Freud - Complete Works (52 page)
Studies On Hysteria
268
It is impossible to carry any
analysis to a conclusion unless we know how to meet the resistance
arising in these three ways. But we can find a way of doing so if
we make up our minds that this new symptom that has been produced
on the old model must be treated in the same way as the old
symptoms. Our first task is to make the ‘obstacle’
conscious to the patient. In one of my patients, for instance, the
pressure procedure suddenly failed. I had reason to suppose that
there was an unconscious idea of the kind mentioned under (2)
above, and I dealt with it at the first attempt by taking her by
surprise. I told her that some obstacle must have arisen to
continuing the treatment, but that the pressure procedure had at
least the power to show her what this obstacle was; I pressed on
her head, and she said in astonishment: ‘I see you sitting on
the chair here; but that’s nonsense. What can it mean?’
I was then able to enlighten her. With another patient the
‘obstacle’ used not to appear directly as a result of
my pressure, but I was always able to discover it if I took the
patient back to the moment at which it had originated. The pressure
procedure never failed to bring this moment back for us. When the
obstacle had been discovered and demonstrated the first difficulty
was cleared out of the way. But a greater one remained. It lay in
inducing the patient to produce information where apparently
personal relations were concerned and where the third person
coincided with the figure of the physician.
To begin with I was greatly
annoyed at this increase in my psychological work, till I came to
see that the whole process followed a law; and I then noticed, too,
that transference of this kind brought about no great addition to
what I had to do. For the patient the work remained the same: she
had to overcome the distressing affect aroused by having been able
to entertain such a wish even for a moment; and it seemed to make
no difference to the success of the treatment whether she made this
psychical repudiation the theme of her work in the historical
instance or in the recent one connected with me. The patients, too,
gradually learnt to realize that in these transferences on to the
figure of the physician it was a question of a compulsion and an
illusion which melted away with the conclusion of the analysis. I
believe, however, that if I had neglected to make the nature of the
‘obstacle’ clear to them I should simply have given
them a new hysterical symptom - though, it is true, a milder one -
in exchange for another which had been generated spontaneously.
Studies On Hysteria
269
I have now given enough
indications, I think, of the way in which these analyses have been
carried out and of the observations that I have made in the course
of them. What I have said may perhaps make some things seem more
complicated than they are. Many problems answer themselves when we
find ourselves engaged in such work. I did not enumerate the
difficulties of the work in order to create an impression that, in
view of the demands a cathartic analysis makes on physician and
patient alike, it is only worth while undertaking one in the rarest
cases. I allow my medical activities to be governed by the contrary
assumption, though I cannot, it is true, lay down the most definite
indications for the application of the therapeutic method described
in these pages without entering into an examination of the more
important and comprehensive topic of the treatment of the neuroses
in general. I have often in my own mind compared cathartic
psychotherapy with surgical intervention. I have described my
treatments as psychotherapeutic operations; and I have brought out
their analogy with the opening up of a cavity filled with pus, the
scraping out of a carious region, etc. An analogy of this kind
finds its justification not so much in the removal of what is
pathological as in the establishment of conditions that are more
likely to lead the course of the process in the direction of
recovery.
When I have promised my patients
help or improvement by means of a cathartic treatment I have often
been faced by this objection: ‘Why, you tell me yourself that
my illness is probably connected with my circumstances and the
events of my life. You cannot alter these in any way. How do you
propose to help me, then?’ And I have been able to make this
reply: ‘No doubt fate would find it easier than I do to
relieve you of your illness. But you will be able to convince
yourself that much will be gained if we succeed in transforming
your hysterical misery into common unhappiness. With a mental life
that has been restored to health you will be better armed against
that unhappiness.’
270
PREFACE TO FREUD’S SHORTER WRITINGS 1893-1906
(1906)
271
Intentionally left blank
272
PREFACE TO FREUD’S COLLECTION OF SHORTER WRITINGS ON
THE THEORY OF THE NEUROSES FROM THE YEARS 1893-1906
In response to many wishes that have reached
me, I have decided to lay before my colleagues in collected form
the minor works on the neuroses which I have published since 1893.
