arises, how is he to come to terms with those autonomic forces, represented by the black men, which threaten to overwhelm him? It is only in so far as he is so identified with his persona and clings to it with all the tenacity of narcissism, that he is in the grip of unconscious autonomic forces. This constitutes the deadlock to which I have referred. The third and last dream of this patient which I shall quote is the following:

"The leader took us down the road leading into a wood. As we were entering the wood we were ambushed by Sinn Feiners. One of them told us to lay down our rifles and the leader, a corporal, complied with the order. A man, who was supposed to be a scout for us, ran into the wood as if to join the Sinn Feiners." In relating the dream the patient implied that there was a certain amount of complaisance about capture on the part of the corporal and that the scout frankly went over to the side of the enemy. There is therefore not the same deadlock which is represented in the preceding dream. It is as if the possibility or the need to yield were mooted. The idea of a surrender to the unconscious forces, here represented by the Sinn Feiners, is germinating. These forces of evil, inimical to his conscious estimate of himself, should be included as an accepted content in consciousness. It has already been said that these forces have their counterpart in the objective world, again as those qualities of human nature and of those aspects of human existence which appear inimical and perverse to the patient. Only after surrender to, or in other words, acceptance of these forces, can a new point of orientation be reached. Psychologically, this process must not be regarded simply as a passive process, but rather as an active affirmation of human nature as it is, and not an expurgated edition of it prescribed by some rigid moral or aesthetic code. This involves a sacrifice or renunciation of certain cherished ideals, wide enough in theory perhaps, but limited in application. It therefore has the quality of a moral act which gains its motive force from a new and wider understanding. The possibility of the acquirement of the latter must of necessity rest with the physician and success or otherwise will depend as much on his general knowledge and experience of the world as on his ability to give form and enduring value to the progressive and constructive tendencies which appear from time to time in the unconscious material of the patient. Thus, in general, is the bigoted, narrow and morbid attitude replaced by a sound new attitude. Energy which had been draining away in negative emotions is thus conserved and is now available once more for the ordinary activities of life. The conservation of energy effected also brings about a better

t

physiological, as well as psychological functioning. In the case in question this improvement is beginning to take place.

The second case to which I wish to refer is that of a sergeant-major, aged forty-five, who developed an anxiety condition towards the end of the war. He had not been abroad but was instructor in a training centre in England. His chief trouble before his breakdown seems to have been due to the fact that his officers had not quite such rigorous ideas about discipline as he himself had. He felt he was unsupported by the officers in his efforts to maintain discipline. At the same time he complained of being blamed for incidents which he considered arose out of the inattention to discipline which he deplored. It was certainly a difficult position. It ended in a breakdown. He had been sleeping badly, worrying over trifles, ever since. Lately he had had suicidal ideas. The first dream he brought was, "I saw ballet-girls dressed in large shield-like arrangements, walking in half-sections, a policeman escorting them." Unfortunately this is a dream which I did not analyse, so I cannot throw any light on the shield-like arrangements. But I think, taken as it stands, it gives a clue to the situation. It is possible to regard this manifest content as a representation of his own jockeying, disciplinary and regular attitude, symbolized by the policeman, towards his own feelings of a more free, spontaneous and irregular character, symbolized by the ballet-girls. I shall not attempt to elaborate this idea further. Much emerged in the course of treatment which would support and confirm it. In fact it may be said that in a realization of this lay the way to a cure of his neurosis. It is also a significant fact that on the two nights succeeding this dream, he dreamt of policemen.

Both of these cases of war neurosis in my opinion have arisen in consequence of an already existing neurotic attitude. They bear out Jung's dictum that in the greater number of ordinary cases of neurosis there is no traumatic aetiology, in the sense that the origin of the neurosis can be traced back to one specific incident. This view has been and still is very widely held and the so-called buried memory is often ardently searched for and usually found! But to quote Jung's paper already referred to: "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 on the compliancy of the patient are secondary events, consequences of an already existing neurotic attitude." (Here it may be said that the sergeant-major found

the actions of his officers unbearable. In a sense therefore they were traumatic or causative but only effective in so far as a one-sided neurotic attitude already existed in the form of an over-sensitiveness to authority in others, and an over-valuation of authority in himself. They were therefore only secondary.)

