Further Contributions to the Theory and Technique of Psychoanalysis

NOSOLOGY

I

THE ANALYTIC CONCEPTION OF THE PSYCHO-NEUROSES¹

THERE are many ways in which the flattering request of the Medical Association, that I should deliver a lecture reviewing the progress in the study of the neuroses, might be treated. I might discuss various functional neuroses seriatim and mention the novelties that have appeared among the individual kinds of neuroses in the course of the last few years. On a little reflection I rejected this plan, because if I mentioned merely the names of all the disease-phenomena nowadays included under the heading ‘functional neurosis’ it would create such a chaos of new Græco-Latin words that I should only increase the confusion reigning at present where the neuroses are concerned. I shall therefore try to carry out my task in a different way. Instead of going into details I shall review matters individually and give the general impression which a nerve specialist acquires of the present state of his department of medicine.

One of the wittiest of German writers, Georg Christian Lichtenberg, once asked the paradoxical question why did it never strike researchers that discoveries could be made not only with a magnifying glass but also, perhaps, with a diminishing lens? He obviously meant that the increasing search for details in which science gets tied up and loses its perspective over things as a whole might from time to time be given up for the consideration, individually and from a distance, of the results already achieved. He means, therefore, approximately the same thing that Herbert Spencer mentions as the necessary phase in all natural evolution, namely, that differentiation should occasionally be freed from the work of correlation and integration.

When, therefore, I consider the various neuroses through a diminishing lens, their multiplicity reduces itself to a twofold division that cannot be further integrated.

One kind of neurosis is, though it does not leave the mental life untouched (there is, indeed, no illness without psychic participation), mainly confined to the somatic domain. Another great group of the neuroses on the other hand, though not wholly without concomitant bodily phenomena, manifests itself chiefly in psychic changes—indeed, owes its origin exclusively to psychic shocks.

You will, perhaps, be surprised that such a dualistic division of diseases is possible to-day in this age of monism. I hasten also to add here that this nosological dualism agrees quite well with the agnostic monism of the philosophers, since the latter—as its name indicates—only postulates the uniform conformity to law throughout the whole of nature, but at the same time is frank enough to allow that we can say nothing about the nature of this conformity. In my opinion the monistic conception is in the meantime only a philosophic declaration of faith or an ideal that one would fain approach, but which is still so remote from the confines of our present knowledge that we are as yet unable to make practical use of its teachings. It is useless to attempt to palliate facts; as things stand to-day we can analyse one set of phenomena only physically and another set only psychologically. Psycho-physical parallelism, too, is certainly a possible but really very improbable philosophic theorem by which we need not let ourselves be misled in our observations. In a word, we call it disingenuous when—as is at present customary—psychic happenings are defined by anatomical and physiological conceptions, for the truth is that we know nothing of either the physiological side of psychic life or of the anatomical substratum of its mechanism. The most we learnt in this respect from natural science is the fact of cerebral localization of sensory functions and the recognition of individual co-ordinating centres for movements. Flechsig, indeed, attempted to construct a modern phrenology on the basis of the chronological sequence of the embryonic brain tissues, but the whole complicated system of the three to four dozen psychic centres and their projection and association fibres which he assumed is only an extremely unstable even if ingenious theoretical edifice about which the clinician need not greatly trouble himself.

So far, too, all search for the anatomical brain changes accompanying mental disease has remained quite fruitless, as has also the endeavour to correlate the pathological-anatomical findings with the mental symptoms noted during life for the purpose of drawing conclusions about the psychic functions of individual parts of the brain. Neither in mania nor in melancholia, in paranoia, hysteria nor in obsessional neurosis were any changes found on microscopical examination of the brain; in other diseases such as paralysis, alcoholism, and senile dementia, changes were certainly found, but the relation of the brain lesion to the psychic symptoms could not be stated, so that we may confidently say that we can to-day as little speak of a pathological anatomy of the psychoses and psycho-neuroses as of the material correlation of mental functioning in general.

Our learned men, even if they allow that they do not yet know the functional mechanism of ‘thinking matter’, show an extraordinary resistance against acknowledging their ignorance as regards the pathology of this matter. If it is a fallacy to speak of ‘molecular movements’ of the brain cells instead simply of feeling, thinking, and willing, then it is no less disingenuous to throw anatomical, physiological, physical, and chemical expressions about when describing the so-called functional psychoses and neuroses. Our learned men seem to be of the opinion that a docta ignorantia is more supportable than an indocta ignorantia, that, therefore, the naïve acknowledgement of our ignorance is more shameful than a lack of knowledge that cloaks itself in scientific language.

Let us suppose, however, that man at last manages to observe directly in himself the brain changes occurring parallel with his own sensations; the twofold division of the phenomenal series, the separation of what is observed from the exterior, and what is seen inwardly would nevertheless persist. Even the most accurate description of the movements of the brain molecules would not render introspective psychology superfluous.

