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  Transcriber’s Note:

  The name Freund at page 8, which is likely to be a reference to Freud,
  has been corrected accordingly.

  The erroneous Roman number vli in footnote 15 is corrected to be vii
  just as a guess.
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  THE INTERNATIONAL PSYCHO-ANALYTICAL LIBRARY

  EDITED BY ERNEST JONES

  NO. 2




  PSYCHO-ANALYSIS

  AND THE

  WAR NEUROSES

  by

  Drs. S. FERENCZI (Budapest), KARL ABRAHAM (Berlin),
  ERNST SIMMEL (Berlin) and ERNEST JONES (London)

  Introduction by
  Prof. SIGM. FREUD (Vienna)

  [Illustration]

  THE INTERNATIONAL PSYCHO-ANALYTICAL PRESS
  LONDON    VIENNA    NEW YORK

  1921

  Copyright, 1921

  C. Fromme, Printer, Vienna




CONTENTS


  PAGE

    I. Introduction by Prof. Sigm. Freud                             1

   II. Symposium held at the Fifth International Psycho-Analytical
      Congress at Budapest, September 1918:

        1. Dr. S. Ferenczi                                           5

        2. Dr. Karl Abraham                                         22

        3. Dr. Ernst Simmel                                         30

  III. War Shock and Freud’s Theory of the Neuroses, by Dr.
       Ernest Jones                                                 44




I.

INTRODUCTION

BY PROFESSOR SIGM. FREUD, Vienna.


This little book on the War Neuroses, with which the Verlag opens the
“Internationale psychoanalytische Bibliothek”, deals with a subject
which until lately engaged the greatest current interest. When the
subject came up for discussion at the Fifth Psycho-Analytical Congress
at Budapest (September, 1918), official representatives of the Central
European Powers were present to obtain information from the lectures
and discussions. The hopeful result of this first meeting was the
promise that psycho-analytical institutions should be established,
where medical men qualified in analysis might find the means and time
to study the nature of these puzzling illnesses and the therapeutic
value of psycho-analysis in them. However, before these results could
be achieved the war came to an end, the government organisations broke
down, and interest in war neuroses gave place to other concerns. At
the same time, significantly enough, most of the neurotic diseases
which had been brought about by the war disappeared on the cessation
of the war conditions. The opportunity, therefore, for a thorough
investigation of these affections was unfortunately missed. However,
one must add, it is to be hoped that it will be a very long time
before such an opportunity again occurs. This episode, now a thing
of the past, has not been without importance for the spread of the
knowledge of psycho-analysis. Many medical men, who had previously held
themselves aloof from psycho-analysis, have been brought into close
touch with its theories through their service with the army compelling
them to deal with the question of the war neuroses. The reader can
easily gather from Ferenczi’s contribution to the subject with what
hesitation and misgivings this advance was made. Some of the factors,
such as the psycho-genetic origin of the symptoms, the significance
of unconscious impulses, and the part that the primary advantage of
being ill plays in the adjusting psychical conflicts (“flight into
disease”), all of which had long before been discovered and described
as operating in the neuroses of peace time, were found also in the
war neuroses and almost generally accepted. The work of E. Simmel has
shown what results may be obtained if the war neurotic is treated by
the cathartic method, which, as is well known, was the first stage of
the psycho-analytic technique.

From the advance thus made towards psycho-analysis, however, one
need not assume that the opposition to it has been reconciled or
neutralised. One might think that when a man, who had hitherto not
accepted any of a number of connected conclusions, suddenly finds
himself in the position of being convinced of the truth of a part
of them, he would weaken in his opposition and adopt an attitude of
respectful attention, lest the other part, of which he has no personal
experience, and therefore upon which he is unable to form a personal
opinion, should also prove to be correct.

This other part of the psycho-analytical theory which is not touched
upon in the study of the war neuroses is that the driving forces which
find expression in the formation of symptoms are sexual in nature, and
that the neurosis is the result of the conflict between the ego and the
sexual impulses which it has repudiated. The term “sexuality” is to be
taken here in the broader sense customary in psycho-analysis, and not
to be confused with the narrower sense of “genitality”. Now it is quite
correct, as Ernest Jones points out in his contribution, that this part
of the theory has not hitherto been demonstrated in relation to the
war neuroses. The work which could prove this part has not yet been
carried out. It may be that the war neuroses are unsuitable material
for this proof. However, the opponents of psycho-analysis, whose
repugnance to sexuality has shown itself to be stronger than their
logic, have hastened to proclaim that investigation of the war neuroses
has finally disproved this part of the psycho-analytical theory. In
this pronouncement they have been guilty of a slight confusion. If
the—up to the present superficial—investigation of war neuroses has not
shown that the sexual theory of the neuroses is correct, that is quite
another matter from showing that this theory is incorrect.

With an impartial attitude and some willingness it should not be
difficult to find the way to further elucidation.

The war neuroses, in so far as they differ from the ordinary neuroses
of peace time through particular peculiarities, are to be regarded
as traumatic neuroses, whose existence has been rendered possible or
promoted through an ego-conflict. In Abraham’s contribution there
are plain indications of this ego-conflict; the English and American
authors whom Jones quotes have also recognised it. The conflict takes
place between the old ego of peace time and the new war-ego of the
soldier, and it becomes acute as soon as the peace-ego is faced with
the danger of being killed through the risky undertakings of his newly
formed parasitical double. Or one might put it, the old ego protects
itself from the danger to life by flight into the traumatic neurosis in
defending itself against the new ego which it recognises as threatening
its life. The National Army was therefore the condition, and fruitful
soil, for the appearance of war neuroses; they could not occur in
professional soldiers, or mercenaries.

The other feature of the war neurosis is that it is a traumatic
neurosis, such as is well known to occur in peace time after fright or
severe accidents, without any reference to an ego-conflict.

The theory of the sexual aetiology of the neuroses, or as we prefer to
call it, the sexual hunger (libido) theory, was originally put forward
only as regards the transference neuroses of peace conditions, and can
be easily demonstrated in them by using the analytic technique. But
its application to those other affections, which more recently we have
grouped together as the narcissistic neuroses, meets with difficulties.
Ordinary cases of Dementia praecox, Paranoia and Melancholia are
fundamentally very unsuitable material for the proof of the sexual
hunger (libido) theory and for reaching an understanding of it, for
which reason psychiatrists, who neglect the transference neuroses
cannot be reconciled to it. The traumatic neuroses (of peace time) have
always been reckoned to be the most refractory in this respect, so that
the appearance of the war neuroses does not add any fresh factor to the
former situation.

Only by advancing and making use of the idea of a “narcissistic sexual
hunger (libido)”, that is to say, a mass of sexual energy that attaches
itself to the ego and satisfies itself with this as otherwise it
does only with an object, has it been possible to extend the sexual
hunger (libido) theory to the narcissistic neuroses, and this entirely
legitimate development of the concept of sexuality bids fair to do for
these severer neuroses and for the psychoses all that one can expect
from an empirically and tentatively progressing theory. The traumatic
neurosis of peace time will also fit into this group when researches
into the correlation undoubtedly subsisting between shock, anxiety, and
narcissistic sexual hunger (libido) have reached success.

If the traumatic and war neuroses emphasise the influence of the danger
to life and not at all, or not clearly enough, that of the “denial of
love”, on the other hand the aetiological claim of the former factor
appearing there so powerfully, is lacking in the usual transference
neuroses of peace time. Indeed it is vulgarly supposed that these
latter sufferings are only promoted by indulgence, high-living and
ease, which provide an interesting contrast to the conditions of life
under which the war neuroses break out. If psycho-analysts, who find
their patients have become ill through the “denial of love”, through
the ungratified demands of the sexual hunger (libido), were to follow
the example of their opponents, they would maintain that either there
are no danger neuroses, or that the affections following on terror
are not neuroses. This has naturally never crossed their minds. On
the contrary, they see the convenient possibility of combining in one
conception the two apparently divergent sets of facts. In the traumatic
and war neuroses the ego of the individual protects itself from a
danger that either threatens it from without, or is embodied in a form
of the ego itself, in the transference neuroses of peace time the ego
regards its own sexual hunger (libido) as a foe, the demands of which
appear threatening to it. In both cases the ego fears an injury; in
the one case through the sexual hunger (libido) and in the other from
outside forces. One might even say that in the case of the war neuroses
the thing feared, is after all an inner foe, in distinction from the
pure traumatic neuroses and approximating to the transference neuroses.
The theoretical difficulties which stand in the way of such a unifying
conception do not appear to be insurmountable; one can with full right
designate the repression which underlies every neurosis, as a reaction
to a trauma, as an elementary traumatic neurosis.

Spring 1919.




II.

SYMPOSIUM

HELD AT THE FIFTH INTERNATIONAL PSYCHO-ANALYTICAL CONGRESS BUDAPEST,
SEPTEMBER 1918

1. DR. S. FERENCZI, Budapest.


  _Ladies and Gentlemen_,

With your permission I will commence my exposition of the very serious
and important subject that is the theme of my lecture to-day with
the recital of a little story which will lead us straightway into
the revolutionising events of this war. A Hungarian, who had the
opportunity of observing at close quarters a part of the revolutionary
upheaval in Russia, told me that the new revolutionary rulers of a
Russian town found with consternation that the change from the old to
the new regime had not taken place as rapidly as it should have done
according to their doctrinal calculations. According to the teachings
of the materialistic idea of history they could have set up the new
social order immediately after they had got the entire power into their
hands. Instead of this, irresponsible elements, which were antagonistic
to any new order of things, obtained the upper hand, so that the power
gradually slipped from the hands of the originators of the revolution.
Then the leaders of the movement put their heads together in order to
find out what had gone wrong in their calculations. Finally they agreed
that perhaps the materialistic idea was after all too one-sided, as it
only took into consideration the economic and commercial relations,
and had forgotten to take into account one small matter, the feelings
and thoughts of man, in a word, the psyche. They were sufficiently
consistent to send emissaries immediately to German speaking countries,
in order to obtain psychological works, so that they might get at least
subsequently some knowledge of this neglected science. Many thousands
of human lives fell victims, perhaps to no purpose, to this omission
of the revolutionaries; the failure of their efforts resulted in their
making one discovery however, namely, that of the mind.

A somewhat similar thing has occurred among neurologists during
the war. The war has produced an enormous number of nervous
disorders which call for elucidation and cure; however, the
familiar organic-mechanistic explanation hitherto adopted—which
in some way corresponds to the materialistic idea of history in
sociology—completely failed. The mass-experiment of the war has
produced various severe neuroses, including those in which there could
be no question of a mechanical influence, and the neurologists have
likewise been forced to recognise that something was missing in their
calculations, and this something was again—the psyche.

To some extent we can forgive sociology for this omission; indeed
the estimation of mental elements in the science of society has
hitherto been in fact a very trifling one. However, we cannot spare
neurologists the reproach of having so long disregarded the pioneer
researches of Breuer and Freud concerning the psychical determination
of many nervous disturbances, and of having required the terrible
experiences of the war to set them right in this respect. And yet a
science—psycho-analysis—has existed for more than twenty years to which
many investigators had devoted the whole of their efforts, and which
had helped us to unexpected and important knowledge of the mechanisms
of mental life and its disturbances.

In my lecture today I shall confine myself to demonstrating the
introduction of psycho-analysis into modern neurology, an introduction
which has been effected to some small extent openly, but for the
most part with hesitation and under false colours, and I will
briefly communicate the theoretical principles upon which rest the
psycho-analytical conceptions of the “traumatic neuroses” which have
been observed during the war[1].

Soon after the outbreak of the war there flamed up again the great
controversy, which had been carried on for more than ten years,
concerning the nature of the traumatic neuroses which Oppenheim had in
his time placed in a class by themselves. Oppenheim hastened to make
use of the experiences of the war, which exposed so many thousands of
men to sudden shocks, as supporting his old views, according to which
the phenomena of these neuroses always came about, as the result of
physical alterations in the nervous centres, (or in the peripheral
nerves which secondarily affect those of the centre). The nature of
the shock itself and its influence upon the method of functioning
he described in very general, one might even say, phantastic terms.
Links were “cut out” from the chain of the innervation mechanism,
most delicate elements “displaced”, paths “blocked”, connections torn
asunder, obstacles to conduction created, etc. With these and similar
comparisons, from which, however, all basis in fact was tacking,
Oppenheim sketched an impressive picture of the material correlation of
the traumatic neuroses.

The alterations in structure which would take place in the brain
through the trauma Oppenheim conceived as a delicate physical process
similar to that which occurs in the iron filing when it comes into
contact with the magnet.

The sarcastic Gaupp designates such specious physical and physiological
speculations as brain mythology and molecular mythology. But in our
opinion he does mythology an injustice.

The material brought forward by Oppenheim to support his views was
in no way suited to uphold his abstruse theories. To be sure, he
described with his usual precision characteristic symptoms, which this
war has produced in deplorable numbers, and also gave to them somewhat
high-sounding names (Akinesia amnestica, Myotonoklonia trepidans) that
said nothing as to their nature; these descriptions, however, are not
especially convincing with reference to his theoretical conceptions[2].

There were, it is true, many who agreed with Oppenheim’s views, though
for the most part with limitations. Goldscheider holds that the cause
of these nervous symptoms is partly physical and partly psychical;
Cassierer, Schuster and Birnbaum are of the same opinion. Wollenberg’s
question, as to whether the war neuroses were caused through emotion
or shock, Aschaffenburg answered by stating that there was here
concerned the joint effect of emotion and concussion. As one of the few
who obstinately persisted in maintaining the mechanistic idea I will
mention Lilienstein, who categorically demanded that the word and the
concept of “mind”, also that of “functional” and “psychic”, and more
especially that of “psycho-genesis” should be struck out of the medical
terminology; he maintained that this would simplify the conflict
and facilitate the investigation, treatment and examination of the
casualties; the progressive anatomical technique would certainly sooner
or later discover the material foundations of the neuroses.

We must here refer to the train of thought pursued by V. Sarbó,
who seeks for the cause of the war neuroses in the microscopical
destruction of tissue and hemorrhages in the central organ of the
nervous system; these, he says, originate through direct concussion,
sudden pressure of the cerebro-spinal fluid, compression of the spinal
cord in the foramen magnum, etc. V. Sarbó’s theory is only supported
by a few authors. In this connection I might mention Sachs and Freud,
who consider that the shock puts the nerve cells into a condition
of heightened excitability and exhaustability, which is then the
immediate cause of the neuroses. Finally, Bauer and Fauser look upon
the traumatic neuroses as the nervous results of disturbances of the
endocrine glands produced by the shock, and as similar therefore to the
post-traumatic Basedow’s disease.

