atrophy of the gland. Is it good for us that this gland should cease work during our active life rather than as an accompaniment to old age? And is it good that it should precede its retirement by a period of over activity when our fires are made to blaze too fiercely?

Case K. A typical anxiety case of over forty in whom nothing of importance was found on physical examination. He had a row, walked to his room, and fell dead. Post mortem, there was found the appearance of atrophy of the thyroid and other endocrine glands and some persistence of the thymus.

Case L. Another sudden death occurred in a young man, of healthy body, who had fits in which he re-enacted certain terror situations. He was found dead in bed in the hospital ward, and nothing could be found wrong at the autopsy. It is possible that he foundered on the rock of fear occurring in a terror dream, and that the violent emotion caused reflex inhibition of medullary centres.

Glycosuria.

Case M. An old lady, subject for years to a mild degree of glycosuria, was put through the first stage of the operation for cataract. She developed the neurasthenia that is common in these circumstances, possibly due to special symbolic importance of the eyes. She was also frightened by the sudden, violent and tactless warning she received that her glycosuria must be stopped or her sight would be lost. She became worse mentally, and with regard to the glycosuria, and had to have insulin and a strict diet for a time.

Cannon found glycosuria, not only in the players in an American Football Final, but in the reserve men, who only stood by in case they should be wanted. He said that worry was more injurious than work, while Crile remarked that "when stocks go down in New York diabetes goes up!" Langdon Brown states that no theory of diabetes is adequate which leaves out the sympathetic nervous system, and he leans to the polyglandular theory of Eppinger and Hess, namely, that the thyroid, pituitary and adrenals act in opposition to the islets of the pancreas, and that some glycosuria depends on upset in this balance.

Here is the sympathetic again at work, and we are entitled once more to raise a question: Can a harmful glycosuria be produced by emotional disturbance from mental illness, and, if it can, how should we treat it?

Asthma.

Quoting Langdon Brown once more we find that one of the causes of asthma is psychic stimulation, presumably acting on an inherently prepared reflex arc, or through associations. He says that there is a definite group of asthmatics of psychic origin, produced by suggestion, or by deeper conflict. But he quotes a case that was profoundly depressed, and would have passed for a neurasthenic with functional asthma as a symptom. The patient belonged, in fact, to the group of protein-sensitives. Treated for this he recovered completely. Here is another warning of the necessity of examining patients from every point of view.

Haemorrhage.

Case N. This man had frequent hysterical dissociations depending on war experiences in France. Each was initiated by nose bleeding, without known or discovered physical cause, but which directly linked on to part of the incident in the shell hole, the memory of which underlay the dissociation.

Case 0. Another man has been reported to have had haematuria on the anniversary of the day on which he crashed in an aeroplane and bruised his kidney so that it bled.

Nutrition.

The loss of weight and general poorliness in the neurasthenic is an everyday experience. It is due, obviously, to sympathetic inhibition of digestion mechanisms. The patient usually thinks he has phthisis!

A Renal Syndrome.

Jelliffe describes the case of a woman with a severe renal syndrome, blood pressure 240 mm., and so on, who was given six months to live. He did an analysis, found fixations on urinary and intestinal functions, and produced a state of health as the analysis proceeded.

This is an extraordinarily interesting case, and tends to show that very early infantile fixations may determine the methods of physiological response, or mal-function, in adult life.

The conclusion to the above argument is two-fold. In the first place, when a man or woman comes to the psychotherapist's consulting room he should make a thorough and systematic examination. When a diagnosis of mental illness has been reached it is still necessary to remember that the patient has both a body and a mind, and that either

may react on the other. Just as worry or a fright will produce white hair and a wrinkled face, which are physical changes, so may a disordered mind, through emotional disturbance, produce bodily disorder which may become a matter of importance in itself.

It is essential, therefore, that the psychotherapist should remember that he is not only a psychotherapist dealing with psychic disturbances. He is, and must always be, a physician, in the broadest sense, who deals with a person who is ill.

DESCRIPTIVE NOTICE

HEMMUNG, SYMPTOM UND ANGST.

Von Prof. SIGM. FREUD. Internationaler Psychoanalytischer Verlag. Leipzig, Wien, Zurich. 1926. Pp. 136.

PART I. ABSTRACT OF FREUD'S BOOK.

Freud approaches the problem of anxiety by considering the relation of inhibition to symptom formation. In itself the distinction is of no great importance, but, as will be seen later, the part these formations play in prevention of anxiety renders some differentiation necessary.

