IN HIS EARLY TEENS, Freud seemed headed, as the itinerant poet had prophesied, to pursue law or politics. But during his final year in Gymnasium, captivated by Darwin’s evolutionary theories, Freud turned to the biological sciences. For a poor boy, this choice meant the study of medicine, although Freud later recalled, “Neither at that time, nor indeed in my later life, did I feel any particular predilection for the career of a doctor.”
Although Freud would later complain that anti-Semitism impeded his professional progress, medicine was a calling open to Jews. In the 1880s, some 60 percent of the physicians in Vienna were Jewish, as were half of the students in the medical school. Jews served as the emperor’s physician and the army’s surgeon general.
At age seventeen, Freud enrolled in the medical faculty at the University of Vienna. Initially, he contemplated a career that combined philosophy and zoology. The inspiration was a professor, Franz Brentano, whose work linked theology, phenomenology, psychology, and Darwinism. Brentano was concerned with the soul—he believed that it stood outside ordinary awareness and yet provided motivation—and with the disturbing effects of a divided consciousness, a state he believed could be soothed by a retrospective review of otherwise unexamined intentions.
Like many medical students, Freud experienced a serial attraction to various callings, from laboratory research to clinical practice. By 1875, Freud was ensconced in the laboratory of Carl Claus, a prominent Darwinian. Freud’s research sent him to Trieste, where he undertook a partly successful attempt to determine whether eels were hermaphroditic. Freud’s industriousness—he had searched for testes in four hundred specimens, almost all of which proved fully female—brought him into the ambit of the great physiologist Ernst Brücke.
Brücke was fighting a battle not yet won, to put medicine on a scientific basis. His positivism meshed with Freud’s philosophical interests, in setting reason ahead of superstition and biology in place of faith. Under Brücke, Freud studied the nervous system, from fish to human, clarifying evolutionary developments. Freud came close to formulating the theory of neurons and neuronal communication—it had been unclear whether the nervous system was a syncytium, with all its elements physically connected, or a network of independent cells separated by gaps—but that honor went to others.
Through the work with Brücke, Freud met Josef Breuer, a successful physician and accomplished physiologist. Freud treated Breuer, fourteen years his senior, as a surrogate father. Breuer admired Freud’s intellect, writing, “I gaze after him as a hen at a hawk.” For years, Breuer served as Freud’s personal physician and supported him emotionally and financially. In conversation, Breuer would regale Freud with clinical vignettes, including the story of Bertha Pappenheim, whom the two men would later immortalize, under the name “Anna O.,” as the first psychoanalytic patient.
In 1879, Freud had left for a year of military ser vice, a tedious duty that he fulfilled while pursing other interests. Through his contact with Brentano, Freud obtained an invitation to translate into German a volume of the writings of John Stuart Mill that included essays on socialism and the emancipation of women. Freud received his medical degree in 1881, but he stayed on with Brücke until a development in his private life required the transition to active medical practice.
Freud met Martha Bernays in April 1882 and fell in love immediately. He proposed within two months. (Freud would later write that while deliberation might help with inconsequential choices, “in vital matters, however, such as the choice of a mate or profession, the decision should come from the unconscious.”) It would be four years before the couple could marry.
There were differences in social class and religion. The Bernays family was orthodox. Freud’s parents had been married in a reform ser vice, and Freud himself, though never shy to be identified culturally as a Jew, was an atheist, contemptuous of even token religious practice. But religious differences had not prevented Martha’s brother Eli from marrying Freud’s sister Anna in 1882. The chief obstacle to Freud’s marriage was money. As a junior researcher, Freud had limited prospects. Martha was from Hamburg, and her mother moved her back near home shortly after Freud’s courtship began.
When separated, the couple corresponded daily—fifteen hundred letters survive. In his, Freud was often didactic, as he had been with his sisters. Writing Martha in 1883, for instance, he shared his opinion of John Stuart Mill:
I recollect that in the essay I translated a prominent argument was that a married woman could earn as much as her husband…[Mill ignores] that human beings consist of men and women and that this distinction is the most significant one that exists. In his whole presentation it never emerges that women are different beings—we will not say lesser, rather the opposite—from men….
