1. Simple explanation and encouragement.

2. Hypnotic and post-hypnotic suggestion.

3. Preliminary psychological investigation with the revival in a hypnoidal condition of the emotional experience on which the attacks depend.

4. Complete psycho-analysis.

It is very rarely that simple explanation has the slightest effect, and in my experience hypnosis and post-hypnotic suggestion is equally unsatisfactory. Although this method may abolish the attacks, such relief is, as a rule, only temporary. In this connection Myers (17) points out that it is a well-established fact of experimental psychology that one process does not destroy but can at most merely inhibit an antagonistic process, and that other things being equal the older process tends to outlast the later acquired activity.

The forms of gross suggestion that have been employed in the attempt to relieve narcoleptic attacks (e.g. false operations, trephining (as in Carlill's (5) case), without impugning the purity of motive of the physicians concerned, cannot be too strongly condemned.

I believe the most satisfactory of the shorter inethods of treatment to be (1) a preliminary modified 'psychoanalysis' with a detailed investigation into the history of the onset of the attacks, and of the individual, followed by (2) reconstruction of the origin of the narcolepsy, or of the emotional experience giving rise to the condition, under light hypnosis. It is well known that a light degree of hypnosis is most effective for the process of reassociation, and its value, for the elicitation of memories which one is unable to revive in a waking state, is undoubted. The following is an example of a case of narcolepsy which responded favourably to this form of treatment.

F. L. T. aet. 21, was first seen on March 22nd, 1920, the diagnosis being one of traumatic minor epilepsy.

History. No illness of any importance prior to war service; no previous fits or nervous disorders. His mother suffers from Graves' disease; family history otherwise negative.

He enlisted in the R.A.F. in March, 1917, was commissioned in December, 1917, and proceeded to France in April, 1918. Having made several successful observations and bombing flights soon after arrival, he was acting as observer on one occasion during May, 1918, when his aeroplane came under the fire of enemy anti-aircraft guns at fairly close range; one shell exploded underneath the machine, whereupon his pilot lost control and a crash resulted. F. L. T. was apparently thrown upon

his head and lost consciousness; he 'came round' about an hour later in a dressing station, and while he was still an inmate there was bombed by enemy aircraft. He felt very nervous but immediately fell asleep; these attacks of sleep recurred almost daily even after he was evacuated to England. After a few months the attacks averaged three per week. Finally, he was discharged from the Army in much the same condition in February, 1919.

Condition on admission. He states that all attacks are diurnal and are preceded by no warning whatever. He was unable to assign any causes to individual attacks. Following the attacks, he occasionally became emotional and also suffered from intense headache. He was depressed, somewhat irritable, and stated that he was too nervous to go to sleep at night; dreams were few and far between and were not of a startling character. He had a definite fear that he would become insane. At this time, owing to erroneous diagnosis of epilepsy, he was taking 30 grains of potassium bromide a day, and two drachms of paraldehyde at night, and was not allowed to go about alone.

The physical examination did not reveal any evidence of organic nervous disease; he appeared very apprehensive, and exhibited slight general tremors. He said the last attack of sleep had occurred on the previous day, quite suddenly while he was talking to a nurse; he recollected sinking down but remembered nothing further until he found himself in bed with an intense headache. He related the history of the crash and the development of the nervous disorder quite clearly and without any sign of increased emotion.

Progress, etc. Following a detailed investigation of his case history, the first step was to bring about the omission of the paraldehyde and a rapid reduction in the amount of bromide he was taking. As a result there was no appreciable increase in the frequency or severity of the sleeping attacks, and after three weeks bromide was stopped entirely. A further discussion of the experiences of the crash, and an endeavour to revive in the waking state the emotions associated with it, did not meet with any success. In the meantime he was encouraged to go about alone. At his next visit, he was lightly hypnotised and the 'crash' experience again revived. After a few preliminary suggestions that he was in the air, over the enemy lines, and was apprehensive of crashing, he went through the whole experience without any further exhortation, and exhibited all the emotion that one would associate with such an experience. He trembled, sweated, and clung to imaginary stays, and finally finished by shouting, "We are going to have a hell of a crash."

Incidentally I ascertained that a thought of a crash or similar accident had immediately preceded his attacks of sleep. From that time, which was in June, 1920, he has had no more attacks, has quite lost his fear of insanity, and has worked continuously as an election agent, passing through the stress of a general election.

C. S. Myers (17) has also recorded a case which was much relieved by the revival under hypnosis of a repressed incident in which the patient was face to face with an orang-utang and had to shoot the animal. In this case there was no emotional abreaction during the return of the lost memories, and from this case and others Myers concludes that for a successful result an emotional 'abreaction' during the revival of the dissociated memories is not essential. He believed that it is not the emotional component of the experience that is primarily repressed, but the 'unpleasant' component (cognitive experience) and that the resistance against revival expresses the inability to admit the unpleasant, not the inability to face the emotion. Of the veracity of this latter view I am not entirely convinced, as I have seldom been fortunate enough to obtain a satisfactory result in any form of neurosis by a mere revival of a repressed experience in the absence of an emotional component.

REFERENCES.

(1) ABRAHAMSON. Journal of Nervous and Mental Diseases, LII. 193. (New York.) 1920.

(2) ACHARD. Paris Med. 209. Sept. 18th (38th year). 1920.

(3) BALLET, G. Rev. de Med. 925. 1882.

