Part 5

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

III.

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

By

DR. ERNEST JONES, London.

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

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

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

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

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