For the understanding of the healthy and diseased mind, therefore, analysis of direct inner perception remains the chief source of psychological knowledge; indeed, it has more prospect of permanence than the purely materialistic point of view. It has been our experience that a few unforeseen discoveries have been able to shake physics to its foundations, while the principles of introspection always remain the same.

I could not spare you this philosophical excursion, although it constantly reminds me of another witty saying of the above-mentioned Lichtenberg, that one can as easily do oneself an injury with philosophy as with a sharp razor blade if one does not proceed with the utmost care. I, therefore, lay this dangerous weapon aside and confine myself to repeating once more that the dualistic division of the neuroses is, according to the present position of our knowledge, fully justified.

Amongst the organic neuroses, or, as I should like to call them, the physio-neuroses, we reckon, for instance, chorea, myxœdema, Basedow’s disease, neurasthenia and the anxiety neuroses in Freud’s sense and other conditions in which the cause of the disease is sought for or has already been found in disturbances of metabolism and such like. In my lecture to-day I should like to direct your attention exclusively towards the other great group of neuroses—to the psycho-neuroses—those neuroses whose causation, pathological nature, and symptomatology are at present open only to an introspective psychical scrutiny, and particularly to hysteria and obsessional neurosis. I would remark here at once that the psycho-neuroses cannot be sharply distinguished either from ‘normal’ mental functioning or from the functional psychoses; it is mainly practical considerations that compel the doctor to treat normality, psycho-neurosis, and psychosis as separate chapters in psychology. From the scientific point of view there is no fundamental difference between the outbursts of passion in the ‘normal’ person, the attacks of the hysteric, and the ravings of the insane.

The ‘psycho-genetic’ view of the psychoses and neuroses is of primeval antiquity.

The dominance of the materialistic and mechanistic point of view in the nineteenth century first misled psychologists and psycho-pathologists to renounce the naïve but honest introspective psychology and to imitate the experimental methods so successful in the natural sciences. Finally, it went so far that doctors and natural philosophers handed over as though unworthy of their consideration the great and little mental problems of humanity to the writers of belles lettres, and confined themselves more and more to the task of the registration of the physiology of the senses. Since Fechner and Wundt, hardly anyone has animated the dead matter of experimental psychology with an in any way informative idea. Freud’s exertions have succeeded recently in joining up the broken threads connecting scientific psychology and daily life, and in making a scientific field that had long lain fallow fruitful once more.

I have already had an opportunity of telling you, honoured colleagues, about the evolution of Freud’s theory and method—about psycho-analysis. This time I shall indicate the advances that the study of the psycho-neuroses owes to psycho-analysis.

This new psychology starts from a theory of instinct. The controller-in-chief of all our actions and thoughts is the ‘pleasure-principle’, the endeavour to escape if possible from unpleasant situations, the desire to obtain the greatest possible gratification with the smallest possible effort.

No person, however, can exist for himself alone, but must adapt himself to a complicated, almost unmodifiable milieu. Already in early childhood he must learn to renounce a great part of his natural impulses; when he is grown up, culture requires of him that he should even regard self-sacrifice for the community as something beautiful, good, and worth striving for. The greatest sacrifice the individual has to make in the interests of society, however, is in regard to his sexual desires. All educational factors work towards the suppression of these desires, and most people adapt themselves to these requirements without any particular injury.

Psycho-analysis proceeded to show that this adaptation occurred with the help of a peculiar psychic mechanism, the essential feature of which is that the unfulfillable wishes, and the ideas, memories, and thought-processes belonging thereto, are submerged in the unconscious. To put it more simply: one ‘forgets’ these wishes and all the thoughts associated with them. This forgetting, however, does not mean the complete destruction of those tendencies and ideational groups; the forgotten complexes continue to exist below the threshold of consciousness: they preserve their potential power and can in suitable circumstances appear again. The healthy person protects himself successfully against the return of these wishes and the sudden appearance of the objects of desire by erecting moral ramparts round these ‘repressed complexes’. Feelings of shame and disgust conceal from him all his life the fact that he still really cherishes those despised, disgusting, shameful things as wish-ideas. Things happen in this way, however, only with healthy people; but where, owing to some peculiarity of temperament or to too great a strain on those protective ramparts, the psychic mechanism of repression fails, a ‘return of the repressed material’ occurs, and with it the formation of symptoms of disease.

The question is often asked why psycho-analysis ascribes so great a part in the ætiology of the psycho-neuroses precisely to sexual repression. But those who ask this forget that since the beginning of time ‘hunger and love’ have ruled the world, that the impulses for self- and race-preservation are equally powerful instincts in every living creature. Were there a society in which the taking of food was as shameful a manifestation of life as coitus is with us, that is to say, something that one must indeed do but about which one may not speak, of which one may scarcely think, and were the manner of eating there as sternly restricted as sexual gratification is with us, then perhaps the repression of the instinct of self-preservation would play there the chief part in the ætiology of the psycho-neuroses. The predominance of sexuality in the origination of mental disease is therefore in great part due to social causes.

