Part 9

In the autumn of 1886 I settled down in Vienna as a physician, and married the girl who had been waiting for me in a distant city for more than four years. I may here go back a little and explain how it was the fault of my _fiancée_ that I was not already famous at that early age. A side interest, though it was a deep one, had led me in 1884 to obtain from Merck some of what was then the little-known alkaloid cocaine and to study its physiological action. While I was in the middle of this work, an opportunity arose for making a journey to visit my _fiancée_, from whom I had been parted for two years. I hastily wound up my investigation of cocaine and contented myself in my book on the subject with prophesying that further uses for it would soon be found. I suggested, however, to my friend, L. Königstein, the ophthalmologist, that he should investigate the question of how far the anæsthetizing properties of cocaine were applicable in diseases of the eye. When I returned from my holiday I found that not he, but another of my friends, Carl Koller (now in New York), to whom I had also spoken about cocaine, had made the decisive experiments upon animals’ eyes and had demonstrated them at the Ophthalmological Congress at Heidelberg. Koller is therefore rightly regarded as the discoverer of local anæsthesia by cocaine, which has become so important in minor surgery; but I bore my _fiancée_ no grudge for my neglected opportunity.

I will now return to the year of 1886, the time of my settling down in Vienna as a specialist in nervous diseases. The duty devolved upon me of giving a report before the “Gesellschaft der Aerzte” [Society of Medicine] upon what I had seen and learnt with Charcot. But I met with a bad reception. Persons of authority, such as the chairman (Bamberger, the physician), declared that what I said was incredible. Meynert urged me to find some cases in Vienna similar to those which I had described and to present them before the Society. I tried to do so; but the senior physicians in whose departments I found any such cases, refused to allow me to observe them or to work at them. One of them, an old surgeon, actually broke out with the exclamation: “But, my dear sir, how can you talk such nonsense? _Hysteron_ (sic) means the uterus. So how can a man be hysterical?” I objected in vain that what I wanted was, not to have my diagnosis approved, but to have the case put at my disposal. At length, outside the hospital, I came upon a case of classical hysterical hemi-anæsthesia in a man, and demonstrated it before the “Gesellschaft der Aerzte.” This time I was applauded, but no further interest was taken in me. The impression that the great authorities had rejected my innovations remained unshaken; and, with my hysteria in men and my production of hysterical paralyses by suggestion, I found myself forced into the Opposition. As I was soon afterwards excluded from the laboratory of cerebral anatomy and for a whole term had nowhere to deliver my lectures, I withdrew from academic life and ceased to attend the learned societies. It is a whole generation since I have visited the “Gesellschaft der Aerzte.”

Anyone who wanted to make a living from the treatment of nerve-patients must clearly be able to do something to help them. My therapeutic arsenal contained only two weapons, electrotherapy and hypnosis, for prescribing a visit to a hydropathic establishment after a single consultation was an inadequate source of income. My knowledge of electrotherapy was derived from W. Erb’s text-book, which provided detailed instructions for the treatment of all the symptoms of nervous diseases. Unluckily I was soon driven to see that following these instructions was of no help whatever and that what I had taken for an epitome of exact observations was merely the construction of phantasy. The realization that the work of the greatest name in German neuropathology had no more relation to reality than some “Egyptian” dream-book, such as are sold in cheap book-shops, was painful, but it helped to rid me of yet another piece of the innocent faith in authority by which I was still obsessed. So I put my electrical apparatus aside, even before Möbius had solved the problem by explaining that the successes of electric treatment in nervous disorders (in so far as there were any) were the effect of suggestion on the part of the physician.

With hypnosis the case was better. While I was still a student I had attended a public exhibition given by the “magnetist” Hansen and had noticed that one of the persons experimented upon had became deathly pale at the onset of cataleptic rigidity and had remained so as long as that condition lasted. This firmly convinced me of the genuineness of the phenomena of hypnosis. Scientific support was soon afterwards given to this view by Heidenhain; but that did not restrain the professors of psychiatry from declaring for a long time to come that hypnosis was not only fraudulent but dangerous and from regarding hypnotists with contempt. In Paris I had seen hypnosis used freely as a method for producing symptoms in patients and then removing them again. And now the news reached us that a school had arisen at Nancy which made an extensive and remarkably successful use of suggestion, with or without hypnosis, for therapeutic purposes. It thus came about, as a matter of course, that in the first years of my activity as a physician my principal instrument of work, apart from haphazard and unsystematic psycho-therapeutic methods, was hypnotic suggestion.

