of necessity specialize on hygiene and sanitation. These subjects offer abundant opportunity for further specialization, and the experience has been that in order to attain his highest efficiency, an officer must be permitted to continue uninterruptedly the particular work or special investigations in which he is most interested. Certain officers have for years devoted practically their entire time to studies of a particular disease. Others specialize in medical work in relation to immigration, and still others in quarantine management. A fair quota of officers are engaged in special studies in the Hygienic Laboratory and elsewhere as occasion arises. The newly appointed assistant surgeon is, as a rule, first stationed at a Marine Hospital where he soon learns to know the corps and to partake of its esprit. He has opportunity for scientific work in relation to the treatment of diseases, can take advantage. of the privilege of meeting doctors, health authorities and others in localities far removed from the surroundings of his youth, and can if so disposed, identify himself with the public health movement of the community in which he is stationed. The first detail is usually of short duration. Young officers look forward to travel, and it has been found that this is an excellent means for fitting them for the important and responsible work which they will subsequently be called upon to do. The second detail may, therefore, be to a quarantine station, an immigration station, or on some revenue cutter destined to Alaska or to a foreign port. If the second detail is an immigration station, the next one may be a quarantine station. By this means, the of ficer learns to know the different lines of work open to him, and his efficiency is thereby increased. Sooner or later the younger officers are assigned to duty in the Hygienic Laboratory, and the course of instruction is planned for their benefit. Those who show special adaptability for research may be retained in that institution, or given some special detail which will permit them to continue their investigations. It is by this means that officers are fitted to make special studies of typhoid fever and other contagious and infectious diseases, and selected to perform important duties of a technical and administrative character. After four years' service the assistant surgeon is entitled to examination. for promotion, and if he is successful he is recommissioned by the President as a passed assistant surgeon. When an officer enters the Service he does so with the understanding that he may be called upon to serve in any climate, and in accordance with law, officers are detailed from time to time for duty in offices of our consuls abroad. These are responsible positions, and those having experience with certain diseases are specially selected for the purpose. In the scientific positions in the government service there is opportunity for advancement, and contrary to the usual belief, the ambitions of its officers to succeed in these positions is fully as high, if not higher, than in private life. Within the last two decades, there has been a great awakening with respect to the needs of improving the public health, and I know of no medical service in the world which holds out the same facilities for the advancement of its officers in public health work. With good previous training, industry, and the exercise of good judgment, an officer is sure to advance and reflect credit on the organization to which he belongs. The needs with respect to the training of sanitarians has not been fully met at the seats of learning in this country. The Public Health Service must, therefore, train its men after it admits them, and herein is an additional great opportunity for advancement. As public health work increases, and as universities take up in earnest the training of men, and the States and municipalities demand the services in greater degree of such men, these great fields will be opened more and more to the officers of the Service. Some have already availed themselves of these opportunities, and on account of the demand, there is difficulty in filling their places. On the whole, it may be expected that public health work will become more and more necessary and supported in greater degree than heretofore, and with the granting of increased compensation to which the officers are entitled, the Public Health and Marine Hospital Service affords an open field which is fully as attractive as any engaging the attention of physicians to-day. A Few Remarks on the Technique of Psychanalysis.1 Clinical Assistant in Psychiatry and Neurology, Columbia University. . It may be said in starting that we have not yet any definite psychanalytic technique, and it is my opinion that it will take many years before we shall have a perfected method for such in vestigation that will compare in any way to the technical means in other branches of science, as histopathology. For contrary to the general belief we can say that examinations of mental processes are more difficult than those of physical ones, and it will therefore take at least as much time and effort to evolve a psychanalytic technique as it took to perfect any of the methods now used in the sciences. In spite of the rapid progress we are now making, thanks to the works of Kraepelin, Bleuler, Adolf Meyer, Hoch and others, it must be admitted that the science of mental diseases is still in the making, and altho Freud has solved for us many obscure riddles we are still in the dark concerning a great many problems. The more we penetrate the mind the more complicated it seems, and I need hardly say that in spite of all knowledge and experience defeat must often be admitted. But as we are here mainly interested in the psychoneuroses I can state that altho we do not as yet possess any definite psychanalytic technique we have nevertheless evolved a working method which enables us to analyze and cure most cases of psychoneuroses. 