Treatment of Hysteria in WWI
Max Nonne (1861 -1939)
A celebrated German therapist, neurologist Max Nonne from Hamburg treated some 1,600 patients over the course of the war.
As a young man he had studied with Charcot in Paris and Bernheim in Nancy, endorsing the Nancy school’s emphasis on the role of suggestion.
In October 1914 he had tried hypnosis on a young lieutenant evacuated from Flanders to Hamburg and unable to speak.
To his amazement the man immediately started to talk again.
Male hysteria was something Nonne had previously seen only in France, and did not believe German males capable of anything so unwürdig (unworthy).
At first he was reluctant to publicise his treatment but its obvious effectiveness soon overcame his inhibitions. Nonne believed there were three requisites for treating cases of hysteria:
“Unfailing self-confidence; feelings of obedience on the patient’s part; the creation of an atmosphere of healing.”
Nonne established a reputation as a Zauberheiler, or magical healer. In 1917 a film was made of his treatments, although for the purpose of the work cured patients were re-hypnotised to produce their original symptoms.
“Against a plain, dark background a series of shuddering, juddering men, naked except for underpants, writhe and twitch tormentedly before the camera. Then, like a ghostly spectre, the doctor appears – tall, erect, a Teutonic high priest in a long white coat. Moving with hieratic authority, he places his hands on their pulsating limbs and stomach, whispers in their ears or clicks his fingers and – pouf! – the symptoms disappear. The extraordinary expressionist effect – like a silent film by F.W.Murnau or Fritz Lang…”
Nonne and Hypnosis
Prior to the outbreak of War Nonne had enjoyed only a modest reputation, largely on the basis of his research into paralysis and physical trauma of the nervous system.
Max Nonne studied in Heidelberg, Freiburg, and Berlin, receiving his doctorate at Hamburg in 1884.
He started his career at Hamburg’s Eppendorf hospital as an assistant in internal medicine, then moved to become an assistant physician in the medical clinic in Heidelberg under Wilhelm Heinrich Erb (1840-1921), in the surgical clinic in Kiel under Johannes Friedrich August von Esmarch (1823- 1908) and in 1889 settled in Hamburg as a neurologist.
That year he became head physician in the department of internal medicine at the Red Cross Hospital, 1896 head physician at the neurological department in the Eppendorf hospital.
Nonne became titular professor in 1913 and in 1919 received the teaching appointment for neurology at the newly founded University of Hamburg, where he became ordinarius in 1925. In Hamburg Nonne worked
with Alfons Maria Jakob (1884-1931).
In 1922 his international status was confirmed when, with a group of three other elite physicians from Germany and Sweden, he was asked to attend Vladimir Ilich Lenin (1870-1924) during his final disease.
In the autumn of 1915, Nonne reported a better than 80% success rate in treating neurotics by means of hypnosis. Between October 1914 and September 1915 he had successfully treated fifty-one out of sixty-three cases:
(Note: At the München Kriegstagung of September 1916, he reported a success rate of around 50%. In 1917 he wrote that this had risen by December 1916 to 72% and subsequently to 80%. “In the last two months I have cured 83% of my cases and in the last three weeks 90%. Nonne: Über erfolgreiche Suggestivbehandlung. P 200)
He further claimed almost immediate cures in the case of twenty-eight of his patients, despite the fact that of these twenty-three were long term sufferers whom other doctors had tried to treat without success.
At the Hamburg conference he publicly demonstrated the effectiveness of hypnosis by treating five patients before the audience of psychiatrists and, despite the fact that their symptoms were of long standing, caused them to disappear instantly.
He later claimed that in order to perform effective hypnotic treatments three conditions were essential. “First was unfailing self-confidence; second feelings of obedience on the part of the patient; third the attitude among the whole staff end environment that curing is ‘self-evident’.” (Ref: Nonne Anfang und Ziel. P 79)
He added that only doctors who were fully persuaded that war neuroses were psychogenic in origin should attempt this form of therapy since the slightest doubt on their part precluded success.
