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Howard C. Herrmann, MD

• Professor of Medicine
• Cardiovascular Division
• University of Pennsylvania School of Medicine
• Director, Interventional Cardiology and Cardiac
• Catheterization Laboratories
• Hospital of the University of Pennsylvania
• Philadelphia, Pennsylvania

What happens is that medicine stone music festival buy meldonium 500 mg with mastercard, with the relaxation of the inhibiting attention in still plainer terms treatment broken toe 250mg meldonium mastercard, as a result of this relaxation the uninhibited stream of associations comes into action medications drugs prescription drugs buy meldonium 500mg. I almost invariably discover a disturbing influence in addition which comes from something outside the intended utterance; and the disturbing element is either a single thought that has remained unconscious 9 medications that can cause heartburn discount meldonium online visa, which manifests itself in the slip of the tongue and which can often be brought to consciousness only by means of searching analysis, or it is a more general psychical motive force which is directed against the entire utterance. I had already begun the quotation once before and had not made a slip of the tongue the first time. The repetition was necessary because the person I was addressing had had her attention distracted from another quarter and she had not been listening to me. I must include the fact of the repetition, together with my impatience to have done with my sentence, among the motives of the slip which made its appearance as a product of condensation. This slip of the tongue is probably connected with a trend towards making articulation easier, for an l is difficult to pronounce after a repeated r. Now slips of the tongue are in a high degree contagious, like the forgetting of names a peculiar fact which Meringer and Mayer have noticed in the case of the latter. Ernst) of a well known Viennese firm in the Karntnerstrasse which used to advertise the sale of contraceptives. The chance arrival at her boarding house of a guest from Paris had awoken the whole series of memories. The interchanging of the sounds was therefore the result of a disturbance by an unconscious thought from an entirely different context. Her memory would not tell her what part of her body had been grasped by a prying and lascivious hand. Immediately afterwards she called on a friend with whom she discussed summer residences. You must of course have thought me a very uneducated person who is always getting foreign words mixed up. The slip of the tongue of the day before had therefore anticipated the memory which at the time had not yet become conscious. It is a frequent occurrence for the idea one wants to withhold to be precisely the one which forces its way through in the form of a slip of the tongue. I once met two old ladies in the Dolomites who were dressed up in walking clothes. Reasons of propriety led her to suppress any mention of the third article of linen. They really were distracted by what the woman said, for she diverted my attention to something much more important to me than carpets. As a matter of fact, the house in which my wife lived when she was my fiancee was in the Matthausgasse. The entrance to the house was in another street, and I now noticed that I had forgotten its name and could only make it conscious in a round about way. The name Matthaus, which I was lingering over, was therefore a substitute name for the forgotten street-name. It was more suitable for this purpose than the name Kaufmann, for Matthaus is exclusively a personal name, while Kaufmann is not, and the forgotten street also bears the name of a person: Radetzky. A woman patient told me a dream: A child had resolved to kill itself by means of a snake-bite. She had now to find the impressions of the previous day which the dream had taken as its starting point. She immediately recalled that on the previous evening she had listened to a public lecture on first aid for snake-bites. I interrupted at this point and asked: Surely he must have said that we have very few poisonous kinds in these parts and he must have told you which are the dangerous onesfi In the ordinary way she knew as well as I did that that species of snake is not among the fauna of our country. We will not blame her for her equal lack of hesitation in transferring the rattlesnake to Egypt, for it is usual for us to lump together everything which is non-European and exotic, and I had myself to reflect for a moment before declaring that the rattlesnake is confined to the New World. The Psychopathology Of Everyday Life 1157 the continuation of the analysis brought further confirmation. On the previous day the dreamer had for the first time inspected the Mark Antony monument by Strasser, which stood in the vicinity of her home. This then was the second exciting cause of the dream (the first having been the lecture on snake bites). From the fact that the names of so many plays made their appearance in the dream-thoughts we may already have a suspicion that in her earlier years the dreamer had cherished a secret passion for the profession of actress. It will be easy, he thought, to remember the word by thinking of the painter Corregio. He had apparently not been successful in replacing the German word by the Italian one in his memory but his efforts were nevertheless not entirely unsuccessful. I could of course have quoted the present case just as appropriately as an example of the for getting of a name rather than of a slip of the tongue. When I was collecting slips of the tongue for the first edition of this book I proceeded by subjecting to analysis every case I was able to observe, and accordingly included the less impressive ones. Since then a number of other people have undertaken the amusing task of collecting and analysing slips of the tongue, and have thus enabled me to select from a richer material. But while he attempted to conceal this from her, his unconscious played a trick on him by betraying his real intentions.