They consist of fourteen short papers, mostly in the nature of
preliminary communications, which have appeared in scientific
proceedings or medical periodicals - three of them in French. The
two last (XIII and XIV), which give a very succinct account of my
present position as regards both the aetiology and the treatment of
the neuroses, are taken from L. Löwefeld’s well-known
volumes,
Die psychischen Zwangserscheinungen
, 1904, and the
fourth edition of
Sexualleben und Nervenleiden
, 1906, having
been written by me at the request of their author, who is an
acquaintance of mine.
The present collection serves as
an introduction and supplement to my larger publications dealing
with the same topics -
Studies on Hysteria
(with Dr. J.
Breuer), 1895;
The Interpretation of Dreams
, 1900;
The
Psychopathology of Everyday Life
, 1901 and 1904;
Jokes and
their Relation to the Unconscious
, 1905;
Three Essays on the
Theory of Sexuality
,1905;
Fragment of an Analysis of a Case
of Hysteria
, 1905. The fact that I have put my Obituary of
J.-M. Charcot at the head of this collection of my short papers
should be regarded not only as the repayment of a debt of
gratitude, but also as an indication of the point at which my own
work branches off from the master’s.
No one who is familiar with the
course of development of human knowledge will be surprised to learn
that I have in the meantime gone beyond some of the opinions which
are expressed here, and have seen my way to modifying others.
Nevertheless, I have been able to retain the greater part of them
unaltered and in fact have no need to withdraw anything as wholly
erroneous or completely worthless.
273
CHARCOT
(1893)
274
Intentionally left blank
275
CHARCOT
On the 16th of August of this year, J.M.
Charcot died suddenly, without pain or illness, after a life of
happiness and fame. In him, all too soon, the young science of
neurology has lost its greatest leader, neurologists of every
country have lost their master teacher and France has lost one of
her foremost men. He was only sixty-eight years old; his physical
strength and mental vigour, together with the hopes he so frankly
expressed, seemed to promise him the long life which has been
granted to not a few mental workers of this century. The nine
imposing volumes of his
Oevres complètes
, in which
his pupils had collected his contributions to medicine and
neuropathology, his
Leçons du mardi
, the yearly
reports of his clinic at the Salpêtrière, and other
works besides - all these publications will remain precious to
science and to his pupils; but they cannot take the place of the
man, who had still much more to give and to teach and whose person
or whose writings no one has yet approached without learning
something from them.
He took an honest, human delight
in his own great success and used to enjoy talking of his
beginnings and the road he had travelled. His scientific curiosity,
he said, had been aroused early, when he was still a young
interne
, by the mass of material presented by the facts of
neuropathology, material which was not in the least understood at
the time. In those days, whenever he went the rounds with his
senior in one of the departments of the Salpêtrière
(the institution for the care of women) amid all the wilderness of
paralyses, spasms and convulsions for which forty years ago there
was neither name nor understanding, he would say:
‘
Faudrait y retourner et y rester
’, and he kept
his word. When he became
médecin des hôspitaux
,
he at once took steps to enter the Salpêtrière in one
of the departments for nervous patients. Having got there, he
stayed where he was instead of doing what French senior physicians
are entitled to do - transferring in regular succession from one
department to another and from hospital to hospital, and at the
same time changing their speciality as well.
Charcot
276
Thus his first impression and the
resolution it led him to were decisive for the whole of his further
development. His having a great number of chronic nervous patients
at his disposal enabled him to make use of his own special gifts.
He was not a reflective man, not a thinker: he had the nature of an
artist - he was, as he himself said, a ‘
visuel
’,
a man who sees. Here is what he himself told us about his method of
working. He used to look again and again at the things he did not
understand, to deepen his impression of them day by day, till
suddenly an understanding of them dawned on him. In his
mind’s eye the apparent chaos presented by the continual
repetition of the same symptoms then gave way to order: the new
nosological pictures emerged, characterized by the constant
combination of certain groups of symptoms. The complete and extreme
cases, the ‘types’, could be brought into prominence
with the help of a certain sort of schematic planning, and, with
these types as a point of departure, the eye could travel over the
long series of ill-defined cases - the ‘
formes
frustes
’ - which, branching off from one or other
characteristic feature of the type, melt away into indistinctness.
