Freud - Complete Works (77 page)

Abstracts Of The Scientific Writings Of Dr. Sigm. Freud 1877-1897

452

APPENDIX

A.
Works written under my influence.

E. Rosenthal,
Contribution à
létude des diplégies cérérebrales de
l’enfance.
Thèse de Lyon. (M
é
daille d’argent.) (1892.)

L. Rosenberg,
Casuistische Beiträge
zur Kenntnis der cerebralen Kinderlähmungen und der Epilepsie.
(No. IV, New Series, of
Beiträge zur
Kinderheilkunde
, edited by Kassowitz.) (1893.)

B.
Translations from the French
.

J.-M Charcot,
Neue Vorlesungen über
die Krankheiten des Nervensystems, insbesondere über Hysterie
. (Toeplitz & Deuticke, Vienna.)

H Bernheim,
Die Suggestion und ihre
Heilwirkung
. (Fr. Deuticke, Vienna.) (Second Edition, 1896.)

H Bernheim,
Neue Studien über
Hypnotismus, Suggestion und Psychotherapie
. (Fr. Deuticke, Vienna.)

J.-M Charcot,
Poliklinische Vortrage
.
Vol. I. (
Leçons du Mardi
.) With notes by the translator. (Fr. Deuticke, Vienna.)

453

SEXUALITY IN THE AETIOLOGY OF THE NEUROSES

(1898)

454

Intentionally left blank

455

SEXUALITY IN THE AETIOLOGY OF THE
NEUROSES

Exhaustive researches during the last few
years have led me to recognize that the most immediate and, for
practical purposes, the most significant causes of every case of
neurotic illness are to be found in factors arising from sexual
life. This theory is not entirely new. A certain amount of
importance has been allowed to sexual factors in the aetiology of
the neuroses from time immemorial and by every writer on the
subject. In certain marginal regions of medicine a cure for
‘sexual complaints’ and for ‘nervous
weakness’ has always been promised in the same breath. When
once the validity of the theory ceases to be denied, therefore, it
will not be hard to dispute its originality.

   In a few short papers which have
appeared during the last years in the
Neurologisches
Zentralblatt
, the
Revue Neurolgique
and the
Wiener
klinische Rundschau
, I have tried to give an indication of the
material and the points of view which offer scientific support for
the theory of the ‘sexual aetiology of the neuroses’. A
full presentation is, however, still wanting, mainly because, in
endeavouring to throw light on what is recognized as the actual
state of affairs, we come upon ever fresh problems for the solution
of which the necessary preliminary work has not been done. It does
not seem to me at all premature, however, to attempt to direct the
attention of medical practitioners to what I believe to be the
facts so that they may convince themselves of the truth of my
assertions and at the same time of the benefits they may derive in
their practice from a knowledge of them.

   I am aware that efforts will be
made, by the use of arguments with an ethical colouring, to prevent
the physician from pursuing the matter further. Anyone who wants to
make certain whether or not his patients’ neuroses are really
connected with their sexual life cannot avoid asking them about
their sexual life and insisting upon receiving a true account of
it. But in this, it is asserted, lies the danger both for the
individual and society. A doctor, I hear it being said, has no
right to intrude upon his patients’ sexual secrets and
grossly injure their modesty (especially with women patients) by an
interrogation of this sort. His clumsy hand can only ruin family
happiness, offend the innocence of young people and encroach upon
the authority of parents; and where adults are concerned he will
come to share uncomfortable knowledge and destroy his own relations
to his patients. It is therefore his ethical duty, the conclusion
is, to keep away from the whole business of sex.

Sexuality In The Aetiology Of The Neuroses

456

   To this one may well reply that
it is the expression of a prudery which is unworthy of a physician
and which inadequately conceals its weakness behind bad arguments.
If factors arising out of sexual life must really be acknowledged
to be causes of illness, then, for that very reason, investigation
and discussion of them automatically falls within the sphere of a
physician’s duty. The injury to modesty of which he is guilty
in this is no different and no worse, one would imagine, than when
he insists on examining a woman’s genital organs in order to
cure a local affection - a demand on which he is pledged to insist
by his medical training itself. Even now one often hears elderly
women who have spent their youth in the provinces tell of how at
one time they were reduced to a state of exhaustion by excessive
genital haemorrhages, because they could not make up their minds to
allow a doctor to see their nakedness. The educative influence
which has been exercised on the public by the medical world has, in
the course of one generation, so altered things that an objection
of this sort is an extremely rare occurrence among the young women
of to-day. If it were to occur, it would be condemned as
unreasonable prudery, as modesty in the wrong place. Are we living
in Turkey, a husband would ask, where all that a sick woman may
show to the physician is her arm through a hole in the wall?

