Further remarks on the neuro-psychoses of defence 7 страница

If one proceeds in this manner with one’s patients, one also gains the conviction that, so far as the theory of the sexual aetiology of neurasthenia is concerned, there are no negative cases. In my mind, at least, the conviction has become so certain that where an interrogation has shown a negative result, I have turned this to account too for diagnostic purposes. I have told myself, that is, that such a case cannot be one of neurasthenia. In this way I have been led in several instances to assume the presence of progressive paralysis instead of neurasthenia, because I had not succeeded in establishing the fact - a fact that was necessary for my theory - that the patient indulged very freely in masturbation; and the further course of those cases later confirmed my view. In another instance the patient, who exhibited no clear organic changes, complained of intracranial pressure, headaches and dyspepsia, but countered my suspicions about his sexual life straightforwardly and with unshaken certainty; and the possibility occurred to me that he might have a latent suppuration in one of his nasal sinuses. A specialist colleague of mine confirmed this inference I had made from the negative sexual results of my interrogation, by removing the pus from the patient’s antrum and relieving him of his ailments.

The appearance of there nevertheless being ‘negative cases’ can arise in another way as well. Sometimes an interrogation discloses the presence of a normal sexual life in a patient whose neurosis, on a superficial view, does in fact closely resemble neurasthenia or anxiety neurosis. But a more deep -going investigation regularly reveals the true state of affairs. Behind such cases, which have been taken for neurasthenia, there lies a psychoneurosis - hysteria or obsessional neurosis. Hysteria in especial, which imitates so many organic affections, can easily assume the appearance of one of the ‘actual neuroses’ by elevating the latter’s symptoms into hysterical ones. Such hysterias in the form of neurasthenia are not even very rare. Falling back on psychoneurosis when a case of neurasthenia shows a negative sexual result, is, however, no cheap way out of the difficulty; the proof that we are right is to be obtained by the method which alone unmasks hysteria with certainty - the method of psycho-analysis, to which we shall refer presently.

There may perhaps be some, however, who are quite willing to recognize the sexual aetiology in their neurasthenic patients, but who nevertheless blame it as one-sidedness if they are not asked to pay attention as well to the other factors which are always mentioned by the authorities as causes of neurasthenia. Now it would never occur to me to substitute a sexual aetiology in neuroses for every other aetiology, and so to assert that the latter have no operative force. This would be a misunderstanding. What I think is rather that in addition to all the familiar aetiological factors which have been recognized - and probably correctly so - by the authorities as leading to neurasthenia, the sexual factors, which have not hitherto been sufficiently appreciated, should also be taken into account. In my opinion, however, these sexual factors deserve to be given a special place in the aetiological series. For they alone are never absent in any case of neurasthenia, they alone are capable of producing the neurosis without any further assistance, so that those other factors seem to be reduced to the role of an auxiliary and supplementary aetiology, and they alone allow the physician to recognize firm relations between their manifold nature and the multiplicity of the clinical pictures. If, on the other hand, I group together all the patients who have ostensibly become neurasthenic from overwork, emotional agitation, as an after-effect of typhoid fever, and so on, they show me nothing in common in their symptoms. The nature of their aetiology gives me no idea of what kind of symptoms to expect, any more than, conversely, does the clinical picture they present enable me to infer what aetiology is at work in them.

