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CHAPTER I

THE PSYCHIC MECHANISM OF HYSTERICAL
PHENOMENA

(PRELIMINARY COMMUNICATION)

By DR. JOSEPH BREUER AND DR. SIGMUND FREUD

Actuated by a number of accidental observations, we have
investigated over a period of years the different forms and symptoms
of hysteria for the purpose of discovering the cause and the process
which first provoked the phenomena in question, and which in a
great many of our cases frequently appeared years before. In the
great majority of cases we did not succeed in elucidating this starting
point from the mere history, no matter how detailed it might have
been, partly because we had to deal with experiences about which
discussion was disagreeable to the patients, but mainly because
they really could not recall anything. Often they had no inkling of
the causal connection between the causative process and the patho-
logical phenomenon. It was generally necessary to hypnotize the
patients and reawaken the memory of the time in which the symptom
first appeared, but we thus succeeded in exposing that connection in a
most precise and convincing manner.

This method of examination in a great number of cases has fur-
nished us with results which seem to be of theoretical as well as of
practical value.

It is of theoretical value because it has shown us that in the deter-
mination of the pathology of hysteria the accidental factor plays a
much greater part than is generally known and recognized. It is
quite evident that in “traumatic” hysteria it is the accident which
evokes the syndrome. Moreover, in hysterical crises, if the patients
state that in each attack they hallucinate the same process which
evoked the first attack, here, too, the causal connection seems quite
clear. But the situation is more obscure in the other phenomena.

Our experiences have shown us that the most varied symptoms
which pass as spontaneous, or, as it were, as idiopathic attainments
of hysteria, stand in just as stringent connection with the causal

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trauma as the transparent phenomena mentioned. To such causal
factors we are able to refer neuralgias as well as the different kind of
anesthesias, often of years’ duration, contractures and paralyses,
hysterical attacks and epileptiform convulsions, which every observer
has taken for real epilepsy, petit mal and tic-
like affections, persistent
vomiting and anorexia, even up to the refusal of nourishment, all
kinds of visual disturbances, constantly recurring visual hallucina-
tions, and similar affections. The disproportion between the hysteri-
cal symptom of years’ duration and the former cause is the same as
the one we are regularly accustomed to see in the traumatic neuroses.
Very often they are experiences of childhood which have established
more or less intensive morbid phenomena for all succeeding years.

The connection is often so clear that it is perfectly manifest how
the causal event produced just this and no other phenomenon. It is
quite clearly determined by the cause. Thus, let us take the most
banal example: if a painful affect originates while eating, and is
repressed, it may produce nausea and vomiting, and then continue
for months as an hysterical symptom. The following examples will
illustrate what we mean:

A very distressed young girl, while anxiously watching at a sick
bed, fell into a dreamy state, had terrifying hallucinations, and her
right arm, which was at the time hanging over the back of the chair,
became numb. This resulted in a paralysis, contracture, and
anesthesia of that arm. She wanted to pray, but could find no words,
but finally succeeded in uttering an English children’s prayer. Later,
on developing a very grave and most complicated hysteria, she spoke,
wrote, and understood only English, whereas her native tongue was
incomprehensible to her for a year and a half.

A very sick child finally fell asleep. The mother exerted all her
will power to make no noise to awaken it, but because she resolved to
do so, she emitted a clicking sound with her tongue (“hysterical
counter-
will”). This was later repeated on another occasion when
she wished to be absolutely quiet, and developed into a tic, which in
the form of tongue clicking accompanied every excitement for years.

A very intelligent man was present while his brother was
anesthetized and his ankylosed hip stretched. At the moment when
the joint yielded and crackled, he perceived severe pain in his own
hip, which continued for almost a year.

In other cases the connection is not so simple, there being only,
as it were, a symbolic relation between the cause and the pathological

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phenomenon, just as in the normal dream. Thus, psychic pain may
result in neuralgia, or the affect of moral disgust may cause vomiting.
We have studied patients, who were wont to make the most prolific
use of such symbolization. In still other cases such a determina-
tion is at first sight incomprehensible, yet in this group we find the
typical hysterical symptoms, such as hemianesthesia, contraction of
the visual field, epileptiform convulsions, and similar symptoms. The
explanation of our views concerning this group must be deferred for
a more detailed discussion of the subject.

