Further remarks on the neuro-psychoses of defence 4 страница

Let us begin our defence with the easier part of the task. It seems to me certain that our children are far more often exposed to sexual assaults than the few precautions taken by parents in this connection would lead us to expect. When I first made enquiries about what was known on the subject, I learnt from colleagues that there are several publications by paediatricians which stigmatize the frequency of sexual practices by nurses and nursery maids, carried out even on infants in arms; and in the last few weeks I have come across a discussion of ‘Coitus in Childhood’ by Dr. Stekel (1895) in Vienna. I have not had time to collect other published evidence; but even if it were only scanty, it is to be expected that increased attention to the subject will very soon confirm the great frequency of sexual experiences and sexual activity in childhood.

Lastly, the findings of my analysis are in a position to speak for themselves. In all eighteen cases (cases of pure hysteria and of hysteria combined with obsessions, and comprising six men and twelve women) I have, as I have said, come to learn of sexual experiences of this kind in childhood. I can divide my cases into three groups, according to the origin of the sexual stimulation. In the first group it is a question of assaults - of single, or at any rate isolated, instances of abuse, mostly practised on female children, by adults who were strangers, and who, incidentally, knew how to avoid inflicting gross, mechanical injury. In these assaults there was no question of the child’s consent, and the first effect of the experience was preponderantly one of fright. The second group consists of cases in which some adult looking after the child - a nursery maid or governess or tutor, or, unhappily all too often, a close relative - has initiated the child into sexual intercourse and has maintained a regular love relationship with it - a love relationship, moreover, with its mental side developed - which has often lasted for years. The third group, finally, contains child-relationships proper - sexual relations between two children of different sexes, mostly a brother and sister, which are often prolonged beyond puberty and which have the most far-reaching consequences for the pair. In most of my cases I found that two or more of these aetiologies were in operation together; in a few instances the accumulation of sexual experiences coming from different quarters was truly amazing. You will easily understand this peculiar feature of my observations, however, when you consider that the patients I was treating were all cases of severe neurotic illness which threatened to make life impossible.

Where there had been a relation between two children I was sometimes able to prove that the boy-who, here too, played the part of the aggressor - had previously been seduced by an adult of the female sex, and that afterwards, under the pressure of his prematurely awakened libido and compelled by his memory, he tried to repeat with the little girl exactly the same practices that he had learned from the adult woman, without making any modification of his own in the character of the sexual activity.

In view of this, I am inclined to suppose that children cannot find their way to acts of sexual aggression unless they have been seduced previously. The foundation for a neurosis would accordingly always be laid in childhood by adults, the children themselves would transfer to one another the disposition to fall ill of hysteria later. I will ask you to consider a moment longer the special frequency with which sexual relations in childhood occur precisely between brothers and sisters and cousins, as a result of their opportunities for being together so often; supposing, then, ten or fifteen years later several members of the younger generation of the family are found to be ill, might not this appearance of a family neurosis naturally lead to the false supposition that a hereditary disposition is present where there is only a pseudo-heredity and where in fact what has taken place is a handing-on, an infection in childhood?

Now let us turn to the other objection, which is based precisely on an acknowledgement of the frequency of infantile sexual experiences and on the observed fact that many people who remember scenes of that kind have not become hysterics. Our first reply is that the excessive frequency of an aetiological factor cannot possibly be used as an objection to its aetiological significance. Is not the tubercle bacillus ubiquitous and is it not inhaled by far more people than are found to fall ill of tuberculosis? And is its aetiological significance impaired by the fact that other factors must obviously be at work too before the tuberculosis, which is its specific effect, can be evoked? In order to establish the bacillus as the specific aetiology it is enough to show that tuberculosis cannot possibly occur without its playing a part. The same doubtless applies to our problem. It does not matter if many people experience infantile sexual scenes without becoming hysterics, provided only that all the people who become hysterics have experienced scenes of that kind. The area of occurrence of an aetiological factor may be freely allowed to be wider than that of its effect, but it must not be narrower. Not everyone who touches or comes near a smallpox patient develops smallpox; nevertheless infection from a smallpox patient is almost the only known aetiology of the disease.

It is true that if infantile sexual activity were an almost universal occurrence the demonstration of its presence in every case would carry no weight. But, to begin with, to assert such a thing would certainly be a gross exaggeration; and secondly, the aetiological pretensions of the infantile scenes rest not only on the regularity of their appearance in the anamneses of hysterics, but, above all, on the evidence of there being associative and logical ties between those scenes and the hysterical symptoms - evidence which, if you were given the complete history of a case, would be as clear as daylight to you.