But what part is there left to be played in our scheme by consciousness treatment 1 degree av block buy meldonium canada, which was once so omnipotent and hid all else from viewfi In accordance with the ideas underlying our attempt at a schematic picture the treatment 2014 buy meldonium visa, we can only regard conscious perception as the function proper to a particular system; and for this the abbreviation Cs medications safe for dogs discount meldonium master card. In its mechanical properties we regard this system as resembling the perceptual systems Pcpt acne natural treatment purchase 500mg meldonium overnight delivery. The psychical apparatus, which is turned towards the external world with its sense-organ of the Pcpt. Here we once more meet the principle of the hierarchy of agencies, which seems to govern the structure of the apparatus. The Interpretation Of Dreams 1041 Those philosophers who have become aware that rational and highly complex thought-structures are possible without consciousness playing any part in them have found difficulty in assigning any function to consciousness; it has seemed to them that it can be no more than a superfluous reflected picture of the completed psychical process. We, on the other hand, are rescued from this embarrassment by the analogy between our Cs. We know that perception by our sense-organs has the result of directing a cathexis of attention to the paths along which the in-coming sensory excitation is spreading: the qualitative excitation of the Pcpt. By perceiving new qualities, it makes a new contribution to directing the mobile quantities of cathexis and distributing them in an expedient fashion. By the help of its perception of pleasure and unpleasure it influences the discharge of the cathexes within what is otherwise an unconscious apparatus operating by means of the displacement of quantities. It seems probable that in the first instance the unpleasure principle regulates the displacement of cathexes automatically. But it is quite possible that consciousness of these qualities may introduce in addition a second and more discriminating regulation, which is even able to oppose the former one, and which perfects the efficiency of the apparatus by enabling it, in contradiction to its original plan, to cathect and work over even what is associated with the release of unpleasure. We learn from the psychology of the neuroses that these processes of regulation carried out by the qualitative excitation of the sense organs play a great part in the functional activity of the apparatus. The automatic domination of the primary unpleasure principle and the consequent restriction imposed upon efficiency are interrupted by the processes of sensory regulation, which are themselves in turn automatic in action. We find that repression (which, though it served a useful purpose to begin with, leads ultimately to a damaging loss of inhibition and mental control) affects memories so much more easily than perceptions because the former can receive no extra cathexis from the excitation of the psychical sense-organs. It is true on the one hand that a thought which has to be warded off cannot become conscious, because it has undergone repression; but on the other hand it sometimes happens that a thought of this kind is only repressed because for other reasons it has been withdrawn from conscious perception. Here are some hints of which we take advantage in our therapeutic procedure in order to undo repressions which have already been effected. The Interpretation Of Dreams 1042 the value of the hypercathexis which is set up in the mobile quantities by the regulating influence of the sense organ of the Cs. Thought-processes are in themselves without quality, except for the pleasurable and unpleasurable excitations which accompany them, and which, in view of their possible disturbing effect upon thinking, must be kept within bounds. In order that thought-processes may acquire quality, they are associated in human beings with verbal memories, whose residues of quality are sufficient to draw the attention of consciousness to them and to endow the process of thinking with a new mobile cathexis from consciousness. The whole multiplicity of the problems of consciousness can only be grasped by an analysis of the thought-processes in hysteria. These give one the impression that the transition from a preconscious to a conscious cathexis