Inhibition may be normal or it may be pathological, hence, a symptom being a sign of illness we might say that an inhibition may be a symptom. Inhibition represents a reduction in function, whilst a symptom represents either an unusual alteration of function or a new variety of function. Here follows a comparative study of certain selected functions of the Ego: (1) sexual, (2) nutritive, (3) locomotor, (4) working capacity. Disturbances of sexual function, chiefly inhibitions, e.g. psycho-sexual impotence, occur at various points in the process-lack of erection, ejaculatio praecox or retardata, etc. Some may be simply failures of function owing to development of anxiety. Classifying these in detail we find that sexual function is disturbed by (a) simple deflection of libido, which is an example of a pure inhibition, (b) difficulties in carrying out the function, (c) imposition of special conditions which prove obstacles, (d) prevention by precautions, (e) interruptions by development of anxiety, (f) postponed reactions from infancy. The other functions are more briefly examined and the generalization is formulated that inhibition represents limitation of Ego-function due to various causes. In particular cases (inhibition of piano playing, writing, etc.) this is due to increased erotization of the organ concerned (e.g. the coitus significance of writer's cramp). Here the Ego abandons function to evade conflict with the Id; in the case of self-punishing inhibitions (professional) the Ego abandons function to avoid conflict with the Super-ego. A third mechanism is to be observed in grief where the Ego has hard psychic work to do, and a fourth in melancholia where there is a general reduction of energy in the Ego. We can now distinguish inhibition from a symptom in that a symptom is not a process occurring in the Ego but is a sign of and substitute for underlying instinctual gratification: it is a result of repression instigated by the Super-ego and directed by the Ego against the Id. There were several unsettled points concerning repression as previously regarded. (1) What is the fate of the excitation activated in the Id? To which the answer heretofore was indirect: the excitation is turned into 'unlust' (pain) by repression. (2) How then could 'unlust' be the result of instinctual gratification? Change in affect after repression is no longer the issue. The Ego prevents the Id excitation being carried out by (a) inhibiting it, (b) diverting it. The Ego influences Id processes by reason of its relation to the Pcs and tries to regulate all excitations from without and within on the basis of the pleasure principle, which it calls up by means of an ‘unlust' signal, just as the Press might invoke public opinion. It defends against

inner stimuli as it does from outer, i.e. by flight. In the case of outer stimuli it first tries to remove cathexis from the perception of danger and later on adopts a better course: it does not deny the perception but takes to motor flight. In the case of inner flight (repression) cathexis is withdrawn from the preconscious presentation of the impulse, and the energy is used for freeing anxiety. The Ego is the true abode of anxiety.'

Freud's earlier idea that the investment energy of the repressed excitation is automatically turned into anxiety is now abandoned. How then can withdrawal of cathexis produce anxiety if, as we have held, this can only be produced by increased cathexis? The answer is that anxiety on repression is not primary but an affective state reproduced on the pattern of existing memories. It is the imprint of former traumatic experiences, reactivated in analogous situations-the normal counterpart of hysterical reproductions.

The act of birth gives colour to all later anxiety attacks, but we must remember that an affect signal of danger is a biological necessity. It is wrong to say that every anxiety is a reproduction of the birth situation. It is doubtful if even hysterical reproductions of original traumas preserve their character permanently.

Actual repression (Nachdrängen) has to be distinguished from the primary repressions (Urverdrängung) from which it borrows force, and in regard to the nature of primary repressions there is a danger of over-estimating the part played by the Super-ego in their formation. The first severe anxiety attacks occur before the Super-ego is formed, and primary repression is probably due to rupture of the defensive barrier against stimuli (Reizschutz) by overstrong excitation. The 'Reizschutz' however only protects against outer not against inner excitation.

If the pain signal is successful, repression follows and we are unaware of any excitation, but if repression is ineffective we get a displaced, distorted and inhibited substitute for the excitation, which is not recognized as a gratification and as a rule gets no motor expression or the latter at least is limited to the individual's body. The Ego in repression is influenced by outer reality and keeps the substitute from contact with outer reality. The original presentation does not get into consciousness, the excitation gets no active discharge. How does this view of the Ego, square with Freud's familiar description of a helpless Ego mastered by the Super-ego and Id?

The fact is we take these abstract divisions too rigorously. The Ego is separated from the Id, but is essentially a differentiated part of the Id, and so long as they are allied in purpose the Ego is strong. The same applies to the Super-ego. Only when conflict arises does the separation of these instances become apparent. The Ego is the organized part of the Id: when it is strong, repression is successful; when it is weak, a symptom is set up outside the Ego boundaries. This applies also to symptom-derivatives and these extend at a territorial cost to the Ego. So that unless the symptom is encapsulated as in conversion, the original combat 'Ego versus Impulse' is continued in the fight 'Ego versus Symptom.'

The Ego however is all for unity between its components. It has a drive towards synthesis; hence it tries to assimilate the foreign body, i.e. the symptom, a fact taken advantage of in symptom formation which both gratifies and punishes. The Ego tries to make the best of it and carries out an inner adaptation instead of an outer. The symptom then begins to represent Ego interests. Obsessional and paranoidal symptoms develop a high Ego