   It is not true that interrogation
of his patients and knowledge about their sexual concerns give the
physician a dangerous degree of power over them. It was possible in
earlier times for the same objection to be made against the uses of
anaesthetics, which deprive the patient of his consciousness and of
the exercise of his will and leave it to the doctor to decide
whether and when he shall regain them. And yet to-day anaesthetics
have become indispensable to us because they are able, better than
anything else, to assist the doctor in his medical work; and among
his many other serious obligations, he has taken over the
responsibility for their use.

Sexuality In The Aetiology Of The Neuroses

457

   A doctor can always do harm if he
is unskilful or unscrupulous, and this is no more and no less true
where it is a question of investigating his patients’ sexual
life than it is in other things. Naturally, if someone, after an
honest self-examination, feels that he does not possess the tact,
seriousness and discretion which are necessary for questioning
neurotic patients, and if he is aware that revelations of a sexual
character would provoke lascivious thrills in him rather than
scientific interest, then he will be right to avoid the topic of
the aetiology of the neuroses. All we ask, in addition, is that he
should also refrain from treating nervous patients.

   Nor is it true that patients put
insuperable obstacles in the way of an investigation into their
sexual life. After some slight hesitation, adults usually adjust
themselves to the situation by saying: ‘After all, I’m
at the doctor’s; I can say anything to him.’ A great
many women who find it difficult enough to go through life
concealing their sexual feelings, are relieved to find that with
the doctor no other consideration outweighs that of their recovery,
and they are grateful to him that for once they are allowed to
behave quite humanly about sexual things. A dim knowledge of the
overwhelming importance of sexual factors in the production of
neuroses (a knowledge which I am trying to capture afresh for
science) seems never to have been lost in the consciousness of
laymen. How often do we witness scenes like this: A married
couple, one of whom is suffering from a neurosis, comes to us for
consultation. After we have made a great many introductory remarks
and apologies to the effect that no conventional barriers should
exist between them and the doctor who wants to be of use in such
cases, and so on, we tell them that we suspect that the cause of
the illness lies in the unnatural and detrimental form of sexual
intercourse which they must have chosen since the wife’s last
confinement. We tell them that doctors do not as a rule concern
themselves with such matters, but that that is reprehensible of
them, even though the patients do not want to be told about things
like that, etc. Thereupon one of the couple nudges the other and
says: ‘You see! I told you all along it would make me
ill.’ And the other answers: ‘Well, I know, I thought
so too; but what is one to do?’

Sexuality In The Aetiology Of The Neuroses

458

   In certain other circumstances,
such as when one is dealing with young girls, who, after all, are
systematically brought up to conceal their sexual life, one will
have to be content with a very small measure of sincere response on
the part of the patient. But an important consideration comes into
play here namely that a doctor who is experienced in these things
does not meet his patients unprepared and as a rule does not have
to ask them for information but only for a confirmation of his
surmises. Anyone who will follow my indications as to how to
elucidate the morphology of the neuroses and translate it into
aetiological terms, will need the addition of very few further
admissions from his patients; in the very description of their
symptoms, which they are only too ready to give, they have usually
acquainted him at the same time with the sexual factors that are
hidden behind.

   It would be a great advantage if
sick people had a better knowledge of the certainty with which a
doctor is now in a position to interpret their neurotic complaints
and to infer from them their operative sexual aetiology. It would
undoubtedly spur such people on to abandon their secretiveness from
the moment they have made up their minds to seek help for their
sufferings. Moreover, it is in the interest of all of us that a
higher degree of honesty about sexual things should become a duty
among men and women than has hitherto been expected of them. This
cannot be anything but a gain for sexual morality. In matters of
sexuality we are at present, every one of us, ill or well, nothing
but hypocrites. It will be all to our good if, as a result of such
general honesty, a certain amount of toleration in sexual concerns
should be attained.

