Studies On Hysteria

STUDIES

O N

HYSTERIA

SIGMUND FREUD IN 1891

JOSEF BREUER

and

SIGMUND FREUD

STUDIES

ON
HYSTERIA

Translated from the German and edited by
JAMES STRACHEY

In collaboration with
ANNA FREUD

Assisted by
ALIX STRACHEY and ALAN TYSON

BASIC BOOKS, INC., PUBLISHERS
NEW YORK

Published in the United States of America
by Basic Books, Inc., by arrangement with

The Hogarth Press, Ltd.

Library of Congress Number: 57-12310

ISBN: 0-465-08274-2 (cloth)

ISBN: 0-465-08275-0 (paper)

10 98765432 i

CONTENTS

STUDIES ON HYSTERIA (1893-1895)

Editor's Introduction page ix

Preface to the First Edition xxix

Preface to the Second Edition xxxi

I ON THE PSYCHICAL MECHANISM OF HYS-
TERICAL PHENOMENA: PRELIMINARY COM-
MUNICATION (1893) (Breuer and Freud) 1

II CASE HISTORIES 19

(1) Fraulein Anna O. (Breuer) 21

(2) Frau Emmy von N. (Freud) 48

(3) Miss Lucy R. (Freud) 106

(4) Katharina (Freud) 125

(5) Fraulein Elisabeth von R. (Freud) 135

III THEORETICAL (Breuer) 183

(1) Are All Hysterical Phenomena Ideogenic? 186

(2) Intracerebral Tonic Excitation Affects 192

(3) Hysterical Conversion 203

(4) Hypnoid States 215

(5) Unconscious Ideas and Ideas Inadmissible to
Consciousness Splitting of the Mind 222

(6) Innate Disposition Development of Hysteria 240

IV THE PSYCHOTHERAPY OF HYSTERIA (Freud) 253

APPENDIX A: The Chronology of the Case of Frau Emmy

von N. 307

APPENDIX B: List of Writings by Freud dealing prin-
cipally with Conversion Hysteria 310

BIBLIOGRAPHY AND AUTHOR INDEX 313

LIST OF ABBREVIATIONS 321

GENERAL INDEX 323

ILLUSTRATIONS

Sigmund Freud in 1891 (Aet. 35) Frontispiece

Josef Breuer in 1897 (Aet. 55) Facing page 185

NOTE

This is a reprint of Volume II of the Standard
Edition of the Complete Psychological Works of
Sigmund Freud (Hogarth Press, 1955). The
editors have to thank Dr. C. F. Rycroft and
Mr. Alan Tyson for reading the volume in
proof and Miss Angela Richards for help in
tracing and verifying references. They are
especially indebted to Miss Anna Freud for the
exhaustive advice she has given at every stage
in the work of translation.

EDITOR'S INTRODUCTION

(A) UBER DEN PSYCHISCHEN MECHANISMUS

HYSTERISCHER PHANOMENE (VORLAUFIGE
MITTEILUNG)

(a) GERMAN EDITIONS:

1893 Jieurol. Centralbl., 12 (1), 4-10 (Sections I-II), and 12
(2), 43-7 (Sections III-V). (January 1 and 15.)

1893 Wien. med. Blatter, 16 (3), 33-5 (Sections I-II), and
16 (4), 49-51 (Sections III-V). (January 19 and 26.)

1895, etc. In Studien fiber Hysterie. (See below.)

1906 S.K.S.W., I, 14-29. (191 1, 2nd. ed.; 1920, 3rd. ed.; 1922,
4th. ed.)

(b) ENGLISH TRANSLATIONS:

'The Psychic Mechanism of Hysterical Phenomena

(Preliminary Communication)'
1909 S.P.H., 1-13. (Tr. A. A. Brill.) (1912, 2nd. ed.; 1920,

3rd. ed.)
1936 In Studies in Hysteria. (See below.)

'On the Psychical Mechanism of Hysterical

Phenomena*
1924 C.P., 1, 24^41. (Tr. J. Rickman.)

(B) STUDIEN USER HYSTERIE
(a) GERMAN EDITIONS:

1895 Leipzig and Vienna: Deuticke. Pp. v + 269.

1909 2nd. ed. Same publishers. (Unchanged, but with new

preface.) Pp. vii + 269.

1916 3rd. ed. Same publishers. (Unchanged.) Pp. vii + 269.
1922 4th. ed. Same publishers. (Unchanged.) Pp. vii + 269.
1925 G.S., 1, 3-238. (Omitting Breuer's contributions; with

extra footnotes by Freud.)
1952 G.W., 1, 77-312. (Reprint of 1925.)

x STUDIES ON HYSTERIA

(b) ENGLISH TRANSLATIONS:

Studies in Hysteria

1909 S.P.H., 1-120. (1912, 2nd. ed.; 1920, 3rd. ed.; 1922,
4th. ed.) (Tr. A. A. Brill.) (In part only: omitting
the case histories of Fraulein Anna O., Frau Emmy
von N. and Katharina, as well as Breuer's theo-
retical chapter.)

1936 New York: Nervous and Mental Disease Publishing Co.
(Monograph Series No. 61.) Pp. ix + 241. (Tr. A. A.
Brill.) (Complete, except for omitting Freud's extra
footnotes of 1925.)

The present, entirely new and complete translation by
James and Alix Strachey includes Breuer's contributions, but
is otherwise based on the German edition of 1925, containing
Freud's extra footnotes. The omission of Breuer's contribu-
tions from the two German collected editions (G.S. and G.W.)
led to some necessary changes and additional footnotes in
them, where references had been made by Freud in the original
edition to the omitted portions. In these collected editions, too,
the numbering of the case histories was altered, owing to the
absence of that of Anna O. All these changes are disregarded
in the present translation. Abstracts both of the 'Preliminary
Communication' and of the main volume were included in
Freud's early collection of abstracts of his own works (1897i,
Nos. XXIV and XXXI).

(1)
SOME HISTORICAL NOTES ON THE STUDIES

The history of the writing of this book is known to us in
some detail.

Breuer's treatment of Fraulein Anna O., on which the whole
work was founded, took place between 1880 and 1882. By that
time Josef Breuer (1842-1925) already had a high reputation
in Vienna both as a physician with a large practice and as a
man of scientific attainments, while Sigmund Freud (1856-
1939) was only just qualifying as a doctor. 1 The two men had,

1 Much of the material in what follows is derived from Ernest Jones's
life of Freud (Vol. I, and especially Chapter XI).

EDITOR'S INTRODUCTION xi

however, already been friends for some years. The treatment
ended early in June, 1882, and in the following November
Breuer related the remarkable story to Freud, who (though
at that time his main interests were centred on the anatomy
of the nervous system) was greatly impressed by it. So much
so, indeed, that when, some three years later, he was studying
in Paris under Charcot, he reported the case to him. 'But the
great man showed no interest in my first outline of the subject,
so that I never returned to it and allowed it to pass from my
mind.' (An Autobiographical Study, 1925<f, Chapter II.)

Freud's studies under Charcot had centred largely on hys-
teria, and when he was back in Vienna in 1886 and settled
down to establish a practice in nervous diseases, hysteria pro-
vided a large proportion of his clientele. To begin with he
relied on such currently recommended methods of treatment
as hydrotherapy, electro-therapy, massage and the Weir
Mitchell rest-cure. But when these proved unsatisfactory his
thoughts turned elsewhere. 'During the last few weeks', he
writes to his friend Fliess on December 28, 1887, 'I have taken
up hypnosis and have had all sorts of small but remarkable
successes.' (Freud, 19500, Letter 2.) And he has given us a
detailed account of one successful treatment of this kind
(1892-Si). But the case of Anna O. was still at the back of his
mind, and 'from the first', he tells us (1925^) 'I made use of
hypnosis in another manner, apart from hypnotic suggestion'.
This 'other manner' was the cathartic method, which is the
subject of the present volume.

The case of Frau Emmy von N. was the first one, as we
learn from Freud (pp. 48 and 284), which he treated by the
cathartic method. 1 In a footnote added to the book in 1925 he
qualifies this and says it was the first case in which he made use
of that method 'to a large extent' (p. 105); and it is true that
at this early date he was still constantly employing hypnosis in
the conventional manner for giving direct therapeutic sug-
gestions. At about this time, indeed, his interest in hypnotic
suggestion was strong enough to lead him to translate one of
Bernheim's books in 1888 and another in 1892, as well as to

1 A remark on p. 103 almost seems to imply, on the other hand, that
the case of Frau Cacilie M. (mentioned below) preceded that of Frau
Emmy. But this impression may perhaps be due to an ambiguity in the
phrasing of the sentence.

xii STUDIES ON HYSTERIA

pay a visit of some weeks to the clinics of Liebeault and Bern-
heim at Nancy in the summer of 1889. The extent to which he
was using therapeutic suggestion in the case of Frau Emmy is
shown very clearly by his day-to-day report of the first two or
three weeks of the treatment, reproduced by him from 'the
notes which I made each evening' (p. 48). We cannot un-
luckily be certain when he began this case (see Appendix A.,
p. 307); it was in May either of 1888 or of 1889 that is,
either about four or about sixteen months after he had first
'taken up hypnotism'. The treatment ended a year later, in
the summer of 1889 or 1890. In either alternative, there is a
considerable gap before the date of the next case history (in
chronological order, though not in order of presentation) . This
was the case of Fraulein Elisabeth von R., which began in the
autumn of 1892 (p. 135) and which Freud describes (p. 139)
as his 'first full-length analysis of a hysteria'. It was soon followed
by that of Miss Lucy R., which began at the end of the same
year (p. 106). 1 No date is assigned to the remaining case, that
of Katharina (p. 125). But in the interval between 1889 and
1892 Freud certainly had experience with other cases. In
particular there was that of Frau Cacilie M., whom he 'got to
know far more thoroughly than any of the other patients
mentioned in these studies' (p. 69 n.) but whose case could not
be reported in detail owing to 'personal considerations'. She
is however frequently discussed by Freud, as well as by Breuer,
in the course of the volume, and we learn (p. 178) from Freud
that 'it was the study of this remarkable case, jointly with
Breuer, that led directly to the publication of our "Preliminary
Communication'* '. 2

1 It is to be noted that neither of these last two analyses had been
more than started at the time of the publication of the 'Preliminary
Communication' .

* The question of when it was that Freud first began using the
cathartic method is complicated still further by a statement made by
him in 1916. The circumstances were these. At the International
Medical Congress held in London in 1913, Pierre Janet had dis-
tinguished himself by making an absurdly ignorant and unfair attack
on Freud and psycho-analysis. A reply was published by Ernest Jones
in the Journal of Abnormal Psychology, 9(1915), 400; and a German trans-
lation of this appeared in the Int. . PsychoanaL, 4 (1916), 34. In the
course of his diatribe Janet had said that whatever was of the slightest
value in psycho-analysis was entirely derived from his own early writings,
and in traversing this assertion Jones had remarked that, though it was

EDITOR'S INTRODUCTION xiii

The drafting of that epoch-making paper (which forms the
first section of the present volume) had begun in June 1892.
A letter to Fliess of June 28 (Freud, 19500, Letter 9) announces
that 'Breuer has agreed that the theory of abreaction and the
other findings on hysteria which we have arrived at jointly
shall also be brought out jointly in a detailed publication'.
'A part of it', he goes on, 'which I at first wanted to write alone,
is finished.' This 'finished' part of the paper is evidently re-
ferred to again in a letter to Breuer written on the following
day, June 29, 1892 (Freud, 19410): The innocent satisfaction
I felt when I handed you over those few pages of mine has
given way to ... uneasiness.' This letter goes on to give a very
condensed summary of the proposed contents of the paper.
Next we have a footnote added by Freud to his translation of a
volume of Charcot's Lefons du Mardi (Freud, 1892-30, 107),
which gives, in three short paragraphs, a summary of the
thesis of the 'Preliminary Communication' and refers to it as
being 'begun'. 1 Besides this, two rather more elaborate drafts
have survived. 2 The first (Freud, 194CW) of these (in Freud's
handwriting, though stated to have been written jointly with

true that the actual publication of Breuer and Freud's findings was later
than that of Janet's (which were published in 1889), the work on which
their first paper was based preceded Janet's by several years. 'The co-
operation of the two authors', he went on, 'antedated their first com-
munication by as much as ten years, and it is expressly stated in the
Studien that one of the cases there reported was treated by the cathartic
method more than fourteen years before the date of the publication.'
At this point in the German translation (ibid., 42) there is a footnote
signed 'Freud', which runs as follows: 'I am obliged to correct Dr. Jones
on a point which is inessential so far as his argument is concerned but
which is of importance to me. All that he says on the priority and
independence of what was later named psycho-analytic work remains
accurate, but it applies only to Brewer's achievements. My own collabora-
tion began only in 1891-2. What I took over I derived not from Janet
but from Breuer, as has often been publicly affirmed.' The date given
here by Freud is a puzzling one. 1891 is two or three years too late for
the beginning of the case of Frau Emmy and a year too early for that of
Fraulein Elisabeth.

1 It is not possible to date this precisely; for though Freud's preface
to his translation is dated 'June 1892', the work came out in parts, some
of which were published quite late in 1893. The footnote in question,
however, appears on a relatively early page of the book, and may
therefore be dated with fair certainty to the summer or autumn of 1892.

1 All of these drafts and summaries will be found in full in the first
volume of the Standard Edition.

xiv STUDIES ON HYSTERIA

Breuer) is dated 'End of November 1892'. It deals with
hysterical attacks and its contents were mostly included, though
in different words, in Section IV of the * Preliminary Com-
munication' (p. 13 ff.). One important paragraph, however,
concerned with the 'principle of constancy', was unaccountably
omitted, and in this volume the topic is treated only by Breuer,
in the later part of the work (p. 197 ff.). Lastly there is a
memorandum (Freud, 194 It) bearing the title 'III'. This is
undated. It discusses 'hypnoid states' and hysterical dissocia-
tion, and is closely related to Section III of the published paper
(p. llff.).

On December 18, 1892 Freud wrote to Fliess (1950*, Letter
11): 'I am delighted to be able to tell you that our theory of
hysteria (reminiscence, abreaction, etc.) is going to appear in
the Neurologisches Centralblatt on January 1, 1893, in the form of
a detailed preliminary communication. It has meant a long
battle with my partner.' The paper, bearing the date 'December
1892', was actually published in two issues of the periodical:
the first two Sections on January 1 and the remaining three on
January 15. The Neurologisches Centralblatt (which appeared
fortnightly) was published in Berlin; and the 'Preliminary
Communication' was almost immediately reprinted in full in
Vienna in the Wiener medizinische Blatter (on January 19 and 26).
On January 11, while the paper was only half published, Freud
gave a lecture on its subject-matter at the Wiener medizinischer
Club. A full shorthand report of the lecture, 'revised by the
lecturer', appeared in the Wiener medizinische Presse on January
22 and 29 (34, 122-6 and 165-7). The lecture (Freud, 1893A)
covered approximately the same ground as the paper, but dealt
with the material quite differently and in a much less formal
manner.

The appearance of the paper seems to have produced little
manifest effect in Vienna or Germany. In France, on the other
hand, as Freud reports to Fliess in a letter of July 10, 1893
(19500, Letter 13), it was favourably noticed by Janet, whose
resistance to Freud's ideas was only to develop later. Janet
included a long and highly laudatory account of the 'Pre-
liminary Communication' in a paper on 'Some Recent Defini-
tions of Hysteria' published in the Archives de Neurologic in June
and July 1893. He used this paper as the final chapter of his book,
Uetat yientaldes hysteriques, published in 1894. More unexpected,

EDITOR'S INTRODUCTION xv

perhaps, is the fact that in April 1893 only three months after
the publication of the 'Preliminary Communication' a fairly
full account of it was given by F. W. H. Myers at a general
meeting- of the Society for Psychical Research in London and
was printed in their Proceedings in the following June. The
'Preliminary Communication' was also fully abstracted and
discussed by Michell Clarke in Brain (1894, 125). The most
surprising and unexplained reaction, however, was the publica-
tion in February and March 1893, in the Gaceta mtdica de
Granada (11, 105-11 and 129-35), of a complete translation of
the 'Preliminary Communication', in Spanish.

The authors' next task was the preparation of the case
material, and already on February 7, 1894, Freud spoke of the
book as 'half-finished: what remains to be done is only a small
minority of the case histories and two general chapters'. In an
unpublished passage in the letter of May 2 1 he mentions that
he is just writing the last case history, and on June 22 (1950fl,
Letter 19) he gives a list of what 'the book with Breuer' is to
contain: 'five case histories, an essay by him, with which I have
nothing at all to do, on the theories of hysteria (summarizing
and critical), and one by me on therapy which I have not
started yet'. After this there was evidently a hold-up, for it is
not until March 4, 1895 (ibid., Letter 22) that he writes to say
that he is 'hurriedly working at the essay on the therapy of
hysteria', which was finished by March 13 (unpublished letter).
In another unpublished letter, of April 10, he sends Fliess the
second half of the proofs of the book, and next day tells him it
will be out in three weeks.

The Studies on Hysteria seem to have been duly published in
May 1895, though the exact date is not stated. The book was
unfavourably received in German medical circles; it was, for
instance, very critically reviewed by Adolf von Strumpell, the
well-known neurologist (Deutsch. . Nervenheilk., 1896, 159).
On the other hand, a non-medical writer, Alfred von Berger,
later director of the Vienna Burgtheater, wrote appreciatively
of it in the Neue Freie Presse (February 2, 1896). In England it
was given a long and favourable notice in Brain (1896, 401) by
Michell Clarke, and once again Myers showed his interest in it
in an address of considerable length, first given in March 1897,
which was ultimately included in his Human Personality (1903).

xvi STUDIES ON HYSTERIA

It was more than ten years before there was a call for a
second edition of the book, and by that time the paths of its
two authors had diverged. In May 1906 Breuer wrote to Freud
agreeing on a reprint, but there was some discussion about
whether a new joint preface was desirable. Further delays
followed, and in the end, as will be seen below, two separate
prefaces were written. These bear the date of July 1908
though the second edition was not actually published till 1909.
The text was unaltered in this and the later editions of the
book. But in 1924 Freud wrote some additional footnotes for
the volume of his collected works containing his share of the
Studies (published in 1925) and made one or two small changes
in the text.

(2)

THE BEARING OF THE STUDIES ON PSYCHO-ANALYSIS

The Studies on Hysteria are usually regarded as the starting-
point of psycho-analysis. It is worth considering briefly whether
and in what respects this is true. For the purposes of this dis-
cussion the question of the shares in the work attributable to
the two authors will be left on one side for consideration below,
and the book will be treated as a whole. An enquiry into the
bearing of the Studies upon the subsequent development of
psycho-analysis may be conveniently divided into two parts,
though such a separation is necessarily an artificial one. To
what extent and in what ways did the technical procedures
described in the Studies and the clinical findings to which they
led pave the way for the practice of psycho-analysis? To what
extent were the theoretical views propounded here accepted
into Freud's later doctrines?

The fact is seldom sufficiently appreciated that perhaps the
most important of Freud's achievements was his invention of
the first instrument for the scientific examination of the human
mind. One of the chief fascinations of the present volume is
that it enables us to trace the early steps of the development
of that instrument. What it tells us is not simply the story of the
overcoming of a succession of obstacles; it is the story of the
discovery of a succession of obstacles that have to be overcome.

EDITOR'S INTRODUCTION xvii

Breuer's patient Anna O. herself demonstrated and overcame
the first of these obstacles the amnesia characteristic of the
hysterical patient. When the existence of this amnesia was
brought to light, there at once followed a realization that the
patient's manifest mind was not the whole of it, that there lay
behind it an unconscious mind (p. 45 ff.). It was thus plain from
the first that the problem was not merely the investigation of
conscious mental processes, for which the ordinary methods of
enquiry used in everyday life would suffice. If there were also
unconscious mental processes, some special instrument was
clearly required. The obvious instrument for this purpose was
hypnotic suggestion hypnotic suggestion used, not for directly
therapeutic purposes, but to persuade the patient to produce
material from the unconscious region of the mind. With
Anna O. only slight use of this instrument seemed necessary.
She produced streams of material from her 'unconscious', and
all Breuer had to do was to sit by and listen to them without
interrupting her. But this was not so easy as it sounds, and the
case history of Frau Emmy shows at many points how difficult
it was for Freud to adapt himself to this new use of hypnotic
suggestion and to listen to all that the patient had to say with-
out any attempt at interference or at making short cuts (e.g.
pp. 60 n. and 62 n. 1). Not all hysterical patients, moreover,
were so amenable as Anna O.; the deep hypnosis into which
she fell, apparently of her own accord, was not so readily
obtained with everyone. And here came a further obstacle:
Freud tells us that he was far from being an adept at hypnotism.
He gives us several accounts in this book (e.g. p. 107 ff.) of
how he circumvented this difficulty, of how he gradually gave
up his attempts at bringing about hypnosis and contented him-
self with putting his patients into a state of 'concentration' and
with the occasional use of pressure on the forehead. But it was
the abandonment of hypnotism that widened still further his
insight into mental processes. It revealed the presence of yet
another obstacle the patients' 'resistance' to the treatment
pp. 154 and 268 ff.), their unwillingness to co-operate in their
own cure. How was this unwillingness to be dealt with? Was
it to be shouted down or suggested away? Or was it, like other
mental phenomena, simply to be investigated? Freud's choice
of this second path led him directly into the uncharted world
which he was to spend his whole life in exploring.

xviii STUDIES ON HYSTERIA

In the years immediately following the Studies Freud aban-
doned more and more of the machinery of deliberate sugges-
tion [cf. p. llOrc.] and came to rely more and more on the
patient's flow of Tree associations'. The way was opened up to
the analysis of dreams. Dream-analysis enabled him, in the
first place, to obtain an insight into the workings of the
'primary process' in the mind and the ways in which it in-
fluenced the products of our more accessible thoughts, and he
was thus put in possession of a new technical device that of
'interpretation'. But dream-analysis made possible, in the
second place, his own self- analysis, and his consequent dis-
coveries of infantile sexuality and the Oedipus complex. All
these things, apart from some slight hints, 1 still lay ahead. But
he had already, in the last pages of this volume, come up
against one further obstacle in the investigator's path the
'transference' (p. 301 ff.). He had already had a glimpse of its
formidable nature and had even, perhaps, already begun to
recognize that it was to prove not only an obstacle but also
another major instrument of psycho-analytic technique.

The main theoretical position adopted by the authors of the
'Preliminary Communication' seems, on the surface, a simple
one. They hold that, in the normal course of things, if an
experience is accompanied by a large amount of 'affect', that
affect is either 'discharged' in a variety of conscious reflex acts
or becomes gradually worn away by association with other
conscious mental material. In the case of hysterical patients,
on the other hand (for reasons which we shall mention in a
moment), neither of these things happens. The affect remains
in a 'strangulated' state, and the memory of the experience to
which it is attached is cut off from consciousness. The affective
memory is thereafter manifested in hysterical symptoms, which
may be regarded as 'mnemic symbols' that is to say as
symbols of the suppressed memory (p. 90) . Two principal
reasons are suggested to explain the occurrence of this patho-
logical outcome. One is that the original experience took place
while the subject was in a particular dissociated state of mind
described *as 'hypnoid'; the other is that the experience was one
which the subject's 'ego' regarded as 'incompatible' with itself

1 See, for instance, the remarks on dreams in a footnote on p. 69,
and a hint at the notion of free association on p. 56.

EDITOR'S INTRODUCTION xix

and which had therefore to be Tended off'. In either case the
therapeutic effectiveness of the 'cathartic' procedure is ex-
plained on the same basis: if the original experience, along
with its affect, can be brought into consciousness, the affect is
by that very fact discharged or 'abreacted', the force that has
maintained the symptom ceases to operate, and the symptom
itself disappears.

This all seems quite straightforward, but a little reflection
shows that much remains unexplained. Why should an affect
need to be 'discharged? And why are the consequences of its
not being discharged so formidable? These underlying prob-
lems are not considered at all in the 'Preliminary Communica-
tion', though they had been alluded to briefly in two of the post-
humously published drafts (1941fl and 194CW) and a hypothesis
to provide an explanation of them was already in existence.
Oddly enough, this hypothesis was actually stated by Freud in
his lecture of January 11, 1893 (see p. xiv), in spite of its
omission from the 'Preliminary Communication' itself. He again
alluded to it in the last two paragraphs of his first paper on
'The Neuro- Psychoses of Defence' ( 18940), where he specifically
states that it underlay the theory of abreaction in the 'Pre-
liminary Communication' of a year earlier. But this basic
hypothesis was first formally produced and given a name in
1895 in the second section of Breuer's contribution to the pre-
sent volume (p. 192 ff.). It is curious that this, the most funda-
mental of Freud's theories, was first fully discussed by Breuer
(attributed by him, it is true, to Freud), and that Freud him-
self, though he occasionally reverted to its subject-matter (as
in the early pages of his paper on 'Instincts and their Vicis-
situdes', 1915r), did not mention it explicitly till he wrote
Beyond the Pleasure Principle (1920^). He did, as we now know,
refer to the hypothesis by name in a communication to Fliess of
uncertain date, possibly 1894 (Draft D, 19500), and he con-
sidered it fully, though under another name (see below, p. xxiv),
in the 'Project for a Scientific Psychology' which he wrote a
few months after the publication of the Studies. But it was not
until fifty-five years later (19500) that Draft D and the 'Project'
saw the light of day.

The 'principle of constancy' (for this was the name given to
the hypothesis) may be defined in the terms used by Freud
himself in Beyond the Pleasure Principle: 'The mental apparatus

xx STUDIES ON HYSTERIA

endeavours to keep the quantity of excitation present in it as
low as possible or at least to keep it constant.' (Standard Ed, y
18, 9.) Breuer states it below (p. 197) in very similar terms,
but with a neurological twist, as 'a tendency to keep intra-
cerebral excitation constant'. 1 In his discussion on p. 201 ff., he
argues that the affects owe their importance in the aetiology of
hysteria to the fact that they are accompanied by the produc-
tion of large quantities of excitation, and that these in turn call
for discharge in accordance with the principle of constancy.
Similarly, too, traumatic experiences owe their pathogenic
force to the fact that they produce quantities of excitation too
large to be dealt with in the normal way. Thus the essential
theoretical position underlying the Studies is that the clinical
necessity for abreacting affect and the pathogenic results of its
becoming strangulated are explained by the much more general
tendency (expressed in the principle of constancy) to keep the
quantity of excitation constant.

It has often been thought that the authors of the Studies
attributed the phenomena of hysteria only to traumas and to
ineradicable memories of them, and that it was not until later
that Freud, after shifting the emphasis from infantile traumas
to infantile phantasies, arrived at his momentous 'dynamic'
view of the processes of the mind. It will be seen, however,
from what has just been said, that a dynamic hypothesis in the
shape of the principle of constancy already underlay the theory
of trauma and abreaction. And when the time came for widen-
ing the horizon and for attributing a far greater importance
to instinct as contrasted with experience, there was no need
to modify the basic hypothesis. Already, indeed, Breuer points
out the part played by 'the organism's major physiological needs
and instincts' in causing increases in excitation which call for
discharge (p. 199), and emphasizes the importance of the
'sexual instinct' as 'the most powerful source of persisting
increases of excitation (and consequently of neuroses)' (p. 200).
Moreover the whole notion of conflict and the repression of

1 Freud's statement of the principle in the lecture of January 11, 1893,
was as follows: 'If a person experiences a psychical impression, some-
thing in his nervous system which we will for the moment call the
"sum of excitation" is increased. Now in every individual there exists
a tendency to diminish this sum of excitation once more, in order to
preserve his health . . .' (Freud, 1893 A.).

EDITOR'S INTRODUCTION xxi

incompatible ideas is explicitly based on the occurrence of
unpleasurable increases of excitation. This leads to the further
consideration that, as Freud points out in Beyond the Pleasure
Principle (Standard Ed. , 18, 7 ff.), the 'pleasure principle' itself is
closely bound up with the principle of constancy. He even goes
further and declares (ibid., 62) that the pleasure principle 'is a
tendency operating in the service of a function whose business
it is to free the mental apparatus entirely from excitation or to
keep the amount of excitation in it constant or to keep it as low
as possible.' The 'conservative' character which Freud attributes
to the instincts in his later works, and the 'compulsion to repeat',
are also seen in the same passage to be manifestations of the
principle of constancy; and it becomes clear that the hypothesis
on which these early Studies on Hysteria were based was still
being regarded by Freud as fundamental in his very latest
speculations.

(3)
THE DIVERGENCES BETWEEN THE Two AUTHORS

We are not concerned here with the personal relations
between Breuer and Freud, which have been fully described in
the first volume of Ernest Jones's biography; but it will be of
interest to discuss briefly their scientific differences. The existence
of such differences was openly mentioned in the preface to the
first edition, and they were often enlarged upon in Freud's
later publications. But in the book itself, oddly enough, they
are far from prominent; and even though the 'Preliminary
Communication' is the only part of it with an explicitly joint
authorship, it is not easy to assign with certainty the responsi-
bility for the origin of the various component elements of the
work as a whole.

We can no doubt safely attribute to Freud the later technical
developments, together with the vital theoretical concepts of
resistance, defence and repression which arose from them. It is
easy to see from the account given on p. 268 ff. how these con-
cepts followed from the replacement of hypnosis by the pressure
technique. Freud himself, in his 'History of the Psycho-
Analytic Movement' (1914*/), declares that 'the theory of re-
pression is the foundation stone on which the structure of

xxii STUDIES ON HYSTERIA

psycho-analysis rests', and gives the same account as he does
here of the way in which it was arrived at. He also asserts his
belief that he reached this theory independently, and the
history of the discovery amply confirms that belief. He remarks
in the same passage that a hint at the notion of repression is
to be found in Schopenhauer (1844), whose works, however, he
read only late in life; and it has recently been pointed out that
the word 'Verdrdngung' ('repression') occurs in the writings of
the early nineteenth century psychologist Herbart (1824) whose
ideas carried great weight with many of those in Freud's en-
vironment, and particularly with his immediate teacher in
psychiatry, Meyncrt. But no such suggestions detract in any
significant degree from the originality of Freud's theory, with
its empirical basis, which found its first expression in the
'Preliminary Communication' (p. 10).

As against this, there can be no question that Breuer origin-
ated the notion of 'hypnoid states', to which we shall return
shortly, and it seems possible that he was responsible for the
terms 'catharsis' and 'abreaction'.

But many of the theoretical conclusions in the Studies must
have been the product of discussions between the two authors
during their years of collaboration, and Breuer himself com-
ments (pp. 185-6) on the difficulty of determining priority in
such cases. Apart from the influence of Charcot, on which Freud
never ceased insisting, it must be remembered, too, that both
Breuer and Freud owed a fundamental allegiance to the school
of Helmholz, of which their teacher, Ernst Brticke, was a
prominent member. Much of the underlying theory in the
Studies on Hysteria is derived from the doctrine of that school
that all natural phenomena are ultimately explicable in terms
of physical and chemical forces. 1

We have already seen (p. xix) that, though Breuer was the
first to mention the 'principle of constancy' by name, he
attributes the hypothesis to Freud. He similarly attaches Freud's
name to the term 'conversion 5 , but (as is explained below,

1 The various influences that may possibly have played a part in
determining Freud's views are very fully discussed by Ernest Jones
(1953, 1, 44 ff. and 407 ff.). In addition to the names referred to in the
text above, special mention should be made of the psycho-physicist
Fechner, to whom Freud himself acknowledged his indebtedness in the
fifth chapter of his Autobiographical Study (1925</).

EDITOR'S INTRODUCTION xxiii

p. 206 n.) Freud himself has declared that this applies only to
the word and that the concept was arrived at jointly. On the
other hand there are a number of highly important concepts
which seem to be properly attributable to Breuer: the notion
of hallucination being a 'retrogression 5 from imagery to per-
ception (p. 189), the thesis that the functions of perception
and memory cannot be performed by the same apparatus
(pp. 188-9 n.), and finally, and most surprisingly, the distinction
between bound (tonic) and unbound (mobile) psychical energy
and the correlated distinction between primary and secondary
psychical processes (p. 194 n.).

The use of the term 'Besetzung* ('cathexis'), which makes its
first appearance on p. 89 in the sense that was to become so
familiar in psycho-analytic theory, is probably to be attributed
to Freud. The idea of the whole or a part of the mental appar-
atus carrying a charge of energy is, of course, presupposed by
the principle of constancy. And though the actual term that
was to be the standard one first came into use in this volume,
the idea had been expressed earlier by Freud in other forms.
Thus we find him using such phrases as 'mil Energie ausgestattet 9
('supplied with energy') (1895), 'mit einer Erregungssumme
behafte? ('loaded with a sum of excitation') (18940), 'munie
d*une valeur affective* ('provided with a quota of affect') (1893c),
' Verschiebungen von Erregungssummen' ('displacements of sums of
excitation') (19410 [1892]) and, as long ago as in his preface to
his first translation of Bernheim (1888-9), ' Verschiebungen von
Erregbarkeit im Nervensysterri ('displacements of excitability in
the nervous system').

But this last quotation is a reminder of something of great
importance that may very easily be overlooked. There can be
no doubt that at the time of the publication of the Studies Freud
regarded the term 'cathexis' as a purely physiological one. This
is proved by the definition of the term given by him in Part I,
Section 2, of his 'Project for a Scientific Psychology' by which
(as is shown in the Fliess letters) his mind was already occupied,
and which was written only a few months later. There, after
giving an account of the recently discovered neurological
entity, the 'neurone', he goes on: 'If we combine this account
of neurones with an approach on the lines of the quantity
theory, we arrive at the idea of a "cathected" neurone, filled
with a certain quantity, though at other times it may be empty.*

xxiv STUDIES ON HYSTERIA

The neurological bias of Freud's theories at this period is
further shown by the form in which the principle of constancy
is stated in the same passage in the 'Project'. It is given the
name of 'the principle of neuronic inertia' and is defined as
asserting 'that neurones tend to divest themselves of quantity'.
A remarkable paradox is thus revealed. Breuer, as will be seen
(p. 185), declares his intention of treating the subject of
hysteria on purely psychological lines: 'In what follows little
mention will be made of the brain and none whatever of
molecules. Psychical processes will be dealt with in the language
of psychology.' But in fact his theoretical chapter is largely
concerned with 'intracerebral excitations' and with parallels
between the nervous system and electrical installations. On
the other hand Freud was devoting all his energies to explain-
ing mental phenomena in physiological and chemical terms.
Nevertheless, as he himself somewhat ruefully confesses (p. 160),
his case histories read like short stories and his analyses are
psychological ones.

The truth is that in 1895 Freud was at a half-way stage in
the process of moving from physiological to psychological ex-
planations of psychopathological states. On the one hand he
was proposing what was broadly speaking a chemical explana-
tion of the 'actual' neuroses neurasthenia and anxiety neu-
rosis (in his two papers on anxiety neurosis, 18954 and 1895/*),
and on the other hand he was proposing an essentially psycho-
logical explanation in terms of 'defence' and 'repression' of
hysteria and obsessions (in his two papers on 'The Neuro-
Psychoses of Defence', 18940 and 18964). His earlier training
and career as a neurologist led him to resist the acceptance of
psychological explanations as ultimate; and he was engaged
in devising a complicated structure of hypotheses intended to
make it possible to describe mental events in purely neuro-
logical terms. This attempt culminated in the 'Project' and
was not long afterwards abandoned. To the end of his life,
however, Freud continued to adhere to the chemical aetiology
of the 'actual' neuroses and to believe that a physical basis for
all mental phenomena might ultimately be found. But in the
meantime he gradually came round to the view expressed by
Breuer that psychical processes can only be dealt with in the
language of psychology. It was not until 1905 (in his book on
jokes, Chapter V) that he first explicitly repudiated all inten-

EDITOR'S INTRODUCTION xxv

lion of using the term 'cathexis' in any but a psychological
sense and all attempts at equating nerve-tracts or neurones
with paths of mental association. 1

What, however, were the essential scientific differences
between Breuer and Freud? In his Autobiographical Study (1925rf)
Freud says that the first of these related to the aetiology of
hysteria and could be described as 'hypnoid states versus
neuroses of defence'. But once again, in this volume itself the
issue is less clear-cut. In the joint 'Preliminary Communica-
tion' both aetiologies are accepted (p. 10 f.). Breuer, in his
theoretical chapter, evidently lays most emphasis on hypnoid
states (p. 215 ff.), but he also stresses the importance of 'defence'
(pp. 214 and 235-6), though a little half-heartedly. Freud seems
to accept the notion of 'hypnoid states' in his 'Katharina' case
history (p. 128) 2 and, less definitely, in that of Frau Elisabeth
(p. 167 w.). It is only in his final chapter that his scepticism
begins to be apparent (p. 286). In a paper on 'The Aetiology
of Hysteria' published in the following year (1896c) this scep-
ticism is still more openly expressed, and in a footnote to his
'Dora' case history (1905*) he declares that the term 'hypnoid
states' is 'superfluous and misleading' and that the hypothesis
'sprang entirely from the initiative of Breuer' (Standard Ed.,
7, 27*.).

But the chief difference of opinion between the two authors
upon which Freud later insisted concerned the part played by
sexual impulses in the causation of hysteria. Here too, however,
the expressed difference will be found less clear than would be
expected. Freud's belief in the sexual origin of hysteria can be
inferred plainly enough from the discussion in his chapter on
psychotherapy (p. 257 ff'.), but he nowhere asserts, as he was
later to do, that in cases of hysteria a sexual aetiology was

1 The insecurity of the neurological position which Freud was still
trying to maintain in 1895 is emphasized by the correction that he felt
obliged to make thirty years later in the very last sentence of the book.
In 1895 he used the word ' Nervensystem > ('nervous system'); in 1925 he
replaced it by ' Seelenleberf ('mental life'). Yet what was ostensibly a
momentous change did not in the least affect the meaning of the
sentence. The old neurological vocabulary had already been no more
than a husk at the time when Freud penned the words.

2 As he already had in his first paper on 'The Neuro-Psychoses of
Defence' (18940) and in the memorandum 'IIP (1941), almost cer-
tainly written in 1892 (see above p. xiv).

xxvi STUDIES ON HYSTERIA

invariably present. 1 On the other hand, Breuer speaks at
several points in the strongest terms of the importance of the
part played by sexuality in the neuroses, particularly in the
long passage on pp. 245-7. He says, for instance (as has already
been remarked, p. xx), that 'the sexual instinct is undoubtedly
the most powerful source of persisting increases of excitation
(and consequently of neuroses)' (p. 200), and declares (p. 246)
that 'the great majority of severe neuroses in women have
their origin in the marriage bed'.

It seems as though, in order to find a satisfactory explanation
of the dissolution of this scientific partnership, we should have
to look behind the printed words. Freud's letters to Fliess show
Breuer as a man full of doubts and reservations, always in-
secure in his conclusions. There is an extreme instance of this
in a letter of November 8, 1895 (19500, Letter 35), about six
months after the publication of the Studies: 'Not long ago
Breuer made a big speech about me at the Doktorenkollegium,
in which he announced his conversion to belief in the sexual
aetiology [of the neuroses]. When I took him on one side
to thank him for it, he destroyed my pleasure by saying: "All
the same I don't believe it." Can you understand that? I can't.'
Something of the kind can be read between the lines of Breuer's
contributions to the Studies, and we have the picture of a man
half-afraid of his own remarkable discoveries. It was inevitable
that he should be even more disconcerted by the premonition
of still more unsettling discoveries yet to come; and it was in-
evitable that Freud in turn should feel hampered and irritated
by his yoke-fellow's uneasy hesitations.

It would be tedious to enumerate the many passages in
Freud's later writings in which he refers to the Studies on
Hysteria and to Breuer; but a few quotations will illustrate the
varying emphasis in his attitude to them.

In the numerous short accounts of his therapeutic methods
and psychological theories which he published during the years
immediately succeeding the issue of the Studies he was at pains
to bring out the differences between 'psycho-analysis' and the
cathartic method the technical innovations, the extension of

1 Indeed, in the fourth of his Five Lectures (19100), he categorically
asserts that at the time of the publication of the Studies he did not yet
believe that this was so.

EDITOR'S INTRODUCTION xxvii

his procedure to neuroses other than hysteria, the establish-
ment of the motive of 'defence', the insistence on a sexual
aetiology and, as we have already seen, the final rejection of
'hypnoid states'. When we reach the first series of Freud's
major works the volumes on dreams (1900fl), on parapraxes
(19016), on jokes (1905<r) and on sexuality (1905rf) there is
naturally little or no retrospective material; and it is not until
the five lectures at Clark University (19100) that we find any
extensive historical survey. In those lectures Freud appeared
anxious to establish the continuity between his work and
Breuer's. The whole of the first lecture and much of the second
are devoted to a summary of the Studies, and the impression
given was that not Freud but Breuer was the true founder of
psycho-analysis.

The next long retrospective survey, in the 'History of the
Psycho-Analytic Movement' (1914rf), was in a very different
key. The whole paper, of course, was polemical in its intent
and it is not surprising that in sketching the early history
of psycho-analysis Freud stressed his differences from Breuer
rather than his debts to him, and that he explicitly retracted
his view of him as the originator of psycho-analysis. In this
paper, too, Freud dilated on Breuer's inability to face the
sexual transference and revealed the 'untoward event' which
ended the analysis of Anna O. (pp. 40-1 .).

Next came what seems almost like an amende it has already
been mentioned or p. xxiii the unexpected attribution to
Breuer of the distinction between bound and unbound psychical
energy and between the primary and secondary processes.
There had been no hint of this attribution when these hypo-
theses were originally introduced by Freud (in The Interpretation
of Dreams) ; it was first made in a footnote to Section V of the
metapsychological paper on 'The Unconscious' (1915*) and
repeated in Beyond the Pleasure Principle (1920^; Standard Ed., 18,
26-7 and 31). Not long after the last of these there were some
appreciative sentences in an article contributed by Freud to
Marcuse's Handworterbuch (19230; Standard Ed., 18, 236): 'In a
theoretical section of the Studies Breuer brought forward some
speculative ideas about the processes of excitation in the mind.
These ideas determined the direction of future lines of thought
. . .' In somewhat the same vein Freud wrote a little later in a
contribution to an American publication (1924/*): 'The cathartic

xxviii STUDIES ON HYSTERIA

method was the immediate precursor of psycho-analysis, and,
in spite of every extension of experience and of every modi-
fication of theory, is still contained within it as its nucleus.'

Freud's next long historical survey, An Autobiographical Study
(1925<f), seemed once more to withdraw from the joint work:
'If the account I have so far given', he wrote, 'has led the
reader to expect that the Studies on Hysteria must, in all essentials
of their material content, be the product of Breuer's mind, that
is precisely what I myself have always maintained ... As
regards the theory put forward in the book, I was partly re-
sponsible, but to an extent which it is to-day no longer possible
to determine. That theory w r as in any case unpretentious and
hardly went beyond the direct description of the observations.'
He added that 'it would have been difficult to guess from the
Studies on Hysteria what an importance sexuality has in the
aetiology' of the neuroses', and went on once more to describe
Breuer's unwillingness to recognize that factor.

It was soon after this that Breuer died, and it is perhaps
appropriate to end this introduction to the joint work with a
quotation from Freud's obituary of his collaborator (1925g).
After remarking on Breuer's reluctance to publish the Studies
and declaring that his own chief merit in connection with them
lay in his having persuaded Breuer to agree to their appearance,
he proceeded: 'At the time when he submitted to my influence
and was preparing the Studies for publication, his judgement of
their significance seemed to be confirmed. "I believe", he told
me, "that this is the most important thing we two have to give
the world." Besides the case history of his first patient Breuer
contributed a theoretical paper to the Studies. It is very far from
being out of date; on the contrary, it conceals thoughts and
suggestions which have even now not been turned to sufficient
account. Anyone immersing himself in this speculative essay
will form a true impression of the mental build of this man,
whose scientific interests were, alas, turned in the direction of
our psychopathology during only one short episode of his long
life.'

PREFACE TO THE FIRST EDITION

IN 1893 we published a * Preliminary Communication' 1 on a
new method of examining and treating hysterical phenomena.
To this we added as concisely as possible the theoretical con-
clusions at which we had arrived. We are here reprinting this
'Preliminary Communication' to serve as the thesis which it is
our purpose to illustrate and prove.

We have appended to it a series of case histories, the selection
of which could not unfortunately be determined on purely
scientific grounds. Our experience is derived from private
practice in an educated and literate social class, and the sub-
ject matter with which we deal often touches upon our patients'
most intimate lives and histories. It would be a grave breach
of confidence to publish material of this kind, with the risk of
the patients being recognized and their acquaintances becoming
informed of facts which were confided only to the physician.
It has therefore been impossible for us to make use of some of
the most instructive and convincing of our observations. This
of course applies especially to all those cases in which sexual
and marital relations play an important aetiological part. Thus
it comes about that we are only able to produce very incom-
plete evidence in favour of our view that sexuality seems to
play a principal part in the pathogenesis of hysteria as a source
of psychical traumas and as a motive for 'defence' that is,
for repressing ideas from consciousness. It is precisely observa-
tions of a markedly sexual nature that we have been obliged
to leave unpublished.

The case histories are followed by a number of theoretical
reflections, and in a final chapter on therapeutics the tech-
nique of the 'cathartic method' is propounded, just as it has
grown up under the hands of the neurologist.

If at some points divergent and indeed contradictory opinions
are expressed, this is not to be regarded as evidence of any
fluctuation in our views. It arises from the natural and justi-
fiable differences between the opinions of two observers who

1 'On the Psychical Mechanism of Hysterical Phenomena', Neu-
rotogisches Centralblatt, 1893, Nos. 1 and 2.

xxx STUDIES ON HYSTERIA

are agreed upon the facts and their basic reading of them, but
who are not invariably at one in their interpretations and
conjectures.

J. BREUER, S. FREUD
April 1895

PREFACE TO THE SECOND EDITION

THE interest which, to an ever-increasing degree, is being
directed to psycho-analysis seems now to be extending to these
Studies on Hysteria. The publisher desires to bring out a new
edition of the book, which is at present out of print. It appears
now in a reprint, without any alterations, though the opinions
and methods which were put forward in the first edition have
since undergone far-reaching and profound developments. So
far as I personally am concerned, I have since that time had
no active dealings with the subject; I have had no part in its
important development and I could add nothing fresh to what
was written in 1895. So I have been able to do no more than
express a wish that my two contributions to the volume should
be reprinted without alteration.

BREUER

As regards my share of the book, too, the only possible
decision has been that the text of the first edition shall be
reprinted without alteration. The developments and changes
in my views during the course of thirteen years of work have
been too far-reaching for it to be possible to attach them to
my earlier exposition without entirely destroying its essential
character. Nor have I any reason for wishing to eliminate this
evidence of my initial views. Even to-day I regard them not as
errors but as valuable first approximations to knowledge which
could only be fully acquired after long and continuous efforts.
The attentive reader will be able to detect in the present book
the germs of all that has since been added to the theory of
catharsis: for instance, the part played by psychosexual factors
and infantilism, the importance of dreams and of unconscious
symbolism. And I can give no better advice to any one inter-
ested in the development of catharsis into psycho-analysis than
to begin with Studies on Hysteria and thus follow the path which
I myself have trodden.

FREUD
VIENNA, July 1908

I

PRELIMINARY COMMUNICATION

(1893)

(BREUER AND FREUD)

I

ON THE PSYCHICAL MECHANISM OF

HYSTERICAL PHENOMENA: PRELIMINARY

COMMUNICATION (1893) 1

(BREUER AND FREUD)

A CHANCE observation has led us, over a number of years, to
investigate a great variety of different forms and symptoms of
hysteria, with a view to discovering their precipitating cause
the event which provoked the first occurrence, often many
years earlier, of the phenomenon in question. In the great
majority of cases it is not possible to establish the point of
origin by a simple interrogation of the patient, however thor-
oughly it may be carried out. This is in part because what is in
question is often some experience which the patient dislikes
discussing; but principally because he is genuinely unable to
recollect it and often has no suspicion of the causal connection
between the precipitating event and the pathological phenom-
enon. As a rule it is necessary to hypnotize the patient and
to arouse his memories under hypnosis of the time at which the
symptom made its first appearance; when this has been done,
it becomes possible to demonstrate the connection in the clearest
and most convincing fashion.

This method of examination has in a large number of cases
produced results which seem to be of value alike from a theor-
etical and a practical point of view.

They are valuable theoretically because they have taught us

1 [As explained above in the preface to the first edition, this first
chapter had appeared originally as a separate paper in 1893. It was
reprinted not only in the present book, but also in the first of Freud's
collected volumes of his shorter works, Sammlung kleiner Schriften zur
Neurosenlehre (1906). The following footnote was appended to this
latter reprint: 'Also printed as an introduction to Studies on Hysteria,
1895, in which Josef Breuer and I further developed the views expressed
here and illustrated them by case histories.']

3

4 I. PRELIMINARY COMMUNICATION

that external events determine the pathology of hysteria to
an extent far greater than is known and recognized. It is
of course obvious that in cases of 'traumatic' hysteria what
provokes the symptoms is the accident. The causal connection
is equally evident in hysterical attacks when it is possible to
gather from the patient's utterances that in each attack he is
hallucinating the same event which provoked the first one.
The situation is more obscure in the case of other phenomena.

Our experiences have shown us, however, that the most various
symptoms, which are ostensibly spontaneous and, as one might say,
idiopathic products of hysteria, are just as strictly related to the pre-
cipitating trauma as the phenomena to which we have just alluded and
which exhibit the connection quite clearly. The symptoms which we
have been able to trace back to precipitating factors of this
sort include neuralgias and anaesthesias of very various kinds,
many of which had persisted for years, contractures and par-
alyses, hysterical attacks and epileptoid convulsions, which
every observer regarded as true epilepsy, petit mat and disorders
in the nature of tic, chronic vomiting and anorexia, carried to
the pitch of rejection of all nourishment, various forms of dis-
turbance of vision, constantly recurrent visual hallucinations,
etc. The disproportion between the many years' duration of
the hysterical symptom and the single occurrence which pro-
voked it is what we are accustomed invariably to find in
traumatic neuroses. Quite frequently it is some event in child-
hood that sets up a more or less severe symptom which persists
during the years that follow.

The connection is often so clear that it is quite evident how
it was that the precipitating event produced this particular
phenomenon rather than any other. In that case the symptom
has quite obviously been determined by the precipitating cause.
We may take as a very commonplace instance a painful
emotion arising during a meal but suppressed at the time, and
then producing nausea and vomiting which persists for months
in the form of hysterical vomiting. A girl, watching beside a
sick-bed in a torment of anxiety, fell into a twilight state and
had a terrifying hallucination, while her right arm, which was
hanging over the back of her chair, went to sleep; from this
there developed a paresis of the same arm accompanied by
contracture and anaesthesia. She tried to pray but could find
no words; at length she succeeded in repeating a children's

THE MECHANISM OF HYSTERICAL PHENOMENA 5

prayer in English. When subsequently a severe and highly
complicated hysteria developed, she could only speak, write
and understand English, while her native language remained
unintelligible to her for eighteen months. 1 The mother of a
very sick child, which had at last fallen asleep, concentrated
her whole will-power on keeping still so as not to waken it.
Precisely on account of her intention she made a 'clacking' noise
with her tongue. (An instance of hysterical counter- will'.) This
noise was repeated on a subsequent occasion on which she
wished to keep perfectly still; and from it there developed a tic
which, in the form of a clacking with the tongue, occurred over
a period of many years whenever she felt excited. 2 A highly
intelligent man was present while his brother had an ankylosed
hip-joint extended under an anaesthetic. At the instant at
which the joint gave way with a crack, he felt a violent pain in
his own hip-joint, which persisted for nearly a year. Further
instances could be quoted.

In other cases the connection is not so simple. It consists
only in what might be called a 'symbolic' relation between the
precipitating cause and the pathological phenomenon a rela-
tion such as healthy people form in dreams. For instance, a
neuralgia may follow upon mental pain or vomiting upon a
feeling of moral disgust. We have studied patients who used
to make the most copious use of this sort of symbolization. 8
In still other cases it is not possible to understand at first sight
how they can be determined in the manner we have suggested.
It is precisely the typical hysterical symptoms which fall into
this class, such as hemi-anaesthesia, contraction of the field of
vision, epileptiform convulsions, and so on. An explanation of
our views on this group must be reserved for a fuller discussion
of the subject.

Observations such as these seem to us to establish an analogy between
the patho genesis of common hysteria and that of traumatic neuroses, and
to justify an extension of the concept of traumatic hysteria. In traumatic
neuroses the operative cause of the illness is not the trifling

1 [This patient is the subject of the first case history; see below,

p- 2!ff -]

2 [This patient is the subject of the second case history; see below,
p. 48 fT. These episodes are also treated at some length in *A Case of
Successful Treatment by Hypnotism' (Freud, 1892-3), where the con-
cept of 'hysterical counter-will' is also discussed.]

8 [See the account of Frau Cacilie M., p. 176 ff. below.]

6 I. PRELIMINARY COMMUNICATION

physical injury but the affect of fright the psychical trauma.
In an analogous manner, our investigations reveal, for many,
if not for most, hysterical symptoms, precipitating causes which
can only be described as psychical traumas. Any experience
which calls up distressing affects such as those of fright,
anxiety, shame or physical pain may operate as a trauma of
this kind; and whether it in fact does so depends naturally
enough on the susceptibility of the person affected (as well
as on another condition which will be mentioned later). In the
case of common hysteria it not infrequently happens that, in-
stead of a single, major trauma, we find a number of partial
traumas forming a group of provoking causes. These have only
been able to exercise a traumatic effect by summation and they
belong together in so far as they are in part components of a
single story of suffering. There are other cases in which an
apparently trivial circumstance combines with the actually
operative event or occurs at a time of peculiar susceptibility
to stimulation and in this way attains the dignity of a trauma
which it would not otherwise have possessed but which thence-
forward persists.

But the causal relation between the determining psychical
trauma and the hysterical phenomenon is not of a kind imply-
ing that the trauma merely acts like an agent provocateur in
releasing the symptom, which thereafter leads an independent
existence. We must presume rather that the psychical trauma
or more precisely the memory of the trauma acts like a
foreign body which long after its entry must continue to be
regarded as an agent that is still at work; and we find the
evidence for this in a highly remarkable phenomenon which at
the same time lends an important practical interest to our
findings.

For we found, to our great surprise at first, that each individual
hysterical symptom immediately and permanently disappeared when we
had succeeded in bringing clearly to light the memory of the event by
which it was provoked and in arousing its accompanying affect, and
when the patient had described that event in the greatest possible detail
and had put the affect into words. Recollection without affect almost
invariably, produces no result. The psychical process which
originally took place must be repeated as vividly as possible;
it must be brought back to its status nascendi and then given
verbal utterance. Where what we are dealing with are pheno-

THE MECHANISM OF HYSTERICAL PHENOMENA 7

mcna involving stimuli (spasms, neuralgias and hallucinations)
these re-appear once again with the fullest intensity and then
vanish for ever. Failures of function, such as paralyses and
anaesthesias, vanish in the same way, though, of course, with-
out the temporary intensification being discernible. 1

It is plausible to suppose that it is a question here of un-
conscious suggestion: the patient expects to be relieved of his
sufferings by this procedure, and it is this expectation, and not
the verbal utterance, which is the operative factor. This, how-
ever, is not so. The first case of this kind that came under
observation dates back to the year 1881, that is to say to the
'pro-suggestion' era. A highly complicated case of hysteria was
analysed in this way, and the symptoms, which sprang from
separate causes, were separately removed. This observation was
made possible by spontaneous auto-hypnoses on the part of
the patient, and came as a great surprise to the observer. 2

We may reverse the dictum 'cessante causa cessat ejfectus' ['when
the cause ceases (he effect ceases'] and conclude from these
observations that the determining process continues to operate
in some way or other for years not indirectly, through a chain
of intermediate causal links, but as a directly releasing cause
just as a psychical pain that is remembered in waking con-
sciousness still provokes a lachrymal secretion long after the
event. Hysterics suffer mainly from reminiscences.*

1 The possibility of a therapeutic procedure of this kind has been
clearly recognized by Delboeuf and Binct, as is shown by the following
quotations: 4 On s'expliquerait des lors comment le magnctiseur aide a
la guerison. II remet le sujet dans 1'etat ou le mal s'est manifeste et
combat par la parole le meme mal, rnais renaissant.' ['We can now
explain how the hypnotist promotes cure. He puts the subject back
into the state in which his trouble first appeared and uses words to
combat that trouble, as it now makes a fresh emergence.'] (Delbcruf,
1889.) *. . . peut-etrc verra-t-on qu'en rcportant le malade par un
artifice mental au moment meme ou le symptome a apparu pour la
premiere fois, on rend ce malade plus docile a une suggestion curative.'
['. . . we shall perhaps find that by taking the patient back by means
of a mental artifice to the very moment at which the symptom first
appeared, we may make him more susceptible to a therapeutic sug-
gestion.'] (Binet, 1892, 243.) In Janet's interesting study on mental
automatism (1889), there is an account of the cure of a hysterical girl
by a method analogous to ours.

2 [The first event of this kind is reported on p. 34.]

3 In this preliminary communication it is not possible for us to dis-
tinguish what is new in it from what has been said by other authors

8 I. PRELIMINARY COMMUNICATION

II

At first sight it seems extraordinary that events experienced
so long ago should continue to operate so intensely that their
recollection should not be liable to the wearing away process to
which, after all, we see all our memories succumb. The following
considerations may perhaps make this a little more intelligible.

The fading of a memory or the losing of its affect depends
on various factors. The most important of these is whether there
has been an energetic reaction to the event that provokes an affect.
By 'reaction' we here understand the whole class of voluntary
and involuntary reflexes from tears to acts of revenge in
which, as experience shows us, the affects are discharged.
If this reaction takes place to a sufficient amount a large
part of the affect disappears as a result. Linguistic usage
bears witness to this fact of daily observation by such phrases
as 'to cry oneself out' ['sick ausweinen'], and to 'blow off steam'
['sick austoben\ literally 'to rage oneself out']. If the reaction is
suppressed, the affect remains attached to the memory. An
injury that has been repaid, even if only in words, is recollected
quite differently from one that has had to be accepted. Lan-
guage recognizes this distinction, too, in its mental and physical
consequences; it very characteristically describes an injury that
has been suffered in silence as 'a mortification' [ ( Krdnkung' 9 lit.
'making ill']. The injured person's reaction to the trauma
only exercises a completely 'cathartic' effect if it is an adequate
reaction as, for instance, revenge. But language serves as a
substitute for action; by its help, an affect can be 'abreacted'
almost as effectively. 1 In other cases speaking is itself the ade-
quate reflex, when, for instance, it is a lamentation or giving
utterance to a tormenting secret, e.g. a confession. If there is
no such reaction, whether in deeds or words, or in the mildest
cases in tears, any recollection of the event retains its affective
tone to begin with.

such as Mocbius and Striimpell who have held similar views on hysteria
to ours. We have found the nearest approach to what we have to say
on the theoretical and therapeutic sides of the question in some
remarks, published from time to time, by Benedikt. These we shall deal
with elsewhere. [See below, p. 210 .]

1 ['Catharsis' and 'abreaction' made their first published appearance
in this passage. Freud had used the term 'abreaction' previously (June
28, 1892), in a letter to Fliess referring to the present paper (Freud,
19500, Letter 9).]

THE MECHANISM OF HYSTERICAL PHENOMENA 9

'Abreaction', however, is not the only method of dealing
with the situation that is open to a normal person who has
experienced a psychical trauma. A memory of such a trauma,
even if it has not been abreacted, enters the great complex
of associations, it comes alongside other experiences, which
may contradict it, and is subjected to rectification by other
ideas. After an accident, for instance, the memory of the danger
and the (mitigated) repetition of the fright becomes associated
with the memory of what happened afterwards rescue and
the consciousness of present safety. Again, a person's memory
of a humiliation is corrected by his putting the facts right, by
considering his own worth, etc. In this way a normal person is
able to bring about the disappearance of the accompanying
affect through the process of association.

To this we must add the general effacement of impressions,
the fading of memories which we name * forgetting ' and which
wears away those ideas in particular that are no longer affec-
tively operative.

Our observations have shown, on the other hand, that the
memories which have become the determinants of hysterical
phenomena persist for a long time with astonishing freshness
and with the whole of their affective colouring. We must, how-
ever, mention another remarkable fact, which we shall later be
able to turn to account, namely, that these memories, unlike
other memories of their past lives, are not at the patients' dis-
posal. On the contrary, these experiences are completely absent from
the patients* memory when they are in a normal psychical state, or are
only present in a highly summary form. Not until they have been
questioned under hypnosis do these memories emerge with the
undiminished vividness of a recent event.

Thus, for six whole months, one of our patients reproduced
under hypnosis with hallucinatory vividness everything that
had excited her on the same day of the previous year (during
an attack of acute hysteria). A diary kept by her mother with-
out her knowledge proved the completeness of the reproduction
[p. 33], Another patient, partly under hypnosis and partly
during spontaneous attacks, re-lived with hallucinatory clarity
all the events of a hysterical psychosis which she had passed
through ten years earlier and which she had for the most part
forgotten till the moment at which it re-emerged. Moreover,
certain memories of aetiological importance which dated back

10 I. PRELIMINARY COMMUNICATION

from fifteen to twenty-five years were found to be astonishingly
intact and to possess remarkable sensory force, and when they
returned they acted with all the affective strength of new
experiences [pp. 178-80].

This can only be explained on the view that these memories
constitute an exception in their relation to all the wearing-away
processes which we have discussed above. // appears, that is to
say, that these memories correspond to traumas that have not been suffi-
ciently abreacted; and if we enter more closely into the reasons
which have prevented this, w r c find at least two sets of condi-
tions under which the reaction to the trauma fails to occur.

In the first group are those cases in which the patients
have not reacted to a psychical trauma because the nature of
the trauma excluded a reaction, as in the case of the apparently
irreparable loss of a loved person or because social circumstances
made a reaction impossible or because it was a question of
things which the patient wished to forget, and therefore inten-
tionally repressed x from his conscious thought and inhibited
and suppressed. It is precisely distressing things of this kind

1 [This is the first appearance of the term 'repressed' ('verdrangt'} in
what was to be its psycho-analytic sense. The concept, though not the
term, had already been used by Breuer and Freud in the joint, post-
humously published draft (1940<f), which was written in November,
1892, only about a month before the present paper. Freud's own first
published use of the word was in the second section of his first paper on
anxiety neurosis (18956); and it occurs several times in his later con-
tributions to the present volume (e.g. on p. 1 16). At this period 'repres-
sion' was used as an equivalent to 'defence' ("Abwehr"), as is shown, for
instance, in the joint Preface to the First Edition (p. xxix, above). The
word 'defence' does not occur in the 'Preliminary Communication',
however. It first appeared in Section I of Freud's first paper on 'The
Neuro- Psychoses of Defence' (18940), and, like 'repression' is freely
used by him in the later parts of the Studies (e.g. on p. 147). Breuer uses
both terms in his theoretical chapter (e.g. on pp. 214 and 245). On
some of its earlier appearances the term 'repressed' is accompanied (as
here) by the adverb 'intentionally' ('absichtlich') or by 'deliberately'
('willkiirtich''). This is expanded by Freud in one place (18940), where he
states that the act of repression is 'introduced by an effort of will, for
which the motive can be assigned'. Thus the word 'intentionally 1
merely indicates the existence of a motive and carries no implication of
conscious intention. Indeed, a little later, at the beginning of his second
paper on 'The Neuro-Psychoses of Defence' (18966), Freud explicitly
describes the psychical mechanism of defence as 'unconscious'. Some
remarks on the origin of the concept of repression will be found in the
Editor's Introduction, p. xxii.]

THE MECHANISM OF HYSTERICAL PHENOMENA 1 1

that, under hypnosis, we find are the basis of hysterical pheno-
mena (e.g. hysterical deliria in saints and nuns, continent
women and well-brought-up children).

The second group of conditions are determined, not by the
content of the memories but by the psychical states in which
the patient received the experiences in question. For we find,
under hypnosis, among the causes of hysterical symptoms ideas
which are not in themselves significant, but whose persistence
is due to the fact that they originated during the prevalence
of severely paralysing affects, such as fright, or during positively
abnormal psychical states, such as the semi-hypnotic twilight
state of day-dreaming, auto-hypnoses, and so on. In such cases
it is the nature of the states which makes a reaction to the event
impossible.

Both kinds of conditions may, of course, be simultaneously
present, and this, in fact, often occurs. It is so when a trauma
which is operative in itself takes place while a severely paralys-
ing affect prevails or during a modified state of consciousness.
But it also seems to be true that in many people a psychical
trauma produces one of these abnormal states, which, in turn,
makes reaction impossible.

Both of these groups of conditions, however, have in common
the fact that the psychical traumas which have not been dis-
posed of by reaction cannot be disposed of either by being
worked over by means of association. In the first group the
patient is determined to forget the distressing experiences and
accordingly excludes them so far as possible from association;
while in the second group the associative working-over fails
to occur because there is no extensive associative connection
between the normal state of consciousness and the pathological
ones in which the ideas made their appearance. We shall have
occasion immediately to enter further into this matter.

It may therefore be said that the ideas which have become pathological
have persisted with such freshness and affective strength because they
have been denied the normal wearing-away processes by means of abre-
action and reproduction in states of uninhibited association.

in

We have stated the conditions which, as our experience shows,
are responsible for the development of hysterical phenomena

12 I. PRELIMINARY COMMUNICATION

from psychical traumas. In so doing, we have already been
obliged to speak of abnormal states of consciousness in which
these pathogenic ideas arise, and to emphasize the fact that
the recollection of the operative psychical trauma is not to
be found in the patient's normal memory but in his memory
when he is hypnotized. The longer we have been occupied with
these phenomena the more we have become convinced that the
splitting of consciousness which is so striking in the well-known classical
cases under the form of 'double conscience' ] is present to a rudimentary
degree in every hysteria, and that a tendency to such a dissociation, and
with it the emergence of abnormal states of consciousness (which we shall
bring together under the term 'hypnoid'} is the basic phenomenon of this
neurosis. In these views we concur with Binct and the two
Janets, 2 though we have had no experience of the remarkable
findings they have made on anaesthetic patients.

We should like to balance the familiar thesis that hypnosis
is an artificial hysteria by another the basis and sine qua non
of hysteria is the existence of hypnoid states. These hypnoid
states share with one another and with hypnosis, however much
they may differ in other respects, one common feature: the
ideas which emerge in them are very intense but are cut off
from associative communication with the rest of the content of
consciousness. Associations may take place between these hyp-
noid states, and their ideational content can in this way reach
a more or less high degree of psychical organization. Moreover,
the nature of these states and the extent to which they are cut
off from the remaining conscious processes must be supposed
to vary just as happens in hypnosis, which ranges from a light
drowsiness to somnambulism, from complete recollection to
total amnesia.

If hypnoid states of this kind are already present before the
onset of the manifest illness, they provide the soil in which the
affect plants the pathogenic memory with its consequent so-
matic phenomena. This corresponds to dispositional hysteria.
We have found, however, that a severe trauma (such as occurs
in a traumatic neurosis) or a laborious suppression (as of a
sexual affect, for instance) can bring about a splitting-off of
groups of 'ideas even in people who are in other respects un-
affected; and this would be the mechanism of psychically acquired

1 [The French term ('dual consciousness').]

2 [Pierre and Jules.]

THE MECHANISM OF HYSTERICAL PHENOMENA 13

hysteria. Between the extremes of these two forms we must
assume the existence of a series of cases within which the
liability to dissociation in the subject and the affective magni-
tude of the trauma vary inversely.

We have nothing new to say on the question of the origin of
these dispositional hypnoid states. They often, it would seem,
grow out of the day-dreams which are so common even in
healthy people and to which needlework and similar occupa-
tions render women especially prone. Why it is that the 'patho-
logical associations' brought about in these states are so stable
and why they have so much more influence on somatic processes
than ideas are usually found to do these questions coincide
with the general problem of the effectiveness of hypnotic sug-
gestions. Our observations contribute nothing fresh on this
subject. But they throw a light on the contradiction between
the dictum 'hysteria is a psychosis' and the fact that among
hysterics may be found people of the clearest intellect, strongest
will, greatest character and highest critical power. This char-
acterization holds good of their waking thoughts; but in their
hypnoid states they are insane, as we all are in dreams. Where-
as, however, our dream-psychoses have no effect upon our
waking state, the products of hypnoid states intrude into wak-
ing life in the form of hysterical symptoms. 1

IV

What we have asserted of chronic hysterical symptoms can
be applied almost completely to hysterical attacks. Charcot, as
is well known, has given us a schematic description of the
'major' hysterical attack, according to which four phases can
be distinguished in a complete attack: (1) the epileptoid phase,
(2) the phase of large movements, (3) the phase of 'attitudes
passionnelles* (the hallucinatory phase), and (4) the phase of
terminal delirium. Charcot derives all those forms of hysterical
attack which are in practice met with more often than the
complete 'grande attaque\ from the abbreviation, absence or
isolation of these four distinct phases. 2

1 [A preliminary sketch of this section of the paper has survived in a
posthumously published memorandum (Freud, 1941 [1892]), which is
headed 'IIP.]

[Gf. Charcot, 1887, 261.]

14 I. PRELIMINARY COMMUNICATION

Our attempted explanation takes its start from the third of
these phases, that of the 'attitudes passionnelles'. Where this is
present in a well-marked form, it exhibits the hallucinatory
reproduction of a memory which was of importance in bringing
about the onset of the hysteria the memory either of a single
major trauma (which we find par excellence in what is called
traumatic hysteria) or of a series of interconnected part- traumas
(such as underlie common hysteria). Or, lastly, the attack
may revive the events which have become emphasized owing
to their coinciding with a moment of special disposition to trauma.

There are also attacks, however, which appear to consist
exclusively of motor phenomena and in which the phase of
attitudes passionnelles is absent. If one can succeed in getting
into rapport with the patient during an attack such as this of
generalized clonic spasms or cataleptic rigidity, or during an
attaque de sommeil [attack of sleep] or if, better still, one can
succeed in provoking the attack under hypnosis one finds
that here, too, there is an underlying memory of the psychical
trauma or series of traumas, which usually comes to our notice
in a hallucinatory phase.

Thus, a little girl suffered for years from attacks of general
convulsions which could well be, and indeed were, regarded
as epileptic. She was hypnotized with a view to a differential
diagnosis, and promptly had one of her attacks. She was asked
what she was seeing and replied 'The dog! the dog's coming!';
and in fact it turned out that she had had the first of her
attacks after being chased by a savage dog. The success of the
treatment confirmed the choice of diagnosis.

Again, an employee who had become a hysteric as a result of
being ill-treated by his superior, suffered from attacks in which
he collapsed and fell into a frenzy of rage, but without uttering
a word or giving any sign of a hallucination. It was possible
to provoke an attack under hypnosis, and the patient then
revealed that he was living through the scene in which his
employer had abused him in the street and hit him with a stick.
A few days later the patient came back and complained of
having had another attack of the same kind. On this occasion
it turned out under hypnosis that he had been re-living the
scene to which the actual onset of the illness was related: the
scene in the law-court when he failed to obtain satisfaction for
his maltreatment.

THE MECHANISM OF HYSTERICAL PHENOMENA 15

In all other respects, too, the memories which emerge, or
can be aroused, in hysterical attacks correspond to the precipi-
tating causes which we have found at the root of chronic hysterical
symptoms. Like these latter causes, the memories underlying
hysterical attacks relate to psychical traumas which have not
been disposed of by abreaction or by associative thought-
activity. Like them, they are, whether completely or in essential
elements, out of reach of the memory of normal consciousness
and are found to belong to the ideational content of hypnoid
states of consciousness with restricted association. Finally, too,
the therapeutic test can be applied to them. Our observations
have often taught us that a memory of this kind which had
hitherto provoked attacks, ceases to be able to do so after the
process of reaction and associative correction have been applied
to it under hypnosis.

The motor phenomena of hysterical attacks can be inter-
preted partly as universal forms of reaction appropriate to the
affect accompanying the memory (such as kicking about and
waving the arms and legs, which even young babies do) , partly
as a direct expression of these memories; but in part, like the
hysterical stigmata 1 found among the chronic symptoms, they
cannot be explained in this way.

Hysterical attacks, furthermore, appear in a specially inter-
esting light if we bear in mind a theory that we have men-
tioned above, namely, that in hysteria groups of ideas originat-
ing in hypnoid states are present and that these are cut off
from associative connection with the other ideas, but can be
associated among themselves, and thus form the more or less
highly organized rudiment of a second consciousness, a condition
seconde. If this is so, a chronic hysterical symptom will cor-
respond to the intrusion of this second state into the somatic
innervation which is as a rule under the control of normal
consciousness. A hysterical attack, on the other hand, is
evidence of a higher organization of this second state. When
the attack makes its first appearance, it indicates a moment at
which this hypnoid consciousness has obtained control of the
subject's whole existence it points, that is, to an acute hysteria;
when it occurs on subsequent occasions and contains a memory,
it points to a return of that moment. Charcot has already

1 [ 4 The permanent symptoms of hysteria.' (Charcot, 1887, 255.)
Stigmata are discussed by Breuer below, p. 244 f.]

16 I. PRELIMINARY COMMUNICATION

suggested that hysterical attacks are a rudimentary form of a
condition seconds. During the attack, control over the whole of
the somatic innervation passes over to the hypnoid conscious-
ness. Normal consciousness, as well-known observations show,
is not always entirely repressed. It may even be aware of the
motor phenomena of the attack, while the accompanying
psychical events are outside its knowledge.

The typical course of a severe case of hysteria is, as we know,
as follows. To begin with, an ideational content is formed
during hypnoid states; when this has increased to a sufficient
extent, it gains control, during a period of 'acute hysteria', of
the somatic innervation and of the patient's whole existence,
and creates chronic symptoms and attacks; after this it clears
up, apart from certain residues. If the normal personality can
regain control, what is left over from the hypnoid ideational
content recurs in hysterical attacks and puts the subject back
from time to time into similar states, which are themselves once
more open to influence and susceptible to traumas. A state of
equilibrium, as it were, may then be established between the
two psychical groups which are combined in the same person:
hysterical attacks and normal life proceed side by side without
interfering with each other. An attack will occur spontaneously,
just as memories do in normal people; it is, however, possible
to provoke one, just as any memory can be aroused in accord-
ance with the laws of association. It can be provoked either by
stimulation of a hysterogenic zone 1 or by a new experience
which sets it going owing to a similarity with the pathogenic
experience. We hope to be able to show that these two kinds
of determinant, though they appear to be so unlike, do not
differ in essentials, but that in both a hyperaesthetic memory
is touched on.

In other cases this equilibrium is very unstable. The attack
makes its appearance as a manifestation of the residue of the
hypnoid consciousness whenever the normal personality is ex-
hausted and incapacitated. The possibility cannot be dismissed
that here the attack may have been divested of its original
meaning and may be recurring as a motor reaction without
any content.

It must be left to further investigation to discover what it is

1 [This is a term regularly used by Gharcot, e.g. 1887, 85 ff.]

THE MECHANISM OF HYSTERICAL PHENOMENA 17

that determines whether a hysterical personality manifests itself
in attacks, in chronic symptoms or in a mixture of the two. 1

It will now be understood how it is that the psychothera-
peutic procedure which we have described in these pages has
a curative effect. // brings to an end the operative force of the idea
which was not abreacted in the first instance, by allowing its strangulated
affect to find a way out through speech; and it subjects it to associative
correction by introducing it into normal consciousness (under light
hypnosis) or by removing it through the physician's suggestion, as is
done in somnambulism accompanied by amnesia.

In our opinion the therapeutic advantages of this procedure
are considerable. It is of course true that we do not cure
hysteria in so far as it is a matter of disposition. We can do
nothing against the recurrence of hypnoid states. Moreover,
during the productive stage of an acute hysteria our procedure
cannot prevent the phenomena which have been so laboriously
removed from being at once replaced by fresh ones. But once
this acute stage is past, any residues which may be left in the
form of chronic symptoms or attacks are often removed, and
permanently so, by our method, because it is a radical one;
in this respect it seems to us far superior in its efficacy to removal
through direct suggestion, as it is practised to-day by psycho-
therapists.

If by uncovering the psychical mechanism of hysterical
phenomena we have taken a step forward along the path first
traced so successfully by Charcot with his explanation and
artificial imitation of hystero-traumatic paralyses, we cannot
conceal from ourselves that this has brought us nearer to an
understanding only of the mechanism of hysterical symptoms
and not of the internal causes of hysteria. We have done no
more than touch upon the aetiology of hysteria and in fact have
been able to throw light only on its acquired forms on the
bearing of accidental factors on the neurosis.

VIENNA, December 1892

1 [A preliminary draft of this discussion on hysterical attacks, written
in November, 1892, was published posthumously (Breuer and Freud,
1940). The subject was dealt with much later by Freud in a paper on
hysterical attacks (19090).]

II

CASE HISTORIES

(BREUER AND FREUD)

II

CASE HISTORIES

(BREUER AND FREUD)

CASE 1
FRAULEIN ANNA O. (Breuer)

AT the time of her falling ill (in 1880) Fraulein Anna O. was
twenty-one years old. She may be regarded as having had a
moderately severe neuropathic heredity, since some psychoses
had occurred among her more distant relatives. Her parents
were normal in this respect. She herself had hitherto been con-
sistently healthy and had shown no signs of neurosis during her
period of growth. She was markedly intelligent, with an aston-
ishingly quick grasp of things and penetrating intuition. She
possessed a powerful intellect which would have been capable
of digesting solid mental pabulum and which stood in need of
it though without receiving it after she had left school. She
had great poetic and imaginative gifts, which were under the
control of a sharp and critical common sense. Owing to this
latter quality she was completely unsuggestible; she was only in-
fluenced by arguments, never by mere assertions. Her will-
power was energetic, tenacious and persistent; sometimes it
reached the pitch of an obstinacy which only gave way out of
kindness and regard for other people.

One of her essential character traits was sympathetic kind-
ness. Even during her illness she herself was greatly assisted
by being able to look after a number of poor, sick people, for
she was thus able to satisfy a powerful instinct. Her states of
feeling always tended to a slight exaggeration, alike of cheer-
fulness and gloom; hence she was sometimes subject to moods.
The element of sexuality was astonishingly undeveloped in her. 1
The patient, whose life became known to me to an extent to

1 [Freud quoted this sentence (not quite verbatim) in a footnote to
the first of his Three Essays on the Theory of Sexuality (1905rf), Standard Ed.,
7, 164 n. y and in Chapter II of his autobiography (1925 </).]

21

22 II. CASE HISTORIES

which one person's life is seldom known to another, had never
been in love; and in all the enormous number of hallucinations
which occurred during her illness that element of mental life
never emerged.

This girl, who was bubbling over with intellectual vitality,
led an extremely monotonous existence in her puritanically-
minded family. She embellished her life in a manner which
probably influenced her decisively in the direction of her illness,
by indulging in systematic day-dreaming, which she described
as her 'private theatre 5 . While everyone thought she was attend-
ing, she was living through fairy tales in her imagination; but
she was always on the spot when she was spoken to, so that no
one was aware of it. She pursued this activity almost continu-
ously while she was engaged on her household duties, which
she discharged unexceptionably. I shall presently have to des-
cribe the way in which this habitual day-dreaming while she
was well passed over into illness without a break.

The course of the illness fell into several clearly separable
phases:

(A) Latent incubation. From the middle of July, 1880, till
about December 10. This phase of an illness is usually hidden
from us; but in this case, owing to its peculiar character, it
was completely accessible; and this in itself lends no small
pathological interest to the history. I shall describe this phase
presently.

(B) The manifest illness. A psychosis of a peculiar kind,
paraphasia, a convergent squint, severe disturbances of vision,
paralyses (in the form of contractures), complete in the right
upper and both lower extremities, partial in the left upper
extremity, paresis of the neck muscles. A gradual reduction of
the contracture to the right-hand extremities. Some improve-
ment, interrupted by a severe psychical trauma (the death of
the patient's father) in April, after which there followed

(C) A period of persisting somnambulism, subsequently alter-
nating with more normal states. A number of chronic symptoms
persisted till December, 1881.

(D) Gradual cessation of the pathological states and symp-
toms up to June, 1882.

In July, 1880, the patient's father, of whom she was passion-
ately fond, fell ill of a peripleuritic abscess which failed to clear

(1) FRAULEIN ANNA O. (BREUER) 23

up and to which he succumbed in April, 1881. During the first
months of the illness Anna devoted her whole energy to nursing
her father, and no one was much surprised when by degrees her
own health greatly deteriorated. No one, perhaps not even the
patient herself, knew what was happening to her; but eventually
the state of weakness, anaemia and distaste for food became so
bad that to her great sorrow she was no longer allowed to
continue nursing the patient. The immediate cause of this was a
very severe cough, on account of which I examined her for the
first time. It was a typical tussis nervosa. She soon began to dis-
play a marked craving for rest during the afternoon, followed
in the evening by a sleep-like state and afterwards a highly
excited condition.

At the beginning of December a convergent squint appeared.
An ophthalmic surgeon explained this (mistakenly) as being
due to paresis of one abducens. On December 1 1 the patient
took to her bed and remained there until April 1 .

There developed in rapid succession a series of severe dis-
turbances which were apparently quite new: left-sided occipital
headache; convergent squint (diplopia), markedly increased
by excitement; complaints that the walls of the room seemed
to be falling over (affection of the obliquus); disturbances
of vision which it was hard to analyse; paresis of the muscles
of the front of the neck, so that finally the patient could
only move her head by pressing it backwards between her
raised shoulders and moving her whole back; contracture and
anaesthesia of the right upper, and, after a time, of the right
lower extremity. The latter was fully extended, adducted and
rotated inwards. Later the same symptom appeared in the left
lower extremity and finally in the left arm, of which, however,
the fingers to some extent retained the power of movement. So,
too, there was no complete rigidity in the shoulder-joints. The
contracture reached its maximum in the muscles of the upper
arms. In the same way, the region of the elbows turned out to
be the most affected by anaesthesia when, at a later stage, it
became possible to make a more careful test of this. At the
beginning of the illness the anaesthesia could not be efficiently
tested, owing to the patient's resistance arising from feelings of
anxiety.

It was while the patient was in this condition that I under-
took her treatment, and I at once recognized the seriousness

24 II. CASE HISTORIES

of the psychical disturbance with which I had to deal. Two
entirely distinct states of consciousness were present which
alternated very frequently and without warning and which be-
came more and more differentiated in the course of the illness.
In one of these states she recognized her surroundings; she was
melancholy and anxious, but relatively normal. In the other
state she hallucinated and was 'naughty 5 that is to say, she
was abusive, used to throw the cushions at people, so far as the
contractures at various times allowed, tore buttons off her bed-
clothes and linen with those of her fingers which she could
move, and so on. At this stage of her illness if something had
been moved in the room or someone had entered or left it
[during her other state of consciousness] she would complain of
having 'lost' some time and would remark upon the gap in her
train of conscious thoughts. Since those about her tried to deny
this and to soothe her when she complained that she was going
mad, she would, after throwing the pillows about, accuse people
of doing things to her and leaving her in a muddle, etc.

These 'absences* l had already been observed before she took
to her bed; she used then to stop in the middle of a sentence,
repeat her last words and after a short pause go on talking.
These interruptions gradually increased till they reached the
dimensions that have just been described; and during the climax
of the illness, when the contractures had extended to the left
side of her body, it was only for a short time during the day
that she was to any degree normal. But the disturbances in-
vaded even her moments of relatively clear consciousness.
There were extremely rapid changes of mood leading to exces-
sive but quite temporary high spirits, and at other times severe
anxiety, stubborn opposition to every therapeutic effort and
frightening hallucinations of black snakes, which was how she
saw her hair, ribbons and similar things. At the same time she
kept on telling herself not to be so silly: what she was seeing
was really only her hair, etc. At moments when her mind was
quite clear she would complain of the profound darkness in
her head, of not being able to think, of becoming blind and
deaf, of having two selves, a real one and an evil one which
forced her to behave badly, and so on.

In the afternoons she would fall into a somnolent state which
lasted till about an hour after sunset. She would then wake up
1 [The French term.]

(1) FRAULEIN ANNA O. (BREUER) 25

and complain that something was tormenting her or rather,
she would keep repeating in the impersonal form 'tormenting,
tormenting'. For alongside of the development of the contrac-
tures there appeared a deep-going functional disorganization
of her speech. It first became noticeable that she was at a loss
to find words, and this difficulty gradually increased. Later she
lost her command of grammar and syntax; she no longer con-
jugated verbs, and eventually she used only infinitives, for the
most part incorrectly formed from weak past participles; and
she omitted both the definite and indefinite article. In the pro-
cess of time she became almost completely deprived of words.
She put them together laboriously out of four or five languages
and became almost unintelligible. When she tried to write (until
her contractures entirely prevented her doing so) she employed
the same jargon. For two weeks she became completely dumb
and in spite of making great and continuous efforts to speak
she was unable to say a syllable. And now for the first time the
psychical mechanism of the disorder became clear. As I knew,
she had felt very much offended over something and had deter-
mined not to speak about it. When I guessed this and obliged
her to talk about it, the inhibition, which had made any other
kind of utterance impossible as well, disappeared.

This change coincided with a return of the power of move-
ment to the extremities of the left side of her body, in March,
1881. Her paraphasia receded; but thenceforward she spoke
only in English apparently, however, without knowing that
she was doing so. She had disputes with her nurse who was,
of course, unable to understand her. It was only some months
later that I was able to convince her that she was talking
English. Nevertheless, she herself could still understand the
people about her who talked German. Only in moments of
extreme anxiety did her power of speech desert her entirely,
or else she would use a mixture of all sorts of languages. At
times when she was at her very best and most free, she talked
French and Italian. There was complete amnesia between these
times and those at which she talked English. At this point, too,
her squint began to diminish and made its appearance only
at moments of great excitement. She was once again able to
support her head. On the first of April she got up for the first
time.

On the fifth of April her adored father died. During her

26 II. CASE HISTORIES

illness she had seen him very rarely and for short periods. This
was the most severe psychical trauma that she could possibly
have experienced. A violent outburst of excitement was suc-
ceeded by profound stupor which lasted about two days and
from which she emerged in a greatly changed state. At first
she was far quieter and her feelings of anxiety were much
diminished. The contracture of her right arm and leg persisted
as well as their anaesthesia, though this was not deep. There
was a high degree of restriction of the field of vision: in a bunch
of flowers which gave her much pleasure she could only see
one flower at a time. She complained of not being able to
recognize people. Normally, she said, she had been able to
recognize faces without having to make any deliberate effort;
now she was obliged to do laborious 'recognizing work' l and
had to say to herself 'this person's nose is such-and-such, his
hair is such-and-such, so he must be so-and-so'. All the people
she saw seemed like wax figures without any connection with
her. She found the presence of some of her close relatives very
distressing and this negative attitude grew continually stronger.
If someone whom she was ordinarily pleased to see came into
the room, she would recognize him and would be aware of
things for a short time, but would soon sink back into her own
broodings and her visitor was blotted out. I was the only per-
son whom she always recognized when I came in; so long as I
was talking to her she was always in contact with things and
lively, except for the sudden interruptions caused by one of her
hallucinatory 'absences'.

