect; or, lastly, the ‘traumatic scene’ leaves us in the lurch in both respects, appearing at once innocuous and unrelated to the character of the hysterical symptom.

(Here I may remark in passing that Breuer’s view of the origin of hysterical symptoms is not shaken by the discovery of traumatic scenes which correspond to experiences that are insignificant in themselves. For Breuer assumed - following Charcot - that even an innocuous experience can be heightened into a trauma and can develop determining force if it happens to the subject when he is in a special psychical condition - in what is described as a hypnoid state. I find, however, that there are often no grounds whatever for presupposing the presence of such hypnoid states. What remains decisive is that the theory of hypnoid states contributes nothing to the solution of the other difficulties, namely that the traumatic scenes so often lack suitability as determinants.)

Moreover, Gentlemen, this first disappointment we meet with in following Breuer’s method is immediately succeeded by another, and one that must be especially painful to us as physicians. When our procedure leads, as in the cases described above, to findings which are insufficient as an explanation both in respect to their suitability as determinants and to their traumatic effectiveness, we also fail to secure any therapeutic gain; the patient retains his symptoms unaltered, in spite of the initial result yielded by the analysis. You can understand how great the temptation is at this point to proceed no further with what is in any case a laborious piece of work.

But perhaps all we need is a new idea in order to help us out of our dilemma and lead to valuable results. The idea is this. As we know from Breuer, hysterical symptoms can be resolved if, starting from them, we are able to find the path back to the memory of a traumatic experience. If the memory which we have uncovered does not answer our expectations, it may be that we ought to pursue the same path a little further; perhaps behind the first traumatic scene there may be concealed the memory of a second, which satisfies our requirements better and whose reproduction has a greater therapeutic effect; so that the scene that was first discovered only has the significance of a connecting link in the chain of associations. And perhaps this situation may repeat itself; inoperative scenes may be interpolated more than once, as necessary transitions in the process of reproduction, until we finally make our way from the hysterical symptom to the scene which is really operative traumatically and which is satisfactory in every respect, both therapeutically and analytically. Well, Gentlemen, this supposition is correct. If the first-discovered scene is unsatisfactory, we tell our patient that this experience explains nothing, but that behind it there must be hidden a more significant, earlier, experience; and we direct his attention by the same technique to the associative thread which connects the two memories - the one that has been discovered and the one that has still to be discovered.¹ A continuation of the analysis then leads in every instance to the reproduction of new scenes of the character we expect. For example, let us take once again the case of hysterical vomiting which I selected before, and in which the analysis first led back to a fright from a railway accident - a scene which lacked suitability as a determinant. Further analysis showed that this accident had aroused in the patient the memory of another, earlier accident, which, it is true, he had not himself experienced but which had been the occasion of his having a ghastly and revolting sight of a dead body. It is as though the combined operation of the two scenes made the fulfilment of our postulates possible, the one experience supplying, through fright, the traumatic force and the other, from its content, the determining effect. The other case, in which the vomiting was traced back to eating an apple which had partly gone bad, was amplified by the analysis somewhat in the following way. The bad apple reminded the patient of an earlier experience: while he was picking up windfalls in an orchard he had accidentally come upon a dead animal in a revolting state.

I shall not return any further to these examples, for I have to confess that they are not derived from any case in my experience but are inventions of mine. Most probably, too, they are bad inventions. I even regard such solutions of hysterical symptoms as impossible. But I was obliged to make up fictitious examples for several reasons, one of which I can state at once. The real examples are all incomparably more complicated: to relate a single one of them in detail would occupy the whole period of this lecture. The chain of associations always has more than two links; and the traumatic scenes do not form a simple row, like a string of pearls, but ramify and are interconnected like genealogical trees, so that in any new experience two or more earlier ones come into operation as memories. In short, giving an account of the resolution of a single symptom would in fact amount to the task of relating an entire case history.

¹ I purposely leave out of this discussion the question of what the category is to which the association between the two memories belong, (whether it is an association by simultaneity, or by causal connections or by similarity of content), and of what psychological character is to be attributed to the various ‘memories’ (conscious or unconscious).

