79INSTITUTE OF CHILD PSYCHOLOGY

epithelium on the growth of fibrous tissue lyingbeneath it. Work had also been done on the hypo-thalamus, and the effect of its stimulation on

gastric tonus.

INSTITUTE OF CHILD PSYCHOLOGY

AT a meeting held on July 2nd the chair wastaken by Prof. H. R. HAMLEY, and Dr. CHARLOTTEBuHLER of Vienna opened a discussion on the

meaning ofNeurosis in the Child

She said that Adler had first used the term " theneurosis " as characterising a definite attitude tolife, common to all who suffered from the manyvarieties. It was a fixed unconscious reaction witha substitute tendency, the real aim being avoided.With her test methods she could, she claimed, dis-

tinguish between neurotic behaviour on the one

hand and critical periods in normal maturation,slow maturation, feeble-mindedness, primary defi-

ciency, and neglect on the other. She illustrated thispoint by cases of obstinacy and jealousy. About85 per cent. of all children passed through an

obstinacy period ; in normal children the necessaryperiod of refusal should not appear after four. Theneurotic child avoided contact, would not even

say " No," turned away, when asked to do some-thing did something else instead, did things to

annoy and watched how people reacted, treated

objects badly, and showed prolonged and rather

stereotyped bad behaviour, lasting after the fourthyear. He avoided every kind of imitation most

definitely.Primary deficiency was of various kinds. It might

be inability to do certain things, producing irritation ;a child who moved very slowly might be annoyed athis inability to do things which he fully understood,and so became averse from work. Such a childshowed no negativism ; the deficiency was a

dependent element and could not appear by itself.It could not have a neurotic origin because it couldnot arise from intention. A neurotic, by contrast,showed social behaviour much below his age and

produced an indirect outlet and not a direct reaction.In cases where tests revealed critical development,emotional trouble, or minor deficiency, treatmentshould be educational. If there was neurotic reactionthe patient belonged to the pathologist.

Dr. MARGARET LowENFELD spoke of the differencebetween children and adults. It was false, she said,to differentiate unsuccessful children into sick,criminal or delinquent, educational failures, and

psychoneurotic. The Institute of Child Psychologydealt with any child who failed to be happy fromany of these four standpoints. The neurotic childwas not a special type. Educationists regarded as" abnormal " any child who did not fit the particulartype of school he was at. The " problem child"was one whose behaviour contravened certain socialstandards. The reasons for which a child was broughtto see a physician varied in different social strata.Children were presented to the doctor to have themadjusted to some background created by the parents.The germ of a child could manifest itself in four

ways : the production of the physical frame, the

possibility of movement, intellectual growth, andemotional growth. All these had some teleologicalend. Life was biologically intended to be creative,and this activity constituted a rough measuring stick.A failure to achieve this biological end might be due

to past disorder in the germ, to remediable errors inenvironment, or to emotional factors. At presentsuch a residuary diagnosis was all that could beobtained. The barriers between the various artificialgroups must be broken down. A neurosis in childrenmight tentatively be defined as a condition in whichit was found that the predominant factor was derivedfrom the emotional nature.

Dr. D. W. WINNICOTT said that his experience asa paediatrist made it difficult to distinguish normalfrom neurotic children; he preferred the vagueterm " finding life difficult." The most importantpoint arising out of psycho-analytic research was thediscovery of the intensity of infantile and child

feeling. Adults were incapable of recapturing thisintensity ; they would be torn to shreds if theycould. Normality depended on forgetting. Adultsexpected babies to be like dolls, and were surprisedat their individuality. The psychological activitiesof the young human included a constant testing andretesting of the inner and outer worlds. The inner

