Martha and Sigmund Freud with their four-year-old daughter, Anna, 1899. (photo credit 9.13)
Sigmund soldiered on, and by the late summer of 1899 he’d emerged with a manuscript of more than 250,000 words, the longest book he would ever write. It begins with a bold declarative statement:
In the pages that follow I shall bring forward proof that there is a psychological technique which makes it possible to interpret dreams and that, if that procedure is employed, every dream reveals itself as a psychical structure which has a meaning and which can be inserted at an assignable point in the mental activities of waking life. I shall further endeavor to elucidate the processes to which the strangeness and obscurity of dreams are due and to deduce from those processes the nature of the physical forces by whose concurrent or mutually opposing action dreams are generated.
Freud sent Fliess a set of proofs from some of the book’s early chapters in August 1899 and explained the volume’s organization:
The whole thing is laid out like the fantasy of a promenade. At the beginning, the dark forest of authors—who do not see the trees—hopelessly lost on the wrong tracks. Then a concealed pass through which I lead the reader—my specimen [model] dream with its peculiarities, details, indiscretions, bad jokes—and then suddenly the high ground and the view and the question: which way do you wish to go now?
Cradling a newly published copy of the book in November 1899, Sigmund proudly pronounced it to be his masterpiece. It is a tome leavened with rich metaphors and allusions to great artists ranging from Sophocles, Shakespeare, and Mozart to Goethe, Offenbach, and Heine. Months later, on March 11, 1900, Sigmund painted a slightly different picture of his great achievement for Fliess:
After last summer’s exhilaration, when in feverish activity I completed the dream [book], fool that I am, I was once again intoxicated with the hope that a step toward freedom and well-being had been taken. The reception of the book and the ensuing silence have again destroyed any budding relationship with my milieu. For the second iron in the fire is after all my work—the prospect of reaching an end somewhere, resolving many doubts, and then knowing what to think of the chances of my therapy. Prospects seemed most favorable in E’s case—and that is where I was dealt the heaviest blow. Just when I believed I had the solution in my grasp, it eluded me and I found myself forced to turn everything around and put it together anew, in the process of which I lost everything that until then had appeared plausible. I could not stand the depression that followed.
Despite Freud’s grand hopes, the first edition of The Interpretation of Dreams sold only 351 copies in its first six years of life, and a second edition did not appear until 1909. With hindsight, and the century of acclaim that followed, it is easier to see how transformative this book really was. After all, The Interpretation of Dreams was the first modern medical treatise to focus on the sleeping individual and, hence, the subconscious or unconscious mind, a striking contrast to virtually all other studies of the mind and brain during Freud’s era, which were based on the premise of “the active, rational subject” articulated by the leading thinkers of the Enlightenment. Indeed, the book is widely regarded as the touchstone of Freud’s psychoanalytical inquiry of human nature. The Oedipus complex; the notion that neuroses are caused not necessarily by actual events but, rather, by fantasies or inner wishes that are unacceptable to the individual; the importance of free association; and wish fulfillment are all articulated on its pages.
Seven months after the book’s publication, in June 1900, the author whimsically asked Fliess about the Belle Vue Castle, a spa hotel on the outskirts of Vienna where he had the “model dream” that figures so prominently in his book: “Do you think that one day there will be a marble tablet on this house saying: Here, on July 24, 1895, the secret of the dream revealed itself to Dr. Sigmund Freud?” Although Freud immediately rejected such a fate in the next line of this letter to Fliess, the “model dream” is today widely known as “Irma’s Injection.” It was based on a series of all-too-real therapeutic mishaps involving cocaine use on a patient named Emma Eckstein and exacerbated by the fact that before finally getting to bed the night he had this now famous dream, Freud had helped himself to a hefty dose of cocaine.
