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CHAPTER III

THEORETICAL MATERIAL

By Dr. J. BREUER

In the “preliminary communication,” which introduces these
studies, we have presented the views to which we were led by our
observations; and I believe that essentially we can adhere to them.
But the “preliminary communication” is so short and scanty that
for the most part we could only indicate what we meant. May we,
therefore, be permitted now that we have illustrated our views with
case histories to discuss these in detail. Naturally, we shall not,
and cannot here deal with the “whole problem of hysteria,” but
those points which have been insufficiently proven and only feebly
stressed in the “preliminary communication” will receive a more
exhaustive, more intelligible, as well as a more restricted discussion.

In these discussions there will be little talk of the brain and
nothing at all of molecules. Psychic processes will be dealt with in
psychological language, for it cannot really be done in any other
way. If instead of “idea” we should say “cortical irritation,” the
latter expression will only convey some sense through the fact that
we will recognize in the disguise our old acquaintance, and thus
quietly restore the “idea.” For while ideas with all their nuances
are familiar to us as objects of our experience, “cortical irritations”
impress us more as a postulate, as an object of future and hoped for
cognition. Such substitution of terms seems only an aimless
masquerade.

We may, therefore, be pardoned for making almost exclusive
use of psychological terminology.

Just now I must also request your consideration for other things.
Wherever a science marches rapidly forward, thoughts which have
at first been expressed by individuals soon become common property.
Thus, no one who attempts to demonstrate today his views on hysteria
and its psychic foundation can avoid expressing and repeating a
multitude of other people’s thoughts, which have passed over from
individual to common possession. It is hardly possible always to
verify who expressed them first. There is also the danger that one

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will consider a product of his own that which has already been said
by others. We may, therefore, be excused if we give here only few
citations, and if we do not sharply distinguish between that which is
ours and that which belongs to others. What will be discussed in
the following pages makes the least claim to originality.

I. Are All Hysterical Phenomena Ideogenic?

In the “preliminary communication” we spoke of the psychic
mechanisms of “hysterical phenomena” and not of “hysteria,”
because we did not wish to claim unrestricted validity for either the
former or for the psychic theories of the hysterical symptoms in
general. For we do not believe that all the manifestations of hysteria
come into being in the manner presented by us, nor do we feel that
they are all ideogenic, i.e., that they are all determined by ideas. In
this we differ from Moebius,¹⁾ who, in 1888, proposed the following
definition: “Hysterical are all these morbid manifestations which
are caused by ideas.” This statement was later explained by the
fact that only a part of the morbid phenomena corresponds contently
to the causative ideas, namely, those symptoms which were produced
by suggestion from within or from without, as, for example, when
the idea, not to be able to move the arm, conditions a paralysis of
the same. Another part of the morbid phenomena may, indeed, be
caused by ideas, but need not contently correspond to them; as for
example, when (as happened in one of our cases) the paralysis of
the arm was produced by the sight of snake-
like objects.

Moebius does not perhaps wish to advocate with this definition
a change in the nomenclature, he does not imply that hereafter only
those ideogenic morbid phenomena which are determined by ideas
should be called hysterical, but he really means that all hysterical
morbid manifestations are ideogenic. To put it in his own words:
“Because ideas are very frequently the cause of hysterical mani-
festations, we believe that they are always so.” He calls this a con-
clusion by analogy, but I would prefer to call it a generalization, the
justification for which must first be investigated.

It would seem that before entering into any discussion one should
first decide what we understand by hysteria. I consider hysteria
something that was empirically discovered, it is a morbid picture
which discovered through observation just like tuberculosis of the

¹⁾Moebius, Über den Begriff der Hysterie. Wiederabgedruckt, in “Neuro-
logische Beiträge,” I Heft, 1894.

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lungs. Such empirically discovered diseases become refined, deep-
ened, and explained through the progress of further cognition, but
they shall not and cannot be destroyed thereby. Thus, etiological
investigation has shown that the various partial processes of phthisis
may be determined by various morbid processes, the tubercle through
Koch’s bacillus, the tissue breakdown, the cavity formation, or the
septic fever through other microbes. Nevertheless, tubercular
phthisis remains a clinical entity, and it would be wrong to destroy
it by adjudging it only as the “specific tuberculosis” conditioned by
the tissue destruction of Koch’s bacillus, and to separate it from all
the others.—In the same way we must also preserve the clinical entity
of hysteria, even if it turns out that its phenomena are conditioned
by various causes, some through a psychic mechanism, while others
through different causes.

According to my conviction, this is really the case. Only one
part of the hysterical mechanism is ideogenic, and Moebius’ assump-
tion, judging from his definition, tears asunder the clinical entity of
hysteria, indeed also the entity of one and the same symptom in one
and the same patient.

We would be quite justified to draw the analogous conclusion to
Moebius’ analogous conclusion, namely, that: “Because ideas and
perceptions very often evoke an erection, we assume that they alone
always do this, and that even peripheral stimuli can release that
vasomotor process only through detours over the psyche.” We know
that this is a mistake, yet this conclusion is surely based on as many
facts as Moebius’ statement about hysteria. Analogous to a large
number of physiological processes, such as saliva and tear secretions,
changes of the heart action and similar ones, it may be assumed as
possible and probable that the same process can be released through
ideas, as well as through peripheral or other stimuli, but not through
psychic stimuli. The contrary must first be proved, and we are still
far from it. Indeed, it seems certain that many of the phenomena
designated as hysterical are not solely caused by ideas.

Let us consider a very ordinary case. As a result of every affect
in the throat, chest, and face, a woman gets first a macular and then
a patchy erythema. As this is conditioned by ideas, it is, according
to Moebius, an hysterical phenomenon. But as the same erythema
also appears, albeit in lesser dissemination, through irritation of the
skin, through touch, etc., this would, therefore, not be hysterical.
Thus, a perfectly unified phenomenon would now belong to hysteria

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and the next time it would not. It is also doubtful whether this
belongs to the vasomotor erethisms or whether it really belongs to
the specific hysterical manifestations, or whether it would not be
better to put it under simple “nervousness.” But, according to
Moebius, that disintegration of a unified process must take place in
any case, and only that erythema which is affectively determined could
be designated as hysterical.

The same is also the case in hysterical algias which are of such
practical importance. They are surely very frequently conditioned
by ideas, they are “pain hallucinations.” But when we examine them
more thoroughly we find that a marked vividness of imagination is
not enough to produce them, but that their origin depends on an
especially abnormal state of the pain conducting and sensitive appa-
ratus, just as an abnormal irritability of the vasomotors is required
for the production of the affective erythemas. The term, “pain hal-
lucinations,” surely designates the nature of this neuralgia in the
most pregnant manner, but it also impels us to classify it under the
views which we have formulated concerning hallucinations in general.
To discuss these exhaustively is not in place here. But I profess the
opinion that the “idea” of the memory picture alone, without the
incitement of the perception-apparatus, despite its greatest vividness
and intensity, would in itself never attain that character of objective
existence which constitutes an hallucination.²⁾

This holds true for sensory hallucinations and still more for pain
hallucinations. For it seems impossible for a healthy person to fur-
nish the memory of a bodily pain with that vividness or even with a
slight resemblance to the real feeling which can be readily attained
through optical and acoustic memory pictures. I believe that even
in the normal hallucinatory state of the healthy person, that is, in

²⁾This perception apparatus, including the cortico-sensory spheres, must be
different from the organ which preserves and reproduces sensory impressions
as memory pictures. For the main determinant of the function of the perception
apparatus lies in the quickest restitutio in statum quo ante; otherwise, no other
correct perception could take place. On the other hand, the condition of
memory lies in the fact that there is no such restitution, but that every percep-
tion creates permanent changes. It is impossible that one and the same organ
should suffice for both contradictory conditions; the mirror of a reflection
telescope cannot at the same time be a photographic plate. I agree with
Meynert in the sense that the stimulation of the perception apparatus—not with
the definite statement that the irritation of the subcortical centers—furnishes
the hallucination the character of objectivity. But if the organ of perception
should become stimulated by the memory picture, we must assume that there
is a changed stimulus contrary to the normal, which makes the hallucinations
possible.

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THEORETICAL MATERIAL

sleep, pains are never dreamed unless there exists a real sensation
of pain. The “retrograding” irritation of the perception apparatus
emanating from the organ of memory is normally even more difficult
when it concerns ideas of pain than visual and auditory sensations.
If pain hallucinations appear in hysteria with such ease, we must,
therefore, assume that there is an anomalous irritation of the pain
sensing apparatus.

This appears not only through ideas, but also through peripheral
stimuli brought into existence precisely as in the above considered
vasomotor erethisms.

It is an every day observation that in normally nervous persons
peripheral pains of pathological processes, though in themselves not
of a painful nature, may produce pain in other organs. Thus, we
have headaches as a result of some insignificant changes in the nose
and the adjacent sinuses, intercostal and brachial neuralgias from
endocarditis, etc. If a patient is endowed with that abnormal sensi-
tiveness which we have to assume as a condition for pain hallucina-
tions, this predisposition is also, as it were, at the disposal of the
above mentioned irradiations. But even those which occur in non-
nervous persons sometimes become more intensive, and then form
such irradiations, which we find in only nervous patients, but which
are, however, conditioned by the same mechanisms as the others.
Thus, I believe that an ovaritis depends on the states of the genital
apparatus. That it is psychically influenced would have to be proven,
but it has not been demonstrated because this, like any other pain,
could be hallucinatorily produced in hypnosis, or because it can also
be of psychic origin. Just like erythema or like one of the normal
secretions it may originate through psychic or through purely somatic
causes. Should we then call only the first kind hysterical? The one,
whose psychic origin we know? Then, we would really have to
eliminate the commonly observed ovaritis from the hysterical symp-
tom complex, which is hardly possible.

If, following a slight trauma of a joint, there gradually develops
a severe neurosis of this region, this process surely contains a psychic
element. It is due to the concentration of attention on the injured
region which enhances the sensibility of the nerve path in question;
yet, one can hardly say that this hyperalgesia was conditioned by ideas.

Nor is there anything different in the case of pathological
diminution of feeling. It is altogether unproved and improbable
that general analgesia, or analgesia of individual parts of the body

138

without anesthesia is determined by ideas. And even if Binet’s and
Janet’s discoveries should be fully confirmed, namely that hemi-
anesthesia is conditioned by the special state of psychic splitting, it
would indeed, be a psychogenetic, but not an ideogenic phenomenon,
and hence, according to Moebius it could not be called hysterical.

Hence, if we cannot assume that a large number of characteristic
hysterical phenomena are ideogenic, it seems only fair to reduce
Moebius’ statement. We do not say that, “Those morbid mani-
festations are hysterical, which are caused by ideas”; but we only
mention that a great many of the hysterical phenomena, probably
more than we know today, are ideogenic. But the common and
fundamental morbid change, which makes it possible for the ideas
as well as for the non-psychological stimuli to act pathogenically, is
an anomalous irritation of the nervous system.³ To what extent
this is in itself of psychic origin is another question.

If, therefore, only one part of the hysterical phenomena should
be considered ideogenic, it should be just these phenomena which
can be designated as specifically hysterical, and hence, their investi-
gation, the exposition of their psychic origin, constitutes the essential
and new progress in the theory of the disease. The question that
then arises is: How do they come about, and what is the “psychic
mechanism” of these phenomena?

The two groups of ideogenic symptoms differentiated by Moebius
assume essentially different attitudes to this question. Those, in
which the morbid phenomenon corresponds to the exciting idea, are
relatively comprehensible and transparent. If the idea of a voice
heard does not simply quietly resound in the “inner hearing” as
in a healthy person, but is perceived hallucinatori-
tive auditory sensation, it thus corresponds to a familiar phenomenon
of normal life (dream), and is quite comprehensible under the
assumption of abnormal irritability. We know that in every volun-
tary motion it is the idea of the result to be attained that releases the
corresponding muscular contraction. It is also quite comprehensible
that the idea, “this is impossible,” will impede the movement (sug-
gestion paralysis).

³Oppenheim’s “Labilität der Molecüle.” It may later perhaps be possible to
substitute the above very vague expression by a more precise and contently
richer formula.

139

The situation is different in those phenomena which have no
logical connection to the causative idea. (For these, too, normal life
offers analogies, as, e.g., erythrophobia, etc.). How do these come
about, why does an idea release in a sick person just this particular,
quite irrational, and not its corresponding movement or hallucination?

We believed that we were able to present something in the “pre-
liminary communication” concerning this causal connection, which
was based on our observation. But in our exposition we have
initiated and utilized, without anything further, the concept “of the
excitement which is discharged or must be abreacted.” Still, this
concept of such fundamental importance for our theme and for the
theory of the neuroses in general, seems to merit a more detailed
examination. But before proceeding to it, I must ask forgiveness
for returning here to the fundamental problem of the nervous system.
Such “return to mother” has something oppressive about it, but an
attempt to uncover the roots of a manifestation always leads unavoid-
ably to the root of the problem, which cannot be avoided. I, there-
fore, hope that the abstruseness of the following considerations will
be judged with consideration.

II. The Intercerebral Tonic Excitements—The Affects

A. We know two extreme states of the central nervous system,
dreamless sleep and clear wakefulness. The transition between them
is formed by all gradations of states of lesser clearness. We are not
interested here in the question of the aim and the physical basis of
sleep (chemical or vasomotor determinants), but in the essential
differences between the two states.

We cannot say anything directly concerning the deepest dream-
less sleep, because every observation and experience is excluded
through that very state of perfect unconsciousness. But concerning
the neighboring state of dream-sleep, we know that there is an effort
of voluntary movements, such as speaking, walking, etc., but that
unlike in the waking state, the corresponding muscular contractions
are not actually released thereby. Sensible stimuli are perhaps per-
ceived (for they frequently enter into the dream), but not apper-
ceived, that is, they do not reach to conscious perception. Unlike
the waking state, emerging ideas do not actuate all the existing ideas
connected with them in potential consciousness, but large masses of
them remain untouched (as, for example, speaking with a dead
person without being reminded of death). Moreover, incompatible

140

ideas can exist simultaneously without reciprocal impediment as in
the waking state, and the associations flow scantily and incompletely.
We can readily assume that in the most profound sleep this abolition
of connection between the psychic elements is even more marked, it
is complete.

In contrast to this, every voluntary act in clear wakefulness pro-
duces the corresponding movement, the sensible impressions become
perceptions, and the ideas become associated with the whole posses-
sion of the potential consciousness. The brain is then a functioning
entity with perfect inner association.