These are of course entirely novel views, standing in the utmost conceivable contrast to everything that has been so far taught by a neurology dealing with anatomical and physiological conceptions. Claude Bernard, indeed, clearly said that when new facts contradicted old theories it was the theories that had to go. It is quite possible, too, that this new libido theory of the neuroses is not the last word that can be said about the neuroses; such a ‘last word’ is unknown to science. It is my conviction, however, that at the present time there is no theory better adapted to the facts and everything associated with them than the psycho-analytic one.

How then does psycho-analysis classify the psycho-neuroses? What is the basis upon which it constructs its nosology? The answer is simple: it distinguishes the disease groups according to the special way in which the ‘complexes’ that have been warded off and have returned from repression manifest themselves as symptoms of disease. The patient suffering from obsessional neurosis knows how to displace the affective value of the complex ideas upon other but more harmless thoughts. In this way apparently quite meaningless obsessional ideas are formed that constantly obtrude themselves.

The hysteric goes still further; he can suffer amongst his thoughts not even these harmless substitutes for the repressed instinctive impulses, and creates a symbol for them in his physical body. He therefore represents by means of motor and sensory symptoms both the desires that are unable to become conscious as well as the defence set up against them. Hysterical anæsthesias, pains, paralyses, and spasms are nothing but symbols of repressed thoughts.

There are other forms of defence against unpleasant ideational complexes. In paranoia, for instance, the patient simply sets the ideas that have become insupportable free from his ‘ego’ and projects them upon other people.

The boundary between ‘ego’ and external world can be displaced; the tendency to attribute unpleasant ideas to others is often seen, even in healthy people. The paranoiac does the same, but of course to a far greater extent. Instead of acknowledging certain forms of love and hate in himself, he allows himself to consider that these feelings and thoughts, which are insupportable for his self-regard, are whispered in his ear by invisible spirits, or he reads them in the countenances or the movements of his fellow-men.

We find a fourth form of self-defence against the complexes referred to in dementia præcox. Since the fundamental work of Jung and Abraham, we know that people who suffer from this trouble do not dement in the sense that they are incapable of logical thought, but that they withdraw their libido so completely from the external world that, so to say, it ceases to exist for them.

The dement transfers the whole of the interest and the affective cathexis that he withdraws from the external world to himself; hence his childish ideas of megalomania, his infantile habits, the revival of auto-erotic forms of gratification, the recklessness in regard to cultural requirements, particularly his utter disregard and carelessness of the external world.

All the kinds of flight from unpleasant ideas referred to are found also in ‘normal’ people. The bodily manifestations of ‘normal’ emotional outbursts have much in common with hysteria; a lover can transfer his love affect to every object, to every person who has an associative connection with the real object of his feelings, and this has no more meaning than an obsessional neurotic displacement of affect; does not the distrustful and the jealous person often simply project the idea of his own good-for-nothingness or unlovableness upon others? and if anyone has been deceived in people, does he not become an egoist, a person turned in upon himself who observes, without sharing, the labour and toil of others, whose sole interest is in his own well-being, his own bodily and mental gratification?

The famous saying of Brücke the physiologist, ‘disease is only life under changed conditions’, applies also, therefore, to the psycho-neuroses. Functional psychoses and psycho-neuroses are distinguished from normal mental activity only by a matter of degrees.

A few words now about the ætiology of these neuroses. No amount of brain anatomy could dissuade novelists, who view life naïvely but with sharp eyes, from the idea that mental excitement of itself was capable of occasioning a mental illness. While we doctors were thrashing the empty straw of physiological catchwords, Ibsen in his ‘Lady from the Sea’ had made an almost faultless psycho-analysis, by which he exposed the origin of an obsessional idea in a psychic conflict. Johann Arany’s¹ ‘Die Frau Agnes’, who constantly washes her white linen cloth in the stream, suffers from dementia præcox, and her stereotypy in the ballad tragedy finds the same explanation as has been given at the Zürich clinic for the stereotyped actions of many mental patients. Lady Macbeth’s washing obsession has become much more plausible since we have convinced ourselves that our neurotics would also fain wipe away the moral stains from their consciences by the same obsessional actions. Formerly the man of science often made merry over the naïveté of the novelist-poet who, when puzzled for an ending, simply made his hero mad, and now to our shame we have to acknowledge that it was not the scholars but the naïve poets who were right. Psycho-analysis showed us that an individual who finds no way out of his mental conflicts takes refuge in a neurosis or a psychosis. In view of the short-sightedness of the professional wiseacres who might overlook this, one is tempted to agree once more with Lichtenberg who in this connection declared ‘professional people often do not know what is best’.