EMMA ECKSTEIN WAS AN ATTRACTIVE young woman who began consulting Dr. Freud in 1892. Immortalizing her as “Irma” in his book, Sigmund presents a somewhat disingenuous explanation of his late-night reverie concerning cocaine and his patient:
I was making frequent use of cocaine at that time to reduce some troublesome nasal swellings, and I had heard a few days earlier that one of my women patients who had followed my example had developed an extensive necrosis of the nasal mucous membrane. I had been the first to recommend the use of cocaine in 1885, and this recommendation had brought serious repercussions down on me. The misuse of that drug had hastened the death of a dear friend of mine. This had been before 1895 [the date of the dream].
The Belle Vue Castle, outside Vienna, where Freud had his model dream about Emma Eckstein and cocaine in July 1895. (photo credit 9.14)
In the dream, a disguised Irma meets Freud at a party hall filled with well-dressed and distinguished guests. She approaches him and complains, in the presence of others, that he had failed to cure her of her ailments and, in fact, had worsened them. Descriptions of scabrous turbinate bones, blood, dirty syringes, injections with a series of agents, including trimethylamine (the organic compound that gives decomposing semen its distinctly fishy smell, a fact recently introduced to Freud by Fliess), infection, and botched surgery abound in this dream.
Upon awakening, Freud was overcome with the unsettling thought that his dream meant he did not take his medical duties seriously enough. After further scrutiny of the fantasy, however, he concluded that
this group of thoughts seemed to have put itself at my disposal, so I could produce evidence of how highly conscientious I was, of how deeply I was concerned about the health of my relations, my friends and my patients. There was an unmistakable connection between this more extensive group of thoughts which underlay the dream and the narrower subject of the dream which gave rise to the wish to be innocent of Irma’s illness.
When contrasting his interpretation with the actual events that inspired it, one must be prepared to take a deep breath and recall that Sigmund was all too human. Indeed, the dream versus the actual lifeevents story serves as an ironic proof of one of Sigmund’s major tenets: “When the work of interpretation is completed we perceive that a dream is the fulfillment of a wish.”
BEFORE SIGMUND EVER DREAMED about “Irma,” he was weary from too many days spent listening to Emma’s litany of psychosomatic symptoms and too many late nights puzzling out what her thoughts and complaints actually meant. Stumped by the root causes of her psychological malaise and her relentless digestive complaints, Sigmund worried that he might have overlooked some physical problem in Emma’s tortured body. It was also at this time that he was experiencing severe chest pain and worrying about succumbing to a heart attack. Like many a perplexed doctor before and since, he asked a surgeon to search for something that might be removed, amputated, or remodeled in the cause of a cure. The surgeon called into consultation was Freud’s good friend and fellow cocaine aficionado Dr. Wilhelm Fliess.
Emma Eckstein of the “Irma dream” at the age of thirty, in 1895. (photo credit 9.15)
There’s an old saying one hears in hospital corridors among those who are disinclined to labor in the operating room: Don’t call up a surgeon unless you want an operation. In many cases, specific and sometimes not so specific symptom patterns suggest that an operation is precisely what is called for. Yet there is also the tendency among the less scrupulous, the ill informed, and the simply overeager to perform unnecessary surgical procedures. In these two cases, it turned out to be the last. Considering that Fliess was the surgeon of record, it is not surprising that he diagnosed Sigmund’s cardiac pain and Emma’s hysteria as being due to a malfunction of the nose requiring su
rgical manipulation of the nasal turbinates, accompanied by copious applications of cocaine to the surgical wounds.
Dr. Fliess traveled from Berlin to Vienna in late January or early February of 1895 and operated on both Freud’s and Emma’s noses. Upon leaving Vienna the following day, the surgeon assigned Freud the task of caring for Emma during her postoperative recuperation period. On March 4, 1895, Freud told Fliess that her nasal swelling was persistent, “going up and down like an avalanche.” Worse, Emma complained of excruciating pain and suffered massive nosebleeds. At one point, a sneeze yielded a jagged bone chip the size of small coin, no doubt a souvenir from Fliess’s recent and ill-conceived surgical expedition. Moreover, Emma’s nostrils were loaded with hardened scabs and pools of thick pus that emitted a powerful stench immediately detectable upon entering her bedroom.