The sexual causes, too, are the ones which most readily offer the physician a foothold for his therapeutic influence. Heredity is no doubt an important factor, when it is present; it enables a strong pathological effect to come about where otherwise only a very slight one would have resulted. But heredity is inaccessible to the physician’s influence; everyone is born with his own hereditary tendencies to illness, and we can do nothing to change them. Nor should we forget that it is precisely in regard to the aetiology of the neurasthenias that we must necessarily deny the first place to heredity. Neurasthenia (in both its forms) is one of those affections which anyone may easily acquire without having any hereditary taint. If it were otherwise, the enormous increase in neurasthenia, of which all the authorities complain, would be unthinkable. In what concerns civilization, among whose sins people so often include responsibility for neurasthenia, these authorities may indeed be right (although the way in which this comes about is probably quite different from what they imagine). Yet the state of our civilization is, once again, something that is unalterable for the individual. Moreover this factor, being common to all the members of the same society, can never explain the fact of selectivity in the incidence of the illness. The physician who is not neurasthenic is exposed to the same influence of an allegedly detrimental civilization as the neurasthenic patient whom he has to treat. Subject to these limitations, the factors of exhaustion retain their significance. But the element of ‘overwork’, which physicians are so fond of producing to their patients as the cause of their neurosis, is too often unduly misused. It is quite true that anyone who, owing to sexual noxae, has made himself disposed to neurasthenia, tolerates intellectual work and the psychical exigencies of life badly; but no one ever becomes neurotic through work or excitement alone. Intellectual work is rather a protection against falling ill of neurasthenia; it is precisely the most unremitting intellectual workers who remain exempt from neurasthenia, and what neurasthenics complain of as ‘overwork that is making them ill’ does not as a rule deserve to be called ‘intellectual work’ at all, either in its quality or quantity. Physicians will have to become accustomed to explaining to an office-worker who has been ‘overworked’ at his desk or to a housewife for whom her domestic activities have become too heavy, that they have fallen ill, not because they have tried to carry out duties which are in fact easily performed by a civilized brain, but because all the while they have been grossly neglecting and damaging their sexual life.

Furthermore, it is only the sexual aetiology which makes it possible for us to understand all the details of the clinical history of neurasthenics, the mysterious improvements in the middle of the course of the illness and the equally incomprehensible deteriorations, both of which are usually related by doctors and patients to whatever treatment has been adopted. In my records, which include more than two hundred cases, there is, for instance, the story of a man who, when the treatment prescribed by his family physician had done him no good, went to Pastor Kneipp and for a year after being treated by him showed an extraordinary improvement in the middle of his illness. But when, a year later, his symptoms grew worse once more and he again went to Wörishofen for help, the second treatment was unsuccessful. A glance into the patient’s family record solved the double riddle. Six and a half months after his first return from Wörishofen his wife bore him a child. This meant that he had left her at the beginning of a pregnancy of which he was not yet aware; after his return he was able to practise natural intercourse with her. At the close of this period, which had a curative effect on him, his neurosis was started up afresh by his once more resorting to coitus interruptus; the second treatment was bound to prove a failure, since this pregnancy of his wife’s remained her last.

There was a similar case, in which, once again, the treatment had an unexpected effect which called for an explanation. This case turned out to be still more instructive, for it exhibited a puzzling alternation in the symptoms of the neurosis. A young neurotic patient had been sent by his physician to a reputable hydropathic establishment on account of a typical neurasthenia. There his condition steadily improved at first, so that there was every prospect that he would be discharged as a grateful disciple of hydrotherapy. But in the sixth week a complete change occurred; the patient ‘could no longer tolerate the water’, became more and more nervous, and finally left the establishment after two more weeks, uncured and dissatisfied. When he complained to me about this therapeutic fraud I asked him a few questions about the symptoms which had overtaken him in the middle of the treatment. Curiously enough, a complete change had come over them. He had entered the sanatorium with intracranial pressure, fatigue and dyspepsia; what had troubled him during the treatment were excitement, attacks of dyspnoea, vertigo in walking, and disturbances of sleep. I was now able to say to him: ‘You are doing hydrotherapy an injustice. As you yourself very well knew, you fell ill as a result of long-continued masturbation. In the sanatorium you gave up this form of satisfaction, and therefore you quickly recovered. When you felt well, however, you unwisely sought to have relations with a lady - a fellow-patient, let us suppose - which could only lead to excitement without normal satisfaction. The beautiful walks in the neighbourhood of the establishment gave you ample opportunity for this. It was this relationship, not a sudden inability to tolerate hydrotherapy, which caused you to fall ill once more. Moreover, your present state of health leads me to conclude that you are continuing this relationship here in town as well.’ I can assure my readers that the patient confirmed what I said, point by point.