“A perceptive doctor,” he wrote,” can very soon tell if there is a “fluid” (Fluidum) between him and the patient. If the fluid isn’t there, then all efforts are in vain.” (Ref: Nonne, Anfang und Ziel) Note: As Lerner rightly points out his choice of the word “fluid” is a curious one and seems to reflect a belief in Fran Anton Mesmer’s theory of “animal magnetism” . It certainly implies that he was well aware of hypnotism’s scientifically murky origins.)
Nonne reported that soldier-patients were especially easy to hypnotise since they were so used to taking orders and offering unquestioning obedience to the commands of their superiors.
In Nonne’s view the goal of hypnosis was to use the patient’s altered state of consciousness to provide him with the “positive will-power” necessary to overcome his symptoms. He would never explain his procedures to the patients and use their ignorance to his therapeutic advantage. The doctor had, he insisted, to instill in the patient the belief that he was in every way the man’s superior, a stern and uncompromising master whose orders had to be obeyed instantly and without question:
“I consider it superfluous and counterproductive to enlighten the patient beforehand,” he wrote. “A discussion about what is going to happen to him is destined to weaken the feeling that the therapist is the superior
(überwertig).” (Ref: Nonne, Therapeutische Erfahrunger, p 109).
A difference must be noted between the type of cathartic hypnotherapy as practiced by doctors influenced by Freud and Breuer’s work with hysterics and suggestive hypnosis advocated by Nonne and his followers. In the former the desire is to cure neurotic symptoms by uncovering repressed memories and fantasies and triggering an abreaction. Suggestive hypnosis is a strategy based on discipline and obedience that was deemed especially suitable for military personnel.
As Lerner succinctly puts it: “In cathartic hypnosis the patient participates actively in the therapeutic process, while with suggestive hypnosis the patient’s subjectivity is neglected, and he is treated as the object or recipient of therapy.
In the latter method the doctor retains full control of the therapeutic process, as would a surgeon, and the results occur quickly and predictably. “ (Ref Lerner, p 167. See also Ruth Leys, “Traumatic Cures: Shell Shock, Janet and the Question of Memory” Critical Inquiry 20 (Summer 1994): pp 623 – 662)
But the apparently speedy and indeed near miraculous cures that Nonne and his followers demonstrated were bought at a price to the patient. Because the deeper causes that underlay their neuroses were never dealt with the possibility, indeed the likelihood, remained that they would reemerge at a later date and in some different pathological form.
Nonne constantly emphasized the speed and simplicity of his approach, keeping careful statistics to support his claims for rapid recovery and even claiming that the phenomenon on “Blitzheilung” – or split-second cure often occurred. (Ref: Nonne, Therapeutische Erfahrunger, p 109).
A tireless publicist for his methods, Nonne produced a movie featuring six to eight patients side by side on stage and then hypnotized them all with a single command. Always something of a showman, Nonne deeply impressed his professional audiences not only through his ability to cure, almost instantly or so it appeared, paralyses, tics and stuttering but to then get them to reproduce their symptoms with “photographic fidelity” through hypnotic
suggestion. (Ref: Nonne, Anfang und Ziel. P 179)
He used this film, together with live demonstrations at both the Kriegstagun in München and at meetings of the Southwest German Association for Psychiatry and Neurology in Baden-Baden.
As a result Nonne’s approach rapidly achieved both national and international attention. (Ref: G. Schaltenbrand, “Max Nonne”, in Kolle ed., Grosse Nervenärzt, Vol 3. Stuttgart, 1963. pp 164-173; F. Stern, “Bericht uber die Kriegstagung des Deutschen Vereins für Psychiatrie in München am 21,,22, und 23. September, 1916. Ärztlische Sachverständige Zeitung 22 (1916): pp 236-239; 249- 252)
Nonne’s Munich appearance contributed significantly to the downfall of Hermann Oppenheim and traumatic neuroses and, by significantly increasing Nonne’s fame and importance opened the way for the new approach of active treatment. Summonsed to appear before the medical section of the Prussian War Ministry to demonstrate his suggestive hypnosis to a group of high ranking military doctors (Ref: Nonne, “Über erfolgreiche Suggestivbehandlung. P 197).