Such observations seem to demonstrate the pathogenic analogy
between simple hysteria and traumatic neurosis, and justify a broader
conception of „traumatic hysteria.“ The active etiological factor in
traumatic neurosis is really not the insignificant bodily injury, but the
affect of the fright; that is, the psychic trauma. In an analogous
manner our investigations show that the causes of many, if not of
all, cases of hysteria can be designated as psychic traumas. Every
experience which produces the painful affect of fear, anxiety, shame,
or of psychic pain may act as a trauma. Whether an experience
becomes of traumatic importance naturally depends on the person
affected, as well as on the condition which will be mentioned later.
In ordinary hysterias we frequently find, instead of one large trauma,
many partial traumas, grouped causes which can be of traumatic
significance only when summarized, and which belong together
insofar as they form small fragments of the sorrowful tale. In still
other cases a connection with a real efficacious event or with a period
of time of special excitability raises seemingly indifferent situations
to traumatic dignity, which they would not have attained otherwise,
but which they retain ever after.

But the causal connection of the causative psychic trauma with
the hysterical phenomena does not mean that the trauma, as an agent
provocateur would release the symptom which would then become
independent and continue as such. On the contrary, we must main-
tain that the psychic trauma or the memory of the same acts like a
foreign body which even long after its penetration must be considered
as an agent of the present, the proof of which we see in a most
remarkable phenomenon, which at the same time adds to our dis-
coveries a distinctly practical interest.

We found, at first to our greatest surprise, that the individual
hysterical symptoms immediately disappeared without returning if
we succeeded in thoroughly awakening the memories of the causal

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process with its accompanying affect, and if the patient circumstan-
tially discussed the process in the most detailed manner and gave
verbal expression to the affect. Recollections without affects are
almost utterly useless. The psychic process, which originally elapsed,
must be reproduced as vividly as possible so as to bring it back into
the statum nascendi, and then thoroughly “talked out.” If it con-
cerns such irritating manifestations as convulsions, neuralgias, and
hallucinations, they are once more brought to the surface with their
full intensity, and they then vanish forever. Functional attacks like
paralyses and anesthesias likewise disappear, but naturally without
any appreciable distinctness of their momentary aggravation.¹

It would be quite reasonable to suspect that one deals here with
an unintentional suggestion. The patient expects to be relieved of
his suffering and it is this expectation and not the discussion that is
the effectual factor. But this is not so. The first observation of this
kind, in which a most complicated case of hysteria was analyzed and
the individual causal symptoms separately abrogated, occurred in
the year 1881, that is, in a “pre-
suggestive” period. It was brought
about through a spontaneous auto-
hypnosis of the patient and caused
the examiner the greatest surprise.

In reversing the sentence: cessante causa cessat effectus, we may
conclude from this observation, that the causal process continues to
act in some way even after years, not indirectly by means of a chain
of causal links, but directly as a provoking cause, just perhaps as in
the wakeful consciousness where the memory of a psychic pain may
later call forth tears. In other words: The hysteric suffers mostly
from reminiscences.²

¹The possibility of such a therapy was clearly recognized by Delboeuf and
Binet, as is shown by the accompanying quotations: Delboeuf, Le magnétisme
animal, Paris, 1889: “On s’expliquerait dès lors comment le magnétiseur aide
à la guérison. Il remet le sujet dans l’état où le mal s’est manifesté et combat
par la parole le même mal, mais renaissant.” (Binet, Les altérations de la per-
sonnalité, 1892, p. 243): “… peut-
être verra-
t-
on qu’en reportant le malade
par un artifice mental, au moment même où le symptome a apparu pour la
première fois, on rend ce malade plus docile à une suggestion curative.” In the
interesting book of Janet, L’Automatisme Psychologique, Paris, 1889, we find
the description of a cure brought about in a hysterical girl by a process similar
to our method.

²We are unable to distinguish in this preliminary contribution what there is
new in this content, and what can be found in such other authors as Moebius
and Strümpell, who present similar views on hysteria. The greatest similarity
to our theoretic and therapeutic accomplishments we accidentally found in some
published observations of Benedict, which we shall discuss later on.

