A brief summary of Hans Asperger’s 1938 “Psychically abnormal child”

Hans Asperger first described the clinical findings that are today associated with Asperger syndrome in a workshop on 3rd October 1938, published as a 4,000 word article Asperger (1938) Das psychisch abnorme Kind. Wiener Klinische Wochenschrift, 49:1314-1317. In English this would be “The psychically abnormal child”, although it might equally be another term such as “mentally” if translated today. The following summarises the content .

[English text in “quotation marks” is my translation, with the original German text in square brackets]

Historically, this workshop took place 6 months after the annexation [Anschluss] of Austria by Nazi Germany on 12 March 1938. Adolf Hitler had been Chancellor and the Nazi party in government for 5 years. Asperger refers to the “Law for the Prevention of Hereditarily Diseased Offspring” [Das Gesetz zur Verhütung erbkranken Nachwuchses] which was proclaimed in Germany on 14th July 1933, initially for the compulsory sterilisation of people with mental illness (schizophfrenia and manic depression), retardation (“congenital feeble-mindedness”), physical deformithy, epilepsy, blindness, deafness, and severe alcolholism. Within less than a year, by July 1939, a programme of euthanasia commenced.

This post is complemented by my previous post on the flowing linguistic, geographical and disciplinary boundaries that shaped the term we currently know as ‘autism’.

Introduction

Asperger begins with a remark about the widespread cultural and medical changes after annexation, following the dramatic ructions in German society over the preceding 5 years: “We are in the midst of a tremendous spiritual transformation sweeping all areas of life, not least medicine. The fundamental idea of the New Reich is that the Whole is greater than the Part, the People more important than the Individual – this leads to profound changes in our whole attitude to the most precious commodity of the Nation, its health.” [Wir stehen mitten in einem gewaltigen Umbau unseres geistigen Lebens, der alle Gebiete dieses Lebens ergriffen hat, nicht zum wenigsten die Medizin. Der tragende Gedanke des neuen Reiches: Das Ganze ist mehr als der Teil, das Volk wichtiger als der einzelne – mußte hier, wo es um das kostbarste Gut der Nation, um seine Gesundheit geht, in unserer ganzen Einstellung zu tiefgreifenden Veränderungen führen.]

Eugenics – a widespread political position through Australia, Britain, the United States and elsewhere – was respectable and part of the physician’s role in society, as “You know the means to prevent the spread of pathological hereditary materials – in very many cases hereditary disorders – and to promote genetic health. We physicians must take full responsibility for our tasks in this area.” [Sie wissen, mit welchen Mitteln man danach strebt, die Weitergabe krankhaften Erbgutes – in sehr vielen Fällen, die hierher gehören, handelt es sich um erbliche Störungen – zu verhindern und das Erbgesunde zu fördern. Wir Ärzte müssen uns den Aufgaben, die uns gerade auf diesem Gebiet erwachsen, mit voller Verantwortung unterziehen.]

There is a balance between the individual and common good, a ‘price’ that might be established on individual worth, and Asperger delineates the worth of the individual to balance against the cost to society: “But today let me discuss the problem not from the standpoint of the Nation – in which case we would have to discuss the “Law for the Prevention of Hereditarily Diseased Offspring” – but from the standpoint of abnormal children. The question should be “How much we can afford these individuals?” And if we help them with all our devotion, so we also best serve the people; not only by preventing the breakdown of community by their antisocial and criminal acts, but also by seeking to achieve that they fulfil their place as workers in the living organism of the people.” [Lassen Sie mich aber heute das Problem nicht vom Standpunkt der Volksgesamtheit aus erörtern – dann müßte man vor allem das Gesetz zur Verhütung erbkranken Nachwuchses besprechen –, sondern vom Standpunkt der abnormen Kinder aus. Wieviel können wir für diese Menschen leisten? soll die Frage sein. Und wenn wir mit all unserer Hingabe ihnen helfen, so tun wir damit auch unserem Volk den besten Dienst; nicht nur dadurch, daß wir verhindern, daß jene durch ihre dissozialen und kriminellen Taten die Volksgemeinschaft belasten, sondern auch dadurch, daß wir zu erreichen suchen, daß sie als arbeitende Menschen ihren Platz in dem lebendigen Organismus des Volkes ausfüllen.]

