Psycho-Analysis and the War Neuroses

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INTERNATIONAL

PSYCHOANALYTIC

UNIVERSITY

DIE PSYCHOANALYTISCHE HOCHSCHULE IN BERLIN

TJIE INTERNATIONAL

PSYCHO- ANALYTICAL

LIJ3RAKY

EDITED BY ERNEST JONES
NO. 2

THE INTERNATIONAL PSYOHO -ANALYTICAL LIBRARY

NO. 2

P8Y(^HO- ANALYSIS

AND THE

WAE NEUROSES

by

Drs. S. FERENCZI (Budapest), KARL ABRAHAM (Berlin),
ERNST SIMMEL (Berlin) and ERNEST JONES (London)

Introduction by
Prof. SIGM. FREUD (Vienna)

THE INTERNATIONAL PSYCHO-ANALYTICAL PRESS
LONDON VIENNA NEW YORK

19 2 1

Copyright, 1921

» • . • • •

C. Fromme, Printer, Vienna

CONTENTS

PAGE

I. Introduction by Prof. Sigm. Freud 1

II. Symposium held at the Fifth International Psycho-Analytical
Congress at Budapest, September 1918:

1. Dr. S. Ferenczi 5

2 Dr. Karl Abraham 22

3. Dr. Ernst Simmel 30

III. War Shock and Freud's Theory of the Neuroses, by Dr.
Ernest Jones 44

I.

I

»

INTRODUCTION
By Professor Sigm. Freud, Vieona.

^TillS little book on the War Neuroses, with which the Verlag opens
the "Internationale psychoanalytische Bibliothek"", deals with a subject
which until lately engaged the greatest current interest When the sub-
ject came up for discussion at the Fifth Psycho-Annlytieal Congi'ess at
Budapest (September^ 1918), official representatives of the Central Euro*
peau Powers were present to obtain information from the lectures and
discussions* The hopeful result of this first meeting was thepx'omise that
psycho-analytical institutions should be established, where medical men
qualified in analysis might find the means and time to study the nature of
these puzzling illnesses and the therapeutic value of psycho-analysis
in thepi* However, before these results could be achieved the war
came to an end, the government organisations broke down, and interest
in war neuroses gave place to other concerns. At the same time,
significantly enough, most of the neurotic diseases which had been
brought about by the war disappeared on the cessation of the war
conditions. The opportunity; therefore, for a thoi'ongh investigation
of these affections was unfortunately missed. However^ one must add,
it is to be hoped that it will be a very long time before such an
opportunity again occurs. This episode, now a thing of the past, has
not been without importance for the spread of the knowledge of
psycho-analysis, ilauy medical men, who had previously held them-
selves aloof from psycho* analysis, have been brought into close touch
with its theories through their service with the army compelling them
to deal with the question of the war neuroses. The reader can easily
gather from Ferenczi^s contribution to the subject with what hesitation
and misgivings this advance was made* Some of the factors, such as
the psycho-genetic origin of the symptoms, the significance of un-
conscious impulses, and the part that the primary advantage of being
ill plays in the adjusting psychical conflicts (''flight into disease")^
all of which had long before been discovered and described as opera-
ting in the neuroses of peace time, were found also in the war neuroses
and almost generally accepted. The work of K, Simmel has shown

War X<'ilTOaei.

1

1

what results may be obtained if the war neurotic is treated by the
cathartic method, which, as is well known, was the first stage of the
psycho-analytic technique.

From the advance thus made towards psycho-analysis, however,
one need not assume that the opposition to it has been reconciled or
neutralised. One might think that when a man, who had hitherto not
accepted any of a number of connected conclusions, suddenly finds
himself in the position of being convinced of the truth of a part of
them, he would weaken in his opposition and adopt an attitude of re-
spectful attention, lest the other part, of which he has no personal expe-
rience, and therefore upon which he is unable to form a personal opinion,
should also prove to be correct.

This other part of the psycho-analytical theory which is not touched
upon in the study of the war neuroses is that the driving forces
which find expression in the formation of symptoms are sexual in
nature, and that the neurosis is the result of the conflict between the
ego and the sexual impulses which it has repudiated. The term
''sexuality" is to be taken here in the broader sense customary in
psycho-analysis, and not to be confused with the narrower sense of
"genitality". Now it is quite correct, as Ernest Jones points out in
his contribution, that this part of the theory has not hitherto been
demonstrated in relation to the war neuroses. The work which could
prove this part has not yet been carried out. It may be that the war
neuroses are unsuitable material for this proof. However, the oppo-
nents of psycho-analysis, whose repugnance to sexuality has shown
itself to be stronger than their logic, have hastened to proclaim that
investigation of the war neuroses has finally disproved this part of
the psycho-analytical theory. In this pronouncement they have been
guilty of a slight confusion. If the — up to the present superficial —
investigation of war neuroses has not shown that the sexual theorj'
of the neuroses is correct, that is quite another matter from showing
that this theory is incorrect.

With an impartial attitude and some willingness it should not be
difficult to find the way to further elucidation.

The war neuroses, in so far as they differ from the ordinary
neuroses of peace time through particular peculiarities; are to be
regarded as traumatic neuroses, whose existence has been rendered
possible or promoted through an ego-conflict. In Abraham's contri-
bution there are plain indications of this ego-conflict; the English
and American authors whom Jones quotes have also recognised it.
The conflict takes place between the old ego of peace time and the
new war-ego of the soldier, and it becomes acute as soon as the

peace-ego is faced with the danger of being killed through the risky
undertakings of his newly formed pai'asitical double. Or one might
put itj the old ego protects itself from the danger to life by flight
into the traumatic neurosis in defendiag itself against 'the ^ new ego
which it recognises as threatening its life. The National Army was
therefore the condition, and fruitful soil, for the appearance of war
neuroses j they could not occur in professional soldiers, or mereenartesp

The other feature of the war neurosis is that it is a traumatic
neurosis, such as is well known to occur in peace time after fright or
severe accidents, without any reference to an ego-conflict

The theory of the sexual aetiology of the neuroses, or as we
prefer to call it, the sexual hunger (libido) theory, was originally put
forward only as regards the transference neuroses of peace conditions^
and can be easily demonstrated in them by using the analytic technique,
But its application to those other affections, which more recently
we have grouped together as the narcissistic neuroses, meets with
difficulties. Ordinary cases of Dementia praacox* Paranoia and Melancholia
are fundamentally very unsuitable material for the proof ol the sexual
hunger (libido) theory and for reaching an understanding of it, for
which reason psychiatrists, who neglect the transference neuroses
cannot be reconciled to it The traumatic neuroses (of peace time) have
always been reckoned to be the most refractory in this respect, so
that the appearance of the war neuroses does not add any fresh factor
to the former situation.

Only by adTancing and making use of the idea of a ''narcissistic sexu-
al hunger (libido)'\ that is to say, a mass of sexual energy that attaches
itself to the ego and satisfies itself with this as otherwise it does only
with an objectt has it been possible to extend the sexual hunger (libido)
theory to the narcissistic neuroses, and this entirely legitimate deve-
lopment of the concept of sexuality bids fair to do for these severer
neuroses and for the psychoses all that one can expect from an empiri-
cally and tentatively progressing theory. The traumatic neurosis of peace
time will also fit into this group when researches into the correlation
undoubtedly subsisting between shock, anxiety, and narcissistic sexual
hunger (libido) have reached success.

If the traumatic and war neuroses emphasise the influence of the
danger to life and not at all, or not clearly enough, that of the "denial
of love'\ on the other hand the aetiological claim of the former factor
appearing there so powerfully, is lacking in the usual transference neu-
roses of peace time. Indeed it is vulgarly supposed that ttiese latter
sufferings are only promoted by indulgence, high-living and ease, which
provide an interesting contrast to the conditions of life under which

I*

the war neuroses break out. If psycho-analysts, who find their patients
have become ill through the "denial of love", through the ungratified
demands of the sexual hunger (libido), were to follow the example of
their opponents, they would maintain that either there are no danger
neuroses, or that the affections following on terror are not neuroses.
This has naturally never crossed their minds. On the contrary, they
see the convenient possibility of combining in one conception the two
apparently divergent sets of facts. In the traumatic and war neuroses
the ego of the individual protects itself from a danger that either
threatens it from without, or is embodied in a form of the ego itself,
in the transference neuroses of peace time the ego regards its own
sexual hunger (libido) as a foe, the demands of which appear threa-
tening to it. In both cases the ego fears an injury; in the one case
through the sexual hunger (libido) and in the other from outside forces.
Qne might even say that in the case of the war neuroses the thing
feared, is after all an inner foe, in distinction from the pure traumatic
neuroses and approximating to the transference neuroses. The theo-
retical difficulties which stand in the way of such a unifying conception
do not appear to be insurmountable; one can with full right designate
the repression which underlies every neurosis, as a reaction to a trauma,
as ah -elementary traumatic neurosis.

Spring 1919.

IL
SYMPOSIUM

HELD AT THE

FIFTH INTERNATIONAL PSYCHO-ANALYTICAL CONGRESS

BUDAPEST, SEPTEMBER 191.S

1. Dr. S. Ferenczi, Budapest.

Ladies and Gentlemen,

With your permission I will commence jny exposition of the
very serious and important subject that is the theme of my lecture
to-day with the recital of a little story which will lead us straightway
into the revolutionising events of this war. A Hungarian, who had the
opportunity of observing at close quarters a part of the revolutionaiy
upheaval in Russia, told me that the new revolutionary rulers of a
Russian town found with consternation that the change from the old
to the new regime had not taken place as rapidly as it should have
done according to their doctrinal calculations. According to the
teachings of the materialistic idea of history they could have set up
the new social order immediately after they had got the entire power
into their hands. Instead of this, irresponsible elements, which were
antagonistic to any new order of things, obtained the upper hand, so
that the power gradually slipped from the hands of the originators
of the revolution. Then the leaders of the movement put their heads
together in order to find out what had gone wrong in their calculations.
Finally they agreed that perhaps the materialistic idea was after all
too one-sided, as it only took into consideration the economic and
commercial relations, and had forgotten to take into account one
small matter, the feelings and thoughts of man, in a word, the psyche.
They were sufficiently consistent to send emissaries immediately to
German speaking countries, in order to obtain psychological works,
so that they might get at least subsequently some knowledge of this
neglected science. Many thousands of human lives fell victims, perhaps
to no purpose, to this omission of the revolutionaries; the failure of
their efforts resulted in their making one discovery however, namely,
that of the mind.