The reforming aspects of law and education, Freud argued, would always “break down in front of the fact that, long before the age at which a man can earn a position in society, Nature has determined woman’s destiny through beauty, charm, and sweetness.” Woman’s role would remain constant, to be “in youth an adored darling and in mature years a loved wife.” There are echoes of Darwinism throughout this odd love letter, but also political views far from the vanguard.
Freud’s openness and his social clumsiness are apparent in a letter he wrote the twenty-two-year-old Martha:
If you insist on strict correctness in the use of words, then I must confess you are not beautiful. But I was not flattering you in what I said…What I meant to convey was how much the magic of your being expresses itself in your countenance and your body…. I myself have always been insensitive to formal beauty. But if there is any vanity left in your little head I will not conceal from you that some people declare you to be beautiful, even strikingly so. I have no opinion in the matter.
To support a marriage, Freud abandoned his research and, late in 1882, enrolled as an apprentice in the General Hospital of Vienna. He moved through assignments in surgery and internal medicine, transferring in May 1883 to the psychiatric clinic. It was only then that he left home, to live in the hospital’s interns’ quarters. Freud was a skilled neuropathologist, known for an ability to pinpoint hard-to-find brain lesions in postmortem dissections. On the strength of his ties with influential professors, Freud emerged in 1885 as a lecturer and Privatdozent, a low-level title that however conferred advantages for a doctor contemplating a private practice.
One set of Freud’s early publications has achieved notoriety. In 1884, Freud took an interest in cocaine, a medication that a German military doctor had used to bolster soldiers’ stamina. Freud tried the medication on himself and noted feelings of “exhilaration and lightness.” Freud became an enthusiast. Freud’s appreciation of cocaine was partly personal. In June 1884, he wrote Martha:
I will kiss you quite red and feed you till you are plump. And if you are forward you shall see who is the stronger, a little girl who doesn’t eat enough or a big strong man with cocaine in his body. In my last serious depression I took cocaine again and a small dose lifted me to the heights in a wonderful fashion. I am just now collecting the literature for a song of praise to this magical substance.
Freud knew that there were many psychoactive compounds, such as the opiates, that lowered a patient’s general level of stimulation, but a medication that enhanced mood, energy, and drive was unusual. Freud was apparently a “good responder” to the drug. He found cocaine at a modest dose to be an effective treatment for a range of conditions he suffered—not only depression, but also social anxiety and migraine. He resorted to cocaine repeatedly over a period of at least ten years, probably without becoming addicted.
Cocaine had been known to European and American doctors for years, but Freud approached the drug as if he were its discoverer. Between 1884 and 1887, he published six papers on cocaine. They are clever but plagued by errors in judgment.
In part because of his own experience, Freud reported that cocaine produced “lasting euphoria which in no way differs from the normal euphoria of the healthy person,” a combination of vitality and self-control. He assured his readers that users develop no craving for the drug. Freud recommended cocaine for a range of disorders, from asthma to stomach ailments. He thought that the drug might be a cure for neurasthenia, a mental affliction characterized by apathy and depression. He also believed that cocaine could help addicts to withdraw from morphine.
A response to Freud’s first papers appeared immediately. A rival doctor laid out the facts. Morphine creates a distinctive feeling of well-being, different from that induced by cocaine. The euphoria that neophytes like Freud experience does not answer the craving for morphine. Not even high doses of cocaine, which cause hallucinations, suffice for the morphine addict. Instead, a double addiction emerges. Another colleague accused Freud of having championed the “third scourge of humanity,” after alcohol and morphine.
Freud’s error seemed to arise from his hunger for early fame. He rushed to publish his observations. Then, when colleagues objected, Freud lashed out at them. He referred to his critic’s “pathetically” calling cocaine a scourge. Freud assured readers that cocaine was safe for most people. Far from becoming addicted, they develop an aversion to the drug. At worst, cocaine is only as addictive as coffee. Freud lectured in favor of cocaine’s use, even by injection. He vetted a preparation of the drug for a commercial manufacturer. But the fight was hopeless. From around the globe, reports of cocaine addiction appeared in print.