(Marc Bush has suggested that Asperger deliberately employed “Nazi-style” vocabulary to deceive the Nazis and protect his child patients, included in Adam Feinstein’s 2010 book Conversations with the Pioneers. However, “In 1942, as part of a seven-member commission, Asperger examined 220 inmates of the Gugging hospital’s children’s facility. Of these, 35 were sent to the Spiegelgrund at the behest of the commission; all 35 children died within a short period of time” – Herwig Czech (2014) Chapter 9, Abusive Medical Practices on “Euthanasia” Victims in Austria during and after World War II”, Rubenfeld, Sheldon & Benedict, Susan [eds] (2014) Human Subjects Research after the Holocaust.)

Two of Hans Asperger’s most famous quotations appear in this paper, the first is “Not everything that falls out of line, which is “abnormal”, must therefore be “inferior”” [Nicht alles, was aus der Reihe fällt, was also „abnorm“ ist, muß deshalb auch schon „minderwertig“ sein]

Two case studies

The paper describes two detailed case studies, a 10-year-old and a 7½-year-old boy. He does not specifically mention these findings in girls, but implies that the boys’ mothers have the same psychopathy.

The first, 10-year-old, case is summarised briefly, “He is intellectually gifted, highly talented, of fine character, a delicate boy with numerous physical and psychological sensitivities.” [Es handelt sich um einen intellektuell besonders begabten, charakterlich fein differenzierten, fein empfindenden Knaben mit zahlreichen körperlichen und psychischen Empfindlichkeiten.]

These fine and coarse traits compete, to the point of over-compensation in the areas in which the child exceeds, “In order to save himself from the inferiority of various of organ systems and the consequent, so very harmful, feelings of inferiority, he overcompensated for the inferiorities with exceptional intellectual achievements; the inferiority is the cause of the worth (such as – to use an example of the individual psychologists – Demosthenes had his stuttering to thank that he was such a great orator; it was the spur to his ascent!).” [Um sich vor der Minderwertigkeit verschiedener seiner Organsysteme und den daraus sich ergebenden, so sehr schädlichen Minderwertigkeitsgefühlen zu retten, hätte er den Weg der Überkompensation dieser Minderwertigkeiten durch besondere geistige Leistungen eingeschlagen; die Minderwertigkeit sei also die Ursache der Hochwertigkeit (so wie – um ein Beispiel der Individualpsychologen zu gebrauchen – Demosthenes es seinem Stottern zu verdanken gehabt hätte, daß er ein so großer Redner wurde; durch dieses nämlich hätte er den Antrieb zu seinem Aufstieg erhalten!).]

A similar situation arose with a pair of identical twin sisters with viral hemichorea, only one of whom was gifted. The viral infection affected the two differently, “The second-mentioned [gifted] sister was always ill to a greater degree than the other, but she also had a much more severe, prolonged chorea, associated with more severe mental symptoms. No coincidence, we are confident; the finer organized brain was more susceptible to the chorea virus” [Die zweitgenannte Schwester hatte nun nicht nur stets alle Krankheiten in weit schwererem Grad als die andere, sondern sie hatte auch die viel schwerere, länger dauernde, mit schwereren psychischen Begleitsymptomen einhergehende Chorea. Kein Zufall, so sind wir überzeugt; das feiner organisierte Gehirn war aus eben diesem Grund anfälliger für das Virus der Chorea]

A “psychopathic type”

Asperger makes it clear that although he is using two detailed cases, they are examples of a ‘type’, a clinical picture that they have observed and treated many times in their clinic. “The children of this psychopathic type, to which the presented boy belongs, mostly correspond not only in character, but often also in physique and motor activity down to the finest details. Before us is a massive, coarse, hulking boy, who acts in all older than he is.” [Die Kinder dieses psychopathischen Typus, dem der vorgestellte Knabe angehört, stimmen meist nicht nur in ihrem Charakter, sondern oft auch in Körperbau und Motorik bis in feinste Einzelheiten überein. Vor uns steht ein massiger, derber, ungeschlachter Bub, der im ganzen älter wirkt als er ist.]