She now spoke only English and could not understand what
was said to her in German. Those about her were obliged to
talk to her in English; even the nurse learned to make herself
to some extent understood in this way. She was, however, able
to read French and Italian. If she had to read one of these
aloud, what she produced, with extraordinary fluency, was an
admirable extempore English translation.

She began writing again, but in a peculiar fashion. She wrote
with her left hand, the less stiff one, and she used Roman
printed letters, copying the alphabet from her edition of
Shakespeare.

She had eaten extremely little previously, but now she refused
nourishment altogether. However, she allowed me to feed her,
1 [In English in the original.]

(1) FRAULEIN ANNA O. (BREUER) 27

so that she very soon began to take more food. But she never
consented to eat bread. After her meal she invariably rinsed
out her mouth and even did so if, for any reason, she had not
eaten anything which shows how absent-minded she was about
such things.

Her somnolent states in the afternoon and her deep sleep
after sunset persisted. If, after this, she had talked herself out
(I shall have to explain what is meant by this later) she was
clear in mind, calm and cheerful.

This comparatively tolerable state did not last long. Some
ten days after her father's death a consultant was brought in,
whom, like all strangers, she completely ignored while I de-
monstrated all her peculiarities to him. 'That's like an examin-
ation,' l she said, laughing, when I got her to read a French
text aloud in English. The other physician intervened in the
conversation and tried to attract her attention, but in vain. It
was a genuine 'negative hallucination' of the kind which has
since so often been produced experimentally. In the end he
succeeded in breaking through it by blowing smoke in her face.
She suddenly saw a stranger before her, rushed to the door to
take away the key and fell unconscious to the ground. There
followed a short fit of anger and then a severe attack of anxiety
which I had great difficulty in calming down. Unluckily I had
to leave Vienna that evening, and when I came back several
days later I found the patient much worse. She had gone entirely
without food the whole time, was full of anxiety and her hallucin-
atory absences were filled with terrifying figures, death's heads
and skeletons. Since she acted these things through as though
she was experiencing them and in part put them into words,
the people around her became aware to a great extent of the
content of these hallucinations.

The regular order of things was: the somnolent state in the
afternoon, followed after sunset by the deep hypnosis for which
she invented the technical name of 'clouds'. 2 If during this she
was able to narrate the hallucinations she had had in the
course of the day, she would wake up clear in mind, calm and
cheerful. She would sit down to work and write or draw far
into the night quite rationally. At about four she would go to
bed. Next day the whole series of events would be repeated.
It was a truly remarkable contrast: in the day-time the

1 [In English in the original.] 2 [In English in the original.]

28 II. CASE HISTORIES

irresponsible patient pursued by hallucinations, and at night
the girl with her mind completely clear.

In spite of her euphoria at night, her psychical condition
deteriorated steadily. Strong suicidal impulses appeared which
made it seem inadvisable for her to continue living on the third
floor. Against her will, therefore, she was transferred to a
country house in the neighbourhood of Vienna (on June 7,
1881). I had never threatened her with this removal from her
home, which she regarded with horror, but she herself had,
without saying so, expected and dreaded it. This event made it
clear once more how much the affect of anxiety dominated her
psychical disorder. Just as after her father's death a calmer
condition had set in, so now, when what she feared had actually
taken place, she once more became calmer. Nevertheless, the
move was immediately followed by three days and nights com-
pletely without sleep or nourishment, by numerous attempts at
suicide (though, so long as she was in a garden, these were not
dangerous), by smashing windows and so on, and by hallucin-
ations unaccompanied by absences which she was able to distin-
guish easily from her other hallucinations. After this she grew
quieter, let the nurse feed her and even took chloral at night.

Before continuing my account of the case, I must go back
once more and describe one of its peculiarities which I have
hitherto mentioned only in passing. I have already said that
throughout the illness up to this point the patient fell into a
somnolent state every afternoon and that after sunset this period
passed into a deeper sleep 'clouds'. (It seems plausible to
attribute this regular sequence of events merely to her experi-
ence while she was nursing her father, which she had had to do
for several months. During the nights she had watched by the
patient's bedside or had been awake anxiously listening till
the morning; in the afternoons she had lain down for a short
rest, as is the usual habit of nurses. This pattern of waking at
night and sleeping in the afternoons seems to have been carried
over into her own illness and to have persisted long after the
sleep had been replaced by a hypnotic state.) After the deep
sleep had lasted about an hour she grew restless, tossed to and
fro and kept repeating 'tormenting, tormenting', with her eyes
shut all the time. It was also noticed how, during her absences
in day-time she was obviously creating some situation or episode

(1) FRAULEIN ANNA O. (BREUER) 29

to which she gave a clue with a few muttered words. It hap-
pened then to begin with accidentally but later intentionally
that someone near her repeated one of these phrases of hers
while she was complaining about the 'tormenting'. She at once
joined in and began to paint some situation or tell some story,
hesitatingly at first and in her paraphasic jargon; but the longer
she went on the more fluent she became, till at last she was
speaking quite correct German. (This applies to the early period
before she began talking English only [p. 25].) The stories were
always sad and some of them very charming, in the style of
Hans Andersen's Picture-book without Pictures, and, indeed, they
were probably constructed on that model. As a rule their
starting-point or central situation was of a girl anxiously sitting
by a sick-bed. But she also built up her stories on quite other
topics. A few moments after she had finished her narrative
she would wake up, obviously calmed down, or, as she called it,
1 gehaglicK . l During the night she would again become restless,
and in the morning, after a couple of hours 5 sleep, she was
visibly involved in some other set of ideas. If for any reason
she was unable to tell me the story during her evening hypnosis
she failed to calm down afterwards, and on the following day
she had to tell me two stories in order for this to happen.

The essential features of this phenomenon the mounting
up and intensification of her absences into her auto-hypnosis in
the evening, the effect of the products of her imagination as
psychical stimuli and the easing and removal of her state of
stimulation when she gave utterance to them in her hypnosis
remained constant throughout the whole eighteen months
during which she was under observation.

The stories naturally became still more tragic after her
father's death. It was not, however, until the deterioration of
her mental condition, which followed when her state of som-
nambulism was forcibly broken into in the way already des-
cribed, that her evening narratives ceased to have the character
of more or less freely-created poetical compositions and changed
into a string of frightful and terrifying hallucinations. (It was
already possible to arrive at these from the patient's behaviour
during the day.) I have already [p. 27] described how com-
pletely her mind was relieved when, shaking with fear and

1 [She used this made-up word instead of the regular German
l behaglich\ meaning 'comfortable'.]

30 II. CASE HISTORIES

horror, she had reproduced these frightful images and given
verbal utterance to them.

While she was in the country, when I was unable to pay her
daily visits, the situation developed as follows. I used to visit
her in the evening, when I knew I should find her in her
hypnosis, and I then relieved her of the whole stock of imagin-
ative products which she had accumulated since my last visit.
It was essential that this should be effected completely if good
results were to follow. When this was done she became per-
fectly calm, and next day she would be agreeable, easy to
manage, industrious and even cheerful; but on the second day
she would be increasingly moody, contrary and unpleasant,
and this would become still more marked on the third day.
When she was like this it was not always easy to get her to talk,
even in her hypnosis. She aptly described this procedure, speak-
ing seriously, as a 'talking cure', while she referred to it jokingly
as 'chimney-sweeping'. 1 She knew that after she had given
utterance to her hallucinations she would lose all her obstinacy
and what she described as her 'energy'; and when, after some
comparatively long interval, she was in a bad temper, she
would refuse to talk, and I was obliged to overcome her un-
willingness by urging and pleading and using devices such as
repeating a formula with which she was in the habit of intro-
ducing her stories. But she would never begin to talk until she
had satisfied herself of my identity by carefully feeling my
hands. On those nights on which she had not been calmed by
verbal utterance it was necessary to fall back upon chloral. I
had tried it on a few earlier occasions, but I was obliged to give
her 5 grammes, and sleep was preceded by a state of intoxica-
tion which lasted for some hours. When I was present this state
was euphoric, but in my absence it was highly disagreeable
and characterized by anxiety as well as excitement. (It may
be remarked incidentally that this severe state of intoxica-
tion made no difference to her contractures.) I had been able
to avoid the use of narcotics, since the verbal utterance of
her hallucinations calmed her even though it might not induce
sleep; but when she was in the country the nights on which
she had not obtained hypnotic relief were so unbearable
that in spite of everything it was necessary to have recourse
1 [These two phrases are in English in the original.]

(1) FRAULEIN ANNA O. (BREUER) 31

to chloral. But it became possible gradually to reduce the
dose.

The persisting somnambulism did not return. But on the
other hand the alternation between two states of consciousness
persisted. She used to hallucinate in the middle of a conversa-
tion, run off, start climbing up a tree, etc. If one caught hold
of her, she would very quickly take up her interrupted sentence
without knowing anything about what had happened in the
interval. All these hallucinations, however, came up and were
reported on in her hypnosis.

Her condition improved on the whole. She took nourish-
ment without difficulty and allowed the nurse to feed her;
except that she asked for bread but rejected it the moment it
touched her lips. The paralytic contracture of the leg dimin-
ished greatly. There was also an improvement in her power of
judgement and she became much attached to my friend Dr. B.,
the physician who visited her. She derived much benefit from
a Newfoundland dog which was given to her and of which she
was passionately fond. On one occasion, though, her pet made
an attack on a cat, and it was splendid to see the way in which
the frail girl seized a whip in her left hand and beat off the
huge beast with it to rescue his victim. Later, she looked after
some poor, sick people, and this helped her greatly.

It was after I returned from a holiday trip which lasted
several weeks that I received the most convincing evidence of
the pathogenic and exciting effect brought about by the idea-
tional complexes which were produced during her absences, or
condition seconde, and of the fact that these complexes were dis-
posed of by being given verbal expression during hypnosis.
During this interval no 'talking cure' had been carried out, for
it was impossible to persuade her to confide what she had to
say to anyone but me not even to Dr. B. to whom she had in
other respects become devoted. I found her in a wretched
moral state, inert, unamenable, ill-tempered, even malicious.
It became plain from her evening stories that her imaginative
and poetic vein was drying up. What she reported was more
and more concerned with her hallucinations and, for instance,
the things that had annoyed her during the past days. These
were clothed in imaginative shape, but were merely formulated
in stereotyped images rather than elaborated into poetic pro-
ductions. But the situation only became tolerable after I had

32 II. CASE HISTORIES

arranged for the patient to be brought back to Vienna for a
week and evening after evening made her tell me three to five
stories. When I had accomplished this, everything that had
accumulated during the weeks of my absence had been worked
off. It was only now that the former rhythm was re-established:
on the day after her giving verbal utterance to her phantasies
she was amiable and cheerful, on the second day she was more
irritable and less agreeable and on the third positively 'nasty'.
Her moral state was a function of the time that had elapsed
since her last utterance. This was because every one of the
spontaneous products of her imagination and every event which
had been assimilated by the pathological part of her mind
persisted as a psychical stimulus until it had been narrated in
her hypnosis, after which it completely ceased to operate.

When, in the autumn, the patient returned to Vienna
(though to a different house from the one in which she had
fallen ill), her condition was bearable, both physically and men-
tally; for very few of her experiences in fact only her more
striking ones were made into psychical stimuli in a patho-
logical manner. I was hoping for a continuous and increasing
improvement, provided that the permanent burdening of her
mind with fresh stimuli could be prevented by her giving regular
verbal expression to them. But to begin with I was disappointed.
In December there was a marked deterioration of her psychical
condition. She once more became excited, gloomy and irritable.
She had no more 'really good days' even when it was impossible
to detect anything that was remaining 'stuck' inside her. To-
wards the end of December, at Christmas time, she was particu-
larly restless, and for a whole week in the evenings she told me
nothing new but only the imaginative products which she had
elaborated under the stress of great anxiety and emotion during
the Christmas of 1880 [a year earlier]. When the scenes had
been completed she was greatly relieved.

A year had now passed since she had been separated from
her father and had taken to her bed, and from this time on her
condition became clearer and was systematized in a very
peculiar manner. Her alternating states of consciousness, which
were characterized by the fact that, from morning onwards,
her absences (that is to say, the emergence of her condition seconde)
always became more frequent as the day advanced and took
entire possession by the evening these alternating states had

(1) FRAULEIN ANNA O. (BREUER) 33

differed from each other previously in that one (the first) was
normal and the second alienated; now, however, they differed
further in that in the first she lived, like the rest of us, in the
winter of 1881-2, whereas in the second she lived in the winter
of 1880-1, and had completely forgotten all the subsequent
events. The one thing that nevertheless seemed to remain
conscious most of the time was the fact that her father had died.
She was carried back to the previous year with such intensity
that in the new house she hallucinated her old room, so that
when she wanted to go to the door she knocked up against the
stove which stood in the same relation to the window as the
door did in the old room. The change-over from one state to
another occurred spontaneously but could also be very easily
brought about by any sense-impression which vividly recalled
the previous year. One had only to hold up an orange before
her eyes (oranges were what she had chiefly lived on during
the first part of her illness) in order to carry her over from the
year 1882 to the year 1881. But this transfer into the past did
not take place in a general or indefinite manner; she lived
through the previous winter day by day. I should only have
been able to suspect that this was happening, had it not been
that every evening during the hypnosis she talked through
whatever it was that had excited her on the same day in 1881,
and had it not been that a private diary kept by her mother in
1881 confirmed beyond a doubt the occurrence of the under-
lying events. This re-living of the previous year continued till
the illness came to its final close in June, 1882.

It was interesting here, too, to observe the way in which these
revived psychical stimuli belonging to her secondary state made
their way over into her first, more normal one. It happened,
for instance, that one morning the patient said to me laughingly
that she had no idea what was the matter but she was angry
with me. Thanks to the diary I knew what was happening; and,
sure enough, this was gone through again in the evening
hypnosis: I had annoyed the patient very much on the same
evening in 1881. Or another time she told me there was some-
thing the matter with her eyes; she was seeing colours wrong.
She knew she was wearing a brown dress but she saw it as a
blue one. We soon found that she could distinguish all the
colours of the visual test-sheets correctly and clearly, and that
the disturbance only related to the dress-material. The reason

34 II. CASE HISTORIES

was that during the same period in 1881 she had been very
busy with a dressing-gown for her father, which was made with
the same material as her present dress, but was blue instead of
brown. Incidentally, it was often to be seen that these emergent
memories showed their effect in advance; the disturbance of
her normal state would occur earlier on, and the memory
would only gradually be awakened in her condition seconded

Her evening hypnosis was thus heavily burdened, for we had
to talk off not only her contemporary imaginative products but
also the events and Vexations 5 2 of 1881. (Fortunately I had
already relieved her at the time of the imaginative products of
that year.) But in addition to all this the work that had to be
done by the patient and her physician was immensely increased
by a third group of separate disturbances which had to be dis-
posed of in the same manner. These were the psychical events
involved in the period of incubation of the illness between July
and December, 1880; it was they that had produced the whole
of the hysterical phenomena, and when they were brought to
verbal utterance the symptoms disappeared.

When this happened for the first time when, as a result of
an accidental and spontaneous utterance of this kind, during
the evening hypnosis, a disturbance which had persisted for a
considerable time vanished I was greatly surprised. It was in
the summer during a period of extreme heat, and the patient
was suffering very badly from thirst; for, without being able to
account for it in any way, she suddenly found it impossible to
drink. She would take up the glass of water she longed for, but
as soon as it touched her lips she would push it away like some-
one suffering from hydrophobia. As she did this, she was
obviously in an absence for a couple of seconds. She lived only
on fruit, such as melons, etc., so as to lessen her tormenting
thirst. This had lasted for some six weeks, when one day during
hypnosis she grumbled about her English lady-companion
whom she did not care for, and went on to describe, with
every sign of disgust, how she had once gone into that lady's
room and how her little dog horrid creature! had drunk
out of a glass there. The patient had said nothing, as she had
wan ted- to be polite. After giving further energetic expression
to the anger she had held back, she asked for something to

1 [Cf. The similar phenomenon in the case of Frau Cacilie, p. 70 .]
8 [In English in the original.]

(1) FRAULEIN ANNA O. (BREUER) 35

drink, drank a large quantity of water without any difficulty
and woke from her hypnosis with the glass at her lips; and
thereupon the disturbance vanished, never to return. A number
of extremely obstinate whims were similarly removed after she
had described the experiences which had given rise to them.
She took a great step forward when the first of her chronic
symptoms disappeared in the same way the contracture of
her right leg, which, it is true, had already diminished a great
deal. These findings that in the case of this patient the hysteri-
cal phenomena disappeared as soon as the event which had
given rise to them was reproduced in her hypnosis made it
possible to arrive at a therapeutic technical procedure which
left nothing to be desired in its logical consistency and syste-
matic application. Each individual symptom in this compli-
cated case was taken separately in hand; all the occasions on
which it had appeared were described in reverse order, starting
before the time when the patient became bed-ridden and going
back to the event which had led to its first appearance. When this
had been described the symptom was permanently removed.

In this way her paralytic contractures and anaesthesias, dis-
orders of vision and hearing of every sort, neuralgias, coughing,
tremors, etc., and finally her disturbances of speech were
'talked away'. Amongst the disorders of vision, the following,
for instance, were disposed of separately: the convergent squint
with diplopia; deviation of both eyes to the right, so that when
her hand reached out for something it always went to the left
of the object; restriction of the visual field; central amblyopia;
macropsia; seeing a death's head instead of her father; inability
to read. Only a few scattered phenomena (such, for instance,
as the extension of the paralytic contractures to the left side of
her body) which had developed while she was confined to bed,
were untouched by this process of analysis, 1 and it is probable,
indeed, that they had in fact no immediate psychical cause
[cf. below, pp. 445].

It turned out to be quite impracticable to shorten the work
by trying to elicit in her memory straight away the first provok-
ing cause of her symptoms. She was unable to find it, grew
confused, and things proceeded even more slowly than if she
was allowed quietly and steadily to follow back the thread of
memories on which she had embarked. Since the latter method,
1 [See footnote 2, p. 48.]

36 II. CASE HISTORIES

however, took too long in the evening hypnosis, owing to her
being over-strained and distraught by talking out' the two
other sets of experiences and owing, too, to the reminiscences
needing time before they could attain sufficient vividness we
evolved the following procedure. I used to visit her in the
morning and hypnotize her. (Very simple methods of doing this
were arrived at empirically.) I would next ask her to concen-
trate her thoughts on the symptom we were treating at the
moment and to tell me the occasions on which it had appeared.
The patient would proceed to describe in rapid succession and
under brief headings the external events concerned and these
I would jot down. During her subsequent evening hypnosis she
would then, with the help of my notes, give me a fairly detailed
account of these circumstances.

An example will show the exhaustive manner in which she
accomplished this. It was our regular experience that the patient
did not hear when she was spoken to. It was possible to dif-
ferentiate this passing habit of not hearing as follows:

(a) Not hearing when someone came in, while her thoughts
were abstracted. 108 separate detailed instances of this, men-
tioning the persons and circumstances, often with dates. First
instance: not hearing her father come in.

(b) Not understanding when several people were talking.
27 instances. First instance: her father, once more, and an
acquaintance.

(c) Not hearing when she was alone and directly addressed.
50 instances. Origin: her father having vainly asked her for
some wine.

(d) Deafness brought on by being shaken (in a carriage, etc.).
15 instances. Origin: having been shaken angrily by her young
brother when he caught her one night listening at the sick-
room door.

(e) Deafness brought on by fright at a noise. 37 instances.
Origin: a choking fit of her father's, caused by swallowing the
wrong way.

(/) Deafness during deep absence. 12 instances.

(g) Deafness brought on by listening hard for a long time, so
that when she was spoken to she failed to hear. 54 instances.

Of course all these episodes were to a great extent identical
in so far as they could be traced back to states of abstraction or
absences or to fright. But in the patient's memory they were so

(1) FRAULEIN ANNA O. (BREUER) 37

clearly differentiated, that if she happened to make a mistake
in their sequence she would be obliged to correct herself and put
them in the right order; if this was not done her report came to
a standstill. The events she described were so lacking in interest
and significance and were told in such detail that there could be
no suspicion of their having been invented. Many of these inci-
dents consisted of purely internal experiences and so could not
be verified; others of them (or circumstances attending them)
were within the recollection of people in her environment.

This example, too, exhibited a feature that was always observ-
able when a symptom was being 'talked away': the particular
symptom emerged with greater force while she was discussing
it. Thus during the analysis of her not being able to hear she
was so deaf that for part of the time I was obliged to com-
municate with her in writing. 1 The first provoking cause was
habitually a fright of some kind, experienced while she was
nursing her father some oversight on her part, for instance.

The work of remembering was not always an easy matter and
sometimes the patient had to make great efforts. On one
occasion our whole progress was obstructed for some time be-
cause a recollection refused to emerge. It was a question of a
particularly terrifying hallucination. While she was nursing
her father she had seen him with a death's head. She and the
people with her remembered that once, while she still appeared
to be in good health, she had paid a visit to one of her relatives.
She had opened the door and all at once fallen down uncon-
scious. In order to get over the obstruction to our progress she
visited the same place again and, on entering the room, again
fell to the ground unconscious. During her subsequent evening
hypnosis the obstacle was surmounted. As she came into the
room, she had seen her pale face reflected in a mirror hanging
opposite the door; but it was not herself that she saw but her
father with a death's head. We often noticed that her dread
of a memory, as in the present instance, inhibited its emergence,
and this had to be brought about forcibly by the patient or
physician.

The following incident, among others, illustrates the high
degree of logical consistency of her states. During this period,

1 [This phenomenon is discussed at some length by Freud below
(p. 296f.)> where he describes it as a symptom 'joining in the con-
versation'.]

38 II. CASE HISTORIES

as has already been explained, the patient was always in her
condition seconde that is, in the year 1881 at night. On one
occasion she woke up during the night, declaring that she had
been taken away from home once again, and became so seri-
ously excited that the whole household was alarmed. The
reason was simple. During the previous evening the talking cure
had cleared up her disorder of vision, and this applied also to
her condition seconde. Thus when she woke up in the night she
found herself in a strange room, for her family had moved
house in the spring of 1881. Disagreeable events of this kind
were avoided by my always (at her request) shutting her eyes
in the evening and giving her a suggestion that she would not be
able to open them till I did so myself on the following morning.
The disturbance was only repeated once, when the patient
cried in a dream and opened her eyes on waking up from it.

Since this laborious analysis for her symptoms dealt with the
summer months of 1880, which was the preparatory period of
her illness, I obtained complete insight into the incubation and
pathogenesis of this case of hysteria, and I will now describe
them briefly.

In July, 1880, while he was in the country, her father fell
seriously ill of a sub-pleUral abscess. Anna shared the duties of
nursing him with her mother. She once woke up during the
night in great anxiety about the patient, who was in a high
fever; and she was under the strain of expecting the arrival
of a surgeon from Vienna who was to operate. Her mother had
gone away for a short time and Anna was sitting at the bedside
with her right arm over the back of her chair. She fell into a
waking dream and saw a black snake coming towards the
sick man from the wall to bite him. (It is most likely that there
were in fact snakes in the field behind the house and that these
had previously given the girl a fright; they would thus have
provided the material for her hallucination.) She tried to keep
the snake off, but it was as though she was paralysed. Her right
arm, over the back of the chair, had gone to sleep and had
become anaesthetic and paretic; and when she looked at it
the fingers turned into little snakes with death's heads (the
nails). (It seems probable that she had tried to use her paralysed
right arm to drive off the snake and that its anaesthesia and
paralysis had consequently become associated with the hallu-
cination of the snake.) When the snake vanished, in her terror

(1) FRAULEIN ANNA O. (BREUER) 39

she tried to pray. But language failed her: she could find no
tongue in which to speak, till at last she thought of some
children's verses in English l and then found herself able to
think and pray in that language. The whistle of the train that
was bringing the doctor whom she expected broke the spell.

Next day, in the course of a game, she threw a quoit into
some bushes; and when she went to pick it out, a bent branch
revived her hallucination of the snake, and simultaneously her
right arm became rigidly extended. Thenceforward the same
thing invariably occurred whenever the hallucination was re-
called by some object with a more or less snake-like appearance.
This hallucination, however, as well as the contracture only
appeared during the short absences which became more and more
frequent from that night onwards. (The contracture did not
become stabilized until December, when the patient broke
down completely and took to her bed permanently.) As a
result of some particular event which I cannot find recorded
in my notes and which I no longer recall, the contracture of
the right leg was added to that of the right arm.

Her tendency to auto-hypnotic absences was from now on
established. On the morning after the night I have described,
while she was waiting for the surgeon's arrival, she fell into such
a fit of abstraction that he finally arrived in the room without
her having heard his approach. Her persistent anxiety inter-
fered with her eating and gradually led to intense feelings of
nausea. Apart from this, indeed, each of her hysterical symp-
toms arose during an affect. It is not quite certain whether in
every case a momentary state of absence was involved, but this
seems probable in view of the fact that in her waking state the
patient was totally unaware of what had been going on.

Some of her symptoms, however, seem not to have emerged
in her absences but merely in an affect during her waking life;
but if so, they recurred in just the same way. Thus we were
able to trace back all of her different disturbances of vision
to different, more or less clearly determining causes. For in-
stance, on one occasion, when she was sitting by her father's
bedside with tears in her eyes, he suddenly asked her what time
it was. She could not see clearly; she made a great effort, and
brought her watch near to her eyes. The face of the watch now

1 [In the 'Preliminary Communication* (pp. 4-5) what she thought of
is described as a prayer. This, of course, involves no contradiction.]

40 II. CASE HISTORIES

seemed very big thus accounting for her macropsia and con-
vergent squint. Or again, she tried hard to suppress her tears so
that the sick man should not see them.

A dispute, in the course of which she suppressed a rejoinder,
caused a spasm of the glottis, and this was repeated on every
similar occasion.

She lost the power of speech (a) as a result of fear, after
her first hallucination at night, (b) after having suppressed a
remark another time (by active inhibition), (c) after having
been unjustly blamed for something and (d) on every analogous
occasion (when she felt mortified). She began coughing for the
first time when once, as she was sitting at her father's bedside,
she heard the sound of dance music coming from a neighbour-
ing house, felt a sudden wish to be there, and was overcome
with self-reproaches. Thereafter, throughout the whole length
of her illness she reacted to any markedly rhythmical music
with a tussis nervosa.

I cannot feel much regret that the incompleteness of my
notes makes it impossible for me to enumerate all the occasions
on which her various hysterical symptoms appeared. She her-
self told me them in every single case, with the one exception
I have mentioned [p. 35, also below, pp. 44-5]; and, as I have
already said, each symptom disappeared after she had described
its first occurrence.

In this way, too, the whole illness was brought to a close.
The patient herself had formed a strong determination that the
whole treatment should be finished by the anniversary of the
day on which she was moved into the country [June 7 (p. 28)].
At the beginning of June, accordingly, she entered into the
'talking cure' with the greatest energy. On the last day by the
help of re-arranging the room so as to resemble her father's
sickroom she reproduced the terrifying hallucination which I
have described above and which constituted the root of her
whole illness. During the original scene she had only been able
to think and pray in English; but immediately after its repro-
duction she was able to speak German. She was moreover free
from the innumerable disturbances which she had previously
exhibited. 1 After this she left Vienna and travelled for a while;

1 [At this point (so Freud once told the present editor, with his finger
on an open copy of the book) there is a hiatus in the text. What he had
in mind and went on to describe was the occurrence which marked the

(1) FRAULEIN ANNA O. (BREUER) 41

but it was a considerable time before she regained her mental
balance entirely. Since then she has enjoyed complete
health.

Although I have suppressed a large number of quite inter-
esting details, this case history of Anna O. has grown bulkier
than would seem to be required for a hysterical illness that
was not in itself of an unusual character. It was, however,
impossible to describe the case without entering into details,
and its features seem to me of sufficient importance to excuse
this extensive report. In just the same way, the eggs of the
echinoderm are important in embryology, not because the sea-
urchin is a particularly interesting animal but because the
protoplasm of its eggs is transparent and because what we
observe in them thus throws light on the probable course of
events in eggs whose protoplasm is opaque. 1 The interest of
the present case seems to me above all to reside in the extreme
clarity and intelligibility of its pathogenesis.

There were two psychical characteristics present in the girl
while she was still completely healthy which acted as pre-
disposing causes for her subsequent hysterical illness:

( 1 ) Her monotonous family life and the absence of adequate
intellectual occupation left her with an unemployed surplus
of mental liveliness and energy, and this found an outlet in the
constant activity of her imagination.

(2) This led to a habit of day-dreaming (her 'private
theatre'), which laid the foundations for a dissociation of her
mental personality. Nevertheless a dissociation of this degree is
still within the bounds of normality. Reveries and reflections

end of Anna O.'s treatment. He made short allusions to it at the begin-
ning of his 'History of the Psycho- Analytic Movement' (1914<f), where
he spoke of it as, from Breuer's point of view, an 'untoward event', and
in Chapter II of his Autobiographical Study (\925d). The whole story is
told by Ernest Jones in his life of Freud (1953, 1, 246 ff.), and it is
enough to say here that, when the treatment had apparently reached a
successful end, the patient suddenly made manifest to Breucr the
presence of a strong unanalysed positive transference of an unmistak-
ably sexual nature. It was this occurrence, Freud believed, that caused
Breuer to hold back the publication of the case history for so many years
and that led ultimately to his abandonment of all further collaboration
in Freud's researches.]

1 [This same analogy was similarly used by Freud many years later
(Freud, 1913A, Standard Ed., 13, 193).]

42 II. CASE HISTORIES

during a more or less mechanical occupation do not in them-
selves imply a pathological splitting of consciousness, since if
they are interrupted if, for instance, the subject is spoken to
the normal unity of consciousness is restored; nor, presum-
ably, is any amnesia present. In the case of Anna O., however,
this habit prepared the ground upon which the affect of
anxiety and dread was able to establish itself in the way I have
described, when once that affect had transformed the patient's
habitual day-dreaming into a hallucinatory absence. It is re-
markable how completely the earliest manifestation of her ill-
ness in its beginnings already exhibited its main character-
istics, which afterwards remained unchanged for almost two
years. These comprised the existence of a second state of
consciousness which first emerged as a temporary absence and
later became organized into a double conscience' '; an inhibition of
speech, determined by the affect of anxiety, which found a
chance discharge in the English verses; later on, paraphasia
and loss of her mother- tongue, which was replaced by excellent
English; and lastly the accidental paralysis of her right arm,
due to pressure, which later developed into a contractural
paresis and anaesthesia on her right side. The mechanism by
which this latter affection came into being agreed entirely with
Charcot's theory of traumatic hysteria a slight trauma occur-
ring during a state of hypnosis.

But whereas the paralysis experimentally provoked by Char-
cot in his patients became stabilized immediately, and whereas
the paralysis caused in sufferers from traumatic neuroses by a
severe traumatic shock sets in at once, the nervous system of
this girl put up a successful resistance for four months. Her con-
tracture, as well as the other disturbances which accompanied
it, set in only during the short absences in her condition seconde
and left her during her normal state in full control of her body
and possession of her senses; so that nothing was noticed either
by herself or by those around her, though it is true that the
attention of the latter was centred upon the patient's sick father
and was consequently diverted from her.

Since, however, her absences with their total amnesia and
accompanying hysterical phenomena grew more and more fre-
quent from the time of her first hallucinatory auto-hypnosis,
the opportunities multiplied for the formation of new symptoms
of the same kind, and those that had already been formed

(1) FRAULEIN ANNA O. (BREUER) 43

became more strongly entrenched by frequent repetition. In
addition to this, it gradually came about that any sudden dis-
tressing affect would have the same result as an absence (though,
indeed, it is possible that such affects actually caused a tem-
porary absence in every case); chance coincidences set up
pathological associations and sensory or motor disturbances,
which thenceforward appeared along with the affect. But
hitherto this only occurred for fleeting moments. Before the
patient took permanently to her bed she had already developed
the whole assemblage of hysterical phenomena, without anyone
knowing it. It was only after the patient had broken down com-
pletely owing to exhaustion brought about by lack of nourish-
ment, insomnia and constant anxiety, and only after she had
begun to pass more time in her condition seconde than in her
normal state, that the hysterical phenomena extended to the
latter as well and changed from intermittent acute symptoms
into chronic ones.

The question now arises how far the patient's statements are
to be trusted and whether the occasions and mode of origin of
the phenomena were really as she represented them. So far as
the more important and fundamental events are concerned, the
trustworthiness of her account seems to me to be beyond
question. As regards the symptoms disappearing after being
'talked away', I cannot use this as evidence; it may very well
be explained by suggestion. But I always found the patient
entirely truthful and trustworthy. The things she told me were
intimately bound up with what was most sacred to her. What-
ever could be checked by other people was fully confirmed.
Even the most highly gifted girl would be incapable of con-
cocting a tissue of data with such a degree of internal con-
sistency as was exhibited in the history of this case. It cannot be
disputed, however, that precisely her consistency may have led
her (in perfectly good faith) to assign to some of her symptoms
a precipitating cause which they did not in fact possess. But
this suspicion, too, I consider unjustified. The very insignificance
of so many of those causes, the irrational character of so many
of the connections involved, argue in favour of their reality.
The patient could not understand how it was that dance music
made her cough; such a construction is too meaningless to have
been deliberate. (It seemed very likely to me, incidentally, that
each of her twinges of conscience brought on one of her regular

44 II. CASE HISTORIES

spasms of the glottis and that the motor impulses which she
felt for she was very fond of dancing transformed the spasm
into a tussis nervosa.) Accordingly, in my view the patient's
statements were entirely trustworthy and corresponded to the
facts.

And now we must consider how far it is justifiable to suppose
that hysteria is produced in an analogous way in other patients,
and that the process is similar where no such clearly distinct
condition seconde has become organized. I may advance in sup-
port of this view the fact that in the present case, too, the story
of the development of the illness would have remained com-
pletely unknown alike to the patient and the physician if it
had not been for her peculiarity of remembering things in
hypnosis, as I have described, and of relating what she re-
membered. While she was in her waking state she knew nothing
of all this. Thus it is impossible to arrive at what is happening
in other cases from an examination of the patients while in a
waking state, for with the best will in the world they can give
one no information. And I have already pointed out how little
those surrounding the present patient were able to observe
of what was going on. Accordingly, it would only be possible
to discover the state of affairs in other patients by means of
some such procedure as was provided in the case of Anna O. by
her auto-hypnoses. Provisionally we can only express the view
that trains of events similar to those here described occur more
commonly than our ignorance of the pathogenic mechanism
concerned has led us to suppose.

When the patient had become confined to her bed, and her
consciousness was constantly oscillating between her normal
and her 'secondary' state, the whole host of hysterical symp-
toms, which had arisen separately and had hitherto been
latent, became manifest, as we have already seen, as chronic
symptoms. There was now added to these a new group of
phenomena which seemed to have had a different origin: the
paralytic contractures of her left extremities and the paresis of
the muscles raising her head. I distinguish them from the other
phenomena because when once they had disappeared they
never returned, even in the briefest or mildest form or during
the concluding and recuperative phase, when all the other
symptoms became active again after having been in abeyance
for some time. In the same way, they never came up in the

(1) FRAULEIN ANNA O. (BREUER) 45

hypnotic analyses and were not traced back to emotional or
imaginative sources. I am therefore inclined to think that their
appearance was not due to the same psychical process as was
that of the other symptoms, but is to be attributed to a secondary
extension of that unknown condition which constitutes the
somatic foundation of hysterical phenomena.

Throughout the entire illness her two states of consciousness
persisted side by side: the primary one in which she was quite
normal psychically, and the secondary one which may well be
likened to a dream in view of its wealth of imaginative products
and hallucinations, its large gaps of memory and the lack of
inhibition and control in its associations. In this secondary
state the patient was in a condition of alienation. The fact that
the patient's mental condition was entirely dependent on the
intrusion of this secondary state into the normal one seems to
throw considerable light on at least one class of hysterical
psychosis. Every one of her hypnoses in the evening afforded
evidence that the patient was entirely clear and well-ordered
in her mind and normal as regards her feeling and volition so
long as none of the products of her secondary state was acting
as a stimulus 'in the unconscious'. 1 The extremely marked
psychosis which appeared whenever there was any considerable
interval in this unburdening process showed the degree to
which those products influenced the psychical events of her
'normal' state. It is hard to avoid expressing the situation by
saying that the patient was split into two personalities of which
one was mentally normal and the other insane. The sharp
division between the two states in the present patient only
exhibits more clearly, in my opinion, what has given rise to a

1 [This seems to be the first published occurrence of the term 'das
Unbewusstc' ('the unconscious') in what was to be its psycho-analytic
sense. It had, of course, often been used previously by other writers,
particularly by philosophers (e.g. Hartmann, 1869). The fact that Breuer
puts it in quotation marks may possibly indicate that he is attributing
it to Freud. The term is used by Freud himself below, e.g. on p. 76 n. The
adjectival form 'unbewuss? (' unconscious') had been used some years
earlier in an unpublished draft drawn up in November, 1892, jointly by
Breuer and Freud (Freud, 1940</). Freud had used the term 'le sub-
conscicn? in a French paper on motor paralyses (1893c) and uses
'unterbewusst* ('subconscious') in the present work (p. 69 w.), as does
Breuer very much more frequently (e.g. p. 222). Later, of course, Freud
objected to the employment of this latter term. (Cf., for instance, the
end of Section I of his paper on 'The Unconscious', 1915f.)]

46 II. CASE HISTORIES

number of unexplained problems in many other hysterical
patients. It was especially noticeable in Anna O. how much
the products of her 'bad self 5 , as she herself called it, affected
her moral habit of mind. If these products had not been con-
tinually disposed of, we should have been faced by a hysteric
of the malicious type refractory, lazy, disagreeable and ill-
natured; but, as it was, after the removal of those stimuli her
true character, which was the opposite of all these, always re-
appeared at once.

Nevertheless, though her two states were thus sharply sep-
arated, not only did the secondary state intrude into the first
one, but and this was at all events frequently true, and even
when she was in a very bad condition a clear-sighted and calm
observer sat, as she put it, in a corner of her brain and looked
on at all the mad business. This persistence of clear thinking
while the psychosis was actually going on found expression in
a very curious way. At a time when, after the hysterical pheno-
mena had ceased, the patient was passing through a temporary
depression, she brought up a number of childish fears and self-
reproaches, and among them the idea that she had not been
ill at all and that the whole business had been simulated.
Similar observations, as we know, have frequently been made.
When a disorder of this kind has cleared up and the two states
of consciousness have once more become merged into one, the
patients, looking back to the past, see themselves as the single
undivided personality which was aware of all the nonsense;
they think they could have prevented it if they had wanted to,
and thus they feel as though they had done all the mischief
deliberately. It should be added that this normal thinking
which persisted during the secondary state must have fluctuated
enormously in its amount and must very often have been
completely absent.

I have already described the astonishing fact that from be-
ginning to end of the illness all the stimuli arising from the
secondary state, together with their consequences, were per-
manently removed by being given verbal utterance in hypnosis,
and I have only to add an assurance that this was not an inven-
tion of mine which I imposed on the patient by suggestion. It
took me completely by surprise, and not until symptoms had
been got rid of in this way in a whole series of instances did I
develop a therapeutic technique out of it.

(1) FRAULEIN ANNA O. (BREUER) 47

The final cure of the hysteria deserves a few more words. It
was accompanied, as I have already said, by considerable dis-
turbances and a deterioration in the patient's mental condition.
I had a very strong impression that the numerous products of
her secondary state which had been quiescent were now forcing
their way into consciousness; and though in the first instance
they were being remembered only in her secondary state, they
were nevertheless burdening and disturbing her normal one.
It remains to be seen whether it may not be that the same
origin is to be traced in other cases in which a chronic hysteria
terminates in a psychosis. 1

1 [A very full summary and discussion of this case history occupies
the greater part of the first of Freud's Five Lectures (1910a).]

CASE 2
FRAU EMMY VON N., AGE 40, FROM LIVONIA (Freud)

ON May 1, 1889, 1 I took on the case of a lady of about forty
years of age, whose symptoms and personality interested me
so greatly that I devoted a large part of my time to her and
determined to do all I could for her recovery. She was a
hysteric and could be put into a state of somnambulism with
the greatest ease; and when I became aware of this I decided
that I would make use of Breuer's technique of investigation
under hypnosis, which I had come to know from the account he
had given me of the successful treatment of his first patient.
This was my first attempt at handling that therapeutic method
[pp. 105 n. and 284]. I was still far from having mastered it; in
fact I did not carry the analysis 2 of the symptoms far enough,
nor pursue it systematically enough. I shall perhaps be able
best to give a picture of the patient's condition and my medical
procedure by reproducing the notes which I made each evening '
during the first three weeks of the treatment. Wherever later
experience has brought me a better understanding, I shall
embody it in footnotes and interpolated comments.

May i, 1889. This lady, when I first saw her, was lying on a
sofa with her head resting on a leather cushion. She still looked
young and had finely-cut features, full of character. Her face
bore a strained and painful expression, her eyelids were drawn
together and her eyes cast down; there was a heavy frown on
her forehead and the naso-labial folds were deep. She spoke in
a low voice as though with difficulty and her speech was

1 [The chronology of this case history is self-contradictory as it stands
and there is a distinct possibility that the treatment began in 1888, not
in 1889. The dates which are given in all the German editions have
been retained in the present translation, but they are evidently in need
of correction. The question is fully discussed in Appendix A (p. 307).]

a [Freud had already used the term 'analysis' (as well as 'psychical
analysis', 'psychological analysis' and 'hypnotic analysis') in his first
paper on 'The Neuro-Psychoses of Defence' (18940). He only later
introduced the word 'psycho-analysis' in a paper on the aetiology of
the neuroses, written in French (1896a).]

48

(2) FRAU EMMY VON N. (FREUD) 49

from time to time subject to spastic interruptions amounting to
a stammer. She kept her fingers, which exhibited a ceaseless
agitation resembling athetosis, tightly clasped together. There
were frequent convulsive Jiolike movements of her face and the
muscles of her neck, during which some of them, especially the
right sterno-cleido-mastoid, stood out prominently. Further-
more she frequently interrupted her remarks by producing a
curious 'clacking' sound from her mouth which defies imitation. 1

What she told me was perfectly coherent and revealed an
unusual degree of education and intelligence. This made it
seem .all the more strange when every two or three minutes
she suddenly broke off, contorted her face into an expression
of horror and disgust, stretched out her hand towards me,
spreading and crooking her fingers, and exclaimed, in a changed
voice, charged with anxiety: 'Keep still! Don't say anything!
Don't touch me!' She was probably under the influence of
some recurrent hallucination of a horrifying kind and was
keeping the intruding material at bay with this formula. 2 These
interpolations came to an end with equal suddenness and the
patient took up what she had been saying, without pursuing her
momentary excitement any further, and without explaining or
apologizing for her behaviour probably, therefore, without
herself having noticed the interpolation. 3

I learned what follows of her circumstances. Her family
came from Central Germany, but had been settled for two
generations in the Baltic Provinces of Russia, where it possessed
large estates. She was one of fourteen children, of which she
herself is the thirteenth. Only four of them survive. She was
brought up carefully, but under strict discipline by an over-
energetic and severe mother. When she was twenty- three she

1 This 'clacking' was made up of a number of sounds. Colleagues of
mine with sporting experience told me, on hearing it, that its final
notes resembled the call of a capercaillie [according to Fisher (1955)
'a ticking ending with a pop and a hiss'].

2 These words did in fact represent a protective formula, and this
will be explained later on. Since then I have come across similar pro-
tective formulas in a melancholic woman who endeavoured by their
means to control her tormenting thoughts wishes that something bad
might happen to her husband and her mother, blasphemies, etc.

3 What we had here was a hysterical delirium which alternated with
normal consciousness, just as a true tic intrudes into a voluntary move-
ment without interfering with it and without being mixed up with it.

50 II. CASE HISTORIES

married an extremely gifted and able man who had made a
high position for himself as an industrialist on a large scale, but
was much older than she was. After a short marriage he died of
a stroke. To this event, together with the task of bringing up her
two daughters, now sixteen and fourteen years old, who were
often ailing and suffered from nervous troubles, she attributed
her own illness. Since her husband's death, fourteen years ago,
she had been constantly ill with varying degrees of severity.
Four years ago her condition was temporarily improved by a
course of massage combined with electric baths. Apart from
this, all her efforts to regain her health have been unsuccessful.
She has travelled a great deal and has many lively interests. She
lives at present in a country seat on the Baltic near a large town. 1
For several months she has once more been very ill, suffering
from depression and insomnia, and tormented with pains; she
went to Abbazia 2 in the vain hope of improvement, and for
the last six weeks has been in Vienna, up till now in the care
of a physician of outstanding merit.

I suggested that she should separate from the two girls, who
had their governess, and go into a nursing home, where I could
see her every day. This she agreed to without raising the
slightest objection.

On the evening of May 2 I visited her in the nursing home.
I noticed that she started violently whenever the door opened
unexpectedly. I therefore arranged that the nurses and the
house physicians, when they visited her, should give a loud
knock at her door and not enter till she had told them to come
in. But even so, she still made a grimace and gave a jump every
time anyone entered.

Her chief complaint to-day was of sensations of cold and pain
in her left leg which proceeded from her back above the iliac
crest. I ordered her to be given warm baths and I shall massage
her whole body twice a day.

She is an excellent subject for hypnotism. I had only to hold
up a finger in front of her and order her to go to sleep, and she
sank back with a dazed and confused look. I suggested that she

1 [This is referred to later on as 'D '. There is reason to believe

that, in order to disguise his patient's identity, Freud had transferred
her home from quite another part of Europe.]

1 [The at that time Austrian resort on the Adriatic.]

(2) FRAU EMMY VON N. (FREUD) 51

should sleep well, that all her symptoms should get better, and
so on. She heard all this with closed eyes but with unmistakably
concentrated attention; and her features gradually relaxed and
took on a peaceful appearance. After this first hypnosis she
retained a dim memory of my words; but already at the second
there was complete somnambulism (with amnesia). I had
warned her that I proposed to hypnotize her, to which she raised
no difficulty. She has not previously been hypnotized, but it is
safe to suppose that she has read about hypnotism, though I
cannot tell what notions she may have about the hypnotic
state. 1

This treatment by warm baths, massage twice a day and
hypnotic suggestion was continued for the next few days. She
slept well, got visibly better, and passed most of the day lying
quietly in bed. She was not forbidden to see her children, to
read, or to deal with her correspondence.

May <9, morning. She entertained me, in an apparently quite
normal state, with gruesome stories about animals. She had
read in the Frankfurter eitung, which lay on the table in front
of her, a story of how an apprentice had tied up a boy and put
a white mouse into his mouth. The boy had died of fright.
Dr. K. had told her that he had sent a whole case of white rats
to Tiflis. As she told me this she demonstrated every sign of
horror. She clenched and unclenched her hand several times.
'Keep still! Don't say anything! Don't touch me! Suppos-
ing a creature like that was in the bed!' (She shuddered.) 'Only
think, when it's unpacked! There's a dead rat in among them
one that's been gn-aw-aw-ed at!'

During the hypnosis I tried to disperse these animal hallu-
cinations. While she was asleep I picked up the Frankfurter
eitung. I found the anecdote about the boy being maltreated,

1 Every time she woke from hypnosis she looked about her for a
moment in a confused way, let her eyes fall on me, seemed to have
come to her senses, put on her glasses, which she took off before going
to sleep, and then became quite lively and on the spot. Although in
the course of the treatment (which lasted for seven weeks in this first
year and eight in the second) we discussed every sort of subject, and
although I put her to sleep twice almost every day, she never made any
comment to me about the hypnosis or asked me a single question about
it; and in her waking state she seemed, so far as possible, to ignore the
fact that she was undergoing hypnotic treatment.

52 II. CASE HISTORIES

but without any reference to mice or rats. So she had intro-
duced these from her delirium while she was reading. (I told
her in the evening of our conversation about the white mice.
She knew nothing of it, was very much astonished and laughed
heartily. 1 )

During the afternoon she had what she called a 'neck-
cramp', 2 which, however, as she said, 'only lasted a short time
a couple of hours'.

Evening. I requested her, under hypnosis, to talk, which,
after some effort, she succeeded in doing. She spoke softly and
reflected for a moment each time before answering. Her ex-
pression altered according to the subject of her remarks, and
grew calm as soon as my suggestion had put an end to the im-
pression made upon her by what she was saying. I asked her
why it was that she was so easily frightened, and she answered :
'It has to do with memories of my earliest youth.' 'When?'
'First when I was five years old and my brothers and sisters
often threw dead animals at me. That was when I had my first
fainting fit and spasms. But my aunt said it was disgraceful and
that I ought not to have attacks like that, and so they stopped.
Then I was frightened again when I was seven and I unex-
pectedly saw my sister in her coffin; and again when I was
eight and my brother terrified me so often by dressing up in
sheets like a ghost; and again when I was nine and I saw my
aunt in her coffin and her jaw suddenly dropped.'

This series of traumatic precipitating causes which she pro-
duced in answer to my question why she was so liable to fright
was clearly ready to hand in her memory. She could not have
collected these episodes from different periods of her child-
hood so quickly during the short interval which elapsed between

1 A sudden interpolation like this of a delirium into a waking state
was not uncommon with her and was often repeated later in my
presence. She used to complain that in conversation she often gave the
most absurd answers, so that people did not understand her. On the
occasion when I first visited her I asked her how old she was and she
answered quite seriously: *I am a woman dating from last century.'
Some weeks later she explained to me she had been thinking at the time
in her Delirium of a beautiful old cupboard which, as a connoisseur of
old furniture, she had bought in the course of her travels. It was to this
cupboard that her answer had referred when my question about her
age raised the topic of dates.

8 A species of migraine. [See p. 71 n.]

(2) FRAU EMMY VON N. (FREUD) 53

my question and her answer. At the end of each separate story
she twitched all over and took on a look of fear and horror. At
the end of the last one she opened her mouth wide and panted
for breath. The words in which she described the terrifying
subject-matter of her experience were pronounced with diffi-
culty and between gasps. Afterwards her features became
peaceful.

In reply to a question she told me that while she was des-
cribing these scenes she saw them before her, in a plastic form
and in their natural colours. She said that in general she thought
of these experiences very often and had done so in the last few
days. Whenever this happened she saw these scenes with all the
vividness of reality. x I now understand why she entertains me
so often with animal scenes and pictures of corpses. My therapy
consists in wiping away these pictures, so that she is no longer
able to see them before her. To give support to my suggestion
I stroked her several times over the eyes.

May $) [morning]. 2 Without my having given her any further
suggestion, she had slept well. But she had gastric pains in the
morning. They came on yesterday in the garden where she
stayed out too long with her children. She agreed to my limiting
the children's visits to two and a half hours. A few days ago she
had reproached herself for leaving the children by themselves.
I found her in a somewhat excited state to-day; her forehead
was lined, her speech was halting and she made her clacking
noises. While she was being massaged she told me only that the
children's governess had brought her an ethnological atlas and
that some pictures in it of American Indians dressed up as
animals had given her a great shock. 'Only think, if they came
to life!' (She shuddered.)

Under hypnosis I asked why she had been so much frightened
by these pictures, since she was no longer afraid of animals.
She said they had reminded her of visions she had had (when
she was nineteen) at the time of her brother's death. (I shall
hold over enquiring into this memory until later.) I then asked

1 Many other hysterical patients have reported to us that they have
memories of this kind in vivid visual pictures and that this applied
especially to their pathogenic memories.

1 [All the German editions read 'evening', which in view of what
follows seems certainly to be a mistake.]

54 II. CASE HISTORIES

her whether she had always spoken with a stammer and how
long she had had her tic (the peculiar clacking sound). 1 Her
stammering, she said, had come on while she was ill; she had
had the tic for the last five years, ever since a time when she was
sitting by the bedside of her younger daughter who was very
ill, and had wanted to keep absolutely quiet. I tried to reduce the
importance of this memory, by pointing out that after all
nothing had happened to her daughter, and so on. The thing
came on, she said, whenever she was apprehensive or frightened.
I instructed her not to be frightened of the pictures of the Red
Indians but to laugh heartily at them and even to draw my
attention to them. And this did in fact happen after she had
woken up: she looked at the book, asked whether I had seen it,
opened it at the page and laughed out loud at the grotesque
figures, without a trace of fear and without any strain in her
features. Dr. Breuer came in suddenly with the house-physician
to visit her. She was frightened and began to make her clacking
noise, so that they soon left us. She explained that she was so
much agitated because she was unpleasantly affected by the
fact that the house-physician came in every time as well.

I had also got rid of her gastric pains during the hypnosis by
stroking her, and I told her that though she would expect the
pain to return after her midday meal it would not do so.

Evening. For the first time she was cheerful and talkative
and gave evidence of a sense of humour that I should not have
expected in such a serious woman; and, among other things, in
the strong feeling that she was better, she made fun of her treat-
ment by rny medical predecessor. She had long intended, she
said, to give up that treatment but had not been able to find
the right method of doing so till a chance remark made by
Dr. Breuer, when he visited her once, showed her a way out.
When I seemed to be surprised at this, she grew frightened
and began to blame herself very severely for having been in-
discreet. But I was able, it seemed, to re-assure her. She had
had no gastric pains, though she had expected them.

Under hypnosis I asked her to tell me further experiences
which had given her a lasting fright. She produced a second
series of this kind, dating from her later youth, with as much
promptitude as the first series and she assured me once more

1 I had already asked her this question about the tic during her
waking state, and she had replied: *I don't know; oh, a very long time.'

(2) FRAU EMMY VON N. (FREUD) 55

that all these scenes appeared before her often, vividly and in
colours. One of them was of how she saw a female cousin taken
off to an insane asylum (when she was fifteen). She tried to
call for help but was unable to, and lost her power of speech
till the evening of the same day. Since she talked so often about
asylums in her waking state, I interrupted her and asked on
what other occasions she had been concerned with insanity.
She told me that her mother had herself been in an asylum for
some time. They had once had a maid-servant one of whose
previous mistresses had spent a long time in an asylum and who
used to tell her horrifying stories of how the patients were tied
to chairs, beaten, and so on. As she told me this she clenched her
hands in horror; she saw all this before her eyes. I endeavoured
to correct her ideas about insane asylums, and assured her that
she would be able to hear about institutions of this kind without
referring them to herself. At this, her features relaxed.

She continued her list of terrifying memories. One, at fifteen,
of how she found her mother, who had had a stroke, lying on
the floor (her mother lived for another four years); again, at
nineteen, how she came home one day and found her mother
dead, with a distorted face. I naturally had considerable
difficulty in mitigating these memories. After a rather lengthy
explanation, I assured her that this picture, too, would only
appear to her again indistinctly and without strength. An-
other memory was how, at nineteen, she lifted up a stone and
found a toad under it, which made her lose her power of speech
for hours afterwards. 1

During this hypnosis I convinced myself that she knew every-
thing that happened in the last hypnosis, whereas in waking
life she knows nothing of it.

May 10, morning. For the first time to-day she was given a
bran bath instead of her usual warm bath. I found her looking
cross and with a pinched face, with her hands wrapped in a
shawl. She complained of cold and pains. When I asked her
what was the matter, she told me that the bath had been un-
comfortably short to sit in and had brought on pains. During
the massage she started by saying that she still felt badly about
having given Dr. Breuer away yesterday. I pacified her with a

1 A special kind of symbolism must, no doubt, have lain behind the
toad, but I unfortunately neglected to enquire into it.

56 II. CASE HISTORIES

white lie and said that I had known about it all along, where-
upon her agitation (clacking, grimaces) ceased. So each time,
even while I am massaging her, my influence has already begun
to affect her; she grows quieter and clearer in the head, and
even without questioning under hypnosis can discover the cause
of her ill-humour on that day. Nor is her conversation during
the massage so aimless as would appear. On the contrary, it
contains a fairly complete reproduction of the memories and
new impressions which have affected her since our last talk,
and it often leads on, in a quite unexpected way, to pathogenic
reminiscences of which she unburdens herself without being
asked to. It is as though she had adopted my procedure and
was making use of our conversation, apparently unconstrained
and guided by chance, as a supplement to her hypnosis. 1 For
instance, to-day she began talking about her family, and in a
very roundabout way got on to the subject of a cousin. He was
rather queer in the head and his parents had all his teeth pulled
out at one sitting. She accompanied the story with horrified
looks and kept repeating her protective formula ('Keep still!
Don't say anything! Don't touch me!'). After this her face
smoothed out and she became cheerful. Thus, her behaviour
in waking life is directed by the experiences she has had during
her somnambulism, in spite of her believing, while she is awake,
that she knows nothing about them.

Under hypnosis I repeated my question as to what it was
that had made her upset and I got the same answers but in
the reverse order: (1) her indiscreet talk yesterday, and (2) her
pains caused by her being so uncomfortable in the bath. I
asked her to-day the meaning of her phrase 'Keep still!', etc.
She explained that when she had frightening thoughts she was
afraid of their being interrupted in their course, because then
everything would get confused and things would be even worse.
The 'Keep still!' related to the fact that the animal shapes which
appeared to her when she was in a bad state started moving
and began to attack her if anyone made a movement in her
presence. The final injunction 'Don't touch me!' was derived
from the following experiences. She told me how, when her
brother, had been so ill from taking a lot of morphine she was
nineteen at the time he used often to seize hold of her; and

1 [This is perhaps the earliest appearance of what later became the
method of free association.]

(2) FRAU EMMY VON N. (FREUD) 57

how, another time, an acquaintance had suddenly gone mad
in the house and had caught her by the arm; (there was a
third, similar instance, which she did not remember exactly;)
and lastly, how, when she was twenty-eight and her daughter
was very ill, the child had caught hold of her so forcibly in its
delirium that she was almost choked. Though these four in-
stances were so widely separated in time, she told me them in a
single sentence and in such rapid succession that they might
have been a single episode in four acts. Incidentally, all the
accounts she gave of traumas arranged like these in groups
began with a 'how', the component traumas being separated
by an 'and'. Since I noticed that the protective formula was
designed to safeguard her against a recurrence of such ex-
periences, I removed this fear by suggestion, and in fact I
never heard the formula from her again.

Evening. I found her very cheerful. She told me, with a
laugh, that she had been frightened by a small dog which
barked at her in the garden. Her face was a little bit drawn,
however, and there was some internal agitation which did not
disappear until she had asked me whether I was annoyed by
something she had said during the massage this morning and
I had said 'no'. Her period began again to-day after an inter-
val of scarcely a fortnight. I promised to regulate this by
hypnotic suggestion and, under hypnosis, set the interval at
28 days. 1

Under hypnosis, I also asked her whether she remembered
the last thing she told me; in asking this what I had in mind
was a task which had been left over from yesterday evening;
but she began quite correctly with the 'don't touch me' from
this mornings hypnosis. So I took her back to yesterday's topic.
I had asked her the origin of her stammering and she had
replied, 'I don't know'. 2 I had therefore requested her to re-
member it by the time of to-day's hypnosis. She accordingly
answered me to-day without any further reflection but in great
agitation and with spastic impediments to her speech: 'How

1 A suggestion which was carried out.

* It is possible that this answer, *I don't know', was correct; but it
may quite as well have indicated reluctance to talk about the causes
of the stammering. I have since observed in other patients that the
greater the effort they have made to repress a thing from their con-
sciousness the more difficulty they have in remembering it under
hypnosis as well as in waking life.

58 II. CASE HISTORIES

the horses bolted once with the children in the carriage; and
how another time I was driving through the forest with the
children in a thunderstorm, and a tree just in front of the
horses was struck by lightning and the horses shied and I
thought: "You must keep quite still now, or your screaming
will frighten the horses even more and the coachman won't be
able to hold them in at all." It came on from that moment.' She
was quite unusually excited as she told me this story. I further
learnt from her that the stammer had begun immediately after
the first of these two occasions, but had disappeared shortly
afterwards and then came on for good after the second, similar
occasion. I extinguished her plastic memory of these scenes,
but asked her to imagine them once more. She appeared to try
to do this and remained quiet as she did so; and from now on
she spoke in the hypnosis without any spastic impediment. 1

Finding her disposed to be communicative, I asked her what
further events in her life had frightened her so much that they
had left her with plastic memories. She replied by giving me
a collection of such experiences: [1] How a year after her
mother's death, she was visiting a Frenchwoman who was a
friend of hers, and had been sent into the next room with an-
other girl to fetch a dictionary, and had then seen someone sit
up in the bed who looked exactly like the woman she had just
left behind in the other room. She went stiff all over and was
rooted to the spot. She learnt afterwards that it was a specially
arranged dummy. I said that what she saw had been a hallu-
cination, and appealed to her good sense, and her face relaxed.
[2] How she had nursed her sick brother and he had had such
fearful attacks as a result of the morphine and had terrified
her and seized hold of her. I remembered that she had already
mentioned this experience this morning, and, as an experiment,
I asked her on what other occasions this 'seizing hold' had
happened. To my agreeable surprise she made a long pause
this time before answering and then asked doubtfully 'My little
girl?' She was quite unable to recall the other two occasions
(see above [p. 57]). My prohibition my expunging of her

1 As .we see from this, the patient's /zV-like clacking and her spastic
stammer were two symptoms which went back to similar precipitating
causes and had an analogous mechanism. I have already commented
on this mechanism in a short paper on hypnotic treatment (1892-36),
and I shall also return to it below. [See p. 91 ff.]

(2) FRAU EMMY VON N. (FREUD) 59

memories had therefore been effective. Further, [3] how,
while she was nursing her brother, her aunt's pale face had
suddenly appeared over the top of the screen. She had come to
convert him to Catholicism.

I saw that I had come to the root of her constant fear of
surprises, and I asked for further instances of this. She went on:
How they had a friend staying at her home who liked slipping
into the room very softly so that all of a sudden he was there;
how she had been so ill after her mother's death and had gone
to a health resort and a lunatic had walked into her room
several times at night by mistake and come right up to her
bed; and lastly, how, on the journey here from Abbazia a
strange man had four times opened the door of her com-
partment suddenly and had fixed his eyes on her each time
with a stare. She was so much terrified that she sent for the
conductor.

I wiped out all these memories, woke her up and assured
her she would sleep well to-night, having omitted to give her
this suggestion in her hypnosis. The improvement of her general
condition was shown by her remark that she had not done any
reading to-day, she was living in such a happy dream she,
who always had to be doing something because of her inner
unrest.

May ii, morning. To-day she had an appointment with Dr.
N., the gynaecologist, who is to examine her elder daughter
about her menstrual troubles. I found Frau Emmy in a rather
disturbed state, though this was expressed in slighter physical
signs than formerly. She called out from time to time: Tm
afraid, so afraid, I think I shall die.' I asked her what she was
afraid of? Was it of Dr. N.? She did not know, she said; she was
just afraid. Under hypnosis, which I induced before my col-
league arrived, she declared that she was afraid she had
offended me by something she had said during the massage
yesterday which seemed to her to have been impolite. She was
frightened of anything new, too, and consequently of the new
doctor. I was able to soothe her, and though she started once
or twice in the presence of Dr. N., she behaved very well apart
from this and produced neither her clacking noises nor any
inhibition of speech. After he had gone I put her under hypnosis
once more, to remove any possible residue of the excitement

60 II. CASE HISTORIES

caused by his visit. She herself was very much pleased with her
behaviour and put great hopes in the treatment; and I tried
to convince her from this example that there is no need
to be afraid of what is new, since it also contains what is
good. 1

Evening. She was very lively and unburdened herself of a
number of doubts and scruples during our conversation before
the hypnosis. Under hypnosis I asked her what event in her life
had produced the most lasting effect on her and came up most
often in her memory. Her husband's death, she said. I got her
to describe this event to me in full detail, and this she did with
every sign of deepest emotion but without any clacking or
stammering: How, she began, they had been at a place on
the Riviera of which they were both very fond, and while they
were crossing a bridge he had suddenly sunk to the ground and
lain there lifeless for a few minutes but had then got up again
and seemed quite well; how, a short time afterwards, as she
was lying in bed after her second confinement, her husband,
who had been sitting at breakfast at a small table beside her
bed, reading a newspaper, had got up all at once, looked at her
so strangely, taken a few paces forward and then fallen down
dead; she had got out of bed, and the doctors who were called
in had made efforts to revive him which she had heard from the
next room; but it had been in vain. And, she then went on to
say, how the baby, which was then a few weeks old, had been
seized with a serious illness which had lasted for six months,
during which she herself had been in bed with a high fever.
And there now followed in chronological order her grievances
against this child, which she threw out rapidly with an angry
look on her face, in the way one would speak of someone
who had become a nuisance. This child, she said, had been
very queer for a long time; it had screamed all the time and did
not sleep, and it had developed a paralysis of the left leg which
there had seemed very little hope of curing. When it was four
it had had visions; it had been late in learning to walk and to
talk, so that for a long time it had been believed to be imbecile.
According to the doctors it had had encephalitis and inflamma-
tion of the spinal cord and she did not know what else besides.
I interrupted her here and pointed out to her that this same

1 Didactic suggestions of this kind always missed fire with Frau
Emmy, as will be seen from what follows.

(2) FRAU EMMY VON N. (FREUD) 61

child was to-day a normal girl and in the bloom of health, and
I made it impossible for her to see any of these melancholy
things again, not only by wiping out her memories of them in
their plastic form but by removing her whole recollection of
them, as though they had never been present in her mind. I
promised her that this would lead to her being freed from the
expectation of misfortune which perpetually tormented her and
from the pains all over her body, of which she had been
complaining precisely during her narrative, after we had heard
nothing of them for several days. 1

To my surprise, after this suggestion of mine, she began
without any transition speaking of Prince L., whose escape from
an asylum was being talked about a great deal at the time.
She brought out new fears about asylums that people in
them were treated with douches of ice-cold water on the head
and put into an apparatus which turned them round and round
till they were quiet. When, three days ago, she had first com-
plained about her fear of asylums, I had interrupted her after
her first story, that the patients were tied on to chairs. I now
saw that I had gained nothing by this interruption and that I
cannot evade listening to her stories in every detail to the very
end. After these arrears had been made up, I took this fresh
crop of fears from her as well. I appealed to her good sense and
told her she really ought to believe me more than the silly girl
from whom she had had the gruesome stories about the way in
which asylums are run. As I noticed that she still stammered
occasionally in telling me these further things, I asked her once
more what the stammer came from. No reply. 'Don't you know?'
'No.' 'Why not?' 'Why not? Because I mayrftV (She pronounced
these words violently and angrily.) This declaration seemed to
me to be evidence of the success of my suggestion, but she

1 On this occasion my energy seems to have carried me too far.
When, as much as eighteen months later, I saw Frau Emmy again in a
relatively good state of health, she complained that there were a number
of most important moments in her life of which she had only the
vaguest memory [p. 84], She regarded this as evidence of a weakening
of her memory, and I had to be careful not to tell her the cause of this
particular instance of amnesia. The overwhelming success of the
treatment in this respect was no doubt also due to the great detail in
which I had got her to repeat these memories to me (in far greater
detail than is shown in my notes), whereas with other memories I was
too often satisfied with a mere mention.

62 II. CASE HISTORIES

expressed a desire for me to wake her up from her hypnosis,
and I did so. 1

May I2> [morning]. Contrary to my expectation, she had
slept badly and only for a short time. I found her in a state of
great anxiety, though, incidentally, without showing her usual
physical signs of it. She would not say what the matter was, but
only that she had had bad dreams and kept seeing the same
things. 'How dreadful it would be,' she said, 'if they were to
come to life.' During the massage she dealt with a few points
in reply to questions. She then became cheerful; she told me
about her social life at her dower house on the Baltic, of the
important people whom she entertains from the neighbouring
town, and so on.

Hypnosis. She had had some fearful dreams. The legs and
arms of the chairs were all turned into snakes; a monster with
a vulture's beak was tearing and eating at her all over her body;
other wild animals leapt upon her, etc. She then passed on to
other animal-deliria, which, however, she qualified with the
addition 'That was real' (not a dream): how (on an earlier
occasion) she had been going to pick up a ball of wool, and it
was a mouse and ran away; how she had been on a walk, and
a big toad suddenly jumped out at her, and so on. I saw that
my general prohibition had been ineffective and that I should
have to take her frightening impressions away from her one by
one. 2 I took an opportunity of asking her, too, why she had

1 It was not until the next day that I understood this little scene.
Her unruly nature, which rebelled, both in her waking state and in
artificial sleep, against any constraint, had made her angry with me
because I had assumed that her narrative was finished and had inter-
rupted it by my concluding suggestion. I have come across many other
proofs that she kept a critical eye upon my work in her hypnotic con-
sciousness. She had probably wanted to reproach me with interrupting
her story to-day just as I had previously interrupted her accounts of
the horrors in the asylum; but she had not ventured to do so. Instead
of this, she had produced these further stories [about asylums], appar-
ently without any transition and without revealing the connecting
thoughts. My blunder was made plain to me next day by a depreciatory
comment on her part.

8 I unfortunately failed to enquire into the significance of Frau
Emmy's animal visions to distinguish, for instance, what was symbolic
in her fear of animals from what was primary horror, such as is char-
acteristic of many neuropaths from youth onwards.

(2) FRAU EMMY VON N. (FREUD) 63

gastric pains and what they came from. (I believe that all her
attacks of zoopsia [animal hallucinations] are accompanied by
gastric pains.) Her answer, which she gave rather grudgingly,
was that she did not know. I requested her to remember by
tomorrow. She then said in a definitely grumbling tone that I
was not to keep on asking her where this and that came from,
but to let her tell me what she had to say. I fell in with this, and
she went on without preface: 'When they carried him out, I
could not believe he was dead.' (So she was talking of her
husband again, and I saw now that the cause of her ill-humour
was that she had been suffering from the residues of this story
which had been kept back.) After this, she said, she had hated
her child for three years, because she always told herself that
she might have been able to nurse her husband back to health
if she had not been in bed on account of the child. And then
after her husband's death there had been nothing but insults
and agitations. His relatives, who had always been against the
marriage and had then been angry because they had been so
happy together, had spread a rumour that she had poisoned
him, so that she had wanted to demand an enquiry. Her
relatives had involved her in all kinds of legal proceedings with
the help of a shady journalist. The wretch had sent round
agents to stir people up against her. He got the local papers to
print libellous articles about her, and then sent her the cuttings.
This had been the origin of her unsociability and her hatred of
all strangers. After I had spoken some calming words about
what she had told me, she said she felt easier.

May 13, [morning]. Once again she had slept badly, owing to
gastric pains. She had not eaten any supper. She also com-
plained of pains in her right arm. But she was in a good mood;
she was cheerful, and, since yesterday, has treated me with
special distinction. She asked me my opinion about all sorts of
things that seemed to her important, and became quite un-
reasonably agitated, for instance, when I had to look for the
towels needed in massage, and so on. Her clacking and facial
tic were frequent.

Hypnosis. Yesterday evening it had suddenly occurred to
her why the small animals she saw grew so enormous. It

happened to her for the first time at D during a theatrical

performance in which a huge lizard appeared on the stage.

64 II. CASE HISTORIES

This memory had tormented her a great deal yesterday as
well. 1

The reason for the re-appearance of the clacking was that
yesterday she had abdominal pains and had tried not to show
it by groaning. She .knew nothing of the true precipitating
cause of the clacking (see p. [54]). She remembered, too, that
I had instructed her to discover the origin of her gastric pains.
She did not know it, however, and asked me to help her. I
asked whether, perhaps, on some occasion after a great excite-
ment, she had forced herself to eat. She confirmed this. After
her husband's death she had for a long time lost her appetite
completely and had only eaten from a sense of duty; and her
gastric pains had in fact begun at that time. I then removed
her gastric pains by stroking her a few times across the epigas-
trium. She then began of her own accord to talk about the
things that had most affected her. 'I have told you,' she said,
'that I was not fond of the child. But I ought to add that one
could not have guessed it from my behaviour. I did everything
that was necessary. Even now I reproach myself for being fonder
of the elder one.'

May 14, [morning]. She was well and cheerful and had slept
till 7.30 this morning. She only complained of slight pains in
the radial region of her hand and in her head and face. What
she tells me before the hypnosis becomes more and more signifi-
cant. To-day she had scarcely anything dreadful to produce.
She complained of pains and loss of sensation in her right leg.
She told me that she had had an attack of abdominal inflam-
mation in 1871; when she had hardly recovered from this, she
had nursed her sick brother, and it was then that the pains
first came on. They had even led to a temporary paralysis of
her right leg.

During the hypnosis I asked her whether it would now be

1 The visual memory of the big lizard had no doubt only attained its
great importance owing to its coinciding in time with a powerful affect
which she must have experienced during the theatrical performance.
In treating the present patient, as I have already confessed [pp. 55 n.
and 62 n.] , I was often content to receive the most superficial explana-
tions. In this instance, too, I failed to make any further investigation.
We shall be reminded, moreover, of hysterical macropsia. Frau Emmy
was extremely short-sighted and astigmatic, and her hallucinations may
often have been provoked by the indistinctness of her visual perceptions.

(2) FRAU EMMY VON N. (FREUD) 65

possible for her to take part in social life or whether she was
still too much afraid. She said it was still disagreeable to have
anyone standing behind her or just beside her. In this connec-
tion she told me of some more occasions on which she had
been disagreeably surprised by someone suddenly appearing.
Once, for instance, when she had been going for a walk with
her daughters on the island of Rugen, two suspicious-looking
individuals had come out from some bushes and insulted them.
In Abbazia, while she was out for a walk one evening, a beggar
had suddenly emerged from behind a rock and had knelt down
in front of her. It seems that he was a harmless lunatic. Lastly,
she told me of how her isolated country house had been broken
into at night, which had very much alarmed her. It is easy to
see, however, that the essential origin of this fear of people was
the persecution to which she had been subjected after her
husband's death. 1

Evening. Though she appeared to be in high spirits, she
greeted me with the exclamation: Tm frightened to death; oh,
I can hardly tell you, I hate myself!' I learned at last that she
had had a visit from Dr. Breuer and that on his appearance she
had given a start of alarm. As he noticed it, she had assured him
that it was 'only this once'. She felt so very sorry on my account
that she should have had to betray this relic of her former
nervousness. I have more than once had occasion to notice
during these last few days how hard she is on herself, how liable
she is to blame herself severely for the least signs of neglect
if the towels for the massage are not in their usual place or if
the newspaper for me to read when she is asleep is not instantly
ready to hand. After the removal of the first and most super-
ficial layer of tormenting recollections, her morally over-
sensitive personality, with its tendency to self-depreciation, has
come into view. Both in her waking state and under hypnosis,
I duly told her (what amounted to the old legal tag *de minimis
non cur at lex'} that there is a whole multitude of indifferent,
small things lying between what is good and what is evil
things about which no one need reproach himself. She did not
take in my lesson, I fancy, any more than would an ascetic

1 At the time I wrote this I was inclined to look for a psychical origin
for all symptoms in cases of hysteria. I should now explain this sexually
abstinent woman's tendency to anxiety as being due to neurosis (i.e.
anxiety neurosis). [See below, p. 88.]

66 II. CASE HISTORIES

mediaeval monk, who sees the finger of God or a temptation of
the Devil in every trivial event of his life and who is incapable
of picturing the world even for a brief moment or in its smallest
corner as being without reference to himself.

In her hypnosis she brought up some further horrifying
images (in Abbazia, for instance, she saw bloody heads on every
wave of the sea). I made her repeat the lessons I had given her
while she was awake.

May 75, [morning]. She had slept till 8.30 a.m. but had
become restless towards morning, and received me with some
slight signs of her tic, clacking and speech-inhibition. Tm fright-
ened to death,' she said once more. In reply to a question she
told me that the Pension in which her children were staying
was on the fourth floor of a building and reached by a lift. She
had insisted yesterday that the children should make use of the
lift for coming down as well as going up, and was now reproach-
ing herself about this, because the lift was not entirely to be
trusted. The owner of the Pension had said so himself. Had I
heard, she asked, the story of the Countess Sch. who had been
killed in Rome in an accident of that kind? I happen to be
acquainted with the Pension and I know that the lift is the
private property of the owner of the Pension; it does not seem
to me very likely that this man, who makes a special point of
the lift in an advertisement, would himself have warned anyone
against using it. It seemed to me that we had here one of the
paramnesias that are brought about by anxiety. I told her my
view and succeeded without any difficulty in getting her her-
self to laugh at the improbability of her fears. For that very
reason I could not believe that this was the cause of her anxiety
and determined to put the question to her hypnotic conscious-
ness. During massage, which I resumed to-day after a few days'
interval, she told me a loosely connected string of anecdotes,
which may have been true about a toad which was found in a
cellar, an eccentric mother who looked after her idiot child in
a strange fashion, a woman who was shut up in an asylum
because she had melancholia and which showed the kind of
recollections that passed through her head when she was in a
disquieted frame of mind. When she had got these stories out
she became very cheerful. She described her life on her estate
and her contacts with prominent men in German Russia and

(2) FRAU EMMY VON N. (FREUD) 67

North Germany; and I really found it extremely hard to recon-
cile activities of this kind with the picture of such a severely
neurotic woman.

I therefore asked her in hypnosis why she was so restless this
morning. In place of her doubts about the lift, she informed
me that she had been afraid that her period was going to start
again and would again interfere with the massage. 1

1 The sequence of events had accordingly been as follows: When she
woke up in the morning she found herself in an anxious mood, and to
account for it she grasped at the first anxious idea that came to mind.
On the previous afternoon she had had a conversation about the lift
at the Pension. Over-careful of her children as usual, she had asked
their governess whether her elder daughter, who could not walk much
on account of ovarian neuralgia on the right side and pains in the right
leg, used the lift for going down as well as up. A paramnesia then en-
abled her to link the anxiety she was conscious of with the idea of the
lift. Her consciousness did not present her with the real cause of her
anxiety; that only emerged but now it did so without any hesitation
when I questioned her about it in hypnosis. The process was the same
as that studied by Bernheim and others after him in persons who carry
out in a post-hypnotic condition instructions given them during
hypnosis. For instance, Bernheim (1886, 29) suggested to a patient
that after he woke up he should put both his thumbs in his mouth. He
did so, and excused his action by saying that his tongue had been giving
him pain since the previous day when he had bitten it in an epileptiform
attack. Again, in obedience to a suggestion, a girl made an attempt to
murder a law-court officer who was totally unknown to her. When she
was seized and questioned as to the motives of her act, she invented a
story of a wrong done to her which called for revenge. There seems to
be a necessity for bringing psychical phenomena of which one becomes
conscious into causal connection with other conscious material. In cases
in which the true causation evades conscious perception one does not
hesitate to attempt to make another connection, which one believes,
although it is false. It is clear that a split in the content of consciousness
must greatly facilitate the occurrence of 'false connections' of this kind.
[See below, p. 302 f.J

I shall dwell a little on this example I have given of a false connection,
since in more than one respect it deserves to be described as typical. It
is typical, in the first place, of the present patient's behaviour; for in the
further course of the treatment she afforded me many opportunities of
resolving such false connections by explanations arrived at in hypnosis,
and of removing their effects. I will give a detailed account of one of
these instances, since it throws a strong light on the psychological
phenomenon in question. I had recommended Frau Emmy to try re-
placing her usual luke-warm bath by a hip-bath of cool water, which I
told her would be more refreshing. She used to obey medical instructions
implicitly, but never ceased to view them with profound mistrust. I

68 II. CASE HISTORIES

I then got her to tell me the history of her pains in the leg.
She began in the same way as yesterday [about having nursed
her brother] and then went on with a long series of instances of
experiences, alternately distressing and irritating, which she

have already said that she had hardly ever derived any benefit from her
medical treatment. My advice to her to take cool baths was not delivered
in such an authoritative manner as to prevent her from having the
courage to give open expression to her hesitations: 'Whenever I have
taken a cool bath,' she said, 'it has made me melancholy for the rest of
the day. But I will try it again, if you like; you mustn't think I won't
do whatever you tell me to.' I pretended to give up my proposal, but in
her next hypnosis I suggested to her that she should herself put forward
the idea of cool baths having thought it over, she would like to try
the experiment after all, and so on. This in fact happened. Next day,
she took up the idea of having cool hip-baths; she tried to convince me
with all the arguments which I had previously used to her, and I agreed
without much enthusiasm. But on the day after she had had the hip-
bath I did in fact find her in a deep depression. *Why are you like this
to-day?' I asked. 'I knew beforehand that it would happen,' she
answered, 'it's because of the cold bath; it always happens.' 'It was you
yourself who asked for it,' I said. 'Now we know they don't suit you.
We'll go back to the luke-warm ones.' Afterwards I asked her in her
hypnosis, 'Was it really the cool bath that depressed you so much?'
'Oh,' was her answer, 'the cool bath had nothing to do with it. But I
read in the paper this morning that a revolution had broken out in
San Domingo. Whenever there is any unrest there the whites are always
the sufferers; and I have a brother in San Domingo who has already
caused us a lot of concern, and I am worried now in case something
happens to him.' This brought to a close the issue between us. Next
morning she took her cool hip-bath as though it were a matter of
course and continued doing so for several weeks without ever attribut-
ing any depression to that source.

It will be agreed that this instance is typical also of the behaviour of
a large number of neuropaths in regard to the therapeutic procedures
recommended by their physicians. The patient who develops a symptom
on a particular day whether owing to unrest in San Domingo or else-
where is always inclined to attribute it to his doctor's latest advice.
Of the two conditions necessary for bringing about a false connection
of this kind, one, mistrust, seems always to be present; while the other,
the splitting of consciousness, is replaced by the fact that most neuro-
paths have in part no knowledge of the true causes (or at any rate the
releasing causes) of their disorder, and in part deliberately avoid such
knowledge, because they are unwilling to be reminded of that share
of the causes for which they themselves are to blame.

It might be thought that these psychical conditions which we have
laid down for neuropaths as distinct from hysterics namely, ignorance
or deliberate overlooking would necessarily be more favourable for

(2) FRAU EMMY VON N. (FREUD) 69

had had at the same time as her pains in the leg and the effect
of which had each time been to make them worse, even to the
point of her having bilateral paralysis of the legs with loss of
sensation in them. The same was true of the pains in her arm.

the production of a false connection than would be the presence of a
split in consciousness, which, after all, withdraws material for causal
connections from consciousness. The split, however, is rarely a clear-
cut one. As a rule, portions of the subconscious [cf. p. 45 n.] complex
of ideas intrude into the subject's ordinary consciousness, and it is
precisely they that provoke this kind of disturbance. What is usually
perceived consciously, as in the instances I have quoted above, is the
general feeling attached to the complex a mood of anxiety, it may be,
or of grief; and it is this feeling that, by a kind of 'compulsion to associ-
ate', must have a connection found for it with some complex of ideas
which is present in consciousness. (Compare, too, the mechanism of
obsessional ideas, described in two papers, 1894a and 1895r.)

Not long ago I was able to convince myself of the strength of a com-
pulsion of this kind towards association from some observations made
in a different field. For several weeks I found myself obliged to exchange
my usual bed for a harder one, in which I had more numerous or more
vivid dreams, or in which, it may be, I was unable to reach the normal
depth of sleep. In the first quarter of an hour after waking I remembered
all the dreams I had had during the night, and I took the trouble to
write them down and try to solve them. I succeeded in tracing all these
dreams back to two factors: (1) to the necessity for working out any
ideas which I had only dwelt upon cursorily during the day which
had only been touched upon and not finally dealt with; and (2) to the
compulsion to link together any ideas that might be present in the same
state of consciousness. The senseless and contradictory character of the
dreams could be traced back to the uncontrolled ascendancy of this
latter factor.

It is a quite regular thing for the mood attaching to an experience
and the subject-matter of that experience to come into different rela-
tions to the primary consciousness. This was shown in the case of another
patient, Frau Cacilie M., whom I got to know far more thoroughly than
any of the other patients mentioned in these studies. I collected from her
very numerous and convincing proofs of the existence of a psychical
mechanism of hysterical phenomena such as I have put forward above.
Personal considerations unfortunately make it impossible for me to
give a detailed case history of this patient, though I shall have occasion
to refer to it from time to time. Frau Cacilie had latterly been in a
peculiar hysterical state. This state was certainly not a unique one,
though I do not know if it has hitherto been recognized. It might be
called a 'hysterical psychosis for the payment of old debts'. The patient
had experienced numerous psychical traumas and had spent many
years in a chronic hysteria which was attended by a great variety of
manifestations. The causes of all these states of hers were unknown to her

70 II. CASE HISTORIES

They too had come on while she was nursing someone who was
ill, at the same time as the 'neck-cramps'. Concerning the
latter, I only learnt that they succeeded some curious restless

and everyone else. Her remarkably well-stocked memory showed the
most striking gaps. She herself complained that it was as though her
life was chopped in pieces. One day an old memory suddenly broke in
upon her clear and tangible and with all the freshness of a new sensation.
For nearly three years after this she once again lived through all the
traumas of her life long-forgotten, as they seemed to her, and some,
indeed, never remembered at all accompanied by the acutest suffering
and by the return of all the symptoms she had ever had. The 'old debts'
which were thus paid covered a period of thirty-three years and made it
possible to discover the origins, often very complicated, of all her
abnormal states. The only way of relieving her was to give her an
opportunity of talking off under hypnosis the particular reminiscence
which was tormenting her at the moment, together with all its accom-
panying load of feelings and their physical expression. When I was
prevented from doing so, so that she was obliged to say these things to
a person in whose presence she felt embarrassed, it sometimes happened
that she would tell him her story quite calmly and would subsequently,
in hypnosis, produce for me all the tears, all the expressions of despair,
with which she would have wished to accompany her recital. For a
few hours after a purgation of this kind during hypnosis she used to
be quite well and on the spot. After a short interval the next reminis-
cence of the series would break its way in. But this reminiscence would
be preceded some hours earlier by the mood which was proper to it.
She would become anxious or irritable or despairing without ever
suspecting that this mood did not belong to the present moment but to
the state to which she would next be subject. During this transition period
she would habitually make a false connection to which she would obstin-
ately cling until her next hypnosis. For instance, she once greeted me
with the question: 'Am I not a worthless person? Is it not a sign of worth-
lessness that I said to you what I did yesterday?' What she had actually
said to me the day before did not in fact seem to me to justify this
damning verdict. After a short discussion, she clearly recognized this;
but her next hypnosis brought to light a recollection of an occasion,
twelve years earlier, which had aroused severe self-reproaches in
her though, incidentally, she no longer subcribecl to them in the
least.