This implied, of course, that I abandoned the treatment of organic nervous diseases; but that was of little importance. For on the one hand the prospects in the treatment of such disorders were in any case never promising, while on the other hand, in the private practice of a physician working in a large town, the quality of such patients was nothing compared to the crowds of neurotics, whose number seemed further multiplied by the manner in which they hurried, with their troubles unsolved, from one physician to another. And apart from this, there was something positively seductive in working with hypnosis. For the first time there was a sense of having overcome one’s impotence; and it was highly flattering to enjoy the reputation of being a miracle-worker. It was not until later that I was to discover the drawbacks of the procedure. At the moment there were only two points to complain of: first, that I could not succeed in hypnotizing every patient, and secondly, that I was unable to put individual patients into as deep a state of hypnosis as I should have wished. With the idea of perfecting my hypnotic technique, I made a journey to Nancy in the summer of 1889 and spent several weeks there. I witnessed the moving spectacle of old Liébault working among the poor women and children of the laboring classes, I was a spectator of Bernheim’s astonishing experiments upon his hospital patients, and I received the profoundest impression of the possibility that there could be powerful mental processes which nevertheless remained hidden from the consciousness of men. Thinking it would be instructive, I had persuaded one of my patients to follow me to Nancy. She was a very highly gifted hysteric, a woman of good birth, who had been handed over to me because no one knew what to do with her. By hypnotic influence I had made it possible for her to lead a tolerable existence and I was always able to take her out of the misery of her condition. But she always relapsed again after a short time, and in my ignorance I attributed this to the fact that her hypnosis had never reached the stage of somnambulism with amnesia. Bernheim now attempted several times to bring this about, but he too failed. He frankly admitted to me that his great therapeutic successes by means of suggestion were only achieved in his hospital practice and not with his private patients. I had many stimulating conversations with him, and undertook to translate into German his two works upon suggestion and its therapeutic effects.

During the period from 1886 to 1891 I did little scientific work, and published scarcely anything. I was occupied with establishing myself in my new profession and with assuring my own material existence as well as that of a rapidly increasing family. In 1891 there appeared the first of my studies upon the cerebral palsies of children, which was written in collaboration with my friend and assistant, Dr. Oskar Rie. An invitation which I received in the same year to contribute to an encyclopædia of medicine led me to investigate the theory of aphasia, which was at that time dominated by the views of Wernicke and Lichtheim, which laid stress exclusively upon localization. The fruit of this inquiry was a small critical and speculative book, _Zur Auffassung der Aphasie_. But I must now show how it happened that scientific research once more became the chief interest of my life.

II

I must supplement what I have just said by explaining that from the very first I made use of hypnosis in another manner, apart from hypnotic suggestion. I used it for questioning the patient upon the origin of his symptom, which in his waking state he could often describe only very imperfectly or not at all. Not only did this method seem more effective than bald suggestive commands or prohibitions, but it also satisfied the curiosity of the physician, who, after all, had a right to learn something of the origin of the phenomenon which he strove to remove by the monotonous procedure of suggestion.

The manner in which I arrived at this other procedure was as follows: While I was still working in Brücke’s laboratory I had made the acquaintance of Dr. Josef Breuer, who was one of the most respected family physicians in Vienna, but who also had a scientific past, since he had produced several works of permanent value upon the physiology of breathing and upon the organ of equilibrium. He was a man of striking intelligence and fourteen years older than myself. Our relations soon became more intimate and he became my friend and helper in my difficult circumstances. We grew accustomed to share all our scientific interests with each other. In this relationship the gain was naturally mine. The development of psychoanalysis afterwards cost me his friendship. It was not easy for me to pay such a price, but I could not escape it.

Even before I went to Paris, Breuer had told me about a case of hysteria which, between 1880 and 1882, he had treated in a peculiar manner which had allowed him to penetrate deeply into the causation and significance of hysterical symptoms. This was at a time, therefore, when Janet’s works still belonged to the future. He repeatedly read me pieces of the case history, and I had an impression that it accomplished more towards an understanding of neuroses than any previous observation. I determined to inform Charcot of these discoveries when I reached Paris, and I actually did so. But the great man showed no interest in my first outline of the subject, so that I never recurred to it and allowed it to pass from my mind.