Strümpell was one of the first to oppose the purely organic-mechanistic
idea of the war neuroses. He had, moreover, for some time previously
referred to certain psychical factors in the causation of the traumatic
neuroses. He made the accurate observation that in railway accidents,
etc., those who suffered from a severe neurosis were for the most
part those who had an _interest_ in being able to prove an injury as
caused by the trauma: for example, persons who were insured against
accidents and wished to obtain a large sum of money, or those who
instituted proceedings against the railway company for compensation
for injury. Similar or much more severe shocks have, however, no
lasting nervous results if the accident happens during sport through
one’s own carelessness, especially under circumstances that exclude
the hope of compensation for injury as those mentioned, so that the
patient has no interest in remaining ill, but every interest in the
speediest recovery. Strümpell asserts that the shock neuroses always
develop secondarily and purely psycho-genetically as the result of
desire of gain; he gave medical men the well-meant advice not to
take seriously the complaints of these patients, like Oppenheim,
but to bring them back as soon as possible to life and work through
the smallest allowance or through withdrawal of their pension. The
representations of Strümpell created a great impression in the medical
world even in peace time; they led to the idea of the “compensation
hysteria”; the sufferers, however, were treated not much better than
if they were malingerers. Strümpell now suggests that the war neuroses
are also neuroses of covetousness, which serve the patients’ purpose in
getting free from the military authorities with the highest possible
pension. Accordingly he demands a strict examination and expert opinion
of the neuroses occurring in military persons. The content of the
pathogenic ideas is always a wish—the wish for material compensation,
for remaining far from infections and danger—and this wish acts
along auto-suggestive paths in fixing more firmly the symptoms, the
persistence of morbid sensations and of innervation disturbances of
motility.

Much of the foregoing train of thought of Strümpell sounds to the
analyst very probable. For he knows from his analytical experience that
neurotic symptoms in general represent wish fulfilments, and also the
fixation of unpleasant mental impressions and their pathogenic state
is familiar to him. Still he has to reproach the one-sidedness of
Strümpell’s train of thought: for instance, in the undue prominence of
the cognitive aspect of the pathogenic experience and the neglect of
its affective side, as well as the complete ignoring of the unconscious
psychical processes, with which already Kurt Singer, Schuster and
Gaupp had reproached him. Strümpell also has a presentiment that these
neurotic forms of illness can only be explained by means of a psychical
investigation; he does not, however, tell us his method of work with
reference to this. Probably he understands by psychical exploration
simply a careful questioning of the patient as to his material
circumstances and concerning his motives for seeking a pension. We must
on the other hand protect ourselves in that he calls this exploration
“a method of individual psycho-analysis”. There is only one procedure
that has a right to this name, that which the strict method of
psycho-analysis has made its own.

As an argument in favour of the psycho-genesis of the war neuroses it
is a remarkable fact, which has been pointed out by Mörchen, Bonhöffer
and others, that the traumatic neuroses are practically never seen in
prisoners of war. The prisoners of war have no interest in remaining
sick after being captured, and they cannot reckon on compensation,
pension and sympathy from their surroundings while they are away from
home. They feel themselves in their captivity secure for the time
being from the dangers of the war. The theory of the mechanistic shock
can never explain to us this difference in the behaviour of our own
soldiers and prisoners of war.

Evidence as regards the psycho-genesis rapidly accumulated. Schuster
and many other observers refer to the disproportion between the trauma
and its results on the nervous system. Severe neuroses arise from
minimal shocks, while it is just the severe wounds accompanied by great
shock that for the most part are not followed by nervous disturbances.
Kurt Singer lays still greater stress on the disproportion between
trauma and neurosis, and even endeavours to explain this fact
psychologically: “In the kind of psychic trauma that comes on in a
flash, in the terror, in the paralysing horror, we are concerned with
cases of difficulty or impossibility of adaptation to the stimulus”.
In a severe wound there is a discharge of the suddenly increased
tension without anything further; when, however, no severe external
injury exists the excessive affect is discharged “by means of a sudden
abreaction through physical phenomena”. As the Freudian expression
“abreaction” shows, psycho-analysis must have been in the mind of
the writer when he thought out this theory. The expression sounds
like a delayed response to the Breuer-Freudian conversion theory.
However, it soon appears that Singer represents this process far too
rationalistically; he looks upon the symptoms of the traumatic neuroses
as the result of an effort on the part of the patient to find a
comprehensible explanation of the (to him) inexplicable morbid process.
Thus the work of this author is still far removed from the dynamic
conception of the psychical processes of which psycho-analysis has
taught us.

Hauptmann, Schmidt and others drew attention to the relation in time
in the development of the symptoms in the war neuroses. If it is a
question of a mechanical injury then the effect should be strongest
immediately after the operation of the force. Instead of which one
finds that the men thrown into a state of shock still make purposive
endeavours to arrange for their safety the moment after the trauma,
such as to get to the dressing station, etc., and only after having
put themselves under safe conditions do they collapse and the symptoms
develop. In some cases the symptoms appear only when the men have to
return to the firing line after a period of rest. Schmidt is quite
right when he refers this conduct of the patients to the psychical
factors; he suggests that the neurotic symptoms develop only after the
state of a transitory disturbance of consciousness has disappeared
and the men who have suffered the shock re-experience in memory the
dangerous situation. We would say: These injured men behave like the
mother who rescues her child from a danger which threatens its life
with calm imperturbability and disregard of death, but faints after the
act has been accomplished. It is immaterial as regards the judgment
of the psychological situation that here the person saved was not a
beloved stranger, but the beloved person himself.

I place Nonne in the forefront of those authors who have laid
particular stress on the psycho-genesis of the traumatic neuroses of
the war. Not only because he recognised that the symptoms of the war
shock neuroses were without exception hysterical, but because he was
also able to cause the severest war neurotic symptoms to disappear for
a time or to recall them by hypnotic and suggestive measures. This
excluded the possibility even of a “molecular” disturbance in the
nerve tissues; a disturbance that can be set right by means of psychic
influences can itself have been nothing else than psychical.

This therapeutic argument had the greatest effect; by degrees a marked
silence fell over the mechanistic school, and attempts were frequently
made to explain their former utterances psycho-genetically. The quarrel
from now onwards lay entirely between the supporters of the various
psychological theories.

How is one to explain the method of working of psychical factors, and
also the fact of the psychogenic condition being more severe than the
impressive forms of disorders of organic origin?

One is reminded of the old theory of Charcot, that terror and the
memory of it can produce in a similar manner physical symptoms
after the nature of hypnosis and auto-hypnosis, just as they are
intentionally brought about by the post-hypnotic command of the
hypnotist.

This reverting to Charcot means nothing less than paving the way to
fruitless speculations and the re-discovery of the sources from which
finally psycho-analysis sprang; for we know that the first researches
of Breuer and Freud into the psychical mechanisms of hysterical
phenomena originated directly from the influence of Charcot’s clinical
and experimental experiences. Hysterics suffer from reminiscences:
this, the primary axiom of the germinating psycho-analysis, is really
the continuation, deepening, and generalisation of the ideas of Charcot
applied to the neuroses of shock; the idea of the lasting effect of a
sudden affect and of the association of certain expressions of affect
with the memory of the thing experienced is common to both.

Let us now compare with this the views of German neurologists on
the genesis of the war neuroses. Goldscheider says: “Sudden and
terrifying impressions can leave behind affects direct and also with
the associative help of ideation; to these memory pictures are due the
results of increased and lowered excitability. Thus it is the emotion,
the terror, which bestows upon the trauma the distribution and fixation
of the nervous results of the stimulus, which never occurs with the
purely physical stimulus itself”. It is easy to recognise that this
description is borrowed from the traumatic theory of Charcot and the
Freudian conversion theory.

Gaupp’s opinion is similar: “In spite of all the methods of modern
experimental psychology and of all the more precise and more delicate
methods of technique for neurological and psychiatric investigation,
there remains a residue, and not an insignificant one, in which we do
not arrive at a diagnosis by means of the present exact neurological
and psychiatric investigation of the condition at the moment present,
but only through its connection with an exact anamnesis and with a
laborious exploration of the pathogenesis of the existing condition”.
Gaupp accepts even explicitly a Freudian postulation, in that he
describes the war neuroses as a flight from psychic conflicts into
illness and, alluding to psycho-analysis, he says: “Much preferable
is the postulate of the effects of the unconscious on consciousness
and the physical system than a psychological theory which seeks by
words taken from the sciences of anatomy and physiology to gloss over
the fact that the path from the physical to the mental and vice versa
is entirely unknown to us”. In another place he goes still further
and puts the psycho-analytical postulate of the unconscious in the
centre of the whole problem. “If one only admits that mental processes
can react upon the body even when they do not lie in the conscious
field of vision, then most of the supposed difficulties disappear”.
In this connection Hauptmann must also be mentioned. He looks upon
the traumatic neuroses as mental illnesses psycho-genetically
elaborated and caused through emotional factors, and their symptoms as
“unconscious further elaboration of the emotional factors along paths
of least resistance”.

Bonhoeffer seems to have completely accepted the psychologically
complex experiences of psycho-analysis. He holds that the traumatic
symptoms are “psycho-neurotic fixations, dissociation phenomena which
have been rendered possible through the resultant splitting off of the
affect from its ideational content under the influence of the violent
emotion”.

Birnbaum showed in his excellent summary of the literature of the
traumatic neuroses that in many of the explanations of these neuroses
(for example, in Strümpell’s theory of covetousness) is summed up a
psychogenic wish of hysteria, and says: “If the psychogenic wish,
the wish fixation, etc. is an essential component of hysteria then
it belongs unconditionally in the definition of the disorder”.
Psycho-analysis has long maintained this; as is well known, it regards
the neurotic symptoms as expressions of unconscious wishes or as
reactions to them.

Vogt also refers to the “famous Freudian statement” according to which
the troubled mind flies into illness and he acknowledges that “the
compulsion which originates from this is more often unconscious than
conscious”. Liepmann divides the symptoms of the traumatic neuroses
into the direct results of the psychic trauma and into “finally
adjusted psychic mechanisms”. Schuster speaks of symptoms which are
evoked by means of “unconscious processes”.

You see, therefore, ladies and gentlemen, that the experiences among
war neurotics gradually led further than to the discovery of the mind;
they led neurologists very nearly to the discovery of psycho-analysis.
When we read in the more recent literature on the subject, of the ideas
and views which have become so familiar,—abreaction, unconscious,
psychic mechanisms, separation of the affect from its idea, etc.,—we
might easily imagine ourselves to be in a circle of psycho-analysts,
and yet it has never occurred to these investigators to ask
themselves whether, after these experiences in the war neuroses, the
psycho-analytical concepts cannot be made use of in the explanation of
the usual neuroses and psychoses which were well known to us in peace
times. The specificity of the war trauma is universally denied; in
general, it is said, that the war neuroses contain nothing and have
added nothing new to the already known symptomatology of the neuroses;
even the Munich Congress of German Neurologists formally demanded the
elimination of the word and concept, “war neurosis”. If, however, the
peace and war neuroses are identical in their nature, then neurologists
will be obliged to make use of all these ideas of emotional shock, of
the fixation of pathogenic memories, and of their continued activity in
the unconscious, etc., also in the explanation of the usual hysterias,
the obsessional neuroses and the psychoses. They will be astonished how
easy it will be for them to traverse the path trodden by Freud, and
will regret having shown such obstinate resistance to his hints.

To the question of the disposition to fall sick with a war neurosis
the authors gave contradictory answers. Most of them follow the views
of Gaupp, Laudenheimer and others, according to whom most of the war
neurotics are _ab ovo_ neuropaths or psychopaths, the shock merely
playing the part of the releasing factor. Bonhoeffer says direct:
“The possibility of a psychopathological condition being evoked by
psychogenic factors is the criterion of a degenerative predisposition”.
Forster and Jendrassik say the same thing. Nonne, on the contrary,
finds that the deciding factor in falling a victim to war neuroses
lies less in the personal constitution than in the nature of the
operating injury. Psycho-analysis takes a median position with regard
to this question, which Freud has frequently and expressly stated.
It speaks of an “aetiological succession” in the predisposition,
the traumatic occasion figuring as reciprocal value with this. A
trifling predisposition and severe shock can produce the same effects
as an increased predisposition and a much lesser degree of shock.
Psycho-analysis, however, is not content with the theoretical allusion
to this condition, but it endeavours—with success—to separate the
complex idea of the “disposition” into simpler elements and establish
those constitutional factors that influence the choice of neurosis (the
special tendency to fall sick with this or that neurosis). I shall
return later to the question as to where psycho-analysis looks for the
special disposition to falling sick with a traumatic neurosis.

The literature concerning the symptomatology of the neuroses of the
war is simply immense. According to Gaupp, for example, the following
hysterical symptoms are to be observed. “Attacks of a slight nature
up to those of the severest kind, with an _arc de cercle_ lasting for
hours, sometimes with epileptic frequency, astasia-abasia, anomalies of
the position and movement of the body even to going on all fours, all
the varieties of tic and shaking tremors, paralyses and contractures
in monoplegic, hemiplegic and paraplegic forms, deafness and deaf and
dumbness, stuttering and stammering, aphonia and rhythmical screaming,
blindness with or without blepharo-spasm, all kinds of disturbances of
sensation, and most of all twilight states in quantities never before
met with and in combination with phenomena of physical irritation
and disorders”. You see, it is like a museum of glaring hysterical
symptoms, and whoever has once seen it will plainly have to decline
Oppenheim’s view, according to which purely neurotic symptoms are
rarely seen in the traumatic neuroses of the war. Schuster draws
attention to the frequent vasomotor and trophic phenomena; according to
him, these are no longer psychogenic. Psycho-analysis, however, will
agree with those who hold that these symptoms can originate to some
extent from psychic causes, analogous to the physical alterations which
can be produced under hypnosis. Finally, all the authors allude to the
alterations in disposition, apathy and over-excitability, etc. after
the trauma.

Out of this chaos of symptoms the “trembling” neurosis stands out
through its frequency and conspicuousness. You all know those
pathetic creatures who hobble along through the streets with shaking
knees, uncertain gait and peculiar motor disturbances. They give
the impression of being helpless and incurable invalids; and yet
experience shows that also this traumatic form of illness is purely
psychogenic. A single treatment with electricity and suggestion, a
few hypnotic sittings are often sufficient in rendering these men
capable of doing some work, if only temporarily and under certain
conditions. Erben has made the most careful investigation into these
disturbances of innervation; he found that these disturbances are
only suspended or increased when the respective group of muscles
carry out an action or intend to do so. His explanation for this
is, that here the “volitional impulse makes a path for the spasm”,
which, however, is only the physiological paraphrase of the facts
of the case. Psycho-analysis suspects here a psychical motivation:
the activity of an unconscious contrary wish which puts itself in the
way of the consciously wished act. This is indeed most striking in
those patients of Erben who are prevented from going forward through
the most violent attacks of shaking, but can carry out the much more
difficult task of going backwards without trembling. Erben also here
has a complicated physiological explanation ready, but forgets that
the movement backwards, which removes the patient from the dangerous
goal of the forward movement—and finally from the front line—does
not need to be disturbed by any contrary wish. The remaining kinds
of motor disturbances demand a similar interpretation, in particular
the striking, uncontrollable running of many neurotics, so like the
propulsion in paralysis agitans. These are the men who do not recover
from the effect of the terror and are still always flying from dangers
to which they were once exposed.