Before psycho-analysis the question of the ætiology of functional mental disease was considered to be answered by the catchword ‘hereditary stigma’. But just as it was premature and of no avail to force the solution of the problem of the neuroses by means of cerebral anatomy, physics, and chemistry, so also it was very premature to invoke hereditary disposition in explanation of the ætiology of the neuroses before the possibilities of the post-natal influences leading to disease had been exhausted. It is, of course, unquestioned that heredity plays an important part in the origin of mental disease. But as yet we know absolutely nothing about these temperamental factors,¹ so that to trace the neuroses to ‘degeneration’ is equivalent to a confession of complete ignorance as to their pathology and of helplessness as to their therapy. According to the psycho-analytic view, no one is completely secure against a too powerful or too prolonged emotional strain or shock, the only significance of temperament being that the individual who is severely taxed from birth is damaged by lesser, and the more robustly constituted by greater shocks. Of course psycho-analysis recognizes the possibility that inherited factors can also influence the particular form of neurosis. Freud compares the inheritance of the neuroses with that of tuberculosis. Just as in inherited tuberculosis, a thorough examination often shows that one has to deal with an infection acquired in childhood from a diseased environment and not merely with a congenital organic weakness; in the same way, in the case of children of neurotic parents, we must, along with heredity, attribute great importance also to the abnormal mental impressions to which they have been exposed since earliest childhood. Every boy and every girl longs to be father or mother respectively, and we need not be surprised if the children appropriate not only the real or supposed advantages of their parents but also their peculiarities and neurotic symptoms.

That psycho-neurosis is more frequent among women is comprehensible when we consider the difference in degree of the cultural pressure that weighs upon the two sexes. Much is permitted to men in youth that is denied to women not only in reality but also in fantasy. Marriage, too, knows two moralities, of which one applies to the husband and the other to the wife. Society punishes sexual lapses much more strictly in women than in men. The periodic pulsations in feminine sexuality (puberty, the menses, pregnancies and parturitions, the climacterium) require a much more powerful repression on the woman’s part than is necessary for the man. All this increases the incidence of the psycho-neuroses among them. Women are in overwhelmingly the greater number, especially among the hysterics, while men take refuge rather in obsessional neuroses. As regards paranoia and dementia, there are no reliable data as to how they are divided according to sex; my own personal impression is that paranoia finds its victims more among men and dementia more among women.

In what I have said I have given you a sketch—very rough and primitive, to be sure—of the psycho-analytic theory of the neuroses. I am aware, however, that as practitioners you expect from me some orientation towards therapeutic procedures hitherto in use, and at least some suggestions about analytic therapy.

This is really not so much a matter of course. ‘Why does one not demand’, asks Dietl, ‘of the astronomer that he should change day into night, of the meteorologist cold winter into hot summer, of the chemist water into wine?’ and with what right does one demand precisely of the doctor that he should concern himself with the linking-up of the causes of the intricate processes of life and should change the diseased condition of the most complicated of nature’s creatures—of man—into health? Happily scientific brooding over this question only came about when medical treatment had been at work already for thousands of years and could point to really significant successes. After all, ‘healing is the oldest handicraft and the youngest science’ (Nussbaum). Were it otherwise, and had we to base our attempts at treatment not on a rough empiricism but on logical deduction, we would not even now be so daring as merely to attempt the difficult task of healing. In the therapy of the psycho-neuroses also, action far outstripped thought. After what has been mentioned above we are still only at the beginning of the road in progress along which we hope to win a more definite idea of the nature of the neuroses, and yet already the books concerned with their therapy are sufficient to fill a library. How then does the neurologist, who is also at home with psycho-analysis, stand in regard to the matter of therapy? Biegansky’s book Logik in der Heilkunde (Logic in Medical Science), to which, of course, every special branch of medicine must submit, sets up as the therapeutic signpost the not quite new but undoubtedly correct principle that a method of treatment is only right in so far as it persecutes the noxious and encourages the beneficial symptoms. This is the idea of pathological teleology; it rests on the basis of a theory of purpose according to which only some of the symptoms are considered noxious, while others are the expression of an automatic repairing and compensatory tendency. It is, therefore, not reasonable to want blindly to ‘cure’ the symptoms of the disease. We are only fitted for our task when we endeavour to assist, so far as in us lies, the diseased organism’s attempts at self-cure.

It is to be assumed that the hitherto purely empiric therapy of the neuroses achieved success in those cases in which the doctor, even if not fully consciously, succeeded in imitating the automatic healing tendencies of nature. The symptoms, too, of the psycho-neuroses are often ‘teleologically’ understandable. The patient who displaces unpleasant ideas, converts them into bodily symptoms, projects them into the external world or withdraws himself from them into his ‘ego’, strives in this way for a state of mental peace and insensibility. In paranoia and dementia the escape from painful stimulation is so completely successful that, according to our present experience, these two afflictions are therapeutically quite inaccessible. The distrust of the insane, the lack of interest of the dement, rendered any influencing of the mental condition impossible. In hysteria and obsessional neurosis, however, pre-analytic therapy, too, had many, even if mostly impermanent, successes to record. Many patients became well when they were removed out of their surroundings to another milieu, but they mostly relapsed again when they had to return to the old environment. In many cases it was possible more or less to achieve a success by improving nutrition and strengthening the physical condition. But even in these cases it was constantly to be feared that if later for any reason the organic powers of resistance were again lowered, the mental disease, the seeds of which had not been eradicated, would burst forth afresh. Also, we only understand the usually ephemeral success of change of surroundings since psycho-analysis has been able to establish that the repressed pathogenic ideas of the neurotic usually refer to individuals of his nearest environment, and that the doctor is only imitating the patient’s instinctive aversion to his complexes when he removes him from his home, in which the pathogenic ideational groups can get no peace.