It is perhaps only a paraphrasing of this fact when we say that
during sleep the association and conducting cerebral tracks, though
not awake, are perfectly accessible to stimuli of the psychic elements
(cortical cells?).

The existence of these two different states of the conducting paths
becomes comprehensible only through the assumption that during
wakefulness they are in a state of tonic excitement (Exner’s inter-
cellular tetanus); that this tonic intracellular excitement conditions
the conducting capacity, and that its decrease and disappearance
brings about the actual state of sleep.

We should not imagine that a cerebral (conducting) path is like
a telephone wire which is only stimulated by electricity when it
functions, that is, when it carries a signal; but rather as one of these
telephone conduits through which there runs a constant galvanic
stream and which becomes inactive when the latter stops.–Or per-
haps better still, let us imagine an elaborate electrical system for
transmission of light and motive power, which is to put into opera-
tion every light and motor by the simple production of a contact.
In order to make this possible for the purpose of preparedness for
work, it requires a certain sum of tension in the whole conduction
net, even during the functional rest, which in turn necessitates an
expenditure of a definite sum of energy by the dynamo.–Likewise,
there exists a certain amount of excitability in the conducting paths
of the resting, wakeful brain, which is always ready to function.⁴⁾

⁴⁾It is permitted here to allude briefly to the idea which lies at the basis of
the above discussion. We usually think of the sensory nerve cells as a passive
receptive apparatus, which is unjust. For the very existence of the system of
association fiber shows that excitement flows from them into the nerve fibers.
There must be a state of tension in a nerve fiber which connects two motor
cells by continuity or contiguity if excitement flows into it from both cells.
This state influences the discharging excitement, e.g., in a peripheral motor
fiber, as hydrostatic pressure to the force of the flowing water, or like electric

141

In favor of this view is the fact that the waking state itself, even
without any functional activity, causes fatigue and a need for sleep;
it conditions in itself an expenditure of energy.

Let us imagine a man in a state of expectant tension, which is
not, however, confined to a sensory region. We are then confronted
with a quiescent, but ready to function, brain. We may even assume
that all the conducting paths are here adjusted to the maximum of
their functional capacity; that is, they are in a state of tonic excite-
ment. Language justly designates this state by the word “tension.”
Experience teaches how exerting and exhausting this state is, in
which, however, no motor or psychic work has actually been
performed.

This is an exceptional state, which just because of its large
expenditure of energy cannot be long endured. But also the normal
state of clear wakefulness produces intercerebral excitement, which
shows moderate fluctuations corresponding in their diminution of
the state of excitement to the various shades of consciousness from
wakefulness to sleepiness and to actual sleep.

Real functional activity of the brain certainly requires a larger
expenditure of energy than the mere readiness for work (as in the
above given example of the electrical system, a larger amount of
electrical energy must be passed through the conduits if many lights
and machines are switched for action). In normal functioning no
more energy is set free than is immediately consumed in the par-
ticular activity. But the brain behaves like such a system of restricted
functional capacity, which cannot perhaps simultaneously produce
large amounts of light and mechanical work. If the motive power
transmission functions, there is little energy available for lighting,
and vice versa. Thus, we see that in strong muscular exertion it is
impossible to think continuously, that concentration of attention on
one sensory sphere diminishes the functional capacity of other
cerebral organs; in brief, that the brain works with an alternating,
but restricted mass of energy.

The unequal distribution of energy is probably conditioned by

tension to the electric stream. If all the nerve cells are in a state of average
excitement and stimulate their nervous appendages, the whole enormous net-
work then forms a unified reservoir of “nerve-tension.” Hence, besides the
potential energy, which is in the chemical composition of the cell and that, to
the unknown form of kinetic energy which discharges in the state of excitement
of the fiber, we must assume still another, as it were, resting state of nervous
excitement, or the tonic excitement of the nervous system.

142

the “attentional paths” (Exner) in that the conductive capacity of
the utilized paths is heightened and that of the others diminished,
and so also is the “intercerebral tonic excitement” unequally dis-
tributed in the active brain.⁵

We awaken a sleeper; that is, we suddenly increase the quantum
of his tonic intercerebral excitement by allowing a vivid sensory
stimulus to influence him. Whether the changes caused thereby in
the cerebral circulation are essential links in the causal chain, whether
the blood vessels are primarily dilated through the stimulus, or
whether this is the result of the excitement of the cerebral elements—
all this is undecided. Certain it is, that the state of excitement forced
in through a sensory gate afterwards spreads over the brain, becomes
diffused, and puts all paths in a higher state of activity.

How spontaneous awakening occurs, whether one and the same
cerebral region always first merges into the state of being awakened,
and then functions as an awakener now on one, now on the other
group of elements—all this is not perfectly clear.

Nevertheless, spontaneous awakening, which also occurs in per-
fect rest and darkness without outer stimuli, demonstrates that the
development of energy in the life process of the cerebral elements is
self-conditioned.

The muscle remains unstimulated and quiet no matter how long
it has rested and accumulated in itself the maximum of tensions. But
this is not so with the cerebral elements. We justly assume that in
sleep they restore their stability and gather tension. If that continues
up to a certain degree, if it reaches, so to say, a certain level, the
excess flows off into paths, forms connections, and produces the intra-
cerebral excitement of waking.

We can observe the same process in an instructive manner in the
waking state. If the waking brain remains long in a state of rest,
without changing tension into living energy through functioning,
there appears the need and urge for action. Long motor rest pro-
duces the need for motion (aimless movements of animals in cages)
if that need cannot be gratified. Lack of sensory impressions, such
as darkness and soundless quietude become painful; mental rest,
absence of perceptions, ideas and association activity, produce the

⁵The conception of the energy of the central nervous system as a quantity
of fluctuating and alternating distribution over the brain is old. Cabanis states:
“La sensibilité semble se comporter à la manière d’un fluide dont la quantité
totale est déterminée et qui, toutes les fois qu’il se jette en plus grande
abondance dans un de ses canaux, diminue proportionellement dans les autres.”
Cited from Janet, État mental II, p. 277.

143

torture of monotony. These painful feelings correspond to an
“agitation,” or to an enhancement of the normal intracerebral
excitement.

The perfectly restored cerebral elements, therefore, set free a
certain amount of energy even in a state of rest, which if not func-
tionally utilized increases the intracerebral excitement. This pro-
duces a feeling of pain, which always originates when a need of the
organism finds no gratification. But as those mentioned here vanish,
when the free excessive quantity of excitement is functionally
utilized, we conclude that this abrogation of excessive excitement is
a need of the organism, and for the first time we encounter here the
fact that in the organism “there is a tendency to preserve at a constant
level the intracerebral excitement” (Freud).

An excess of it becomes burdensome and annoying, and there
then arises an urge to consume it. If it cannot be consumed through
sensory or ideational activity the excess flows off in aimless motor
action, in up and down or similar motions, a behavior which we shall
encounter later as the most frequent manner of discharging excessive
tension.

How great the individual difference is in this respect is well
known. Note, for example, the marked difference between vivacious
and indolently torpid persons; those who cannot sit quietly, from
those who show a congenital talent for warming the arm-chair; those
who are mentally alert, from those who are so dull as to tolerate an
immeasurable period of rest. These differences, which constitute the
“emotional temperament” of people, surely depend upon profound
differences of their nervous system; that is, on the amount of energy
set free by the functionally resting cerebral elements.

We spoke of a tendency of the organism to preserve at a constant
level the tonic cerebral excitement; but this can be understood only
if we can see what need will, thereby, be fulfilled. We comprehend
the tendency to preserve the average temperature at a constant level
in the mammalia, because experience teaches us that this is the
optimum of organic functioning. A similar constancy we also pre-
supposed for the amount of water in the blood, etc. I believe that we
can also assume a level of the intracerebral tonic excitement, namely,
that it also has an optimum. On this level of tonic excitement, the
brain is accessible to all external stimuli, the paths between the
reflexes are open, but only to the extent of normal reflex activity.
The sum of ideas is accessible to stimuli and associations in that

144

reciprocal and relative relation of the single ideas, which corresponds
to clear presence of mind. It is the state most suitable for action,
But that uniform increase of the tonic excitement, which constitutes
“expectation” already changes this relationship. It causes hyper-
esthesia of the sense organs, which soon becomes painful, and raises
the reflex irritability beyond the useful need (frightfulness). This
state is surely useful for some situations and purposes, but if it
appears spontaneously without such preliminary condition it does
not improve our functional capacity, on the contrary, it hurts it. In
ordinary life we call this “to be nervous.” By far in the greater
number of forms of increased excitement we deal with dispropor-
tionate overexcitement which is directly damaging to the functional
capacity. We designate this as “agitation.” It is not inconceivable,
but in analogy to other regulations of the organism, it strives to
adhere to the optimum of excitement and to reattain it after it has
exceeded its level.

We may here again be permitted to return to the comparison of
the electric light system. The tension in the net of distribution has
also such an optimum; if it is exceeded the function is easily dam-
aged, as, for example, through the rapid burning out of the incandes-
cent wires. Concerning the damage to the system itself through
“short-circuiting,” etc., we will speak later.

B. Our language, which is the resultant of the experience of
many generations, distinguishes with admirable precision those forms
and degrees of increase of excitement which are still useful to the
psychic activity, because they equally raise the free energy of all
cerebral functions, from those which damage the same, because dis-
proportionately they partly enhance and partly inhibit the psychic
functions.

It designates the first as inciting or stimulating and the second as
exciting. An interesting conversation, tea, or coffee, incites or stimu-
lates, while a quarrel, or a larger dose of alcohol excites. While
incitement only awakens the impulse for functional utilization of
enhanced irritability, excitement seeks disburdenment in a more or
less violent manner; it either verges on or constitutes a real patho-
logical process. It forms the psycho-physical foundation of the
affects, of which we shall say more in the following chapter, but before
this we must still rapidly touch on the physiological or endogenic
causes of increased excitement.

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THEORETICAL MATERIAL

These constitute, in the first place, the great physiological needs
and impulses of the organism, such as hunger for oxygen and for
nourishment, and thirst. As the excitement, which they produce,
becomes connected with definite sensations and aims, it cannot be as
well observed as the pure enhancement of excitement in those dis-
cussed above, which originate only through rest of the brain elements.
It always has its special coloring, but it is unmistakable in the anxious
excitement of dyspnoea, as well as in the restlessness of those who
are starving.

The increased excitement, which is discharged from these sources,
is conditioned by chemical changes of the brain elements themselves,
which are short of oxygen, or by tension, or by water. It is dis-
charged through preformed motor paths which lead to gratification
of the generated need. The dyspnoea through the exertion of the
breath, hunger and thirst, through seeking and obtaining nourish-
ment and water. The principle of constancy of excitement hardly
comes into play in this excitement, for the interests served by this
increase of excitement are more important for the organism than for
the restoration of the normal functional relations of the brain. To
be sure, we see the animals in the menagerie running to and fro
excitedly in their cages before the feeding hour, but this may well be
a remnant of the preformed motor activity of searching for nourish-
ment, which became aimless through captivity, and may, therefore,
not be a means of freeing the nervous system from excitement.

If the chemical structure of the nervous system has become per-
manently changed through a continuous supply of foreign material,
the lack of these excitable states, conditions the excitement of
abstinence from narcotics, in the same way as the lack of normal
nourishing material in a healthy person.

The transition from these endogenic enhancements of excitement
to the psychic affects in the narrower sense is formed by the sexual
excitement and the sexual affect. Sexuality appears first as a vague,
indefinite and aimless advancer of excitement during puberty. In
the further course of its development there normally occurs a firm
association between this endogenic increase of excitement, glands,
and the perceptions or ideas of the opposite sex. This is glaringly
observed in the wonderful phenomenon of being in love with a single
person. This person becomes endowed with the whole quantity of

146

excitement set free by the sexual instinct; she becomes, so to say,
an “affective idea.” That is, in assuming actuality in consciousness,
she sets free the increased excitement which really originates in
another source, namely, in the sexual glands.

The sexual instinct is certainly the mightiest source of long and
continual increase of excitement, and as such, also of neuroses. This
increase is most unequally distributed in the nervous system. In
higher grades of intensity the flow of ideas is disturbed, the relative
value of ideas is altered, and in the orgasm of the sexual act thought
is almost entirely extinguished.

Also, perception, that is, the psychic elaboration of the sensory
feeling, suffers. The animal, which is ordinarily shy and careful
becomes blind and deaf to danger. On the other hand, at least in
the male, there results an increase in the intensity of the aggressive
impulse, the hitherto peaceful animal becomes dangerous, until the
excitement is discharged in the motor functions of the sexual act.

C. A similar disturbance of the dynamic equilibrium in the
nervous system, the disproportionate distribution of the increased
excitement, constitutes the psychic side of the affect.

We shall not attempt to give here either a psychology or a
physiology of the affects. Only one single point of pathological
importance will be examined, namely, the one referring to the
ideogenic affects, or to those which are produced by perceptions and
ideas. Lange ⁶ has justly pointed out again that the affects can
almost entirely be conditioned by toxic material, as demonstrated by
psychiatry, primarily through pathological changes, as well as by
ideas.

There is hardly any need for further confirmation of the fact that
all these disturbances of the psychic equilibrium, which we call acute
affects, appear with an increase of excitement. (In the chronic
affects, such as grief and worry, i.e., in protracted anxiety, there is
the complication of a deep state of exhaustion, which produces an
unequal distribution of excitement and with it a disturbance of
equilibrium, but it diminishes its height.) But this increased excite-
ment cannot be utilized in psychic activity. All strong. affects
infringe upon the associations of the trend of ideas. In anger and
fear one becomes “mad.” Only that group of ideas which has stimu-

⁶Lange, Über Gemütsbewegungen, 1887.

147

lated the affect persists in consciousness with highest intensity, so
that a balancing of the excitement through associative activity is
impossible.

However, the “active,” “sthenic” affects equalize the increased
excitement through motor discharge. The jubilance and leaping of
pleasure, the increased muscular tone in anger, the angry speech, and
the rewarded deed, all permit a discharge of excitement through
acts of motion. Psychic pain disburdens the same in respiratory
exertions and in a secretory act, such as sobbing, weeping. That
these reactions decrease the excitement and calm is a matter of
everyday experience. As already mentioned, language expresses this
in such terms as to “weep one’s self out,” “to spend one’s rage,”
etc.; what is really given or spent thereby is the increased cerebral
excitement.