[The last paragraph but one of this footnote gives us the earliest
published report of a tentative approach by Freud to the problem of the
interpretation of dreams. Both the two factors which he brings forward
here were given a place in his ultimate analysis, though only a second-
ary one. The first of them was the theory championed by Robert and
was discussed in Chapter I (G) of The Interpretation of Dreams (1900a).
Standard Ed., 4, 78-80, and was partly accepted by Freud in Chapter
VII (D), ibid., 5, 579. The second of the factors brought forward here
will be found mentioned in Chapter V (A), ibid., 4, 179.]

(2) FRAU EMMY VON N. (FREUD) 71

states accompanied by depression which had been there pre-
viously. They consist in an 'icy grip' on the back of the neck,
together with an onset of rigidity and a painful coldness in all
her extremities, an incapacity to speak and complete prostra-
tion. They last from six to twelve hours. My attempts to show
that this complex of symptoms represented a recollection failed.
I put some questions to her with a view to discovering whether
her brother, while she was nursing him during his delirium, had
ever caught hold of her by the neck; but she denied this. She
said she did not know where these attacks came from. 1

1 On subsequent reflection, I cannot help thinking that these 'neck-
cramps' may have been determined organically and have been anal-
ogous to migraine. In medical practice we come across a number of
conditions of this kind which have not been described. These show such
a striking resemblance to the classical attack of hemicrania that we are
tempted to extend the concept of the latter and to attach only secondary
importance to the localization of the pain. As we know, many neuro-
pathic women very often have hysterical attacks (spasms and deliria)
along with an attack of migraine. Every time I observed a 'neck-cramp*
in Frau Emmy it was accompanied by an attack of delirium. [Gf. p. 96.]

As regards the pains in her arm and leg, I am of opinion that what
we have here is the not very interesting and correspondingly common
case of determination by chance coincidence. She had pains of this kind
while she was in an agitated state nursing her sick brother; and, owing
to her exhaustion, she felt them more acutely than usual. These pains,
which were originally associated only accidentally with those experi-
ences, were later repeated in her memory as the somatic symbol of the
whole complex of associations. I shall be able below [p. 174 ff.] to give
several more examples in confirmation of this process. It seems probable
that in the first instance these pains were rheumatic; that is to say, to
give a definite sense to that much misused term, they were of a kind
which resides principally in the muscles, involves a marked sensitive-
ness to pressure and modification of consistency in the muscles, is at its
most severe after a considerable period of rest and immobilization of
the extremity (i.e. in the morning), is improved by practising the
painful movement and can be dissipated by massage. These myogenic
pains, which are universally common, acquire great importance in
neuropaths. They themselves regard them as nervous and are encour-
aged in this by their physicians, who are not in the habit of examining
muscles by digital pressure. Such pains provide the material of countless
neuralgias and so-called sciaticas, etc. I will only refer briefly here to
the relation of these pains to the gouty diathesis. My patient's mother
and two of her sisters suffered very severely from gout (or chronic
rheumatism). Some part of the pains which she complained of at the
time of the treatment may, like her original pains, have been of con-
temporary origin. I cannot tell, since I had no experience then in
forming a judgement of this state of the muscles. [See below, p. 90.]

72 II. CASE HISTORIES

Evening. She was in very good spirits and showed a great
sense of humour. She told me incidentally that the affair of the
lift was not as she had reported it. The proprietor had only
said what he did in order to give an excuse for the lift not being
used for downward journeys. She asked me a great many
questions which had nothing pathological about them. She has
had distressingly severe pains in her face, in her hand on the
thumb side and in her leg. She gets stiff and has pains in her
face if she sits without moving or stares at some fixed point for
any considerable time. If she lifts anything heavy it brings on
pains in her arm. An examination of her right leg showed
fairly good sensibility in her thigh, a high degree of anaesthesia
in the lower part of the leg and in the foot and less in the region
of the buttock and hip.

In hypnosis she informed me that she still occasionally has
frightening ideas, such as that something might happen to her
children, that they might fall ill or lose their lives, or that her
brother, who is now on his honeymoon, might have an accident,
or his wife might die (because the marriages of all her brothers
and sisters had been so short). I could not extract any other fears
from her. I forbad her any need to be frightened when there
was no reason for it. She promised to give it up 'because you ask
me to'. I gave her further suggestions for her pains, her leg, etc.

May 16, [morning]. She had slept well. She still complained
of pains in her face, arms and legs. She was very cheerful. Her
hypnosis yielded nothing. I applied a faradic brush to her
anaesthetic leg.

Evening. She gave a start as soon as I came in. 'I'm so glad
you've come,' she said, 'I am so frightened.' At the same time
she gave every indication of terror, together with stammering
and tic. I first got her to tell me in her waking state what had
happened. Crooking her fingers and stretching out her hands
before her, she gave a vivid picture of her terror as she said:
'An enormous mouse suddenly whisked across my hand in the
garden and was gone in a flash; things kept on gliding back-
wards and forwards.' (An illusion from the play of shadows?)
'A whole lot of mice were sitting in the trees. Don't you hear
the horses stamping in the circus? There's a man groaning in
the next room; he must be in pain after his operation. Can
I be in Riigen? Did I have a stove there like that?' She was

(2) FRAU EMMY VON N. (FREUD) 73

confused by the multitude of thoughts crossing one another in
her mind and by her efforts to sort out her actual surroundings
from them. When I put questions to her about contemporary
things, such as whether her daughters were here, she could
make no answer.

I tried to disentangle the confusion of her mind under hyp-
nosis. I asked her what it was that frightened her. She repeated
the story of the mouse with every sign of terror, and added that
as she went down the steps she saw a dreadful animal lying
there, which vanished at once. I said that these were hallucina-
tions and told her not to be frightened of mice; it was only
drunkards who saw them (she disliked drunkards intensely). I
told her the story of Bishop Hatto. 1 She knew it too, and listened
to it with extreme horror. 'How did you come to think of the
circus? 1 I went on to ask. She said that she had clearly heard
the horses stamping in their stables near-by and getting tied
up in their halters, which might injure them. When this
happened Johann used to go out and untie them. I denied that
there were stables near-by or that anyone in the next room had
groaned. Did she know where she was? She said she knew now,
but had thought earlier that she was in Riigen. I asked her how
she got on to this memory. They had been talking in the garden,
she said, of how hot it was in one part of it, and all at once the
thought had come to her of the shadeless terrace in Rugen.
Well then, I asked, what were her unhappy memories of her
stay in Rugen? She produced a series of them. She had had the
most frightful pains there in her legs and arms; when she was
out on excursions there she had several times been caught in a
fog and lost her way; twice, while she was on a walk, a bull had
come after her, and so on. How was it that she had had this
attack to-day? How (she answered)? She had written a great
many letters; it had taken her three hours and had given her a
bad head. I could assume, accordingly, that her attack of
delirium was brought on by fatigue and that its content was
determined by associations from such things as the shadeless
place in the garden, etc. I repeated all the lessons I have been
in the habit of giving her and left her composed to sleep.

May 77, [morning]. She had a very good night. In the bran
bath which she had to-day, she gave some screams because she
1 [Who, according to legend, was eaten by rats.]

74 II. CASE HISTORIES

took the bran for worms. I heard this from the nurse. She her-
self was reluctant to tell me about it. She was almost exagger-
atedly cheerful, but she kept interrupting herself with cries of
'ugh!' and made faces expressive of terror. She also stammered
more than she has for the last few days. She told me she had
dreamt last night that she was walking on a lot of leeches. The
night before she had had horrible dreams. She had had to lay
out a number of dead people and put them in coffins, but
would not put the lids on. (Obviously, a recollection of her
husband.) She told me further that in the course of her life she
had had a large number of adventures with animals. The
worst had been with a bat which had got caught in her ward-
robe, so that she had rushed out of the room without any
clothes on. To cure her of this fear her brother had given her a
lovely brooch in the form of a bat; but she had never been able
to wear it.

Under hypnosis she explained that her fear of worms came
from her having once been given a present of a pretty pin-
cushion; but next morning, when she wanted to use it, a lot of
little worms had crept out of it, because it had been filled with
bran which was not quite dry. (A hallucination? Perhaps a
fact.) I asked her to tell me some more animal stories. Once,
she said, when she had been walking with her husband in a
park in St. Petersburg, the whole path leading to a pond had
been covered with toads, so that they had had to turn back.
There had been times when she had been unable to hold out
her hand to anyone, for fear of its turning into a dreadful
animal, as had so often happened. I tried to free her from her
fear of animals by going through them one by one and asking
her if she was afraid of them. In the case of some of them she
answered 'no'; in the case of others, 'I mustn't be afraid of
them.' 1 I asked her why she had stammered and jerked about
so much yesterday. She replied that she always did this when she
was very frightened. 2 But why had she been so frightened

1 The procedure I was following here can scarcely be regarded as a
good one: none of it was carried out exhaustively enough.

1 Her stammering and clacking were not completely relieved after
they had been traced back to the two initial traumas [the occasion of
her daughter's illness and the frightened horses, cf. pp. 54 and 58],
though from then on the two symptoms were strikingly improved. The
patient herself explained the incompleteness of the success as follows.
She had got into the habit of stammering and clacking whenever she

(2) FRAU EMMY VON N. (FREUD) 75

yesterday? Because all kinds of oppressive thoughts had come
into her head in the garden: in particular, how she could pre-
vent something from heaping up again inside her after her
treatment had come to an end. I repeated the three reasons
for feeling reassured which I had already given her: (1) that
she had become altogether healthier and more capable of
resistance, (2) that she would get the habit of telling her
thoughts to someone she was on close terms with, and (3) she
would henceforth regard as indifferent a .whole number of
things which had hitherto weighed upon her. She went on to
say that she had been worried as well because she had not
thanked me for my visiting her late in the day; and she was
afraid that I would lose patience with her on account of her
recent relapse. She had been very much upset and alarmed be-
cause the house physician had asked a gentleman in the garden
whether he was now able to face his operation. His wife had been
sitting beside him, and she (the patient) could not help thinking
that this might be the poor man's last evening. After this last
piece of information her depression seemed to be cleared up. 1

Evening. She was very cheerful and contented. The hyp-
nosis produced nothing whatever. I devoted myself to dealing
with her muscular pains and to restoring sensibility in her
right leg. This was very easily accomplished in hypnosis, but
her restored sensibility was in part lost again when she woke
up. Before I left her she expressed her astonishment that it was
such a long time since she had had any neck-cramps, though
they usually came on before every thunderstorm.

May 18. She had slept last night better than she had for years.
But after her bath she complained of cold at the back of her

was frightened, so that in the end these symptoms had come to be
attached not solely to the initial traumas but to a long chain of memories
associated with them, which I had omitted to wipe out. This is a state
of things which arises quite often and which always limits the beauty and
completeness of the therapeutic outcome of the cathartic procedure.

1 It was here that I learnt for the first time, what was confirmed on
countless later occasions, that when one is resolving a current hysterical
delirium, the patient's communications are given in a reverse chrono-
logical order, beginning with the most recent and least important
impressions and connections of thought and only at the end reaching
the primary impression, which is in all probability the most important
one causally. [The same phenomenon is mentioned by Breuer, p. 35.]

76 II. CASE HISTORIES

neck, tightness and pains in the face, hands and feet. Her
features were strained and her hands clenched. The hypnosis
brought out no psychical content underlying her neck-cramp. I
improved it by massage after she had woken up. 1

I hope that this extract from the history of the first three
weeks of the treatment will be enough to give a clear picture
of the patient's state, of the character of my therapeutic efforts
and of the measure of their success. I shall now proceed to
amplify the case history.

The delirium which I have last described was also the last
considerable disturbance in Frau Emmy von N.'s condition.
Since I did not take the initiative in looking for the symptoms
and their basis, but waited for something to come up in the
patient or for her to tell me some thought that was causing her
anxiety, her hypnoses soon ceased to produce material. I there-

1 Her astonishment the evening before at its being so long since she
had had a neck-cramp was thus a premonition of an approaching con-
dition which was already in preparation at the time and was perceived
in the unconscious [cf. p. 49 n.]. This curious kind of premonition oc-
curred regularly in the case already mentioned [p. 69 n.] of Frau Cacilie
M. If, for instance, while she was in the best of health, she said to me,
'It's a long time since I've been frightened of witches at night', or, 'how
glad I am that I've not had pains in my eyes for such a long time', I
could feel sure that the following night a severe onset of her fear of
witches would be making extra work for her nurse or that her next
attack of pains in the eyes was on the point of beginning. On each
occasion what was already present as a finished product in the uncon-
scious was beginning to show through indistinctly. This idea, which
emerged as a sudden notion, was worked over by the unsuspecting
'official' consciousness (to use Charcot's term) into a feeling of satis-
faction, which swiftly and invariably turned out to be unjustified. Frau
Cacilie, who was a highly intelligent woman, to whom I am indebted
for much help in gaining an understanding of hysterical symptoms,
herself pointed .out to me that events of this kind may have given rise
to superstitions about the danger of being boastful or of anticipat-
ing evils. We must not vaunt our happiness on the one hand, nor, on
the other, must we talk of the worst or it will happen. The fact is that
we do not boast of our happiness until unhappiness is in the offing, and
we become aware of our anticipation in the form of a boast, because
in such cases the subject-matter of what we are recollecting emerges
before the feeling that belongs to it that is to say, because an agreeable
contrasting idea is present in consciousness.- -[An allusion to this same
point will be found in a footnote near the beginning of a work of Freud's
written some thirty years later: 'Negation' (1925^).]

(2) FRAU EMMY VON N. (FREUD) 77

fore made use of them principally for the purpose of giving her
maxims which were to remain constantly present in her mind
and to protect her from relapsing into similar conditions when
she had got home. At that time I was completely under the
sway of Bernheim's book on suggestion 1 and I anticipated
more results from such didactic measures than I should to-day.
My patient's condition improved so rapidly, that she soon
assured me she had not felt so well since her husband's death.
After a treatment lasting in all for seven weeks I allowed her to
return to her home on the Baltic.

It was not I but Dr. Breiier who received news of her about
seven months later. Her health had continued good for several
months but had then broken down again as a result of a fresh
psychical shock. Her elder daughter, during their first stay in
Vienna, had already followed her mother in developing neck-
cramps and mild hysterical states; but in particular, she had
suffered from pains in walking owing to a retroverted uterus.
On my advice she had gone for treatment to Dr. N., one of our
most distinguished gynaecologists, who had put her uterus
right by massage, and she had remained free from trouble for
several months. Her trouble recurred, however, while they were
at home, and her mother called in a gynaecologist from the
neighbouring University town. He prescribed a combined
local and general treatment for the girl, which, however,
brought on a severe nervous illness (she was seventeen at the
time). It is probable that this was already an indication of her
pathological disposition which was to manifest itself a year
later in a character-change. [See below, p. 83.] Her mother,
who had handed the girl over to the doctors with her usual
mixture of docility and mistrust, was overcome by the most
violent self-reproaches after the unfortunate outcome of the
treatment. A train of thought which I have not investigated
brought her to the conclusion that Dr. N. and I were to-
gether responsible for the girl's illness because we had made
light of her serious condition. By an act of will as it were,
she undid the effects of my treatment and promptly relapsed
into the states from which I had freed her. A distinguished
physician in her neighbourhood, to whom she went for advice,
and Dr. Breuer, who was in correspondence with her, succeeded

1 [Freud himself translated this book (Bernheim, 1886), and the trans-
lation was published in 1888-9.]

78 II. CASE HISTORIES

in convincing her of the innocence of the two targets of her
accusations; but even after this was cleared up, the aversion to
me which she formed at the time was left over as a hysterical
residue, and she declared that it was impossible for her to take
up her treatment with me again. On the advice of the same
medical authority she turned for help to a Sanatorium in North
Germany. At Breuer's desire I explained to the physician in
charge the modifications of hypnotic therapy which I had
found effective in her case.

This attempted transfer l failed completely. From the very
first she seems to have been at cross- purposes with the doctor.
She exhausted herself in resisting whatever was done for her.
She went downhill, lost sleep and appetite, and only recovered
after a woman friend of hers who visited her in the Sanatorium
in effect secretly abducted her and looked after her in her
house. A short time afterwards, exactly a year after her first
meeting with me, she was again in Vienna and put herself once
more into my hands.

I found her much better than I had expected from the
accounts I had received by letter. She could get about and
was free from anxiety; much of what I had accomplished the
year before was still maintained. Her chief complaint was of
frequent states of confusion 'storms in her head' as she called
them. Besides this she suffered from sleeplessness, and was often
in tears for hours at a time. She felt sad at one particular time of
day (five o'clock). This was the regular hour at which, during
the winter, she had been able to visit her daughter in the
nursing home. She stammered and clacked a great deal and
kept rubbing her hands together as though she was in a rage,
and when I asked her if she saw a great many animals, she only
replied: 'Oh keep still!'

At my first attempt to induce hypnosis she clenched her fists
and exclaimed: 'I won't be given any antipyrin injections; I
would rather have my pains! I don't like Dr. R.; he is anti-
pathetic to me.' I perceived that she was involved in the
memory of being hypnotized in the sanatorium, and she calmed
down as soon as I brought her back to the present situation.

At the very beginning of the [resumed] treatment I had an

1 [Though the German word here is ''Uhertragung', it is evidently not
used in the technical sense of 'transference' which is first found at the
end of this volume, on p. 302.]

(2) FRAU EMMY VON N. (FREUD) 79

instructive experience. I had asked her how long she had had a
recurrence of the stammering, and she had hesitatingly answered

(under hypnosis) that it was ever since a shock she had at D

during the winter. A waiter at the hotel in which she was stay-
ing had concealed himself in her bedroom. In the darkness, she
said, she had taken the object for an overcoat and put out her
hand to take hold of it; and the man had suddenly 'shot up
into the air'. I took this memory-picture away, and in fact from
that time on she ceased to stammer noticeably either in hyp-
nosis or in waking life. I cannot remember what it was that led
me to test the success of my suggestion, but when I returned
the same evening I asked her in an apparently innocent voice
how I could manage to fasten the door when I went away
(while she was lying asleep) so that no one could slip into the
room. To my astonishment she gave a violent start and began
grinding her teeth and rubbing her hands. She indicated that

she had had a severe shock of that kind at D , but could not

be persuaded to tell me the story. I observed that she had in
mind the same story which she had told me that morning
during the hypnosis and which I thought I had wiped out.
In her next hypnosis she told me the story in greater detail and
more truthfully. In her excitement she had been walking up
and down the passage and found the door of her maid's bed-
room open. She had tried to go in and sit down. Her maid had
stood in the way, but she refused to be stopped and walked in,
and then caught sight of the dark object against the wall which
turned out to be a man. It was evidently the erotic factor in
this little adventure which had caused her to give an untrue
account of it. This taught me that an incomplete story under
hypnosis produces no therapeutic effect. I accustomed myself
to regarding as incomplete any story that brought about no
improvement, and I gradually came to be able to read from
patients' faces whether they might not be concealing an essen-
tial part of their confessions.

The work that I had to do with her this time consisted in
dealing in hypnosis with the disagreeable impressions she had
received during her daughter's treatment and during her own
stay in the sanatorium. She was full of suppressed anger with
the physician who had compelled her under hypnosis to spell
out the word c t . . . o . . . a . . . d' and she made me promise
never to make her say it. In this connection I ventured upon a

80 II. CASE HISTORIES

practical joke in one of my suggestions to her. This was the only
abuse of hypnosis and a fairly innocent one at that of which
I have to plead guilty with this patient. I assured her that her
stay in the sanatorium at '-to/' [-Vale'] would become so re-
mote to her that she would not even be able to recall its name
and that whenever she wanted to refer to it she would hesitate
between '-berg ['-hill'], '-to/', '-wald y ['-wood'] and so on. This
duly happened and presently the only remaining sign of her
speech-inhibition was her uncertainty over this name. Eventu-
ally, following a remark by Dr. Breuer, I relieved her of this
compulsive paramnesia.

I had a longer struggle with what she described as 'the
storms in her head' than with the residues of these experiences.
When I first saw her in one of these states she was lying on the
sofa with her features distorted and her whole body unceasingly
restless. She kept on pressing her hands to her forehead and
calling out in yearning and helpless tones the name 'Emmy',
which was her elder daughter's as well as her own. Under
hypnosis she informed me that this state was a repetition of the
many fits of despair by which she had been overcome during
her daughter's treatment, when, after she had spent hours in
trying to discover some means of correcting its bad effects, no
way out presented itself. When, at such a time, she felt her
thoughts becoming confused, she made it a practice to call out
her daughter's name, so that it might help her back to clear-
headedness. For, during the period when her daughter's illness
was imposing fresh duties on her and she felt that her own
nervous condition was once again gaining strength over her,
she had determined that whatever had to do with the girl
must be kept free from confusion, however chaotic everything
else in her head was.

In the course of a few weeks we were able to dispose of these
memories too and Frau Emmy remained under my observa-
tion for some time longer, feeling perfectly well. At the very
end of her stay something happened which I shall describe in
detail, since it throws the strongest light on the patient's
character and the manner in which her states came about.

I called on her one day at lunch-time and surprised her in
the act of throwing something wrapped up in paper into the
garden, where it was caught by the children of the house-
porter. In reply to my question, she admitted that it was her

(2) FRAU EMMY VON N. (FREUD) 81

(dry) pudding, and that this went the same way every day. This
led me to investigate what remained of the other courses and I
found that there was more than half left on the plates. When I
asked her why she ate so little she answered that she was not
in the habit of eating more and that it would be bad for her if
she did; she had the same constitution as her late father, who
had also been a small eater. When I enquired what she drank
she told me she could only tolerate thick fluids, such as milk,
coffee or cocoa; if she ever drank water or minerals it ruined her
digestion. This bore all the signs of a neurotic choice. I took a
specimen of her urine and found it was highly concentrated and
overcharged with urates.

I therefore thought it advisable to recommend her to drink
more and decided also to increase the amount of her food. It
is true that she did not look at all noticeably thin but I never-
theless thought it worth while to aim at feeding her up a little.
When on my next visit I ordered her some alkaline water and
forbad her usual way of dealing with her pudding, she showed
considerable agitation. Til do it because you ask me to, 3 she
said, 'but I can tell you in advance that it will turn out badly,
because it is contrary to my nature, and it was the same with
my father.' When I asked her under hypnosis why it was that
she could not eat more or drink any water, she answered in a
rather sullen tone: 'I don't know.' Next day the nurse reported
that she had eaten the whole of her helpings and had drunk a
glass of the alkaline water. But I found Frau Emmy herself
lying in a profoundly depressed state and in a very ungracious
mood. She complained of having very violent gastric pains. 'I
told you what would happen,' she said. 'We have sacrificed all
the successful results that we have been struggling for so long.
I've ruined my digestion, as always happens if I eat more or
drink water, and I have to starve myself entirely for five days
to a week before I can tolerate anything.' I assured her that
there was no need to starve herself and that it was impossible
to ruin one's digestion in that way: her pains were only due to
the anxiety over eating and drinking. It was clear that this
explanation of mine made not the slightest impression on her.
For when, soon afterwards, 1 tried to put her to sleep, for the
first time I failed to bring about hypnosis; and the furious look
she cast at me convinced me that she was in open rebellion and
that the situation was very grave. I gave up trying to hypnotize

82 II. CASE HISTORIES

her, and announced that I would give her twenty-four hours to
think things over and accept the view that her gastric pains
came only from her fear. At the end of this time I would ask
her whether she was still of the opinion that her digestion could
be ruined for a week by drinking a glass of mineral water and
eating a modest meal; if she said yes, I would ask her to leave.
This little scene was in very sharp contrast to our normal rela-
tions, which were most friendly.

I found her twenty-four hours later, docile and submissive.
When I asked her what she thought about the origin of her
gastric pains, she answered, for she was incapable of prevarica-
tion: 'I think they come from my anxiety, but only because you
say so. 5 1 then put her under hypnosis and asked her once again:
'Why can't you eat more?'

The answer came promptly and consisted once more in her
producing a series of chronologically arranged reasons from her
store of recollections: 'I'm thinking how, when I was a child, it
often happened that out of naughtiness I refused to eat my
meat at dinner. My mother was very severe about this and
under the threat of condign punishment I was obliged two hours
later to eat the meat, which had been left standing on the same
plate. The meat was quite cold by then and the fat was set so
hard' (she showed her disgust) '. . . I can still see the fork in
front of me . . . one of its prongs was a little bent. Whenever I
sit down to a meal I see the plates before me with the cold
meat and fat on them. And how, many years later, I lived with
my brother who was an officer and who had that horrible
disease. I knew it was contagious and was terribly afraid of
making a mistake and picking up his knife and fork' (she
shuddered) '. . . and in spite of that I ate my meals with him so
that no one should know that he was ill. And how, soon after
that, I nursed my other brother when he had consumption so
badly. We sat by the side of his bed and the spittoon always
stood on the table, open' (she shuddered again) '. . . and he
had a habit of spitting across the plates into the spittoon. This
always made me feel so sick, but I couldn't show it, for fear of
hurting his feelings. And these spittoons are still on the table
whenever I have a meal and they still make me feel sick.' I
naturally made a thorough clearance of this whole array of
agencies of disgust and then asked why it was that she could not
drink water. When she was seventeen, she replied, the family

(2) FRAU EMMY VON N. (FREUD) 83

had spent some months in Munich and almost all of them had
contracted gastric catarrh owing to the bad drinking water.
In the case of the others the trouble was quickly relieved by
medical attention, but with her it had persisted. Nor had she
been improved by the mineral water which she was recom-
mended. When the doctor had prescribed it she had thought
at once 'that won't be any use 5 . From that time onwards this
intolerance both of ordinary water and mineral water had re-
curred on countless occasions.

The therapeutic effect of these discoveries under hypnosis
was immediate and lasting. She did not starve herself for a week
but the very next day she ate and drank without making any
difficulty. Two months later she wrote in a letter: 'I am eating
excellently and have put on a great deal of weight. I have
already drunk forty bottles of the water. Do you think I should
go on with it?*

I saw Frau von N. again in the spring of the following year

at her estate near D . At this time her elder daughter,

whose name she had called out during her 'storms in the head',
entered on a phase of abnormal development. She exhibited
unbridled ambitions which were out of all proportion to the
poverty of her gifts, and she became disobedient and even
violent towards her mother. I still enjoyed her mother's con-
fidence and was sent for to give my opinion on the girl's con-
dition. I formed an unfavourable impression of the psychological
change that had occurred in the girl, and in arriving at a prog-
nosis I had also to take into account the fact that all her step-
brothers and sisters (the children of Herr von N. by his first
marriage) had succumbed to paranoia. In her mother's family,
too, there was no lack of a neuropathic heredity, although none
of her more immediate relatives had developed a chronic
psychosis. I communicated to Frau von N. without any reserva-
tion the opinion for which she had asked and she received it
calmly and with understanding. She had grown stout, and
looked in flourishing health. She had felt relatively very well
during the nine months that had passed since the end of her
last treatment. She had only been disturbed by slight neck-
cramps and other minor ailments. During the several days
which I spent in her house I came for the first time to realize
the whole extent of her duties, occupations and intellectual
interests. I also met the family doctor, who had not many

84 II. CASE HISTORIES

complaints to make about the lady; so she had to some degree
come to terms with the profession.

She was thus in very many respects healthier and more
capable, but in spite of all my improving suggestions there had
been little change in her fundamental character. She seemed
not to have accepted the existence of a category of 'indifferent
things'. Her inclination to torment herself was scarcely less
than it had been at the time of her treatment. Nor had her
hysterical disposition been quiescent during this good period.
She complained, for instance, of an inability to make journeys
of any length by train. This had come on during the last few
months. A necessarily hurried attempt to relieve her of this
difficulty resulted only in her producing a number of trivial
disagreeable impressions left by some recent journeys she had

made to D and its neighbourhood. She seemed reluctant,

however, to be communicative under hypnosis, and even then
I began to suspect that she was on the point of withdrawing
once more from my influence and that the secret purpose of
her railway inhibition was to prevent her making a fresh
journey to Vienna.

It was during these days, too, that she made her complaints
about gaps in her memory 'especially about the most important
events' [p. 61 .], from which I concluded that the work I had
done two years previously had been thoroughly effective and
lasting. One day, she was walking with me along an avenue
that led from the house to an inlet in the sea and I ventured to
ask whether the path was often infested by toads. By way of
reply she threw a reproachful glance at me, though unaccom-
panied by signs of horror; she amplified this a moment later
with the words 'but the ones here are real\ During the hypnosis,
which I induced in order to deal with her railway inhibition,
she herself seemed dissatisfied with the answers she gave me,
and she expressed a fear that in future she was likely to be less
obedient under hypnosis than before. I determined to convince
her of the contrary. I wrote a few words on a piece of paper,
handed it to her and said: 'At lunch to-day you will pour me
out a glass of red wine, just as you did yesterday. As I raise the
glass to my lips you will say: "Oh, please pour me out a glass,
too", and when I reach for the bottle, you will say: "No thank
you, I don't think I will after all". You will then put your hand
in your bag, draw out the piece of paper and find those same

(2) FRAU EMMY VON N. (FREUD) 85

words written on it. 5 This was in the morning. A few hours later
the little episode took place exactly as I had pre-arranged it,
and so naturally that none of the many people present noticed
anything. When she asked me for the wine she showed visible
signs of an internal struggle for she never drank wine and
after she had refused the drink with obvious relief, she put her
hand into her bag and drew out the piece of paper on which
appeared the last words she had spoken. She shook her head
and stared at me in astonishment.

After my visit in May, 1890, my news of Frau von N. became
gradually scantier. I heard indirectly that her daughter's de-
plorable condition, which caused her every kind of distress and
agitation, did eventually undermine her health. Finally, in the
summer of 1893, I had a short note from her asking my per-
mission for her to be hypnotized by another doctor, since she
was ill again and could not come to Vienna. At first I did not
understand why my permission was necessary, till I remembered
that in 1890 I had, at her own request, protected her against
being hypnotized by anyone else, so that there should be no
danger of her being distressed by coming under the control of a
doctor who was antipathetic to her, as had happened at -berg
(-/#/, -wald). I accordingly renounced my exclusive prerogative
in writing.

DISCUSSION

Unless we have first come to a complete agreement upon the
terminology involved, it is not easy to decide whether a par-
ticular case is to be reckoned as a hysteria or some other neu-
rosis (I am speaking here of neuroses which are not of a purely
neurasthenic type); and we have still to await the directing
hand which shall set up boundary-marks in the region of the
commonly occurring mixed neuroses and which shall bring out
the features essential for their characterization. If, accordingly,
we are still accustomed to diagnosing a hysteria, in the narrower
sense of the term, from its similarity to familiar typical cases,
we shall scarcely be able to dispute the fact that the case of
Frau Emmy von N. was one of hysteria. The mildness of her
deliria and hallucinations (while her other mental activities
remained intact), the change in her personality and store of
memories when she was in a state of artificial somnambulism,

86 II. CASE HISTORIES

the anaesthesia in her painful leg, certain data revealed in her
anamnesis, her ovarian neuralgia, etc., admit of no doubt as
to the hysterical nature of the illness, or at least of the patient.
That the question can be raised at all is due only to one par-
ticular feature of the case, which also provides an opportunity
for a comment that is of general validity. As we have explained
in the 'Preliminary Communication' which appears at the
beginning of this volume, we regard hysterical symptoms as
the effects and residues of excitations which have acted upon
the nervous system as traumas. Residues of this kind are not
left behind if the original excitation has been discharged by
abreaction or thought-activity. It is impossible any longer at
this point to avoid introducing the idea of quantities (even
though not measurable ones). We must regard the process as
though a sum of excitation impinging on the nervous system is
transformed into chronic symptoms in so far as it has not been
employed for external action in proportion to its amount. 1 Now
we are accustomed to find in hysteria that a considerable part
of this 'sum of excitation 5 of the trauma is transformed into
purely somatic symptoms. It is this characteristic of hysteria
which has so long stood in the way of its being recognized as a
psychical disorder.

If, for the sake of brevity, we adopt the term 'conversion' 2
to signify the transformation of psychical excitation into chronic
somatic symptoms, which is so characteristic of hysteria, then
we may say that the case of Frau Emmy von N. exhibited only
a small amount of conversion. The excitation, which was
originally psychical, remained for the most part in the psychical
sphere, and it is easy to see that this gives it a resemblance to
the other, non-hysterical neuroses. There are cases of hysteria
in which the whole surplus of stimulation undergoes conversion,
so that the somatic symptoms of hysteria intrude into what
appears to be an entirely normal consciousness. An incomplete
transformation is however more usual, so that some part at

1 [For a detailed account of Freud's attempt at explaining psychology
on a quantitative basis see his posthumously published 'Project for a
Scientific Psychology' (1950a), written a few months after the present
work. He had already expressed these views briefly in the last para-
graph but one of his first paper on the 'Neuro-Psychoses of Defence'
(1894a). See also the Editor's Introduction, p. xix ff.]

8 [Freud had introduced this term in his first paper on the 'Neuro-
Psychoses of Defence' (1894a). See, however, p. 206 n.]

(2) FRAU EMMY VON N. (FREUD) 87

least of the affect that accompanies the trauma persists in con-
sciousness as a component of the subject's state of feeling.

The psychical symptoms in our present case of hysteria with
very little conversion can be divided into alterations of mood
(anxiety, melancholic depression), phobias and abulias (in-
hibitions of will). The two latter classes of psychical disturbance
are regarded by the French school of psychiatrists as stigmata of
neurotic degeneracy, but in our case they are seen to have been
adequately determined by traumatic experiences. These phobias
and abulias were for the most part of traumatic origin, as I
shall show in detail.

Some of the phobias, it is true, corresponded to the
primary phobias of human beings, and especially of neuro-
paths in particular, for instance, her fear of animals (snakes
and toads, as well as all the vermin of which Mephistopheles
boasted himself master 1 ), and of thunderstorms and so on.
But these phobias too were established more firmly by trau-
matic events. Thus her fear of toads was strengthened by her
experience in early childhood of having a dead toad thrown at
her by one of her brothers, which led to her first attack of
hysterical spasms [p. 52] ; and similarly, her fear of thunder-
storms was brought out by the shock which gave rise to her
clacking fp. 58], and her fear of fogs by her walk on the Island
of Riigen [p. 73], Nevertheless, in this group the primary or,
one might say, the instinctive fear (regarded as a psychical
stigma) plays the preponderant part.

The other, more specific phobias were also accounted for by
particular events. Her dread of unexpected and sudden shocks
was the consequence of the terrible impression made on her
by seeing her husband, when he seemed to be in the best of
health, succumb to a heart-attack before her eyes. Her dread
of strangers, and of people in general, turned out to be derived
from the time when she was being persecuted by her [husband's]
family and was inclined to see one of their agents in every
stranger and when it seemed to her likely that strangers knew
of the things that were being spread abroad about her in
writing and by word of mouth [p. 63]. Her fear of asylums and
their inmates went back to a whole series of unhappy events

1 [The lord of rats and eke of mice,

Of flies and bed-bugs, frogs and lice.
Goethe, Faust, Part I, Scene 3 (Bayard Taylor's translation).]

88 II. CASE HISTORIES

in her family and to stories poured into her listening ears by a
stupid servant-girl [p. 55], Apart from this, this phobia was
supported on the one hand by the primary and instinctive
horror of insanity felt by healthy people, and on the other hand
by the fear, felt by her no less than by all neurotics, of going
mad herself. Her highly specific fear that someone was standing
behind her [p. 65] was determined by a number of terrifying
experiences in her youth and later life. Since the episode in the
hotel [p. 79], which was especially distressing to her because
of its erotic implications, her fear of a stranger creeping into
her room was greatly emphasized. Finally, her fear of being
buried alive, which she shared with so many neuropaths, was
entirely explained by her belief that her husband was not dead
when his body was carried out a belief which gave such
moving expression to her inability to accept the fact that her
life with the man she loved had come to a sudden end. In my
opinion, however, all these psychical l factors, though they
may account for the choice of these phobias, cannot explain their
persistence. It is necessary, I think, to adduce a neurotic factor
to account for this persistence the fact that the patient had
been living for years in a state of sexual abstinence. Such
circumstances are among the most frequent causes of a tendency
to anxiety. 2

Our patient's abulias (inhibitions of will, inability to act)
admit even less than the phobias of being regarded as psychical
stigmata due to a general limitation of capacity. On the con-
trary, the hypnotic analysis of the case made it clear that her
abulias were determined by a twofold psychical mechanism
which was at bottom a single one. In the first place an abulia
may simply be the consequence of a phobia. This is so when
the phobia is attached to an action of the subject's own instead
of to an expectation [of an external event] for instance, in our
present case, the fear of going out or of mixing with people, as
compared with the fear of someone creeping into the room.
Here the inhibition of will is caused by the anxiety attendant

1 [In the first German edition only, this word reads 'physical', which
was clearly a misprint.]

2 [See Freud's contemporary paper on anxiety neuroses (1895).
In the previous sentence he is using the term 'neurotic', as he sometimes
does at this period, in relation to what he later (18980) termed the
'actual-neuroses'.]

(2) FRAU EMMY VON N. (FREUD) 89

upon the performance of the action. It would be wrong to
regard abulias of this kind as symptoms distinct from the
corresponding phobias, though it must be admitted that such
phobias can exist (provided they are not too severe) with-
out producing abulias. The second class of abulias depends
on the presence of affectively-toned and unresolved associa-
tions which are opposed to linking up with other associations,
and particularly with any that are incompatible with them.
Our patient's anorexia offers a most brilliant instance of this
kind of abulia [p. 82 f.]. She ate so little because she did not
like the taste, and she could not enjoy the taste because the act
of eating had from the earliest times been connected with
memories of disgust whose sum of affect had never been to any
degree diminished; and it is impossible to eat with disgust and
pleasure at the same time. Her old-established disgust at meal-
times had persisted undiminished because she was obliged con-
stantly to suppress it, instead of getting rid of it by reaction. In
her childhood she had been forced, under threat of punishment,
to eat the cold meal that disgusted her, and in her later years
she had been prevented out of consideration for her brothers
from expressing the affects to which she was exposed during
their meals together.

At this point I may perhaps refer to a short paper in which
I have tried to give a psychological explanation of hysterical
paralyses (Freud 1893^). I there arrived at a hypothesis that
the cause of these paralyses lay in the inaccessibility to fresh
associations of a group of ideas connected, let us say, with one
of the extremities of the body; this associative inaccessibility
depended in turn on the fact that the idea of the paralysed
limb was involved in the recollection of the trauma a recol-
lection loaded with affect that had not been disposed of. I
showed from examples from ordinary life that a cathexis * such
as this of an idea whose affect is unresolved always involves a
certain amount of associative inaccessibility and of incom-
patibility with new cathexes.

I have not hitherto succeeded in confirming, by means of
hypnotic analysis, this theory about motor paralyses, but I can

1 [This seems to be the first published appearance of the term
'Besetzung* ('cathexis') in the special sense in which Freud used it to
denote one of the most fundamental concepts in his psychological
theory. See the Editor's Introduction, p. xxiii.]

90 II. CASE HISTORIES

adduce Frau von N.'s anorexia as proving that this mechanism
is the operative one in certain abulias, and abulias are nothing
other than a highly specialized or, to use a French expression,
'systematized' kind of psychical paralysis.

Frau von N.'s psychical situation can be characterized in all
essentials by emphasizing two points. (1) The distressing affects
attaching to her traumatic experiences had remained unre-
solved for instance, her depression, her pain (about her
husband's death), her resentment (at being persecuted by his
relatives), her disgust (at the compulsory meals), her fear
(about her many frightening experiences), and so on. (2) Her
memory exhibited a lively activity which, sometimes spon-
taneously, sometimes in response to a contemporary stimulus
(e.g. the news of the revolution in San Domingo [p. 68 n.]) y
brought her traumas with their accompanying affects bit by bit
into her present-day consciousness. My therapeutic procedure
was based on the course of this activity of her memory and
endeavoured day by day to resolve and get rid of whatever
that particular day had brought to the surface, till the accessible
stock of her pathological memories seemed to be exhausted.

These two psychical characteristics, which I regard as gener-
ally present in hysterical paroxysms, opened the way to a
number of important considerations. I will, however, put off
discussing them till I have given some attention to the mechan-
ism of the somatic symptoms.

It is not possible to assign the same origin to all the somatic
symptoms of these patients. On the contrary, even from this
case, which was not rich in them, we find that the somatic
symptoms of a hysteria can arise in a variety of ways. I will
venture, in the first place, to include pains among somatic
symptoms. So far as I can see, one set of Frau von N.'s pains
were certainly determined organically by the slight modifica-
tions (of a rheumatic kind) in the muscles, tendons or fascia
which cause so much more pain to neurotics than to normal
people. Another set of pains were in all probability memories of
pains were mnemic symbols 1 of the times of agitation and

1 [Gf. above, footnote, p. 71. Freud had already used this term in
Section I of his first paper on 'The Neuro-Psychoses of Defence' (1894*),
and he repeatedly uses it in the present work. It rarely occurs in his
later writings, though it is explained at some length in the first of his
Five Lectures (1910a).]

(2) FRAU EMMY VON N. (FREUD) 91

sick-nursing which played such a large part in the patient's life.
These pains, too, may well have been originally justified on
organic grounds but had since then been adapted for the pur-
poses of the neurosis. I base these assertions about Frau von N.'s
pains mainly on observations made elsewhere which I shall
report on a later page. 1 On this particular point little informa-
tion could be gathered from the patient herself.

Some of the striking motor phenomena exhibited by Frau
von N. were simply an expression of the emotions and could
easily be recognized in that light. Thus, the way in which she
stretched her hands in front of her with her fingers spread out
and crooked expressed horror, and similarly her facial play.
This, of course, was a more lively and uninhibited way of
expressing her emotions than was usual with women of her
education and race. Indeed, she herself was restrained, almost
stiff in her expressive movements when she was not in a
hysterical state. Others of her motor symptoms were, according
to herself, directly related to her pains. She played restlessly
with her fingers (1888) [p. 49] or rubbed her hands against
one another (1889) [p. 78] so as to prevent herself from scream-
ing. This reason reminds one forcibly of one of the principles
laid down by Darwin to explain the expression of the emotions
the principle of the overflow of excitation [Darwin, 1872,
Chap. Ill], which accounts, for instance, for dogs wagging
their tails. We are all of us accustomed, when we are affected
by painful stimuli, to replace screaming by other sorts of
motor innervations. A person who has made up his mind at
the dentist's to keep his head and mouth still and not to put his
hand in the way, may at least start drumming with his feet. 2

A more complicated method of conversion is revealed by
Frau von N.'s tic-like movements, such as clacking with the
tongue and stammering, calling out the name 'Emmy' in con-
fusional states [p. 80], using the composite formula 'Keep still!
Don't say anything! Don't touch me!' (1888) [p. 49]. Of
these motor manifestations, the stammering and clacking can
be explained in accordance with a mechanism which I have
described, in a short paper on the treatment of a case by

1 [The subject of rheumatic pains and their relation to hysteria is
discussed at some length in the case of Fraulein Elisabeth von R. below,
p. 174. See also above, p. 71 n.]

1 [Cf. Breuer's remarks on the same topic, p. 202.]

92 II. CASE HISTORIES

hypnotic suggestion (1892-36), as 'the putting into effect of
antithetic ideas'. 1 The process, as exemplified in our present
instance [p. 54], would be as follows. Our hysterical patient,
exhausted by worry and long hours of watching by the bedside
of her sick child which had at last fallen asleep, said to herself:
'Now you must be perfectly still so as not to awaken the child.'
This intention probably gave rise to an antithetic idea in the
form of a fear that she might make a noise all the same that
would wake the child from the sleep which she had so long
hoped for. Similar antithetic ideas arise in us in a marked
manner when we feel uncertain whether we can carry out
some important intention.

Neurotics, in whose self-feeling we seldom fail to find a
strain of depression or anxious expectation, form greater
numbers of these antithetic ideas than normal people, or per-
ceive them more easily; and they regard them as of more
importance. In our patient's state of exhaustion the antithetic
idea, which was normally rejected, proved itself the stronger.
It is this idea which put itself into effect and which, to the
patient's horror, actually produced the noise she dreaded. In
order to explain the whole process it may further be assumed
that her exhaustion was only a partial one; it affected, to use
the terminology of Janet and his followers, only her 'primary 5
ego and did not result in a weakening of the antithetic idea as
well.

It may further be assumed that it was her horror at the noise
produced against her will that made the moment a traumatic
one, and fixed the noise itself as a somatic mnemic symptom 2
of the whole scene. I believe, indeed, that the character of the
tic itself, consisting as it did of a succession of sounds which
were convulsively emitted and separated by pauses and which
could be best likened to clackings, reveals traces of the process
to which it owed its origin. It appears that a conflict had
occurred between her intention and the antithetic idea (the
counter-will) and that this gave the tic its discontinuous
character and confined the antithetic idea to paths other than

1 [The concept of antithetic ideas, as well as that of 'counter-will',
which is mentioned just below, was discussed in this same paper.]

2 ['Symptom 9 in all the German editions. It seems probable that this is
a misprint for 'Symbol*. * Mnemic symbol' appears to give the better
sense and is the term used throughout the book. (See footnote, p. 90.)]

(2) FRAU EMMY VON N. (FREUD) 93

the habitual ones for innervating the muscular apparatus of
speech.

The patient's spastic inhibition of speech, her peculiar
stammer, was the residue of an essentially similar exciting
cause [p. 58], Here, however, it was not the outcome of the final
innervation the exclamation but the process of innervation
itself the attempted convulsive inhibition of the organs of
speech which was made into a symbol of the event for her
memory.

These two symptoms, the clacking and the stammering,
which were thus closely related through the history of their
origin, continued to be associated and were turned into chronic
symptoms after being repeated on a similar occasion. There-
after they were put to a further use. Having originated at a
moment of violent fright, they were thenceforward joined to
an? fright (in accordance with the mechanism of monosympto-
matic hysteria which will be described in Case 5 [p. 149 f.]),
even when the fright could not lead to an antithetic idea being
put into effect.

The two symptoms were eventually linked up with so many
traumas, had so much reason for being reproduced in memory,
that they perpetually interrupted the patient's speech for no
particular cause, in the manner of a meaningless tic. 1 Hypnotic
analysis, however, was able to demonstrate how much meaning
lay concealed behind this apparent tic; and if the Breuer pro-
cedure did not succeed in this case in getting rid of the two
symptoms completely at a single blow, that was because the
catharsis had extended only to the three principal traumas and
not to the secondarily associated ones. 2

1 [Scarcely any references to tic occur in Freud's later writings. In a
paper on the subject, Ferenczi (1921) writes: Trofessor Freud, whom
I had occasion to question on the meaning and significance of tic,
suggested that some organic factor might be at work in it.']

2 I may here be giving an impression of laying too much emphasis
on the details of the symptoms and of becoming lost in an unnecessary
maze of sign-reading. But I have come to learn that the determination
of hysterical symptoms does in fact extend to their subtlest manifesta-
tions and that it is difficult to attribute too much sense to them. Let me
give an example to justify this statement. Some months ago I had under
my treatment an eighteen-year-old girl belonging to a family with a
bad heredity. Hysteria played its full part in her complex neurosis. The
first thing I heard from her was a complaint that she suffered from
attacks of despair of two varieties. In one variety she felt drawing and

94 II. CASE HISTORIES

In accordance with the rules governing hysterical attacks,
the exclamation of 'Emmy' during her attacks of confusion re-
produced, it will be remembered, her frequent states of helpless-
ness during her daughter's treatment. This exclamation was
linked to the content of the attack by a complex train of thought
and was in the nature of a protective formula against the
attack. The exclamation would probably, through a more ex-
tended application of its meaning, have degenerated into a tic,
as had in fact already happened in the case of the complicated
protective formula 'Don't touch me', etc. In both these in-
stances hypnotic treatment prevented any further development
of the symptoms; but the exclamation 'Emmy' had only just

pricking sensations in the lower part of her face, from her cheeks down
towards her mouth; in the other variety the toes of both her feet were
stretched out convulsively and kept on wriggling about. To begin with
I myself was unwilling to attach much importance to these details, and
there can be no doubt that earlier students of hysteria would have been
inclined to regard these phenomena as evidence of the stimulation of
cortical centres during a hysterical attack. It is true that we are ignorant
of the locality of the centres for paraesthesias of this kind, but it is well
known that such paraesthesias usher in partial epilepsy and constitute
Charcot's sensory epilepsy. Symmetrical cortical areas in the immediate
vicinity of the median fissure might be held responsible for the move-
ment of the toes. But the explanation turned out to be a different one.
When I had come to know the girl better I put a straight question to
her as to what kind of thoughts came to her during these attacks. I
told her not to be embarrassed and said that she must be able to give an
explanation of the two phenomena. The patient turned red with shame,
but I was able to persuade her in the end, without using hypnosis, to
give the following account, the truth of which was fully confirmed by
her companion, who was present at the time. From the time when her
periods first set in she had suffered for years from cephalalgia adolescen-
tium which had made any regular occupation impossible and had in-
terfered with her education. When at last she was freed from this
disability, this ambitious and rather simple-minded child was deter-
mined to work extremely hard at her own improvement, so as to catch
up once more with her sisters and contemporaries. In doing so she made
quite unreasonable efforts, and an effort of this kind usually ended in
an outburst of despair at having over-estimated her powers. She also,
of course, compared herself with other girls physically and felt unhappy
when she discovered some physical disadvantage in herself. Her teeth
projected noticeably, and she began to feel upset about this. She got the
idea of correcting the defect by practising for a quarter of an hour at a
time pulling down her upper lip over the projecting teeth. The failure
of these childish efforts once led to a fit of despair; and thenceforward
the drawing and pricking sensations from the cheek downwards were

(2) FRAU EMMY VON N. (FREUD) 95

come into existence, and I caught it while it was still on its
native soil, restricted to attacks of confusion.

As we have seen, these motor symptoms originated in various
ways: by putting an antithetic idea into effect (as in the clack-
ing), by a simple conversion of psychical excitation into motor
activity (as in the stammering), or by a voluntary action during
a hysterical paroxysm (as in the protective measures exemplified
by the exclamation 'Emmy' and the longer formula). But how-
ever these motor symptoms may have originated, they all have
one thing in common. They can be shown to have an original
or long-standing connection with traumas, and stand as sym-
bols for them in the activities of the memory.

established as the content of one of her two varieties of attack. The
origin of the other variety with its motor symptoms of stretching out
and wriggling the toes was no less easily found. I was told that her
first attack of this kind followed after an excursion on the Schafberg
near Ischl [in Upper Austria] , and her relatives were naturally inclined
to set it down to over-exertion. But the girl herself told me a different
story. It seems that it was a favourite habit of the sisters to tease one
another about the large size of their feet an undeniable fact. The
patient had long felt unhappy over this blemish and tried to force her
feet into the tightest possible boots. Her observant father, however,
would not allow this and saw to it that she only wore comfortably-fitting
footgear. She was much dissatisfied with this regulation. She thought
about it all the time and acquired the habit of wriggling her toes about
in her shoes, as people do when they want to discover whether a shoe is
much too large, how much smaller a size they could take, etc. During
the excursion on the Schafberg (which she was far from finding an
exertion) there was once again, of course, an opportunity for her atten-
tion to be drawn to the subject of shoes, in view of the shortened skirts
she wore. One of her sisters said to her in the course of the walk: 'You've
put extra big shoes on to-day.' She experimented by wriggling her toes
and got the same impression. Thenceforward she could not escape from
her agitation about the unlucky size of her feet, and when they got back
from the walk her first attack came on; her toes curled up and moved
about involuntarily as a mnemic symbol of the whole depressing train
of thought.

I may point out that what we are dealing with here are attacks and
not chronic symptoms. I may also add that after the patient's confession
her first variety of symptoms ceased, but the second variety her attacks
of wriggling her toes persisted. There must therefore have been some-
thing left over, which she had not confessed.

Postscript [in all editions] . I learnt later that the reason why the foolish
girl worked so hard at beautifying herself was that she wanted to attract
a young cousin of hers. [Added 1924:] Some years later her neurosis
turned into a dementia praecox.

96 II. CASE HISTORIES

Others of the patient's somatic symptoms were not of a
hysterical nature at all. This is true, for example, of the neck-
cramps, which I regard as a modified form of migraine
[p. 71 n.] and which as such are not to be classed as a neurosis
but as an organic disorder. Hysterical symptoms, however,
regularly become attached to these. Frau von N.'s neck-cramps,
for instance, were employed for the purpose of hysterical
attacks, whereas she did not have the typical symptomatology
of hysterical attacks at her disposal.

I will amplify this description of Frau von N.'s psychical state
by considering the pathological changes of consciousness which
could be observed in her. Like her neck-cramps, distressing
present-day events (cf. her last delirium in the garden [p. 73])
or anything which powerfully recalled any of her traumas
brought her into a state of delirium. In such states and the
few observations I made led me to no other conclusion there
was a limitation of consciousness and a compulsion to associate
similar to that prevailing in dreams [p. 69 n.] ; hallucinations
and illusions were facilitated to the highest degree and feeble-
minded or even nonsensical inferences were made. This state,
which was comparable to one of hallucinatory alienation,
probably represented an attack. It might be regarded as an
acute psychosis (serving as the equivalent of an attack) which
would be classified as a condition of 'hallucinatory confusion'.
A further resemblance between such states of hers and a typical
hysterical attack was shown by the fact that a portion of the
old-established traumatic memories could usually be detected
underlying the delirium. The transition from a normal state to
a delirium often occurred quite imperceptibly. She would be
talking quite rationally at one moment about matters of small
emotional importance, and as her conversation passed on to
ideas of a distressing kind I would notice, from her exaggerated
gestures or the appearance of her regular formulas of speech,
etc., that she was in a state of delirium. At the beginning of the
treatment the delirium lasted all day long; so that it was difficult
to decide with certainty whether any given symptoms like her
gestures formed part of her psychical state merely as symp-
toms of an attack, or whether like the clacking and stammering
they had become genuine chronic symptoms. It was often
only possible after the event to distinguish between what had
happened in a delirium and what had happened in her normal

(2) FRAU EMMY VON N. (FREUD) 97

state. For the two states were separated in her memory, and
she would sometimes be highly astonished to hear of the things
which the delirium had introduced piecemeal into her normal
conversation. My very first interview with her was the most
remarkable instance of the way in which the two states were
interwoven without paying any attention to each other. Only
at one moment of this psychical see-sawing did it happen that
her normal consciousness, in touch with the present day, was
affected. This was when she gave me an answer which origin-
ated from her delirium and said she was 'a woman dating from
last century' [p. 52 n.].

The analysis of these states of delirium in Frau von N. was
not exhaustively carried out. This was mainly because her
condition improved so rapidly that the deliria became sharply
differentiated from her normal life and were restricted to the
periods of her neck-cramps. On the other hand, I gathered a
great deal of information about the patient's behaviour in a
third state, that of artificial somnambulism. Whereas in her
normal state she had no knowledge of the psychical experiences
during her deliria and during her somnambulism, she had
access during somnambulism to the memories of all three
states. In point of fact, therefore, she was at her most normal
in the state of somnambulism. Indeed, if I leave on one side the
fact that in somnambulism she was far less reserved with me
than she was at her best moments in ordinary life that is, that
in somnambulism she gave me information about her family
and such things, while at other times she treated me as a
stranger and if, further, I disregard the fact that she ex-
hibited the full degree of suggestibility characteristic of som-
nambulism, I am bound to say that during her somnambulism
she was in a completely normal state. It was interesting to
notice that on the other hand her somnambulism showed no
trace of being super-normal, but was subject to all the mental
failings that we are accustomed to associate with a normal state
of consciousness.

The examples which follow throw light on the behaviour of
her memory in somnambulism. In conversation one day she
expressed her delight at the beauty of a plant in a pot which
decorated the entrance hall of the nursing-home. 'But what is
its name, doctor? Do you know? I used to know its German and
its Latin names, but I've forgotten them both.' She had a wide

98 II. CASE HISTORIES

knowledge of plants, while I was obliged on this occasion to
admit my lack of botanical education. A few minutes later I
asked her under hypnosis if she now knew the name of the plant
in the hall. Without any hesitation she replied: 'The German
name is "Turkenlilie" [Turk's-cap lily]; I really have forgotten
the Latin one.' Another time, when she was feeling in good
health, she told me of a visit she had paid to the Roman
Catacombs, but could not recall two technical terms; nor could
I help her with them. Immediately afterwards I asked her under
hypnosis which words she had in mind. But she did not know
them in hypnosis either. So I said to her: 'Don't bother about
them any more now, but when you are in the garden to-morrow
between five and six in the afternoon nearer six than five
they will suddenly occur to you.' Next evening, while we were
talking about something which had no connection with cata-
combs, she suddenly burst out: ' "Crypt", doctor, and "Colum-
barium". 3 'Ah! those are the words you couldn't think of
yesterday. When did they occur to you?' 'In the garden this
afternoon just before I went up to my room.' I saw that she
wanted to let me know in this way that she had followed out
my instructions as to time exactly, as she was in the habit of
leaving the garden at about six o'clock.

Thus we see that even in somnambulism she did not have
access to the whole extent of her knowledge. Even in that state
there was an actual and a potential consciousness. It used often
to happen that when I asked her during her somnambulism
where this or that phenomenon was derived from, she would
wrinkle her forehead, and after a pause would answer in a
deprecatory tone: 'I don't know.' On such occasions I had
made it my practice to say: 'Think a moment; it will come to
mind directly'; and after a short reflection she would be able
to give me the desired information. But it sometimes happened
that nothing came to her mind and that I was obliged to leave
her with the task of remembering it by the next day; and this
never failed to occur.

In her ordinary life Frau von N. scrupulously avoided any
un truthfulness, nor did she ever lie to me under hypnosis.
Occasionally, however, she would give me incomplete answers
and keep back part of her story until I insisted a second time
on her completing it. It was usually as in the instance quoted
on p. 79 the distaste inspired by the topic which closed her

(2) FRAU EMMY VON N. (FREUD) 99

mouth in somnambulism no less than in ordinary life. Never-
theless, in spite of these restrictive traits, the impression made
by her mental behaviour during somnambulism was, on the
whole, one of an uninhibited unfolding of her mental powers
and of a full command over her store of memories.

Though it cannot be denied that in a state of somnambulism
she was highly suggestible, she was far from exhibiting a path-
ological absence of resistance. It can be asserted on the whole
that I did not make more impression on her in that state than
I might have expected to do if I were making an investigation
of this kind into the psychical mechanisms of someone in full
possession of his faculties who put complete confidence in what
I said. The only difference was that Frau von N. was unable,
in what passed as her normal state, to meet me with any such
favourable mental attitude. If, as with her animal phobia, I
failed to give her convincing reasons, or did not go into the
psychical history of the origin of a symptom but tried to operate
by the agency of authoritative suggestion, I invariably observed
a strained and dissatisfied expression on her face; and when, at
the end of the hypnosis, I asked her whether she would still be
afraid of the animal, she would answer: 'No since you insist.'
A promise like this, based only on her obedience to me, never
met with any success, any more than did the many general in-
junctions which I laid upon her, instead of which I might just
as well have repeated the single suggestion that she should get
well.

But this same person who clung so obstinately to her symp-
toms in the face of suggestion and would only abandon them
in response to psychical analysis or personal conviction, was on
the other hand as amenable as the best medium to be found in
any hospital, so far as irrelevant suggestions were concerned
so far as it was a question of matters not connected with her
illness. I have given instances of her post-hypnotic obedience
in the course of the case history. There does not seem to me to
be anything contradictory in this behaviour. Here, too, the
stronger idea was bound to assert itself. If we go into the
mechanism of 'idees fixes", we find that they are based upon and
supported by so many experiences operating with such intensity
that we cannot be surprised to find that these ideas are able to
put up a successful resistance against the opposing idea brought
forward by suggestion, which is clothed with only limited powers.

100 II. CASE HISTORIES

It would have to be a truly pathological brain from which it
was possible to blow away by mere suggestion such well-
founded products of intense psychical events. 1

1 I have been deeply impressed in another of my patients by this
interesting contrast during somnambulism between a most far-reaching
obedience in everything unconnected with the symptoms and the
obstinacy with which those symptoms persist because they are deeply
rooted and inaccessible to analysis. A lively and gifted girl, who had
suffered for eighteen months from severe disturbances of her power of
walking, was under my treatment for more than five months without
my being able to help her. She was analgesic and had painful areas in
both legs and a rapid tremor in her hands. She walked bent forward,
dragging her legs and with short steps; she staggered as though she was
a cerebellar case and, indeed, often fell down. Her temperament was
strikingly cheerful. One of the leading authorities in Vienna at the time
was misled by this syndrome into diagnosing her case as one of multiple
sclerosis. Another specialist recognized her as a hysteric a diagnosis
which was supported by the complicated picture presented by the
disease in its beginnings (pains, fainting-fits, amaurosis) and handed
her on to me for treatment. I tried to improve her gait by suggestion,
manipulation of her legs under hypnosis, etc., but I had no success in
spite of her being an excellent subject for somnambulism. One day, after
she once more came tottering into the room, one arm supported on her
father's, the other on an umbrella whose tip was already much worn
down, I lost patience and shouted at her in her hypnosis: 'This has gone
on too long. To-morrow morning that umbrella of yours will break in
your hands and you'll have to walk without it, and from that time on
you will never need an umbrella again.' I cannot imagine how I came
to be so foolish as to give a suggestion to an umbrella. Afterwards I
felt ashamed of myself, and did not suspect that my clever patient
would save my reputation in the eyes of her father, who was a physician
and was present during her hypnoses. Next day her father said to me:
'What do you think she did yesterday? We were walking along the
Ringstrasse [the main boulevard in Vienna] when she suddenly got into
the highest spirits. She began singing in the very middle of the street
"Ein freies Leben fiihren wir" ['We live a free life', from the popularly-
sung robbers' chorus in Schiller's play, Die Rduber] and beat time on the
pavement with her umbrella and broke it.' Of course she herself had no
notion that she had wittily transformed a nonsensical suggestion into
a brilliantly successful one. Since her condition was not improved by
assurances, commands and treatment under hypnosis, I turned to
psychical analysis and requested her to tell me what emotion had pre-
ceded the onset of her illness. She answered (under hypnosis but without
any signs of feeling) that a short time previously a young relative of hers
had died to whom she had for many years considered herself engaged.
This piece of information, however, produced no alteration whatever
in her condition. Accordingly, during her next hypnosis, I told her I was
quite convinced that her cousin's death had had nothing at all to do

(2) FRAU EMMY VON N. (FREUD) 101

It was while I was studying Frau von N.'s abulias that I
began for the first time to have grave doubts about the validity
of Bernheim's assertion, 'tout est dans la suggestion 9 ['suggestion
is everything'] and about his clever friend Delboeuf 's inference:
'Comme quoi il rfy a pas d'hypnotismi ['That being so, there is no
such thing as hypnotism']. And to this day I cannot understand
how it can be supposed that by merely holding up a finger
and saying once 'go to sleep' I had created in the patient the
peculiar psychical state in which her memory had access to all
her psychical experiences. I may have called up the state by my
suggestion but I did not create it, since its features which are,
incidentally, found universally came as such a surprise to me.

The case history makes sufficiently plain the way in which
therapeutic work was carried out during somnambulism. As is
the usual practice in hypnotic psychotherapy, I fought against
the patient's pathological ideas by means of assurances and pro-
hibitions, and by putting forward opposing ideas of every sort.
But I did not content myself with this. I investigated the genesis
of the individual symptoms so as to be able to combat the
premises on which the pathological ideas were erected. In the
course of such an analysis it habitually happened that the
patient gave verbal utterance with the most violent agitation
to matters whose accompanying affect had hitherto only found
outlet as an expression of emotion. [Cf. p. 91.] I cannot say how
much of the therapeutic success each time was due to my suggest-
ing the symptom away in statu nascendi and how much to my
resolving the affect by abreaction, since I combined both these
therapeutic factors. Accordingly, this case cannot strictly be
used as evidence for the therapeutic efficacy of the cathartic
procedure; at the same time I must add that only those symp-
toms of which I carried out a psychical analysis were really
permanently removed.

The therapeutic success on the whole was considerable; but
it was not a lasting one. The patient's tendency to fall ill in a
similar way under the impact of fresh traumas was not got rid

with her state, but that something else had happened which she had
not mentioned. At this she gave way to the extent of letting fall a single
significant phrase; but she had hardly said a word before she stopped,
and her old father, who was sitting behind her, began to sob bitterly.
Naturally I pressed my investigation no further; but I never saw the
patient again.

102 II. CASE HISTORIES

of. Anyone who wanted to undertake the definitive cure of a
case of hysteria such as this would have to enter more thoroughly
into the complex of phenomena than I attempted to do. Frau
von N. was undoubtedly a personality with a severe neuro-
pathic heredity. It seems likely that there can be no hysteria
apart from a disposition of this kind. But on the other hand
disposition alone does not make hysteria. There must be reasons
that bring it about, and, in my opinion, these reasons must be
appropriate: the aetiology is of a specific character. I have
already mentioned that in Frau von N. the affects of a great
number of traumatic experiences had been retained and that
the lively activity of her memory brought now one and now
another of these traumas to the surface of her mind. I shall now
venture to put forward an explanation of the reason why she
retained the affects in this way. That reason, it is true, was con-
nected with her hereditary disposition. For, on the one hand,
her feelings were very intense; she was of a vehement nature,
capable of the strongest passions. On the other hand, since her
husband's death, she had lived in complete mental solitude;
her persecution by her relatives had made her suspicious of
friends and she was jealously on guard against anyone acquiring
too much influence over her actions. The circle of her duties
was very wide, and she performed the whole of the mental work
which they imposed on her by herself, without a friend or
confidant, almost isolated from her family and handicapped by
her conscientiousness, her tendency to tormenting herself and
often, too, by the natural helplessness of a woman. In short the
mechanism of the retention of large sums of excitation, apart from
everything else, cannot be overlooked in this case. It was based
partly on the circumstances of her life and partly on her natural
disposition. Her dislike, for instance, of saying anything about
herself was so great, that, as I noticed to my astonishment in
1891, none of the daily visitors to her house recognized that she
was ill or were aware that I was her doctor.

Does this exhaust the aetiology of this case of hysteria? I do
not think so. For at the time of her two treatments I had not
yet raised in my own mind the questions which must be an-
swered before an exhaustive explanation of such a case is
possible. I am now of the opinion that there must have been
some added factor to provoke the outbreak of illness precisely
in these last years, considering that operative aetiological con-

(2) FRAU EMMY VON N. (FREUD) 103

ditions had been present for many years previously. It has also
struck me that amongst all the intimate information given me
by the patient there was a complete absence of the sexual
element, which is, after all, more liable than any other to
provide occasion for traumas. It is impossible that her excita-
tions in this field can have left no traces whatever; what I was
allowed to hear was no doubt an editio in usum delphini [a
bowdlerized edition] of her life-story. The patient behaved with
the greatest and to all appearances with the most unforced sense
of propriety, without a trace of prudishness. When, however, I
reflect on the reserve with which she told me under hypnosis
about her maid's little adventure in the hotel, I cannot help
suspecting that this woman who was so passionate and so
capable of strong feelings had not won her victory over her
sexual needs without severe struggles, and that at times her
attempts at suppressing this most powerful of all instincts had
exposed her to severe mental exhaustion. She once admitted
to me that she had not married again because, in view of her
large fortune, she could not credit the disinterestedness of her
suitors and because she would have reproached herself for
damaging the prospects of her two children by a new marriage.
I must make one further remark before bringing Frau von N.'s
case history to a close. Dr. Breuer and I knew her pretty well
and for a fairly long time, and we used to smile when we com-
pared her character with the picture of the hysterical psyche
which can be traced from early times through the writings
and the opinions of medical men. We had learnt 1 from our
observations on Frau Cacilie M. that hysteria of the severest
type can exist in conjunction with gifts of the richest and most
original kind a conclusion which is, in any case, made plain
beyond a doubt in the biographies of women eminent in history
and literature. In the same way Frau Emmy von N. gave us an
example of how hysteria is compatible with an unblemished
character and a well-governed mode of life. The woman we
came to know was an admirable one. The moral seriousness
with which she viewed her duties, her intelligence and energy,
which were no less than a man's, and her high degree of educa-
tion and love of truth impressed both of us greatly; while her
benevolent care for the welfare of all her dependents, her
humility of mind and the refinement of her manners revealed
1 [See Editor's Introduction, p. xi n.]

104 II. CASE HISTORIES

her qualities as a true lady as well. To describe such a woman
as a 'degenerate' would be to distort the meaning of that word
out of all recognition. We should do well to distinguish between
the concepts of 'disposition' and 'degeneracy' as applied to
people; otherwise we shall find ourselves forced to admit that
humanity owes a large proportion of its great achievements to
the efforts of 'degenerates'.

I must confess, too, that I can see no sign in Frau von N.'s
history of the 'psychical inefficiency' l to which Janet attributes
the genesis of hysteria. According to him the hysterical dis-
position consists in an abnormal restriction of the field of con-
sciousness (due to hereditary degeneracy) which results in a
disregard of whole groups of ideas and, later, to a disintegration
of the ego and the organization of secondary personalities. If
this were so, what remains of the ego after the withdrawal of
the hysterically-organized psychical groups would necessarily
also be less efficient than a normal ego; and in fact, accord-
ing to Janet, the ego in hysteria is afflicted by psychical stig-
mata, condemned to mono-ideism and incapable of the voli-
tional acts of ordinary life. Janet, I think, has made the mistake
here of promoting what are after-effects of changes in con-
sciousness due to hysteria to the rank of primary determinants
of hysteria. The subject is one that deserves further considera-
tion elsewhere; 2 but in Frau von N. there was no sign of any
such inefficiency. During the times of her worst states she was
and remained capable of playing her part in the management
of a large industrial business, of keeping a constant eye on the
education of her children, of carrying on her correspondence
with prominent people in the intellectual world in short, of
fulfilling her obligations well enough for the fact of her illness
to remain concealed. I am inclined to believe, then, that all this
involved a considerable excess of efficiency, which could perhaps
not be kept up in the long run and was bound to lead to ex-
haustion to a secondary 'misere psychologique* ['psychological
impoverishment']. It seems likely that disturbances of this
kind in her efficiency were beginning to make themselves felt

1 [This passage seems to be based mainly on Janet, 1 894, 300. (See
footnote p. 230.) The German phrase 'psychische Minderleistung* ', here
translated as 'psychical inefficiency', is evidently Freud's version of
Janet's 'insujfisance psychologique'.]

* [It is discussed below by Breuer on p. 231 ff.]

(2) FRAU EMMY VON N. (FREUD) 105

at the time when I first saw her; but however that may be,
severe hysteria had been present for many years before the
appearance of the symptoms of exhaustion. 1

1 (Footnote added 1924:) I am aware that no analyst can read this
case history to-day without a smile of pity. But it should be borne in
mind that this was the first case in which I employed the cathartic
procedure to a large extent. [Cf. p. 48.] For this reason I shall leave
the report in its original form. I shall not bring forward any of the
criticisms which can so easily be made on it to-day, nor shall I attempt
to fill in any of the numerous gaps in it. I will only add two things:
what I afterwards discovered about the immediate aetiology of the ill-
ness and what I heard of its subsequent course.

When, as I have mentioned, I spent a few days as Frau Emmy's
guest in her country house, there was a stranger present at one of the
meals who clearly tried to make himself agreeable. After his departure
my hostess asked me how I had liked him and added as it were in
passing: 'Only imagine, the man wants to marry me!' When I took this
in connection with some other remarks which she had made, but to
which I had not paid sufficient attention, I was led to conclude that she
was longing at that time to be married again but found an obstacle
to the realization of her purpose in the existence of her two daughters,
who were the heiresses of their father's fortune.

A few years later at a Scientific Congress I met a prominent physician
from Frau Emmy's part of the country. I asked him if he was acquainted
with the lady and knew anything of her condition. Yes, he said, he knew
her, and had himself given her hypnotic treatment. She had gone
through the same performance with him and with many other
doctors as she had with me. Her condition had become very bad; she
had rewarded his hypnotic treatment of her by making a remarkable
recovery, but had then suddenly quarrelled with him, left him, and
once more set her illness going to its full extent. It was a genuine in-
stance of the Compulsion to repeat'.

It was not for another quarter of a century that I once more had
news of Frau Emmy. Her elder daughter the one of whom I had
earlier made such an unfavourable prognosis approached me with a
request for a report on her mother's mental condition on the strength
of my former treatment of her. She was intending to take legal pro-
ceedings against her mother, whom she represented as a cruel and ruth-
less tyrant. It seems that she had broken off relations with both her
children and refused to assist them in their financial difficulties. The
daughter who wrote to me had obtained a doctor's degree and was
married.

[This case history had already been discussed briefly by Freud in his
paper on 'A Case of Successful Treatment by Hypnotism' (1892-Si),
and he made a short allusion to it in the first of his Five Lectures (1910a).]

CASE 3
Miss LUCY R., AGE 30 (Freud)

AT the end of the year 1892 a colleague of my acquaintance
referred a young lady to me who was being treated by him for
chronically recurrent suppurative rhinitis. It subsequently
turned out that the obstinate persistence of her trouble was due
to caries of the ethmoid bone. Latterly she had complained of
some new symptoms which the well-informed physician was
no longer able to attribute to a local affection. She had entirely
lost her sense of smell and was almost continuously pursued
by one or two subjective olfactory sensations. She found these
most distressing. She was, moreover, in low spirits and fatigued,
and she complained of heaviness in the head, diminished
appetite and loss of efficiency.

The young lady, who was living as a governess in the house
of the managing director of a factory in Outer Vienna, came
to visit me from time to time in my consulting hours. She was
an Englishwoman. She had a delicate constitution, with a poor
pigmentation, but was in good health apart from her nasal
affection. Her first statements confirmed what the physician
had told me. She was suffering from depression and fatigue
and was tormented by subjective sensations of smell. As regards
hysterical symptoms, she showed a fairly definite general anal-
gesia, with no loss of tactile sensibility, and a rough examination
(with the hand) revealed no restriction of the visual field. The
interior of her nose was completely analgesic and without re-
flexes; she was sensitive to tactile pressure there, but the per-
ception proper to it as a sense-organ was absent, alike for
specific stimuli and for others (e.g. ammonia or acetic acid). The
purulent nasal catarrh was just then in a phase of improvement.

In our first attempts at making the illness intelligible it was
necessary to interpret the subjective olfactory sensations, since
they were recurrent hallucinations, as chronic hysterical symp-
toms. Her depression might perhaps be the affect attaching to
the trauma, and it should be possible to find an experience in
which these smells, which had now become subjective, had
been objective. This experience must have been the trauma

106

(3) MISS LUCY R. (FREUD) 107

which the recurring sensations of smell symbolized in memory.
It might be more correct to regard the recurrent olfactory
hallucinations, together with the depression which accompanied
them, as equivalents of a hysterical attack. The nature of recur-
rent hallucinations makes them unsuitable in point of fact for
playing the part of chronic symptoms. But this question did not
really arise in a case like this which showed only a rudimentary
development. It was essential, however, that the subjective
sensations of smell should have had a specialized origin of a
sort which would admit of their being derived from some quite
particular real object.

This expectation was promptly fulfilled. When I asked her
what the smell was by which she was most constantly troubled
she answered: 'A smell of burnt pudding.' Thus I only needed
to assume that a smell of burnt pudding had actually occurred
in the experience which had operated as a trauma. It is very
unusual, no doubt, for olfactory sensations to be chosen as
mnemic symbols of traumas, but it was not difficult to account
for this choice. The patient was suffering from suppurative
rhinitis and consequently her attention was especially focused
on her nose and nasal sensations. What I knew of the circum-
stances of the patient's life was limited to the fact that the two
children whom she was looking after had no mother; she had
died some years earlier of an acute illness.

I therefore decided to make the smell of burnt pudding the
starting-point of the analysis. I will describe the course of this
analysis as it might have taken place under favourable condi-
tions. In fact, what should have been a single session spread
over several. This was because the patient could only visit me
in my consulting hours, when I could only devote a short time
to her. Moreover, a single discussion of this sort used to extend
over more than a week, since her duties would not allow her
to make the long journey from the factory to my house very
often. We used therefore to break our conversation off short and
take up the thread at the same place next time.

Miss Lucy R. did not fall into a state of somnambulism when
I tried to hypnotize her. I therefore did without somnambulism
and conducted her whole analysis while she was in a state
which may in fact have differed very little from a normal one.

I shall have to go into this point of my technical procedure

108 II. CASE HISTORIES

in greater detail. When, in 1889, I visited the Nancy clinics,
I heard Dr. Liebeault, the doyen of hypnotism, say : 'If only
we had the means of putting every patient into a state of som-
nambulism, hypnotic therapy would be the most powerful of
all.' In Bernheim's clinic it almost seemed as though such an
art really existed and as though it might be possible to learn it
from Bernheim. But as soon as I tried to practise this art on
my own patients, I discovered that my powers at least were
subject to severe limits, and that if somnambulism were not
brought about in a patient at the first three attempts I had no
means of inducing it. The percentage of cases amenable to
somnambulism was very much lower in my experience than
what Bernheim reported.

I was accordingly faced with the choice of either abandoning
the cathartic method in most of the cases which might have
been suitable for it, or of venturing on the experiment of
employing that method without somnambulism and where the
hypnotic influence was light or even where its existence was
doubtful. It seemed to me a matter of indifference what degree
of hypnosis according to one or other of the scales that have
been proposed for measuring it was reached by this non-
somnambulistic state; for, as we know, each of the various
forms taken by suggestibility is in any case independent of the
others, and the bringing about of catalepsy, automatic move-
ments, and so on, does not work either for or against what I
required for my purposes, namely that the awakening of for-
gotten memories should be made easier. Moreover, I soon
dropped the practice of making tests to show the degree of
hypnosis reached, since in quite a number of cases this roused
the patients' resistance and shook their confidence in me, which
I needed for carrying out the more important psychical work.
Furthermore, I soon began to tire of issuing assurances and
commands such as: 'You are going to sleep! . . . sleep!' and of
hearing the patient, as so often happened when the degree of
hypnosis was light, remonstrate with me: 'But, doctor, I'm not
asleep', and of then having to make highly ticklish distinctions:
'I don't mean ordinary sleep; I mean hypnosis. As you see,
you are hypnotized, you can't open your eyes', etc., 'and in any
case, there's no need for you to go to sleep', and so on. I feel
sure that many other physicians who practise psychotherapy
can get out of such difficulties with more skill than I can. If so,

(3) MISS LUCY R. (FREUD) 109

they may adopt some procedure other than mine. It seems to
me, however, that if one can reckon with such frequency on
finding oneself in an embarrassing situation through the use
of a particular word, one will be wise to avoid both the word
and the embarrassment. When, therefore, my first attempt did
not lead either to somnambulism or to a degree of hypnosis
involving marked physical changes, I ostensibly dropped
hypnosis, and only asked for 'concentration 5 ; and I ordered the
patient to lie down and deliberately shut his eyes as a means of
achieving this 'concentration 5 . It is possible that in this way I
obtained with only a slight effort the deepest degree of hypnosis
that could be reached in the particular case.

But in doing without somnambulism I might be depriving
myself of a precondition without which the cathartic method
seemed unusable. For that method clearly rested on the patients
in their changed state of consciousness having access to memories
and being able to recognize connections which appeared not
to be present in their normal state of consciousness. If the
somnambulistic extension of memory were absent there could
also be no possibility of establishing any determining causes
which the patient could present to the physician as something
unknown to him (the patient) ; and, of course, it is precisely
the pathogenic memories which, as we have already said in
our 'Preliminary Communication 5 [p. 9] are 'absent from
the patients 5 memory, when they are in a normal psychical
state, or are only present in a highly summary form 5 .

I was saved from this new embarrassment by remembering
that I had myself seen Bernheim producing evidence that the
memories of events during somnambulism are only apparently
forgotten in the waking state and can be revived by a mild
word of command and a pressure with the hand intended
to indicate a different state of consciousness. He had, for in-
stance, given a woman in a state of somnambulism a negative
hallucination to the effect that he was no longer present, and
had then endeavoured to draw her attention to himself in a
great variety of ways, including some of a decidedly aggressive
kind. He did not succeed. After she had been woken up he
asked her to tell him what he had done to her while she thought
he was not there. She replied in surprise that she knew nothing
of it. But he did not accept this. He insisted that she could
remember everything and laid his hand on her forehead to

110 II. CASE HISTORIES

help her to recall it. And lo and behold! she ended by describing
everything that she had ostensibly not perceived during her
somnambulism and ostensibly not remembered in her waking
state.

This astonishing and instructive experiment served as my
model. I decided to start from the assumption that my patients
knew everything that was of any pathogenic significance and
that it was only a question of obliging them to communicate
it. Thus when I reached a point at which, after asking a patient
some question such as: 'How long have you had this symptom? 1
or: 'What was its origin?', I was met with the answer: 'I really
don't know', I proceeded as follows. I placed my hand on the
patient's forehead or took her head between my hands and
said: 'You will think of it under the pressure of my hand. At
the moment at which I relax my pressure you will see some-
thing in front of you or something will come into your head.
Catch hold of it. It will be what we are looking for. Well,
what have you seen or what has occurred to you?'

On the first occasions on which I made use of this procedure
(it was not with Miss Lucy R. 1 ) I myself was surprised to find

1 [Freud's first use of the 'pressure technique' seems to have been
with Fraulein Elisabeth von R. (see below, p. 145), though his statement
there is not completely unambiguous. Further accounts of this pro-
cedure, in addition to those in the text above and in the passage just
referred to, will be found on pp. 155 f. and 270 ff. There is a slight
apparent inconsistency in these accounts. In the present one, the patient
is told that she will see something or have some idea 'at the moment
at which I relax my pressure'; on p. 145, she is told that this will occur
'at the moment of the pressure'; and on p. 270 that it will occur 'all the
time the pressure lasts'. It is not known exactly when Freud abandoned
this pressure technique. He had certainly done so before 1904, since in
his contribution of that date to Loewenfeld's book on obsessions he
explicitly remarks that he avoids touching his patients in any way
(1904<z, Standard Ed., 7, 250). But it seems likely that he had already
given up the practice before 1900, for he makes no mention of it in the
short account of his procedure given near the beginning of Chapter II
of The Interpretation of Dreams (19000), Standard Ed., 4, 101. Incidentally,
in this latter passage Freud still recommends that the patient should
keep his eyes shut during analysis. This last remnant (apart from lying
down) of the original hypnotic procedure was also explicitly disrecom-
mended in the sentence already quoted from his contribution to
Loewenfeld (1904a). We have fairly exact information upon the
period of Freud's use of hypnotism proper. In a letter to Fliess of
December 28, 1887 (Freud, 1950a, Letter 2) he wrote: 'During the last

(3) MISS LUCY R. (FREUD) 111

that it yielded me the precise results that I needed. And I can
safely say that it has scarcely ever left me in the lurch since
then. It has always pointed the way which the analysis should
take and has enabled me to carry through every such analysis
to an end without the use of somnambulism. Eventually I
grew so confident that, if patients answered, 'I see nothing' or
'nothing has occurred to me', I could dismiss this as an impos-
sibility and could assure them that they had certainly become
aware of what was wanted but had refused to believe that that
was so and had rejected it. I told them I was ready to repeat
the procedure as often as they liked and they would see the
same thing every time. I turned out to be invariably right.
The patients had not yet learned to relax their critical faculty.
They had rejected the memory that had come up or the idea
that had occurred to them, on the ground that it was unservice-
able and an irrelevant interruption; and after they had told it
to me it always proved to be what was wanted. Occasionally,
when, after three or four pressures, I had at last extracted the
information, the patient would reply: 'As a matter of fact I
knew that the first time, but it was just what I didn't want to
say', or: 'I hoped that would not be it.'

This business of enlarging what was supposed to be a re-
stricted consciousness was laborious far more so, at least,
than an investigation during somnambulism. But it never-
theless made me independent of somnambulism, and gave
me insight into the motives which often determine the 'for-
getting' of memories. I can affirm that this forgetting is often
intentional and desired; and its success is never more than
apparent.

I found it even more surprising perhaps that it was possible
by the same procedure to bring back numbers and dates which,
on the face of it, had long since been forgotten, and so to reveal
how unexpectedly accurate memory can be.

The fact that in looking for numbers and dates our choice is
so limited enables us to call to our help a proposition familiar

few weeks I have taken up hypnosis.' And in a lecture given before the
Vienna 'Medizinisches Doktorencollegium' on December 12, 1904
(Freud, 1905a, Standard Ed., 7, 260) he declared: 'I have not used
hypnosis for therapeutic purposes for some eight years (except for a few
special experiments).' His use of hypnotism therefore fell approximately
between the years 1887 and 1896.]

112 II. CASE HISTORIES

to us from the theory of aphasia, namely that recognizing
something is a lighter task for memory than thinking of it
spontaneously. 1 Thus, if a patient is unable to remember the
year or month or day when a particular event occurred, we
can repeat to him the dates of the possibly relevant years, the
names of the twelve months and the thirty-one numbers of the
days of the month, assuring him that when we come to the
right number or the right name his eyes will open of their own
accord or that he will feel which is the right one. In the great
majority of cases the patient will in fact decide on a particular
date. Quite often (as in the case of Frau Cacilie M.) it is
possible to prove from documents belonging to the period in
question that the date has been recognized correctly; while in
other cases and on other occasions the indisputable accuracy
of the date thus chosen can be inferred from the context of the
facts remembered. For instance, after a patient had had her
attention drawn to the date which had been arrived at by this
Counting over 5 method, she said: 'Why, that's my father's
birthday!' and added: 'Of course! It was because it was his
birthday that I was expecting the event we were talking about.'
Here I can only touch upon the theme in passing. The con-
clusion I drew from all these observations was that experiences
which have played an important pathogenic part, and all their
subsidiary concomitants, are accurately retained in the patient's
memory even when they seem to be forgotten when he is un-
able to call them to mind. 2

After this long but unavoidable digression I will return to

1 [Freud had written his book on aphasia (1891 b) not long before.]

