Physician, Heal Thyself: Part II

1.

In the first part of this essay, a review of books by Gerald Imber and Howard Markel, we saw that William Halsted and Sigmund Freud, though superficially alike in their concern for medical applications of cocaine, were attracted to the drug for different reasons.¹ Halsted had one goal in mind, to develop nerve-blocking subcutaneous anesthesia. In contrast, Freud initially seized upon cocaine as a means to private ends: fame, solvency, and a hastening of his long-deferred marriage. When, knowing little about its risks, he employed the drug to treat the morphine addiction of his friend Ernst Fleischl von Marxow in 1884, the outcome was calamitous—a fact that didn’t prevent Freud, in several papers between then and 1887, from continuing to represent the treatment as a major success.

In order to show that normal people have nothing to fear from cocaine, the last of Freud’s cocaine essays cited his own harmless consumption of the drug “for months” (it had actually been more than three years) without his “perceiving or experiencing…any desire for continued use.”² The preceding papers, in which he had portrayed himself as an experimenter in pharmaceutical research, had already made it clear that since 1884 he had been a consumer of the drug. It was that fact, surely, and not just embarrassment over Fleischl’s double addiction and early death, that later prompted him to purge the telltale papers from his résumé and to dismiss his whole involvement with cocaine as having been only a passing hobby.

The truth about Freud’s cocaine habit was very different. Although the trail of evidence is spotty, it is consistent enough to show, first, that neither Fleischl’s addiction nor the mounting toll of other such reported cases dissuaded Freud from continuing to make use of cocaine for at least twelve years, though possibly with interruptions; second, that his purpose in doing so was primarily self-therapeutic rather than exploratory; and third, that his most intoxicating means of application—brushing the laboratory-grade powder into his nostrils—was practiced during the very years when he was incubating psychoanalytic theory. As for his 1887 denial of attraction to the drug, it bears comparison with a gallantry he had addressed to his fiancée, Martha Bernays, on January 9, 1885: “I think I would give all my cocaine for one hour in Wandsbek.”³

Soon after he first tasted the drug on April 30, 1884, Freud had noticed that it provided a quick high and seemed to banish his headaches, indigestion, depression, writer’s block, and sexual self-doubt. Thus the stimulant quickly became indispensable to the management of his daily life. In spite of ample opportunity for self-observation, he didn’t comprehend the rebound effects that were rendering cocaine a trigger for the very miseries he was treating with it.

According to the official version of Freud’s career, sexuality scarcely entered his mind as a topic of interest until, to his shock and embarrassment, it was forced upon him by his patients’ indecent confessions. His early psychological papers and his letters to Wilhelm Fliess, however, show just the opposite: it was a sex-obsessed Freud who tried to harangue those patients into admitting that they harbored the perverse desires and guilty secrets that were already on his mind. But when and why had sexual issues become paramount for him? His surviving letters from adolescence are those of a moralizing, misogynistic prude,⁴ and the same qualities appear in his early engagement letters, beginning in 1882.

Perhaps the best-known result of taking cocaine is sexual disinhibition. By June 2, 1884, Freud was already inserting innuendoes into his formerly prim love letters, admonishing Martha that on his next visit she would see “who is the stronger, a gentle little girl…or a big wild man who has cocaine in his body.”⁵ Freud wasn’t threatening to rape his fiancée, but his imagination was erotically inflamed, and there was a trace of sadism in his banter.

The same note was struck on May 4, 1885, when, announcing that he had brought along a whole gram of cocaine to prevent fatigue on a strenuous walking trip, Freud looked forward to covering the same ground with his future wife. “You’ll be fed [gefüttert] with cocaine,” he wrote, “and will have to give me a kiss at every resting place.”⁶ Freud’s use of the verb for giving fodder to an animal hinted at an insecure and coercive approach to his beloved. She would have to surrender to his will, but cocaine would be needed to make it happen.

Such passages led Freud’s authorized biographer, Ernest Jones, to infer that the primary psychological function of cocaine for him in the 1880s had been an erotic one: “to achieve virility and enjoy the bliss of reunion with the beloved.”⁷ On that point the otherwise propagandistic Jones can be trusted, because he had studied many letters that still remain unpublished, and his observation was hardly flattering. Deficient heterosexual desire appears to have been Freud’s main worry as a prospective husband; he needed cocaine to convince himself that he was feeling ardent rather than fearful about his approaching conjugal obligation. Cocaine encouraged a febrile emphasis on breaking through sexual resistance, his own as well as Martha’s.⁸

In the months preceding Ernst Fleischl’s collapse from his addiction in June 1885, it was the cultivated Fleischl himself, in all-night, frenetic talk sessions, who rekindled the intellectual daring that Freud had felt as an undergraduate but had then tried to curb in his first career as an anatomist. Would it be possible, after all, to examine human nature without wearing the blinders required by scientific positivism? Fleischl seems to have played Mephistopheles to Freud’s Faust. And later, Freud would often think of himself as possessing the forbidden insight for which Faust—the imbiber of an elixir that also granted him sexual power—had been willing to trade his soul. “With all his intellectual gifts,” Freud would complain of his one-time mentor Josef Breuer, “there was nothing Faustian in his nature.”⁹ In Freud’s view that was a scientific deficiency—an unwillingness to penetrate beneath respectable illusions.