On March 8, Sigmund wrote Fliess that Emma was improving somewhat but added that he had to report something that “will probably upset you as much as it did me.” Freud was urgently called to Emma’s bedside because she was bleeding uncontrollably from her nose. One of Freud’s colleagues, a highly regarded surgical man named Robert Gersuny, had inserted a drainage tube a few days earlier, hoping to clean the infection out of her nose, but was unavailable to take the emergency call until later that evening. Consequently, Freud contacted another ear, nose, and throat man, Ignaz Rosanes, who came to Emma’s home at noon to look at her incisions and persistent bleeding from the nose and mouth. At Freud’s direction, Rosanes began removing a series of sticky blood clots until his probe came upon a fetid, tangled, threadlike structure that demanded a delicate tug-of-war.
Freud’s recollections of these events are absolutely disgusting:
Before either of us had time to think, at least half a meter of gauze had been removed from the cavity. The next moment came a flood of blood. The patient turned white, her eyes bulged, and she had no pulse. Immediately thereafter, however, he again packed the cavity with fresh iodoform gauze and the hemorrhage stopped. It lasted about a half a minute, but this was enough to make the poor creature, whom by then we had lying flat, unrecognizable. In the meantime—that is, afterward,—something else happened. At the moment the foreign body came out and everything became clear to me—and I immediately afterward was confronted by the sight of the patient—I felt sick.
Sigmund and Rosanes restored themselves with a glass of cognac and stayed with the patient until they could have her removed to a sanatorium. In the weeks that followed, Freud grew mortified by the knowledge that his best friend had committed one of the worst surgical errors in the book: Fliess had nicked an artery and left a piece of gauze, a sponge really, inside Emma’s surgical incision that had nearly killed her with inflammation, infection, and blood loss. Fortunately, the physically, if not mentally, strapping Emma recuperated, even though the surgical faux pas left her face permanently disfigured. After the bloody event but while still convalescing in bed, Emma admonished a woozy and pale Sigmund with the cutting remark “So this is the strong sex.”
The episode was so troubling to Sigmund that he dreamed about it, ruminated over it, and even attempted to cover it up. He had little choice but to adopt such a course. Acknowledging and then revealing the role cocaine had played in his poor medical judgment with Emma would have resulted in professional ruin. To avoid this fate, Sigmund performed a series of mental calisthenics as he obscured responsibility for the fiasco. He reassured Fliess on March 28 that he was hardly to blame, having had to travel to a foreign city to conduct a complex operation, and further noted that the “tearing off of the iodoform gauze remains one of those accidents that happens to the most fortunate and circumspect of surgeons.” Sigmund also informed Fliess of Emma’s steady improvement, adding that “she is a very nice, decent girl who does not hold the affair against either of us and refers to you with great respect.” In retrospect, such agile attempts at burying his malpractice appear to be a superb example of denial—later described to perfection by Freud as a defense mechanism.
On April 20, Freud wrote Fliess about a subsequent hemorrhage during the first week of April, but now Emma finally appeared to be on the mend. It is perhaps more indicative of the emotional toll the mishap was taking that Sigmund also reported that he was suffering from a “horrible attack of sinusitis” demanding copious cocaine applications. A week later, on April 26, he noted that Emma, “my tormentor and yours, now appears to be doing well” but confessed to another round of self-medication with cocaine. He also wondered if Fliess might have to perform another cauterization procedure on him. Apparently not: the following day Freud wrote, “Since the last cocainization three circumstances have continued to coincide: 1) I feel well; 2) I am discharging ample amounts of pus; 3) I am feeling very well.” A week later, on May 4, the ever-rationalizing Sigmund speculated that Emma welcomed the bleeding spells as “an unfailing means of rearousing my affection.”