(4) CAMUS and Roussy. Bull. et Mem. Soc. Med. des Hôp. de Paris, XLVI. 1238. 1922.

(5) CARLILL, H. Lancet, 1128. Dec. 20, 1919.

(6) ECONOMO. 35th "Congress of Internal Medicine." Vienna, 1923.

(7) FÉRÉ. Semaine Medicale. 1893.

(8) FRIEDMAN. Zeit. Für. Neurolog. XXX.

(9) GÉLINEAU. De la Narcolepsie. Paris, 1881; Gaz. des Hôp. de Paris. 1880.

(10) GOWERS, W. Diseases of the Nervous System, 1. 953. 1888.

(11) GUTHRIE. Allbutt and Rolleston's System, VIII. 814. 1910.

(12) HALL, A. J. Lancet, 739. April 14th, 1923.

(13) JANET. Major Symptoms of Hysteria. Paris.

(14) JELLIFFE and WHITE. Diseases of the Nervous System. 1919.

(15) KÜLPE, O. Outlines of Psychology. 1909.

(16) LAMARCQ. Rev. de Med. 1897.

(17) MYERS, C. S. Lancet, 491. Feb. 28th, 1920.

(18) OPPENHEIM. Diseases of Nervous System, г. 1117. 1911.

(19) STEWART, PURVES. Diagnosis of Nervous Disorders. 1911. (20) STODDART. Mind and its Disorders. 1921.

(21) THOMSON, J. Brit. Journ. of Children's Diseases, xx. 1923.

PSYCHO-ANALYTIC VIEWS ON SOME CHARACTERISTICS OF EARLY INFANTILE THINKING1.

BY KARL ABRAHAM (BERLIN).

PSYCHO-ANALYTIC interest is focussed on the question of the origin of psychic phenomena. In terms of psycho-analysis the problem is this: By what instinctive forces, conscious and unconscious, are these phenomena determined? The analysis of psychological products regularly reveals in them the combined workings of the 'ego-instincts' and the 'sexual instincts.' Psycho-analysis attributes to the latter a far wider significance than that ascribed to them by other schools of thought. It is not necessary for the purpose of this paper to enter upon a discussion as to whether psycho-analysis is right in this respect; the task before us is a more general one.

Psycho-analysis took as its starting-point the investigation of neurotic symptom-formation. But the more thoroughly was the psychogenesis of a symptom explored the more definitely did the associations of the patients lead back into the past, and ultimately to early childhood. In this way certain necessary hypotheses suggested themselves with reference to the instinctive life, and especially the sexual life, of the child, which were in opposition to the traditional views. These hypotheses were confirmed by direct observation of children, and thus we attained new points of view about the psychology of childhood. Amongst other results we came to know that thinking in early childhood is in a special degree under the influence of the instinctive life. My intention now is to show how certain phenomena of infantile thinking are determined by peculiarities, with which we are familiar, of the instinctive life of the child. As the title of this paper indicates, I do not pretend to give an exhaustive account of the subject; I am conscious of the fragmentary character of my essay.

Thinking is the intellectual side of our relation to the outside world; it is based upon sense-perceptions, the experience of the individual. At the earliest period of our lives the contact with the outside world. which is of the greatest practical significance is made by means of

1 Read before the International Congress of Psychology at Oxford, on July 31st, 1923. Translation by Cecil Baines.

Med. Psych. III

19

the mouth. The twofold importance of the mouth as an organ of nourishment and an erotogenic zone is a matter which, as I have said, I do not propose to discuss here. Without passing any judgment, therefore, as to the correctness or otherwise of that psycho-analytical conception I will merely lay stress upon the fact that at this earliest period of life the instinct of sucking is the most powerful one that there is. At a rather later stage the instinct of biting acquires a similar importance. It is only gradually that the child apprehends the outside world by means of eye and ear. The tendency to put every object into his mouth and chew it with his teeth, with a view to completely incorporating it, becomes strikingly evident from the moment that his hands have the power of grasping. To the child at this stage the outside world consists of all those objects which delight him and which he would like to incorporate in himself but has not as yet so incorporated. The ego and its interests are more important than the object-world. At the stage of the primitive pleasure in biting there is as yet no inhibition to check the destruction of objects: the child is still wholly without adaptation to the outside world. In the realm of the ego-instincts egoism is wholly dominant, as is narcissism in that of childish sexuality. Thus we see that the child's primitive attitude towards objects is a simple matter of pleasure or pain. The outside world is regarded purely subjectively according to its effect, pleasurable or painful, upon the ego. This is true to a considerable extent with regard to the thinking of adults as well, but there is nevertheless a great quantitative difference in the two cases. In adults the function of consciousness has a moderating and regulating influence upon the instinctive life; consciousness has the power of confronting the impulses with criticism and applies to our desires the standard of reality.

Thus the psychic attitude of the young child towards objects is determined simply and solely by the pleasurable or painful effect produced upon him by those objects. Side by side with this important fact of the infantile mental life let us hasten to set another phenomenon which is closely related to it. I refer to the discovery that, when two objects arouse in the child similar feelings of pleasure or of pain, he proceeds unhesitatingly to identify them. The critical mode of thinking by which we compare and differentiate is wholly absent at this early stage. A few examples may serve to illustrate this mode of thinking by identification which belongs to early childhood.

A little girl of eighteen months was somewhat afraid of dogs. If she saw one she would cry out in alarm: "Bow-wow bite!" ("Wau-wau