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.
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.
Another very prevalent misconception, one strengthened by the official use of that unfortunate catch-word “shell-shock”, is that war neuroses constitute a more or less unitary syndrome. It is so often forgotten that the term “shell-shock” can only mean, and no doubt was originally intended to mean, a certain ætiological factor, and not the disease itself. I have preferred to use the less ambiguous and more obviously ætiological term “war-shock,” one coined, I think, by Eder[9]. Even when the term “shell-shock” is avoided, its place is usually taken by the all-embracing expression “neurasthenia”—in most cases, in fact, where there are no physical symptoms of hysteria present. True neurasthenia in its strict sense, on the contrary, is a relatively rare complaint, certainly in anything like a pure form; I have not come across a single case myself in connection with the war. The results of war strain are anything but unitary; most of the diverse forms of neurosis and psychoneurosis are found to be represented, and until these are adequately distinguished one from another it is impossible to make any satisfactory study of their individual pathology. A further point still more often overlooked, and perhaps even more important, is that not only are the results diverse, but the ætiological factors concerned in war strain are much more complex than is sometimes realised. Careful study of the cases shews that what was the most important pathogenetic agent with one patient had nothing to do with the neurosis of a second patient, although he may have been equally exposed to its influence. For instance, the sight of a near friend being killed may have greatly affected one soldier and been closely related to his subsequent neurosis, whereas with a second patient who has gone through the same experience there may be no connection between it and his neurosis; the same applies to the other painful features of warfare, the tension of waiting under shell fire, the experience of being buried alive, and so on. These considerations indicate the great importance of the individual factor predisposing to particular neurotic reactions, and point to the necessity for careful dissection of the various pathogenetic factors in a number of cases before making generalisations as to the way in which the numerous separate influences grouped together as war strain may operate.
Coming now to the points of contact between war experience and Freud’s theory, one may remark, to begin with, how well the facts of the war itself accord with Freud’s view of the human mind as containing beneath the surface a body of imperfectly controlled and explosive forces which in their nature conflict with the standards of civilisation. Indeed, one may say that war is an official abrogation of civilised standards. The manhood of a nation is in war not only allowed, but encouraged and ordered to indulge in behaviour of a kind that is throughout abhorrent to the civilised mind, to commit deeds and witness sights that are profoundly revolting to our æsthetic and moral disposition. All sorts of previously forbidden and buried impulses, cruel, sadistic, murderous and so on, are stirred to greater activity, and the old intrapsychical conflicts, which, according to Freud, are the essential cause of all neurotic disorders, and which had been dealt with before by means of “repression” of one side of the conflict, are now reinforced, and the person compelled to deal with them afresh under totally different circumstances.
It is plain, as MacCurdy has well pointed out[10], that men entering the Army, and particularly on approaching the battle-field, have to undergo a very considerable readjustment of their previous attitudes of mind and standards of conduct, a readjustment which is much greater in the case of some men than in that of others, and also one which some men find it much more easy to accomplish satisfactorily than do others. The man’s previous standards of general morality, of cleanliness and æsthetic feeling, and of his relation to his fellow-man, have all to undergo a very considerable alteration. In all directions he has to do things that previously were repugnant to his strongest ideals. These ideals are ascribed by some—e.g., Trotter[11], and, following him, MacCurdy—to the operation of the herd instinct, in other words to the influence of the social milieu in which he may happen to have been brought up. I think personally that behind this influence there are still deeper factors at work of a more individual order, derived essentially from hereditary tendencies and the earliest relation of the child to its parents. However this may be, it is certain that every one has such ideals, though he may not describe them under this name, and that in the course of development he insensibly builds up a series of standards of which his ego approves—and which I therefore propose to refer to by Freud’s term of the “ego ideal”—together with a contrasting series of which his ego disapproves.