Only some of these reactions are purposeful, insofar as they
change something in the situation, as in the case of an angry actor’s
speech. The others are entirely aimless, or better, they have no other
aim than to adjust the increased excitement and to establish the
psychic equilibrium. Insofar as they accomplish this, they serve the
“tendency to preserve a constant level of the cerebral excitement.”

The “asthenic” affects of fright and anxiety lack this reactive
disburdening. Fright paralyzes quite directly the motility as well as
the associations, and likewise anxiety, if we exclude the one pur-
poseful reaction of running away through the cause of the anxiety
affect and other circumstances. The excitement of fear disappears
only through gradual settlement.

Anger is discharged in adequate reactions, which correspond to
its causation. Should this become impossible through inhibition,
substitutes takes its place, the angry speech is a case in question.
But also other, quite aimless acts can take its place. If one has
to suppress his angry excitement before his superior, he may alleviate
his feeling by smashing a costly vase. This voluntary replacement
of a motor act by another, corresponds altogether to the substitu-
tion of the natural pain-reflex by another muscular contraction; the
preformed reflex at a tooth extraction is to push the doctor away
and cry. If instead we contract the arm muscles by pressing against
the chair, we thus transfer the sum of excitement of the released
pain from one group of muscles to another. In a spontaneous, severe
toothache, which has no preformed reflex besides groaning, the
excitement manifests itself in a to and fro aimless running. In the

148

same way we transport the excitement of anger from the adequate
reaction to others, and feel relieved only if it is consumed through a
strong motor innervation.

However, if the affect is altogether prevented from such a dis-
charge of excitement, the state of affairs is the same in anger as it
is in fear and anxiety, namely, the intracerebral excitement becomes
enormously increased, but is neither utilized in associative or motor
activity. In the normal person the disturbance gradually settles
down, but in some it produces anomalous reactions, or Oppenheim’s
“anomalous expression of the emotions.”

III. The Hysterical Conversion

It will hardly arouse the suspicion that I identify nervous excite-
ment with electricity if I once more return to its comparison with
an electrical system. If the tension in the latter becomes excessive,
there is the danger that some weak spots in the insulation will break
through. Electrical manifestations will then appear in abnormal
places, or if two wires touch it may result in a short circuit. As
a permanent change is produced in these places, the disturbance con-
ditioned by it can always reappear if the tension is sufficiently
increased, because an abnormal path has been established.

I can justly assert that the relationship of the nervous system
is somewhat similar. It is a thoroughly connected entity, but in
many places there are inserted large, yet not insuperable resistances,
which prevent the general and equalized distribution of excitement.
Thus, in the normal, conscious man the excitement from the ideation
system does not pass over to the perceptual systems, we do not halluci-
nate. The nervous apparatus of the important organ-complexes, such
as the circulation, and digestion, are separated by strong resistances
from the organs of ideas, in the interest of security and functional
capacity of the organism; their independence is guaranteed, they are
not directly influenced by ideas. But only resistances of individually
different forces impede the transition of the intracerebral excitement
to the circulatory and digestive apparatus. Between the absolutely
“non-nervous” person–a rare ideal today–whose heart action
remains at a constant level in every state of life, and is only influenced
by the work to be accomplished, who in every danger has a pro-
portionably good appetite and digestion, and the nervous person, in
whom every event produces palpitation and diarrhoea–between
these two we find all gradations of affective excitability.

149

At all events, there are resistances in the normal man against
the transition of cerebral excitement to the vegetative organs. They
correspond to the insulation of electrical conduction. In those places
where they are slightly anomalous, a very tense cerebral excitement
causes a break-
through, and these, the excitements of the affects,
then pass over to the peripheral organ, and bring about the
“anomalous expression of the emotions.”

Of the two conditions just mentioned, one has already been
exhaustively discussed. It represents a high degree of intracerebral
excitement to which both adjustment through psychic, as well as
through motor outlet is closed, or it is too high to be sufficiently
discharged by the latter paths.

The second condition represents an abnormal weakness of the
resistance in individual paths. This weakness may lie in the original
make-
up of the person (congenital disposition), or it can be con-
ditioned by long continued states of excitement, which slacken, as
it were, the structures of the nervous system and reduce all resist-
ances (disposition of puberty), or it may be conditioned by debili-
tating influences, such as diseases, undernourishment, etc. (disposition
of exhaustion). The resistance of an individual path can also become
reduced through a previous disease of the concerned organ, whereby
paths were formed to and from the brain. A weak heart succumbs
more quickly to the influence of the affects than a healthy one. “I
have a sounding board in my abdomen,” said a woman suffering
from a chronic parametritis, “whatever happens awakens the old
pain”—(disposition through local disease).

The motor acts, through which the excitement of the affects is
normally disburdened, are ordinated and coördinated, even if often
aimlessly. But the excessive excitement can get around the coördi-
nating centres, or break through them, and flow off in elementary
movements. In the suckling, besides the respiratory act of crying,
we see only such incoördinated muscular contractions as rearing and
kicking, which are the effects, as well as the expressions, of the
affect. With the advancement of development, the muscles become
more subjected to the domination of coördination and will. But
opisthotonus, which represents the maximum motor strain of the
muscles of the whole body, and the clonic movements of fidgeting
and kicking, remain throughout life as forms of reaction of the
highest excitement of the brain, both for the purely physical expres-
sions of the epileptic attacks, and for the discharge of the highest

150

affects in the form of greater or lesser epileptoid convulsions. (The
purely motor part of the hysterical attack.)

Such abnormal affective reactions certainly belong to hysteria,
but they may also occur outside of this disease; they merely indi-
cate a more or less high degree of nervousness and not necessarily
hysteria. Such phenomena can be designated as hysterical only if
they appear not as results of high graded, but objectively conditioned
affects, but seemingly spontaneously, as morbid manifestations. Many
observations, including our own, have demonstrated that they are
based on memories which renew the original affect. Or better
expressed, they would renew, if those reactions would not have
already originated before.

Probably in all more active minded people, while psychically
calm, there flows quietly through consciousness a stream of ideas
and memories; most of the time the ideas are hardly vivid enough
to leave any trace, so that one cannot tell how the associations have
taken place. But if an idea comes to the surface which had origi-
nally been connected with a strong affect, it renews itself with greater
or lesser intensity. This so “affectively accentuated” idea then comes
into consciousness clearly and vividly. The force of the affect, which
a memory can release, differs widely, depending on the time it was
exposed to the diverse “usurping” influences. Above all, it depends
on whether the original affect was “abreacted.” In our “preliminary
communication” we have called attention to the various degrees of
affectivity, which are recalled to memory, let us say, in the case of
anger over an insult, which was retaliated or silently endured. If
the psychic reflex actually followed during the original causation, the
memory releases a much smaller quantity of excitement.⁷⁾ If not, the
memory continually forces on one’s lips the scolding words which
were suppressed at the time, and which would have been the psychic
reflex of that stimulus.

⁷⁾The impulse of revenge, which is so strong in primitive man and which in
culture became more masked than suppressed, is really nothing but the excite-
ment of an unreleased reflex. To defend an injury in a fight and thereby
injure the adversary represents an adequately preformed psychic reflex. If
this does not occur, or if it was insufficiently performed, it is then repeatedly
released in memory, and gives origin to the “impulse for revenge,” which like
all other “impulses” is an irrational impulse of the will. The proof of this is
its irrationality, its independence of all usefulness and of all expediency; indeed,
its victory over all consideration of one’s own security. But as soon as the
reflex has been discharged, this irrationality can then come into consciousness.

151

If the original affect was discharged not in a normal, but in an
“abnormal reflex,” the latter, too, is again released by the memory,
and the excitement emanating from the affective idea becomes
converted into a physical phenomenon (Freud).

If this abnormal reflex has carved a perfect path for itself by
means of frequent repetitions, the influence of the freed ideas can
seemingly so fully exhaust itself thereby that the affect itself con-
sists only of minimal strength, or is not at all generated, the “hys-
terical conversion” is then perfect. The idea, however, which now
no longer exerts any psychic influence, can be overlooked by the
individual, or its emergence is soon forgotten just as happens in
other affectless ideas.

Such a substitution of cerebral excitement, which should have
conditioned an idea, by an excitement of peripheral paths, becomes
perhaps more acceptable through the memory of the opposite behavior
at the emission of a preformed reflex. To illustrate this I choose
a most trivial example, the sneezing reflex. If a stimulus of the
mucous membrane of the nose does not for some reason release this
preformed reflex, we know that it produces a feeling of excitement
and tension. It is the excitement which could not now flow off on the
motor paths, which now inhibits every other activity and spreads itself
over the brain. This most banal example offers, nevertheless, the
scheme for the process which also takes place in the omission of
the most complicated psychic reflexes. The above discussed
excitement of the revenge impulse is essentially the same, and we
can pursue this process into the highest spheres of human activity.
Goethe was never through with an experience until he settled it in
some poetic activity; to him this was the preformed reflex of an
affect, and as long as it was not accomplished, he suffered from a
painful enhancement of excitement.

The intracerebral excitement and the process of excitement in
the peripheral paths are of reciprocal magnitude; the former grows
if, and as long as, a reflex is not discharged, and sinks and vanishes
if it has become transformed into peripheral nerve excitement.
Thus, it also seems conceivable that no perceptible affect originates,
if the idea which should have caused it has immediately released an
abnormal reflex through which the generated excitement was at once
discharged. The “hysterical conversion” is then complete, for the
original intracerebral excitement of the affect was changed into the
process of intracerebral excitement of the peripheral paths, and the original

152

affective idea no longer evokes the affect, but only the abnormal
reflex.⁸

With this we have advanced one step further in the study of
the “abnormal expression of the emotions.” The hysterical phe-
nomenon (abnormal reflex) does not seem ideogenic even to intel-
ligent and observing patients, because the causative idea is no longer
affectively accentuated and no longer distinguished from other ideas
and memories. It appears as a purely somatic phenomenon, seemingly
without psychological roots.

What now determines the discharge of the affective excitement
to produce just the one abnormal reflex, and no other kind? Our
observations answer this question for many cases by showing that
this discharge, too, follows the “principle of least resistance,” and
occurs in those paths in which the resistance had become weakened
through concurrent circumstances. We might mention the case
already discussed above, namely, that some reflexes carve paths for
themselves through somatic illness, e.g., if one frequently suffers
from cardialgias, the latter will also be evoked by the affect.—Or a
path is formed for a reflex through the fact that there was a wilful
intention for the particular muscular innervation during the incipi-
ence of the affect. Thus, Anna O. (Obs. I) during the fear affect
attempted to extend the right arm, which was motionless from the
paralysis, and henceforth, the sight of all snake-like objects evoked
a tetanus of the right arm. Or, she strongly converged her eyes
while in the throes of the affect in order to see the watch hands,
and this convergent strabismus then became one of the reflexes of
this later affect, etc.

For this very effect of simultaneity dominates also our normal
associations, every sensory perception calls back to consciousness
another which originally appeared simultaneously with it.

Hence, if a vivid sensory impression existed simultaneously with

⁸I do not wish to work to death the comparison with an electrical system;
considering the fundamental differences of the relations it can hardly illustrate
the processes of the nervous system, and certainly cannot explain them. But
we may here still recall the case that due to high tension the insulation of a
light system had become damaged and in one place there was a “short circuit.”
If electrical phenomena like small sparks, etc., should appear in this place, the
lamp, to which this conduction leads, will give no light, just as the affect does
not come into being, if the excitement is discharged as an abnormal reflex and
becomes converted into a somatic phenomena.

153

the original affect, it is again evoked by the renewed affect, espe
cially because it dealt at the time with a discharge of an excess of
excitement, not as a memory, but as an hallucination. Almost all
our observations offer examples of this kind. Such an example
is also the case of a woman who went through a painful affect while
suffering from severe toothache as a result of periostitis, and there
after every renewal of the affect, indeed every recollection of it,
provoked an infra-orbital neuralgia.

This represents the path of abnormal reflexes following the gen
eral laws of association. Sometimes, however (to be sure only in
the higher grades of hysteria), one finds a real series of associated
ideas between the affect and its reflex, which thus represents a deter
mination through a symbol. Frequently these connections are in
the form of ridiculous play of words and clang associations, but this
only occurs in dream-like states with diminished criticism, and hence,
they do not belong to the group of phenomena considered here.

In a great many cases the determination remains incomprehen
sible because our insight into the psychic state and our knowledge
of the ideas which were actual at the origin of the hysterical phe
nomena, are often most incomplete. However, we may assume that
the process is not quite dissimilar from one which is clear to us in
more favorable cases.

The experience, which generated the original affect, the excite
ment of which was later converted into a somatic phenomenon, we
designate as a psychic trauma, and the morbid manifestations which
so originated as hysterical symptoms of traumatic origin. (The
designation, “traumatic hysteria,” has already been given to that
phenomenon, which, as a result of physical injuries, in the narrowest
sense, traumas, constitute a part of the “traumatic neurosis.”)

In perfect analogy with the origin of traumatically determined
hysterical phenomena is the hysterical conversion of that psychic
excitement, which originates not from external stimuli, not from
inhibition of normal psychic reflexes, but from inhibitions in the
stream of associations.

The elementary example and paradigm, which demonstrates this
is furnished by the excitement which is generated, because we can
not recall a name or solve a riddle, etc. As soon as the name is
uttered or the riddle solved, the excitement disappears because the
chain of association closes just as in the closure of a reflex chain.
The force of the excitement which emanates from such an impedi-
ment

154

STUDIES IN HYSTERIA

ment is proportionate to the interest which the situation has for us,
that is, it depends on the force which stimulates the will. But as
the search for the solution of the problem, etc., entails hard work,
even if this work is unsuccessful, even strong excitement becomes
consumed and does not press for discharge, and hence, never becomes
pathogenic.

This actually happens if the stream of associations is so inhibited
that equivalent ideas are incompatible with one another, as e.g., when
new thoughts get into a conflict with firmly rooted ideation com-
plexes. The torment of religious doubt, to which so many people
succumb and so many more have succumbed, is of this nature. It
causes a rise in the excitement, which in turn enhances the psychic
pain. This is particularly the case when a volitional interest of the
individual is thereby brought into play, as when the doubter believes
himself threatened in his happiness and welfare.

