that the patients have been examined and that disease such as G.P.I., post-encephalitic lethargica, cerebral syphilis, etc., are excluded from the psychotherapeutic clinic.) Physical illness plays a secondary part in the aetiology of the psycho-neurosis, but may figure prominently among the symptoms. I will put a question to those who say that they always 'clear up' the physical trouble before turning to the mental and ask them how they explain the fact that patients have allowed their own physical condition to deteriorate while at the same time complaining often for years of aches and pains. The answer to my mind is that the bodily disorder is employed as a screen which serves the purpose of concealing secondary epinosic gain and primary epinosic gain (which often is the need for punishment). To attempt to abolish the physical disorder without investigating its psychical utilization in vivo so to speak is to loose a fine opportunity for studying the depths of the patient's mind. In regard to other illnesses the transference-neurosis is an insurance against intercurrent disease of a remarkably effective kind, those who tamper with the transference by physical therapy before psychotherapy begins lose the golden moments which the early hours of treatment or investigation afford.

This brings us to investigation again and me to my conclusion: investigation and treatment depend on the employment of psychopathology to the fullest extent of our knowledge. It is a grave responsibility to let any other consideration than pathology guide the selection of treatment between analysis, suggestion or what not. Happily the nature of neurotic disease is such that it can be thoroughly investigated and adequately treated at an out-patient clinic.

DR BERNARD HART, from the Chair, made a brief summary of the discussion and was followed by Dr T. A. Ross, Dr Stoddart, Dr Culpin, Dr Potts, Dr Hardcastle, Dr Edward Glover, Dr Dillon and Dr Dawson.

DR D. N. HARDCASTLE thought the discussion had been very interesting and, while agreeing with many points in Dr Rickman's paper, felt that the standard of treatment had been set rather too high, the percentage of cases suitable for psycho-analysis or any form of profound psychological treatment among those attending an out-patient department being in his experience necessarily low, owing to the kind of patient, frequently of a poor type mentally and physically, unable to make much effort to adapt themselves to their environment, or else suffering from exhaustion, the result of toxic absorption or infection.

Dr Hardcastle felt that the greatest scope of the mental out-patient department lay in attempting to bridge the gap for the bulk of the patients rather than aiming at a cure for the few. To this end all forms of treatment should be utilized, drugs, change of environment, general reassurance or suggestion treatment. He did not share Dr Glover's dread of the transference persisting after the treatment, so long as the physician knows what he is doing, for he had not found that it had materially hindered the patients' independence nor made them patients for life.

He was rather amazed that no one had mentioned the social worker in the London out-patient departments. They enjoyed the services of one at Bethlem-after the first visit of a new patient she visits the home and makes a point of interviewing some relative of the patient and extracting as clear a life and family history as possible, together with a picture of the home conditions. With very little imagination the physician can from this typed report picture the patient in his home environment, a point of course of the greatest value in deciding the necessary form of treatment for the particular case.

The social worker, who is a link between the patient's home and the hospital, undertakes no form of treatment; in his opinion she is a very valuable adjunct to any mental out-patient department.

DR DAWSON wished to correct Dr Crichton-Miller's suggestion that Dr Mapother discouraged his staff by his summing-up of psychotherapeutic results in the out-patient department at the Maudsley Hospital. The medical staff at the Maudsley were in no need of any sympathy. As a matter of fact, the figures on the chart displayed by Dr Mapother were compiled from the spontaneous and independent verdicts of the members of the medical staff upon their own work. Representatives of many schools of thought were to be found amongst the doctors at the Maudsley Hospital, and Dr Miller might be reassured that even ductless gland therapy was not overlooked.

As regards Dr Good's paper, there were a number of points which the members would like to discuss did time permit. Dr Dawson regretted that Dr Good had not included re-education among his psychotherapeutic methods, using the term to include the social rehabilitation of poorly adjusted individuals. Dr Good had made no mention of social service and of the invaluable work which might be performed by a lady almoner in assisting the physicians by the collecting of data and lay after-care. Dr Dawson had also hoped that Dr Good would speak about the attendance of children at the clinic and about preventive measures and mental hygiene.