Amongst the various methods of psycho-therapy the worst proceeding is the so-called ‘encouraging’ and ‘explanatory’ one. We tell the patient in vain that his trouble is not ‘organic’, that he is not but only feels as if he were ill; we explain in vain that he only needs to make use of his will—we only deepen the patient’s despair by all this. If we smile at Münchhausen mendaciously relating that he drew himself and his horse out of the swamp by his own hair, we should not require of the neurotic that he should ‘pull himself together’. Dubois’s moralizing procedure merits the same criticism. I will only touch briefly here on the question of hypnosis and suggestion, and remark forthwith that some successes are to be achieved by these means. Charcot already explained that hypnosis is a kind of artificial hysteria, and psycho-analysis further supported this by confirming that suggestion, whether employed during hypnosis or in the waking state, merely suppresses the symptoms, i.e. it employs the method in which the hysteric failed in his wish for self-cure. The ideational group occasioning the disease remains untouched by the treatment in the unconscious of the neurotic whose symptoms we strangled by hypnotism. Indeed in a certain sense it is enlarged, that is, the hitherto existing symptoms are now joined by a new one that can certainly for a time prevent the expression of pre-existing symptoms. When the force of the suggested prohibition weakens (and for this it suffices that the patient leave the doctor’s environment), the symptoms may immediately manifest themselves again. I regard hypnosis and suggestion as usually safe and harmless methods of treatment, but as holding out little promise of success, and their employment, moreover, is much circumscribed by the fact that only quite a small number of people can really be hypnotized.

Sanatorium treatment combines the advantages of change of surroundings with those of suggestion. The chief means of sanatorium treatment is the pleasant, impressive appearance, the amiability or severity of the doctor. Women particularly show an exalted enthusiasm for the person of the sanatorium doctor, and for love of him can even suppress their hysterical moods. Once they have reached home again, however, the spell soon vanishes. The habit of living in sanatoria can itself become a kind of disease that might be called sanatorium-disease; many people are by it completely estranged from their homes and occupations.

Occupational therapy, physical and mental work, is an approved method of treating the psycho-neuroses; it also assists a flight from the tormenting mental conflicts. Unfortunately in the severe cases the patient is usually incapable of directing to more useful ends the energy that he squanders upon his symptoms.

Electricity, massage, baths, etc., are only vehicles for suggestion, and only deserve mention as such in the therapy of the psycho-neuroses.

Anti-neurotic medicaments fall into two groups. The narcotics (bromides, opium, etc.) stun the patient for a time, and with the mental alertness diminishes also for a period the force with which the symptoms are manifested. If the patient becomes habituated to them, or if they are stopped, the symptoms return. In principle, then, one cannot approve of the dealing out of drugs, even if one is sometimes compelled to have recourse to them. The so-called specific cures for the neuroses are mostly completely inactive drugs, or at best they act by suggestion.

If we glance over the methods and means of treatment so far discussed, we do actually see that those that have some effect are those that succeed in strengthening the tendency to self-cure, the repression. This effect, however, cannot be permanent, because the conflict giving rise to the disease remains unresolved concealed in the unconscious, and as soon as external circumstances become less favourable makes itself felt again.

Psycho-analysis, on the contrary, is a proceeding that seeks to cure neurotic conflict not by a fresh displacement or temporary repression, but radically. It endeavours not to tie up psychic wounds but to lay them bare, to render them conscious. Of course, not without ‘re-educating’ the patient, and accustoming him to endure the painful ideas instead of fleeing from them to disease. This psychic method of treatment is in many cases successful. It certainly usually takes many months to get there, even if the doctor occupies himself with the patient daily for an hour. The interpretation of the ideas cropping up in ‘free association’, the analysis of dreams and of the symptoms themselves, gradually makes the patient intimate with the hitherto unconscious part of his ideational life, with, so to say, his second ‘ego’, which so long as it was not under the control of consciousness was able to disturb the mental functions.

The fullest possible knowledge of one’s self attained by analysis is what makes it possible to render the disease-causing complexes innocuous, that is, to subject them to the control of reason.

The laying bare of the buried layers of the mind not only increased the understanding of the pathological nature of the psycho-neuroses; not only opened up new passable roads to treatment, but made the prophylaxis of these afflictions more hopeful. What had hitherto been scribbled about prophylaxis for the neuroses could have no more meaning in our ignorance of the real pathogenesis of these troubles than the ordinance of the village magistrate that the casks were to be filled with water three days before every conflagration. Real prophylaxis for the psycho-neuroses is only to be hoped for from a change in educational methods, and in social arrangements that will confine repression to the unavoidable minimum.