But this is always the case when there is a conflict between a
complex of firmly instilled moral ideas and the memory of one’s
own acts, or even only of one’s thoughts, which are incompatible
with them, namely, the pangs of conscience. The volitional interest
to find pleasure in one’s own personality, to be satisfied with it, is
thereby put into play, and thus increases to the highest degree the
excitement of the inhibiting associations. That such a conflict of
incompatible ideas becomes pathogenic is a matter of everyday expe-
rience. It is mostly a question of ideas and processes of the sexual
life, such as masturbation in a morally sensitive adolescent, or the
consciousness of a desire for a strange man in a strictly moral
woman. Indeed, the first appearance of sexual feelings and ideas
often enough suffices to produce a high degree of emotivity as a
result of a conflict with firmly rooted ideas of moral purity.⁹

The consequences of such conflict are usually pathological depres-
sions and attacks of anxiety (Freud). Concurrent circumstances
frequently determine an anomalous somatic phenomenon in which
the excitement disburdens itself in vomiting, if the feeling of moral
soiling produces a physical disgust, or in a nervous cough, as in
the case of Anna O., if the conscience anxiety evokes a spasm of
the glottis, etc.¹⁰

⁹Cf. here some interesting reports and observations of Benedikt (1889)
reprinted in the Journal, “Hypnotismus und Suggestion,” p. 54, 1894.
¹⁰In Mach’s Bewegungsempfindungen I find an observation which is
pertinent here: “The reported (dizziness) experiments repeatedly showed
that a feeling of disgust appeared mainly only when it was difficult to bring
into harmony the feelings of motion with the optical impressions. It seemed as

155

The excitement which is produced by very vivid and irreconcil-
able ideas finds adequate reaction in verbal communications. The
impulse for this we encounter with comic exaggeration in the story
of the Barber of Midas, who cried out his secret to the ship. We
also find it as one of the foundations of a great historical institution
in the Catholic church, the auricular confession. Verbal communi-
cation eases and disburdens the tension even if it does not take
place in the presence of a priest and is not followed by absolution.
If this escape is closed to the excitement, it sometimes becomes con-
verted into a somatic phenomenon just as in the excitement of
traumatic affects, and we know a whole group of hysterical mani-
festations which have this origin and which are designated by Freud
as hysterical retention phenomena.

The discussion hitherto given about the mechanics of the psychic
origin of hysterical phenomena is open to the reproach that it
schematizes and represents the process in a simpler way than it
really is. In order that a real hysterical symptom should develop
in a healthy, originally non-neuropathic person, with its apparent
independence of the psyche and its self-dependent somatic existence,
there must always be a concurrence of many circumstances.

The following case may serve as an example for the complicated-
ness of this process. A boy of twelve years, who formerly suffered
from pavor nocturnus, the son of a very nervous father, returned
home from school one day feeling ill. He complained of pain on
swallowing, that is, he could only swallow with difficulty, and of
headaches. The family physician thought that the cause of his con-
dition was an angina, but even after many days the condition did
not improve. The boy did not wish to eat, and vomited when he
was urged to do so. He dragged himself around in a tired and
dull manner, always wished to remain in bed, and was considerably
reduced physically. When I saw him after five weeks he made the
impression of a shy, shut-in child, and I became convinced that his
illness was psychically conditioned. On urgent questioning he gave
a banal reason, a strict rebuke from his father, which was apparently
not the real reason for the disease. Nor was there anything to be

¹⁾if a part of the stimulus emanating from the labyrinth would have been forced
to leave the optic tract closed to it by another stimulus, and take an entirely
new course. . . . ” “I have also repeatedly observed a feeling of disgust in
the experiment of combining stereoscopic views with strong differences.” Here
we have the exact physiological scheme for the origin of pathological, hysterical
phenomena through the coexistence of vivid and incompatible ideas.

156

found from his school. I thought that I would have to obtain infor-
mation in a state of hypnosis, but that became unnecessary. When
his wise and energetic mother once persisted in questioning him, he
tearfully told the following story. On the way home from school,
he stopped in a urinal, and there a man held his penis before him
with the request that he should take it in his mouth. He ran away
full of fright, and nothing else happened to him. But from this
moment on, he was sick. From the time he made the confession,
he had remained in perfect health.—In order to produce the phe-
nomena of anorexia, difficulty in swallowing and vomiting, the
following elements were here necessary: A congenital neurotic dis-
position, fright, the incursion of sexuality in the most brutal form
into the child’s mind, and as a determining factor the disgusting
idea. The persistence of the disease was due to his silence, which
prevented the excitement from normal discharge.

As in this case, many factors must always coöperate in order
that the hysterical symptom should be formed in one hitherto healthy.
As Freud expresses it, “The symptom is always over-determined.”
Such over-determination can also be produced when the same
affect is evoked through many and repeated causes. The patient and
the people of the environment attribute the hysterical symptom only
to the last event, which in most cases has only brought to the surface
that which had already been accomplished through other traumas.

A young girl had her first hysterical attack, which was later
followed by a series of others, when a cat jumped on her shoulder
in the dark. It seemed like a simple effect of fright, but more
precise investigation showed that this strikingly beautiful and over-
guarded 17-year-old girl was recently the object of many more or
less brutal pursuits, and thus merged into sexual excitement (Dis-
position). On the same dark stairway she was attacked a few days
before by a young man, from whose grasp she escaped with effort.
This was the actual psychic trauma, the effect of which became mani-
fest only through the cat. But in how many cases is such a cat
responsible for a perfectly adequate causa efficiens?

For the production of the conversion through repetition of the
affect it is not always necessary to have a number of external events.
A renewal of the affect in the memory often suffices, if this follows in
rapid and frequent repetitions soon after the trauma and before the
affect had become blurred. That is sufficient, if the affect was very

157

forceful, which is the case in traumatic hysterias in the narrow sense
of the word.

Thus, during the days following a railroad accident, one relives
the frightful scenes in sleep and in the waking state. The affect of
fright is forever renewed until finally after this period of “psychic
elaboration” (Charcot), or incubation, there occurs the conversion
into a psychic phenomenon. (To be sure, there is also a coöperation
of another factor, which will be discussed later.)

But usually the affective idea soon succumbs to the influences
touched upon in the “preliminary communication” (p. 8) which
gradually rob it of its affective value. A constantly decreasing
amount of excitement conditions its return to the surface, and the
memory thus loses the capacity to contribute to the formation of a
somatic phenomenon. The path of the abnormal reflex then becomes
lost and this restores the status quo ante.

However, the usurping influences are all functions of the asso-
ciations, of thinking, and of correcting through other ideas. These
become impossible if the affective idea is withdrawn from the “asso-
ciation tracks”; if that happens, the former retains all of its affec-
tive value. But as at every renewal it again sets free the whole
sum of excitement of the original affect, the path of the abnormal
reflex begun at that time is finally completed, or the one which
then came into existence is retained and stabilized. The phenomena
of hysterical conversion is then fully established and for a long time.

From our observations we know two forms of such exclusion
of affective ideas from the associations.

The first is the “defense,” or the voluntary suppression of pain-
ful ideas, through which man feels a threat to his joy of life or to
his self-esteem. In his report on the “Defense-Neuro-Psychoses” ¹⁾
and in case histories given here, Freud spoke about this process,
which surely is of high pathological importance.

It is not clearly conceivable how an idea can voluntarily be
repressed from consciousness. But we know intimately the corre-
sponding positive process, namely, the concentration of the attention
on an idea, and can say just as little as to how we accomplish it.

We have, moreover, found that another class of ideas is kept
away from the usurping influences by thought, not because one does
not wish to remember, but because one cannot do so. This is due
to the fact that these ideas originally came to the surface in certain

¹⁾Neurol. Central-Blatt, Nov. 10, 1894.

158

states, and were invested with an affect for which there is an amnesia
in the waking consciousness, that is, they originated in hypnotic or
hypnoid states. The latter seem to be of the highest importance
for the theory of hysteria and, hence, merit a somewhat more
exhaustive discussion.¹²

IV. Hypnoid States

When we expressed the view in the “preliminary communica-
tion” that the basis and condition of hysteria is the existence of
hypnoid states, we overlooked the fact that Moebius had already
said quite the same in 1890. To quote his words: “The assump-
tion of the pathogenic action of ideas is congenital, i.e., there is on
the one hand the hysterical disposition, and on the other a special
state of mind. Concerning this state of mind, one can have only
a vague idea. It must be similar to the hypnotic state, it must cor-
respond to a certain void of consciousness, in which the emerging
idea is not confronted by any resistances from the others, in which
the throne is, so to speak, free for anybody. We know that such
a state can be produced through hypnosis as well as through
mental shock (fright, anger, etc.), and through states of exhaustion
(insomnia, hunger, etc.).”¹³

The question, the near solution of which Moebius herewith first
attempts, refers to the origin of somatic phenomena through ideas.
He calls to our attention the ease with which such an idea occurs
in hypnosis, and he considers the efficacy of the affects as analogous
to it. Our—in some respects—divergent view concerning this
affective force was exhaustively discussed above. I do not, there-
fore, find it necessary to enter further into the difficulty which lies
in the fact that Moebius assumes “a void of consciousness”¹⁴ (which
surely exists in fright and in the protracted anxiety), and into the
question of how difficult it really is to form an analogy between the
exciting state of the affect and the restfulness of the hypnosis. We

¹²If we speak here and thereafter about ideas which are actual, active, and
still unconscious, it is only seldom a question of single ideas (like perhaps the
hallucinated, large snake of Anna O., which produced the contracture) but
almost always about a complex of ideas, associations, and memories of external
processes and inner mental processes. The individual ideas contained in this
complex are all occasionally consciously perceived, only the definite combination
is banned from consciousness.

¹³Moebius: Ueber Astasie-Abasie, Neurol. Beiträge I, Heft. p. 17.

¹⁴Moebius perhaps means by this designation nothing more than the inhi-
bition in the course of ideas, which surely exists in the affect, even if it orig-
inates altogether from other causes than in the hypnosis.

159

shall, however, later return to the statements of Moebius, which I
believe contain an important truth.

For us, the importance of the hypnosis-
like “hypnoid” states
lies above all in the amnesia and in its capacity to condition that
splitting of the psyche, to be discussed later, which is of fundamental
importance for “major hysteria.” This importance we admit even
now, yet we must essentially restrict our statement. The conver-
sion, or the ideogenic origin of somatic phenomena takes place also
outside of the hypnoid states, and as for the formation of ideation
complexes, which are excluded from the association paths, Freud
found a second independent source in the voluntary amnesia of the
‘defense.’ But with this restriction, I still believe that the latter
are the cause and condition of many, indeed of most, major and
complicated hysterias.

To the hypnoid states we must naturally add first of all the
real auto-hypnoses, which differ from the artificial ones only in
their spontaneous origin. We find them in some fully developed
hysterias with changing frequency and different duration, frequently
in the most rapid alternation with the state of normal wakefulness.¹⁵⁾
Due to their dream-like ideational content they often deserve the
name of delirium hystericum. In the waking state there is a more
or less complete amnesia for the inner processes of this state, whereas
in the artificial hypnosis they are perfectly recalled. The psychic
results of these states, and the associations formed in them are
kept away by the amnesia from all corrections of the waking state.
And as criticism and control have been reduced in auto-hypnosis
by other ideas, and mostly almost entirely vanish, it may give rise to
the craziest delusions, which may maintain themselves for a long
time. Thus, almost only such states give origin to a somewhat more
complicated and irrational “symbolic relationship between the causa-
tive and the pathological phenomenon,” which is quite frequently
based on the most ridiculous sound similarities, and word associa-
tions. The indiscrimination of the same frequently permits the
origin of auto-suggestions, as, e.g., when an hysterical attack leaves
behind a paralysis. Due perhaps to accident, we hardly ever came
across in our analyses this origin of an hysterical phenomenon. We
have always found it also in auto-hypnosis, where it was conditioned
by the same process as outside of the same, namely by the conversion
of an affective excitement.

¹⁵⁾Observations I and II.

160

This “hysterical conversion” develops easier in auto-
hypnosis than in the waking state, precisely as in artificial hypnosis, where
suggestive ideas realize themselves much more easily physically, as
hallucinations and motions. But the process of conversion excite-
ment is essentially the same as it was described above. Once this
comes into being the somatic phenomenon repeats itself, whenever
affect and auto-
hypnosis meet again. And it seems that the hyp-
notic state can later be provoked by the affect alone. As long as
hypnosis alternates with full consciousness, the hysterical symptom
remains above all restricted to the hypnotic state, and becomes
reënforced by it through repetition. But the causative idea is
protected against correction by the waking thought and its critique
because it really never comes to the surface in clear wakefulness.

Thus, the contracture of the right arm in Anna O. (Observ. I),
which associated itself in her auto-
hypnosis with the anxiety affect
and the snake idea, remained restricted for four months to the
moments of the hypnotic state (or–if this name be considered
inappropriate for absences of very short duration–the hypnoid), but
repeated itself frequently. The same happened in other conversions
which took place in the hypnoid state. Thus, there formed itself in
complete latency that major complex of hysterical phenomena, which
became manifest when the hypnoid state became continuous.

Phenomena of such origin only appeared in clear wakefulness
after the occurrence of psychic splitting and after the alternations
between waking and hypnoid states gave place to the co-
existence of
normal and hypnoid, ideational complexes.

Have such hypnoid states already existed before the illness, and
how did they develop? I can say very little about it, because except
in the case of Anna O., who could have informed us about it,
we have no other observations at our disposal. It seems certain
that in this patient the state of auto-
hypnosis was prepared by the
habitual day-
dreaming, and that it was then fully established through
a protracted affect of anxiety, which in itself conditioned a hypnoid
state. It does not seem improbable that this process is quite general.

Very diverse states produce “absent-
mindedness,” but only
some of them form a disposition for auto-
hypnosis or directly pass
over into such state. The investigator who is absorbed in a problem
is to a certain extent probably also anesthetic, and forms no con-
scious perceptions out of large groups of sensory impressions, he is
just like one versifying with phantastic vividness (Anna O.’s “pri-
 

161

vate theater”). Nevertheless, energetic psychic work is accom-
plished in these states, which thus consume the excitement set free
in the nervous system. On the other hand, in states of distrac-
tion or in crepuscular states, the intracerebral excitement sinks below
the level of clear wakefulness. These states border on sleepiness and
pass over into sleep. But if a group of affectively accentuated ideas
come to life in such states of engrossment and in inhibited streams
of ideas, it then creates a high level of the intracerebral excitement,
which is not consumed by psychic work, and therefore, becomes
available for anomalous functions, for conversion.

