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caped the psychoanalysts. I have carefully searched the literature and the looseness with which they couple the neuroses, the hysterias, the compulsions with this distinctly different mental state is something which should not be allowed to continue without criticism. If psychoanalysts will accept for experimentation cases showing these mental defects then in all fairness we should allow them a free hand to demonstrate their principles. If, after application of psychoanalytic methods in a considerable number of cases of very early dementia præcox, they fail to disclose their value, it may then be possible that psychiatrists in this country will throw off the shackles that have been impeding progress in the elucidation of this problem and that medical men will return to anotomical and physiological investigations as an aid to its solution. We must have definite scientific data and not beautifully descriptive systems of philosophy from our psychoanalytic friends, if they are to help us in this particular problem.
An instance of how far the pendulum has swung from a consideration of the medical aspects of dementia præcox to the purely psychological can be had by a scrutiny of what appears to be at present the most popular of these psychoanalytic viewpoints. I have reference more particularly to the work of Adler as expressed in his book “The Neurotic Constitution.” The number of unconfirmed views and unsupported statements presented by this author as facts cannot be allowed to go unquestioned. Some assertions made in this book are characteristic of a great deal of the psychoanalytic literature and this brief, critical review is undertaken as a check on what we regard as the baneful influence which this particular work has had on the minds of a great many of those interested in psychiatric subjects. Particular reference is made wherever possible to his discussions of dementia præcox.
Referring to the instinct that the child has of obtaining security by striving towards a fixed point where he sees himself greater and stronger, where he finds himself rid of the helplessness of infancy, Adler says (page 53), “ The qualities of greatness, power, knowledge and ability are constructed in the image of father, mother, older brother or sister or some hero, etc. These stand like idols of clay and they receive from the imagination of mind the force which afterwards reacts on the psyche which has created them. In so far as the child is able at all times to free himself from the bonds of his fiction, these artifices of thinking show the only difference from the manner of thinking in paranoid and dementia præcox conditions.” The main difference is, therefore, according to this conception, that the normal is able to free himself from his fancies and return quickly to reality, whereas in the case of the psychoses mentioned, this is not possible. But, as Adler says, “ there is this similarity of adherence to a fiction in normal persons, neurotics and the insane.” On page 76, making reference to the "psychotic individual," Adler takes issue with Freud, whom he says stopped at the point "of discovering the actual or possible sexual formula in these symbols and has not pursued their further elucidation into the dynamic eventuality of the masculine protest of striving upward.” His philosophy of the neurotic constitution is thus summarized and consists of what he designates as the guiding line or striving upward manifested by the “masculine protest ” in individuals whom he calls somatically inferior. This, in a few words, is his conception.
On page 92, Adler makes the statement that the child (meaning probably the neurotic child) brings forward into consciousness an acute sense of inferiority which is permanent and depends on the presence in such individuals of inferior organs, and that as a result of this consciousness of inferiority, a formula is established by which the neurotic strives to become master of the situation. These attempts at compensation of physical inferiority lead to the symptomatology of the neuroses and psychoses. According to Adler, all the symptoms of these conditions can be explained on the grounds of a more or less conscious striving to hide and overcompensate this inferiority. He says that in the organs which fall below the normal standard are to be seen the more frequent referred somatic complaints. Therefore, it is said that these inferior, neurotic individuals, in order to hide their inferiority, set an unusually high goal which it is never possible for them to attain. On page 95, he says, “ Nervousness, by preference, utilizes organic defectiveness, the infantile defects, the sense of ill-health in general on the one hand, for the purpose of securing the ego-consciousness against the requirements of parental authority, usually by means of a stubborn revolt. . . . . Indeed, the neurotic individual often seeks minor defects, even brings them about artificially, or assumes dangerous outlooks in order thereby to justify his neurotic acts and caution.” To this fiction which Adler calls the masculine protest he ascribes everything in the neurotic constitution. In differing from the Freudians, he says (page 106), “That a further pursuance of the matter leads irrevocably to a realization of the untenableness of the libidotheory, to a doing away with the sexual etiology and to an understanding of the neurotic sexual conduct as a fiction."