But we must not fail to lay special emphasis on one conclusion to which analytic work along these chains of memory has unexpectedly led. We have learned that no hysterical experience can arise from a real experience alone, but that in every case the memory of earlier experiences awakened in association to it plays a part in causing the symptom. If - as I believe - this proposition holds good without exception, it furthermore shows us the basis on which a psychological theory of hysteria must be built.

You might suppose that the rare instances in which analysis is able to trace the symptom back direct to a traumatic scene that is thoroughly suitable as a determinant and possesses traumatic force, and is able, by thus tracing it back, at the same time to remove it (in the way described in Breuer’s case history of Anna O.) - you might suppose that such instances must, after all, constitute powerful objections to the general validity of the proposition I have just put forward. It certainly looks so. But I must assure you that I have the best grounds for assuming that even in such instances there exists a chain of operative memories which stretches far back behind the first traumatic scene, even though the reproduction of the latter alone may have the result of removing the symptom.

It seems to me really astonishing that hysterical symptoms can only arise with the co-operation of memories, especially when we reflect that, according to the unanimous accounts of the patients themselves, these memories did not come into their consciousness at the moment when the symptom first made its appearance. Here is much food for thought; but these problems must not distract us at this point from our discussion of the aetiology of hysteria. We must rather ask ourselves: where shall we get to if we follow the chains of associated memories which the analysis has uncovered? How far do they extend! Do they come anywhere to a natural end? Do they perhaps lead to experiences which are in some way alike, either in their content or the time of life at which they occur, so that we may discern in these universally similar factors the aetiology of hysteria of which we are in search?

The knowledge I have so far gained already enables me to answer these questions. If we take a case which presents several symptoms, we arrive by means of the analysis, starting from each symptom, at a series of experiences the memories of which are linked together in association. To begin with, the chains of memories lead backwards separately from one another; but, as I have said, they ramify. From a single scene two or more memories are reached at the same time, and from these again side-chains proceed whose individual links may once more be associatively connected with links belonging to the main chain. Indeed, a comparison with the genealogical tree of a family whose members have also intermarried, is not at all a bad one. Other complications in the linkage of the chains arise from the circumstance that a single scene may be called up several times in the same chain, so that it has multiple relationships to a later scene, and exhibits both a direct connection with it and a connection established through intermediate links. In short, the concatenation is far from being a simple one; and the fact that the scenes are uncovered in a reversed chronological order (a fact which justifies our comparison of the work with the excavation of a stratified ruined site) certainly contributes nothing to a more rapid understanding of what has taken place.

If the analysis is carried further, new complications arise. The associative chains belonging to the different symptoms begin to enter into relation with one another; the genealogical trees become intertwined. Thus a particular symptom in, for instance, the chain of memories relating to the symptom of vomiting, calls up not only the earlier links in its own chain but also a memory from another chain, relating to another symptom, such as a headache. This experience accordingly belongs to both series, and in this way it constitutes a nodal point. Several such nodal points are to be found in every analysis. Their correlate in the clinical picture may perhaps be that from a certain time onwards both symptoms have appeared together, symbiotically, without in fact having any internal dependence on each other. Going still further back, we come upon nodal points of a different kind. Here the separate associative chains converge. We find experiences from which two or more symptoms have proceeded; one chain has attached itself to one detail of the scene, the second chain to another detail.

But the most important finding that is arrived at if an analysis is thus consistently pursued is this. Whatever case and whatever symptom we take as our point of departure, in the end we infallibly come to the field of sexual experience. So here for the first time we seem to have discovered an aetiological precondition.

From previous experience I can foresee that it is precisely against this assertion or against its universal validity that your contradiction, Gentlemen, will be directed. Perhaps it would be better to say, your inclination to contradict; for none of you, no doubt, have as yet any investigations at your disposal which, based upon the same procedure, might have yielded a different result. As regards the controversial matter itself, I will only remark that the singling out of the sexual factor in the aetiology of hysteria springs at least from no preconceived opinion of my part. The two investigators as whose pupil I began my studies of hysteria, Charcot and Breuer, were far from having any such presupposition; in fact they had a personal disinclination to it which I originally shared. Only the most laborious and detailed investigations have converted me, and that slowly enough, to the view I hold to-day. If you submit my assertion that the aetiology of hysteria lies in sexual life to the strictest examination, you will find that it is supported by the fact that in some eighteen cases of hysteria I have been able to discover this connection in every single symptom, and, where the circumstances allowed, to confirm it by therapeutic success. No doubt you may raise the objection that the nineteenth or the twentieth analysis will perhaps show that hysterical symptoms are derived from other sources as well, and thus reduce the universal validity of the sexual aetiology to one of eighty percent. By all means let us wait and see; but, since these eighteen cases are at the same time all the cases on which I have been able to carry out the work of analysis and since they were not picked out by anyone for my convenience, you will find it understandable that I do not share such an expectation but am prepared to let my belief run ahead of the evidential force of the observations I have so far made. Besides, I am influenced by another motive as well, which for the moment is of merely subjective value. In the sole attempt to explain the physiological and psychical mechanism of hysteria which I have been able to make in order to correlate my observations, I have come to regard the participation of sexual motive forces as an indispensable premiss.

