study of organ inferiority and its psychical compensation

Preface

The purpose of this book is to add to clinical medicine a further principle of research. From the completeness and the import of these early results I am sure that I have come upon very fruitful territory.

To me, moreover, it was an attractive task to see our benumbed and thwarted conceptions of disease completely dissolved; to be able to observe human pathology in its making.

Many a valuable bit of knowledge has supported my theory of the inferiority of organs. I have been unable to give acknowledgment to all at the proper places, as I should have liked. In this paper, in addition to the authors named} the range of thought of Martius, Rosenbach, Exner, Hering, Obersteiner, Haeckel, Schwalbe, and many another has played a large part.

This work is to count as a beginning. Perhaps, at some future time, I shall be permitted to make the connection with clinical mediline, with psychology, and pedagogy still closer by bringing together all previous works on the subject.?

1 The author has advanced this purpose in his monograph on the “ Neryous Character,” a translation of which has been published by Drs. Glueck and Lind.

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Contents

CHapP. I. OUTLINE OF r Teeohy ON ORGANIC INFERIORITY. . CHAP. TE HEREDITY 2... 3 CuHap. III. ANAmMNestic DEMONSTRATION Cuap. IV. MorpHotocic INDICATIONS CHAP. V. REFLEX ANOMALIES AS INDICATIONS OF INFERI- G) han oar ere ea re een oe aes aot Cuap. VI. MANIFOLD ORGANIC INFERIORITIES ........... CuHap. VII. THe Part PLAYED BY THE CENTRAL NERVOUS SYSTEM IN THE THEORY OF ORGANIC INFERI- ORITY—PSYCHOGENESIS AND FOUNDATIONS OF NEUROSES, AND PSYCHONEUROSES........... ‘ Cuap. VIII. Biotocic PoINT oF VIEW IN THE THEORY OF ORGANIC. INFERIORITY cs osc diens uss APPENDIX: THE INFERIORITY OF THE URINARY APPARATUS, —FATE OF ENURETICS AND THEIR DESCENDANTS ... mrss eect ees ascent as 8 eee ee eee eee eee ee ee we we ee ose eee eee

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Foreword

At the beginning of the twentieth century Alfred Adler (1870- 1937) investigated the influence of physical inferiority on the development of normal and pathologic mental trends, joining in 1902 the group gathered around Freud. As early as 1907, however, his studies on organ inferiority resulted in conclusions that were irreconcilable with Freud’s theories. Circa 1912 he separated from Freud and founded his own school of Individual Psychology.

What Adler called “ organ inferiority ” is a condition that might occur as a familial tendency or as a situation in one individual. When the tendency was familial in nature one might find that a whole series of members suffered from a disorder that tended to attack one organ, and when organ inferiority is an individual tendency a disease would be liable to localize in the inferior organ since it is a common experience to find that inferior organs fail first in their functions when the organism is infected or under a particular stress. For example, a child may be born with a congenital heart defect. It is well known that such defects invite infective processes or at least they tend to focus there not only during childhood but also in adult life when serious infections in this organ may result in death.

It is possible for an inferiority to affect the whole of one half of the body or there may be a segmental inferiority or again there may be an inferior organization of a whole organ system like the nervous system or the gastro-intestinal apparatus.

To Adler the inferiority represented a defect in the material available for the construction of a normal well balanced personality pattern, and it became a point of crystallization for the mental superstructure of compensation and hypercompensation ; moreover, this organ inferiority tends to increase the feeling of inferiority experienced by every child resulting in an intensification of the striving towards an often unattainable goal. In the course of this striving the personality may become distorted and exhibit the traits of a “neurosis” or of a character disorder.

In contrast to the Freudian school, Adler tended to minimize the rdle of infantile sexuality and to place greater emphasis on the ego mechanisms. He studied thoroughly the feelings of inferiority resulting from organic deficiency and abnormality, as indicated above, and described the unconscious attempt of the ego to compensate for such defects.

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Vili FOREWORD

This whole concept later became known popularly as the “ inferiority complex” and was extended to include psychical deficiencies the personality reaction to which was often one of overcorrection of the original disorder.

Professor Adler believed that the driving force is an urge toward the gaining of superiority and thus he tended to reduce much if not all of mental life to the individual’s striving for power, a formulation not universally, accepted since many believe that it refers to only one phase or aspect of life.

Adler, in commenting on an inferiority of an organ as the constitutional cause of the neurosis said: “ The digestive apparatus, the respiratory organs, the heart, the skin, the sexual apparatus, the motor organs, the sense organs, and the pain paths become thrown into excitement according to their fitness for the expression of the wish for power and show the forms of hostile aggressive attack or of quiescence and of flight, inhibition of aggression both in harmony with the ‘ vital line’ of the patient with his secret life plan.”

Everything is teleologic. All is purpose even in the dream; the expression of the “will to power” or desire for superiority over others. A successful striving for power results in the attainment of ambitions, a failure leads to neurosis, a flight from reality or the development of symptoms to explain the failure.

In 1912 an important study entitled “ Psychoanalyse und Ethik”’ appeared by Karl Fortmiiller. He started from Adler’s basic hypothesis and sought to explain the ethical imperative as a defense against the feeling of inferiority (Minderwertigkeitgefiil).