is marked by a censorship similar to that between the Ucs. This censorship, too, only comes into force above a certain quantitative limit, so that thought-structures of low intensity escape it. Examples of every possible variety of how a thought can be withheld from consciousness or can force its way into consciousness under certain limitations are to be found included within the framework of psychoneurotic phenomena; and they all point to the intimate and reciprocal relations between censorship and consciousness. I will bring these psychological reflections to an end with a report of two such examples. The Interpretation Of Dreams 1043 I was called in to a consultation last year to examine an intelligent and unembarrassed-looking girl. She complained of having pains in her leg and, without being asked, exposed her calf. The girl herself had no notion of the bearing of her remarks; for if she had, she would never have given voice to them. In this case it had been possible to hoodwink the censorship into allowing a phantasy which would normally have been kept in the preconscious to emerge into consciousness under the innocent disguise of making a complaint. A fourteen-year-old boy came to me for psycho-analytic treatment suffering from tic convulsif, hysterical vomiting, headaches, etc. I began the treatment by assuring him that if he shut his eyes he would see pictures or have ideas, which he was then to communicate to me. He thought of various positions, favourable or unfavourable, and of moves that one must not make. He then saw a dagger lying on the board an object that belonged to his father but which his imagination placed on the board. His suppressed rage against his father was what had constructed this series of pictures with their understandable allusions. The sickle was the one with which Zeus castrated his father; the scythe and the picture of the old peasant represented Kronos, the violent old man who devoured his children and on whom Zeus took such unfilial vengeance. The Interpretation Of Dreams 1044 Thus I would look for the theoretical value of the study of dreams in the contributions it makes to psychological knowledge and in the preliminary light it throws on the problems of the psychoneuroses. Who can guess the importance of the results which might be obtained from a thorough understanding of the structure and functions of the mental apparatus, since even the present state of our knowledge allows us to exert a favourable therapeutic influence on the curable forms of psychoneurosisfi But what of the practical value of this study I hear the question raised as a means towards an understanding of the mind, towards a revelation of the hidden characteristics of individual menfi Have not the unconscious impulses brought out by dreams the importance of real forces in mental lifefi Is the ethical significance of suppressed wishes to be made light of wishes which, just as they lead to dreams, may some day lead to other thingsfi I think however, that the Roman emperor was in the wrong when he had one of his subjects executed because he had dreamt of murdering the emperor. He should have begun by trying to find out what the dream meant; most probably its meaning was not what it appeared to be. If we look at unconscious wishes reduced to their most fundamental and truest shape, we shall have to conclude, no doubt, that psychical reality is a particular form of existence not to be confused with material reality. When the mode of functioning of the mental apparatus is rightly appreciated and the relation between the conscious and the unconscious understood, the greater part of what is ethically objectionable in our dream and phantasy lives will be found to disappear. Actions deserve to be considered first and foremost; for many impulses which force their way through to consciousness are then brought to nothing by the real forces of mental life before they can mature into deeds. In fact, such impulses often meet with no psychical obstacles to their progress, for the very reason that the unconscious is certain that they will be stopped at some other stage. It is in any case instructive to get to know the much trampled soil from which our virtues proudly spring. Very rarely does the complexity of a human character, driven hither and thither by dynamic forces, submit to a choice between simple alternatives, as our antiquated morality would have us believe.