Freud narrowly missed the acclaim he had sought. He had been present when a colleague noted that a cocaine solution caused numbing of the lips and nose. Freud predicted that this property would lead to further medical uses, and he mentioned the finding to an ophthalmologist. Before pursuing this lead, Freud went off on a rare trip to visit Martha. He returned to begin testing the effects of a cocaine solution on a dog’s eye. But another doctor present at the original conversation had already performed similar experiments and published the results, thereby gaining international fame. Cocaine was an effective anesthetic for eye surgery.
Freud was bitter over the loss of priority. He had written Martha, “We need no more than one stroke of luck of this kind to consider setting up house.” Instead, his engagement had cost him eternal glory. Many years later, he would write: “I have borne my fiancée no grudge for her interruption of my work”—a “Freudian” statement that seems to encompass its opposite.
Freud’s broader enthusiasm for cocaine would prove costly. Freud had supplied the drug to a friend, Ernst von Fleischl-Marxow, to treat his morphine addiction. Fleischl and Freud worked together in Brücke’s laboratory. The two young men would stay up late into the night discussing the meaning of life. Fleischl was handsome and wealthy—he helped Freud with gifts of money—and Freud had an adolescent crush on him. Freud wrote Martha, “I love him not so much as a human being, but as one of Creation’s precious achievements.”
Fleischl suffered from chronic nerve pain, a result of an infection. He took cocaine via hypodermic needle, eventually in the high doses that cause hallucinations. Freud’s supporters at the medical school—Brücke and Breuer—witnessed these crises. When Fleischl died five years later, Freud believed that cocaine addiction was a contributing cause.
Freud exonerated himself by claiming that he had never advocated injections of the drug. In fact, Freud had published a paper reporting that “Prof. Dr. E. v. Fleischl, in Vienna,…has determined that the cocaine, by hypodermic injection, has proved itself to be an invaluable adjuvant against the continued use of morphia; also against a single fatal dose. This fact alone should give the remedy an enduring place among the treasures of the physician.”
The cocaine episode was a minor detour for Freud, but its pattern foreshadowed future difficulties. Freud’s personal needs drove his investigation, and he moved quickly to generalize from his own psychology. The claims of benefit for others that Freud cited turned out to be unreliable. Despite his review of past literature, Freud took a proprietary attitude, implicitly claiming discovery of a field of therapeutics. Though he began by proposing treatments of specific conditions, Freud soon suggested that the intervention was useful for a broad range of nervous disorders. He went on to claim benefits for normal people. As legitimate objections to Freud’s conclusions emerged, he became combative. In the face of an unfortunate outcome, he mounted a defense based on a rewriting of history. Rather than feel shame, Freud considered himself beleaguered.
Also like his subsequent work, Freud’s cocaine essays were visionary. They describe a number of the drug’s characteristics accurately. The applications that Freud claims for cocaine overlap substantially with the uses that were in time found for various classes of antidepressants. He seemed to understand how mood disorders were likely to be organized in the brain. Based on the cocaine papers, Freud has been called one of the founders of modern psychopharmacology.
Fortunately, Freud had not staked his whole future on research into the effects of cocaine. He had aspirations as a neuroanatomist, with a thought to specializing in disorders of infants and children. In 1885, he won a fellowship that allowed him to spend five months doing brain studies at the clinic of Jean-Martin Charcot in Paris. Charcot was then what Freud would become, a celebrity known for his expertise in diseases of mind and brain. Charcot’s facilities proved unsuitable for the research Freud had hoped to conduct. But Freud soon became absorbed by the subject in which Charcot was most expert, hysteria.
Hysteria was an unfortunate starting point for an inquiry into psychopathology. The term referred first to patients who showed neurological symptoms, such as epileptic seizures or paralysis of a limb, without having the underlying brain or nerve damage that would explain the dysfunction. But mood symptoms, such as anxiety and depression, and abnormalities of thought, such as hallucinations, might also be counted as manifestations of hysteria, so that the category was impossibly broad. In women in particular, almost any mental or unexplained physical disturbance that had a histrionic cast sufficed to make the diagnosis.