The present treatment of neurasthenia - which is, perhaps, carried out most successfully in hydropathic establishments - has as its aim the amelioration of the nervous condition by means of two factors: shielding the patient and strengthening him. I have nothing to say against such a method of treatment, except that it takes no account of the circumstances of the patient’s sexual life. According to my experience, it is highly desirable that the medical directors of such establishments should become properly aware that they are dealing, not with victims of civilization or heredity, but - sit venia verbo - with people who are crippled in sexuality. They would then, on the one hand, be more easily able to account for their successes as well as their failures; and, on the other, they would achieve new successes which, till now, have been at the mercy of chance or of the patient’s unguided behaviour. If we take a neurasthenic woman, suffering from anxiety, away from her home and send her to a hydropathic establishment, and if there, freed from all duties, she is made to bathe and take exercise and eat plenty of food, we shall certainly be inclined to think that the improvement - often a brilliant one - which is achieved in a few weeks or months is due to the rest which she has enjoyed and to the invigorating effects of hydrotherapy. That may be so: but we are overlooking the fact that her removal from home also entails an interruption of marital intercourse, and that it is only the temporary elimination of this pathogenic cause which makes it possible for her to recover under favourable treatment. Neglect of this aetiological point of view brings its subsequent revenge, when what seemed such a gratifying cure turns out to be a very transitory one. Soon after the patient has returned to ordinary life the symptoms of the complaint appear once more and oblige him either to spend a part of his existence unproductively from time to time in establishments of this kind or to direct his hopes of recovery elsewhere. It is therefore clear that with neurasthenia the therapeutic problems must be attacked, not in hydropathic institutions but within the framework of the patient’s life.

In other cases our aetiological theory can help the physician in charge of the institution by throwing light on the source of failures which occur in the institution itself, and can suggest to him means of avoiding them. Masturbation is far commoner among grown-up girls and mature men than is generally supposed, and it has a harmful effect not only by producing neurasthenic symptoms, but also because it keeps the patients under the weight of what they feel to be a disgraceful secret. Physicians who are not accustomed to translate neurasthenia into masturbation account for the patient’s pathological state by referring it to some catchword like anaemia, undernourishment, overwork, etc., and then expect to cure him by applying a therapy devised against those conditions. To their astonishment, however, periods of improvement in him alternate with periods in which all his symptoms grow worse and are accompanied by severe depression. The outcome of such a treatment is, in general, doubtful. If physicians knew that all the while the patient was struggling against his sexual habit and that he was in despair because he had once more been obliged to give way to it, if they understood how to win his secret from him, to make it less serious in his eyes and to support him in his fight against the habit, then the success of their therapeutic efforts might in this way well be assured.

To break the patient of the habit of masturbating is only one of the new therapeutic tasks which are imposed on the physician who takes the sexual aetiology of the neurosis into account; and it seems that precisely this task, like the cure of any other addiction, can only be carried out in an institution and under medical supervision. Left to himself, the masturbator is accustomed, whenever something happens that depresses him, to return to his convenient form of satisfaction. Medical treatment, in this instance, can have no other aim than to lead the neurasthenic, who has now recovered his strength, back to normal sexual intercourse. For sexual need, when once it has been aroused and has been satisfied for any length of time, can no longer be silenced; it can only be displaced along another path. Incidentally, the same thing applies to all treatments for breaking an addiction. Their success will only be an apparent one, so long as the physician contents himself with withdrawing the narcotic substance from his patients, without troubling about the source from which their imperative need for it springs. ‘Habit’ is a mere form of words, without any explanatory value. Not everyone who has occasion to take morphia, cocaine, chloral hydrate, and so on, for a period, acquires in this way an ‘addiction’ to them. Closer enquiry usually shows that these narcotics are meant to serve - directly or indirectly - as a substitute for a lack of sexual satisfaction; and whenever normal sexual life can no longer be re-established, we can count with certainty on the patient’s relapse.