We know that Fleischl was injecting himself with both morphine and cocaine as Freud occasionally sat with him in passive fascination. Freud’s extant engagement letters never hint that he wanted Fleischl to stop using the cocaine that was igniting his mental fireworks. Whether Freud was sharing the drug during those vigils and, if so, by what means can only be conjectured. But thanks to Fleischl’s temporarily exhilarating influence and to his own solitary cocaine ingestion, Freud was beginning to feel that a choice was looming between directly intuitive, audacious knowledge and narrowly focused laboratory science. Returning from one of his nocturnal rendezvous with a suffering but voluble Fleischl, he wrote excitedly of “the intellectual elation, the stimulation and the clarifying of so many opinions,” and added, “This magic world of intellect and unhappiness contributes a great deal, of course, to my estrangement from my surroundings.”¹⁰ “Magic,” we may recall, was Freud’s favorite term for characterizing cocaine itself.

When, in the fall of 1885, Freud left for a five-month fellowship stay in Paris, he was already feeling dismissive toward his former professors and ready to make a break with their scientific premises. In one letter to Martha Bernays, moreover, he disclosed that he sensed within himself the makings of a defiant hero, one who would gladly endure martyrdom in the cause of Jewish freedom.¹¹ For the moment, however, he felt lonely, neglected, and socially awkward; and again, the remedy he chose for his depression was cocaine. Indeed, he had needed “a bit of cocaine,” he confided to Martha, just in order to become sufficiently talkative (geschwätzig) to share with her his fantasy of history-making valor. In view of the well-known touchiness and grandiosity of habitual cocaine users, it is hard to avoid the inference that the drug contributed to the subsequent prominence of the contentious, self-dramatizing, and persecution-minded side of Freud’s personality.

It isn’t surprising, given Freud’s unhappiness and his hunger for a new source of authority, that in Paris he became an immediate convert to the charismatic Jean-Martin Charcot’s controversial precepts on hysteria. We look in vain, in the known letters, for any indication that he was rationally weighing Charcot’s theory against others or considering the charges of self-deception and fraud that were then being raised against it. Freud had found a master from whom to extract vicarious power, and he had begun aspiring to become another Charcot in his own right. On his return to Vienna, although he was still quite inexperienced as a neurologist, he offended his elder colleagues by presumptuously lecturing them about the superiority of Charcot’s views to their own.

Already by 1886, then, Freud was displaying premature certainty, impatience with methodological safeguards, truculence, and a belief that he was destined for great things. Those weren’t traits that blossomed after he developed psychoanalysis and felt a need to defend it. They were the very engine of invention.

2.

Psychoanalysis was a quilt whose patches were assembled from such diverse sources as animal magnetism, Victorian sexology, materialist determinism, Romantic vitalism, reflex neurology, the Lamarckian doctrine of heredity, Charcot’s, Breuer’s, and Pierre Janet’s theories of trauma-induced hysteria, and Freud’s own curiosity about the origin of his psychological troubles. As we have known since the publication of Frank J. Sulloway’s Freud, Biologist of the Mind in 1979, however, the theory also took some of its impetus from the psychobiological notions of the Berlin surgeon Wilhelm Fliess, with whom Freud shared an intense friendship from 1892 until the end of the century.¹²

One of the strongest ties between Fliess and Freud was their shared admiration for cocaine, not as a drug to be directly ingested but as a topical medicine. Neither of them realized that cocaine crystals, when applied to the nose and thereby inadvertently inhaled, are more intoxicating than the dilute solutions that Freud had been swallowing in the 1880s. The resultant euphoria apparently spurred each of the two friends to imagine that the other, as well as himself, was a brilliant scientific pioneer.

