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diff --git a/.gitattributes b/.gitattributes new file mode 100644 index 0000000..d7b82bc --- /dev/null +++ b/.gitattributes @@ -0,0 +1,4 @@ +*.txt text eol=lf +*.htm text eol=lf +*.html text eol=lf +*.md text eol=lf diff --git a/LICENSE.txt b/LICENSE.txt new file mode 100644 index 0000000..6312041 --- /dev/null +++ b/LICENSE.txt @@ -0,0 +1,11 @@ +This eBook, including all associated images, markup, improvements, +metadata, and any other content or labor, has been confirmed to be +in the PUBLIC DOMAIN IN THE UNITED STATES. + +Procedures for determining public domain status are described in +the "Copyright How-To" at https://www.gutenberg.org. + +No investigation has been made concerning possible copyrights in +jurisdictions other than the United States. Anyone seeking to utilize +this eBook outside of the United States should confirm copyright +status under the laws that apply to them. diff --git a/README.md b/README.md new file mode 100644 index 0000000..08b4380 --- /dev/null +++ b/README.md @@ -0,0 +1,2 @@ +Project Gutenberg (https://www.gutenberg.org) public repository for +eBook #55443 (https://www.gutenberg.org/ebooks/55443) diff --git a/old/55443-0.txt b/old/55443-0.txt deleted file mode 100644 index 9614f7c..0000000 --- a/old/55443-0.txt +++ /dev/null @@ -1,3014 +0,0 @@ -The Project Gutenberg EBook of Psycho-Analysis and the War Neuroses, by -Sándor Ferenczi and Karl Abraham and Ernst Simmel and Ernest Jones and Sigmund Freud - -This eBook is for the use of anyone anywhere in the United States and most -other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms of -the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you'll have -to check the laws of the country where you are located before using this ebook. - -Title: Psycho-Analysis and the War Neuroses - -Author: Sándor Ferenczi - Karl Abraham - Ernst Simmel - Ernest Jones - Sigmund Freud - -Release Date: August 27, 2017 [EBook #55443] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK PSYCHO-ANALYSIS AND WAR NEUROSES *** - - - - -Produced by Turgut Dincer and the Online Distributed -Proofreading Team at http://www.pgdp.net (This file was -produced from images generously made available by The -Internet Archive) - - - - - - - —————————————————————————————————————————————————————————————————————— - 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. - —————————————————————————————————————————————————————————————————————— - - - 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. - - - - - - -End of the Project Gutenberg EBook of Psycho-Analysis and the War Neuroses, by -Sándor Ferenczi and Karl Abraham and Ernst Simmel and Ernest Jones and Sigmund Freud - -*** END OF THIS PROJECT GUTENBERG EBOOK PSYCHO-ANALYSIS AND WAR NEUROSES *** - -***** This file should be named 55443-0.txt or 55443-0.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/5/5/4/4/55443/ - -Produced by Turgut Dincer and the Online Distributed -Proofreading Team at http://www.pgdp.net (This file was -produced from images generously made available by The -Internet Archive) - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the United -States without permission and without paying copyright -royalties. 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You may copy it, give it away or re-use it under the terms of -the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you'll have -to check the laws of the country where you are located before using this ebook. - -Title: Psycho-Analysis and the War Neuroses - -Author: Sándor Ferenczi - Karl Abraham - Ernst Simmel - Ernest Jones - Sigmund Freud - -Release Date: August 27, 2017 [EBook #55443] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK PSYCHO-ANALYSIS AND WAR NEUROSES *** - - - - -Produced by Turgut Dincer and the Online Distributed -Proofreading Team at http://www.pgdp.net (This file was -produced from images generously made available by The -Internet Archive) - - - - - - -</pre> - - -<div class="transnote"> -<p>The name Freund at page 8, which is likely to be a reference to Freud, has been corrected accordingly.</p> - -<p>The erroneous Roman number vli in footnote 15 is corrected to be vii just as a guess.