Another task is set to the physician by the aetiology of anxiety neurosis. It consists in inducing the patient to give up all detrimental forms of sexual intercourse and to adopt normal sexual relations. This duty, it will be understood, falls primarily on the patient’s trusted physician - his family doctor; and he will do his patient a serious injury if he regards himself as too respectable to intervene in this field.

Since in these instances it is most often a question of a married couple, the physician’s efforts at once encounter Malthusian plans for limiting the number of conceptions in marriage. There seems to me no doubt that such proposals are gaining ground more and more among our middle classes. I have come across some couples who have already begun practising methods for preventing conception as soon as they have had their first child, and others whose sexual intercourse was from their wedding-night designed to comply with that purpose. The problem of Malthusianism is far-reaching and complicated, and I have no intention of handling it here in the exhaustive manner which would actually be necessary for the treatment of neuroses. I shall only consider what attitude a physician who recognizes the sexual aetiology of the neuroses had best take up towards the problem.

The worst thing he can do is obviously - under whatever pretext - to try to ignore it. Nothing that is necessary can be beneath my dignity as a doctor; and it is necessary to give a married couple who contemplate limiting the number of their offspring the assistance of one’s medical advice if one does not want to expose one or both of them to a neurosis. It cannot be denied that in any marriage Malthusian preventive measures will become necessary at some time or other; and, from a theoretical point of view, it would be one of the greatest triumphs of humanity, one of the most tangible liberations from the constraints of nature to which mankind is subject, if we could succeed in raising the responsible act of procreating children to the level of a deliberate and intentional activity and in freeing it from its entanglement with the necessary satisfaction of a natural need.

A perspicacious physician will therefore take it upon himself to decide under what conditions the use of measures for preventing conception are justified, and, among those measures, he will have to separate the harmful from the harmless ones. Everything is harmful that hinders the occurrence of satisfaction. But, as we know, we possess at present no method of preventing conception which fulfils every legitimate requirement - that is, which is certain and convenient, which does not diminish the sensation of pleasure during coitus and which does not wound the woman’s sensibilities. This sets physicians a practical task to the solution of which they could bend their energies with rewarding results. Whoever fills in this lacuna in our medical technique will have preserved the enjoyment of life and maintained the health of numberless people; though, it is true, he will also have paved the way for a drastic change in our social conditions.

This does not exhaust the possibilities which flow from a recognition of the sexual aetiology of the neuroses. The main benefit which we obtain from it for neurasthenics lies in the sphere of prophylaxis. If masturbation is the cause of neurasthenia in youth, and if, later on, it acquires aetiological significance for anxiety neurosis as well, by reason of the reduction of potency which it brings about, then the prevention of masturbation in both sexes is a task that deserves more attention than it has hitherto received. When we reflect upon all the injuries, both the grosser and the finer ones, which proceed from neurasthenia - a disorder which we are told is growing more and more prevalent - we see that it is positively a matter of public interest that men should enter upon sexual relations with full potency. In matters of prophylaxis, however, the individual is relatively helpless. The whole community must become interested in the matter and give their assent to the creation of generally acceptable regulations. At present we are still far removed from such a state of affairs which would promise relief, and it is for this reason that we may with justice regard civilization, too, as responsible for the spread of neurasthenia. Much would have to be changed. The resistance of a generation of physicians who can no longer remember their own youth must be broken down; the pride of fathers, who are unwilling to descend to the level of humanity in their children’s eyes, must be overcome; and the unreasonable prudery of mothers must be combated - the mothers who at present look upon it as an incomprehensible and undeserved stroke of fate that ‘their children should have been the ones to become neurotic’. But above all, a place must be created in public opinion for the discussion of the problems of sexual life. It will have to become possible to talk about these things without being stamped as a trouble-maker or as a person who makes capital out of the lower instincts. And so here, too, there is enough work left to do for the next hundred years - in which our civilization will have to learn to come to terms with the claims of our sexuality.