What can the other factors be which the ‘specific aetiology’ of hysteria still needs in order actually to produce the neurosis? That, Gentlemen, is a theme in itself, which I do not propose to enter upon. To-day I need only indicate the point of contact at which the two parts of the topic - the specific and the auxiliary aetiology - fit into one another. No doubt a considerable quantity of factors will have to be taken into account. There will be the subject’s inherited and personal constitution, the inherent importance of the infantile sexual experiences, and, above all, their number:a brief relationship with a strange boy, who afterwards becomes indifferent, will leave a less powerful effect on a girl than intimate sexual relations of several years’ standing with her own brother. In the aetiology of the neuroses quantitative preconditions are as important as qualitative ones: there are threshold-values which have to be crossed before the illness can become manifest. Moreover, I do not myself regard this aetiological series as complete; nor does it solve the riddle of why hysteria is not more common among the lower classes. (You will remember, by the way, what a surprisingly large incidence of hysteria was reported by Charcot among working-class men). I may also remind you that a few years ago I myself pointed out a factor, hitherto little considered, to which I attribute the leading role in provoking hysteria after puberty. I then put forward the view that the outbreak of hysteria may almost invariably be traced to a psychical conflict arising through an incompatible idea setting in action a defence on the part of the ego and calling up a demand for repression. What the circumstances are in which a defensive endeavour of this kind has the pathological effect of actually thrusting the memory which is distressing to the ego into the unconscious and of creating a hysterical symptom in its place I was not able to say at that time. But to-day I can repair the omission. The defence achieves its purpose of thrusting the incompatible idea out of consciousness if there are infantile sexual scenes present in the (hitherto normal) subject in the form of unconscious memories, and if the idea that is to be repressed can be brought into logical or associative connection with an infantile experience of that kind.

Since the ego’s efforts at defence depend upon the subject’s total moral and intellectual development, the fact that hysteria is so much rarer in the lower classes than its specific aetiology would warrant is no longer entirely incomprehensible.

Let us return once again, Gentlemen, to the last group of objections, the answering of which has led us such a long way. We have heard and have acknowledged that there are numerous people who have a very clear recollection of infantile sexual experiences and who nevertheless do not suffer from hysteria. This objection has no weight; but it provides an occasion for making a valuable comment. According to our understanding of the neurosis, people of this kind ought not to be hysterical at all, or at any rate, not hysterical as a result of the scenes which they consciously remember. With our patients, those memories are never conscious; but we cure them of their hysteria by transforming their unconscious memories of the infantile scenes into conscious ones. There was nothing that we could have done or needed to do about the fact that they have had such experiences. From this you will perceive that the matter is not merely one of the existence of the sexual experiences, but that a psychological precondition enters in as well. The scenes must he present as unconscious memories; only so long as, and in so far as, they are unconscious are they able to create and maintain hysterical symptoms. But what decides whether those experiences produce conscious or unconscious memories - whether that is conditioned by the content of the experiences, or by the time at which they occur, or by later influences - that is a fresh problem, which we shall prudently avoid. Let me merely remind you that, as its first conclusion, analysis has arrived at the proposition that hysterical symptoms are derivatives of memories which are operating unconsciously.

426 (c) Our view then is that infantile sexual experiences are the fundamental precondition for hysteria, are, as it were, the disposition for it and that it is they which create the hysterical symptoms, but that they do not do so immediately, but remain without effect to begin with and only exercise a pathogenic action later, when they have been aroused after puberty in the form of unconscious memories. If we maintain this view, we shall have to come to terms with the numerous observations which show that a hysterical illness may already make its appearance in childhood and before puberty. This difficulty, however, is cleared up as soon as we examine more closely the data gathered from analyses concerning the chronology of the infantile experiences. We then learn that in our severe cases the formation of hysterical symptoms begins - not in exceptional instances, but, rather, as a regular thing - at the age of eight, and that the sexual experiences which show no immediate effect invariably date further back, into the third or fourth, or even the second year of life. Since in no single instance does the chain of effective experiences break off at the age of eight, I must assume that this time of life, the period of growth in which the second dentition takes place, forms a boundary line for hysteria, after which the illness cannot be caused. From then on, a person who has not had sexual experiences earlier can no longer become disposed to hysteria; and a person who has had experiences earlier, is already able to develop hysterical symptoms. Isolated instances of the occurrence of hysteria on the other side of this boundary line (that is, before the age of eight) may be interpreted as a phenomenon of precocious maturity. The existence of this boundary-line is very probably connected with developmental processes in the sexual system. Precocity of somatic sexual development may often be observed, and it is even possible that it can be promoted by too early sexual stimulation.