In the 1884–1887 period Freud had been the world’s most influential cocaine evangelist until he was silenced, but never convinced, by outraged protest from other physicians. In the 1890s, thanks to a proliferation of worrisome symptoms, he enlisted Fliess as his doctor-at-a-distance; and what the doctor regularly prescribed, besides abstention from cigars, was cocaine. On Fliess’s counsel Freud brushed the laboratory-grade powder into his nostrils for the treatment of various ills, including the nasal swellings and suppurations whose obvious cause was cocaine itself. “I need a lot of cocaine,” confessed Freud to Fliess on June 12, 1895.¹³

Wilhelm Fliess has proved to be the most disconcerting of several skeletons in the psychoanalytic closet. He was a numerological crank, a perpetrator of unnecessary and grotesque surgeries, and a propagator of the ludicrous “nasal reflex neurosis”—whereby, for example, a malfunctioning of the stomach or the genitals could be causally linked to the nose and actually corrected by a nasal intervention. We have been assured that Freud, thanks to the self-analysis that disclosed his own and everybody else’s Oedipus complex, was able at last to dispense with Fliess and his embarrassing ideas. In 1898, however, nearly a year after Freud’s oedipal revelation, the infatuated psychologist dubbed his friend “the Kepler of biology.”¹⁴ And he was still citing Fliess’s astuteness in the “Dora” case history, written in 1901 and not published until 1905:

It is well known that gastric pains occur especially often in those who masturbate. According to a personal communication made to me by Wilhelm Fliess, it is precisely gastralgias of this character which can be interrupted by an application of cocaine to the “gastric spot” discovered by him in the nose, and which can be cured by the cauterization of the same spot.¹⁵

Freud, then, whose own afflicted nose was cauterized or surgically altered by Fliess at least twice, subscribed to the nasal reflex neurosis throughout the period when he was shaping his theory about the psychoneuroses. The two doctrines converged in the horrendous case of Freud’s patient Emma Eckstein, whose gastrointestinal symptoms he dubiously traced to hysteria and thence, apparently, to early masturbation. In 1895, at Freud’s urging, Fliess clumsily removed a bone from Eckstein’s nose, permanently disfiguring her.¹⁶ But it was Freud who characterized her later hemorrhaging not as a physiological event but as a love call, “an unfailing means of rearousing my affection.”¹⁷ Nothing in Fliess’s system of bizarre causes and effects was quite so regressive as that throwback to the psychosomatic medicine of antiquity and the Middle Ages.

Unlike William Halsted, who appears to have understood his sexual leaning and kept it apart from his work, Freud based psychological laws on peculiarities of his constitution that he could neither entirely disown nor accept without shame. After his friendship with Fliess ended, he privately characterized his feeling for the lost comrade as having been homosexual.¹⁸ Horror of his own resisted urgings, along with a wish to ascribe Fliess’s subsequent abandonment of him to mental illness, then shaped his ingenious but baseless etiology of paranoia as an unconscious strategy for disowning homosexual impulses. Precisely by virtue of recognizing such impulses in himself, he believed, he had managed to avoid becoming paranoid. But had he?

It could be argued that signs of incipient paranoia are already discernible in Freud’s engagement letters, including some that predate his introduction to cocaine.¹⁹ It was in the mid-1890s, however, when he was subordinating his judgment to Fliess’s and painting his nose with cocaine, that cognitive and behavioral changes of a more ominous kind appeared. That was when he manifested a fierce, unprovoked hatred of the formerly beloved Josef Breuer, who came to feel, regretfully, that Freud was no longer capable of thinking like a scientist.²⁰

In the same period, Freud began finding a paranoiac’s ciphered significance in telephone numbers and the numbers of hotel rooms, which supposedly prophesied when he would die. No less rashly, Freud and Fliess together applied Fliessian numerology to the timing of “male menstruation” and, retrospectively, to the predestined dates of other people’s birth, disease formation, and death. Such a folie à deux, flouting the scientific ethos, would have been unlikely without the irrational sense of conviction fostered in both partners by cocaine.²¹

3.

Ought we, however, to regard Freud as having succumbed to cocaine addiction?²² From the outset, as some of his loquacious and unguarded letters attest, he was often mildly intoxicated with the drug. But he typically calculated how much cocaine he required for a specific end, such as halting a migraine attack or refreshing his strength. That was not the conduct of an addict, who cannot stop taking his drug in excessive doses even when he knows he is being harmed by them.

No one in the immediate grip of cocaine could have written the impressive neurological tracts—notably on aphasia and cerebral palsy—that Freud was still publishing as late as 1897. They display a deft command of medical literature, of scientific reasoning, and of the conventions of collegial citation and measured disputation. Nor, for that matter, did Freud’s psychoanalytic prose ever suffer from the incoherence into which Halsted had briefly plunged. Cocaine was the early Freud’s means not of stupefying himself but of staving off hypochondria and getting ready for productive work, which he then performed with little or no impairment.