As every student of genetic psychology knows, this gradual building up is never performed smoothly, but always after a number of both conscious and unconscious internal conflicts between the conscious ego on the one side and various impulses and desires on the other, after a series of partial renunciations and compromises. Further, it is exceptional for the whole result to be satisfactory; there always remain certain fields—more especially in the realm of sex—where the resolution of the conflict is an imperfect one, and it is just from this imperfect resolution that, according to Freud, neurotic affections arise. The question whether a neurosis will result in a given case is essentially a quantitative one. The mind has the capacity of tolerating without harm a certain amount of stimulation from these internal impulses and desires that are not in unison with the ego, and when this limit is passed the energy derived from them flows over into neurotic manifestations. The mind has several methods for dealing with the energy of the anti-ego impulses successfully—that is to say, without the impairment of mental health—and it is only when these methods are inadequate to deal with the whole that neurosis ensues. Two of these methods may especially be noted. One is the deflection of the energy in question from its primitive and forbidden goal to another one in harmony with the more social standards of the ego; as every schoolmaster knows, sport is an excellent example of this. When the primitive goal was a sexual one, this process of deflection, here on to a non-sexual goal, has been given the name of “sublimation”, but there are similar refining and modifying processes at work in connection with all anti-ego impulses—e.g., cruelty. A second method is to keep the energy in a state of repression in the unconscious, the conscious mind refusing to deal directly with it and guarding itself against its influence by erecting a dam or barrier against it, known as a reaction-formation. Thus in the case of primitive cruelty, a cruel child may develop into a person to whom the very idea of inflicting cruelty is alien and abhorrent, the original impulse having been quite split off from the ego into the unconscious, and its place taken in consciousness by the reaction-formation barrier of horror and sensitiveness to pain and suffering. In such ways as these a state of practical equilibrium is attained in the normal, the power of the ego-ideal having proved sufficient either to utilise for its own purposes (by means of modifying) or to keep at bay, the impulses and desires that are out of harmony with it. In some people the state of equilibrium thus attained is of considerable stability, they have what is popularly called a reserve of mental and moral force with which they can meet disappointments, difficulties, and emergencies of various kinds in life, which means in practice that their capacity for readjustment to radically new situations is fairly elastic.
Now, on approaching the field of war the readjustment necessary is one of the more difficult ones experienced in life, although it is by no means so difficult as can arise in various situations appertaining to the field of sex. It is an adjustment which practice shews is possible to the large majority of men, but there is no doubt that the success with which it is carried out is extremely variable in different people; and it probably varies in the same person from time to time for either internal reasons or for external reasons relating to the precise environment at the moment, to the precise war experiences through which they may be passing. It is further clear that the readjustment is likely to vary in its success almost entirely with the success with which the earlier adjustments were made during the development of the individual. This statement is meant to carry more than its obvious meaning that the more stable a man is the more surely can he meet the problems and difficulties of warfare; it has a deeper implication. Namely, there is an important relationship between the two phases of difficult adjustment, the current one and the older one. Fundamentally it is the same difficulty, the same conflict; it is only the form that is different. Let us suppose, for instance, that the original difficulty in adjustment was over the matter of cruelty, that in childhood the conflict between strong tendencies of this kind and perhaps specially strong ideals of the contrary sort was an exceptionally sharp one, so that it was never very satisfactorily resolved, though a working equilibrium may have been established on the basis of powerful reaction-formations and various protective devices for avoiding in every possible way contact with the subject of cruelty. Such a man may well have unusual difficulty in adapting himself to the cruel aspects of war, which really means that his long-buried and quite unconscious impulses to cruelty, impulses the very possibility of whose existence he would repudiate with horror, are stimulated afresh by the unavoidable sights and deeds of war. In bayonet practice, for instance, the man is taught how best to inflict horrible injuries, and he is encouraged to indulge in activities of this order from the very thought of which he has all his life been trying to escape. He now has to deal afresh with the old internal conflict between the two sides of his nature, with the added complication that there has to take place an extensive revaluation of his previous standards, and in important respects an actual reversal of them. He has to formulate new rules of conduct, to adopt new attitudes of mind, and to accustom himself to the idea that tendencies of which he had previously disapproved with the whole strength of his ego-ideal are now permissible and laudatory under certain conditions. One would get a very erroneous view of the picture I am trying to draw if one imagined that the process of readjustment in question goes on in the person’s consciousness. This is never entirely true, and often not at all true; the most important part of the readjustment, and often the whole of it, is quite unconscious. We thus see that to obtain a proper understanding of the problems of an individual case, and to be able to deal with them practically in therapeutics, it is often necessary to appreciate the relation between a current conflict and an older one, for the real strength and importance of the current one is often due to the fact that it has aroused buried and imperfectly controlled older ones.
