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 symptoms, 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 reversion to an infantile stage of
not-being-able-to-walk or 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 represents more 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 corresponds
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 Strümpell considers,
of the production of illnesses on account of an actual gain (pension,
compensation for injury, flight from the front) which are only
secondary illness gains; the primary motive for the illness is the
pleasure itself of remaining in the secure retreat of the childish
situation once 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 appreciated, 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 contribute to the
adjustment of the disturbed equilibrium in the psychical 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.
[Illustration]
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
infant’s life. He says: “If one lays 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 artificially produced a little shock
(or traumatic) 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[4].
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 psychological
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
reactions of the ego impulses to the trauma, and they keep entirely to
the manifest expressions of the neurosis. In the following remarks,
besides those factors which we do not dispute, 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 contravenes
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 unimportance 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 surmises
connected with such observations. Moreover, the recurrence of certain
definite symptoms in war neurotics, which were familiar to me not only
in the traumatic neuroses of peace time, but also in the non-traumatic
cases, seems to me worth noting. I refer particularly to the complex of
symptoms which we could so often observe during the war in the anxiety
cases with trembling, such as trembling, agitation, irritability,
sensitiveness, sleeplessness, headaches, anxiety, depression of
spirits and feelings of incompetency. Two neurotic types with the
same symptoms—although these do not appear so prominently as in the
war—would be the impotent man and the frigid woman. A similarity 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 sexuality 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
participating in the war, hence we are unable to dispense with the
assumption of an individual disposition, but we are in the position to
define it far more accurately than the prevailing school of neurology.
A couple of examples will make the problem before us clearer.
At the beginning of the war a soldier at the front was wounded on
August, 12th, 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 doing
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 conditions
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 narcissism: 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 demanded 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 the 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 their
sexuality. They frequently find this in their wife on whom their
sexual hunger (libido) is completely dependent, or they have to defend
themselves from their feelings of insecurity sexually by having
constantly to convince themselves that they are potent by going 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 situation, 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
of 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-sacrifice 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 similar significance to that of dying. The symptoms in part
are only comprehensible in this sense. The case of a man who in the
field suffered from a relapse of a neurosis which he had had six
years previously is especially instructive. At that time he was taken
with a tremor 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 produced through dangerous situations, terror, etc., but not
infrequently an act of aggression which he has 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 activity finds in the expression its motor discharge.
The complete instability of many war neurotics, their disconcerting
depression, their propensity to thoughts of death, find a further
explanation in a particular effect of the trauma. Many of the
neurotically disposed persons, up to the moment when the trauma upsets
them, have supported themselves only through an illusion connected
with their narcissism, namely, through the belief in their immortality
and invulnerability. The effect of an explosion, a wound, or things of
a like nature suddenly destroys this belief. The narcissistic security
gives way to a feeling of powerlessness 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
undoubted signs of an affection of the Conus Medullaris, 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 disquietening 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
already had enucleation performed in another hospital. They were in
no way depressed but gave themselves up to a careless, serene frame
of mind. When they—all at the same time—received their artificial
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 experienced
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
belong to it[5].
All the experiences here communicated speak unanimously in the
sense that the war neuroses are 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 I 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 furlough 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 case. In
1915 when I was acting at a surgical station a man was treated there
for a gunshot wound of the penis. The operation, which was carried out
by a well known surgeon, was quite successful. Two years later the same
patient came to my psychiatric station. The man who was previously
unaffected psychically now showed a paranoid mental disturbance. On
questioning him it appeared that in consequence of the 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 important
basis of the belief in himself. A man injured by an accident before 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
dominates. The genital zone has lost its predominance; anal erotism
is strengthened. 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 particularly that of the
psycho-analytic.