REVIEWS

Psychopathology, Its Development and its Place in Medicine. By BERNARD HART, M.D. (Lond.), F.R.C.P. (Lond.). Cambridge, at the University Press, 1927. Pp. 153. Price 7s. 6d. net.

The greater part of this book is taken up by Dr Hart's Goulstonian Lectures. Besides these there is an appendix to Lecture II on "The Conceptions of the Subconscious, Co-conscious, and Unconscious," based upon the author's well-known paper which appeared in the Journal of Abnormal Psychology in 1909. The "Psychology of Rumour" and "The Methods of Psychotherapy" are reprinted from the Proceedings of the Royal Society of Medicine.

Although the plan of the book leads to a certain amount of repetition, there is nothing repeated that does not well bear repetition; for there are few writers on these topics at the present time whose views are so well worth hearing as Dr Hart's. The three Goulstonian Lectures are a brilliant essay on the principles of psychopathology, in which a strenuous effort is made to justify the claims of psychopathology to be ranked as a legitimate department of science. Dr Hart rightly recognizes that this is part of a wider question, namely, whether psychology has a right to be called a science; for he defines psychopathology as "an explanation of disorder by psychological conceptions." He has no difficulty in showing that psychology has as good a right to be called a science as any other discipline that deals with 'facts' according to the method of science; for, as he points out, "science is characterized, not by the nature of the facts with which it deals, but by the method of its attack." Yet he has to confess that the 'facts' of psychology are on a different plane from those of the physical sciences. Only the facts of introspection are directly observed; all other psychological facts are inferred from the observation of behaviour. Objective verification of facts thus observed or inferred is not possible.

But although Dr Hart fully recognizes this limitation of psychological inquiry of every kind, it is in respect of the validity of certain psychopathological conceptions that he lays most stress on it. And, indeed, he tempts the unwary reader to believe that this inherent weakness of psychological method is a ground for discrediting the method of psycho-analysis in a greater degree than other methods of psychological investigation. He is of opinion that it is "impossible to accept the contention that Freud's theories are based on facts of observation, if the term 'fact of observation' is given the significance which it possesses in other branches of science" (p. 74). Rejection of psychoanalysis on this ground, however, is nullified on a subsequent page, where he says, "It is true that the facts are not of the order to which the facts of observation of other sciences belong, but this character appertains in some degree to all the facts of psychology" (p. 77). Presumably Dr Hart does not reject the facts of observation in normal psychology, although they have not the significance which they possess in other branches of science.

The real ground of Dr Hart's scepticism concerning the facts of observation in psycho-analysis is his fear that they are not "facts of simple observation," but that they are facts that have been distorted or 'prepared' by the method

employed to elicit them. The distortion produced by forces arising within the patient's own mind, as in the formation of phantasies, is allowed to pass; but Dr Hart thinks "it is quite another matter, however, when the flow of thought is not influenced by purely intrapsychic factors, but by the intervention of the psycho-analyst" (p. 73).

It is not clear what is meant by "simple observation." When we speak of observation and experiment, there is sometimes a suggestion of opposition between the two methods, but no one rejects the facts observed by experimental methods on the ground that they are not facts of 'simple observation.' The part played by the analyst who "listens, attempts to direct the patient's thought processes, reminds him, forces his attention in certain directions, gives him explanations and observes the reactions of understanding or denial thus evoked," differs in no important respect from that of the experimental psychologist who studies the responses of his subject to prescribed conditions. Why, it may be asked, should the prescribed conditions of the psycho-analytic method "call for a considerable modification of the claim that psycho-analytical theory is based upon facts of observation"? Dr Hart says the method "intervenes between the actual facts of observation and the prepared facts upon which the concepts are based." Is it not rather that what Dr Hart calls the 'prepared facts' are the actual 'facts of observation' elicited by the method? They are always facts relevant to the workings of the patient's mind, and whether they are prepared' or 'distorted' facts or not, they are always the individual response of the subject to the prescribed conditions of analysis. There is no need for the analyst to be afraid of distorted facts. His work may indeed be described as mainly consisting in the observation and analysis of distorted facts. The very symptoms of the neurosis he is called upon to cure are distorted facts. They are nevertheless 'facts of observation,' although they do not tell the truth until they are analysed.

Apart from his doubts about the validity of its method, based chiefly on the fear of distortion of the facts observed, Dr Hart's attitude towards psychoanalysis may be described as friendly. He shows an admirable grasp of its principles and its aims, and a most praiseworthy open-mindedness towards those features of its theory and practice which he cannot at present accept. Psycho-analysts may welcome him as a valuable and powerful ally. For it may be said that his criticism of psycho-analysis is primarily an indictment of all the methods of psychology in so far as they deal with facts of observation that are not open to objective verification. Yet we have his assurance that psychology has "a right to contribute its quota to the scientific understanding of life and behaviour" so long as its facts are rigidly observed and its conceptions constructed according to the rules of scientific method.