1 Read before the New York Psychanalytic Society. Now what is this working method? To answer this question it will be necessary to touch upon another subject which, altho strictly speaking does not belong to the subject under discussion, nevertheless goes hand in hand with it. I refer to the knowledge upon which psychanalysis is based, viz., the psychology of Freud. If we should attempt to follow the analogy formed above we would soon have to stop. You all know that any intelligent "Diener" may learn the technical part of histopathology, or for that matter the technique of any other branch of science, but the technique of psychanalysis presupposes not only a knowledge of Freud's psychology but also a thoro training in nervous and mental diseases. Recently I had the pleasure of talking to some who claimed to have used psychanalysis in the treatment of patients, and who spoke rather discouragingly, saying that it produced no result. Thus one complained that the patient did not improve in spite of the fact that he did an association experiment. Another endeavored to cure a case of homosexuality in about a dozen sessions, and then spoke against "the therapeutic efficacies of the Freudian treatment." Still another stated that altho he questioned a young lady for hours about sex she showed no improvement in her hysteria. These statements readily show that none of these had any knowledge of the work, and I have no doubt that they did much harm. For it is not the treatment of a few hours, weeks, or even months, that cures; it is the psychic elaboration accomplished during a long period by one thoroly conversant with the work. I do not think that it is too much to ask of one who wishes to make use of a certain technical method that he should first learn its basic principles. One cannot expect to do anything with psychanalysis unless he has mastered at least Freud's theories of the neuroses, the interpretation of dreams, the sexual theories, the psychopathology of everyday life, and his book on wit, and last but not least who has not had a thoro training in nervous and mental work. It must be remembered that Freud, Jung, and all the other pioneers in this work have been neurologists and psychiatrists first. To practice psychanalysis without a previous active training in neurology and psychiatry is as absurd and dangerous as practicing surgery without any knowledge of a recent lecture on anatomy. In psychanalysis, Prof. James J. Putnam of Harvard stated that psychanalytic practice is more difficult than the hardest kind of surgery. I am sure that none of you would be willing to be operated upon by one who has had no training in surgery, yet I know a number of men who claim to do psychanalytic work without ever having learned the elements of nervous and mental work. Now assuming that one possesses the qualifications mentioned, there are still many questions to be considered. It has been wrongly supposed that we claim to be able to cure everything. Neither Freud nor any of his pupils On has ever advanced such claims. the contrary, Freud has repeatedly emphasized that psychanalysis has a limited field, and that it should be used only in selected cases. Let us hear what he says: "I. The former value of the person should not be overlooked in the disease, and you should refuse a patient who does not possess a certain degree of education, and whose character is not in a measure reliable. We must not forget that there are also healthy persons who are good for nothing, and that if they only show a mere touch of the neurosis, one is only too much inclined to blame the disease for incapacitating such inferior persons. I maintain that the neurosis does not in any way stamp its bearer as a dégéneré, but that, frequently enough, it is found in the same individual associated with the manifestations of degeneration. The analytic psychotherapy is therefore no procedure for the treatment of neuropathic degeneration, on the contrary it is limited by it. It is also not to be applied in persons who are not prompted by their own suffering to seek treatment, but subject themselves to it by order of their relatives. The characteristic feature upon which the usefulness of the psychoanalytic treatment depends, the educability, we still have to consider from another point of view." and "2. If one wishes to take a safe course he should limit his selection to persons of a normal state, for, in psychoanalytic procedures, it is from the normal that we seize upon the morbid. Psychoses, confusional confusional states, marked (I might say toxic) depressions, are unsuitable for analysis, at least as it is practiced to-day. I do not think it at all impossible that with the proper changes in the procedure it will be possible to disregard this contraindication, and thus claim a psychotherapy for the psychoses." "3. The age of the patient also plays a part in the selection for the psychoanalytic treatment. Persons near or over the age of fifty lack, on the one hand, the plasticity of the psychic processes upon which the therapy depends-old people are no longer educable and on the other hand, the material which has to be elaborated, and the duration of the treatment is immensely increased. The earliest age limit is to be individually determined: youthful persons, even before puberty, are excellent subjects for influence." "4. One should not attempt psychoanalysis when it is a question of rapidly removing a threatening mani festation, as, for example, in the case of an hysterical anorexia." 2 From my own experience I can fully corroborate Freud's statements, and I would add: do not analyze your relatives, and when in private practice do not analyze any patient without receiving some compensation for it. We should begin with a thoro physical and neurological examination, and if the diagnosis of psychoneurosis is made we can proceed with the analysis. Prof. Freud and many of his pupils ask the patient to relax in a supine position on a lounge so as to remain free from all external influences and impressions. I have found that I can do as well by allowing the patient to sit in front of me in a comfortable chair. I usually begin by asking the patient to tell me his symptoms in the order of their importance, and I write them down. To gain some knowledge of the patient's milieu I have elaborated a set of about 150 psychanalytic questions which I put to the patient. Following this I explain some of the theories of our work and impress the patient with the fact that he will have to cooperate with me by being absolutely frank and honest in his statements, and that he should tell me whatever comes to his mind without criticising or rejecting. This is always promised but never kept. The association experiment is not necessary, tho it is often a valuable help, especially in cases into whose minds we cannot readily enter.3 2 See Freud: Papers on Hysteria and Other Psychoneuroses, translated by A. A. Brill, Jour. Nervous and Mental Disease Pub. Co., 1900. page 181. 3 For the technique of the association experiment see Jung: The Association Method. Translated by A. A. Brill, Amer. Journ. of Psychology, Apr., 1910; and Brill: Psychological Factors in Dementia Praecox, Jour. of Abnormal Psychology, Oct.-Nov., 1908; and A Case of Schizophrenia, Amer. Journal of Insanity, July, 1909. |