Disorders that in- tem orchestrates higher order cognitive functions such as volve disruption of dopaminergic modulation (for exam- task switching treatment jiggers purchase generic meldonium line, inhibitory control medications while breastfeeding order genuine meldonium on-line, confiict resolution medicine 018 generic 500 mg meldonium visa, ple medications a to z order 250mg meldonium mastercard, schizophrenia) frequently demonstrate dysfunctions error detection, attentional resource allocation, planning, of executive attention. Thus, that there were three elements of attention: focus-execute, if you were proofreading a recent paper that you had pre- sustain, and shift. A battery of neuropsychological mea- pared for a class, the anterior cingulate would be active sures considered sensitive to attentional functioning was with regard to identifying errors in the text. The test late are jointly activated, depending on the nature of the data revealed four factors, three of which corresponded presented demand or task. The involvement of the lateral with the elements of attention proposed by Mirsky, and prefrontal cortex in the executive attention system relates an additional element that was labeled encode. Subse- to its role in holding mental representations of specific in- quently, the battery was extended to healthy children with formation in temporary memory. Once erations is consistent with the definition of working mem- again, four factors were identified, each similar to the ele- ory. The Stroop test (1935) illustrates the roles of the ments of attention identified in the adult studies. The four elements of attention, and their hypothesized the attention systems and structures presented here supportive neural substrates, are presented in Table 9. Focus-execute attention involves selective attention studies of auditory spatial attention, similar to visuospa- and rapid perceptual-motor output. There is agreement that, at a corti- change attentional focus in a fiexible and adaptive cal level, the right hemisphere, particularly the parietal manner. Recently, a fifth component of attention, stable, was identified, and represents the consistency of attentional effort. The five elements of attention are believed to be Executive Functioning supported by relatively distinct neuroanatomic regions (see Table 9. The distribution of the attention system throughout frontal lobes are unique in organization and function. Accordingly, the attention system more than a century, controversy, confusion, and specula- is quite vulnerable to disruption when brain injury is sus- tion have existed over the function(s) of the frontal lobes. Chapter 11 discusses the application of emotional regulation, and moral judgment). Be- of rudimentary executive functions and the later develop- cause of the significant afferent and efferent connectivity ment of more complex functions, such as abstract reason- of the frontal lobes with other brain regions, disruption to ing and judgment, parallel the lengthy development of any one these connecting systems can produce pathologic the prefrontal cortex. Interestingly, the emergence of rudi- behaviors similar to those caused by direct frontal damage. However, ganglia can result in pathologic behaviors similar to those more complex functions continue to evolve long after seen with dorsolateral prefrontal damage. Although the maximum synaptic density is reached, and refiect a term executive functioning does not denote a specific host of other developmental advances such as synaptic anatomic basis for behavior, it does implicate the frontal pruning and sculpting, axonal myelination, and neuro- cortex and its interconnective neural circuitry. Goldman-Rakic has studied the relation of planning, fiexible problem solving, working memory, at- prefrontal development to the emergence of the cognitive tentional allocation, inhibition, and at the highest levels, operation of object permanence, that is, the capacity to the self-monitoring and self-assessment of behavior. By the age of 2 to and associated subcortical regions linked to emotional and 4 months, the rhesus monkeys could perform the memory social functioning, can produce some of the most devastat- tasks at delay intervals of 2 to 5 seconds. Executive functioning impairments be- 4-month period, researchers observed maximum synaptic come more evident in the most complex aspects of human density in the prefrontal lobes of the rhesus monkeys. The conscious activity, or those activities of higher problem corresponding period of synaptic density in the human in- solving, reasoning, abstraction, critical self-awareness, and fant occurs between 8 and 24 months (Huttenlocher, 1990). Culbertson Diamond (1991) has adapted a number of tasks that Jean Piaget initially used in studying cognitive development to inves- tigate executive functions. In her study of infants, Diamond endeavored to relate the development of executive functions to the maturation of the underlying frontal circuitry. Contiguous Object Task the contiguous object task involves the use of a transparent box that is open at the top (Figure 9. The experimenter places a toy block behind the wall of the box and prompts the infant to pick up the toy block. Infants of 7 months can reach the block behind the wall