Many investigators, including non-psycho-analysts, came to the
conclusion from these and similar observations, that these disturbances
are not the direct effects of the trauma, but psychical reactions to it
and act in the service of the instinct of self-preservation against the
repetition of the unpleasant occurrence. We know that also the normal
organism has at its disposal such protective measures. The symptoms of
the terror, such as the immovable legs, the tremblings, the hesitating
speech, seem to be useful automatisms; one is reminded by them of
certain animals which simulate being dead when danger threatens. And if
Bonhoeffer looks upon these traumatic disturbances as fixations of the
means of expression of the terrible emotion which has been suffered,
Nonne goes further and discovers that “the hysterical symptoms
represent partly a reminiscence of inborn guard and defence mechanisms,
the suppression of which in those individuals whom we call hysterical
has not taken place in the normal degree or not at all”. According
to Hamburger the most frequently occurring type of disturbances of
standing, walking and speech associated with shaking tremors represents
a “complex of ideas of feebleness, weakness, refusal and exhaustion”,
and Gaupp sees in the same symptoms the lapse into infantile and
puerile states of obvious helplessness. Some authors actually speak of
the “fixation” in the traumatic posture of the body and innervation.

It cannot escape the notice of anyone with a knowledge of
psycho-analysis how near these authors, without knowing it, are to
psycho-analysis. The “expressions of fixations of movements” described
by them are in reality only paraphrases of the Breuer-Freudian
hysterical conversion, and the lapse into atavistic and infantile
methods of reaction is nothing more nor less than what Freud called
special attention to as the regressive character of the neurotic
symptoms, all of which according to him only signify reversions into
ontogenetic and phylogenetic stages of development already overcome.
At any rate we have definite proof that neurologists have now decided
to _interpret_ certain nervous symptoms, that is to say, refer them
to unconscious psychical contents, which would never have occurred to
anyone to do before the introduction of psycho-analysis.

I will now speak of the few authors who occupy themselves with the war
neuroses from the psycho-analytical points of view.

Stern has published a work on the psycho-analytical treatment of the
war neuroses in war hospitals. I have not been able to see the work in
the original, but I learn from the abstracts that the author proceeds
from the point of view of repression and finds the situation of the
serving soldier particularly suited to the production of neuroses in
consequence of the suppression of affects which his service demands.
Schuster admits that the investigations of Freud “however one may feel
towards them” have thrown a ray of light on the psycho-genesis of
the neuroses; they assist in revealing the hidden connection between
symptom and psychical content which still exists though difficult to
discover. Mohr treats the war neuroses by the cathartic method of
Breuer and Freud, by getting the patients to live through the critical
scenes again and brings about an abreaction of their affects by
letting them re-experience the terrible emotion. Simmel is the only
one up to the present who has occupied himself methodically with the
psycho-catharsis of the war neuroses, and he will give his own report
of his experiences to the Congress. Finally, I will mention my own
investigations concerning the psychology of the war neuroses, in which
I made the attempt to bring the traumatic forms of disorder into the
category of psycho-analysis.

In this connection I will allude to a discussion which branches
out in all directions on the question whether an affect can still
act psycho-genetically when the person concerned immediately loses
consciousness. Goldscheider and many others still maintain that a
psychical effect is made impossible through swooning, and Aschaffenburg
adheres to the view that loss of consciousness before falling ill
guards against the neurosis. Nonne rightly opposes this view, and
points out that unconscious mental streams could act psychically in
spite of the loss of consciousness. L. Mann, relying on Breuer’s
hypnoidal theory, puts forward the view that the loss of consciousness
before falling ill does not protect but disposes to the appearance of
the neurosis, by preventing the discharge of the affects. Orlovsky
expresses himself the most rationally on this vexed question; he points
out the possibility that the swooning itself can be a psychogenic
symptom, a flight into unconsciousness, which would spare the person
concerned the conscious experiencing of the painful situation and
sensations.

The possibility of the psychogenic formation of symptoms during a faint
is quite comprehensible to those of us who are psycho-analysts. This
problem could be started only by authors who take up a standpoint,
obsolete to psycho-analysis, that equates mental with conscious.

I do not know, ladies and gentlemen, whether you also have obtained
the impression from all these quotations and references (which are
only taken at random from the literature) that an advance, even though
one that is not admitted, has taken place in the attitude of leading
neurologists towards the teachings of psycho-analysis. Moreover, candid
recognition is not lacking; for example, the expression of Nonne, that
Freud’s experiences concerning the elaboration in the unconscious have
received interesting illuminations and corroborations through the
experiences of the war.

However, the same sentence of acknowledgement also contains a
nihilistic opinion of Nonne concerning psycho-analysis; he states
that Freud’s idea of the almost exclusively sexual foundation of
hysteria has been conclusively disproved during the war. We can no
longer leave this unanswered, which after all is only a partial
denial of psycho-analysis: also we can very easily give the answer.
The war neuroses, according to psycho-analysis, belong to a group of
neuroses in which not only is the genital sexuality affected, as in
ordinary hysteria, but also its precursor, the so-called narcissism,
self-love, just as in dementia praecox and paranoia. I grant that
the sexual foundation of these so-called narcissistic neuroses is
less easily apparent, particularly to those who equate sexuality and
genitality and have neglected to use the word “sexual” in the sense
of the old platonic Eros. Psycho-analysis, however, returns to this
extremely ancient standpoint when it treats all tender and sensual
relations of the man to his own or to the opposite sex, emotional
feelings towards friends, relatives and fellow-creatures generally,
even the affective behaviour towards one’s own ego and body, partly
under the rubric “erotism”, otherwise “sexuality”. It cannot be denied
that those to whom this idea is strange cannot so easily be convinced
of the correctness of Freud’s postulation of the sexual theory in a
narcissistic neurosis in particular, for example, in the traumatic
neurosis. We should like to advise them to examine themselves into the
usual (non-traumatic) hysteria and obsessional neuroses also, and to
keep strictly to the methods of free association, dream and symptom
interpretation proposed by Freud; then they will be much more easily
convinced of the correctness of the sexual theories of the neuroses,
and agreement about the sexual background of the war neuroses will
follow. At any rate the triumph concerning the overthrow of the sexual
theories is somewhat premature.

The observation that I have made as regards the participation of sexual
factors in the formation of symptoms in the traumatic neuroses also
shows that in traumatic neurotics the genital sexual hunger (libido)
and potency is generally greatly injured; in many cases it can even be
entirely suspended and that for long periods. This condition which is a
positive one is alone sufficient to demonstrate the rashness of Nonne’s
conclusion[3].

Ladies and gentlemen: With what I have said I have discharged the chief
task of my paper, which was the critical survey of the literature on
the war neuroses from the standpoint of psycho-analysis. However,
I will make use of this rare opportunity to tell you some of the
observations I have made myself, and I will present points of view
which may help to explain these conditions psycho-analytically.

In the psychical sphere of the traumatic neuroses there predominate
such symptoms as hypochondriacal depression, terror, anxiousness, and a
high degree of irritability with a tendency to outbursts of anger. Most
of these symptoms can be traced back to _increased ego-sensitiveness_
(in particular the hypochondria and the incapability of tolerating
physical or mental discomfort). This over-sensitiveness arises from
the fact that in consequence of the shock, which has been experienced
once or repeatedly, the interest and sexual hunger (libido) of the
patients is withdrawn from the object into the ego. There thus comes
about a damming-up of the sexual hunger (libido) in the ego, which is
expressed in those abnormal hypochondriacal organic sensations and
over-sensitiveness. Frequently this heightened ego-love degenerates
into a kind of infantile narcissism: the patients would like to be
pampered, cared for, and pitied like children. One can therefore speak
of a reversion into the childish stage of self-love. This heightening
corresponds to the diminution of object-love, often also of genital
potency. A man who is already predisposed to narcissism will of course
sooner fall a victim to a traumatic neurosis; still no one is entirely
immune from it, since the stage of narcissism forms a significant
fixation point in the development of the sexual hunger (libido) of
every human being. The combination with other narcissistic neuroses,
especially paranoia and dementia, frequently occurs.

The symptom of anxiety is the sign of the shock to the self-confidence
occasioned by the trauma. This is most strikingly expressed in men who,
in consequence of an explosion, have been knocked down, hurled over
or blown up and have thereby permanently lost their self-confidence.
The characteristic disturbances of walking (astasia-abasia with
trembling) are protective measures against the repetition of the
anxiety, therefore phobias in Freud’s sense. The cases in which these
symptoms predominate are called anxiety-hysteria. Those symptoms, on
the contrary, which simply express the situation at the moment of the
explosion (innervation, position of the body) are conversion-hysterias
in the psycho-analytical sense. Also in the anxiety there is naturally
a constitutional predisposition; those persons more easily fall ill in
this way who, in spite of real cowardice, are compelled from ambition
to perform courageous deeds. The anxiety-hysterical disturbance in
walking is at the same time a reversion to an infantile stage of
not-being-able-to-walk or of learning-to-walk.

Also the tendency to outbursts of rage and anger is a highly primitive
method of reaction to a superior force; it can increase up to epileptic
attacks, and represents more or less incoordinate discharges of affect
analogous to those observed in the period of suckling. A milder variety
of this loss of restraint is the lack of adaptation to discipline,
which is practically never missing in the traumatic neuroses. The
excessive need for love and the narcissism also give rise to this
increased irritability.

The entire personality of most of the victims of trauma corresponds
therefore to the child who is fretting, whimpering, unrestrained and
naughty in consequence of a fright. The excessive importance which
almost all the persons suffering from trauma attach to good food fits
in with this picture. The slightest neglect in this respect may produce
in them the most violent outbreaks of affect and even induce fits. Most
of them are unwilling to work, they wish to be supported and provided
for like a child.

It is here, therefore, not only a question, as Strümpell considers,
of the production of illnesses on account of an actual gain (pension,
compensation for injury, flight from the front) which are only
secondary illness gains; the primary motive for the illness is the
pleasure itself of remaining in the secure retreat of the childish
situation once so unwillingly left behind. Both these narcissistic and
apprehensive manifestations of illness have their atavistic prototype;
it is even possible that the neurosis often reverts to methods of
reaction which play no part at all in the individual development
(feigning of death by animals, methods of progress and protection of
the young of animals in the ancestral series). It is as though an
over-strong affect could no longer be compensated along normal paths,
but had to regress to previously abandoned but virtually existent
mechanisms of reaction. I do not doubt that many other pathological
reactions will yet be revealed as recapitulations of overcome methods
of adaptation.

As symptoms of the traumatic neuroses which are less appreciated, I
might mention the over-sensitiveness of all the senses (shunning of
light, hyperacusis, extreme ticklishness) and the anxiety dreams. The
real terrors that have been experienced, or things similar to them, are
lived through again and again in these dreams. I am following a hint of
Freud’s when I look upon these terrors and anxiety dreams, as well as
the state of terror by day, as spontaneous attempts of cure on the part
of the patient. They serve to bring piecemeal to conscious abreaction
the shock, which in its totality was intolerable and unintelligible
and was therefore converted into symptoms, and to contribute to the
adjustment of the disturbed equilibrium in the psychical economy.

Ladies and gentlemen, I hope these few remarks of mine may serve as
proof that the psycho-analytical conception discloses points of view
where the rest of neurology leaves us in the lurch.

From the methodical psycho-analysis of many cases we ought to expect
the full explanation of these morbid conditions and perhaps also their
radical cure.

[Illustration]

While this article was in the press, I read the interesting work of
Prof. E. Moro, the childrens’ specialist of Heidelberg, on “the first
Trimenon”, _i. e._ the peculiarities of the first three months of the
infant’s life. He says: “If one lays a young infant on a pillow on a
table and strikes the pillow on either side with the hands, then there
results a peculiar reflex action. Both arms are thrown up symmetrically
apart and then come together again in a curve with easy tonic
movements. A similar movement is carried out simultaneously by the
legs”. We would say: Moro has here artificially produced a little shock
(or traumatic) neurosis. The remarkable thing in this action is that
this reflex to the shock in the young infant of less than three months
old shows signs of the natural reflexes of clasping, which characterise
the “carried offspring”, _i. e_. the young of animals (monkeys) which
are compelled with the help of a pronounced clasping reflex to hold
fast with the fingers to the mother’s fur while she climbs about the
trees. We would say: Atavistic reversion of the method of reaction in
sudden terror[4].




2. DR. KARL ABRAHAM, Berlin.

During the war academic neurologists have come round more and more
to regard the aetiology of the traumatic neuroses from psychological
points of view. However, in spite of the approach towards our views,
mentioned by Ferenczi, their ideas differ from ours in two respects,
namely, they for the most part only take into consideration the
reactions of the ego impulses to the trauma, and they keep entirely to
the manifest expressions of the neurosis. In the following remarks,
besides those factors which we do not dispute, I intend to deal with
the unconscious and sexual ones.

When in peace times psycho-analysis upheld the sexual aetiology of the
neuroses it was often pointed out as a contrary argument that this
could not hold good for the traumatic neuroses. Similarly now the
opinion is expressed that the genesis of the war neuroses contravenes
our ideas. Terror, anxiety lest the dangerous situation be repeated,
seeking for a pension, and some vague idea of disposition are supposed
to be adequate explanations of the illness; in the mass of the neuroses
which have broken out during the war the unimportance of the sexual
aetiology is thought to be clearly shown.

My investigations of the traumatic neuroses in peace time had for
a long time led me to conclude the importance of sexuality in them
similar to that in the other neuroses, but they have not yet been
sufficiently numerous and conclusive enough for publication. I might
mention the case of a young girl who met with a slight tram accident
when she was in the throes of a serious erotic conflict. The analysis
showed that the accident in a certain measure gave a pretext for the
outbreak of the neurosis. The symptoms were in connection with the
conflict in question; the importance of the trauma receded quite
into the background. I might also add that some litigious cases of
traumatic neurosis which I observed in greater detail all suffered from
impotence; this disturbance was produced by the accident, but seemed to
have its real basis in old and unconscious sexual resistances.

The investigation of war neurotics has fully confirmed my surmises
connected with such observations. Moreover, the recurrence of certain
definite symptoms in war neurotics, which were familiar to me not only
in the traumatic neuroses of peace time, but also in the non-traumatic
cases, seems to me worth noting. I refer particularly to the complex of
symptoms which we could so often observe during the war in the anxiety
cases with trembling, such as trembling, agitation, irritability,
sensitiveness, sleeplessness, headaches, anxiety, depression of
spirits and feelings of incompetency. Two neurotic types with the
same symptoms—although these do not appear so prominently as in the
war—would be the impotent man and the frigid woman. A similarity which
is so marked in external phenomena leads one to expect a similarity
also in internal processes.

All my experience fully coincides with that which Ferenczi has just
communicated. The trauma acts on the sexuality of many persons in
the sense that it gives the impulse to a regressive alteration which
endeavours to reach narcissism. I might add that we both arrived at
this idea without having previously even mentioned it to one another.
The trauma, however, has this effect only in a portion of those
participating in the war, hence we are unable to dispense with the
assumption of an individual disposition, but we are in the position to
define it far more accurately than the prevailing school of neurology.
A couple of examples will make the problem before us clearer.

At the beginning of the war a soldier at the front was wounded on
August, 12th, 1914. Before his wound was completely healed he secretly
left the hospital and went again to the front, soon getting a second
and after a few months a third wound. After repeated returns to the
front he was one day blown up by a shell explosion and was unconscious
for two days. After these four traumata he certainly presented the
phenomena following upon shock, but no neurotic picture, being neither
particularly anxious, depressed nor excited. Another man at the front
during a night attack fell into a hole without injuring himself, but
immediately developed neurotic trembling of a most severe kind, and
presented the picture of a mental breakdown. How are such differences
to be explained?