</p> - -</div> - - - - -<p class="center">THE INTERNATIONAL<br /> -PSYCHO-ANALYTICAL<br /> -LIBRARY<br /><br /> - -<small>EDITED BY ERNEST JONES<br /><br /> - -NO. 2</small></p> - -<hr /> - -<p class="center">THE INTERNATIONAL PSYCHO-ANALYTICAL LIBRARY<br /> -NO. 2</p> - -<hr class="full" /> - -<h1><span class="gesperrt">PSYCHO-ANALYSIS</span><br /> - -<small><small>AND THE</small></small><br /> - -<span class="gesperrt">WAR NEUROSES</span></h1> - -<p class="center"><small>by<br /> - -Drs. S. FERENCZI (Budapest), KARL ABRAHAM (Berlin),<br /> -ERNST SIMMEL (Berlin) and ERNEST JONES (London)<br /> -<br /> - -Introduction by<br /> -Prof. SIGM. FREUD (Vienna)</small></p> - -<div class="figcenter" style="width: 150px;"> -<img src="images/mark.jpg" width="150" height="147" alt="" /> -</div> - -<table summary="publisher"><tr> -<td class="tdc" colspan="3">THE INTERNATIONAL PSYCHO-ANALYTICAL PRESS</td> -</tr><tr> -<td class="tdl">LONDON</td><td class="tdc">VIENNA</td><td class="tdr">NEW YORK</td> -</tr><tr> -<td class="tdc" colspan="3">1921</td> -</tr></table> - -<hr /> - -<p class="center"><small><small><small>Copyright, 1921<br /> -<br /> -C. Fromme, Printer, Vienna</small></small></small></p> - -<hr /> - -<h2>CONTENTS</h2> - -<table summary="contents" border="0"><tr> -<td class="tdr" colspan="3"><small>PAGE</small></td> -</tr><tr> -<td class="tdr vertt">I.</td><td class="tdl">Introduction by Prof. Sigm. Freud</td><td class="tdr"><a href="#Page_1">1</a></td> -</tr><tr> -<td class="tdr vertt">II.</td><td class="tdl">Symposium held at the Fifth International Psycho-Analytical -Congress at Budapest, September 1918:</td><td class="tdr"> </td> -</tr><tr> -<td class="tdl padl4" colspan="2">1. Dr. S. Ferenczi</td><td class="tdr"><a href="#Page_5">5</a></td> -</tr><tr> -<td class="tdl padl4" colspan="2">2. Dr. Karl Abraham</td><td class="tdr"><a href="#Page_22">22</a></td> -</tr><tr> -<td class="tdl padl4" colspan="2">3. Dr. Ernst Simmel</td><td class="tdr"><a href="#Page_30">30</a></td> -</tr><tr> -<td class="tdr vertt">III.</td><td class="tdl">War Shock and Freud’s Theory of the Neuroses, by Dr. -Ernest Jones</td><td class="tdr vertb"><a href="#Page_44">44</a></td> -</tr></table> - -<hr /> - -<p><span class="pagenum"><a name="Page_1" id="Page_1">1</a></span></p> - -<h2>I.<br /> - -INTRODUCTION</h2> - -<p class="center"><span class="smcap">By Professor Sigm. Freud</span>, Vienna.</p> - - -<p><span class="smcap">This</span> 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<span class="pagenum"><a name="Page_2" id="Page_2">2</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>With an impartial attitude and some willingness it should not be -difficult to find the way to further elucidation.</p> - -<p>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<span class="pagenum"><a name="Page_3" id="Page_3">3</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_4" id="Page_4">4</a></span> -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.</p> - -<p>Spring 1919.</p> - -<hr /> - -<p><span class="pagenum"><a name="Page_5" id="Page_5">5</a></span></p> - -<h2>II.<br /> - -SYMPOSIUM</h2> - -<p class="center">HELD AT THE<br /> -FIFTH INTERNATIONAL PSYCHO-ANALYTICAL CONGRESS<br /> -BUDAPEST, SEPTEMBER 1918<br /><br /></p> - -<h3>1. <span class="smcap">Dr. S. Ferenczi</span>, Budapest.</h3> - -<p class="p padl4"> -<em>Ladies and Gentlemen</em>,<br /> -</p> - -<p><span class="smcap">With</span> 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.</p> - -<p><span class="pagenum"><a name="Page_6" id="Page_6">6</a></span></p> - -<p>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.</p> - -<p>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.</p> - -<p>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<a name="FNanchor_1_1" id="FNanchor_1_1"></a><a href="#Footnote_1_1" class="fnanchor">1</a>.</p> - -<p>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<span class="pagenum"><a name="Page_7" id="Page_7">7</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<a name="FNanchor_2_2" id="FNanchor_2_2"></a><a href="#Footnote_2_2" class="fnanchor">2</a>.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_8" id="Page_8">8</a></span></p> - -<p>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.</p> - -<p>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 <em>interest</em> 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<span class="pagenum"><a name="Page_9" id="Page_9">9</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_10" id="Page_10">10</a></span> -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.</p> - -<p>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.</p> - -<p>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” dis<span class="pagenum"><a name="Page_11" id="Page_11">11</a></span>turbance -in the nerve tissues; a disturbance that can be set right by -means of psychic influences can itself have been nothing else than -psychical.</p> - -<p>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.</p> - -<p>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?