"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 intra-uterine existence, thereby involving the physical and psychical disposition of the parents at the time of pregnancy and conception-a view which in certain cases seems not 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.”

The danger of the trauma theory seems to me that the physician's preoccupation with the need to find a specific incident in the past, blinds him to the general attitude of the patient towards the 'here and now,' in which the main cause of the neurosis lies. The truth is that the idea of the 'buried memory' has been pushed to ridiculous extremes. It makes the problem of war neurosis appear so easy that one might well wonder why there are any neurotics left at all.

To quote again from Jung's article: "It is self-evident that the cathartic method (abreaction), when dealing with ordinary neuroses, will, as a rule, meet with poor success. Since, in general, it has nothing whatever to do with the nature of the neurosis, the schematic application of the method is, in such cases, quite ludicrous. Even when apparently partial success is obtained it can have no more significance than would the success of any other method that admittedly had nothing to do with the nature of the neurosis. The success is due to suggestion. It is often of very limited duration, and clearly accidental. This success arises always out of the transference to the physician, which is established without too great difficulty if only the physician has an earnest belief in his method. Because it has just as little to do with the nature of the ordinary neurosis as, for instance, hypnosis and other such remedies, the cathartic method has with only a few exceptions long been abandoned and replaced by analytic methods."

In conclusion I should like to say that in my opinion the stress and strain of war simply unmasked a tendency to neurosis or rather fulfilled the potentiality of neurosis in a great many people, who up till that

time had been considered 'normal.' No one theory will satisfactorily explain all the facts of the war neuroses. In the end in many cases we are brought face to face with the ultimate consideration of the personal factor, after we have dealt with the factors of environment and experience as far as may be. This factor is particularly evident in the case of those nondescripts who under the all-embracing shelter of the term warneurosis, cloak an innate ineptitude and feebleness in face of the ordinary problems of life. In an article written two years ago1, Dr Nicoll and I stated that any form of treatment which gives some adequate explanation-one carefully adapted to the intelligence-will be of use. A good transference and a suitable explanation will effect relief in a great many cases. I am inclined to think, however, that a certain proportion must be allowed to find their way back into life in their own way.

1 "Functional Nerve Disease." (H. Crichton Miller.)

NOTE ON THE MENTAL AFTER-EFFECTS OF
SLEEPING SICKNESS IN SCHOOL CHILDREN.

BY CYRIL BURT.

In a recent article in The Lancet1, Dr Donald Paterson, the Medical Registrar at the Great Ormond Street Hospital for Children, working in collaboration with Dr Spence, of the Children's Department at St Thomas's Hospital, has published and discussed some interesting records of the after-effects of epidemic encephalitis lethargica in children. In such diseases the question invariably arises as to what is the chance of complete recovery, and what is the likelihood of some degree of physical or mental impairment. In previous epidemics no records appear to have been kept which enabled a satisfactory answer to be given to this question.

Dr Paterson and Dr Spence selected 25 cases between the ages of 3 months and 11 years in which the diagnosis appeared to be incontrovertible. They carefully excluded all patients who, before the onset of the illness, were not of normal health or intelligence. The selected cases they followed up for a considerable period after leaving the hospital. Their conclusions are as follows:

In the majority of cases epidemic encephalitis in children is followed by permanent after-effects, either physical or mental. In only 25 per cent. of the cases in their series was the recovery complete.

In about 30 per cent. of the cases organic residual paralyses persisted after the original illness, the cases showing such conditions as hemiplegia, spastic diplegia, symptomatic paralysis agitans, muscular rigidity and tremors. In general, however, all the children seem well-nourished and have preserved the ability to gain weight and thrive.

The most significant results, however, are to be seen in the mental condition of the children. These observations are of especial interest. Recently, imbued with the importance of inherited mental defect, psychologists have been prone to attach less weight than formerly to diseases of the nervous system supervening during childhood as a factor

1 "The After-Effects of Epidemic Encephalitis in Children," by Donald Paterson, M.B., B.Ch. Edin., M.R.C.P. Lond., Medical Registrar, Hospital for Sick Children, Great Ormond Street: and J. C. Spence, M.C., M.D. Durh., M.R.C.P. Lond., John and Temple Research Fellow, Children's Department, St Thomas's Hospital. The Lancet, Vol. п, 1921, p. 491.