Thus, neither “absent mindedness” during energetic work, nor
the unemotional dawny state is pathogenic, but the affectful reveries
as well as the exhaustion from protracted affect are really so. The
brooding of the worrier, the anxiety of those who watch at the sick
bed of a beloved person, and the reveries of lovers represent such
states. The “absence” is conditioned in the first place by the concen-
tration on an affective idea. The ideation stream slows up gradually,
finally almost to the point of stagnation, but the affective idea with
its affect remains vivid and with it also the large quantity of excite-
ment, which was not functionally used up. The similarity of the
relations to those which condition hypnosis is unmistakable. More-
over, the person to be hypnotized need not really fall asleep, that is,
his intracerebral excitement need not sink to the level of sleep, but
the stream of ideas must be inhibited. The whole mass of excitement
is then at the disposal of the suggested idea.

Pathogenic auto-hypnosis may originate in some persons through
the entrance of the affect into the habitual reveries. This is perhaps
one of the reasons for the fact that in hysterical amnesia we fre-
quently encounter the two major pathogenic factors, namely, being
in love, and nursing the sick. With the longing desires for the
absent lover, the first creates a “displacement” or a dimming of
the environmental reality and then an affectful stoppage of thought.
In nursing, the outer calm, the concentration on an object, the listen-
ing to the patient’s breathing, produce exactly the same conditions
which are employed in inducing hypnotism. The twilight state thus
produced is then filled with the affect of anxiety. It is possible that
these states differ only in quantity from real auto-hypnosis and can
change into it.

Once this has been established, the hypnosis-like state repeats
itself again and again under the same circumstances, so that instead

162

of the two normal psychic states the individual then has three, namely
wakefulness, sleep, and hypnoid state, precisely as we observe it in
frequent repetitions of deep artificial hypnosis.

I do not know whether spontaneous hypnotic states can develop
also without such influences of the affect, as a result of an original
predisposition, but I think that this is quite probable. When we see
how the capacity for artificial hypnosis differs in the normal and in
the sick, and how easily it manifests itself in some, the presumption
is justified, that in the latter they might also occur spontaneously.
And, in order to change the reveries into auto-hypnosis, a special
predisposition may perhaps be required. I am, therefore, far from
assuming that the mechanisms of origin, which we learned from
Anna O., exist in all hysterias.

I speak of hypnoid states instead of hypnosis itself because the
former are very poorly demarcated in the development of these very
important states of hysteria. We do not know whether revery,
which was designated above as the prodromal stage of auto-hypnosis,
cannot itself already produce the same pathogenic effects, and whether
they could not also be produced by the protracted affect of anxiety.
They can surely be produced by fright. Insofar as fright inhibits the
ideation stream while an affective idea (danger) is still very active,
it is perfectly parallel to the affectful revery; and, as the continually
renewed memory always reproduces this psychic state, there develops
a “fright-hypnoidal state,” in which the conversion is either formed
or stabilized, that is, the incubation period of “traumatic hysteria,”
in the strict sense of the term.

As so many different states conjoin in auto-hypnosis, of which all,
however, agree in the most important point, the term, ” hypnoid,”
recommends itself because it emphasizes this inner similarity. It
sums up that view, which Moebius had maintained in the above cited
statements.

But above all it designates the auto-hypnosis itself, the importance
of which for the origin of hysterical phenomena is based on the
facilitation of the conversion, on the protection of the converted
phenomena from usurpation (through amnesia) and from the psychic
splitting, which ultimately results from it.

Now, if a physical symptom is caused by an idea and is always
released again by it, one would expect that intelligent patients capable

163

THEORETICAL MATERIAL

of self-observation would become aware of this connection, that they
would learn from experience that somatic phenomena can come
simultaneously with the recollection of a definite idea. To be sure,
the inner causal connection is unknown to them, but we all always
know what ideas can make us cry, laugh, or blush, even if the nervous
mechanism of these ideogenic phenomena are far from clear.—
Sometimes, the patients really observe the connection and are con-
scious of it. Thus, a woman said that her mild hysterical attack
in the form of trembling and palpitation came from a severe mental
excitement and repeated itself only at every process which recalled
it to her. But that is not true of many, probably not of the majority
of hysterical symptoms. Even intelligent patients do not know that
they appear in consequence of an idea, but they consider them as inde-
pendent physical phenomena. If that were different, the psychic
theory of hysteria must have had a hoary age.

We obviously can believe that the morbid manifestations in ques-
tion may have actually originated ideogenically, but to borrow an
expression from Romberg, the repetitions have been “impressed”
on the body, and now they no longer depend on a psychic process,
but on the changes in the nervous system, which have meanwhile
developed. They, as it were, became independent, or real somatic
symptoms.

This view is from the beginning, neither impossible nor improb-
able. But I believe that the new views, which our observations
bring to the theory of hysteria, definitely show that the older theories
are wide of the mark, at least in a great many cases. We saw that
the “individual hysterical symptoms immediately disappeared with-
out returning if we succeeded in thoroughly awakening the memories
of the causal process with its accompanying affect, and if the patient
circumstantially discussed the process in the most detailed manner
and gave verbal expression to the affect.” The case histories here
reported furnish some illustrations for this assertion. “In reversing
the sentence: cessante causa cessat effectus, we may surely conclude
from this observation that the causative process (i.e., the memory
of it) continues to act even after years not indirectly through the
agency of causal links, but directly as a releasing cause, somewhat
the same as a recollected psychic pain in waking consciousness will
evoke the secretion of tears in later times. The hysteric suffers
mostly from reminiscences.”

However, if this is the case, if the memory of the psychic trauma

164

behaves in the manner of a foreign body for a long time after its
intrusion, acting as an active agent of the present, and yet the
patient has no knowledge of this memory and its emergence-
if that is so, we must admit that unconscious ideas exist and are active.

Such ideas we find in the analysis of hysterical phenomena, not
isolated ones, but as has actually been shown, large complexes of
ideas and complicated and consequential psychic processes, which in
some patients remain altogether unconscious, and exist hand in hand
with the conscious psychic life. We also find that splitting of the
psychic activity occurs, and is of fundamental importance for the
understanding of complicated hysterias.

May we now be permitted to enter slightly into this difficult and
dark region? The need for establishing the meaning of the expres-
sions which we have used may perhaps excuse the theoretical
explanation.

V. Unconscious and Ideas Incapable of Consciousness.
Splitting of the Psyche

That idea which we know we call conscious. In the human
being there exists the wonderful fact of self-consciousness, we are
able to follow successively ideas which emerge in us and consider
them like objects. This does not always happen,
as there are only rare occasions of self-observation. But it is a
capability which is common to all human beings, for everybody says:
“I have thought of this and that.” Those ideas which we observe
in us as active or would observe, if we paid attention to them, we
call conscious. There are very few of these at all periods of time;
and if besides these still others should be present, we would have to
call them unconscious ideas.

To speak for the existence of actual, but unconscious or sub-
conscious ideas now hardly seems necessary. These are facts of
everyday life. If I have forgotten to make a professional visit, I
experience vivid restlessness. From experience I know what this
feeling signifies: forgetting. It is futile to test my memory, I can-
not find the cause, until it suddenly flashes into consciousness, often
after hours. But throughout the whole time I am restless. Well,
is the idea of this visit always active, that is always existing, but
not in consciousness?—A busy man has had an annoyance in the
morning. He is thoroughly engrossed in his work, and during his
activity his conscious thinking is fully occupied and he does not

165

think of his annoyance. But his decisions are influenced thereby,
and he actually says “No” when he would otherwise say “Yes.”
Despite this the memory is active, hence, the idea exists. A large
part of what we call “moods” come from such sources, that is,
from ideas which exist and act under the threshold of conscious-
ness.—Indeed, our whole conduct of life is continually influenced by
unconscious ideas. We see daily, as for example, in psychic deterio-
ration of incipient paresis, how the inhibitions, which otherwise
impede some acts, become weaker and vanish. But the paretic who
tells smutty jokes to ladies was not detained from it in his healthy
days by conscious memories or reflections. He avoided it ‘instinc-
tively’ and ‘automatically,’ that is to say, he was detained from it
by ideas which the impulse for such an act awakened. The ideas,
however, remained under the threshold of consciousness and still
impeded the impulse.—All intuitive action is guided by ideas which
are for the most part unconscious. Only the clearest and most inten-
sive ideas of self-consciousness are perceived, while the large mass
of actual but weaker ideas remains unconscious.

The arguments against the existence and activity of “uncon-
scious ideas” mostly amount to verbal chicanery. Of course, the
word, “idea,” belongs to the terminology of conscious thinking,
and hence, the term, “unconscious idea,” is a contradictory expres-
sion. But the physical process which lies at the basis of the idea
is contently and formally (even if not quantitatively) the same,
whether the idea appears above the threshold of consciousness or
remains below. It would suffice to coin a term like “idea-sub-
stratum,” to contravene the contradiction and escape the reproach.

It seems, therefore, that in principle there is no hindrance against
the recognition of unconscious ideas also as causes of pathogenic
phenomena. However, on closer examination of this matter other
difficulties present themselves. If the intensity of unconscious ideas
increases, they eo ipso appear in consciousness. They remain uncon-
scious only when the intensity is low. But it is difficult to under-
stand how an idea could at the same time be sufficiently intensive
to evoke, for example, lively motor action, and still not active
enough to become conscious.

I have already expressed a view before, which should not perhaps
be lightly dismissed. The clearness of our ideas and with it their
capacity to be observed by the self-consciousness, that is, to be con-
scious, depends also on the feeling of pleasure-pain which they

166

arouse, or on their affective value. If an idea immediately releases
an active somatic result, the excitement emanating from it, which
would have been disseminated in the brain, flows off into the par-
ticular path. And precisely because this has physical results, because
its psychic sum of excitement has become converted into the somatic,
it loses that clearness which would have otherwise characterized it in
the stream of ideas; it, as it were, loses itself among the others.

For example, while partaking of a meal, someone experienced
a violent affect, which was not abre-
acted. In consequence, the
patient later experienced choking and vomiting while eating, which
he interpreted as purely physical symptoms. The hysterical vomit-
ing existed for a long time, but it disappeared after it was revived in
hypnosis, related and reacted to. There is no doubt that the attempt
to eat has each time revived that memory, and thus released the
act of vomiting. Nevertheless, it did not appear clearly in conscious-
ness, because it was now affectless, whereas the entire attention was
absorbed by the vomiting.

For this reason it is conceivable that some ideas, which release
hysterical phenomena, are not recognized as the cause of the same.
But it is impossible that such neglect of ideas, which became affectless,
because of conversion, should be the cause of it when in other cases,
complexes of ideas, which are no less affectless, do not enter into
consciousness. Our case histories offer many examples of this sort.

In such patients it is the rule that moodiness, anxiety, angry
irritation, and grief precede the somatic symptom, or soon follow it,
and increase until the solution is either attained through expression,
or the affect and the somatic phenomena gradually disappear again.
If the former happened, the quality of the affect then became quite
evident, even though its intensity must have seemed out of propor-
tion to the normal person, and after the solution, also to the patient.
These are, therefore, ideas, which are intensive enough, to produce
not only strong physical phenomena, but to awaken also their appro-
priate affect, and to influence the associations by giving preference
to related ideas,–and yet, they, themselves, remain outside of con-
sciousness. To bring them to consciousness it requires hypnosis
(as shown in Observations I and II), or intensive subsequent
help from the physician through most painstaking searching (as in
Observations IV and V).

Such ideas, which are (actual but) unconscious, we may call

167

incapable of consciousness, not on account of their relatively weak
activity, but despite their great intensity.

The existence of such ideas, which are incapable of conscious-
ness, is pathological. In healthy persons all ideas which can at all
become actual, enter consciousness if they possess sufficient intensity.
In our patients we found next to each other a large complex of
ideas capable of consciousness and a smaller one which was incapable
of consciousness. The realm of ideational psychic activity does not,
therefore, coincide in them with the potential consciousness, but the
latter is more limited than the former. The psychic ideational activity
is here divided into conscious and unconscious parts, while the ideas
are divided into those capable of consciousness and those not capable
of consciousness. Hence we cannot speak of a splitting of conscious-
ness, but rather of a splitting of the psyche.

Conversely, these subconscious ideas cannot even be influenced or
corrected by conscious thought. In many cases, it is a question of
experiences, which have since become devoid of meaning, as fear
of events which did not come to pass, or fright which has changed to
laughter or joy, because the individual was saved. These after-
effects take away all affectivity from the memory for conscious
thought, while the unconscious idea which produces somatic phe-
nomena remains entirely unaffected by them.

Let me cite still another case: For some time a young woman
lived in deep apprehension concerning the fate of her younger sister.
This situation prolonged her otherwise regular menstrual period by
two weeks, she also felt pain in the left hypogastric region, and on
two occasions she found herself lying rigidly on the floor, coming
out of a “fainting spell.” These spells were followed by a left-sided
ovaritis with signs of a severe peritonitis. A contracture of the left
leg (and the back) characterized the disease as a pseudo-peritonitis,
but when the patient died a few years later, the autopsy showed
only “a slight cystic degeneration” of both ovaries without any
remnant of a former peritonitis. The severe symptoms gradually
subsided leaving the ovaritis and contraction of the muscles of the
back, so that the trunk was as rigid as a beam, and the contraction
of the left leg. This last symptom was removed in hypnosis through
direct suggestion. The contraction of the back remained unin-
fluenced. Meanwhile, her sister’s affair was perfectly settled, so that
all fear from this direction vanished. But the hysterical phenomena

168

which must have resulted from it continued unchanged. It was an
obvious presumption that we dealt with changes in the innervation
which became independent and no longer associated with the causa-
tive ideas. But, when the patient was forced to relate in hypnosis
the whole history until the appearance of “peritonitis” (which she
did reluctantly), she sat up freely in bed immediately thereafter,
and the contractures disappeared forever. (The ovaritis, the first
origin of which was surely much older, remained uninfluenced.)
The pathogenic idea of anxiety, nevertheless, continued very vividly
throughout months, and she remained absolutely impervious to all
corrections.

If we are then forced to recognize the existence of complexes
of ideas which never appear in waking consciousness and are never
influenced by conscious thinking, we thus already admit that in the
just discovered simple hysterias there is a splitting of the psyche
into two relatively independent parts. I do not maintain that every
thing called hysteria has such splitting as a basis and determinant,
but I feel that “that splitting of the psychic activity, which is so
striking in the familiar cases of double consciousness, exists in rudi-
mentary form in every “major” hysteria, and that the capacity and
tendency for this dissociation forms the basic phenomenon of this
neurosis.”