Eventually, then, after the chains of memories have converged, we come to the field of sexuality and to a small number of experiences which occur for the most part at the same period of life - namely, at puberty. It is in these experiences, it seems, that we are to look for the aetiology of hysteria, and through them that we are to learn to understand the origin of hysterical symptoms. But here we meet with a fresh disappointment and a very serious one. It is true that these experiences, which have been discovered with so much trouble and extracted out of all the mnemic material, and which seemed to be the ultimate traumatic experiences, have in common the two characteristics of being sexual and of occurring at puberty; but in every other respect they are very different from each other both in kind and in importance. In some cases, no doubt, we are concerned with experiences which must be regarded as severe traumas - an attempted rape, perhaps, which reveals to the immature girl at a blow all the brutality of sexual desire, or the involuntary witnessing of sexual acts between parents, which at one and the same time uncovers unsuspected ugliness and wounds childish and moral sensibilities alike, and so on. But in other cases the experiences are astonishingly trivial. In one of my women patients it turned out that her neurosis was based on the experience of a boy of her acquaintance stroking her hand tenderly and, at another time, pressing his knee against her dress as they sat side by side at table, while his expression let her see that he was doing something forbidden. For another young lady, simply hearing a riddle which suggested an obscene answer had been enough to provoke the first anxiety attack and with it to start the illness. Such findings are clearly not favourable to an understanding of the causation of hysterical symptoms. If serious and trifling events alike, and if not only experiences affecting the subject’s own body but visual impressions too and information received through the ears are to be recognized as the ultimate traumas of hysteria, then we may be tempted to hazard the explanation that hysterics are peculiarly constituted creatures - probably on account of some hereditary disposition or degenerative atrophy - in whom a shrinking from sexuality, which normally plays some part at puberty, is raised to a pathological pitch and is permanently retained; that they are, as it were, people who are psychically inadequate to meeting the demands of sexuality. This view, of course, leaves hysteria in men out of account. But even without blatant objections such as that, we should scarcely be tempted to be satisfied with this solution. We are only too distinctly conscious of an intellectual sense of something half-understood, unclear and insufficient.

Luckily for our explanation, some of these sexual experiences at puberty exhibit a further inadequacy, which is calculated to stimulate us into continuing our analytic work. For it sometimes happens that they, too, lack suitability as determinants although this is much more rarely so than with the traumatic scenes belonging to later life. Thus, for instance, let us take the two women patients whom I have just spoken of as cases in which the experiences at puberty were actually innocent ones. As a result of those experiences the patients had become subject to peculiar painful sensations in the genitals which had established themselves as the main symptoms of the neurosis. I was unable to find indications that they had been determined either by the scenes at puberty or by later scenes; but they were certainly not normal organic sensations nor signs of sexual excitement. It seemed an obvious thing, then, to say to ourselves that we must look for the determinants of these symptoms in yet other experiences, in experiences which went still further back - and that we must, for the second time, follow the saving notion which had earlier led us from the first traumatic scenes to the chains of memories behind them. In doing so, to be sure, we arrive at the period of earliest childhood, a period before the development of sexual life; and this would seem to involve the abandonment of a sexual aetiology. But have we not a right to assume that even the age of childhood is not wanting in slight sexual excitations, that later sexual development may perhaps be decisively influenced by childhood experiences? Injuries sustained by an organ which is as yet immature, or by a function which is in process of developing, often cause more severe and lasting effects than they could do in maturer years. Perhaps the abnormal reaction to sexual impressions which surprises us in hysterical subjects at the age of puberty is quite generally based on sexual experiences of this sort in childhood, in which case those experiences must be of a similar nature to one another, and must be of an important kind. If this is so, the prospect is opened up that what has hitherto had to be laid at the door of a still unexplained hereditary predisposition may be accounted for as having been acquired at an early age. And since infantile experiences with a sexual content could after all only exert a psychical effect through their memory-traces, would not this view be a welcome amplification of the finding of psycho-analysis which tells us that hysterical symptoms can only arise with the co-operation of memories?