</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 neuro<span class="pagenum"><a name="Page_12" id="Page_12">12</a></span>logical -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”.</p> - -<p>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”.</p> - -<p>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.</p> - -<p>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”.</p> - -<p><span class="pagenum"><a name="Page_13" id="Page_13">13</a></span></p> - -<p>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.</p> - -<p>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 <em>ab ovo</em> 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<span class="pagenum"><a name="Page_14" id="Page_14">14</a></span> -“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.</p> - -<p>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 <em lang="fr" xml:lang="fr">arc de cercle</em> 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.</p> - -<p>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<span class="pagenum"><a name="Page_15" id="Page_15">15</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_16" id="Page_16">16</a></span> -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 <em>interpret</em> 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.</p> - -<p>I will now speak of the few authors who occupy themselves -with the war neuroses from the psycho-analytical points of view.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_17" id="Page_17">17</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 trau<span class="pagenum"><a name="Page_18" id="Page_18">18</a></span>matic -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.</p> - -<p>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<a name="FNanchor_3_3" id="FNanchor_3_3"></a><a href="#Footnote_3_3" class="fnanchor">3</a>.</p> - -<p>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.</p> - -<p>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 <em>increased ego-sensitiveness</em> -(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<span class="pagenum"><a name="Page_19" id="Page_19">19</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_20" id="Page_20">20</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_21" id="Page_21">21</a></span></p> - -<div class="figcenter" style="width: 500px;"> -<img src="images/i_p21.jpg" width="500" height="252" alt="" /> -</div> - -<p>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>i. e.</i> 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>i. e</i>. 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<a name="FNanchor_4_4" id="FNanchor_4_4"></a><a href="#Footnote_4_4" class="fnanchor">4</a>.</p> - -<hr /> - -<p><span class="pagenum"><a name="Page_22" id="Page_22">22</a></span></p> - -<h3>2. <span class="smcap">Dr. Karl Abraham</span>, Berlin.</h3> - - -<p><span class="smcap">During</span> 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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_23" id="Page_23">23</a></span> -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.</p> - -<p>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.</p> - -<p>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?</p> - -<p>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<span class="pagenum"><a name="Page_24" id="Page_24">24</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>Such men with labile heterosexual impulses need a support for<span class="pagenum"><a name="Page_25" id="Page_25">25</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_26" id="Page_26">26</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_27" id="Page_27">27</a></span> -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<a name="FNanchor_5_5" id="FNanchor_5_5"></a><a href="#Footnote_5_5" class="fnanchor">5</a>.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_28" id="Page_28">28</a></span> -wound there existed entire genital anaesthesia. Also here the psychosis -appeared to stand in close connection with the cessation of genital -manliness.</p> - -<p>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.</p> - -<p>Now as regards the question of the therapy and particularly that -of the psycho-analytic.</p> - -<p>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,<span class="pagenum"><a name="Page_29" id="Page_29">29</a></span> -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.</p> - -<p>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.</p> - -<p>The objection that psycho-analysis works too slowly does not -hold good as far as our experience goes up to the present.