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Kaufmann method frequently relapsed when they were withdrawn from the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.