Part 4

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it has appeared that the patients treated accordingly by the Kaufmann method frequently relapsed when they were withdrawn from the influence of the doctor, or were again exposed to the dangers of the front.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.