Furthermore, the ‘type’ has well-defined boundaries determined by a clearly-identified function of ‘narrowed relations with the environment’, “Within this well-characterized group of children, whom we refer to as “autistic psychopaths”, because of the narrowing of their relations with the environment, because of the limitation to one’s own self (αύτος), there are, of course, quite different people to be assessed.” [Innerhalb dieser wohl charakterisierten Gruppe von Kindern, die wir wegen der Einengung ihrer Beziehungen zur Umwelt, wegen der Beschränkung auf das eigene Selbst (αύτος) „autistische Psychopathen“ nennen, gibt es nun freilich wieder recht verschiedene, auch recht verschieden zu bewertende Menschen.]

Asperger’s second famous quotation appears here, “originality of thinking (in which there is always some “autism”!)” [die Originalität des Denkens (zu der immer etwas „Autismus“ gehört!)]

The mother

Asperger suggests a hereditary basis to the psychopathy, shared by mother and child, providing a deeper understanding of the disorder. That many of these cases are only children is a consequence of this shared heredity, with the mother having little interest in or warmth for her child, and no inclination to have subsequent children. [Daß diese Frau, die ihrem Sohn in diesem Fall seine psychopathische Anlage vererbt hat, nicht die warme Mütterlichkeit aufbringt, sich den Schmerzen und Unbequemlichkeiten mehrerer Schwangerschaften, den Mühen der Aufzucht vieler Kinder zu unterziehen, liegt auf der Hand.] The tone is undoubtedly mother-blame, but more nuanced than Kanner or Bettelheim in later publications. “The mother of this boy is very similar in character to her son: she is quite unfemininely intellectual, peculiar in her essence, has little sense of relationship with her child.” [Die Mutter dieses Buben ist charakterlich ganz ähnlich geartet wie ihr Sohn: sie ist ganz unweiblich intellektuell, sonderlinghaft in ihrem Wesen, hat wenig Gefühlsbeziehungen zu ihrem Kind.]

Educational conclusions

The instruction of normal children acts through personality, through expression of voice, face and gesture. Resistance by the child is countered by insistence and intensity, in the extreme case a “holy thunder”. However, “this makes no impression on autistic children, it is only an interesting sensation, which they enjoy with malicious pleasure and are therefore provocative (“I am happy when mother bangs on the table,” exclaims the aforementioned boy with flashing eyes).” [eben das macht auf solche autistische Kinder gar keinen Eindruck, ist ihnen nur eine interessante Sensation, die sie mit boshafter Freude genießen und darum geradezu provozieren („ich freue mich, wenn die Mutter auf den Tisch haut“, erzählt der vorgestellte Knabe mit boshaft blitzenden Augen).]

Autistic children require factual “rules of conduct” – somewhat like an arithmetic problem. Objective rules, timetables and pedantic accuracy (on both sides) and conscious, “intellectual” training, over years of painstaking, conflictual work work better than self-conscious, unconscious, instinctive habit.

The new role of medical assessors

Asperger states that “These latter cases are important – or will be to us when the “Law for the Prevention of Hereditarily Diseased Offspring” comes into force. If a physician acts as an assessors in such cases before a decision is taken, he may not do so solely on the result of a questionnaire or the value of intelligence quotient, but primarily from his knowledge of the child’s personality, knowledge that takes into account all the child’s skills, not just abstract intelligence.” [Diese letzteren Fälle sind wichtig – oder werden es bei uns werden, wenn das „Gesetz zur Verhütung erbkranken Nachwuchses“ auch bei uns in Kraft tritt. Wird der Arzt als Begutachter in solchen Fällen vor eine Entscheidung gestellt, so wird er diese nicht allein nach dem Ergebnis der Beantwortung eines Fragebogens oder nach der Ziffer des Intelligenzquotienten treffen dürfen, sondern in erster Linie nach seiner Kenntnis der kindlichen Persönlichkeit, eine Kenntnis, die alle Fähigkeiten des Kindes, nicht nur die abstrakte Intelligenz in Rechnung zieht.]