In this way we obtain an indication that a certain infantile state of the psychical functions, as well as of the sexual system, is required in order that a sexual experience occurring during this period shall later on, in the form of a memory, produce a pathogenic effect. I do not venture as yet, however, to make any more precise statement on the nature of this psychical infantilism or on its chronological limits. (d) Another objection might arise from exception being taken to the supposition that the memory of infantile sexual experiences produces such an enormous pathogenic effect, while the actual experience itself has none. And it is true that we are not accustomed to the notion of powers emanating from a mnemic image which were absent from the real impression. You will moreover notice the consistency with which the proposition that symptoms can only proceed from memories is carried through in hysteria. None of the later scenes, in which the symptoms arise, are the effective ones; and the experiences which are effective have at first no result. But here we are faced with a problem which we may very justifiably keep separate from our theme. It is true that we feel impelled to make a synthesis, when we survey the number of striking conditions that we have come to know: the fact that in order to form a hysterical symptom a defensive effort against a distressing idea must be present, that this idea must exhibit a logical or associative connection with an unconscious memory through a few or many intermediate links, which themselves, too, remain unconscious at the moment, that this unconscious memory must have a sexual content, that its content must be an experience which occurred during a certain infantile period of life. It is true that we cannot help asking ourselves how it comes about that this memory of an experience that was innocuous at the time it happened, should posthumously produce the abnormal effect of leading a psychical process like defence to a pathological result, while it itself remains unconscious.

But we shall have to tell ourselves that this is a purely psychological problem, whose solution may perhaps necessitate certain hypotheses about normal psychical processes and about the part played in them by consciousness, but that this problem may be allowed to remain unsolved for the time being, without detracting from the value of the insight we have so far gained into the aetiology of hysterical phenomena.

III

Gentlemen, the problem, the approaches to which I have just formulated, concerns the mechanism of the formation of hysterical symptoms. We find ourselves obliged, however, to describe the causation of those symptoms without taking that mechanism into account, and this involves an inevitable loss of completeness and clarity in our discussion. Let us go back to the part played by the infantile sexual scenes. I am afraid that I may have misled you into over-estimating their power to form symptoms. Let me, therefore, once more stress the fact that every case of hysteria exhibits symptoms which are determined, not by infantile but by later, often by recent, experiences. Other symptoms, it is true, go back to the very earliest experiences and belong, so to speak, to the most ancient nobility. Among these latter are above all to be found the numerous and diverse sensations and paraesthesias of the genital organs and other parts of the body, these sensations and paraesthesias being phenomena which simply correspond to the sensory content of the infantile scenes, reproduced in a hallucinatory fashion, often painfully intensified.

Another set of exceedingly common hysterical phenomena - painful need to urinate, the sensation accompanying defaecation, intestinal disturbances, choking and vomiting, indigestion and disgust at food - were also shown in my analyses (and with surprising regularity) to be derivatives of the same childhood experiences and were explained without difficulty by certain invariable peculiarities of those experiences. For the idea of these infantile sexual scenes is very repellent to the feelings of a sexually normal individual; they include all the abuses known to debauched and impotent persons, among whom the buccal cavity and the rectum are misused for sexual purposes. For physicians, astonishment at this soon gives way to a complete understanding. People who have no hesitation in satisfying their sexual desires upon children cannot be expected to jib a finer shades in the methods of obtaining that satisfaction; and the sexual impotence which is inherent in children inevitably forces them into the same substitutive actions as those to which adults descend if they become impotent. All the singular conditions under which the ill-matched pair conduct their love-relations - on the one hand the adult, who cannot escape his share in the mutual dependence necessarily entailed by a sexual relationship, and who is yet armed with complete authority and the right to punish, and can exchange the one role for the other to the uninhibited satisfaction of his moods, and on the other hand the child, who in his helplessness is at the mercy of this arbitrary will, who is prematurely aroused to every kind of sensibility and exposed to every sort of disappointment, and whose performance of the sexual activities assigned to him is often interrupted by his imperfect control of his natural needs - all these grotesque and yet tragic incongruities reveal themselves as stamped upon the later development of the individual and of his neurosis, in countless permanent effects which deserve to be traced in the greatest detail. Where the relation is between two children, the character of the sexual scenes is none the less of the same repulsive sort, since every such relationship between children postulates a previous seduction of one of them by an adult. The psychical consequences of these child-relations are quite extraordinarily far-reaching; the two individuals remain linked by an invisible bond throughout the whole of their lives.