if a single straight movement is required (frame A). Development as progressive inhibitory searcher hides the toy in the opposite well, control of action: Retrieval of a contiguous object. The task involves a small transparent box that the experimenter places in front of the infant with one of its sides open (Figure 9. In the following frames, the infant continues to gaze at the well holding the toy, yet lifts the cover from the the same time with the other hand. Neuropsychological insights into the establishing a direct line of sight to the toy. The child withdraws her hand from the opening and though he or she has seen the researcher ing at the well containing the toy. However, tries, unsuccessfully, to reach for the toy place the toy in the opposite well. The researcher then placed Success on this task requires the emergence reaching through another side. In the first two of working memory capability and the ability child can raise the box with one hand, and frames (top left and right), the infant is look- to inhibit a previously reinforced response. Furthermore, executive function performance does not Her findings demonstrated that the ability to inhibit re- appear to correlate significantly with intelligence, sup- fiexive reactions to contact (elicitation of the grasp refiex porting the proposition that these two cognitive con- when touching an object) and to combine two or more structs are relatively independent from each other. The ex- layed response task (A not B) and the detour reaching aminer asks the child to replicate a series of bead patterns task, respectively, refiects the development of the ability of increasing difficulty while adhering to specific problem- to relate information across time and space. The goal is to solve each pattern in a mini- mance of these tasks requires inhibitory control and work- mum number of moves without violating the rules. Chil- ing memory capabilities, functions that the dorsolateral pre- dren who fail to plan, or plan superficially, require additional frontal cortex support (Goldman-Rakic, 1987b). That is, the infant can execute an action with one hand and simultaneously perform a different action with the other. That is, the action of each hand must coordinate with the other, but each is inhibited from performing the same movement as the other. Other researchers (Denckla, 1996; Pennington, 1997b) have also made notable contributions to the identification of emerging childhood executive functions. For example, Welsh and coworkers (1991) have traced the development of executive functions in healthy children, ages 3 to 12, and young adults. The investigators determined that sub- jects achieved adult-like performance at three different age levels: 6 years old, 10 years old, and during adoles- cence. Simple functions, such as visual search (searching an array of stimuli for targets), emerge early, followed by the more complex inhibitory skills, and finally, the most Figure 9. The Tower of London: A standardized approach to Age-related changes in the development of the executive assessing executive functioning in children.

We are inclined to make the simple connection that continued bed-wetting is a result of masturbation and that its suppression is regarded by boys as an inhibition of their genital activity that is treatment kidney disease generic meldonium 500mg fast delivery, as having the meaning of a threat of castration; but whether we are always right in supposing this remains to be seen schedule 8 medications list buy meldonium overnight. Masturbation medicine sans frontiers meldonium 500 mg low cost, as well as the two attitudes in the Oedipus complex medicine while breastfeeding meldonium 250mg without prescription, later on become attached to this early experience, the child having subsequently interpreted its meaning. Thus the prehistory of the Oedipus complex, even in boys, raises all of these questions for sifting and explanation; and there is the further problem of whether we are to suppose that the process invariably follows the same course, or whether a great variety of different preliminary stages may not converge upon the same terminal situation. Some Psychical Consequences Of the Anatomical Distinction Between the Sexes 4149 In little girls the Oedipus complex raises one problem more than in boys. In both cases the mother is the original object; and there is no cause for surprise that boys retain that object in the Oedipus complex. But how does it happen that girls abandon it and instead take their father as an objectfi In pursuing this question I have been able to reach some conclusions which may throw light precisely on the prehistory of the Oedipus relation in girls. Every analyst has come across certain women who cling with especial intensity and tenacity to the bond with their father and to the wish in which it culminates of having a child by him. We have good reason to suppose that the same wishful phantasy was also the motive force of their infantile masturbation, and it is easy to form an impression that at this point we have been brought up against an elementary and unanalysable fact of infantile sexual life. But a thorough analysis of these very cases brings something different to light namely, that here the Oedipus complex has a long prehistory and