All the facts and theories with which I have acquainted you in the present lecture are still subjects of fierce controversy amongst the learned men, and then really only the theoretical conclusions—for the opponents of Freud’s psychology mostly confine themselves to announcing the improbability of his statements: as a rule they do not undertake the irksome task of inquiring into their actuality.

Psycho-analysis occupies itself with excavating hidden archaic memorials in the depths of the mind; from them it deciphers the hieroglyphs of the neuroses. Only those have the right to sit in judgement on those researches who learn to read the hieroglyphs, certainly not those who base their opinions on prejudices or on judgements of moral values.

¹ From a series of lectures delivered in 1908 to the Budapest Medical Association. Published in Populäre Vorträge über Psychoanalyse.

¹ A noted Hungarian epic poet and ballad writer.

¹ This sentence, thanks to psycho-analytic researches, does not hold good any longer to-day. (Note added when correcting the [German] proofs.)—S. F.

II

ACTUAL- AND PSYCHO-NEUROSES IN THE LIGHT OF FREUD’S INVESTIGATIONS AND PSYCHO-ANALYSIS¹

ON the occasion of the third Hungarian Psychiatric Congress in Budapest I delivered several years ago a lecture on ‘neurasthenia’, in which I asked for the correct nosological classification of this far too varied clinical picture, this cloak for so many wrong or wanting diagnoses. And although I was in the right when I maintained that real exhaustion neurasthenia is to be sharply distinguished from all other nervous states, amongst others from those only explicable on psychiatric grounds, nevertheless I made a mistake difficult to remedy when I left out of account Professor Freud’s investigations of the neuroses. This omission was all the greater as I was acquainted with Freud’s work. Already in 1893 I had read the paper he wrote, along with Breuer, concerning the psychic mechanism of hysterical symptoms, and, later, another independent paper in which he discusses infantile sexual dreams as the causes or starting-points for the psycho-neuroses. To-day, when I have convinced myself in so many cases of the correctness of Freud’s theories, I may well ask myself why did I reject them so rashly at that time, why did they from the first seem to me improbable and artificial, and particularly, why did the assumption of a purely sexual pathogenesis of the neuroses rouse such a strong aversion in me that I did not even honour it with a closer scrutiny? In excuse I must at any rate mention that by far the greater number of men of my profession, amongst them men of the eminence of Kraepelin and Aschaffenburg, take up a similar standpoint even to-day in opposition to Freud. The few, however, who nevertheless did attempt later to solve the peculiar problems of the neuroses by means of Freud’s laborious methods, became enthusiastic followers of the hitherto quite unnoticed movement.

However tempting it would be, nevertheless I cannot undertake to recount the history of the development of Freud’s line of thought, and to relate how Breuer and Freud discovered in the peculiarities, which might have been regarded simply as accidents, of a case of hysteria psychic manifestations of general validity destined to play a part of inestimable importance in the future development of normal and pathological psychology. Here, too, I must deny myself accompanying Freud any further, who henceforth paces solitary the laborious way by which he attained his present standpoint. I content myself with elucidating, in so far as it is possible in a lecture, the main points of his theory and their significance by examples taken from life.

One of the fundamental principles of the new teaching is that sexuality plays a specific part in the neuroses, that most neuroses are at bottom nothing else than screen-symptoms of an abnormal vita sexualis, and that these abnormalities and the manifestations of disease in the neuroses are only rendered comprehensible and, on the basis of this comprehension, accessible to treatment, by being unmasked.

As the first group of the neuroses Freud distinguishes that nervous condition in which any actual irregularity in the physiology of the sexual function acts as the cause of disease without the assistance of psychological factors. Two diseased conditions belong to this group to which Freud gives the name of ‘actual-neuroses’, but which in contrast to the psycho-neuroses might also be called physio-neuroses. These are neurasthenia in the narrower sense, and a sharply circumscribed group of symptoms entitled anxiety-neuroses.

If we separate out from the cases of illness hitherto designated as neurasthenia everything that should be relegated to other, more natural nosological classifications, there remain behind a well-characterized group in which there predominate, pressure in the head, spinal irritation, constipation, paræsthesias, diminished potency, and from the effect of these conditions, a depression of spirits. Freud found excessive masturbation to be the causal factor of neurasthenic neurosis in this narrower sense. To forestall the immediate objection of banality, I emphasize that we are dealing here with an excessive onanism mostly continued long after puberty, therefore not merely with the ordinary onanism of childhood. The latter is, according to my experience, so widely distributed that I am more inclined to doubt an individual’s normality from an entire absence of auto-erotic antecedents.

The estimation of the ætiological significance of onanism is constantly fluctuating; at the crest of the wave it is assumed to be the cause of tabes, in the trough to be completely innocuous. I agree with those who estimate the significance of onanism neither too high nor too low, and can confirm from my own observations that in neurasthenia, in Freud’s sense, excessive self-gratification is never absent and is a sufficient explanation for the signs of the disease.

