clinician; but the rest of the book presents an embarrassing wealth of material that cries aloud for criticism. In his introduction he lays down that

"the phenomena of abnormal mental life do not present any purpose in the present; they are repetitions, recurrences of a past, but they have no aim, no purpose, no meaning in the present life existence of the patient. In fact, the symptoms are pathological, just because they have no purpose, no meaning in the life of the patient" (p. viii).

Dr Sidis evidently attaches value to literary repetition, but the memory of these phrases raises wonder why

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we must learn to know the working of the patient's mind, we must learn his ideals of life, his attitude towards man and the world, his actions and his total reactions in his adaptations to his environment" (p. xviii). One suspects that his antagonism towards certain views often leads the author to express opinions which, like those first quoted, are not consistent with his own practice. Psycho-analysis he attacks by the method of vituperation and, after concluding that "Psycho-analysis is sheer humbug," he modestly says of Psychognosis:

'All I wish to convey by it is what the term means, namely a study, an acquisition of a working knowledge of the patient's soul, so to say" (p. xvii). A fourth part of the book is devoted to illusions and hallucinations, and four and a half pages suffice for the consideration of "fixed ideas, morbid impulses, and emotions"; this is a badly balanced distribution. A chapter on delusions opens with the thought-provoking remark that "delusions do not belong to the domain of functional psychology." Such bald statements abound, but are sometimes more intelligible than this one; in fact, they are often primitive in their simplicity. Simple is his classification of nervous and mental diseases: first come organopathies or necropathies, in which there is a pathological modification of the nerve cell ending in the death of the neuron; these include general paresis and dementia precox. Then come neuropathies,

“in which the neuron undergoes degenerative changes which at first bring about an apparent increase and then a suspension of function not necessarily terminating in the death of the neuron....Here belong all the temporary maniacal, melancholic and delusional states... and, in general, all the mental states known at present under the description of manicdepressive insanity" (p. 97).

These states may or may not be due to degenerative changes in the neuron, but the unsuspecting reader would believe that such changes are commonplaces of pathological anatomy instead of a matter of speculation.

The pathology of what are commonly known as 'functional nervous disorders' is equally simple. In these, which he calls psychopathies,

"the neuron itself may remain healthy, the trouble being due to associations with systems of neurons which are usually not called into action by the function of that particular neuron or system of neurons" (p. 98). A little further on we find reference to hysterical disturbances of various organs

"over the functions of which the personal consciousness is found on examination to have lost control by reason of neuron disaggregation and dissociation" (p. 100).

The method of examination leading to such a discovery ought to be definitely described, for the result obtained should throw a great light upon the age-long problem of the relation of brain and mind. And it all seems so simple.

Unfortunately the simplicity is not maintained. In a chapter on the aphasias he talks of "a lesion of the temporo-sphenoidal convolution" causing auditory apraxia (p. 251); then the next paragraph begins "Systems of tactual presentations may similarly become disaggregated" and he goes on to talk about one cannot say 'describe' other disaggregations causing alexia, apraxia, etc. On p. 255 he returns to "a lesion of such extent as to prevent the associative activity of all the special sense areas," and finishes the chapter with

"The forms of reviewed aphasias may be of an organic nature, or of a functional psychopathic character which may closely simulate organic conditions.'

He leaves out the question of differential diagnosis, and is certainly wise not to try to extricate himself or his readers from this tangle of highly speculative 'neuron disaggregation' and observed pathological facts. 'Neuron disaggregation' is a plain statement of supposed fact that has, however, no basis in actual observation and only confuses discussion. If it had the slightest use in helping us to understand cases, or in helping the author to describe them, one might endure it for its pragmatic value; but when the author comes to describe clinical work all this speculation is discarded and we hear no more about neurons or their disaggregation.

A similar objection applies to the classification of the energy of the neuron as dynamic, static, reserve and organic; it is a presumption that leads nowhere, except to the production of a diagram that has served the reviewer to while away some of his Christmas holiday in an unsuccessful attempt to understand it. The five-page chapter on "The Diagnosis of Psychopathic States" provides a sort of 'find the missing picture' puzzle. Under this caption we expect to find information of clinical value in diagnosis, but expect in vain. We try to imagine some possible condition to which the wordy descriptions can apply, for example:

"Another important characteristic is the periodicity of remissions in the appearance of the morbid system. The attacks of functioning of the dissociated morbid system run in cycles. During the attack the mind works in a circle. This is an important pathognomonic symptom of psychopathic affected: cyclical and circular mental movements" (p. 391).