The previous history of such people, and naturally, still more, a
penetrating analysis, teaches us why the one in spite of the severest
physical and mental influences of the war remains to all intents and
purposes healthy, and why the other reacts to relatively trifling
stimuli with a severe neurosis. It transpires with great regularity
that the war neurotics already before the trauma were labile people—to
designate it, to begin with, by a general expression—and especially
so as regards their sexuality. Many of these men were unable to carry
out their tasks in practical life, others that were capable of doing
this, however, showed little initiative and manifested little impelling
energy. In all of them sexual activity was diminished, their sexual
hunger (libido) being checked through fixations; in many of them
already before the campaign potency was weak or they were only potent
under certain conditions. Their attitude towards the female sex was
more or less disturbed through partial fixation of the sexual hunger
(libido) in the developmental stage of narcissism. Their sexual and
social capacity of functioning was dependent on their making certain
concessions to their narcissism.

In the war these men were placed under completely changed conditions
and in the face of extraordinary demands. They had always to be
prepared for unconditional self-sacrifice in favour of the mass.
This signifies the renunciation of all narcissistic privileges. The
healthy person is able to accomplish such a complete suppression of
his narcissism: he loves according to the transference type, and so is
capable of sacrificing his ego for the whole. In this respect those
disposed to neuroses are inferior to healthy persons.

It is not only demanded of these men in the field that they must
tolerate dangerous situations—a purely passive performance—but there is
a second demand which has been much too little considered, I allude to
the aggressive acts for which the soldier must be hourly prepared, for
besides the readiness to die, the readiness to kill is demanded of him.

A further factor which operates on the labile sexuality of those
disposed to neuroses is the almost exclusive association with men.
The sexuality of the normal person takes no harm from this, but it
is otherwise in men with strong narcissistic traits. The knowledge
of the connection between homosexuality and narcissism enables us to
understand this.

The previously unstable attitude towards women begins to waver under
such conditions. If the lability of the attitude towards the other
sex is very great then it does not need even a war trauma to cause
a neurosis to break out in such men. For instance, I observed a man
who on return from furlough at home had a convulsive attack and was
brought into the hospital showing signs of anxiety and depression. The
man had always been noted for his effeminate disposition, and in his
married life was weakly potent and always inclined to jealousy. When he
was home on leave he failed absolutely in the attempt to have sexual
relations with his wife. His fears that his wife would be unfaithful to
him reached a crisis, and soon after his departure from home he had his
convulsive attack.

Such men with labile heterosexual impulses need a support for their
sexuality. They frequently find this in their wife on whom their
sexual hunger (libido) is completely dependent, or they have to defend
themselves from their feelings of insecurity sexually by having
constantly to convince themselves that they are potent by going with
prostitutes. And so in war they constantly need a support for their
wavering activity. Their military usefulness also is dependent upon
conditions. They are frequently useful in rank and file, supporting
their activity upon that of their comrades. A changed situation, and
occurrence, which with a marked disposition needs only to be very
trifling, upsets the balance, making the previously weakly-active man
wholly passive. The passivity is expressed then not only in the sphere
of the ego impulses, but likewise in that of the sexual impulses. The
narcissism breaks out. The capability of the transference of the sexual
hunger (libido) dies away as well as the capacity of self-sacrifice in
favour of the community. On the contrary, we now have a patient before
us who himself needs care and consideration on the part of others, who
in a typically narcissistic manner is in constant anxiety about his
life and health. The obtrusiveness of the symptoms (tremors, attacks,
etc.) is also narcissistic. Many of the patients show themselves
completely female-passive in the surrender to their suffering. In their
symptoms they are experiencing anew the situation which had caused the
neurosis to break out, and soliciting the sympathy of other people.

At this juncture we must again refer to the previously mentioned
circumstance that in our patients the anxiety as regards killing is
of a similar significance to that of dying. The symptoms in part
are only comprehensible in this sense. The case of a man who in the
field suffered from a relapse of a neurosis which he had had six
years previously is especially instructive. At that time he was taken
with a tremor of his arm which arose in connection with a dream in
which he murdered someone; a hand-to-hand fight in the field caused
the old symptom to reappear. Hysterical convulsive attacks are not
only produced through dangerous situations, terror, etc., but not
infrequently an act of aggression which he has failed to carry out is
expressed in them. Such an attack is especially often associated with
an exchange of words with his superiors; the suppressed impulse to
forcible activity finds in the expression its motor discharge.

The complete instability of many war neurotics, their disconcerting
depression, their propensity to thoughts of death, find a further
explanation in a particular effect of the trauma. Many of the
neurotically disposed persons, up to the moment when the trauma upsets
them, have supported themselves only through an illusion connected
with their narcissism, namely, through the belief in their immortality
and invulnerability. The effect of an explosion, a wound, or things of
a like nature suddenly destroys this belief. The narcissistic security
gives way to a feeling of powerlessness and the neurosis sets in.

To what an extent the regression can go is shown in those cases,
described also in the literature, in which the patients display the
conduct of little children. One of my patients who was previously
neurotic was thrown into this kind of condition through the terrifying
effect of a mine explosion. For a long time he behaved like a terrified
little child. For many weeks he could only reply to all questions about
his trouble with the two words, “Mine bombs”. He had therefore gone
back to the mode of expression of a child hardly two years old.

What apparently is an exception to the statement made at the
commencement is the following noteworthy case in which a previously
healthy, proficient and sexually completely potent young man was
taken in the field with a severe astasia-abasia coupled with a very
great over-excitability of affect. An explosion had hurled the lower
part of his back against the side of the trench; he had therefore
suffered a trauma, and had been already treated by various neurologists
for “traumatic hysteria”. A careful physical examination showed me
undoubted signs of an affection of the Conus Medullaris, manifestly a
haematomyelia. The patient remembered that after the trauma he could
not retain his urine and faeces, still he continued at his post because
he looked upon this condition as the result of terror. These symptoms
improved in the following weeks. However, during the same period he
noticed the disappearance of all sexual feelings. At first he was not
inclined to look upon this condition, which was disquietening to him,
at all seriously, having no idea that he had an organic impotence.
During leave at home he had to come to the conclusion that the sexual
insensitiveness was in no way to be overcome. Now the neurosis
appeared, not as the result of the psychic impression of the explosion,
but as a reaction to the organic impotence of traumatic origin. This
neurosis differed, by the way, from the usual traumatic neuroses
through the euphoristic, at times even manic state of mind.

This difference needs special appreciation and explanation. Also
other men who have received severe organic injuries show such mental
attitudes which must surprise us. For example, I have always found
that in the amputation hospitals a strikingly cheerful mood prevails.
At the beginning of the war I had my attention drawn to the euphoria
of the severely wounded men by a particular occurrence. I had to treat
four soldiers in a general hospital, who through the splintering of
the same shell had had their eyes severely injured. All four had
already had enucleation performed in another hospital. They were in
no way depressed but gave themselves up to a careless, serene frame
of mind. When they—all at the same time—received their artificial
eyes a remarkable scene took place. They jumped, danced, and laughed
in boisterous spirits, just like children who work themselves up into
a frenzy of joy. Also here there is without doubt a regression to
narcissism, it is however of a more partial nature. These patients
repress the knowledge that through the mutilation they have experienced
a depreciation in a more or less high degree, especially in the eyes
of the female sex. What they lose in love from outside they seek to
compensate by means of self-love. The damaged part of the body receives
for them a significance as an erotogenic zone which did not previously
belong to it[5].

All the experiences here communicated speak unanimously in the
sense that the war neuroses are not to be understood without taking
the sexuality into consideration. This view receives a valuable
confirmation by means of the mental disturbances observed in the war,
which—like mental troubles in general—very often more easily manifest
the latent content of their ideas than the neuroses. The mental
disturbances which have broken out in the field, as other observers
have confirmed, are associated only in a trifling part with the
formation of delusions. However, if there is a delusion then it has
even a manifest sexual content. In the cases I have seen the delusions
are partly of jealousy, partly of homosexual persecution by comrades.
I might mention the paranoid illness of a soldier which broke out when
he, after long service in the field, went home on furlough and turned
out to be impotent with his wife. A very transparent symbolism and
other signs pointed with certainty to the significance of homosexual
components as the fundamental cause of the delusion. Another man had
the delusion of being, during sleep, infected with syphilis in the
hospital by his comrades, the origin of the delusion was here also the
result of imperfectly repressed homosexuality.

In this connection I should like to mention another remarkable case. In
1915 when I was acting at a surgical station a man was treated there
for a gunshot wound of the penis. The operation, which was carried out
by a well known surgeon, was quite successful. Two years later the same
patient came to my psychiatric station. The man who was previously
unaffected psychically now showed a paranoid mental disturbance. On
questioning him it appeared that in consequence of the wound there
existed entire genital anaesthesia. Also here the psychosis appeared to
stand in close connection with the cessation of genital manliness.

The so-called “seeking for pension” of many men injured in the war is
as little explained by means of the current ideas on the matter as
the symptoms of the neurosis. This also stands in connection with the
alterations of the sexual hunger (libido), just as do the neurotic
symptoms. The patient only apparently fights for compensation for the
stiffened wrist, for the shot-off finger, for his neurotic trouble. It
is quite overlooked as a rule that the neurotic inwardly perceives the
alteration which has taken place as regards his sexual hunger (libido).
He is filled with the feeling of an enormous injury. And he is so
far right when he actually has suffered loss from his capability for
transference of his sexual hunger (libido) and therewith an important
basis of the belief in himself. A man injured by an accident before the
war once told me that he had come to an agreement with his insurance
company for a definite compensation. Hardly had this occurred when
the thought came to him that this sum did not even remotely cover
his actual injury. Henceforth the sum which according to his idea he
ought to have claimed rapidly rose to an enormous amount. The pension
compensates only for the diminution of the capacity for earning a
livelihood, so far as this is objectively demonstrable, not for that
which the patient subjectively feels; he cannot be compensated for his
reduced capacity for object-love. Narcissism also explains here the
conduct of the patients. Where previously the capability of surrender
(in every sense of the word) existed, now the narcissistic avarice
dominates. The genital zone has lost its predominance; anal erotism
is strengthened. It is clear that the state pension favours the
development of the character traits described; this only takes place,
however, when the tendency already exists in the injured person to
react narcissistically to an external injury to his integrity.

Now as regards the question of the therapy and particularly that of the
psycho-analytic.

At the commencement of the war one took little notice of the neurotics,
they were placed perchance in a convalescent home but practically
without treatment. The increasing number of neurotic cases necessitated
other measures. The old method of “surprisal” was again dug up. Then
came the period of “active” curative procedures, the best known of
which is Kaufmann’s. These methods were at first deceptive from the
fact that they led to the rapid improvement of a great number of
patients. As regards, however, the duration of the cure, they have
not yielded what was hoped of them, and, in addition, they produced
certain unwished-for phenomena. The military medical authorities
therefore display a lively interest in putting on one side the too
“active” methods in favour of other effective but less severe ones.

Is psycho-analysis able to step into the breach? Theoretically we are
justified in assuming that it is, because psycho-analysis alone of all
methods of treatment is a causal one. We also have already practical
experience to go upon; I refer to the publications of Simmel. I will
now briefly speak of my own therapeutic experiences. We psycho-analysts
had to be extremely cautious in our treatment of war neuroses, for
the addresses at medical congresses and the literature before the war
had demonstrated very clearly the refusal of the medical profession
to accept the conclusions of our ideas and efforts. When in 1916
I founded a station for neuroses and mental diseases I abstained
entirely from all forcible therapy, likewise from hypnosis and other
suggestive means, but allowed the patients to abreact in the waking
state and sought to make intelligible to them by a kind of simplified
psycho-analysis the origin and nature of their suffering. I aimed at
arousing in the patients the feeling of being understood, complete
relaxation, and improvement. Later the station became that of a pure
observation station, chiefly for mental diseases; hence I could only
collect isolated therapeutic experiences.

The objection that psycho-analysis works too slowly does not hold good
as far as our experience goes up to the present.

Latterly it has appeared that the patients treated accordingly by the
Kaufmann method frequently relapsed when they were withdrawn from the
influence of the doctor, or were again exposed to the dangers of the
front. Time will show whether the psycho-analytic methods will procure
more lasting cures. I will communicate in conclusion the result,
instructive in this connection, of the recent treatment of a neurosis
carried out in my private practice. I was able in a few weeks to remove
a severe phobia in a boy twelve years old, which referred to air raids.
The cure persisted when the boy returned home; he was there again daily
exposed to the risk of air raids and put up with this situation just
like a healthy person. Perhaps this result justifies the expectation
that psycho-analysis will in fact in the permanence of its cures fill
up the gaps that exist at present. Psycho-analysis, which enables us to
penetrate deeper than any other method into the structure of the war
neuroses, will perhaps take therapeutic precedence also in the sphere
of the war neuroses[6].




3. DR. ERNST SIMMEL, Berlin.

For the past eighteen months I have been in charge of a special
hospital for war neuroses, and the mass treatment necessary in such an
institution has enabled me to make a comparative study of the different
so-called psycho-therapeutic methods. Apart from the serious objections
that can be raised with regard to all forcible and restrictive methods,
which for the most part produce new psychic injuries, there are serious
doubts as to the use of pure suggestion in the form of hypnosis when
carried out indiscriminately as a blind technique for war neurotics.
The removal of the symptom, which is done regardless of the remaining
psychic constellations of the patient, generally produces at the
same time a considerable general disturbance with marked subjective
symptoms, such as headache, feelings of pressure on the head, insomnia,
diminution of intellectual capacity, sexual impotence, etc.

On the other hand, the frequently observed fact that with the
disappearance of the manifest symptom the neurosis appears in another
form, has proved that with all these kinds of palliative measures the
root cause of the suffering has not been touched.

A medical treatment that is to be effective can only be built up on the
pathogenesis of a disease. The psycho-pathogenesis of the war neurosis,
(and no intelligent man any longer doubts its psychic origin),
obviously can be elucidated only by means of psycho-analysis. It is
intelligible that a hospital regime necessitating the simultaneous
treatment of a large number of cases and calling for rapid curative
results, would allow a more extensive individual analysis only in a
few cases. On account of this I had from the beginning to cut down
the length of the treatment. A combination of analytical-cathartic
hypnosis with analytical conversations during the waking state, and
dream interpretation carried out both in the waking state and in deep
hypnosis, has given me a method which on an average of two or three
sittings brought about relief of the symptoms. This mode of treatment
implies a systematic investigation of the symptoms that have appeared
in consequence of the incongruity of the war experience and the
psychic preparedness of the patient; such investigation being both
aetiologically conditioned as to its nature and automatically effective
as to its working. With the disappearance of the symptoms the
essential treatment of the war neurotics, according to modern hospital
methods, was looked upon as being at an end. An analytical cure of the
entire personality by a shortened and combined method will have to be
reserved for the psychological clinic of the future.