The value of making a correct diagnostic separation of the psychoneuroses from neurasthenia is also shown by the fact that the psychoneuroses call for a different practical assessment and for special therapeutic measures. They make their appearance as a result of two kinds of determinants, either independently or in the train of the ‘actual neuroses’ (neurasthenia and anxiety neurosis). In the latter case we are dealing with a new type of neurosis - incidentally, a very frequent one - a mixed neurosis. The aetiology of the ‘actual neuroses’ has become an auxiliary aetiology of the psychoneuroses. A clinical picture arises in which, let us say, anxiety neurosis predominates but which also contains traits of genuine neurasthenia, hysteria and obsessional neurosis. When confronted with a mixture of this kind, we shall nevertheless not be wise to give up separating out the clinical pictures proper to each neurotic illness; for after all it is not difficult to explain the case to oneself in the following manner. The predominant place taken by the anxiety neurosis shows that the illness has come into being under the aetiological influence of an ‘actual’ sexual noxa. But the person concerned was, apart from that, disposed to one or more of the psychoneuroses owing to a special aetiology and would at some time or other have fallen ill of a psychoneurosis either spontaneously or with the advent of some other weakening factor. In this way the auxiliary aetiology for the psychoneurosis which is still lacking is supplied by the actual aetiology of the anxiety neurosis.

For such cases it has quite correctly come to be the therapeutic practice to disregard the psychoneurotic components in the clinical picture and to treat the ‘actual neurosis’ exclusively. In very many cases it is possible to overcome the neurosis as well which it has brought along with it, provided that the neurasthenia is effectively dealt with. But a different view must be taken in those cases of psychoneurosis which either appear spontaneously or remain behind as an independent entity after an illness composed of neurasthenia and psychoneurosis has run its course. When I speak of a ‘spontaneous’ appearance of a psychoneurosis, I do not mean that anamnestic investigation shows us no aetiological element whatever. It may do so, no doubt; but it may also happen that our attention is directed to some indifferent factor - an emotional state, an enfeeblement owing to physical illness, and so on. It must, however, be borne in mind in all these cases that the true aetiology of the psychoneuroses does not lie in such precipitating causes, but remains beyond the reach of ordinary anamnestic examination.

As we know, it is in an attempt to bridge this gap that the assumption has been made of a special neuropathic disposition (which, incidentally, if it existed, would not leave much hope of success for the treatment of such pathological conditions). The neuropathic disposition itself is regarded as a sign of a general degeneracy, and thus this convenient technical term has come to be superabundantly used against the wretched patients whom the doctors are quite incapable of helping. Fortunately, the state of affairs is different. The neuropathic disposition does no doubt exist, but I must deny that it suffices for the creation of a psychoneurosis. I must further deny that the conjunction of a neuropathic disposition with precipitating causes occurring in later life constitutes an adequate aetiology of the psychoneuroses. In tracing back the vicissitudes of an individual’s illness to the experiences of his ancestors, we have gone too far; we have forgotten that between his conception and his maturity there lies a long and important period of life - his childhood - in which the seeds of later illness may be acquired. And that- is what in fact happens with a psychoneurosis. Its true aetiology is to be found in childhood experiences, and, once again - and exclusively - in impressions concerned with sexual life. We do wrong to ignore the sexual life of children entirely; in my experience, children are capable of every psychical sexual activity, and many somatic sexual ones as well. Just as the whole human sexual apparatus is not comprised in the external genitals and the two reproductive glands, so human sexual life does not begin only with puberty, as on a rough inspection it may appear to do. Nevertheless it is true that the organization and evolution of the human species strives to avoid any great degree of sexual activity during childhood. It seems that in man the sexual instinctual forces are meant to be stored up so that, on their release at puberty, they may serve great cultural ends. (W. Fliess.) Consideration of this sort may make it possible to understand why the sexual experiences of childhood are bound to have a pathogenic effect. But they produce their effect only to a very slight degree at the time at which they occur; what is far more important is their deferred effect, which can only take place at later periods of growth. This deferred effect originates - as it can do in no other way - in the psychical traces which have been left behind by infantile sexual experiences. During the interval between the experiences of those impressions and their reproduction (or rather, the reinforcement of the libidinal impulses which proceed from them), not only the somatic sexual apparatus but the psychical apparatus as well has undergone an important development; and thus it is that the influence of these earlier sexual experiences now leads to an abnormal psychical reaction, and psychopathological structures come into existence.

