by the infection there was a strong psychic factor, for which I referred him to Dr Crichton Miller. He reacted to every obstacle or disability like an infant in the presence of an omnipotent mother. The mother substitute in this case was his sister. He could not cast aside childish trammels, but had been able to conceal this psychic disability until the toxic factor had lowered his endocrine resistance. Psychotherapy produced a dramatic improvement in his symptoms.

The nutritional factor would seem to be chiefly associated with lack of vitamines which, as McCarrison has shown, causes enlargement of the adrenals and pituitary while causing some atrophy of the other endocrine glands. In pellagra we have a striking example of a deficiency disease producing actual structural changes in the adrenals and sympathetic ganglia and leading to mental deterioration. In this connection it is of great interest to note that pellagra is much more likely to affect defeated than victorious soldiers, showing the influence of depressing emotion in permitting a disease directly due to lack of assimilable protein to obtain its hold on the endocrine system. Whereas toxic and nutritional influences play chiefly on the glandular part of the apparatus, psychic factors naturally act primarily on the nervous part; though ultimately both parts will become affected, whichever is involved first. It is to fear, pain and rage that the sympathetic particularly reacts since these are the stimuli which normally lead to those violent motor responses for which sympathetic action prepares the way. Rage, as McDougall has shown, is particularly excited when other primitive emotions are baulked of their expression. That pain is a developed phase of all primitive sensation is highly probable, as Trotter has shown, and I think a good case could be made out for regarding fear as the intensified form of the primitive emotion that leads either to immobility, i.e. the "shamming dead" reflex through the parasympathetic, or the violent response by flight through the sympathetic. In the civilised state the response appropriate to primitive man has often to be repressed. Such repressions are particularly likely to be necessitated when the great instincts of selfpreservation, reproduction and gregariousness which relate respectively to the life of the individual, of the species and of the community come into conflict with one another. The effect of this repression may show itself at any of the three great levels of the nervous system, at the psychic level as a phobia or an obsession, at the sensori-motor level as a paralysis, contracture, tic or paraesthesia, or at the sympathetic level in some cardiac or digestive neurosis, or in some endocrine disease. The autonomic level of the nervous system works through the endocrines; just as the

psychic level expresses itself through symbols (Smith Jelliffe). Just as in the psychoses the symbols acquire an abnormal significance, so in vegetative neuroses the endocrine glands behave abnormally.

One of the general phenomena of disease is dissociation. Normally the sympathetic should act as a whole, but in emotional glycosuria we have a good example of dissociated action affecting entirely or mainly carbohydrate tolerance. The adrenals, thyroid and pituitary are alike stimulated by the sympathetic and lower carbohydrate tolerance. The pancreas is innervated by the parasympathetic and raises carbohydrate tolerance. When the former group is stimulated the latter is inhibited, hence any of the emotions which excite the sympathetic will tend both directly and indirectly to flood the blood with sugar. If this is not utilised for muscular energy and heat production it is liable to overflow into the urine.

The influence of excitement and emotion in causing glycosuria is well recognised. It is commonest in Jews, a notoriously emotional race. When stocks go down in New York, says Crile, diabetes goes up. Temporary glycosuria occurred in a number of men who merely watched a football cup tie without participating in it. Glycosuria has been, unfortunately, comparatively common in young officers entrusted with heavy responsibilities during the war. Singer and Clark have recorded two cases in which there was alternation between glycosuria and the exhibition of mental symptoms, as if the emotional discharge asserted itself either at the metabolic or the psychic level but not at both.

The thyroid gland provides us with some of the best examples of the association between the endocrines and the psychoneuroses, for here the influence of the basal tripod is clearly revealed, and toxic, nutritional and psychic factors alike may be seen at work. The thyroid tends to enlarge at puberty, marriage and in pregnancy; and alimentary toxaemia has been shown to play a definite part in its pathological enlargement. Sympathetic stimulation has also been proved to be followed by thyroid enlargement, as in Cushing's experiments on the production of Graves' disease in cats by suturing the phrenic nerve to the cervical sympathetic so that the thyroid was stimulated by each respiration. I am convinced that it is a mistake to look upon Graves' disease as purely a primary hyperthyroidism; there is always an underlying sympathetic irritation, which produces hyperthyroidism which in turn increase the sympathetic response, thus establishing a vicious circle.

Crile says: "I have never known a case of Graves' disease caused by success or happiness alone, or by hard physical labour unattended

by psychic strain or to be the result of energy voluntarily discharged." My own belief is that if a distressing emotion has a matrimonial origin it is particularly likely to induce Graves' disease for here each limb of the basic tripod is involved.