The psycho-analytical explanation of the war neuroses has proved with
wonderful clearness the correctness of the Freudian views on hysteria,
according to which all physical symptoms represent conversions of
something psychical. The body is the instrument of the mind upon
which it (the mind) allows its unconscious to manifest itself in
plastic and mimic expression. The functions of the unconscious are the
deciding factor in the formation and building up of the war neuroses,
also the frequently observed instances of the forgetting of events
accompanied by feelings hostile to the ego, even when these events
are very recent, permits us to recognise from the outside alone the
submergence and repression of ideas and affects of a painful nature. It
is comprehensible that under the pressure of years of discipline, which
limits the personality and thereby prevents every individual reaction
to events, the disposition to repression is extraordinarily favoured.
To what degree an enforced sexual abstinence further increases this
could not be tested.

The unconscious meaning of the _symptoms_ of the war neurotics, as
we may state by anticipation, is for the most part of a non-sexual
nature, there being exhibited in them all those war-produced affects
of terror, anxiety, rage, etc. associated with ideas corresponding
with the actual occurrences of the war. Stekel is quite wrong in
concluding from my statements that I categorically deny a sexual basis
for neuroses in general, since at present only the _symptomatology_
of the war neuroses is explained on the basis of these analytical
investigations. The fact of the predisposition to neuroses is still
a long way from being exhausted. The fact that in the midst of the
self-same experiences one soldier remains well while another becomes
a neurotic may, so far as my experience goes, be very well connected
with the psycho-sexual constellation of the particular person. The
systematic investigation of the dream-life of the soldier, even after
the removal of the war neurotic symptoms, has indeed made it possible
to recognise quite frequently threads that lead down to the primordial
network of infantile sexuality. Also many soldiers who have broken down
solely under the pressure of discipline show even in this abortive
form of analysis an attitude of father defiance in consequence of an
infantile mother fixation as the subconscious condition of their need
for opposition. In some cases even the sexual trauma of childhood
becomes evident as the latent basis of the war neurosis just in the
quick and deep view which is gained by hypnosis in the combined form of
treatment. The war affects and ideas which form the symptoms have, on
the other hand, a certain intrinsic relation to sexuality inasmuch as
they are closely bound with the most primitive instincts in man,—those
connected with the self-preservation instinct. If the sexual affect in
the last resort originates in the instinct which is directed towards
the preservation of the species, the affects of anxiety, horror, rage,
etc. produced by the war are connected with the elementary urging of
the preservation of the individual, and not, as superficial observers
imagine, solely for the purpose of preserving the physical existence,
but above all that of the psychic existence.

The war neuroses are essentially interposed guarantees, the object of
which is to protect the soldier against a psychosis. Anyone who has
examined a great number of patients for eighteen months with perception
that has been analytically sharpened, must recognise that the
proportionately small number of war psychoses is only to be explained
by the proportionately large number of war neuroses.

One must have experienced the war occurrences themselves or their
recapitulation under analytical-cathartic hypnosis in order to
understand to what attacks the mental life of a man is exposed in time
of war. For instance, a man after being wounded several times has to
return to the front, or is separated from important events in his
family for an indefinite time, or finds himself exposed irretrievably
to that murderous monster, the tank, or to an enemy gas attack which is
rolling towards him; again, shot and wounded by shrapnel he has often
to lie for hours or days among the gory and mutilated bodies of his
comrades, and, not least of all, his self-respect is sorely tried by
unjust and cruel superiors who are themselves dominated by complexes,
yet he has to remain calm and mutely allow himself to be overwhelmed by
the fact that he has no individual value, but is merely one unimportant
unit of the whole.

It is now explicable why the war neurosis of the officer does not
generally exhibit such gross symptoms as that of the ordinary soldier.
The officer has raised himself above the crowd, and, with a higher
mental development, has more possibilities of individually sublimating
his own particular injuries. Nevertheless, the neuroses in officers
will claim our psycho-therapeutic treatment in a far higher degree
as soon as our colleagues agree not to look upon them from moral
standpoints and to consider their comrades of the officer class under
the courtesy diagnoses of Neurasthenia, Ischia, Neuralgia, etc.

The war neurosis, like the peace neurosis, is the expression of a
splitting of the personality. The conditions for such a splitting are
brought about by the consistent narrowing of the personality complex as
a result of the compulsory discipline and above all by the psychic and
physical exhaustion of one or more years of war. The soldier severely
burdened with undischarged mental material is compelled to meet
abnormally heavy demands. An accident or a disastrous event then causes
the obstructed personality to break down. Complexes with accentuated
feelings held down in the unconscious become unduly powerful, and
the neurosis becomes manifest. The passage from the psychical to the
physical, however, signifies here more than a self-preserving process
of the psyche. The act of falling ill is, in my opinion, at the same
time the commencement of the healing process. The consistent use of
analytic hypnosis has repeatedly shown that the physical symptoms in
their mute expression strive to bring to the notice of the man the
elements that are disturbing his personality and which are imprisoned
and obstructed in his unconscious. Since the union between conscious
and unconscious is interrupted within by the strong barrier of the
resistance, a detour by way of external physical paths is necessary
in order to re-establish the harmonious fitting together of the
personality.

If the predominant physical symptoms of the war neuroses are modes of
expression of unconsciously determined ideas, the more psychic forms
of these neuroses, the states of inhibition or excitement, are due to
an effort on the part of the repressed affects to re-establish the
disturbed psychic balance. A strict demarcation between aetiologically
effective ideas and sensations is naturally not conceivable. The
relationship can only be a quantitative one. All ideas obviously stand
in a quite special relationship to the ego of the patient through their
accentuation of feelings; on the other hand, the affects are bound to
their causative ideas.

The first part of our mental analytic therapy is to recognise the
meaning of the neurotic healing tendency, the second, to convey our
knowledge to the patient. The crowning point of our treatment consists
in securing the spontaneous cooperation of the neurotic who, freed of
his emotional inhibition, and now in harmony with himself, has, through
his wider mental field of vision, a greater scope for the activity of
his will power. Man can only desire what he knows. By reason of this
the analyst comes to realise that the diagnosis, “mala voluntas”, which
so often brings the doctor who is untrained in analysis into conflict
with his patient, mostly betokens a “mala potentia” of the doctor who
knows nothing about the functions of the unconscious.

The weakening of the personality complexes of the soldier, as just
described, his subjection to other ideas with accentuated feelings
which are held down in the subconscious and thus connected with the
constant readiness to subordination under the strivings of ego-hostile
feelings, represents the so-called morbid suggestibility. To make use
of this suggestibility for curative purposes without exposing its
foundations is to increase the illness instead of bringing about a cure.

The neurotic, in my opinion, succumbs in the first instance to
auto-suggestion, that is to say, to over-strong emotionally toned ideas
which have arisen in him at a time when the ego-complex is weakened in
power or completely suspended.

According to my observations, narrowings and suppressions of
consciousness represent the initial stages of the war neuroses. In the
smallest loss of consciousness, the shock effects of terror, up to the
severe fainting attacks and the long continued loss of consciousness
after being buried, we see the self-conscious of the personality
more or less obliterated and the way opened to the unconscious. Here
undoubtedly at the commencement are operating those teleological
mechanisms which constitute the foundation of the neuroses and their
formation of symptoms. Consciousness refuses to take up ideas or to
assimilate at the moment those things which are too horrible in their
reality to be consciously tolerated. Therefore those psychic shocks,
those fainting attacks and profound loss of consciousness denote,
provided there is no injury _in cerebro_, a power of the unconscious
that attracts to itself the entire psychosis in a salutary manner.

Hypnosis gives us a clear picture of these processes. It shows us the
patient in the same state of consciousness as that in which during the
war he had acquired the origin of the illness. During hypnosis the
soldier relates, or once again lives through, all the things that he
had experienced in former circumstances only unconsciously. We learn
of distressing pains of which, when he was buried, he never became
conscious. In such a hypnosis we see his anxiety displayed, his anger
arise, feelings which at the moment of the excitation were benumbed and
like lightning were dragged violently into the unconscious.

I can best illustrate what I have said by a few examples. For instance,
the simplest cases, which occurred so often, of a flaccid paralysis of
the arm after a slight gunshot wound that had been well healed for a
long time and which seemed to be of a purely physical nature, showed
its unconscious connections very quickly in one sitting. Consciousness
only knows, “I cannot move my arm”, and no amount of reasoning was of
any avail. However, the unconscious spoke during hypnosis: “In the
excitement of the attack my mind became a blank. When I was hit the
impact of the shrapnel was so great that my arm felt as though it was
pulled violently backwards, and I immediately thought it was torn off”.
The correction of the unconscious idea in hypnosis which again united
the idea of the torn off arm with consciousness here quickly settled
the question of an organic basis of the symptom, It can be easily
understood that an arm which is no longer recognised as existing is
also completely analgesic.

The neurotic symptoms which owe their origin to such suddenly occurring
events we can consequently regard in their effects as realised
post-hypnotic auto-suggestions. I have confirmed this view by numerous
examples, I might mention the case of a soldier who suffered from a
severe facial tic by which he was constantly making a grimace, and who
at the same time had a contracture of the right knee joint, both of
which symptoms had proved quite refractory to the usual treatment by
suggestion. Hypnosis, which restored the conscious situation of the
initial blowing up, very soon yielded the following information. While
the patient lay unconscious under a wreckage of stones and while scenes
of his native place appeared to him as in a dream, he was constantly
compelled to make grimaces in order to remove the mass of sand which
lay on his face and also for the purpose of breathing freely. At
the same time a sharp stone was pressing on his right heel which
compelled him to keep his leg bent. This compulsion which was united
with unconscious ideas acted therefore as a post-hypnotic suggestion
for more than a year afterwards, until at last the command which
the unconscious had imposed on the patient could be annulled during
hypnosis by means of my correction. In this way was the removal of
these symptoms brought about. I could quote further similar examples in
which these kinds of contractures represent a compulsory holding of a
part in a position of ease which is based on unconscious sensations of
pain.

Apart from repressed physical sensations of pain the affects themselves
also naturally play an important part in the neurotic compulsion to
maintain a particular position, I remember a soldier who for several
months had a compulsion to keep both eyes fixed and turned upwards and
to the left. This symptom failed to react to methods of suggestion.
Analysis under hypnosis within a few minutes gave the explanation and
at the same time the removal of the symptom. The patient had anxiously
expected the falling down of trunks of trees from above and to the
left through the bursting of shells during a drum fire. His eyes
became fixed in dread before the fate threatening him. The original
situation had in the meantime become unreal, nevertheless the anxiety
in itself was valid. The patient was still a soldier and retained
in his neurosis the anxiety—an anxiety of similar situations. The
neurosis of another soldier, which for a long time had been considered
of an organic nature, a bulbar paralysis being suspected, was very
instructive and the success of the treatment most gratifying. This man
in addition to an apparently harmless superficial gunshot wound of the
back suffered from a spasm of the muscles of the throat, a dysphagia,
that made it impossible for him to take solid food, while liquid
food was only possible in small quantities. The spasm of the throat
and muscles of mastication turned out to be “suppressed rage”. This
soldier who was cut off when on patrol was stealing alone through a
wood when he saw a comrade being ill-treated by Frenchmen on the main
road. This scene he reproduced fully and dramatically under hypnosis
in which he stealthily crawled about, ground his teeth together and
gnashed them in impotent rage over the scene which he had witnessed.
At that time he was struck in the back by a chance shot which caused
him to faint for a short time. He then succeeded in getting back to his
company and was sent into hospital on account of his superficial wound.
The living through this scene again with its accompanying emotions
completely freed him from his dysphagia. This example also shows how
repressed rage manifests itself as a more positive feeling tone through
physical increase of tonus in contrast to the previously described
cases with negative and depressed accentuation of feelings which are
physically represented by a lowering of tone and in flaccid paralyses.
Here an opportunity may be taken of alluding to the fact that one can
demonstrate without difficulty during hypnosis the displacement from
the psychical into the physical. If we interrupt the patient in the
abreaction of his rage during hypnosis then he reacts with a general
tremor or the tremor of an extremity which is already in some way
psychically affected.

Further I might mention the case of a neurotic who suffered from a
shaking tremor of the right arm with peculiar circular movements of the
thumb and fore-finger. This tremor had been removed by pure suggestive
methods, but one morning it returned, as the patient expressed it “by
itself”. On closer questioning he remembered that the shaking had
re-appeared in conjunction with a terrifying dream during the previous
night; the actual content of the dream he had forgotten. During
hypnosis the patient immediately became conscious again of the dream,
and by means of it of those events which still compelled him to shake
his arm. During the night he had dreamed of a Russian with a black
beard who sprang on to his bed in order to strangle him. He awoke in
anxiety and terror with his arm shaking. The patient had seen the face
of this Russian appear over the parapet during a furious hand grenade
fight just when he was on the point of fixing a grenade fuse and was
suddenly blown over. He lost consciousness with his rage undischarged
and an incipient movement which served as a mimic abreaction of this
anger.

From this example, to which I could add many more, it becomes evident
that dream material directly forces itself on the attention of the
intelligent psycho-therapeutists as of great assistance in the
treatment of war neuroses.

I do not treat any patients whose dreams I do not know. I have learnt
for a long time now to estimate the dreams of my war neurotic patients
as an attempt at self-healing, especially in the psycho-cathartic
sense. I never give drugs for the dreams of anxiety, terror and rage. I
am glad of the cooperation of the patient, I learn by listening to his
dreams his own tendency to cure, then I get him to continue the dream
under hypnosis where it has stopped the previous night, or, this I have
several times found successful, I cause the patient to continue in his
dreams at night from where the hypnosis has left off. Incidentally it
may be remarked that after all these experiences I look upon hypnosis
not as an artificial sleep but as a definite stage of natural sleep,
which by virtue of its artificial induction enables one to maintain a
direct rapport with the sleeper.

The initial stage of auto-hypnosis, hypnosis, and dreams represents the
same _niveau_ as that in which the germs of the illness lie embedded
and can be removed.

In corroboration of this view I might mention a patient who was in
a stuporose condition, with paralysis of all the limbs, and who was
also almost deaf and dumb. By means of suggestion _en masse_, _i.e_.
when lying down among other patients who were being hypnotised, it at
length became possible to hypnotise him. Even then the patient remained
completely stuporose. Only when his sister succeeded in getting from
him a few words concerning an anxiety dream, and after I had repeated
these words to him during hypnosis did marked excitation take place in
the stuporose man. The unconscious became sensitised and with effective
discharge came the recapitulation of the causative occurrence. The
patient having been forced by some jealous and stronger companions to
drag along some branches of trees was overturned into a mass of mud in
which he threatened to suffocate. The subconscious idea was that his
mouth and ears were filled with mud and his limbs pressed into it.
During hypnosis he cleared away this imaginary mud with all his might.

There are, on the other hand, patients who inversely take over the
impulse for curative discharge from the hypnosis into the dream. A
young lieutenant assisted thus very practically in the reduction of
his pent-up affects. For weeks after being blown up he was mentally
deranged and delirious, and still suffered from states of excitement
being unable to carry out the simplest intellectual processes, such as
counting, reading, etc. After the first hypnosis which brought about
a recapitulation of the most recent occurrences with a corresponding
discharge of affect, there followed an intense fury dream. The patient
wrenched out several iron bars from his bed and battered the wall with
them. In the dream he was striking a canal worker with them whom he
had seen daily from the window of the hospital. The conversation next
morning showed that the canal worker had the features of an orderly who
had wanted to detain him in the field hospital and thus prevent him
going back to the front to avenge his brother. The patient’s brother
had recently been killed whilst serving in the same regiment, and the
lieutenant had been fighting with fury and grief in order to avenge
him when he was blown up. His first delirious attack had been directed
against this particular orderly.

