Freud - Complete Works (682 page)

An Autobiographical Study

4199

   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 communication,
‘On the Psychical Mechanism of Hysterical Phenomena’,
and in 1895 there followed our book,
Studies on
Hysteria
.

An Autobiographical Study

4200

   If the account I have so far
given has led the reader to expect that the
Studies on
Hysteria
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 to-day 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 affect, and an economic factor, by
regarding that same symptom as the product of the transformation of
an amount 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
quota of affect used for maintaining the symptom, which had got on
to the wrong lines and had, as it were, become strangulated there,
should be directed on to 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
favour. Its value as an abridged method of treatment was shown
afresh by Simmel in his 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
Studies
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
Studies on Hysteria
what an importance sexuality
has in the aetiology of the neuroses.

An Autobiographical Study

4201

   The stage of development which
now followed, the transition from catharsis to psycho-analysis
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
the 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 be dealt with normally - Breuer
preferred what might be called a physiological theory: he thought
that the processes which could not find a 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 ‘neuroses of
defence’. 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
Studies
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 to which he found
it impossible to reconcile himself.

An Autobiographical Study

4202

   The theory which we had attempted
to construct in the
Studies
remained, as I have said, very
incomplete; and in particular we had scarcely touched on the
problem of aetiology, on 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 neurosis but
habitually 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
inactive 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 to-day,
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 substitutive 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 had a different abnormality of
sexual life as its corresponding aetiological factor: in the
former,
coitus interruptus
, unconsummated excitation 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 alteration in the clinical
picture from one type to the other, it could be proved 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.

An Autobiographical Study

4203

   I was thus led into regarding the
neuroses as being without exception disturbances of the sexual
function, the so-called ‘
actual neuroses
’ being
the direct toxic expression of such disturbances and the
psychoneuroses
their mental expression. My medical
conscience felt pleased at my having arrived at this conclusion. I
hoped that I had filled up a gap in medical science, which, in
dealing with a function of such great biological importance, had
failed to take into account any injuries beyond those caused by
infection or by gross anatomical lesions. The medical aspect of the
matter was, moreover, supported by the fact that sexuality was not
something purely mental. It had a somatic side as well, and it was
possible to assign special chemical processes to it and to
attribute sexual excitation to the presence of some particular,
though at present unknown, substances. There must also have been
some good reason why the true spontaneous neuroses resembled no
group of diseases more closely than the phenomena of intoxication
and abstinence, which are produced by the administration or
privation of certain toxic substances, or than exophthalmic goitre,
which is known to depend upon the product of the thyroid gland.

   Since that time I have had no
opportunity of returning to the investigation of the ‘actual
neuroses’; nor has this part of my work been continued by
anyone else. If I look back to-day at my early findings, they
strike me as being the first rough outlines of what is probably a
far more complicated subject. But on the whole they seem to me
still to hold good. I should have been very glad if I had been
able, later on, to make a psycho-analytic examination of some more
cases of simple juvenile neurasthenia, but unluckily the occasion
did not arise. To avoid misconceptions, I should like to make it
clear that I am far from denying the existence of mental conflicts
and of neurotic complexes in neurasthenia. All that I am asserting
is that the symptoms of these patients are not mentally determined
or removable by analysis, but that they must be regarded as direct
toxic consequences of disturbed sexual chemical processes.

   During the years that followed
the publication of the
Studies
, having reached these
conclusions upon the part played by sexuality in the aetiology of
the neuroses, I read some papers on the subject before various
medical societies, but was only met with incredulity and
contradiction. Breuer did what he could for some time longer to
throw the great weight of his personal influence into the scales in
my favour, but he effected nothing and it was easy to see that he
too shrank from recognizing the sexual aetiology of the neuroses.
He might have crushed me or at least disconcerted me by pointing to
his own first patient, in whose case sexual factors had ostensibly
played no part whatever. But he never did so, and I could not
understand why this was, until I came to interpret the case
correctly and to reconstruct, from some remarks which he had made,
the conclusion of his treatment of it. After the work of catharsis
had seemed to be completed, the girl had suddenly developed a
condition of ‘transference love’; he had not connected
this with her illness, and had therefore retired in dismay. It was
obviously painful to him to be reminded of this apparent
contretemps
. His attitude towards me oscillated for some
time between appreciation and sharp criticism; then accidental
difficulties arose, as they never fail to do in a strained
situation, and we parted.