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.