Before I enter, however, into the discussion of these phenomena
I must add still another observation in regard to unconscious ideas,
which cause somatic manifestations. As in the above reported case
of contracture, many of the hysterical phenomena are really of long
and continual duration. Shall we, and can we assume, that through-
out this whole time the causative idea was always active and was
actually existing? I believe, yes. In the normal we certainly see
the psychic activity carried into effect with rapid changes of ideas.
But the severe melancholiac is for a long time continually sunk in
the same painful idea, which is always active and actual. Indeed,
we may well believe that the normal, too, may be harassed by a
profound worry, judging by the dominating effect of his facial expres-
sion, even though his consciousness is filled with other thoughts.
But that dissociated part of the psychic activity, which we imagine
in the hysterical individual to be filled with the unconscious ideas, is
mostly so poorly cathected by it, so inaccessible to the change of outer
impressions, that we can believe it possible that we have here an idea
of continuous activity.

169

If we believe with Binet and Janet that the splitting of a part
of the psychic activity seems to form the central point of hysteria, we,
therefore, feel obliged to search for possible clearness concerning this
phenomenon. One falls only too easily into the mental habit of
assuming substance behind a substantive, or of gradually conceiving
an object by the term, consciousness. And if one has formed the
habit of using such local relationships as “unconscious” meta-
phorically, he will in time actually build up an idea, in which the
metaphor will be forgotten, and which he will manipulate as if it
were real. Thus, mythology came into being.

Spatial relationships obtrude themselves as companions and
helpers of all our thoughts, and we speak in spatial metaphors. Thus,
there almost forcibly appear the images of the trunk of the tree
which stands in the light, and its roots which are in the dark, or of
the building and its dark basement, when we speak of the ideas
which exist in clear consciousness and in the unconscious which
never appear in the clearness of self-consciousness. But if we
always bear in mind that everything spatial is here metaphorical,
and are not perhaps misled to localize it in the brain, we may at
any rate, speak of a conscious and an unconscious. But only with
this reservation.

We are surely in danger of being duped by our own figures of
speech, if we always bear in mind that it is really the same brain,
and most probably the same cerebral cortex in which the conscious
and unconscious ideas originate. But we really know so little of
the psychic activity of the cortex, that a puzzling complication will
hardly magnify still more our infinite ignorance. We must acknowl-
edge the fact that in hysterics a part of the psychic activity is inacces-
sible to perception through the self-consciousness of the wakeful
person, and in this way the psyche is split.

A well known case of such division of the psychic activity is
the hysterical attack in many of its forms and stages. In its begin-
ning conscious thinking is frequently quite blurred, but it then grad-
ually awakens. One hears from many intelligent patients that their
conscious ego was quite clear during the attack and that they could
have inhibited the attack with their firm will, and they are inclined
to blame themselves for it. They say that they did not have to do it.
(The self-reproach of simulation is based in a large measure on
this feeling.) But at the next attack the conscious ego can do as
little to master the processes as in the former one.—Here we have

170

the thinking and ideas of the conscious wakeful ego side by side
with the ideas which are ordinarily in the depth of the unconscious,
but which have now won control over the musculature and speech;
indeed, even over a large part of the ideational activity, thus the
splitting of the psyche is manifest.

The name of splitting not only of the psychic activity but also
of consciousness is well deserved according to the findings of Binet
and Janet. As is known, these observers succeeded in putting them-
selves in touch with the “subconscious” of their patients, or with
every part of the psychic activity of which the conscious wakeful ego
knows nothing. In some cases they have thereby demonstrated all
psychic functions, including self-consciousness. For one finds therein
the memory of former psychic processes. This half psyche is, there-
fore, totally complete and conscious in itself. The split-off part of
the psyche in our cases is “brought into darkness”; like the Titans
banned in the chasm of Etna, they may shake the earth, but can
never come to light. In Janet’s cases a complete division of the
realms took place. There was still a differentiation of rank, but this,
too, disappeared if the two halves of consciousness alternated as in
the familiar cases of double conscience, and did not differentiate
themselves in their functioning capacity.

Let us, however, return to those ideas which we have demon-
strated in our patients as causes of their hysterical phenomena. We
lack much to enable us to call them all precisely unconscious and
“incapable of consciousness.” From the perfectly conscious idea
which releases an unusual reflex to those which never enter into con-
sciousness in the waking state, except in hypnosis, there is a
hardly interrupted step-ladder, which runs through all grades of
shadows and unclearness. Nevertheless, we maintain that we have
demonstrated that a splitting of psychic activity exists in the higher
degrees of hysteria, and that alone seems to make it possible to give
a psychic theory of the disease.

What can one now say or conjecture with probability concerning
the cause and origin of this phenomenon?

P. Janet, to whom we are extremely indebted for a very large
part of the theory of hysteria and with whom we agree in most
points, has developed a new view about it, which we cannot adopt
as our own.

Janet maintains that the “splitting of personality” is based on

171

an original psychic weakness (insufficience psychologique). All
normal psychic activity presumes a certain capacity of synthesis, or
the possibility of connecting many ideas into one complex. Such
synthetic activity no doubt represents a fusion of the various sense
perceptions into an image of the environment. This capacity of
the psyche is found to be below normal in hysterics. If attention
is highly concentrated on one point, e.g., on the perception of one
of the senses, a normal person will probably lose for the moment the
capacity to apperceive the other senses, i.e., to absorb them into
his conscious thinking, but in hysterics this may occur without any
special concentration of attention. If they perceive anything, they
are at the time inaccessible to other sense perceptions. Indeed, they
are not even capable of perceiving altogether the impressions of
only one sense. They are able, for example, to apperceive the tactile
perceptions of only one half of the body; those of the other side
reach the center and are used up for co-
ördinating movements, but
they are not apperceived. Such a person is hemianesthetic.

In the normal person one idea associatively evokes other ideas
into consciousness, which form for example a friendly or antagonistic
relationship with the first, and only ideas of the highest activity
are really so excessively strong as to keep the associations below the
threshold of consciousness. In hysterics this is always the case.
Every idea entirely absorbs the whole lighter psychic activity. This
accounts for the patient’s enormous affectivity.

This peculiarity of their psyche Janet designates by the name
of “narrowing of the field of consciousness” of hysterics, in analogy
to the “narrowing of the field of vision.” The sensory impressions
which are not apperceived and those ideas which were aroused, but
did not enter consciousness, are mostly wiped out without any further
consequences. Sometimes, however, they collect together and form
complexes: the sub-
conscious, or the psychic stratum withdrawn from
consciousness.

Hysteria, which is based essentially on this splitting of the
psyche, is “une malade de faiblesse” (a disease of feebleness) and
hence, it develops best if other enfeebling influences act on the
original weak psyche, or if they put high demands upon it in contrast
to which the psychic force seems still more inferior.

In this exposition of his views, Janet has also already answered
the important question of the disposition to hysteria. He assumes a
typus hystericus in the same sense as the typus phtisicus, by which

172

we understand the long, narrow thorax, the small heart, etc. Janet
assumes a definite form of congenital psychic weakness for the dis-
position for hysteria. In contrast to this, we would like to formu-
late briefly our own view as follows: The splitting of consciousness
does not occur because the patients are weak-minded, but the
patients seem weak-minded because their psychic activity is divided,
and only a part of the functional capacity is at the disposal of con-
scious thought. We cannot consider psychic weakness as the typus
hystericus, or as the essence of the disposition for hysteria.

What is meant by the first sentence may be elucidated by an
example. On many occasions we could observe the following course
in one of our patients (Mrs. Cecilia M.): During relative well
being, there appeared an hysterical symptom, a tormenting and
obsessing hallucination, a neuralgia, or something similar, which
increased in intensity for some time. Simultaneously with it the
psychic activity became continually reduced, and after a few days
even an uninitiated observer was forced to call the patient weak-
minded. She was then disburdened of the unconscious idea (the
memory of a long past psychic trauma), either through the phy-
sician in hypnosis or through the fact that she suddenly merged
into an excited state and recited the situation with lively affectivity.
Thereafter, she not only became calm and cheerful as if freed from
the tormenting symptoms, but we were again and again astonished
at the rich and clear intellect and the keenness of her intelligence
and judgment. She was fond of playing (excellent) chess and
liked to play two games at the same time, which is hardly a sign
of a lack of psychic synthesis. The impression was indisputable,
that during such attacks the unconscious idea drew to itself a con-
tinually increasing part of her psychic activity. The longer this
continued, the smaller became the share of her psychic activity, until
it became reduced to almost complete imbecility, but later she was
herself again, to use a popular expression, and she possessed an
excellent psychic functional capacity.

As a comparison from normal states we would prefer to use
preoccupation instead of concentration of attention. If a person is
“preoccupied” by, let us say, worry, his psychic functional capacity
will be reduced in a similar manner.

Every observer is preponderately under the influence of the
objects of his observation, and we would like to believe that Janet’s
conception was formed from his comprehensive study of those weak-
 

173

minded hysterics who are usually in hospitals or sanatoria, because
as a result of their illness and the psychic weakness conditioned by it,
they could not maintain themselves at large. Our observations of
educated hysterics force us to an essentially different opinion of their
psyche. We believe “that among hysterics one can find persons who
are most clear mentally, who have the strongest will power, the
best character, and the clearest judgment.” Hysteria does not exclude
any amount of real and genuine psychic endowment, even though
the disease makes real accomplishment impossible. Was not the
patron saint of hysteria, St. Theresa, a genial woman of the greatest
practical thoroughness?

But it is also true, that no amount of stupidity, uselessness, and
weak-mindedness guarantees against hysteria. But even if one dis-
regards all that which is only the result of the disease, one must
admit that the type of the weak-minded hysteric exists in large
numbers. But here, too, it is not a question of torpid and phlegmatic
stupidity, but rather of an excessively high degree of psychic
mobility, which causes unfitness. We shall later discuss the question
of the original disposition. Here, we only wish to repeat that Janet’s
opinion that psychic weakness is generally at the bottom of hysteria
and of psychic splitting is unacceptable to us.

In absolute opposition to Janet’s view, I believe that in a great
many cases the disaggregation depends on the psychic over-function-
ing or on the habitual co-existence of two heterogenous series of
ideas. It was pointed out that frequently we are not merely
“mechanically” active, while a series of ideas, which have nothing
in common with our activities flow through our conscious thinking,
but that we are also undoubtedly capable of mental functioning while
our thoughts are “wandering elsewhere,” as e.g., when we read
aloud with the proper intonation and later know nothing of what
we have read.

There is undoubtedly a large number of activities running from
the mechanical, like knitting, scale-playing, to such as are still con-
ditioned by some psychic functioning, which are performed by many
people with only half of their presence of mind. This is especially
true of temperamental people who, irritated by monotonous, simple,
and unstimulating occupations, have in the first place deliberately
created for themselves the diversion of thinking of something else.
A good example of this kind is the “private theater of Anna O.,”
mentioned above. Another, but similar case, is found in the intrusion

174

of an interesting group of ideas from reading or plays. This intrusion
becomes more energetic if the foreign ideas are of strong “emotional
accentuations,” as in worry and amorous longing. This furnishes
the above-
mentioned state of preoccupation which does not, however,
prevent many people from performing moderately complicated acts.
Social relations often force such doubling of very intensive thinking,
as in the case of a woman tormented by worry or passionate excite-
ment, who, nevertheless, fulfills her social duties and functions as an
amiable hostess. Lighter activities of this sort we all accomplish in
our vocations. But self-
observation seems to prove to everyone that
the affective group of ideas is not associatively awakened now and
then, but that it continually exists actually in the psyche, and appears
in consciousness if the latter is not held by a vivid external impres-
sion or by an act of will.

Even in people in whom no habitual daydreaming runs side by
side with their everyday activities, some situations may for a long time
condition such continuity of alternating impressions and reactions
of the outer life, as well as an emotionally accentuated group of ideas.
Post equitem sedet atra cura. Such situations are above all common
in the nursing of those dear to us, and in love affairs. According to
our experience, nursing of the sick and love affects also played the
principal part in most of the case histories of hysterics, who were
more thoroughly analyzed.

I believe that the habitual or the conditioned doubling of psychic
activity through affectful situations would essentially predispose to
a real pathological psychic splitting. If the two co-
existing groups
of ideas no longer have the same kind of content, if one of them
contains ideas which are incapable of consciousness, that is, ideas
which are rejected, or came about in hypnoid states, a psychic split-
ting may then develop. The confluence of the two temporarily
separated groups, which always takes place in the normal, then
becomes impossible, and a split-
off region of unconscious psychic
activity establishes itself here permanently. This hysterical splitting
behaves towards the “double-
ego” of the normal like the hypnoid
state to the normal day-
dreaming. The pathological quality is here
determined by the amnesia, and there, by the incapacity to become
conscious of the ideas.

The observation of Anna O., to whom I must always return,
offers us clear insight into this process. The girl was in perfect
health, but had the habit of letting phantastic ideas flow next to her

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usual activities. In one situation favorable for auto-hypnosis, an
anxiety affect entered into the day-dreaming and created a hypnoid
state for which she had an anmesia. This repeated itself on various
occasions, and its ideational content gradually became richer, but it
still alternated with the state of perfectly normal and conscious
thinking.

After four months, the hypnoid state entirely dominated the
patient, and as the individual attacks coalesced, there developed an
état de mal, a most severe acute hysteria. After many months’ dura-
tion in different forms (somnambulic period) this state was violently
interrupted, and now alternated again with the normal psychic
behavior. But even in this state there was a persistence of the somatic
and psychic phenomena, concerning which we we now know that they
were based on the hypnoid state (contractures, hemianesthesia, and
change of speech). This proves that even during the normal
behavior of the ideational complex of the hypnoid state, the “uncon-
scious” is actual, and that the splitting of the psyche continues.

I cannot give here a second example of such development, but I
believe that this throws some light on the development of the
traumatic neuroses. In the latter, the memory of this fright-
hypnoidal state repeats itself a few days after the accident. But
while this occurs more and more frequently, its intensity, neverthe-
less, diminishes to such an extent that it no longer alternates with
wakeful thinking, but exists next to it. However, I can only con-
jecture that it proceeds in this manner, as I have not analyzed such
a case.