The psyche and the soma have developed together through the stages of evolution in the relationship of function and structure. They are probably inseparable practically, and even theoretically, on the basis of any logical system of thought. As Bently has said “ The bodily system alone does but it physiologically does only by an active interaction with other physical systems and it psychologically does only by making use of its own products and issues.” It must always be kept in mind that integration is not merely addition or summation of multiples but it is a multitude of multiples plus organization. There are literally thousands of written treatises on the “ constitution ” in disease and many of these are of psychiatric import, but the scientific correlation of psychological aspects and symptoms with | organ defects and diseases remains to be completed. This may be due in part to the fact that most students concern themselves chiefly with studying physiological, morphological, chemical, or psychobiological units instead of taking into account the total situation and

FOREWORD ix breaking it down into even finer divisions where relationships may be revealed.

This little book has not only an important historical value but it presents a number of foci for future research. A thorough investigation of organ inferiority concepts should be undertaken and included as a part of the present day trends in psychosomatic medicine.

Introduction

An examination of the diseases of the urinary apparatus can be very extensively carried on so far as their symptomatology is concerned. In renal pathology, as in all other diseases, the schema of symptoms is built up empirically, and accordingly rests on a firm basis. It is richly enough equipped to lead the diagnostics of renal diseases along safe paths. The compass is at once reduced, however, when the examination is directed towards etiology. The theories of the causes of renal diseases read like a short collection of truisms, in which terms such as predisposition, chill, poisons, infection, disturbance of the circulation appear and reappear and play their part, just as they do in other organic diseases.

The fact that a definition of these casual factors themselves is notably lacking ought not even to be particularly emphasized. More important is the fact that there is so little positive material available to decide the question concerning the localization of disease in the kidney. What has been emphasized, the sickening of the kidneys through poisoning or infection as well as through the progressive changes in affections of the circulatory system, all this is in line with the basal concepts of pathology, for the urinary organs are affected like all others proportionately to their relation to the disease centers.

The conditions in those cases which one is forced to designate as “genuine,” or “primary” diseases of the kidney are less clear. A long list of diseases falls under these heads. They all have this in common, namely, that the final cause of their pathologic form cannot be traced beyond the kidney, and that a more remote or even an exogenous etiology—from the very name—seems out of the question. Here may be reckoned, if all other distinguishing indications are put aside, true contracted kidney, renal tumors, localized lues and tuberculosis, cystic degenration, nephrolithiasis, nephralgie hematurique, renal hematuria, floating kidney, imperfect development and hypoplasia and analogous diseases in the pelvis of the kidney and ureter. I must add also that the genetic course of development in secondary diseases must not under any consideration be deemed exhausted by reference to the causa movens, but, rather, in these cases too, the selection of the kidney is determined in a hitherto unexplained manner.

If one turns aside from an explanatory attempt which limits

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INTRODUCTION x1 itself to causes of disease which are purely local and situated in the kidney, one can divide the notions on localization of disease in the kidney synoptically into three groups, of which each one has reference to secondary as well as primary diseases. The one hypothesis tries to make the selection of the kidney as center of the disease tenable on the ground of “nephrotoxic” action of a number of poisons. The strength of this hypothesis lies in experimentation, as well as in a number of recorded cases which bring to mind a noxa especially harmful to the kidney, such as is present in scarlet fever, diphtheria and other infections. On the other hand it is inapplicable to a great number of renal affections, does not offer an explanation for the kidney’s remaining unaffected upon the appearance of renal poisons, and should only be generalized with the utmost caution on the basis of animal experimentation. At any rate we know of no poison at present that invariably harms the kidneys, and at the same time, only the kidneys. A second conception sees the cause of the greater number of renal diseases in the exposed position of the kidney as an organ of excretion through which the waste material of the body is constantly passing. This hypothesis is supposed to serve as a sufficient explanation for most of the renal affections. Its application is surely greater and its bearing unquestionable, since it has to do, not only with true toxins, but also with the increase of waste products and with heightened external demands upon the kidney. But even with this conception we are not in a position to give satisfactory explanations. It also leaves us in the lurch when we ask why, with the admission of the premises, that is, the presence of bacteria in the blood, of toxins and poisons, of chronic metabolic anomalies, of alcoholism, pregnancy or chill, the kidneys are so often found healthy. It also fails us in attempting to explain one-sided disease of the kidneys, as in cases of tuberculosis, lues, and tumors. These and other inadequacies force us to a third view, which will be championed, and with good cause, I believe, in this book, a conception according to which most renal diseases are caused by a fundamental inferiority of the urine-excreting apparatus.