(phantasy) world was helped by the satisfactions andvalues supplied by the outer world, and the outerworld was seen more richly because of the phantasyfrom the inner world. Typical early human feelingswere love, longing, rage, guilt, sadness, anxiety, fear,happiness, and the urge to put right in external realitywhat became harmed in phantasy. Every normalbaby experienced all these emotions and was verymuch at their mercy. It was abnormal when the

symptoms were of a kind that produced a hostileor unfriendly environment; or when they causedbodily harm (e.g., refusing food, or constipation) ;if play was inhibited ; or if the child was unable toshow neurotic symptoms. When play was inhibited,or no playmates could be obtained, nothing of thenature of reparation or restitution could be attemptedto deal with hopelessness in regard to phantasy, andno aggression could be expressed. In his attempt todeal with internal stress the child ought to be ableto display symptoms such as dependence, sulking,rage, bed-wetting, restlessness, digestive disturbances,and minor illnesses. Each method worked in itsown way and only in a popular sense could a childbe called neurotic if he manifested such symptoms.The term neurosis expressed the popular fallacy thatneurotic symptoms were in themselves abnormal.There was a place for the term, to describe tendenciesand symptoms that had no physical basis, but thepsychologist could only use it if he was clear thatchildren normally employed neurotic symptoms.Dr. ETHEL DUKES remarked on the frequency of

spontaneous recovery and expressed appreciation ofDr. Buhler’s testing methods. The Institute had

always stressed the intensity of feeling in childhoodand sought to get back to the child himself.

Prof. MILLAIS CULPIN agreed with Dr. Lowenfeld’sdefinition of neurosis. The problem of the influenceof emotion had occupied mankind for 2000 years,but neurosis was a modern product. He hated theword. It had been used to include dysentery, leadcolic, epilepsy, asthma, and dementia precox. Stillworse was the word " neurotic," a mixture of falsemetaphysics, pseudo-psychology, and moral con-

demnation. The currency of the word marked oneof the dark ages in medicine. He himself shirked

dealing with children and greatly admired those whodid. He thought neurosis, or benign psychosis, inchildren was not very different from the same

disorder in adults. The analytical examination ofthe adult gave great knowledge of what went on inthe mind of the child. Living in an uncertain world,

80 ROYAL MEDICO-PSYCHOLOGICAL ASSOCIATION

the child often found it a great relief to turn to asphere where two and two always made four, or totoy trains which always kept on the rails. Mathe-maticians were usually people who avoided personalcontacts. The best work in the world was done byneurotic persons, who had to get out of the rut.The key to handling a child from the earliest dayswas to avoid emotional emphasis and to "keep offhis back " as much as possible. Excretory andsexual education were matters often associated withimmense emotional emphasis. Information in sex

matters could look after itself, provided emotion wereavoided.

Dr. DoRis ODLUM expressed agreement with theimportance of emotional disharmony and objectionto the word neurosis, which confused everybody, layand medical alike. She had suggested the worddysthymia.1 Attention had originally been drawnto emotional disharmony by symptoms related tothe autonomic nervous system, and from this pointof view the term neurosis was justified. Neverthelessit seemed a thousand pities not to have the courageto break away from custom and show clearly that anemotional disturbance was what was really underdiscussion.

Prof. E. M. LIGON (New York) thought parentswould be quite as concerned at having their childrencalled dysthymic as neurotic; the question was :

did anyone know what they were talking aboutunder either term ? Dr. Buhler’s distinction betweendifferent types was of the greatest importance.

Mr. R. J. BARTLETT said he had been impressedby the importance of the will in the life of the child.There was a time when it was good for the child tosay " No. I won’t." It was difficult to draw theline between emotion, conation, and volition. Thechild must not have his own way completely; hemust fit into the social environment and find restric-tions against which to use his will up to a point.

Dr. GRACE CALVER spoke of the child who wastrying to react to something within himself; theneurotic went a stage further and suffered from aconflict of two repressed tendencies which came outin some altered form. He was always a solitaryindividual, whereas the first type was not. Dr.Buhler’s tests showed up these reactions very clearly,and worked well with deaf-and-dumb children.

