The medical clinic gives us a valuable suggestion (observed by many research workers) for the comprehension of the true neuroses. In all the details of their symptomatology, and as well in their characteristic power to influence all organic systems and all functions, the true neuroses reveal a marked similarity to the conditions of those diseases which originate through the chronic influence of foreign poisons and as well through their acute diminution; with conditions prevalent in intoxication and abstinence. The two groups of conditions are brought still closer together by the relation of intermediate conditions, which, following M. Basedowi, we have learned to attribute to the influence of toxic substances, but of toxins, however, which are not introduced into the body from without, but arise in its own metabolism. These analogies, I think, lead us directly to the consideration of these neuroses as disturbances in sexual metabolism. It may be that more sexual toxins are produced than the individual can dispose of, or that inner, even psychic conditions, stand in the way of the proper elaboration of these substances. The language of the people has always favored such assumptions as to the nature of sexual desires. It calls love an “intoxication”; it will have love-madness aroused through potions, and thus sees the motive force removed, as it were, to the outer world. For the rest, the phrase “sexual metabolism” or “chemism of sexuality” is a chapter-head without content. We know nothing about it and cannot even decide whether we are to assume two sexual substances, the male and the female, or, if there is only one sexual toxin, which to consider the carrier of all the stimulating power of the libido. The structure of psychoanalysis that we have erected is really only a superstructure which at some future time must be placed upon its organic foundation; but what this is we do not know as yet.
Psychoanalysis is characterized as a science, not by reason of the subject matter it handles but by the technique it employs. This can be employed in dealing with the history of civilization, the science of religion or mythology, as well as with the theory of neurosis, without altering its character. The revealing of the unconscious in psychic life is all it aims to accomplish. The problems of the true neuroses, whose symptoms probably originate in direct toxic damage, yield no point of attack to psychoanalysis. Psychoanalysis can do little for their elucidation, and must leave the task to biological-medical research. Perhaps you understand now why I did not choose to organize my material differently. If I had given to you an Introduction to the Theory of the Neuroses as you wished, it would unquestionably have been correct to proceed from the simple forms of the true neuroses to those complex illnesses caused by a disturbance of the libido. In discussing the true neuroses I would have had to bring together the facts we have gleaned from various quarters and present what we think we know of them. Only later, under the psychoneuroses, would psychoanalysis have been discussed as the most important technical aid for insight into these conditions. I had, however, intended and announced A General Introduction to Psychoanalysis, and it seemed to me more important to give you an idea of psychoanalysis than to present certain positive facts about neuroses; and so I could not place the true neuroses into the foreground, for they prove sterile for the purposes of psychoanalysis. I believe that I have made the wiser choice for you, since psychoanalysis deserves the interest of every educated person because of its profound hypotheses and far-reaching connections. The theory of neurosis, on the other hand, is a chapter of medicine like any other.
You are, however, justified in expecting some interest on our part in the true neuroses. Because of their intimate connection with psychoneuroses we find this decidedly necessary. I shall tell you then that we distinguish three pure forms of true neuroses: neurasthenia, anxiety neurosis and hypochondria. Even this classification has not remained uncontradicted. The terms are all widely used, but their connotation is vague and uncertain. Besides, there are in this world of confusion physicians who object to any distinctions between manifestations, any emphasis of clinical detail, who do not even recognize the separation of true neuroses and psychoneuroses. I think they have gone too far and have not chosen the road which leads to progress. The types of neuroses we have mentioned occur occasionally in pure form; more often they are blended with one another or with a psychoneurotic condition. This need not discourage us to the extent of abandoning the task of distinction. Think of the difference between the study of minerals and that of ores in mineralogy. Minerals are described as individuals; frequently of course they occur as crystals, separated sharply from their surroundings. Ores consist of an aggregate of minerals which have coalesced not accidentally, but as a result of the conditions of their origin. We understand too little of the process of development of neuroses, to create anything similar to the study of ores. But we are surely working in the right direction when we isolate the known clinical factors, comparable to the separate minerals, from the great mass.
A noteworthy connection between the symptoms of the true neuroses and the psychoneuroses adds a valuable contribution to our knowledge of symptom formation in the latter. The symptom in the true neuroses is frequently the nucleus and incipient stage of development of the psychoneurotic symptom. Such a connection is most easily observed between neurasthenia and the transference neuroses, which are termed conversion hysteria, between anxiety neurosis and anxiety hysteria, but also between hypochondria and paraphrenia (dementia praecox and paranoia), forms of neuroses of which we shall speak subsequently. Let us take as an illustration the hysteric headache or backache. Analysis shows that through elaboration and displacement this pain has become the gratification substitute for a whole series of libidinous phantasies or reminiscences. But once upon a time this pain was real, a direct sexual toxic symptom, the physical expression of libidinous excitation. We do not wish to assert, by any means, that all hysteric symptoms can be traced to such a nucleus, but it is true that this is frequently the case, and that all influences upon the body through libidinous excitation, whether normal or pathological, are especially significant for the symptom development in hysteria. They play the part of the grain of sand which the mollusc has enveloped in mother-of-pearl. In the same way passing signs of sexual excitation, which accompany the sexual act, are used by psychoneurosis as the most convenient and appropriate material for symptom formation.
A similar procedure is of diagnostic and therapeutic interest especially. Persons who are disposed to be neurotic, without suffering from a flourishing neurosis, frequently set in motion the work of symptom development as the result of an abnormal physical change — often an inflammation or an injury. This development rapidly makes the symptom given by reality the representative of the unconscious phantasies that had been lurking for an opportunity to seize upon a means of expression. In such a case the physician will try different ways of therapy. Either he will try to do away with the organic basis without bothering about its noisy neurotic elaboration, or he will struggle with the neurosis brought out by the occasion, and ignore its organic cause. The result will justify now one, now the other method of procedure; no general laws can be laid down for such mixed cases.
TWENTY-FIFTH LECTURE
GENERAL THEORY OF THE NEUROSES
FEAR AND ANXIETY
Probably you will term what I told you about ordinary nervousness in my last lecture most fragmentary and unsatisfactory information. I know this, and I think you were probably most surprised that I did not mention fear, which most nervous people complain of and describe as their greatest source of suffering. It can attain a terrible intensity which may result in the wildest enterprises. But I do