A somewhat similar thing has occurred among neurologists during
the war. The war has produced an enormous number of nervous dis-
orders which call for elucidation and cure; however, the familiar
organic-mechanistic explanation hitherto adopted — which in some
way corresponds to the materialistic idea of history in sociology —
completely failed. The mass-experiment of the war has produced
various severe neuroses, including those in- which there could be no
question of a mechanical influence, and the neurologists have likewise
been forced to recognise that something wa? , missing in their calcu-
lations, and this something was again — the psyche.

To some extent we can forgive sociology for this omission; indeed
the estimation of mental elements in the science of society has hitherto
been in fact a very trifling one. However, we cannot spare neurologists
the reproach of having so long disregarded the pioneer researches of
Breuer and Freud concerning the psychical determination of many
nervous disturbances, and of having required the terrible experiences
of. the war to set them right in this respect. And yet a science —
psycho-analysis -T- has existed for more than twenty years to which
many investigators had devoted . the whole of their efforts, and which
had helped us to unexpected and important knowledge of the mechan-
isms of mental life and its disturbances.

In my lecture today I shall confine myself to demonstrating the
introduction of psycho-analysis into modern iieurology, an introduction
which has been effected to some small extent openly, but for the most
part with hesitation and under false colours, and I will briefly com-
municate the theoretical principles upon which rest the psycho-analytical
conceptions of the "traumatic neuroses" which have been observed
during the war^

Soon after the outbreak of the war there flamed up again the
great controversy, which had been carried on for more than ten years,
concerning the nature of the traumatic neuroses which Oppenheim
had in his time placed in a class by themselves. Oppenheim hastened
to jnake use of the experiences of the war, which exposed so many
thousands of men to sudden shocks, as supporting his old views,
according to which the phenomena of these neuroses always came
about as the result of physical alterations in the nervous centres, (or
in the peripheral nerves which secondarily affect those of the centre).
The nature of the shock itself and its influence upon the method of

1 I shall only here take into consideration the most important publications out
of the enormous amount of neurological literature of the war, and only in so far
as this refers to psycho-analysis. I am indebted to Dr. M. Eitingon and Prof. Dr.
A. V. Sarbo for access to the necessary authorities.

I

fiinctioning be deBcribed in very genera], one might even say, phan-
tastic terms. Links were ''cut out'* from the chain of the mnervatiou
mechanism, most delicate elements "displaced'^ paths '^blocked" con-
nections torn asundeFp obstacles to conduction created, etc. With
these and similar comparisons, from which^ however, all basis in fact
was lacking, Oppenheim sketched an impressive picture of the material
correlation of the traumatic neuroses.

The alterations in structure which would take place in the brain
through the trauma Oppenheim conceived as a delicate physical process
similar to that which occurs in the iron filing when it comes into
contact with the magnet.

The sarcastic Gaupp designates such specious physical and physio-
logical speculations as brain mythology and molecular mythology.
But in our opinion he does mythology an injustice.

The material brought forward by Oppenheim to support his view$
was in no way suited to uphold his abstruse theories. To be sure, he
described with his usual precision characteristic symptoms, which this
war has produced in deplorable numbers, and also gave to them some-
what high-sounding names (Akinesia amnestica, Myotonoklonia tre-
pidans) that said nothing as to their nature; these descriptions, how^
ever, are not especially convincing with reference to Ms theoretical
conceptions*.

There were, it is true, many who agreed with Oppenheim's viewsi
though for the most part with limitations. Goidscheider holds that
the cause of these nervous symptoms is partly physical and partly
psychical; Cassierer, Schuster and Birnbaum are of the same opinion,
Wollenberg's question, as to whether the war neuroses were caused
through emotion or shock, Aschaffenburg answered by stating that
there wa^^ here concerned the joint effect of emotion and concussion.
As one of the few who obstinately persisted in maintaining the mechan-
istic idea I will mention LiUenstein, who categorically demanded that
the word and the concept of "mind", also that of "functional" and
"psychic", and more especially that of "psycho-gen esis'* should be
struck out of the medical terminology; he maintained that this would
simplify the conflict and facilitate the investigation, treatment and
examiaation of the casualties; the progressive anatomical technique
w^ould certainly sooner or later discover the material foundations of
the neuroses.

1 One of Oppeolieim*a critics has 3Uggeste<i that these words so difficult to
pronounce might be used as tcit wordi in the examination of paralytic disturbancei
of speech, so that Ih^y might at leist be of some good.

8

We must here refer to the train of thought pursued by v. Sarbo,
who seeks for the cause of the war neuroses in the microscopical de-
struction of tissue and hemorrhages in the central organ of the nerv-
ous system; these, he says, originate through direct concussion, sudden
pressure of the cerebro-spinal fluid, compression of the spinal cord
in the foramen magnum, etc. V. Sarbo's theory is only supported by
a few authors. In this connection I might mention Sachs and Freund,
who consider that the shock puts the nerve cells into a condition of
heightened excitability and exhaustability, which is then the immediate
cause of the neuroses. Finally, Bauer and Fauser look upon the trau-
matic neuroses as the nervous results of disturbances of the endo-
crine glands produced by the shock, and as similar therefore to the
post-traumatic Basedow's disease.

Striimpell was one of the first to oppose the purely organic-me-
chanistic idea of the war neuroses. He had, moreover, for some time
previously referred to certain psychical factors in the causation of
the traumatic neuroses. He made the accurate observation that in
railway accidents, etc., those who suffered from a severe neurosis
were for the most part those who had an interest in being able to
prove an injury as caused by the trauma: for example, persons who
were insured against accidents and wished to obtain a large sum of
money, or those who instituted proceedings against the railway com-
pany for compensation for injury. Similar or much more severe shocks
have, however, no lasting nervous results if the accident happens
during sport through one's own carelessness, especially under circum-
stances that exclude the hope of compensation for injur}^ as those
mentioned, so that the patient has no interest in remaining ill. but
every interest in the speediest recovery. Strumpell asserts that the
shock neuroses always develop secondarily and purely psycho-geneti
cally as the result of desire of gain; he gave medical men the well-
meant advice not to take seriously the complaints of these patients,
like Oppenheim, but to bring them back as soon as possible to life
and work through the smallest allowance or through withdrawal of
their pension. The representations of Strumpell created a great im-
pression in the medical world even in peace time; they led to the
idea of the "compensation hysteria"; the sufferers, however, were trea-
ted not much better than if they were malingerers. Striimpell now
suggests that the war neuroses are also neuroses of covetousness,
which serve the patients* purpose in getting free from the military
authorities with the highest possible pension. Accordingly he demands
a strict examination and expert opinion of the neuroses occurring in
military persons. The content of the pathogenic ideas is always a

wish — the wish for matenal compensatiou, for remaining^ far from
infections and danger — and this wish acts along auto-suggestive jiaths
ill fixing more firmly the symptoms, the persistence of morbid sen-
sations and of innervation disturbances of motility.

Much of the foregoing train of thought of Striimpell sounds to
the analyst very probable. For he knows from his analytical expe-
rience that neurotic symptoms in general represent wish fulfilments,
and also the fixation of unpleasant mental impressions and their patho-
genic state is familiar to him. Still he has to reproach the one-sided-
ness of Strumpeirs train of thought: for instance, in the undue promi-
nence of the cognitive aspect of the pathogenic experience and the
neglect of its affective side, as well as the complete ignoring of the
uneouscious psychical processes, with which already Kurt Singer.
Schuster and Gaupp had reproached him. Striimpell also has a presen-
timent that these neurotic forms of illness can only be explained by
njeans of a psychical investigation; he does not, however, tell us his
method of work with reference to this. Probably he understands by
psychical exploration simply a careful questioning of the patient as
to his material circumstances and concerning his motives for seekmir
a pension. We must on the other hand protect ourselves in that he
calls this exploration "a method of individual psycho-analysis'** There
is only one procedure that has a right to this name, that which the
strict method of psycho-analysis has made its own.

As an argument in favour of the psycho- genesis of the war neu-
roses it is a remarkable fact, which has bean pointed out by Morehen,
Bonhoffer and otherSp that the traumatic neuroses are practically never
seen in prisoners of war. The prisoners of war iiave no interest in
remaining sick after being captured, and they cannot reckon on com-
pensation, pension and sympathy from their suri'oundings while they
are away from home. They feel themselves in their captivit}^ secure
for the time being from the dangers of the war. The theory of the
mechanistic shock can never explain to us this difference in the beha-
viour of our own soldiers and prisoners of war.

Evidence as regards the psycho-genesis rapidly accumulated.
Schuster and many other observers refer to the disproportion betweeu
the trauma and its results on the nervous system. Severe neuroses
arise from minimal shocks, while it is just the severe wounds accom-
panied by great shock that for the most part are not followed by
nervous disttirbances- Kurt Singer lays still greater stress on the dis-
proportion between trauma and neurosis, and even endeavours to ex-
plain this fact psychologically: 'In the kind of psychic trauma that
<)omes on in a flash, in the terror^ in the paralysing horror, we are

10

concerned with cases of difficulty or impossibility of adaptation to
the stimulus". In a severe wound there is a discharge of the suddenly
increased tension without anything further; when, however, no severe
external injury exists the excessive affect is discharged *'by means of
a sudden abreactipn through physical phenomena''. As the Freudian
expression "abreaction" shows, psycho-analysis must have been in the
mind of the writer when he thought out this theory. The expression
sounds like a delayed response to the Breuer-Freudian conversion
/ theory. However, it soon appears that Singer represents this process
far too rationalistically; he looks upon the symptoms of the traumatic
neuroses as the result of an effort on the part of the patient to find
a comprehensible explanation of the (to him) inexplicable morbid
process. Thus the work of this author is still far removed from the
dynamic conception of the psychical processes of which psycho-
analysis has taught us.