As a result for the rest of the war military doctors were sent to Hamburg to learn his methods and by 1918 he had trained dozens from hospitals all over Germany. An eagerly sought after speaker he toured the country giving hour long lectures psychological associations and military doctors in such major cities as Munich, Berlin, Metz and Koblenz but also making practical demonstrations on neurotic patients.
Nonne had studied under Charcot in Paris is 1889, although he remained at the Saltpêtrière for only six weeks, apparently impressed by the great man’s charisma while disgusted at the “circus like showmanship” (Ref: Edward Shorter 1992 pp 181-186) surrounding his public demonstrations. However he would later adopt many of the same touches of drama and theatricality in his own demonstrations.
As Lerner puts it: “Nonne’s wartime demonstrations bear a striking resemblance to Charcot’s performances, in which the Parisian neurologist routinely hypnotized a stagefull of patients who stood bathed in a spotlight before a captivated audience.” (Ref: Lerner 173-174)
Nonne’s next visit was to Nancy where he studied the therapeutic use of hypnosis Hippolyte Bernheim who disputed Charcot’s contention that hypnosis and hysteria were related, disagreed with his view that there was a physical dimension to hysteria and his notion that suggestibility was an indication of pathology.
Impressed by what he saw and heard, Nonne quickly came down on the side of Bernheim and the Nancy school in their disagreement with Charcot and his followers. Later he went to Switzerland to study under August Florel who headed the Burghölzi Sanitarium who was using hypnosis, suggestion and therapy in his treatment of hysterical illnesses. “Here it became clear to me how correct Bernheim had been when he attributed Charcot’s influence to suggestion,” he later wrote. But from 1889 until the outbreak of war Noone abandoned his interest in hypnosis and pursued organically orientated work more typical of main stream German psychiatric thought, and began to regard hypnosis as increasingly incompatible with modern scientific thought and goals. (Ref: Hannah Decker in her book Freud in Germany: Revolution and Reaction in Science, 1893-1907, New York 1977, describes the very different responses to hypnosis that existed in Germany and France during the latter part of the 19th and early decade of the 20th century)
Notes from Brunner – Psychiatry etc. Jrn History of Behavioural Sciences 1991
Indeed when he first decided to try and use hypnosis to treat the flood of German soldiers presenting with hysteria during the second year of the war, he did so with considerable reluctance and trepidation, fearing that he would be accused by his more conversation colleagues as turning back the clock on medical progress. Shocked by his own audacity he explained: “I first had the courage to recommend the usage of hypnosis, which was considered by many as obsolete, that is to say, unscienitific.” (Ref: Nonne, “Über erfolgreiche Suggestivbehandlung, p 194)
“In February 1915 Max Nonne demonstrated at a medical congress in Hamburg that symptoms of war neuroses could be removed by hypnotic suggestion, which clearly contradicted Oppenheim’s organic etiology.” (p 353).
These methods were condemned by many physicians as a return to medieval mysticism and a disgrace (unwürdig) to the honour of the fighting man. However by September 1916 the tide turned in favour of his theories and at the War Congress of the German Association for Psychiatry and Neurology in Munich, most of the 241 doctors present changed to Nonne’s psychogenic approach. “Symptoms were explained by a “malady of the will” (Willenssperrung (inhibition of the will), Willensversagung (withdrawal of the will), Willenshemmung (arrest of the will)” (p353)
These were said to arise from a neurosis of defence (Abwehrneurose) designed to serve the individuals need for self-preservation. At the end of the war, Nonne wrote that: “The term “purpose neurosis” or “neurosis of defence” is to express the fact that these neuroses serve an inner purpose and that their appearance reflects a real interest of the patient.