Here I must at once say that this directly neurasthenic effect of masturbation is not so damaging as is the mental distress that is its consequence. People suffer unspeakably from the consciousness of the supposed harmfulness and immorality of these acts of onanism. Most frequently they endeavour to suppress this passion, but while they are escaping the Charybdis of neurasthenia they may suffer shipwreck on the Scylla of an anxiety-neurosis or of a psycho-neurosis.

Masturbation is a pathogenic factor because it endeavours to lower the organism’s sexual tension by means of worthless surrogates, or, as Freud says, by an inadequate discharge. This form of gratification, when excessive, exhausts the neuro-psychic sources of energy. Normal intercourse is a complicated but nevertheless reflex process, the reflex arcs passing mainly only through the spinal cord and the subcortical centres, although the higher psychical centres also play a part. In masturbation, on the contrary, where the external stimuli are so meagre, the erection and ejaculation centres borrow chiefly from phantasy (from a source of psychic energy therefore) the degree of tension needed to set the reflex mechanism going. It is comprehensible that such a willed gratification requires a greater consumption of energy than the almost unconscious act of coitus.

In the second form of actual-neurosis, the anxiety-neurosis of Freud, we find the following symptom-complex: general irritability, which shows itself mostly in sleeplessness and auditory hyperæsthesia; a peculiar chronic anxious expectation, for instance, persistent anxiety about one’s own health or safety as well as about that of one’s relations; anxiety attacks with cardiac or respiratory difficulties, with vasomotor and secretory disturbances that make the patient dread cardiac failure and cerebral hæmorrhage. The anxiety attacks may be rudimentary in form—attacks of sweating, palpitations, sudden attacks of hunger, or diarrhœa. Sometimes they may be manifested only in anxiety-dreams and night terrors. Fits of giddiness often play a great part in anxiety-neurosis; they may be so serious that they interfere more or less with the patient’s liberty of movement. The great majority of agoraphobias are really the remote results of such attacks of giddiness; the patient is afraid to go about, that is, he dreads that he may be surprised by an anxiety attack on the open street. The phobia is like a protective measure against the anxiety, but the anxiety itself is a manifestation explicable on purely physiological lines and psychologically not further analysable.

The much misused name of hysteria or neurasthenia could easily be applied to all these anxiety symptoms and symptom-complexes had Freud not succeeded in demonstrating their ætiological unity. Anxiety-neuroses occur whenever sexual libido is separated in any way from the psyche. It is one of the most important of Freud’s discoveries that this keeping of the psyche apart from the libido makes itself felt subjectively as anxiety, and therefore sexual excitement that is withheld from orgasm evokes physiological effects, the psychological correlate of which is anxiety. In this respect anxiety-neurosis stands in diametrical opposition to masturbatory neurasthenia, where we are dealing with an excessive demand upon psychic cathexis for a process that would naturally evolve automatically. By means of a comparison borrowed from physics we could draw an analogy between neurotic anxiety, the transformation of pleasure into anxiety on exclusion of the psychical, with the transformation of electricity into heat on the narrowing of its channel. In any case Freud is not pledged to a physical but to a chemical explanation of the actual-neuroses; he regards them as a chronic intoxication by sexual substances.

Virginal anxiety is one of the best known forms of anxiety-neurosis described by Freud. It arises from the fact that the unprepared psyche cannot associate itself with the libido on the occasion of the first sexual experiences. Very often anxiety-neurosis is a result of frustrated excitement, which frequently occurs in the case of engaged couples. Severer forms of anxiety-neurosis are caused in men by coitus interruptus and in women by the absence of orgasm due to ejaculatio præcox, which, in the man, again, is mostly the result of masturbation. Considering the tremendous prevalence of premature seminal discharge it is not to be wondered at that the combination, neurasthenic husband and nervously anxious wife, is so extraordinarily frequent. Besides the constant coincidence of one of these troubles with anxiety-neurosis, therapeutic success also vouches for Freud’s accuracy when he declared the specific cause of anxiety-neurosis to be the separation of libido from the psyche. For if the hurtful conditions or disturbances are corrected the symptoms of anxiety-neurosis vanish too. The cure for virginal anxiety is habituation, that for the other anxiety-neuroses is abstention from unsuitable forms of gratification; the wife’s anxiety very often disappears if the husband’s potency is increased. Even the severest cases of these neuroses, in which every known sedative has failed, recover if the sexual difficulties are dealt with. This discovery of Freud’s therefore not only extends our insight into the genesis of many nervous conditions, it also puts us in a position to base a rational and effective therapy upon this insight.

The second, more difficult chapter of the Freudian theory, his conception of the psycho-neuroses, discards the chemico-mechanistic and anatomico-physiological basis; Freud can explain them only psychologically.

He considers two diseased conditions, hysteria and obsessional neurosis, as belonging to this group.