I have taken the one instance of cruelty, but there are many others in connection with warfare. It may, indeed, be said in general that the process of re-adaptation in regard to war consists of two distinct sides: on the one hand, war effects an extensive release of previously tabooed tendencies, a release shewn in endless ways—for instance, even in the language of camps; and on the other hand the acquiring of a strict discipline and self-control along lines widely different from those of peace-times. The one is a correlative of the other, and we have perhaps in these considerations a psychological explanation of the feature of military life that is so puzzling to most civilians—namely, the extraordinary punctiliousness that a rigid discipline attaches to matters which to the outsider appear so trivial. An indisciplined army has always been the bane of commanders, and perhaps the risks attaching to indiscipline are related to the release of imperfectly controlled impulses that war deliberately effects.
The way in which a relative failure in war adaptation may lead to a neurosis can be illustrated by a parallel drawn from the more familiar problems of peace neuroses. Imagine a young woman who has never been able to reconcile the sexual sides of her nature with her ego ideal, and whose only way of dealing with that aspect of life has been to keep it at as great a distance from her consciousness as possible. If now she gets married, it may happen that she will find it impossible to effect the necessary reconciliation, and that, being deprived of the modus vivendi—namely, the keeping sexuality at a distance—which previously made it possible to maintain a mental equilibrium, she develops a neurosis in which the repressed sexual desires achieve a symbolic and disguised expression. Similarly in a war neurosis when the old adjustment between the ego-ideal and the repressed impulses is taken away, it may prove impossible to establish a fresh one on the new conditions, and then the repressed impulses will find expression in some form of neurotic symptom.
So far as I can judge, the specific problems characteristic of the war neuroses are to be found in connection with two broad groups of mental processes. One of these relates to the question of war adapttation considered above, the other to that of fear. The latter is hardly to be regarded as a sub-group of the former, inasmuch as there is no readjustment or transvaluation of values concerned, as there typically is with the former. The moral attitude towards fear, and the conflicts arising in connection with it, remain the same in war as in peace. In both cases it is considered a moral weakness to display or be influenced by fear, and especially to give in to it at the cost of not doing one’s duty. The soldier who would like to escape from shell fire is, so far as moral values are concerned, in the same position as a man in peace-time who will not venture his life to save a drowning child. Indeed, the conflict cannot be as sharp in the case of the soldier, for he would find very widespread and thorough sympathy for his quite comprehensible desire, and there would be much less social blame or guilt attaching to him than to the man in the other situation mentioned. So that the problem of fear, which we all agree plays a central part in connection with the typical war neuroses, seems to be apart from that of war adaptation in general as expounded above.
Before discussing the problem of fear, however, I should like at this point to review the position and see how far we have got in the attempt to approximate the facts of war neuroses to the psycho-analytical theory. This theory of the neuroses is a very elaborate one, including many problems of unconscious mechanisms, distinctions between the predispositions and mechanisms characteristic of the different neuroses, and so on, but it is possible to formulate the main principles of it along fairly simple lines, and I now propose to do this in a series of statements.
(1) The first principle in Freud’s theory of neurotic symptoms is that they are of volitional origin. This principle, long suspected by both the medical and the lay public, and the real reason why in the past they have been so confounded with malingering, would be at once evident were it not for the fact that it is not true of volition in the ordinary sense of conscious deliberate voluntary purpose. In other words, it is not true of the will as a whole, but only of a part of it—namely, a part that the patient is not aware of. Thus, neuroses are not diseases or accidents that happen to a person, as the French school of psychopathology maintains, but are phenomena produced and brought about by some tendency in the person’s mind, and for specific purposes. Freud distinguishes three classes of motives that operate in this way, one essential, the other two not. The indispensable one is an unconscious desire to obtain pleasure by gratifying in the imagination some repressed and dissociated impulse, a motive, therefore, arising in the part of the mind that is not in harmony with the ego-ideal. A second motive is to achieve some end in the outer world; for instance sympathy from an unkind husband, which the person finds easier to do by means of a neurosis than in other ways. The third set of motives has the same purpose as the last, but may be distinguished from it in that they concern the making use of an already existing neurosis rather than the helping to bring one about. Both the latter sets are usually, but not always, unconscious: more strictly, they are preconscious—that is, they do not relate to deeply buried tendencies, and so are correspondingly easy to reveal; Freud terms them the primary and secondary “gain of illness” respectively. Now I take it that this principle of volitional origin is no longer very widely questioned by modern psychopathologists, and in the case of war neuroses the main motives are visible and comprehensible enough—namely, the desire to find some good reason for escaping from the horrors of warfare.