From our perspective, nineteenth-century hysterics had afflictions ranging across many categories of disease: mood disorders, such as depression and manic depression; personality disorders, such as borderline states; post-traumatic conditions; psychoses; and dramatic responses to social pressures that today would not be understood as mental illness. The core disorder, involving unexplained neurological symptoms in the absence of other mental illness, is still seen today, but it is not nearly so protean as the condition Charcot studied, and it is rare. There was, in retrospect, no chance that Charcot, or Freud after him, would solve the mystery of hysteria by discovering a single cause.
In his prime, Charcot had been an extraordinary figure. He had studied kidney and lung diseases and moved on to head part of the Salpêtrière Hospital, a village-sized facility that served as a poorhouse for women in Paris. Charcot turned the Salpêtrière into a research and teaching center. Concentrating in neurology, he identified a number of new diseases, including amyotrophic lateral sclerosis or ALS. Charcot became part of France’s glory, along with Louis Pasteur.
Doctors had long debated whether hysteria had a physical or a psychological basis. For millennia, hysteria—the word derives from Greek terms for the womb and the afterbirth—had been understood as a disease of women, caused by problems in the uterus. By the sixteenth century, some authorities located the disease in the brain and said that hysteria could affect men. Even after the uterus had been removed from the picture, frustrated sexual drives were understood to be at the root of the affliction.
In the 1850s, the French internist Paul Briquet put the study of hysteria on a scientific basis, investigating 430 cases. He concluded that hysteria was a brain disease affecting the passions, but that it was not due to sexual repression. (It was more common in prostitutes than in nuns.) He believed that vulnerability to hysteria was inherited, but that stressors like grief, family conflicts, and complications of romance were also implicated. So were social factors like poverty and rural life. Men accounted for 4 or 5 percent of cases of hysteria. It was these thoughtful observations—in form, similar to today’s views of the causation of mental illness—that Charcot set out to supplement.
The choice was a dangerous one. The study of hysteria involved male doctors in the care of dramatic women whose symptoms fluctuated wildly. It was a field where quackery flourished. Worse, Charcot linked hysteria to hypnosis, a suspect intervention. But for a while, Charcot’s prestige put an imprint of legitimacy on both subjects.
Charcot was able to demonstrate that hysterical symptoms could be reproduced under hypnosis, and he could use hypnosis to remove symptoms. In explanation, Charcot made reference to layers of mind. He believed that hysterical symptoms arose from implanted ideas that stood at a distance from conscious thought. Like Briquet, Charcot argued that hysteria was not exclusively a disease of women and that it could be triggered by different sorts of stressors. It was evident that frank trauma, like the terror of enduring a train crash, could cause paralyses (called “railway spine”) that did not follow the pathways known to neurologists. Hysteria, as Charcot understood it, was also grounded in hereditary neurological pathology that worsened across generations.
As for the role of sexual problems, Charcot, in his writings, was less clear. But at a dinner party in 1886, Freud heard Charcot argue that a young woman’s nervous disorder was invariably due to her husband’s sexual inadequacy. “In similar cases, it is always ‘la chose genitale, toujours…toujours…toujours.’”
Arriving at these conclusions, Charcot put his stamp on beliefs that had been sometimes dismissed and sometimes widely held, for decades. Where Charcot was more original, he was often wrong. Charcot had staked his reputation on the claim that hysteria could be understood as a narrowly defined entity characterized by a consistent progression through a succession of stages that resembled a deepening hypnotic trance.
Each Tuesday, Charcot gave an impromptu neurology talk, inspired by a new patient whom he would diagnose on the spot. Fridays were devoted to formal lectures, illustrated by live case material. Both performances were widely attended; sometimes they involved dramatic presentations of the suggestibility of attractive women prone to hysteria. The demonstrations and theories led to charges of charlatanism that, if not quite true, still had a basis in fact.
