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.
At the commencement of the war one took little notice of the neurotics, they were placed perchance in a convalescent home but practically without treatment. The increasing number of neurotic cases necessitated other measures. The old method of “surprisal” 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, they produced certain unwished-for phenomena. The military medical authorities therefore display a lively interest in putting on one side the too “active” methods in favour of other effective but less severe ones.
Is 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 briefly speak of my own therapeutic experiences. We psycho-analysts had 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 conclusions of our ideas and efforts. When in 1916 I founded a station for neuroses and mental diseases I abstained entirely from all forcible therapy, likewise from hypnosis and other suggestive 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 feeling 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-analysis 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 Kaufmann 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 conclusion the result, instructive in this connection, of the recent treatment 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 the gaps that exist at present. Psycho-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[6].