Sometimes one succeeded in directly stimulating the self-treatment of
the patient in the dream. I recollect a neurotic who suffered from
a severe disturbance of speech and also of walking, the result of a
spastic paralysis of the legs and muscles of the mouth in consequence
of a strong repression of rage. The discharge which took place
under hypnosis was so dangerous to those in the vicinity that I had
prematurely to break off the treatment. However, before waking the
patient I told him to discharge the unreleased part in his dream. I
let him sleep alone with an orderly. In the middle of the night he
sprang up and again lived through an experience of anxiety and rage
accompanied with shouting and raving, and although previously paralysed
he ran down the whole length of the staircase of the hospital.

An especially frequent symptom in the war neuroses—the convulsive
attacks—directly represents, in my opinion, an auto-hypnotic state
appearing in the form of an attack.

Being buried (as the result of an explosion) with its total
obliteration of the conscious ego, naturally the most frequent
originator of the war neuroses, acts most often as the first cause. The
loss of consciousness during the convulsive attack and the subsequent
amnesia is that beneficent not-knowing into which the neurotic person
flies before the memory of that all too horrible situation, or before
the knowledge of some act of his own which he may have to perform as
a result of his affective damming-up, but which nevertheless brings
him into grave danger. I have already in my earlier work alluded to
the fact that the physical form of expression of the convulsion varies
according to its unconscious symbolic meaning. The most frequent form
of the convulsion simply represents a repetition of those defence
movements which the patient made when he was threatened with being
shattered when he was buried. The convulsive attacks always take
place when the ideas regarding those events are subconscious, and the
strongly repressed affects which are bound to them, are associatively
stimulated. A door slammed, a thunder-clap, a distant shot, makes
the patient break down, and his previously unconscious anxiety idea
becomes over-weighted. Terror and dread of death here generally form
the primary basis for the dissociation of the psyche and for the
attack-like mastery of the conscious by the unconscious.

A soldier who has once been paralysed for a time through the emotion of
terror in his conscious ego is in many ways no longer in the position
to satisfy consciously the repression which the pressure of discipline
demands. It is almost always the anger towards his superiors which
brings on further convulsive attacks. During hypnosis, which lifts
the curtain of this originally hallucinated dream-action during the
attack, we see again and again the patient struggling with his highest
superiors. He strikes, bites, stabs and shoots them, treads them under
foot with terrible oaths. He here lets free the fiercest instincts
against persons who restrained his conscious ego.

It is quite explicable why these kinds of attacks before they come for
treatment are often associated with mutism. The patient denies himself
in a certain degree the faculty of speech, because he is afraid of
speaking certain words that might bring misfortune upon him.

In one case I succeeded even without hypnosis in directly making use
of the convulsive attacks of the patient for treatment. I was able to
become _en rapport_ with the patient in the attack so that he informed
me about the events which he actually hallucinated during the single
convulsive attack.

The sphere of the purely psychic war injuries without any physical
signs which can be treated in this way is also great. I mentioned
above a case of stupor. It is quite comprehensible that it is more
particularly the mental inhibitory phenomena which are accessible to
this treatment, because the cessation of mental processes is brought
about through an accumulation of affect which entirely owes its origin
to definite war occurrences. The psycho-catharsis as a foundation for a
further analytic treatment here works wonders.

I will take this opportunity of mentioning that as regards the war
neurotic an abreaction by means of words is mostly not sufficient in
this compressed form of treatment. The soldier is under the suggestion
of the deed “an eye for an eye, a tooth for a tooth”. His overburdened
subconscious now is freed by means of an acted abreaction. On account
of this I have for a long time proceeded to construct an upholstered
dummy against which the neurotic fighting in his primitive human
instinct victoriously frees himself.

The neuroses of anxiety and terror, so far as they have become manifest
through war experiences, can be treated successfully. Nevertheless, it
is to be noted that also in the feeling of guilt of the war neurotic
not only are real, specific and complex conditioned war atrocities
the inner kernel, but that things experienced only in phantasy may be
important.

One of the most frequent war psycho-neurotic symptoms represents what
after all is comprehensible without anything further, loss of memory.
It may extend over a limited period of the war or over the whole of
it, or even into pre-war times. The whole memory is blotted out in
order that definite things should not be brought to mind. When these
have once become conscious by means of the dream or hypnosis, and are
pondered over, the tendency of the unconscious is robbed of its objects
and the memory is again automatically re-introduced.

The frequent loss of other intellectual capabilities likewise is
mostly made good after sufficient discharge of affect. It is easy to
understand that just those capabilities which represent the person’s
highest art of sublimation, like artistic ones, would particularly
suffer through the war experiences. Thus, a not unknown painter when
a recruit in the war lost his ability for colour perception. My
suggestion during hypnosis that he should at night dream in a picture
the subconscious circumstances of his illness and then sketch it next
day he promptly carried out and therewith contributed to the removal of
a symptom which meant so much to him.

Regarding the condition of excitement and frenzy which I have had
ample opportunity of treating, I need say nothing further after what
has been said concerning the convulsive attacks. They represent
the positive side to the negative one of the convulsions. They are
evoked by association and refer in the direction of their affects to
definite persons or events that in a characteristic manner have more
or less been forgotten by the patients. The nature of the associative
production often enables one to recognise the typical neurotic
displacement, a projection outwards. There are numerous patients
of this kind who readily have an attack of rage at the sight of an
officer’s shoulder knot or a doctor’s overall, because they once had
had to repress their rage against a definite officer or doctor by
whom they had psychically felt themselves ill-used. A word further
concerning the psychic illness of the genuine pension neurosis. Here
again the interpretation of dreams particularly during hypnosis enables
us to decide whether we are dealing with a genuine war psycho-neurosis
or the frequently falsely accused conscious “ideas of covetousness”.
I have found that the real pension neurosis represents a kind of
inferiority neurosis. The patient values himself higher than he feels
he is valued by his environment. He has generally, in his opinion,
performed some special military achievement. He has counted on a
distinction or at least a certain promotion which he does not attain.
An illness or wound finally raises him above the general mass of the
unknown, and now the pension is the substitute for the missing iron
cross or the lance corporal’s button with which the patient endeavours
to prove his particular value in opposition to the state.

It can be understood that relapses occur in what is on the whole
a comparatively hasty treatment. However, with the help of the
pure analytic method described the character of the relapse can be
established without difficulty. Frequently it is solely a question of
the patients getting into the old surroundings through re-employment by
the military to which they are not psychically equal, and from which
they have escaped with the help of their neurosis, and now they in
defence react with a relapse.

On the other hand, it can frequently be established that the treatment
on account of its shortness has not removed all the unconscious
material. I might mention as an example a soldier who had suffered
from states of excitement and convulsive attacks. After two treatments
the states of excitement disappeared and within four weeks the attacks
had ceased. The patient had to be discharged in spite of the fact that
he still seemed somewhat distressed. After a few months he came back
into the hospital on account of a recurrence of the attacks. In the
treatment carried out when he had first been admitted into the hospital
only those things came to light which were connected with his being
blown up. During hypnosis on his second admission the patient said
that he still had the feeling as though “someone was behind him”. This
feeling of anxiety often increased so terribly that he would have a
convulsive attack. In this attack he constantly saw a dead Russian in
a white shirt who threateningly demanded back a gold ring which the
patient had taken from the Russian after killing him. This occurrence
the patient had completely forgotten, but after I had talked it over
with him when he was awake he became changed, alert and keen to work,
and was now permanently cured of his convulsions.

These theoretical points which I have supported by means of
practical examples will suffice for a primary representation of the
symptomatology of the war neuroses. It is impossible within the compass
of this contribution, with the abundance of material at my disposal, to
represent the numerous forms of the neuroses not mentioned here, and
still further as regards their unconscious conditionality.

In conclusion I should like to give a short description of the neurosis
of a young civil servant, which despite the brevity of the treatment
revealed with classical clearness a modified picture of the nature of
the neurotic predisposition and the actual outbreak of the illness.

This illness, when looked at from the outside, seemed to be a complete
war neurosis without any kind of “civilian” origin. The patient had
been for a long time in the field and constantly in the front line and
had been exposed to extraordinary hardships. He had been wounded and
only fell ill with his neurosis after being blown up twice. He had a
severe impediment in his speech in consequence of an almost complete
intention spasm of his lips, combined with states of excitement and
rage, and attacks of loss of consciousness. The first conversation
showed that all the physical disabilities signified nothing to the
patient, on the contrary, he was completely broken down in mind and
body through his struggles and friction with his superiors. In the
first dream the patient received a letter, which to his unbounded rage
his father had already opened, so that the red lining to the envelope
hung in shreds. In the hypnosis the patient during the reading aloud
of this dream underwent an extraordinary state of excitation, in which
he re-experienced his last blowing up with unspeakable anxiety and
terror. The red envelope lining was the torn out jaw bone of a dear
friend and comrade who had been shattered beside him at that explosion.
His relation to his father came out, with anger at the thought that he
(the father) did not esteem all the great performances which he had
accomplished in the field and communicated to him. The next dream after
this hypnosis brought up a scene between the father and son. The father
in the robe of the public prosecutor forbade his son, according to the
law, to speak with some women imprisoned and kept in an underground
dungeon. The son started up in anger and said that he had his own law
book which lay by one of those women. He went to get it and wandered
through underground passages. He found in several rooms earlier loved
women, but not his law book. At last he came into the last room and on
the threshold his mother met him in her nightdress.

I do not think I need to add many words to this audience to arrive at
the interpretation. The patient fulfilled his “law” when he volunteered
for the war, in order to put himself over his father through his
manliness and obtain his mother. The symbol of the envelope, which,
destined for the son, was unjustly opened by the father, is clear in
its significance. It is peculiar and interesting how in this letter,
which contained for the patient the secret of his life, is shown in
combined representation the uninterrupted connection of the origin and
outbreak of the neurosis—from the female genitals to the corpse of the
shattered friend, to the memory of the last complete breakdown of the
ego through the explosion.

I have come to the end of my remarks, and hope that I have proved that
the combined psycho-analytical method gives us to-day a true medical
treatment for war neurotics. Those doctors who have devised a system
of tortures, such as hunger cures, dark rooms, prohibition of letters,
painful electric currents, etc. in order to extort from the patients
the abandonment of their neurotic symptoms, unconsciously recognise the
Freudian theory by the inversion of its fundamental principles. They
make a torture of the treatment in order to force the neurotic “to flee
into health”. The doctor schooled in psycho-analysis does not need to
hound in the opposite direction his patients who have been driven into
illness. He releases him from the fetters of his unconscious mind and
thus is in the position to guide the neurotic into health and save him.




III.

WAR SHOCK AND FREUD’S THEORY OF THE NEUROSES[7]

By

DR. ERNEST JONES, London.


A matter that used to hamper the opponents of psycho-analysis to
some extent was that there was no alternative theory of the neuroses
seriously tenable. It was clearly impossible to explain all neurotic
manifestations by the catch-word use of the two terms “heredity” and
“suggestion”, for our conceptions of heredity, however important
in this connection they may well become in the future when more is
known of the subject, are at present too vague to explain any complex
psychological phenomena, and the idea of suggestion merely introduces
yet another problem without solving any of the old ones.

The experience of neurotic affections engendered by the war, however,
has enabled the critics of psycho-analysis to put forward the view
that the factors invoked by Freud in explanation of these affections
need not be present, and therefore cannot be regarded as essential,
in the way maintained by him, whereas, on the other hand, a different
set of factors is undeniably present and operative; not only so, but
these latter factors are held to be all-sufficing, so that it is not
necessary to search for any others in the ætiology of the conditions in
question. Some opponents of psycho-analysis, particularly those more
concerned with combating an unwelcome theory than with ascertaining
truth, have even maintained that the experience of the war has proved
_all_ Freud’s views to be utterly untenable and false.

It would be easy to criticise the standpoint thus adopted, though
that is in no sense my purpose here. Two points alone may be raised.
If, as some writers assert, the strain of war conditions is in itself
sufficient to account for the development of a psychoneurosis without
the introduction of any other factor, then how is one to explain the
actual incidence of war neuroses? Neurotic symptoms amounting to a
definite clinico-pathological condition are by no means so common as
is sometimes stated. I do not know of any statistics on the matter,
but I should be surprised to hear that more than 2 per cent. of the
Army serving in France are affected in this way. This consideration
in itself shews that some other factors than war strain must be
involved, factors relating to the previous disposition of the men
affected, and the problem is to determine what these are. In the
second place, as to the dogmatic assertion that Freud’s theory of the
psychoneuroses cannot apply to those arising under war conditions.
An essential feature of this theory is that psychoneuroses result
from unconscious mental conflicts. To ascertain whether these are
operative in a given case, therefore, it is obviously necessary to
employ some method, such as psycho-analysis, which gives access to
the unconscious. It may, I think, be taken as certain that those who
deny the action of these conflicts in either the war neuroses or in
what, by way of contradistinction, must be called the peace neuroses,
have not thought it necessary to use any such method, and they thus
place themselves in a position very similar to that of a writer who
would on _a priori_ grounds deny the details or even the existence of
histology without ever having looked through a microscope, the only
avenue to histology. I choose this simile because it seems to me that
the relation of psycho-analysis to clinical psychiatry is not at all
inaptly described[8] as being like that of histology to anatomy. Or
one might draw an analogy from a strictly medical field. If some one
were to take a series of cases of tuberculosis supervening on measles
or typhoid, and then maintain that because this ætiological factor was
present therefore no microorganism could be, so that Koch’s views as to
the causation of tuberculosis were entirely unfounded, one would surely
have the right to ask whether any search for the bacillus had been made
in the cases in question, and to satisfy oneself that the observer had
grasped the difference between essential and merely exciting causes of
disease. If the answer to both these inquiries were in the negative,
I think it will be agreed that no great weight would be attached to
the claim that Koch’s theory of the nature of tuberculosis had been
demolished. Yet this is precisely the order of scientific thinking
evinced by those who maintain that Freud’s theory of the neuroses
has been demolished by the simple observation that they may manifest
themselves under the stress of warfare.

I do not mean, however, to assert the contrary of this
proposition—namely, that the validity of Freud’s theory has been
proved in the case of war neuroses, as I should maintain it has been
in the case of peace neuroses. I simply hold that the matter is at
present _sub judice_, and must remain so until sufficiently extensive
investigations shall have settled the question one way or the other. It
so happens that the traumatic neuroses are the field in psychopathology
that has hitherto been the least explored by psycho-analysis even in
peace time, while the opportunity of psycho-analytic investigation of
the war neuroses has, in this country at least, been so meagre that
the time is not ripe for any generalisation on the subject. Personally
I have examined a considerable number of cases in the cursory way
that is usual in hospital work, but I have been able to make an
intensive study in only some half-dozen cases, and I do not know of
any other cases that have been investigated by the psycho-analytic
method. In spite of this paucity of material, a feature inherent in
intensive work, the critic of psycho-analysis may legitimately demand
of the analyst, who advances considerable pretensions in regard to
understanding the pathology of neurotic affections in general, that he
should be able to formulate some tentative conception of the relation
between the phenomena commonly observed in the war neuroses and the
psycho-analytical theory. In the following remarks an attempt will
be made to meet this demand, although, as has just been explained,
there can be no question of solving the numerous and as yet unstudied
problems raised by the observations made in connection with war shock.