The obsessional neuroses are nowadays mostly ranked among the ‘neurasthenias’; on the other hand it has long been known of hysteria that it is a psychogenic neurosis the symptoms of which are caused by psychological automatisms. But however much they have increased neurological knowledge in this connection, by observations and experiments, writers have nevertheless not succeeded in reviewing the varying clinical aspects of hysteria from one uniform point of view. Nor could they explain what it was that in one patient determined this and in another that group or series of hysterical symptoms. So long, however, as this could not be done, every case of hysteria like the sphinx merely asked questions that were unanswerable. While, however, the sphinx gazes with inflexible calm into infinity, hysteria is never done distorting her face—as though she meant to mock our ignorance—into remarkable and always unexpected grimaces. This illness finally becomes a torment, not only for the sufferer, but for the doctor and those of the environment as well. The doctor soon wearies of changing and combining medicaments and Spa treatments, he gives up the ephemeral successes of suggestion and longingly awaits the summer when hysterical patients can be sent away—the farther the better—into the country. But even if they return improved, on the first occasion of any serious psychic excitement a relapse indubitably takes place. This goes on for years and decennia until no practical doctor any longer believes in the benign course of hysteria so esteemed in the text-books. In these circumstances Freud’s evangel of the discovery of the real key to hysteria proclaims a veritable release for doctors and patients.

Breuer was the first who succeeded in tracing the disease manifestations of a hysterical patient to psychic traumata, to psychic shocks of which the patient had no memory but the memory pictures of which together with the corresponding affect lurked in the unconscious and, enclosed in the mind like a foreign body, evoked permanent or recurrent states of excitement in the neuro-psychic domain. Breuer and Freud succeeded in many cases of hysteria in showing by means of hypnotic hyperamnesia that the disease manifestations were really the symbols for such latent memories. If on waking the patient was consciously reminded of the antecedents thus discovered, the immediate result was an affective outburst, after the full discharge of which, however, the symptoms vanished. According to Breuer and Freud’s original idea the locking up of affect was due to the subject being prevented at the moment of psychic shock from reacting by an adequate motor discharge in speech, gesture, mimicry, tears, laughter, or the movements expressive of anger or hate, or by dispersing these feelings along ideational associative paths. The feelings belonging to the unconscious memory thus left undischarged in the psyche were then able to radiate into the bodily sphere, to ‘convert’ themselves into hysterical symptoms. The treatment—called ‘catharsis’ by these authors—afforded the patient opportunity to recapture what he had lost, to ‘abreact’ the undischarged feelings, whereupon the pathogenic influences of the now conscious and effect-free memory ceased.

From this seed sprang psycho-analysis, the Freudian method of psychic investigation. This procedure renounces hypnotism and is employed with the patient in the waking state. This renders it applicable to a larger number of patients, and at the same time disposes of the objection that the results achieved by the analysis depend upon suggestion.

In explaining the meaning of this proceeding we may start with Freud’s view of forgetting.

Freud made the remarkable discovery that not all forgetting is due to the natural fading of memory-traces with time, but that we are unable to recall many impressions only because a critical factor in the mind, a censorship, succeeds in suppressing below the conscious threshold the idea that is irksome or insupportable to consciousness. This defensive proceeding Freud calls repression and adduces proof that many normal and morbid psychic processes are comprehensible only on the assumption of this mechanism. Nevertheless, repression as well as the permanent suppression of unpleasant memories is hardly ever completely successful; the struggle between the repressed thought-complexes endeavouring to reproduce themselves and the censorship repressing them, usually ends in a compromise; the complex as such remains forgotten (unconscious), but is replaced in consciousness by some superficial association or other. As such substitutes or symbols for complexes Freud instanced free ideas, that is, the thoughts which irrupting into logical thought series suddenly crop up in consciousness apparently quite disconnectedly. For instance, experiences of childhood are almost completely forgotten. If one wishes to recall them ridiculously trivial, unimportant, and innocuous matters recur to one. We should be unable to say why our memory should have been burdened with them had Freud not successfully shown that these memories are ‘screen memories’ for much more significant and usually not in the least innocuous childish impressions. Hidden complexes, besides screen memories, may be suspected, too, behind apparently insignificant disturbances of speech and movement (slips of the tongue, clumsiness, mislaying things), as well as behind certain stereotyped playful meaningless movements (Freud’s ‘symptomatic acts’).

Jung has shown experimentally that in so-called free association to stimulus words every ‘disturbed’ reaction (prolongation of the reaction time, ‘indirect’ or otherwise remarkable reaction words, forgetting the reaction word on reproducing the test, etc.) proves on closer analysis to be constellated by a ‘complex’. On observing the reactions simultaneously with the variations in intensity of a weak galvanic current led through the body, Jung found every time at the ‘complex reactions’ a rise in the curve which had to be interpreted as indicating a variation in electrical resistance caused by the liberation of affect. Jung now starts his analyses with the stimulus words of the complex reactions thus found and shows that the ideas associated with such words lead easily and rapidly to pathogenic groups