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II

It would seem at first rather strange that long-
forgotten experi-
ences should exert so intensive an influence, and that their recollec-
tions should not be subject to the decay into which all our memories
sink. We will perhaps gain some understanding of these facts by the
following examinations.

The blurring or loss of an affect of memory depends on a great
many factors. In the first place, it is of great consequence whether
there was an energetic reaction to the affectful experience or not.
By reaction we here understand a whole series of voluntary or invol-
untary reflexes, ranging from crying to an act of revenge, through
which according to experience affects are discharged. If the success
of this reaction is of sufficient strength, it results in the disappearance
of a great part of the affect. Language attests to this fact of daily
observation, in such expressions as “to give vent to one’s feeling,”
to be “relieved by weeping,” etc. If the reaction is suppressed, the
affect remains united with the memory. An insult retaliated, be it
only in words, is differently recalled than one that had to be taken
in silence. Language also recognizes this distinction between the
psychic and physical results, and designates most characteristically
the silently endured suffering as “grievance.” The reaction of an
injured person to a trauma has really only then a perfect “cathartic”
effect if it is expressed in an adequate reaction like revenge. But
man finds a substitute for this action in speech through which help
the affect can well-nigh be ab-reacted ⁸ (abreagirt). In other cases
talking in the form of deploring and giving vent to the torments of
the secret (confession) is in itself an adequate reflex. If such
reaction does not result through deeds, words, or in the most
elementary case through weeping, the memory of the occurrence
retains above all an affective accentuation.

The “ab-reaction,” however, is not the only form of discharge
at the disposal of the normal psychic mechanism of the healthy person
who has experienced a psychic trauma. The memory of the trauma,
even where it has not been ab-reacted, enters into the great complex
of the associations. It joins the other experiences which are perhaps

⁸The German abreagiren has no exact English equivalent. It will, therefore,
be rendered throughout the text by “ab-react”; the literal meaning is to react
away or to react off. It is the act of giving vent in speech and action to
repressed experiences, and thereby disburdening one’s self of their unconscious
influences. It has different shades of meaning, from defense reaction to emo-
tional catharsis, which can be discerned from the context.

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antagonistic to it, and thus undergoes correction through other ideas.
For example, after an accident the memory of the danger and
(dimmed) repetition of the fright is accompanied by the recollection
of the further course, the rescue, and the consciousness of present
security. The memory of a grievance may be corrected by a rectifi-
cation of the state of affairs by reflecting upon one’s own dignity and
similar things. A normal person is in this way capable of dissipating
the accompanying affect by means of association.

In addition, there appears that general blurring of impressions,
that fading of memories which we call “forgetting,” and which above
all wears out the affective ideas no longer active.

It follows from our observations that those memories which
become the causes of hysterical phenomena have been preserved for
a long time with wonderful freshness and with their perfect emotional
tone. As a further striking and a later realizable fact, we have to
mention that the patients do not perhaps have the same control of
these as of their other memories of life. On the contrary, these
experiences are either completely lacking from the memory of the
patients in their usual psychic state, or at most exist in greatly
abridged form. Only after the patients are questioned in the hypnotic
state do these memories appear with the undiminished vividness of
fresh occurrences.

Thus, one of our patients in a hypnotic state reproduced with
hallucinatory vividness throughout half a year everything that excited
her during an acute hysteria on the same days of the preceding year.
Her mother’s diary, which was unknown to the patient, proved the
faultless accuracy of the reproductions. Partly in hypnosis and
partly in spontaneous attacks, another patient lived through with hal-
lucinatory distinctness all experiences of a hysterical psychosis
which she went through ten years before, and for the greatest part
of which she had been amnesic until its reappearance. Also, some
individual memories of etiological importance showed surprising
integrity and sentient force of fifteen to twenty-five years’ duration,
and on their return exerted the full affective force of new experiences.

The reason for this we can seek only in the fact that these memo-
ries occupy an exceptional position in all the above mentioned rela-
tions, as far as vividness is concerned. For it was really shown that
these memories correspond to traumas which were not sufficiently
‘ab-reacted,’ and on closer investigation of the reasons for this

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hindrance, we can find at least two series of determinants through
which the reaction to the trauma was omitted.