It is desirable in the first place to clear away some general
misconceptions on the subject. The task of assimilating our new
experiences in connection with the war with any previously held theory
of neurotic affections has undoubtedly been rendered more difficult by
the attitude of those workers whose interest in such problems is of
contemporary origin. They lay much too much emphasis on the newer and
perhaps more sensational aspects of the phenomena observed, instead
of trying to correlate the more familiar and better understood ones.
This attitude has been so pronounced with some writers that one
might almost imagine that before the war there had never been such
calamities as wrecks, earthquakes, and railway accidents, and that men
had never been tried to the limit of their endurance with privation,
fatigue, and danger, while familiar symptoms like hysterical blindness
and paralysis are thought worthy of detailed description and are
treated almost as novelties in psychological medicine. So far as I
know, however, although some symptoms—e.g., dread of shells—assume a
form that is coloured by war experiences, no symptom, and hardly any
grouping of symptoms, occurs in war neuroses that is not to be met
with in the neuroses of peace, a fact which in itself would suggest
that fundamentally very similar agents must be at work to produce the
neurosis in both cases.

Another very prevalent misconception, one strengthened by the official
use of that unfortunate catch-word “shell-shock”, is that war neuroses
constitute a more or less unitary syndrome. It is so often forgotten
that the term “shell-shock” can only mean, and no doubt was originally
intended to mean, a certain ætiological factor, and not the disease
itself. I have preferred to use the less ambiguous and more obviously
ætiological term “war-shock,” one coined, I think, by Eder[9]. Even
when the term “shell-shock” is avoided, its place is usually taken
by the all-embracing expression “neurasthenia”—in most cases, in
fact, where there are no physical symptoms of hysteria present. True
neurasthenia in its strict sense, on the contrary, is a relatively rare
complaint, certainly in anything like a pure form; I have not come
across a single case myself in connection with the war. The results
of war strain are anything but unitary; most of the diverse forms of
neurosis and psychoneurosis are found to be represented, and until
these are adequately distinguished one from another it is impossible to
make any satisfactory study of their individual pathology. A further
point still more often overlooked, and perhaps even more important,
is that not only are the results diverse, but the ætiological factors
concerned in war strain are much more complex than is sometimes
realised. Careful study of the cases shews that what was the most
important pathogenetic agent with one patient had nothing to do with
the neurosis of a second patient, although he may have been equally
exposed to its influence. For instance, the sight of a near friend
being killed may have greatly affected one soldier and been closely
related to his subsequent neurosis, whereas with a second patient who
has gone through the same experience there may be no connection between
it and _his_ neurosis; the same applies to the other painful features
of warfare, the tension of waiting under shell fire, the experience
of being buried alive, and so on. These considerations indicate the
great importance of the individual factor predisposing to particular
neurotic reactions, and point to the necessity for careful dissection
of the various pathogenetic factors in a number of cases before making
generalisations as to the way in which the numerous separate influences
grouped together as war strain may operate.

Coming now to the points of contact between war experience and Freud’s
theory, one may remark, to begin with, how well the facts of the war
itself accord with Freud’s view of the human mind as containing beneath
the surface a body of imperfectly controlled and explosive forces
which in their nature conflict with the standards of civilisation.
Indeed, one may say that war is an official abrogation of civilised
standards. The manhood of a nation is in war not only allowed, but
encouraged and ordered to indulge in behaviour of a kind that is
throughout abhorrent to the civilised mind, to commit deeds and
witness sights that are profoundly revolting to our æsthetic and moral
disposition. All sorts of previously forbidden and buried impulses,
cruel, sadistic, murderous and so on, are stirred to greater activity,
and the old intrapsychical conflicts, which, according to Freud, are
the essential cause of all neurotic disorders, and which had been dealt
with before by means of “repression” of one side of the conflict, are
now reinforced, and the person compelled to deal with them afresh under
totally different circumstances.

It is plain, as MacCurdy has well pointed out[10], that men entering
the Army, and particularly on approaching the battle-field, have to
undergo a very considerable readjustment of their previous attitudes of
mind and standards of conduct, a readjustment which is much greater in
the case of some men than in that of others, and also one which some
men find it much more easy to accomplish satisfactorily than do others.
The man’s previous standards of general morality, of cleanliness and
æsthetic feeling, and of his relation to his fellow-man, have all to
undergo a very considerable alteration. In all directions he has to
do things that previously were repugnant to his strongest ideals.
These ideals are ascribed by some—e.g., Trotter[11], and, following
him, MacCurdy—to the operation of the herd instinct, in other words to
the influence of the social _milieu_ in which he may happen to have
been brought up. I think personally that behind this influence there
are still deeper factors at work of a more individual order, derived
essentially from hereditary tendencies and the earliest relation of the
child to its parents. However this may be, it is certain that every one
has such ideals, though he may not describe them under this name, and
that in the course of development he insensibly builds up a series of
standards of which his ego approves—and which I therefore propose to
refer to by Freud’s term of the “ego ideal”—together with a contrasting
series of which his ego disapproves.

As every student of genetic psychology knows, this gradual building
up is never performed smoothly, but always after a number of both
conscious and unconscious internal conflicts between the conscious
ego on the one side and various impulses and desires on the other,
after a series of partial renunciations and compromises. Further, it
is exceptional for the whole result to be satisfactory; there always
remain certain fields—more especially in the realm of sex—where the
resolution of the conflict is an imperfect one, and it is just from
this imperfect resolution that, according to Freud, neurotic affections
arise. The question whether a neurosis will result in a given case
is essentially a quantitative one. The mind has the capacity of
tolerating without harm a certain amount of stimulation from these
internal impulses and desires that are not in unison with the ego,
and when this limit is passed the energy derived from them flows over
into neurotic manifestations. The mind has several methods for dealing
with the energy of the anti-ego impulses successfully—that is to say,
without the impairment of mental health—and it is only when these
methods are inadequate to deal with the whole that neurosis ensues.
Two of these methods may especially be noted. One is the deflection
of the energy in question from its primitive and forbidden goal to
another one in harmony with the more social standards of the ego; as
every schoolmaster knows, sport is an excellent example of this. When
the primitive goal was a sexual one, this process of deflection, here
on to a non-sexual goal, has been given the name of “sublimation”,
but there are similar refining and modifying processes at work in
connection with all anti-ego impulses—e.g., cruelty. A second method
is to keep the energy in a state of repression in the unconscious,
the conscious mind refusing to deal directly with it and guarding
itself against its influence by erecting a dam or barrier against
it, known as a reaction-formation. Thus in the case of primitive
cruelty, a cruel child may develop into a person to whom the very idea
of inflicting cruelty is alien and abhorrent, the original impulse
having been quite split off from the ego into the unconscious, and
its place taken in consciousness by the reaction-formation barrier of
horror and sensitiveness to pain and suffering. In such ways as these
a state of practical equilibrium is attained in the normal, the power
of the ego-ideal having proved sufficient either to utilise for its
own purposes (by means of modifying) or to keep at bay, the impulses
and desires that are out of harmony with it. In some people the state
of equilibrium thus attained is of considerable stability, they have
what is popularly called a reserve of mental and moral force with
which they can meet disappointments, difficulties, and emergencies of
various kinds in life, which means in practice that their capacity for
readjustment to radically new situations is fairly elastic.

Now, on approaching the field of war the readjustment necessary is one
of the more difficult ones experienced in life, although it is by no
means so difficult as can arise in various situations appertaining
to the field of sex. It is an adjustment which practice shews is
possible to the large majority of men, but there is no doubt that the
success with which it is carried out is extremely variable in different
people; and it probably varies in the same person from time to time
for either internal reasons or for external reasons relating to the
precise environment at the moment, to the precise war experiences
through which they may be passing. It is further clear that the
readjustment is likely to vary in its success almost entirely with
the success with which the earlier adjustments were made during the
development of the individual. This statement is meant to carry more
than its obvious meaning that the more stable a man is the more surely
can he meet the problems and difficulties of warfare; it has a deeper
implication. Namely, there is an important relationship between the
two phases of difficult adjustment, the current one and the older
one. Fundamentally it is the same difficulty, the same conflict; it
is only the form that is different. Let us suppose, for instance,
that the original difficulty in adjustment was over the matter of
cruelty, that in childhood the conflict between strong tendencies of
this kind and perhaps specially strong ideals of the contrary sort was
an exceptionally sharp one, so that it was never very satisfactorily
resolved, though a working equilibrium may have been established on the
basis of powerful reaction-formations and various protective devices
for avoiding in every possible way contact with the subject of cruelty.
Such a man may well have unusual difficulty in adapting himself to
the cruel aspects of war, which really means that his long-buried and
quite unconscious impulses to cruelty, impulses the very possibility of
whose existence he would repudiate with horror, are stimulated afresh
by the unavoidable sights and deeds of war. In bayonet practice, for
instance, the man is taught how best to inflict horrible injuries, and
he is encouraged to indulge in activities of this order from the very
thought of which he has all his life been trying to escape. He now has
to deal afresh with the old internal conflict between the two sides of
his nature, with the added complication that there has to take place
an extensive revaluation of his previous standards, and in important
respects an actual reversal of them. He has to formulate new rules of
conduct, to adopt new attitudes of mind, and to accustom himself to the
idea that tendencies of which he had previously disapproved with the
whole strength of his ego-ideal are now permissible and laudatory under
certain conditions. One would get a very erroneous view of the picture
I am trying to draw if one imagined that the process of readjustment
in question goes on in the person’s consciousness. This is never
entirely true, and often not at all true; the most important part of
the readjustment, and often the whole of it, is quite unconscious.
We thus see that to obtain a proper understanding of the problems
of an individual case, and to be able to deal with them practically
in therapeutics, it is often necessary to appreciate the relation
between a current conflict and an older one, for the real strength and
importance of the current one is often due to the fact that it has
aroused buried and imperfectly controlled older ones.

I have taken the one instance of cruelty, but there are many others
in connection with warfare. It may, indeed, be said in general that
the process of re-adaptation in regard to war consists of two distinct
sides: on the one hand, war effects an extensive release of previously
tabooed tendencies, a release shewn in endless ways—for instance, even
in the language of camps; and on the other hand the acquiring of a
strict discipline and self-control along lines widely different from
those of peace-times. The one is a correlative of the other, and we
have perhaps in these considerations a psychological explanation of the
feature of military life that is so puzzling to most civilians—namely,
the extraordinary punctiliousness that a rigid discipline attaches to
matters which to the outsider appear so trivial. An indisciplined army
has always been the bane of commanders, and perhaps the risks attaching
to indiscipline are related to the release of imperfectly controlled
impulses that war deliberately effects.

The way in which a relative failure in war adaptation may lead to a
neurosis can be illustrated by a parallel drawn from the more familiar
problems of peace neuroses. Imagine a young woman who has never been
able to reconcile the sexual sides of her nature with her ego ideal,
and whose only way of dealing with that aspect of life has been to
keep it at as great a distance from her consciousness as possible. If
now she gets married, it may happen that she will find it impossible
to effect the necessary reconciliation, and that, being deprived of
the _modus vivendi_—namely, the keeping sexuality at a distance—which
previously made it possible to maintain a mental equilibrium, she
develops a neurosis in which the repressed sexual desires achieve a
symbolic and disguised expression. Similarly in a war neurosis when
the old adjustment between the ego-ideal and the repressed impulses is
taken away, it may prove impossible to establish a fresh one on the new
conditions, and then the repressed impulses will find expression in
some form of neurotic symptom.

So far as I can judge, the specific problems characteristic of the war
neuroses are to be found in connection with two broad groups of mental
processes. One of these relates to the question of war adaptation
considered above, the other to that of fear. The latter is hardly to
be regarded as a sub-group of the former, inasmuch as there is no
readjustment or transvaluation of values concerned, as there typically
is with the former. The moral attitude towards fear, and the conflicts
arising in connection with it, remain the same in war as in peace.
In both cases it is considered a moral weakness to display or be
influenced by fear, and especially to give in to it at the cost of
not doing one’s duty. The soldier who would like to escape from shell
fire is, so far as moral values are concerned, in the same position as
a man in peace-time who will not venture his life to save a drowning
child. Indeed, the conflict cannot be as sharp in the case of the
soldier, for he would find very widespread and thorough sympathy for
his quite comprehensible desire, and there would be much less social
blame or guilt attaching to him than to the man in the other situation
mentioned. So that the problem of fear, which we all agree plays a
central part in connection with the typical war neuroses, seems to be
apart from that of war adaptation in general as expounded above.

Before discussing the problem of fear, however, I should like at this
point to review the position and see how far we have got in the attempt
to approximate the facts of war neuroses to the psycho-analytical
theory. This theory of the neuroses is a very elaborate one, including
many problems of unconscious mechanisms, distinctions between the
predispositions and mechanisms characteristic of the different
neuroses, and so on, but it is possible to formulate the main
principles of it along fairly simple lines, and I now propose to do
this in a series of statements.

(1) The first principle in Freud’s theory of neurotic symptoms is
that they are of volitional origin. This principle, long suspected by
both the medical and the lay public, and the real reason why in the
past they have been so confounded with malingering, would be at once
evident were it not for the fact that it is not true of volition in
the ordinary sense of conscious deliberate voluntary purpose. In other
words, it is not true of the will as a whole, but only of a part of
it—namely, a part that the patient is not aware of. Thus, neuroses
are not diseases or accidents that happen to a person, as the French
school of psychopathology maintains, but are phenomena produced and
brought about by some tendency in the person’s mind, and for specific
purposes. Freud distinguishes three classes of motives that operate in
this way, one essential, the other two not. The indispensable one is an
unconscious desire to obtain pleasure by gratifying in the imagination
some repressed and dissociated impulse, a motive, therefore, arising
in the part of the mind that is not in harmony with the ego-ideal. A
second motive is to achieve some end in the outer world; for instance
sympathy from an unkind husband, which the person finds easier to do
by means of a neurosis than in other ways. The third set of motives
has the same purpose as the last, but may be distinguished from it
in that they concern the making use of an already existing neurosis
rather than the helping to bring one about. Both the latter sets
are usually, but not always, unconscious: more strictly, they are
preconscious—that is, they do not relate to deeply buried tendencies,
and so are correspondingly easy to reveal; Freud terms them the primary
and secondary “gain of illness” respectively. Now I take it that this
principle of volitional origin is no longer very widely questioned by
modern psychopathologists, and in the case of war neuroses the main
motives are visible and comprehensible enough—namely, the desire to
find some good reason for escaping from the horrors of warfare.