(2) The second principle is that all neurotic symptoms are the product of an intrapsychical conflict which the person has failed satisfactorily to resolve, and that they constitute a compromise formation between the two conflicting forces. Here, again, I think that those who have been investigating the psychology of war neuroses will agree with this principle. MacCurdy,[12] in particular, has described in great detail the conflict that arises in soldiers between, on the one hand, the motives actuating to continuance at duty and concealment of growing sense of incapacity and apprehension, and, on the other, the awful sense of failure accompanying the sometimes almost overwhelming desire to escape from the horrors of their position. The neurosis offers a way out of this dilemma, the only way that the particular person is able to find, and the actual symptoms, which are often grossly incapacitating, such as blindness, represent the fulfilment of the desire against which the man has been fighting. We reach, therefore, the wish-fulfilment part of Freud’s theory.
(3) The third principle is that the operative wish that leads to the creation of the neurosis is an unconscious one. Freud means this in the full sense of the word, and in this sense the principle has not yet been confirmed from the experience of the war neuroses. There are, however, different degrees of unconsciousness of a mental process, and the important point to Freud is not so much the degree of the unawareness in itself—this being largely an index of the repression—as the repression or dissociation that has led to the unawareness. What he maintains is that the wish producing the neurosis is one that is not in harmony with the ego-ideal, and which is therefore kept at as great a distance as possible from it. Anyone who has read the touching accounts given by MacCurdy or Rivers[13] of the shame that soldiers feel at their increasing sense of fear, and the efforts they make to fight against it, to conceal it from others, and if possible from themselves, will recognise that the wish in question is one alien to the ego-ideal and is well on in the first stages of repression, even if it is half-avowed.
(4) The fourth principle is that current repressed wishes cannot directly produce a neurosis, but do so only by reviving and reinforcing the wishes that have been repressed in older unresolved conflicts. According to Freud, a pathogenetic disappointment or difficulty in readjustment leads first to an introversion or turning inwards of feeling, and the wish that has been baulked seeks some other mode of gratification. It tends to regress back to an older period of life, and thus to become associated with similarly baulked and repressed wishes belonging to older conflicts. It is the combination of these two, the present and the old, that is the characteristic mark of the pathogenesis of neurotic disorders as distinct from other modes of reaction to the difficulties of life.
Freud considers that there are probably always three factors in the causation of any neurosis: a specific hereditary predisposition, secondly an unresolved infantile conflict which means that the person has not satisfactorily developed past a given stage of individual evolution—in other words, that he has been subjected to what is called an “infantile fixation” at a given point in development, and thirdly the current difficulty. There is a reciprocal relationship between these three factors, so that if any one is especially pronounced the others may be correspondingly less important. For instance, if the hereditary factor is very pronounced then a person may become neurotic from the quite ordinary experiences of childhood and adult life, for he is incapable of dealing adequately with them. In the case of war neuroses it is evident that the current factor is of the greatest importance, being, indeed, the only one that so far has attracted attention. The only traces of infantile factors I have seen noted have been the instances where the localisation of hysterical symptoms seems to have been determined in part by the site of old injuries, and in a general way the many traits of childhood, such as sensitiveness to slights, self-centredment, and desire to be guarded, protected, and helped, which are sometimes very evident in the cases of war neurosis.
We thus see that only one half of the psycho-analytical theory has so far been confirmed by the observations of war neuroses. According to this theory, there are typically two sets of wishes concerned in the production of any neurosis. One of these, the “primary gain of illness”, a current one, alien to the conscious ego ideal, and therefore half repressed and only half conscious—if that—has not only been demonstrated by a number of observers, but has been shewn to be of tremendous importance, and certainly the effects of treatment largely turn on the way in which it is dealt with. The other factor, the infantile and altogether repressed and unconscious one, which, according to psycho-analysis, is also essential to the production of a neurosis, has not been systematically sought for, though I have found it in the few cases of which I have been able to make a full study. Its presence or absence is a matter of greater theoretical importance than might perhaps appear, even though its practical importance may often not be great. For my own part I have the utmost difficulty in believing that a current wish, however strong that is half conscious and sometimes fully conscious can ever in itself produce a neurosis, for it contradicts all one’s knowledge concerning the nature of neuroses, as well as my experience, such as it is, of war neuroses themselves. I would therefore urge that no conclusion is possible on the matter one way or the other until adequate investigations have been carried out. That it has its practical side also will be pointed out when we come to consider the chronic cases where war neuroses pass over into peace ones.