But that is not the whole story. The use of cocaine favored a certain manner of thinking—associative, self-confirming, visionary, and all-explanatory—that was inappropriate to the traditional practice of science and medicine but well suited to the original mode of inquiry that Freud increasingly favored. The fact that he could switch between those paradigms at will indicates that he was never cocaine’s abject slave. But from 1884 onward, he became increasingly convinced that he was fated to be a solitary hero. And his new theory, defying conventional authority, purporting to solve mysteries from which all previous investigators had shrunk, and aiming at a worldwide transvaluation of values, was the enactment of that fantasy.

Freud’s psychoanalytic inquiries put into play a deliberate lowering of his empirical guard: suspending skepticism, ignoring the judgments of his peers, and ascribing cryptic meaning to his own presumptive memories and to words tendentiously plucked from his clients’ rambling. If a metaphor or a suggestive pun came to his own mind, he would assume it had emanated from his patient’s unconscious and that it constituted evidence for whatever supposition he was favoring at the time. And still more self-indulgently, he believed that such insight gave him veridical access to the patient’s traumatic past. That was divination, not research, and it entailed the same erasure of commonsense boundaries that occurs in drug states.

Here, for example, is Freud telling Fliess what he gleaned from a patient’s language one day in January 1897, the birth year of the Oedipus complex:

Thus I was able to trace back, with certainty, a hysteria that developed in the context of a periodic mild depression to a seduction, which occurred for the first time at 11 months[,] and [I could] hear again the words that were exchanged between two adults at that time! It is as though it comes from a phonograph.²³

If the writer of this passage weren’t the esteemed Freud, we would assume that we were reading the words of a lunatic. Instead, we seem to be witnessing effects of the same euphoria that prompts a drug user, at bedtime, to scribble down the just-revealed meaning of life, only to awaken the next morning and find that his text is gibberish. As Freud wrote to Fliess regarding a premature attempt to chart a psychoanalytic neurology, “the barriers suddenly lifted, the veils dropped, and everything became transparent”; but five weeks later, “I no longer understand the state of mind in which I hatched the psychology;…to me it appears to have been a kind of madness.”²⁴

In the absence of any experimentation for testing his ideas, this process of soaring, crashing, and soaring again was the means by which Freud lurched toward his central dogma regarding the formation of psychoneuroses. Afterward, however, he was sure that he held the master key to an enormous range of phenomena: dreams, jokes, slips, myths, religion, works of art and literature, the stages of psychosexual development, the prehistory of the human species, the instincts coursing through us all, and finally the lineage and fate of an Egyptian prince named Moses. The possibility that he was wrong about such matters was of little concern to him. When scientific absurdities or mistakes of fact were pointed out, he would remain unmoved, because he had learned to trust the hunches that had outlasted his misgivings. He felt affectionate toward his most daring guesswork, and he had long since forgotten that self-satisfaction is not an epistemic advantage but a risk factor.

Psychoanalysis, then, was not the product of a cocaine addict, but it emerged from what we might call Freud’s cocaine self—the side of his personality for which “everything became transparent” in bursts of illumination, and for which a sense of personal destiny and intuitive rightness replaced the customs of scientific testing. He made an unequivocal commitment to that self with the publication, in November 1899, of The Interpretation of Dreams—a book that “proved” his intricate dream theory merely by illustrating it. Somewhere around that time, it would appear, the actual drug cocaine, having served its heuristic purpose but also having finally made its less pleasant effects plain to Freud, or perhaps to his alarmed wife, was set aside for good.²⁵

4.

In outline and in most of its details, the history I have surveyed was well known, but not at all welcome, to those bearers of Freud’s legacy who calculatingly shaped his image after his death in 1939 and the hiatus of World War II.²⁶ They wished us to perceive him as a noble and painstaking researcher, austere in his habits, lacking preconceptions, hesitant to draw conclusions, forbearing with his enemies, and, in Ernest Jones’s strangled phrase, “quite peculiarly monogamous.”²⁷ Public awareness that the actual Freud had taken cocaine during a dozen or more years would have gravely undermined that fiction. Indeed, it would have menaced the whole psychoanalytic enterprise, which had offered no backing for its core postulates beyond an assurance that the sober and circumspect Freud had found them to be true.