As regards the types of case attending an out-patient department for mental disorders, it was of interest to note that at the Phipps Institute, Baltimore, U.S.A., with a steadily increasing turnover, there had been a gradual drop in the percentage of psychotics and certifiable cases, and a greater number of neurotics, social misfits and children. Perhaps this was due to the close liaison existing between the clinic and numerous social and welfare organizations.

DR GOOD thanked the members of the Medical Section for the way in which they discussed his paper. He felt that the paper was rather inadequate, and it was obvious that he did not express his views as clearly as he might have done. So many members had spoken that he found it difficult at that hour in the evening to take each of the points raised by different members individually.

Replying to Dr Mapother's remarks on the paper, he was not surprised that he had rather severe criticisms from him, but he ventured to point out to Dr Mapother that there was one point upon which he wished to join issue with him, namely Dr Mapother's remark to the effect that he had not practised psychotherapy, but only supervised, whereas Dr Good was speaking, to the best of his ability, not only as one who had supervised, but as one with absolute clinical experience.

In reply to Dr Stoddart's remarks, he expressed himself to be in entire agreement with him in not employing a mixture of the endocrine extracts. Nevertheless, he realized that endocrines were of enormous value, and provided one could find which endocrine was affected much might be done by the proper use of the appropriate extract. He quoted a case of Graves' disease as an instance where menstrual functions were interfered with, as well as many cases where the exhibition of ovarian extract seemed to have been one of the great factors in causing improvement in the general condition.

As regards the group of cases which are designated by the term 'dementia praecox,' Dr Good suggested that perhaps further research with endocrine extracts might prove the truth of Freud's theories and that Sir Frederick Mott's discovery, that the testicle and ovary showed degenerative changes in cases of dementia praecox, might possibly be a physical proof that where the physiological functions of the sexual glands were interfered with there was a corresponding blocking of the libido in so far as that, as the individual was unable physically to propagate, his libido could have no discharge in this direction and he was forced back into himself, and therefore he would have, in a physiological sense, an accentuation of his narcissism.

Dr Good admitted that he had replied very inadequately to many points raised in the discussion, but felt that it was difficult on the spur of the moment to think out some of the points raised and reply to them in the proper manner. He felt that he had really said quite enough considering the lateness of the hour, and he wished to express to the meeting his appreciation of the way in which they had received his paper, and of the assistance it had been to himself to hear the views of the various members on the points raised.

OBSERVATIONS ON THE FORMATION AND
FUNCTION OF THE SUPER-EGO IN NORMAL
AND ABNORMAL PSYCHOLOGICAL STATES1

BY SYLVIA M. PAYNE

THE theory and practice of psycho-analysis have advanced side by side; the theoretical formulations are the outcome of laborious clinical observations on the psychology of the individual. The theory of repression is accepted by a large number of psychopathologists who recognize its manifestations day by day in their consulting rooms, even if they are not familiar with the technique by means of which repression may be lifted. The psycho-analyst is familiar with the nature of the repressed, and in each particular case will have varying difficulty in ascertaining the exact content of the repression or, in other words, in interpreting the symptom presented by the patient. The task of interpretation, however, plays only a subsidary part in the technique of the treatment, and is preceded by the overcoming of the repressing forces; the success or failure of this attempt is the factor on which the therapeutic result rests.

Progress in technique necessitated the study of the repressing forces, and the attempt to formulate the mental institutions concerned, to discover their genesis and relation to instinct impulse. Freud's work in this direction is familiar to most of us, but for the sake of clarity I would remind you that he speaks of the undifferentiated instinctual reservoir of mental impulses, with which the individual is endowed at birth, as the id. With the necessity for adaptation (to the interplay of internal instinct stimuli and the stimuli from the outer world) differentiation takes place in the mental apparatus, forming an organization which is familiar ` as the ego.

The organization of the ego is the first modification which can be recognized. It has the function of inhibition and control of instinct impulses by internal adjustment or external motor action in the interests of self-preservation. The internal adjustment includes the formation of a grade in the ego. The formation of this grade is primarily the result of the helplessness of the child in the face of the refusal of its infantile desires by the all-powerful parental figures, and consists of a psychological identification, and introjection or incorporation into the ego

1 A paper read before the Medical Section of the British Psychological Society, February 23rd, 1927.