(5) The principle of the psycho-analytical theory that has aroused the strongest opposition is that the primary repressed wish ultimately responsible for the neurosis is always of a sexual nature, so that the conflict is between the two groups of instincts that go to make up the whole personality, those concerned respectively with preservation of the self and of the species. Dr. MacCurdy has suggested to me that this is so only because, apart from war, there is no instinct that comes into such strong conflict with the ego-ideal as does the sexual one, but that in war the conflict between the instinct for self-preservation and the ego-ideal is enough to lead to a neurosis. This may seem very plausible, but I shall be surprised if it is confirmed by future research. That a neurosis, which after all is a disorder of the unconscious imagination, should arise from a conflict between two states of mind that are fully in contact with reality would be something entirely contradictory of our past experience, as would also a neurosis arising from a conflict between two tendencies both belonging to the ego. I shall venture to put forward an alternative hypothesis presently when discussing the subject of fear, which we have next to consider.
Freud states[14] that from one point of view all psychoneurotic symptoms may be regarded as having been constructed in order to prevent the development of fear—another point of contact between his theory and the observers of war neuroses, who would surely agree that fear is the central problem they have to deal with. By fear is here meant rather the mental state of dread and apprehension, increasing even into terror, and accompanied by well-marked bodily manifestations, a state for which psychopathologists have agreed to use the term “morbid anxiety” (or, shortly, “anxiety”) in a special technical sense as being the nearest equivalent of the German word Angst.
Morbid anxiety is certainly the commonest neurotic symptom, and the theory of its pathogenesis has been the occasion of a very great deal of investigation,[15] with, in my opinion, very fruitful results. We meet it in the form of a general apprehensiveness of impending danger and evil, as the anxiety-neurosis, and also in hysteria in the form both of apparently causeless attacks of dread and of innumerable specific phobias. In all its forms its most striking feature is the disproportion between its intensity and its apparent justification, so that it seems at first sight extremely difficult to correlate with the biological view of fear as a useful instinct that guards against danger. Practically all modern investigations into its pathogenesis agree that it stands in the closest relation with unsatisfied and repressed sexuality, and, in my judgment, the conclusion that morbid anxiety represents the discharge of repressed and unconscious sexual hunger is one of the most securely established in the whole of psychopathology; it is impossible here to consider the extensive evidence in support of this conclusion, and I can only refer to the published work on the subject[16].
The next question is: What is the relation between morbid anxiety as seen in peace neuroses and real—i.e., objectively justified—fear, as seen in various situations of acute danger and so prominently in the war neuroses? The point of connection is the defensive character of the reaction. Morbid anxiety, as we are familiar with it in the peace neuroses, is a defensive reaction of the ego against the claims of unrecognised “sexual hunger” (Libido), which it projects on to the outside world—e.g., in the form of phobias—and treats as if it were an external object; it is, in a word, the ego’s fear of the unconscious. But there appears to be an important difference between it and “real” dread in that the latter concerns only the ego itself, arises only in connection with external danger to the ego, and has nothing to do with the desires of repressed sexual hunger. One is tempted to say that the latter (real dread) is a normal protective mechanism that has nothing to do with the abnormal mechanism of morbid anxiety. Here, however, as elsewhere, the line between normality and abnormality is not so absolute as might appear, and consideration of the matter leads one to examine more closely into the nature of real dread itself. We then see that this can be dissected into three components, and that the whole reaction is not appropriate and useful as is commonly assumed. The reaction to external danger consists normally of a mental state of fear, which will be examined further in a moment, and in various activities suited to the occasion—flight, concealment, defence by fighting, or even sometimes by attacking. On the affective side there is, to begin with, a state of anxious preparedness and watchfulness, with its sensorial attentiveness and its motor tension. This is clearly a useful mental state, but it often goes on further into a condition of developed dread or terror which is certainly the very reverse of useful, for it not only paralyses whatever action may be suitable, but even inhibits the functioning of the mind, so that the person cannot judge or decide what he ought best to do were he able to do it. The whole reaction of “real” fear is thus seen to consist of two useful components and one useless one, and it is just this useless one that most resembles in all its phenomena the condition of morbid anxiety. Further, there is seen to be a complete lack of relation between development of dread and the degree or imminence of danger, nor does it bear any relation to the useful defensive activities. Thus, one does not flee because one is frightened, but because one perceives danger; in situations of extreme danger men very often respond with suitable measures of flight, fight, or what not, when they are not in the least degree frightened; on the other hand, the neurotic can be extremely frightened when there is no external danger whatever. The inference from these considerations is that even in situations of real danger a state of developed dread is not part of the useful biological mechanism of defence, but is an abnormal response akin to the neurotic symptom of morbid anxiety.
