Freud - Complete Works (54 page)

   Furthermore, the aetiological
theories supported by Charcot in his doctrine of the
‘
famille névropathique
’, which he made
the basis of his whole concept of nervous disorders, will no doubt
soon require sifting and emending. So greatly did Charcot
over-estimate heredity as a causative agent that he left no room
for the acquisition of nervous illness. To syphilis he merely
allotted a modest place among the ‘
agents
provocateurs
’; nor did he make a sufficiently sharp
distinction between organic nervous affections and neuroses, either
as regards their aetiology or in other respects. It is inevitable
that the advance of our science, as it increases our knowledge,
must at the same time lessen the value of a number of things that
Charcot taught us; but neither changing times nor changing views
can diminish the fame of the man whom - in France and elsewhere -
we are mourning to-day.

VIENNA
,
August 1893.

285

ON THE PSYCHICAL MECHANISM OF HYSTERICAL PHENOMENA: A LECTURE

(1893)

286

Intentionally left blank

287

ON THE PSYCHICAL MECHANISM OF HYSTERICAL PHENOMENA ¹

Gentlemen, - I am appearing before you to-day
with the object of giving you a report on a work the first part of
which has already been published in the
Zentralblatt für
Neurologie
under the names of Josef Breuer and myself. As you
may gather from the title of the work, it deals with the
pathogenesis of hysterical symptoms and suggests that the immediate
reasons for the development of hysterical symptoms are to be looked
for in the sphere of psychical life.

   But before I enter further into
the contents of this joint work, I must explain the position it
occupies and name the author and the discovery which, in substance
at least, we have taken as our starting point, although our
contribution has been developed quite independently.

   As you know, Gentlemen, all the
modern advances made in the understanding and knowledge of hysteria
are derived from the work of Charcot. In the first half of the
eighties, Charcot began to turn his attention to the ‘major
neurosis’, as the French call hysteria. In a series of
researches he has succeeded in proving the presence of regularity
and law where the inadequate or half-hearted clinical observations
of other people saw only malingering or a puzzling lack of
conformity to rule. It may safely be said that everything new that
has been learnt about hysteria in recent times goes back directly
or indirectly to his suggestions. But among Charcot’s
numerous works, none, in my estimate, is of higher value than the
one in which he taught us to understand the traumatic paralyses
which appear in hysteria; and since it is precisely this work of
which ours appears as a continuation, I hope you will allow me to
lay this subject before you once again in some detail.

   ¹
A lecture delivered by Dr. Sigm. Freud at a
meeting of the ‘Wiener medizinischer Club’ on January
11, 1893. Special shorthand report by the
Wiener medizinische
Presse
, revised by the lecturer.

On The Psychical Mechanism Of Hysterical Phenomena

288

   We will take the case of a person
who is subjected to a trauma without having been ill previously and
perhaps without ever having any hereditary taint. The trauma must
fulfil certain conditions. It must be severe - that is, it must be
of a kind involving the idea of mortal danger, of a threat to life.
But it must not be severe in the sense of bringing psychical
activity to an end. Otherwise it will not produce the result we
expect from it. Thus, for instance, it must not involve concussion
of the brain or any really serious injury. Moreover, the trauma
must have a special relation to some part of the body. Let us
suppose that a heavy billet of wood falls on a workman’s
shoulder The blow knocks him down, but he soon realizes that
nothing has happened and goes home with a slight contusion. After a
few weeks, or after some months, he wakes up one morning and
notices that the arm that was subjected to the trauma is hanging
down limp and paralysed, though in the interval, in what might be
called the incubation period, he has made perfectly good use of it.
If the case is a typical one, it may happen that peculiar attacks
set in - that, after an aura, the subject suddenly collapses,
raves, and becomes delirious; and, if he speaks in his delirium,
what he says may show that the scene of his accident is being
repeated in him, embellished, perhaps, with various imaginary
pictures. What has been happening here? How is this phenomenon to
be explained?