</p> - -<p>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<a name="FNanchor_6_6" id="FNanchor_6_6"></a><a href="#Footnote_6_6" class="fnanchor">6</a>.</p> - -<hr /> - -<p><span class="pagenum"><a name="Page_30" id="Page_30">30</a></span></p> - -<h3>3. <span class="smcap">Dr. Ernst Simmel</span>, Berlin.</h3> - - -<p><span class="smcap">For</span> 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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_31" id="Page_31">31</a></span> -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.</p> - -<p>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.</p> - -<p>The unconscious meaning of the <em>symptoms</em> 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 <em>symptomatology</em> 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 be<span class="pagenum"><a name="Page_32" id="Page_32">32</a></span>comes -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_33" id="Page_33">33</a></span></p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_34" id="Page_34">34</a></span></p> - -<p>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.</p> - -<p>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.</p> - -<p>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 <em>in cerebro</em>, a power of the unconscious that attracts to itself -the entire psychosis in a salutary manner.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_35" id="Page_35">35</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_36" id="Page_36">36</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_37" id="Page_37">37</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>The initial stage of auto-hypnosis, hypnosis, and dreams represents -the same <em lang="fr" xml:lang="fr">niveau</em> as that in which the germs of the illness lie embedded -and can be removed.</p> - -<p>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 <em lang="fr" xml:lang="fr">en masse</em>, <i>i.e</i>. -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<span class="pagenum"><a name="Page_38" id="Page_38">38</a></span> -mud and his limbs pressed into it. During hypnosis he cleared away -this imaginary mud with all his might.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_39" id="Page_39">39</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 <em lang="fr" xml:lang="fr">en rapport</em> with the patient in the attack so that he -informed me about the events which he actually hallucinated during -the single convulsive attack.</p> - -<p>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<span class="pagenum"><a name="Page_40" id="Page_40">40</a></span> -to definite war occurrences. The psycho-catharsis as a foundation for -a further analytic treatment here works wonders.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_41" id="Page_41">41</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_42" id="Page_42">42</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_43" id="Page_43">43</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<hr /> -<p><span class="pagenum"><a name="Page_44" id="Page_44">44</a></span></p> - -<h2>III.<br /> - -WAR SHOCK AND FREUD’S THEORY OF THE -NEUROSES<a name="FNanchor_7_7" id="FNanchor_7_7"></a><a href="#Footnote_7_7" class="fnanchor">7</a></h2> - -<p class="center">By<br /> - -<span class="smcap">Dr. Ernest Jones</span>, London.</p> - - -<p><span class="smcap">A matter</span> 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.</p> - -<p>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 <em>all</em> Freud’s views to be utterly untenable and false.</p> - -<p>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<span class="pagenum"><a name="Page_45" id="Page_45">45</a></span> -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 <em>a priori</em> 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<a name="FNanchor_8_8" id="FNanchor_8_8"></a><a href="#Footnote_8_8" class="fnanchor">8</a> 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.</p> - -<p>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<span class="pagenum"><a name="Page_46" id="Page_46">46</a></span> -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 <em>sub judice</em>, 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.</p> - -<p>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<span class="pagenum"><a name="Page_47" id="Page_47">47</a></span> -similar agents must be at work to produce the neurosis in both -cases.</p> - -<p>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<a name="FNanchor_9_9" id="FNanchor_9_9"></a><a href="#Footnote_9_9" class="fnanchor">9</a>. -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 <em>his</em> 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.