T. W. M.

Aphasia. By S. A. KINNIER WILSON, M.D., B.Sc. (Edin.), F.R.C.P. (Lond.). London, 1926: Kegan Paul, Trench, Trubner and Co., Ltd. Pp. 108. Price 2s. 6d. net.

This little book is a striking example of the art of condensation. So complex a topic as Aphasia is not easily expounded in a few small pages, and the success with which it is here done is a remarkable achievement. The reader is left in no doubt about Dr Kinnier Wilson's views on any of the main problems presented by disorders of speech.

These views may be described as 'orthodox' and are in line with the teaching in this country before Head's work appeared. The division of aphasic disorders into 'motor' and 'sensory' forms is adhered to, but since the physiological disturbance underlying aphasic defects is a disorder of transcortical association systems, not of sensory and motor projection areas, the author prefers to speak of 'expressive' and 'receptive' aphasia. Expressive aphasia is regarded as an apraxia of the speech musculature, and receptive aphasia as a form of agnosia.

Although speech is an intellectual function, Dr Wilson says it must be clearly distinguished from thought in so far as the two are not identical in the sense of being coterminous. He is therefore in accord with those who believe that aphasic defects ray co-exist with perfect preservation of the general intellectual level. He criticizes Moutier's view that in every case of (sensory') aphasia there is some degree of defect of general intelligence in addition to the special intellectual defect of language. Still more open to criticism, he thinks, is Moutier's corollary "that the intensity in degree of the psychical disorders produced by lesions in Wernicke's zone is 'very notably proportional to the extent of the lesions in the zone'." Yet the cases which he cites in contravention of Moutier's opinion do not seem very relevant. He relies on "two cases of motor aphasia" and some mild sensory cases" for his conviction of "the complete general integrity of the intellect." But the amount of general intellectual defect observable in mild sensory cases would be practically inappreciable, and the "two cases of motor aphasia" do not seem to have any bearing on Moutier's contention. The lesion in these cases was presumably not in the zone of Wernicke, although we are told that in one of them it led, "by action at a distance," to amnesia verbalis. It may be, however, that the need for condensation has here led to some obscurity in the argument.

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Dr Kinnier Wilson's views on the mechanism of speech processes are closely in accord with those of Charlton Bastian, although his statement of them keeps more definitely to the physiological plane. Thus he says: "In speaking, the processes underlying words are aroused in the auditory area, whence stimuli reach the kinaesthetic area for speech situated in the vicinity of the cortical projection-centre for tongue, lips, vocal cords, etc." He holds amnesia verbalis to be a specific amnesia which is found most commonly in association with lesion of the temporal lobe, and he thinks the clinical evidence furnishes no support to Head's view that amnesia verbalis (inter alia) is a hypothetical condition which cannot be associated with limited destruction of any part of the brain. Because of the diversity of the forms of word-blindness that may be met with, he adopts the disputable doctrine that "the visual centres for speech form a sort of physiological mosaic in which distinct groups can be segregated, one or more of which may be lost through disease while others are still in activity."

In this little book, as in every book written on aphasia, personal opinion on matters that are still in dispute may be found on every page; and the student who desires to know all that has been said about these matters must be prepared to undertake a long course of reading; but if he wants only a general outline of the subject, he is not likely to find another source from which he can glean so much information in so short a time as he can from Dr Kinnier Wilson's essay.

T. W. M.

The Psycho-pathology of Tuberculosis. By D. G. MACLEOD MUNRO, M.D., C.M., M.R.C.P. (Edin.). 1926. Humphrey Milford, Oxford University Press. Pp. 92. Price 5s. net.

The psychological factors operating in organic disease have been so persistently neglected in current text-books that one cannot but welcome the appearance of a small volume dealing exclusively with the psycho-pathological aspects of pulmonary tuberculosis. American writers, it is true, have paid more attention to this subject than their European confrères, but have rarely departed from somewhat stereotyped generalities. Dr Munro has endeavoured to give a more systematic account of the mental accompaniments of this disorder and has described what he calls the psycho-neuroses of incipient, middle and terminal stages respectively. Separate chapters are devoted to the sexual factor in tuberculosis and to the relation between tuberculosis and genius. The author accepts the toxaemic theory of the mental manifestations and classifies the latter in accordance with various types, e.g. 'erethic,' 'asthenic,' etc.