is in some respects a secondary formation. The old paediatrician Lindner once remarked that a child discovers the genital zones (the penis or the clitoris) as a source of pleasure while indulging in sensual sucking (thumb sucking). Be that as it may, the genital zone is discovered at some time or other, and there seems no justification for attributing any psychical content to the first activities in connection with it. But the first step in the phallic phase which begins in this way is not the linking-up of the masturbation with the object-cathexes of the Oedipus complex, but a momentous discovery which little girls are destined to make. They notice the penis of a brother or playmate, strikingly visible and of large proportions, at once recognize it as the superior counterpart of their own small and inconspicuous organ, and from that time forward fall a victim to envy for the penis. Some Psychical Consequences Of the Anatomical Distinction Between the Sexes 4150 There is an interesting contrast between the behaviour of the two sexes. It is not until later, when some threat of castration has obtained a hold upon him, that the observation becomes important to him: if he then recollects or repeats it, it arouses a terrible storm of emotion in him and forces him to believe in the reality of the threat which he has hitherto laughed at. These developments, however, belong to the future, though not to a very remote one. I believed that the sexual interest of children, unlike that of pubescents, was aroused, not by the difference between the sexes, but by the problem of where babies come from. With boys it may no doubt happen sometimes one way and sometimes the other; or with both sexes chance experiences may determine the event. Some Psychical Consequences Of the Anatomical Distinction Between the Sexes 4151 Here what has been named the masculinity complex of women branches off. It may put great difficulties in the way of their regular development towards femininity, if it cannot be got over soon enough. The hope of some day obtaining a penis in spite of everything and so of becoming like a man may persist to an incredibly late age and may become a motive for strange and otherwise unaccountable actions. Thus a girl may refuse to accept the fact of being castrated, may harden herself in the conviction that she does possess a penis, and may subsequently be compelled to behave as though she were a man. The psychical consequences of envy for the penis, in so far as it does not become absorbed in the reaction-formation of the masculinity complex, are various and far-reaching. After a woman has become aware of the wound to her narcissism, she develops, like a scar, a sense of inferiority. When she has passed beyond her first attempt at explaining her lack of a penis as being a punishment personal to herself and has realized that that sexual character is a universal one, she begins to share the contempt felt by men for a sex which is the lesser in so important a respect, and, at least in holding that opinion, insists on being like a man. On the other hand, one hears of analysts who boast that, though they have worked for dozens of years, they have never found a sign of the existence of a castration complex. We must bow our heads in recognition of the greatness of this achievement, even though it is only a negative one, a piece of virtuosity in the art of overlooking and mistaking. The two theories form an interesting pair of opposites: in the latter not a trace of a castration complex, in the former nothing else than its consequences. Some Psychical Consequences Of the Anatomical Distinction Between the Sexes 4152 Even after penis-envy has abandoned its true object, it continues to exist: by an easy displacement it persists in the character-trait of jealousy. Of course, jealousy is not limited to one sex and has a wider foundation than this, but I am of opinion that it plays a far larger part in the mental life of women than of men and that that is because it is enormously reinforced from the direction of displaced penis-envy. The child which is being beaten (or caressed) may ultimately be nothing more nor less than the clitoris itself, so that at its very lowest level the statement will contain a confession of masturbation, which has remained attached to the content of the formula from its beginning in the phallic phase till later life. The way in which this comes about historically is often that soon after the girl has discovered that her genitals are unsatisfactory she begins to show jealousy of another child on the ground that her mother is fonder of it than of her, which serves as a reason for her giving up her affectionate relation to her mother. It will fit in with this if the child which has been preferred by her mother is made into the first object of the beating-phantasy which ends in masturbation. Some Psychical Consequences Of the Anatomical Distinction Between the Sexes 4153 There is yet another surprising effect of penis-envy, or of the discovery of the inferiority of the clitoris, which is undoubtedly the most important of all. In the past I had often formed an impression that in general women tolerate masturbation worse than men, that they more frequently fight against it and that they are unable to make use of it in