The fact that a psychic factor has not been found does not mean that it is not present. Thus in a young man suffering severely from this disease in hospital, I was for a long time unable to discover that factor. In the course of routine examination I had found that he had hyperglycaemia, without glycosuria. One day however he passed sugar. The previous day was visiting day, and the Sister of the Ward told me she had detected in one of the visitors a source of grave psychic conflict.

The effect of fear in producing hyperthyroidism was well shown during the air-raids on London. Indeed the air-raids were almost an "acid test" of race. An uncontrollable impulse to flight from London or into the tubes was almost diagnostic of Semitic origin. More selfcontrolled people, who nevertheless suffered acutely, repressed their impulses from the motor to the vegetative level and received their reward in hyperthyroidism, amounting in some cases to Graves' disease. Similar outbreaks of this disease followed the San Francisco earthquake and the Kishineff massacres. That Graves' disease, like sympathetic stimulation, is characterised by exaggerated katabolism is proved by recent studies on basal metabolism, which then shows an increase up to 40 per cent. of normal. Whereas in hypothyroidism basal metabolism may be reduced to 40 per cent. of normal. Once the thyroid has been started on this evil course through sympathetic stimulation the emotional agitation is kept up at such a level that psychoneuroses are the rule, and actual insanity is far from uncommon. In the same way fear and anxiety keep up a sympathetic stimulation of the adrenals. If this is met by a hypertrophy of the gland, high pressure symptoms are apt to develope, but if not thus met some degree of exhaustion ensues, as in many war neuroses and other functional states characterised by vasomotor instability, low blood pressure and myasthenia. And it was frequently observed that so-called "disordered action of the heart" was much more likely to occur in soldiers who had recently suffered from an infective condition, which would tend to prevent the adrenals from rising to an emergency.

I hope that I have shown justification for the statement that endocrine glands being influenced by toxic, functional and psychic factors, may, alike, cause or be affected by a psychoneurosis. It is clear that whether the change starts in the gland or in the emotional nervous system, a

vicious circle is soon set up. But just as the sympathetic nervous system is closely associated with the endocrine glands outside the central nervous system so it is inextricably intertwined with the higher levels inside it. Hence, as Stragnell puts it: "No endocrine inferiority can be present without a psychological change, a retreat or a compensation." Or, as Pottenger says: "The great number of disease processes which express themselves in the vegetative structures (i.e. autonomic nervous system and endocrine glands)...either interfere with the mechanism of defence or the providing of the organism with sustenance...and the individual who has an abnormal vegetative balance wages his struggle for existence with a handicap.... The ultimate effects are distributed to every system of the body, vegetative, voluntary and psychic. Between the vegetative and psychical systems a vicious circle is established, and each harmful stimulus in the one influences the other. Every disease process of a serious nature, therefore, must have a psychical side to it."

I have not attempted to discuss complex polyglandular syndromes nor the details of the resulting symptoms. I am content if I have been able to indicate the broad biological considerations which seem to me to underlie the influence of the endocrines in the psychoneuroses.

THE QUESTION OF THE THERAPEUTIC VALUE OF "ABREACTION."

By C. G. JUNG.

In the discussion of a paper by William Brown concerning "The Revival of Emotional Memories and its Therapeutic Value," William McDougall, writing in this Journal (Medical Section), vol. I, part 1, gave expression to some important considerations which I wish to underline. The warneuroses with their eminently traumatic aetiology have revived the whole general question of the trauma theory of neurosis. During the years of peace this theory was rightly held in the background of scientific discussion, since it is an inadequate conception of neurotic aetiology.

Breuer and Freud were the originators of the theory. Freud, who carried on the investigation of the neuroses, soon adopted a deeper view which took the real neurotic origins more into account. In by far the greater number of ordinary cases of neurosis there is no question of a traumatic aetiology.

In order to create the impression that the neurosis is derived from a traumatic moment, inessential, secondary occurrences must, for love of the theory, artificially be brought into prominence. As a rule these traumata, when they are not mere artefacts of medical phantasy, or from other reasons dependent upon the compliancy of the patient, are secondary events, consequences of an already existing neurotic attitude. The neurosis is, as a rule, a morbid, one-sided development of personality, arising from very slender, indeed ultimately invisible beginnings, which can be followed back, as it were indefinitely, into the earliest years of childhood. An arbitrary judgment could alone decide where such a neurosis really begins.

If its determination were shifted back into the intra-uterine existence, thereby involving the psychical and physical disposition of the parents at the time of pregnancy and conception-a view which in certain cases seems not at all improbable such a standpoint would, in any case, have more justification than the arbitrary selection of a definite point of neurotic origin in the individual life of the patient.

Clearly, in the handling of such a question, one must never remain