2 As an example of the technique which I have described above of
carrying out investigations in non-somnambulistic states that is, where
there is no extension of consciousness I will describe an instance which
I happen to have analysed in the course of the last few days. I was
treating a woman of thirty-eight, suffering from anxiety neurosis
(agoraphobia, attacks of fear of death, etc.). Like so many such patients,
she had a disinclination to admitting that she had acquired these
troubles in her married life and would have liked to push them back
into her early youth. Thus she told me that she was seventeen when she
had had a first attack of dizziness, with anxiety and feelings of faintness,
in the street in her small native town, and that these attacks had re-
curred from time to time, till a few years ago they had given place to
her present disorder. I suspected that these first attacks of dizziness, in
which the anxiety faded more and more into the background, were

(3) MISS LUCY R. (FREUD) 113

the case of Miss Lucy R. As I have said, then, my attempts at
hypnosis with her did not produce somnambulism. She simply
lay quietly in a state open to some mild degree of influence,
with her eyes closed all the time, her features somewhat rigid,

hysterical and I made up my mind to embark on an analysis of them.
To begin with she only knew that this first attack came over her while
she was out shopping in the principal street. 'What were you going to
buy?' 'Different things, I believe; they were for a ball I had been
invited to.' 'When was this ball to take place?' Two days later, I
think.' 'Something must have happened to agitate you a few days
before, something that made an impression on you.' 'I can't think of
anything. After all, it was twenty-one years ago.' 'That makes no
difference; you will remember all the same. I shall press on your head,
and when I relax the pressure, you will think of something or see some-
thing, and you must tell me what that is.' I went through this procedure;
but she remained silent. 'Well, has nothing occurred to you?' 'I have
thought of something, but it can't have any connection with this.'
'Tell it to me anyway.' 'I thought of a friend of mine, a girl, who is
dead. But she died when I was eighteen a year later, that is.' 'We
shall see. Let's stick to this point. What about this friend of yours?'
'Her death was a great shock to me, as I used to see a lot of her. A few
weeks earlier another girl had died, and that had made a great stir in the
town. So after all, I must have been seventeen at the time.' 'There,
you see, I told you we could rely on the things that come into your head
under the pressure of my hand. Now, can you remember what you were
thinking about when you felt dizzy in the street?' 'I wasn't thinking
of anything; I only felt dizzy.' That's not possible. States like that
never happen without being accompanied by some idea. I shall press
once more and the thought you had will come back to you. . . . Well,
what has occurred to you?' The idea that I am the third.' 'What
does that mean?' 'When I got the attack of dizziness I must have
thought: "Now I am dying, like the other two girls." ' That was the
idea, then. As you were having the attack you thought of your friend.
So her death must have made a great impression on you.' 'Yes, it did.
I can remember now that when I heard of her death I felt it was dread-
ful to be going to a ball, while she was dead. But I was looking forward
so much to the ball and was so busy with preparations for it; I didn't
want to think of what had happened at all.' (We may observe here a
deliberate repression from consciousness, which rendered the patient's
memory of her friend pathogenic.)

The attack was now to some extent explained. But I still required to
know of some precipitating factor which had provoked the memory at
that particular time. I formed what happened to be a lucky conjecture.
'Do you remember the exact street you were walking along just then?'
'Certainly. It was the principal street, with its old houses. I can see
them now.' 'And where was it that your friend lived?' 'In a house
in the same street. I had just passed it, and I had the attack a couple of
houses further on.' 'So when you went by the house it reminded you

114 II. CASE HISTORIES

and without moving hand or foot. I asked her if she could
remember the occasion on which she first had the smell of
burnt pudding. 'Oh yes, I know exactly. It was about two
months ago, two days before my birthday. I was with the
children in the schoolroom and was playing at cooking with
them' (they were two little girls). 'A letter was brought in that
had just been left by the postman. I saw from the postmark
and the handwriting that it was from my mother in Glasgow
and wanted to open it and read it; but the children rushed at
me, tore the letter out of my hands and cried: "No, you shan't
read it now! It must be for your birthday; we'll keep it for
you!" While the children were having this game with me there
was suddenly a strong smell. They had forgotten the pudding
they were cooking and it was getting burnt. Ever since this I
have been pursued by the smell. It is there all the time and
becomes stronger when I am agitated.'

'Do you see this scene clearly before your eyes?' 'As large
as life, just as I experienced it.' 'What could there be about
it that was so agitating?' 'I was moved because the children

of your dead friend, and you were once more overcome by the contrast
which you did not want to think of.'

I was still not satisfied. There might, I thought, be something else at
work as well that had aroused or reinforced the hysterical disposition
of a girl who had till then been normal. My suspicions turned to her
monthly periods as an appropriate factor, and I asked: 'Do you know
at what time in the month your period came on?' The question was not
a welcome one. 'Do you expect me to know that, too? I can only tell you
that I had them very seldom then and very irregularly. When I was
seventeen I only had one once.' 'Very well, then, we will find out
when this once was by counting over.' I did the counting over, and she
decided definitely on one particular month and hesitated between two
days immediately preceding the date of a fixed holiday. 'Does that fit
in somehow with the date of the ball?' She answered sheepishly: 'The
ball was on the holiday. And now I remember, too, what an impression
it made on me that my only period that year should have had to come
on just before the ball. It was my first ball.'

There is no difficulty now in reconstructing the interconnection
between the events, and we can now see into the mechanism of this
hysterical attack. It is true that the achievement of this result had been
a laborious business. It required complete confidence in my technique
on my side, and the occurrence to the patient of a few key ideas, before
it was possible to re-awaken, after an interval of twenty-one years, these
details of a forgotten experience in a sceptical person who was, in fact,
in a waking state. But once all this had been gone through, the whole
thing fitted together.

(3) MISS LUCY R. (FREUD) 115

were so affectionate to me.' 'Weren't they always?' 'Yes
but just when I got the letter from my mother.' C I don't under-
stand why there is a contrast between the children's affection
and your mother's letter, for that's what you seem to be sug-
gesting.' 'I was intending to go back to my mother's, and
the thought of leaving the dear children made me feel so sad.'
'What's wrong with your mother? Has she been feeling lonely
and sent for you? Or was she ill at the time, and were you
expecting news of her?' 'No; she isn't very strong, but she's
not exactly ill, and she has a companion with her.' 'Then why
must you leave the children?' 'I couldn't bear it any longer
in the house. The housekeeper, the cook and the French
governess seem to have thought that I was putting myself above
my station. They joined in a little intrigue against me and said
all sorts of things against me to the children's grandfather, and
I didn't get as much support as I had expected from the two
gentlemen when I complained to them. So I gave notice to the
Director' (the children's father). 'He answered in a very friendly
way that I had better think the matter over for a couple of
weeks before I finally gave him my decision. I was in this state
of uncertainty at the time, and thought I should be leaving
the house; but I have stayed on.' 'Was there something par-
ticular, apart from their fondness for you, which attached you
to the children?' 'Yes. Their mother was a distant relation
of my mother's, and I had promised her on her death-bed
that I would devote myself with all my power to the children,
that I would not leave them and that I would take their
mother's place with them. In giving notice I had broken this
promise.'

This seemed to complete the analysis of the patient's sub-
jective sensation of smell. It had turned out in fact to have
been an objective sensation originally, and one which was inti-
mately associated with an experience a little scene in which
opposing affects had been in conflict with each other: her regret
at leaving the children and the slights which were nevertheless
urging her to make up her mind to do so. Her mother's letter
had not unnaturally reminded her of her reasons for this
decision, since it was her intention to join her mother on leav-
ing here. The conflict between her affects had elevated the
moment of the letter's arrival into a trauma, and the sensation
of smell that was associated with this trauma persisted as its

116 II. CASE HISTORIES

symbol. It was still necessary to explain why, out of all the
sense-perceptions afforded by the scene, she had chosen this
smell as a symbol. I was already prepared, however, to use the
chronic affection of her nose as a help in explaining the point.
In response to a direct question she told me that just at that
time she had once more been suffering from such a heavy cold
in the nose that she could hardly smell anything. Nevertheless,
while she was in her state of agitation she perceived the smell
of the burnt pudding, which broke through the organically-
determined loss of her sense of smell.

But I was not satisfied with the explanation thus arrived at.
It all sounded highly plausible, but there was something that I
missed, some adequate reason why these agitations and this
conflict of affects should have led to hysteria rather than any-
thing else. Why had not the whole thing remained on the level
of normal psychical life? In other words, what was the justi-
fication for the conversion which occurred? Why did she not
always call to mind the scene itself, instead of the associated
sensation which she singled out as a symbol of the recollection?
Such questions might be over-curious and superfluous if we
were dealing with a hysteric of long standing in whom the
mechanism of conversion was habitual. But it was not until this
trauma, or at any rate this small tale of trouble, that the girl
had acquired hysteria.

Now I already knew from the analysis of similar cases that
before hysteria can be acquired for the first time one essential
condition must be fulfilled: an idea must be intentionally re-
pressed from consciousness 1 and excluded from associative modifica-
tion. In my view this intentional repression is also the basis
for the conversion, whether total or partial, of the sum of
excitation. The sum of excitation, being cut off from psychical
association, finds its way all the more easily along the wrong
path to a somatic innervation. The basis for repression itself
can only be a feeling of unpleasure, the incompatibility between
the single idea that is to be repressed and the dominant mass
of ideas constituting the ego. The repressed idea takes its re-
venge, however, by becoming pathogenic.

I accordingly inferred from Miss Lucy R.'s having suc-
cumbed to hysterical conversion at the moment in question
that among the determinants of the trauma there must have
1 [See footnote p. 10.]

(3) MISS LUCY R. (FREUD) 117

been one which she had sought intentionally to leave in
obscurity and had made efforts to forget. If her fondness for
the children and her sensitiveness on the subject of the other
members of the household were taken together, only one con-
clusion could be reached. I was bold enough to inform my
patient of this interpretation. I said to her: 'I cannot think that
these are all the reasons for your feelings about the children.
I believe that really you are in love with your employer, the
Director, though perhaps without being aware of it yourself,
and that you have a secret hope of taking their mother's place
in actual fact. And then we must remember the sensitiveness
you now feel towards the servants, after having lived with them
peacefully for years. You're afraid of their having some inkling
of your hopes and making fun of you.'

She answered in her usual laconic fashion: 'Yes, I think
that's true.' 'But if you knew you loved your employer why
didn't you tell me?' 'I didn't know or rather I didn't want
to know. I wanted to drive it out of my head and not think of
it again; and I believe latterly I have succeeded.' l 'Why was
it that you were unwilling to admit this inclination? Were you
ashamed of loving a man?' 'Oh no, I'm not unreasonably
prudish. We're not responsible for our feelings, anyhow. It was
distressing to me only because he is my employer and I am in
his service and live in his house. I don't feel the same complete
independence towards him that I could towards anyone else.
And then I am only a poor girl and he is such a rich man of
good family. People would laugh at me if they had any idea
of it.'

1 I have never managed to give a better description than this of the
strange state of mind in which one knows and does not know a thing
at the same time. It is clearly impossible to understand it unless one has
been in such a state oneself. I myself have had a very remarkable
experience of this sort, which is still clearly before me. If I try to re-
collect what went on in my mind at the time I can get hold of very
little. What happened was that I saw something which did not fit in
at all with my expectation; yet I did not allow what I saw to disturb
my fixed plan in the least, though the perception should have put a
stop to it. I was unconscious of any contradiction in this; nor was I
aware of my feelings of repulsion, which must nevertheless undoubtedly
have been responsible for the perception producing no psychical effect.
I was afflicted by that blindness of the seeing eye which is so astonishing
in the attitude of mothers to their daughters, husbands to their wives
and rulers to their favourites.

118 II. CASE HISTORIES

She now showed no resistance to throwing light on the origin
of this inclination. She told me that for the first few years she
had lived happily in the house, carrying out her duties and free
from any unfulfillable wishes. One day, however, her employer,
a serious, overworked man whose behaviour towards her had
always been reserved, began a discussion with her on the lines
along which children should be brought up. He unbent more
and was more cordial than usual and told her how much he
depended on her for looking after his orphaned children; and
as he said this he looked at her meaningly. . . . Her love for
him had begun at that moment, and she even allowed herself
to dwell on the gratifying hopes which she had based on this
talk. But when there was no further development, and when
she had waited in vain for a second hour's intimate exchange
of views, she decided to banish the whole business from her
mind. She entirely agreed with me that the look she had caught
during their conversation had probably sprung from his
thoughts about his wife, and she recognized quite clearly that
there was no prospect of her feelings for him meeting with any
return.

I expected that this discussion would bring about a funda-
mental change in her condition. But for the time being this did
not occur. She continued to be in low spirits and depressed.
She felt somewhat refreshed in the mornings by a course of
hydropathic treatment which I prescribed for her at the same
time. The smell of burnt pudding did not disappear completely,
though it became less frequent and weaker. It only came on,
she said, when she was very much agitated. The persistence of
this mnemic symbol led me to suspect that, in addition to the
main scene, it had taken over the representation of the many
minor traumas subsidiary to that scene. We therefore looked
about for anything else that might have to do with the scene
of the burnt pudding; we went into the subject of the domestic
friction, the grandfather's behaviour, and so on, and as we did
so the burnt smell faded more and more. During this time, too,
the treatment was interrupted for a considerable while, owing
to a fresh attack of her nasal disorder, and this now led to the
discovery of the caries of the ethmoid [p. 106],

On her return she reported that at Christmas she had re-
ceived a great many presents from the two gentlemen of the
house and even from the servants, as though they were all

(3) MISS LUCY R. (FREUD) 119

anxious to make it up with her and to wipe out her memory
of the conflicts of the last few months. But these signs of good-
will had not made any impression on her.

When I enquired once more about the smell of burnt pud-
ding, she informed me that it had quite disappeared but that
she was being bothered by another, similar smell, resembling
cigar-smoke. It had been there earlier as well, she thought, but
had, as it were, been covered by the smell of the pudding.
Now it had emerged by itself.

I was not very well satisfied with the results of the treatment.
What had happened was precisely what is always brought up
against purely symptomatic treatment: I had removed one
symptom only for its place to be taken by another. Nevertheless,
I did not hesitate to set about the task of getting rid of this new
mnemic symbol by analysis.

But this time she did not know where the subjective olfactory
sensation came from on what important occasion it had been
an objective one. 'People smoke every day in our house,' she
said, 'and I really don't know whether the smell I notice refers
to some special occasion.' I then insisted that she should try
to remember under the pressure of my hand. I have already
mentioned [p. 1 14] that her memories had the quality of plastic
vividness, that she was a Visual' type. And in fact, at my
insistence, a picture gradually emerged before her, hesitatingly
and piecemeal to begin with. It was the dining-room in her
house, where she was waiting with the children for the two
gentlemen to return to luncheon from the factory. 'Now we are
all sitting round the table, the gentlemen, the French governess,
the housekeeper, the children and myself. But that's like what
happens every day.' 'Go on looking at the picture; it will
develop and become more specialized.' 'Yes, there is a guest.
It's the chief accountant. He's an old man and he is as fond of
the children as though they were his own grandchildren. But
he comes to lunch so often that there's nothing special in that
either.' 'Be patient and just keep looking at the picture; some-
thing's sure to happen.' 'Nothing's happening. We're getting
up from the table; the children say their good-byes, and they
go upstairs with us as usual to the second floor.' 'And then?'
'It is a special occasion, after all. I recognize the scene now.
As the children say good-bye, the accountant tries to kiss
them. My employer flares up and actually shouts at him:

L20 II. CASE HISTORIES

"Don't kiss the children!" I feel a stab at my heart; and as the
gentlemen are already smoking, the cigar-smoke sticks in my
memory.'

This, then, was a second and deeper-lying scene which, like
the first, operated as a trauma and left a mnemic symbol
behind it. But to what did this scene owe its effectiveness?
'Which of the two scenes was the earlier,' I asked, 'this one or
the one with the burnt pudding?' 'The scene I have just told
you about was the earlier, by almost two months.' Then why
did you feel this stab when the children's father stopped the
old man? His reprimand wasn't aimed at you.' 'It wasn't
right of him to shout at an old man who was a valued friend of
his and, what's more, a guest. He could have said it quietly.'
'So it was only the violent way he put it that hurt you? Did
you feel embarrassed on his account? Or perhaps you thought:
"If he can be so violent about such a small thing with an old
friend and guest, how much more so might he be with me if I
were his wife".' 'No, that's not it.' 'But it had to do with
his violence, hadn't it?' 'Yes, about the children being kissed.
He has never liked that.'

And now, under the pressure of my hand, the memory of a
third and still earlier scene emerged, which was the really
operative trauma and which had given the scene with the chief
accountant its traumatic effectiveness. It had happened a few
months earlier still that a lady who was an acquaintance of her
employer's came to visit them, and on her departure kissed the
two children on the mouth. Their father, who was present,
managed to restrain himself from saying anything to the lady,
but after she had gone, his fury burst upon the head of the
unlucky governess. He said he held her responsible if anyone
kissed the children on the mouth, that it was her duty not to
permit it and that she was guilty of a dereliction of duty if she
allowed it; if it ever happened again he would entrust his
children's upbringing to other hands. This had happened at a
time when she still thought he loved her, and was expecting a
repetition of their first friendly talk. The scene had crushed
her hopes. She had said to herself: 'If he can fly out at me like
this and make such threats over such a trivial matter, and one
for which, moreover, I am not in the least responsible, I must
have made a mistake. He can never have had any warm feelings
for me, or they would have taught him to treat me with more

(3) MISS LUCY R. (FREUD) 121

consideration.' It was obviously the recollection of this dis-
tressing scene which had come to her when the chief accountant
had tried to kiss the children and had been reprimanded by
their father.

After this last analysis, when, two days later, Miss Lucy
visited me once more, I could not help asking her what had
happened to make her so happy. She was as though trans-
figured. She was smiling and carried her head high. I thought
for a moment that after all I had been wrong about the situ-
ation, and that the children's governess had become the
Director's fiancee. But she dispelled my notion. 'Nothing has
happened. It's just that you don't know me. You have only seen
me ill and depressed. I'm always cheerful as a rule. When I
woke yesterday morning the weight was no longer on my mind,
and since then I have felt well.'- 'And what do you think of
your prospects in the house?' 'I am quite clear on the subject.
I know I have none, and I shan't make myself unhappy over
it.' 'And will you get on all right with the servants now?'
'I think my own oversensitiveness was responsible for most of
that.' 'And are you still in love with your employer?' 'Yes, I
certainly am, but that makes no difference. After all, I can
have thoughts and feelings to myself.'

I then examined her nose and found that its sensitivity to
pain and reflex excitability had been almost completely re-
stored. She was also able to distinguish between smells, though
with uncertainty and only if they were strong. I must leave it
an open question, however, how far her nasal disorder may have
played a part in the impairment of her sense of smell.

This treatment lasted in all for nine weeks. Four months
later I met the patient by chance in one of our summer resorts.
She was in good spirits and assured me that her recovery had
been maintained.

DISCUSSION

I am not inclined to under-estimate the importance of the
case that I have here described, even though the patient was
suffering only from a slight and mild hysteria and though only
a few symptoms were involved. On the contrary it seems to me
an instructive fact that even an illness such as this, so unpro-
ductive when regarded as a neurosis, called for so many

122 II. CASE HISTORIES

psychical determinants. Indeed, when I consider this case
history more closely, I am tempted to regard it as a model
instance of one particular type of hysteria, namely the form
of this illness which can be acquired even by a person of
sound heredity, as a result of appropriate experiences. It should
be understood that I do not mean by this a hysteria which
is independent of any pre-existing disposition. It is probable
that no such hysteria exists. But we do not recognize a dis-
position of this sort in a subject until he has actually become a
hysteric; for previously there was no evidence of its existence.
A neuropathic disposition, as generally understood, is some-
thing different. It is already marked out before the onset of the
illness by the amount of the subject's hereditary taint or the
sum of his individual psychical abnormalities. So far as my
information goes, there was no trace in Miss Lucy R. of either
of these factors. Her hysteria can therefore be described as an
acquired one, and it presupposed nothing more than the pos-
session of what is probably a very widespread proclivity the
proclivity to acquire hysteria. We have as yet scarcely a notion
of what the features of this proclivity may be. In cases of
this kind, however, the main emphasis falls upon the nature
of the trauma, though taken in conjunction, of course, with
the subject's reaction to it. It turns out to be a sine qua non
for the acquisition of hysteria that an incompatibility should
develop between the ego and some idea presented to it. I hope
to be able to show elsewhere l how different neurotic dis-
turbances arise from the different methods adopted by the
'ego' in order to escape from this incompatibility. The hysterical
method of defence for which, as we have seen, the possession
of a particular proclivity is necessary lies in the conversion
of the excitation into a somatic innervation; and the advantage
of this is that the incompatible idea is repressed from the ego's
consciousness. In exchange, that consciousness now contains the
physical reminiscence which has arisen through conversion (in
our case, the patient's subjective sensations of smell) and suffers
from the affect which is more or less clearly attached to pre-

1 [Freud sketched out the distinction between the mechanisms used
in hysteria, obsessions and paranoia in a communication to Fliess of
January 1, 1896 (Freud, 1950a, Draft K); in the following May he
published these findings in his second paper on 'The Neuro-Psychoses
of Defence' (1896).]

(3) MISS LUCY R. (FREUD) 123

cisely that reminiscence. The situation which has thus been
brought about is now not susceptible to further change; for
the incompatibility which would have called for a removal of
the affect no longer exists, thanks to the repression and con-
version. Thus the mechanism which produces hysteria repre-
sents on the one hand an act of moral cowardice and on the
other a defensive measure which is at the disposal of the ego.
Often enough we have to admit that fending off increasing
excitations by the generation of hysteria is, in the circumstances,
the most expedient thing to do; more frequently, of course, we
shall conclude that a greater amount of moral courage would
have been of advantage to the person concerned.

The actual traumatic moment, then, is the one at which the
incompatibility forces itself upon the ego and at which the
latter decides on the repudiation of the incompatible idea. That
idea is not annihilated by a repudiation of this kind, but merely
repressed into the unconscious. 1 When this process occurs for
the first time there comes into being a nucleus and centre of
crystallization for the formation of a psychical group divorced
from the ego a group around which everything which would
imply an acceptance of the incompatible idea subsequently
collects. The splitting of consciousness in these cases of acquired
hysteria is accordingly a deliberate and intentional one. At least
it is often introduced by an act of volition; for the actual outcome
is something different from what the subject intended. What he
wanted was to do away with an idea, as though it had never
appeared, but all he succeeds in doing is to isolate it psychically.

In the history of our present patient the traumatic moment
was the moment of her employer's outburst against her about
his children being kissed by the lady. For a time, however, that
scene had no manifest effect. (It may be that her oversensitive-
ness and low spirits began from it, but I cannot say.) Her
hysterical symptoms did not start until later, at moments which
may be described as 'auxiliary'. 2 The characteristic feature of
such an auxiliary moment is, I believe, that the two divided
psychical groups temporarily converge in it, as they do in the
extended consciousness which occurs in somnambulism. In

1 [See footnote, p. 45 above.]

2 [Freud had already discussed such 'auxiliary' traumatic moments
in Section I of his first paper on 'The Neuro-Psychoses of Defence*
(1894*).]

124 II. CASE HISTORIES

Miss Lucy R.'s case the first of the auxiliary moments, at which
conversion took place, was the scene at table when the chief
accountant tried to kiss the children. Here the traumatic
memory was playing a part: she did not behave as though she
had got rid of everything connected with her devotion to her
employer. (In the history of other cases these different moments
coincide; conversion occurs as an immediate effect of the
trauma.)

The second auxiliary moment repeated the mechanism of the
first one fairly exactly. A powerful impression temporarily re-
united the patient's consciousness, and conversion once more
took the path which had been opened out on the first occasion.
It is interesting to notice that the second symptom to develop
masked the first, so that the first was not clearly perceived
until the second had been cleared out of the way. It also seems
to me worth while remarking upon the reversed course which
had to be followed by the analysis as well. I have had the same
experience in a whole number of cases; the symptoms that had
arisen later masked the earlier ones, and the key to the whole
situation lay only in the last symptom to be reached by the
analysis.

The therapeutic process in this case consisted in compelling
the psychical group that had been split off to unite once more
with the ego-consciousness. Strangely enough, success did not
runparipassu with the amount of work done. It was only when
the last piece of work had been completed that recovery sud-
denly took place.

CASE 4
KATHARINA (Freud)

IN the summer vacation of the year 189- I made an excursion
into the Hohe Tauern l so that for a while I might forget
medicine and more particularly the neuroses. I had almost
succeeded in this when one day I turned aside from the main
road to climb a mountain which lay somewhat apart and which
was renowned for its views and for its well-run refuge hut. I
reached the top after a strenuous climb and, feeling refreshed and
rested, was sitting deep in contemplation of the charm of the
distant prospect. I was so lost in thought that at first I did not
connect it with myself when these words reached my ears: 'Are
you a doctor, sir?' But the question was addressed to me, and
by the rather sulky-looking girl of perhaps eighteen who had
served my meal and had been spoken to by the landlady as
'Katharina'. To judge by her dress and bearing, she could not
be a servant, but must no doubt be a daughter or relative of
the landlady's.

Coming to myself I replied: 'Yes, I'm a doctor: but how did
you know that?'

'You wrote your name in the Visitors' Book, sir. And I
thought if you had a few moments to spare . . . The truth is,

sir, my nerves are bad. I went to see a doctor in L about

them and he gave me something for them; but I'm not well yet.'

So there I was with the neuroses once again for nothing
else could very well be the matter with this strong, well-built
girl with her unhappy look. I was interested to find that
neuroses could flourish in this way at a height of over 6,000 feet;
I questioned her further therefore. I report the conversation
that followed between us just as it is impressed on my memory
and I have not altered the patient's dialect. 2

4 Well, what is it you suffer from?'

'I get so out of breath. Not always. But sometimes it catches
me so that I think I shall suffocate.'

1 [One of the highest ranges in the Eastern Alps.]

2 [No attempt has been made in the English translation to imitate
this dialect.]

125

126 II. CASE HISTORIES

This did not, at first sight, sound like a nervous symptom.
But soon it occurred to me that probably it was only a descrip-
tion that stood for an anxiety attack: she was choosing shortness
of breath out of the complex of sensations arising from anxiety
and laying undue stress on that single factor.

'Sit down here. What is it like when you get "out of breath'? 1

'It comes over me all at once. First of all it's like something
pressing on my eyes. My head gets so heavy, there's a dreadful
buzzing, and I feel so giddy that I almost fall over. Then
there's something crushing my chest so that I can't get my
breath.'

'And you don't notice anything in your throat?'

'My throat's squeezed together as though I were going to
choke.'

'Does anything else happen in your head?'

'Yes, there's a hammering, enough to burst it.'

'And don't you feel at all frightened while this is going on?'

'I always think I'm going to die. I'm brave as a rule and
go about everywhere by myself into the cellar and all over the
mountain. But on a day when that happens I don't dare to go
anywhere; I think all the time someone's standing behind me
and going to catch hold of me all at once.'

So it was in fact an anxiety attack, and introduced by the
signs of a hysterical 'aura' 1 or, more correctly, it was a
hysterical attack the content of which was anxiety. Might there
not probably be some other content as well?

'When you have an attack do you think of something? and
always the same thing? or do you see something in front of
you?'

'Yes. I always see an awful face that looks at me in a dreadful
way, so that I'm frightened.'

Perhaps this might offer a quick means of getting to the
heart of the matter.

'Do you recognize the face? I mean, is it a face that you've
really seen some time?'

'No.'

'Do you know what your attacks come from?'

'No.'.

'When did you first have them?'

1 [The premonitory sensations preceding an epileptic or hysterical
attack.]

(4) KATHARINA (FREUD) 127

'Two years ago, while I was still living on the other moun-
tain with my aunt. (She used to run a refuge hut there, and we
moved here eighteen months ago.) But they keep on happening.'

Was I to make an attempt at an analysis? I could not venture
to transplant hypnosis to these altitudes, but perhaps I might
succeed with a simple talk. I should have to try a lucky guess.
I had found often enough that in girls anxiety was a conse-
quence of the horror by which a virginal mind is overcome
when it is faced for the first time with the world of sexuality. 1

So I said: 'If you don't know, I'll tell you how / think you
got your attacks. At that time, two years ago, you must have
seen or heard something that very much embarrassed you, and
that you'd much rather not have seen.'

'Heavens, yes!' she replied, 'that was when I caught my uncle
with the girl, with Franziska, my cousin.'

'What's this story about a girl? Won't you tell me all about it?'

'You can say anything to a doctor, I suppose. Well, at that
time, you know, my uncle the husband of the aunt you've seen

here kept the inn on the kogel. 2 Now they're divorced,

and it's my fault they were divorced, because it was through
me that it came out that he was carrying on with Franziska.'

'And how did you discover it?'

'This way. One day two years ago some gentlemen had
climbed the mountain and asked for something to eat. My aunt
wasn't at home, and Franziska, who always did the cooking,
was nowhere to be found. And my uncle was not to be found
either. We looked everywhere, and at last Alois, the little boy,
my cousin, said: "Why, Franziska must be in Father's room!"

1 I will quote here the case in which I first recognized this causal
connection. I was treating a young married woman who was suffering
from a complicated neurosis and, once again [cf. p. 112 n.], was un-
willing to admit that her illness arose from her married life. She objected
that while she was still a girl she had had attacks of anxiety, ending in
fainting fits. I remained firm. When we had come to know each other
better she suddenly said to me one day: Til tell you now how I came
by my attacks of anxiety when I was a girl. At that time I used to sleep
in a room next to my parents'; the door was left open and a night-light
used to burn on the table. So more than once I saw my father get into
bed with my mother and heard sounds that greatly excited me. It was
then that my attacks came on.' [Two cases of this kind are mentioned
by Freud in a letter to Fliess of May 30, 1893 (Freud, 19500, Letter
12). Cf. also Section II of the first paper on anxiety neurosis (1895).]

1 [The name of the 'other* mountain.]

128 II. CASE HISTORIES

And we both laughed; but we weren't thinking anything bad.
Then we went to my uncle's room but found it locked. That
seemed strange to me. Then Alois said: "There's a window in
the passage where you can look into the room." We went into
the passage; but Alois wouldn't go to the window and said
he was afraid. So I said: "You silly boy! I'll go. I'm not a bit
afraid." And I had nothing bad in my mind. I looked in. The
room was rather dark, but I saw my uncle and Franziska; he
was lying on her.'

'Well?'

'I came away from the window at once, and leant up against
the wall and couldn't get my breath just what happens to me
since. Everything went blank, my eyelids were forced together
and there was a hammering and buzzing in my head.'

'Did you tell your aunt that very same day?'

'Oh no, I said nothing.'

'Then why were you so frightened when you found them to-
gether? Did you understand it? Did you know what was going
on?'

'Oh no. I didn't understand anything at that time. I was
only sixteen. I don't know what I was frightened about.'

'Fraulein Katharina, if you could remember now what was
happening in you at that time, when you had your first attack,
what you thought about it it would help you.'

'Yes, if I could. But I was so frightened that I've forgotten
everything.'

(Translated into the terminology of our 'Preliminary Com-
munication' [p. 12], this means: 'The affect itself created a
hypnoid state, whose products were then cut off from associ-
ative connection with the ego-consciousness.')

'Tell me, Fraulein. Can it be that the head that you always
see when you lose your breath is Franziska's head, as you saw
it then?'

'Oh no, she didn't look so awful. Besides, it's a man's head.'

'Or perhaps your uncle's?'

'I didn't see his face as clearly as that. It was too dark in the
room. And why should he have been making such a dreadful
face just then?'

'You're quite right.'

(The road suddenly seemed blocked. Perhaps something
might turn up in the rest of her story.)

(4) KATHARINA (FREUD) 129

'And what happened then?'

'Well, those two must have heard a noise, because they came
out soon afterwards. I felt very bad the whole time. I always
kept thinking about it. Then two days later it was a Sunday and
there was a great deal to do and I worked all day long. And
on the Monday morning I felt giddy again and was sick, and I
stopped in bed and was sick without stopping for three days.'

We [Breuer and I] had often compared the symptomatology
of hysteria with a pictographic script which has become in-
telligible after the discovery of a few bilingual inscriptions.
In that alphabet being sick means disgust. So I said: 'If you
were sick three days later, I believe that means that when you
looked into the room you felt disgusted.'

'Yes, I'm sure I felt disgusted,' she said reflectively, 'but
disgusted at what?'

'Perhaps you saw something naked? What sort of state
were they in?'

'It was too dark to see anything; besides they both of them
had their clothes on. Oh, if only I knew what it was I felt
disgusted at!'

/ had no idea either. But I told her to go on and tell me
whatever occurred to her, in the confident expectation that she
would think of precisely what I needed to explain the case.

Well, she went on to describe how at last she reported her
discovery to her aunt, who found that she was changed and
suspected her of concealing some secret. There followed some
very disagreeable scenes between her uncle and aunt, in the
course of which the children came to hear a number of things
which opened their eyes in many ways and which it would
have been better for them not to have heard. At last her aunt
decided to move with her children and niece and take over the
present inn, leaving her uncle alone with Franziska, who had
meanwhile become pregnant. After this, however, to my aston-
ishment she dropped these threads and began to tell me two
sets of older stories, which went back two or three years earlier
than the traumatic moment. The first set related to occasions
on which the same uncle had made sexual advances to her
herself, when she was only fourteen years old. She described
how she had once gone with him on an expedition down into
the valley in the winter and had spent the night in the inn there.
He sat in the bar drinking and playing cards, but she felt

130 II. CASE HISTORIES

sleepy and went up to bed early in the room they were to share
on the upper floor. She was not quite asleep when he came up;
then she fell asleep again and woke up suddenly 'feeling his
body' in the bed. She jumped up and remonstrated with him:
'What are you up to. Uncle? Why don't you stay in your
own ued?' He tried to pacify her: 'Go on, you silly girl, keep
still. You don't know how nice it is.' 'I don't like your "nice"
things; you don't even let one sleep in peace.' She remained
standing by the door, ready to take refuge outside in the pas-
sage, till at last he gave up and went to sleep himself. Then
she went back to her own bed and slept till morning. From the
way in which she reported having defended herself it seems to
follow that she did not clearly recognize the attack as a sexual
one. When I asked her if she knew what he was trying to do to
her, she replied: 'Not at the time.' It had become clear to her
much later on, she said; she had resisted because it was un-
pleasant to be disturbed in one's sleep and 'because it wasn't
nice'.

I have been obliged to relate this in detail, because of its
great importance for understanding everything that followed.
She went on to tell me of yet other experiences of somewhat
later date: how she had once again had to defend herself
against him in an inn when he was completely drunk, and
similar stories. In answer to a question as to whether on these
occasions she had felt anything resembling her later loss of
breath, she answered with decision that she had every time felt
the pressure on her eyes and chest, but with nothing like the
strength that had characterized the scene of discovery.

Immediately she had finished this set of memories she began
to tell me a second set, which dealt with occasions on which
she had noticed something between her uncle and Franziska.
Once the whole family had spent the night in their clothes in
a hay loft and she was woken up suddenly by a noise; she
thought she noticed that her uncle, who had been lying between
her and Franziska, was turning away, and that Franziska was
just lying down. Another time they were stopping the night

at an inn at the village of N ; she and her uncle were in one

room and Franziska in an adjoining one. She woke up suddenly
in the night and saw a tall white figure by the door, on the
point of turning the handle: 'Goodness, is that you, Uncle?
What are you doing at the door?' 'Keep quiet. I was only

(4) KATHARINA (FREUD) 131

looking for something.' 'But the way out's by the other door.'
* I'd just made a mistake' . . . and so on.

I asked her if she had been suspicious at that time. 'No, I
didn't think anything about it; I only just noticed it and
thought no more about it.' When I enquired whether she had
been frightened on these occasions too, she replied that she
thought so, but she was not so sure of it this time.

At the end of these two sets of memories she came to a stop.
She was like someone transformed. The sulky, unhappy face
had grown lively, her eyes were bright, she was lightened and
exalted. Meanwhile the understanding of her case had become
clear to me. The later part of what she had told me, in an
apparently aimless fashion, provided an admirable explanation
of her behaviour at the scene of the discovery. At that time
she ha^ carried about with her two sets of experiences which
she remembered but did not understand, and from which she
drew no inferences. When she caught sight of the couple in
intercourse, she at once established a connection between the
new impression and these two sets of recollections, she began to
understand them and at the same time to fend them off. There
then followed a short period of working-out, of 'incubation', 1
after which the symptoms of conversion set in, the vomiting
as a substitute for moral and physical disgust. This solved the
riddle. She had not been disgusted by the sight of the two people
but by the memory which that sight had stirred up in her. And,
taking everything into account, this could only be the memory of
the attempt on her at night when she had 'felt her uncle's body'.

So when she had finished her confession I said to her: 'I
know now what it was you thought when you looked into the
room. You thought: "Now he's doing with her what he wanted
to do with me that night and those other times." That was
what you were disgusted at, because you remembered the feel-
ing when you woke up in the night and felt his body.'

'It may well be,' she replied, 'that that was what I was dis-
gusted at and that that was what I thought.'

'Tell me just one thing more. You're a grown-up girl now
and know all sorts of things . . .'

'Yes, now I am.'

'Tell me just one thing. What part of his body was it that
you felt that night?'

* [Gf. below, p. 134.]

132 II. CASE HISTORIES

But she gave me no more definite answer. She smiled in an
embarrassed way, as though she had been found out, like
someone who is obliged to admit that a fundamental position
has been reached where there is not much more to be said. I
could imagine what the tactile sensation was which she had
later learnt to interpret. Her facial expression seemed to me to
be saying that she supposed that I was right in my conjecture.
But I could not penetrate further, and in any case I owed her
a debt of gratitude for having made it so much easier for me
to talk to her than to the prudish ladies of my city practice,
who regard whatever is natural as shameful.

Thus the case was cleared up. But stop a moment! What
about the recurrent hallucination of the head, which appeared
during her attacks and struck terror into her? Where did it
come from? I proceeded to ask her about it, and, as though her
knowledge, too, had been extended by our conversation, she
promptly replied: 'Yes, I know now. The head is my uncle's
head I recognize it now but not from that time. Later, when
all the disputes had broken out, my uncle gave way to a senseless
rage against me. He kept saying that it was all my fault: if I
hadn't chattered, it would never have come to a divorce.* He
kept threatening he would do something to me; and if he
caught sight of me at a distance his face would get distorted
with rage and he would make for me with his hand raised.
I always ran away from him, and always felt terrified that he
would catch me some time unawares. The face I always see
now is his face when he was in a rage.'

This information reminded me that her first hysterical
symptom, the vomiting, had passed away; the anxiety attack
remained and acquired a fresh content. Accordingly, what we
were dealing with was a hysteria which had to a considerable
extent been abreacted. And in fact she had reported her dis-
covery to her aunt soon after it happened.

'Did you tell your aunt the other stories about his making
advances to you?'

'Yes. Not at once, but later on, when there was already talk
of a divorce. My aunt said: "We'll keep that in reserve. If he
causes trouble in the Court, we'll say that too." '

I can well understand that it should have been precisely this
last period when there were more and more agitating scenes
in the house and when her own state ceased to interest her aunt,

(4) KATHARINA (FREUD) 133

who was entirely occupied with the dispute that it should
have been this period of accumulation and retention that left
her the legacy of the mnemic symbol [of the hallucinated face] .
I hope this girl, whose sexual sensibility had been injured at
such an early age, derived some benefit from our conversation.
I have not seen her since.

DISCUSSION

If someone were to assert that the present case history is not
so much an analysed case of hysteria as a case solved by guess-
ing, I should have nothing to say against him. It is true that
the patient agreed that what I interpolated into her story was
probably true; but she was not in a position to recognize it as
something she had experienced. I believe it would have re-
quired hypnosis to bring that about. Assuming that my guesses
were correct, I will now attempt to fit the case into the schematic
picture of an 'acquired' hysteria on the lines suggested by
Case 3. It seems plausible, then, to compare the two sets of
erotic experiences with 'traumatic' moments and the scene of
discovering the couple with an 'auxiliary' moment. [Cf. p.!23f.]
The similarity lies in the fact that in the former experiences
an element of consciousness was created which was excluded
from the thought-activity of the ego and remained, as it were,
in storage, while in the latter scene a new impression forcibly
brought about an associative connection between this separated
group and the ego. On the other hand there are dissimilarities
which cannot be overlooked. The cause of the isolation was not,
as in Case 3, an act of will on the part of the ego but ignorance
on the part of the ego, which was not yet capable of coping
with sexual experiences. In this respect the case of Katharina
is typical. In every analysis of a case of hysteria based on sexual
traumas we find that impressions from the pre-sexual period
which produced no effect on the child attain traumatic power
at a later date as memories, when the girl or married woman
has acquired an understanding of sexual life. 1 The splitting-off

1 [Freud had discussed this at considerable length in the later sections
of Part II of his 1895 'Project' (Freud, 1950a) and expressed the same
view in Section I of his second paper on 'The Neuro-Psychoses of
Defence' (\896b). It was not until some years later that he came to
recognize the part played in the production of neuroses by sexual
impulses already present in early childhood. Cf. the Editor's Note to the
Three Essays (1905<f), Standard Ed., 7, 127-9.]

134 II. CASE HISTORIES

of psychical groups may be said to be a normal process in
adolescent development; and it is easy to see that their later re-
ception into the ego affords frequent opportunities for psychical
disturbances. Moreover, I should like at this point to express
a doubt as to whether a splitting of consciousness due to ignor-
ance is really different from one due to conscious rejection, and
whether even adolescents do not possess sexual knowledge far
oftener than is supposed or than they themselves believe.

A further distinction in the psychical mechanism of this case
lies in the fact that the scene of discovery, which we have
described as 'auxiliary', deserves equally to be called 'trau-
matic'. It was operative on account of its own content and not
merely as something that revived previous traumatic experi-
ences. It combined the characteristics of an 'auxiliary' and a
'traumatic' moment. There seems no reason, however, why this
coincidence should lead us to abandon a conceptual separation
which in other cases corresponds also to a separation in time.
Another peculiarity of Katharina's case, which, incidentally,
has long been familiar to us, is seen in the circumstance that
the conversion, the production of the hysterical phenomena,
did not occur immediately after the trauma but after an interval
of incubation. Charcot liked to describe this interval as the
'period of psychical working-out' [elaboration]. 1

The anxiety from which Katharina suffered in her attacks
was a hysterical one; that is, it was a reproduction of the
anxiety which had appeared in connection with each of the
sexual traumas. I shall not here comment on the fact which I
have found regularly present in a very large number of cases
namely that a mere suspicion of sexual relations calls up the
affect of anxiety in virginal individuals. 2 [Cf. p. 127, n. 1.]

1 [See Gharcot 1 888, 1 , 99. Gf. also Breuer's remarks on the subject on
p. 213 below.]

2 (Footnote added 1924:) I venture after the lapse of so many years to
lift the veil of discretion and reveal the fact that Katharina was not the
niece but the daughter of the landlady. The girl fell ill, therefore, as a
result of sexual attempts on the part of her own father. Distortions like
the one which I introduced in the present instance should be altogether
avoided in reporting a case history. From the point of view of under-
standing the case, a distortion of this kind is not, of course, a matter
of such indifference as would be shifting the scene from one mountain
to another.

CASE 5
FRAULEIN ELISABETH VON R. (Freud)

IN the autumn of 1892 I was asked by a doctor I knew to
examine a young lady who had been suffering for more than
two years from pains in her legs and who had difficulties in
walking. When making this request he added that he thought
the case was one of hysteria, though there was no trace of the
usual indications of that neurosis. He told me that he knew the
family slightly and that during the last few years it had met
with many misfortunes and not much happiness. First the
patient's father had died, then her mother had had to undergo
a serious eye-operation and soon afterwards a married sister
had succumbed to a heart-affection of long standing after a
confinement. In all these troubles and in all the sick-nursing
involved, the largest share had fallen to our patient.

My first interview with this young woman of twenty-four
years of age did not help me to make much further progress
in understanding the case. She seemed intelligent and mentally
normal and bore her troubles, which interfered with her social
life and pleasures, with a cheerful air the belle indifference of a
hysteric, 1 I could not help thinking. She walked with the upper
part of her body bent forward, but without making use of any
support. Her gait was not of any recognized pathological type,
and moreover was by no means strikingly bad. All that was
apparent was that she complained of great pain in walking and
of being quickly overcome by fatigue both in walking and in
standing, and that after a short time she had to rest, which
lessened the pains but did not do away with them altogether.
The pain was of an indefinite character; I gathered that it was
something in the nature of a painful fatigue. A fairly large, ill-
defined area of the anterior surface of the right thigh was
indicated as the focus of the pains, from which they most often
radiated and where they reached their greatest intensity. In
this area the skin and muscles were also particularly sensitive
to pressure and pinching (though the prick of a needle was, if

1 [Freud quotes this phrase again towards the end of his paper on
repression (\9\5d), where he attributes it to Gharcot.]

135

136 II. CASE HISTORIES

anything, met with a certain amount of unconcern). This
hyperalgesia of the skin and muscles was not restricted to this
area but could be observed more or less over the whole of both
legs. The muscles were perhaps even more sensitive to pain
than the skin; but there could be no question that the thighs
were the parts most sensitive to both these kinds of pain. The
motor power of the legs could not be described as small, and
the reflexes were of medium strength. There were no other
symptoms, so that there was no ground for suspecting the
presence of any serious organic affection. The disorder had
developed gradually during the previous two years and varied
greatly in intensity.

I did not find it easy to arrive at a diagnosis, but I decided
for two reasons to assent to the one proposed by my colleague,
viz. that it was a case of hysteria. In the first place I was struck
by the indefiniteness of all the descriptions of the character of
her pains given me by the patient, who was nevertheless a
highly intelligent person. A patient suffering from organic
pains will, unless he is neurotic in addition, describe them
definitely and calmly. He will say, for instance, that they are
shooting pains, that they occur at certain intervals, that they
extend from this place to that and that they seem to him to
be brought on by one thing or another. Again, when a neuras-
thenic x describes his pains, he gives an impression of being
engaged on a difficult intellectual task to which his strength is
quite unequal. His features are strained and distorted as though
under the influence of a distressing affect. His voice grows
more shrill and he struggles to find a means of expression. He
rejects any description of his pains proposed by the physician,
even though it may turn out afterwards to have been un-
questionably apt. He is clearly of opinion that language is too
poor to find words for his sensations and that those sensations
are something unique and previously unknown, of which it
would be quite impossible to give an exhaustive description.
For this reason he never tires of constantly adding fresh details,
and when he is obliged to break off he is sure to be left with
the conviction that he has not succeeded in making himself
understood by the physician. All this is because his pains have
attracted his whole attention to themselves. Fraulein von R.

1 (A hypochondriac or a person affected with anxiety neurosis.)
[These brackets are the author's.]

(5) FRAULEIN ELISABETH VON R. (FREUD) 137

behaved in quite an opposite way; and we are driven to con-
clude that, since she nevertheless attached sufficient importance
to her symptoms, her attention must be dwelling on something
else, of which the pains were only an accessory phenomenon
probably on thoughts and feelings, therefore, which were
connected with them.

But there is a second factor which is even more decisively
in favour of this view of the pains. If one stimulates an area
sensitive to pain in someone with an organic illness or in a
neurasthenic, the patient's face takes on an expression of dis-
comfort or physical pain. Moreover he flinches and draws back
from the examination and resists it. In the case of Fraulein von
R., however, if one pressed or pinched the hyperalgesic skin
and muscles of her legs, her face assumed a peculiar expression,
which was one of pleasure rather than pain. She cried out
and I could not help thinking that it was as though she was
having a voluptuous tickling sensation her face flushed, she
threw back her head and shut her eyes and her body bent
backwards. None of this was very exaggerated but it was dis-
tinctly noticeable, and it could only be reconciled with the
view that her disorder was hysterical, and that the stimulation
had touched upon a hysterogenic l zone.

Her expression of face did not fit in with the pain which was
ostensibly set up by the pinching of her muscles and skin; it
was probably more in harmony with the subject-matter of the
thoughts which lay concealed behind the pain and which had
been aroused in her by the stimulation of the parts of the body
associated with those thoughts. I had repeatedly observed ex-
pressions of similar significance in undoubted cases of hysteria,
when a stimulus was applied to their hyperalgesic zones. Her
other gestures were evidently very slight hints of a hysterical
attack.

To begin with there was no explanation of the unusual
localization of her hysterogenic zone. The fact that the hyper-
algesia mainly affected the muscles also gave food for thought.
The disorder which is most usually responsible for diffuse and
local sensitivity to pressure in the muscles is a rheumatic infil-
tration of those muscles common chronic muscular rheuma-
tism. I have already [p. 71 n.] spoken of its tendency to simulate

1 [So in the first edition. All later editions have, no doubt erroneously,
'hysterical'.]

138 II. CASE HISTORIES

nervous affections. This possibility was not contradicted by
the consistency of the patient's hyperalgesic muscles. There
were numerous hard fibres in the muscular substance, and
these seemed to be especially sensitive. Thus it was probable
that an organic change in the muscles of the kind indicated was
present and that the neurosis attached itself to this and made
it seem of exaggerated importance.

Treatment proceeded on the assumption that the disorder
was of this mixed kind. We recommended the continuation of
systematic kneading and faradization of the sensitive muscles,
regardless of the resulting pain, and I reserved to myself treat-
ment of her legs with high tension electric currents, in order
to be able to keep in touch with her. Her question whether she
should force herself to walk was answered with a decided c yes'.

In this way we brought about a slight improvement. In
particular, she seemed to take quite a liking to the painful
shocks produced by the high tension apparatus, and the stronger
these were the more they seemed to push her own pains into
the background. In the meantime my colleague was preparing
the ground for psychical treatment, and when, after four weeks
of my pretence treatment, I proposed the other method and
gave her some account of its procedure and mode of operation,
I met with quick understanding and little resistance.

The task on which I now embarked turned out, however,
to be one of the hardest that I had ever undertaken, and the
difficulty of giving a report upon it is comparable, moreover,
with the difficulties that I had then to overcome. For a long
time, too, I was unable to grasp the connection between the
events in her illness and her actual symptom, which must
nevertheless have been caused and determined by that set of
experiences.

When one starts upon a cathartic treatment of this kind, the
first question one asks oneself is whether the patient herself is
aware of the origin and the precipitating cause of her illness.
If so, no special technique is required to enable her to reproduce
the story of her illness. The interest shown in her by the
physician, the understanding of her which he allows her to feel
and the hopes of recovery he holds out to her all these will
decide the patient to yield up her secret. From the beginning it
seemed to me probable that Fraulein Elisabeth was conscious

(5) FRAULEIN ELISABETH VON R. (FREUD) 139

of the basis of her illness, that what she had in her consciousness
was only a secret and not a foreign body. Looking at her, one
could not help thinking of the poet's words:

Das Maskchen da weissagt verborgnen Sinn. 1

In the first instance, therefore, I was able to do without
hypnosis, with the reservation, however, that I could make
use of it later if in the course of her confession material arose
to the elucidation of which her memory was unequal. Thus it
came about that in this, the first full-length analysis of a hysteria
undertaken by me, I arrived at a procedure which I later
developed into a regular method and employed deliberately.
This procedure was one of clearing away the pathogenic
psychical material layer by layer, and we liked to compare it
with the technique of excavating a buried city. I would begin
by getting the patient to tell me what was known to her and I
would carefully note the points at which some train of thought
remained obscure or some link in the causal chain seemed to
be missing. And afterwards I would penetrate into deeper
layers of her memories at these points by carrying out an
investigation under hypnosis or by the use of some similar
technique. The whole work was, of course, based on the ex-
pectation that it would be possible to establish a completely
adequate set of determinants for the events concerned. I shall
discuss presently the methods used for the deep investigation.

The story which Fraulein Elisabeth told of her illness was a
wearisome one, made up of many different painful experiences.
While she told it she was not under hypnosis; but I made her
lie down and keep her eyes shut, though I made no objection
to her occasionally opening them, changing her position, sitting
up, and so on. When she was more deeply moved than usual
by a part of her story she seemed to fall into a state more or
less resembling hypnosis. She would then lie motionless and
keep her eyes tightly shut.

I will begin by repeating what emerged as the most super-
ficial layer of her memories. The youngest of three daughters,
she was tenderly attached to her parents and spent her youth
on their estate in Hungary. Her mother's health was frequently

1 ['Her mask reveals a hidden sense.' Adapted from Goethe's Faust,
Part I (Scene 16).] Nevertheless, it will be seen later that I was mis-
taken in this.

140 II. CASE HISTORIES

troubled by an affection of the eyes as well as by nervous states.
Thus it came about that she found herself drawn into especially
intimate contact with her father, a vivacious man of the world,
who used to say that this daughter of his took the place of a son
and a friend with whom he could exchange thoughts. Although
the girl's mind found intellectual stimulation from this relation-
ship with her father, he did not fail to observe that her mental
constitution was on that account departing from the ideal
which people like to see realized in a girl. He jokingly called
her 'cheeky' and 'cock-sure', and warned her against being too
positive in her judgements and against her habit of regardlessly
telling people the truth, and he often said she would find it
hard to get a husband. She was in fact greatly discontented
with being a girl. She was full of ambitious plans. She wanted
to study or to have a musical training, and she was indignant
at the idea of having to sacrifice her inclinations and her free-
dom of judgement by marriage. As it was, she nourished herself
on her pride in her father and in the prestige and social position
of her family, and she jealously guarded everything that was
bound up with these advantages. The unselfishness, however,
with which she put her mother and elder sisters first, when an
occasion arose, reconciled her parents completely to the harsher
side of her character.

In view of the girls' ages it was decided that the family should
move to the capital, where Elisabeth was able for a short time
to enjoy a fuller and gayer life in the home circle. Then, how-
ever, the blow fell which destroyed the happiness of the family.
Her father had concealed, or had perhaps himself overlooked,
a chronic affection of the heart, and he was brought home un-
conscious one day suffering from a pulmonary oedema. He was
nursed for eighteen months, and Elisabeth saw to it that she
played the leading part at his sick-bed. She slept in his room,
was ready to wake if he called her at night, looked after him
during the day and forced herself to appear cheerful, while he
reconciled himself to his hopeless state with uncomplaining
resignation. The beginning of her illness must have been con-
nected with this period of nursing, for she remembered that
during its last six months she had taken to her bed for a day
and a half on account of the pains we have described. She
asserted, however, that these pains quickly passed off and had
not caused her any uneasiness or attracted her attention. And

(5) FRAULEIN ELISABETH VON R. (FREUD) 141

in fact it was not until two years after her father's death that
she felt ill and became incapable of walking on account of her
pains.

The gap that was caused in the life of this family of four
women by her father's death, their social isolation, the break-
ing-off of so many connections that had promised to bring her
interest and enjoyment, her mother's ill-health which was now
becoming more marked all this cast a shadow over the patient's
state of feeling; but at the same time it kindled a lively desire
in her that her family might soon find something to replace
their lost happiness, and led her to concentrate her whole
affection and care on the mother who was still living.

When the year of mourning had passed, her elder sister
married a gifted and energetic man. He occupied a responsible
position and his intellectual powers seemed to promise him a
great future. But to his closer acquaintances he exhibited a
morbid sensitiveness and an egoistic insistence on his fads; and
he was the first in the family circle to venture to show lack of
consideration for the old lady. This was more than Elisabeth
could bear. She felt called upon to take up the fight against
her brother-in-law whenever he gave her occasion, while the
other women did not take his temperamental outbursts to
heart. It was a painful disappointment to her that the re-
building of their former family happiness should be thus in-
terrupted; and she could not forgive her married sister for the
feminine pliancy with which she persistently avoided taking
sides. Elisabeth retained a number of scenes in her memory in
this connection, involving complaints, in part not expressed in
words, against her first brother-in-law. But her chief reproach
against him remained the fact that, for the sake of a prospective
promotion, he moved with his small family to a remote town
in Austria and thus helped to increase her mother's isolation.
On this occasion Elisabeth felt acutely her helplessness, her in-
ability to afford her mother a substitute for the happiness she
had lost and the impossibility of carrying out the intention she
had formed at her father's death.

The marriage of her second sister seemed to promise a
brighter future for the family, for the second brother-in-law,
though less outstanding intellectually, was a man after the
heart of these cultivated women, brought up as they had been
in a school of consideration for others. His behaviour reconciled

142 II. CASE HISTORIES

Elisabeth to the institution of marriage and to the thought of
the sacrifices it involved. Moreover the second young couple
remained in her mother's neighbourhood, and their child be-
came Elisabeth's favourite. Unfortunately another event cast
a shadow over the year in which this child was born. The
treatment of her mother's eye-trouble necessitated her being
kept in a dark room for several weeks, during which Elisabeth
was with her. An operation was then pronounced unavoidable.
The agitation at this prospect coincided with the preparations
for her first brother-in-law's move. At last her mother came
through the operation, which was performed by a master hand.
The three families were united at a summer holiday resort, and
it was hoped that Elisabeth, who had been exhausted by the
anxieties of the last few months, would make a complete
recovery during what was the first period of freedom from
sorrows and fears that the family had enjoyed since her father's
death.

It was precisely during this holiday, however, that Elisabeth's
pains and locomotor weakness started. She had been to some
extent aware of the pains for a short while, but they came on
violently for the first time after she had had a warm bath in
the bath establishment of the little watering-place. A few days
earlier she had been for a long walk in fact a regular tramp
lasting half a day and this they connected with the appearance
of the pains, so that it was easy to take the view that Elisabeth
had first been 'overtired* and had then 'caught cold'.

From this time on Elisabeth was the invalid of the family.
She was advised by her doctor to devote the rest of the same
summer to a course of hydropathic treatment at Gastein [in
the Austrian Alps], and she went there with her mother. But
a fresh anxiety now arose. Her second sister had become preg-
nant again and reports of her condition were most unfavourable,
so that Elisabeth could hardly make up her mind to travel
to Gastein. She and her mother had been there for barely
a fortnight when they were called back by the news that
her sister, who had now taken to her bed, was in a very bad
state.

There followed an agonizing journey, during which Elisabeth
was tormented not only by her pains but by dreadful expecta-
tions; on their arrival at the station there were signs that led
them to fear the worst; and when they entered the sick-room

(5) FRAULEIN ELISABETH VON R. (FREUD) 143

there came the certainty that they had come too late to take
their leave of a living person.

Elisabeth suffered not only from the loss of this sister, whom
she had dearly loved, but almost as much from the thoughts
provoked by her death and the changes which it brought along
with it. Her sister had succumbed to an affection of the heart
which had been aggravated by her pregnancy. The idea now
presented itself that heart disease was inherited from the father's
side of the family. It was then recalled that the dead sister had
suffered during her early girlhood from chorea accompanied
by a mild cardiac disorder. They blamed themselves and the
doctors for having permitted the marriage, and it was impos-
sible to spare the unhappy widower the reproach of having
endangered his wife's health by bringing on two pregnancies
in immediate succession. From that time onwards Elisabeth's
thoughts were occupied without interruption with the gloomy
reflection that when, for once in a way, the rare conditions for
a happy marriage had been fulfilled, this happiness should
have come to such an end. Furthermore, she saw the collapse
once more of all she had desired for her mother. Her widowed
brother-in-law was inconsolable and withdrew from his wife's
family. It appeared that his own family, which had been
estranged from him during his short, happy marriage, thought
this was a favourable moment for drawing him back into their
own circle. There was no way of preserving the unity that had
existed formerly. It was not practicable for him to live with her
mother in view of Elisabeth's unmarried state. Since, also, he
refused to allow the two women to have the custody of the
child, which was the dead woman's only legacy, he gave them
occasion for the first time to accuse him of hard-heartedness.
Lastly and this was not the least distressing fact a rumour
reached Elisabeth that a dispute had arisen between her two
brothers-in-law. She could only guess at its cause; it seemed,
however, that the widower had put forward financial demands
which the other declared were unjustifiable and which, indeed,
in view of the mother's present sorrow, he was able to char-
acterize as blackmail of the worst description.

Here, then, was the unhappy story of this proud girl with her
longing for love. Unreconciled to her fate, embittered by the
failure of all her little schemes for re-establishing the family's
former glories, with those she loved dead or gone away or

144 II. CASE HISTORIES

estranged, unready to take refuge in the love of some unknown
man she had lived for eighteen months in almost complete
seclusion, with nothing to occupy her but the care of her
mother and her own pains.

If we put greater misfortunes on one side and enter into a
girl's feelings, we cannot refrain from deep human sympathy
with Fraulein Elisabeth. But what shall we say of the purely
medical interest of this tale of suffering, of its relations to her
painful locomotor weakness, and of the chances of an explan-
ation and cure afforded by our knowledge of these psychical
traumas?

As far as the physician was concerned, the patient's confession
was at first sight a great disappointment. It was a case history
made up of commonplace emotional upheavals, and there was
nothing about it to explain why it was particularly from hysteria
that she fell ill or why her hysteria took the particular form
of a painful abasia. It threw light neither on the causes nor the
specific determination of her hysteria. We might perhaps sup-
pose that the patient had formed an association between her
painful mental impressions and the bodily pains which she
happened to be experiencing at the same time, and that now,
in her life of memories, she was using her physical feelings as a
symbol of her mental ones. But it remained unexplained what
her motives might have been for making a substitution of this
kind and at what moment it had taken place. These, incident-
ally, were not the kind of questions that physicians were in the
habit of raising. We were usually content with the statement
that the patient was constitutionally a hysteric, liable to develop
hysterical symptoms under the pressure of intense excitations of
whatever kind.

Her confession seemed to offer even less help towards the
cure of her illness than it did towards its explanation. It was
not easy to see what beneficent influence Fraulein Elisabeth
could derive from recapitulating the tale of her sufferings of
recent years with which all the members of her family were
so familiar to a stranger who received it with only a moderate
sympathy. Nor was there any sign of the confession producing
a curative effect of this kind. During this first period of her
treatment she never failed to repeat that she was still feeling
ill and that her pains were as bad as ever; and, when she
looked at me as she said this with a sly look of satisfaction at

(5) FRAULEIN ELISABETH VON R. (FREUD) 145

my discomfiture, I could not help being reminded of old Herr
von R.'s judgement about his favourite daughter that she
was often 'cheeky' and 'ill-behaved'. But I was obliged to
admit that she was in the right.

If I had stopped the patient's psychical treatment at this
stage, the case of Fraulein Elisabeth von R. would clearly have
thrown no light on the theory of hysteria. But I continued my
analysis because I firmly expected that deeper levels of her
consciousness would yield an understanding both of the causes
and the specific determinants of the hysterical symptoms. I
therefore decided to put a direct question to the patient in an
enlarged state of consciousness and to ask her what psychical
impression it had been to which the first emergence of pains in
her legs had been attached.

With this end in view I proposed to put the patient into a
deep hypnosis. But, unfortunately, I could not help observing
that my procedure failed to put her into any state other than
the one in which she had made her recital. I was glad enough
that on this occasion she refrained from triumphantly pro-
testing: 'I'm not asleep, you know; I can't be hypnotized.'
In this extremity the idea occurred to me of resorting to the
device of applying pressure to the head, the origin of which I
have described in full in the case history of Miss Lucy [p. 107 ff.].
I carried this out by instructing the patient to report to me
faithfully whatever appeared before her inner eye or passed
through her memory at the moment of the pressure. She re-
mained silent for a long time and then, on my insistence,
admitted that she had thought of an evening on which a
young man had seen her home after a party, of the conversation
that had taken place between them and of the feelings with
which she had returned home to her father's sick-bed.

This first mention of the young man opened up a new vein
of ideas the contents of which I now gradually extracted. It
was a question here of a secret, for she had initiated no one,
apart from a common friend, into her relations with the young
man and the hopes attached to them. He was the son of a
family with which they had long been on friendly terms and
who lived near their former estate. The young man, who was
himself an orphan, was devotedly attached to her father and
followed his advice in pursuing his career. He had extended

146 II. CASE HISTORIES

his admiration for her father to the ladies of the family. Numer-
ous recollections of reading together, of exchanging ideas, and
of remarks made by him which were repeated to her by other
people, bore witness to the gradual growth in her of a con-
viction that he loved, her and understood her and that marriage
with him would not involve the sacrifices on her part which
she dreaded from marriage in general. Unluckily, he was
scarcely any older than herself and was still far from being
self-supporting. But she was firmly determined to wait for him.

After her father had fallen seriously ill and she had been so
much taken up with looking after him, her meetings with her
friend became more and more rare. The evening which she had
first remembered represented what had actually been the
climax of her feeling; but even then there had been no eclair-
cissement between them. On that occasion she had allowed her-
self to be persuaded, by the insistence of her family and of her
father himself, to go to a party at which she was likely to
meet him. She had wanted to hurry home early but had been
pressed to stay and had given way when he promised to see
her home. She had never had such warm feelings towards him
as while he was accompanying her that evening. But when she
arrived home late in this blissful frame of mind, she found her
father was worse and reproached herself most bitterly for hav-
ing sacrificed so much time to her own enjoyment. This was
the last time she left her sick father for a whole evening. She
seldom met her friend after this. After her father's death the
young man seemed to keep away from her out of respect for
her sorrow. The course of his life then took him in other
directions. She had to familiarize herself by degrees with the
thought that his interest in her had been displaced by others
and that she had lost him. But this disappointment in her first
love still hurt her whenever she thought of him.

It was therefore in this relationship and in the scene des-
cribed above in which it culminated that I could look for the
causes of her first hysterical pains. The contrast between the
blissful feelings she had allowed herself to enjoy on that occasion
and the worsening of her father's state which had met her on
her return home constituted a conflict, a situation of incom-
patibility. The outcome of this conflict was that the erotic idea
was repressed from association and the affect attaching to that
idea was used to intensify or revive a physical pain which was

(5) FRAULEIN ELISABETH VON R. (FREUD) 147

present simultaneously or shortly before. Thus it was an in-
stance of the mechanism of conversion for the purpose of de-
fence, which I have described in detail elsewhere. 1

A number of comments might of course be made at this
point. I must emphasize the fact that I did not succeed in
establishing from her memory that the conversion took place
at the moment of her return home. I therefore looked about
for similar experiences during the time she was nursing her
father and elicited a number of them. Among these, special
prominence attached, on account of their frequent occurrence,
to scenes in which, at her father's call, she had jumped out of
bed with bare feet in a cold room. I was inclined to attribute
some importance to these factors, since in addition to com-
plaining about the pain in her legs she also complained of
tormenting sensations of cold. Nevertheless, even here I was
unable to get hold of any scene which it was possible to identify
as that at which the conversion had occurred. I was inclined
for this reason to think that there was a gap in the explanation
at this point, until I recollected that the hysterical pains in the
legs had in fact not made their appearance during the period
when she was nursing her father. She only remembered a
single attack of pain, which had only lasted a day or two and
had not attracted her attention [p. 140], I now directed my
enquiries to this first appearance of the pains. I succeeded in
reviving the patient's memory of it with certainty. At that very
time a relative had visited them and she had been unable to
receive him, owing to being laid up in bed. This same man had
been unlucky enough, when he visited them again two years
later, to find her in bed once more. But in spite of repeated
attempts we failed to trace any psychical cause for the first
pains. I thought it safe to assume that they had in fact appeared
without any psychical cause and were a mild rheumatic
affection; and I was able to establish that this organic disorder,
which was the model copied in her later hysteria, had in any
case to be dated before the scene of her being accompanied
back from the party. From the nature of things it is nevertheless
possible that these pains, being of organic origin, may have
persisted for some time to a mitigated degree without being
very noticeable. The obscurity due to the fact that the analysis

1 [See Freud's first paper on 'The Neuro-Psychoses of Defence'
(18940), and the footnote on p. 10 above.]

148 II. CASE HISTORIES

pointed to the occurrence of a conversion of psychical excitation
into physical pain though that pain was certainly not perceived
at the time in question or remembered afterwards this is a
problem which I hope to be able to solve later on the basis
of further considerations and later examples. 1 [See below,
p. 168 ff.]

The discovery of the reason for the first conversion opened
a second, fruitful period of the treatment. The patient sur-
prised me soon afterwards by announcing that she now knew
why it was that the pains always radiated from that particular
area of the right thigh and were at their most painful there:
it was on this place that her father used to rest his leg every
morning, while she renewed the bandage round it, for it was
badly swollen. This must have happened a good hundred
times, yet she had not noticed the connection till now. In
this way she gave me the explanation that I needed of the
emergence of what was an atypical hysterogenic zone. Further,
her painful legs began to 'join in the conversation' during our
analyses. [See p. 296.] What I have in mind is the following
remarkable fact. As a rule the patient was free from pain when
we started work. If, then, by a question or by pressure upon
her head I called up a memory, a sensation of pain would make
its first appearance, and this was usually so sharp that the
patient would give a start and put her hand to the painful spot.
The pain that was thus aroused would persist so long as she
was under the influence of the memory; it would reach its
climax when she was in the act of telling me the essential and
decisive part of what she had to communicate, and with the
last word of this it would disappear. I came in time to use
such pains as a compass to guide me; if she stopped talking but
admitted that she still had a pain, I knew that she had not
told me everything, and insisted on her continuing her story
till the pain had been talked away. Not until then did I arouse
a fresh memory.

During this period of 'abreaction' the patient's condition,
both physical and mental, made such a striking improvement
that I used to say, only half-jokingly, that I was taking away a

1 I cannot exclude the possibility, though I cannot establish the fact,
that these pains, which chiefly affected the thighs, were of a neuras-
thenic nature. [Cf. p. 175 n.]

(5) FRAULEIN ELISABETH VON R. (FREUD) 149

certain amount of her motives for pain every time arid that
when I had cleared them all away she would be well. She soon
got to the point of being without pain most of the time; she
allowed herself to be persuaded to walk about a great deal and
to give up her former isolation. In the course of the analysis I
sometimes followed the spontaneous fluctuations in her condi-
tion; and I sometimes followed my own estimate of the situation
when I considered that I had not completely exhausted some
portion of the story of her illness.

During this work I made some interesting observations,
whose lessons I subsequently found confirmed in treating
other patients. As regards the spontaneous fluctuations, in the
first place, I found that in fact none had occurred which had
not been provoked by association with some contemporary
event. On one occasion she had heard of an illness of one of her
acquaintances which reminded her of a detail of her father's
illness; another time her dead sister's child had been on a visit
to them, and its likeness to its mother had stirred up her feelings
of grief; and yet another time a letter from her distant sister
showed clear evidence of her unfeeling brother-in-law's influ-
ence and gave rise to a pain which required her to produce the
story of a family scene which she had not yet told me about.
Since she never brought up the same precipitating cause of a
pain twice over, it seemed that we were justified in supposing
that we should in this way exhaust the stock of them; and I
therefore did not hesitate to get her into situations which were
calculated to bring up fresh memories which had not yet
reached the surface. For instance, I sent her to visit her sister's
grave, and I encouraged her to go to a party at which she
might once more come across the friend of her youth.

In the next place, I obtained some insight into the manner
of origin of what might be described as a 'monosymptomatic'
hysteria. For I found that her right leg became painful under
hypnosis when the discussion turned on her nursing her sick
father, on her relations with the friend of her youth or on other
events falling within the first period of her pathogenic experi-
ences; on the other hand, the pain made its appearance in her
other, left, leg as soon as I stirred up a memory relating to her
dead sister or her two brothers-in-law in short, to an impres-
sion from the second half of the story of her illness. Having
thus had my attention aroused by the regularity of this relation,

150 II. CASE HISTORIES

I carried my investigation further and formed an impres-
sion that this differentiation went still further and that every
fresh psychical determinant of painful sensations had become
attached to some fresh spot in the painful area of her legs. The
original painful spot in her right thigh had related to her
nursing her father; the area of pain had extended from this
spot to neighbouring regions as a result of fresh traumas. Here,
therefore, what we were dealing with was not strictly speaking
a single physical symptom, linked with a variety of mnemic
complexes in the mind, but a number of similar symptoms
which appeared, on a superficial view, to be merged into one
symptom. But I did not pursue further the delimitation of
zones of pain corresponding to different psychical determinants,
since I found that the patient's attention was directed away
from this subject.

I did, however, turn my attention to the way in which the
whole symptomatic complex of abasia might have been built
up upon these painful zones, and in that connection I asked
her various questions, such as what was the origin of her pains
in walking? in standing? and in lying down? Some of these
questions she answered spontaneously, some under the pressure
of my hand. Two things emerged from this. In the first place
she divided all the scenes with painful impressions attached to
them into groups for me, according as she had experienced
them while she was sitting or standing, and so on. For instance,
she was standing by a door when her father was brought home
with his heart attack [p. 140], and in her fright she stood stock
still as though she was rooted to the ground. She went on to
add a number of other memories to this first example of fright
while she was standing, till she came to the fearful scene in
which once again she stood, as though spellbound, by her
sister's death-bed [pp. 142-3]. This whole chain of memories
might be expected to show that there was a legitimate con-
nection between her pains and standing up; and it might indeed
be accepted as evidence of an association. But we must bear in
mind that another factor must be proved to be present in all
these events, one which directed her attention precisely to her
standing (or, as the case may be, to her walking, sitting, etc.)
and consequently led to conversion. The explanation of her
attention taking this direction can scarcely be looked for else-
where than in the circumstance that walking, standing and

(5) FRAULEIN ELISABETH VON R. (FREUD) 151

lying are functions and states of those parts of her body which
in her case comprised the painful zones, namely, her legs. It
was therefore easy in the present case to understand the con-
nection between the astasia-abasia and the first occurrence of
conversion.

Among the episodes which, according to this catalogue,
seemed to have made walking painful, one received special
prominence: a walk which she had taken at the health resort
in the company of a number of other people [p. 142] and which
was supposed to have been too long. The details of this episode
only emerged with hesitation and left several riddles unsolved.
She had been in a particularly yielding mood, and eagerly
joined her party of friends. It was a fine day, not too hot. Her
mother stopped at home and her elder sister had already gone
away. Her younger sister felt unwell, but did not want to spoil
her enjoyment; the brother-in-law began by saying that he
would stay with his wife, but afterwards decided to join the
party on Elisabeth's account. This scene seemed to have had a
great deal to do with the first appearance of the pains, for she
remembered being very tired and suffering from violent pain
when she returned from the walk. She said, however, that she
was not certain whether she had already noticed the pains
before this. I pointed out to her that she was unlikely to have
undertaken such a long walk if she had had any considerable
pains. I asked her what it was in the walk that might have
brought on the pain and she gave me the somewhat obscure
reply that the contrast between her own loneliness and her sick
sister's married happiness (which her brother-in-law's be-
haviour kept constantly before her eyes) had been painful to her.

Another scene, which was very close to the former one in
time, played a part in linking the pains with sitting. It was a
few days later. Her sister and brother-in-law had already left
the place. She found herself in a restless, yearning mood. She
rose early in the morning and climbed a small hill to a spot
which they had often been to together and which afforded a
lovely view. She sat down there on a stone bench and gave
herself up to her thoughts. These were once again concerned
with her loneliness and the fate of her family; and this time
she openly confessed to a burning wish that she might be as
happy as her sister. She returned from this morning medita-
tion with violent pains, and that same evening had the bath after

152 II. CASE HISTORIES

which the pains made their final and permanent appearance
[p. 142].

It was further shown without any doubt that her pain in
walking and standing used, to begin with, to be allayed when
she was lying down. The pains were not linked to lying down as
well until, after hearing the news of her sister's illness, she
travelled back from Gastein [loc. cit] and was tormented dur-
ing the night alike by. worry about her sister and by raging
pains, as she lay, sleepless, stretched out in the railway carriage.
And for quite a time after this, lying down was actually more
painful to her than walking or standing.

In this way, firstly, the painful region had been extended by
the addition of adjacent areas: every fresh theme which had
a pathogenic effect had cathected a new region in the legs;
secondly, each of the scenes which made a powerful impression
on her had left a trace behind it, bringing about lasting and
constantly accumulating cathexis of the various functions of
the legs, a linking of these functions with her feelings of pain.
But a third mechanism had unmistakably been involved in the
building up of her astasia-abasia. The patient ended her des-
cription of a whole series of episodes by complaining that they
had made the fact of her 'standing alone' painful to her. In
another series of episodes, which comprised her unsuccessful
attempts to establish a new life for her family, she was never
tired of repeating that what was painful about them had been
her feeling of helplessness, the feeling that she could not 'take
a single step forward'. In view of this, I was forced to suppose
that among the influences that went to the building up of her
abasia, these reflections of hers played a part; I could not help
thinking that the patient had done nothing more nor less than
look for a symbolic expression of her painful thoughts and that
she had found it in the intensification of her sufferings. The
fact that somatic symptoms of hysteria can be brought about
by symbolization of this kind was already asserted in our
'Preliminary Communication' [p. 5]. In the Discussion on
the present case I shall bring forward two or three conclusive
instances of this. [See p. 1 76 ff.] This psychical mechanism of
symbolization did not play a prominent part with Fraulein
Elisabeth von R. It did not create her abasia. But everything
goes to show that tho abasia which was already present received
considerable reinforcement in this way. Accordingly, this

(5) FRAULEIN ELISABETH VON R. (FREUD) 153

abasia, at the stage of development at which I came across it,
was to be equated not only with a functional paralysis based on
psychical associations but also with one based on symbolization.
Before I resume my account of the case I will add a few
words on the patient's behaviour during this second phase of
the treatment. Throughout the analysis I made use of the
technique of bringing out pictures and ideas by means of
pressing on the patient's head, a method, that is, which would
be unworkable without the patient's full co-operation and wil-
ling attention. [Cf. p. 1 10 f.j Sometimes, indeed, her behaviour
fulfilled my highest expectations, and during such periods it
was surprising with what promptitude the different scenes
relating to a given theme emerged in a strictly chronological
order. It was as though she were reading a lengthy book of
pictures, whose pages were being turned over before her eyes.
At other times there seemed to be impediments of whose nature
I had no suspicion then. When I pressed her head she would
maintain that nothing occurred to her. I would repeat my
pressure and tell her to wait, but still nothing appeared. The
first few times when this recalcitrance exhibited itself I allowed
myself to be led into breaking off the work: it was an un-
favourable day; we would try another time. Two observations,
however, decided me to alter my attitude. I noticed, in the
first place, that the method failed in this way only when I found
Elisabeth in a cheerful state and free from pain, never when
she was feeling badly. In the second place, that she often made
such assertions as that she saw nothing, after she had allowed
a long interval to pass during which her tense and preoccupied
expression of face nevertheless betrayed the fact that a mental
process was taking place in her. I resolved, therefore, to adopt
the hypothesis that the procedure never failed: that on every
occasion under the pressure of my hand some idea occurred to
Elisabeth or some picture came before her eyes, but that she
was not always prepared to communicate it to me, and tried
to suppress once more what had been conjured up. I could
think of two motives for this concealment. Either she was
applying criticism to the idea, which she had no right to do,
on the ground of its not being important enough or of its being
an irrelevant reply to the question she had been asked; or she
hesitated to produce it because she found it too disagreeable
to tell. I therefore proceeded as though I was completely

154 II. CASE HISTORIES

convinced of the trustworthiness of my technique. I no longer
accepted her declaration that nothing had occurred to her,
but assured her that something must have occurred to her.
Perhaps, I said, she had not been sufficiently attentive, in
which case I should be glad to repeat my pressure. Or perhaps
she thought that her idea was not the right one. This, I told her,
was not her affair; she was under an obligation to remain
completely objective and say what had come into her head,
whether it was appropriate or not. Finally I declared that I
knew very well that something had occurred to her and that
she was concealing it from me; but she would never be free of
her pains so long as she concealed anything. By thus insisting,
I brought it about that from that time forward my pressure on
her head never failed in its effect. I could not but conclude
that I had formed a correct opinion of the state of affairs, and
I derived from this analysis a literally unqualified reliance on
my technique. It often happened that it was not until I had
pressed her head three times that she produced a piece of
information; but she herself would remark afterwards: 'I could
have said it to you the first time.' 'And why didn't you?' *I
thought it wasn't what was wanted', or 'I thought I could,avoid
it, but it came back each time.' In the course of this difficult
work I began to attach a deeper significance to the resistance
offered by the patient in the reproduction of her memories and
to make a careful collection of the occasions on which it was
particularly marked. 1

I have now arrived at the third period of the treatment. The
patient was better. She had been mentally relieved and was
now capable of successful effort. But her pains had manifestly
not been removed; they recurred from time to time, and with all
their old severity. This incomplete therapeutic result corres-
ponded to an incompleteness in the analysis. I still did not
know exactly at what moment and by what mechanism the
pains had originated. During the reproduction of the great
variety of scenes in the second period and while I was observing
the patient's resistance to telling me about them, I had formed
a particular suspicion. I did not venture yet, however, to adopt
it as the basis of my further action. But a chance occurrence

1 [This is the first mention of the important clinical fact of 'resistance'.
It is discussed at greater length below, p. 268 ff.]

(5) FRAULEIN ELISABETH VON R. (FREUD) 155

decided the matter. One day while I was working with the
patient, I heard a man's footsteps in the next room and a
pleasant voice which seemed to be asking some question. My
patient thereupon got up and asked that we might break off for
the day: she had heard her brother-in-law arrive and enquire for
her. Up to that point she had been free from pain, but after the
interruption her facial expression and gait betrayed the sudden
emergence of severe pains. My suspicion was strengthened by
this and I determined to precipitate the decisive explanation.
I therefore questioned her about the causes and circum-
stances of the first appearance of the pains. By way of answer
her thoughts turned towards her summer visit to the health
resort before her journey to Gastein, and a number of scenes
turned up once more which had not been treated very com-
pletely. She recalled her state of feeling at the time, her
exhaustion after her anxieties about her mother's eyesight and
after having nursed her at the time of her operation, and her
final despair of a lonely girl like her being able to get any
enjoyment out of life or achieve anything in it. Till then she
had thought herself strong enough to be able to do without the
help of a man; but she was now overcome by a sense of her
weakness as a woman and by a longing for love in which, to
quote her own words, her frozen nature began to melt. In this
mood she was deeply affected by her second sister's happy
marriage by seeing with what touching care he looked after
her, how they understood each other at a single glance and how
sure they seemed to be of each other. It was no doubt to be
regretted that the second pregnancy followed so soon after the
first, and her sister knew that this was the reason of her illness;
but how willingly she bore it because he was its cause. On the
occasion of the walk which was so intimately connected with
Elisabeth's pains, her brother-in-law had at first been unwilling
to join in it and had wanted to stay by his sick wife. She,
however, persuaded him with a look to go with them, because
she thought it would give Elisabeth pleasure. Elisabeth re-
mained in his company all through the walk. They discussed
every kind of subject, among them the most intimate ones. She
found herself in complete agreement with everything he said,
and a desire to have a husband like him became very strong in
her. Then, a few days later, came the scene on the morning
after the departure of her sister and brother-in-law when she

156 II. CASE HISTORIES

made her way to the place with a view, which had been a
favourite object of their walks. There she sat down and dreamt
once again of enjoying such happiness as her sister's and of
finding a husband who would know how to capture her heart
like this brother-in-law of hers. She was in pain when she stood
up, but it passed off once more. It was not until the afternoon,
when she had had the warm bath, that the pains broke out, and
she was never again free from them. I tried to discover what
thoughts were occupying her mind while she was having the
bath; but I learnt only that the bath-house had reminded her
of the members of her family who had gone away, because
that was the building in which they had stayed.

It had inevitably become clear to me long since what all this
was about; but the patient, deep in her bitter-sweet memories,
seemed not to notice the end to which she was steering, and
continued to reproduce her recollections. She went on to her
visit to Gastein, the anxiety with which she looked forward to
every letter, finally the bad news about her sister, the long wait
till the evening, which was the first moment at which they
could get away from Gastein, then the journey, passed in
tormenting uncertainty, and the sleepless night all of these
accompanied by a violent increase in her pains. I asked her
whether during the journey she had thought of the grievous
possibility which was afterwards realized. She answered that
she had carefully avoided the thought, but she believed that
her mother had from the beginning expected the worst. Her
memories now went on to their arrival in Vienna, the im-
pression made on them by the relatives who met them, the
short journey from Vienna to the summer resort in its neigh-
bourhood where her sister lived, their reaching there in the
evening, the hurried walk through the garden to the door of
the small garden house, the silence within and the oppressive
darkness; how her brother-in-law was not there to receive
them, and how they stood before the bed and looked at her
sister as she lay there dead. At that moment of dreadful
certainty that her beloved sister was dead without bidding
them farewell and without her having eased her last days with
her care at that very moment another thought had shot
through Elisabeth's mind, and now forced itself irresistibly upon
her once more, like a flash of lightning in the dark: 'Now he is
free again and I can be his wife.'

(5) FRAULEIN ELISABETH VON R. (FREUD) 157

Everything was now clear. The analyst's labours were richly
rewarded. The concepts of the Tending off' of an incompatible
idea, of the genesis of hysterical symptoms through the con-
version of psychical excitations into something physical and the
formation of a separate psychical group through the act of will
which led to the fending-off all these things were, in that
moment, brought before my eyes in concrete form. Thus and
in no other way had things come about in the present case.
This girl felt towards her brother-in-law a tenderness whose
acceptance into consciousness was resisted by her whole moral
being. She succeeded in sparing herself the painful conviction
that she loved her sister's husband, by inducing physical pains
in herself instead; and it was in the moments when this con-
viction sought to force itself upon her (on her walk with him,
during her morning reverie, in the bath, by her sister's bedside)
that her pains had come on, thanks to successful conversion.
At the time when I started her treatment the group of ideas
relating to her love had already been separated from her
knowledge. Otherwise she would never, I think, have agreed
to embarking on the treatment. The resistance with which she
had repeatedly met the reproduction of scenes which operated
traumatically corresponded in fact to the energy with which
the incompatible idea had been forced out of her associations.

The period that followed, however, was a hard one for the
physician. The recovery of this repressed idea had a shattering
effect on the poor girl. She cried aloud when I put the situation
drily before her with the words: 'So for a long time you had
been in love with your brother-in-law.' She complained at this
moment of the most frightful pains, and made one last desperate
effort to reject the explanation: it was not true, I had talked
her into it, it could not be true, she was incapable of such
wickedness, she could never forgive herself for it. It was easy to
prove to her that what she herself had told me admitted of no
other interpretation. But it was a long time before my two
pieces of consolation that we are not responsible for our
feelings, and that her behaviour, the fact that she had fallen
ill in these circumstances, was sufficient evidence of her moral
character it was a long time before these consolations of mine
made any impression on her.

In order to mitigate the patient's sufferings I had now to
proceed along more than one path. In the first place I wanted

158 II. CASE HISTORIES

to give her an opportunity of getting rid of the excitation that
had been piling up so long, by 'abreacting' it. We probed into
the first impressions made on her in her relations with her
brother-in-law, the beginning of the feelings for him which she
had kept unconscious. Here we came across all the little pre-
monitory signs and intuitions of which a fully-grown passion
can make so much in retrospect. On his first visit to the house
he had taken her for the girl he was to marry and had greeted
her before her elder but somewhat insignificant-looking sister.
One evening they were carrying on such a lively conversation
together and seemed to be getting on so well that his fiancee
had interrupted them half-seriously with the remark: 'The
truth is, you two would have suited each other splendidly.'
Another time, at a party where they knew nothing of his en-
gagement, the young man was being discussed and a lady
criticized a defect in his figure which suggested that he had had
a disease of the bones in his childhood. His fiancee herself
litsened quietly, but Elisabeth flared up and defended the
symmetry of her future brother-in-law's figure with a zeal
which she herself could not understand. As we worked through
these recollections it became clear to Elisabeth that her tender
feeling for her brother-in-law had been dormant in her for a
long time, perhaps even from the beginning of her acquaintance
with him, and had lain concealed all that time behind the
mask of mere sisterly affection, which her highly-developed
family feeling could enable her to accept as natural.