circumstances in which a man would seize upon it as a way of escape without any hesitation. Experience would no doubt elicit innumerable exceptions to this statement, if we attempted to turn it into a rule. The reactions of human individuals of both sexes are of course made up of masculine and feminine traits. But it appeared to me nevertheless as though masturbation were further removed from the nature of women than of men, and the solution of the problem could be assisted by the reflection that masturbation, at all events of the clitoris, is a masculine activity and that the elimination of clitoridal sexuality is a necessary precondition for the development of femininity. Analyses of the remote phallic period have now taught me that in girls, soon after the first signs of penis-envy, an intense current of feeling against masturbation makes its appearance, which cannot be attributed exclusively to the educational influence of those in charge of the child. It may happen that this first opposition to auto-erotic activity fails to attain its end. The conflict continued, and both then and later the girl did everything she could to free herself from the compulsion to masturbate. Many of the later manifestations of sexual life in women remain unintelligible unless this powerful motive is recognized. I cannot explain the opposition which is raised in this way by little girls to phallic masturbation except by supposing that there is some concurrent factor which turns her violently against that pleasurable activity. It cannot be anything else than her narcissistic sense of humiliation which is bound up with penis-envy, the reminder that after all this is a point on which she cannot compete with boys and that it would therefore be best for her to give up the idea of doing so. Some Psychical Consequences Of the Anatomical Distinction Between the Sexes 4154 So far there has been no question of the Oedipus complex, nor has it up to this point played any part.

Purchase 250mg meldonium mastercard. "Common Pediatric Respiratory Problems" by Monica Kleinman MD for OPENPediatrics.

The antithesis active-passive coalesces later with the antithesis masculine-feminine symptoms 4-5 weeks pregnant buy generic meldonium 250mg line, which medications prednisone purchase 500mg meldonium free shipping, until this has taken place symptoms 0f food poisoning buy meldonium on line amex, has no psychological meaning treatment glaucoma meldonium 250 mg amex. The coupling of activity with masculinity and of passivity with femininity meets us, indeed, as a biological fact; but it is by no means so invariably complete and exclusive as we are inclined to assume. The three polarities of the mind are connected with one another in various highly significant ways. Originally, at the very beginning of mental life, the ego is cathected with instincts and is to some extent capable of satisfying them on itself. During this period, therefore, the ego-subject coincides with what is pleasurable and the external world with what is indifferent (or possibly unpleasurable, as being a source of stimulation). Those sexual instincts which from the outset require an object, and the needs of the ego-instincts, which are never capable of auto-erotic satisfaction, naturally disturb this state and so pave the way for an advance from it. Indeed, the primal narcissistic state would not be able to follow the development if it were not for the fact that every individual passes through a period during which he is helpless and has to be looked after and during which his pressing needs are satisfied by an external agency and are thus prevented from becoming greater. Instincts And Their Vicissitudes 2971 In so far as the ego is auto-erotic, it has no need of the external world, but, in consequence of experiences undergone by the instincts of self-preservation, it acquires objects from that world, and, in spite of everything, it cannot avoid feeling internal instinctual stimuli for a time as unpleasurable. Under the dominance of the pleasure principle a further development now takes place in the ego. For the pleasure-ego the external world is divided into a part that is pleasurable, which it has incorporated into itself, and a remainder that is extraneous to it. It has separated off a part of its own self, which it projects into the external world and feels as hostile. After this new arrangement, the two polarities coincide once more: the ego-subject coincides with pleasure, and the external world with unpleasure (with what was earlier indifference). When, during the stage of primary narcissism, the object makes its appearance, the second opposite to loving, namely hating, also attains its development. As we have seen, the object is brought to the ego from the external world in the first instance by the instincts of self-preservation; and it cannot be denied that hating, too, originally characterized the relation of the ego to the alien external world with the stimuli it introduces. Indifference falls into place as a special case of hate or dislike, after having first appeared as their forerunner. At the very beginning, it seems, the external world, objects, and what is hated are identical. If later on an object turns out to be a source of pleasure, it is loved, but it is also incorporated