Each patient when he enters the hospital receives a psychometric examination unless it be inexpedient for some special reason or impossible because of extreme 'dementia' or firm refusal to cooperate in the hour's undertaking. By the results of this intellectual test the hospital is able to pick out those who are mentally defective by birth, thus at once explaining social behaviour otherwise oftentimes inexplicable. It clears up perhaps a majority of the mixed and discordant diagnoses. It helps materially in discriminating between possible diagnoses of psychosis by deciding the presence or absence of regression. It orients the hospital in the grade of occupational therapy suited to the individual.

In addition to these advantages this examination provides a sort of medical 'bench-mark' as the surveyors say, from which the intellectual regression or progression from year to year may be judged. Such examinations help us to pick out those ready or not ready for groundsparole; for a visit home on three-months parole; for discharge under the various conditions, etc.

Research is needed as to the relation in the various psychoses between affective, behaviouristic, and intellectual regression and progression. That there is a fairly definite ratio, for example in precox, between the affective regression and the intellectual regression there may be no doubt, the catatonic, paranoid, and hebephrenic 'types' so called (these names are more and more seen to be of little moment) showing for the time being a fairly definite difference in this ratio. Useful answer to this interesting problem must await a scale for measuring the affective aspect of mind which must be based in turn on more extensive knowledge of the autonomic nervous system and its relations to vasomotion, the glands, the musculatures, and the central nervous system.

Owing largely to the insistent but controlled vigour with which the patient oftentimes has to be ‘jacked-up' to attend and to do his best, this new intensive manner of using our most important psychometric scale requires hard and attentive, alert, intelligent work on the part of the examiner-continual intensive effort, properly adapted every single moment to that moment's psychologic needs. It is tiresome work this and conscientious, and moreover requires much longer than does the plain psychometry of the normal or the feeble-minded. Not infrequently an hour and a half is required-hard, annoying, wearing inquiry in the strictly prescribed way of all accurate psychometry. Much patience is required, and much ingenuity and initiative. But patience unending, as we all know, and ingenious intelligence are part of the indispensable equipment of the psychiatrist.

In this case all this expense of time and nerve-force is well worth while, for it enables us to furnish, perhaps better than heretofore, definite information in mathematically comparable terms of extreme importance in the diagnosis and the prognosis of the psychotic and the psychoneurotic. On the basis of this information oftentimes our patients may be all the better cared for inside or outside of our hospitals.

In the case files and the staff-conference records of the Veterans Hospital in which, during four years, the new method has been developed and tentatively established, there are thousands of corroborations of its practical psychiatric usefulness. Out of 3000 such examinations about 60 per cent. proved to have mental ages of 12 years (I.Q. 75) or lower. Out of nearly 6000 admitted to this one hospital (including readmissions) since its opening in 1922, more than half for one good reason or another have really needed psychometric examination, and, of course, just which patients require it can be determined only by trial. Experience has shown the necessity that every patient should have one on admission.

Cooperation is requested in trying out this method under various conditions and in standardizing it further so that its applications may be extended. At present the writer is engaged in a qualitative differentiation of the various kinds of deterioration.

A SURVEY

THE DEVELOPMENT OF THE PSYCHO-ANALYTICAL
THEORY OF THE PSYCHOSES

1894-19261

BY JOHN RICKMAN

TABLE OF CONTENTS

PART III

§ 12. The Ego and the Id (pp. 322-324).

(a) Introduction (p. 322). (b) The Id (pp. 322-323). (c) The Relation of the Ego to Consciousness (pp. 323-324). (d) The Oedipus Complex (p. 324). (e) Changes in the Ego (p. 324).

§ 13. The Sense of Reality (pp. 325-328).

(a) Introduction (p. 325). (b) The Incorporation of Pleasant Experience with and the Expulsion of Unpleasant Experience from the Ego (First Stage) (p. 325). (c) Negation of Unpleasant Ideas (Second Stage) (p. 326). (d) The Acceptance of Unpleasant Ideas (Third Stage) (p. 326-327). (e) Reviewing the Situation from another Aspect: Ego-Libidinal Polarity (p. 327). (f) Utraquism (p. 327). (g) Delusion and Dream (p. 328).

§14. Anxiety (pp. 328-337).

(a) Introduction (pp. 328-329). (b) Brief History: (a) Period of Shock Aetiology, (8) Period of Wish Aetiology, (y) Narcissism explains Libidinal Component of Traumatic Neurosis, (8) Theory of Repetition Compulsion, (e) The Threefold Division of the Psychic Apparatus (pp. 329-331). (c) The Danger Signal: (i) Fear and Anxiety, (ii) Neurotic Danger, (iii) Grief and Anxiety, (iv) Pain, (v) Defence: (a) Repression, (B) Isolating and Undoing, (y) Reaction Formation, (8) Regression (pp. 331-334). (d) Inhibitions and Symptoms: (a) 'Locus' of Inhibitions, (B) 'Locus' of Symptom-action, (y) Ego-unity and Symptomderivatives, (8) Affective reproduction of past situations (pp. 334-337).

§ 15. Classification of the Neuroses, Psycho-Neuroses and Psychoses. With Tables (pp. 337-340).

§ 16. Miscellaneous (pp. 340-357).

(a) On the Early Stages of Psychotic Conditions (pp. 340–342). (b) On Decomposition (pp. 342-343). (c) On Depersonalization (p. 343). (d) On the Wish to get Well (p. 344). (e) On Remissions (p. 345). (f) On a Diagnostic Technique (pp. 345-347). (g) On Organ Speech and Restitution (pp. 347-349). (h) On Cerebral Pathoneuroses (p. 349). (i) On Orgasm (p. 350). (j) Some Brief Descriptions by way of approach to Definition (pp. 351-356). (k) Conclusion (pp. 356-357).