Effectively, Charcot was a victim of his own preeminence. His assistants had gotten into the habit of training patients so that they would exhibit symptoms conforming to Charcot’s rules. Because grand hysteria presented a possible route to renown, and because the hysterical patients lived together on special wards, the women learned to imitate one another’s flamboyant behaviors. Under Charcot’s leadership, the proportion of hysterics at the Salpêtrière rose from 1 percent to 15 or 20 percent.
Charcot’s most celebrated patient was Blanche Wittmann, “la reine des hysteriques.” She is the subject of a well-known painting (Freud hung a lithograph of it in his consulting room) that shows her arched backward in a trance, shoulder and décolletage revealed by an attractive blouse, while Charcot, standing beside her, instructs his students in the stages of hysteria.
Unfortunately for Charcot, Wittmann came under the care of the brother of Charcot’s former student Pierre Janet. In that treatment, Wittmann revealed a second, more ordinary personality. According to Wittmann, this conventional self had been present even when the histrionic one marched through the paces for Charcot. Wittmann returned to the Salpêtrière, worked in a radiology laboratory, and became an early victim of radiation-induced cancer, an ordeal she endured with no sign of hysteria. Immediately after his death in 1893, Charcot was ridiculed as a self-deluding Napoleon responsible for an epidemic of doctor-inspired illness. Indeed, Blanche Wittmann had reprised her trances in the theater, in a popular stage satire. It is no wonder then that certain of Freud’s contemporaries understood hysteria to be, in effect, a disorder of the doctor-patient relationship.
Freud came to the Salpêtrière in 1885, when Charcot was at the height of his influence. Freud had always been prone to adopt father figures, Brücke and Breuer among them. Charcot was a third. (Freud would name a daughter Mathilde, after Breuer’s wife; a son Jean Martin, after Charcot; and another son Ernst, after Brücke.) Freud attended the biweekly séances. He witnessed Charcot’s success with a paralytic patient who threw away her crutches. Freud also saw a male hysteric, whose symptoms were set off by a fall from a scaffold. Freud wrote Martha, “After some lectures I walk away as from Notre Dame, with a new perception of perfection.”
Freud endeared himself to Charcot by offering to translate certain of his lectures into German. Charcot invited Freud to parties at his home. (For these events, Freud quelled his social anxiety and combated his boredom with cocaine.) The contact with Charcot, Freud wrote, made his own detailed neurological research seem trivial. He returned to Vienna to open a private practice, with Charcot’s approach to patients in mind. As he had with cocaine, Freud saw the French understanding of hysteria as a quick ticket to acclaim in Vienna. In this belief, he was again mistaken.
In October 1886, Freud gave a talk about male hysteria to the Viennese Society of Physicians. Freud’s later account of the response cast him in a heroic light. He expressed novel views and was ridiculed. Challenged to find a male hysteric, Freud agreed—and was then prevented from interviewing prospects on the hospital wards. When he did in time locate and present such a patient, Freud was applauded by his audience—but still confronted with skepticism. He proudly withdrew from academic life, abandoning convention to pursue knowledge.
This autobiographical version of events turns out to have been almost entirely false. Historians have located six contemporary accounts of the response to Freud’s lecture. The first audience member to comment reminded his colleagues that he had published observations of two male hysterics sixteen years prior. The head of the hospital clinic then indicated that he had just a month ago published a similar report—and he invited Freud to come to his clinic and study any material that might be of interest.
The chair of the meeting said, “In spite of my great admiration for Charcot and my high interest for the subject, I was unable to find anything new in the report of Dr. Freud because all that has been said has already long been known.” The teacher who had supplied Freud with his letter of introduction to Charcot had described male hysteria twenty years prior. One doctor present wrote in his own memoir that the senior physicians in the audience did not take to Freud’s so admiring Charcot for views they themselves had championed.
Once again, Freud failed because he was unfamiliar with observations that were well known to his colleagues. This time, he disgraced himself not because he had championed shocking views but because he had claimed originality for findings that others had worked hard to establish. This stumble must have been humiliating to a “neurological practitioner without patients,” as a contemporary characterized Freud.