Hauptmann, Schmidt and others drew attention to the relation in
time in the development of the symptoms in the war neuroses. If it
is a question of a mechanical injury then the effect should be strongest
immediately after the operation of the force. Instead of which one
finds that the men thrown into a state of shock still make purposive
endeavours to arrange for their safety the moment after the trauma,
such as to get to the dressing station, etc., and only after having put
themselves under safe conditions do they collapse and the symptoms
develop. In some cases the symptoms appear only when the men
have to return to the firing line after a period of rest. Schmidt is
quite right when he refers this conduct of the patients to the psychical
factors; he suggests that the neurotic symptoms develop only after
the state of a transitory disturbance of consciousness has disappeared
and the men who have suffered the shock re-experience in memory
the dangerous situation. We would say: These injured men behave
like the mother who rescues her child from a danger which threatens
its life with calm imperturbability and disregard of death, but faints
after the act has been accomplished. It is immaterial as regards the
judgment of the psychological situation that here the person saved
was not a beloved stranger, but the beloved person himself.

I place Nonne in the forefront of those authors who have laid
particular stress on the psycho-genesis of the traumatic neuroses of
the war. Not only because he recognised that the symptoms of
the war shock neuroses were without exception hysterical, but because
he was also able to cause the severest war neurotic symptoms to
disappear for a time or to recall them by hypnotic and suggestive
measures. This excluded the possibility even of a "molecular" dis-

11

turban CQ in the nerve tissues; a disturbance that can be set right by
means of psychic influences can itself haTe been nothing else than
psychical.

This therapeutic argument had the greatest effect; by degrees, a

marked silence fell over the mechanistic schoolj and attempts were
frequently made to explain their former utterances psycho-genetically*
The quarrel from now onwards lay entirely between the supporters
of the various psychological theories.

How is one to explain the method of working of psychical factors,
and also the fact of the psychogenic condition being more severe
than the impressive forms of disorders of organic origin?

One is reminded of the old theory of Charcot, that terror and
the memory of it can produce in a similar manner physical symptoms
after the nature of hypnosis and auto-hypnosis, just as they are inten-
tionally brought about by the poit-hj^notic command of the hypnotist*

This reverting to Charcot means nothing less than paving the
way to fruitless speculations and the re-discovery of the sources from
which finally psycho-analysis sprang: for we know that the first rese-
arches of Breuer and Freud into the psychical mechanisms o-f hysterical
phenomena originated directly from the influence of Charcot's chnical
and experimental experiences. Hysterics suffer from reminiscences:
this, the primary axiom of the germinating psycho-analysis, is really
the continuation^ deepening, and generalisation of the ideas of Charcot
applied to the neuroses of shock; the idea of the lasting effect
of a sudden affect and of the association of certain expressions of
affect with the memory of the thing experienced is common to
both.

Let us now compare with this the views of German neurologists
on the genesis of the war neuroses. Goldscheider says: "Sudden and
terrifying impressions can leave behind affects direct and also with
the associative help of ideation; to these memory pictures are due
the results of increased and lowered excitability. Thus it is the emo-
tion, the terror, which bestows upon the trauma the distribution and
fixation of the nervous results of the stimulus, which never occurs
with the purely physical stimulus itself '\ It is easy to recognise that
this description is borrowed from the traumatic theory of Charcot and
the Freudian conversion theory,

Gaupp's opinion is similar: 'In spite of all the methods of modern
experimental psychology and of all the more precise and more deli-
cate methods of technique for neurological and ps3"chiatric investi-
gation, there remains a residue, and not an insignificant one, in which
we do not aiTive at a diagnosis by means of the present exact neuro-

i2

logical and psychiatric investigation of the condition at the moment
present, but only through its connection with an exact anamnesis and
with a laborious exploration of the pathogenesis of the existing con-
dition". Gaupp accepts even explicitly a Freudian postulation, in that
he describes the war neuroses as a flight from psychic conflicts into
illness and, alluding to psycho-analysis, he says: "Much preferable is
the postulate of the effects of the unconscious on consciousness and
the physical system than a psychological theory which seeks by words
taken from the sciences of anatomy and physiology to gloss over the
fact that the path from the physical to the mental and vice versa is
entirely unknown to us". In another place he goes still further and
puts the psycho- analytical postulate of the unconscious in the centre
of the whole proWem. "If one only admits that mental processes can
react upon the bodj^ even when they do not lie in the conscious field
of vision, then most of the supposed difficulties disappear". In this
connection Hauptmann must also be mentioned. He looks upon the
traumatic neuroses as mental illnesses psycho-genetically elaborated
and caused through emotional factors, and their symptoms as "un-
conscious further elaboration of the emotional factors along paths of
least resistance".

Bonhoeffer seems to have completely accepted the psychologically
complex experiences of psycho-analysis. He holds that the traumatic
symptoms are "psycho-neurotic fixations, dissociation phenomena which
have been rendered possible through the resultant splitting off of the
affect from its ideational content under the influence of the violent
emotion".

Birnbaum showed in his excellent summary of the literature of
the traumatic neuroses that in many of the explanations of these neu-
roses (for example, in Striimpeirs theory of covetousness) is summed
up a psychogenic wish of hysteria, and says : "If the psychogenic wish,
the wish fixation, etc. is an essential component of hysteria then it
belongs unconditionally in the definition of the disorder. Psycho-
analysis has long maintained this; as is well known, it regards the
neurotic symptoms as expressions of unconscious wishes or as reactions
to them.

Vogt also refers to the "famous Freudian statement" according
to which the troubled mind flies into illness and he acknowledges
that "the compulsion which originates from this is more often un-
conscious than conscious". Liepmann divides the symptoms of the
traumatic neuroses into the direct results of the psychic trauma
and into "finally adjusted psychic mechanisms". Schuster speaks of
symptoms which are evoked by means of "unconscious processes".

IS

I

I

You see* therefore, ladies and gontlemen, that the experiences
among irar neurotics gradually led further than to the discovery of
the mmd; tbey led neurologists very nearly to the discovery of psycho-
analysis. When we read in the more recent literature on the subject,
of the ideas and views which have become so familiar, - abreactiou,
uneonseious, psychic mechanisms^ separation of the affect from its
idea, etc., — we might easily imagine ourselves to be in a circle of
psycho-analysts, and yet it has never occurred to these iuvestigatorts
to ask themselves whether, after these experiences in the war neu-
roses, the psycho-analytical concepts cannot be made use of in the
explanation of the usual neuroses and psychoses which were well
known to us in peace times. The specificity of the war trauma is uni-
versally denied; in general, it is said, that the war neuroses contain
nothing and have added nothing new to the already known sympto-
matology of the neurosesj even the Munich Congress of German Neu-
rologists formally demanded the elimination of the word and concept,
^'war neurosis*'. If, however, the peace and war neuroses are identical
in their nature, then neurologists will be obliged to make use of all
these ideas of emotional shock, of the fixation of pathogenic memo-
ries, and of their continued activity in the unconscious, etc., also in
the explanation of the usual hysterias, the obsessional neuroses and
the psychoses. They will be astonished how easy it will be for them
to traverse The path trodden by Freud, and will regret having shown
f?uch obstinate resistance to his hints-

To the question of the disposition to fall sick with a war neurosis
the authors gave contradictur}^ answers. Most of them follow the views
of Gauppp Laudenheimer and others, according to whom most of the
war neurotics are ab ovo neuropaths or psychopaths, the shock merely
playing the part of the releasing factor, Bonhoeffer says direct: 'The
possibility of a psychopathological condition being evoked by psycho-
genic factors is the criterion of a degenerative predisposition''. Forster
and Jendrassik say the same thing. Nonne, on the contrary, finds that
the deciding factor in falling a victim to war neuroses lies less in
the personal constitution than in the nature of the operating injury.
Psycho-analysis takes a median position with regard to this question,
which Freud has frequently and expressly stated. It speaks of an
"aetiological succession** in the predisposition, the traumatic occasion
figuring as reciprocal value with this. A trifling predisposition and
severe shock can produce the same effects as an increased predis-
position and a much lesser degree of shock. Psycho-analysis, however,
is not content with the theoretical allusion to this condition, but it
endeavours — with success — to separate the complex idea of the

14

"'disposition'' into simpler elements and establish those constitutional
factors that influence the choice of neurosis (the special tendency to
fall sick with this or that neurosis). I shall return later to the question
as to where psycho-analysis looks for the special disposition to falling
sick with a traumatic neurosis.

The literature concerning the symptomatology of the neuroses of
the war is simply immense. According to Gaupp, for example, the
following hysterical symptoms are to be observed. ''Attacks of a slight
nature up to those of the severest kind, with an arc de cercle lasting
for hours, sometimes with epileptic frequency, astasia-abasia, anomalies
of the position and movement of the body even to going on all fours,
all the varieties of tic and shaking tremors, paralyses and contrac-
tures in monoplegic, hemiplegic and paraplegic forms, deafness and
deaf and dumbness, stuttering and stammering, aphonia and rhythmical
screaming, blindness with or without blepharo-spasm, all kinds of
disturbances of sensation, and most of all twilight states in quantities
never before met with and in combination with phenomena of physical
irritation and disorders". You see, it is like a museum of glaring
hysterical symptoms, and whoever has once seen it will plainly have
to decline Oppenheim's view, according to which purely neurotic
symptoms are rarely seen in the traumatic neuroses of the war.
Schuster draws attention to the frequent vasomotor and trophic pheno-
mena; according to him, these are no longer psychogenic. Psycho-
analysis, however, will agree with those who hold that these symptoms
can originate to some extent from psychic causes, analogous to the
physical alterations which can be produced under hypnosis. Finally',
all the authors allude to the alterations in disposition, apathy and
over-excitability, etc. after the trauma.