   Doctors usually take very little
interest in a good many of the questions which are discussed among
neuropathologists in connection with the neuroses: whether, for
instance, one is justified in making a strict differentiation
between hysteria and neurasthenia, whether one may distinguish
hystero-neurasthenia alongside of them, whether obsessions should
be classed with neurasthenia or recognized as a separate neurosis,
and so on. And, indeed, such distinctions may well be a matter of
indifference to a practitioner, so long as no further consequences
follow from the decisions arrived at - no deeper insight and no
pointers for therapeutic treatment - and so long as the patient
will in every instance be sent off to a hydropathic establishment,
and be told that there is nothing the matter with him. But it will
be a different thing if our point of view about the causative
relations between sexuality and the neuroses is adopted. Fresh
interest is then aroused in the symptomatology of the different
neurotic cases, and it becomes of practical importance that one
should be able correctly to break down the complicated picture into
its components and correctly to name them. For the morphology of
the neuroses can with little difficulty be translated into
aetiology and a knowledge of the latter leads on quite naturally to
new indications for methods of cure.

Sexuality In The Aetiology Of The Neuroses

459

   Now the important decision we
have to make - and this can be done with certainty in every
instance if the symptoms are carefully assessed - is whether the
case bears the characteristics of neurasthenia or of a
psychoneurosis (hysteria, obsessions).(Mixed cases in which signs
of neurasthenia are combined with signs of a psychoneurosis are of
very frequent occurrence; but we will leave consideration of them
till later.) It is only in neurasthenias that questioning the
patient succeeds in disclosing the aetiological factors in his
sexual life. These factors are, of course, known to him and belong
to the present time, or, more properly, to the period of his life
since sexual maturity (though this delimitation does not cover
every case). In psychoneuroses questioning of this kind has little
result. It may perhaps give us a knowledge of the factors which
have to be recognized as precipitating ones, and these may or may
not be connected with sexual life. If they are, they show
themselves to be no different in kind from the aetiological factors
of neurasthenia; that is, they entirely lack any specific relation
to the causation of the psychoneurosis. And yet, in every instance,
the aetiology of the psychoneuroses, too, lies in the field of
sexuality. By a curious circuitous path, of which I shall speak
later, it is possible to arrive at a knowledge of this aetiology
and to understand why the patient was unable to tell us anything
about it. For the events and influences which lie at the root of
every psychoneurosis, belong, not to the present day, but to an
epoch of life which is long past and which is, as it were, a
prehistoric one-to the time of early childhood; and that is why the
patient, too, knows nothing of them. He has - though only in a
particular sense - forgotten them.

Sexuality In The Aetiology Of The Neuroses

460

   Thus, in every case of neurosis
there is a sexual aetiology; but in neurasthenia it is an aetiology
of a present-day kind, whereas in the psychoneuroses the factors
are of an infantile nature. This is the first great contrast in the
aetiology of the neuroses. 1 A second one emerges when we take
account of a difference in the symptomatology of neurasthenia
itself. Here, on the one hand, we find cases in which certain
complaints characteristic of neurasthenia (intracranial pressure,
proneness to fatigue, dyspepsia, constipation, spinal irritation,
etc.) are prominent; in other cases these signs play a minor part
and the clinical picture is composed of other symptoms, all of
which exhibit a relation to the nuclear symptom, that of anxiety
(free anxiousness, unrest, expectant anxiety, complete, rudimentary
or supplementary anxiety attacks, locomotor vertigo, agoraphobia,
insomnia, increased sensitivity to pain, and so on). I have left
the name of neurasthenia to the first type, but have distinguished
the second type as ‘anxiety neurosis’; and I have given
reasons for this separation in another place, where I have also
taken account of the fact that as a rule both neuroses appear
together. For the present purpose it is enough to emphasize that
parallel to the difference in the symptoms of these two forms of
illness there goes a difference in their aetiology. Neurasthenia
can always be traced back to a condition of the nervous system such
as is acquired by excessive masturbation or arises spontaneously
from frequent emissions; anxiety neurosis regularly discloses
sexual influences which have in common the factor of reservation or
of incomplete satisfaction - such as coitus interruptus, abstinence
together with a lively libido, so-called unconsummated excitation,
and so on. In my short paper intended to introduce anxiety neurosis
I put forward the formula that anxiety is always libido which has
been deflected from its employment.