In this way Adler throws a sop to those who object to the predominance of sex in the Freudian theories and explains the sexual conflicts of the neurotic on the theory that they are part of the means by which these individuals obtain the mastery over their environment. According to Adler, therefore, these sex matters are not the causative factor in the development of the neurosis, but are only one of the means used by the neurotic as an aid in making the masculine protest. This twist in the presentation of the sexual side of this question does not prevent the greater part of the pages of this book from being given over to a full discussion of the sex problems which have been much more conclusively and convincingly set forth by Freud and others. When one examines the evidence on which Adler bases his ideas that the neurotics are possessed of inferior organs, we find that he points as confirmation to ulcer of the stomach, appendicitis, cancer, diabetes, liver and gall-bladder disease, as evidences of such inferiority. Why he omitted typhoid fever from this classification it is hard to understand unless one considers that possibly Adler has met and been conquered by the bacillus typhosus. On the same page (122) one finds further evidence of the extravagant lengths to which Adler carries his unconvincing reasoning. He says that a number of neurotic symptoms such as obstipation, colic, asthma, vertigo, vomiting, headache and migraine are symbolic of "a voluntary but unconsciously co-operating activity of anus contraction and abdominal pressure,” which are used as an aid by the neurotic for domination. In these individuals Adler says that greed for gold and power are in the foreground of their ideals, which is nothing more or less than a repetition of the ideas of Freud and Jung, who associate these traits with what they call the anal neurotic types.
It is on such flimsy and ephemeral data that Adler builds his conception and it is upon principles such as this that a great many attempt to explain the development of dementia præcox, various other psychoses and neuroses. It is with an idea of presenting to these individuals and to certain medical psychologists the possibility that they are in error that this paper is primarily written. It is also hoped that we may give them a definite opportunity to prove to us the truth of their data in a scientific way.
Further reference to the work of Adler shows that he regards certain purely mechanical pathological conditions as evidences of inferiority. Particularly important in this regard does Adler place the inguinal hernia (page 145) which we have always understood to be a rather innocuous, mechanically produced condition. The idea that inguinal hernia is an evidence of organic inferiority will certainly be interesting. The idea, however, that individuals possessing this condition have a (fatal) determinant of neurotic manifestations will perhaps be startling. Even more startling than this will be the statement made on page 318, “I have in various instances learned to recognize this connection with epilepsy, sciatica, trigeminal neuralgia. I have proved that these latter conditions were psychogenic in nature and originated whenever strong securities were demanded.” In this connection the author also mentions migraine. These conditions, which we have always felt had a pathological foundation, are ascribed by Adler as symbolical, more or less voluntary, aids in the struggle of neurotics against the feeling of being beneath or as a struggle against femininity-or as an expression of the masculine protest.
As against the correlations which Southard, Kleist, Kræpelin, Alzheimer and others have attempted to make between the symptomatology of dementia præcox and the pathological findings, we have Adler's views on the pathogenesis of the delusions, hallucinations, attitudes and other symptoms. On pages 234 and 237 we find this explanation of the origin of delusion and hallucination. Speaking about a patient whose analysis he presents, he says, “ The essential part of a psychosis depends upon a dogmatic anticipatory representation of a fear or a wish, which the craving for security offers for the better testimony in a phase of great insecurity, in strong dependence on the fictitious guiding line for the conservation of the ego-consciousness.” Explaining the symptom of tearing off the clothes which so many excited patients have, he says (page 237) that they "tear the clothes from the body as though they would divest themselves of the modesty which they regard as feminine, as though they wished to make a parade of fictitious, large, masculine, genital organs and thus belittle others.” On page 266, concerning hallucinations, he says, “Hallucinations as well as dreams are, like other tentatives of the psyche, fitted for finding the way which leads to the maximation or preservation of the ego-consciousness. In it are reflected the faiths, the hopes or the fears of the patient.” On the bottom of page 267 he says, “ In paranoia and dementia præcox, the emotions leading to the masculine protest disguise themselves in the form of hallucinations and assure the psychotic scheme through their acoustic or visual complement.”
If these explanations of the production of delusions and hallucinations are true, it is of the utmost importance that this fact be demonstrated to the satisfaction of all psychiatrists. If they are found to be true upon investigation, then a good deal of the work which is being done in neuropathology may just as well be stopped. These matters must not be settled by acquiescence in unsupported statements such as these. Nowhere in this book does Adler give any idea of the results of his psychoanalytic treatment. It is essential that a sharp therapeutic test be made of these matters and that careful records be published, not only of the methods followed but also of the results obtained. The fallacy or the truth of statements like these must be settled soon if psychiatry is to make any progress in solving the problem of dementia præcox. Concerning the symptoms of stereotypy and the delusion of grandeur in a catatonic, Adler says (page 276), “Stereotypies were manifested, among other ways, by an occasional upright position of the body and by holding the head high, a motion which I was able to interpret as symbolic, as a phantasy of the erection of the male organ."
Not referring for the moment to the intensely boastful "I" of the author (we are sure many other psychoanalysts are capable of making the same deductions in like cases), I should like to inquire whether everyone is prepared to accept this explanation of stereotypy as against the possibility that it may depend upon changes in the cortex of the cerebellum, the dentate and other cerebellar nuclei and their connections with the basal ganglia, the cerebral cortex, the spinal cord and anterior horn cells.