We are given no hint as to the clinical nature of the 'morbid system,' or of the 'attacks,' and as the 'psychopathic affected' gives us a range over all the functional nervous disorders the value of the 'pathognomonic symptom' lies chiefly in its power of provoking curiosity. Does Dr Sidis here refer to hysterical seizures, to the exacerbations that sometimes recur in anxiety states, or to those 'nervous breakdowns' that occur several times in the course of years and prove to be exaggerations of an obsessional neurosis? Dr Sidis has many selves: one of them says (p. 269):

"Nothing so much impresses itself upon the mind and is remembered so lastingly as some extremely painful experience.... Experiments performed on the oblivescence of the painful tend to prove that it is the painful that remains for a long time specially vivid in consciousness."

Another, his psychognostic self, writes chapters describing the process of restoring to consciousness unpleasant and horrible memories, and, having thus disposed of the beliefs of the first self, declares:

"Unless this nucleus of the set of subconscious symptoms is reached and disintegrated the patient cannot be regarded as cured" (p. 380).

To this another self counters:

"Many psychopathic cases have been treated by me and cured permanently [author's italics] by hypnosis alone" (p. 70).

Yet there is no apparent result of conflict: Dr Sidis has no doubts; what he believes is final; and one pictures in him, as a natural gift, that cheery and confident manner which medical text-books tell us is so important in the successful psychotherapist. The Great War and the hand of Time have dealt lightly with his views, and what he wrote in 1914 he reproduces unchanged in 1921.

It must not be thought that the author is incapable of making sound observations. His work on hypnosis has practical value for those who use the method either for suggestion or mental exploration, and he was, after Freud and Breuer, a leader in demonstrating the clinical utility of exploring hidden memories. The chapter on "Somopsychosis and Psychoneurosis" shows that he has independently arrived at the distinction between the extrovert and the introvert. But he loses himself in a maze of repetition and inconsistency, and of speculation which poses as fact; these faults overpower the value of the actual observations recorded in the book.

MILLAIS CULPIN.

Therapeutic Immunization in Asylum and General Practice. By W. FORD ROBERTSON, M.D., Pathologist to the Scottish Asylums. Edinburgh: E. & S. Livingstone, 1921. pp. vii + 278.

Co-operation between the clinical psychologist on the one hand and the physiologist and pathologist on the other is essential to progress in the working out of the problems of nervous and mental disease. It is true that the development of histological methods in the last century raised false hopes of finding in the cells of nerve tissue the cause of all mental disorders; of a disease such as paranoia, for example, histology has taught us no more than it has, let us say, of the formation of political opinions or a dislike for tomatoes. But laboratory work has found a new field of research into the bodily accompaniments of emotion, and the close connection between the endocrine glands and emotional disturbance is proving of more than theoretical value, even if we are as yet unable to reach agreement as to what is cause and what effect.

We could possibly arrange the 'functional nervous disorders' in a series, at one end of which would appear those obsessional neuroses almost or entirely lacking in bodily disturbance that is to say, purely mental in origin and symptomatology, and at the other end certain physical disturbances, digestive, respiratory or circulatory, in which there is a combination of toxic and mental

causes.

In the study of such a combination the medical psychologist has an initial advantage, not of his own seeking, and one which he would rejoice to see equalised. He has had perforce to acquire a minimal knowledge of physiology and pathology and has at least a speaking acquaintance with the subjects of bacteriology and vaccine therapy; his knowledge of psychology and, to a great extent, of psychoneurotic disorders he has acquired outside his student curriculum. In no other speciality is the student at such a disadvantage, and although these disorders will form a fair proportion of the cases that the

practitioner will meet yet his knowledge of them frequently consists in the assumption that they consist of two diseases, hysteria and neurasthenia, the first being something akin to malingering, to be treated with moral advice and firmness, whilst the second is to be handled by hunting for some bodily disease which his one-sided training will allow him to treat. Of anxiety states and obsessional neuroses he has scarcely heard, and it is common enough to meet sufferers from these conditions who have been under lengthy treatment without their real symptoms ever being investigated.

As a result of this gap in medical education we find that clinical observations on the treatment of 'neurasthenia,' though of possible importance, are often valueless. According to recent publications neurasthenia has been cured by treating flat-foot or dilated stomach, or by excluding white bread from the diet, and we are familiar with the influence ascribed to errors of refraction and pyorrhoea, and the benefit derived from treating them. Unfortunately, we are left in ignorance of what the neurasthenia is-whether a state of fatigue, of anxiety, obsessions or what-not-and the clinical value of the reports is equal to reports of the cure of so many cases of 'fever.'