Out of this chaos of symptoms the "trembling" neurosis stands
out through its frequency and conspicuousness. You all know those
pathetic creatures who hobble along through the streets with shaking
knees, uncertain gait and peculiar motoy disturbances. They give the
impression of being helpless and incurable invalids; and yet experience
shows that also this traumatic form of illness is purely psychogenic.
A single treatment with electricity and suggestion, a few hypnotic
sittings are often sufficient in rendering these men capable of doing
some work, if only temporarily and under certain conditions. Erben
has made the most careful investigation into these disturbances of
innervation; he found that these disturbances are only suspended or
increased when the respective group of muscles carry out an action
or intend to do so. His explanation for this is, that here the "voli-
tional impulse makes a path for the spasm", which, however, is only

15

tlie physiological paraphrase of the facts of the case* Psycho-analysis

suspects here a psychical motivation; the activity of an UBCOnscious
contrary wish which puts itself in the way of the consciously wished
act This is indeed most striking in those patients of Erben who are
prevented from going forward through the most violent attacks of
shaking, but caE carry out the much more difficult task of going
backwards without trembling. Erben also here has a complicated
physiological explanation ready, but forgets that the movement back-
wards, which removes the patient from the dangerous goal of the
forward movement — and finally from the front line — does not
need to be disturbed by any contrary wish. The remaining kinds of
motor disturbances demand a similar interpretation, in particular the
striking, uncontrollable running of many neurotics, so like the pro-
pulsion in paralysis agitaus* These are the men who do not recover
from the effect of the terror and are still always flying from dangers
to which they were once exposed.

Many investigatoreSi including non -psycho^ anal^^sts, came to the
conclusion from these and similar observations, that these disturbances
are not the direct effects of the trauma, but psychical reactions to it
and act in the service of the instinct of self-preservation against the
repetition of the unpleasant occurrence. We know that also the normal
organism has at its disposal such protective measures. The symptoms
of the terror, such as the immovable legs, the tremblings, the hesi-
tating speech, seem to be useful automatisms; one is reminded by
them of certain animals which simulate being dead when danger
threatens. And if Bonhoeffer looks upon these traumatic disturbances
as fixations of the means of expression of the terrible emotion which
has beensuffex*ed, Nonne goes further and discovers that ''the hysterical
symptoms represent partly a reminiscence of inborn guard and defence
mechanisms, the suppression of which in those individuals whom we
call hysterical has not taken place in the normal degree or not at
air\ Acccri'ding to Hamburger the most frequently occurring type of
disturbances of standing, walking and speech associated with shakiutr
tremors represents a ''complex of ideas of feebleness, weakness, refusal
and exhaustion'', and Gaupp sees in the same symptoms the lapse
into iofantile and puerile states of obvious helplessness. Some authors
actually speak of the '"fixation" in the traumatic posture of the body
and innervation.

It cannot escape the notice of anyone with a knowledge of psycho-
analysis how near these authors, without knowing it, are to psycho-
analysis. The ^'expressions of fixatioDs of movements'' descnbed by
them are in reality only paraphrases of the Breuer- Freudian hysterical

16

coDversioD, and the lapse into atavistic and infantile methods of
reaction is nothing more nor less than what Freud called special
attention to as the regressive character of the neurotic symptoms^
all of which according to him only Signify reversions into onto-
genetic and phylogenetic stages of development already overcome.
At any rate we have definite proof that neurologists have now decided
to interpret certain nervous symptoms, that is to say, refer them to
unconscious psychical contents, which would never have occurred to
anyone to do before the introduction of psycho-analysis.

I will now speak of the few authors who occupy themselves
with the war neuroses from the psycho-analytical points of view.

Stern has published a work on the psycho-analyticsd treatment
of the war neuroses in war hospitals. I have not been able to see
the work in the original, but I learn from the abstracts that the
author proceeds from the point of view of repression and finds the
situation of the serving soldier particularly suited to the production
of neuroses in consequence of the suppression of affects which his
service demands. Schuster admits that the investigations of Freud
"however one may feel towards them" have thrown a ray of light
on the psycho-genesis of the neuroses; they assist in revealing the
hidden connection between symptom and psychical content which
"still exists though difficult to discover. Mohr treats the war neuroses
by the cathartic method of Breuer and Freud, by getting the patients
to live through the critical scenes again and brings about an abre-
action of their affects by letting them re-experience the ten:ible
emotion. Simmel is the only one up to the present who has occupied
himself methodically with the psycho-catharsis of the war neuroses,
and he will give his own report of his experiences to the Congress.
Finally, I will mention my own investigations concerning the
psychology of the war neuroses, in which I made the attempt to
bring the traumatic forms of disorder into the category of psycho-
analysis.

In this connection I will allude to a discussion which branches
out in all directions on the question whether an affect can still act
psycho-genetically when the person concerned immediately loses
consciousness. Goldscheider and many others still maintain that a
psychical effect is made impossible through swooning, and Aschaffen-
burg adheres to the view that loss of consciousness before falling
ill guards against the neurosis. Nonne rightly opposes this view,
and points out that unconscious mental streams could act psychically
in spite of the loss of consciousness. L. Mann, relying on Breuer's
hypnoidal theory, puts forward the view that the loss of consciousness

17

before falling ill does not protect but disposes to the appearance of
the neurosis, by preventing the discharge of the affects. Orluvsky
expresses himself the most rationally on this vexed question; he
points out the possibility that the swooning itself can be a psycho-
genic symptom, a flight into unconsciousness^ which would spare the
person concerned the conscious experiencing of the painful situation
and sensations.

The possibility of the psychogenic formation of symptoms during
a faint is quite comprehensible to those of us who are psycho-analysta
This problem could be started only by authors who take up a
standpoint, obsolete to psycho-analysis, that equates mental with
conscious.

I do not know, ladies and gentlemen, whether you also have obtained
the impression from all these quotations and references (which are only
taken at random from the literature) that an advance, even though one
that is not admitted, has taken place in the attitude of leading neu-
rologists towards the teachings of psycho-analysis. Moreover, candid
recognition is not lacMngj for example, the expression of Xonne, that
Freud's experiences concerning the elaboration in the unconscious have
received interesting illuminations and corroborations through the ex-
periences of the war.

However, the same sentence of acknowledgement also contains a
nihilistic opinion of Nonne concerning psycho-analysis; he states that
Freud' s idea of the almost exclusively sexual foundation of hysteria
has been conclusively disproved during the war. We can no longer leave
this unanswered, ivhich after all is only a partial denial of psycho-analysis:
also we can very easily give tlie answer. The war neuroses, according
to psycho-analysis, belong to a group of neuroses in which not only
is the genital sexuality affected, as in ordinary hysteria, but also its
precursor, the so-called narcissism, self-love, just as in dementia praeeox
and paranoia. I grant that the sexual foundation of these so -called
narcissistic neuroses is less easily apparent, particularly to those who
equate sexuality and genitahty and have neglected to use the word
"sexual'' in the sense of the old platonic Eros, Psycho-analysis, however^
returns to this extremely ancient standpoint when it treats all tender
and sensual relations of the man to his own or to the opposite sex,
emotional feelings towards friends, relatives and fellow-creatures gene-
rally, even the affective behaviour towards one's own ego and body,
jiartly under the rubric "erotism'\ otherwise "sexuality"'. It cannot be
denied that those to whom this idea is strange cannot so easily be
convinced of the correctness of Freud's postulation of the sexual
theory in a narcissistic neurosis in particular, for exaBiple, in the trau-

^Viir Keuro SSI'S.

2

18

matic neurosis. We should like to advise them to examine themselves
into the usual (non-traumatic) hysteria and obsessional neuroses also,
and to keep strictly to the methods of free association, dream and
symptom interpretation proposed by Freud; then they will be much
more easily convinced of the correctness of the sexual theories of the
neuroses, and agreement about the sexual background of the war neu-
roses will follow. At any rate the triumph concerning the overthrow
of the sexual theories is somewhat premature.

The observation that I have made as regards the participation of
sexual factors in the formation of symptoms in the traumatic neuroses
also shows that in traumatic neurotics the genital sexual hunger (libido)
and potency is generally greatly injured; in many cases it can even be
entirely suspended and that for long periods. This condition which is a
positive one is alone sufficient to demonstrate the rashness of Nonne's
conclusion \

Ladies and gentlemen: With what I have said I have discharged
the chief task of my paper, which was the critical survey of the lite-
rature on the war neuroses from the standpoint of psycho-analysis.
However, I will make use of this rare opportunity to tell you some
of the observations I have made myself, and I will present points
of view which may help to explain these conditions psycho-analy-
tically.