II

You will no doubt have guessed, Gentlemen, that I should not have carried this last line of thought so far if I had not wanted to prepare you for the idea that it is this line alone which, after so many delays, will lead us to our goal. For now we are really at the end of our wearisome and laborious analytic work, and here we find the fulfilment of all the claims and expectations upon which we have so far insisted. If we have the perseverance to press on with the analysis into early childhood, as far back as a human memory is capable of reaching, we invariably bring the patient to reproduce experiences which, on account both of their peculiar features and of their relations to the symptoms of his later illness, must be regarded as the aetiology of his neurosis for which we have been looking. These infantile experiences are once more sexual in content, but they are of a far more uniform kind than the scenes at puberty that had been discovered earlier. It is now no longer a question of sexual topics having been aroused by some sense impression or other, but of sexual experiences affecting the subject’s own body - of sexual intercourse (in the wider sense). You will admit that the importance of such scenes needs no further proof; to this may now be added that, in every instance, you will be able to discover in the details of the scenes the determining factors which you may have found lacking in the other scenes - the scenes which occurred later and were reproduced earlier.

I therefore put forward the thesis that at the bottom of every case of hysteria there are one or more occurrences of premature sexual experience, occurrences which belong to the earliest years of childhood but which can be reproduced through the work of psycho-analysis in spite of the intervening decades. I believe that this is an important finding, the discovery of a caput Nili in neuropathology; but I hardly know what to take as a starting-point for a continuation of my discussion of this subject. Shall I put before you the actual material I have obtained from my analyses? Or shall I rather try first to meet the mass of objections and doubts which, as I am surely correct in supposing, have now taken possession of your attention? I shall choose the latter course; perhaps we shall then be able to go over the facts more calmly.

(a) No one who is altogether opposed to a psychological view of hysteria, who is unwilling to give up the hope that some day it will be possible to trace back its symptoms to ‘finer anatomical changes’ and who has rejected the view that the material foundations of hysterical changes are bound to be of the same kind as those of our normal mental processes - no one who adopts this attitude will, of course, put any faith in the results of our analyses; however, the difference in principle between his premisses and ours absolves us from the obligation of convincing him on individual points.

But other people, too, although they may be less averse to psychological theories of hysteria, will be tempted, when considering our analytic findings, to ask what degree of certainty the application of psycho-analysis offers. Is it not very possible either that the physician forces such scenes upon his docile patients, alleging that they are memories, or else that the patients tell the physician things which they have deliberately invented or have imagined and that he accepts those things as true? Well, my answer to this is that the general doubt about the reliability of the psycho-analytic method can be appraised and removed only when a complete presentation of its technique and results is available. Doubts about the genuineness of the infantile sexual scenes can, however, be deprived of their force here and now by more than one argument. In the first place, the behaviour of patients while they are reproducing these infantile experiences is in every respect incompatible with the assumption that the scenes are anything else than a reality which is being felt with distress and reproduced with the greatest reluctance. Before they come for analysis the patients know nothing about these scenes. They are indignant as a rule if we warn them that such scenes are going to emerge. Only the strongest compulsion of the treatment can induce them to embark on a reproduction of them. While they are recalling these infantile experiences to consciousness, they suffer under the most violent sensations, of which they are ashamed and which they try to conceal; and, even after they have gone through them once more in such a convincing manner, they still attempt to withhold belief from them, by emphasizing the fact that, unlike what happens in the case of other forgotten material, they have no feeling of remembering the scenes.¹

This latter piece of behaviour seems to provide conclusive proof. Why should patients assure me so emphatically of their unbelief, if what they want to discredit is something which - from whatever motive - they themselves have invented?