This process of abreaction certainly did her much good. But
I was able to relieve her still more by taking a friendly interest
in her present circumstances. With this end in view I arranged
for an interview with Frau von R. I found her an understanding
and sensitive lady, though her vital spirits had been reduced by
her recent misfortunes. I learned from her that on closer ex-
amination the charge of unfeeling blackmail which had been
brought by the elder brother-in-law against the widower and
which had been so painful to Elisabeth had had to be with-
drawn. No stain was left on the young man's character. It was a
misunderstanding due to the different value which, as can
readily be seen, would be attached to money by a business man,
to whom money is a tool of his trade, and a civil servant.
Nothing more than this remained of the painful episode. I
begged her mother from that time forward to tell Elisabeth

(5) FRAULEIN ELISABETH VON R. (FREUD) 159

everything she needed to know, and in the future to give her
the opportunity for unburdening her mind to which I should
have accustomed her.

I was also, of course, anxious to learn what chance there was
that the girl's wish, of which she was now conscious, would
come true. Here the prospects were less favourable. Her mother
told me that she had long ago guessed Elisabeth's fondness for
the young man, though she had not known that the feeling had
already been there during her sister's lifetime. No one seeing
the two of them together though in fact this had now become
a rare event could doubt the girl's anxiety to please him. But,
she told me, neither she (the mother) nor the family advisers
were particularly in favour of a marriage. The young man's
health was by no means good and had received a fresh set-back
from the death of his beloved wife. It was not at all certain,
either, that his mental state was yet sufficiently recovered for
him to contract a new marriage. This was perhaps why he was
behaving with so much reserve; perhaps, too, it was because
he was uncertain of his reception and wished to avoid comments
that were likely to be made. In view of these reservations on
both sides, the solution for which Elisabeth longed was un-
likely to be achieved.

I told the girl what I had heard from her mother and had
the satisfaction of benefiting her by giving her the explanation
of the money affair. On the other hand I encouraged her to
face with calmness the uncertainty about the future which it
was impossible to clear up. But at this point the approach of
summer made it urgent for us to bring the analysis to an end.
Her condition was once more improved and there had been no
more talk of her pains since we had been investigating their
causes. We both had a feeling that we had come to a finish,
though I told myself that the abreaction of the love she had so
long kept down had not been carried out very fully. I regarded
her as cured and pointed out to her that the solution of her
difficulties would proceed on its own account now that the path
had been opened to it. This she did not dispute. She left Vienna
with her mother to meet her eldest sister and her family and
to spend the summer together.

I have a few words to add upon the further course of Fraulein
Elisabeth von R.'s case. Some weeks after we had separated I
received a despairing letter from her mother. At her first

160 II. CASE HISTORIES

attempt, she told me, to discuss her daughter's affairs of the
heart with her, the girl had rebelled violently and had since
then suffered from severe pains once more. She was indignant
with me for having betrayed her secret. She was entirely in-
accessible, and the treatment had been a complete failure.
What was to be done now? she asked. Elisabeth would have
nothing more to do with me. I did not reply to this. It stood to
reason that Elisabeth after leaving my care would make one
more attempt to reject her mother's intervention and once
more take refuge in isolation. But I had a kind of conviction
that everything would come right and that the trouble I had
taken had not been in vain. Two months later they were back
in Vienna, and the colleague to whom I owed the introduction
of the case gave me news that Elisabeth felt perfectly well and
was behaving as though there was nothing wrong with her,
though she still suffered occasionally from slight pains. Several
times since then she has sent me similar messages and each
time promised to come and see me. But it is a characteristic
of the personal relationship which arises in treatments of this
kind that she has never done so. As my colleague assures me,
she is to be regarded as cured. Her brother-in-law's connection
with the family has remained unaltered.

In the spring of 1894 I heard that she was going to a private
ball for which I was able to get an invitation, and I did not
allow the opportunity to escape me of seeing my former patient
whirl past in a lively dance. Since then, by her own inclination,
she has married someone unknown to me.

DISCUSSION

I have not always been a psychotherapist. Like other neuro-
pathologists, I was trained to employ local diagnoses and
electro-prognosis, and it still strikes me myself as strange that
the case histories I write should read like short stories and that,
as one might say, they lack the serious stamp of science. I must
console myself with the reflection that the nature of the subject
is evidently responsible for this, rather than any preference of
my own. The fact is that local diagnosis and electrical reactions
lead nowhere in the study of hysteria, whereas a detailed des-
cription of mental processes such as we are accustomed to find
in the works of imaginative writers enables me, with the use of a

(5) FRAULEIN ELISABETH VON R. (FREUD) 161

few psychological formulas, to obtain at least some kind of in-
sight into the course of that affection. Case histories of this kind
are intended to be judged like psychiatric ones; they have,
however, one advantage over the latter, namely an intimate
connection between the story of the patient's sufferings and the
symptoms of his illness a connection for which we still search
in vain in the biographies of other psychoses.

In reporting the case of Fraulein Elisabeth von R. I have
endeavoured to weave the explanations which I have been able
to give of the case into my description of the course of her
recovery. It may perhaps be worth while to bring together the
important points once more. I have described the patient's
character, the features which one meets with so frequently in
hysterical people and which there is no excuse for regarding as
a consequence of degeneracy: her giftedness, her ambition, her
moral sensibility, her excessive demand for love which, to begin
with, found satisfaction in her family, and the independence of
her nature which went beyond the feminine ideal and found ex-
pression in a considerable amount of obstinacy, pugnacity and
reserve. No appreciable hereditary taint, so my colleague told
me, could be traced on either side of her family. It is true that
her mother suffered for many years from a neurotic depression
which had not been investigated; but her mother's brothers
and sisters and her father and his family could be regarded as
well-balanced people free from nervous trouble. No severe case
of neuro- psychosis had occurred among her close relatives.

Such was the patient's nature, which was now assailed by
painful emotions, beginning with the lowering effect of nursing
her beloved father through a long illness.

There are good reasons for the fact that sick-nursing plays
such a significant part in the prehistory of cases of hysteria. A
number of the factors at work in this are obvious: the disturb-
ance of one's physical health arising from interrupted sleep, the
neglect of one's own person, the effect of constant worry on
one's vegetative functions. But, in my view, the most important
determinant is to be looked for elsewhere. Anyone whose mind
is taken up by the hundred and one tasks of sick-nursing which
follow one another in endless succession over a period of weeks
and months will, on the one hand, adopt a habit of suppressing
every sign of his own emotion, and on the other, will soon

162 II. CASE HISTORIES

divert his attention away from his own impressions, since he
has neither time nor strength to do justice to them. Thus he
will accumulate a mass of impressions which are capable of
affect, which are hardly sufficiently perceived and which, in
any case, have not been weakened by abreaction. He is creating
material for a 'retention hysteria 5 . 1 If the sick person recovers,
all these impressions, of course, lose their significance. But if he
dies, and the period of mourning sets in, during which the only
things that seem to have value are those that relate to the
person who has died, these impressions that have not yet been
dealt with come into the picture as well; and after a short
interval of exhaustion the hysteria, whose seeds were sown
during the time of nursing, breaks out.

We also occasionally come across this same fact of the traumas
accumulated during sick-nursing being dealt with subsequently,
where we get no general impression of illness but where the
mechanism of hysteria is nevertheless retained. Thus I am
acquainted with a highly-gifted lady who suffers from slight
nervous states and whose whole character bears evidence of
hysteria, though she has never had to seek medical help or been
unable to carry on her duties. She has already nursed to the
end three or four of those whom she loved. Each time she
reached a state of complete exhaustion; but she did not fall ill
after these tragic efforts. Shortly after her patient's death, how-
ever, there would begin in her a work of reproduction which
once more brought up before her eyes the scenes of the illness
and death. Every day she would go through each impression
once more, would weep over it and console herself at her
leisure, one might say. This process of dealing with her im-
pressions was dovetailed into her everyday tasks without the
two activities interfering with each other. The whole thing
would pass through her mind in chronological sequence. I
cannot say whether the work of recollection corresponded day
by day with the past. I suspect that this depended on the
amount of leisure which her current household duties allowed. 2

In addition to these outbursts of weeping with which she
made up arrears and which followed close upon the fatal ter-

1 [See p. 211 and footnote.]

1 [In this account of the 'work of recollection* Freud seems to be
anticipating the 'work of mourning* which he described much later in
his paper 'Mourning and Melancholia' (1917*).]

(5) FRAULEIN ELISABETH VON R. (FREUD) 163

initiation of the illness, this lady celebrated annual festivals of
remembrance at the period of her various catastrophes, and on
these occasions her vivid visual reproduction and expressions
of feeling kept to the date precisely. For instance, on one
occasion I found her in tears and asked her sympathetically
what had happened that day. She brushed aside my question
half-angrily: 'Oh no,' she said, 'it is only that the specialist was
here again to-day and gave us to understand that there was no
hope. I had no time to cry about it then.' She was referring to
the last illness of her husband, who had died three years earlier.
I should be very much interested to know whether the scenes
which she celebrated at these annual festivals of remembrance
were always the same ones or whether different details pre-
sented themselves for abreaction each time, as I suspect in view
of my theory. 1 But I cannot discover with certainty. The lady,

1 I once learnt to my surprise that an 'abreaction of arrears' of this
kind though the impressions concerned were not derived from sick-
nursing can form the subject-matter of an otherwise puzzling neurosis.
This was so in the case of Fraulein Mathilde H., a good-looking,
nineteen-year-old girl. When I first saw her she was suffering from a
partial paralysis of the legs. Some months later, however, she came
to me for treatment on account of a change in her character. She had
become depressed to the point of a taedium vitae, utterly inconsiderate
to her mother, irritable and inaccessible. The patient's picture as a
whole forbad my assuming that this was a common melancholia. She
was very easily put into a state of deep somnambulism, and I availed
myself of this peculiarity of hers in order to give her commands and
suggestions at every visit. She listened to these in deep sleep, to the
accompaniment of floods of tears; but, apart from this, they caused
very little change in her condition. One day she became talkative in her
hypnosis and told me that the cause of her depression was the breaking
off of her engagement, which had occurred several months earlier.
Closer acquaintance with her fiance had brought out more and more
things that were unwelcome to her and her mother. On the other hand,
the material advantages of the connection had been too obvious for it to
be easy to decide to break it off. So for a long time they had both
wavered and she herself had fallen into a state of indecision in which
she regarded all that happened to her with apathy. In the end her
mother uttered the decisive negative on her behalf. A little later she
had woken up as though from a dream and begun to occupy her
thoughts busily with the decision that had already been made and to
weigh the pros and cons. This process, she told me, was still going on:
she was living in the period of doubt, and every day she was possessed
by the mood and thoughts which were appropriate to the day in the
past with which she was occupied. Her irritability with her mother,
too, had its basis only in the circumstances which prevailed at that

164 II. CASE HISTORIES

who had no less strength of character than intelligence, was
ashamed of the violent effect produced in her by these
reminiscences.

I must emphasize once more: this woman is not ill; her
postponed abreaction was not a hysterical process, however
much it resembled one. We may ask why it should be that one
instance of sick-nursing should be followed by a hysteria and
another not. It cannot be a matter of individual predisposition,
for this was present to an ample degree in the lady I have in
mind.

But I must now return to Fraulein Elisabeth von R. While
she was nursing her father, as we have seen, she for the first
time developed a hysterical symptom a pain in a particular
area of her right thigh. It was possible by means of analysis to
find an adequate elucidation of the mechanism of the symptom.
It happened at a moment when the circle of ideas embracing
her duties to her sick father came into conflict with the content
of the erotic desire she was feeling at the time. Under the
pressure of lively self-reproaches she decided in favour of the
former, and in doing so brought about her hysterical pain.

According to the view suggested by the conversion theory of
hysteria what happened may be described as follows. She
repressed her erotic idea from consciousness and transformed
the amount of its affect into physical sensations of pain. It did
not become clear whether she was presented with this first
conflict on one occasion only or on several; the latter alternative
is the more likely. An exactly similar conflict though of higher
ethical significance and even more clearly established by the
analysis developed once more some years later and led to an
intensification of the same pains and to an extension beyond
their original limits. Once again it was a circle of ideas of an
erotic kind that came into conflict with all her moral ideas; for
her inclinations centred upon her brother-in-law, and, both

time. In comparison with these activities of her thoughts, her present
life seemed like a mere appearance of reality, like something in a
dream. I did not succeed in inducing the girl to talk again. I con-
tinued to address her while she was in deep somnambulism and saw her
burst into tears each time without ever answering me; and one day,
round about the anniversary of her engagement, her whole state of
depression passed off an event which brought me the credit of a great
therapeutic success by hypnotism.

(5) FRAULEIN ELISABETH VON R. (FREUD) 165

during her sister's lifetime and after her death, the thought of
being attracted by precisely this man was totally unacceptable
to her. The analysis provided detailed information about this
conflict, which constituted the central point in the history of the
illness. The germs of the patient's feeling for her brother-in-
law may have been present for a long time; its development was
favoured by physical exhaustion owing to more sick-nursing and
by moral exhaustion owing to disappointments extending over
many years. The coldness of her nature began to yield and she
admitted to herself her need for a man's love. During the several
weeks which she passed in his company at the health resort her
erotic feelings as well as her pains reached their full height.

The analysis, moreover, gave evidence that during the same
period the patient was in a special psychical state. The connec-
tion of this state with her erotic feelings and her pains seems to
make it possible to understand what happened on the lines of
the conversion theory. It is, I think, safe to say that at that time
the patient did not become clearly conscious of her feelings for
her brother-in-law, powerful though they were, except on a few
occasions, and then only momentarily. If it had been otherwise,
she would also inevitably have become conscious of the con-
tradiction between those feelings and her moral ideas and
would have experienced mental torments like those I saw her
go through after our analysis. She had no recollection of any
such sufferings; she had avoided them. It followed that her
feelings themselves did not become clear to her. At that time,
as well as during the analysis, her love for her brother-in-law
was present in her consciousness like a foreign body, without
having entered into relationship with the rest of her ideational
life. With regard to these feelings she was in the peculiar situa-
tion of knowing and at the same time not knowing a situation,
that is, in which a psychical group was cut off. But this and
nothing else is what we mean when we say that these feelings
were not clear to her. We do not mean that their consciousness
was of a lower quality or of a lesser degree, but that they were
cut off from any free associative connection of thought with the
rest of the ideational content of her mind.

But how could it have come about that an ideational group
with so much emotional emphasis on it was kept so isolated?
In general, after all, the part played in association by an idea
increases in proportion to the amount of its affect.

166 II. CASE HISTORIES

We can answer this question if we take into account two
facts which we can make use of as being established with
certainty. (1) Simultaneously with the formation of this separ-
ate psychical group the patient developed her hysterical pains.
(2) The patient offered strong resistance to the attempt to
bring about an association between the separate psychical group
and the rest of the content of her consciousness; and when, in
spite of this, the connection was accomplished she felt great
psychical pain. Our view of hysteria brings these two facts into
relation with the splitting of her consciousness by asserting that
the second of them indicates the motive for the splitting of con-
sciousness, while the first indicates its mechanism. The motive
was that of defence, the refusal on the part of the patient's
whole ego to come to terms with this ideational group. The
mechanism was that of conversion: i.e. in place of the mental
pains which she avoided, physical pains made their appearance.
In this way a transformation was effected which had the ad-
vantage that the patient escaped from an intolerable mental
condition; though, it is true, this was at the cost of a psychical
abnormality the splitting of consciousness that came about
and of a physical illness her pains, on which an astasia-
abasia was built up.

I cannot^ I must confess, give any hint of how a conversion
of this kind is brought about. It is obviously not carried
out in the same way as an intentional and voluntary action.
It is a process which occurs under the pressure of the motive
of defence in someone whose organization or a temporary
modification of it has a proclivity in that direction. 1

This theory calls for closer examination. We may ask: what
is it that turns into physical pain here? A cautious reply would
be: something that might have become, and should have become,
mental pain. If we venture a little further and try to represent
the ideational mechanism in a kind of algebraical picture, we
may attribute a certain quota of affect to the ideational com-
plex of these erotic feelings which remained unconscious, and
say that this quantity (the quota of affect) is what was converted.
It would follow directly from this description that the 'un-
conscious love' would have lost so much of its intensity through
a conversion of this kind that it would have been reduced to

1 [Cf. p. 122. The term 'somatic compliance' used in the 'Dora*
case (Standard Ed., 7, 40-2) may perhaps refer to this proclivity.]

(5) FRAULEIN ELISABETH VON R. (FREUD) 167

no more than a weak idea. This reduction of strength would
then have been the only thing which made possible the exist-
ence of these unconscious feelings as a separate psychical group.
The present case, however, is not well fitted to give a clear
picture of such a delicate matter. For in* this case there was
probably only partial conversion; in others it can be shown with
likelihood that complete conversion also occurs, and that in it
the incompatible idea has in fact been 'repressed', as only an
idea of very slight intensity can be. The patients concerned
declare, after associative connection with the incompatible idea
has been established, that their thoughts had not been con-
cerned with it since the appearance of the hysterical symptoms.
I have asserted [p. 165] that on certain occasions, though
only for the moment, the patient recognized her love for her
brother-in-law consciously. As an example of this we may
recall the moment when she was standing by her sister's bed
and the thought flashed through her mind: 'Now he is free and
you can be his wife' [p. 156]. I must now consider the sig-
nificance of these moments in their bearing on our view of the
whole neurosis. It seems to me that the concept of a 'defence
hysteria' in itself implies that at least one moment of this kind
ipust have occurred. Consciousness, plainly, does not know in
advance when an incompatible idea is going to crop up. The
incompatible idea, which, together with its concomitants, is
later excluded and forms a separate psychical group, must
originally have been in communication with the main stream of
thought. Otherwise the conflict which led to their exclusion
could not have taken place. 1 It is these moments, then, that are
to be described as 'traumatic': it is at these moments that con-
version takes place, of which the results are the splitting of
consciousness and the hysterical symptom. In the case of
Fraulein Elisabeth von R. everything points to there having
been several such moments the scenes of the walk, the morn-
ing reverie, the bath, and at her sister's bedside. It is even
possible that new moments of the same kind happened during
the treatment. What makes it possible for there to be several
of these traumatic moments is that an experience similar to the
one which originally introduced the incompatible idea adds

1 It is otherwise in hypnoid hysteria, where the content of the
separate psychical group would never have been in the ego-conscious-
ness. [Gf. p. 286.]

168 II. CASE HISTORIES

fresh excitation to the separated psychical group and so puts a
temporary stop to the success of the conversion. The ego is
obliged to attend to this sudden flare-up of the idea and to
restore the former state of affairs by a further conversion.
Fraulein Elisabeth, who was much in her brother-in-law's
company, must have been particularly liable to the occurrence
of fresh traumas. From the point of view of my present exposi-
tion, I should have preferred a case in which the traumatic
history lay wholly in the past.

I must now turn to a point which I have described [pp. 147-8]
as offering a diffictjty to the understanding of this case history.
On the evidence of the analysis, I assumed that a first conversion
took place while the patient was nursing her father, at the time
when her duties as a nurse came into conflict with her erotic
desires, and that what happened then was the prototype of the
later events in the Alpine health resort which led to the out-
break of the illness. But it appeared from the patient's account
that while she was nursing her father and during the time that
followed what I have described as the 'first period' she had
no pains whatever and no locomotor weakness. It is true that once
during her father's illness she was laid up for a few days with
pains in her legs, but it remained a question whether this attack
was already to be ascribed to hysteria. No causal connection
between these first pains and any psychical impression could
be traced in the analysis. It is possible, and indeed probable,
that what she was suffering from at that time were common
rheumatic muscular pains. Moreover, even if we were inclined
to suppose that this first attack of pains was the effect of a
hysterical conversion as a result of the repudiation of her erotic
thoughts at the time, the fact remains that the pains disappeared
after only a few days, so that the patient had behaved differ-
ently in reality from what she seemed to indicate in the analysis.
During her reproduction of what I have called the first period
she accompanied all her stories about her father's illness and
death, about her impressions of her dealings with her first
brother-in-law, and so on, with manifestations of pain, whereas
at the time of actually experiencing these impressions she had
felt no'ne. Is not this a contradiction which is calculated to
reduce very considerably our belief in the explanatory value
of an analysis such as this?

I believe I can solve this contradiction by assuming that the

(5) FRAULEIN ELISABETH VON R. (FREUD) 169

pains the products of conversion did not occur while the
patient was experiencing the impressions of the first period,
but only after the event, that is, in the second period, while
she was reproducing those impressions in her thoughts. That
is to say, the conversion did not take place in connection with
her impressions when they were fresh, but in connection with
her memories of them. I even believe that such a course of
events is nothing unusual in hysteria and indeed plays a regular
part in the genesis of hysterical symptoms. But since an assertion
like this is not self-evident, I will try to make it more plausible
by bringing forward some other instances.

It once happened to me that a new hysterical symptom
developed in a patient during the actual course of an analytic
treatment of this kind so that I was able to set about getting
rid of it on the day after its appearance. I will interpolate the
main features of the case at this point. It was a fairly simple
one, yet not without interest.

Fraulein Rosalia H., aged twenty-three, had for some years
been undergoing training as a singer. She had a good voice,
but she complained that in certain parts of its compass it was
not under her control. She had a feeling of choking and con-
striction in her throat so that her voice sounded tight. For this
reason her teacher had not yet been able to consent to her
appearing as a singer in public. Although this imperfection
affected only her middle register, it could not be attributed to
a defect in the organ itself. At times the disturbance was com-
pletely absent and her teacher expressed great satisfaction; at
other times, if she was in the least agitated, and sometimes
without any apparent cause, the constricted feeling would re-
appear and the production of her voice was impeded. It was
not difficult to recognize a hysterical conversion in this very
troublesome feeling. I did not take steps to discover whether
there was in fact a contracture of some of the muscles of the
vocal cords. 1 In the course of the hypnotic analysis which I

1 I had another case of a singer under my observation in which a
contracture of the masseters made it impossible for her to practise her
art. This young woman had been obliged to go on the stage by un-
fortunate events in her family. She was singing at a rehearsal in Rome
at a time when she was in a state of great emotional excitement, and
suddenly had a feeling that she could not close her open mouth and
fell to the floor in a faint. The doctor who was called in brought her

170 II. CASE HISTORIES

carried out with the girl, I learned the following facts about
her history and consequently about the cause of her trouble.
She lost her parents early in life and was taken to live with an
aunt who herself had numerous children. In consequence of
this she became involved in a most unhappy family life. Her
aunt's husband, who was a manifestly pathological person,
brutally ill-treated his wife and children. He wounded their
feelings more particularly by the way in which he showed an
open sexual preference for the servants and nursemaids in the
house; and the more the children grew up the more offensive
this became. After her aunt's death Rosalia became the pro-
tector of the multitude of children who were now orphaned
and oppressed by their father. She took her duties seriously and
fought through all the conflicts into which her position led her,
though it required a great effort to suppress the hatred and
contempt which she felt for her uncle. 1 It was at this time that
the feeling of constriction in her throat started. Every time she
had to keep back a reply, or forced herself to remain quiet in
the face of some outrageous accusation, she felt a scratching in
her throat, a sense of constriction, a loss of voice all the sensa-
tions localized in her larynx and pharynx which now interfered
with her singing. It was not to be wondered at that she sought
an opportunity of making herself independent and escaping
the agitations and distressing experiences which were of daily
occurrence in her uncle's house. A highly competent teacher of
singing came to her assistance disinterestedly and assured her
that her voice justified her in choosing the profession of singer.
She now began to take lessons with him in secret. But she used
often to hurry off to her singing lesson while she still had the
constriction in her throat that used to be left over after violent
scenes at home. Consequently a connection was firmly estab-
lished between her singing and her hysterical paraesthesia a
connection for which the way was prepared by the organic

jaws together forcibly. But thenceforward the patient was unable to
open her jaws by more than a finger's breadth and had to give up her
new profession. When, several years later, she came to me for treatment,
the causes of her emotional excitement had obviously long since dis-
appeared, for some massage while she was in a state of light hypnosis
sufficed to enable her mouth to open wide. Since then the lady has
sung in public.

1 (Footnote added 1924:) In this instance, too [cf. p. 134 n. 2], it was
in fact the girl's father, not her uncle.

(5) FRAULEIN ELISABETH VON R. (FREUD) 171

sensations set up by singing. The apparatus over which she
ought to have had full control when she was singing turned
out to be cathected with residues of innervations left over from
the numerous scenes of suppressed emotion. Since then, she had
left her uncle's house and had moved to another town in order
to be away from her family. But this did not get over her
difficulty.

This good-looking and unusually intelligent girl exhibited
no other hysterical symptoms.

I did my best to get rid of this 'retention hysteria' * by
getting her to reproduce all her agitating experiences and to
abreact them after the event. I made her abuse her uncle,
lecture him, tell him the unvarnished truth, and so on, and this
treatment did her good. Unfortunately, however, she was living
in Vienna under very unfavourable conditions. She had no
luck with her relatives. She was being put up by another uncle,
who treated her in a friendly way; but for that very reason her
aunt took a dislike to her. This woman suspected that her
husband had a deeper interest in his niece, and therefore chose
to make her stay in Vienna as disagreeable as possible. The
aunt herself in her youth had been obliged to give up a desire
for an artistic career and envied her niece for being able to
cultivate her talent, though in the girl's case it was not her
desire but her need for independence that had determined her
decision. Rosalie 2 felt so constrained in the house that she did
not venture, for instance, to sing or play the piano while her
aunt was within earshot and carefully avoided singing or play-
ing to her uncle (who, incidentally, was an old man, her
mother's brother) when there was a possibility of her aunt
coming in. While I was trying to wipe out the traces of old
agitations, new ones arose out of these relations with her host
and hostess, which eventually interfered with the success of my
treatment as well as bringing it to a premature end.

One day the patient came for her session with a new symp-
tom, scarcely twenty-four hours old. She complained of a dis-
agreeable pricking sensation in the tips of her fingers, which,
she said, had been coming on every few hours since the day
before and compelled her to make a peculiar kind of twitching

1 [See below, p. 211 and footnote.]

1 [The name is given this form at this point and below in all the
German editions.]

172 II. CASE HISTORIES

movement with her fingers. I was not able to observe an attack;
otherwise I should no doubt have been able to guess from the
nature of the movements what it was that had occasioned them.
But I immediately tried to get on the track of the explanation
of the symptom (it was in fact a minor hysterical attack) by
hypnotic analysis. Since the whole thing had only been in
existence such a short time I hoped that I should quickly be
able to explain and get rid of the symptom. To my astonish-
ment the patient produced a whole number of scenes, without
hesitation and in chronological order, beginning with her early
childhood. 1 They seemed to have in common her having had
some injury done to her, against which she had not been able to
defend herself, and which might have made her fingers jerk.
They were such scenes, for instance, as of having had to hold
out her hand at school and being struck on it with a ruler by
her teacher. But they were quite ordinary occasions and I should
have been prepared to deny that they could play a part in the
aetiology of a hysterical symptom. But it was otherwise with
one scene from her girlhood which followed. Her bad uncle,
who was suffering from rheumatism, had asked her to massage
his back and she did not dare to refuse. He was lying in bed
at the time, and suddenly threw off the bed-clothes, sprang up
and tried to catch hold of her and throw her down. Massage,
of course, was at an end, and a moment later she had escaped
and locked herself in her room. She was clearly loth to re-
member this and was unwilling to say whether she had seen
anything when he suddenly uncovered himself. The sensations
in her fingers might be explained in this case, by a suppressed
impulse to punish him, or simply by her having been engaged
in massaging him at the time. It was only after relating this
scene that she came to the one of the day before, after which the
sensations and jerking in her fingers had set in as a recurrent
mnemic symbol. The uncle with whom she was now living had
asked her to play him something. She sat down to the piano
and accompanied herself in a song, thinking that her aunt had
gone out; but suddenly she appeared in the door. Rosalie
jumped up, slammed the lid of the piano and threw the music
away. We can guess what the memory was that rose in her
mind and what the train of thought was that she was fending

1 [Apparently an exception to the general rule of inverse chronological
order stated in the footnote on p. 75.]

(5) FRAULEIN ELISABETH VON R. (FREUD) 173

off at that moment: it was a feeling of violent resentment at the
unjust suspicion to which she was subjected and which should
have made her leave the house, while in fact she was obliged to
stay in Vienna on account of the treatment and had nowhere
else where she could be put up. The movement of her fingers
which I saw her make while she was reproducing this scene
was one of twitching something away, in the way in which one
literally and figuratively brushes something aside tosses away
a piece of paper or rejects a suggestion.

She was quite definite in her insistence that she had not
noticed this symptom previously that it had not been occa-
sioned by the scenes she had first described. We could only
suppose, therefore, that the event of the previous day had in
the first instance aroused the memory of earlier events with a
similar subject-matter and that thereupon a mnemic symbol
had been formed which applied to the whole group of memories.
The energy for the conversion had been supplied, on the one
hand, by freshly experienced affect and, on the other hand, by
recollected affect.

When we consider the question more closely we must recog-
nize that a process of this kind is the rule rather than the
exception in the genesis of hysterical symptoms. Almost in-
variably when I have investigated the determinants of such
conditions what I have come upon has not been a single trau-
matic cause but a group of similar ones. (This is well exemplified
in the case of Frau Emmy Case History 2.) In some of these
instances it could be established that the symptom in question
had already appeared for a short time after the first trauma
and had then passed off, till it was brought on again and
stabilized by a succeeding trauma. There is, however, in
principle no difference between the symptom appearing in this
temporary way after its first provoking cause and its being
latent from the first. Indeed, in the great majority of instances
we find that a first trauma has left no symptom behind, while
a later trauma of the same kind produces a symptom, and yet
that the latter could not have come into existence without the
co-operation of the earlier provoking cause; nor can it be
cleared up without taking all the provoking causes into account.

Stated in terms of the conversion theory, this incontrovert-
ible fact of the summation of traumas and of the preliminary

174 II. CASE HISTORIES

latency of symptoms tells us that conversion can result equally
from fresh symptoms and from recollected ones. This hypo-
thesis completely explains the apparent contradiction that we
observed between the events of Fraulein Elisabeth von R.'s
illness and her analysis. There is no doubt that the continued
existence in consciousness of ideas whose affect has not been
dealt with can be tolerated by healthy individuals up to a great
amount. The view which I have just been putting forward
does no more than bring the behaviour of hysterical people
nearer to that of healthy ones. What we are concerned with is
clearly a quantitative factor the question of how much affec-
tive tension of this kind an organism can tolerate. Even a
hysteric can retain a certain amount of affect that has not been
dealt with; if, owing to the occurrence of similar provoking
causes, that amount is increased by summation to a point beyond
the subject's tolerance, the impetus to conversion is given. Thus
when we say that the construction of hysterical symptoms can
proceed on the strength of recollected affects as well as fresh
ones, we shall not be making any unfamiliar assertion, but
stating something that is almost accepted as a postulate.

I have now discussed the motives and mechanism of this case
of hysteria; it remains for me to consider how precisely the
hysterical symptom was determined. Why was it that the
patient's mental pain came to be represented by pains in the
legs rather than elsewhere? The circumstances indicate that this
somatic pain was not created by the neurosis but merely used,
increased and maintained by it. I may add at once that I have
found a similar state of things in almost all the instances of
hysterical pains into which I have been able to obtain an in-
sight. [Cf. above, pp. 96-7.) There had always been a genuine,
organically-founded pain present at the start. It is the common-
est and most widespread human pains that seem to be most
often chosen to play a part in hysteria: in particular, the
periosteal and neuralgic pains accompanying dental disease,
the headaches that arise from so many different sources and,
not less often, the rheumatic muscular pains that are so often
unrecognized [p. 71 n.]. In the same way I attribute an organic
foundation to Fraulein Elisabeth von R.'s first attack of pain
which occurred as far back as while she was nursing her father.
I obtained no result when I tried to discover a psychical cause
for it and I am inclined, I must confess, to attribute a power

(5) FRAULEIN ELISABETH VON R. (FREUD) 175

of differential diagnosis to my method of evoking concealed
memories, provided it is carefully handled. This pain, which
was rheumatic in its origin, 1 then became a mnemic symbol of
her painful psychical excitations; and this happened, so far as I
can see, for more than one reason. The first and no doubt the
most important of these reasons was that the pain was present
in her consciousness at about the same time as the excitations.
In the second place, it was connected, or could be connected,
along a number of lines with the ideas in her mind at the time.
The pain, indeed, may actually have been a consequence,
though only a remote one, of the period of nursing of the lack
of exercise and reduced diet that her duties as a sick-nurse en-
tailed. But the girl had no clear knowledge of this. More im-
portance should probably be attached to the fact that she must
have felt the pain during that time at significant moments, for
instance, when she sprang out of bed in the cold of winter
in response to a call from her father [p. 147]. But what must
have had a positively decisive influence on the direction taken
by the conversion was another line of associative connection
[p. 148]: the fact that on a long succession of days one of her
painful legs came into contact with her father's swollen leg
while his bandages were being changed. The area on her right
leg which was marked out by this contact remained thereafter
the focus of her pains and the point from which they radiated.
It formed an artificial hysterogenic zone whose origin could in
the present case be clearly observed.

If anyone feels astonished at this associative connection be-
tween physical pain and psychical affect, on the ground of its
being of such a multiple and artificial character, I should reply
that this feeling is as little justified as astonishment at the fact
that it is the rich people who own the most money. 2 Where
there are no such numerous connections a hysterical symptom
will not, in fact, be formed; for conversion will find no path
open to it. And I can affirm that the example of Fraulein
Elisabeth von R. was among the simpler ones as regards its
determination. I have had the most tangled threads to unravel,
especially in the case of Frau Cacilie M.

1 It may, however, have been of a spinal-neurasthenic sort. [Cf.
p. 148 n.]

* [The allusion is to an epigram of Lessing's which Freud quotes
again in The Interpretation of Dreams (Standard Ed., 4, 176).]

176 II. CASE HISTORIES

I have already discussed in the case history [p. 150 ff. ] the way
in which the patient's astasia-abasia was built up on these
pains, after a particular path had been opened up for the con-
version. In that passage, however, I also expressed my view
that the patient had created, or increased, her functional dis-
order by means of symbolization, that she had found in the
astasia-abasia a somatic expression for her lack of an inde-
pendent position and her inability to make any alteration in
her circumstances, and that such phrases as 'not being able to
take a single step forward', 'not having anything to lean upon',
served as the bridge for this fresh act of conversion [p. 152].

I shall try to support this view by other examples. Conversion
on the basis of simultaneity, where there is also an associative
link, seems to make the smallest demands on a hysterical dis-
position; conversion by symbolization, on the other hand, seems
to call for the presence of a higher degree of hysterical modifica-
tion. This could be observed in the case of Fraulein Elisabeth,
but only in the later stage of her hysteria. The best examples
of symbolization that I have seen occurred in Frau Cacilie M.,
whose case I might describe as my most severe and instructive
one. I have already explained [p. 69 n.] that a detailed report of
her illness is unfortunately impossible.

Frau Cacilie suffered among other things from an extremely
violent facial neuralgia which appeared suddenly two or three
times a year, lasted for from five to ten days, resisted any kind
of treatment and then ceased abruptly. It was limited to the
second and third branches of one trigeminal, and since an
abnormal excretion of urates was undoubtedly present and a
not quite clearly defined 'acute rheumatism' played some part
in the patient's history, a diagnosis of gouty neuralgia was
plausible enough. This diagnosis was confirmed by the different
consultants who were called in at each attack. Treatment of the
usual kind was ordered: the electric brush, alkaline water,
purges; but each time the neuralgia remained unaffected until
it chose to give place to another symptom. Earlier in her life
the neuralgia was fifteen years old her teeth were accused of
being responsible for it. They were condemned to extraction,
and one fine day, under narcosis, the sentence was carried out
on seven of the criminals. This was not such an easy matter;
her teeth were so firmly attached that the roots of most of them

(5) FRAULEIN ELISABETH VON R. (FREUD) 177

had to be left behind. This cruel operation had no result,
either temporary or permanent. At that time the neuralgia
raged for months on end. Even at the time of my treatment, at
each attack of neuralgia the dentist was called in. On each
occasion he diagnosed the presence of diseased roots and began
to get to work on them; but as a rule he was soon interrupted.
For the neuralgia would suddenly cease, and at the same time
the demand for the dentist's services. During the interval her
teeth did not ache at all. One day, when an attack was raging
once more, the patient got me to give her hypnotic treatment.
I laid a very energetic prohibition on her pains, and from that
moment they ceased. I began at that time to harbour doubts
of the genuineness of the neuralgia.

About a year after this successful hypnotic treatment Frau
Cacilie's illness took a new and surprising turn. She suddenly
developed new pathological states, different from those that had
characterized the last few years. But after some reflection the
patient declared that she had had all of them before at various
times during the course of her long illness, which had lasted for
thirty years. There now developed a really surprising wealth
of hysterical attacks which the patient was able to assign to
their right place in her past. And soon, too, it was possible to
follow the often highly involved trains of thought that deter-
mined the order in which these attacks occurred. They were like
a series of pictures with explanatory texts. Pitres must have had
something of the sort in mind in putting forward his description
of what he termed 'delire ecmnesiqui . l It was most remarkable to
see the way in which a hysterical state of this kind belonging to
the past was reproduced. There first came on, while the patient
was in the best of health, a pathological mood with a particular
colouring which she regularly misunderstood and attributed
to some commonplace event of the last few hours. Then, to the
accompaniment of an increasing clouding of consciousness,
there followed hysterical symptoms: hallucinations, pains,
spasms and long declamatory speeches. Finally, these were
succeeded by the emergence in a hallucinatory form of an
experience from the past which made it possible to explain her

z', according to Pitres (1891, 2, 290), 'is a form of partial
amnesia, in which the memory of events prior to a particular period
in the patient's life is preserved in its entirety, whereas the memory of
events subsequent to that period is completely abolished.']

178 II. CASE HISTORIES

initial mood and what had determined the symptoms of her
present attack. With this last piece of the attack her clarity of
mind returned. Her troubles disappeared as though by magic and
she felt well once again till the next attack, half a day later.
As a rule I was sent for at the climax of the attack, induced a
state of hypnosis, called up the reproduction of the traumatic
experience and hastened the end of the attack by artificial
means. Since I assisted at several hundreds of such cycles with
the patient, I gained the most instructive information on the
way in which hysterical symptoms are determined. Indeed, it
was the study of this remarkable case, jointly with Breuer, that
led directly to the publication of our 'Preliminary Communica-
tion 5 [of 1893, which introduces the present volume].

In this phase of the work we came at last to the reproduction
of her facial neuralgia, which I myself had treated when it
appeared in contemporary attacks. I was curious to discover
whether this, too, would turn out to have a psychical cause.
When I began to call up the traumatic scene, the patient saw
herself back in a period of great mental irritability towards her
husband. She described a conversation which she had had
with him and a remark of his which she had felt as a bitter
insult. Suddenly she put her hand to her cheek, gave a loud
cry of pain and said: 'It was like a slap in the face.' With this
her pain and her attack were both at an end.

There is no doubt that what had happened had been a sym-
bolization. She had felt as though she had actually been given
a slap in the face. Everyone will immediately ask how it was
that the sensation of a 'slap in the face' came to take on the out-
ward forms of a trigeminal neuralgia, why it was restricted to the
second and third branches, and why it was made worse by open-
ing the mouth and chewing though, incidentally, not by talking.

Next day the neuralgia was back again. But this time it was
cleared up by the reproduction of another scene, the content of
which was once again a supposed insult. Things went on like
this for nine days. It seemed to be the case that for years insults,
and particularly spoken ones, had, through symbolization,
brought on fresh attacks of her facial neuralgia.

But ultimately we were able to make our way back to her
first attack of neuralgia, more than fifteen years earlier. Here
there was no symbolization but a conversion through simultan-
eity. She saw a painful sight which was accompanied by feelings

(5) FRAULEIN ELISABETH VON R. (FREUD) 179

of self-reproach, and this led her to force back another set of
thoughts. Thus it was a case of conflict and defence. The
generation of the neuralgia at that moment was only explicable
on the assumption that she was suffering at the time from slight
toothache or pains in the face, and this was not improbable, since
she was just then in the early months of her first pregnancy.

Thus the explanation turned out to be that this neuralgia
had come to be indicative of a particular psychical excitation
by the usual method of conversion, but that afterwards it could
be set going through associative reverberations from her mental
life, or symbolic conversion. In fact, the same behaviour that
we found in Fraulein Elisabeth von R.

I will give a second example which demonstrates the action
of symbolization under other conditions. At a particular period,
Frau Cacilie was afflicted with a violent pain in her right heel
a shooting pain at every step she took, which made walking
impossible. Analysis led us in connection with this to a time when
the patient had been in a sanatorium abroad. She had spent a
week in bed and was going to be taken down to the common
dining-room for the first time by the house physician. The pain
came on at the moment when she took his arm to leave the room
with him; it disappeared during the reproduction of the scene,
when the patient told me she had been afraid at the time that
she might not 'find herself on a right footing' with these strangers.

This seems at first to be a striking and even a comic example
of the genesis of hysterical symptoms through symbolization by
means of a verbal expression. Closer examination of the cir-
cumstances, however, favours another view of the case. The
patient had been suffering at the time from pains in the feet
generally, and it was on their account that she had been con-
fined to bed so long. All that could be claimed on behalf of
symbolization was that the fear which overcame the patient, as
she took her first steps, picked out from among all the pains that
were troubling her at the time the one particular pain which
was symbolically appropriate, the pain in her right heel, and de-
veloped it into a psychical pain and gave it special persistence.

In these examples the mechanism of symbolization seems to
be reduced to secondary importance, as is no doubt the general
rule. But I have examples at my disposal which seem to prove
the genesis of hysterical symptoms through symbolization alone.
The following is one of the best, and relates once more to Frau

180 II. CASE HISTORIES

Cacilie. When a girl of fifteen, she was lying in bed, under
the watchful eye of her strict grandmother. The girl sud-
denly gave a cry; she had felt a penetrating pain in her forehead
between her eyes, which lasted for weeks. During the analysis
of this pain, which was reproduced after nearly thirty years, she
told me that her grandmother had given her a look so 'piercing*
that it had gone right into her brain. (She had been afraid that
the old woman was viewing her with suspicion.) As she told me
this thought she broke into a loud laugh, and the pain once
more disappeared. In this instance I can detect nothing other
than the mechanism of symbolization, which has its place, in
some sense, midway between autosuggestion and conversion.

My observation of Frau Cacilie M. gave me an opportunity
of making a regular collection of symbolizations of this kind.
A whole set of physical sensations which would ordinarily be
regarded as organically determined were in her case of psychical
origin or at least possessed a psychical meaning. A particular
series of experiences of hers were accompanied by a stabbing
sensation in the region of the heart (meaning 'it stabbed me to
the heart'). The pain that occurs in hysteria of nails being
driven into the head was without any doubt to be explained in
her case as a pain related to thinking. ('Something's come into
my head.') Pains of this kind were always cleared up as soon
as the problems involved were cleared up. Running parallel to
the sensation of a hysterical 'aura' l in the throat, when that
feeling appeared after an insult, was the thought 'I shall have
to swallow this'. She had a whole quantity of sensations and
ideas running parallel with each other. Sometimes the sensa-
tion would call up the idea to explain it, sometimes the idea
would create the sensation by means of symbolization, and not
infrequently it had to be left an open question which of the two
elements had been the primary one.

I have not found such an extensive use of symbolization in
any other patient. It is true that Frau Cacilie M. was a woman
who possessed quite unusual gifts, particularly artistic ones, and
whose highly developed sense of form was revealed in some
poems Of great perfection. It is my opinion, however, that when
a hysteric creates a somatic expression for an emotionally-
coloured idea by symbolization, this depends less than one
1 [See footnote, p. 126.]

(5) FRAULEIN ELISABETH VON R. (FREUD) 181

would imagine on personal or voluntary factors. In taking a
verbal expression literally and in feeling the c stab in the heart*
or the 'slap in the face' after some slighting remark as a real
event, the hysteric is not taking liberties with words, but is
simply reviving once more the sensations to which the verbal
expression owes its justification. How has it come about that we
speak of someone who has been slighted as being 'stabbed to the
heart* unless the slight had in fact been accompanied by a
precordial sensation which could suitably be described in that
phrase and unless it was identifiable by that sensation? What
could be more probable than that the figure of speech 'swallow-
ing something', which we use in talking of an insult to which
no rejoinder has been made, did in fact originate from the
innervatory sensations which arise in the pharynx when we
refrain from speaking and prevent ourselves from reacting to
the insult? All these sensations and innervations belong to the
field of 'The Expression of the Emotions', which, as Darwin
[1872] has taught us, consists of actions which originally had a
meaning and served a purpose. These may now for the most
part have become so much weakened that the expression of
them in words seems to us only to be a figurative picture of
them, whereas in all probability the description was once meant
literally; and hysteria is right in restoring the original meaning
of the words in depicting its unusually strong innervations. In-
deed, it is perhaps wrong to say that hysteria creates these
sensations by symbolization. It may be that it does not take
linguistic usage as its model at all, but that both hysteria and
linguistic usage alike draw their material from a common source. 1

1 In states in which mental alteration goes deeper, we clearly also
find a symbolic version in concrete images and sensations of more
artificial turns of speech. Frau CScilie M. passed through a period during
which she transformed every thought she had into a hallucination, the
explanation of which often called for much ingenuity. She complained
to me at that time of being troubled by a hallucination that her two
doctors Breuer and I were hanging on two trees next each other
in the garden. The hallucination disappeared after the analysis had
brought out the following explanation. The evening before, Breuer had
refused to give her a drug she had asked for. She had then set her hopes
on me but had found me equally hard-hearted. She was furious with
us over this, and in her anger she thought to herself: 'There's nothing
to choose between the two of them; one's the pendant [match] of the
other.' [A short summary of the case history of Fraulein Elisabeth
was given by Freud in the second of his Five Lectures (1910a).]

Ill

THEORETICAL

(BREUER)

JOSEF BREUER IN 1897

Ill

THEORETICAL

(BREUER)

IN the 'Preliminary Communication' which introduces this
work we laid down the conclusions to which we were led by our
observations, and I think that I can stand by them in the main.
But the 'Preliminary Communication' is so short and concise
that for the most part it was only possible in it to hint at our
views. Now, therefore, that the case histories have brought
forward evidence in support of our conclusions it may be per-
missible to state them at greater length. Even here, there is, of
course, no question of dealing with the whole field of hysteria.
But we may give a somewhat closer and clearer account (with
some added reservations, no doubt) of those points for which
insufficient evidence was adduced or which were not given
enough prominence in the 'Preliminary Communication'.

In what follows little mention will be made of the brain and
none whatever of molecules. Psychical processes will be dealt
with in the language of psychology; and, indeed, it cannot
possibly be otherwise. If instead of 'idea' we chose to speak of
'excitation of the cortex', the latter term would only have any
meaning for us in so far as we recognized an old friend under
that cloak and tacitly reinstated the 'idea'. For while ideas
are constant objects of our experience and are familiar to us in
all their shades of meaning, 'cortical excitations' are on the
contrary rather in the nature of a postulate, objects which we
hope to be able to identify in the future. The substitution of one
term for another would seem to be no more than a pointless
disguise. Accordingly, I may perhaps be forgiven if I make
almost exclusive use of psychological terms.

There is another point for which I must ask in advance for
the reader's indulgence. When a science is making rapid ad-
vances, thoughts which were first expressed by single individ-
uals quickly become common property. Thus no one who
attempts to put forward to-day his views on hysteria and its

185

186 III. THEORETICAL (BREUER)

psychical basis can avoid repeating a great quantity of other
people's thoughts which are in the act of passing from personal
into general possession. It is scarcely possible always to be
certain who first gave them utterance, and there is always a
danger of regarding as a product of one's own what has already
been said by someone else. I hope, therefore, that I may be
excused if few quotations are found in this discussion and if no
strict distinction is made between what is my own and what
originates elsewhere. Originality is claimed for very little of
what will be found in the following pages.

(1) ARE ALL HYSTERICAL PHENOMENA IDEOGENIC?

In our 'Preliminary Communication* we discussed the psy-
chical mechanism of 'hysterical phenomena', not of 'hys-
teria', because we did not wish to claim that this psychical
mechanism or the psychical theory of hysterical symptoms in
general has unlimited validity. We are not of the opinion that
all the phenomena of hysteria come about in the manner
described by us in that paper, nor do we believe that they are
all ideogenic, that is, determined by ideas. In this we differ
from Moebius, who in 1888 proposed to define as hysterical all
pathological phenomena that are caused by ideas. This state-
ment was later elucidated to the effect that only a part of the
pathological phenomena correspond in their content to the
ideas that cause them those phenomena, namely, that are
produced by allo- or auto-suggestion, as, for instance, when the
idea of not being able to move one's arm causes a paralysis of it;
while another part of the hysterical phenomena, though caused
by ideas, do not correspond to them in their content as, for
instance, when in one of our patients a paralysis of the arm was
caused by the sight of snake-like objects [p. 39],

In giving this definition, Moebius is not merely proposing a
modification in nomenclature and suggesting that in future we
should only describe as hysterical those pathological phenomena
which are ideogenic (determined by ideas); what he thinks is
that all hysterical symptoms are ideogenic. 'Since ideas are
very frequently the cause of hysterical phenomena, I believe
that they always are.' He terms this an inference by analogy.
I prefer to call it a generalization, the justification for which
must first be tested.

(1) HYSTERIA AND PSYCHOGENESIS 187

Before any discussion of the subject, we must obviously
decide what we understand by hysteria. I regard hysteria as a
clinical picture which has been empirically discovered and is
based on observation, in just the same way as tubercular pul-
monary phthisis. Clinical pictures of this kind that have been
arrived at empirically are made more precise, deeper and
clearer by the progress of our knowledge; but they ought not
to be and cannot be disrupted by it. Aetiological research has
shown that the various constituent processes of pulmonary
phthisis have various causes: the tubercle is due to bacillus
jCochii, and the disintegration of tissue, the formation of cavities
and the septic fever are due to other microbes. In spite of this,
tubercular phthisis remains a clinical unity and it would be
wrong to break it up by attributing to it only the 'specifically
tubercular' modifications of tissue caused by Koch's bacillus
and by detaching the other modifications from it. In the same
way hysteria must remain a clinical unity even if it turns out
that its phenomena are determined by various causes, and that
some of them are brought about by a psychical mechanism and
others without it.

It is my conviction that this is in fact so; only a part of the
phenomena of hysteria are ideogenic, and the definition put
forward by Moebius tears in half the clinical unity of hysteria,
and indeed the unity of one and the same symptom in the same
patient.

We should be drawing an inference completely analogous to
Moebius's 'inference by analogy' if we were to say that because
ideas and perceptions very often give rise to erections we may
assume that they alone ever do so and that peripheral stimuli
set this vasomotor process in action only by a roundabout
path through the psyche. We know that this inference would
be false, yet it is based on at least as many facts as Moebius's
assertion about hysteria. In conformity with our experience of a
large number of physiological processes, such as the secretion
of saliva or tears, changes in the action of the heart, etc., it is
possible and plausible to assume that one and the same process
may be set in motion equally by ideas and by peripheral and
other non-psychical stimuli. The contrary would need to be
proved and we are very far short of that. Indeed, it seems
certain that many phenomena which are described as hysterical
are not caused by ideas alone.

188 III. THEORETICAL (BREUER)

Let us consider an everyday instance. A woman may, when-
ever an affect arises, produce on her neck, breast and face an
erythema appearing first in blotches and then becoming con-
fluent. This is determined by ideas and therefore according to
Moebius is a hysterical phenomenon. But this same erythema
appears, though over a less extensive area, when the skin is
irritated or touched, etc. This would not be hysterical. Thus a
phenomenon which is undoubtedly a complete unity would on
one occasion be hysterical and on another occasion not. It may
of course be questioned whether this phenomenon, the erethism
of the vasomotors, should be regarded as a specifically hysterical
one or whether it should not be more properly looked upon
simply as 'nervous*. But on Moebius's view the breaking up of
the unity would necessarily result in any case and the affect-
ively-determined erythema would alone be called hysterical.

This applies in exactly the same way to the hysterical pains
which are of so much practical importance. No doubt these are
often determined directly by ideas. They are 'hallucinations of
pain*. If we examine these rather more closely it appears that the
fact of an idea being very vivid is not enough to produce them
but that there must be a special abnormal condition of the
apparatuses concerned with the conduction and sensation of
pain, just as in the case of affective erythema an abnormal
excitability of the vasomotors must be present. The phrase
'hallucinations of pain' undoubtedly gives the most pregnant
description of the nature of these neuralgias, but it compels us,
too, to carry over to them the views that we have formed on
hallucinations in general. A detailed discussion of these views
would not be in place here. I subscribe to the opinion that
'ideas', mnemic images pure and simple, without any excitation
of the perceptual apparatus, never, even at their greatest
vividness and intensity, attain the character of objective
existence which is the mark of hallucinations. 1

1 This perceptual apparatus, including the sensory areas of the cor-
tex, must be different from the organ which stores up and reproduces
sense-impressions in the form of mnemic images. For the basic essential
of the function of the perceptual apparatus is that its status quo ante
should -be capable of being restored with the greatest possible rapidity;
otherwise no proper further perception could take place. The essential
of memory, on the other hand, is that no such restoration should occur
but that every perception should create changes that are permanent.
It is impossible for one and the same organ to fulfil these two contra-

(1) HYSTERIA AND PSYCHOGENESIS 189

This applies to sensory hallucinations and still more to
hallucinations of pain. For it does not seem possible for a
healthy person to endow the memory of a physical pain with
even the degree of vividness, the distant approximation to the
real sensation, which can, after all, be attained by optical and
acoustic mnemic images. Even in the normal hallucinatory
state of healthy people which occurs in sleep there are never, I
believe, dreams of pain unless a real sensation of pain is present.
This 'retrogressive' excitation, 1 emanating from the organ of
memory and acting on the perceptual apparatus by means of
ideas, is therefore in the normal course of things still more
difficult in the case of pain than in that of visual or auditory
sensations. Since hallucinations of pain arise so easily in hys-
teria, we must posit an abnormal excitability of the apparatus
concerned with sensations of pain.

This excitability makes its appearance not only under the
spur of ideas but of peripheral stimuli in just the same way as
the erethism of the vasomotors which we discussed above.

It is a matter of daily observation to find that in people with
normal nerves peripheral pains are brought on by pathological
processes, not in themselves painful, in other organs. Thus

dictory conditions. The mirror of a reflecting telescope cannot at the
same time be a photographic plate. I am in agreement with Meynert,
in the sense of believing, as I have said, that what gives hallucinations
their objective character is an excitation of the perceptual apparatus
(though I do not agree with him when he speaks of an excitation of the
subcortical centres). If the perceptual organ is excited by a mnemic
image, we must suppose that that organ's excitability has been changed
in an abnormal direction, and that this change is what makes hallucina-
tion possible. [The thesis that a single apparatus could not perform the
functions both of perception and memory was adopted by Freud in the
seventh chapter of his Interpretation of Dreams (19000), Standard Ed., 5 f
538. He had already accepted it in his posthumous 'Project' (1950a,
Part I, Section 3), written a few months after the publication of the
present work, as well as in a letter to Fliess of December 6, 1896, anfl he
recurred to it in Chapter IV of Beyond the Pleasure Principle (1920^,
Standard Ed., 18, 25) and in his paper on the 'mystic writing-pad*
(1925fl). In the last but one of these he explicitly attributes this line of
thought to Breuer.]

1 [This idea of the retrogressive nature of hallucination was adopted
by Freud in his discussion of dreams in the posthumous 'Project',
Part I, Section 20. It will also be found in the seventh chapter of The
Interpretation of Dreams, Standard Ed. 9 5, 542 ff., where the term 're-
gression' is used.]

190 III. THEORETICAL (BREUER)

headaches arise from relatively insignificant changes in the
nose or neighbouring cavities, and again, neuralgias of the
intercostal and brachial nerves from the heart, etc. If the
abnormal excitability, which we have been obliged to postulate
as a necessary condition of hallucinations of pain, is present in a
patient, that excitability is also at the disposal, so to speak, of the
irradiations that I have just mentioned. The irradiations that
occur also in non-neurotic people are made more intense, and
irradiations are formed of a sort which, it is true, we only find
in neurotic patients but which are based on the same mechanism
as the others. Thus, ovarian neuralgia depends, I believe, on
states of the genital apparatus. That its causes are psychical
would have to be proved, and this is not achieved by showing
that that particular kind of pain, like any other, can be pro-
duced under hypnosis as a hallucination, or that its causes
can be psychical. Like erythema or one of the normal secretions,
it arises both from psychical and from purely somatic causes.
Are we to describe only the first kind as hysterical cases which
we know have a psychical origin? If so, the commonly observed
cases of ovarian neuralgia would have to be excluded from the
hysterical syndrome, and this will hardly do.

If a slight injury to a joint is gradually followed by a severe
arthralgia, no doubt the process involves a psychical element,
viz. a concentration of attention on the injured part, which
intensifies the excitability of the nerve tracts concerned. But
this can hardly be expressed by saying that the hyperalgesia
has been caused by ideas.

The same is true of the pathological diminution of sensation.
It is quite unproved and improbable that general analgesia or
analgesia of individual parts of the body unaccompanied by
anaesthesia is caused by ideas. And even if the discoveries of
Binet and Janet were to be fully confirmed to the effect that
hemi-anaesthesia is determined by a peculiar psychical con-
dition, by a splitting of the psyche, the phenomenon would be a
psychogenic but not an ideogenic one, and therefore, according
to Moebius, should not be termed hysterical.

If, therefore, there are a large number of characteristic
hysterical phenomena which we cannot suppose to be ideo-
genic, it would seem right to limit the application of Moebius's
thesis. We shall not define as hysterical those pathological
phenomena which are caused by ideas, but only assert that a

(1) HYSTERIA AND PSYCHOGENESIS 191

great number of hysterical phenomena, probably more than we
suspect to-day, are ideogenic. But the fundamental pathological
change which is present in every case and enables ideas as well
as non-psychological stimuli to produce pathological effects
lies in an abnormal excitability of the nervous system. 1 How far
this excitability is itself of psychical origin is another question.

Yet even though only some of the phenomena of hysteria are
ideogenic, nevertheless it is precisely they that may be des-
cribed as the specifically hysterical ones, and it is the investiga-
tion of them, the discovery of their psychical origin, which
constitutes the most important recent step forward in the
theory of the disorder. The further question then arises: how
do these phenomena come about? What is their 'psychical
mechanism?

This question requires a quite different answer in the case of
each of the two groups into which Moebius divides ideogenic
symptoms [p. 186]. Those pathological phenomena which
correspond in their content to the instigating idea are relatively
understandable and clear. If the idea of a heard voice does not
merely cause it to echo faintly in the 'inward ear', as it does in
healthy people, but causes it to be perceived in a hallucinatory
manner as a real, objective acoustic sensation, this may be
equated with familiar phenomena of normal life with dreams
and is quite intelligible on the hypothesis of abnormal excit-
ability. We know that with every voluntary movement it is the
idea of the result to be achieved which initiates the relevant
muscular contraction; and it is not very hard to see that the
idea that this contraction is impossible will impede the move-
ment (as happens in paralysis by suggestion).

The situation is otherwise with those phenomena which have
no logical connection with the determining idea. (Here, too,
normal life offers parallels, as, for instance, blushing for shame.)
How do they arise? Why does an idea in a sick man evoke one
particular entirely irrational movement or hallucination which
does not in any way correspond to it?

In our 'Preliminary Communication' we felt able to say

1 Attributed by Oppenheim [1890] to 'instability of the molecules'.
It may be possible at a later stage to replace the very vague statement in
the text above by a more precise and significant formula. [Of. below,
p. 241 ff.]

192 III. THEORETICAL (BREUER)

something about this causal relation on the basis of our observa-
tions. In our exposition of the subject, however, we introduced
and employed without apology the concept of 'excitations which
flow away or have to be abreacted'. 1 This concept is of funda-
mental importance for our theme and for the theory of the
neuroses in general, and it seems to demand and to deserve a
more detailed examination. Before I proceed to this, I must
ask to be forgiven for taking the reader back to the basic
problems of the nervous system. A feeling of oppression is
bound to accompany any such descent to the 'Mothers' [i.e.,
exploration of the depths]. 2

But any attempt at getting at the roots of a phenomenon
inevitably leads in this way to basic problems which cannot be
evaded. I hope therefore that the abstruseness of the following
discussion may be viewed with indulgence.

(2) INTRAGEREBRAL TONIC EXCITATIONS AFFECTS

(A)

We know two extreme conditions of the central nervous
system: a clear waking state and dreamless sleep. A transition
between these is afforded by conditions of every degree of de-
creasing clarity. What interests us here is not the question of
the purpose of sleep and its physical basis (its chemical or
vasomotor determinants) but the question of the essential dis-
tinction between the two conditions.

We can give no direct information about the deepest, dream-
less sleep, for the very reason that all observations and exper-
iences are excluded by the state of total unconsciousness. But as
regards the neighbouring condition of sleep accompanied by
dreams, the following assertions can be made. In the first place,
when in that condition we intend to make voluntary movements
of walking, speaking, etc. this does not result in the corres-
ponding contractions of the muscles being voluntarily initiated,
as they are in waking life. In the second place, sensory stimuli

1 [This is not an actual quotation from the 'Preliminary Communica-
tion,', where this underlying hypothesis is nowhere explicitly mentioned.
Cf. the remarks on this in the Editor's Introduction, p. xix ff.]

* [An allusion to Faust's mysterious researches (in Goethe's Faust y
Part II, Act I).]

(2) INTRACEREBRAL TONIC EXCITATION 193

are perhaps perceived (for they often make their way into
dreams) but they are not apperceived, i.e. do not become con-
scious perceptions. Again, ideas that emerge do not, as in
waking life, activate all the ideas which are connected with
them and which are present in potential consciousness; a great
number of the latter remain unexcited. (For instance, we find
ourselves talking to a dead person without remembering that
he is dead.) Furthermore, incompatible ideas can be present
simultaneously without mutually inhibiting each other, as they
do in waking life. Thus, association is defective and incomplete.
We may safely assume that in the deepest sleep this severance
of connections between the psychical elements is carried still
further and becomes total.

On the other hand, when we are fully awake every act of
will initiates the corresponding movement; sense-impressions
become conscious perceptions; and ideas are associated with the
whole store present in potential consciousness. In that con-
dition the brain functions as a unit with complete internal
connections.

We shall perhaps only be describing these facts in other words
if we say that in sleep the paths of connection and conduction
in the brain are not traversable by excitations of the psychical
elements (? cortical cells), whereas in waking life they are
completely so traversable.

The existence of these two different conditions of the paths
of conduction can, it seems, only be made intelligible if we
suppose that in waking life those paths are in a state of tonic
excitation (what Exner [1894, 93] calls 'intercellular tetanus'),
that this intracerebral excitation is what determines their con-
ductive capability, and that the diminution and disappearance
of that excitation is what sets up the state of sleep.

We ought not to think of a cerebral path of conduction as
resembling a telephone wire which is only excited electrically
at the moment at which it has to function (that is, in the present
context, when it has to transmit a signal). We ought to liken it
to a telephone line through which there is a constant flow of
galvanic current and which can no longer be excited if that
current ceases. Or better, let us imagine a widely-ramified
electrical system for lighting and the transmission of motor
power; what is expected of this system is that simple establish-
ment of a contact shall be able to set any lamp or machine in

194 III. THEORETICAL (BREUER)

operation. To make this possible, so that everything shall be
ready to work, there must be a certain tension present through-
out the entire network of lines of conduction, and the dynamo
engine must expend a given quantity of energy for this purpose.
In just the same way there is a certain amount of excitation
present in the conductive paths of the brain when it is at rest
but awake and prepared to work. 1

This view of the matter is supported by the fact that merely
being awake, without doing any work, gives rise to fatigue and
produces a need for sleep. The state of waking in itself causes a
consumption of energy.

Let us imagine a man in a state of intense expectation, which
is not, however, directed to any particular sensory field. We
then have before us a brain which is quiescent but prepared for

1 1 may perhaps venture here to indicate briefly the notion on which
the above statements are based. We usually think of the sensory nerve-
cells as being passive receptive organs. This is a mistake. For the mere
existence of a system of associative fibres proves that these sensory
nerve-cells also send out excitation into the nerve-fibres. If excitation
from two sensory cells flows into a nerve-fibre that connects them
whether /^r continuitatem or per contiguitatem [i.e. whether it is an extension
of them or is in contact with them] then a state of tension must exist
in it. This state of tension has the same relation to the excitation flow-
ing away in, for instance, a -peripheral motor fibre as hydrostatic
pressure has to the living force of flowing water or as electric tension
has to an electric current. If all the nerve-cells are in a state of mean
excitation and are exciting their nerve-processes [axones], the whole
immense network forms a single reservoir of 'nervous tension'. Apart
then from a potential energy which lies quiescent in the chemical
substance of the cell and an unknown form of kinetic energy which is
discharged when the fibres are in a state of excitation, we must assume
the existence of yet another quiescent state of nervous excitation: tonic
excitation or nervous tension. [This footnote and the corresponding
passage in the text above seem to have been regarded by Freud as his
ground for attributing to Breuer the distinction between the 'free' and
'bound' forms of psychical energy and the allied distinction between
the primary and secondary systems of psychical functioning. In his
paper on 'The Unconscious* (1915*, end of Section V) and in Beyond
the Pleasure Principle (1920^, Chapter IV, Standard Ed., 18, 26-7) he
definitely asserts that these ideas are derived from Breuer's contribution
to Studies on Hysteria, but he gives no more precise reference. Freud had
already adopted the idea in Chapter VII of The Interpretation of Dreams
(19000, Standard Ed., 5, 599 ff.); but the question is discussed at greater
length towards the end of the first Section of Part III of the posthum-
ously-published 'Project' (19500).]

(2) INTRACEREBRAL TONIC EXCITATION 195

action. We may rightly suppose that in such a brain all the paths
of conduction are at the maximum of their conductive capa-
bility that they are in a state of tonic excitation. It is a signifi-
cant fact that in ordinary language we speak of such a state as
one of tension. Experience teaches us what a strain this state is
and how fatiguing, though no actual motor or psychical work
is performed in it.

This is an exceptional state, which, precisely on account of
the great consumption of energy involved, cannot be tolerated
for long. But even the normal state of being wide awake calls
for an amount of intracerebral excitation varying between
limits that are not very widely separated. Every diminishing
degree of wakefulness down to drowsiness and true sleep is
accompanied by correspondingly lower degrees of excitation.

When the brain is performing actual work, a greater con-
sumption of energy is no doubt required than when it is merely
prepared to perform work. (In just the same way the electrical
system described above by way of comparison must cause a
greater amount of electrical energy to flow into the conducting
lines when a large number of lamps or motors are switched into
the circuit.) Where functioning is normal no more energy is
liberated than is immediately employed in activity. The brain,
however, behaves like one of those electrical systems of re-
stricted capability which are unable to produce both a large
amount of light and of mechanical work at the same time. If it
is transmitting power, only a little energy is available for light-
ing, and vice versa. Thus we find that if we are making great
muscular efforts we are unable to engage in continuous thought,
or that if we concentrate our attention in one sensory field the
efficiency of the other cerebral organs is reduced that is to
say, we find that the brain works with a varying but limited
amount of energy.

The non-uniform distribution of energy is no doubt de-
termined by what Exner [1894, 165] calls 'facilitation by
attention' by an increase in the conductive capability of the
paths in use and a decrease in that of the others; and thus in a
working brain the 'intracerebral tonic excitation', too, is non-
uniformly distributed.' 1

1 The conception of the energy of the central nervous system as being
a quantity distributed over the brain in a changing and fluctuating
manner is an old one. 'La sensibilite', wrote Cabanis [1824, 3, 153],

196 III. THEORETICAL (BREUER)

We wake up a person who is sleeping that is, we suddenly
raise the quantity of his tonic intracerebral excitation by
bringing a lively sensory stimulus to bear upon him. Whether
alterations in the blood-circulation in the brain are essential
links here in the causal chain, and whether the blood-vessels
are directly dilated by the stimulus, or whether the dilatation is
a consequence of the excitation of the cerebral elements all
this is undecided. What is certain is that the state of excitation,
entering through a gateway of the senses, spreads over the
brain from that point, becomes diffused and brings all the
paths of conduction into a state of higher facilitation.

It is still not in the least clear, of course, how spontaneous
awakening occurs whether it is always one and the same
portion of the brain that is the first to enter a state of waking
excitation and the excitation then spreads from there, or
whether sometimes one and sometimes another group of ele-
ments acts as the awakener. Nevertheless spontaneous awaken-
ing, which, as we know, can take place in complete quiet and
darkness without any external stimulus, proves that the de-
velopment of energy is based on the vital process of the cerebral
elements themselves. A muscle remains unstimulated, quiescent,
however long it has been in a state of rest and even though it
has accumulated a maximum of tensile force. This is not so
with the cerebral elements. We are no doubt right in supposing
that during sleep the latter regain their previous condition
and gather tensile force. When this has happened to a certain
degree, when, as we may say, a certain level has been reached,
the surplus flows away into the paths of conduction, facilitates
them and sets up the intracerebral excitation of the waking
state.

We can find an instructive example of the same thing in
waking life. When the waking brain has been quiescent for a
considerable time without transforming tensile force into live
energy by functioning, there arises a need and an urge for
activity. Long motor quiescence creates a need for movement

'semble se comporter a la maniere d'une fluide dont la quantite totale
est determinee et qui, toutes les fois qu'il se jette en plus grande abends
ance dans un de ses canaux, diminue proper tionellement dans le-
autres.' (Quoted from Janet, 1894, 277.) ['Sensibility seems to behave
like a fluid whose total quantity is fixed and which, whenever it pours
into one of its channels in greater abundance, becomes proportionally
less in the others.']

(2) INTRAGEREBRAL TONIC EXCITATION 197

(compare the aimless running round of a caged animal) and if
this need cannot be satisfied a distressing feeling sets in. Lack
of sensory stimuli, darkness and complete silence become a
torture; mental repose, lack of perceptions, ideas and associ-
ative activity produce the torment of boredom. These un-
pleasurable feelings correspond to an 'excitement', to an in-
crease in normal intracerebral excitation.

Thus the cerebral elements, after being completely restored,
liberate a certain amount of energy even when they are at rest;
and if this energy is not employed functionally it increases the
normal intracerebral excitation. The result is a feeling of un-
pleasure. Such feelings are always generated when one of the
organism's needs fails to find satisfaction. Since these feelings
disappear when the surplus quantity of energy which has been
liberated is employed functionally, we may conclude that the
removal of such surplus excitation is a need of the organism.
And here for the first time we meet the fact that there exists in
the organism a 'tendency to keep intracerebral excitation constant*
(Freud). 1

Such a surplus of intracerebral excitation is a burden and a
nuisance, and an urge to use it up arises in consequence. If it
cannot be used in sensory or ideational activity, the surplus
flows away in purposeless motor action, in walking up and down,
and so on, and this we shall meet with later as the commonest
method of discharging excessive tensions.

We are familiar with the great individual variations which
are found in this respect: the great differences between lively
people and inert and lethargic ones, between those who 'cannot
sit still' and those who have an 'innate gift for lounging on
sofas' and between mentally agile minds and dull ones which
can tolerate intellectual rest for an unlimited length of time.

1 [This seems to be the first explicit enunciation of Freud's 'principle
of constancy'. It had been used previously by him in writings that were
only posthumously published (1941* [1892] and 1940</ [1892]). Freud
developed the subject further in another posthumously published work,
his * Project' (1950a), which was written a few months after the publica-
tion of the present Studies , and in which he names the hypothesis 'the
principle of neuronic inertia'. (See, in particular, Section 1 of Part I
of that work.) He had, however, stated its essence in the lecture (1893 h)
which he delivered at about the time of publication of the 'Preliminary
Communication'. The subject is discussed more fully in the Editor's
Introduction, p. xix ff.]

198 III. THEORETICAL (BREUER)

These differences, which make up a man's 'natural tempera-
ment', are certainly based on profound differences in his nervous
system on the degree to which the functionally quiescent
cerebral elements liberate energy.

We have spoken of a tendency on the part of the organism
to keep tonic cerebral excitation constant. A tendency of
this kind is, however, only intelligible if we can see what need
it fulfils. We can understand the tendency in warm-blooded
animals that to keep a constant mean temperature, because our
experience has taught us that that temperature is an optimum
for the functioning of their organs. And we make a similar
assumption in regard to the constancy of the water-content
of the blood; and so on. I think that we may also assume that
there is an optimum for the height of the intracerebral tonic
excitation. At that level of tonic excitation the brain is accessible
to all external stimuli, the reflexes are facilitated, though only
to the extent of normal reflex activity, and the store of ideas
is capable of being aroused and open to association in the
mutual relation between individual ideas which corresponds to
a clear and reasonable state of mind. It is in this state that the
organism is best prepared for work.

The situation is already altered by the uniform [pp. 194-5]
heightening of tonic excitation which constitutes 'expectation'.
This makes the organism hyperaesthetic towards sensory
stimuli, which quickly become distressing, and also increases
its reflex excitability above what is useful (proneness to fright) .
No doubt this state is useful for some situations and purposes;
but if it appears spontaneously and not for any such reasons,
it does not improve our efficiency but impairs it. In ordinary
life we call this being 'nervous'. In the great majority of forms
of increase in excitation, however, the over-excitation is not
uniform, and this is always detrimental to efficiency. We call
this 'excitement'. That the organism should tend to maintain
the optimum of excitation arid to return to that optimum after
it has been exceeded is not surprising, but quite in keeping
with other regulating factors in the organism.

I shall venture once more to recur to my comparison with an
electrical lighting system. The tension in the network of lines
of conduction in such a system has an optimum too. If this is
exceeded its functioning may easily be impaired; for instance,
the electric light filaments may be quickly burned through. I

(2) INTRACEREBRAL TONIC EXCITATION 199

shall speak later of the damage done to the system itself through
a break-down of its insulation or through 'short-circuiting'.

(B)

Our speech, the outcome of the experience of many genera-
tions, distinguishes with admirable delicacy between those
forms and degrees of heightening of excitation which are still
useful for mental activity [i.e. in spite of rising above the
optimum (see last paragraph but one)] because they raise the
free energy of all cerebral functions uniformly, and those forms
and degrees which restrict that activity because they partly
increase and partly inhibit these psychical functions in a manner
that is not uniform. The first are given the name of 'incitement',
and the second 'excitement'. 1 An interesting conversation, or
a cup of tea or coffee has an 'inciting' [stimulating] effect; a
dispute or a considerable dose of alcohol has an 'exciting' one.
While incitement only arouses the urge to employ the increased
excitation functionally, excitement seeks to discharge itself in
more or less violent ways which are almost or even actually
pathological. Excitement constitutes the psycho-physical basis
of the effects, and these will be discussed below. But I must
first touch briefly on some physiological and endogenous
causes of increases of excitation.

Among these, in the first place, are the organism's major
physiological needs and instincts: need for oxygen, craving for
food, and thirst. Since the excitement which they set going is
linked to certain sensations and purposive ideas, it is not such
a pure example of increase of excitation as the one discussed
above [pp. 196-7], which arose solely from the quiescence of
the cerebral elements. The former always has its special colour-
ing. But it is unmistakable in the anxious agitation which accom-
panies dyspnoea and in the restlessness of a starving man.

The increase of excitation that comes from these sources is
determined by the chemical change in the cerebral elements
themselves, which are short of oxygen, of tensile force or of
water. It flows away along preformed motor paths, which lead
to the satisfaction of the need that set it going: dyspnoea leads
to breathing with effort, and hunger and thirst to a search
for and attainment of food and water. The principle of the

1 [In German 'Anregung* = 'incitement', 'stimulation'; 'Aufregung* =
'excitement', 'agitation'.]

200 III. THEORETICAL (BREUER)

constancy of excitation scarcely comes into operation as far as
this kind of excitation is concerned; for the interests which are
served by the increase in excitation in these cases are of far
greater importance to the organism than the re-establishment of
normal conditions of functioning in the brain. It is true that we
see animals in a zoo running backwards and forwards excitedly
before feeding- time; but this may no doubt be regarded as a
residue of the preformed motor activity of looking for food,
which has now become useless owing to their being in captivity,
and not as a means of freeing the nervous system of excitement.
If the chemical structure of the nervous system has been
permanently altered by a persistent introduction of foreign
substances, then a lack of these substances will cause states of
excitation, just as the lack of normal nutritive substances does
in healthy people. We see this in the excitement occurring in
abstinence from narcotics.

A transition between these endogenous increases of excita-
tion and the psychical affects in the narrower sense is provided
by sexual excitation and sexual affect. Sexuality at puberty
appears in the first of these forms, as a vague, indeterminate,
purposeless heightening of excitation. As development proceeds,
this endogenous heightening of excitation, determined by the
functioning of the sex-glands, becomes firmly linked (in the
normal course of things) with the perception or idea of the
other sex and, indeed, with the idea of a particular individual,
where the remarkable phenomenon of falling in love occurs.
This idea takes over the whole quantity of excitation liberated
by the sexual instinct. It becomes an 'affective idea'; that is to
say, when it is actively present in consciousness it sets going the
increase of excitation which in point of fact originated from
another source, namely the sex-glands.

The sexual instinct is undoubtedly the most powerful source
of persisting increases of excitation (and consequently of neu-
roses). Such increases are distributed very unevenly over the
nervous system. When they reach a considerable degree of
intensity the train of ideas becomes disturbed and the relative
value of the ideas is changed; and in orgasm * thought is almost
completely extinguished.

1 ['Orgasmus* in the first and second editions. In later editions this is
misprinted 'Organismus'.]

(2) INTRACEREBRAL TONIC EXCITATION 201

Perception too the psychical interpretation of sense-im-
pressions is impaired. An animal which is normally timid and
cautious becomes blind and deaf to danger. On the other hand,
at least in males, there is an intensification of the aggressive
instinct. Peaceable animals become dangerous until their ex-
citation has been discharged in the motor activities of the
sexual act.

(C)

A disturbance like this of the dynamic equilibrium of the
nervous system a non-uniform distribution of increased ex-
citation is what makes up the psychical side of affects.

No attempt will be made here to formulate either a psy-
chology or a physiology of the affects. I shall only discuss a
single point, which is of importance for pathology, and more-
over only for ideogenic affects those which are called up by
perceptions and ideas. (Lange, 1885 [62 ff.], has rightly pointed
out that affects can be caused by toxic substances, or, as
psychiatry teaches us, above all by pathological changes, almost
in the same way as they can by ideas.)

It may be taken as self-evident that all the disturbances of
mental equilibrium which we call acute affects go along with
an increase of excitation. (In the case of chronic affects, such as
sorrow and care, that is to say protracted anxiety, the com-
plication is present of a state of severe fatigue which, though it
maintains the non-uniform distribution of excitation, neverthe-
less reduces its height.) But this increased excitation cannot be
employed in psychical activity. All powerful affects restrict
association the train of ideas. People become 'senseless* with
anger or fright. Only the group of ideas which provoked the
affect persists in consciousness, and it does so with extreme
intensity. Thus the excitement cannot be levelled out by
associative activity.

Affects that are 'active' or 'sthenic' do, however, level out
the increased excitation by motor discharge. Shouting and jump-
ing for joy, the increased muscular tone of anger, angry words
and retaliatory deeds all these allow the excitation to flow
away in movements. Mental pain discharges it in difficult
breathing and in an act of secretion: in sobs and tears. It is a
matter of everyday experience that such reactions reduce ex-
citement and allay it. As we have already remarked [p. 8],

202 III. THEORETICAL (BREUER)

ordinary language expresses this in such phrases as 'to cry
oneself out', 'to blow off steam', etc. What is being got rid of is
nothing else than the increased cerebral excitation.

Only some of these reactions, such as angry deeds and words,
serve a purpose in the sense of making any change in the actual
state of affairs. The rest serve no purpose whatever, or rather
their only purpose is to level out the increase of excitation and
to establish psychical equilibrium. In so far as they achieve this
they serve the 'tendency to keep [in tra-] cerebral excitation
constant* [p. 197].

The 'asthenic' affects of fright and anxiety do not bring about
this reactive discharge. Fright paralyses outright the power of
movement as well as of association, and so does anxiety if the
single useful reaction of running away is excluded by the cause
of the affect of anxiety or by circumstances. The excitation of
fright disappears only by a gradual levelling out.

Anger has adequate reactions corresponding to its cause. If
these are not feasible, or if they are inhibited, they are re-
placed by substitutes. Even angry words are substitutes of this
kind. But other, even quite purposeless, acts may appear as
substitutes. When Bismarck had to suppress his angry feelings in
the King's presence, he relieved himself afterwards by smashing
a valuable vase on the floor. This deliberate replacement of one
motor act by another corresponds exactly to the replacement of
natural pain-reflexes by other muscular contractions. When
a tooth is extracted the preformed reflex is to push away the
dentist and utter a cry; if, instead of that, we contract the
muscles of our arms and press against the sides of the chair, we
are shifting the quantum of excitation that has been generated
by the pain from one group of muscles to another. [Cf. p. 91.]
In the case of violent spontaneous toothache, where there is no
preformed reflex apart from groaning, the excitation flows off
in aimless pacing up and down. In the same way we transpose
the excitation of anger from the adequate reaction to another
one, and we feel relieved provided it is used up by any strong
motor innervation.

If, however, the affect can find no discharge of excitation of
any kind along these lines, then the situation is the same with
anger as with fright and anxiety. The intracerebral excitation
is powerfully increased, but is employed neither in associative
nor in motor activity. In normal people the disturbance is

(3) HYSTERICAL CONVERSION 203

gradually levelled out. But in some, abnormal reactions appear.
An 'abnormal expression of the emotions', as Oppenheim
[1890] says, is formed.

(3) HYSTERICAL CONVERSION

I shall scarcely be suspected of identifying nervous excitation
with electricity, if I return once more to the comparison with
an electrical system. If the tension in such a system becomes
excessively high, there is danger of a break occurring at weak
points in the insulation. Electrical phenomena then appear at
abnormal points; or, if two wires lie close beside each other,
there is a short circuit. Since a permanent change has been
produced at these points, the disturbance thus brought about
may constantly recur if the tension is sufficiently increased.
An abnormal 'facilitation' has taken place.

That the conditions applying in the nervous system are to
some extent similar can well be maintained. It forms throughout
an interconnected whole; but at many points in it great,
though not insurmountable, resistances are interposed, which
prevent the general, uniform distribution of excitation. Thus
in normal people in a waking state excitation in the organ of
ideation does not pass over to the organs of perception: such
people do not hallucinate [cf. p. 189]. In the interests of the
safety and efficiency of the organism, the nervous apparatuses
of the complexes of organs which are of vital importance
the circulatory and digestive organs are separated by strong
resistances from the organs of ideation. Their independence is
assured. They are not affected directly by ideas. But the resist-
ances which prevent the passage of intracerebral excitation to
the circulatory and digestive apparatuses vary in strength from
one individual to another. All degrees of affective excitability
are to be found between, on the one hand, the ideal (which is
rarely met with to-day) of a man who is absolutely free from
'nerves', whose heart-action remains constant in every situation
and is only affected by the particular work it has to perform,
the man who has a good appetite and digestion, whatever
danger he is in between a man of this kind and, on the other
hand, a 'nervous' man who has palpitations and diarrhoea on
the smallest provocation.

However this may be, there are resistances in normal people

204 III. THEORETICAL (BREUER)

against the passage of cerebral excitation to the vegetative
organs. These resistances correspond to the insulation of elec-
trical conducting lines. At points at which they are abnormally
weak they are broken through when the tension of cerebral
excitation is high, and this the affective excitation passes
over to the peripheral organs. There ensues an 'abnormal
expression of emotion'.

Of the two factors which we have mentioned as being re-
sponsible for this result, one has already been discussed by us
in detail. This first factor is a high degree of intracerebral
excitation which has failed to be levelled down either by idea-
tional activities or by motor discharge, or which is too great
to be dealt with in this way.

The second factor is an abnormal weakness of the resist-
ances in particular paths of conduction. This may be determined
by the individual's initial constitution (innate disposition); or
it may be determined by states of excitation of long duration
which, as one might say, loosen the whole structure of his
nervous system and lower all its resistances (pubertal disposi-
tion) ; or it may be determined by weakening influences, such
as illness and under-nourishment (disposition due to states of
exhaustion). The resistance of particular paths of conduction
may be lowered by a previous illness of the organ concerned,
which has facilitated the paths to and from the brain. A
diseased heart is more susceptible to the influence of an affect
than is a healthy one. 'I have a sounding-board in my abdomen',
I was told by a woman who suffered from parametritis, 'if any-
thing happens, it starts up my old pain.' (Disposition through
local illness.)

The motor actions in which the excitation of affects is norm-
ally discharged are ordered and co-ordinated even though
they are often useless. But an excessively strong excitation may
by-pass or break through the co-ordinative centres and flow
off in primitive movements. In infants, apart from the respir-
atory action of screaming, affects only produce and find expres-
sion in unco-ordinated contractions of the muscles of this
primitive kind in arching the body and kicking about. As
development proceeds, the musculature passes more and more
under the control of the power of co-ordination and the will.
But the opisthotonus, which represents the maximum of motor
effort of the total somatic musculature, and the clonic move-

(3) HYSTERICAL CONVERSION 205

ments of kicking and threshing about, persist throughout life as
the form of reaction for the maximal excitation of the brain
for the purely physical excitation in epileptic attacks as well
as for the discharge of maximal affects in the shape of more
or less epileptoid convulsions (viz. the purely motor part of
hysterical attacks).

It is true that abnormal affective reactions of this kind are
characteristic of hysteria. But they also occur apart from that
illness. What they indicate is a more or less high degree of
nervous disorder, not hysteria. Such phenomena cannot be
described as hysterical if they appear as consequences of an
affect which, though of great intensity, has an objective basis,
but only if they appear with apparent spontaneity as mani-
festations of an illness. These latter, as many observations,
including our own, have shown, are based on recollections
which revive the original affect or rather, which would revive it
if those reactions did not, in fact, occur instead.