When I was back in Vienna I turned once more to Breuer’s observation and made him tell me more about it. The patient had been a young girl of unusual education and gifts, who had fallen ill while she was nursing her father, of whom she was devotedly fond. When Breuer took over her case it presented a variegated picture of paralyses and contractures, inhibitions and states of mental confusion. A chance observation showed her physician that she could be relieved of these clouded states of consciousness if she was induced to express in words the affective phantasy by which she was at the moment dominated. From this discovery, Breuer arrived at a new method of treatment. He put her into deep hypnosis and made her tell him each time what it was that was oppressing her mind. After the attacks of depressive confusion had been overcome in this way, he employed the same procedure for removing her inhibitions and physical disorders. In her waking state the girl could no more describe than other patients how her symptoms had arisen, and she could discover no link between them and any experiences of her life. In hypnosis she immediately revealed the missing connection. It turned out that all of her symptoms went back to moving events which she had experienced while nursing her father; that is to say, her symptoms had a meaning and were residues or reminiscences of those emotional situations. It turned out in most instances that there had been some thought or impulse which she had had to suppress while she was by her father’s sick-bed, and that, in place of it, as a substitute for it, the symptom had afterwards appeared. But as a rule the symptom was not the precipitate of a single such “traumatic” scene, but the result of a summation of a number of similar situations. When the patient recalled a situation of this kind in a hallucinatory way under hypnosis and carried through to its conclusion, with a free expression of emotion, the mental act which she had originally suppressed, the symptom was wiped away and did not return. By this procedure Breuer succeeded, after long and painful efforts, in relieving his patient of all her symptoms.

The patient had recovered and had remained well and, in fact, had become capable of doing serious work. But over the final stage of this hypnotic treatment there rested a veil of obscurity, which Breuer never raised for me; and I could not understand why he had so long kept secret what seemed to me an invaluable discovery instead of making science the richer by it. The immediate question, however, was whether it was possible to generalize from what he had found in a single case. The state of things which he had discovered seemed to me to be of so fundamental a nature that I could not believe it could fail to be present in any case of hysteria if it had been proved to occur in a single one. But the question could only be decided by experience. I therefore began to repeat Breuer’s investigations with my own patients and eventually, especially after my visit to Bernheim in 1889 had taught me the limitations of hypnotic suggestion, I worked at nothing else. After observing for several years that his findings were invariably confirmed in every case of hysteria that was accessible to such treatment, and after having accumulated a considerable amount of material in the shape of observations analogous to his, I proposed to him that we should issue a joint publication. At first he objected vehemently, but in the end he gave way, especially since, in the meantime, Janet’s works had anticipated some of his results, such as the tracing back of hysterical symptoms to events in the patient’s life, and their removal by means of hypnotic reproduction _in statu nascendi_. In 1893 we issued a preliminary paper, “On the Psychical Mechanism of Hysterical Phenomena,”[8] and in 1895 there followed our book, _Studien über Hysterie_.

If the account I have so far given has led the reader to expect that the _Studien über Hysterie_ must, in all essentials of their material content, be the product of Breuer’s mind, that is precisely what I myself have always maintained and what it has been my aim to repeat here. As regards the theory put forward in the book, I was partly responsible, but to an extent which it is today no longer possible to determine. That theory was in any case unpretentious and hardly went beyond the direct description of the observations. It did not seek to establish the nature of hysteria but merely to throw light upon the origin of its symptoms. Thus it laid stress upon the significance of the life of the emotions and upon the importance of distinguishing between mental acts which are unconscious and those which are conscious (or rather capable of being conscious); it introduced a dynamic factor, by supposing that a symptom arises through the damming-up of an effect, and an economic factor, by regarding that same symptom as the product or equivalent of a quantity of energy which would otherwise have been employed in some other way. (This latter process was described as _conversion_.) Breuer spoke of our method as _cathartic_; its therapeutic aim was explained as being to provide that the accumulated affect used for maintaining the symptom, which had got onto the wrong lines and had, as it were, become stuck there, should be directed onto the normal path along which it could obtain discharge (or _abreaction_). The practical results of the cathartic procedure were excellent. Its defects, which became evident later, were those of all forms of hypnotic treatment. There are still a number of psychotherapists who have not gone beyond catharsis as Breuer understood it and who still speak in its favor. Its value as an abridged method of treatment was shown afresh in the hands of E. Simmel in the treatment of war neuroses in the German army during the Great War. The theory of catharsis had not much to say on the subject of sexuality. In the case histories which I contributed to the _Studien_, sexual factors played a certain part, but scarcely more attention was paid to them than to other emotional excitations. Breuer wrote of the girl, who has since become famous as his first patient, that her sexual side was extraordinarily undeveloped. It would have been difficult to guess from the _Studien über Hysterie_ what an importance sexuality has in the ætiology of the neuroses.