It is less easy to refute the idea that the doctor forces reminiscences of this sort on the patient, that he influences him by suggestion to imagine and reproduce them. Nevertheless it appears to me equally untenable. I have never yet succeeded in forcing on a patient a scene I was expecting to find, in such a way that he seemed to be living through it with all the appropriate feelings. Perhaps others may be more successful in this.

¹ (Footnote added 1924:) All this is true; but it must be remembered that at the time I wrote it I had not yet freed myself from my overvaluation of reality and my low valuation of phantasy.

There are, however, a whole number of other things that vouch for the reality of infantile sexual scenes. In the first place there is the uniformity which they exhibit in certain details, which is a necessary consequence if the preconditions of these experiences are always of the same kind, but which would otherwise lead us to believe that there were secret understandings between the various patients. In the second place, patients sometimes describe as harmless events whose significance they obviously do not understand, since they would be bound otherwise to be horrified by them. Or again, they mention details, without laying any stress on them, which only someone of experience in life can understand and appreciate as subtle traits of reality.

Events of this sort strengthen our impression that the patients must really have experienced what they reproduce under the compulsion of analysis as scenes from their childhood. But another and stronger proof of this is furnished by the relationship of the infantile scenes to the content of the whole of the rest of the case history. It is exactly like putting together a child’s picture-puzzle: after many attempts, we become absolutely certain in the end which piece belongs in the empty gap; for only that one piece fills out the picture and at the same time allows its irregular edges to be fitted into the edges of the other pieces in such a manner as to leave no free space and to entail no overlapping. In the same way, the contents of the infantile scenes turn out to be indispensable supplements to the associative and logical framework of the neurosis, whose insertion makes its course of development for the first time evident, or even, as we might often say, self-evident.

Without wishing to lay special stress on the point, I will add that in a number of cases therapeutic evidence of the genuineness of the infantile scenes can also be brought forward. There are cases in which a complete or partial cure can be obtained without our having to go as deep as the infantile experiences. And there are others in which no success at all is obtained until the analysis has come to its natural end with the uncovering of the earliest traumas. In the former cases we are not, I believe, secure against relapses; and my expectation is that a complete psycho-analysis implies a radical cure of the hysteria. We must not, however, be led into forestalling the lessons of observation.

There would be one other proof, and a really unassailable one, of the genuineness of childhood sexual experiences namely, if the statements of someone who is being analysed were to be confirmed by someone else, whether under treatment or not. These two people will have had to have taken part in the same experience in their childhood - perhaps to have stood in some sexual relationship to each other. Such relations between children are, as you will hear in a moment, by no means rare. Moreover, it quite often happens that both of those concerned subsequently fall ill of neuroses; yet I regard it as a fortunate accident that, out of eighteen cases, I have been able to obtain an objective confirmation of this sort in two. In one instance, it was the brother (who had remained well) who of his own accord confirmed - not, it is true, his earliest sexual experiences with his sister (who was the patient) - but at least scenes of that kind from later childhood, and the fact that there had been sexual relations dating further back. In the other instance, it happened that two women whom I was treating had as children had sexual relations with the same man, in the course of which certain scenes had taken place à trois. A particular symptom, which was derived from these childhood events, had developed in both women, as evidence of what they had experienced in common.

(b) Sexual experiences in childhood consisting in stimulation of the genitals, coitus-like acts, and so on, must therefore be recognized, in the last analysis, as being the traumas which lead to a hysterical reaction to events at puberty and to the development of hysterical symptoms. This statement is certain to be met from different directions by two mutually contradictory objections. Some people will say that sexual abuses of this kind, whether practised upon children or between them, happen too seldom for it to be possible to regard them as the determinant of such a common neurosis as hysteria. Others will perhaps argue that, on the contrary, such experiences are very frequent-much too frequent for us to be able to attribute an aetiological significance to the fact of their occurrence. They will further maintain that it is easy, by making a few enquiries, to find people who remember scenes of sexual seduction and sexual abuse in their childhood years, and yet who have never been hysterical. Finally we shall be told, as a weighty argument, that in the lower strata of the population hysteria is certainly no more common than in the highest ones, whereas everything goes to show that the injunction for the sexual safeguarding of childhood is far more frequently transgressed in the case of the children of the proletariat.

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