It may be taken for granted that a stream of ideas and recol-
lections runs through the consciousness of any reasonably
intelligent person while his mind is at rest. These ideas are so
little vivid that they leave no trace behind in the memory and
it is impossible afterwards to say how the associations occurred.
If, however, an idea comes up that originally had a strong
affect attached to it, that affect is revived with more or less
intensity. The idea which is thus 'coloured' by affect emerges
in consciousness clearly and vividly. The strength of the affect
which can be released by a memory is very variable, according
to the amount to which it has been exposed to 'wearing-away'
by different influences, and especially according to the degree
to which the original affect has been 'abreacted'. We pointed
out in our 'Preliminary Communication' [p. 8] to what a
varying extent the affect of anger at an insult, for instance, is
called up by a recollection, according to whether the insult has
been repaid or endured in silence. If the psychical reflex was
fully achieved on the original occasion, the recollection of
it releases a far smaller quantity of excitation. 1 If not, the

1 The instinct of revenge, which is so powerful in the natural man
and is disguised rather than repressed by civilization, is nothing what-
ever but the excitation of a reflex that has not been released. To
defend oneself against injury in a fight and, in doing so, to injure one's

206 III. THEORETICAL (BREUER)

recollection is perpetually forcing on to the subject's lips the
abusive words which were originally suppressed and which
would have been the psychical reflex to the original stimulus.

If the original affect was discharged not in a normal but in
an 'abnormal 5 reflex, this latter is equally released by recollec-
tion. The excitation arising from the affective idea is 'converted*
(Freud) 1 into a somatic phenomenon.

Should this abnormal reflex become completely facilitated
by frequent repetition, it may, it seems, drain away the opera-
tive force of the releasing ideas so totally that the affect itself
emerges to a minimal extent only, or not at all. In such a case
the 'hysterical conversion' is complete. The idea, moreover,
which now no longer produces any psychical consequences,
may be overlooked by the subject, or may be promptly for-
gotten if it emerges, like any other idea which is unaccompanied
by affect.

It may be easier to accept the possibility of a cerebral excita-
tion which should have given rise to an idea being replaced in
this way by an excitation of some peripheral path, if we call to
mind the inverse course of events which follows when a pre-
formed reflex fails to occur. I will select an extremely trivial
example the sneezing reflex. If a stimulus of the mucous mem-
brane of the nose fails for any reason to release this preformed

opponent is the adequate and preformed psychical reflex. If it has been
carried out insufficiently or not at all, it is constantly released again by
recollection, and the 'instinct of revenge* comes into being as an ir-
rational volitional impulse, just as do all other 'instincts'. The proof of
this lies precisely in the irrationality of the impulse, its divorce from any
question of usefulness or expediency, indeed in its disregard of all con-
siderations of the subject's own safety. As soon as the reflex has been
released, the irrational nature of the impulse can become conscious.

Ein andres Antlitz, eh sie geschehen,
Ein anderes zeigt die vollbrachte Tat.

[Literally: 'A deed shows one countenance before it has happened
and another after it has been accomplished.' Schiller, Die Braut von
Messina, III, 5.]

1 [Freud comments, near the beginning of his 'History of the Psycho-
Analytic Movement' (1914^), on the appearance here of his name in
brackets. He remarks that Breuer seemed to be implying that the
priority for this piece of theory belonged to Freud. 'I believe,' he goes
on, 'that actually the distinction relates only to the name, and that the
conception came to us simultaneously and together.' See also foot-
note 2, p. 86.]

(3) HYSTERICAL CONVERSION 207

reflex, a feeling of excitation and tension arises, as we all
know. The excitation, which has been unable to flow off
along motor paths, now, inhibiting all other activity, spreads
over the brain. This everyday example gives us the pattern of
what happens when a psychical reflex, even the most compli-
cated one, fails to occur. The excitement which we have dis-
cussed above [pp. 205-6 n.] as characteristic of the instinct of
revenge is in essentials the same. And we can follow the same
process even up to the highest regions of human achievement.
Goethe did not feel he had dealt with an experience till he had
discharged it in creative artistic activity. This was in his case
the preformed reflex belonging to affects, and so long as it had
not been carried out the distressing increase in his excitation
persisted.

Intracerebral excitation and the excitatory process in peri-
pheral paths are of reciprocal magnitudes: the former increases
if and so long as no reflex is released; it diminishes and dis-
appears when it has been transformed into peripheral nervous
excitation. Thus it seems understandable that no observable
affect is generated if the idea that should have given rise to it
immediately releases an abnormal reflex into which the excita-
tion flows away as soon as it is generated. The 'hysterical
conversion' is then complete. The original intracerebral excita-
tion belonging to the affect has been transformed into the
excitatory process in the peripheral paths. What was originally
an affective idea now no longer provokes the affect but only
the abnormal reflex. 1

We have now gone a step beyond the Abnormal expression
of the emotions'. Hysterical phenomena (abnormal reflexes) do
not seem to be ideogenic even to intelligent patients who are
good observers, because the idea that gave rise to them is no
longer coloured with affect and no longer marked out among

1 I am anxious not to drive the analogy with an electrical system to
death. In view of the totally dissimilar conditions it can scarcely illus-
trate the processes in the nervous system, and can certainly not explain
them. But I may once more recall the case in which, owing to excessively
high tension, the insulation of the wires in a lighting system breaks
down and a 'short circuit' occurs at some point in it. If electrical
phenomena (such as overheating or sparking) occur at this point, the
lamp to which the wire leads fails to light. In just the same way, the
affect fails to appear if the excitation flows away in an abnormal reflex
and is converted into a somatic phenomenon.

208 III. THEORETICAL (BREUER)

other ideas and memories. They emerge as purely somatic
phenomena, apparently without psychical roots.

What is it that determines the discharge of affect in such a
way that one particular abnormal reflex is produced rather
than some other? Our observations answer this question in
many instances by showing that here again the discharge
follows the 'principle of least resistance' and takes place along
those paths whose resistances have already been weakened by
concurrent circumstances. This covers the case which we have
already mentioned [p. 204] of a particular reflex being facilit-
ated by already-existing somatic illness. If, for instance, some-
one suffers often from cardiac pains, these will also be provoked
by affects. Alternatively, a reflex may be facilitated by the fact
that the muscular innervation concerned was deliberately in-
tended at the moment at which the affect originally occurred.
Thus, Anna O. (in our first case history) [p. 38] tried, in her
fright, to stretch out her right arm that had gone to sleep
owing to pressure against the back of the chair, in order to
ward off the snake; and from that time on the tetanus in her
right arm was provoked by the sight of any snake-like object.
Or again [pp. 39-40], in her emotion, she brought her eyes
forcibly together in order to read the hands of the watch, and
thereupon a convergent squint became one of the reflexes of
that affect. And so on.

This is due to the operation of simultaneity, which, indeed,
governs our normal associations. Every sense-perception calls
back into consciousness any other sense-perception that appeared
originally at the same time. (Cf. the text-book example of the
visual image of a sheep and the sound of its bleating, etc.) If
the original affect was accompanied by a vivid sense-impression,
the latter is called up once more when the affect is repeated;
and since it is a question of discharging excessively great
excitation, the sense-impression emerges, not as a recollection,
but as a hallucination. Almost all our case histories provide
instances of this. It is also what happened in the case of a
woman who experienced a painful affect at a time when she
was having violent toothache due to periostitis, and who thence-
forward suffered from infra-orbital neuralgia whenever the
affect was renewed or even recollected [pp. 176-9].

What we have here is the facilitation of abnormal reflexes

(3) HYSTERICAL CONVERSION 209

according to the general laws of association. But sometimes
(though, it must be admitted, only in higher degrees of hysteria)
true sequences of associated ideas lie between the affect and its
reflex. Here we have determination through symbolism. What unites
the affect and its reflex is often some ridiculous play upon
words or associations by sound, but this only happens in dream-
like states when the critical powers are low and lies outside the
group of phenomena with which we are here dealing.

In a large number of cases the path taken by the train of
determination remains unintelligible to us, because we often
have a very incomplete insight into the patient's mental state
and an imperfect knowledge of the ideas which were active at
the time of the origin of the hysterical phenomenon. But we
may assume that the process is not entirely unlike what we can
observe clearly in more favourable cases.

The experiences which released the original affect, the ex-
citation of which was then converted into a somatic phe-
nomenon, are described by us as psychical traumas, and the
pathological manifestation arising in this way, as hysterical
symptoms of traumatic origin. (The term 'traumatic hysteria' has
already been applied to phenomena which, as being conse-
quences of physical injuries traumas in the narrowest sense of
the word form part of the class of 'traumatic neuroses'.)

The genesis of hysterical phenomena that are determined by
traumas finds a perfect analogy in the hysterical conversion of
the psychical excitation which originates, not from external
stimuli nor from the inhibition of normal psychical reflexes,
but from the inhibition of the course of association. The
simplest example and model of this is afforded by the excita-
tion which arises when we cannot recollect a name or cannot
solve a riddle, and so on. If someone tells us the name or gives
us the answer to the riddle, the chain of associations is ended,
and the excitation vanishes, just as it does on the ending of a
reflex chain. The strength of the excitation caused by the
blocking of a line of associations is in direct ratio to the interest
which we take in them that is, to the degree to which they
set our will in motion. Since, however, the search for a solution
of the problem, or whatever it may be, always involves a large
amount of work, though it may be to no purpose, even a
powerful excitation finds employment and does not press for
discharge, and consequently never becomes pathogenic.

210 III. THEORETICAL (BREUER)

It does, however, become pathogenic if the course of associa-
tions is inhibited owing to ideas of equal importance being
irreconcilable if, for instance, fresh thoughts come into con-
flict with old-established ideational complexes. Such are the
torments of religious doubt to which many people succumb and
many more succumbed in the past. Even in such cases, however,
the excitation and the accompanying psychical pain (the feeling
of unpleasure) only reach any considerable height if some
volitional interest of the subject's comes into play if, for
instance, a doubter feels himself threatened in the matter of
his happiness or his salvation. Such a factor is always present,
however, when the conflict is one between firmly-rooted com-
plexes of moral ideas in which one has been brought up and
the recollection of actions or merely thoughts of one's own
which are irreconcilable with them; when, in other words, one
feels the pangs of conscience. The volitional interest in being
pleased with one's own personality and satisfied with it comes
into operation here and increases to the highest degree the
excitation due to the inhibition of associations. It is a matter
of everyday experience that a conflict like this between irrecon-
cilable ideas has a pathogenic effect. What are mostly in
question are ideas and processes connected with sexual life:
masturbation in an adolescent with moral sensibilities; or, in a
strictly conscientious married woman, becoming aware of an
attraction to a man who is not her husband. Indeed, the first
emergence of sexual feelings and ideas is very often in itself
enough to bring about an intense state of excitation, owing to
its conflicting with a deeply-rooted idea of moral purity. 1

A state of excitation of this kind is usually followed by psychi-
cal consequences, such as pathological depression and anxiety-
states (Freud [1895i]). Sometimes, however, concurrent circum-
stances bring about an abnormal somatic phenomenon in which
the excitation is discharged. Thus there may be vomiting when
the feeling of uncleanness produces a physical feeling of nausea,
or a tussis nervosa, as in Anna O. (Case History 1 [pp. 43-4]),
when moral anxiety provokes a spasm of the glottis, and so on. 2

1 Qf. on this point some interesting observations and comments by
Benedikt [1894, 51 ff.].

2 Compare a passage in Mach's 'Bewegungsempfindungen' [1875]
which deserves to be recalled in this connection: 'It has often been
found during the experiments (on giddiness) which I have described,

(3) HYSTERICAL CONVERSION 211

There is a normal, appropriate reaction to excitation caused
by very vivid and irreconcilable ideas namely, to communi-
cate them by speech. An amusingly exaggerated picture of
the urge to do this is given in the story of Midas's barber, who
spoke his secret aloud to the reeds. 1 We meet the same urge
as one of the basic factors of a major historical institution the
Roman Catholic confessional. Telling things is a relief; it dis-
charges tension even when the person to whom they are told
is not a priest and even when no absolution follows. If the
excitation is denied this outlet it is sometimes converted into a
somatic phenomenon, just as is the excitation belonging to
traumatic affects. The whole group of hysterical phenomena
that originate in this way may be described, with Freud, as
hysterical phenomena of retention. 2

The account that we have hitherto given of the mechanism
by which hysterical phenomena originate is open to the criticism
that it is too schematic and simplifies the facts. In order that a
healthy person who is not initially neuropathic may develop a
genuine hysterical symptom, with its apparent independence
of the mind and with a somatic existence in its own right,
there must always be a number of concurrent circumstances.

The following case will serve as an example of the compli-
cated nature of the process. A twelve-year-old boy, who had
previously suffered from pavor nocturnus and whose father was
highly neurotic, came home from school one day feeling un-
well. He complained of difficulty in swallowing and headache.

that in general a feeling of nausea set in if it was difficult to bring the
sensations of movement into harmony with the optical impressions. It
appeared as though a part of the stimulus proceeding from the labyrinth
had been compelled to leave the optic tracts, which were closed to it on
account of another stimulus, and to enter upon quite other tracts . . .
I have also repeatedly observed a feeling of nausea in making an
attempt to combine stereoscopic images which are widely separated.'

Here we have nothing less than the physiological pattern for the
generation of pathological, hysterical phenomena as a result of the co-
existence of vivid ideas which are irreconcilable with one another.

1 [Viz.: 'King Midas has ass's ears.']

2 [The first publication in which Freud used the term 'retention
hysteria' was his first paper on the 'Neuro-Psychoses of Defence'
(1894a, Section I). It was briefly mentioned on pp. 162 and 171 above,
and is discussed at greater length below on pp. 285-6, where Freud
appears to attribute the term jointly to Breuer and himself, and where,
incidentally, he throws doubts on the importance of the concept.]

212 III. THEORETICAL (BREUER)

The family doctor assumed that the cause was a sore throat.
But the condition did not improve even after several days. The
boy refused food and vomited when it was pressed on him. He
moved about listlessly, without energy or enjoyment; he wanted
to lie in bed all the time and was very much run down physic-
ally. When I saw him five weeks later, he gave the impression
of being a shy and shut-in child, and I became convinced that
his condition had a psychical basis. On being questioned
closely, he brought up a trivial explanation a severe reproof
given by his father which had clearly not been the real cause
of his illness. Nor could anything be learnt from his school. I
promised that I would extract the information later under
hypnosis. This, however, turned out to be unnecessary. In
response to strong appeals from his clever and energetic mother,
he burst into tears and told the following story. While he was
on his way home from school he had gone into a urinal, and a
man had held out his penis to him and asked him to take it into
his mouth. He had run away in terror, and nothing else had
happened to him. But he was ill from that instant. As soon as
he had made his confession he recovered completely. In
order to produce the anorexia, the difficulty in swallowing and
the vomiting, several factors were required: the boy's innate
neurotic nature, his severe fright, the irruption of sexuality in
its crudest form into his childish temperament and, as the
specifically determining factor, the idea of disgust. The illness
owed its persistence to the boy's silence, which prevented the
excitation from finding its normal outlet.

In all other cases, as in this one, there must be a convergence
of several factors before a hysterical symptom can be generated
in anyone who has hitherto been normal. Such symptoms are
invariably 'overdetermined', to use Freud's expression. 1

It may be assumed that an overdetermination of this sort is
also present when the same affect has been called out by a series
of several provoking causes. The patient and those about him

1 [This seems to be the first published appearance of the term
'uberdeterminierf, which is used by Freud himself below on p. 263. On
p. 290 he uses the synonymous German word * uberbestimm? , and this
already occurs in his monograph on aphasia (18916, 76) in a passage
on learning to speak which will be found translated in an appendix to
the paper on 'The Unconscious' (1915*), Standard Ed., 14. It is, it must
be added, unlikely that the notion of multiple causation should never
have been expressed earlier by other writers in similar terminology.]

(3) HYSTERICAL CONVERSION 213

attribute the hysterical symptom only to the last cause, though
that cause has as a rule merely brought to light something
that had already been almost accomplished by other traumas.

A girl of seventeen 1 had her first hysterical attack (which
was followed by a number of others) when a cat jumped on her
shoulder in the dark. The attack seemed simply to be the result
of fright. Closer investigation showed, however, that the girl,
who was particularly good-looking and was not properly looked
after, had recently had a number of more or less brutal attempts
made on her, and had herself been sexually excited by them.
(Here we have the factor of disposition.) A few days before, a
young man had attacked her on the same dark staircase and she
had escaped from him with difficulty. This was the actual
psychical trauma, which the cat did no more than make mani-
fest. But it is to be feared that in many such cases the cat is
regarded as the causa efficient.

In order for the repetition of an affect to bring about a
conversion in this way, it is not always necessary that there
should be a number of external provoking causes; the renewal
of the affect in memory is often also enough, if the recollection is
repeated rapidly and frequently, immediately after the trauma
and before its affect has become weakened. This is enough if
the affect was a very powerful one. Such is the case in traumatic
hysteria, in the narrower sense of the word. During the days
following a railway accident, for instance, the subject will live
through his frightful experiences again both in sleeping and
waking, and always with the renewed affect of fright, till at
last, after this period of 'psychical working-out [elaboration]' (in
Charcot's phrase [cf. p. 134]) or of 'incubation', conversion
into a somatic phenomenon takes place. (Though there is an-
other factor concerned which we shall have to discuss later.)

As a rule, however, an affective idea is promptly subjected
to 'wearing away 5 , to all the influences touched on in
our 'Preliminary Communication' (p. 9), which deprive it
little by little of its quota of affect. 2 Its revival causes an

1 I have to thank Herr Assistant Dr. Paul Karplus for this case.

2 ['AffektwerC (here and a few lines lower down), literally 'affective
value'. This is an approximate synonym for ' Affektbetrag\ as is shown
by a sentence in Freud's paper in French on organic and hysterical
paralyses (1893f). He there uses the words 'valeur affective* and adds in
parenthesis the German ' Affektbetrag\ This latter term is regularly trans-
lated here as 'quota of affect', e.g. on p. 166.]

214 III. THEORETICAL (BREUER)

ever-diminishing amount of excitation, and the recollection
thus loses the capacity to contribute to the production of a
somatic phenomenon. The facilitation of the abnormal reflex
disappears and the status quo ante is thereupon re-established.

The 'wearing-away' influences, however, are all of them
effects of association, of thinking, of corrections by reference to
other ideas. This process of correction becomes impossible if
the affective idea is withdrawn from 'associative contact'. When
this happens the idea retains its whole quota of affect. Since at
every renewal the whole sum of excitation of the original affect
is liberated once more, the facilitation of the abnormal reflex
that was started at the time is finally completed; or, if the
facilitation was already complete, it is maintained and stabil-
ized. The phenomenon of hysterical conversion is in this way
permanently established.

Our observations show two ways in which affective ideas can
be excluded from association.

The first is 'defence', 1 the deliberate suppression of distressing
ideas which seem to the subject to threaten his happiness or
his self-esteem. In his [first] paper on 'The Neuro-Psychoses of
Defence' (18940) and in his case histories in the present volume,
Freud has discussed this process, which undoubtedly possesses
very high pathological significance. We cannot, it is true,
understand how an idea can be deliberately repressed from
consciousness. But we are perfectly familiar with the correspond-
ing positive process, that of concentrating attention on an idea,
and we are just as unable to say how we effect that. Ideas, then,
from which consciousness is diverted, which are not thought
about, are also withdrawn from the wearing-away process and
retain their quota of affect undiminished.

We have further found that there is another kind of idea that
remains exempt from being worn away by thought. This may
happen, not because one does not want to remember the idea,
but because one cannot remember it: because it originally
emerged and was endowed with affect in states in respect of
which there is amnesia in waking consciousness that is, in
hypnosis or in states similar to it. The latter seem to be of the
highest importance for the theory of hysteria, and accordingly
deserve a somewhat fuller examination. 2

1 [See footnote, p. 10.]

2 When, here and later on, we speak of ideas that are currently present

(4) HYPNOID STATES 215

(4) HYPNOID STATES

When, in our 'Preliminary Communication' [p. 12] we put
forward the thesis that the basis and sine qua non of hysteria is
the existence of hypnoid states, we were overlooking the fact
that Moebius had already said exactly the same thing in 1890.
'The necessary condition for the (pathogenic) operation of
ideas is, on the one hand, an innate that is, hysterical dis-
position and, on the other, a special frame of mind. We can
only form an imprecise idea of this frame of mind. It must
resemble a state of hypnosis; it must correspond to some kind
of vacancy of consciousness in which an emerging idea meets
with no resistance from any other in which, so to speak, the
field is clear for the first comer. We know that a state of this
kind can be brought about not only by hypnotism but by
emotional shock (fright, anger, etc.) and by exhausting factors
(sleeplessness, hunger, and so on).' [Moebius, 1894, 17.]

The problem to whose solution Moebius was here making a
tentative approach is that of the generating of somatic phe-
nomena by ideas. He here recalls the ease with which this can
occur under hypnosis, and regards the operation of affects as
analogous. Our own, somewhat different, view on the operation
of the affects has been fully explained above [p. 201 ff.]. I need
not, therefore, enter further into the difficulty involved in
Moebius's assumption that in anger there is a 'vacancy of
consciousness' x (which admittedly exists in fright and pro-
longed anxiety) or into the more general difficulty of drawing
an analogy between the state of excitation in an affect and the
quiescent state in hypnosis. We shall come back later [p. 220],
however, to these remarks by Moebius, which in my opinion
embody an important truth.

and operative but yet unconscious, we are seldom concerned with single
ideas (such as the big snake hallucinated by Anna O. which started her
contracture). It is almost always a question of complexes of ideas, of re-
collections of external events and trains of thought of the subject's own.
It may sometimes happen that every one of the individual ideas com-
prised in such a complex of ideas is thought of consciously, and that
what is exiled from consciousness is only the particular combination
of them.

1 It is possible that by this description Moebius means nothing else
than the inhibition of the current of ideas an inhibition which cer-
tainly occurs in the case of affects, though owing to entirely different
causes from those operating in hypnosis.

216 III. THEORETICAL (BREUER)

For us, the importance of these states which resemble
hypnosis 'hypnoid' states lies, in addition and most especi-
ally, in the amnesia that accompanies them and in their power
to bring about the splitting of the mind which we shall discuss
presently and which is of fundamental significance for c major
hysteria'. We still attribute this importance to hypnoid states.
But I must add a substantial qualification to our thesis. Con-
version the ideogenic production of somatic phenomena
can also come about apart from hypnoid states. Freud has
found in the deliberate amnesia of defence a second source,
independent of hypnoid states, for the construction of idea-
tional complexes which are excluded from associative contact.
But, accepting this qualification, I am still of opinion that
hypnoid states are the cause and necessary condition of many,
indeed of most, major and complex hysterias.

First and foremost, of course, among hypnoid states are to be
numbered true auto-hypnoses, which are distinguished from
artificial hypnoses only by the fact of their originating spon-
taneously. We find them in a number of fully-developed hys-
terias, occurring with varying frequency and duration, and
often alternating rapidly with normal waking states (cf. Case
Histories 1 and 2). On account of the dream-like nature of
their content, they often deserve the name of 'delirium hystericum\
What happens during auto-hypnotic states is subject to more or
less total amnesia in waking life (whereas it is completely re-
membered in artificial hypnosis). The amnesia withdraws the
psychical products of these states, the associations that have
been formed in them, from any correction during waking
thought; and since in auto-hypnosis criticism and supervision
by reference to other ideas is diminished, and, as a rule, dis-
appears almost completely, the wildest delusions may arise from
it and remain untouched for long periods. Thus it is almost
only in these states that there arises a somewhat complicated
irrational 'symbolic relation between the precipitating cause
and the pathological phenomenon' [p. 5], which, indeed, is
often based on the most absurd similarities of sound and verbal
associations. The absence of criticism in auto-hypnotic states is
the reason why auto-suggestions so frequently arise from them
as, for instance, when a paralysis remains behind after a
hysterical attack. But, and this may be merely by chance, we
have scarcely ever in our analyses come across an instance of a

(4) HYPNOID STATES 217

hysterical phenomenon originating in this manner. We have
always found it happen, in auto-hypnosis no less than outside it,
as a result of the same process namely, conversion of an
affective excitation.

In any case, this 'hysterical conversion' takes place more
easily in auto-hypnosis than in the waking state, just as sug-
gested ideas are realized physically as hallucinations and
movements so much more easily in artificial hypnosis. Never-
theless the process of conversion of excitation is essentially the
same as has been described above. When once it has taken
place, the somatic phenomenon is repeated if the affect and the
auto-hypnosis occur simultaneously. And in that case it seems
as though the hypnotic state has been called up by the affect
itself. Accordingly, so long as there is a clear-cut alternation
between hypnosis and full waking life, the hysterical symptom
remains restricted to the hypnotic state and is strengthened
there by repetition; moreover, the idea that gave rise to it is
exempt from correction by waking thoughts and their criticism,
precisely because it never emerges in clear waking life.

Thus with Anna O. (Case History 1) the contracture of her
right arm, which was associated in her auto-hypnosis with the
affect of anxiety and the idea of the snake, remained for four
months restricted to the moments during which she was in a
hypnotic state (or, if we consider this term inappropriate for
absences of very short duration, a hypnoid one), though it re-
curred frequently. The same thing happened with other
conversions that were carried out in her hypnoid state; and in
this way the great complex of hysterical phenomena grew up
in a condition of complete latency and came into the open when
her hypnoid state became permanent. [Cf. p. 42 f.]

The phenomena which have arisen in this way emerge into
clear consciousness only when the split in the mind, which I
shall discuss later, has been completed, and when the alterna-
tion between waking and hypnoid states has been replaced by a
co-existence between the normal and the hypnoid complexes of
ideas.

Are hypnoid states of this kind in existence before the patient
falls ill, and how do they come about? I can say very little about
this, for apart from the case of Anna O. we have no observations
at our disposal which might throw light on the point. It seems
certain that with her the auto-hypnosis had the way paved for

218 III. THEORETICAL (BREUER)

it by habitual reveries and that it was fully established by an
affect of protracted anxiety, which, indeed, would itself be the
basis for a hypnoid state. It seems not improbable that this
process holds good fairly generally.

A great variety of states lead to 'absence of mind' but only a
few of them predispose to auto-hypnosis or pass over immedi-
ately into it. An investigator who is deep in a problem is also no
doubt anaesthetic to a certain degree, and he has large groups
of sensations of which he forms no conscious perception; and
the same is true of anyone who is using his creative imagination
actively (cf. Anna O.'s 'private theatre' [p. 22]). But in such
states energetic mental work is carried on, and the excitation
of the nervous system which is liberated is used up in this work.
In states of abstraction and dreaminess, on the other hand,
intracerebral excitation sinks below its clear waking level. These
states border on sleepiness and pass over into sleep. If during
such a state of absorption, and while the flow of ideas is in-
hibited, a group of affectively-coloured ideas is active, it creates
a high level of intracerebral excitation which is not used up by
mental work and is at the disposal of abnormal functioning,
such as conversion.

Thus neither 'absence of mind' during energetic work nor
unemotional twilight states are pathogenic; on the other hand,
reveries that are filled with emotion and states of fatigue
arising from protracted affects are pathogenic. The broodings
of a care-ridden man, the anxiety of a person watching at the
sick-bed of someone dear to him, the day-dreams of a lover
these are states of this second kind. Concentration on the
affective group of ideas begins by producing 'absence of mind'.
The flow of ideas grows gradually slower and at last almost
stagnates; but the affective idea and its affect remain active,
and so consequently does the great quantity of excitation which
is not being used up functionally. The similarity between this
situation and the determinants of hypnosis seems unmistakable.
The subject who is to be hypnotized must not really go to
sleep, that is to say, his intracerebral excitation must not sink
to the level of sleep; but his flow of ideas must be inhibited.
When this is so, the whole mass of excitation is at the disposal
of the suggested idea.

This is the way in which pathogenic auto-hypnosis would
seem to come about in some people by affect being introduced

(4) HYPNOID STATES 219

into a habitual reverie. This is perhaps one of the reasons why
in the anamnesis of hysteria we so often come across the two
great pathogenic factors of being in love and sick-nursing. In
the former, the subject's longing thoughts about his absent
loved one create in him a 'rapt' state of mind, cause his real
environment to grow dim, and then bring his thinking to a
standstill charged with affect; while in sick-nursing the quiet
by which the subject is surrounded, his concentration on an
object, his attention fixed on the patient's breathing all this
sets up precisely the conditions demanded by many hypnotic
procedures and fills the twilight state produced in this way with
the affect of anxiety. It is possible that these states differ only
quantitatively from true auto-hypnoses and that they pass over
into them.

Once this has happened, the hypnosis-like state is repeated
again and again when the same circumstances arise; and the
subject, instead of the normal two conditions of mind, has three:
waking, sleeping and the hypnoid state. We find the same thing
happening when deep artificial hypnosis has been frequently
brought on.

I cannot say whether spontaneous hypnotic states may also
be generated without an affect intervening in this way, as a
result of an innate disposition; but I consider it very probable.
When we see the difference in susceptibility to artificial hyp-
nosis both among healthy and sick people and how easily it is
brought on in some, it seems reasonable to suppose that in such
people it can also appear spontaneously. And a disposition for
this is perhaps necessary before a reverie can turn into an
auto-hypnosis. I am therefore far from attributing to all
hysterical patients the generating mechanism which we have
been taught by Anna O.

I speak of hypnoid states rather than of hypnosis itself
because it is so difficult to make a clear demarcation of these
states, which play such an important part in the genesis of
hysteria. We do not know whether reveries, which were des-
cribed above as preliminary stages of auto-hypnosis, may not
themselves be able to produce the same pathological effect as
auto-hypnosis, and whether the same may not also be true of a
protracted affect of anxiety. It is certainly true of fright. Since
fright inhibits the flow of ideas at the same time at which an
affective idea (of danger) is very active, it offers a complete

220 III. THEORETICAL (BREUER)

parallel to a reverie charged with affect; and since the recollec-
tion of the affective idea, which is constantly being renewed,
keeps on re-establishing this state of mind, 'hypnoid fright'
comes into being, in which conversion is either brought about
or stabilized. Here we have the incubation stage of 'traumatic
hysteria' in the strict sense of the words.

In view of the fact that states of mind which are so different
though they agree with one another in the most important
respect can be classed with auto-hypnosis, it seems desirable to
adopt the expression 'hypnoid', which lays stress on this internal
similarity. It sums up the view put forward by Moebius in the
passage quoted above [p. 215]. Most of all, however, it points
to auto-hypnosis itself, the importance of which in the genesis
of hysterical phenomena rests on the fact that it makes conver-
sion easier and protects (by amnesia) the converted ideas from
wearing-away a protection which leads, ultimately, to an
increase in the psychical splitting.

If a somatic symptom is caused by an idea and is repeatedly
set going by it, we should expect that intelligent patients
capable of self-observation would be conscious of the connec-
tion; they would know by experience that the somatic phe-
nomenon appeared at the same time as the memory of a
particular event. The underlying causal nexus is, it is true,
unknown to them; but all of us always know what the idea is
which makes us cry or laugh or blush, even though we have not
the slightest understanding of the nervous mechanism of these
ideogenic phenomena. Sometimes patients do really observe
the connection and are conscious of it. For instance, a woman
may say that her mild hysterical attack (trembling and palpita-
tions, perhaps) comes from some great emotional disturbance
and is repeated when, and only when, some event reminds her
of it. But this is not the case with very many or indeed the
majority of hysterical symptoms. Even intelligent patients are
unaware that their symptoms arise as the result of an idea and
regard them as physical phenomena on their own account. If
it were otherwise the psychical theory of hysteria must already
have reached a respectable age.

It would be plausible to believe that, though the symptoms
in question were ideogenic in the first instance, the repetition
of them has, to use Romberg's phrase [1840, 192], 'imprinted'

(4) HYPNOID STATES 221

them into the body, and they would now no longer be based on a
psychical process but on modifications in the nervous system
which have occurred in the meantime: they would have become
self-sufficient, genuinely somatic symptoms.

This view is in itself neither untenable nor improbable. But
I believe that the new light which our observations have thrown
on the theory of hysteria lies precisely in its having shown that
this view is inadequate to meet the facts, at any rate in many
instances. We have seen that hysterical symptoms of the most
various kinds which have lasted for many years 'immediately
and permanently disappeared when we had succeeded in
bringing clearly to light the memory of the event by which they
were provoked and in arousing their accompanying affect, and
when the patient had described that event in the greatest
possible detail and had put the affect into words' [p. 6]. The
case histories which have been reported in these pages provide
some pieces of evidence in support of these assertions. 'We may
reverse the dictum "cessante causa cessat effectus" ["when the cause
ceases the effect ceases' 5 ], and conclude from these observations
that the determining process' (that is, the recollection of it)
'continues to operate for years not indirectly, through a chain
of intermediate causal links, but as a directly releasing cause
just as a psychical pain that is remembered in waking con-
sciousness still provokes a lachrymal secretion long after the
event. Hysterics suffer mainly from reminiscences. 5 [P. 7.]
But if this is so if the memory of the psychical trauma must
be regarded as operating as a contemporary agent, like a
foreign body, long after its forcible entrance, and if nevertheless
the patient has no consciousness of such memories or their
emergence then we must admit that unconscious ideas exist and
are operative.

Moreover, when we come to analyse hysterical phenomena
we do not only find such unconscious ideas in isolation. We
must recognize the fact that in reality, as has been shown by
the valuable work carried out by French investigators, large
complexes of ideas and involved psychical processes with im-
portant consequences remain completely unconscious in a
number of patients and co-exist with conscious mental life; we
must recognize that there is such a thing as a splitting of
psychical activity, and that this is of fundamental value for our
understanding of complicated hysterias.

222 III. THEORETICAL (BREUER)

I may perhaps be allowed to explore this difficult and
obscure region rather more fully. The need to establish the
meaning of the terminology that has been used may to some
extent excuse the theoretical discussion which follows.

(5) UNCONSCIOUS IDEAS AND IDEAS INADMISSIBLE TO
CONSCIOUSNESS SPLITTING OF THE MIND

We call those ideas conscious which we are aware of. There
exists in human beings the strange fact of self-consciousness.
We are able to view and observe, as though they were objects,
ideas that emerge in us and succeed one another. This does not
happen always, since occasions for self-observation are rare.
But the capacity for it is present in everyone, for everyone can
say: 'I thought this or that.' We describe as conscious those
ideas which we observe as active in us, or which we should so
observe if we attended to them. At any given moment of time
there are very few of them; and if others, apart from those,
should be current at the time, we should have to call them
unconscious ideas.

It hardly seems necessary any longer to argue in favour of
the existence of current ideas that are unconscious or sub-
conscious. 1 They are among the commonest facts of everyday
life. If I have forgotten to make one of my medical visits, I have
feelings of lively unrest. I know from experience what this
feeling means: that I have forgotten something. I search my
memories in vain; I fail to discover the cause, till suddenly,
hours later perhaps, it enters my consciousness. But I have been
uneasy the whole time. Accordingly, the idea of the visit has
been all the time operative, that is to say present, but not in my
consciousness. Or again, a busy man may have been annoyed
by something one morning. He is entirely absorbed by his
office work; while he is doing it his conscious thoughts are fully
occupied, and he gives no thought to his annoyance. But his
decisions are influenced by it and he may well say 'no* where
he would otherwise have said 'yes'. So in spite of everything
this memory is operative, that is to say present. A great deal of
what we describe as 'mood' comes from sources of this kind,
from ideas that exist and are operative beneath the threshold

1 [See footnote, p. 45.]

(5) UNCONSCIOUS IDEAS 223

of consciousness. Indeed, the whole conduct of our life is con-
stantly influenced by subconscious ideas. We can see every day
how, where there is mental degeneration, as for instance in the
initial stages of general paralysis, the inhibitions which normally
restrain certain actions become weaker and disappear. But the
patient who now makes indecent jokes in the presence of
women was not, in his healthy days, prevented from doing so
by conscious memories and reflections; he avoided it 'instinc-
tively' and 'automatically' that is to say, he was restrained by
ideas which were called up by the impulse to behave in this
way, but which remained beneath the threshold of conscious-
ness, though they nevertheless inhibited the impulse. All in-
tuitive activity is directed by ideas which are to a large extent
subconscious. For only the clearest and most intense ideas are
perceived by self-consciousness, whilst the great mass of current
but weaker ideas remains unconscious.

The objections that are raised against 'unconscious ideas'
existing and being operative seem for the most part to be
juggling with words. No doubt 'idea 5 is a word belonging to the
terminology of conscious thinking, and 'unconscious idea' is
therefore a self-contradictory expression. But the physical pro-
cess which underlies an idea is the same in content and form
(though not in quantity) whether the idea rises above the
threshold of consciousness or remains beneath it. It would only
be necessary to construct some such term as 'ideational sub-
stratum' in order to avoid the contradiction and to counter the
objection.

Thus there seems to be no theoretical difficulty in also
recognizing unconscious ideas as causes of pathological phe-
nomena. But if we go into the matter more closely we come
upon other difficulties. As a rule, when the intensity of an un-
conscious idea increases it enters consciousness ipso facto. Only
when its intensity is slight does it remain unconscious. What
seems hard to understand is how an idea can be sufficiently
intense to provoke a lively motor act, for instance, and at the
same time not intense enough to become conscious.

I have already [p. 205 f.] mentioned a view which should not,
perhaps, be dismissed out of hand. On this view the clarity of
our ideas, and consequently their capacity for being observed
by our self-consciousness that is, for being conscious is de-
termined, among other things, by the feelings of pleasure or

224 III. THEORETICAL (BREUER)

unpleasure which they arouse, by their quota of affect. 1 When
an idea immediately produces lively somatic consequences,
this implies that the excitation engendered by it flows off into
the paths concerned in these consequences, instead of, as would
happen otherwise, becoming diffused in the brain; and pre-
cisely because this idea has physical consequences, because its
sums of psychical stimuli have been 'converted* into somatic
ones, it loses the clarity which would otherwise have marked
it out in the stream of ideas. Instead of this it is lost among the
rest.

Suppose, for instance, that someone has had a violent affect
during a meal and has not 'abreacted' it. When subsequently
he attempts to eat he is overtaken by choking and vomiting
and these seem to him purely somatic symptoms. His hysterical
vomiting continues for some considerable time. It disappears
after the affect has been revived, described and reacted to
under hypnosis. There can be no doubt that every attempt to
eat called up the memory concerned. This memory started the
vomiting but did not appear clearly in consciousness, because
it was now without affect, whereas the vomiting absorbed the
attention completely.

It is conceivable that the reason which has just been given
explains why some ideas that release hysterical phenomena are
not recognized as their causes. But this reason the fact that
ideas that have lost their affect because they have been con-
verted are overlooked cannot possibly explain why, in other
cases, ideational complexes that are anything but devoid of
affect do not enter consciousness. Numerous examples of this
are to be found in our case histories.

In patients like these we found that it was the rule for the
emotional disturbance apprehensiveness, angry irritability,
grief to precede the appearance of the somatic symptom or to
follow it immediately, and to increase, either until it was
cleared up by being given utterance in words or until the affect
and the somatic phenomenon gradually disappeared again.
Where the former happened the quality of the affect always

1 [Breuer seems here to be using the term 'affect', in a sense quite
exceptional in the present volume (though one sometimes employed by
other psychologists), to indicate specifically feelings of pleasure arid un-
pleasure. The same word 'AffektwerC is used by him above (p. 213f.) in
his regular sense of an unspecified emotion or feeling.]

(5) UNCONSCIOUS IDEAS 225

became quite understandable, even though its intensity could
not fail to seem to a normal person (and to the patient himself,
after it had been cleared up) to be out of all proportion. These,
then, were ideas which were intense enough not merely to
cause powerful somatic phenomena but also to call out the
appropriate affect and to influence the course of association by
bringing allied ideas into prominence but which, in spite of
all this, remained outside consciousness themselves. In order
to bring them into consciousness hypnosis was necessary (as in
Case Histories 1 and 2), or (as in Case Histories 4 and 5)
a laborious search had to be made with strenuous help from the
physician.

Ideas such as these which, though current, are unconscious,
not because of their relatively small degree of liveliness, but in
spite of their great intensity, may be described as ideas that are
'inadmissible to consciousness'. 1

The existence of ideas of this kind that are inadmissible to
consciousness is pathological. In normal people all ideas that
can become current at all enter consciousness as well if they are
sufficiently intense. In our patients we find a large complex
of ideas that are admissible to consciousness existing side by
side with a smaller complex of ideas that are not. Thus in them
the field of ideational psychical activity does not coincide with
potential consciousness. The latter is more restricted than the
former. Their psychical ideational activity is divided into a
conscious and an unconscious part, and their ideas are divided
into some that are admissible and some that are inadmissible
to consciousness. We cannot, therefore, speak of a splitting of
consciousness, though we can of a splitting of the mind.

Conversely, these subconscious ideas cannot be influenced or
corrected by conscious thought. They are very often concerned
with experiences which have in the meantime lost their mean-
ing dread of events which did not occur, fright that turned

1 This expression ['Bewusstseinsunfdhig'] is not unambiguous and for
that reason leaves much to be desired. It is, however, constructed on the
analogy of'Hojfahig' ['admissible to Court', 'having the tntrce'] and may
in the meantime be used for lack of a better term. [Though on the
analogy of 'Hqffahig* the word is here translated 'inadmissible to con-
sciousness', its literal meaning is 'incapable of consciousness'. It could
equally well be translated 'incapable of being (or becoming) conscious'.
The word was adopted by Freud and frequently used by him, and the
context then often calls for one of these other renderings.]

226 III. THEORETICAL (BREUER)

to laughter or joy after a rescue. Such subsequent developments
deprive the memory of all its affect so far as consciousness is
concerned; but they leave the subconscious idea, which pro-
vokes somatic phenomena, completely untouched.

Perhaps I may be allowed to quote another example. A
young married woman was for some time very much worried
about her younger sister's future. As a result of this her period,
normally regular, lasted for two weeks; she was tender in the
left hypogastrium, and twice she found herself lying stiff on
the floor, coming out of a Taint'. There followed an ovarian
neuralgia on the left side, with signs of a severe peritonitis.
The absence of fever, and a contracture of the left leg (and of
her back), showed that the illness was a /wMfifo-peritonitis; and
when, a few years later, the patient died and an autopsy was
performed, all that was found was a 'microcystic degeneration'
of both ovaries without any traces of an old peritonitis. The
severe symptoms disappeared by degrees and left behind an
ovarian neuralgia, a contracture of the muscles of the back, so
that her trunk was as stiff as a board, and a contracture of the
left leg. The latter was got rid of under hypnosis by direct sug-
gestion. The contracture of her back was unaffected by this.
Meanwhile her younger sister's difficulties had been completely
smoothed out and all her fears on that score had vanished.
But the hysterical phenomena, which could only have been
derived from them, persisted unaltered. It was tempting to
suppose that what we were faced by were changes in innerva-
tion, which had assumed an independent status and were no
longer attached to the idea that had caused them. But after
the patient had been compelled under hypnosis to tell the whole
story up to the time when she had fallen ill of 'peritonitis'
which she did most unwillingly she immediately sat up in bed
without assistance, and the contracture of her back disappeared
for ever. (Her ovarian neuralgia, which was undoubtedly much
older in its origin, remained unaffected.) Thus we see that her
pathogenic anxious idea had persisted in active operation for
months on end, and that it had been completely inaccessible
to any correction by actual events.

If we are obliged to recognize the existence of ideational
complexes that never enter consciousness and are not influ-
enced by conscious thought, we shall have admitted that,
even in such simple cases of hysteria as the one I have just

(5) UNCONSCIOUS IDEAS 227

described, there is a splitting of the mind into two relatively
independent portions. I do not assert that everything that
we call hysterical has a splitting of this kind as its basis and
necessary condition; but I do assert that 'the splitting of
psychical activity which is so striking in the well-known cases
in the form of "double conscience" is present to a rudimentary
degree in every major hysteria', and that 'the liability and
tendency to such a dissociation is the basic phenomenon of
this neurosis'. 1

But before entering into a discussion of this subject, I must
add. a comment with regard to the unconscious ideas which
produce somatic effects. Many hysterical phenomena last con-
tinuously for a long time, like the contracture in the case
described above. Should we and may we suppose that during
all this time the causative idea is perpetually active and cur-
rently present? I think so. It is true that in healthy people we
see their psychical activity going forward to the accompani-
ment of a rapid change of ideas. But we find sufferers from
severe melancholia immersed continuously for long periods in
the same distressing idea which is perpetually active and
present. Indeed, we may well believe that even when a healthy
person has a great care on his mind it is present all the time,
since it governs his facial expression even when his conscious-
ness is filled with other thoughts. But the portion of psychical
activity which is separated off in hysterical subjects and which
we think of as filled with unconscious ideas contains as a rule
such a meagre store of them and is so inaccessible to inter-
change with external impressions that it is easy to believe that
a single idea can be permanently active in it.

If it seems to us, as it does to Binet and Janet, that what lies
at the centre of hysteria is a splitting off of a portion of psychical
activity, it is our duty to be as clear as possible on this subject.
It is only too easy to fall into a habit of thought which assumes
that every substantive has a substance behind it which
gradually comes to regard 'consciousness* as standing for
some actual thing; and when we have become accustomed to
make use metaphorically of spatial relations, as in the term

1 [This passage, which is in inverted commas in the original but has
no page reference, is a slightly modified version of a sentence which will
be found in italics on p. 12 of the 'Preliminary Communication'.]

228 III. THEORETICAL (BREUER)

'sub-consciousness', we find as time goes on that we have
actually formed an idea which has lost its metaphorical nature
and which we can manipulate easily as though it was real.
Our mythology is then complete.

All our thinking tends to be accompanied and aided by
spatial ideas, and we talk in spatial metaphors. Thus when we
speak of ideas which are found in the region of clear conscious-
ness and of unconscious ones which never enter the full light
of self-consciousness, we almost inevitably form pictures of a
tree with its trunk in daylight and its roots in darkness, or of a
building with its dark underground cellars. If, however, we con-
stantly bear in mind that all such spatial relations are meta-
phorical and do not allow ourselves to be misled into supposing
that these relations are literally present in the brain, we may
nevertheless speak of a consciousness and a subconsciousness.
But only on this condition.

We shall be safe from the danger of allowing ourselves to be
tricked by our own figures of speech if we always remember
that after all it is in the same brain, and most probably in the
same cerebral cortex, that conscious and unconscious ideas
alike have their origin. 1 How this is possible we cannot say. But
then we know so little of the psychical activity of the cerebral
cortex that one puzzling complication the more scarcely in-
creases our limitless ignorance. We must take it as a fact that
in hysterical patients a part of their psychical activity is in-
accessible to perception by the self-consciousness of the waking
individual and that their mind is thus split.

A universally known example of a division of psychical
activity like this is to be seen in hysterical attacks in some of
their forms and stages. At their beginning, conscious thought is
often extinguished; but afterwards it gradually awakens. Many
intelligent patients admit that their conscious ego was quite
lucid during the attack and looked on with curiosity and sur-
prise at all the mad things they did and said. Such patients
have, furthermore, the (erroneous) belief that with a little good-
will they could have inhibited the attack, and they are inclined
to blame themselves for it. 'They need not have behaved like
that.'- (Their self-reproaches of being guilty of simulation are

1 [Gf. some remarks to a similar effect towards the end of the last
paragraph but one of Freud's preface to his translation of Bernhcim's
De la suggestion (Freud, 1888-9).]

(5) UNCONSCIOUS IDEAS 229

also to a great extent based on this feeling.) 1 But when the next
attack comes on, the conscious ego is as little able to control
what happens as in earlier ones. Here we have a situation
in which the thought and ideation of the conscious waking ego
stands alongside of the ideas which normally reside in the dark-
ness of the unconscious but which have now gained control
over the muscular apparatus and over speech, and indeed even
over a large part of ideational activity itself: the splitting of the
mind is manifest.

It may be remarked that the findings of Binet and Janet
deserve to be described as a splitting not merely of psychical
activity but of consciousness. As we know, these observers have
succeeded in getting into contact with their patients' 'sub-
consciousness', with the portion of psychical activity of which
the conscious waking ego knows nothing; and they have been
able in some of their cases to demonstrate the presence of all
the psychical functions, including self-consciousness, in that
portion, since it has access to the memory of earlier psychical
events. This half of a mind is therefore quite complete and
conscious in itself. In our cases the part of the mind which is
split off is 'thrust into darkness', 2 as the Titans are imprisoned
in the crater of Etna, and can shake the earth but can never
emerge into the light of day. In Janet's cases the division of the
realm of the mind has been a total one. Nevertheless, there is
still inequality in status. But this, too, disappears when the
two halves of consciousness alternate, as they do in the well-
known cases of double conscience, and when they do not differ in
their functional capability.

But let us return to the ideas which we have shown in our
patients as the causes of their hysterical phenomena. It is far
from being possible for us simply to describe them all as being
'unconscious' and 'inadmissible to consciousness'. They form
an almost unbroken scale, passing through every gradation of
vagueness and obscurity, between perfectly conscious ideas
which release an unusual reflex and those which never enter
consciousness in waking life but only in hypnosis. In spite of
this, we regard it as established that a splitting of psychical

1 [These points are exemplified in the case of Anna O. See above,
p. 46.]

* ['In die Finsternis gebracht\ a phrase used by Mephistopheles of him-
self, in Faust, Part I (Scene 4).]

230 III. THEORETICAL (BREUER)

activity occurs in the more severe degrees of hysteria and that
it alone seems to make a psychical theory of the illness possible.

What, then, can be asserted or suspected with probability
about the causes and origin of this phenomenon?

Janet, to whom the theory of hysteria owes so very much and
with whom we are in agreement in most respects, has expressed
a view on this point which we are unable to accept.

Janet's view is the following. 1 He considers that the 'splitting
of a personality 5 rests on an innate psychological weakness
('insuffisance psychologiqui] . All normal mental activity pre-
supposes a certain capacity for 'synthesis', the ability to unite
several ideas into a complex. The combination of the various
sense-perceptions into a picture of the environment is already
a synthetic activity of this kind. This mental function is found
to be far below the normal in hysterical patients. If a normal
person's attention is directed as fully as possible upon some
point, e.g. upon a perception by a single sense, it is true that
he temporarily loses the capacity to apperceive impressions
from the other senses that is, to take them up into his conscious
thought. But in hysterical subjects this happens without any
special concentration of the attention. As soon as they perceive
anything they are inaccessible to other sense-perceptions. In-
deed, they are not even in a position to take in together a
number of impressions coming from a single sense. They can,
for instance, only apperceive tactile sensations in one half of
the body; those from the other side reach the centre and are
used for the co-ordination of movement, but are not apper-
ceived. A person like this is hemi-anaesthetic. In normal people,
an idea calls into consciousness a great number of others by
association; these may be related to the first one, for instance,
in a confirmatory or an inhibiting manner, and only the most
vivid ideas are so extremely powerful that their associations
remain below the threshold of consciousness. In hysterical
people this is always the case. Every idea takes possession of
the whole of their limited mental activity, and this accounts

1 [The account of Janet's views which follows seems to be derived
principally from the concluding chapter of Janet, 1894. This chapter
was a reprint of a paper published in the Archives de Neurologic in 1893
(June and July) which was largely concerned with the Breuer and
Freud Treliminary Communication*. Cf. also above, p. 104.]

(5) UNCONSCIOUS IDEAS 231

for their excessive affectivity. This characteristic of their mind
is described by Janet as the 'restriction of the field of con-
sciousness' of hysterical patients, on the analogy of a 'restriction
of the field of vision'. For the most part the sense-impressions
that are not apperceived and the ideas that are aroused but do
not enter consciousness cease without producing further conse-
quences. Sometimes, however, they accumulate and form com-
plexes 1 mental strata withdrawn from consciousness; they
form a subconsciousness. Hysteria, which is essentially based
on this splitting of the mind, is a 'maladie par faiblesse' ['disease
due to weakness'], and that is why it develops most readily
when a mind which is innately weak is submitted to influences
that weaken it still further or is faced by heavy demands in
relation to which its weakness stands out still more.

Janet's opinions, as thus summarized, already give his answer
to the important question as to the disposition to hysteria as
to the nature of the typus hystericus (taking the term in the sense
in which we speak of a typus phthisicus, by which we understand
the long narrow thorax, the small heart, etc.). Janet regards
a particular form of congenital mental weakness as the dis-
position to hysteria. In reply, we should like to formulate our
own view briefly as follows. It is not the case that the splitting
of consciousness occurs because the patients are weak-minded;
they appear to be weak-minded because their mental activity
is divided and only a part of its capacity is at the disposal of
their conscious thought. We cannot regard mental weakness
as the typus hystericus, as the essence of the disposition to hysteria.

An example makes plain what is intended by the first of these
two sentences. We were frequently able to observe the following
course of events with one of our patients (Frau Cacilie M.).
While she was feeling comparatively well a hysterical symptom
would appear a tormenting, obsessive hallucination, a neural-
gia, or something of the kind and would for some time in-
crease in intensity. Simultaneously the patient's mental capacity
would continuously decrease, and after a few days any un-
initiated observer would have been bound to call her weak-
minded. She would then be relieved of the unconscious idea

1 [This use of the word 'complex' seems to come very close to that
which Jung is generally regarded as having introduced some ten years
later. Cf. Part II of Freud's 'History of the Psycho- Analytic Movement'

232 III. THEORETICAL (BREUER)

(the memory of a psychical trauma, often belonging to the
remote past), either by the physician under hypnosis or by her
suddenly describing the event in a state of agitation and to the
accompaniment of a lively emotion. When this had happened
she did not merely become quiet and cheerful and free from the
tormenting symptom; it was always astonishing to observe the
width and clarity of her intellect and the acuteness of her
understanding and judgement. Chess, which she played excel-
lently, was a favourite occupation of hers, and she enjoyed
playing two games at a time, which can scarcely be regarded
as indicating a lack of mental synthesis. It was impossible to
escape the impression that during a course of events such as
we have just described the unconscious idea drew to itself an
ever-increasing portion of her psychical activity and that the
more this happened the smaller became the part played by
conscious thought, till it was reduced to total imbecility; but
that when, to use the remarkably apt Viennese expression, she
was 'beisammer? [literally 'together', meaning 'in one's right
mind'], she possessed quite remarkable mental powers.

As a comparable state in normal people we would adduce,
not concentration of attention, but preoccupation. If someone is
'preoccupied 5 by some vivid idea, such as a worry, his mental
capacity is similarly reduced.

Every observer is largely under the influence of the subjects
of his observation, and we are inclined to believe that Janet's
views were mainly formed in the course of a detailed study of
the feeble-minded hysterical patients who are to be found in
hospitals or institutions because they have not been able to
hold their own in life on account of their illness and the mental
weakness caused by it. Our own observations, carried out on
educated hysterical patients, have forced us to take an essenti-
ally different view of their minds. In our opinion 'among
hysterics may be found people of the clearest intellect, strongest
will, greatest character and highest critical power' [cf. p. 13],
No amount of genuine, solid mental endowment is excluded
by hysteria, though actual achievements are often made im-
possible by the illness. After all, the patron saint of hysteria,
St. Theresa, was a woman of genius with great practical
capacity.

But on the other hand no degree of silliness, incompetence
and weakness of will is a protection against hysteria. Even if

(5) UNCONSCIOUS IDEAS 233

we disregard what is merely a result of the illness, we must
recognize the type of feeble-minded hysteric as a common one.
Yet even so, what we find here is not torpid, phlegmatic stupidity
but an excessive degree of mental mobility which leads to in-
efficiency. I shall discuss later the question of innate disposition.
Here I merely propose to show that Janet's opinion that mental
weakness is in any way at the root of hysteria and splitting of
the mind is untenable. 1

In complete opposition to Janet's views, I believe that in a
great many cases what underlies dissociation is an excess of
efficiency, the habitual co-existence of two heterogeneous
trains of ideas. It has frequently been pointed out that we are
often not merely 'mechanically' active while our conscious
thought is occupied by trains of ideas which have nothing in
common with our activity, but that we are also capable of what
is undoubtedly psychical functioning while our thoughts are
'busy elsewhere' as, for instance, when we read aloud cor-
rectly and with the appropriate intonation, but afterwards have
not the slightest idea of what we have been reading.

There are no doubt a whole number of activities, from mech-
anical ones such as knitting or playing scales, to some requiring
at least a small degree of mental functioning, all of which are
performed by many people with only half their mind on them.
This is specially true of people who are of a very lively dis-
position, to whom monotonous, simple and uninteresting occu-
pation is a torture, and who actually begin by deliberately
amusing themselves with thinking of something different (cf.
Anna O.'s 'private theatre' [p. 22]). Another situation, but a
similar one, occurs when an interesting set of ideas, derived
for instance from books or plays, forces itself upon the subject's
attention and intrudes into his thoughts. This intrusion is still
more vigorous if the extraneous set of ideas is strongly coloured
with affect (e.g. worry or the longing of someone in love). We
then have the state of preoccupation that I have touched upon
above, which, however, does not prevent many people from
performing fairly complicated actions. Social circumstances
often necessitate a duplication of this kind even when the
thoughts involved are of an exacting kind, as for instance when
a woman who is in the throes of extreme worry or of passionate

1 [Cf. in this connection Freud's remarks on Frau Emmy von N.
(p. 103 ff.).]

234 III. THEORETICAL (BREUER)

excitement carries out her social duties and the functions of an
affable hostess. We all of us manage minor achievements of this
kind in the course of our work; and self-observation seems
always to show that the affective group of ideas are not merely
aroused from time to time by association but are present in the
mind all the time and enter consciousness unless it is taken up
with some external impression or act of will.

Even in people who do not habitually allow day-dreams to
pass through their minds alongside their usual activity, some
situations give rise during considerable periods of time to this
simultaneous existence of changing impressions and reactions
from external life on the one hand, and an affectively-coloured
group of ideas on the other. Post equitem sedet atra cura ['black
care sits behind the rider']. 1 Among these situations the most
prominent are those of looking after someone dear to us who
is ill, and of being in love. Experience shows that sick-
nursing and sexual affects also play the principal part in the
majority of the more closely analysed case histories of hysterical
patients.

I suspect that the duplication of psychical functioning,
whether this is habitual or caused by emotional situations in
life, acts as a substantial predisposition to a genuine pathological
splitting of the mind. This duplication passes over into the latter
state if the content of the two co-existing sets of ideas is no
longer of the same kind, if one of them contains ideas which are
inadmissible to consciousness which have been fended off,
that is, or have arisen from hypnoid states. When this is so,
it is impossible for the two temporarily divided streams to re-
unite, as is constantly happening in healthy people, and a region
of unconscious psychical activity becomes permanently split
off. This hysterical splitting of the mind stands in the same
relation to the 'double ego' of a healthy person as does the
hypnoid state to a normal reverie. In this latter contrast what
determines the pathological quality is amnesia, and in the
former what determines it is the inadmissibility of the ideas to
consciousness.

Our first case history, that of Anna O., to which I am obliged

to keep on returning, affords a clear insight into what happens.

The girl was in the habit, while she was in perfect health, of

allowing trains of imaginative ideas to pass through her mind

1 [Horace, Odes, III, 1.]

(5) UNCONSCIOUS IDEAS 235

during her ordinary occupations. While she was in a situation
that favoured auto-hypnosis, the affect of anxiety entered into
her reverie and created a hypnoid state for which she had
amnesia. This was repeated on different occasions and its
ideational content gradually became richer and richer; but it
continued to alternate with states of completely normal waking
thought. After four months the hypnoid state gained entire
control of the patient. The separate attacks ran into one another
and thus an etat de mal arose, an acute hysteria of the most
severe type. This lasted for several months in various forms
(the period of somnambulism) ; it was then forcibly interrupted
[p. 27], and thereafter alternated once again with normal
psychical behaviour. But even during her normal behaviour
there was a persistence of somatic and psychical phenomena
(contractures, hemi-anaesthesia and changes in speech) of
which in this case we know as a fact that they were based on
ideas belonging to the hypnoid state. This proves that even
during her normal behaviour the ideational complex belonging
to the hypnoid state, the 'subconsciousness', was in existence
and that the split in her mind persisted.

I have no second example to offer of a similar course of
development. I think, however, that the case throws some light
also on the growth of traumatic neuroses. During the first few
days after the traumatic event, the state of hypnoid fright is
repeated every time the event is recalled. While this state recurs
more and more often, its intensity so far diminishes that it
no longer alternates with waking thought but only exists side
by side with it. It now becomes continuous, and the somatic
symptoms, which earlier were only present during the attack
of fright, acquire a permanent existence. I can, however, only
suspect that this is what happens, as I have never analysed a
case of this kind.

Freud's observations and analyses show that the splitting of
the mind can also be caused by 'defence', by the deliberate
deflection of consciousness from distressing ideas: only, how-
ever, in some people, to whom we must therefore ascribe a
mental idiosyncracy. In normal people, such ideas are either
successfully suppressed, in which case they vanish completely,
or they are not, in which case they keep on emerging in con-
sciousness. I cannot tell what the nature of this idiosyncracy is.
I only venture to suggest that the assistance of the hypnoid

236 III. THEORETICAL (BREUER)

state is necessary if defence is to result not merely in single
converted ideas being made into unconscious ones, but in
a genuine splitting of the mind. Auto-hypnosis has, so to speak,
created the space or region of unconscious psychical activity
into which the ideas which are fended off are driven. But,
however this may be, the fact of the pathogenic significance of
'defence' is one that we must recognize.

I do not think, however, that the genesis of splitting of the
mind is anything like covered by the half- understood processes
that we have discussed. Thus, in their initial stages hysterias
of a severe degree usually exhibit for a time a syndrome that
may be described as acute hysteria. (In the anamnesis of male
cases of hysteria we generally come across this form of illness
represented as being 'encephalitis'; in female cases ovarian
neuralgia leads to a diagnosis of 'peritonitis'.) In this acute
stage of hysteria psychotic traits are very distinct, such as manic
and angry states of excitement, rapidly changing hysterical
phenomena, hallucinations, and so on. In states of this kind the
splitting of the mind may perhaps take place in a different
manner from that which we have tried to describe above.
Perhaps the whole of this stage is to be regarded as a long
hypnoid state, the residues of which provide the nucleus of
the unconscious ideational complex, while waking thought is
amnesic for it. Since we are for the most part ignorant of the
causes that lead to an acute hysteria of this kind (for I do not
venture to regard the course of events with Anna O. as having
general application), there would seem to be another sort of
psychical splitting which, in contrast to those discussed above,
might be termed irrational. 1 And no doubt yet other forms of
this process exist, which are still concealed from our young
psychological science; for it is certain that we have only taken
the first steps in this region of knowledge, and our present views
will be substantially altered by further observations.

Let us now enquire what the knowledge of splitting of the
mind that has been gained during the last few years has

1 I must, however, point out that precisely in the best-known and
clearest example of major hysteria with manifest 'double conscience'
precisely in the case of Anna O. no residue of the acute stage was
carried over into the chronic one, and all the phenomena of the latter
had already been produced during the 'incubation period* in hypnoid
and affective states.

(5) UNCONSCIOUS IDEAS 237

achieved towards an understanding of hysteria. It seems to
have been great in amount and in importance.

These discoveries have in the first place made it possible for
what are apparently purely somatic symptoms to be traced
back to ideas, which, however, are not discoverable in the
patients' consciousness. (It is unnecessary to enter into this
again.) In the second place, they have taught us to understand
hysterical attacks, in part at least, as being products of an
unconscious ideational complex. (Cf. Charcot.) But, besides
this, they have also explained some of the psychical character-
istics of hysteria, and this point perhaps deserves a more detailed
discussion.

It is true that 'unconscious ideas' never, or only rarely and
with difficulty, enter waking thought; but they influence it.
They do so, first, through their consequences when, for in-
stance, a patient is tormented by a hallucination which is
totally unintelligible and senseless, but whose meaning and
motivation become clear under hypnosis. Further, they influ-
ence association by making certain ideas more vivid than they
would have been if they had not been thus reinforced from
the unconscious. So particular groups of ideas constantly force
themselves on the patient with a certain amount of com-
pulsion and he is obliged to think of them. (The case is similar
with Janet's hemi-anaesthetic patients. When their anaesthetic
hand is repeatedly touched they feel nothing; but when they
are told to name any number they like, they always choose the
one corresponding to the number of times they have been
touched.) Again, unconscious ideas govern the patient's
emotional tone, his state of feeling. When, in the course of
unrolling her memories, Anna O. approached an event which
had originally been bound up with a lively affect, the cor-
responding feeling made its appearance several days in advance
and before the recollection appeared clearly even in her
hypnotic consciousness.

This makes the patients' 'moods' intelligible their inex-
plicable, unreasonable changes of feeling which seem to wak-
ing thought without motive. The impressionability of hysterical
patients is indeed to a large extent determined simply by their
innate excitability; but the lively affects into which they are
thrown by relatively trivial causes become more intelligible if
we reflect that the 'split-off mind' acts like a sounding-board

238 III. THEORETICAL (BREUER)

to the note of a tuning-fork. Any event that provokes uncon-
scious memories liberates the whole affective force of these
ideas that have not undergone a wearing-away, and the affect
that is called up is then quite out of proportion to any that
would have arisen in the conscious mind alone.

I have spoken above (p. 231 f.) of a patient whose psychical
functioning always stood in inverse ratio to the vividness of
her unconscious ideas. The diminution of her conscious think-
ing was based partly, but only partly, on a peculiar kind of
abstraction. After each of her momentary 'absences' and
these were constantly occurring she did not know what she
had thought of in the course of it. She oscillated between her
'conditions primes' and 'secondes', between the conscious and the
unconscious ideational complexes. But it was not only on that
account that her psychical functioning was reduced, nor on
account of the affect which dominated her from the unconscious.
While she was in this state her waking thought was without
energy, her judgement was childish and she seemed, as I have
said, positively imbecile. I believe that this was due to the fact
that waking thought has less energy at its disposal if a great
amount of psychical excitation is appropriated by the un-
conscious.

If this state of things is not merely temporary, if the split-off
mind is in a constant state of excitation, as it was with Janet's
hemi-anaesthetic patients in whom, moreover, all the sensa-
tions in no less than one half of the body were perceived only
by the unconscious mind if this is the case, so little cerebral
functioning is left over for waking thought that the weakness
of mind which Janet describes and regards as innate is fully
accounted for. There are only very few people of whom it could
be said, as of Uhland's Bertrand de Born, that they never
need more than half their mind. 1 Such a reduction in their
psychical energy does make the majority of people weak-
minded.

This weakness of mind caused by a splitting of the psyche
seems also to be a basis of a momentous characteristic of some
hysterical patients their suggestibility. (I say 'some', since it
is certain that among hysterical patients are to be found people
of the soundest and most critical judgement as well.)

By suggestibility we understand, in the first instance, only an
1 [A famous troubadour about whom Uhland wrote a ballad.]

(5) UNCONSCIOUS IDEAS 239

inability to criticize ideas and complexes of ideas (judgements)
which emerge in the subject's own consciousness or are intro-
duced into it from outside through the spoken word or through
reading. All criticism of ideas like these which come freshly
into consciousness is based on the fact that they awaken other
ideas by association and amongst them some that are irrecon-
cilable with the fresh ones. The resistance to these latter is thus
dependent on the store of antagonistic ideas in potential con-
sciousness, and the strength of the resistance corresponds to the
ratio between the vividness of the fresh ideas and that of those
aroused from memory. Even in normal intellects this ratio is
very various. What we describe as an intellectual temperament
depends on it to a great extent. A 'sanguine' man is always
delighted by new people and things, and this is no doubt so
because the intensity of his mnemic images is less in comparison
with that of new impressions than it is in a quieter, 'phlegmatic*
man. In pathological states the preponderance of fresh ideas
and the lack of resistance to them increases in proportion to the
fewness of the mnemic images aroused that is, in proportion
to the weakness and poorness of their associative powers. This
is already what happens in sleep and dreams, in hypnosis and
whenever there is a reduction in mental energy, so long as this
does not also reduce the vividness of the fresh ideas.

The unconscious, split-off mind in hysteria is pre-eminently
suggestible on account of the poverty and incompleteness of
its ideational content. But the suggestibility of the conscious
mind, too, in some hysterical patients seems to be based on
this. They are excitable from their innate disposition; in them,
fresh ideas are very vivid. In contrast to this, their intellectual
activity proper, their associative function, is reduced, because
only a part of their psychical energy is at the disposal of their
waking thought, owing to a splitting-ofT of an 'unconscious'.
As a result of this their power of resistance both to auto- and
allo-suggestions is diminished and sometimes abolished. The
suggestibility of their will also seems to be due to this alone. On
the other hand, hallucinatory suggestibility, which promptly
changes every idea of a sense-perception into an actual percep-
tion, demands, like all hallucinations, an abnormal degree of
excitability of the perceptual organ and cannot be traced back
solely to a splitting of the mind.

240 III. THEORETICAL (BREUER)

(6) INNATE DISPOSITION DEVELOPMENT OF HYSTERIA

At almost every stage of these discussions I have been
obliged to recognize that most of the phenomena which we have
been endeavouring to understand can be based, among other
things, on an innate idiosyncracy. This defies any explanation
that seeks to go beyond a mere statement of the facts. But the
capacity to acquire hysteria is also undoubtedly linked with an
idiosyncracy of the person concerned, and an attempt to define
it more accurately will perhaps not be entirely unprofitable.

I have explained above why I cannot accept Janet's view
that the disposition to hysteria is based on innate psychical
weakness. The medical practitioner who, in his capacity as
family doctor, observes the members of hysterical families at
all ages will certainly be inclined to regard this disposition as
lying in an excess rather than in a defect. Adolescents who are
later to become hysterical are for the most part lively, gifted
and full of intellectual interests before they fall ill. Their energy
of will is often remarkable. They include girls who get out of
bed at night so as secretly to carry on some study that their
parents have forbidden from fear of their overworking. The
capacity for forming sound judgements is certainly not more
abundant in them than in other people; but it is rare to find
in them simple, dull intellectual inertia and stupidity. The
overflowing productivity of their minds has led one of my
friends to assert that hysterics are the flower of mankind, as
sterile, no doubt, but as beautiful as double flowers.

Their liveliness and restlessness, their craving for sensations
and mental activity, their intolerance of monotony and bore-
dom, may be formulated thus: they are among those people
whose nervous system while it is at rest liberates excess of
excitation which requires to be made use of (cf. p. 197). During
development at puberty, and in consequence of it, this original
excess is supplemented by the powerful increase in excitation
which arises from the awakening of sexuality, from the sex-
glands. From then on there is a surplus quantity of free nervous
energy available for the production of pathological phenomena.

But in order for these phenomena to appear in the form of
hysterical symptoms there must evidently also be another,
specific idiosyncracy in the individual concerned. For after all,
the great majority of lively and excitable people do not become

(6) INNATE DISPOSITION 241

hysterical. I was only able, above [p. 191], to describe this
idiosyncracy in the vague and unenlightening phrase, 'abnor-
mal excitability of the nervous system'. But it may be possible
to go further and say that this abnormality lies in the fact that
in such people the excitation of the central organ can flow
into the sensory nervous apparatuses which are normally acces-
sible only to peripheral stimuli, as well as into the nervous
apparatuses of the vegetative organs which are isolated from
the central nervous system by powerful resistances. It may be
that this idea of there being a surplus of excitation constantly
present which has access to the sensory, vasomotor and visceral
apparatuses already accounts for some pathological phenomena.

In people of this kind, as soon as their attention is forcibly
concentrated on some part of the body, what Exner [1894,
1 65 ff.] speaks of as the 'facilitation of attention' in the sensory
path of conduction concerned exceeds the normal amount.
The free, floating excitation is, as it were, diverted into this
path, and a local hyperalgesia is produced. As a result, every
pain, however caused, reaches maximum intensity, every ail-
ment is 'fearful' and 'unbearable'. Further, whereas in normal
people a quantity of excitation, after cathecting a sensory
path, always leaves it again, this is not so in these cases. That
quantity, moreover, not only remains behind but is constantly
increased by the influx of fresh excitations. A slight injury to a
joint thus leads to arthralgia, and the painful sensations due to
ovarian swelling lead to chronic ovarian neuralgia; and since
the nervous apparatuses of the circulation are more accessible
to cerebral influence than in normal people, we find nervous
palpitation of the heart, a tendency to fainting, proneness to
excessive blushing and turning pale, and so on.

However, it is not only in regard to central influences that
the peripheral nervous apparatuses are more easily excitable.
They also react in an excessive and perverse fashion to appro-
priate, functional stimuli. Palpitations follow from moderate
effort no less than from emotional excitement, and the vaso-
motor nerves cause the arteries to contract ('dead fingers'),
apart from any psychical influence. And just as a slight injury
leaves behind an arthralgia, a short attack of bronchitis is
followed by nervous asthma, and indigestion by frequent
cardiac pains. We must accordingly recognize that accessibility
to sums of excitation of central origin is no more than a special

242 III. THEORETICAL (BREUER)

case of general abnormal excitability, 1 even though it is the
most important one from the point of view of our present topic.

It seems to me, therefore, that the old 'reflex theory' of these
symptoms, which would perhaps be better described simply as
'nervous' ones but which form part of the empirical clinical
picture of hysteria, should not be completely rejected. The
vomiting, which of course accompanies the dilatation of the
uterus in pregnancy, may, where there is abnormal excitability,
quite well be set going in a reflex manner by trivial uterine
stimuli, or perhaps even by the periodic changes in size of the
ovaries. We are acquainted with so many remote effects re-
sulting from organic changes, so many strange instances of
'referred pain', that we cannot reject the possibility that a
host of nervous symptoms which are sometimes determined
psychically may in other cases be remote effects of reflex action.
Indeed, I venture to put forward the highly unmodern heresy
that even motor weakness in a leg may sometimes be determined
by a genital affection, not psychically, but by direct reflex
action. I think we shall do well not to insist too much on the
exclusiveness of our new discoveries or to seek to apply them in
all cases.

Other forms of abnormal sensory excitability still escape our
understanding completely: general analgesia, for instance,
anaesthetic areas, real restriction of the field of vision, and so
on. It is possible and perhaps probable that further observations
will prove the psychical origin of one or other of these stigmata 2
and so explain the symptom; but this has not yet happened (for
I do not venture to generalize the findings presented by our
first case history), and I do not think it is justifiable to presume
that this is their origin before it has been properly traced.

On the other hand the idiosyncracy of the nervous system and
of the mind which we have been discussing seems to explain
one or two very familiar properties of many hysterical patients.
The surplus of excitation which is liberated by their nervous
system when in a state of rest determines their incapacity to
tolerate a monotonous life and boredom their craving for
sensations which drives them, after the onset of their illness,
to interrupt the monotony of their invalid life by all kinds of
'incidents', of which the most prominent are from the nature

1 Oppenheim's 'instability of the molecules'. [See footnote, p. 191.]
8 [See footnote, p. 15.]

(6) INNATE DISPOSITION 243

of things pathological phenomena. They are often supported
in this by autosuggestion. They are led further and further
along this road by their need for being ill, a remarkable trait
which is as pathognomonic for hysteria as is fear of being ill
for hypochondria. 1 I know a hysterical woman who inflicted
on herself injuries which were often quite severe, merely for
her own use and without those about her or her physician
learning of them. If she did nothing else she used to play all
kinds of tricks while she was alone in her room simply to prove
to herself that she was not normal. For she had in fact a distinct
feeling of not being well and could not discharge her duties
satisfactorily, and she tried to justify herself in her own eyes
by actions such as these. Another patient, a very sick woman
suffering from pathological conscientiousness and full of dis-
trust of herself, felt every hysterical phenomenon as something
guilty, because, she said, she need not have had it if she had
really wanted not to. When a paresis of her legs was wrongly
diagnosed as a disease of the spine she felt it as an immense
relief, and when she was told that it was 'only nervous* and
would pass off, that was enough to bring on severe pangs of
conscience. The need to be ill arises from the patient's desire
to convince herself and other people of the reality of her illness.
When this need is further associated to the distress caused by
the monotony of a sick-room, the inclination to produce more
and more new symptoms is developed to its fullest.

If, however, this turns into deceitfulness and actual simula-
tion (and I think that we now err just as far on the side of
denying simulation as we used to on the side of accepting it),
that is based, not on the hysterical disposition but, as Moebius
has so aptly said, on its being complicated by other forms of
degeneracy by innate, moral inferiority. In just the same way
the 'malicious hysteric 5 comes into existence when someone
who is innately excitable but poor in emotion is also a victim
to the egoistic stunting of character which is so easily produced
by chronic ill-health. Incidentally, the 'malicious hysteric' is
scarcely commoner than the malicious patient in the later
stages of tabes.

A surplus of excitation also gives rise to pathological phe-
nomena in the motor sphere. Children having this characteristic
very easily develop tic-like movements. These may be started
1 [Gf. a remark of Freud's, p. 258.]

244 III. THEORETICAL (BREUER)

in the first instance by some sensation in the eyes or face or
by an uncomfortable article of clothing, but they become
permanent unless they are promptly checked. The reflex paths
are very easily and quickly dug in deep.

Nor can the possibility be dismissed of there being purely
motor convulsive attacks which are independent of any psychi-
cal factor and in which all that happens is that the mass of
excitation accumulated by summation is discharged, in just
the same way as the mass of stimuli caused by anatomical
modifications is discharged in an epileptic fit. Here we should
have the non-ideogenic hysterical convulsion.

We so often find adolescents who had previously been
healthy, though excitable, falling ill of hysteria during pubertal
development, that we must ask ourselves whether that process
may not create the disposition to hysteria where it was not
present innately. And in any case we must attribute more to it
than a simple raising of the quantity of excitation. Sexual
maturation impinges on the whole nervous system, increasing
excitability and reducing resistances everywhere. We are taught
this from the observation of adolescents who are not hysterical
and we are thus justified in believing that sexual maturation
also establishes the hysterical disposition in so far as it consists
precisely in this characteristic of the nervous system. In saying
this we are already recognizing sexuality as one of the major
components of hysteria. We shall see that the part it plays in it
is very much greater still and that it contributes in the most
various ways to the constitution of the illness.

If the stigmata spring directly from this innate breeding-
ground of hysteria and are not of ideogenic origin, it is also
impossible to give ideogenesis such a central position in hysteria
as is sometimes done nowadays. What could be more genuinely
hysterical than the stigmata? They are pathognomonic findings
which establish the diagnosis; and yet precisely they seem not
to be ideogenic. But if the basis of hysteria is an idiosyncracy
of the whole nervous system, the complex of ideogenic, psychic-
ally determined symptoms is erected on it as a building is on
its foundations. And it is a building of several storeys. Just as it is
only possible to understand the structure of such a building if
we distinguish the plans of the different floors, it is, I think,
necessary in order to understand hysteria for us to pay attention

(6) INNATE DISPOSITION 245

to the various kinds of complication in the causation of the
symptoms. If we disregard them and try to carry through an
explanation of hysteria by employing a single causal nexus, we
shall always find a very large residue of unexplained phenomena
left over. It is just as though we tried to insert the different
rooms of a many-storeyed house into the plan of a single storey.

Like the stigmata, a number of other nervous symptoms
some pains and vasomotor phenomena and perhaps purely
motor convulsive attacks are, as we have seen, not caused by
ideas but are direct results of the fundamental abnormality
of the nervous system.

Closest to them are the ideogenic phenomena which are
simply conversions of affective excitation (p. 203). They arise
as the consequences of affects in people with a hysterical dis-
position and in the first instance they are only an 'abnormal
expression of the emotions' (Oppenheim [1890]). 1 This becomes
by repetition a genuine and apparently purely somatic hysterical
symptom, while the idea that gave rise to it becomes unnotice-
able (p. 206) or is fended off and therefore repressed from
consciousness. The most numerous and important of the ideas
that are fended off and converted have a sexual content. They
are at the bottom of a great deal of the hysteria of puberty.
Girls who are approaching maturity and it is they who are
chiefly concerned behave very differently towards the sexual
ideas and feelings which crowd in on them. Some girls meet
them with complete unembarrassment, among whom a few
ignore and overlook the whole subject. Others accept them like
boys, and this is no doubt the rule with peasant and working-
class girls. Others again, with more or less perverse curiosity,
run after anything sexual that they can get hold of in talk or
books. And lastly there are natures of a refined organization
who, though their sexual excitability is great, have an equally
great moral purity and who feel that anything sexual is some-
thing incompatible with their ethical standards, something
dirtying and smirching. 2 They repress sexuality from their

1 This disposition is nothing else than what Strumpell [1892] speaks
of as the 'disturbance in the psycho-physical sphere' which underlies
hysteria.

1 Some observations lead us to believe that the fear of touching, or,
more properly, the fear of being dirtied, which compels women to keep
on washing their hands all the time, very often has this derivation. Their
washing is derived from the same mental process as Lady Macbeth's.

246 III. THEORETICAL (BREUER)

consciousness, and the affective ideas with a content of this
kind which have caused the somatic phenomena are fended off
and thus become unconscious.

The tendency towards fending off what is sexual is further
intensified by the fact that in young unmarried women sensual
excitation has an admixture of anxiety, of fear of what is com-
ing, what is unknown and half-suspected, whereas in normal
and healthy young men it is an unmixed aggressive instinct.
The girl senses in Eros the terrible power which governs and
decides her destiny and she is frightened by it. All the greater,
then, is her inclination to look away and to repress from her
consciousness the thing that frightens her.

Marriage brings fresh sexual traumas. It is surprising that
the wedding night does not have pathogenic effects more fre-
quently, since unfortunately what it involves is so often not an
erotic seduction but a violation. But indeed it is not rare to
find in young married women hysterias which can be traced
back to this and which vanish if in the course of time sexual
enjoyment emerges and wipes out the trauma. Sexual traumas
also occur in the later course of many marriages. The case
histories from whose publication we have been obliged to
refrain include a great number of them perverse demands
made by the husband, unnatural practices, etc. I do not think
I am exaggerating when I assert that the great majority of severe
neuroses in women have their origin in the marriage bed. 1

Certain sexual noxae, which consist essentially in insufficient
satisfaction (coitus interruptus, ejaculatio praecox, etc.), result
according to the discovery of Freud (1895i) not in hysteria
but in an anxiety neurosis. I am of opinion, however, that even
in such cases the excitation of the sexual affect is quite fre-
quently converted into hysterical somatic phenomena.

It is self-evident and is also sufficiently proved by our observa-
tions that the non-sexual affects of fright, anxiety and anger
lead to the development of hysterical phenomena. But it is
perhaps worth while insisting again and again that the sexual

1 It is a most unfortunate thing that clinical medicine ignores one of
the most important of all the pathogenic factors or at least only hints
at it delicately. This is certainly a subject in which the acquired know-
ledge of experienced physicians should be communicated to their
juniors, who as a rule blindly overlook sexuality at all events so far
as their patients are concerned.

(6) INNATE DISPOSITION 247

factor is by far the most important and the most productive
of pathological results. The unsophisticated observations of our
predecessors, the residue of which is preserved in the term
'hysteria 5 [derived from the Greek word for 'uterus'], came
nearer the truth than the more recent view which puts sexuality
almost last, in order to save the patients from moral reproaches.
The sexual needs of hysterical patients are no doubt just as
variable in degree from individual to individual as in healthy
people and are no stronger than in them; but the former fall
ill from them, and, for the most part, precisely owing to strug-
gling against them, owing to their defence against sexuality.

Alongside sexual hysteria we must at this point recall hysteria
due to fright traumatic hysteria proper which constitutes
one of the best known and recognized forms of hysteria.

In what may be called the same stratum as the phenomena
which arise from the conversion of affective excitation are to
be found those which owe their origin to suggestion (mostly
auto-suggestion) in individuals who are innately suggestible.
A high degree of suggestibility that is to say, the unrestricted
preponderance of ideas that have been freshly aroused is not
among the essential features of hysteria. It can, however, be
present as a complication in people with a hysterical disposition,
in whom this very idiosyncracy of the nervous system makes
possible the somatic realization of supervalent x ideas. More-
over, it is for the most part only affective ideas which are realized
in somatic phenomena by suggestion, and consequently the
process may often be regarded as a conversion of the accom-
panying affect of fright or anxiety.

These processes the conversion of affect, and suggestion
remain identical even in the complicated forms of hysteria
which we must now consider. They merely find more favourable
conditions in such cases: it is invariably through one of these
two processes that psychically-determined hysterical pheno-
mena come into being.

The third constituent of the hysterical disposition, which
appears in some cases in addition to those that have been
already discussed, is the hypnoid state, the tendency to auto-
hypnosis (p. 215). This state favours and facilitates in the

1 ['Uberwertig.' Freud attributes this term to Wernicke in his analysis
of 'Dora' (1905*), Standard Ed., 7, 54.]

248 III. THEORETICAL (BREUER)

greatest degree both conversion and suggestion; and in this way
it erects, as we might say, on the top of the minor hysterias,
the higher storey of major hysteria. The tendency to auto-
hypnosis is a state which is to begin with only temporary and
which alternates with the normal one. We may attribute to it
the same increase of mental influence on the body that we
observe in artificial hypnosis. This influence is all the more
intense and deep-going here in that it is acting upon a nervous
system which even outside hypnosis is abnormally excitable. 1
We cannot tell how far and in what cases the tendency to
auto-hypnosis is an innate property of the organism. I have
expressed the view above (pp. 218-19) that it develops from
reveries that are charged with affect. But there can be no doubt
that innate disposition plays a part in this as well. If this view
is correct, it will be clear here once again how great an influ-
ence on the development of hysteria is to be ascribed to sexu-
ality. For, apart from sick-nursing, no psychical factor is so
well-calculated to produce reveries charged with affect as are
the longings of a person in love. And over and above this the
sexual orgasm 2 itself, with its wealth of affect and its restriction
of consciousness, is closely akin to hypnoid states.

The hypnoid element is most clearly manifested in hysterical
attacks and in those states which can be described as acute
hysteria and which, it seems, play such an important part in
the development of hysteria (p. 236). These are obviously
psychotic states which persist for a long time, often for several
months and which it is frequently necessary to describe as
hallucinatory confusion. Even if the disturbance does not go
as far as this, a great variety of hysterical phenomena emerge in
it, a few of which actually persist after it is over. The psychical
content of these states consists partly in precisely the ideas
which have been fended off in waking life and repressed from

1 It is tempting to identify the disposition to hypnosis with innate
abnormal excitability; for artificial hypnosis, too, exhibits ideogenic
changes in secretion and local blood-supply, formation of vesicles, etc.
This seems to be the view held by Moebius. But in my opinion it would
involve us in a vicious circle. The miraculous workings of hypnosis arc,
so far as I can see, only observable in hysterical patients. What we
should be doing would be first to assign the phenomena of hysteria to
hypnosis, and then to assert that hypnosis is the cause of those
phenomena.