(2) The second principle is that all neurotic symptoms are the
product of an intrapsychical conflict which the person has failed
satisfactorily to resolve, and that they constitute a compromise
formation between the two conflicting forces. Here, again, I think that
those who have been investigating the psychology of war neuroses will
agree with this principle. MacCurdy,[12] in particular, has described
in great detail the conflict that arises in soldiers between, on the
one hand, the motives actuating to continuance at duty and concealment
of growing sense of incapacity and apprehension, and, on the other, the
awful sense of failure accompanying the sometimes almost overwhelming
desire to escape from the horrors of their position. The neurosis
offers a way out of this dilemma, the only way that the particular
person is able to find, and the actual symptoms, which are often
grossly incapacitating, such as blindness, represent the fulfilment
of the desire against which the man has been fighting. We reach,
therefore, the wish-fulfilment part of Freud’s theory.

(3) The third principle is that the operative wish that leads to the
creation of the neurosis is an unconscious one. Freud means this in
the full sense of the word, and in this sense the principle has not
yet been confirmed from the experience of the war neuroses. There are,
however, different degrees of unconsciousness of a mental process,
and the important point to Freud is not so much the degree of the
unawareness in itself—this being largely an index of the repression—as
the repression or dissociation that has led to the unawareness. What
he maintains is that the wish producing the neurosis is one that is
not in harmony with the ego-ideal, and which is therefore kept at as
great a distance as possible from it. Anyone who has read the touching
accounts given by MacCurdy or Rivers[13] of the shame that soldiers
feel at their increasing sense of fear, and the efforts they make to
fight against it, to conceal it from others, and if possible from
themselves, will recognise that the wish in question is one alien to
the ego-ideal and is well on in the first stages of repression, even if
it is half-avowed.

(4) The fourth principle is that current repressed wishes cannot
directly produce a neurosis, but do so only by reviving and reinforcing
the wishes that have been repressed in older unresolved conflicts.
According to Freud, a pathogenetic disappointment or difficulty in
readjustment leads first to an introversion or turning inwards of
feeling, and the wish that has been baulked seeks some other mode of
gratification. It tends to regress back to an older period of life,
and thus to become associated with similarly baulked and repressed
wishes belonging to older conflicts. It is the combination of these
two, the present and the old, that is the characteristic mark of the
pathogenesis of neurotic disorders as distinct from other modes of
reaction to the difficulties of life.

Freud considers that there are probably always three factors in the
causation of any neurosis: a specific hereditary predisposition,
secondly an unresolved infantile conflict which means that the person
has not satisfactorily developed past a given stage of individual
evolution—in other words, that he has been subjected to what is called
an “infantile fixation” at a given point in development, and thirdly
the current difficulty. There is a reciprocal relationship between
these three factors, so that if any one is especially pronounced the
others may be correspondingly less important. For instance, if the
hereditary factor is very pronounced then a person may become neurotic
from the quite ordinary experiences of childhood and adult life, for
he is incapable of dealing adequately with them. In the case of war
neuroses it is evident that the current factor is of the greatest
importance, being, indeed, the only one that so far has attracted
attention. The only traces of infantile factors I have seen noted have
been the instances where the localisation of hysterical symptoms seems
to have been determined in part by the site of old injuries, and in
a general way the many traits of childhood, such as sensitiveness to
slights, self-centredment, and desire to be guarded, protected, and
helped, which are sometimes very evident in the cases of war neurosis.

We thus see that only one half of the psycho-analytical theory has
so far been confirmed by the observations of war neuroses. According
to this theory, there are typically two sets of wishes concerned
in the production of any neurosis. One of these, the “primary gain
of illness”, a current one, alien to the conscious ego ideal, and
therefore half repressed and only half conscious—if that—has not only
been demonstrated by a number of observers, but has been shewn to
be of tremendous importance, and certainly the effects of treatment
largely turn on the way in which it is dealt with. The other factor,
the infantile and altogether repressed and unconscious one, which,
according to psycho-analysis, is also essential to the production of a
neurosis, has not been systematically sought for, though I have found
it in the few cases of which I have been able to make a full study. Its
presence or absence is a matter of greater theoretical importance than
might perhaps appear, even though its practical importance may often
not be great. For my own part I have the utmost difficulty in believing
that a current wish, however strong that is half conscious and
sometimes fully conscious can ever in itself produce a neurosis, for
it contradicts all one’s knowledge concerning the nature of neuroses,
as well as my experience, such as it is, of war neuroses themselves. I
would therefore urge that no conclusion is possible on the matter one
way or the other until adequate investigations have been carried out.
That it has its practical side also will be pointed out when we come to
consider the chronic cases where war neuroses pass over into peace ones.

(5) The principle of the psycho-analytical theory that has aroused the
strongest opposition is that the primary repressed wish ultimately
responsible for the neurosis is always of a sexual nature, so that the
conflict is between the two groups of instincts that go to make up
the whole personality, those concerned respectively with preservation
of the self and of the species. Dr. MacCurdy has suggested to me
that this is so only because, apart from war, there is no instinct
that comes into such strong conflict with the ego-ideal as does the
sexual one, but that in war the conflict between the instinct for
self-preservation and the ego-ideal is enough to lead to a neurosis.
This may seem very plausible, but I shall be surprised if it is
confirmed by future research. That a neurosis, which after all is a
disorder of the unconscious imagination, should arise from a conflict
between two states of mind that are fully in contact with reality would
be something entirely contradictory of our past experience, as would
also a neurosis arising from a conflict between two tendencies both
belonging to the ego. I shall venture to put forward an alternative
hypothesis presently when discussing the subject of fear, which we
have next to consider.

Freud states[14] that from one point of view all psychoneurotic
symptoms may be regarded as having been constructed in order to prevent
the development of fear—another point of contact between his theory
and the observers of war neuroses, who would surely agree that fear
is the central problem they have to deal with. By fear is here meant
rather the mental state of dread and apprehension, increasing even
into terror, and accompanied by well-marked bodily manifestations, a
state for which psychopathologists have agreed to use the term “morbid
anxiety” (or, shortly, “anxiety”) in a special technical sense as being
the nearest equivalent of the German word _Angst_.

Morbid anxiety is certainly the commonest neurotic symptom, and the
theory of its pathogenesis has been the occasion of a very great deal
of investigation,[15] with, in my opinion, very fruitful results. We
meet it in the form of a general apprehensiveness of impending danger
and evil, as the anxiety-neurosis, and also in hysteria in the form
both of apparently causeless attacks of dread and of innumerable
specific phobias. In all its forms its most striking feature is the
disproportion between its intensity and its apparent justification,
so that it seems at first sight extremely difficult to correlate with
the biological view of fear as a useful instinct that guards against
danger. Practically all modern investigations into its pathogenesis
agree that it stands in the closest relation with unsatisfied and
repressed sexuality, and, in my judgment, the conclusion that morbid
anxiety represents the discharge of repressed and unconscious sexual
hunger is one of the most securely established in the whole of
psychopathology; it is impossible here to consider the extensive
evidence in support of this conclusion, and I can only refer to the
published work on the subject[16].

The next question is: What is the relation between morbid anxiety as
seen in peace neuroses and real—_i.e_., objectively justified—fear, as
seen in various situations of acute danger and so prominently in the
war neuroses? The point of connection is the defensive character of
the reaction. Morbid anxiety, as we are familiar with it in the peace
neuroses, is a defensive reaction of the ego against the claims of
unrecognised “sexual hunger” (_Libido_), which it projects on to the
outside world—e.g., in the form of phobias—and treats as if it were an
external object; it is, in a word, the ego’s fear of the unconscious.
But there appears to be an important difference between it and “real”
dread in that the latter concerns only the ego itself, arises only in
connection with external danger to the ego, and has nothing to do with
the desires of repressed sexual hunger. One is tempted to say that the
latter (real dread) is a normal protective mechanism that has nothing
to do with the abnormal mechanism of morbid anxiety. Here, however,
as elsewhere, the line between normality and abnormality is not so
absolute as might appear, and consideration of the matter leads one
to examine more closely into the nature of real dread itself. We then
see that this can be dissected into three components, and that the
whole reaction is not appropriate and useful as is commonly assumed.
The reaction to external danger consists normally of a mental state
of fear, which will be examined further in a moment, and in various
activities suited to the occasion—flight, concealment, defence by
fighting, or even sometimes by attacking. On the affective side there
is, to begin with, a state of anxious preparedness and watchfulness,
with its sensorial attentiveness and its motor tension. This is clearly
a useful mental state, but it often goes on further into a condition
of developed dread or terror which is certainly the very reverse of
useful, for it not only paralyses whatever action may be suitable, but
even inhibits the functioning of the mind, so that the person cannot
judge or decide what he ought best to do were he able to do it. The
whole reaction of “real” fear is thus seen to consist of two useful
components and one useless one, and it is just this useless one that
most resembles in all its phenomena the condition of morbid anxiety.
Further, there is seen to be a complete lack of relation between
development of dread and the degree or imminence of danger, nor does it
bear any relation to the useful defensive activities. Thus, one does
not flee because one is frightened, but because one perceives danger;
in situations of extreme danger men very often respond with suitable
measures of flight, fight, or what not, when they are not in the least
degree frightened; on the other hand, the neurotic can be extremely
frightened when there is no external danger whatever. The inference
from these considerations is that even in situations of real danger a
state of developed dread is not part of the useful biological mechanism
of defence, but is an abnormal response akin to the neurotic symptom of
morbid anxiety.

In a recent publication[17] Freud has made the striking suggestion
that the developed dread sometimes found in situations of real danger
is derived, not from the repressed sexual hunger that is directed
towards external objects, as is the case with morbid anxiety of the
peace neuroses, but from the narcissistic part of the sexual hunger
that is attached to the ego, and I venture to suggest that we may here
have the key to the states of terror with which we are so familiar in
the war neuroses. The psycho-analytic investigations of recent years
have laid increasing stress on the distinction between “object-libido”,
the sexual impulses that are directed outwards, and the “ego-libido”,
the narcissistic portion that is directed inwards and constitutes
self-love. There is good reason to suppose that the latter is the
more primary of the two, and also the more extensive—though the least
explored as yet—so that it constitutes, as it were, a well from which
externally directed sexuality is but on overflow. The analogy naturally
occurs to one of the protoplasmic outpourings in the pseudopodia of
the amœba, and the reciprocal relation of these to the main body
seems to be similar to that between love of others and self-love. It
has been known for some time that there is a limit on the part of the
organism to tolerate without suffering more than a given quantity of
sexual hunger in its familiar sense of impulses directed outwards, and
analytic study of the psychoses, notably of paraphrenia, has shewn
that the same is even more profoundly true of the narcissistic sexual
hunger. In both cases, before other symptoms are formed so as to deal
with the energies in question and bind them, the first thing that
happens is a discharge in the form of morbid anxiety, so that we reach
the comforting conclusion that a normal man would be entirely free from
dread in the presence of any danger, however imminent, that he would be
as fearless as Siegfried; it is a gratifying thought that there seem
to be many such in our Army to-day. It seems to me probable that the
intolerance of narcissistic sexual hunger which leads to dread in the
presence of real danger is to be correlated with the inhibition of the
other manifestations of the fear instinct, with the accumulated tension
characteristic of the mode of life in the trenches.

I would suggest, therefore, that investigations be undertaken from
this point of view with cases of war neurosis, especially the anxiety
cases. Many of the features noted by MacCurdy[18], for instance,
accord well with the picture of wounded self-love: thus, the lack of
sociability, the sexual impotence and lack of affection for relatives
and friends, the feeling that their personality has been neglected,
or slighted, that their importance is not sufficiently recognised,
and so on. Perhaps a new light may also be thrown in this way on the
attitude of such patients towards death. I understand that a great part
of the war neurotic symptoms, and the battle dreams in particular,
have been widely interpreted as symbolising the desire to die so as
to escape from the horrors of life, an interpretation that does not
accord well with the equally widespread view that the fundamental
cause of such neuroses is a fear of death. I greatly doubt, on the
contrary, whether the fundamental attitude is either a fear of death
in the literal sense or a desire for death. The conscious mind has
difficulty enough in encompassing in the imagination the conception
of absolute annihilation, and there is every reason to think that the
unconscious mind is totally incapable of such an idea. When the idea of
death reaches the unconscious mind it is at once interpreted in one of
two ways: either as a reduction of essential vital activity, of which
castration is a typical form, or as a state of nirvana in which the ego
survives, but freed from the disturbances of the outer world.

A word in conclusion as to the therapeutic aspects of psycho-analysis
in the war neuroses. Even if it were possible, I see no reason whatever
why a psycho-analysis should be undertaken in the majority of the
cases, for they can be cured in much shorter ways. But I consider that
a training in psycho-analysis is of the very highest value in treating
such cases, from the understanding it gives of such matters as the
symbolism of symptoms, the mechanisms of internal conflict, the nature
of the forces at work, and so on, and there is certainly a considerable
class of cases where psycho-analysis holds out the best, and sometimes
the only, prospect of relief—namely, in those chronic cases where
the war neurosis proper has, by association of current with older
conflicts, passed over into a peace neurosis and become consolidated as
such.

FOOTNOTES:

[1] I shall only here take into consideration the most important
publications out of the enormous amount of neurological literature of
the war, and only in so far as this refers to psycho-analysis. I am
indebted to Dr. M. Eitingon and Prof. Dr. A. v. Sarbó for access to the
necessary authorities.

[2] One of Oppenheim’s critics has suggested that these words so
difficult to pronounce might be used as test words in the examination
of paralytic disturbances of speech, so that they might at least be of
some good.

[3] These facts have been confirmed in the course of the conference by
all taking part in the discussions.

[4] (“_Münchner Mediz. Wochenschrift_”. 1918, No. 42, P. 1150.)

[5] The hallucinations, which those persons who having had an
amputation experience, that that part of the body which has been taken
away is still there, might find an explanation from this source.

[6] The intention of the medical department of the Prussian War
Ministry in regard to the organisation of psycho-analytical treatment
stations was not carried out in consequence of the altered political
situation, which took place soon after the Congress.

[7] Read before the Royal Society of Medicine, Section of Psychiatry,
April 9, 1918. Published in the Proceedings, Vol. XI. Reprinted in
“Papers on Psycho-Analysis”: Jones, 2nd. Ed. 1918, Ch. XXXIII, p. 564.
(Baillière, Tindall & Cox.).

[8] By Freud, “Allgemeine Neurosenlehre”, 1917, S. 286.

[9] Eder, “War Shock,” 1917.

[10] MacCurdy, “War Neuroses”, _Psychiatric Bull._, July, 1917, pp.
252, 253.

[11] Trotter, “Instincts of the Herd in Peace and War”, 1916.

[12] MacCurdy, _op. cit._

[13] Rivers, “The Repression of War Experience”, _Proceedings of the
Royal Society of Medicine_, 1918, xi (Sect. of Psych.), p. 1, Dec. 4,
1917.

[14] Freud, _op. cit._, S. 470.

[15] The latest discussion of the subject will be found in Freud’s
“Allgemeine Neurosenlehre,” 1917, chapter xxv, “Die Angst”. See also
his papers in “Sammlung kleiner Schriften zur Neurosenlehre,” 1906,
chapters v, vi, vii, and a general review of the subject in my “Papers
on Psycho-Analysis,” 2nd ed., 1918, chapter xxvii, “The Pathology of
Morbid Anxiety”.

[16] _See_ also Stekel, “Angstzustände,” 2e. Aufl., 1912.

[17] Freud, _op. cit._, S. 502.

[18] MacCurdy, _op. cit._, pp. 269-272.