To the first group we add those cases in which the patient had not
reacted to psychic traumas because the nature of the trauma pre-
cluded a reaction, or because social relations made the reaction impos-
sible, or because it concerned things which the patient wished to
forget and which he, therefore, intentionally inhibited and repressed
from his conscious memory. It is just such painful things which are
found in the hypnotic state as the basis of hysterical phenomena
(hysterical delirium of saints, nuns, abstinent women, and well-
bred
children).

The second series of determinants is not conditioned by the con-
tent of the memories, but by the psychic states with which the
corresponding experiences in the patient have united. As a cause
of hysterical symptoms, one finds in hypnosis even ideas which are
insignificant in themselves, but which owe their preservation to the
fact that they originated during a severe palayzing affect like fright,
or directly in abnormal psychic conditions, as in the semi-
hypnotic
twilight states of day-
dreaming, in auto-
hypnosis, and similar states.
Here, it is the nature of these conditions which makes a reaction to
the incident impossible.

To be sure, both determinants can naturally unite, and as a matter
of fact, they often do. This is the case when a trauma, in itself
effectual, occurs in a state of a severely paralyzing affect, or from a
transformed consciousness. But it may also happen that the psychic
trauma evokes in many persons one of these abnormal states, which
in turn makes the reaction impossible.

What is common to both groups of determinants is the fact that
those psychic traumas which are not adjusted by reaction are also
prevented from adjustment by associative elaboration. In the first
group it is the resolution of the patient which strives to forget the
painful experiences and in this way, if possible, to exclude them from
association; in the second group the associative elaboration does not
succeed because between the normal and pathological state of con-
sciousness, in which these ideas originated, there is no productive
associative relationship. We shall soon have occasion to discuss more
fully these relationships.

Hence, we can say, that the reason why the pathogenically formed
ideas retain their freshness and affective force is because they are

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not subject to the normal fading through abreaction and through
reproduction in states of uninhibited association.

III

When we discussed the conditions which, according to our experi-
ence, are decisive in the development of hysterical phenomena from
psychic traumas, we were forced to speak of abnormal states of con-
sciousness in which such pathogenic ideas originate, and we had to
emphasize the fact that the recollection of the effectual psychic
trauma is not to be found in the normal memory of the patient, but
in the hypnotized memory. The more we occupied ourselves with
these phenomena the more certain became our convictions that the
splitting of consciousness, so striking in the familiar classical cases of
double consciousness, exists rudimentarily in every hysteria, and that
the tendency to this dissociation, and with it the appearance of abnor-
mal states of consciousness which we comprise as “hypnoid,” is the
basic phenomenon of this neurosis. In this view we agree with Binet
and Janet, though we have had no experience with their remarkable
findings in anesthetic patients.

Hence, to the often cited axiom, “Hypnosis is artificial hysteria,”
we should like to add another: “The existence of hypnoid states is
the basis and determination of hysteria.” These hypnoid states agree
in all their diversities among themselves and with hypnosis in the
one point, namely that the ideas arising in them are very intensive,
but are excluded from associative relations with the rest of the content
of consciousness. These hypnoid states are associable among them-
selves, and their ideation may thus attain various high degrees of
psychic organization. In other respects the nature of these states
and the degree of their exclusiveness differ from the rest of the con-
scious processes, as do the various states of hypnosis, which range
from light somnolence to somnambulism, and from perfect memory
to absolute amnesia.

If such hypnoid states have already existed before the manifest
disease, they prepare the soil upon which the affect establishes the
pathogenic memories with their resulting somatic manifestations.
This behavior corresponds to hysteria, based on a predisposition.
But our observations show that a severe trauma (like a traumatic
neurosis) or a severe suppression (perhaps of a sexual affect) may
bring about a splitting of ideas even in persons without predispo-
sitions. This represents the mechanism of the psychically acquired

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hysteria. Between these two extremes we have a series, in which
the facility of dissociation in a particular individual and the magni-
tude of the affective trauma vary inversely.