What makes them pathological is that they do not originate in a conscious wish. A wish alone cannot create an illness. Illness is created by an unconscious drive to self-preservation mediated by strong affects with acute or chronic origins in the subconscious.” (Ref: Nonne, “Über erfolgreiche Suggestivbehandlung)
Despite Nonne’s successes, suggestive hypnosis remained a highly controversial approach and one many doctors found they had little flair for. Many reported themselves incapable to reproducing his rapid and reliable results, and found the process demanding of their time – it could not be carried out by assistants – and mentally exhausting, a point with which Nonne was in complete agreement: “One should not imagine that it is easier on the doctor,” he wrote, “since the demand of extreme attention and the necessity of absolute concentration strain the practitioner greatly”. (Ref Nonne, Therapeutische Erfahrungen, p 109) “He who has at his disposal a great deal of physical endurance and patients will favour (hypnosis). To practice hypnosis demands an exceptional ability to judge the whole personality correctly, I would almost say artistic blood, the ability to take note of the slightest movements of the object, to interpret them and to judge them in a split second.” (Ref Nonne, Therapeutische Erfahrungen, p 112).
“The physical and – even more the emotional – disposition of the doctor plays a role, I believe a certain degree of ‘temperament’ is necessary for this method of treatment. One must be able to strike a chord that will resonate with the patient. In certain circumstances one must also be able to wrestle with the patient. I said that already in Munich, and many of my colleagues have in the mean time witnesses my wrestling”. (Ref: Nonne, “Über erfolgreiche Suggestivbehandlung, p 202).
“In my opinion, personal vigour and the talent to hold the person spellbound are greater qualifications than acquired diagnostic-neurological abilities.” (Ref: Nonne, “Über erfolgreiche Suggestivbehandlung, p 213)
But was not just the doctor who had to be “right” for Nonne’s approach to yield results, so too did the patient. With some individuals it proved impossible to obtain any worthwhile results, so resistant to hypnosis did they prove.
This requirement for patients of the right “type” was one of the criticisms levelled against Nonne’s procedures by such authorities as Forster’s own department chief Hermann Oppenheim.
Oppenheim who had used hypnosis on his private patients before the war, believed that Nonne’s cures although dramatic would prove short lived and that they would, anyhow, only be even temporarily effective in patients with a single hysterical symptom. When, as often happened, they were suffering from a combination of organic and psychological hysterical difficulties, “suggestive therapy” could do nothing to help. “We have also attained some rapid cures through hypnosis and suggestion,” he agreed,” but in the greater part of our trials hypnotic treatment failed, even in those cases
where the patient could be placed into deep hypnotic sleep. I myself and three of my assistants and colleagues have devoted ourselves to hypnotic treatment in this hospital, and none of us is a beginner.” (Ref: Hermann Oppenheim, “Für und wider die traumatische Neurose” Neurologisches Centralblatt, 35, 1916. p 227)
After the war Nonne responded to the charge that his cures were short-lived by surveying a group of his former patients. Of the 46 who responded to his follow-up study, 26 had returned to their pre-war occupations and had suffered no further difficulties and 16 had returned to work but in less demanding and lower paid occupations. Only four had experienced a relapse and had to be readmitted to military hospitals.
(Ref: Nonne, “Über erfolgreiche Suggestivbehandlung, p 204)
Even Nonne who treated more than 1600 soldiers using hypnosis was perfectly prepared, should these gentler methods not obtain the desired results, opt for painful electric shocks.
“I had patients always undress to complete nakedness, since I found that one could thereby increase their feelings of dependence or helplessness.” (Ref Nonne op cit. p 109-110)
Thoracic outlet syndrome with compression of the nerves and vessels in the outlet of the thorax and the costoclavicular area or between the clavicle and the first rib.
The cerebrospinal fluid, obtained by lumbar puncture, is yellow and the protein content is raised.
A hereditary disease of the nervous system, with cerebellar ataxia caused by bilateral cortical atrophy of the cerebellum.
Sensitive, qualitative method for demonstrating fibrine-globuline in liquor cerebrospinalis.
Chronic familial lymphoedema of the limbs, which manifests with pittings and painless brawny swellings (lymphedema) of the ankles and shins.
Intracranial hypertension of unknown origin.
(Ref p99. 10/11: Nonne) Developed Nonnes Test (also known as Ross-Jones test for globulin in the cerebrospinal fluid).
* References: See Reference Section of this site for all references mentioned in these notes.