Part 2

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.