ROYAL MEDICO-PSYCHOLOGICAL

ASSOCIATIONANNUAL MEETING AT FOLKESTONE

THE ninety-fifth annual meeting of the Associationtook place at Leas Cliff Hall, Folkestone, on July1st, 2nd, and 3rd, under the presidency of Dr.M. ABDY COLLINS.The president presented the Gaskell prize to Dr.

S. W. Hardwick, of Tooting Bec Hospital, and the prizedissertation award to Dr. D. K. Bruce, of Storthes HallMental Hospital. The president delivered an addresson the Law and the Present Position of Psychiatry,in which he traced the history of the specialty, anddealt with recent research and present tendencies.The special subject for the annual meeting was the

Manic-depressive PsychosesDr. AUBREY J. LEwIS, dealing with the prognosis

of these psychoses, said that prognosis was oftenconceived as the natural history of disease, or the

1 THE LANCET, 1932, ii., 754.

course which it would follow if it was not interferedwith. Treatment was valued for the good modifica-tion which it produced in this so-called natural orderof events. It might expedite the process of recovery,or it might bring about recovery which would nototherwise have occurred; or it might lessen theharm wrought by the disease. Stated differently,the efficacy of treatment was assessed by the changesproduced in the duration of the illness and the formit took. In the case of such a disease as malariathis conception of prognosis and this use of it for

assessing the treatment could be demonstrated. Butin psychiatry one was not, as a rule, dealing withparasites, bacteria, or other exogenous agents whichlived and exerted their influence in a definite orderof time and place. Causes of mental illness had nosequence or constancy. Those external to the

patient were variable and manifold, as much so asthe pattern of daily life, and those intrinsic in thepatient were seldom capable of forcing their wayand becoming manifest as illness. Another importantpoint to remember in mental disease was the uncer-tainty as to the criteria of recovery or improvement.Individual studies were the only ones which couldtake all the modifying and significant factors intoaccount ; but with them there was a risk of

generalising from an exceptional happening or froma plausible explanation which was really deceptive.Larger, statistically sufficient data were subject todirectly opposite objections and advantages ; but itwas possible to collect a manageable number of caseswhich had been well worked over, and to continueto follow them up for years. This was a preferablemethod to that of dealing with old case material asrecorded by other psychiatrists in the light of formerclinical interests, which differed from present ones.Dr. Lewis gave in detail his findings in 61 manic-depressive cases, which he had followed up for eightyears, and compared these findings with those ofother investigators.

Dr. P. K. MCCowAN referred to work done byhimself in association with Mr. J. H. Quastel, D.Sc.,on the hyperglycsemic index in psychotic patients. 1Since their paper was published, Dr. Quastel and hehad examined some hundreds of further cases ofmanic-depressive insanity, and had found no reasonto modify their former statements. When, in thecourse of the illness, the blood-sugar fell, it was offavourable prognostic import, and the value of theindex was seen particularly in cases showing nostriking objective evidence of depression and who

. denied depression and wished to be discharged.Should the index of such a patient remain high, hisor her discharge would be dangerous. In a certainnumber of cases, particularly involutional and senilemelancholies-in the absence of menstruation or

toxaemia or glandular dysfunction-there was a

persistently low hyperglycaemic index, and this wasregarded as showing a large hysterical element. In

benign stupor the index was low, in katatonic stuporit was high in a general way.Dr. H. TÓMASSON (Reikjavik, Iceland) dealt with

efforts to treat cases of manic-depressive psychosis.He said that in a group of phasic manic-depressivepatients a humoral instability was found to existwhich was characterised by abnormal fluctuationsin the calcium level of the serum. At the same timefluctuations had been found in the serum con-

centration of sodium, but in the opposite directionto the calcium values-i.e., with a general tendencyto values lower than in normals. Fluctuations had

1See THE LANCET, 1931, ii., 734.