In the psychical sphere of the traumatic neuroses there predominate
such symptoms as hypochondriacal depression, terror, anxiousness, and
a high degree of irritability with a tendency to outbursts of anger.
Most of these symptoms can be traced back to increased egO'Sensitiveness
(in particular the hypochondria and the incapability of tolerating phy-
sical or mental discomfort). This over-sensitiveness arises from the fact
that in consequence of the shock, which has been experienced onoe or
repeatedly, the interest and sexual hunger (libido) of the patients is
withdrawn from the object into the ego. There thus comes about a
damming-up of the sexual hunger (libido) in the ego, which is expressed
in those abnormal hypochondriacal organic sensations and over-sensi-
tiveness. Frequently this heightened ego-love degenerates into a kind
of infantile narcissism: the patients would like to be pampered, cared
for, and pitied like children. One can therefore speak of a reversion
into the childish stage of self-love. This heightening corresponds to
the diminution of object-love, often also of genital potency. A man who
is already predisposed to narcissism will of course sooner fall a victim
to a traumatic neurosis; still no one is entirely immune from it, since

1 These facts have been confirmed in the course of the conference by aU taking
part in the discussions.

Id

I

I
I

I
I

the stage of narcissism forms a significant fixation point in the deve-
lopment of the sexual hunger (libido) of every human being. The com-
bination with other narcissistic neuroses, especially paranoia and demen-
tia, frequently occurs.

The symptom of anxiety is the sign of the shock to the self-
confidence occasioned by the trauma. This is most strikingly expressed
in men who, in consequence of an explosion, have been knocked down,
hurled over or blown up and have thereby permanently lost their
self-confidence. The characteristic disturbances of walking (astasia-
abasia with trembling) are protective measures against the repetition
of the anxiety, therefore phobias in Freud's sense. The cases in which
these symptoms predominate are called anxiety-hysteria. Those sym-
ptoms, on the contrary, which simply express the situation at the
moment of the explosion (innervation, position of the body) are
conversion-hysterias in the psycho-analytical sense. Also in the anxiety
there is naturally a constitutional predisposition • those persons more
easily fall ill in this way who, in spite of real cowardice ^ are
compelled from ambition to perform courageous deeds. The
anxiety-hysterical disturbance in walking is at the same time a re-
version to an infantile stage of not-being-able-to-walk oi* of learning-
to-walk.

Also the tendency to outbursts of rage and anger is a highly
primitive method of reaction to a superior force; it can increase up
to epileptic attacks, and represeutamore or less incoordinate discharges
of affect analogous to those observed in the period of suckling. A
milder variety of this loss of restraint is the lack of adaptation to
discipline, which is practically never missing in the traumatic neuroses.
The excessive need for love and the narcissism also give rise to
this increased irritability.

The entire personality of most of the victims of trauma corre-
sponds therefore to the child who is fretting, whimpering, unrestrained
and naughty in consequence of a fright The excessive importance
which almost all the persons suffering from trauma attach to good
food fits in with this picture. The slightest neglect in this respect
may produce in them the most violent outbreaks of affect and even
induce fits. Most of them are unwilling to work, they wish to be
supported and provided for like a child.

It is here, therefore, not only a question, as Striimpell considers^
of the production of illnesses on account of an actual gain (pension,
compensation for injury, flight from the front) which are only secon-
dary illness gains; the primary motive for the illness is the pleasure
itself of remaining in the secure retreat of the childish situation once

20

so unwillingly left behind. Both these narcissistic and apprehensive
manifestations of illness have their atavistic prototype; it is even
possible that the neurosis often reverts to methods of reaction which
play no part at all in the individual development (feigning of death
by animals, methods of progress and protection of the young of
animals in the ancestral series). It is as though an over-strong affect
could no longer be compensated along normal paths, but had to
regress to previously abandoned but virtually existent mechanisms
of reaction. I do not doubt that many other pathological reactions
will yet be revealed as recapitulations of overcome methods of
adaptation.

As symptoms of the traumatic neuroses which are less appre-
ciated, I might mention the over-sensitiveness of all the senses (shunning
of light, hyperacusis, extreme ticklishness) and the anxiety dreams.
The real terrors that have been experienced, or things similar to them,
are lived through again and again in these dreams. I am following
a hint of Freud's when I look upon these terrors and anxiety dreams,
as well as the state of terror by day, as spontaneous attempts of cure
on the part of the patient. They serve to bring piecemeal to conscious
abreaction the shock, which in its totality was intolerable and
unintelligible and was therefore converted into symptoms, and to con-
tribute to the adjustment of the disturbed equilibrium in the psj^chical
economy.

Ladies and gentlemen, I hope these few remarks of mine may
serve as proof that the psycho-analytical conception discloses points
of view where the rest of neurology leaves us in the lurch.

From the methodical psycho-analysis of many cases we ought to
expect the full explanation of these morbid conditions and perhaps
also their radical cure.

• 21

While this article was in the press, I .read the interesting work
of Prof. E. Moro, the childrens' specialist of Heidelberg, on "the first
Trimenon", i. e. the peculiarities of the first three months of the in-
fant's life. He says: "If one laj^s a young infant on a pillow on a table
and strikes the pillow on either side with the hands, then there results
a peculiar reflex action. Both arms are thrown up symmetrically apart
and then come together again in a curve With easy tonic movements.
A similar movement is carried out simultaneously by the legs''. We

would say: Moro has here artificiallj'^ produced a little shock (or trau-
matic) neurosis. The remarkable thing in this action is that this reflex
to the shock in the young infant of less than three months old shows
signs of the natural reflexes of clasping, which characterise the "carried
offspring", i e. the young of animals (monkeys) which are compelled
with the help of a pronounced clasping reflex to hold fast with the
fingers to the mother's fur while she climbs about the trees We
would say: Atavistic reversion of the method of reaction in sudden
terror 1.

1 {"Miinchner Uediz. Wochenschriff\ 1918, No. 42, P. 1150.)

2. Dr. Karl Abraham, Berlin.

During the war academic neurologists have come round more and
more to regard the aetiology of the traumatic neuroses from psycho-
logical points of view. However, in spite of the approach towards our
views, mentioned by Ferenczi, their ideas differ from ours in two
respects, namely, they for the most part only take into consideration
the reaction^ of the ego impulses to the trauma, and they keep enti-
rely to the manifest expressions of the neurosis. In the following
emarks, besides those factors which we do not di<e>pute, I intend to
deal with the unconscious and sexual ones.

When in peace times psycho-analysis upheld the sexual aetiology
of the neuroses it was often pointed out as a contrary argument that
this could not hold good for the traumatic neuroses. Similarly now
the opinion is expressed that the genesis of the war neuroses contra-
venes our ideas. Terror, anxiety lest the dangerous situation be
repeated, seeking for a pension, and some vague idea of disposition
are supposed to be adequate explanations of the illness; in the mass
of the neuroses which have broken out during the war the unimpor-
tance of the sexual aetiology is thought to be clearly shown.

My investigations of the traumatic neuroses in peace time had
for a long time led me to conclude the importance of sexuality in
them similar to that in the other neuroses, but they have not yet
been sufficiently numerous and conclusive enough for publication.
I might mention the case of a young girl who met with a slight tram
accident when she was in the throes of a serious erotic conflict. The
analysis showed that the accident in a certain measure gave a pretext
for the outbreak of the neurosis. The symptoms were in connection
with the conflict in question; the importance of the trauma receded
quite into the background. I might also add that some litigious cases
of traumatic neurosis which I observed in greater detail all suffered
from impotence; this disturbance was produced by the accident,
but seemed to have its real basis in old and unconscious sexual
resistances.

The investigation of war neurotics has fully confirmed my sjir-
mises connected with such observations. Moreover, the recurrence of
certain definite symptoms in war neurotics, which were familiar to

22

23

I

me not only in the traumatic neuroses of peaee time, but also in the
non'traumatie cases, seems to me worth noting, I refer particularly
to the complex of symptoms which we eould so often observe during
the war in the anxiety cases with trembling, such as trembling, agi-
tation, irritability, sensitiveness, sleeplessness, headaches, anxiety, de-
pression of spirits and feelings of incompetency. Two neurotic types
with the same symptoms — although these do not appear so pro-
mmently ae in the war — would be the impotent man and the frigid
womao- A similanty which is so marked in external phenomena leads
one to expect a similarity also in internal processes.

All my experience fully coincides with that which Ferenczi has
just communicated. The trauma acts on the sexualily of many persons
in the sense that it gives the impulse to a regressive alteration which
endeavours to reach narcissism. I might add that we both arrived at
this idea without having previously even mentioned it to one another.
The trauma, however, has this effect only in a portion of those par-
ticipating in the war, hence we are unable to dispense with the
assumption of an individual disposition, bat we are in the position
to define it far more accurately than the prevailing school of neu-
rology. A couple of examples will make the problem before us
clearer.

At the begin niDg of the war a soldier at the front was wounded
on August, 13th., 1914, Before his wound was completely healed he
secretly left the hospital and went again to the front, soon getting a
second and after a few months a third wound. After repeated returns
to the front he was one day blown up by a shell explosion and was
unconscious for two days. After these four traumata he certainly
presented the phenomena following upon shock, but no neurotic
picture, being neither particularly anxious, depressed nor excited.
Another man at the front during a night attack fell into a hole without
injuring himself, but immediately developed neurotic trembling of a
most severe kind, and presented the picture of a mental breakdown.
How are such differences to be explained?

The previous history of such people, and naturally, still more, a
penetrating analysis, teaches us why the one in spite of the severest
physical and mental influences of the war remains to all intents and
purposes healthy, and why the other reacts to relatively trifling stimuli
with a severe neurosis. It transpires with great regularity that the
war neurotics already before the trauma were labile people — to
designate it, to begin with, by a general expression — and especially
so as regards their sexuality. Many of these men were unable to carry
out their tasks in practical life» others that were capable of doinsr

24

this, however, showed little initiative and manifested little impelling
energy. In all of them sexual activity was diminished, their sexual
hunger (libido) being checked through fixations; in many of them
already before the campaign potency was weak or they were only
potent under certain conditions. Their attitude towards the female
sex was more or less disturbed through partial fixation of the sexual
hunger (libido) in the developmental stage of narcissism. Their sexual
and social capacity of functioning was dependent on their making
certain concessions to their narcissism.