Judged by current standards this is no doubt an advance, but one cannot help thinking that Dr Munro would have been able to give us a more illuminating account of the mentality of tuberculous subjects had he chosen a more dynamic approach to the subject. It cannot be questioned that the, sometimes profound, toxaemia manifested is an important factor. But it is not necessarily a specific factor, and the variations in intensity of toxaemia at different stages do not permit of any accurate distinction according to stage, nor do they account for the difference between reactions shown in pulmonary cases and those exhibited in so-called surgical tuberculosis or in lymphatic tuberculosis. On the contrary it can be maintained that the mental changes accompanying tuberculosis, or any other organic disorder, can be understood satisfactorily only with the help of the libido theory. Thus the erotogenic function of the pulmonary system promises to explain some of the characteristic reactions to tuberculosis of this area. Again, it can be held with some fairness that the earlier reactions to the disease correspond to changes in the distribution of organ libido and that the regressions characteristic of later stages are the result of a more profound disturbance of egolibido. There is in fact little to distinguish these regressional characteristics from the changes occurring in chronic organic disease of a non-tuberculous nature, and the fact that in so-called tuberculous insanity the changes can only be described in accordance with maniacal or melancholic (and it might have been added paranoidal) types suggests that the key to the riddle lies in compensatory narcissistic regression. Moreover, if the assistance of the libido theory were invoked, the frequently described 'sexual' proclivities of tuberculous subjects would be seen in more accurate and less emotional perspective. The chapter on psycho-therapy (in collaboration with Dr Leonard Brown) lays emphasis very properly on the important part played by transference in the handling of this disease. The authors do not go so far as to suggest, what is certainly plausible, that a good deal of the efficacy of 'fresh air' depends also on a suggestive factor. Indeed, since the work of Piery and Bard on 'tuberculose abortive,' all Sanatorium statistics are open to revision. Incidentally one misses from the bibliography any reference to the work of Ferenczi or Deutsch which must at least be taken into account in any consideration of the mental reactions to organic disorder.

EDWARD GLOVER.

Freudian Essays on Religion and Science. By CAVENDISH MOXON. Gorham Press, Boston.

Many of these essays, particularly the later ones in the book, give a good popular exposition of certain parts of psycho-analytical doctrine. To much that the author has to say, however, the word Freudian cannot be strictly applied. It is not so much that the author's views are in marked contradiction to those of Freud as that in many places the author does not quite say what a Freudian would say. On page 14 we read, "there is abundant psycho-analytical proof of the jealous hatred felt by many boys for their father...." A psycho-analyst would not say 'many,' he would say 'all.' On page 20 we read, "...narcissistic craving of the beloved ego for an omnipotent projection for its own adoration." Fantasies of omnipotence are well known to psycho-analysts and projection is one of their technical terms, but 'omnipotent projection' would hardly be used by a psycho-analyst in the context where this sentence occurs. In this and in other passages one finds use of Freudian technical terms detached from the Freudian meaning. On page 21, the remark with reference to Jesus, "...his desire for self-abasement in order to enjoy parental lifting up..." could hardly be written by a true psychoanalyst. The problem of masochism would present itself to him differently. Frequently the emphasis is not placed where a true Freudian would place it. In the footnote to page 64 we read, "the crowd facilitates repression of the birth trauma by submerging the rational functions under a flood of emotions." Surely a psycho-analyst would rather say that gratifications obtainable from the crowd compensated; from the Freudian point of view the technical term 'repression' has got into the wrong place here.

An important divergence between the views expressed by the author of this book and the psycho-analytical doctrine is in the lack of emphasis given by the author to the super-ego and the sense of guilt. This is perhaps most marked in the Essay on Freudian Criminology, where the important part played by the super-ego and sense of guilt in the formation of the criminal is not mentioned at all. It is not inconsistent with this omission on the part of the author that he places considerable emphasis on Rank's doctrine of the birth trauma. Since the super-ego and the sense of guilt it may engender are in the Freudian system definitely post-natal products, it is clear that the more psychological disturbances are attributed to birth trauma, the less importance will be attached to the sense of guilt as a determining factor.

According to the Freudian doctrine that is one of the most serious dangers in the Rankian psychology, and also one of the reasons why the Rankian psychology is likely to be more acceptable to the general public than is the Freudian: it gives the student too good a chance to avoid an appreciation of the painful unconscious conflicts in which the super-ego is a protagonist.

Notwithstanding the fact that Mr Moxon's approach to psychology just misses being that of the psycho-analyst, the book under review shows considerable familiarity with the writings of Freud and other psychologists; it frequently reveals penetrating psychological insight on the part of its author as well as a wide range of interest.

REGINALD O. KAPP.