We might consider why 'neurasthenia,' which in the loose meaning of the word comprises so many cases the obstinate and persistent nature of which impresses the psychotherapist, should be the subject of claims to cure by the most diverse methods. Its variable nature in the individual case allows of amelioration by any treatment that provides relief from irritation or toxic influence, and the transitory nature of the amelioration may be overlooked, but the chief pitfall is probably to be found in the replacement of one symptom by another. An anxiety state is sometimes completely replaced by a definite physical symptom; or one symptom may be replaced by another of unrecognized psychical origin, as when headache with 'lack of concentration' is relieved by glasses and followed by 'gastritis,' the underlying condition, whatever it may be, remaining unrecognized. One sees patients in whom several organs have received attention, the result of treatment being satisfactory, but some new affection occurring as each one is 'cured'; these cases are examples of the cure of 'neurasthenic' conditions.

In Dr Ford Robertson's work we look for that co-operation with his psychological fellow-workers for which his position offers every advantage. Seeking for evidence of his being in touch with present-day views we read (p. 218) "The distinctive signs and symptoms of neurasthenia are capable of fairly precise definition, and there need rarely be any doubt, or difference of opinion, as to whether a particular case is to be classed as of this nature or not. The chief symptoms are a constant feeling of fatigue, not relieved by rest, and the occurrence of various forms of hyperaesthesia, paraesthesia and localised pain. Two important physical signs constantly occur exaggeration of the patellar reflex and tremor of the eyelids when the eyes are half closed. Added to these, there are, in greater or less degree, characteristic mental features which constitute the picture of psychasthenia-namely, incoercible ideas, obsessions and monophobias."

This 'fairly precise definition' is disappointing. It places in one group the anergic victim of a hard world, the tremulous sufferer from an anxiety state, and the active and physically fit intellectual man who finds himself worried by obsessive doubts. The hysterical nature of many phobias prompts inquiry whether Dr Robertson places hysteria in this group, and on the next page the phrase "neurasthenia and all the psycho-neuroses" leaves us guessing what

are 'psycho-neuroses' as distinguished from the author's conception of neurasthenia.

The book is devoted largely to bacteriological theory and technique; immunization by autogenous vaccines is its main theme and in its general principles this is so fully and authoritatively accepted that it would be presumption to criticise it in this journal. The writer, however, departs from orthodoxy in attributing to certain diphtheroid organisms a pathological importance, especially in the production of neurasthenia. Other neurotoxic organisms are accountable for a great amount of mental and nervous disease. His evidence in regard to neurasthenia rests upon three statements: firstly, the finding of particular organisms in cases of neurasthenia; secondly, the aggravation of all the neurasthenic symptoms (p. 224) by overdoses of vaccine derived from the organism; and, thirdly, the benefit resulting from immunization.

The second statement is baldly put with no information as to what the symptoms are that are aggravated. Any lowering of bodily health may influence mental symptoms and most of us harbour organisms which, if grown in culture and injected as a vaccine, would produce at least malaise. In fact, experience of typhoid inoculation teaches that a vaccine derived from a bacillus presumably foreign to the patient can produce a severe reaction, and in the army the reviewer was familiar with cases in which the inoculation was followed by an outbreak of neurotic symptoms in men already predisposed to neurosis. The results claimed for vaccine therapy cannot be discussed in the absence of clinical information.

Dr Robertson seems to be aggrieved with his brother bacteriologists who reject his evidence concerning diphtheroid organisms, and (p. 219) protests against the total neglect, by certain writers, of bacterial toxic factors in the pathogenesis of neurasthenia: "They have done nothing to refute the evidence; they have simply ignored it."

His evidence in the case of Dementia Precox is as irrefutable, because of its elusiveness, as that concerning neurasthenia; six cases are described in which old friends like streptococcus pyogenes and micrococcus catarrhalis were found freely with their diphtheroid companion, and in one case recovery from 'dementia precox in its early phase' took place after a course of immunization.

Dr Robertson is plainly a man of independent opinions and with his skill in technique should be a valuable co-worker in our subject; but his attitude towards psychological research is unfortunate. Mind is "only a concomitant of a reaction in the psychical centres of the brain" and "such a view of the nature of mind has no place for the unconscious, or subconscious mind" (p. 221). Further, "The psycho-analysts are also in error in holding that a so-called subconscious suppressed complex can act as a pathogenic agent, disturbing the course of normal mentalization. Tanzi and Lugaro have dwelt upon this error and exposed it."

The phrase "subconscious suppressed complex" suggests that its user has no first-hand acquaintance with the literature. There have been many_confirmations of and contributions to the theory of the unconscious since Tanzi and Lugaro exposed its error in 1916.

One wishes that Dr Ford Robertson could recognise the present limitations of the purely physiological view of mental processes; in his own words, "Science demands that, in seeking to reach the truth regarding any of its problems, all the known factors shall be taken into consideration."

MILLAIS CULPIN.