We are unable to say anything new as to the determination of the
predisposed hypnoid states. We presume that they often develop
from “reveries,” which are so frequent even in normal persons, for
which, for example, the feminine handwork offers so much oppor-
tunity. The questions why “the pathological associations” formed
in such states are so firm, and why they exert a stronger influence
on the somatic processes than other ideas, are all indissolubly
linked with the problem of the effectiveness of hypnotic suggestions
in general. Our experiences in this matter do not show us anything
new; but they rather throw light on the contradiction between the
statement, “Hysteria is a psychosis,” and the fact that among
hysterics one may meet persons of the clearest intellects, the strongest
wills, greatest principles, and of the subtlest minds. In these cases
such characteristics hold true only in the person’s waking thought;
in his hypnotic state he is alienated just as we all are in our dreams.
Yet, whereas our dream psychoses do not influence our waking
state, the products of hypnotic states are projected into the waking
state, as hysterical phenomena.

IV

Almost the same assertions that we have advanced about hysteri-
cal symptoms we may also repeat concerning hysterical attacks. As
is known, we have Charcot’s schematic description of the “major”
hysterical attack, which in complete form shows four phases: (1) The
epileptoid, (2) the major movements, (3) the attitudes passionelles
(hallucinatory phase), and (4) the concluding delirium. By shorten-
ing or prolonging the attack and by isolating the individual phases,
Charcot obtained all those forms of the hysterical attack, which are
really observed more frequently than the complete grande attaque.

Our tentative explanation refers to the third phase, the attitudes
passionelles. Wherever it is prominent, it contains the hallucinatory
reproduction of a memory which was significant for the hysterical
onset. It is the memory of a major trauma, the κατ ἐξοχήν of the
so-called traumatic hysteria, or of a series of partial traumas belong-
ing together as they are found at the basis of the ordinary hysteria.
Or, finally the attack may bring back those occurrences which,

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because of their encounter with a factor of a special predisposition,
have become raised to traumas.

But there are also other attacks which ostensibly consist only of
motor phenomena and lack the passionelle phase. If it is possible
during such an attack of general twitching, cataleptic rigidity or an
attaque de sommeil, to put one’s self en rapport with the patient, or
still better, if one succeeds in evoking the attack in a hypnotic state,
it will then be found that here, too, the root of it is the memory of a
psychic trauma, or of a series of traumas which make themselves
otherwise prominent in an hallucinatory phase. Thus, a little girl
had suffered for years from attacks of general convulsions, which
could be, and were, taken for epilepsy. For differential diagnostic
reasons she was hypnotized and she immediately lapsed into one of
her attacks. On being asked what she saw, she said, “The dog, the
dog is coming,” and it actually turned out that the first attack of this
kind appeared after she was pursued by a mad dog. The success of
the therapy then verified our diagnostic decision.

An official, who became hysterical as a result of ill treatment by
his employer, suffered from attacks during which he fell to the floor
raging furiously without uttering a word or displaying any hallucina-
tions. The attack was provoked in a state of hypnosis and he then
stated that he lived through the scene during which his employer
insulted him in the street and struck him with his cane. A few days
later he came to me complaining that he had the same attack, but it
was shown in the hypnosis this time that he went through the scene
which was really connected with the onset of his disease; it was the
scene in the court room, when he was unable to get satisfaction for
the ill treatment which he received, etc.

The memories, which appear in hysterical attacks or which can
be awakened in them, correspond in all other respects to the causes
which we have found as the basis of continuous hysterical symptoms.
Like these, they refer to psychic traumas which were prevented from
adjustment through abreaction or through associative elaboration;
like these, they were absent entirely or in their essential components
in the total memory of normal consciousness, and showed themselves
as parts of the ideation content of hypnoid states of consciousness
with restricted associations. Finally they were also amenable to the
therapeutic test. Our observations have often taught us that a
memory which has hitherto provoked attacks becomes incapable of it

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THE PSYCHIC MECHANISM OF HYSTERICAL PHENOMENA
when it is brought to reaction and associative correction in a hypnotic
state.

