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) ââââââââââââââââââââââââââââââââââââââââââââââââââââââââââââââââââââââ Transcriberâs 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. ââââââââââââââââââââââââââââââââââââââââââââââââââââââââââââââââââââââ 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 Freudâs 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 âInternationale psychoanalytische Bibliothekâ, 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 Ferencziâs 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 (âflight into diseaseâ), 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 âsexualityâ is to be taken here in the broader sense customary in psycho-analysis, and not to be confused with the narrower sense of âgenitalityâ. 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 theâup to the present superficialâinvestigation 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 Abrahamâs 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 ânarcissistic sexual hunger (libido)â, 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 âdenial of loveâ, 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 âdenial of loveâ, 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 adoptedâwhich in some way corresponds to the materialistic idea of history in sociologyâcompletely 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 againâthe 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 scienceâpsycho-analysisâhas 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 âtraumatic neurosesâ 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 âcut outâ from the chain of the innervation mechanism, most delicate elements âdisplacedâ, paths âblockedâ, 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 Oppenheimâs 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. Wollenbergâs 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 âmindâ, also that of âfunctionalâ and âpsychicâ, and more especially that of âpsycho-genesisâ 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. SarbÃ³, 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. SarbÃ³âs 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 Basedowâs disease. StrÃ¼mpell 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 oneâs 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. StrÃ¼mpell 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 StrÃ¼mpell created a great impression in the medical world even in peace time; they led to the idea of the âcompensation hysteriaâ; the sufferers, however, were treated not much better than if they were malingerers. StrÃ¼mpell now suggests that the war neuroses are also neuroses of covetousness, which serve the patientsâ 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 wishâthe wish for material compensation, for remaining far from infections and dangerâand 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 StrÃ¼mpell 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 StrÃ¼mpellâs 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. StrÃ¼mpell 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 âa method of individual psycho-analysisâ. 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 MÃ¶rchen, BonhÃ¶ffer 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: âIn 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 stimulusâ. 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 âby means of a sudden abreaction through physical phenomenaâ. As the Freudian expression âabreactionâ 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 âmolecularâ 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 Charcotâs 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: âSudden 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 itselfâ. It is easy to recognise that this description is borrowed from the traumatic theory of Charcot and the Freudian conversion theory. Gauppâs opinion is similar: âIn 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 conditionâ. 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: âMuch 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 usâ. In another place he goes still further and puts the psycho-analytical postulate of the unconscious in the centre of the whole problem. âIf 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 disappearâ. 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 âunconscious further elaboration of the emotional factors along paths of least resistanceâ. Bonhoeffer seems to have completely accepted the psychologically complex experiences of psycho-analysis. He holds that the traumatic symptoms are âpsycho-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 emotionâ. 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 StrÃ¼mpellâs theory of covetousness) is summed up a psychogenic wish of hysteria, and says: âIf the psychogenic wish, the wish fixation, etc. is an essential component of hysteria then it belongs unconditionally in the definition of the disorderâ. 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 âfamous Freudian statementâ according to which the troubled mind flies into illness and he acknowledges that âthe compulsion which originates from this is more often unconscious than consciousâ. Liepmann divides the symptoms of the traumatic neuroses into the direct results of the psychic trauma and into âfinally adjusted psychic mechanismsâ. Schuster speaks of symptoms which are evoked by means of âunconscious processesâ. 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,âabreaction, unconscious, psychic mechanisms, separation of the affect from its idea, etc.,âwe 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, âwar neurosisâ. 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: âThe possibility of a psychopathological condition being evoked by psychogenic factors is the criterion of a degenerative predispositionâ. 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 âaetiological successionâ 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 endeavoursâwith successâto separate the complex idea of the âdispositionâ 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. âAttacks 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 disordersâ. You see, it is like a museum of glaring hysterical symptoms, and whoever has once seen it will plainly have to decline Oppenheimâs 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 âtremblingâ 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 âvolitional impulse makes a path for the spasmâ, 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 movementâand finally from the front lineâdoes 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 âthe 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 allâ. According to Hamburger the most frequently occurring type of disturbances of standing, walking and speech associated with shaking tremors represents a âcomplex of ideas of feebleness, weakness, refusal and exhaustionâ, and Gaupp sees in the same symptoms the lapse into infantile and puerile states of obvious helplessness. Some authors actually speak of the âfixationâ 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 âexpressions of fixations of movementsâ 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 âhowever one may feel towards themâ 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 Breuerâs 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 Freudâs 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 Freudâs 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 âsexualâ 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 oneâs own ego and body, partly under the rubric âerotismâ, otherwise âsexualityâ. It cannot be denied that those to whom this idea is strange cannot so easily be convinced of the correctness of Freudâs 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 Nonneâs 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 Freudâs 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 StrÃ¼mpell 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 Freudâs 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
{'title': 'Psycho-Analysis and the War Neuroses by Abraham, Ferenczi, Freud, Jones, and Simmel', 'source': 'Project Gutenberg', 'lang': 'en'}