   Charcot explains the process by
reproducing it, by inducing the paralysis in a patient
artificially. In order to bring this about, he needs a patient who
is already in a hysterical state; he further requires the condition
of hypnosis and the method of suggestion. He puts a patient of this
kind into deep hypnosis and gives him a light blow on the arm. The
arm drops; it is paralysed and shows precisely the same symptoms as
occur in spontaneous traumatic paralysis. The blow may also be
replaced by a direct verbal suggestion: ‘Look! your arm is
paralysed!’ In this case too the paralysis exhibits the same
characteristics.

On The Psychical Mechanism Of Hysterical Phenomena

289

   Let us try to compare the two
cases: on the one hand a trauma, on the other a traumatic
suggestion. The final result, the paralysis, is exactly the same in
both cases. If the trauma in the one case can be replaced in the
other case by a verbal suggestion, it is plausible to suppose that
an idea of this kind was responsible for the development of the
paralysis in the case of the spontaneous traumatic paralysis as
well. And in fact a number of patients report that at the moment of
the trauma they actually had a feeling that their arm was smashed.
If this were so, the trauma could really be completely equated with
the verbal suggestion. But to complete the analogy a third factor
is required. In order that the idea ‘your arm is
paralysed’ should be able to provoke a paralysis in the
patient, it was necessary for him to be in a state of hypnosis. But
the workman was not in a state of hypnosis. Nevertheless, we may
assume that he was in a special state of mind during the trauma;
and Charcot is inclined to equate that affect with the artificially
induced state of hypnosis. This being so, the traumatic spontaneous
paralysis is completely explained and brought into line with the
paralysis produced by suggestion; and the genesis of the symptom is
unambiguously determined by the circumstances of the trauma.

   Charcot has, moreover, repeated
the same experiment in order to explain the contractures and pains
which appear in traumatic hysteria; and in my opinion there is
scarcely any point at which he has penetrated into the
understanding of hysteria more deeply than here. But his analysis
goes no further: we do not learn how other symptoms are generated,
and above all we do not learn how hysterical symptoms come about in
common, non-traumatic hysteria.

   At about the same time,
Gentlemen, at which Charcot was thus throwing light on
hystero-traumatic paralyses, Dr. Breuer between 1880 and 1882,
undertook the medical care of a young lady who - with a
non-traumatic aetiology - fell ill of a severe and complicated
hysteria (accompanied by paralyses, contractures, disturbances of
speech and vision, and psychical peculiarities of every kind),
while she was nursing her sick father. This case will retain an
important place in the history of hysteria, since it was the first
one in which a physician succeeded in elucidating all the symptoms
of the hysterical state, in learning the origin of each symptom and
at the same time in finding a means of causing that symptom to
disappear We may say that it was the first case of hysteria to be
made intelligible. Dr. Breuer kept back the conclusions which
followed from this case till he could be certain that it did not
stand alone. After I returned, in 1886, from a course of study
under Charcot, I began, with Breuer’s constant co-operation,
to make close observations on a fairly large number of hysterical
patients and to examine them from this point of view; and I found
that the behaviour of this first patient had in fact been typical
and that the inferences which were justified by that case could be
carried over to a considerable number of hysterical patients, if
not to all.

On The Psychical Mechanism Of Hysterical Phenomena

290

   Our material consisted of cases
of common, that is of non-traumatic, hysteria. Our procedure was to
take each separate symptom and enquire into the circumstances in
which it had made its first appearance; and we endeavoured in this
way to arrive at a clear idea of the precipitating cause that
symptom. Now you must not suppose that this is a simple job. If you
question patients along these lines, you will as a rule receive no
answer at all to begin with. In a small group of cases the patients
have their reasons for not saying what they know. But in a greater
number of cases the patients have no notion of the context of their
symptoms. The method by which something can be learnt is an arduous
one. It is as follows. The patients must be put under hypnosis and
then questioned as to the origin of some particular symptom - as to
when it first appeared and what they remember in that connection.
While they are in this state, the memory, which was not at their
disposal in a waking state, returns. We have learnt in this manner
that, to put it roughly, there is an affectively coloured
experience behind most, if not all, phenomena of hysteria; and
further, that this experience is of such a kind that it at once
makes the symptom to which it relates intelligible and shows
accordingly that the symptom, once again, is unambiguously
determined. If you will allow me to equate this affectively
coloured experience with the major traumatic experience underlying
traumatic hysteria, I can at once formulate the first thesis at
which we have arrived: ‘
There is a complete analogy
between traumatic paralysis and common, non-traumatic
hysteria
.’ The only difference is that in the former a
major trauma has been operative, whereas in the latter there is
seldom a
single
major event to be signalized, but rather a
series
of affective impressions - a whole story of
suffering. But there is nothing forced in equating such a story,
which appears as the determining factor in hysterical patients,
with the accident which occurs in traumatic hysteria. For no one
doubts any longer to-day that even in the case of the major
mechanical trauma in traumatic hysteria what produces the result is
not the mechanical factor but the affect of fright, the
psychical
trauma. The first thing that follows from all
this, then, is that the pattern of traumatic hysteria, as it was
laid down by Charcot for hysterical paralyses, applies quite
generally to all hysterical phenomena, or at least to the great
majority of them. In every case what we have to deal with is the
operation of psychical traumas, which unambiguously determine the
nature of the symptoms that arise.