2 ['Orgasmus.' In the first edition only this is misprinted ' Organismus'.]

(6) INNATE DISPOSITION 249

consciousness. (Cf. the 'hysterical deliria in saints and nuns,
continent women and well-brought-up children 5 [p. 11].)

Since these states are so often nothing less than psychoses and
are yet derived immediately and exclusively from hysteria, I
cannot agree with Moebius's opinion that 'apart from the
deliria attached to attacks, it is impossible to speak of an actual
hysterical insanity' (1895, 18). In many cases these states con-
stitute an insanity of this kind; and psychoses like these also
recur in the further course of a hysteria. It is true that essentially
they are nothing other than the psychotic stage of an attack,
but since they last for months they can nevertheless hardly be
described as attacks.

How does one of these acute hysterias arise? In the best-
known case (Case History 1) it developed out of an accumula-
tion of hypnoid attacks; in another case (where there was
already a complicated hysteria present) it arose in association
with a withdrawal of morphine. The process is for the most part
completely obscure and awaits clarification from further
observations.

Accordingly, we may apply to the hysterias which have been
discussed here Moebius's pronouncement (ibid., 16): 'The essen-
tial change that occurs in hysteria is that the mental state of
the hysterical patient becomes temporarily or permanently
similar to that of a hypnotized subject.'

The persistence in the normal state of the symptoms that
have arisen during the hypnoid one corresponds entirely to
our experiences with post-hypnotic suggestion. But this already
implies that complexes of ideas that are inadmissible to con-
sciousness co-exist with the trains of ideas that pursue a con-
scious course, that the splitting of the mind has taken place
(p. 229). It seems certain that this can happen even without
a hypnoid state, from the wealth of thoughts which have been
fended off and repressed from consciousness but not suppressed.
In one way or another there comes into existence a region of
mental life sometimes poor in ideas and rudimentary, some-
times more or less on a par with waking thought our know-
ledge of which we owe, above all, to Binet and Janet. The
splitting of the mind is the consummation of hysteria. I have
shown above (in Section 5) how it explains the principal char-
acteristics of the disorder. One part of the patient's mind is in
the hypnoid state, permanently, but with a varying degree of

250 III. THEORETICAL (BREUER)

vividness in its ideas, and is always prepared whenever there
is a lapse in waking thought to assume control over the whole
person (e.g. in an attack or delirium). This occurs as soon as
a powerful affect interrupts the normal course of ideas, in twi-
light states and states of exhaustion. Out of this persisting
hypnoid state unmotivated ideas, alien to normal association,
force their way into consciousness, hallucinations are intro-
duced into the perceptual system and motor acts are innervated
independently of the conscious will. This hypnoid mind is in
the highest degree susceptible to conversion of affects and to
suggestion, and thus fresh hysterical phenomena appear easily,
which without the split in the mind would only have come
about with great difficulty and under the pressure of repeated
affects. The split-off mind is the devil with which the un-
sophisticated observation of early superstitious times believed
that these patients were possessed. It is true that a spirit alien
to the patient's waking consciousness holds sway in him; but
the spirit is not in fact an alien one, but a part of his own.

The attempt that has been made here to make a synthetic
construction of hysteria out of what we know of it to-day is
open to the reproach of eclecticism, if such a reproach can be
justified at all. There were so many formulations of hysteria,
from the old 'reflex theory' to the 'dissociation of personality 1 ,
which have had to find a place in it. But it can scarcely be
otherwise; for so many excellent observers and acute minds
have concerned themselves with hysteria. It is unlikely that
any of their formulations was without a portion of the truth.
A future exposition of the true state of affairs will certainly
include them all and will merely combine all the one-sided
views of the subject into a corporate reality. Eclecticism, there-
fore, seems to me nothing to be ashamed of.

But how far we still are to-day from the possibility of any
such complete understanding of hysteria! With what uncertain
strokes have its outlines been drawn in these pages, with what
clumsy hypotheses have the gaping lacunas been concealed
rather than bridged! Only one consideration is to some extent
consoling: that this defect attaches, and must attach, to all
physiological expositions of complicated psychical processes.
We must always say of them what Theseus in A Midsummer
Nighfs Dream says of tragedy: 'The best in this kind are but

(6) INNATE DISPOSITION 251

shadows.' And even the weakest is not without value if it
honestly and modestly tries to hold on to the outlines of the
shadows which the unknown real objects throw upon the wall.
For then, in spite of everything, the hope is always justified that
there may be some degree of correspondence and similarity
between the real processes and our idea of them.

IV

THE PSYCHOTHERAPY OF
HYSTERIA

(FREUD)

IV
THE PSYCHOTHERAPY OF HYSTERIA

(FREUD)

IN our 'Preliminary Communication' we reported how, in the
course of our investigation into the aetiology of hysterical
symptoms, we also came upon a therapeutic method which
seemed to us of practical importance. For 'we found, to our great
surprise at first, that each individual hysterical symptom immediately
and permanently disappeared when we had succeeded in bringing clearly
to light the memory of the event by which it was provoked and in arousing
its accompanying affect, and when the patient had described that event
in the greatest possible detail and had put the affect into words'. (P. 6.)

We further endeavoured to explain the way in which our
psychotherapeutic method works. 'It brings to an end the operative
force of the idea which was not abreacted in the fast instance, by allowing
its strangulated affect to find a way out through speech; and it subjects
it to associative correction by introducing it into normal consciousness
(under light hypnosis) or by removing it through the physician's suggestion,
as is done in somnambulism accompanied by amnesia.' (P. 17.)

I will now try to give a connected account of how far this
method carries us, of the respects in which it achieves more
than other methods, of the technique by which it works and
of the difficulties it meets with. Much of the substance of this
is already contained in the case histories printed in the earlier
portion of this book, and I shall not be able to avoid repeating
myself in the account which follows.

For my own part, I too may say that I can still hold by what
is contained in the 'Preliminary Communication'. None the
less I must confess that during the years which have since passed
in which I have been unceasingly concerned with the prob-
lems touched upon in it fresh points of view have forced them-
selves on my mind. These have led to what is in part at least

255

256 IV. PSYCHOTHERAPY OF HYSTERIA (FREUD)

a different grouping and interpretation of the factual material
known to me at that time. It would be unfair if I were to try
to lay too much of the responsibility for this development upon
my honoured friend Dr. Josef Breuer. For this reason the con-
siderations which follow stand principally under my own name.
When I attempted to apply to a comparatively large number
of patients Breuer's method of treating hysterical symptoms by
an investigation and abreaction of them under hypnosis, I came
up against two difficulties, in the course of dealing with which
I was led to an alteration both in my technique and in my view
of the facts, (1)1 found that not everyone could be hypnotized
who exhibited undoubted hysterical symptoms and who, it was
highly probable, was governed by the same psychical mech-
anism. (2) I was forced to take up a position on the question
of what, after all, essentially characterizes hysteria and what
distinguishes it from other neuroses.

I will put off until later my account of how I got over the
first of these two difficulties and what I have learnt from it, and
I will begin by describing the attitude I adopted in my daily
practice towards the second problem. It is very hard to obtain
a clear view of a case of neurosis before one has submitted it
to a thorough analysis an analysis which can, in fact, only
be brought about by the use of Breuer's method; but a decision
on the diagnosis and the form of therapy to be adopted has to
be made before any such thorough knowledge of the case has
been arrived at. The only course open to me, therefore, was to
select for cathartic treatment such cases as could be provision-
ally diagnosed as hysteria, which exhibited one or more of the
stigmata or characteristic symptoms of hysteria. It then some-
times happened that in spite of the diagnosis of hysteria the
therapeutic results turned out to be very scanty and that even
analysis brought nothing significant to light. On other occasions
again, I tried applying Breuer's method of treatment to
neuroses which no one could have mistaken for hysteria, and
I found that in that manner they could be influenced and in-
deed cleared up. I had this experience, for instance, with
obsessional ideas, genuine obsessional ideas of the Westphal
type, 1 in cases without a single trait which recalled hysteria.

1 [Westphal (1877) had given a detailed descriptive classification of
these.]

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 257

Consequently, the psychical mechanism revealed by the 'Pre-
liminary Communication 5 could not be pathognomonic for
hysteria. Nor could I resolve, merely for the sake of preserving
that mechanism as a criterion of it, to lump all these other
neuroses in with hysteria. I eventually found a way out of all
these emerging doubts by the plan of treating all the other
neuroses in question in the same way as hysteria. I determined
to investigate their aetiology and the nature of their psychical
mechanism in every case and to let the decision as to whether
the diagnosis of hysteria was justified depend upon the outcome
of that investigation.

Thus, starting out from Breuer's method, I found myself
engaged in a consideration of the aetiology and mechanism of
the neuroses in general. I was fortunate enough to arrive at
some serviceable findings in a relatively short time. 1 In the first
place I was obliged to recognize that, in so far as one can speak
of determining causes which lead to the acquisition of neuroses,
their aetiology is to be looked for in sexual factors. There fol-
lowed the discovery that different sexual factors, in the most
general sense, produce different pictures of neurotic disorders.
And it then became possible, in the degree to which this
relation was confirmed, to venture on using aetiology for the
purpose of characterizing the neuroses and of making a sharp
distinction between the clinical pictures of the various neuroses.
Where the aetiological characteristics coincided regularly with
the clinical ones, this was of course justified.

In this manner I found that neurasthenia presented a mon-
otonous clinical picture in which, as my analyses showed, a
'psychical mechanism' played no part. There was a sharp
distinction between neurasthenia and 'obsessional neurosis', the

1 [The findings reported in this and the next three paragraphs had
already been published by Freud in his first paper on 'The Neuro-
Psychoses of Defence' (18940) and his first paper on anxiety neurosis
(1895). In reading what follows, it should be borne in mind that
Freud subsequently separated off a further clinical entity to which he
gave the name 'anxiety hysteria' and which, though anxiety was its
most obvious feature, had a traceable psychical mechanism parallel to
that of conversion hysteria. Freud's first lengthy discussion of anxiety
hysteria appeared in the case history of 'Little Hans' (1909), Standard
Ed., 10, 1 15-7. The distinction between 'anxiety neurosis' and 'anxiety
hysteria' is brought out very clearly in the paper on 'wild' psycho-
analysis (1910*).]

258 IV. PSYCHOTHERAPY OF HYSTERIA (FREUD)

neurosis of obsessional ideas proper. In this latter one I was
able to recognize a complicated psychical mechanism, an
aetiology similar to that of hysteria and an extensive possibility
of reducing it by psychotherapy. On the other hand, it seemed
to me absolutely necessary to detach from neurasthenia a com-
plex of neurotic symptoms which depend on a quite different
and indeed at bottom a contrary aetiology. The component
symptoms of this complex are united by a characteristic which
has already been recognized by Hecker (1893). For they are
either symptoms or equivalents and rudiments of manifestations
of anxiety i and for this reason I have given to this complex
which is to be detached from neurasthenia the name of 'anxiety
neurosis'. I have maintained [Freud 1895] that it arises from
an accumulation of physical tension, which is itself once more
of sexual origin. This neurosis, too, has no psychical mech-
anism, but it invariably influences mental life, so that 'anxious
expectation 5 , phobias, hyperaesthesia to pains, etc., are among
its regular manifestations. This anxiety neurosis, in my sense
of the term, no doubt coincides in part with the neurosis which,
under the name of 'hypochondria', finds a place in not a few
descriptions alongside hysteria and neurasthenia. But I cannot
regard the delimitation of hypochondria in any of the works in
question as being the correct one, and the applicability of its
name seems to me to be prejudiced by the fixed connection of
that term with the symptom of 'fear of illness'. 1

After I had in this way fixed the simple pictures of neur-
asthenia, anxiety neurosis and obsessional ideas, I went on to
consider the cases of neurosis which are commonly included
under the diagnosis of hysteria. I reflected that it was not right
to stamp a neurosis as a whole as hysterical because a few
hysterical signs were prominent in its complex of symptoms.
I could well understand this practice, since after all hysteria
is the oldest, best-known and most striking of the neuroses
under consideration; but it was an abuse, for it put down to the

1 [Gf. above, p. 243. Freud had already considered the relations
between hypochondria, neurasthenia and anxiety neurosis in Part I of
his first paper on anxiety neurosis (1895). Much later, in the course of
his closing remarks in a discussion on masturbation ( 1912/), he suggested
that hypochondria should be regarded, together with neurasthenia and
anxiety neurosis, as a third 'actual neurosis' that is, as having a purely
physical aetiology. He took up this idea at much greater length at the
beginning of Section II of his paper on narcissism (1914c).]

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 259

account of hysteria so many traits of perversion and degeneracy.
Whenever a hysterical sign, such as an anaesthesia or a char-
acteristic attack, was found in a complicated case of psychical
degeneracy, the whole condition was described as one of
'hysteria', so that it is not surprising that the worst and the
most contradictory things were found together under this label.
But just as it was certain that this diagnosis was incorrect, it
was equally certain that we ought also to separate out the vari-
ous neuroses; and since we were acquainted with neurasthenia,
anxiety neurosis, etc., in a pure form, there was no longer any
need to overlook them in the combined picture.

The following view, therefore, seemed to be the more prob-
able one. The neuroses which commonly occur are mostly to
be described as 'mixed'. Neurasthenia and anxiety neuroses are
easily found in pure forms as well, especially in young people.
Pure forms of hysteria and obsessional neurosis are rare; as a
rule these two neuroses are combined with anxiety neurosis.
The reason why mixed neuroses occur so frequently is that their
aetiological factors are so often intermixed, sometimes only
by chance, sometimes as a result of causal relations between the
processes from which the aetiological factors of the neuroses
are derived. There is no difficulty in tracing this out and de-
monstrating it in detail. As regards hysteria, however, it fol-
lows that that disorder can scarcely be segregated from the
nexus of the sexual neuroses for the purposes of study, that as a
rule it represents only a single side, only one aspect, of a
complicated case of neurosis, and that it is only in marginal
cases that it can be found and treated in isolation. We may
perhaps say in a number of instances: a potion Jit denominatio
[i.e. it has been given its name from its more important
feature].

I will now examine the case histories that have been reported
here, with a view to seeing whether they speak in favour of
my opinion that hysteria is not an independent clinical entity.

Breuer's patient, Anna O., seems to contradict my opinion
and to be an example of a pure hysterical disorder. This case,
however, which has been so fruitful for our knowledge of
hysteria, was not considered at all by its observer from the
point of view of a sexual neurosis, and is now quite useless for
this purpose. When I began to analyse the second patient, Frau
Emmy von N., the expectation of a sexual neurosis being the

260 IV. PSYCHOTHERAPY OF HYSTERIA (FREUD)

basis of hysteria was fairly remote from my mind. I had come
fresh from the school of Charcot, and I regarded the linking of
hysteria with the topic of sexuality as a sort of insult just as
the women patients themselves do. When I go through my
notes on this case to-day there seems to me no doubt at all
that it must be looked on as a case of severe anxiety neurosis
accompanied by anxious expectation and phobias an anxiety
neurosis which originated from sexual abstinence and had be-
come combined with hysteria. Case 3, that of Miss Lucy R.,
can perhaps best be described as a marginal case of pure
hysteria. It was a short hysteria which ran an episodic course
and had an unmistakable sexual aetiology, such as would cor-
respond to an anxiety neurosis. The patient was an over-mature
girl with a need to be loved, whose affections had been too
hastily aroused through a misunderstanding. The anxiety
neurosis, however, did not become visible, or it escaped me.
Case 4, Katharina, was nothing less than a model of what I
have described as 'virginal anxiety 5 . 1 It was a combination of
anxiety neurosis and hysteria. The former created the symp-
toms, while the latter repeated them and operated with them.
Incidentally, it was a case typical of a large number of neuroses
in young people that are described as 'hysteria'. Case 5, that of
Fraulein Elisabeth von R., was once again not investigated as
a sexual neurosis. I was only able to express, without con-
firming it, a suspicion that a spinal neurasthenia may have
been its basis [p. 175, footnote].

I must add, though, that in the meantime pure hysterias
have become even rarer in my experience. If it was possible
for me to bring together these four cases as hysterias and if in
reporting them I was able to overlook the points of view that
were of importance as regards sexual neuroses, the reason is
that these histories date some distance back, and that I did not
at that time as yet submit such cases to a deliberate and
searching investigation of their neurotic sexual foundation. And
if, instead of these four, I did not report twelve cases whose
analysis provides a confirmation of the psychical mechanism
of hysterical phenomena put forward by us, this reticence was
necessitated by the very circumstance that the analysis revealed
these cases as being simultaneously sexual neuroses, although
certainly no diagnostician would have refused them the name
1 [Sec footnote 1, p. 127.]

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 261

of hysteria. But an elucidation of these sexual neuroses would
overstep the bounds of the present joint publication.

I should not like it to be wrongly thought that I do not wish
to allow that hysteria is an independent neurotic affection,
that I regard it merely as a psychical manifestation of anxiety
neurosis and that I attribute to it 'ideogenic' symptoms only
and am transferring the somatic symptoms (such as hystero-
genic points and anaesthesias) to anxiety neurosis. Nothing of
the sort. In my opinion it is possible to deal with hysteria, freed
from any admixture, as something independent; and to do so
in every respect except in that of therapeutics. For in thera-
peutics we are concerned with a practical aim, with getting
rid of the pathological state as a whole. And if hysteria generally
appears as a component of a mixed neurosis, the situation
resembles that in which there is a mixed infection, where pre-
serving life sets a problem which does not coincide with that of
combating the operation of one particular pathogenic agent.

It is very important for me to distinguish the part played by
hysteria in the picture of the mixed neuroses from that played
by neurasthenia, anxiety neurosis and so on, because, once I
have made this distinction, I shall be able to express concisely
the therapeutic value of the cathartic method. For I am in-
clined to venture the assertion that that method is as a matter
of theory very well able to get rid of any hysterical symptom,
whereas, as will be easily understood, it is completely powerless
against the phenomena of neurasthenia and is only able rarely
and in roundabout ways to influence the psychical effects of
anxiety neurosis. Its therapeutic effectiveness in any particular
case will accordingly depend on whether the hysterical com-
ponents of the clinical picture do or do not assume a position
of practical importance in comparison with the other neurotic
components.

There is another obstacle in the way of the effectiveness of
the cathartic method, which we have already indicated in the
'Preliminary Communication' [p. 17]. It cannot affect the
underlying causes of hysteria: thus it cannot prevent fresh
symptoms from taking the place of the ones which had been got
rid of. On the whole, then, I must claim a prominent place
for our therapeutic method as employed within the framework
of a therapy of the neuroses; but I should like to advise against
assessing its value or applying it outside this framework. Since,

262 IV. PSYCHOTHERAPY OF HYSTERIA (FREUD)

however, I cannot in these pages offer a 'therapy of the neuroses'
of the sort needed by practitioners, what I have just said is
equivalent to postponing my account of the subject to a possible
later publication. But I am able, I think, to add the following
remarks by way of expansion and elucidation.

(1) I do not maintain that I have actually got rid of all the
hysterical symptoms that I have undertaken to influence by the
cathartic method. But it is my opinion that the obstacles have
lain in the personal circumstances of the patients and have not
been due to any question of theory. I am justified in leaving
these unsuccessful cases out of account in arriving at a judge-
ment, just as a surgeon disregards cases of death which occur
under anaesthesia, owing to post-operational haemorrhage,
accidental sepsis, etc., in making a decision about a new
technique. When I come to deal with the difficulties and draw-
backs of the procedure later on, I shall return to a consideration
of failures from this source. [See p. 301.]

(2) The cathartic method is not to be regarded as worthless
because it is a symptomatic and not a causal one. For a causal
therapy is in fact as a rule only a prophylactic one; it brings
to a halt any further effects of the noxious agency, but does not
therefore necessarily get rid of the results which that agency
has already brought about. As a rule a second phase of treat-
ment is required to perform this latter task, and in cases of
hysteria the cathartic method is quite invaluable for this
purpose.

(3) Where a period of hysterical production, an acute hysteri-
cal paroxysm, has been overcome and all that is left over are
hysterical symptoms in the shape of residual phenomena, the
cathartic method suffices for every indication and brings about
complete and permanent successes. A favourable therapeutic
constellation of this kind is not seldom to be found precisely
in the region of sexual life, owing to the wide oscillations in
the intensity of sexual needs and the complications of the
conditions necessary in order to bring about a sexual trauma.
Here the cathartic method does all that can be asked of it, for
the physician cannot set himself the task of altering a constitu-
tion such as the hysterical one. He must content himself with
getting rid of the troubles to which such a constitution is
inclined and which may arise from it with the conjunction of
external circumstances. He will feel satisfied if the patient

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 263

regains her working capacity. Moreover, he is not without con-
solation for the future when he considers the possibility of a
relapse. He is aware of the principal feature in the aetiology of
the neuroses that their genesis is as a rule overdetermined, 1
that several factors must come together to produce this result;
and he may hope that this convergence will not be repeated at
once, even though a few individual aetiological factors remain
operative.

It might be objected that, in cases of hysteria like this, in
which the illness has run its course, the residual symptoms in
any case pass away spontaneously. It may be said in reply,
however, that a spontaneous cure of this kind is very often
neither rapid nor complete enough and that it can be assisted
to an extraordinary degree by our therapeutic intervention.
We may readily leave it for the moment as an unresolved ques-
tion whether by means of the cathartic therapy we cure only
what is capable of spontaneous cure or sometimes also what
would not have been cleared up spontaneously.

(4) Where we meet with an acute hysteria, a case which is
passing through the period of the most active production of
hysterical symptoms and in which the ego is being constantly
overwhelmed by the products of the illness (i.e. during a
hysterical psychosis), even the cathartic method will make little
change in the appearance and course of the disorder. In such
circumstances we find ourselves in the same position as regards
the neurosis as a physician faced by an acute infectious disease.
The aetiological factors have performed their work sufficiently
at a time which has now passed and is beyond the reach of any
influence; and now, after the period of incubation has elapsed,
they have become manifest. The illness cannot be broken off
short. We must wait for it to run its course and in the mean-
time make the patient's circumstances as favourable as possible.
If, during an acute period like this, we get rid of the products
of the illness, the freshly generated hysterical symptoms, we
must also be prepared to find that those that have been got
rid of will promptly be replaced by others. The physician will
not be spared the depressing feeling of being faced by a Sis-
yphean task. The immense expenditure of labour, and the dis-
satisfaction of the patient's family, to whom the inevitable
length of an acute neurosis is not likely to be as familiar as the
1 [Sec footnote, p. 212.]

264 IV. PSYCHOTHERAPY OF HYSTERIA (FREUD)

analogous case of an acute infectious disease these and other
difficulties will probably make a systematic application of the
cathartic method as a rule impossible in any given case. Never-
theless, it remains a matter for serious consideration whether it
may not be true that even in an acute hysteria the regular
clearing up of the products of the illness exercises a curative
influence, by supporting the patient's normal ego which is
engaged in the work of defence, and by preserving it from
being overwhelmed and falling into a psychosis and even per-
haps into a permanent state of confusion.

What the cathartic method is able to accomplish even in
acute hysteria, and how it even restricts the fresh production of
pathological symptoms in a manner that is of practical impor-
tance, is quite clearly revealed by the case history of Anna O.,
in which Breuer first learnt to employ this psychotherapeutic
procedure.

(5) Where it is a question of hysterias which run a chronic
course, accompanied by a moderate but constant production
of hysterical symptoms, we find the strongest reason for re-
gretting our lack of a therapy which is effective causally, but
we also have most ground for the appreciation of the value of
the cathartic procedure as a symptomatic therapy. In such cases
we have to do with the mischief produced by an aetiology
that persists chronically. Everything depends on reinforcing
the patient's nervous system in its capacity to resist; and we
must reflect that the existence of a hysterical symptom means
a weakening of the resistance of that nervous system and repre-
sents a factor predisposing to hysteria. As can be seen from
the mechanism of monosymptomatic hysteria, a new hysterical
symptom is most easily formed in connection with, and on the
analogy of, one that is already present. The point at which a
symptom has already broken through once (see p. 203) forms a
weak spot at which it will break through again the next time.
A psychical group that has once been split off plays the part of
a 'provoking* crystal from which a crystallization which would
otherwise not have occurred will start with the greatest facility
[p. 123]. To get rid of the symptoms which are already present,
to undo the psychical changes which underlie them, is to give
back to patients the whole amount of their capacity for re-
sistance, so that they can successfully withstand the effects of
the noxious agency. A very great deal can be done for such

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 265

patients by means of prolonged supervision and occasional
'chimney-sweeping' (p. 30).

(6) It remains for me to mention the apparent contradiction
between the admission that not all hysterical symptoms are
psychogenic and the assertion that they can all be got rid of
by a psychotherapeutic procedure. The solution lies in the fact
that some of these non-psychogenic symptoms (stigmata, for
instance) are, it is true, indications of illness, but cannot be
described as ailments; and consequently it is not of practical
importance if they persist after the successful treatment of the
illness. As regards other such symptoms, it seems to be the
case that in some roundabout way they are carried off along
with the psychogenic symptoms, just as, perhaps, in some
roundabout way they are after all dependent on a psychical
causation.

I must now consider the difficulties and disadvantages of our
therapeutic procedure, so far as they do not become obvious
to everyone from the case histories reported above or from the
remarks on the technique of the method which follow later. I
will enumerate and indicate these difficulties rather than
elaborate them.

The procedure is laborious and time-consuming for the
physician. It presupposes great interest in psychological hap-
penings, but personal concern for the patients as well. I cannot
imagine bringing myself to delve into the psychical mechanism
of a hysteria in anyone who struck me as low-minded and re-
pellent, and who, on closer acquaintance, would not be capable
of arousing human sympathy; whereas I can keep the treatment
of a tabetic or rheumatic patient apart from personal approval
of this kind. The demands made on the patient are not less.
The procedure is not applicable at all below a certain level of
intelligence, and it is made very much more difficult by any
trace of feebleness of mind. The complete consent and com-
plete attention of the patients are needed, but above all their
confidence, since the analysis invariably leads to the disclosure
of the most intimate and secret psychical events. A good num-
ber of the patients who would be suitable for this form of
treatment abandon the doctor as soon as the suspicion begins
to dawn on them of the direction in which the investigation is
leading. For patients such as these the doctor has remained a

266 IV. PSYCHOTHERAPY OF HYSTERIA (FBEUD)

stranger. With others, who have decided to put themselves in
his hands and place their confidence in him a step which in
other such situations is only taken voluntarily and never at the
doctor's request with these other patients, I say, it is almost
inevitable that their personal relation to him will force itself,
for a time at least, unduly into the foreground. It seems, indeed,
as though an influence of this kind on the part of the doctor is
a sine qua non to a solution of the problem. 1 I do not think any
essential difference is made in this respect whether hypnosis
can be used or whether it has to be by-passed and replaced by
something else. But reason demands that we should emphasize
the fact that these drawbacks, though they are inseparable
from our procedure, cannot be laid at its door. On the con-
trary, it is quite clear that they are based on the predetermining
conditions of the neuroses that are to be cured and that they
must attach to any medical activity which involves intense
preoccupation with the patient and leads to a psychical change
in him. I have not been able to attribute any deleterious effects
or danger to the employment of hypnosis, though I made
copious use of it in some of my cases. Where I caused damage,
the reasons lay elsewhere and deeper. If I survey my therapeutic
efforts during the last few years since the communications made
by my honoured teacher and friend Josef Breuer showed me
the use of the cathartic method, I believe that in spite of every-
thing, I have done much more, and more frequent, good than
harm and have accomplished some things which no other
therapeutic procedure could have achieved. It has on the
whole, as the 'Preliminary Communication' put it, brought
'considerable therapeutic advantages' [p. 17].

There is one other advantage in the use of this procedure
which I must emphasize. I know of no better way of getting
to understand a severe case of complicated neurosis with a
greater or lesser admixture of hysteria than by submitting it
to an analysis by Breuer's method. The first thing that happens
is the disappearance of whatever exhibits a hysterical mech-
anism. In the meantime I have learnt in the course of the
analysis to interpret the residual phenomena and to trace their
aetiology; and in this way I have secured a firm basis for
deciding which of the weapons in the therapeutic armoury
against the neuroses is indicated in the case concerned. When
1 [This topic is discussed at greater length below, p. 301 ff.]

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 267

I reflect on the difference that I usually find between my
judgement on a case of neurosis before and after an analysis of
this kind, I am almost inclined to regard an analysis as essential
for the understanding of a neurotic illness. Moreover, I have
adopted the habit of combining cathartic psychotherapy with
a rest-cure which can, if need be, be extended into a complete
treatment of feeding-up on Weir Mitchell lines. This gives me
the advantage of being able on the one hand to avoid the very
disturbing introduction of new psychical impressions during a
psychotherapy, and on the other hand to remove the boredom
of a rest-cure, in which the patients not infrequently fall into
the habit of harmful day-dreaming. It might be expected that
the often very considerable psychical work imposed on the
patients during a cathartic treatment, and the excitations
resulting from the reproduction of traumatic experiences,
would run counter to the intentions of the Weir Mitchell rest-
cure and would hinder the successes which we are accustomed
to see it bring about. But the opposite is in fact the case. A
combination such as this between the Breuer and Weir Mitchell
procedures produces all the physical improvement that we
expect from the latter, as well as having a far-reaching psychi-
cal influence such as never results from a rest-cure without
psychotherapy. 1

(2)

I will now return to my earlier remark [p. 256] that in my
attempts to apply Breuer's method more extensively I came
upon the difficulty that a number of patients could not be
hypnotized, although their diagnosis was one of hysteria and
it seemed probable that the psychical mechanism described
by us operated in them. I needed hypnosis to extend their
memory in order to find the pathogenic recollections which
were not present in their ordinary consciousness. I was obliged
therefore either to give up the idea of treating such patients
or to endeavour to bring about this extension in some other
way.

I was able as little as anyone else to explain why it is that
one person can be hypnotized and another not, and thus I

1 [Weir Mitchell's book on The Treatment of Certain Forms of Neuras-
thenia and Hysteria had been favourably reviewed by Freud (1887).J

268 IV. PSYCHOTHERAPY OF HYSTERIA (FREUD)

could not adopt a causal method of meeting the difficulty. I
noticed, however, that in some patients the obstacle lay still
further back: they refused even any attempt at hypnosis. The
idea then occurred to me one day that the two cases might be
identical and that both might signify an unwillingness; that
people who were not hypnotizable were people who had a
psychical objection to hypnosis, whether their objection was
expressed as unwillingness or not. I am not clear in my mind
whether I can maintain this view.

The problem was, however, how to by-pass hypnosis and yet
obtain the pathogenic recollections. This I succeeded in doing
in the following manner.

When, at our first interview, I asked my patients if they
remembered what had originally occasioned the symptom con-
cerned, in some cases they said they knew nothing of it, while
in others they brought forward something which they described
as an obscure recollection and could not pursue further. If,
following the example of Bernheim when he awoke in his
patients impressions from their somnambulistic state which had
ostensibly been forgotten (cf. p. 109 f.), I now became insistent
if I assured them that they did know it, that it would occur to
their minds, then, in the first cases, something did actually
occur to them, and, in the others, their memory went a step
further. After this I became still more insistent; I told the
patients to lie down and deliberately close their eyes in order
to 'concentrate' all of which had at least some resemblance to
hypnosis. I then found that without any hypnosis new recol-
lections emerged which went further back and which probably
related to our topic. Experiences like this made me think that
it would in fact be possible for the pathogenic groups of ideas,
that were after all certainly present, to be brought to light by
mere insistence; and since this insistence involved effort on my
part and so suggested the idea that I had to overcome a re-
sistance, the situation led me at once to the theory that by
means of my psychical work I had to overcome a psychical force in the
patients which was opposed to the pathogenic ideas becoming conscious
(being remembered). A new understanding seemed to open
before my eyes when it occurred to me that this must no doubt
be the same psychical force that had played a part in the
generating of the hysterical symptom and had at that time
prevented the pathogenic idea from becoming conscious. What

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 269

kind of force could one suppose was operative here, and what
motive could have put it into operation? I could easily form an
opinion on this. For I already had at my disposal a few com-
pleted analyses in which I had come to know examples of ideas
that were pathogenic, and had been forgotten and put out of
consciousness. From these I recognized a universal character-
istic of such ideas: they were all of a distressing nature, calcu-
lated to arouse the affects of shame, of self-reproach and of
psychical pain, and the feeling of being harmed; they were all
of a kind that one would prefer not to have experienced, that
one would rather forget. From all this there arose, as it were
automatically, the thought of defence. It has indeed been gener-
ally admitted by psychologists that the acceptance of a new
idea (acceptance in the sense of believing or of recognizing as
real) is dependent on the nature and trend of the ideas already
united in the ego, and they have invented special technical
names for this process of censorship 1 to which the new arrival
must submit. The patient's ego had been approached by an
idea which proved to be incompatible, which provoked on the
part of the ego a repelling force of which the purpose was
defence against this incompatible idea. This defence was in fact
successful. The idea in question was forced out of consciousness
and out of memory. The psychical trace of it was apparently
lost to view. Nevertheless that trace must be there. If I en-
deavoured to direct the patient's attention to it, I became
aware, in the form of resistance, of the same force as had shown
itself in the form of repulsion when the symptom was generated.
If, now, I could make it appear probable that the idea had
become pathogenic precisely as a result of its expulsion and
repression, the chain would seem complete. In several of the
discussions on our case histories, and in a short paper on The
Neuro-Psychoses of Defence' (1894a), I have attempted to
sketch out the psychological hypotheses by the help of which
this causal connection the fact of conversion can be
demonstrated.

Thus a psychical force, aversion on the part of the ego,
had originally driven the pathogenic idea out of association
and was now 2 opposing its return to memory. The hysterical

1 [This appears to be Freud's first published use of the term.]
1 [\7tef.' This word is found only in the first edition. It is omitted,
probably by accident, in all the later editions.]

270 IV. PSYCHOTHERAPY OF HYSTERIA (FREUD)

patient's 'not knowing' was in fact a 'not wanting to know'
a not wanting which might be to a greater or less extent con-
scious. The task of the therapist, therefore, lies in overcoming
by his psychical work this resistance to association. He does this
in the first place by 'insisting', by making use of psychical
compulsion to direct the patients' attention to the ideational
traces of which he is in search. His efforts, however, are not
exhausted by this, but, as I shall show, they take on other
forms in the course of an analysis and call in other psychical
forces to assist them.

I must dwell on the question of insistence a little longer.
Simple assurances such as 'of course you know it', 'tell me all
the same', 'you'll think of it in a moment' do not carry us
very far. Even with patients in a state of 'concentration' the
thread breaks off after a few sentences. It should not be for-
gotten, however, that it is always a question here of a quantitative
comparison, of a struggle between motive forces of different
degrees of strength or intensity. Insistence on the part of a
strange doctor who is unfamiliar with what is happening is
not powerful enough to deal with the resistance to association
in a serious case of hysteria. We must think of stronger means.

In these circumstances I make use in the first instance of a
small technical device. 1 I inform the patient that, a moment
later, I shall apply pressure to his forehead, and I assure him
that, all the time the pressure lasts, he will see before him a
recollection in the form of a picture or will have it in his
thoughts in the form of an idea occurring to him; and I pledge
him to communicate this picture or idea to me, whatever it
may be. He is not to keep it to himself because he may happen
to think it is not what is wanted, not the right thing, or because
it would be too disagreeable for him to say it. There is to be
no criticism of it, no reticence, either for emotional reasons or
because it is judged unimportant. Only in this manner can we
find what we are in search of, but in this manner we shall find
it infallibly. Having said this, I press for a few seconds on the
forehead of the patient as he lies in front of me; I then leave
go and ask quietly, as though there were no question of a dis-
appointment: 'What did you see?' or 'What occurred to you?'

This procedure has taught me much and has also invariably
achieved its aim. To-day I can no longer do without it. I am
1 [See p. 1 10 and footnote.]

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 271

of course aware that a pressure on the forehead like this could
be replaced by any other signal or by some other exercise of
physical influence on the patient; but since the patient is lying
in front of me, pressure on his forehead, or taking his head
between my two hands, seems to be the most convenient way
of applying suggestion for the purpose I have in view. It would
be possible for me to say by way of explaining the efficacy of
this device that it corresponded to a 'momentarily intensified
hypnosis'; but the mechanism of hypnosis is so puzzling to me
that I would rather not make use of it as an explanation. I am
rather of opinion that the advantage of the procedure lies in the
fact that by means of it I dissociate the patient's attention from
his conscious searching and reflecting from everything, in
short, on which he can employ his will in the same sort of
way in which this is effected by staring into a crystal ball, and
so on. 1 The conclusion which I draw from the fact that what I
am looking for always appears under the pressure of my hand
is as follows. The pathogenic idea which has ostensibly been
forgotten is always lying ready 'close at hand' and can be
reached by associations that are easily accessible. It is merely
a question of getting some obstacle out of the way. This obstacle
seems once again to be the subject's will, and different people
can learn with different degrees of ease to free themselves from
their intentional thinking and to adopt an attitude of com-
pletely objective observation towards the psychical processes
taking place in them. 2

What emerges under the pressure of my hand is not always a
'forgotten' recollection; it is only in the rarest cases that the
actual pathogenic recollections lie so easily to hand on the
surface. It is much more frequent for an idea to emerge which
is an intermediate link in the chain of associations between the
idea from which we start and the pathogenic idea which we are
in search of; or it may be an idea w r hich forms the starting
point of a new series of thoughts and recollections at the end

1 [The part played in the technique of hypnotism by distracting con-
scious attention was discussed by Freud much later, in Chapter X of his
Group Psychology (192k), Standard Ed., 18, 126. Further references to
the use of the same mechanism in telepathy and in joking are enumer-
ated in a footnote to that passage.]

8 [The difficulty felt by some people in adopting this non-critical
attitude was discussed by Freud at some length in Chapter II of The
Interpretation of Dreams (19000), Standard Ed., 4, 101-3.]

272 IV. PSYCHOTHERAPY OF HYSTERIA (FREUD)

of which the pathogenic idea will be found. It is true that where
this happens my pressure has not revealed the pathogenic idea
which would in any case be incomprehensible, torn from its
context and without being led up to but it has pointed the
way to it and has shown the direction in which further investi-
gation is to be made. The idea that is first provoked by the
pressure may in such cases be a familiar recollection which has
never been repressed. If on our way to the pathogenic idea the
thread is broken off once more, it only needs a repetition of the
procedure, of the pressure, to give us fresh bearings and a fresh
starting-point.

On yet other occasions the pressure of the hand provokes
a memory which is familiar in itself to the patient, but the
appearance of which astonishes him because he has forgotten
its relation to the idea from which we started. This relation is
then confirmed in the further course of the analysis. All these
consequences of the pressure give one a deceptive impression
of there being a superior intelligence outside the patient's
consciousness which keeps a large amount of psychical material
arranged for particular purposes and has fixed a planned order
for its return to consciousness. I suspect, however, that this
unconscious second intelligence is no more than an appearance.

In every fairly complicated analysis the work is carried on
by the repeated, indeed continuous, use of this procedure of
pressure on the forehead. Sometimes this procedure, starting
from where the patient's waking retrospection breaks off, points
the further path through memories of which he has remained
aware; sometimes it draws attention to connections which have
been forgotten; sometimes it calls up and arranges recollections
which have been withdrawn from association for many years but
which can still be recognized as recollections; and sometimes,
finally, as the climax of its achievement in the way of repro-
ductive thinking, it causes thoughts to emerge which the patient
will never recognize as his own, which he never remembers,
although he admits that the context calls for them inexorably,
and while he becomes convinced that it is precisely these ideas
that are leading to the conclusion of the analysis and the removal
of his symptoms.

I will try to enumerate a few instances of the excellent results
brought about by this technical procedure.

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 273

I treated a girl suffering from an intolerable tussis nervosa
which had dragged on for six years. It obviously drew nourish-
ment from every common catarrh, but must nevertheless have
had strong psychical motives. All other kinds of therapy had
long proved impotent against it. I therefore tried to remove the
symptom by means of psychical analysis. All she knew was that
her nervous cough began when, at the age of fourteen, she was
boarding with an aunt. She maintained that she knew nothing
of any mental agitations at that time and did not believe that
there was any motive for her complaint. Under the pressure
of my hand she first of all remembered a big dog. She then
recognized the picture in her memory: it was a dog of her
aunt's which became attached to her, followed her about
everywhere, and so on. And it now occurred to her, without
further prompting, that this dog died, that the children gave
it a solemn burial and that her cough started on the way back
from the funeral. I asked why, but had once more to call in the
help of a pressure. The thought then came to her: 'Now I am
quite alone in the world. No one here loves me. This creature
was my only friend, and now I have lost him.' She continued
her story. The cough disappeared when I left my aunt's, but
it came on again eighteen months later.' 'Why was that?' 'I
don't know.' I pressed again. She recalled the news of her
uncle's death, when the cough started again, and also recalled
having a similar train of thought. Her uncle seems to have been
the only member of the family who had shown any feeling for
her, who had loved her. Here, then, was the pathogenic idea.
No one loved her, they preferred everyone else to her, she did
not deserve to be loved, and so on. But there was sonv thing
attaching to the idea of 'love' which there was a strong resist-
ance to her telling me. The analysis broke off before this was
cleared up.

Some time ago I was asked to relieve an elderly lady of her
attacks of anxiety, though judging by her traits of character
she was scarcely suitable for treatment of this kind. Since her
menopause she had become excessively pious, and she used to
receive me at each visit armed with a small ivory crucifix con-
cealed in her hand, as though I were the Evil One. Her anxiety
attacks, which were of a hysterical character, went back to her
early girlhood and, according to her, originated from the use
of a preparation of iodine intended to reduce a moderate

274 IV. PSYCHOTHERAPY OF HYSTERIA (FREUD)

swelling of her thyroid gland. I naturally rejected this deriva-
tion and tried to find another instead of it which would har-
monize better with my views on the aetiology of the neuroses.
I asked her first for an impression from her youth which stood
in a causal relation to her anxiety attacks, and, under the
pressure of my hand, a memory emerged of her reading what
is known as an 'edifying' book, in which there occurred a
mention, in a sufficiently pious strain, of the sexual processes.
The passage in question made an impression on the girl which
was quite the reverse of the author's intention: she burst into
tears and flung the book away. This was before her first anxiety
attack. A second pressure on the patient's forehead conjured
up a further reminiscence the recollection of a tutor of her
brothers who had manifested a great admiration for her and
towards whom she herself had had feelings of some warmth.
This recollection culminated in the reproduction of an evening
in her parents' house when they had all sat round the table
with the young man and had enjoyed themselves immensely in
an entertaining conversation. During the night following that
evening she was woken up by her first anxiety attack which,
it is safe to say, had more to do with a repudiation of a sensual
impulse than with any contemporary doses of iodine. What
prospect should I have had by any other method of revealing
such a connection, against her own views and assertions, in this
recalcitrant patient who was so prejudiced against me and every
form of mundane therapy?

Another example concerns a young, happily-married woman.
As long ago as in her early girlhood she used for some time to
be found every morning in a stuporose condition, with her
limbs rigid, her mouth open and her tongue protruding; and
now once again she was suffering, on waking, from attacks
which were similar though not so severe. Since deep hypnosis
turned out not to be obtainable, I began to investigate while
she was in a state of concentration. At my first pressure I assured
her that she would see something that was directly related to
the causes of her condition in her childhood. She was quiet and
co-operative. She saw once more the house in which she had
spent her early girlhood, her own room, the position of her bed,
her grandmother, who had lived with them at that time, and
one of her governesses of whom she had been very fond. A
number of small scenes, all of them unimportant, which took

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 275

place in these rooms and between these people followed one
after the other; they were concluded by the departure of the
governess, who left in order to get married. I could make
nothing at all of these reminiscences; I could not establish
any relation between them and the aetiology of the attacks.
Various circumstances showed, however, that they belonged to
the same period at which the attacks first appeared. But before
I was able to proceed with the analysis I had occasion to talk
to a colleague who in former years had been the family doctor
of my patient's parents. He gave me the following information.
At the time at which he was treating the girl, who was approach-
ing maturity and very well developed physically, for her first
attacks, he was struck by the excessive affectionateness of the
relation between her and the governess who was at that time
in the house. He became suspicious and induced the grand-
mother to keep an eye on this relationship. After a short time
the old lady was able to report to him that the governess was
in the habit of visiting the child in bed at night and that after
such nights the child was invariably found next morning in an
attack. They did not hesitate after this to arrange for the silent
removal of this corrupter of youth. The children and even the
mother were encouraged to believe that the governess had left
in order to get married. My therapy, which was immediately
successful, consisted in giving the young woman the information
I had received.

The revelations which one obtains through the procedure of
pressing occasionally appear in a very remarkable form and in
circumstances which make the assumption of there being an
unconscious intelligence even more tempting. Thus I remember
a lady who had suffered for many years from obsessions and
phobias and who referred me to her childhood for the genesis
of her illness but was also quite unable to say what might be to
blame for it. She was frank and intelligent and she put up
only a remarkably small conscious resistance. (I may remark
in parenthesis that the psychical mechanism of obsessions has a
very great deal of internal kinship with hysterical symptoms
and that the technique of analysis is the same for both of them.)
When I asked this lady whether she had seen anything or had
any recollection under the pressure of my hand, she replied:
'Neither the one nor the other, but a word has suddenly
occurred to me.' 'A single word?' 'Yes, but it sounds too silly.'

276 IV. PSYCHOTHERAPY OF HYSTERIA (FREUD)

'Say it all the same.' 'Concierge.' 'Nothing else?' 'No.' I pressed
a second time and once more an isolated word shot through
her mind: 'Night-gown.' I saw now that this was a new sort
of method of answering, and by pressing repeatedly I brought
out what seemed to be a meaningless series of words: 'Concierge'
'night-gown' 'bed' 'town' 'farm-cart.' 'What does all
this mean?' I asked. She reflected for a moment and the follow-
ing thought occurred to her: 'It must be the story that has just
come into my head. When I was ten years old and my next
elder sister was twelve, she went raving mad one night and
had to be tied down and taken into the town on a farm-cart.
I remember perfectly that it was the concierge who over-
powered her and afterwards went with her to the asylum as
well.' We pursued this method of investigation and our oracle
produced another series of words, which, though we were not
able to interpret all of them, made it possible to continue this
story and lead on from it to another one. Soon, moreover, the
meaning of this reminiscence became clear. Her sister's illness
had made such a deep impression on her because the two of
them shared a secret; they slept in one room and on a particular
night they had both been subjected to sexual assaults by a
certain man. The mention of this sexual trauma in the patient's
childhood revealed not only the origin of her first obsessions
but also the trauma which subsequently produced the patho-
genic effects.

The peculiarity of this case lay only in the emergence of
isolated key- words which we had to work into sentences; for
the appearance of disconnectedness and irrelevance which
characterized the words emitted in this oracular fashion applies
equally to the complete ideas and scenes which are normally
produced under my pressure. When these are followed up, it
invariably turns out that the apparently disconnected reminis-
cences are closely linked in thought and that they lead quite
straight to the pathogenic factor we are looking for. For this
reason I am glad to recall a case of analysis in which my
confidence in the products of pressure were first put to a hard
test but afterwards brilliantly justified.

A 'very intelligent and apparently happy young married
woman had consulted me about an obstinate pain in her
abdomen which was resistant to treatment. I recognized that
the pain was situated in the abdominal wall and must be

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 277

referred to palpable muscular indurations, and I ordered local
treatment. Some months later I saw the patient again and she
said to me: 'The pain I had then passed off after the treatment
you recommended, and it stayed away for a long time; but now
it has come back in a nervous form. I know that is so, because
I no longer have it, as I used to, when I make certain move-
ments, but only at particular times for instance, when I wake
up in the morning and when I am agitated in certain ways.'
The lady's diagnosis was quite correct. It was now a question
of finding out the cause of the pain, and she could not help me
about this while she was in an uninfluenced state. When I
asked her, in concentration and under the pressure of my hand,
whether anything occurred to her or whether she saw anything,
she decided in favour of seeing and began to describe her visual
pictures. She saw something like a sun with rays, which I
naturally took to be a phosphene, produced by pressure on the
eyes. I expected that something more serviceable would follow.
But she went on: 'Stars of a curious pale blue light, like moon-
light' and so on, all of which I took to be no more than flicker-
ing, flashes and bright specks before her eyes. I was already
prepared to regard this experiment as a failure and I was
wondering how I could make an inconspicuous retreat from
the affair, when my attention was attracted by one of the
phenomena which she described. She saw a large black cross,
leaning over, which had round its edges the same shimmer of
light with which all her other pictures had shone, and on
whose cross-beam a small flame flickered. Clearly there could
no longer be any question of a phosphene here. I now listened
carefully. Quantities of pictures appeared bathed in the same
light, curious signs looking rather like Sanskrit; figures like
triangles, among them a large triangle; the cross once more. . . .
This time I suspected an allegorical meaning and asked what
the cross could be. 'It probably means pain,' she replied. I
objected that by 'cross' one usually meant a moral burden.
What lay concealed behind the pain? She could not say, and
went on with her visions: a sun with golden rays. And this
she was also able to interpret. 'It's God, the primaeval force.'
Then came a gigantic lizard which regarded her enquiringly
but not alarmingly. Then a heap of snakes. Then once more a
sun, but with mild, silver rays; and in front of her, between
her and this source of light, a grating which hid the centre of

278 IV. PSYCHOTHERAPY OF HYSTERIA (FREUD)

the sun from her. I had known for some time that what I had
to deal with were allegories and at once asked the meaning of
this last picture. She answered without hesitation: 'The sun is
perfection, the ideal, and the grating represents my weaknesses
and faults which stand between me and the ideal.' 'Are you
reproaching yourself, then? Are you dissatisfied with yourself?'
'Yes indeed.' 'Since when?' 'Since I have been a member of
the Theosophical Society and have been reading its publica-
tions. I always had a low opinion of myself.' 'What has made
the strongest impression on you recently?' 'A translation from
the Sanskrit which is just now coming out in instalments.' A
minute later I was being initiated into her mental struggles
and her self-reproaches, and was hearing about a small episode
which gave rise to a self-reproach an occasion on which what
had previously been an organic pain now for the first time
appeared as the consequence of the conversion of an excitation.
The pictures which I had first taken for phosphenes were
symbols of trains of thought influenced by the occult and were
perhaps actually emblems from the title-pages of occult books.

Hitherto I have been so warm in my praises of the achieve-
ments of pressure as an auxiliary procedure, and I have the
whole time so greatly neglected the aspect of defence or resist-
ance, that I may no doubt have created an impression that this
little device has put us in a position to master the psychical
obstacles to a cathartic treatment. But to believe this would be
to make a serious mistake. Gains of this kind, so far as I can
see, are not to be looked for in treatment. Here, as elsewhere,
a large change requires a large amount of work. The procedure
by pressure is no more than a trick for temporarily taking
unawares an ego which is eager for defence. In all fairly serious
cases the ego recalls its aims once more and proceeds with its
resistance.

I must mention the different forms in which this resistance
appears. One is that, as a rule, the pressure procedure fails on
the first or second occasion. The patient then declares, very
disappointedly: 'I expected something would occur to me, but
all I* thought was how tensely I was expecting it. Nothing
came.' The fact of the patient putting himself on his guard
like this does not yet amount to an obstacle. We can say in
reply: 'It's precisely because you were too curious; it will work

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 279

next time.' And in fact it does work. It is remarkable how often
patients, even the most docile and intelligent, can completely
forget their undertaking, though they had agreed to it before-
hand. They promised to say whatever occurred to them under
the pressure of my hand, irrespectively of whether it seemed
to them relevant or not, and of whether it was agreeable to them
to say it or not to say it, that is, without selecting and without
being influenced by criticism or affect. But they do not keep
this promise; it is evidently beyond their strength to do so. The
work keeps on coming to a stop and they keep on maintaining
that this time nothing has occurred to them. We must not
believe what they say, we must always assume, and tell them,
too, that they have kept something back because they thought it
unimportant or found it distressing. We must insist on this, we
must repeat the pressure and represent ourselves as infallible,
till at last we are really told something. The patient then adds:
'I could have told you that the first time.' 'Why didn't you say
it?' 'I couldn't believe it could be that. It was only when it
came back every time that I made up my mind to say it. 5 Or
else: 'I hoped it wouldn't be that of all things. I could well do
without saying that. It was only when it refused to be repressed
that I saw I shouldn't be let off.' Thus after the event the
patient betrays the motives for a resistance which he refused
to admit to begin with. He is evidently quite unable to do any-
thing but put up resistance.

This resistance often conceals itself behind some remarkable
excuses. 'My mind is distracted to-day; the clock (or the piano
in the next room) is disturbing me.' I have learned to answer
such remarks: 'Not at all. You have at this moment come up
against something that you had rather not say. It won't do
any good. Go on thinking about it.' The longer the pause
between my hand-pressure and the patient's beginning to speak,
the more suspicious I become and the more it is to be feared
that the patient is re-arranging what has occurred to him and
is mutilating it in his reproduction of it. A most important piece
of information is often announced as being a redundant acces-
sory, like an opera prince disguised as a beggar. 'Something
has occurred to me now, but it has nothing to do with the
subject. I'm only saying it because you want to know every-
thing.' Accompanying words such as these usually introduce
the long-sought solution. I always prick up my ears when I

280 IV. PSYCHOTHERAPY OF HYSTERIA (FREUD)

hear a patient speak so disparagingly of something that has
occurred to him. For it is an indication that defence has been
successful if the pathogenic ideas seem, when they re-emerge,
to have so little importance. From this we can infer in what the
process of defence consisted: it consisted in turning a strong
idea into a weak one, in robbing it of its affect.

A pathogenic recollection is thus recognizable, among other
things, by the fact that the patient describes it as unimportant
and nevertheless only utters it under resistance. There are cases,
too, in which the patient tries to disown it even after its return.
'Something has occurred to me now, but you obviously put
it into my head. 5 Or, 'I know what you expect me to answer.
Of course you believe I've thought this or that.' A particularly
clever method of disavowal lies in saying: 'Something has
occurred to me now, it's true, but it seems to me as if I'd put
it in deliberately. It doesn't seem to be a reproduced thought
at all. 1 In all such cases, I remain unshakably firm. I avoid
entering into any of these distinctions but explain to the patient
that they are only forms of his resistance and pretexts raised by
it against reproducing this particular memory, which we must
recognize in spite of all this.

When memories return in the form of pictures our task is in
general easier than when they return as thoughts. Hysterical
patients, who are as a rule of a 'visual' type, do not make such
difficulties for the analyst as those with obsessions.

Once a picture has emerged from the patient's memory, we
may hear him say that it becomes fragmentary and obscure in
proportion as he proceeds with his description of it. The patient
is, as it were, getting rid of it by turning it into words. We go on to
examine the memory picture itself in order to discover the
direction in which our work is to proceed. 'Look at the picture
once more. Has it disappeared?' 'Most of it, yes, but I still see
this detail.' 'Then this residue must still mean something. Either
you will see something new in addition to it, or something will
occur to you in connection with it.' When this work has been
accomplished, the patient's field of vision is once more free
and. we can conjure up another picture. On other occasions,
however, a picture of this kind will remain obstinately before
the patient's inward eye, in spite of his having described it;
and this is an indication to me that he still has something
important to tell me about the topic of the picture. As soon as

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 281

this has been done the picture vanishes, like a ghost that has
been laid.

It is of course of great importance for the progress of the
analysis that one should always turn out to be in the right
vis-d-vis the patient, otherwise one would always be dependent
on what he chose to tell one. It is therefore consoling to know
that the pressure technique in fact never fails, apart from a
single case, which I shall have to discuss later [p. 301 ff.] but
of which I can at once say that it corresponds to a particular
motive for resistance. It can of course happen that one makes
use of the procedure in circumstances in which there is nothing
for it to reveal. For instance, we may ask for the further aetio-
logy of a symptom when we already have it completely before
us, or we may investigate a psychical genealogy of a symptom,
such as a pain, which is in fact a somatic one. In such cases
the patient will equally assert that nothing has occurred to him
and this time he will be in the right. We can avoid doing the
patient an injustice if we make it a quite general rule all
through the analysis to keep an eye on his facial expression as
he lies quietly before us. We can then learn to distinguish
without any difficulty the restful state of mind that accompanies
the real absence of a recollection from the tension and signs of
emotion with which he tries to disavow the emerging recol-
lection, in obedience to defence. Moreover, experiences like
these make it possible also to use the pressure technique for
purposes of differential diagnosis.

Thus even with the assistance of the pressure technique the
work is by no means easy. The one advantage that we gain is
of learning from the results of this procedure the direction in
which we have to conduct our enquiries and the things that
we have to insist upon to the patient. With some cases this
suffices. The principal point is that I should guess the secret
and tell it to the patient straight out; and he is then as a rule
obliged to abandon his rejection of it. In other cases more is
required. The patient's persisting resistance is indicated by the
fact that connections are broken, solutions fail to appear, the
pictures are recalled indistinctly and incompletely. Looking
back from a later period of an analysis to an earlier one, we are
often astonished to realize in what a mutilated manner all
the ideas and scenes emerged which we extracted from the
patient by the procedure of pressing. Precisely the essential

282 IV. PSYCHOTHERAPY OF HYSTERIA (FREUD)

elements of the picture were missing its relation to himself
or to the main contents of his thoughts and that is why it
remained unintelligible.

I will give one or two examples of the way in which a
censoring of this kind operates when pathogenic recollections
first emerge. For instance, the patient sees the upper part of a
woman's body with the dress not properly fastened out of
carelessness, it seems. It is not until much later that he fits a
head to this torso and thus reveals a particular person and his
relation to her. Or he brings up a reminiscence from his child-
hood of two boys. What they look like is quite obscure to him,
but they are said to have been guilty of some misdeed. It is
not until many months later and after the analysis has made
great advances that he sees this reminiscence once more and
recognizes himself in one of the children and his brother in the
other.

What means have we at our disposal for overcoming this
continual resistance? Few, but they include almost all those by
which one man can ordinarily exert a psychical influence on
another. In the first place, we must reflect that a psychical
resistance, especially one that has been in force for a long time,
can only be resolved slowly and by degrees, and we must wait
patiently. In the next place, we may reckon on the intellectual
interest which the patient begins to feel after working for a short
time. By explaining things to him, by giving him information
about the marvellous world of psychical processes into which
we ourselves only gained insight by such analyses, we make
him himself into a collaborator, induce him to regard himself
with the objective interest of an investigator, and thus push
back his resistance, resting as it does on an affective basis. But
lastly and this remains the strongest lever we must en-
deavour, after we have discovered the motives for his defence,
to deprive them of their value or even to replace them by more
powerful ones. This no doubt is where it ceases to be possible
to state psychotherapeutic activity in formulas. One works to
the best of one's power, as an elucidator (where ignorance has
given rise to fear), as a teacher, as the representative of a freer
or superior view of the world, as a father confessor who gives
absolution, as it were, by a continuance of his sympathy and
respect after the confession has been made. One tries to give
the patient human assistance, so far as this is allowed by the

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 283

capacity of one's own personality and by the amount of
sympathy that one can feel for the particular case. It is an
essential precondition for such psychical activity that we should
have more or less divined the nature of the case and the motives
of the defence operating in it, and fortunately the technique of
insistence and pressure takes us as far as this. The more such
riddles we have already solved, the easier we may find it to
guess a new one and the sooner we shall be able to start on the
truly curative psychical work. For it is well to recognize this
clearly: the patient only gets free from the hysterical symptom
by reproducing the pathogenic impressions that caused it and
by giving utterance to them with an expression of affect, and
thus the therapeutic task consists solely in inducing him to do so;
when once this task has been accomplished there is nothing left
for the physician to correct or to remove. Whatever may be
required for this purpose in the way of counter-suggestions has
already been expended during the struggle against the resist-
ance. The situation may be compared with the unlocking of a
locked door, after which opening it by turning the handle offers
no further difficulty.

Besides the intellectual motives which we mobilize to over-
come the resistance, there is an affective factor, the personal
influence of the physician, which we can seldom do without,
and in a number of cases the latter alone is in a position to
remove the resistance. The situation here is no different from
what it is elsewhere in medicine and there is no therapeutic
procedure of which one may say that it can do entirely without
the co-operation of this personal factor.

(3)

In view of what I have said in the preceding section about
the difficulties of my technique, which I have unsparingly
exposed (I brought them together, incidentally, from the
severest cases; things often turn out very much more con-
veniently) in view of all this, then, everyone will no doubt
feel inclined to ask whether it would not be more expedient,
instead of putting up with all these troubles, to make a more
energetic use of hypnosis or to restrict the use of the cathartic
method to patients who can be put under deep hypnosis. As
regards the latter proposal I should have to answer that in that

284 IV. PSYCHOTHERAPY OF HYSTERIA (FREUD)

case the number of suitable patients, so far as my skill is con-
cerned, would dwindle far too much; and I would meet the
first piece of advice with the suspicion that the forcible imposi-
tion of hypnosis might not spare us much resistance. My experi-
ences on this point, oddly enough, have not been numerous,
and I cannot, therefore, go beyond a suspicion. But where I
have carried out a cathartic treatment under hypnosis instead of
under concentration, I did not find that this diminished the
work I had to do. Not long ago I completed a treatment of this
kind in the course of which I caused a hysterical paralysis of
the legs to clear up. The patient passed into a state which was
very different psychically from waking and which was char-
acterized physically by the fact that it was impossible for her
to open her eyes or get up till I had called out to her: 'Now
wake up!' None the less I have never come across greater
resistance than in this case. I attached no importance to these
physical signs, and towards the end of the treatment, which
lasted ten months, they had ceased to be noticeable. But in spite
of this the patient's state while we were working lost none of its
psychical 1 characteristics the capacity she possessed for remem-
bering unconscious material and her quite special relation to
the figure of the physician. On the other hand, I have given an
example in the case history of Frau Emmy von N. of a cathartic
treatment in the deepest Somnambulism in which resistance
played scarcely any part. But it is also true that I learnt from
that lady nothing whose telling might have called for any
special overcoming of objections, nothing that she could not
have told me even in a waking state, supposing we had been
acquainted for some time and she had thought fairly highly
of me. I never reached the true causes of her illness, which
were no doubt identical with the causes of her relapse after my
treatment (for this was my first attempt with this method);
and the only occasion on which I happened to ask her for a
reminiscence which involved an erotic element [p. 79] I
found her just as reluctant and untrustworthy in what she told
me as I did later with any of my non-somnambulistic patients.
I have already spoken in that lady's case history of the resist-
ance which she put up even during somnambulism to other
requests and suggestions of mine. I have become altogether
sceptical about the value of hypnosis in facilitating cathartic
1 ['Psychical' in the first edition only; omitted in all the later editions.]

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 285

treatments, since I have experienced instances in which during
deep somnambulism there has been absolute therapeutic recal-
citrance, where in other respects the patient has been perfectly
obedient. I reported a case of this kind briefly on p. 100 72., and
I could add others. I may admit, too, that this experience has
corresponded pretty well to the requirement I insist upon that
there shall be a quantitative relation between cause and effect
in the psychical field as well [as in the physical one]. 1

In what I have hitherto said the idea of resistance has forced
its way into the foreground. I have shown how, in the course
of our therapeutic work, we have been led to the view that
hysteria originates through the repression of an incompatible
idea from a motive of defence. On this view, the repressed idea
would persist as a memory trace that is weak (has little inten-
sity), while the affect that is torn from it would be used for a
somatic innervation. (That is, the excitation is 'converted'.)
It would seem, then, that it is precisely through its repression
that the idea becomes the cause of morbid symptoms that is
to say, becomes pathogenic. A hysteria exhibiting this psychical
mechanism may be given the name of 'defence hysteria 5 .

Now both of us, Breuer and I, have repeatedly spoken of two
other kinds of hysteria, for which we have introduced the terms
'hypnoid hysteria' and 'retention hysteria'. It was hypnoid
hysteria which was the first of all to enter our field of study.
I could not, indeed, find a better example of it than Breuer's
first case, which stands at the head of our case histories. 2
Breuer has put forward for such cases of hypnoid hysteria a
psychical mechanism which is substantially different from that
of defence by conversion. In his view what happens in hypnoid
hysteria is that an idea becomes pathogenic because it has
been received during a special psychical state and has from
the first remained outside the ego. No psychical force has there-
fore been required in order to keep it apart from the ego and
no resistance need be aroused if we introduce it into the ego
with the help of mental activity during somnambulism. And

1 [Some remarks on the length of the period during which Freud
made use of the techniques of 'pressure' and hypnotism respectively
will be found above in a footnote on p. 110 f.]

2 [The last nine words are omitted in the German collected editions,
G.S., 1925 and G.W., 1952, in which the case of Anna O. is not included.]

286 IV. PSYCHOTHERAPY OF HYSTERIA (FREUD)

Anna O.'s case history in fact shows no sign of any such
resistance.

I regard this distinction as so important that, on the strength
of it, I willingly adhere to this hypothesis of there being a
hypnoid hysteria. Strangely enough, I have never in my own
experience met with a genuine hypnoid hysteria. Any that I
took in hand has turned into a defence hysteria. It is not,
indeed, that I have never had to do with symptoms which
demonstrably arose during dissociated states of consciousness
and were obliged for that reason to remain excluded from the
ego. This was sometimes so in my cases as well; but I was able
to show afterwards that the so-called hypnoid state owed its
separation to the fact that in it a psychical group had come
into effect which had previously been split off by defence. In
short, I am unable to suppress a suspicion that somewhere or
other the roots of hypnoid and defence hysteria come together,
and that there the primary factor is defence. But I can say
nothing about this.

My judgement is for the moment equally uncertain as re-
gards 'retention hysteria 5 , 1 in which the therapeutic work is
supposed equally to proceed without resistance. I had a case
which I looked upon as a typical retention hysteria and I
rejoiced in the prospect of an easy and certain success. But this
success did not occur, though the work was in fact easy. I
therefore suspect, though once again subject to all the reserve
which is proper to ignorance, that at the basis of retention
hysteria, too, an element of defence is to be found which has
forced the whole process in the direction of hysteria. It is to
be hoped that fresh observations will soon decide whether I
am running the risk of falling into one-sidedness and error in
thus favouring an extension of the concept of defence to the
whole of hysteria.

I have dealt so far with the difficulties and technique of the
cathartic method, and I should like to add a few indications
as to the form assumed by an analysis when this technique is
adopted. For me this is a highly interesting subject, but I
cannot expect it to arouse similar interest in others, who have
not yet carried out an analysis of this kind. I shall, it is true,
once more be talking about the technique, but this time it
1 [Gf. above, p. 211 and footnote.]

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 287

will be about inherent difficulties for which we cannot hold the
patients responsible and which must be partly the same in a
hypnoid or retention hysteria as in the defence hysterias which
I have before my eyes as a model. I approach this last part of
my exposition with the expectation that the psychical char-
acteristics which will be revealed in it may one day acquire a
certain value as raw material for the dynamics of ideation.

The first and most powerful impression made upon one dur-
ing such an analysis is certainly that the pathogenic psychical
material which has ostensibly been forgotten, which is not
at the ego's disposal and which plays no part in association and
memory, nevertheless in some fashion lies ready to hand and in
correct and proper order. It is only a question of removing the
resistances that bar the way to the material. In other respects
this material is known, 1 in the same way in which we are able
to know anything; the correct connections between the separate
ideas and between them and the non-pathogenic ones, which
are frequently remembered, are in existence; they have been
completed at some time and are stored up in the memory. The
pathogenic psychical material appears to be the property of
an intelligence which is not necessarily inferior to that of the
normal ego. The appearance of a second personality is often
presented in the most deceptive manner.

Whether this impression is justified, or whether in thinking
this we are not dating back to the period of the illness an
arrangement of the psychical material which in fact was made
after recovery these are questions which I should prefer not
to discuss as yet, and not in these pages. The observations made
during such analyses can in any case be most conveniently and
clearly described if we regard them from the position that we
are able to assume after recovery for the purpose of surveying
the case as a whole.

As a rule, indeed, the situation is not as simple as we have
represented it in particular cases for instance, where there is
one symptom only, which has arisen from one major trauma.
We do not usually find a single hysterical symptom, but a
number of them, partly independent of one another and partly
linked together. We must not expect to meet with a single

1 ['Gewusst* ('known') in the first edition only. In all later German
editions 'bewusst* ('conscious') which seems to make much less good
sense.]

288 IV. PSYCHOTHERAPY OF HYSTERIA (FREUD)

traumatic memory and a single pathogenic idea as its nucleus;
we must be prepared for successions of partial traumas and con-
catenations of pathogenic trains of thought. A monosymptomatic
traumatic hysteria is, as it were, an elementary organism, a
unicellular creature, as compared with the complicated struc-
ture of such comparatively severe x neuroses as we usually meet
with.

The psychical material in such cases of hysteria presents itself
as a structure in several dimensions which is stratified in at least
three different ways. (I hope I shall presently be able to justify
this pictorial mode of expression.) To begin with there is a
nucleus consisting in memories of events or trains of thought
in which the traumatic factor has culminated or the pathogenic
idea has found its purest manifestation. Round this nucleus
we find what is often an incredibly profuse amount of other
mnemic material which has to be worked through in the
analysis and which is, as we have said, arranged in a threefold
order.

In the first place there is an unmistakable linear chronological
order which obtains within each separate theme. As an example
of this I will merely quote the arrangement of the material in
Breuer's analysis of Anna O. Let us take the theme of becoming
deaf, of not hearing. This was differentiated according to seven
sets of determinants, and under each of these seven headings
ten to over a hundred individual memories were collected in
chronological series (p. 36). It was as though we were examin-
ing a dossier that had been kept in good order. The analysis of
my patient Emmy von N. contained similar files of memories
though they were not so fully enumerated and described. These
files form a quite general feature of every analysis and their
contents always emerge in a chronological order which is as
infallibly trustworthy as the succession of days of the week or
names of the month in a mentally normal person. They make
the work of analysis more difficult by the peculiarity that, in
reproducing the memories, they reverse the order in which these
originated. The freshest and newest experience in the file
appears first, as an outer cover, and last of all comes the experi-
ence with which the series in fact began.

I have described such groupings of similar memories into

1 ['Schwereren' ('comparatively severe') in the first and second editions
only; 'schwererC ('severe') in all later editions.]

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 289

collections arranged in linear sequences (like a file of docu-
ments, a packet, etc.) as constituting 'themes'. These themes
exhibit a second kind of arrangement. Each of them is I can-
not express it in any other way stratified concentrically round
the pathogenic nucleus. It is not hard to say what produces
this stratification, what diminishing or increasing magnitude
is the basis of this arrangement. The contents of each particular
stratum are characterized by an equal degree of resistance,
and that degree increases in proportion as the strata are nearer
to the nucleus. Thus there are zones within which there is an
equal degree of modification of consciousness, and the different
themes extend across these zones. The most peripheral strata
contain the memories (or files), which, belonging to different
themes, are easily remembered and have always been clearly
conscious. The deeper we go the more difficult it becomes for
the emerging memories to be recognized, till near the nucleus
we come upon memories which the patient disavows even in
reproducing them.

It is this peculiarity of the concentric stratification of the
pathogenic psychical material which, as we shall hear, lends
to the course of these analyses their characteristic features.
A third kind of arrangement has still to be mentioned the
most important, but the one about which it is least easy to
make any general statement. What I have in mind is an
arrangement according to thought-content, the linkage made
by a logical thread which reaches as far as the nucleus and
tends to take an irregular and twisting path, different in every
case. This arrangement has a dynamic character, in contrast
to the morphological one of the two stratifications mentioned
previously. While these two would be represented in a spatial
diagram by a continuous line, curved or straight, the course
of the logical chain would have to be indicated by a broken
line which would pass along the most roundabout paths from
the surface to the deepest layers and back, and yet would in
general advance from the periphery to the central nucleus,
touching at every intermediate halting-place a line resem-
bling the zig-zag line in the solution of a Knight's Move
problem, which cuts across the squares in the diagram of the
chess-board.

I must dwell for a moment longer on this last simile in order
to emphasize a point in which it does not do justice to the

290 IV. PSYCHOTHERAPY OF HYSTERIA (FREUD)

characteristics of the subject of the comparison. The logical
chain corresponds not only to a zig-zag, twisted line, but rather
to a ramifying system of lines and more particularly to a con-
verging one. It contains nodal points at which two or more
threads meet and thereafter proceed as one; and as a rule
several threads which run independently, or which are con-
nected at various points by side-paths, debouch into the nucleus.
To put this in other words, it is very remarkable how often a
symptom is determined in several ways, is 'overdetermined 1 . 1

My attempt to demonstrate the organization of the patho-
genic psychical material will be complete when I have intro-
duced one more complication. For it can happen that there
is more than one nucleus in the pathogenic material if, for
instance, we have to analyse a second outbreak of hysteria
which has an aetiology of its own but is nevertheless connected
with a first outbreak of acute hysteria which was got over years
earlier. It is easy to imagine, if this is so, what additions there
must be to the strata and paths of thought in order to establish
a connection between the two pathogenic nuclei.

I shall now make one or two further remarks on the picture
we have just arrived at of the organization of the pathogenic
material. We have said that this material behaves like a foreign
body, and that the treatment, too, works like the removal of a
foreign body from the living tissue. We are now in a position
to see where this comparison fails. A foreign body does not
enter into any relation with the layers of tissue that surround
it, although it modifies them and necessitates a reactive in-
flammation in them. Our pathogenic psychical group, on the
other hand, does not admit of being cleanly extirpated from
the ego. Its external strata pass over in every direction into
portions of the normal ego; and, indeed, they belong to the
latter just as much as to the pathogenic organization. In analysis
the boundary between the two is fixed purely conventionally,
now at one point, now at another, and in some places it cannot
be laid down at all. The interior layers of the pathogenic organ-
ization are increasingly alien to the ego, but once more without
there being any visible boundary at which the pathogenic
material begins. In fact the pathogenic organization does not
behave like a foreign body, but far more like an infiltrate. In
this simile the resistance must be regarded as what is infiltrating.
1 ['Ubcrbestimmt: See footnote, p. 212.]

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 291

Nor does the treatment consist in extirpating something
psychotherapy is not able to do this for the present but in
causing the resistance to melt and in thus enabling the circu-
lation to make its way into a region that has hitherto been
cut off.

(I am making use here of a number of similes, all of which
have only a very limited resemblance to my subject and
which, moreover, are incompatible with one another. I am
aware that this is so, and I am in no danger of over-estimating
their value. But my purpose in using them is to throw light
from different directions on a highly complicated topic which
has never yet been represented. I shall therefore venture to
continue in the following pages to introduce similes in the
same manner, though I know this is not free from objection.)

If it were possible, after the case had been completely cleared
up, to demonstrate the pathogenic material to a third person
in what we now know is its complicated and multi-dimensional
organization, we should rightly be asked how a camel like this
got through the eye of the needle. For there is some justification
for speaking of the 'defile' of consciousness. The term gains
meaning and liveliness for a physician who carries out an
analysis like this. Only a single memory at a time can enter
ego-consciousness. A patient who is occupied in working
through such a memory sees nothing of what is pushing after
it and forgets what has already pushed its way through. If
there are difficulties in the way of mastering this single patho-
genic memory as, for instance, if the patient does not relax
his resistance against it, if he tries to repress or mutilate it
then the defile is, so to speak, blocked. The work is at a stand-
still, nothing more can appear, and the single memory which
is in process of breaking through remains in front of the patient
until he has taken it up into the breadth of his ego. The whole
spatially-extended mass of psychogenic material is in this way
drawn through a narrow cleft and thus arrives in consciousness
cut up, as it were, into pieces or strips. It is the psychotherapist's
business to put these together once more into the organization
which he presumes to have existed. Anyone who has a craving
for further similes may think at this point of a Chinese puzzle.

If we are faced with starting such an analysis, in which we
have reason to expect an organization of pathogenic material
like this, we shall be assisted by what experience has taught

292 IV. PSYCHOTHERAPY OF HYSTERIA (FREUD)

us, namely that it is quite hopeless to try to penetrate directly to the
nucleus of the pathogenic organization. Even if we ourselves could
guess it, the patient would not know what to do with the
explanation offered to him and would not be psychologically
changed by it.

There is nothing for it but to keep at first to the periphery
of the psychical structure. We begin by getting the patient to
tell us what he knows and remembers, while we are at the same
time already directing his attention and overcoming his slighter
resistances by the use of the pressure procedure. Whenever we
have opened a new path by thus pressing on his forehead, we
may expect him to advance some distance without fresh
resistance.

After we have worked in this way for some time, the patient
begins as a rule to co-operate with us. A great number of
reminiscences now occur to him, without our having to ques-
tion him or set him tasks. What we have done is to make a
path to an inner stratum within which the patient now has
spontaneously at his disposal material that has an equal degree
of resistance attaching to it. It is best to allow him for a time
to reproduce such material without being influenced. It is
true that he himself is not in a position to uncover important
connections, but he may be left to clear up material lying
within the same stratum. The things that he brings up in this
way often seem disconnected, but they offer material which
will be given point when a connection is discovered later on.

Here we have in general to guard against two things. If we
interfere with the patient in his reproduction of the ideas that
pour in on him, we may 'bury' things that have to be freed
later with a great deal of trouble. On the other hand we must
not over-estimate the patient's unconscious 'intelligence' and
leave the direction of the whole work to it. If I wanted to give
a diagrammatic picture of our mode of operation, I might
perhaps say that we ourselves undertake the opening up of
inner strata, advancing radially, whereas the patient looks after
the peripheral extension of the work.

Advances are brought about, as we know, by overcoming
resistance in the manner already indicated. But before this,
we have as a rule another task to perform. We must get hold
of a piece of the logical thread, by whose guidance alone we
may hope to penetrate to the interior. We cannot expect that

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 293

the free communications made by the patient, the material
from the most superficial strata, will make it easy for the analyst
to recognize at what points the path leads into the depths or
where he is to find the starting-points of the connections of
thought of which he is in search. On the contrary. This is pre-
cisely what is carefully concealed; the account given by the
patient sounds as if it were complete and self-contained. It is
at first as though we were standing before a wall which shuts
out every prospect and prevents us from having any idea
whether there is anything behind it, and if so, what.

But if we examine with a critical eye the account that the
patient has given us without much trouble or resistance, we shall
quite infallibly discover gaps and imperfections in it. At one
point the train of thought will be visibly interrupted and
patched up by the patient as best he may, with a turn of speech
or an inadequate l explanation; at another point we come
upon a motive which would have to be described as a feeble
one in a normal person. The patient will not recognize these
deficiencies when his attention is drawn to them. But the
physician will be right in looking behind the weak spots for an
approach to the material in the deeper layers and in hoping
that he will discover precisely there the connecting threads for
which he is seeking with the pressure procedure. Accordingly,
we say to the patient: 'You are mistaken; what you are putting
forward can have nothing to do with the present subject. We
must expect to come upon something else here, and this will
occur to you under the pressure of my hand.'

For we may make the same demands for logical connection
and sufficient motivation in a train of thought, even if it ex-
tends into the unconscious, from a hysterical patient as we
should from a normal individual. It is not within the power
of a neurosis to relax these relations. If the chains of ideas in
neurotic and particularly in hysterical patients produce a
different impression, if in them the relative intensity of different
ideas seems inexplicable by psychological determinants alone,
we have already found out the reason for this and can attribute
it to the existence of hidden unconscious motives. We may thus suspect
the presence of such secret motives wherever a breach of this
kind in a train of thought is apparent or when the force ascribed
by the patient to his motives goes far beyond the normal.
1 [In the first edition only, 'a quite inadequate'.]

294 IV. PSYCHOTHERAPY OF HYSTERIA (FREUD)

In carrying out this work we must of course keep free from
the theoretical prejudice that we are dealing with the abnormal
brains of 'degeneres' and * dtsequilibrts\ l who are at liberty, owing
to a stigma, to throw overboard the common psychological
laws that govern the connection of ideas and in whom one
chance idea may become exaggeratedly intense for no motive
and another may remain indestructible for no psychological
reason. Experience shows that the contrary is true of hysteria.
Once we have discovered the concealed motives, which have
often remained unconscious, and have taken them into account,
nothing that is puzzling or contrary to rule remains in hysterical
connections of thought, any more than in normal ones.

In this way, then, by detecting lacunas in the patient's first
description, lacunas which are often covered by 'false con-
nections' [see below, p. 302], we get hold of a piece of the
logical thread at the periphery, and from this point on we clear
a further path by the pressure technique.

In doing this, we very seldom succeed in making our way
right into the interior along one and the same thread. As a rule
it breaks off half-way: the pressure fails and either produces
no result or one that cannot be clarified or carried further in
spite of every effort. We soon learn, when this happens, to avoid
the mistakes into which we might fall. The patient's facial
expression must decide whether we have really come to an
end, or whether this is an instance which requires no psychical
elucidation, or whether what has brought the work to a stand-
still is excessive resistance. In the last case, if we cannot promptly
overcome the resistance we may assume that we have followed
the thread into a stratum which is for the time being still
impenetrable. We drop it and take up another thread, which
we may perhaps follow equally far. When we have arrived at
this stratum along all the threads and have discovered the
entanglements on account of which the separate threads could
not be followed any further in isolation, we can think of
attacking the resistance before us afresh.

It is easy to imagine how complicated a work of this kind
can become. We force our way into the internal strata, over-
coming resistances all the time; we get to know the themes
accumulated in one of these strata and the threads running

1 ['Degenerate' and 'unbalanced* persons. The view then currently
held by French psychopathologists.]

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 295

through it, and we experiment how far we can advance with
our present means and the knowledge we have acquired; we
obtain preliminary information about the contents of the next
strata by means of the pressure technique; we drop threads and
pick them up again; we follow them as far as nodal points;
we are constantly making up arrears; and every time that we
pursue a file of memories we are led to some side-path, which
nevertheless eventually joins up again. By this method we at
last reach a point at which we can stop working in strata and
can penetrate by a main path straight to the nucleus of the
pathogenic organization. With this the struggle is won, though
not yet ended. We must go back and take up the other threads
and exhaust the material. But now the patient helps us ener-
getically. His resistance is for the most part broken.

In these later stages of the work it is of use if we can guess
the way in which things are connected up and tell the patient
before we have uncovered it. If we have guessed right, the
course of the analysis will be accelerated; but even a wrong
hypothesis helps us on, by compelling the patient to take sides
and by enticing him into energetic denials which betray his
undoubted better knowledge.

We learn with astonishment from this that we are not in a
position to force anything on the patient about the things of which he is
ostensibly ignorant or to influence the products of the analysis by arousing
an expectation. I have never once succeeded, by foretelling some-
thing, in altering or falsifying the reproduction of memories
or the connection of events; for if I had, it would inevitably
have been betrayed in the end by some contradiction in the
material. If something turned out as I had foretold, it was
invariably proved by a great number of unimpeachable remin-
iscences that I had done no more than guess right. We need
not be afraid, therefore, of telling the patient what we think his
next connection of thought is going to be. It will do no harm.

Another observation, which is constantly repeated, relates
to the patient's spontaneous reproductions. It may be asserted
that every single reminiscence which emerges during an analysis
of this kind has significance. An intrusion of irrelevant mnemic
images (which happen in some way or other to be associated
with the important ones) in fact never occurs. An exception
which does not contradict this rule may be postulated for
memories which, unimportant in themselves, are nevertheless

296 IV. PSYCHOTHERAPY OF HYSTERIA (FREUD)

indispensable as a bridge, in the sense that the association be-
tween two important memories can only be made through
them.

The length of time during which a memory remains in the
narrow defile in front of the patient's consciousness is, as has
already been explained [p. 291], in direct proportion to its
importance. A picture which refuses to disappear is one which
still calls for consideration, a thought which cannot be dis-
missed is one that needs to be pursued further. Moreover, a
recollection never returns a second time once it has been dealt
with; an image that has been 'talked away' is not seen again.
If nevertheless this does happen we can confidently assume
that the second time the image will be accompanied by a new
set of thoughts, or the idea will have new implications. In
other words, they have not been completely dealt with. Again,
it frequently happens that an image or thought will re-appear
in different degrees of intensity, first as a hint and later with
complete clarity. This, however, does not contradict what I
have just asserted.

Among the tasks presented by analysis is that of getting rid
of symptoms which are capable of increasing in intensity or of
returning: pains, symptoms (such as vomiting) which are due
to stimuli, sensations or contractures. While we are working
at one of these symptoms we come across the interesting and
not undesired phenomenon of 'joining in the conversation'. 1
The problematical symptom re-appears, or appears with greater
intensity, as soon as we reach the region of the pathogenic
organization which contains the symptom's aetiology, and
thenceforward it accompanies the work with characteristic
oscillations which are instructive to the physician. The intensity
of the symptom (let us take for instance a desire to vomit)
increases the deeper we penetrate into one of the relevant
pathogenic memories; it reaches its climax shortly before the
patient gives utterance to that memory; and when he has
finished doing so it suddenly diminishes or even vanishes com-
pletely for a time. If, owing to resistance, the patient delays
his telling for a long time, the tension of the sensation of the
desire to vomit becomes unbearable, and if we cannot force
him to speak he actually begins to vomit. In this way we obtain

1 [An example of this will be found in the case history of Fraulein
Elisabeth von R. (p. 148). It is also mentioned by Breuer on p. 37.]

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 297

a plastic impression of the fact that Vomiting' takes the place
of a psychical act (in this instance, the act of utterance), exactly
as the conversion theory of hysteria maintains.

This oscillation in intensity on the part of the hysterical
symptom is then repeated every time we approach a fresh
memory which is pathogenic in respect of it. The symptom, we
might say, is on the agenda all the time. If we are obliged
temporarily to drop the thread to which this symptom is
attached, the symptom, too, retires into obscurity, to emerge
once more at a later period of the analysis. This performance
goes on until the working-over of the pathogenic material dis-
poses of the symptom once and for all.

In all this, strictly speaking, the hysterical symptom is not
behaving in any way differently from the memory-picture or
the reproduced thought which we conjure up under the pressure
of our hand. In both cases we find the same obsessionally
obstinate recurrence in the patient's memory, which has to be
disposed of. The difference lies only in the apparently spon-
taneous emergence of the hysterical symptoms, while, as we
very well remember, we ourselves provoked the scenes and
ideas. In fact, however, there is an uninterrupted series, extend-
ing from the unmodified mnemic residues of affective experiences
and acts of thought to the hysterical symptoms, which are the
mnemic symbols of those experiences and thoughts.