</p> - -<p>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<span class="pagenum"><a name="Page_48" id="Page_48">48</a></span> -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.</p> - -<p>It is plain, as MacCurdy has well pointed out<a name="FNanchor_10_10" id="FNanchor_10_10"></a><a href="#Footnote_10_10" class="fnanchor">10</a>, 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<a name="FNanchor_11_11" id="FNanchor_11_11"></a><a href="#Footnote_11_11" class="fnanchor">11</a>, and, following him, MacCurdy—to -the operation of the herd instinct, in other words to the -influence of the social <em lang="fr" xml:lang="fr">milieu</em> 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.</p> - -<p>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<span class="pagenum"><a name="Page_49" id="Page_49">49</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_50" id="Page_50">50</a></span> -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<span class="pagenum"><a name="Page_51" id="Page_51">51</a></span> -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.</p> - -<p>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.</p> - -<p>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 <em>modus vivendi</em>—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.</p> - -<p>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 adapt<span class="pagenum"><a name="Page_52" id="Page_52">52</a></span>tation -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.</p> - -<p>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.</p> - -<p>(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<span class="pagenum"><a name="Page_53" id="Page_53">53</a></span> -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.</p> - -<p>(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,<a name="FNanchor_12_12" id="FNanchor_12_12"></a><a href="#Footnote_12_12" class="fnanchor">12</a> 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.</p> - -<p>(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<span class="pagenum"><a name="Page_54" id="Page_54">54</a></span> -kept at as great a distance as possible from it. Anyone who has read -the touching accounts given by MacCurdy or Rivers<a name="FNanchor_13_13" id="FNanchor_13_13"></a><a href="#Footnote_13_13" class="fnanchor">13</a> 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.</p> - -<p>(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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_55" id="Page_55">55</a></span></p> - -<p>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.</p> - -<p>(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<span class="pagenum"><a name="Page_56" id="Page_56">56</a></span> -presently when discussing the subject of fear, which we have next -to consider.</p> - -<p>Freud states<a name="FNanchor_14_14" id="FNanchor_14_14"></a><a href="#Footnote_14_14" class="fnanchor">14</a> 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 <em lang="de" xml:lang="de">Angst</em>.</p> - -<p>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,<a name="FNanchor_15_15" id="FNanchor_15_15"></a><a href="#Footnote_15_15" class="fnanchor">15</a> 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<a name="FNanchor_16_16" id="FNanchor_16_16"></a><a href="#Footnote_16_16" class="fnanchor">16</a>.</p> - -<p>The next question is: What is the relation between morbid anxiety -as seen in peace neuroses and real—<i>i.e</i>., 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” (<em>Libido</em>), which it projects on to the outside<span class="pagenum"><a name="Page_57" id="Page_57">57</a></span> -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.</p> - -<p>In a recent publication<a name="FNanchor_17_17" id="FNanchor_17_17"></a><a href="#Footnote_17_17" class="fnanchor">17</a> 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 to<span class="pagenum"><a name="Page_58" id="Page_58">58</a></span>wards -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.</p> - -<p>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<a name="FNanchor_18_18" id="FNanchor_18_18"></a><a href="#Footnote_18_18" class="fnanchor">18</a>, 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<span class="pagenum"><a name="Page_59" id="Page_59">59</a></span> -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.</p> - -<p>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.</p> - -<hr /> -<h2>FOOTNOTES:</h2> - -<div class="footnote"> - -<p><a name="Footnote_1_1" id="Footnote_1_1"></a><a href="#FNanchor_1_1"><span class="label">1</span></a> 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.