On The Psychical Mechanism Of Hysterical Phenomena

291

   I will now give you a few
instances of this. First, here is an example of the occurrence of
contractures. Throughout the whole period of her illness,
Breuer’s patient, whom I have already mentioned, exhibited a
contracture of the right arm. It emerged under hypnosis that at a
time before she had fallen ill she was subjected to the following
trauma. She was sitting half-dozing at the bedside of her sick
father; her right arm was hanging over the back of her chair and
went to sleep. At this moment she had a terrifying hallucination;
she tried to fend it off with her arm but was unable to do so. This
gave her a violent fright, and for the time being the matter ended
there. It was not until the outbreak of her hysteria that the
contracture of the arm set in. In another woman patient, I observed
that her speech was interrupted by a peculiar
‘clacking’  with her tongue, which resembled the
cry of a capercaillie. I had been familiar with this symptom for
months and regarded it as a
tic
. It was only after I once
happened to question her under hypnosis about its origin that I
discovered that the noise had first appeared on two occasions. On
each of these she had made a firm decision to keep absolutely
quiet. This happened once when she was nursing a child of hers who
was seriously ill. (Nursing sick people often plays a part in the
aetiology of hysteria.) The child had fallen asleep and she was
determined not to make any noise that might wake it. But fear that
she might make a noise turned into actually making one - an
instance of ‘hysterical counter-will’;  she
pressed her lips together and made the clacking noise with her
tongue. Many years later the same symptom had arisen a second time,
once again when she had made a decision to be absolutely quiet, and
it had persisted ever afterwards. A single precipitating cause is
often not enough to fixate a symptom; but if this same symptom
appears several times accompanied by a particular affect, it
becomes fixated and chronic.

On The Psychical Mechanism Of Hysterical Phenomena

292

   One of the commonest symptoms of
hysteria is a combination of anorexia and vomiting. I know of a
whole number of cases in which the occurrence of this symptom is
explained quite simply. Thus in one patient vomiting persisted
after she had read a humiliating letter just before a meal and had
been violently sick after it. In other cases disgust at food could
be quite definitely related to the fact that, owing to the
institution of the ‘common table’, a person may be
compelled to eat his meal with someone he detests. The disgust is
then transferred from the person to the food. The woman with the
tic
whom I have just mentioned was particularly interesting
in this respect. She ate uncommonly little and only under pressure.
I learnt from her in hypnosis that a series of psychical traumas
had eventually produced this symptom of disgust at food. While she
was still a child, her mother, who was very strict, insisted on her
eating any meat she had left over at her midday meal two hours
later, when it was cold and the fat was all congealed. She did so
with great disgust and retained the memory of it; so that later on,
when she was no longer subjected to this punishment, she regularly
felt disgust at mealtimes. Ten years later she used to sit at table
with a relative who was tubercular and kept constantly spitting
across the table into the spitoon during meals. A little while
later she was obliged to share her meals with a relative who, as
she knew, was suffering from a contagious disease. Breuer’s
patient, again, behaved for some time like someone suffering from
hydrophobia. During hypnosis it turned out that she had once
unexpectedly seen a dog drinking out of a tumbler of water of
hers.