Sometimes it is the accidental circumstances of these infantile sexual scenes which in later years acquire a determining power over the symptoms of the neurosis. Thus, in one of my cases the circumstance that the child was required to stimulate the genitals of a grown-up woman with his foot was enough to fixate his neurotic attention for years on to his legs and to their function, and finally to produce a hysterical paraplegia. In another case, a woman patient suffering from anxiety attacks which tended to come on at certain hours of the day could not be calmed unless a particular one of her many sisters stayed by her side all the time. Why this was so would have remained a riddle if analysis had not shown that the man who had committed the assaults on her used to enquire at every visit whether this sister, who he was afraid might interrupt him, was at home.

It may happen that the determining power of the infantile scenes is so much concealed that, in a superficial analysis, it is bound to be overlooked. In such instances we imagine that we have found the explanation of some particular symptom in the content of one of the later scenes - until, in the course of our work, we come upon the same content in one of the infantile scenes, so that in the end we are obliged to recognize that, after all, the later scene only owes its power of determining symptoms to its agreement with the earlier one. I do not wish because of this to represent the later scenes being unimportant; if it was my task to put before you the rules that govern the formation of hysterical symptoms, I should have to include as one of them that the idea which is selected for the production of a symptom is one which has been called up by a combination of several factors and which has been aroused from various directions simultaneously. I have elsewhere tried to express this in the formula: hysterical symptoms are overdetermined.

One thing more, Gentlemen. It is true that earlier I put the relation between recent and infantile aetiology aside as a separate theme. Nevertheless, I cannot leave the subject without overstepping this resolution at least with one remark. You will agree with me that there is one fact above all which leads us astray in the psychological understanding of hysterical phenomena, and which seems to warn us against measuring psychical acts in hysterics and in normal people with the same yardstick. That fact is the discrepancy between psychically exciting stimuli and psychical reactions which we come upon in hysterical subjects. We try to account for it by assuming the presence in them of a general abnormal sensitivity to stimuli, and we often endeavour to explain it on a physiological basis, as if in such patients certain organs of the brain which serve to transmit stimuli were in a peculiar chemical state (like the spinal centres of a frog, perhaps, which has been injected with strychnine) or as if these cerebral organs had withdrawn from the influence of higher inhibiting centres (as in animals being experimented on under vivisection). Occasionally one or other of these concepts may be perfectly valid as an explanation of hysterical phenomena; I do not dispute this. But the main part of the phenomenon - of the abnormal, exaggerated, hysterical reaction to psychical stimuli - admits of another explanation, an explanation which is supported by countless examples from the analyses of patients. And this is as follows: The reaction of hysterics is only apparently exaggerated; it is bound to appear exaggerated to us because we only know a small part of the motives from which it arises.

In reality, this reaction is proportionate to the exciting stimulus; thus it is normal and psychologically understandable. We see this at once when the analysis has added to the manifest motives, of which the patient is conscious, those other motives, which have been operative without his knowing about them, so that he could not tell us of them.

I could spend hours demonstrating the validity of this important assertion for the whole range of psychical activity in hysteria, but I must confine myself here to a few examples. You will remember the mental ‘sensitiveness’ which is so frequent among hysterical patients and which leads them to react to the least sign of being depreciated as though they had received a deadly insult. What would you think, now, if you were to observe this high degree of readiness to feel hurt on the slightest occasion, if you came across it between two normal people, a husband and wife, perhaps? You would certainly infer that the conjugal scene you had witnessed was not solely the result of this latest trifling occasion, but that inflammable material had been piling up for a long time and that the whole heap of it bad been set alight by the final provocation.