Therapy

As with education, therapy also acts through “The powerfully acting personality of the physician causing the patient to let go of his morbid symptoms, whatever their ultimate cause, from whatever disturbed personality they might come. What eventually causes healing is the confidence of the patient in the healing power of the physician; this confidence causes the healing retuning of the nervous apparatus.” [Die mächtig wirkende Persönlichkeit des Arztes veranlaßt den Kranken, von seinen krankhaften Symptomen abzulassen, was immer auch deren letzte Ursache sein mag, aus welch gestörter Persönlichkeit immer sie kommen mögen. Was die Heilung letztlich bewirkt, ist das Vertrauen des Kranken in das Heilvermögen des Arztes; dieses Vertrauen bewirkt die heilende Umstimmung des nervösen Apparates.]

(In his 1944 paper, Asperger explains more clearly that the behavior and mood of the educator, coming from the mind (θυμος), automatically, without intention, without consciousness, influences the mood and behavior of the child – this is called ‘thymogenic automatism by Hamburger, the head of the clinic. [das aus dem Gemüt (θυμος) kommende Verhalten des Erziehers, seine gemütsmäßige Einstellung beeinflußt automatisch , ohne Willen, ohne Bewußtsein, die Stimmung und das Verhalten des Kindes])

Conclusions

Asperger concludes that the balance of the cost to society and the value of the individual must include a full assessment of the individual, even those with hereditary burdens – “By no means should the finding that it is primary, constitutional injury, even hereditarily burdened people, lead to the that one can do nothing – just as the knowledge of endogenous disorders must not lead to educational nihilism.” [Keineswegs darf die Feststellung, daß es sich um primär, konstitutionell geschädigte, etwa auch erblich belastete Menschen handelt, zu der Ansicht führen, da könnte man eben nichts machen – ebenso wie die Erkenntnis endogener Störungen nicht zum pädagogischen Nihilismus führen darf.]

Not all of this worth is visible in early childhood, nor on a numeric score such as intelligence quotient, “in these people at some time, perhaps at puberty, powers and abilities might arise, which of course must have been present, but which we did not foresee in the children, or of it was impossible to foresee that they would once gain this significance.” [daß in diesen Menschen auf einmal, etwa in der Pubertät, Kräfte und Fähigkeiten auftreten können, die freilich angelegt sein mußten, von denen wir aber bei den Kindern nichts ahnten oder von denen es unmöglich vorauszusehen war, daß sie einmal diese Bedeutung erlangen würden.]

Asperger concludes with the pivotal role of medicine in assessing the balance between the competing needs of individual and society, “The physician has the right and duty, which I hope to have shown in these few words, to be an educator to influence not only educators of all to a healthy life, he also has to decisively influence the education of the abnormal. His clear view of natural relationships, his understanding must succeed, to provide advice and assistance, to serve not only the Individual, but also the People.” [Der Arzt hat das Recht und die Pflicht, das hoffe ich Ihnen in diesen kurzen Worten gezeigt zu haben, Erzieher zu sein, nicht nur Erzieher der Gesamtheit zu einem gesunden Leben, er hat auch die Erziehung Abnormer entscheidend zu beeinflussen. Seinem klar in die Zusammenhänge der Natur schauenden Blick, seinem Verstehen muß es gelingen, auch hier Rat und Hilfe zu gewähren und damit nicht nur dem einzelnen, sondern auch dem Volke zu dienen.]

Further reading

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