In corresponding privately with the psychoanalyst Siegfried Bernfeld and with Bernfeld’s wife in 1952, Jones estimated that Freud had used cocaine “on and off for 15 years.” “I am afraid that Freud took more cocaine than he should,” he confided, “though I am not mentioning that [in my biography].” And he noted the homoerotic passion of the Freud–Fliess relationship, judging it to have been entangled in “the symbolic use of Freud’s magic cocaine which meant a lot to both of them.”²⁸

Here Jones showed himself to be sufficiently detached and knowledgeable to have included in his book, if he had wished to, an account of the way cocaine had magnified Freud’s self-absorption, loosened his thought processes, and encouraged the turning of private obsessions into general laws. But Jones understood that his assignment, delegated by Anna Freud, was just the opposite: to weave a fable whereby the founding event of psychoanalysis in the 1890s, the discovery of the universal Oedipus complex, had been made possible by a blend of Freud’s pristine induction (the collecting of wholly unexpected data from the couch) and his insight into the childhood basis of his own nervous state.

Jones couldn’t altogether duck the topic of drugs. Freud’s published cocaine papers would be easy for inquisitive scholars to find, and his celebrated “Irma’s Injection” analysis in The Interpretation of Dreams contained the awkward and indelible admission, “I was making frequent use of cocaine at that time [1895] to reduce some troublesome nasal swellings.”²⁹ Thus the biographer faced the delicate task of acknowledging Freud’s having taken cocaine in both of the nineteenth century’s closing decades without arousing suspicion that this fact might have some bearing on the gestation of psychoanalysis.

Jones’s strategy of damage control hinged on characterizing the 1884–1887 “Cocaine Episode” (singular) as a youthful aberration, an encounter with a distracting aphrodisiac that had left no traces on the methodical scientist’s mode of thought.³⁰ He touched only glancingly on Fliess’s cocaine therapy for Freud’s ailments, making sure to saddle Fliess with all of the responsibility. And then, taking a big gamble, he granted that in the 1890s Freud had suffered from many debilities, amounting altogether to a “very considerable psychoneurosis” that was supposedly overcome through his descent into the psychic underground.³¹ “It was just in the years when the neurosis was at its height, 1897–1900,” wrote Jones, “that Freud did his most original work.”³²

Few of Freud’s quirks, however, had disappeared after his murky self-analysis in the later 1890s. As Jones knew, moreover, all of them were consistent with cocaine poisoning. He didn’t list them, but his readers could gather from scattered passages that they must have included heart palpitations, fainting spells, anxiety attacks, a deeper depression than usual, irrational fears, a travel phobia, morbid superstitions, belief in paranormal thought transference, “a twilight condition of mind,”³³ and the otherwise unaccountable fury toward Josef Breuer. And there were still other likely footprints of cocaine: unusually vivid dreams and fantasies, lurid sexual notions, secretiveness, solipsism, and grandiosity, not to mention that swollen and infected nose.

It defied credence that someone so burdened, relying largely on introspection and reaching his most important conclusions at the apex of his nervous crisis, had made and corroborated objective findings about the mind. Jones, however, benefited from two advantages that spared his narrative from collapsing. First, Freud’s heirs would see to it that most of the documents pertaining to his cocaine use—letters that Anna Freud had lent to Jones on the condition that he would submit his draft chapters to her for censorship—would be locked away for many decades. And second, postwar faith in “depth psychology” and its founder was on the rapid upswing. Thus the very implausibility of Freud’s breakthrough could be rhetorically exploited as a sign of his Herculean strength. As Jones had already gushed in an obituary essay, “How one man alone could have broken all this new ground, and overcome all difficulties unaided, must ever remain a cause for wonder. It was the nearest to a miracle that human means can compass….”³⁴

From a miracle drug to a near-miraculous “science”: that was Freud’s progress as an exponent of purported therapeutic marvels. At no point in either campaign did he place the safety and welfare of patients ahead of ambition. When cocaine was found to be tragically addictive for physicians and patients who had followed his thoughtless advice, he fought back desperately in 1887, bending the truth in order to exculpate himself. And when, after decades of claiming that psychoanalysis is the sovereign remedy for psychoneuroses, he allowed that he had “never been a therapeutic enthusiast,”³⁵ he didn’t apologize; by then his fame as the Columbus of the unconscious was secure.

Freud’s triumph in reaching that pinnacle without the aid of any confirmed discoveries or cures may be the most amazing chapter in the entire history of self-promotion. Neither Rousseau nor Nietzsche enjoyed such success in reconstituting the intellectual world to match his idiosyncrasies. But Freud’s own transformation was remarkable as well. Without cocaine, the polite and unhappy young doctor of April 1884 might never have become so reckless, so adamant, so sex preoccupied, and so convinced of his own importance that the contagion was caught by millions. Cocaine, along with nicotine, was Freud’s drug of choice—but in the century to come, the opiate of the educated classes would be psychoanalysis.

—This is the second of two articles.