I would ask you to carry this line of thought over on to hysterical patients. It is not the latest slight - which, in itself, is minimal - that produces the fit of crying, the outburst of despair or the attempt at suicide, in disregard of the axiom that an effect must be proportionate to its cause; the small slight of the present moment has aroused and set working the memories of very many, more intense, earlier slights, behind all of which there lies in addition the memory of a serious slight in childhood which has never been overcome. Or again, let us take the instance of a young girl who blames herself most frightfully for having allowed a boy to stroke her hand in secret, and who from that time on has been overtaken by a neurosis. You can, of course, answer the puzzle by pronouncing her an abnormal, eccentrically disposed and over-sensitive person; but you will think differently when analysis shows you that the touching of her hand reminded her of another, similar touching, which had happened very early in her childhood and which formed part of a less innocent whole, so that her self-reproaches were actually reproaches about that old occasion. Finally, the problem of the hysterogenic points is of the same kind. If you touch a particular spot, you do something you did not intend: you awaken a memory which may start off a convulsive attack, and since you know nothing of this psychical intermediate link you refer the attack directly to the operation of your touch. The patients are in the same state of ignorance and therefore fall into similar errors. ie they too are unaware of the re-awakening of the unconscious memory They constantly establish ‘false connections’ between the most recent cause, which they are conscious of, and the effect, which depends on so many intermediate links. If, however, the physician has been able to bring together the conscious and unconscious motives for the purpose of explaining a hysterical reaction, he is almost always obliged to recognize that the seemingly exaggerated reaction is appropriate and is abnormal only in its form.

You may, however, rightly object to this justification of the hysterical reaction to psychical stimuli and say that nevertheless the reaction is not a normal one. For why do healthy people behave differently? Why do not all their excitations of long ago come into operation once more when a new, present-day, excitation takes place? One has an impression, indeed, that with hysterical patients it is as if all their old experiences - to which they have already reacted so often and, moreover, so violently - had retained their effective power; as if such people were incapable of disposing of their psychical stimuli. Quite true, Gentlemen, something of the sort must really be assumed. You must not forget that in hysterical people when there is a present-day precipitating cause, the old experiences come into operation in the form of unconscious memories. It looks as though the difficulty of disposing of a present impression, the impossibility of transforming it into a powerless memory, is attached precisely to the character of the psychical unconscious. You see that the remainder of the problem lies once more in the field of psychology - and, what is more, a psychology of a kind for which philosophers have done little to prepare the way for us.

To this psychology, which has yet to be created to meet our needs - to this future psychology of the neuroses - I must also refer you when, in conclusion, I tell you something which will at first make you afraid that it may disturb our dawning comprehension of the aetiology of hysteria. For I must affirm that the aetiological role of infantile sexual experience is not confined to hysteria but holds good equally for the remarkable neurosis of obsessions, and perhaps also, indeed, for the various forms of chronic paranoia and other functional psychoses. I express myself on this with less definiteness, because I have as yet analysed far fewer cases of obsessional neurosis than of hysteria; and as regards paranoia, I have at my disposal only a single full analysis and a few fragmentary ones. But what I discovered in these cases seemed to be reliable and filled me with confident expectations for other cases. You will perhaps remember that already, at an earlier date, I recommended that hysteria and obsessions should be grouped together under the name of ‘neuroses of defence’, even before I had come to know of their common infantile aetiology. I must now add that although this need not be expected to happen in general - every one of my cases of obsessions revealed a substratum of hysterical symptoms, mostly sensations and pains, which went back precisely to the earliest childhood experiences. What, then, determines whether the infantile sexual scenes which have remained unconscious will later on, when the other pathogenic factors are super-added, give rise to hysterical or to obsessional neurosis or even to paranoia? This increase in our knowledge seems, as you see, to prejudice the aetiological value of these scenes, since it removes the specificity of the aetiological relation.

I am not yet in a position, Gentlemen, to give a reliable answer to this question. The number of cases I have analysed is not large enough nor have the determining factors in them been sufficiently various. So far, I have observed that obsessions can be regularly shown by analysis to be disguised and transformed self-reproaches about acts of sexual aggression in childhood, and are therefore more often met with in men than in women, and that men develop obsessions more often than hysteria. From this I might conclude that the character of the infantile scenes - whether they were experienced with pleasure or only passively - has a determining influence on the choice of the later neurosis; but I do not want to underestimate the significance of the age at which these childhood actions occur, and other factors as well. Only a discussion of further analyses can throw light on these points. But when it becomes clear which are the decisive factors in the choice between the possible forms of the neuro-psychoses of defence, the question of what the mechanism is in virtue of which that particular form takes shape will once again be a purely psychological problem.

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