I can do no more in these brief hints than mention the chief factors on which the theory of the psychoneuroses is based: the deferred nature of the effect and the infantile state of the sexual apparatus and of the mental instrument. To reach a true understanding of the mechanism by which the psychoneuroses come about, a more extended exposition would be necessary. Above all, it would be indispensable to put forward as worthy of belief certain hypotheses, which seem to me to be new, about the composition and mode of operation of the psychical apparatus. In a book on the interpretation of dreams on which I am now engaged I shall find occasion to touch upon those fundamental elements of a psychology of the neuroses. For dreams belong to the same set of psychopathological structures as hysterical idées fixes, obsessions, and delusions.

Since the manifestations of the psychoneuroses arise from the deferred action of unconscious psychical traces, they are accessible to psychotherapy. But in this case the therapy must pursue paths other than the only one so far followed of suggestion with or without hypnosis. Basing myself on the ‘cathartic’ method introduced by Josef Breuer, I have in recent years almost completely worked out a therapeutic procedure which I propose to describe as ‘psycho-analytic’. I owe a great number of successes to it, and I hope I may be able further to increase it effectiveness considerably. The first accounts of the technique and scope of this method were given in Studies on Hysteria, written jointly with Breuer and published in 1895. Since then a good deal, as I think I may say, has been altered for the better. Whereas at that time we modestly declared that we could undertake to only to remove the symptoms of hysteria, not to cure hysteria itself, this distinction has since come to seem to me without substance, so that there is a prospect of a genuine cure of hysteria and obsessions. It is therefore with very lively interest that I have read in the publications of colleagues that ‘in this case the ingenious procedure devised by Breuer and Freud has failed’, or that ‘the method has not performed what it seemed to promise’. This gave me something of the feelings of a man who reads his own obituary in the paper, but who is able to reassure himself by his better knowledge of the facts. For the method is so difficult that it has quite definitely to be learned; and I cannot recall that a single one of my critics has expressed a wish to learn it from me. Nor do I believe that, like me, they have occupied themselves with it intensely enough to have been able to discover it for themselves. The remarks in the Studies on Hysteria are totally inadequate to enable a reader to master the technique, nor are they in any way intended to give any such complete instruction.

Psycho-analytic therapy is not at present applicable to all cases. It has, to my knowledge, the following limitations. It demands a certain degree of maturity and understanding in the patient and is therefore not suited for the young or for adults who are feeble-minded or uneducated. It also fails with people who are very advanced in years, because, owing to the accumulation of material in them, it would take up so much time that by the end of the treatment they would have reached a period of life in which value is no longer attached to nervous health. Finally, the treatment is only possible if the patient has a normal psychical state from which the pathological material can be mastered from which to work ie a relatively normal ego. During a condition of hysterical confusion, or an interpolated mania or melancholia, nothing can be effected by psycho-analytic means. Such cases can nevertheless be treated by analysis after the violent manifestations have been quieted by the usual measures. In actual practice, chronic cases of psychoneurosis are altogether more amenable to the method than cases with acute crises, in which the greatest stress is naturally laid on the speed with which the crises can be dealt with. For this reason, the most favourable field of work for this new therapy is offered by hysterical phobias and the various forms of obsessional neurosis.

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