The motor phenomena of the hysterical attack can in part be
interpreted as the memory of general forms of reaction of the accom-
panying affect (like the fidgeting of the whole body to which the
infant already resorts), in part as a direct motor expression of this
memory, and in other parts they, like the hysterical stigmata in the
permanent symptoms, elude this explanation.

A special estimation of the hysterical attack is obtained if one also
takes into account the fact that in hysteria there are groups of ideas
which originated in hypnoid states, which are excluded from associ-
ative activity with the rest, but are associable among themselves, and
thus represent a more or less highly organized rudimentary second
consciousness, a condition seconde. A persistent hysterical symp-
tom, therefore, corresponds to an impingement of this second state
upon a bodily innervation otherwise controlled by the normal con-
sciousness. But an hysterical attack gives evidence of a higher
organization of this second state, and if of recent origin, signifies a
moment in which this hypnoid consciousness has gained control of
the whole existence, that is, we have an acute hysteria; but if it is a
recurrent attack containing a memory, we simply have a repetition
of the same. Charcot has already given utterance to the thought that
the hysterical attack must be the rudiment of a condition seconde.
During the attack, the control of the whole bodily innervation passes
over to the hypnoid consciousness. As familiar experiences show,
the normal consciousness is not always entirely repressed by it; it
may even perceive the motor phenomenon of the attack while the
psychic processes of the same escape all knowledge of it.

The typical course of a grave hysteria, as is well known, is as
follows: At first an ideation is formed in the hypnoid state, which,
after sufficient growth, gains control in a period of “acute hysteria”
of the bodily innervation and the existence of the patient, and creates
permanent symptoms and attacks, and with the exception of some
residuum then ends in recovery. If the normal personality can
regain the upper hand, all that has survived the hypnoid ideation
content then returns in hysterical attacks, and now and then it brings
the person back into similar states which are again amenable to
influences and eligible for traumas. Frequently a sort of equilibrium
is then established between the psychic groups which are united in

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the same person; attack and normal life go hand in hand without
influencing each other. The attack then comes spontaneously just
as memories are wont to come, but just like memories it can also be
provoked by the laws of association. The provocation of the attack
results either through stimulating a hysterogenic zone or through a
new experience which by similarity recalls the pathogenic experi-
ence. We hope to be able to show that there is no essential difference
between the apparently two diverse determinants, and that in both
cases a hyperesthetic memory is touched. In other cases this
equilibrium shows a marked lability, the attack appears as a mani-
festation of the hypnoidal remnant of consciousness, as often as the
normal person becomes exhausted and functionally incapacitated.
We cannot disregard the fact that in such cases the attack becomes
stripped of its original significance and may return as a contentless
motor reaction.

It remains a task for future investigation to discover what con-
ditions are decisive in determining whether an hysterical individuality
should manifest itself in attacks, in persistent symptoms, or in a
mingling of both.

V

We can now understand in what manner the psychotherapeutic
method propounded by us exerts its curative effect. It abrogates the
efficacy of the original non-abreacted ideas by affording an outlet to
their strangulated affects through speech. It brings them to associ-
ative correction by drawing them into normal consciousness (in mild
hypnosis) or by eliminating them through medical suggestion in the
same way as in somnambulism with amnesia.

We maintain that the therapeutic gain obtained by applying this
process is quite significant. To be sure, we do not cure the hysteria
insofar as it represents a predisposition, for we really do not block
the way for the recurrence of hypnoid states. Nor is our procedure
capable of preventing the replacement of the laboriously abrogated
phenomena by new ones. But once this acute stage has run its
course and its remnants continue as permanent hysterical symptoms
and attacks, our radical method can frequently remove them forever,
and herein it seems to surpass the efficacy of direct suggestion, as
practised at present by psychotherapists.

If by disclosing the psychic mechanisms of hysterical phenomena

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we have taken a step forward on the path so successfully started by
Charcot with his explanation and experimental imitation of hystero-
traumatic paralysis, we are well aware that in so doing we have only
advanced our knowledge in the mechanisms of hysterical symptoms
and not in the subjective causes of hysteria. We have grazed only
the etiology of hysteria, and can only throw light on the causes of
the acquired forms, i.e., on the significance of the accidental factors
of the neurosis.