In the war these men were placed under completely changed con-
ditions and in the face of extraordinary demands. They had always
to be prepared for unconditional self-sacrifice in favour of the mass.
This signifies the renunciation of all narcissistic privileges. The healthy
person is able to accomplish such a complete suppression of his nar-
cissism: he loves according to the transference type, and so is capable
of sacrificing his ego for the whole. In this respect those disposed to
neuroses are inferior to healthy persons.

It is not only demanded of these men in the field that they must
tolerate dangerous situations — a purely" passive performance — but
there is a second demand which has been much too little considered,
I allude to the aggressive acts for which the soldier must be hourly
prepared, for besides the readiness to die, the readiness to kill is de-
manded of him.

A further factor which operates on the labile sexuality of those
disposed to neuroses is the almost exclusive association with men.
The sexuality of tbe normal person takes no harm from this, but it
is otherwise in men with strong narcissistic traits. The knowledge of
the connection between homosexuality and narcissism enables us to
understand this.

The previously unstable attitude towards women begins to waver
under such conditions. If the lability of the attitude towards the other
sex is very great then it does not need even a war trauma to cause
a neurosis to break out in such men. For instance. I observed a man
who on return from furlough at home had a convulsive attack and
was brought into the hospital showing signs of anxiety and depression.
The man had always been noted for his effeminate disposition, and in
his married life was weakly potent and always inclined to jealousy.
When he was home on leave he failed absolutely in the attempt to
have sexual relations with his wife. His fears that his wife would be
unfaithful to him reached a crisis, and soon after his departure from
home he had his convulsive attack.

Such men with labile heterosexual impulses need a support for

25

their sexuality. They frequently find this in their wife on whom their
sexual buuger (libido) is completely dependent, or they have to defend
themselves ivom their feelings of insecurity sexually by having con-
stantly to t^onviiioe themselves that they are potent by goin^ with
prostitutes. And so in war they constantly need a support for their
wavering activity. Their military usefulness also is dependent upon
conditions. They are frequently useful in rank and file^ supporting
their activity upon that of their comrades. A changed sitnation, and
occurrence, which with a marked disposition needs only to be very
trifling, upsets the balance, making the previously weakly-active man
wholly passive. The passivity is expressed then not only in the sphere
cf the ego impulses, but likewise in that of the sexual impulses* The
narcissism breaks out The capability of the transference of the sexual
hunger (libido) dies away as well as the capacity of self-saerifice in
favour of the community. On the contrary, we now have a patient
before us who himself needs care and consideration on the part of
others, who in a typically narcissistic manner is in constant anxiety
about his life and health. The obtrusiveness of the symptoms (tremors^
attacks, etc) is also narcissistic, Many of the patients show themselves
completely female-passive in the surrender to their suffering. In their
symptoms they are experiencing anew the situation which had caused
the neurosis to break out, and soliciting the sympathy of other
people.

At this juncture we must again refer to the previously mentioned
circumstance that in our patients the anxiety as regards killing is of
a simiiar significance to that of dying. The symptoms in part are only
comprehensible in this sense. The case of a man who in the field suf-
fered from a relapse of a neurosis which he had had six years previ-
ously is especially instructive. At that time he was taken with a tre-
mor of his arm which arose in connection with a dream in which he
murdered someone; a hand-to-hand fight in the field caused the old
symptom to reappear. Hysterical convulsive attacks are not only pro-
duced through dangerouB situations, terror^ ete., but not infrequently
an act of aggression which he lias failed to carry out is expressed in
them. Such an attack is especially often associated with an exchange
of words with his superiors; the suppressed impulse to forcible acti-
vity finds in the expression its motor discharge.

The complete instability of many war neurotics, their disconcer-
ting depression, their propensity to thoughts of death, find a further
explanation in a particular effect of the trauma. Many of the neuroti-
cally disposed persons, up to the moment when the trauma upsets
them, have supported themselves only through an illusion connected

26

with their narcissism, namely, through the belief in their immortality
and invulnerability. The effect of an explosioD, a wound, or things of
a like nature suddenly destroys this belief. The narcissistic security
gives way to a feeling of powerleesness and the neurosis sets in.

To what an extent the regression can go is shown in those cases,;
described also in the literature, in which the patients display the
conduct of little children. One of my patients who was previously
neurotic was thrown into this kind of condition through the terrifying^
effect of a mine explosion. For a long time he behaved like a terrified
little child. For many weeks he could only reply to all questions about
his trouble with the two words, *'Mine bombs". He had therefore gone
back to the mode of expression of a child hardly two years old.

What apparently is an exception to the statement made at the
commencement is the following noteworthy case in which a previously
healthy, proficient and sexually completely potent young man was^
taken in the field with a severe astasia-abasia coupled with a very great
over-excitability of affect. An explosion had hurled the lower part of
his back against the side of the trench; he had therefore suffered a
trauma, and had been already treated by various neurologists for
''traumatic hysteria". A careful physical examination showed me un-
doubted signs of an affection of the Conus MeduUaris, manifestly a
haematomyelia. The patient remembered that after the trauma he
could not retain his urine and faeces, still he continued at his post
because he looked upon this condition as the result of terror. These
symptoms improved in the following weeks. However, during the same
period he noticed the disappearance of all sexual feelings. At first
he was not inclined to look upon this condition, which was dis-
quietening to him, at all seriously, having no idea that he had an
organic impotence. During leave at home he had to come to the
conclusion that the sexual insensitiveness was in no way to be overcome.
Now the neurosis appeared, not as the result of the psychic impression
of the explosion, but as a reaction to the organic impotence of traumatic
origin. This neurosis differed, by the way, from the usual traumatic
neuroses through the euphoristic, at times even manic state of mind.

This difference needs special appreciation and explanation. Also
other men who have received severe organic injuries show such mental
attitudes which must surprise us. For example, I have always found
that in the amputation hospitals a strikingly cheerful mood prevails.
At the beginning of the war I had my attention drawn to the euphoria
of the severely wounded men by a particular occurrence. I had to
treat four soldiers in a general hospital, who through the splintering
of the same shell had had their eyes severely injured. All four had

27

already had enuoleation pei'formed in another hospital They were in
no way depressed but gave themselves up to a careless^ serene frame
of mincl. Wheo they ^ aU at the same time — received their arti-
ficial eyes a remarkable scene took place. They jumped, danced, and
laughed in boisterous spirits, just like children who work themselves
up into a frenzy of joy. Also here there is without doubt a regression
to narcissism, it is however of a more partial nature. These patients
repress the knowledge that through the mutilation they have experien-
ced a depreciation in a more or less high degree, especially in the
eyes of the female sex. What they lose in love from outside they
seek to compensate by means of self-love. The damaged part of the
body receives for them a significance as an erotogenic zone which
did not previously beloog to it^.

All the experlenoeB here communioated speak unanimously in
the sense that the war neuroses ara not to be understood without
taking the sexuality into consideration. This view receives a valuable
confirmation by means of the mental disturbances observed in the
war, which — like mental troubles in general — very often more
easily manifest the latent content of their ideas than the neuroses. The
mental disturbances which have broken out in the field, as other
observers have confirmed^ are associated only in a trifling part with
the formation of delusions. However, if there is a delusion then it
has even a manifest sexual content. In the cases 1 have seen the
delusions are partly of jealousy, partly of homosexual persecution
by comrades. I might mention the paranoid illness of a soldier which
broke out when he, after long service in the field, went home on fur-
lough and turned out to be impotent with his wife, A very transparent
symbolism and other signs pointed with certainty to the significance
of homosexual components as the fundamental cause of the delusion.
Another man had the delusion of being, during sleep, infected with
syphilis in the hospital by his comrades^ the origin of the delusion
was here also the result of imperfectly repressed homosexuality.

In this connection I should like to mention another remarkable
ease. In 1915 when I was acting at a surgical station a man was ti'eated
there for a gunshot wound of the penis. The operation, which was carried
out by a well known surgeon, was quite success fuL Two years later
the same patient came to my psychiatric station. The man who was
previously unaffected psychically now showed a paranoid mental dis-
turbance. On questioning him it appeared that in consequence of the

^ The hanucinaiioaa, which thoae persons who having had an amputation ex-
perience, that Ihal part of the body which has been taken away is still there, mighl
find an explanation from thia sou roe.

28

wound there existed entire genital anaesthesia. Also here the psychosis
appeared to stand in close connection with the cessation of genital
manliness.

The so-called "seeking for pension' of many men injured in the
war is as little explained by means of the current ideas on the matter
as the symptoms of the neurosis. This also stands in connection with
the alterations of the sexual hunger (libido), just as do the neurotic
symptoms. The patient only apparently fights for compensation for
the stiffened wrist, for the shot-off finger, for his neurotic trouble.
It is quite overlooked as a rule that the neurotic inwardly perceives
the alteration which has taken place as .regards his sexual hunger
(libido). He is filled with the feeling of an enormous injury. And he is
so far right when he actually has suffered loss from his capability
for transference of his sexual hunger (libido) and therewith an impor-
tant basis of the belief in himself. A man injured by an accident be-
fore the war once told me that he had come to an agreement with
his insurance company for a definite compensation. Hardly had this
occurred when the thought came to him that this sum did not even
remotely cover his actual injury. Henceforth the sum which according
to his idea he ought to have claimed rapidly rose to an enormous
amount. The pension compensates only for the diminution of the capacity
for earning a livelihood, so far as this is objectively demonstrable, not
for that which the patient subjectively feels; he cannot be compensated
for his reduced capacity for object-love. Narcissism also explains here
the conduct of the patients. Where previously the capability of surrender
(in every sense of the word) existed, now the narcissistic avarice domi-
nates. The genital zone has lost its predominance; anal erotism is streng-
thened. It is clear that the state pension favours the development of
the character traits described; this only takes place, however, when the
tendency already exists in the injured person to react narcissistically
to an external injury to his integrity.

Now as regards the question of the therapy and particular!}^ that
of the psycho-analytic.