In a recent publication[17] Freud has made the striking suggestion that the developed dread sometimes found in situations of real danger is derived, not from the repressed sexual hunger that is directed towards external objects, as is the case with morbid anxiety of the peace neuroses, but from the narcissistic part of the sexual hunger that is attached to the ego, and I venture to suggest that we may here have the key to the states of terror with which we are so familiar in the war neuroses. The psycho-analytic investigations of recent years have laid increasing stress on the distinction between “object-libido”, the sexual impulses that are directed outwards, and the “ego-libido”, the narcissistic portion that is directed inwards and constitutes self-love. There is good reason to suppose that the latter is the more primary of the two, and also the more extensive—though the least explored as yet—so that it constitutes, as it were, a well from which externally directed sexuality is but on overflow. The analogy naturally occurs to one of the protoplasmic outpourings in the pseudopodia of the amœba, and the reciprocal relation of these to the main body seems to be similar to that between love of others and self-love. It has been known for some time that there is a limit on the part of the organism to tolerate without suffering more than a given quantity of sexual hunger in its familiar sense of impulses directed outwards, and analytic study of the psychoses, notably of paraphrenia, has shewn that the same is even more profoundly true of the narcissistic sexual hunger. In both cases, before other symptoms are formed so as to deal with the energies in question and bind them, the first thing that happens is a discharge in the form of morbid anxiety, so that we reach the comforting conclusion that a normal man would be entirely free from dread in the presence of any danger, however imminent, that he would be as fearless as Siegfried; it is a gratifying thought that there seem to be many such in our Army to-day. It seems to me probable that the intolerance of narcissistic sexual hunger which leads to dread in the presence of real danger is to be correlated with the inhibition of the other manifestations of the fear instinct, with the accumulated tension characteristic of the mode of life in the trenches.
I would suggest, therefore, that investigations be undertaken from this point of view with cases of war neurosis, especially the anxiety cases. Many of the features noted by MacCurdy[18], for instance, accord well with the picture of wounded self-love: thus, the lack of sociability, the sexual impotence and lack of affection for relatives and friends, the feeling that their personality has been neglected, or slighted, that their importance is not sufficiently recognised, and so on. Perhaps a new light may also be thrown in this way on the attitude of such patients towards death. I understand that a great part of the war neurotic symptoms, and the battle dreams in particular, have been widely interpreted as symbolising the desire to die so as to escape from the horrors of life, an interpretation that does not accord well with the equally widespread view that the fundamental cause of such neuroses is a fear of death. I greatly doubt, on the contrary, whether the fundamental attitude is either a fear of death in the literal sense or a desire for death. The conscious mind has difficulty enough in encompassing in the imagination the conception of absolute annihilation, and there is every reason to think that the unconscious mind is totally incapable of such an idea. When the idea of death reaches the unconscious mind it is at once interpreted in one of two ways: either as a reduction of essential vital activity, of which castration is a typical form, or as a state of nirvana in which the ego survives, but freed from the disturbances of the outer world.
A word in conclusion as to the therapeutic aspects of psycho-analysis in the war neuroses. Even if it were possible, I see no reason whatever why a psycho-analysis should be undertaken in the majority of the cases, for they can be cured in much shorter ways. But I consider that a training in psycho-analysis is of the very highest value in treating such cases, from the understanding it gives of such matters as the symbolism of symptoms, the mechanisms of internal conflict, the nature of the forces at work, and so on, and there is certainly a considerable class of cases where psycho-analysis holds out the best, and sometimes the only, prospect of relief—namely, in those chronic cases where the war neurosis proper has, by association of current with older conflicts, passed over into a peace neurosis and become consolidated as such.