Freud’s observations and analyses demonstrate that the splitting
of the psyche can also be conditioned by a “defense,” or by an inten-
tional turning away of consciousness from the painful ideas. This
is true only in some people to whom we must, therefore, attribute a
special psychic peculiarity. In the normal person the suppression
of such ideas is successful, and then they disappear in consciousness.
In what this peculiarity consists, I am not able to state. I only
venture the assumption that if the defense does not merely make
single, converted ideas unconscious, but brings about a real splitting
of the psyche it requires help from the hypnoidal state. The auto-
hypnosis produces, so to say, the space, the region of unconscious
psychic activity, into which the rejected ideas are pushed. Be that
as it may, we must recognize the fact of the pathogenic significance
of the “defense” mechanism.

176

I do not believe, however, that with the discussion of half-
understandable processes we have even nearly exhausted the genesis
of psychic splitting. Thus, incipient hysterias of a higher grade
present a syndrome mostly lasting some time, which can justly be
designated as acute hysteria. In the anamnesis of male hysterics we
encounter this form of illness, frequently under the name of inflam-
mation of the brain; in women, the ovaritis that sometimes accom-
panies it, leads to the diagnosis of peritonitis.

Psychotic features are very distinct in this acute state of hysteria.
Thus, we encounter manic and irascible states of excitement, rapid
alteration of hysterical phenomena, hallucinations, etc. In such
states the splitting of the psyche may perhaps proceed in a different
manner than the one we attempted to describe above.

This whole stage may perhaps be looked upon as a long hypnoidal
state, the residuum of which furnishes the nucleus of the unconscious
complex of ideas, while the wakeful thoughts show an amnesia for it.
As the conditions for the origin of such acute hysteria are mostly
unknown (I do not dare to consider the origin of the case of Anna O.
as general), this would be another, and in contrast to the one dis-
cussed above, it might be designated as an irrational form of psychic
splitting.¹⁶⁾ And there probably exist still other forms of this process
which have still escaped the new psychological cognition. For we
have surely taken only the first steps in this realm, and further
experiences will essentially transform the present views.

Let us ask what the knowledge of the psychic splitting gained
during the last years has done for the understanding of hysteria. It
seems to be much and of great importance.

This cognition makes it possible to trace seemingly pure somatic
symptoms to ideas. It would be superfluous to discuss this again.

It has at least partially taught us that the attack is an accomplish-
ment of an unconscious complex of ideas (Charcot).

But it also explains some of the psychic peculiarities of hysteria,
and this point merits perhaps a more detailed discussion.

The “unconscious ideas” certainly never, or only seldom and

¹⁶⁾I must state, however, that precisely in the most familiar and transparent
cases of major hysteria, with a manifest double consciousness (I am referring
to the case of Anna O.) no remnant from the acute stage was carried over into
the chronic stage, and all the phenomena of the latter have already been pro-
duced in the “period of incubation,” in the hypnoid, and affective states.

177

THEORETICAL MATERIAL

with difficulty, appear in wakeful thinking, but they influence it
through their efforts, as when the patient is tormented by a perfectly
incomprehensible and senseless hallucination whose meaning and
motivation becomes clear in the hypnosis.

Moreover, they influence the associations by permitting some
ideas to become more active than they would have been without the
reënforcement emanating from the unconscious. Thus, the same
definite groups of ideas then obtrude themselves on the patient with
such force that he is compelled to think of them.¹⁷ Furthermore, they
dominate the emotional situation, the feelings. At the unwinding of
her recollections, whenever Anna O. was approaching a process which
had originally been connected with a vivid affect, the corresponding
emotional feelings became evident days before the memory seemed
clear, even in the hypnotic consciousness.

This also explains the “moods,” or those incomprehensible,
unfounded and unconscious unmotivated depressions of the patient.
For the impressionability of hysterics is for the most part actually
conditioned by their original irritability, but the lively affects into
which they merge for relatively slight reasons, become comprehen-
sible only when we bear in mind that the “split-off” psyche acts
like a sounding board for the tone of the tuning fork. Every occur-
rence, which stimulates “unconscious” memories, sets free the whole
affective force of these usurped ideas, and the evoked affect is then
quite disproportionate to the one which would have originated solely
in the conscious psyche.

We have reported above (p. 172) the case of a patient, whose
mental activity always stood in reversed relation to the vividness of
her unconscious ideas. The reduction of her conscious thinking was
based partially, but only partially, on a peculiar kind of distracti-
bility. After each momentary “absence,” which appeared continu-
ally, she did not know what she had thought of during this time. She
oscillated between the “condition prime” and “seconde,” between
the conscious and the unconscious ideational complex. But it was
not solely through this that her mental activity diminished, not also
through the affect which dominated her from her unconscious. Her
conscious thinking in such state lacked energy, her judgment was
infantile she seemed to say, quite imbecilic. I believe that this was

¹⁷This resembles Janet’s hemianaesthetic patients, who though failing to
feel the repeated touching of their anaesthetic hands, nevertheless when
requested to mention any number, always selected the number which cor-
responded to the touches.

178

determined by the fact, that her conscious thinking had a smaller
amount of energy at its disposal, because a large mass of the psychic
excitement was usurped by the unconscious.

If such a case is not merely temporary, if the split-
off psyche is in continuous excitement as in Janet’s hemianesthetics in whom all
sensations from one side of the body could only be perceived by the
unconscious, there remains so little of the cerebral function for con-
scious thinking that the psychic weakness, described by Janet and
considered by him as original, can be fully explained by it. Of only
very few people can one say, as of Uhland’s “Bertrand de Born,”
that “they never need more than half of their mind.” The majority
of people show just such a weakmindedness whenever there is reduc-
tion of their psychic energy.

The very consequential peculiarity of some hysterics, their sug-
gestibility, can seemingly also be explained by the mental weakness
conditioned by the psychic splitting. I said “some hysterics”
because it is certain that among patients of this sort one also finds
people who are most sure of their judgment and criticism.

By suggestibility we understand in the first place only that lack
of criticism of ideas and ideational complexes (judgments) which
appear in one’s own consciousness, or are inducted into it from
without, through outside talk or reading. All criticism of such ideas
which have just appeared in consciousness is based upon the fact that
associatively they arouse other thoughts and among them some which
are incompatible with them. The resistance against them, therefore,
depends on the possession of a potential consciousness of such
resistive ideas, and its force corresponds to the relationship between
the vividness of the new ideas and those aroused from memory. This
relationship varies markedly even in normal intellects. What we call
an intellectual temperament mostly depends on this. The sanguine
nature who is always enthused by new people and things behaves in
this manner, because the intensity of his memory pictures, in com-
parison to those of the new impressions, is less than in the more calm
“phlegmatic” individual. In pathological states, the preponderance
of fresh ideas and the lack of resistance against them depends on the
memory pictures; the less the latter are aroused, the weaker and
poorer are the associations. This can be readily seen in sleep, in
dreaming, in hypnosis, and wherever there is a reduction of psychic
energy, as long as it does not injure also the activity of the fresh
ideas.

179

The unconscious split psyche of hysteria is eminently suggestible
due to the poverty and deficiency of its ideational content. But the
suggestibility also of the conscious psyche of some hysterics seems to
be based on this. According to their original predisposition, they
are irritable, and fresh ideas assume in them great vivacity. In con-
trast to this, the actual intellectual activity, the associations, are
reduced, because due to a split-off “unconscious,” the wakeful
thought has only a part of the psychic energy at its disposal.

It is for this reason that their resistance capacity to auto-sugges-
tion and to outside suggestions is reduced and sometimes destroyed.
The suggestibility of their will, too, probably arises solely from that.
On the other hand, the hallucinatory suggestibility, which imme-
diately transforms every idea of a sense perception into the percep-
tion itself, requires, as does every hallucination, an abnormal degree
of excitability of the organ of perception, and cannot have its origin
in the psychic splitting only.

VI. Original Disposition; the Development of Hysteria

Almost at every stage of this explanation I have had to admit
that most of the manifestations which we strove to understand can
also be based on a congenital peculiarity. This withdraws itself
from every explanation, which should lead to the confirmation of the
facts. But as the capacity to acquire hysteria must surely also be
connected with something peculiar to man, the attempt, therefore, to
define it more precisely may not perhaps entirely be without value.

I have explained above why Janet’s view, that the disposition to
hysteria is based on psychic weakness, is untenable. The practi-
tioner, who as family physician, observes the members of an hysterical
family in all stages of existence, will surely be inclined to seek this
disposition in a surplus rather than in a defect. The adolescents who
later become hysterical are before their illness mostly vivacious,
talented, and full of mental interests; their will power is often
remarkable. Among them one sees those girls who get up at night
to study something which the parents prohibit, lest they should over-
work. The capacity of thoughtful judgment is surely not more
granted to them than to other people. But one rarely finds among
them simple-mindedness, dullness, mental laziness, and stupidity.
The ebullient productivity of their psyche brought one of my friends
to the assertion that hysterics are the bloom of mankind, to be sure,
as sterile, but also as beautiful as blooming flowers.

180

Their vivacity and restlessness, their craving for sensations and
mental activity, their inability to endure monotony and tediousness,
may be formulated by saying, that they belong to those people whose
nervous system sets free an excessive quantity of free nervous excite-
ment, which craves utilization (see p. 143). During the development
of puberty, and as a result of it, the original surplus becomes enriched
with an enormous increase of excitement, which emanates from the
awakened sexuality, or from the sexual glands. In this manner there
results an excessive quantity of free nervous excitement which
becomes available for pathological phenomena. But in order that
these should take the form of hysterical manifestations, there is an
apparent need of still another specific peculiarity of the individual.
For the great majority of vivacious and excitable people do not
necessarily become hysterical.

This peculiarity I could only designate above in the vague and
empty words: “abnormal irritability of the nervous system.” Still,
one can perhaps go still further and say that this abnormality lies in
the very fact that in such people the excitement can flow into the
sensory nervous apparatus which is normally accessible only to
peripheral stimuli, and into those of the vegetative organs, which are
isolated by strong resistances from the central nervous system. This
concept of the constantly existing surplus of excitement, to which
the sensible vasomotor and visceral apparatus are accessible, can
perhaps already account for some pathological phenomena.

As the attention is forcibly concentrated on one part of the body
in people so constituted, the “attentional connection” (Exner) of
the concerned sensible path exceeds the normal measure. The free
floating excitement then settles, so to say, on this path, and there
develops a local hyperalgesia, which produces a maximum intensity
of all pains which are in any way conditioned, so that they are all felt
as “frightful” and “intolerable.” But when the quantity of excite-
ment once occupies a path, it never leaves it again as in the case of a
normal person; it does not just remain there, but it increases through
a flowing in of new excitement. Thus, after a slight trauma to a
joint, there develops a neurosis of the joint, and the painful feeling
of an ovarian enlargement frequently becomes a permanent ovaritis.

The nervous apparatus of the circulation is more accessible to
cerebral influence than in the normal, and hence, we find nervous
palpitation, tendency to syncope, excessive blushing and paling, etc.

But to be sure, the peripheral nervous apparatus is not only more

181

amenable to excitement through central influences, but it also reacts
to the adequate, functional stimuli in excessive and perverse manner.
Palpitation follows moderate exertion like emotional excitement, and
the vasomotors produce a contraction of the arteries (“dying
fingers”) without any psychic influence. And just as a slight
trauma may be followed by a neurosis of the joint, a mild bronchitis
may be followed by nervous asthma, and indigestion frequently by
cardialgias. We must thus recognize that the accessibility of sums
of excitement of central origin is nothing but a special form of the
general abnormal excitability,¹⁸ even though it is most important for
our theme.

Hence, I also do not believe that the old “reflex theory” of these
symptoms, which might perhaps better be called simple “nervous-
ness,” which, however, belongs to the empirical morbid picture of
hysteria, should be entirely rejected. The vomiting which really
accompanies the distention of the gravid uterus may in abnormal
irritability well be the result of a reflex from slight uterine stimuli;
indeed, perhaps also from the fluctuating enlargement of the ovaries.
We know so many distant effects of organic changes, so many strange
“conjugated points” that we cannot dismiss the fact that a large
number of nervous symptoms which are sometimes psychically con-
ditioned might in other cases be the effects reflected from a distance.
Indeed, I venture into the highest unmodern heresy, when I say that
even the motor weakness of a leg could sometimes be determined not
psychically, but by a direct reflex from a genital disease. I believe,
however, that it is well not to concede too much exclusiveness to our
theories and not to generalize about all cases.

Other forms of abnormal sensible excitement, such as general
analgesia, anesthetic plaques, etc., are still beyond our understand-
ing. It is possible and perhaps probable that further observations
will demonstrate the psychic origin of the one or the other stigmata
and thus explain the symptom; until now this has not happened (I
do not dare generalize the points of support obtained from our first
observation), and I do not consider it justified to presume it before
we have succeeded in demonstrating such a derivation.

On the other hand, the described peculiarity of the nervous system
and the psyche seems to explain some, only too familiar, qualities of
many hysterics. The excess of excitement, which their nervous
system sets free while at rest, conditions their incapacity to endure

¹⁸Oppenheim’s “Labilität der Molecüle.”

182

a monotonous and irksome existence. Their hankering for sensa-
tion impels them, after the outbreak of the disease to interrupt the
monotony of their sick existence through all sorts of happenings
among which pathological phenomena naturally play a part. In this
way they are supported by their auto-
suggestion. They are led into
it more and more by their need for sickness, that remarkable trait
which is as pathognomonic for hysteria as is the fear of disease for
hypochondria. I know an hysterical woman whose self-
injuries,
which were frequently quite serious, were meant for her own use,
and neither those about her nor her physician discovered anything
of them. If she had nothing to do, she performed all sorts of mischief
in her room, if only to prove to herself that she was not normal. She
really had a distinct feeling of her morbidity, she fulfilled her duties
incompletely and through such acts she sought to justify herself.
Another patient, a very sick woman of a morbid conscientiousness,
and full of distrust of herself, conceived every hysterical symptom as
guilt: “because she wouldn’t have had this if she had been decent.”
When the paralysis of her legs was mistakenly diagnosed as a spinal
disease, she felt pleased, and the explanation that it was “just ner-
vousness” and would soon disappear sufficed to produce in her deep
pangs of conscience. The need for the disease originated through the
patient’s longing to convince herself and others of the reality of her
illness. If it then associated itself with the torment, which was con-
ditioned by the monotony of the sick room, there developed the
strongest desire to get more new symptoms.