At some level, one wonders if the personality that is open to trying mind-altering drugs is more likely to be open to exploring mind-altering ideas. And do such ideas actually emerge when one is under the influence? In terms of the last question, most intellectual historians, not to mention a majority of addiction scientists, psychiatrists, and neurologists, would heatedly answer no. There may well have been a spark of cocaine in Sigmund’s misfiring neurons as they disturbed his sleep with the Irma affair. Yet as tempting as it is to singularly ascribe all of Sigmund’s revolutionary ideas about dreams and exploring the unconscious to his cocaine use, this tack ultimately constitutes a simplistic and unsatisfying explanation. The Interpretation of Dreams covers a skein of thoughts and ideas beyond those set in motion by the Irma episode. Freud’s psychological constitution was marked by multiple compulsions, perfectionism, risk taking, resentments, loneliness, alienation, emotional pain, traumatic family experiences, phobias, neuroses, depression, denials and secretiveness about his sexuality, a possible sexual relationship with his sister-in-law, a brief flirtation with excessive drinking, and his self-documented cocaine abuse, to name some of his demons. What makes Sigmund Freud’s life and work so remarkable is that instead of sinking under the weight of these psychic challenges, he was able to process them all through his formidable intellect and thereby create a means for exploring the depths of the mind.
On November 2, 1896, several months after Emma’s botched surgery and about a year before he began working on his dream book in earnest, Freud wrote a now famous letter to Fliess about the funeral of his beloved father. A father’s death, he would observe in the preface to the second edition of The Interpretation of Dreams, is “the most important event, the most poignant loss, of a man’s life.” On the night following Jacob’s funeral, the grieving Freud told Fliess, he had experienced a “nice dream” in which he saw a sign outside his favorite barbershop that declared, “You are requested to close the eyes.” Freud interpreted this as a reflection of his filial duty and “the inclination to self-reproach that regularly sets in among the survivors.” Distraught by his loss and neuroses, Freud soon after embarked on what he was to call “the most essential thing I have at present”: his now famous self-analysis and, of course, the composition of his book.
The Freud family at the unveiling of Jacob Freud’s grave site, c. 1896–97. (photo credit 9.16)
Less heralded by Freud scholars is a letter he wrote to Fliess only a few days earlier, on October 26, a day after returning from the cemetery. It is the last extant letter in which he documents his cocaine abuse: “Next time I shall write more and in greater detail; incidentally, the cocaine brush has been completely put aside.” Many Freudians have concluded that Sigmund was the rara avis of chronic cocaine abusers in that he meant what he said when he pledged a future of abstinence. Alas, the paper trail ends there.
Emma, too, disappears as a topic in the Freud-Fliess correspondence by the spring of 1896. One assumes that Freud’s clinical experiences with Emma, if not with Fleischl-Marxow, taught him that cocaine was far too dangerous for any therapeu
tic application. But in 1896, and probably for the remaining days of his life, Freud had far greater difficulty in fully comprehending the realities of his own substance abuse. He decidedly and repeatedly misinterpreted his famous dream of cocaine. Instead, he chose to elaborate a far more flattering and positive analysis that epitomizes an addiction’s power of subterfuge. The man who invented psychoanalysis, a revolutionary pursuit of self-truth, succumbed to the same “big lie” most every practicing addict tells himself.
CHAPTER 10
“The Professor”
THE OPERATING ROOM was pristine and hushed. The tiled floor was spotless and sparkling. The light from the overhead electric lamps gleamed onto the table directly below. Supervising nurses wearing overflowing robes and gauze face masks scurried about making sure every instrument and suture was laid out just so. The patient, still awake and baffled by the strange dance taking place around him, waited nervously while lying perfectly still on the operating table. The muscular resident surgeons held their hands upward, scrubbed and dripping with corrosive antiseptic chemicals, as a harem of student nurses attentively gowned and gloved them.
In strode Professor William Halsted. He rarely spoke to his underlings other than to demand a scalpel or a forceps. If he did venture a comment, it was to criticize a junior surgeon’s handiwork or scold an assisting nurse for not anticipating his next move. Decades later, a colleague recalled that Halsted was so “bitingly sarcastic as to completely shrivel those with him at the operating table.” He refused to move his body from the operative field to allow interns even one educational peek. This was his theater, his room. In it no one could approach or challenge him. No surgical complication or mishap could distract or distress him. He was in complete control.
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