</p></div> - -<div class="footnote"> - -<p><a name="Footnote_2_2" id="Footnote_2_2"></a><a href="#FNanchor_2_2"><span class="label">2</span></a> 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.</p></div> - -<div class="footnote"> - -<p><a name="Footnote_3_3" id="Footnote_3_3"></a><a href="#FNanchor_3_3"><span class="label">3</span></a> These facts have been confirmed in the course of the conference by all taking -part in the discussions.</p></div> - -<div class="footnote"> - -<p><a name="Footnote_4_4" id="Footnote_4_4"></a><a href="#FNanchor_4_4"><span class="label">4</span></a> (“<cite lang="de" xml:lang="de">Münchner Mediz. Wochenschrift</cite>”. 1918, No. 42, P. 1150.)</p></div> - -<div class="footnote"> - -<p><a name="Footnote_5_5" id="Footnote_5_5"></a><a href="#FNanchor_5_5"><span class="label">5</span></a> 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.</p></div> - -<div class="footnote"> - -<p><a name="Footnote_6_6" id="Footnote_6_6"></a><a href="#FNanchor_6_6"><span class="label">6</span></a> 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.</p></div> - -<div class="footnote"> - -<p><a name="Footnote_7_7" id="Footnote_7_7"></a><a href="#FNanchor_7_7"><span class="label">7</span></a> 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.).</p></div> - -<div class="footnote"> - -<p><a name="Footnote_8_8" id="Footnote_8_8"></a><a href="#FNanchor_8_8"><span class="label">8</span></a> By Freud, <span lang="de" xml:lang="de">“Allgemeine Neurosenlehre”</span>, 1917, S. 286.</p></div> - -<div class="footnote"> - -<p><a name="Footnote_9_9" id="Footnote_9_9"></a><a href="#FNanchor_9_9"><span class="label">9</span></a> Eder, “War Shock,” 1917.</p></div> - -<div class="footnote"> - -<p><a name="Footnote_10_10" id="Footnote_10_10"></a><a href="#FNanchor_10_10"><span class="label">10</span></a> MacCurdy, “War Neuroses”, <cite>Psychiatric Bull.</cite>, July, 1917, pp. 252, 253.</p></div> - -<div class="footnote"> - -<p><a name="Footnote_11_11" id="Footnote_11_11"></a><a href="#FNanchor_11_11"><span class="label">11</span></a> Trotter, “Instincts of the Herd in Peace and War”, 1916.</p></div> - -<div class="footnote"> - -<p><a name="Footnote_12_12" id="Footnote_12_12"></a><a href="#FNanchor_12_12"><span class="label">12</span></a> MacCurdy, <i>op. cit.</i></p></div> - -<div class="footnote"> - -<p><a name="Footnote_13_13" id="Footnote_13_13"></a><a href="#FNanchor_13_13"><span class="label">13</span></a> Rivers, “The Repression of War Experience”, <cite>Proceedings of the Royal Society -of Medicine</cite>, 1918, xi (Sect. of Psych.), p. 1, Dec. 4, 1917.</p></div> - -<div class="footnote"> - -<p><a name="Footnote_14_14" id="Footnote_14_14"></a><a href="#FNanchor_14_14"><span class="label">14</span></a> Freud, <i>op. cit.</i>, S. 470.</p></div> - -<div class="footnote"> - -<p><a name="Footnote_15_15" id="Footnote_15_15"></a><a href="#FNanchor_15_15"><span class="label">15</span></a> The latest discussion of the subject will be found in Freud’s “Allgemeine Neurosenlehre,” -1917, chapter xxv, <span lang="de" xml:lang="de">“Die Angst”</span>. See also his papers in <span lang="de" xml:lang="de">“Sammlung kleiner -Schriften zur Neurosenlehre,”</span> 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”.</p></div> - -<div class="footnote"> - -<p><a name="Footnote_16_16" id="Footnote_16_16"></a><a href="#FNanchor_16_16"><span class="label">16</span></a> <i>See</i> also Stekel, “<span lang="de" xml:lang="de">Angstzustände,</span>” 2e. Aufl., 1912.</p></div> - -<div class="footnote"> - -<p><a name="Footnote_17_17" id="Footnote_17_17"></a><a href="#FNanchor_17_17"><span class="label">17</span></a> Freud, <i>op. cit.</i>, S. 502.</p></div> - -<div class="footnote"> - -<p><a name="Footnote_18_18" id="Footnote_18_18"></a><a href="#FNanchor_18_18"><span class="label">18</span></a> MacCurdy, <i>op. cit.</i>, pp. 269-272.</p></div> - - - - - - - - - -<pre> - - - - - -End of the Project Gutenberg EBook of Psycho-Analysis and the War Neuroses, by -Sándor Ferenczi and Karl Abraham and Ernst Simmel and Ernest Jones and Sigmund Freud - -*** END OF THIS PROJECT GUTENBERG EBOOK PSYCHO-ANALYSIS AND WAR NEUROSES *** - -***** This file should be named 55443-h.htm or 55443-h.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/5/5/4/4/55443/ - -Produced by Turgut Dincer and the Online Distributed -Proofreading Team at http://www.pgdp.net (This file was -produced from images generously made available by The -Internet Archive) - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the United -States without permission and without paying copyright -royalties. 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