The stage of development which now followed, the transition from catharsis to psychoanalysis proper, has been described by me several times already in such detail that I shall find it difficult to bring forward any new facts. The event which formed the opening of this period was Breuer’s retirement from our common work, so that I became sole administrator of his legacy. There had been differences of opinion between us at quite an early stage, but they had not been a ground for our separating. In answering the question of when it is that a mental process becomes pathogenic, that is, when it is that it becomes impossible for it to find a normal discharge, Breuer preferred what might be called a physiological theory: he thought that the processes which could not find normal outcome were such as had originated during unusual, hypnoid, mental states. This opened the further question of the origin of these hypnoid states. I, on the other hand, was inclined to suspect the existence of an interplay of forces and the operation of intentions and purposes such as are to be observed in normal life. Thus it was a case of “Hypnoid Hysteria” versus “Defence Neurosis.” But such differences as this would scarcely have alienated him from the subject if there had not been other factors at work. One of these was undoubtedly that his work as a physician and family doctor took up much of his time and that he could not, like me, devote his whole strength to the work of catharsis. Again, he was affected by the reception which our book had received both in Vienna and in Germany. His self-confidence and powers of resistance were not developed so fully as the rest of his mental organization. When, for instance, the _Studien_ met with a severe rebuff from Strümpell, I was able to laugh at the lack of comprehension which his criticism showed, but Breuer felt hurt and grew discouraged. But what contributed chiefly to his decision was that my own further work led in a direction with which he found it impossible to reconcile himself.

The theory which we had attempted to construct in the _Studien_ remained, as I have said, very incomplete; and in particular we had scarcely touched upon the problem of ætiology, upon the question of the ground in which the pathogenic process takes root. I now learned from my rapidly increasing experience that it was not _any_ kind of emotional excitation that was in action behind the phenomena of the neurosis but regularly one of a sexual nature, whether it was a current sexual conflict or the effect of earlier sexual experiences. I was not prepared for this conclusion and my expectations played no part in it, for I had begun my investigation of neurotics quite unsuspectingly. While I was writing my “History of the Psycho-Analytic Movement” in 1914, there recurred to my mind some remarks that had been made to me by Breuer, Charcot and Chrobak, which might have led me to this discovery earlier. But at the time I heard them I did not understand what these authorities meant; indeed they had told me more than they knew themselves or were prepared to defend. What I heard from them lay dormant and passive within me, until the chance of my cathartic experiments brought it out as an apparently original discovery. Nor was I then aware that in deriving hysteria from sexuality, I was going back to the very beginnings of medicine and following up a thought of Plato’s. It was not until later that I learnt this from an essay by Havelock Ellis.

Under the influence of my surprising discovery, I now took a momentous step. I went beyond the domain of hysteria and began to investigate the sexual life of the so-called neurasthenics who used to visit me in numbers during my consultation hours. This experiment cost me, it is true, my popularity as a doctor, but it brought me convictions which today, almost thirty years later, have lost none of their force. There was a great deal of equivocation and mystery-making to be overcome, but once that had been done, it turned out that in all of these patients grave abuses of the sexual function were present. Considering how extremely widespread are these abuses on the one hand and neurasthenia on the other, a frequent coincidence between the two would not have proved much; but there was more in it than that one bald fact. Closer observation suggested to me that it was possible to pick out from the confused jumble of clinical pictures covered by the name of neurasthenia two fundamentally different types, which might appear in any degree of mixture but which were nevertheless to be observed in their pure forms. In the one type the central phenomenon was the anxiety attack with its equivalents, rudimentary forms and chronic surrogate symptoms; I consequently gave it the name of _anxiety neurosis_, and limited the term _neurasthenia_ to the other type. Now it was easy to establish the fact that each of these types have a different abnormality of sexual life as its corresponding ætiological factor: in the former case _coitus interruptus_, undischarged excitement and sexual abstinence, and in the latter, excessive masturbation and too numerous nocturnal emissions. In a few specially instructive cases, which had shown a surprising alternation in the clinical picture from one type to the other, it was possible to prove that there had been a corresponding change in the underlying sexual _régime_. If it was possible to put an end to the abuse and allow its place to be taken by normal sexual activity, a striking improvement in the condition was the reward.