But if this develops into lying and leads to real simulation—and I
believe that we now reject the idea of simulation as much as we for-
merly accepted it—then it is not based on the hysterical disposition,
but as Moebius so excellently expressed it, on a complication of the
same with other degenerations, or with an original moral deficiency.
In the same way the “irascible hysterica” develops through the fact
that an original irritable and unsocial personality becomes additionally
afflicted with an egotistically spoiled character, which is easily
imposed by chronic suffering. Moreover, the irascible hysterica
hardly exists more frequently than the irascible tabetic in the later
stages of the disease.

The excess of irritability produces pathological phenomena also
in the motor spheres. Thus, some children easily develop tic-
like
movements, which were at first stimulated by some sensation in the
eyes or in the face or through an article of dress, which become per-
 

183

sistent if not immediately treated. The reflex paths are easily and
quickly formed.

Nor can it be denied, that there is a purely motor convulsive
attack, independent of all psychic factors which discharges a mass of
excitement accumulated only by a summation, just like the mass of
excitement of the epileptic attack, which is conditioned by automatic
changes. That would represent the non-ideogenic, hysterical attack.
We so frequently see adolescents, who though excitable have
remained healthy until the development of puberty when they became
ill with hysteria, that we must ask ourselves whether this process
does not create a disposition where it had not originally existed. And
we certainly must attribute more to puberty than the simple increase
in the quantity of excitement. For sexual maturity affects the whole
nervous system, it produces a general enhancement of the excitement
and a diminution of the resistances. Observation of non-hysterical
adolescents teaches this, and we therefore are justified in believing
that it also produces the hysterical disposition, insofar as the latter
consists of this quality of the nervous system. With this, we already
recognize sexuality as one of the great components of hysteria, and
we shall see later that its rôle in hysteria is still greater, that it par-
ticipates in many ways in the construction of the disease.

If the stigmata originate directly from the original native soil of
hysteria and are not ideogenic, then it is also impossible to place
ideogeny as the central point of hysteria, as is sometimes done today.
For what can be more genuinely hysterical than the stigmata or
those pathognomonic findings which confirm the diagnosis, and yet
they do not seem to be ideogenic. But if the basis of hysteria is a
peculiarity of the whole nervous system, the complex of ideogenic
and psychically determined symptoms rises on it like a building on its
foundation. And it is a building of many floors. But just as such a
structure can only be understood by distinguishing the ground plans
of the various floors, so I believe that the understanding of hysteria
is conditioned by the observations of the different etiological com-
plication of the symptoms. If one disregards this and attempts to
explain hysteria by the application of one causal connection, there
always remains a very large remnant of unexplained phenomena; it
is, as if one wished to put the various rooms of the many floored
house into the sketch of one floor.

Like the stigmata there is a group of other nervous symptoms, as

184

we saw above, which are not caused by ideas, but are direct results
of the fundamental anomaly of the nervous system, such as some
algias, vasomotor phenomena, and perhaps also the purely motor
convulsive attack.

Next to them we have the ideogenic phenomena, which are simple
conversions of affective excitement (p. 148). They originate as
results of affects in persons of hysterical disposition, and represent,
to begin with, only the anomalous expression of the emotions
(Oppenheim).¹⁹⁾ Through repetition the latter develops into a real,
seemingly pure somatic hysterical symptom, while the causative ideas
remain imperceptible (p. 151), or repressed from consciousness as a
result of a defense reaction. Most of the rejected and converted
ideas, or the most important of them, have a sexual content. They
are at the basis of a large part of hysteria of puberty. The maturing
girls, whom we have mostly in mind, behave in different ways
towards the sexual ideas and feelings which obtrude themselves on
them; sometimes, with complete ingenuousness, whereby some ignore
and overlook the whole situation. Others look upon sex in the same
way as boys, and this is especially the rule in peasant and working
girls. Still others seize, with more or less perverse curiosity, every-
thing containing anything sexual in speech or writing. And finally,
we have the delicately organized natures of marked sexual excita-
bility, but of equally great moral purity, who conceive everything
sexual as incompatible with their moral content, as something that
soils and pollutes.²⁰⁾ They repress the sexuality from their conscious-
ness, and the affective ideas of such content which have caused
somatic phenomena become unconscious through the “reaction of
defense.”

The tendency to defend herself against the sexual become
reenforced through the fact that the sensuous excitement in a virgin
contains a mixture of anxiety, the fear of the unknown, and the
presentiment of what is to happen, whereas in the natural and
healthy young man it is simply a pure aggressive impulse. The
young girl senses in Eros the frightful force which dominates and
decides her fate, and is frightened by it. The greater, therefore, is

¹⁹⁾That disposition is precisely that, which Strümpell designates as “the
disturbance in the psycho-physical,” which is at the basis of hysteria.

²⁰⁾Some observations lead us to believe that the fear of touching, or really
the fear of dirt, which compels women to wash their hands every moment, has
this origin. The washing is aroused by the same psychic process as in Lady
Macbeth.

185

the inclination to look away and to repress from consciousness that
which causes anxiety.

Marriage brings new sexual traumas. One wonders that the
wedding night does not more frequently act pathogenically, for unfor-
tunately it is more often rape than an erotic seduction. To be sure,
hysterias of young women, traceable to this experience, are not rare,
and they disappear when, in the course of time, sexual pleasure
appears and the trauma is wiped out. But also in the further course
of many marriages sexual traumas occur. Those case histories which
we could not publish contain a large number of perverse demands by
husbands, unnatural practices, etc. I do not think that I exaggerate
when I assert that the great majority of severe neuroses in women
originate in the marriage bed.²¹

According to Freud’s discovery, a part of the sexual injuries,
which mainly consist in insufficient gratification (coitus interruptus,
ejaculatio praecox, etc.), leads not to hysteria, but to anxiety
neurosis.²² But in my opinion even in such cases the excitement of
the sexual affect is frequently converted into hysterical somatic
phenomena.²³

It is quite evident, and has also been sufficiently shown in our
observations, that the non-sexual affects of fright, anxiety, and anger,
lead to the origin of hysterical phenomena. But it is perhaps not too
superfluous to emphasize again that the sexual factor is by far the
most important and pathologically the most fertile etiological factor.
The naive observations of our predecessors, the residuum of which
we retained in the word, “hysteria,” came nearer to the truth than
the modern views which put sexuality almost in the last line, in order
to guard the patients against moral reproaches. Of course, the
sexual needs of hysterics show as many individual variations as in
normal persons, and are not stronger than in the latter. But the
hysterics become sick from it, and what is more, mostly through the
struggle of defending themselves against sexuality.

²¹It is certainly sad that one of the most important pathogenic factors is
ignored in the clinic, or only delicately touched upon by allusions. This is
really a subject where the experience of the experienced should be imparted to
the young physician, who quite usually blindly passes over sexuality, at least
insofar as concerns his patients.

²²Freud: On the Right to Separate from Neurasthenia a Definite Symp-
tom-Complex, as Anxiety Neurosis. Chapter V in Selected Papers on Hysteria,
translated by Brill, Monograph Series.

²³This has later been verified by Freud and his pupils. There is really no
pure anxiety neurosis. Cf. Freud’s Introduction to Stekel’s “Nervöse
Angstzustände,” Urban and Schwarzenberg, Wien, 1908.

186

Next to the sexual we must here also mention the fright-
hysteria, the actual traumatic hysteria. It forms one of the most familiar and
most recognized types of hysteria.

In the same stratum, so to say, with the phenomena which orig-
inated through conversion of emotional excitement, there are those
which owe their origin to suggestion (mostly auto-suggestion) in
originally suggestible individuals. High graded suggestibility, i.e.,
an uninhibited preponderance of freshly excited ideas, does not
belong to the nature of hysteria, but it may be found as a compli-
cation in those hysterically predisposed, in whom this very peculiarity
of the nervous system makes possible the physical realization of the
overvalued idea. For the rest, they are mostly only affective ideas
which become realized suggestively in somatic phenomena, and hence,
we can often also conceive the process as a conversion of the accom-
panying fright or anxiety affect.

These processes of affect conversion and of suggestibility remain
identical also in the complicated forms of hysteria which are now to
be considered. There they find only more favorable conditions,
but psychically determined hysterical phenomena always originate
through one of these two processes.

The hypnoid state, or the tendency to auto-hypnosis (p. 158),
forms the third constituent of the hysterical disposition which joined
some of the cases discussed above. This state favors and alleviates
conversion as well as suggestion to the highest extent, and thereby,
so to speak, constructs over the petty hysteria, which presents only
a single hysterical phenomenon, the upper floors of the major
hysteria. It constitutes a state which is at first only transient, and
alternating with the normal. We may ascribe to it the same increase
of psychic influence on the body, which we have observed in the
artificial hypnosis. But here this influence is all the more intensive
and further reaching because it concerns a nervous system which has
an anomalous irritability even without the hypnosis.²⁴ To what
extent, and in which cases, the tendency to auto-hypnosis is an

²⁴It would be in order to identify the disposition for hypnosis with the
original abnormal excitement, because even the artificial hypnosis shows
ideogenic changes of the secretion, of local hyperaemia, formation of blisters,
etc. This seems to be the view of Moebius. But I believe that this makes one
move about in a vicious circle. This thaumaturgy of hypnosis we observe, as
far as I see, only in hysterics. We would, therefore, attribute to hypnosis the
functions of hysteria, and then trace this back again to hysteria.

187

original peculiarity of the organism we do no-
expressed above (p. 161) the view that this state develops from
affectful reveries. But it is certain that an original disposition also
belongs to it. If that view is correct, it becomes quite clear here,
how great an influence must be attributed to sexuality in the develop-
ment of hysteria. For besides nursing, there is no psychic factor
which is as apt to produce reveries as amorous longing. And besides,
the sexual organism by virtue of its superfluous affects and narrowing
of consciousness is closely related to the hypnoid states.

The hypnoid state manifests itself most distinctly in the hysterical
attack, in that state which can be designated as acute hysteria, and
which it seems plays so significant a part in the development of
major hysteria (p. 176). These states last long, sometimes many
months, and are distinctly of a psychotic nature, so that one must
frequently designate them as hallucinatory confusions. But even if
the disturbance does reach so far in such states, there appear mani-
fold hysterical phenomena, some of which continue persistently. The
psychic content of these states consists in part of those very ideas
which were rejected in the waking state and repressed into the uncon-
scious (“hysterical deliria of saints and nuns, of abstinent women,
and of well bred children”).

As these states are so often real psychoses and, nevertheless, origi-
nate directly and exclusively from hysteria, I cannot accept Moebius’
opinion that “disregarding those whose attacks are associated with
deliria, one cannot speak of an actual hysterical insanity.”²⁵ These
states are of such a nature in many cases, and in the further course
of the hysteria such psychoses also repeat themselves. In their nature
they are, of course, nothing but the psychotic stage of the attack, but
as they continue for months they cannot really be designated as
attacks.

How do these acute hysterias originate? In the most familiar
cases (Observation I), it developed from a summation of hypnoid
attacks. In another case (of an already existing, complicated
hysteria), it appeared as an appendage to a withdrawal of morphine.
For the most part, the process is quite obscure and awaits elucidation
through further observations.

The cases of hysteria discussed here fit into the following state-
ment of Moebius: “The essential change of hysteria consists in the

²⁵Moebius: Gegenwärtige Auffassung der Hysterie. Monatsschrift für
Geburtshilfe und Gynäkologie, 1895, I Bd., p. 18.

188

fact that whether transient or persistent, the psychic state of the
hysteric resembles the state of those hypnotized.²⁶⁾

The continuation of the hysterical symptoms which originated in
the hypnoid state, during the normal state, agrees perfectly with our
experiences concerning post-hypnotic suggestions. But this also
implies that complexes of ideas incapable of consciousness co-
exist with groups of ideas which function consciously; that is to say, there
is a splitting of the psyche (p. 170). It seems certain that this, too,
can originate without hypnoidism from an abundance of rejected
ideas which were repressed, but not suppressed from consciousness.
In this or that way there develops a sphere of psychic existence,
which is now ideationally impoverished and rudimentary, and now
more or less equal to the waking thoughts, for the cognition of
which we are indebted above all to Binet and Janet. The splitting
of the psyche is the consummation of hysteria, and it was demon-
strated above how it explained the fundamental character traits of the
disease. Permanent, but with vivid fluctuations of its ideas, a part
of the patient’s psyche is in a hypnoid state and is always prepared
to gain control of the whole person whenever conscious thought
becomes reduced (attack, delirium). This occurs as soon as a strong
affect disturbs the normal flow of ideas as in twilight, or exhaustive
states. From this persistent hypnoidism there obtrude themselves
into consciousness unmotivated ideas, which are foreign to the normal
associations, hallucinations which are thrust into the perceptions, and
motor acts independent of the conscious will become innervated.
This hypnoid psyche is capable to the highest degree of producing
conversions of affects and suggestions, thus giving rise with ease to
new hysterical phenomena, which without the psychic splitting could
have come into existence only with difficulty and under the pressure
of repetitive affects. The split-off psyche is that demon of whom the
patients were believed possessed by the naïvely observing age of
superstitious times. That a ghost who is a stranger to the wakeful
consciousness of the patient holds sway in him, is true, only he is no
real stranger, but a part of himself.

The attempt ventured here to reconstruct hysteria synthetically
from our present knowledge is open to the reproach of eclecticism,
if this is at all justified. So many formulations of hysteria from the

²⁶⁾See p. 15.

189

old “reflex theory” to the “dissociation of the personality” had to
find a place here. But it could hardly be otherwise. So many excel-
lent observers and ingenious heads have interested themselves in
hysteria. It is improbable that each of their formulations does not
contain a part of the truth. The future presentation of the real state
of affairs will surely contain them all, and will only combine all the
one-sided views of the subject into a material reality. Eclecticism,
therefore, seems to me no reproach.

But how far are we today from the possibility of such complete
understanding of hysteria! With what uncertain features have the
contours been outlined, with what clumsy new ideas have the gaping
chasms been covered rather than filled. The only consideration that
is somewhat mitigating lies in the fact that this evil sticks, and must
stick to all physiological explanations of complicated psychic proc-
esses. What Theseus said of the tragedy in “Midsummer Night’s
Dream” is also true of them: “The best of this kind are but
shadows” (Act V, Scene 1). And even the feeblest is not worth
less, if it seeks faithfully and humbly to hold firmly to the silhouettes
which were thrown on the wall by the unknown real objects. More
over, the hope is always justified that some measure of agreement
and similarity will endure between the real processes and our
conception.