Bibliography (pp. 358-374).

1 Part I appeared in vol. VI, p. 270. Part II in vol. VII. p. 94.

§ 12. The Ego and the Id1.

(a) Introduction.

(b) The Id.

(c) The Relation of the Ego to Consciousness.
(d) The Oedipus Complex.

(e) Changes in the Ego.

(a) Introduction. Freud's paper on narcissism had changed the psychoanalytical theory by introducing a new 'partner' in every love relationship, the self; his brochure on The Ego and the Id introduces no new concept but restates so many old ones and shows up their relationships so clearly that it may be used as a boundary post in this survey to separate the second or narcissism period from the third period, which deals chiefly with the functions of the ego. For our present purpose, of the views contained in The Ego and the Id only those which immediately concern these ego processes will be summarised.

(b) The Id. The psychical apparatus has been described as an organ whose duty is to keep the amount of excitation within the organism as low and as constant as possible. Excitation proceeds from two sources, external and internal, the former being in the nature of impacts (stimuli), the latter (instinct impulses) exciting a continuous influence (though varying in intensity). The latter concept presupposes a source continually creating a state of tension; this has been thought to be the erotic element in life which throws the psychical apparatus into a state of unrest. The view now put forward is that this source is an undifferentiated part of the apparatus called the ‘id,' it is a reservoir of libidinal 'tensions' which have to find outlet in gratification. Another part of the psychical apparatus is specially modified to bring unity or coherence into the various modes of discharge. This modified part furthermore is subject to influences from without, so that it is a correlating organ of internal and external stimuli, is in short an adapting mechanism which is influenced by both and can in turn modify both. In popular language the id is the function of passion; the modified part, which we can now call the 'ego,' corresponds to the function of reason and sanity.

The tension created by the id is libidinal in nature, it becomes effective in producing a change in the orientation of the organism when attached to presentations, but it is characteristic of id-cathexes that they can be shifted from one presentation to another without apparently altering them to any great extent. The ego as the regulating mechanism for discharge of tension has to deal with these cathexes, it can do so without difficulty if the external obstacles are not strong; if they are it must either employ some device for shifting the cathexes to an object which will allow of discharge without interference from without or else by damming the outflow of discharge endure the tension which results. In practice it does both, the cathexis is shifted on to the ego itself (becoming ego-libido), the libido is desexualized and is used up or partly used up in the process of making a change in the character of the ego itself; put in another way the ego substitutes itself for the libidinal object of the id, which it is able to do by behaving as the object behaves, i.e. by identifying itself with the object. This affords an explanation of secondary narcissism in which one part

1 Bibliographical references: 178, 182, 184, 196, 198, 200, 244, 246, 251, 263, 293, 295, 395. [The Ego and the Id is a short book-81 pages-which should on no account be left unread.]

of the psychical system can take another part as a love object, a concept that is unintelligible without the additional hypothesis that the latter alone is in perceptual contact with and can adapt itself to the outer world.

Enough has been said already about the first object-identifications which result in the formation of the super-ego to make the task of giving the details of the process again unnecessary, but it may be pointed out how much more intelligible becomes the concept of the super-ego with the addition of the concept of the id, for it was in the process of mastering id impulses that the ego was forced to modify itself to the extent of forming this specialized portion.

(c) The Relation of the Ego to Consciousness. We now have four elements to deal with in examining mental life, (1) the external world, (2) the ego (these two are able to influence each other), (3) the id (which is not in direct contact with the external world), and (4) the super-ego (which is not in direct contact with the external world but does appear to be in very close connection with the id). The question now presents itself: What is the relation of the three elements of the mind (ego, id, super-ego) to consciousness? The psycho-analyst defines four states of consciousness, which do not correspond to the four elements above mentioned; this point cannot be made too emphatic.

The term conscious is descriptive of the state of an idea; but we are not conscious of our ideas for long, most of the time they are latent, when they may be called preconscious; they may become conscious in the psycho-analytical sense when they receive an increase of cathexis and affect that part of the psychical apparatus which registers perceptions, the perceptual consciousness. But there are ideas which can affect behaviour without being conscious; these are unconscious in the sense that they cannot by mere increase of cathexis become conscious. An idea which before was unconscious becomes conscious by a coupling of it to a word-presentation, it then becomes preconscious and from being that takes the next step and stirs the system perceptual-consciousness, which is commonly called 'consciousness.' Word-presentations originate in the outer world so that it follows that there is no consciousness of anything except through the mediation of memory images. Analysis may be defined as the work of attaching word-presentations to ideas which were formerly incapable of making the union owing to 'resistance' (which is an ego function); put in another way analysis aims at increasing the power of the ego so that it shall not set up these resistances (which are due to fear) and ultimately that the field of consciousness shall be extended.

In analysis a patient is asked to say all that comes to his mind; in the course of a longer or shorter time he falls into silence and does not know why; he feels the presence of something in his mind; his behaviour, restlessness, nervous apprehension or what not, betray the fact that his mind is troubled but he can give no satisfactory explanation. What is the cause of this? His ego "the coherent organization of mental processes"-which controls the outlet of excitations presumably is inhibiting the passage of a thought to the preconscious and so to the perceptual consciousness systems: this is nothing else than saying that a part of the ego is unconscious, indeed that part which puts up the inhibition or resistance. That the part of the ego which is unconscious is an important and powerful part is shown by the fact that it can inhibit powerful and important ideas1. The unconscious then does not coincide

1 It follows therefore that to ascribe neuroses to a conflict between conscious and unconscious parts of the mind is inaccurate, rather the conflict is between the organized ego and what is repressed and dissociated from it. [Ego and Id, p. 17.]