into the ego; so that for the purified pleasure-ego once again objects coincide with what is extraneous and hated. Now, however, we may note that just as the pair of opposites love-indifference reflects the polarity ego- external world, so the second antithesis love-hate reproduces the polarity pleasure-unpleasure, which is linked to the first polarity. When the purely narcissistic stage has given place to the object-stage, pleasure and unpleasure signify relations of the ego to the object. If the object becomes a source of pleasurable feelings, a motor urge is set up which seeks to bring the object closer to the ego and to incorporate it into the ego. Conversely, if the object is a source of unpleasurable feelings, there is an urge which endeavours to increase the distance between the object and the ego and to repeat in relation to the object the original attempt at flight from the external world with its emission of stimuli. Thus we become aware that the attitudes of love and hate cannot be made use of for the relations of instincts to their objects, but are reserved for the relations of the total ego to objects. But if we consider linguistic usage, which is certainly not without significance, we shall see that there is a further limitation to the meaning of love and hate. The distinction between the ego-instincts and the sexual instincts which we have imposed upon our psychology is thus seen to be in conformity with the spirit of our language. The ego hates, abhors and pursues with intent to destroy all objects which are a source of unpleasurable feeling for it, without taking into account whether they mean a frustration of sexual satisfaction or of the satisfaction of self-preservative needs. So we see that love and hate, which present themselves to us as complete opposites in their content, do not after all stand in any simple relation to each other. They did not arise from the cleavage of any originally common entity, but sprang from different sources, and had each its own development before the influence of the pleasure-unpleasure relation made them into opposites. It now remains for us to put together what we know of the genesis of love and hate. Love is derived from the capacity of the ego to satisfy some of its instinctual impulses auto-erotically by obtaining organ- pleasure. It is originally narcissistic, then passes over on to objects, which have been incorporated into the extended ego, and expresses the motor efforts of the ego towards these objects as sources of pleasure. It becomes intimately linked with the activity of the later sexual instincts and, when these have been completely synthesized, coincides with the sexual impulsion as a whole. Preliminary stages of love emerge as provisional sexual aims while the sexual instincts are passing through their complicated development. At the higher stage of the pregenital sadistic-anal organization, the striving for the object appears in the form of an urge for mastery, to which injury or annihilation of the object is a matter of indifference. Love in this form and at this preliminary stage is hardly to be distinguished from hate in its attitude towards the object. Not until the genital organization is established does love become the opposite of hate. Instincts And Their Vicissitudes 2974 Hate, as a relation to objects, is older than love. As an expression of the reaction of unpleasure evoked by objects, it always remains in an intimate relation with the self-preservative instincts; so that sexual and ego-instincts can readily develop an antithesis which repeats that of love and hate. When the ego-instincts dominate the sexual function, as is the case at the stage of the sadistic-anal organization, they impart the qualities of hate to the instinctual aim as well. The hate which is admixed with the love is in part derived from the preliminary stages of loving which have not been wholly surmounted; it is also in part based on reactions of repudiation by the ego-instincts, which, in view of the frequent conflicts between the interests of the ego and those of love, can find grounds in real and contemporary motives. In both cases, therefore, the admixed hate has as its source the self-preservative instincts. If a love-relation with a given object is broken off, hate not infrequently emerges in its place, so that we get the impression of a transformation of love into hate. This account of what happens leads on to the view that the hate, which has its real motives, is here reinforced by a regression of the love to the sadistic preliminary stage; so that the hate acquires an erotic character and the continuity of a love relation is ensured. The third antithesis of loving, the transformation of loving into being loved, corresponds to the operation of the polarity of activity and passivity, and is to be judged in the same way as the cases of scopophilia and sadism. We may sum up by saying that the essential feature in the vicissitudes undergone by instincts lies in the subjection of the instinctual impulses to the influences of the three great polarities that dominate mental life. Of these three polarities we might describe that of activity-passivity as the biological, that of ego-external world as the real, and finally that of pleasure-unpleasure as the economic polarity.