Psycho-Analysis and the War Neuroses · Sándor Ferenczi
SYMPOSIUM
HELD AT THE FIFTH INTERNATIONAL PSYCHO-ANALYTICAL CONGRESS BUDAPEST, SEPTEMBER 1918 1. DR. S. FERENCZI, Budapest. _Ladies and Gentlemen_, With your permission I will commence my 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 revolutionary 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 disorders 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 was missing in their calculations, 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—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 mechanisms of mental life and its disturbances. In my lecture today I shall confine myself to demonstrating the introduction of psycho-analysis into modern neurology, 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 communicate the theoretical principles upon which rest the psycho-analytical conceptions of the “traumatic neuroses” which have been observed during the war[1].
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 make 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 functioning he described in very general, one might even say, phantastic terms. Links were “cut out” from the chain of the innervation mechanism, most delicate elements “displaced”, paths “blocked”, connections torn asunder, obstacles to conduction created, etc. With these and similar comparisons, from which, however, all basis in fact was tacking, 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 physiological 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 views 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 somewhat high-sounding names (Akinesia amnestica, Myotonoklonia trepidans) that said nothing as to their nature; these descriptions, however, are not especially convincing with reference to his theoretical conceptions[2]. There were, it is true, many who agreed with Oppenheim’s views, though for the most part with limitations. Goldscheider 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 was here concerned the joint effect of emotion and concussion. As one of the few who obstinately persisted in maintaining the mechanistic idea I will mention Lilienstein, who categorically demanded that the word and the concept of “mind”, also that of “functional” and “psychic”, and more especially that of “psycho-genesis” should be struck out of the medical terminology; he maintained that this would simplify the conflict and facilitate the investigation, treatment and examination of the casualties; the progressive anatomical technique would certainly sooner or later discover the material foundations of the neuroses.
We must here refer to the train of thought pursued by V. Sarbó, who seeks for the cause of the war neuroses in the microscopical destruction of tissue and hemorrhages in the central organ of the nervous 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. Sarbó’s theory is only supported by a few authors. In this connection I might mention Sachs and Freud, 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 traumatic neuroses as the nervous results of disturbances of the endocrine glands produced by the shock, and as similar therefore to the post-traumatic Basedow’s disease.
Strümpell was one of the first to oppose the purely organic-mechanistic 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 company 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 circumstances that exclude the hope of compensation for injury as those mentioned, so that the patient has no interest in remaining ill, but every interest in the speediest recovery. Strümpell asserts that the shock neuroses always develop secondarily and purely psycho-genetically 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 Strümpell created a great impression in the medical world even in peace time; they led to the idea of the “compensation hysteria”; the sufferers, however, were treated not much better than if they were malingerers. Strümpell 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 material compensation, for remaining far from infections and danger—and this wish acts along auto-suggestive paths in fixing more firmly the symptoms, the persistence of morbid sensations and of innervation disturbances of motility.
Much of the foregoing train of thought of Strümpell sounds to the analyst very probable. For he knows from his analytical experience that neurotic symptoms in general represent wish fulfilments, and also the fixation of unpleasant mental impressions and their pathogenic state is familiar to him. Still he has to reproach the one-sidedness of Strümpell’s train of thought: for instance, in the undue prominence of the cognitive aspect of the pathogenic experience and the neglect of its affective side, as well as the complete ignoring of the unconscious psychical processes, with which already Kurt Singer, Schuster and Gaupp had reproached him. Strümpell also has a presentiment that these neurotic forms of illness can only be explained by means 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 seeking 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 neuroses it is a remarkable fact, which has been pointed out by Mörchen, Bonhöffer and others, that the traumatic neuroses are practically never seen in prisoners of war. The prisoners of war have no interest in remaining sick after being captured, and they cannot reckon on compensation, pension and sympathy from their surroundings while they are away from home. They feel themselves in their captivity 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 behaviour 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 between the trauma and its results on the nervous system. Severe neuroses arise from minimal shocks, while it is just the severe wounds accompanied by great shock that for the most part are not followed by nervous disturbances. Kurt Singer lays still greater stress on the disproportion between trauma and neurosis, and even endeavours to explain this fact psychologically: “In the kind of psychic trauma that comes on in a flash, in the terror, in the paralysing horror, we are 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 abreaction 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” disturbance in the nerve tissues; a disturbance that can be set right by means of psychic influences can itself have been nothing else than psychical. This therapeutic argument had the greatest effect; by degrees a marked silence fell over the mechanistic school, 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 intentionally brought about by the post-hypnotic 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 researches of Breuer and Freud into the psychical mechanisms of hysterical phenomena originated directly from the influence of Charcot’s clinical 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 emotion, 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 delicate methods of technique for neurological and psychiatric investigation, there remains a residue, and not an insignificant one, in which we do not arrive at a diagnosis by means of the present exact neurological 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 condition”. 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 problem. “If one only admits that mental processes can react upon the body 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 “unconscious 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 neuroses (for example, in Strümpell’s 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 unconscious 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”.
You see, therefore, ladies and gentlemen, that the experiences among war neurotics gradually led further than to the discovery of the mind; they 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,—abreaction, unconscious, 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 investigators to ask themselves whether, after these experiences in the war neuroses, 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 universally denied; in general, it is said, that the war neuroses contain nothing and have added nothing new to the already known symptomatology of the neuroses; even the Munich Congress of German Neurologists 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 memories, 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 such obstinate resistance to his hints.
To the question of the disposition to fall sick with a war neurosis the authors gave contradictory answers. Most of them follow the views of Gaupp, 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 psychogenic 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 predisposition 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 “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 contractures 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 phenomena; 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 motor 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 “volitional impulse makes a path for the spasm”, which, however, is only the physiological paraphrase of the facts of the case. Psycho-analysis suspects here a psychical motivation: the activity of an unconscious 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 can 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 backwards, 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 propulsion in paralysis agitans. 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.
Ideas discussed in this chapter
Text from Project Gutenberg, public domain in the United States.