At the commencement of the war one took little notice of the
neurotics, they were placed perchantje in a convalescent home but
practically without treatment. The increasing number of neurotic cases
necessitated other measures. The old method of ''surprisaF' was again
dug up. Then came the period of ''active" curative procedures, the best
known of which is Kaufmann's. These methods were at first deceptive
from the fact that they led to the rapid improvement of a great
number of patients. As regards, however, the duration of the cure,
they have not yielded what was hoped of them, and, in addition,

29

they produced cei'tain unwished-for phenomena* The military medical
authorities thei'efore display a lively interest in putting on one side
the too "active" methods in favour of other effective but less
severe ones,

l9 psycho-analysis able to step into the breach? Theoretically we
are justified in assuming that it is, because psycho-analysis alone of
all methods of treatment is a causal one. We also have already practical
experience to go upon; I refer to the publications of Simmel> I will
now fcjriefly speak of my own therapeutic experiences. We psycho-ana-
lysts bad to be extremely cautious in our treatment of war neuroses,
for the addresses at medical congresses and the literature before the
war had demonstrated very clearly the refusal of the medical profession
to accept the concUisions of our ideas and efforts. When in 1916 I
founded a statioQ for neuroses and mental diseases I abstained entirely
from all forcible therapy, likewise from hypnosis and other sug-
gestive means, but allowed the patients to abreact in the waking state
and sought to make intelligible to them by a kind of simplified psycho-
analysis the origin and nature of their suffering- I aimed at arousing
in the patients the feelin^^ of being understood, complete relaxation,
and improvement Later the station became that of a pure observation
station, chiefly for mental diseases; hence I could only collect isolated
therapeutic experiences.

The objection that psycho-aualys^is works too slowly does not
hold good as far as our experience goes up to the present.

Latterly it has appeared that the patients treated accordingly by
the Kanfmann method frequently relapsed when they were withdrawn
from the influence of the doctor, or were again exposed to the dangers
of the front Time will show whether the psycho-analytic methods will
procure more lasting cures. I will communicate in concliision the result,
instructive in this connection, of the recent ti*eatment of a neurosis
carried out in my private practice. I was able in a few weeks to remove
a severe phobia in a boy twelve years old, which referred to air raids.
The cure persisted when the boy returned home; he was there again
daily exposed to the risk of air raids and put up with this situation
just like a healthy person. Perhaps this result justifies the expectation
that psycho-analysis will in fact in the permanence of its cures fill up
tile gaps that exist at present. I^sycho-analysis, which enables us to
penetrate deeper than any other method into the structure of the war
neuroses, will perhaps take therapeutic precedence also in the sphere
of the war neuroses i.

^ The intenUon of the medical department of tbe Prussian War MiDistry In regoM
to tlie organieaiion of psycbo>ana]ytical treaimeDt stations was not oarHed out in
eonsequfuceof the altered political situation, which took place soon after the Congress.

3. Dr. Ernst Simmel, Berlin,

For the past eighteen months I have been in charge of a special
boBpital for war neuroses, aod 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 regard-
less of the remaining psychic constellations of the patient, generally
produces at the same time a considerable general disturbance with
marked subjective symptoms, sneh 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 J (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 treat-
ment of a large number of eases and calling for rapid curative results,
would allow n more extensive individual analysis only in a few cases.
On account of this I had from the begioning to cut down the length
of the treatment A combination of analytical-cathartic hypnosis with
analytical conversations during the waking state, and dream inter-
pretation 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

30

31

working. With the disappearance of the symptoms the essential treat-
ment of the war Beurotics, aceordingr to modern hospital methods,
was looked upon as beiog 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, accordiog to which all physical symptoms represent eon-
versions of something psychical. The body is the instrument of the
mind upon which it (the mind) allows its unconscrous to manifest
itself in plastic and mimic expression. The functions of the unconscious
are the deciding factor in the formation and buijding 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 extra*
ordinarily favoured* To what degree an enforced sexual abstinence
further increases this could not be tested.

The unconscious meaning of the mpnjitortis 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 con^esponding with
the actual occurrences of the war» Stekel is quite wrong in concluding
from my statements that I categorically deny a sexual basis for neu-
roses 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 investi-
gation 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 be-

32

comes 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 sym-
ptoms 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 ele-
mentary 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 exi-
stence.

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 irretrie-
vably 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, jsi^nd, 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 stand-
points and to consider their comrades of the officer class under the
courtesy diagnoses of Neurasthenia, Ischia, Neuralgia, etc.

33

The war neurosis, like the peace neurosis, is the expressioa of a
splitting of the personality. The conditions for such a splittiog are
brought about by the consistent narrowirg of the personality complex
as a result of the compulsory discipline and above all by the psychic
and physical exhauation 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 un-
duly 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
opiuioiij 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 tmd obstructed in Ms unconscious* Since
the union between conscious aod unconscious is interrupted within
by the strong barrier of the resistance, a detour by w^ay 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 aetiolo-
gically 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 onr
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, haSj 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,

Wilt >'euTOiea. q

34

The weakening of the personality complexes of the soldier^ as
just describedp liis aubjection 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-hostije
feelings, represents the so-called morbid suggestibility. To make use
of this suggestibility for curative purposes without exposing its founda-
tions is to increase the illness instead of bringing about a cure.

The neurotic, in my opinion, succumbs in the first instance tciJ
autO'SUggestion, that is to say, to over-strong emotionally toned ideas
which have axisen in him at a time when the e^^o- complex is weakened
in power or completely suspended.

According to my observations, narrow! ngs 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 un-
doubtedly at the commencement are operating those teleological mecha-
nisms 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 certbro, a power of the unconscious that attracts to itself
the entire psychosis in a salutarj^ 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 un-
conscious.

I can best illustrate what I have said by a few examples. For in-
stance, the simplest cases^ which occurred so often, of a flaccid para-
lysis 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 sit-
ting. Consciousness only knows, "1 cannot move my arm", and no
amount of reasoning was of any avail. However, the unconscious spoke

35

daring hypnosis: *'In the excitement of the attack my mind became
a blank. When I was hit the impact of the shrapnel WBii 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 uncon-
scious Idea in hypnosis which again united the idea of the torn off
arm with consciousness here quickly settled the question of an orga-
nic 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 rea-
lised post-hypnotic auto-suggestions. I have confirmed this view by
numerous examples, 1 might mention the case of a soldier who suffer-
ed 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 con-
scious situation of the initial blowing up, very soon yielded the follow-
ing inform ation* 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 pur-
pose of breathing freely. At the same time a shai'p 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
ai last the command which the unconscious had imposed on the patient
could be annulled during hypnoms by means of my correction < In
this wa}' was the removal of these symptoms brought about. I could
quote further similar examples in which these Idnds of contractures
represent a compulsory holding of a part in a position of ease which
is based od unconscious sensations of pain.

Apart from repressed physical sensations of pain the affects them-
selves also naturally play an important part in the neurotic compul-
sion to maintain a particular position, I remember a soldier who for
several months had a compulsion to keep both eyas 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

36

him. The original situation had in the meantime become unreal, never-
theless the anxiety in itself was valid. The patient was still a soldier
and retained in his neurosis the anxiety — an anxiety of similar situ-
ations. The neurosis of another soldier, which for a long time had
been considered of an organic nature, a bulbar paralysis being suspec-
ted, was very instructive and the success of the treatment most grati-
fying. 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-trea-
ted 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 th&
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 in-
crease 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 demon-
strate without difficulty during hypnosis the displacement from the
psychical into the physical. If we interrupt the patient in the abreac-
tion of his rage during hypnosis then he reacts with a general tremor
or the tremor of an extremity which is already in some way psychic-
ally affected.

Further I might mention the case of a neurotic who suffered
from a shaking tremor of the right arm with peculiar circular move-
ments 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

37

dreamed of a Russian with a blaek beard who sprang on to his bed
in order to strangle him. He awoke in anxiety and terror with his
trm shaking. The patient had seen the face of this Eussian 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 un<iischarged and an
incipient movement which served as a mimic abreaction of this
anger.

From this ej^ample, to which 1 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 treat-
ment of war neuroses.

I do not treat any patients whose dreams I do not know\ 1 have
learnt for a long time now to estimate the dreams of my war neurotic
patients as an attempt at self- healiog, especially in the psycho^cathartic
sense. I never gi\B drugs for the dreams of anxiet}^ terror and rage.
I am glad of the cooperation of the patient^ 1 learn by listening to
his dreams his own tendency to cure, then 1 get him to continue
the dream under hj^pnosis where it has stopped the previous night,
or, this 1 have sevei'al 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 1 look
upon hypnosis not as an artificial sleep but as a definite stage of
natural sleep, which by virtue of its ai'tificial induction enables one
to maintain a direct rapport with the sleeper.

The initial stage of auto-hypnosiSj hypnosis, and dreams represents
the same nivean 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 massi'^ i, e^
w^hen 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 bim 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 braoehes 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

38

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 corres-
ponding 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 pre-
maturely 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 con-
vulsive 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 obli-
teration 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

39

before the memory of that all too horrible situation, or before tht)
knowledge of some act of his own which he may have to perforai as

a result of his affective dammiBg-up, but which Eevertheless brings
him into grave danger. I have already in my earlier work alluded
to the fact that the phyBical 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 ha 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-actiOD
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

40

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 sug-
gestion 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 memor}'- is again automatically re-intro-
duced.

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 sub-
conscious circumstances of his illness and then sketch it next daj'' 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 opporunity 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

41

produotion often enables one to recogoise the typical neurotic displace-
ment, a projection outwards. There are numerous patients of tliis 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
ra^e against a definite officer or doctor by whom they had psychically
felt themselves iU-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 psych o-neurosis or the frequently falsely accused
conscious '*ideas of covetousaess''. I have found that the real pension
neurosis represents a kind of inferiority neurosis. The patient values
himself higher thao he feels he is valued by bis environment. He has
generallj^, in his opinion, performed some special military acbievemeDt.
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 corporars button with which
the patient endeavoura 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 esta-
blished 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 the}" in
defence react with a relapse.