He called this kind of intellectual work, in which he had no equal,
‘practising nosography’, and he took pride in it. He
might be heard to say that the greatest satisfaction a man could
have was to see something new - that is, to recognize it as new;
and he remarked again and again on the difficulty and value of this
kind of ‘seeing’. He would ask why it was that in
medicine people only see what they have already learned to see. He
would say that it was wonderful how one was suddenly able to see
new things - new states of illness - which must probably be as old
as the human race; and that he had to confess to himself that he
now saw a number of things which he had overlooked for thirty years
in his hospital wards. No physician needs to be told what a wealth
of forms were acquired by neuropathology through him, and what
increased precision and sureness of diagnosis were made possible by
his observations. But the pupil who spent many hours with him going
round the wards of the Salpêtrière - that museum of
clinical facts, the names and peculiar characteristics of which
were for the most part derived from him would be reminded of
Cuvier, whose statue, standing in front of the Jardin des Plantes,
shows that great comprehender and describer of the animal world
surrounded by a multitude of animal forms; or else he would recall
the myth of Adam, who, when God brought the creatures of Paradise
before him to be distinguished and named, may have experienced to
the fullest degree that intellectual enjoyment which Charcot
praised so highly.
Charcot, indeed, never tired of
defending the rights of purely clinical work, which consists in
seeing and ordering things, against the encroachments of
theoretical medicine. On one occasion there was a small group of
us, all students from abroad, who, brought up on German academic
physiology, were trying his patience with our doubts about his
clinical innovations. ‘But that can’t be true,’
one of us objected, ‘it contradicts the Young-Helmholtz
theory.’ He did not reply ‘So much the worse for the
theory, clinical facts come first’ or words to that effect;
but he did say something which made a great impression on us:
‘
La theorie, c’est bon, mais ca n’empeche pas
d’exister
’.
Charcot
277
For a whole number of years
Charcot occupied the Chair of Pathological Anatomy in Paris, and he
carried on his neuropathological studies and lectures, which
quickly made him famous abroad as well as in France, on a voluntary
basis and as a secondary occupation. It was a piece of good fortune
for neuropathology that the same man could undertake the discharge
of two functions: on the one hand he created the nosological
picture through clinical observation, and on the other he
demonstrated that the same anatomical changes underlay the disease
whether it appeared as a type or as a
forme fruste
. It is
very generally recognized how successful this anatomical clinical
method of Charcot’s was in the field of organic nervous
diseases - in tabes, multiple sclerosis, amyotrophic lateral
sclerosis, and so on. Years of patient waiting were often necessary
before the presence of organic change could be proved in those
chronic illnesses which are not directly fatal; and only in a
hospital for incurables like the Salpêtrière was it
possible to keep the patients under observation for such long
periods of time. Charcot made his first demonstration of this kind
before he had charge of a department. While he was still a student
he happened to engage a maid-servant who suffered from a peculiar
tremor and could not find a situation on account of her clumsiness.
Charcot recognized her condition as a
paralysie
choréiforme
, a disease which had already been described
by Duchenne, but whose basis was unknown. Charcot kept this
interesting servant, although in the course of the years she cost
him a small fortune in dishes and plates. When at last she died he
was able to demonstrate from her case that
paralysie
choréiforme
was the clinical expression of multiple
cerebro-spinal sclerosis.
Pathological anatomy has to serve
neuropathology in two ways. Besides demonstrating the presence of a
morbid change, it must establish the localization of that change;
and we all know that during the last two decades the second part of
this task has aroused the greater interest of the two and has been
more actively pursued. Charcot played a most distinguished part in
this work, too, although the pioneer discoveries were not made by
him. To begin with he followed in the footsteps of our
fellow-countryman, Türck, who is said to have lived and
carried on his researches in comparative isolation among us. When
the two great innovations came - the Hitzig-Fritsch stimulation
experiments and Flechsig’s findings on the development of the
spinal cord - which ushered in a new epoch in our knowledge of the
‘localization of nervous diseases’, Charcot’s
lectures on localization played the largest and best part towards
bringing the new theories into touch with the clinical work and
making them fruitful for it. As regards in especial the
relationship of the somatic muscular apparatus to the motor area of
the human cerebrum, I may remind the reader of the long time during
which the more exact nature and topography of this relationship was
in question. (Was there a common representation of both extremities
in the same areas? or was there a representation of the upper
extremity in the anterior central convolution and if the lower
extremity in the posterior one - that is, a vertical disposition?)