The phenomenon of hysterical symptoms joining in the con-
versation during the analysis involves a practical drawback, to
which we ought to be able to reconcile the patient. It is quite
impossible to effect an analysis of a symptom at a single stretch
or to distribute the intervals in our work so that they fit in
precisely with pauses in the process of dealing with the symptom.
On the contrary, interruptions which are imperatively pres-
cribed by incidental circumstances in the treatment, such as the
lateness of the hour, often occur at the most inconvenient
points, just as one may be approaching a decision or just as a
new topic emerges. Every newspaper reader suffers from the
same drawback in reading the daily instalment of his serial
story, when, immediately after the heroine's decisive speech or
after the shot has rung out, he comes upon the words: 'To be
continued.' In our own case the topic that has been raised but
not dealt with, the symptom that has become temporarily in-
tensified and has not yet been explained, persists in the patient's

298 IV. PSYCHOTHERAPY OF HYSTERIA (FREUD)

mind and may perhaps be more troublesome to him than it
has otherwise been. He ! will simply have to make the best of
this; there is no other way of arranging things. There are
patients who, in the course of an analysis, simply cannot get
free of a topic that has once been raised and who are obsessed
by it in the interval between two treatments; since by them-
selves they cannot take any steps towards getting rid of it, they
suffer more, to begin with, than they did before the treatment.
But even such patients learn in the end to wait for the doctor
and to shift all the interest that they feel in getting rid of the
pathogenic material on to the hours of treatment, after which
they begin to feel freer in the intervals.

The general condition of patients during an analysis of this
kind also deserves notice. For a time it is uninfluenced by the
treatment and continues to be an expression of the factors that
were operative earlier. But after this there comes a moment
when the treatment takes hold of the patient; it grips his
interest, and thenceforward his general condition becomes
more and more dependent on the state of the work. Every
time something new is elucidated or an important stage in the
process of the analysis is reached, the patient, too, feels relieved
and enjoys a foretaste, as it were, of his approaching liberation.
Every time the work halts and confusion threatens, the psychical
burden by which he is oppressed increases; his feeling of un-
happiness and his incapacity for work grow more intense. But
neither of these things happens for more than a short time.
For the analysis proceeds, disdaining to boast because the patient
feels well for the time being and going on its way regardless of
his periods of gloom. We feel glad, in general, when we have
replaced the spontaneous oscillations in his condition by oscilla-
tions which we ourselves have provoked and which we under-
stand, just as we are glad when we see the spontaneous suc-
cession of symptoms replaced by an order of the day which
corresponds to the state of the analysis.

To begin with, the work becomes more obscure and difficult,
as a rule, the deeper we penetrate into the stratified psychical

1 ['Er' ('he') in the first and second editions. '*' ('it', evidently a
misprint) in the third edition. This was changed to 'Man* ('one') in the
1924 edition, perhaps in order to make sense of the Vr'; but the meaning
was now somewhat changed from the original one.]

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 299

structure which I have described above. But once we have
worked our way as far as the nucleus, light dawns and we need
not fear that the patient's general condition will be subject to
any severe periods of gloom. But the reward of our labours, the
cessation of the symptoms, can only be expected when we have
accomplished the complete analysis of every individual symp-
tom; and indeed, if the individual symptoms are intercon-
nected at numerous nodal points, we shall not even be en-
couraged during the work by partial successes. Thanks to the
abundant causal connections, every pathogenic idea which has
not yet been got rid of operates as a motive for the whole of
the products of the neurosis, and it is only with the last word
of the analysis that the whole clinical picture vanishes, just as
happens with memories that are reproduced individually.

If a pathogenic memory or a pathogenic connection which
had formerly been withdrawn from the ego-consciousness is
uncovered by the work of the analysis and introduced into the
ego, we find that the psychical personality which is thus en-
riched has various ways of expressing itself with regard to what
it has acquired. It happens particularly often that, after we have
laboriously forced some piece of knowledge on a patient, he will
declare: 'I've always known that, I could have told you that
before.' Those with some degree of insight recognize afterwards
that this is a piece of self-deception and blame themselves for
being ungrateful. Apart from this, the attitude adopted by the
ego to its new acquisition depends in general on the stratum
of analysis from which that acquisition originates. Things that
belong to the external strata are recognized without difficulty;
they had, indeed, always remained in the ego's possession, and
the only novelty to the ego is their connection with the deeper
strata of pathological material. Things that arc brought to
light from these deeper strata are also recognized and acknow-
ledged, but often only after considerable hesitations and doubts.
Visual memory-images are of course more difficult to disavow
than the memory-traces of mere trains of thought. Not at all
infrequently the patient begins by saying: 'It's possible that I
thought this, but I can't remember having done so.' And it is
not until he has been familiar with the hypothesis for some time
that he comes to recognize it as well; he remembers and
confirms the fact, too, by subsidiary links that he really did
once have the thought. I make it a rule, however, during the

300 IV. PSYCHOTHERAPY OF HYSTERIA (FREUD)

analysis to keep my estimate of the reminiscence that comes up
independent of the patient's acknowledgement of it. I shall
never be tired of repeating that we are bound to accept what-
ever our procedure brings to light. If there is anything in it
that is not genuine or correct, the context will later on tell us
to reject it. But I may say in passing that I have scarcely ever
had occasion to disavow subsequently a reminiscence that has
been provisionally accepted. Whatever has emerged has, in
spite of the most deceptive appearance of being a glaring
contradiction, nevertheless turned out to be correct.

The ideas which are derived from the greatest depth and
which form the nucleus of the pathogenic organization are also
those which are acknowledged as memories by the patient with
greatest difficulty. Even when everything is finished and the
patients have been overborne by the force of logic and have
been convinced by the therapeutic effect accompanying the
emergence of precisely these ideas when, I say, the patients
themselves accept the fact that they thought this or that, they
often add: 'But I can't remember having thought it. 5 It is easy to
come to terms with them by telling them that the thoughts were
unconscious. But how is this state of affairs to be fitted into our
own psychological views? Are we to disregard this withholding
of recognition on the part of patients, when, now that the work
is finished, there is no longer any motive for their doing so?
Or are we to suppose that we are really dealing with thoughts
which never came about, which merely had a possibility of
existing, so that the treatment would lie in the accomplishment
of a psychical act which did not take place at the time? It is
clearly impossible to say anything about this that is, about
the state which the pathogenic material was in before the
analysis until we have arrived at a thorough clarification of
our basic psychological views, especially on the nature of con-
sciousness. It remains, I think, a fact deserving serious con-
sideration that in our analyses we can follow a train of thought
from the conscious into the unconscious (i.e. into something
that is absolutely not recognized as a memory), that we can
trace it from there for some distance through consciousness
once more and that we can see it terminate in the unconscious
again, without this alternation of 'psychical illumination' mak-
ing any change in the train of thought itself, in its logical
consistency and in the interconnection between its various parts.

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 301

Once this train of thought was before me as a whole I should
not be able to guess which part of it was recognized by the
patient as a memory and which was not. I only, as it were, see
the peaks of the train of thought dipping down into the un-
conscious the reverse of what has been asserted of our normal
psychical processes.

I have finally to discuss yet another topic, which plays an
undesirably large part in the carrying out of cathartic analyses
such as these. I have already [p. 281] admitted the possibility
of the pressure technique failing, of its not eliciting any reminis-
cence in spite of every assurance and insistence. If this happens,
I said, there are two possibilities: either, at the point at which
we are investigating, there is really nothing more to be found
and this we can recognize from the complete calmness of the
patient's facial expression; or we have come up against a re-
sistance which can only be overcome later, we are faced by a
new stratum into which we cannot yet penetrate and this,
once more, we can infer from the patient's facial expression,
which is tense and gives evidence of mental effort [p. 294],
But there is yet a third possibility which bears witness equally
to an obstacle, but an external obstacle, and not one inherent
in the material. This happens when the patient's relation to the
physician is disturbed, and it is the worst obstacle that we can
come across. We can, however, reckon on meeting it in every
comparatively serious analysis.

I have already [p. 266] indicated the important part played
by the figure of the physician in creating motives to defeat the
psychical force of resistance. In not a few cases, especially with
women and where it is a question of elucidating erotic trains
of thought, the patient's co-operation becomes a personal
sacrifice, which must be compensated by some substitute for
love. The trouble taken by the physician and his friendliness
have to suffice for such a substitute. If, now, this relation of the
patient to the physician is disturbed, her co-operativeness fails,
too; when the physician tries to investigate the next patho-
logical idea, the patient is held up by an intervening conscious-
ness of the complaints against the physician that have been
accumulating in her. In my experience this obstacle arises in
three principal cases.

(1) If there is a personal estrangement if, for instance, the

302 IV. PSYCHOTHERAPY OF HYSTERIA (FREUD)

patient feels she has been neglected, has been too little appre-
ciated or has been insulted, or if she has heard unfavourable
comments on the physician or the method of treatment. This
is the least serious case. The obstacle can easily be overcome by
discussion and explanation, even though the sensitiveness and
suspiciousness of hysterical patients may occasionally attain
surprising dimensions.

(2) If the patient is seized by a dread of becoming too much
accustomed to the physician personally, of losing her inde-
pendence in relation to him, and even of perhaps becoming
sexually dependent on him. This is a more important case,
because its determinants are less individual. The cause of this
obstacle lies in the special solicitude inherent in the treatment.
The patient then has a new motive for resistance, which is
manifested not only in relation to some particular reminiscence
but at every attempt at treatment. It is quite common for the
patient to complain of a headache when we start on the pressure
procedure; for her new motive for resistance remains as a rule
unconscious and is expressed by the production of a new
hysterical symptom. The headache indicates her dislike of
allowing herself to be influenced.

(3) If the patient is frightened at finding that she is trans-
ferring on to the figure of the physician the distressing ideas
which arise from the content of the analysis. This is a frequent,
and indeed in some analyses a regular, occurrence. Transfer-
ence x on to the physician takes place through a false con-
nection. 2 I must give an example of this. In one of my patients
the origin of a particular hysterical symptom lay in a wish,
which she had had many years earlier and had at once relegated
to the unconscious, that the man she was talking to at the time

1 [This is the first appearance of 'transference' (Ubertragung) in the
psycho-analytic sense, though it is being used much more narrowly here
than in Freud's later writings. For a somewhat different use of the term
see Chapter VII, Section C., of The Interpretation of Dreams (1900a),
Standard Ed., 5, 562 f. Freud next dealt with the subject of 'transfer-
ences' near the end of the last section of the case history of 'Dora'
(1905*), Standard Ed., 7, 1 16 ff.]

2 .[A long account of 'false connections' and the 'compulsion to
associate' will be found above in a footnote on p. 67 f. Freud had
already discussed them in relation to obsessions at the beginning of
Section II of his first paper on 'The Neuro-Psychoses of Defence'
(1894a).]

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 303

might boldly take the initiative and give her a kiss. On one
occasion, at the end of a session, a similar wish came up in her
about me. She was horrified at it, spent a sleepless night, and at
the next session, though she did not refuse to be treated, was
quite useless for work. After I had discovered the obstacle and
removed it, the work proceeded further; and lo and behold!
the wish that had so much frightened the patient made its
appearance as the next of her pathogenic recollections and
the one which was demanded by the immediate logical con-
text. What had happened therefore was this. The content of the
wish had appeared first of all in the patient's consciousness
without any memories of the surrounding circumstances which
would have assigned it to a past time. The wish which was
present was then, owing to the compulsion to associate which
was dominant in her consciousness, linked to my person, with
which the patient was legitimately concerned; and as the result
of this mesalliance which I describe as a 'false connection'
the same affect was provoked which had forced the patient
long before to repudiate this forbidden wish. Since I have
discovered this, I have been able, whenever I have been simi-
larly involved personally, to presume that a transference and a
false connection have once more taken place. Strangely enough,
the patient is deceived afresh every time this is repeated.

It is impossible to carry any analysis to a conclusion unless
we know how to meet the resistance arising in these three ways.
But we can find a way of doing so if we make up our minds
that this new symptom that has been produced on the old model
must be treated in the same way as the old symptoms. Our first
task is to make the 'obstacle' conscious to the patient. In one
of my patients, for instance, the pressure procedure suddenly
failed. I had reason to suppose that there was an unconscious
idea of the kind mentioned under (2) above, and I dealt with
it at the first attempt by taking her by surprise. I told her that
some obstacle must have arisen to continuing the treatment,
but that the pressure procedure had at least the power to show
her what this obstacle was; I pressed on her head, and she said
in astonishment: 'I see you sitting on the chair here; but that's
nonsense. What can it mean?' I was then able to enlighten her.
With another patient the 'obstacle' used not to appear directly
as a result of my pressure, but I was always able to discover
it if I took the patient back to the moment at which it had

304 IV. PSYCHOTHERAPY OF HYSTERIA (FREUD)

originated. The pressure procedure never failed to bring this
moment back for us. When the obstacle had been discovered
and demonstrated the first difficulty was cleared out of the
way. But a greater one remained. It lay in inducing the patient
to produce information where apparently personal relations
were concerned and where the third person coincided with the
figure of the physician.

To begin with I was greatly annoyed at this increase in my
psychological work, till I came to see that the whole process
followed a law; and I then noticed, too, that transference of
this kind brought about no great addition to what I had to do.
For the patient the work remained the same: she had to over-
come the distressing affect aroused by having been able to
entertain such a wish even for a moment; and it seemed to
make no difference to the success of the treatment whether she
made this psychical repudiation the theme of her work in the
historical instance or in the recent one connected with me.
The patients, too, gradually learnt to realize that in these
transferences on to the figure of the physician it was a question
of a compulsion and an illusion which melted away with the
conclusion of the analysis. I believe, however, that if I had
neglected to make the nature of the 'obstacle' clear to them I
should simply have given them a new hysterical symptom
though, it is true, a milder one in exchange for another which
had been generated spontaneously.

I have now given enough indications, I think, of the way in
which these analyses have been carried out and of the observa-
tions that I have made in the course of them. What I have said
may perhaps make some things seem more complicated than
they are. Many problems answer themselves when we find our-
selves engaged in such work. I did not enumerate the difficulties
of the work in order to create an impression that, in view of
the demands a cathartic analysis makes on physician and
patient alike, it is only worth while undertaking one in the
rarest cases. I allow my medical activities to be governed by
the contrary assumption, though I cannot, it is true, lay down
the most definite indications for the application of the thera-
peutic method described in these pages without entering into
an examination of the more important and comprehensive

IV. PSYCHOTHERAPY OF HYSTERIA (FREUD) 305

topic of the treatment of the neuroses in general. I have often
in my own mind compared cathartic psychotherapy with
surgical intervention. I have described my treatments as
psychotherapeutic operations; and I have brought out their
analogy with the opening up of a cavity filled with pus, the
scraping out of a carious region, etc. An analogy of this kind
finds its justification not so much in the removal of what is
pathological as in the establishment of conditions that are more
likely to lead the course of the process in the direction of
recovery.

When I have promised my patients help or improvement by
means of a cathartic treatment I have often been faced by this
objection: 'Why, you tell me yourself that my illness is probably
connected with my circumstances and the events of my life.
You cannot alter these in any way. How do you propose to
help me, then?' And I have been able to make this reply: c No
doubt fate would find it easier than I do to relieve you of your
illness. But you will be able to convince yourself that much will
be gained if we succeed in transforming your hysterical misery
into common unhappiness. With a mental life l that has been
restored to health you will be better armed against that un-
happiness.'

1 [The German editions previous to 1925 read 'nervous system'.]

APPENDIX A
THE CHRONOLOGY OF THE CASE OF FRAU EMMY VON N.

THERE are serious inconsistencies in the dating of the case
history of Frau Emmy von N. as given in all the German
editions of the work and as reproduced in the present transla-
tion. The beginning of Freud's first course of treatment of Frau
Emmy is assigned to May 1889 twice on p. 48. The course
lasted for about seven weeks (pp. 51 n. and 77). Her second
course of treatment began exactly a year after the first (p. 78),
i.e. in May 1890. This course lasted for about eight weeks
(p. 51 n.). Freud visited Frau Emmy on her Baltic estate in the
spring of the following year (p. 83), i.e. of 1891. A first contra-
diction of this chronology appears on p. 85, where the date of
this visit is given as May 1890. This new system of dating is
maintained at later points. On p. ,91 Freud ascribes a symp-
tom that appeared in the second course of treatment to the year
1889 and symptoms that appeared in the first course of treat-
ment twice to the year 1888. He reverts, however, to his
original system on p. 102, where he gives the date of his visit
to the Baltic estate as 1891.

There is one piece of evidence which speaks in favour of
the earlier chronology that is, of assigning Freud's first treat-
ment of Frau Emmy to the year 1888. On p. 101 he remarks
that it was while he was studying this patient's abulias that he
began for the first time to have grave doubts about the validity
of Bernheim's assertion that 'suggestion is everything*. He ex-
pressed these same doubts very forcibly in his preface to his
translation of Bernheim's book on suggestion (Freud, 1888-9),
and we are told in a letter to Fliess of August 29, 1888 (19500,
Letter 5), that he had already completed the preface by that
date. In this letter, too, he writes: 'I do not share Bernheim's
views, which seem to me one-sided.' If Freud's doubts were first
suggested by his treatment of Frau Emmy, that treatment must
therefore have begun in the May of 1888, not 1889.

307

308 APPENDIX A

Incidentally, this correction would clear up an incon-
sistency in the accepted account of some of Freud's activities
after his return from Paris in the spring of 1886. In his Auto-
biographical Study (1925rf, Chapter II) he remarks that when
using hypnotism he 'from the first' employed it not only
for giving therapeutic suggestions but also for the purpose of
tracing back the history of the symptom from the first, that
is, he made use of Breuer's cathartic method. We learn from a
letter to Fliess of December 28, 1887 (19500, Letter 2), that it
was towards the end of that year that he first took up hypnotism;
while on pp. 48 and 284 of the present volume he tells us that
the case of Frau Emmy was the first in which he attempted to
handle Breuer's technical procedure. If, therefore, that case
dates from May 1889, there was an interval of at least sixteen
months between the two events, and, as Dr. Ernest Jones re-
marks (in Vol. I of his biography, 1953, 263), Freud's memory
was scarcely accurate when he used the phrase 'from the first'.
If however the date of Frau Emmy's treatment were brought
forward to May 1888, the gap would be reduced to only some
four or five months.

It would have clinched the matter if it could have been
shown that Freud was absent from Vienna for a period long
enough to cover a visit to Livonia (or whatever country that
may have represented) during the month of May either of 1890
or of 1891. But unfortunately his extant letters from those
periods afford no evidence of any such absence.

The matter is made still more obscure by yet another in-
consistency. In a footnote on p. 61 Freud comments on the over-
efficiency of some of his suggestions m^de during the first
period of treatment (actually on May 11, 1888 or 1889). The
amnesia which he then produced was, he says, still operative
'eighteen months later'. This certainly refers to the time of his
visit to Frau Emmy's country estate, for, in his account of that
visit, he mentions the episode once more (p. 84). There, how-
ever, he speaks of the original suggestions as having been made
'two years previously'. If the visit to the estate was in May 1890
or 1891, the 'two years' must be correct and the 'eighteen
months* must have been a slip.

But these repeated contradictions suggest a further possi-
bility. There is reason to believe that Freud altered the place
of Frau Emmy's residence. Can it be that, as an extra pre-

APPENDIX A 309

caution against betraying his patient's identity, he altered the
time of the treatment as well, but failed to carry the changes
through consistently? l The whole problem must remain an
open one.

1 Cf. Freud's explanation in Chapter X of The Psychpathology of
Everyday Life (19016) of some of his own unnoticed slips in his Inter-
pretation of Dreams. He accounted for these as unconscious retaliations
for suppressions and distortions deliberately made by him in the
material.

APPENDIX B

LIST OF WRITINGS BY FREUD DEALING PRINCIPALLY
WITH CONVERSION HYSTERIA

[In the following list, the date at the beginning of each entry is that
of the year during which the work in question was probably written.
The date at the end is that of publication; and under that date fuller
particulars of the work will be found in the Bibliography and Author
Index. The items in square brackets were published posthumously .]

1886 'Observation of a Pronounced Hemi- Anaesthesia in a

Hysterical Male.' (1886rf)

1888 'Hysteria' in Villaret's Handworterbuch. (18886)
[1892 'A Letter to Josef Breuer.' (1941*) ]
[1892 'On the Theory of Hysterical Attacks.' (With Breuer.)

(194CW) ]

[1892 'Memorandum "III".' (19416) ]
1892 'A Case of Successful Treatment by Hypnotism.'
(1892-36)

1892 'On the Psychical Mechanism of Hysterical Pheno-

mena: A Preliminary Communication.' (With
Breuer.) (18930)

1893 Lecture 'On the Psychical Mechanism of Hysterical

Phenomena.' (1893A)

1893 'Some Points for a Comparative Study of Organic and

Hysterical Motor Paralyses.' (1893*;)

1894 'The Neuro- Psychoses of Defence', Section I. ( 18940)

1895 Studies on Hysteria. (With Breuer.) (1895<f)

[1895 'Project for a Scientific Psychology', Part II. (19500) ]
[1896 'Draft K.', Last Section. (19500) ]

1896 'Further Remarks on the Neuro- Psychoses of Defence.'

(18966)

1896 'The Aetiology of Hysteria.' (1896c)
1901-5 'Fragment of an Analysis of a Case of Hysteria.'

(1905*)

1908 'Hysterical Phantasies and their Relation to Bisexu-
ality.' (19080)

310

APPENDIX B 311

1909 'Some General Remarks on Hysterical Attacks.' ( 1 909a)

1909 Five Lectures on Psycho-Analysis, Lectures I and II.

(1910a)

1910 'The Psycho-Analytic View of Psychogenic Disturbance

of Vision.' (1910i)

BIBLIOGRAPHY
AND AUTHOR INDEX

[Titles of books and periodicals are in italics; titles of papers are in
inverted commas. Abbreviations are in accordance with the World List
of Scientific Periodicals (London, 1952). Further abbreviations used in this
volume will be found in the List at the end of this bibliography.
Numerals in thick type refer to volumes; ordinary numerals refer to
pages. The figures in round brackets at the end of each entry indicate
the page or pages of this volume on which the work in question is men-
tioned. In the case of the Freud entries, the letters attached to the dates
of publication are in accordance with the corresponding entries in the
complete bibliography of Freud's writings to be included in the last
volume of the Standard Edition.

For non-technical authors, and for technical authors where no
specific work is mentioned, see the General Index.]

BENEDICT, M. (1894) Hypnotismus und Suggestion, Vienna. (210)
BERGER, A. VON (1896) Review of Breuer and Freud's Studien uber

Hysterie, Neue Freie Presse, Feb. 2. (xv)
BERNHEIM, H. (1886) De la suggestion et de ses applications a la therapeutique,

Paris, (xi, 67, 77)
(1891) Hypnotisme, suggestion et psychothtrapie: etudes nouvelles, Paris.

(xi)

BINET, A. (1892) Les alterations de la personnalite, Paris. (7)
BREUER, J., and FREUD, S. (1893) See FREUD, S. (1893a)

(1895) See FREUD, S. (1895<f)
(1940) See FREUD, S. (1940</)

CABANIS, P. J. G. (1824) Rapports du physique et du moral de I'homme,

(Euvres completes, Paris, 3, 153. (195-6)
CHARCOT, J.-M. (1887) Leqons sur les maladies du systtme nerveux, III, Paris.

(13, 15, 16)

(1888) Leqons du mardi a la Salpetriere (1887-8), Paris. (134)
CLARKE, MICHELL (1894) Review of Breuer and Freud's 'tJber den

psychischen Mechanismus hysterischer Phanomene', Brain, 17,

125. (xv)

(1896) Review of Breuer and Freud's Studien uber Hysterie, Brain,
19,401. (xv)

DARWIN, C. (1872) The Expression of the Emotions in Man and Animals,

London. (91, 181)

DELBGEF, J. R. L. (1889) Le magnetisme animal, Paris. (7)
EXNER, S. (1894) Entwurf zu einer physiologischen Erkldrung der psychischen

Erscheinungen, Vienna. (193, 195, 241)

FERENCZI, S. (1921) Tsychoanalytische Betrachtungen liber den Tic',
Int. . Psychoan., 7, 33. (93)

313

314 BIBLIOGRAPHY

[Trans.: ' Psycho- Analytical Observations on Tic', Chapter 12 of

Further Contributions to the Theory and Technique of Psycho- Analysis,

London, 1926.]

FISHER, J. (1955) Bird Recognition III, Penguin Books. (49)
FREUD, S. (18860 1 ) 'Beobachtung einer hochgradigen Hemianasthesie

bei einem hysterischen Marine (Beitrage zur Kasuistik der

Hysteric I)', Wien. med. Wschr., 36, Nr. 49, 1633. (310)
(1887) Review of S. Weir Mitchell's Die Behandlung gewisser Formen

von Neurasthenie und Hysterie, Berlin 1887 (Translated G. Klem-

perer), Wien. med. Wschr., 37, Nr. 5, 138. (267)
(1888) 'Hysteric' in Villaret's Handworterbuch der gesamten Medizin,

1, Stuttgart. (310)
(1888-9) Translation with Introduction and Notes of H. Bern-

heim's De la suggestion et de ses applications a la therapeutique, Paris,

1886, under the title Die Suggestion und ihre Heilwirkung, Vienna.

(xi, xxiii, 77, 228, 307)

[Trans.: Introduction to Bernheim's Die Suggestion und ihre

Heilwirkung, C.P., 5, 11; Standard Ed., 1.]
(1891) ur Auffassung der Aphasien, Vienna. (1 12, 212)

[Trans.: On Aphasia, London and New York, 1953.]
(1892a) Translation of H. Bernheim's Hypnotisme, suggestion et

psychotherapie: etudes nouvelles, Paris, 1891, under the title Neue

Studien iiber Hypnotismus, Suggestion und Psychotherapie, Vienna, (xi)
(1892-30) Translation with Preface and Footnotes of J.-M.

Charcot's Lemons du mardi (1887-8], Paris, 1888, under the title

Poliklinische Vortrdge, 1, Vienna, (xiii)

[Trans.: Preface and Footnotes to Charcot's Poliklinische Vortrdge,

I, Standard Ed., 1.]
(1892-36) 'Ein Fall von hypnotischer Heilung nebst Bemerkungen

iiber die Entstehung hysterischer Symptome durch den "Gegen-

willen" ', G.S., 1, 258; G.W., 1, 3. (5, 91-2, 105, 310)

[Trans.: 'A Case of Successful Treatment by Hypnotism', C.P.,

Substandard Ed., 1.]
(18930) With BREUER, J., 't)ber den psychischen Mechanismus

hysterischer Phanomene: Vorlaufige Mitteilung', G.S., 1, 7;

G.W., 1,81.

[Trans.: 'On the Psychical Mechanism of Hysterical Phenomena:

Preliminary Communication', C.P., 1, 24; Standard Ed., 2, 3.]
(1893^) 'Quelques considerations pour une etude comparative des

paralysies motrices organiques et hysteriques' [in French], G.S.,

1, 273; G.W., 1, 39. (xxiii, 45, 89, 213, 310)

[Trans.: 'Some Points for a Comparative Study of Organic and

Hysterical Motor Paralyses', C.P., 1, 42; Standard Ed., 1.]
(1893A) Vortrag 'Uber den psychischen Mechanismus hysterisrher
' Phanomene' [shorthand report revised by lecturer], Wien. med.

Pr., 34, Nr. 4, 121 and 5, 165. (xiv, xix, xx, 197, 310)

[Trans.: Lecture 'On the Psychical Mechanism of Hysterical

Phenomena', Int. J. Psycho-Anal, 37; Standard Ed., 3.]
(18940) 'Die Abwehr-Neuropsychosen', G.S., 1, 290; G.W., 1, 59.

BIBLIOGRAPHY 315

(xix, xxiii, xxiv, xxv, 10, 48, 69, 86, 90, 123, 147, 211, 214, 257,

269, 302, 310)

[Trans.: 'The Neuro-Psychoses of Defence', C.P., 1, 59; Standard

Ed., 3.]
(18956) 'Ober die Berechtigung, von der Neurasthenic einen

bestimmten Symptomenkomplex als "Angstneurose" abzutren-

nen', G.S., 1, 306; G.W., 1, 315. (xxiii, xxiv, 10, 88, 127, 210,

246, 257, 258)

[Trans.: 'On the Grounds for Detaching a Particular Syndrome

from Neurasthenia under the Description "Anxiety Neurosis'* ',

C.P., 1 , 76; Standard Ed., 3.]
(1895c) 'Obsessions et phobies' [in French], G.S., 1, 334; G.W., 1,

345. (69)

[Trans.: 'Obsessions and Phobias', C.P., 1, 128; Standard Ed., 3.]
( 18950") With BREUER, J., Studien uber Hysterie, Vienna. G.S., 1 ;

G.W., 1, 99. Omitting Breuer's contributions.

[Trans.: Studies on Hysteria, Standard Ed., 2.]
(1895/) 'Zur Kritik der "Angstneurose" ', G.S., 1, 343; G.W., 1,

357. (xxiv)

[Trans.: 'A Reply to Criticisms of my Paper on Anxiety Neurosis',

C.P., 1, 107; Standard Ed., 3.]
(18960) 'L'heredite et 1'etiologie des nevroses' [in French], G.S., 1,

388; G.W., 1,407. (48)

[Trans.: 'Heredity and the Aetiology of the Neuroses', C.P., 1,

138; Standard Ed., 3.]
(18966) 'Weitere Bemerkungen iiber dio Abwehr-Neuropsychosen',

G.S., 1, 363; G.W., 1, 379. (xxiv, 10, 122, 133, 310)

[Trans.: 'Further Remarks on the Neuro-Psychoses of Defence',

C.P., 1, 155; Standard Ed., 3.]
(1896V) 'Zur Atiologie der Hysteric', G.S., 1, 4O4; G.W., 1, 425.

(xxv, 310)

[Trans.: 'The Aetiology of Hysteria', C.P., 1, 183; Standard Ed.,

3.]
(1898a) 'Die Sexualitat in der Atiologie der Neurosen', G.S., 1,

439; G.W., 1,491. (88)

[Trans.: 'Sexuality in the Aetiology of the Neuroses', C.P., 1,

22$', Standard Ed., 3.]
(1900a) Die Traumdeutung, Vienna. G.S., 2-3; G.W., 2-3. (xxvii,

70, 110, 175, 189, 194, 271, 302, 309)

[Trans.: The Interpretation of Dreams, London and New York,

1955; Standard Ed., 4-5.]
(19016) Zur Psychopathologie des Alltagslebens, Berlin, 1904. G.S., 4;

G.W., 4. (xxvii, 309)

[Trans.: The Psychopathology of Everyday Life, Standard Ed., 6.]
(19040) 'Die Freud'sche psychoanalytische Methode', G.S., 6, 3;

G.W., 5,3. (110)

[Trans.: 'Freud's Psycho-Analytic Procedure', C.P., 1, 264;

Standard Ed., 7,249.]
(19050) 't)ber Psychotherapie', G.S., 6, 1 1 ; G.W., 5, 13. (1 11)

316 BIBLIOGRAPHY

[Trans.: 'On Psychotherapy 1 , C.P., 1,249; Standard Ed., 7 , 257.]
(1905r) Der Witz und seine Beziehung zum Unbewussten, Vienna.

G.S., 9, 5; G.W., 6. (xxiv, xxvii)

[Trans.: Jokes and their Relation to the Unconscious, Standard Ed.,

8.]
(1905</) Drei Abhandlungen zur Sexualtheorie, Vienna. G.S., 5, 3;

G.W., 5,29. (xxvii, 21, 133)

[Trans.: Three Essays on the Theory of Sexuality, London, 1949;

Standard Ed., 7, 125.]
(19050 'Bruchstiick einer Hysteric- Analyse', G.S., 8, 3; G.W., 5,

163. (xxv, 166, 247, 302, 310)

[Trans.: 'Fragment of an Analysis of a Case of Hysteria', C.P.,

3, IS; Standard Ed., 7,3.]
(1908a) 'Hysterische Phantasien und ihre Beziehung zur Bisexuali-

tat', G.S., 5, 246; G.W., 7, 191. (310)

[Trans.: 'Hysterical Phantasies and their Relation to Bi-

sexuality', C.P., 2, 51; Standard Ed., 9.]
(1909a) 'Allgemeines iiber den hysterischen Anfall', G.S., 5,

255; G.W., 7,235. (17,311)

[Trans.: 'Some General Remarks on Hysterical Attacks', C.P., 2,

IW; Standard Ed., 9.]
(1909) 'Analyse der Phobic eines fiinfjahrigen Knaben', G.S., 8,

129; G.W., 7,243. (257)

[Trans.: 'Analysis of a Phobia in a Five-Year-Old Boy', C.P., 3,

149; Standard Ed., 10,3.]
(19100) Uber Psychoanalyse, Vienna. G.S., 4, 349; G.W., 8, 3. (xxvi,

xxvii, 47, 90, 105, 181,311)

[Trans.: Five Lectures on Psycho- Analysis, Am. J. Psychol., 21 (1910),

IBl; Standard Ed., 11.]
(1910t) 'Die psychogene Sehstorung in psychoanalytischer Aufias-

sung', G.S., 5, 301; G.W., 8, 94. (311)

[Trans.: 'The Psycho- Analytic View of Psychogenic Disturbance

of Vision', C.P., 2, 105; Standard Ed., 11.]
(1910*) 'Uber "wilde" Psychoanalyse', G.S., 6, 37; G.W., 8, 118.

(257)

[Trans.: ' "Wild" Psycho- Analysis', C.P., 2, 297; Standard Ed.,

11.]
(1912/) 'Zur Onanie-Diskussion', G.S., 3, 324; G.W., 8, 332. (258)

[Trans.: 'Contributions to a Discussion of Masturbation',

Standard Ed., 12.]
(1913A) 'Erfahrungen und Beispiele aus der analytischen Praxis',

Int. %. Psychoan., 1, 377. Partly reprinted G.S., 11, 301; G.W.,

10, 40. Partly included in Die Traumdeutung, G.S., 3, 41, 71f.,

127 and 135; G.W., 2-3, 238, 359ff., 413f. and 433. (41)
. [Trans.: 'Observations and Examples from Analytic Practice',

Standard Ed., 13, 193 (in full); also partly incorporated in The

Interpretation of Dreams, Standard Ed., 4, 232 and 5, 409f.]
(1914c) 'Zur Einfiihrung des Narzissmus', G.S., 6, 155; G.W., 10,

138. (258)

BIBLIOGRAPHY 317

[Trans.: 'On Narcissism: an Introduction', C.P., 4, 30; Standard

Ed., 14.]
(1914<f) 'Zur Geschichtc dcr psychoanalytischen Bewegung', G.S.,

4, 411; G.W., 10, 44. (xxi, xxvii, 41, 206, 231)

[Trans.: 'On the History of the Psycho- Analytic Movement',

C.P., 1, 287; Standard Ed., 14.]
(1915c) 'Triebe und Triebschicksale', G.S., 5, 443; G.W., 10, 210.

(xix)

[Trans.: 'Instincts and their Vicissitudes', C.P., 4, 60; Standard

Ed., 14.]
091 5d) 'Die Verdrangung', G.S., 5, 466; G.W., 10, 248. (135)

[Trans.: 'Repression', C.P., 4, 84; Standard Ed., 14.]
(19150 'Das Unbewusste', G.S., 5, 480; G.W., 10, 264. (xxvii, 45,

194,212)

[Trans.: 'The Unconscious', C.P., 4, 98; Standard Ed., 14.]
(19160 Footnote to Ernest Jones's 'Professor Janet iiber Psycho-
analyse', Int. . Psychoan., 4, 42. (xiii)

[Trans.: Standard Ed., 2, xiii]
(19170 'Trauer und Melancholic', G.S., 5,535; G.H^.,10,428. (162)

[Trans.: 'Mourning and Melancholia', C.P., 4, 152; Standard Ed.,

14.]
(1920^) Jenseits des Lustprinzips, Vienna. G.S., 6, 191; G.W., 13, 3.

(xix-xx, xxi, xxvii, 189, 194)

[Trans.: Beyond the Pleasure Principle, London, 1950; Standard Ed.,

18,7.]
(19210 Massenpsychologie und Ich- Analyse, Vienna. G.S., 6, 261;

G.W., 13, 73. (271)

[Trans.: Group Psychology and the Analysis of the Ego, London; 1922;

New York, 1940; Standard Ed., 18, 69.]
(1923fl) ' "Psychoanalyse" und "Libido Theorie" ', G.S., 11, 201;

G.S., 13,211. (xxvii)

[Trans.: 'Two Encyclopaedia Articles', C.P., 5, 107; Standard Ed.,

18, 235.]

(1924/) 'A Short Account of Psycho- Analysis' [published as 'Psycho-
analysis: Exploring the Hidden Recesses of the Mind'], Chap. 73,

Vol. 2 of Tfoj* Eventful Tears, London and New York; Standard

Ed., 19. (xxvii)

[German Text: 'Kurzer Abriss der Psychoanalyse', G.S., 11, 183;

G.W., 13, 405. German original first appeared in 1928.]
(1925a) 'Notiz uber den "Wunderblock" ', G.S., 6, 415; G.W.,

14, 3. (189)

[Trans.: 'A Note upon the "Mystic Writing-Pad" ', C.P., 5, 175;

Standard Ed., 19.]
(1925rf) Selbstdarstellung, Vienna. G.S., 11, 119; G.W., 14, 33.

(xi, xxii, xxv, xxviii, 21, 41, 308)

[Trans.: An Autobiographical Study, London, 1935 (Autobiography,

New York, 1935); Standard Ed., 20.]
(1925$) 'Josef Breuer', G.S., 11, 281; G.W., 14, 562. (xxviii)

[Trans.: Int. J. Psycho-Anal., 6, 459; Standard Ed., 19.]

318 BIBLIOGRAPHY

(1925/i) 'Die Vcrneinung', G.S., 11,3; G.W., 14, 11. (76)

[Trans.: 'Negation', C.P., 5, 181; Standard Ed., 19.]
(1940</) With BREUER, J., 'Zur Theorie des hysterischen Anfalls',

G.W., 17, 9. (xiii, xix, 10, 17, 45, 197, 310)

[Trans.: 'On the Theory of Hysterical Attacks', C.P., 5, 27;

Standard Ed., 1.]
(19410) Letter to Josef Breuer, G.H^., 17, 5. (xiii, xix, xxiii, 197,

310)

[Trans.: C.P., 5, 25; Standard Ed., 1.]
(1941) 'Notiz "III" ', G.W., 17, 17. (xiv, xxv, 13, 310)

[Trans.: 'Memorandum "III" ', C.P., 5, 31; Standard Ed., 1.]
(1950a) Aus den Anfdngen der Psychoanalyse, London. Includes

'Entwurf einer Psychologic' (1895). (xi, xiii, xiv, xv, xix, xxiii,

xxiv, xxvi, 8, 86, 110-11, 122, 127, 133, 189, 194, 197, 307, 308,

310)

[Trans.: The Origins of Psycho- Analysis, London and New York,

1954. (Partly, including 'A Project for a Scientific Psychology',

in Standard Ed., 1.)]

HARTMANN, E. VON (1869) Philosophie des Unbewussten, Berlin. (45)
HECKER, E. (1893) '(Jber larvirte und abortive Angstzustande bci

Neurasthenic', %bl. Nervenheilk., 16, 565. (258)

HERBART, J. F. (1824) Psychologic als Wissenschaft, Konigsberg. (xxii)
JANET, PIERRE (1889) Lautomatisme psychologique, Paris, (xiii, 7)

(1893) 'Quelques definitions recentes de I'hysterie', Arch. neuroL,
25, No. 76, 417 and 26, No. 77, 1. (xiv, 230)

(1894) tat mental des hysteriques, Paris, (xiv, 104, 196, 230)
(1913) 'Psycho- Analysis. Rapport par M. le Dr. Pierre Janet', Int.

Congr. Med., 17, Section XII (Psychiatry) (1), 13. (xii)
JONES, ERNEST (1915) 'Professor Janet on Psycho- Analysis; a Rejoinder',

J. abnorm. (soc.) Psychol., 9, 400. (xii)

[German trans.: 'Professor Janet iiber Psychoanalyse', Int. .

Psychoan., 4 (1916), 34.] (xii)
(1953) Sigmund Freud: Life and Work, Vol. 1, London and New

York, (x, xxi, xxii, 41, 308)
LANGE, C. G. (1885) Om Sindsbevaegelser, et Psyko-Fysiologisk Studie,

Copenhagen. (201)
MACH, E. (1875) Grundlinien der Lehre von den Bewegungsempfindungen,

Leipzig. (210)
MOEBIUS, P. J. (1888) 'tJber den Begriffder Hysteric', %bl. Nervenheilk.,

11,66. (186)

(1894) 't)ber Astasie-Abasie', in Neurologische Beitrdge I, Leipzig.
(215,220)

(1895) 't)ber die gegenwartige Auffassung der Hysteric', Mschr.
Geburtsh. Gyndk., 1, 12. (249)

MYERS, F. W. H. (1893) 'The Mechanism of Hysteria (The Subliminal

Consciousness, VI)', Proc. Soc. psych. Res., Lond., 9, 3. (xv)
(1903) Human Personality and its Survival of Bodily Death, London and
New York, (xv)

OPPENHEIM, H. (1890) 'Thatsachliches und Hypothetisches ubcr das

BIBLIOGRAPHY 319

Wescn der Hysteric', Berl. klin. Wschr., 27, 553. (191, 203, 242,

245)

PITRES, A. (1891) Leqons diniques sur Vhysterie et /' 'hypnotism , Paris. (177)
ROMBERG, M. H. (1840) Lehrbuch der Nervenkrankheiten des Menschen,

Berlin. (220)
SCHOPENHAUER, A. (1844) Die Welt als Wille und Vorstellung (2nd ed.),

Leipzig, (xxii)
STAOMPELL, A. VON (1892) Ober die Entstehung und die Heilung von Krank-

heiten durch Vorstellungen, Erlangen. (245)
(1896) Review of Breuer and Freud's Studien uber Hysterie, Dtsch.

Z. Nervenheilk., 8, 159. (xv)
WESTPHAL, C. F. O. (1877) 'Uber Zwangsvorstellungen', Berl. klin.

Wschr., 14, 669 and 687. (256)

LIST OF ABBREVIATIONS

G.S. = Freud, Gesammelte Schnften (12 vols.), Vienna, 1924-34

G.W. = Freud, Gesammelte Werke (18 vols.), London, from 1940

C.P. = Freud, Collected Papers (5 vols.), London, 1924-50

Standard Ed. = Freud, Standard Edition (24 vols.), London, from 1953
S.K.S.N. = Freud, Sammlung kleiner Schnften zur Neurosenlehre (5 vols.) ,

Vienna, 1906-22
S.P.H. = Selected Papers on Hysteria and Other Psychoneuroses, New

York, 1909-20

321

GENERAL INDEX

This index includes the names of non-technical authors. It also includes
the names of technical authors where no reference is made in the text to
specific works. For references to specific technical works, the Bibliography
should be consulted. The compilation of the index was undertaken by
Mrs. R. S. Partridge.

Abasia, 144, 150-3, 166, 176
Abbazia, 50, 59, 65-6
Abreaction, xiii-xiv, xix-xx, 8-11,
15, 17, 86, 162, 192, 205, 224,
255

origin of term, xxii, 8 n.
postponed, 162-4
under cathartic therapy, 101, 148,

157-9, 163, 171,256
Absence of mind, 218, 232-4
'Absences' (Anna 0.), 24, 26-9, 31-2,

34, 36, 39,42-3,217,238
Abulias, 87-90, 101, 307
Acoustic (see Auditory)
Actual neuroses, xxiv, 86, 88 n. 2,

258 n.
Adolescence (see also Puberty), 94 n.,

134,210,240,244
Affect

and association of ideas, 165,

201-2, 205, 208-9, 214, 234
asthenic, 202
conflicting, 115-16
conversion of, 146-7, 164-6,
173-5, 188, 203, 211-14, 217,
224-5, 245-7, 285
discharge of (see also Abreaction),
xviii-xx, 8-9, 15, 42, 101,
201-8, 224-5

displacement of, 69 n.-70 n.
in hypnoid states, 217-20, 232-8,

250
in terms of cerebral excitation,

199-202,215

memory and, 8-12, 15, 122-3,

173-4, 205-6, 213-14, 226, 297

quota of, xxiii, 166, 213-14,

223-4

recollection accompanied by, and
disappearance of symptoms,
xix, 6-7, 221, 224, 232, 255,
283

resistance *robs an idea' of,
279-80

sexual, 12, 200-1, 234, 245-8

sthenic, 201-2

strangulated, xviii, xx, 1 7, 89-90,

162, 174,255
trauma and, 6, 1 1-13, 86-90, 128,

211,213

Aggressiveness, 201, 246
Agoraphobia, 112 n.
Allo-hypnosis, 186, 239
Alois, 127-8
Amaurosis, 100 n.
Amblyopia, 35

Amnesia (see also Ecmnesia; Para-
mnesia), xvii, 12, 17, 25, 42,
61 n., 214, 216, 220, 234-6, 255,
308
Anaesthesia, 218

hysterical, 4-5, 7, 12, 23, 26, 35,
38, 42, 64, 69, 72, 75-6, 85,
190, 242, 259, 261
hcmi-, 5, 190, 230, 235, 237-8
Analgesia, hysterical, 100 n., 106,

190,242
Analogies

building of several storeys, 244-5
buried city, 139
Chinese puzzle, 291
crystallization, 264
defile of consciousness, 291, 2%
double flowers (hysterics), 240
eggs of the sea-urchin, 41
electric lighting system, 193-5,

198-9, 203-4, 207 n.
foreign body in living tissue, 6,

221, 290-1

infectious disease, 263-4
Knight's move, 289
medieval monk and finger of God,

65-6
opera prince disguised as beggar,

279

pictographic script, 129
pulmonary phthisis, 187
serial story, 297-8

323

324

GENERAL INDEX

Analogies (cent.)

sounding-board and tuning-fork,

237-8
stratified structure, 288-95, 298-

301

surgical operation, 305
telephone wire, 193
Titans, 229
unlocking a door, 283
wall, 293
Analogy, Moebius* 'inference by',

186-7

Analysis (see Psycho-Analysis)
Andersen, Hans, 29
Anger, 14, 27, 201-2, 205, 215, 224,

236, 246
Animals, 196-7, 200-1

fear of, 14, 51-3, 55-8, 62-4, 66,

72-4, 78-9, 87, 99
hallucinations of, 51-3, 56, 62-4,

72-4,78

Anna 0., Frdulein, x-xi, xvii, xxvii-
xxviii, 4-5, 7, 9, 21-48, 186,
208, 210, 214n.2, 216-19,
225, 229 n. 1, 233-7, 249, 259,
264, 285-6, 288
Anniversaries, 163, 164 n.
Anorexia, 4, 23, 26-8, 31, 39, 80-3,

89-90, 212

Antithetic ideas, 91-3, 95
Anxiety, 6, 92, 201-2, 246-7
as hysterical symptom, 24-32, 39,
42-3, 49, 62, 66, 67 n. 1, 87-9,
134, 210

in hypnoid states, 215, 217-19, 235
sexual abstinence and, 11, 65 n.,

88, 103, 249, 260
virginal, 127, 134, 260

Anxiety attacks, 27, 126, 127 n. 1,

132

Anxiety hysteria, 257 n.
Anxiety neurosis, xxiv, 65 n., 112 n.,

136 n., 246, 258-61
Aphasia, 111-12
Arousal, 196
Arthralgia, 190, 241
Associate, compulsion to, 69 n., 96,

302 n. 2, 303-4
Association, free, xviii, 56 n.
Association

ideas excluded from, 11-12, 15,

89, 116, 128, 146, 165-7, 209-
210,214,216,269-72,287

in dreams, 193

of ideas, xviii, 9, 15, 17, 165, 198,

201-2, 205, 208-9, 214, 225,

230, 234, 237, 239, 255, 270-2

through simultaneity, 71 n., 115-

116, 118-20, 174-9,208-9
Astasia, 150-2, 166, 176
Asthma, 241
Athetosis, 49
Attention

concentration of, 190, 195, 214,

219,230, 241
facilitation of, 241
of patient, in psychotherapy, 265,

271, 292

'Attitudes passionnelles\ 13-14
Auditory

disturbances in hysteria, 24, 35-7,

39, 286

hallucination, 191
Aura, hysterical, 126, 180
Auto-hypnosis (see also Hypnoid
states), 7, 11, 29, 39, 42, 44,
139, 186, 215-20, 235-6, 239,
243, 247-8
Axones, 194n.

'Belle indifference 1 of hysterics, 135
Benedikt, M. (see also Bibliography),

In. 3

Berlin, xiv
Bernheim, H. (see also Bibliography),

xi-xii, 101, 108-10, 228 n., 268,

307
Binct, A. (see also Bibliography),

In. 1, 12, 190,227,229,249
Bismark, 202

'Blindness of the seeing eye', 1 1 7 n.
Blushing, 191,220,241
Boredom, 197, 240, 242
Born, Bertrand de, 238
'Bound* and 'free' psychical energy,

xxiii, xxvii, 194 n.
Braut von Messina, die (Schiller) ,

206 n.

Brain (see Intra-cerebral excitation)
Breuer, Josef (see also Bibliography)
and Anna 0., x-xi, xvii, 40 n.,

259, 264, 285, 288
and Frau Cddlie M., xii, 178,

181 n.
and Frau Emmy von JV., 54-5, 65,

77-8, 80, 103
and the cathartic method, 48, 93,

256, 266-7, 308

GENERAL INDEX

325

Breuer, Josef, collaboration with

Freud, x-xxviii, 3 ., 45 n, 129,

178, 189 n., 194 n., 206 n.

211 ., 2, 285

differences with Freud, xiv, xxi-

xxii, xxv-xxviii
Freud's obituary of, xxviii
Bru'cke, Ernst, xxii
Burying alive, fear of, 88

Cdcilie M., Frau, xi n., xii, 5 . 3,
34 n. 1, 69n.-70n., 76 n., 103,
112, 175-81,208,231-2,238
Cases

of 'Dora', xxv, 166 n., 247 n.,
302 n. 1

ofFrdulein Mathilde //., 163 n.

ofFrdulein Rosalia //., 169-73

or Little Hans 9 , 257 n.

of'Katharina', x, xii, xxv, 125-34,
225, 260

of Frau Cdcilie M.,xin., xii, 5 n. 3,
34 n. 1, 69n.-70n., 76 n., 103,
112, 175-81,231-2,238

of Frau Emmy von N., x, xi, xii,
xvii, 5, 48-105, 173, 216, 225,
259-60, 284, 307-9

of Anna 0., x-xi, xvii, xxvii-
xxviii, 4-5, 7, 9, 21-48, 186,
208, 210, 214 n. 2,216-19, 225,
229 n. 1, 233-7, 249, 259, 264,
285-6, 288

of Frdulein Elisabeth von R., xii,
xxv, 9-10, 91 n. 1, 110*., 135-
161, 164-9, 174-6, 179, 225,
260, 296 n.

of Miss Lucy R., xii, 106-7, 113-

124, 133, 145, 260
Cases (unnamed)

ankylosed hip-joint, 5

cat jumping on shoulder, 2 1 3

dizziness in the street, 112n. 2,
127 n. 1

dog phobia, 14

homosexual relations with govern-
ess, 274-5

homosexual trauma, 211-12

hypnotized umbrella, 100 n.,
285

large feet, 93 n. 2

pathological conscientiousness,
243

pious old lady, 273-4

pseudo-peritonitis, 226-7

rage against employer, 14
self-inflicted injuries, 243
sister's insanity, 275-6
theosophist symbols, 277-8
tussis nervosa, 273
Catharsis, xxii, 8 n.
Cathartic method (see also Hypnosis
in cathartic therapy; Pressure
technique; Therapeutic tech-
nique)
Breuer's use of, 48, 93, 256, 266-7,

308

Freud's use of, xi, xii n. 2, 105 n.
relation to psycho-analysis, xvi,

xxvi-xxviii, xxxi

therapeutic value of, xix, 74 n. 2,
101, 108-9, 261-7, 283-5,
304-5

Cathexis, xxiii-xxv, 89
Censorship, 269, 282
Cephalalgia adolescentium, 94 n.
Character, change of, 77, 83, 85,

163 n.

Charcot, J.-M. (see also Bibliography),

xi, xiii, xxii, 13-17, 42, 76 n.,

94*., 134, 135 n.,2 13, 237, 260

Chemical factors, xxii, xxiv, 199-

200
Childhood impressions as source of

hysterical symptoms, xx, 4
'Chimney-sweeping', 30, 265
Chronological order

of development of symptoms,

124
of patient's communications, 35-

37, 75 n. 1, 153, 172*., 288
Circulatory system, 187, 196, 198,

203, 24 1,248 n. 1
Cleanliness, obsessional, 245 n.
Clonic spasms, 14, 87, 177
Coitus interruptus, 246
Cold, feeling of, as hysterical
symptom, 50, 55, 71, 75-6, 147
'Complex' (Janet), 231
Compulsion

to associate, 69 n., 96, 302 n. 2,
303-4

to repeat, xxi, 105 n.
Condition seconde (see also 'Absences';
Double conscience; Splitting of the
mind), 15-16, 31-4, 37-8,
42-7, 238

Confusional states, 78, 80, 91, 94-6,
248, 264

326

GENERAL INDEX

Connection, false, 67 n.-70 n., 294,

302-3

Conscience, 210, 243
Conscientiousness, pathological, 243
Consciousness

admissibility to, 223-5, 225 n.,

228-31, 234, 237, 249, 268-9
nature of, 227-8, 300
'official' (Charcot), 76 n.
restricted field of, in hysterics, 23 1
'vacancy of, 215
Constancy, principle of, xiv, xix-

xxiv, 197-200, 202
Contracture, hysterical, 4, 22-6,
30-1, 35, 39, 42, 44, 169,
214n.2, 217,226-7, 235, 296
Conversion, hysterical (see also

Ideogenic phenomena)
and hypnoid states, 217-18, 220,

236, 250

and incubation period, 134, 213
and summation of traumas, 173-

175,212-13
defence by, 116, 122-4, 147,

164-7, 236, 269, 285
instances of, 86, 116-17, 123-^t,
131, 134, 147-8, 150-1, 157,
168-9, 278

of affect, 146-7, 164-6, 173-5,
188, 203, 211-14, 217, 224-5,
245-7, 285
of sexual ideas, 245
origin of term, xxii, 206 n.
theory of, xxii-xxiii, 86, 95, 122,

203-14,217,224,247-8,297
Conversion hysteria, 257 n.
Convulsions, hysterical, 4-5
Counter-will (see also Antithetic

ideas), 5, 92
Cramps of neck, 52, 70-1, 75-7, 83,

96-7

Creative artistic activity, 207, 218
Criticism

absence of, in hypnoid states,

216-17

and suggestibility, 238-9
renunciation of, by patient, 111,
153, 270, 271 n. 2, 279

Day-dreaming, 11, 13, 22, 41-2,

217-20, 234-5, 248, 267
Day's residues, 69 n.
'Dead' fingers, 241
Deafness, hysterical, 24, 35-7, 39, 286

Death, fear of, 52, 55, 1 12 n.
Defence (see also Repression)
against sexuality, 247
amnesia as, 216
conversion as, 116, 122-^, 147,

164-7, 236, 269, 285
ego and, 264, 269, 278
resistance as, 278-83
splitting of the mind as, 166,

235-6
theory of, xxi, xxiv, xxv, xxvii,

xxix, 10 n., 214, 285-6
used as equivalent to repression,

10 n.

Defence hysteria, 167, 285-7
Degeneracy, 87, 104, 161, 243,

258-9, 294

Delbceufj J. R. L. (see also Biblio-
graphy), In. 1, 101
Dilire ecmnisique^ 111
Deliria, hysterical, 11, 13, 49 n. 3,
52, 52 rz., 71 n., 73, 76, 85,
96-7, 216, 248-50
Delusions, 216
Dementia praecox, 95 n.
Depression, neurotic (see also Melan-
cholia), 68 n., 71, 78, 81, 87,
90, 92, 93*., 106-7, 118, 161,
163 n., 210

Devil, possession by, 250
Diagnosis of hysteria, 85-6, lOOn.,

136, 244, 256-61, 281
Digestive system, 203
Diplopia, 35
Disgust, 5, 39, 49, 82, 89-90, 129,

131,210,212
Displacement

of affect, 69 n.-70 n.
of sums of excitation, xxiii
Dispositional hysteria, 12-13, 17,
102, 122, 144,215,231,240-9,
264
Dissociation (see Splitting of the

Mind)
Dizziness, as hysterical symptom,

112n. 2, 126, 129
'Dora', xxv, 166 n., 247 n. 9 302 n. 1
Double conscience (see also 'Absences';
Condition seconde; Splitting of the
mind), 12, 42, 227, 229, 236 n.
Dread (see also Expectation), 42,

224-5
Dream

of chair turning to snakes, 62

GENERAL INDEX

327

Dream (cent.)

of laying out corpses, 74

of monster with a vulture's beak,
62

of walking on leeches, 74
Dream-interpretation, xviii, 70 n.
Dreams

compared to neurotic symptoms,
45, 191

compulsion to associate, and,
69 ., 96

contradictory character of, 69 n.

of dead persons, 193

of physical pain, 189

sensory stimuli and, 192-3

symbolism in, 5

'we are all insane in', 13
Drug-addiction, 200, 249
Dumbness, hysterical, 25
Dynamic view of mental processes,

xx
Dyspnoea, 125-6, 128, 130, 199, 201

Ecmnesia (see also Amnesia; Dilire

ccmnisique) , 177 n.
Ego

'double', 234

fending off of incompatible ideas
by, xviii-xix, 116, 122-4, 128,
133-4, 166-8, 269, 285
'ignorance* of, 133
in hysteria, according to Janet,

104

overwhelming of, 263-4
'primary', 92

relation of, to pathogenic mater-
ial, 228-9, 278, 285-7, 290-1,
299

Ejaculatio praecox, 246
Electro-therapy, xi, 138
Elisabeth von R., Fraulein, xii, xxv,
9-10, 91 n. 1, 110/z., 135-61,
164-9, 174-6, 179, 225, 260,
296

Emmy von N., Frau, x-xii, xvii, 5,
48-105, 173, 216, 225, 259-260,
284, 307-9

Energy, psychical (see also Cathexis)
'bound* and 'free', xxiii, xxvii,
194n.

Epilepsy, 4, 94 n., 126 ., 205, 244
Epileptoid convulsions, 4-5, 13-14,

205
Erection, 187

Eros, 246

Erythema, 188-90

Etna, 229

Euphoria (see also Manic states),

23-4, 26, 28, 30

Excitability, abnormal, in hysteria,
191, 203, 230-1, 237, 240-5, 248
Excitation

and dispositional hysteria, 240-2,

244

and hypnoid states, 217-18
and hysterical conversion, 86,

116, 122-3,203-14,224
intra-cerebral, xxiv, 185, 192-207,

218, 224,228

sums of, xix-xxi, xxiii, xxvii
'Excitement' and 'incitement', 197-

199

Expectation (see also Dread), 88, 92,
194-5, 198, 258, 260, 295

Facilitation, 195-6, 203, 206-9, 214,

241

of attention (Exner), 195, 241
Fainting fits, hysterical, 27, 37, 52,

100 n., 112n., 127 n. 1, 169 n.,

226, 241
False connections, 67 n.-70 n., 294,

302-3
Fatigue, 194, 201, 204, 250

hysterical, 104-6, 135, 155, 218
Faust (Goethe), 87 n., 139 n., 192 n. 2,

229 n. 2
Fear (see also Anxiety; Fright;

Phobias)
of animals, 14, 51-3, 55-8, 62-4,

66, 72-4, 78-9, 87, 99
of being buried alive, 88
of being ill, 243,258
of death, 52, 55, 112n.
of fogs, 73,87
of insanity, 55, 59, 61, 62 n. 1, 66,

87-8

of lifts, 66-7, 72
of railway-journeys, 84
of Red Indians, 53-4
of snakes, 24, 38, 62, 87, 186, 208,

214*. 2, 217
of someone standing behind, 65,

88, 126

of surprise, 59, 65, 87
of thunderstorms, 58, 75, 87
of witches, 76 n.
of worms, 73-4

328

GENERAL INDEX

Fechner, G. 7"., xxii n.
Feeble-mindedness and hysteria,

232-3, 238-40, 265
Fliess, Wilhelm, xi, xiii-xv, xix, xxiii,
xxvi, llOn., 122 ., 127 n. 1,
188 n., 307-8
Fogs, fear of, 73, 87
Forgetting (see also Memory; Wear-
ing away), 206, 222
motives for, 10-11, 111, 116-17,

269
only apparently successful, 109,

111-12,268,271-2,287
Frankfurter Zjtitung, 51-2
Franziska, 127-30
Free association, xviii, 56 n.
Fright (see also Fear)

and aetiology of hysteria, 5-6, 1 1 ,
36-7, 93, 208, 212-13, 225-6,
246-7

and expectation, 198
hypnoid, 215, 219-20, 235
relation to association, 9, 201-2

Gastein, 142, 151-2, 155-6, 165,

168
Gastric pain, hysterical, 53-4, 62-4,

81-2
General paralysis of the insane,

223
Goethe, 87, 139 n., 192 n. 2, 207,

229 n. 2
Granada, xv
Guilt, sense of (see Self-reproach)

Hallucination, hysterical, 4, 6-7, 13,

208, 236-7, 250
and perception compared, 188,

203

auditory, 191
in case of 'Katharina', 126, 128,

132-3

in case of Frau Cacilie M., 231
in case of Frau Emmy von N., 49,

85,96
in case of Anna 0., 22, 24, 27-31,

33, 35, 40, 45, 214 n. 2
in case ofFraulein Elisabeth von R.,

177, 181 n.

negative, 26-7, 31, 42
of animals, 51-3, 56, 62-4, 72-4,

78

of pain, 188-90
olfactory, 106-7, 114-16, 118-22

retrogressive character of, xxiii, 189
unconscious meaning of, 237
visual, 4, 24, 27, 35, 37-9, 53, 56,
58, 64 n., 66, 72-4, 126, 128,
132-3, 214 n. 2
Hallucinatory
confusion, 96, 248
suggestibility, 239
vividness of memories, 9
'Hans, Little', 257 n.
Hatto, Bishop, 73
Headache, as hysterical symptom,

23, 302
Hearing, disturbances of (si*

Auditory)
Helmholz, //., xxii
Hemi-anaesthesia, 5, 190, 230, 235,

237-8
Hereditary factors, 12, 17, 21, 83,

102, 104, 122, 161
Hohe Taucrn, 125
Homosexuality, 211-12
Horace, 234
Hunger, 199-200,215
Hydrotherapy, xi, 50-1, 67 n., 118,

142

Hyperaesthesia
hysterical, 258
of expectation, 198
Hyperalgesia (see also Pain, hyster-
ical), 135-8, 190, 241
Hypnoid

fright, 215, 219-20, 235
hysteria, 167 n., 285-7
states (see also Auto-hypnosis;
Splitting of the mind), xiv,
xviii, xxii, xxvi, 11-13, 15-17,
23-35, 128, 214-204, 234-50,
285-6
Hypnosis

allo-, 186, 239

auto-, 7, 11, 29, 39, 42, 44, 139,
186, 215-20, 235-6, 239, 243,
247-8

Delb<Kuf&nd,7n. 1, 101
in cathartic therapy, xi-xii, xvii,
3, 9-14, 48, 67 n., 79-80, 100 n.,
101, llOn., 237, 239, 255-6,
271, 283-5
in relation to hypnoid states,

215-20, 248, 248 n.
revival of memories under, 3,
9-10, 44, 90, 97-101, 108-9,
267, 284

GENERAL INDEX

329

Hypnosis (cont.)

susceptibility to, 107-10, 113,

145, 256, 267-8
without harmful effects, 226
Hypnotic suggestion, xi, xvii-xviii,

13, 17, 77, 79-80, 99, lOOn.,

101, 255, 307-8
allo-, 186, 239
auto-, 186, 215-16, 239, 243,

247-8

post-, 67 n., 84-5, 98-9, 249
Hypochondria, 136 n., 243, 258
Hysteria

anxiety-, 257 n.
conversion-, 257 n.
defence-, 167, 285-7
derivation of word, 247
diagnosis of, 85-6, lOOn., 136,

244, 256-61, 281
dispositional, 12-13, 17, 102, 122,

144,215,231,240-9,264
hypnoid, 167 n., 285-7
'major', 216, 227, 236, 248-9
male, 236
malicious, 243
monosymptomatic, 93, 149-50,

264, 287-8
psychically acquired, 12-13, 122-

123, 133
retention-, 162, 169-73, 211,

285-7
sexual aetiology of, xxv-xxix,

xxxi, 103, 133-4, 164, 234,

244-9, 257-61, 274
sick-nursing and the aetiology of,

161-5, 168, 174-5,218-19, 234,

248
traumatic, 4-5, 14, 42, 209, 213,

220, 247, 288
Hysterical

attacks, xiv, 4, 13-17, 96, 107,

126, 172, 177-8, 205, 228-9,

237, 248-9, 259, 262, 273-4
aura, 126, 180
conversion (see Conversion)
counter-will, 5, 92
psychoses, 9, 13, 22, 45-7, 69 n.,

96, 236, 248-9, 263-4
reminiscence, xiv, 7, 221
sleep, 14
stigmata, 15, 88, 242, 244-5, 256,

265
Hysterical symptoms (see also

Abasia; Abulia; Amaurosis;

Amblyopia; Amnesia; Anaes-
thesia; Analgesia; Anorexia;
Anxiety; Aphasia; Arthralgia;
Astasia; Asthma Athetosis;
Attitudes passionnelles\ Auditory;
disturbances; Cephalalgia ado-
lescentum; Clonic spasms;
Cold, feeling of; Contrac-
tures; Convulsions; Deafness;
Delire ecmnisique\ Deliria; De-
pression; Diplopia; Dizziness;
Dumbness; Dyspnoea; Ec-
mnesia; Epileptoid convulsions;
Erythema; Euphoria; Fainting
fits; Fatigue; Gastric pain;
Hallucination; Headache;

Hemi-anaesthesia; Hyper-
aesthesia; Hyperalgesia; Idees
fixes; Insomnia; Macropsia;
Migraine; Neck-cramps; Neu-
ralgia; Ovarian neuralgia;
Palpitations; Paraesthesia;
Paralysis; Paramnesia; Para-
phasia; Paresis; Petit-mal\
Pseudo-encephalitis: Pseudo-
peritonitis; Smell, disturbances
of; Spasms; Speech, disturb-
ances of; Squint; Stammer;
Stupor; Tears; Throat con-
striction; Tic; Tremor; Tussis
nervosa\ Twitching; Vision, dis-
turbance of; Vomiting; Walk-
ing, disturbances of; Zoopsia)

as ideogenic phenomena (see also
Conversion), 186-91, 201, 205-
216, 220-1, 224-5, 227, 229,
237, 244, 261

as mnemic symbols, xviii, 5,
55 n., 62 n. 2, 71 n., 90-3, 95,
106-7, 133, 144, 152-3, 172-81,
216,295-7

curability of, xix, 7 ., 17, 41,
101-2, 144, 160, 261-6, 296,
299

disappear when recollection is
accompanied by affect, xix,
6-7,221,224,232,255,283

'joining in the conversation', 37,
148, 296-7

over determination of, 212-13,
263, 287-8, 290

precipitating cause of, 3-6, 7 n. 1 ,
15, 34-7, 43, 52, 58 n., 102-3,
105, 138, 149,216,268

330

GENERAL INDEX

Hysterical symptoms, replace one

another, 17, 119,261,263-4
'talking away' of, 25-7, 29-38,
40, 43, 46, 148, 296

Hysterogenic zones, 16, 137, 148-51,
175,261

Idees fixes, 99

Ideogenic phenomena, hysterical
symptoms as (see also Conver-
sion), 186-91, 201, 205-16,
220-1, 224-5, 227, 229, 237,
244, 261

111

fear of being, 243, 258
wish to be, 243

Incestuous sexual attempt, 1 34 n. 2

Incompatible ideas, xviii-xxi, 116,
122-4, 128, 133-4, 157, 165-8,
193,210-11, 239,269, 285

Incubation period in hysteria, 22,
38, 131, 134, 213, 220, 236 n.,
263

Infantile sexuality, xviii, xxxi,
133n.

Insanity, fear of, 55, 59, 61, 62 n. 1,
66, 87-8

Insomnia, 28, 43, 78, 215

Instinct, xx-xxi

sexual, xx, xxvi, 103, 200-1

Intellectual ability of hysterics, 13,
21-2, 103-4, 136, 230-3, 238-
240, 265

Intercellular tetanus (Exner), 193

Intermediate ideas, 271-2

International Medical Congress of
1913, xii *. 2

Interpretation of dreams (see
Dream-interpretation)

Intracerebral excitation, xxiv, 185,
192-207, 218, 224, 228

Inversion, sexual, 211-12, 275

Janet, Jules, 12

Janet, Pierre (see also Bibliography),
xii n. 2, xiv, 12, 92, 104, 190,
227, 229-33, 237-8, 249

Jokes, 271 n. 1

Jones, Dr. Ernest (see also Biblio-
graphy), xii . 2

Karplus,Dr. Paul, 213n. 1

'Katharina* , x, xii, xxv, 125-

34, 225, 260
Koch, R., 187

Language, 8, 178-81, 201-2

Laughter, 220

Lessing, G. E., 175*. 2

Liebeault, A., xii, 108

Lifts, fear of, 66-7, 72

Locomotor weakness, in hysteria,

100 ., 135, 138, 141-2, 144,

151, 179

Loewenfeld, S. L., 1 10 n.
Logical element in pathogenic

material of hysteria, 289-90,

292-4, 300, 303
London, xii n. 2
Love, 200, 218-19, 233-4, 248, 273

unconscious, 166-7
Lucy, R., Miss, xii, 106-7, 113-24,

133, 145, 260

Macbeth, Lady, 245 n.

Macropsia, 35, 40, 63-4, 64 n., 72

Manic states (see also Euphoria),

236

Masturbation, 210
Mathilde, H., Frdulein 163 n.
Melancholia (see also Depression),

49 n. 2, 87, 163 n., 227
Memory (see also Forgetting;

Mnemic symbols)
and affect, 8-12, 122-3, 205, 238
and 'defile of consciousness*, 291,

296

and perception, xxiii, 188-9, 239
and sense of smell, 114-16, 118-

121

gaps in, 45, 61 n., 70 n., 84
revived under hypnosis, 3, 9-10,
44, 90, 97-101, 108-9, 267,
284

revived under pressure technique,
112n., 119-20, 148, 153-4,
270-7, 292, 297, 301
vividness of, in hysterics, 9-11,

53-5, 119, 163,280
with affect, causes disappearance
of symptoms, xix, 6-7, 15, 221,
224, 232, 255, 283
Menstrual irregularity in hysteria,

57, 226

Mephistopheles (in Faust), 87, 229 n. 2
Meynert, T., xxii, 188n.
Midas, 211

Midsummer NighCs Dream, 250-1
Migraine, 52 n. 2, 71 n., 96
'Mixed' neuroses, 85, 256, 261

GENERAL INDEX

331

Mncmic symbols

hysterical symptoms as, xviii, 5,
55n.,62n. 2, 71 n., 90-3, 95,
106-7, 133, 144, 152-3, 172-81,
216,295-7

olfactory, 114-16, 118-20
simultaneous sensation as, 71 n.,
115-16, 118-20, 174-9, 208-9
verbal, 178-81,216,275-6
visual, 133, 277-8, 280-2, 299
Moebius 9 P. J. (see also Bibliography),
In. 3-8 n., 186-8, 190-1, 215,
243, 248 n. 1
'Molecules, instability of, 191 n. 9

242 n.
Monosymptomatic hysteria, 93,

149-50, 264, 287-8
Morality, 210, 245
Morphine, withdrawal of, and

hysteria, 249

Motor activity, 13-15,91,95, 191-3,
195-7, 200-2, 204-8, 223, 243-
245, 250
Mourning, 162

Nancy, xii, 108
Narcotics, 200, 249
Nausea

caused by visual impressions,

210 n. 2
hysterical (see also Vomiting,

hysterical), 4, 210, 296
Neck-cramps, 52, 70-1, 75-7, 83,

96-7
Neuralgia, 190

hysterical, 4-7, 35, 176-9, 188,

208,231,241,276-8
ovarian, 86, 190, 226, 236, 241
Neurasthenia, xxiv, 85, 136-7,

148 n., 257-60

Neurology, mental events in rela-
tion to, xx, xxiii-xxv, 191-207,
218,220-1,241-5
Neurone theory, xxiii-xxv, 197 n.
Neuroses (see also Actual neuroses;
Anxiety neuroses; Mixed neu-
roses; Obsessional neurosis;
Traumatic neuroses)
abreaction and the theory of,

192
over determination in (see also

Over determination), 263
sexual aetiology of, xx, xxvi-
xxviii, 200, 246, 256-61, 274

Nucleus of pathogenic material, in
hysteria, 123, 288-92, 295, 299,
300

Nuns, hysterical deliria in, 11, 249

Nursing (see Sick-nursing)

Obsessional

cleanliness, 245 n.

ideas, xxiv, 69 n., 122 n., 256-8,

275-6, 280
neurosis, 257-9
Oedipus complex, xviii
Olfactory

disturbances in hysteria, 106-7,

114-16, 118-22
sensory stimuli, 106
Organic disease in relation to
hysteria (see also Rheumatism;
Rhinitis), 93m 1, 96, 136-7,
147, 174, 204, 207-8, 241-2,
273

Orgasm, 200, 248
Ovarian neuralgia, 86, 190, 226,

236, 241

Over determination of symptoms,
173-4, 212-13, 263, 287-8; 290

Pain as hysterical symptom (see also
Arthralgia; Cephalalgia; Gas-
tric pain; Hyperalgesia; Mi-
graine; Neuralgia; Ovarian
neuralgia), 55-6, 61, 68-73,
75_6, 90-1, 100 n., 174-7,
179-80, 188-90, 226, 241, 245,
296

and organic pain, 71 n., 90-1,
137-8, 147, 168, 174-6, 188-
190

Pain, organic (see also Rheumatism),

6, 90-1, 189-90, 202
referred, 189-90, 242

Palpitations, 203, 220, 241

Paraesthesia, hysterical, 169-70

Paralysis

general, of the insane, 223
hysterical, 4, 7, 17, 22, 31, 35, 38,
42, 44, 64, 69, 89-90, 153,
163m, 186, 191,216,284

Paramnesia, 66, 67 n., 80

Paranoia, 83, 122 n.

Paraphasia, hysterical, 25, 29, 42

Paresis (see Paralysis)

Paris, xi, 308

Pavor nocturnus, 2 1 1

332

GENERAL INDEX

Perception

and hallucination, xxiii, 188-9,

203

and memory, xxiii, 188
and the sexual instinct, 187, 201
in hysterics, 230, 250
in sleep and waking life, 193
Perversion, 246, 258-9
Petit mal, 4
Phantasies, xx
Phobias (see also Anxiety; Fear),

87-9, 258, 260, 275
Physical basis for mental phenomena

(see also Neurology; Neurones),

xxiii-xxv
Picture-book without Pictures (by Hans

Andersen], 29

Pleasure principle, xxi, 223-4
Post-hypnotic suggestion, 67 n., 84-

85, 98-9, 249
Premonitions, 70 n., 76 n.
Pressure technique, xvii, xxi, 109-

111, 113n., 145, 153-4, 270-9,

281, 283, 285 n. 1, 292-5, 297,

301-4

Primal scene (see also Sexual inter-
course between adults), 127 n. 1
* Primary ego' (Janet). 92
Primary process, xviii, xxiii, xxvii,

194rz.
Trivate theatre' of Anna 0., 22, 41,

218, 233

Problems, solving of, 209
Protective formulae, 30, 49 and n. 2,

51, 56-7, 78, 91,94-5
Pseudo-encephalitis, hysterical, 236
Pseudo-peritonitis, hysterical, 226,

236
Psychical energy (see Energy,

psychical)
'Psychical inefficiency* (Janet), 104,

230-3
Psycho-analysis

attacked by Janet, xii n. 2
cathartic method develops into,

xvi, xxvi-xxviii, xxxi
use of term, 48 n.
Psycho-analytic technique (see

Therapeutic technique)
Psychoses (see also Dementia Prae-

cox; Paranoia), 21, 83, 161
hysterical, 9, 13, 22, 45-7, 69 n.,

96, 236, 248-9, 263-4
Puberty, 200, 204, 240, 244-5

Quantity, xxiii-iv, 86, 196, 205, 241,
270

Railway

accident as trauma, 213
journeys, fear of, 84
Rauber, die (by Schiller), 100 .
Red Indians, fear of, 53-4
Reflex

action, xviii, 8, 198, 202, 205-9,

214,229, 244

theory of hysteria, 242, 250
Religious doubt, 210
Repeat, compulsion to, xxi, 105 n.
Repression

and aetiology of hysteria, xxiv,
10, 116, 122-3, 146, 157, 164,
167, 235, 285
sexual, xxix, 245-9
theory of, xx-xxii, 10 n. 1, 57 n. 2,

214,268-9
used as equivalent to defence,

10 n.
Resistance

principle of least, 208

to hypnosis, 107-10, 113, 145,

256, 267-8

to new ideas, 239, 269
to treatment, xvii, xxi, 23, 154,
157, 166, 268-70, 273-5, 278-
287, 289-96, 301-3
Retention

hysteria, 162, 169-73, 211, 285-7
phenomena of, 102, 162, 169-73,

211

Retrogressive nature of hallucina-
tion, xxiii, 189

Revenge, 8, 67 n., 205 n., 207
Reverie (see Day-dreaming)
Reversal of chronological order
in development of symptoms,

124
in patient's communications, 35,

75 n. 1, 172n., 288
Rheumatic pain and hysteria, 71 n.,
90, 91 n. 1, 137-8 147, 168,
174-6

Rhinitis, 106-7, 116, 118, 121
Robert, W., 70 n.
Roman catacombs, 98
Roman Catholic confessional, 211
Rome, 66, 169n.
Rosalia, //., Frdulein 169-73
Rugen, 65, 72-3, 87

GENERAL INDEX

333

St. Petersburg, 74
San Domingo, 68 n., 90
Schafberg, 95 n.
Schiller, F., lOOn., 206 n.
Sclerosis, multiple, 100 n.
Secondary process, xxiii, xxvii
Seduction (see also Trauma, sexual),

130-2, 134 n. 2, 172,213
Self-consciousness, 222-3, 228-9
Self-reproach, 46, 65, 70 n., 77, 164,

179,228-9,243,269,278
Sensory stimuli, 187-8, 191-3, 196-

198,201,208,230,241,244
olfactory, 106
visual, 210n. 2
Sexual

abstinence and neurotic anxiety,

11, 65m, 88, 103,249, 260
affect, 12, 200-1, 234, 245-8
aetiology of hysteria, xxv-xxvii,
xxix, xxxi, 103, 133-4, 164,
234, 244-9, 257-62, 274
aetiology of neuroses, xx, xxvi,

xxviii, 200, 246, 256-62, 274
curiosity in adolescents, 134, 245
excitation, 200-1, 210, 240,

245-6

instinct, xx, xxvi, 103, 200-1
intercourse between adults, cause
of anxiety in children, 127 n. 1,
128, 131, 134
repression, xxix, 245-9
trauma, 79, 127-34, 172-3, 211-

213, 246, 262, 274, 276
Shakespeare, 26, 245 n. y 250-1
Shame, 6, 191,269
Sick-nursing and aetiology of hys-
teria, 161-5, 168, 174-5, 218-
219, 234, 248

Simultaneity, association through,
71 n., 115-16, 118-20, 174-9,
208-9

Sisyphus, 263
Sleep, 192-6, 239

as hysterical symptom, 14
Smell, sense of

and memory, 114-16, 118-21
disturbances of, in hysteria, 106-

107, 114-16, 118-22
Snakes, fear of, 24, 38, 62, 87, 186,

208, 214 n. 2, 217
Sneezing, 206-7

Society for Psychical Research, xv
Somatic compliance, 166 n.

Spasms, hysterical (see also Con-
tracture; Tic), 7, 14, 71 n., 87,
177
Speech

and relief of tension, 2 1 1
figures of, 228

hysterical disturbances of (see also
Dumbness; Stammering), 5,
25-6, 35, 39-40, 42, 48-9,
53-8, 61, 63-4,66, 71, 74 n. 2,
78, 80, 87, 91-6, 235
Splitting of the mind (see also
Absences; Condition seconde;
Double conscience), xiv, xviii, 11-
12, 23-4, 33-4, 37-47, 67 n.-
69 n., 104, 123-4, 133-4, 166-8,
216-17, 220-1, 225-31, 233-9,
249-50

Janet's view of, 230-1
Squint, 22-3, 25, 35, 40, 208
Stammer, 49, 54, 57-8, 61, 72, 74,

78-9,91,93,95-6
Stigmata, hysterical (see also Hys-
terical symptoms), 15, 88, 242,
244-5, 256, 265

Stimuli, sensory (see Sensory stimuli)
Strangers, fear of, 63, 87-8
Strumpell, A. von (see also Biblio-
graphy) 7 n. 3-8 n.
Stupor, hysterical, 274
Subconscious', 45 n., 69 n., 222-3,

225-9,231,235
Freud' } s rejection of term, 45 n.
Suggestibility

hallucinatory, 239
of hysterics, 238-9, 247-8, 250
Suggestion
allo-, 186, 239
auto-, 186, 215-16, 239, 243,

247-8

hypnotic, xi, xvii-xviii, 13, 17, 77,

79-80,99, lOOn., 101, 255, 307-8

post-hypnotic, 67 n., 84-5, 98-9,

249

Suicidal impulse, 28
Superstitious beliefs, 76 n., 250
Supervalent ideas, 247
Surprise, fear of, 59, 65, 87-8, 126
Symbolism
in dreams, 5
unconscious, xxxi
verbal, 209, 216

Symbols, hysterical symptoms as
(see Mnemic symbols)

334

GENERAL INDEX

Symptoms, hysterical (see Hysterical
Symptoms)

Tabes, 243

Taedium vitae (see also Depression;

Melancholia), 163 n.
Taylor, Bayard, 87 n.
Tears, 8, 201, 220

hysterical, 78, 162-3, 163 n., 221
Technique, therapeutic (see Thera-
peutic technique)
Telepathy, 271 n. 1
Temperamental differences
of cerebral excitation, 1 97-8
in terms of relation to new ideas,

239

Therapeutic technique (see also
Cathartic method; Hypnosis in
cathartic therapy; Pressure
technique), xv-xvi, xxix, 107-
111, 265-72, 278-86, 291-2,
295-305
Concentration', xvii, 109, 228,

270, 274, 277, 284
condition of patient, 298-9
facial expression of patient, 79,

281, 294, 301
'insistence' by doctor, 153^, 268,

270, 283

relation of doctor and patient (see
also Transference), 265-6, 281-
284, 301-4
renunciation of criticism bypatient,

111, 153,270, 271 n. 2, 279
Theresa, Saint, 'patron saint of

hysteria', 232
Theseus (in Midsummer Night's

Dream), 250-1
Thirst, 199
Throat, hysterical constriction of,

43-4, 169-70, 180,210
Thunderstorms, fear of, 58, 75, 87
Tic, 4-5, 49, 49 n. 3, 54, 63, 66, 72,

91-4, 243-4
Tiflis, 51
Titans, 229

Toxic factors, and affect, 201
Transference, xviii, xxvii, 40 n., 266,

283, 301-4
Trauma

and affect, 6, 11-13, 86-90, 128,

211,213

'auxiliary', 123-4, 133-4
homosexual, 211-12

infantile, xx

'major', 6, 14

psychical, and aetiology of hys-
teria, xx, xxix, 5-6, 8-16, 86-
90, 95-6, 101-3, 107, 122-4,
162, 167-8, 173, 178,209,221,
267, 287-8

psychical, instance of, 22, 25-6,
42, 52-60, 63, 69n.-70n.,
74*., 77, 79,92-3, 106, 115-18,
120-2, 140, 142-4, 150, 157,
211-13

sexual, 79, 127-34, 172-3,212-13,
246, 262, 274, 276

summation of, 173-4, 212-13,

287-8
Traumatic

hysteria, 4-5, 14, 42, 209, 213,
220, 247, 288

neuroses, 4-6, 12, 42, 209, 235
Tremor, hysterical, 35, 100 n., 220
Turk's cap lily, 98
Tussis nervosa, 23, 35, 40, 43-4, 210,

273

Twitching of fingers and toes, as
hysterical symptom, 49, 93 n. 2,
171-3

Uhland, J. L., 238
Umbrella, hypnotized, 100 n.
Unconscious
'love', 166-7

mental processes, xvii, 10n.,
214. 2, 221-39, 246, 293,
300

motives, 293-4
wish, 302-4
Unconscious, the, xvii, 45, 45 n.,

76 n., 123, 237-9, 293, 300-2
use of the term, 45 n.
Unpleasure, xxi, 116, 197, 210, 269

Verbal association, memory

through, 275-6

Verbal symbolization, 209, 216
'could not take a single step

forward', 152
'find herself on a right footing',

179

'have to swallow this', 1 80- 1
'slap in the face', 178, 181
'something's come into my head',

180
'stabbed me to the heart', 180-1

GENERAL INDEX

335

Verbal symbolization, 'standing

alone', 152
'woman dating from the last

century', 52 n. 1, 97
Vienna, x-xi, xiv-xv, 27-8, 31-2,
38, 40, 50, 77-8, 84-5, 100.,
106, llln., 156, 159-60, 171,
173,308

Virginal anxiety, 127, 134, 260
Vision, disturbances of, in hysteria
(see also Amaurosis; Amblyopia;
Diplopia; Macropsia; Squint),
4-5, 22-4, 26, 33, 35, 38-40,
100 ., 242
Visual

hallucination, 4, 24, 27, 35, 37-9,

53, 56, 58, 64 n., 66, 72-4, 126,

128, 132-3, 214 n. 2

impressions cause nausea, 210 n. 2

memory, vividness of, in hysterics,

9-11,53-5, 119, 163,280
mnemic symbols, 133, 277-8,

280-2, 299
sensory stimuli, 210 n. 2

Vomiting
hysterical, 4-5, 129, 131-2, 210,

212, 224, 296-7
in pregnancy, 242

Waking, 196

Waking life compared to sleep,
192-6

Walking, disturbances of, in hys-
teria, 100 n., 135, 138, 141-2,
144, 151, 179

'Wearing away' of ideas, xviii, 8-9,
10-11,205,213-14,220,238

Weir Mitchell treatment of hys-
teria, xi, 267

Wernieke, A"., 247 .

Will (see also Abulia; Counter-will),
10 n., 77, 157,239,240,250,271

William /, Emperor of Germany, 202

Wish, unconscious, 302-4

\Vitches, fear of, 76 n.

Worms, fear of, 73-4

Zoopsia (see also Hallucinations,
animal), 62-3

53 5