Chapter 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.

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 psycho-neuroses their mental expression. My conscience as a physician 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 standpoint of medicine was, moreover, favored by the view 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 excitement to the presence of some particular, though at present unknown, substance. 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 Basedow’s disease, 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 today 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 psychoanalytical 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 _Studien_, having reached these conclusions upon the part played by sexuality in the ætiology 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 favor, but he effected nothing and it was easy to see that he too shrank from recognizing the sexual ætiology 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 bitter criticism; then accidental difficulties arose, as they never fail to do in a strained situation, and we parted.

Another result of my taking up the study of nervous disorders in general was that I altered the technique of catharsis. I abandoned hypnosis and sought to replace it by some other method, because I was anxious not to be restricted to treating hysteriform conditions. Increasing experience had also given rise to two grave doubts in my mind as to the use of hypnosis even as a means to catharsis. The first was that even the most brilliant results were liable to be suddenly wiped away if my personal relation with the patient became disturbed. It was true that they became reestablished if a reconciliation could be effected; but such an occurrence showed that the personal emotional relation between doctor and patient was after all stronger than the whole cathartic process, and it was precisely that factor which escaped every effort at control. And one day I had an experience which showed me in the crudest light what I had long suspected. One of my most acquiescent patients, with whom hypnosis had enabled me to bring about the most marvellous results, and whom I was engaged in relieving of her suffering by tracing back her attacks of pain to their origins, as she woke up on one occasion, threw her arms round my neck. The unexpected entrance of a servant relieved us from a painful discussion, but from that time onwards there was a tacit understanding between us that hypnotic treatment should be discontinued. I was modest enough not to attribute the event to my own irresistible personal attraction, and I felt that I had now grasped the nature of the element of mystery that was at work behind hypnosis. In order to exclude it, or at all events to isolate it, it was necessary to abandon hypnosis.

But hypnosis had been of immense help in the cathartic treatment, by widening the field of the patient’s consciousness and putting within his reach knowledge which he did not possess in his waking life. It seemed no easy task to find a substitute for it. While I was in this perplexity, a recollection came to my help of an experiment which I had often witnessed while I was with Bernheim. When the subject awoke from the state of somnambulism, he seemed to have lost all memory of what had happened while he was in that state. But Bernheim maintained that the memory was present all the same; and if he insisted on the subject remembering, if he asseverated that he knew it all and had only to say it, and if at the same time he laid his hand on the subject’s forehead, then the forgotten memories used in fact to return, hesitatingly at first, but eventually in a flood and with complete clarity. I determined that I would act in the same way. My patients, I reflected, must in fact “know” all the things which had hitherto only been made accessible to them by hypnosis; and assurances and encouragement on my part, assisted perhaps by the touch of my hand, would, I thought, have the power of forcing the forgotten facts and connections into consciousness. No doubt this seemed a more laborious process than putting them under hypnosis, but it might prove highly instructive. So I abandoned hypnosis, only retaining my practice of requiring the patient to lie upon a sofa while I sat behind him, seeing him, but not seen myself.