At last, continued clinical observations and experiments in
stimulation and extirpation on living subjects during surgical
operations decided the question in favour of the view of Charcot
and Pitres that the middle third of the central convolutions mainly
serves the representation of the arm, while the upper third and the
mesial portion serve that of the leg - that is to say, that in the
motor area the disposition is a horizontal one.
Charcot
278
An enumeration of Charcot’s
separate contributions would not enable us to establish his
significance for neuropathology. For during the last two decades
there have not been many themes of any importance in whose
formulation and discussion the school of the
Salpêtrière has not had an outstanding share; and the
‘school of the Salpêtrière’ was, of
course, Charcot himself, who, with the wealth of his experience,
the transparent clarity of his diction and the plasticity of his
descriptions, could easily be recognized in every publication of
the school. Among the circle of young men whom he thus gathered
round him and made into participants in his researches, a few
eventually rose to a consciousness of their own individuality and
made a brilliant name for themselves. Now and then, even, it
happened that one of them would come forward with an assertion
which seemed to the master to be more clever than correct; and this
he would argue against with plenty of sarcasm in his conversation
and lectures, but without doing any damage to his affectionate
relationship with his pupil. And in fact Charcot leaves behind him
a host of pupils whose intellectual quality and whose achievements
up to now are a guarantee that the study and practice of
neuropathology in Paris will not so quickly slip down from the
height to which Charcot has brought them.
Charcot
279
In Vienna we have repeatedly had
occasion to realize that the intellectual significance of an
academic teacher is not necessarily combined with a direct personal
influence on younger men which leads to the creation of a large and
important school. If Charcot was so much more fortunate in this
respect we must put it down to the personal qualities of the man -
to the magic that emanated from his looks and from his voice, to
the kindly openness which characterized his manner as soon as his
relations with someone had overcome the stage of initial
strangeness, to the willingness with which he put everything at the
disposal of his pupils, and to his life-long loyalty to them. The
hours he spent in his wards were hours of companionship and of an
exchange of ideas with the whole of his medical staff. He never
shut himself away from them there. The youngest newly-qualified
physician walking the wards had a chance of seeing him at his work
and might interrupt him at it; and the same freedom was enjoyed by
students from abroad, who, in later years, were never lacking at
his rounds. And, lastly, on the evenings when Madame Charcot was at
home to a distinguished company, assisted by a highly-gifted
daughter who was growing up in the likeness of her father, the
pupils and medical assistants who were always present met the
guests as part of the family.
In 1882 or 1883, the
circumstances of Charcot’s life and work took on their final
form. People had come to realize that the activities of this man
were a part of the assets of the nation’s
‘
gloire
’, which, after the unfortunate war of
1870-1, was all the more jealously guarded. The government, at the
head of which was Charcot’s old friend, Gambetta, created a
Chair of Neuropathology for him in the Faculty of Medicine (so that
he could give up the Chair of Pathological Anatomy) and also a
clinic, with auxiliary scientific departments, at the
Salpêtrière. ‘
Le service de M.
Charcot
’ now included, in addition to the old wards for
chronic female patients, several clinical rooms where male
patients, too, were received, a huge out-patient department - the
‘
consultation externe
’ -, a histological
laboratory, a museum, an electro-therapeutic department, an eye and
ear department and a special photographic studio. All these things
were so many means of keeping former assistants and pupils
permanently at the clinic in secure posts. The two-storeyed,
weathered-looking buildings and the courtyards which they enclosed
reminded the stranger vividly of our
Allgemeines
Krankenhaus
; but no doubt the resemblance did not go far
enough. ‘It may not be beautiful here, perhaps,’
Charcot would say when he showed a visitor his domain, ‘but
there is room for everything you want to do.’