On the other hand, it can frequently be established that the treat*
ment 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 (our weeks the attacks
had ceased. The patient had to be discharged in spite of the fact that
be 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 be-
hind him*'. This feeling of anxiet}^ often increased so terribly that
be would have a convulsive attack. In this attack he constantly saw
a dead Russian in a white shirt who threateningly demanded back a

42

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 con-
vulsions.

These theoretical points which 1 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 com-
pass of this contribution; with the abundance of material at my dis-
posal, to represent the numerous forms of the neuroses not mentio-
ned here, and still further as regards their unconscious condi-
tionality.

In conclusion I should like to give a short description of the neu-
rosis of a young civil servant, which despite the brevity of the treat-
ment 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 blowB
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 signi-
fied 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 shatte-
red 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
gi'eat performances which he had accomplished in the field and com-
municated 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

43

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 en-
velope, 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, un-
consciously 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.

WAR SHOCK AND FREUD'S THEORY OF THE

NEUROSES^

By

Dr. Ernest Jones, London.

A MATTER that used to hamper the opponents of psycho-analj^sis
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 "hereditj^" and
"J'uggestion", 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 aetiology 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

1 Read before the Royal Society of Medicine, Section of Psychiatry, April 9, 1918.
Published in the Proceedings, Vol. XI. Reprinted in "Papers on Psycho- Analysis":
Jones, 2nd. Ed. 1918, Ch. XXXIII, p. 664. (Ballliere, TindaU & Cox.).

44

45

actual incideDce of war neuroses? Neurotic symptoms amounting to a
definite clioico-patholDgical 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 Frauce are affected in this way. This consideration
in itself shews that some other factors than war strain must be in-
volved, 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 psycho neuroses
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 thinks
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 tbey thus place themselves in a position
very similar to that of a writer who would on a jiriort grounds deny
the details or evea 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' 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 etiological factor was present therefore no micro-
organism could be, so that Koch's views as to the causation of tuber-
culosis 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 exeiling 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 ihe order of sciemiiic thinking evinced by those
who maintain that Freud^s theory of ihe neuroses has been demolished
by the simple observation that they may manifest themselves under
the stress of ivarfare.

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

i By Freud t *'AlIgemeine Neuroses] ehre', 1917^ B. 280.

46

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
<jritic 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 miscon-
<5eptions 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

47

I

I

I
I

similar agenta must be at work to produce the neurosis in both
cases,

Anotlier very px-evalent miseonception^ one strengthened by the
official use of that unfortunatB catch-word "sheli-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 aetiological factor, and not
the disease itselL I have preferred to use the less ambiguous and more
obviously setiological term ''war- shock,'* one coined, 1 think, by Eder^
Even when the term "shell- shock*' is avoided^ its place is usually
taken by the all-embracing expression ''neurasthenia"— in most casea^
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 bave 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 psych on eurosis are found to be representedi
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 etiological
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 hw 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 import-
ance 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 E^nd
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 con-
taining beneath the surface a body of imperfectly controlled and
Eder, "War Shock/^ 1917.

48

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 allow-
ed, but ejicouraged 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 aesthetic and
moral disposition. All sorts of previously forbidden and buried im-
pulses, 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 con-
flict, 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^ 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 aBSthetic 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^, and, following him, Mac-
Curdy — 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 essen-
tially 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 con-
trasting series of which his ego disapproves.

As every student of genetic psychology knows, this gradual buil-
ding 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

^ MacCurdy, "War Neuroses", Psychiatric Bull.^ July, 1917, pp. 262, 253.
2 Trotter, "Instincts of the Herd in Peace and War'\ 1916.

4Si

I
I

exceptioDal for the whole result to be Batisfactory; there alwaya remain
certain fields — more especially in the realm of sex^ where the resolution
of the conflict is aa imperfect one, and it is jttst from this imperfect
resolution that, according to Freud, ueurotic affections arise. The
question whethei* 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 etimulatitin from these internal impulses
and desires that are not in unisoa 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 impairmeut 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 soeial 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 ''sublimution'*, but
there are similar refiuing and modifying px'ocesses at work in con-
nection 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 dh'octly 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 sensiti-
veness to pain and suffering. In such ways as these a state of practi-
cal 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 radi-
cally 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 difficuU as can arise in various situations appertaining

%Var Netirotes*

i * * J

50

to the field of sex. It is an adjustment which practice shews is pos-
sible 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 re-
adjustment 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 ob-
vious meaning that the more stable a man is the more surely can he
meet the. problems and difficulties of warfare; it has a deeper impli-
cation. 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 ori-
ginal 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 exception-
ally 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 prac-
tice, for instance, the man is taught how best to inflict horrible in-
juries, 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 Ms 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 formu-
late new rules of conduct, to adopt new attitudes of mind, and to
accustom himself to the idea that tendencies of which he had previ-
ously 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 imag-
ined that the process of readjustment in question goes on in the
person's consciousness. This is never entirely true, and often not at

51

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
understandiDg of the problems of an individiial case^ and to be able
to deal with them practiealJy 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 coQueotion 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 explanatioa of the
feature of militaiTr 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 con-
trolled 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
r?lam!liar 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 depri-
ved of the nvtdits vivmdi — 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 expres*
sion 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 adapt-

4*

52

tation 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 in-
fluenced 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-ana-
lytical 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

ill harmon}' with the ego-ideaL A second motive is to achieve some end
in the oater world; for instance sympathy from an unkind huabaad^
which the person finds easier to do by|nieans 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 exisfciag neurosis rather than the helpiug to bring
one about. Both the latter sets are usually^ but not always, unconscious;
more strictly, they are preconscious— that iSrthey 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 nt
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 neurotio symptoms are the
product of an intrapsychical conflict which the person has failed satis-
factorily to resolve, and that they constitute a compromise formation
between the two conflictiug forces. Here, Bgais^t I tMnk that those who
have been investigating the psychology of wai* neuroses will agree
with this principle. MaoCurdyi^ in particular has described in great
detail the conflict tbat 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
senseof 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 wai' 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
unawareoess 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

I Mac Curdy, ^^/u cif.

54

kept at as great a distance as possible from it. Anyone who has read
the touching accounts given by MacCurdy or Rivers^ 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 re-
inforcing 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 turniTig
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 m'eans 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 fidult
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 sensitive-
ness to slights, self-centredment, and desire to be guarded, protected,
and helped, which are sometimes very evident in the cases of war
neurosis.

1 Rivers, "The Repression of War Experience'', Proceedings of the Boyal Society
of Medicine, 1918, xi (Sect, of Psych.), p. 1, Dec. 4, 1917.

55

We thus see tbat 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 con-
cerned in the production of any neurosis. One of these, the "primary
gnin 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 ud conscious
one, which, according to psycho-analysis, is also essential to the pro-
duction of a neurosis, has not been systematically sought lor, though
I have found it in the few cases of which 1 have been able to make
a full study. Its presence ox* 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 investi-
gations 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-preser-
vatioD 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 some-
thing 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

56

presently whea discussing the subject of fear, which we have next
to consider.

Freud states^ 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,^ with, in my opinion, very firuitful 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 subjects

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 un-
recognised "sexual hunger'* (Libido), which it projects on to the outside

1 Freud, op, ciV., S. 470.

> The latest discussion of the subject will be found in Freud^s "AUgemeine Neu-
rosenlehre,'' 1917, ohapter xxv, "Die Angst". See also his papers in *'SammIung kleiner
Sohriften zur Neurosealehre," 1906, chapters v, vi, vii, and a general reylew of the
subject in my "Papers on Psycho-Analj-sis,*' 2nd ed., 1918, chapter xxvii, "The Patho-
logy of Morbid Anxiety".

3 See also Stekel, "Angstzustande,'^ 2e. Aufl , 1912.

57

world — e.g., in the form of phobias— and treats as if it wore an
external object; it is, in a word, the ego^s fear of the imeoBscious.
But there appears to be an important difference between it and "'real"
dread in that the latter concerns only tho ego itself, arises only in con-
nection with external danger to the ego, and has nothing to do with
the desires of repressed sexual hunger. Oae is tempted to say That
tlie latter (real dread) is a normal protective mechanism that has nothing
to do with the abnormal mechanism of morbid anxiety. Here, how-
ever, as elsewhere^ the line between normality and abnormalit}' 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 ia a moment, and in various activities
suited to the occasion — flight, eoneealaient, defence by fighting, or even
sometimes by attacking. On the affective side there is, to begin with,
a state of anxious preparedness and wmtchfulaess, with its sensorial
attentiveness and its motor tension. This is cleai'ly a useful mental
^tate, but it often goes on further into a condition of developed dread
or teiTor 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 ofdanger^ nor does it bear any relation
to the useful defensive activities. Thus, one does not flee because ont)
U 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 neurotio 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^ 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 to-

1 Freud, oj*, Hf,, S. 502.

58

I wards external objects, as is the case with morbid anxiety of the peace
neuroses, but from the narcissistic part of the sexual hunger that is

I 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 amoeba,
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 ener-
gies in question and bind them, the first thing that happens is a dis-
charge in the form of morbid anxiety, so that we reach the comfor-
ting 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^, for instance, accord
well with the picture of wounded self-love: thus, the lack of socia-
bility, the sexual impotence and lack of affection for relatives and
friends, the feeling that their personality has been neglected, or slight-
ed, 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

1 MacCurdy, op cit.^ pp. 269—272.

59

been widely interpreted as symbolising the desire to die so as to es*
cape 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 annihil-
ation, and there is every reason to thinfe 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 free*d from the disturbances of the outer world.

A word in conclusion as to the therapeutic aspects of psycho-
analysis ip 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 con-
sider 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.

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