That such a condition may be accepted for many cases, and plays its part in renal pathology is probably universally recognized. The appearance of true renal diseases can not be sufficiently explained by the acceptance of hypothetical poisons of metabolism. Above all, the pathological findings, as well as the clinical course, both contradict chronic poisoning. This view is refuted almost as strongly by the frequently long duration and by the numerous hereditary /

X11 INTRODUCTION appearances. In the same way, albuminuria of puberty, renal hemophilia, cystic kidney, the pregnancy kidney, orthostatic albuminuria, and albuminuria connected with constipation are all indications which one can hardly overlook. But one of the strongest arguments for inferiority of the urine-excreting apparatus as the cause of renal diseases, is heredity, which is so often found in renal pathology. At most it is still questionable whether certain of these cases of albuminuria should be considered diseases. The difficulties in determining the question will not be denied, for the transition from mild anomalies in the condition of the urine, to severe forms of renal diseases, has not yet been sufficiently studied. But even cessation for a number of years or improvement of the phenomena, whether under medical treatment or not, has no conclusive force. One can, however, justly emphasize that the acceptance of inferiority of the kidney as the cause of renal diseases, regarded from the pathological viewpoint, has many probabilities in its favor, that the transition from abnormal development and functional anomalies to disease can be brought about in the shortest time, and that in many cases it becomes questionable just where the aspect of the disease begins for us. The “physiological” albuminurias play the same part there as, say, the cystic kidney, which can formally appear overnight as a severe illness, after it has existed for some time without any symptoms.

By means of an examination of this sort, from the standpoint of an inferiority theory, these previously mentioned affections of the urinary apparatus attain their proper place in pathology for the first time. Their significance in the field of renal pathology comes out more clearly through the demonstration of a fundamental inferiority. At the same time it: seems necessary to conduct more searchingly the examination of constitutional organic anomalies as the foundation of many, perhaps of most diseases, so that the diagnostician may draw strong support from the facts of the inferiority theory. The value of this view, however, extends to the study of the symptoms also, and to experimental pathology. In regard to the latter, it determines once for all the differences between inferior and normal organs and thus interferes with the unlimited transference of results of animal experimentation to human beings, and of experiences with well people to sick ones. In regard to the first, it seeks to establish a still closer bond between the empirically determined symptoms, and the diseased organ, and makes related organs responsible for symptoms of a more widespread organic disease. There will be particular stress laid on personal prophy-

INTRODUCTION Xiif laxis in all those cases where it is possible to deduce organic inferiority, where signs of disease have not been already proved. Just as is the case at present, when diseases in the parents arouse suspicions in regard to the children. We must determine first of all for therapy whether the inferior organ should be and can be, by means of any sort of a course of treatment, aroused to sufficient function and eventually to additional development, a question to which one can often answer yes, in the case of young people, but which with older patients must frequently be answered by no. The answering of this question will, however, usually call for a deeper knowledge of the nature of the inferiority in question, and its significance for the patient concerned. If one is. obliged to give up an active cure, or training, then the laws of a protective plan of treatment—rest, reliei—come to the fore. Finally, in making the prognosis, quoad vitam, or sanationem, the inferiority theory, likewise, guarantees valuable aid. From the point of view now resorted to, not only the sum of the phenomena presenting themselves, the phases, so to speak, of the contest, will have to be taken into consideration, but the valuation of the organ has also to be effected, and we must fix our eyes upon the relation of this value to the disease-exciting force.

These explanations will serve to substantiate the fact that a study of the inferiority of organs is at the foundation of some of the most important problems of pathology. In the following pages I shall try to establish that this theory may claim to be considered as a valuable “heuristic” method on the basis of the characters or conditions that underlie it.

STUDY OF ORGAN INFERIORITY AND ITS PSYCHICAL COMPENSATION

Chapter I Outline Of A Theory Of Organ Inferiority

After having attempted in the previous pages to sketch the great significance of a study of organ inferiority in renal pathology, to which we will add a few special additional illustrations in the supplement, we find ourselves called upon to enlarge the domain of our research and to take into consideration all of the organs. We must do this so much the more, as, on the one hand, the argument which gave us the authority for declaring the inferiority of the urine-secreting apparatus one of the fundamentals of renal pathology, can be made to apply to all other organic diseases, and on the other hand, the pathological phenomena of the diseased kidney can, in an analogous manner, be demonstrated in the whole field of pathology. Chronic transformation of the parenchyma, pathological form of the supporting tissue, cystic degeneration, formation of concretions, localization of inflammatory and neoplastic tumors, malformation, imperfect development, diminished development in the whole apparatus or in parts of it recur in all or several of the organic diseases, and the theory of inferiority always seems called upon to complete the otherwise insufficient etiology.

We find analogous transformations in the liver, in the pancreas, in the thyroid gland, in the genital tract, in parts of the digestive tract, the respiratory and circulatory systems, and in the central nervous system. A great number of these diseases are marked, by characteristics which are emphasized in renal diseases, such as heredity, chronic course of the disease, typical localization within the organ, an insufficient etiology supported neither by poisons nor bacteria, but they can easily be put into a framework of a theory of inferiority. This is the case in the pathology of the thyroid gland, the etiology of which has proved itself quite insufficient, but which corresponds to all the heretofore mentioned conditions of an inferiority theory, particularly that of heredity. The macroscopic as well as the microscopic pathological changes of the liver show phenomena analogous to those seen in almost every case of renal disease, for which reason the primary diseases naturally interest us most.

It seems superfluous to us, further, to point out in detail how certain transformations may be found in every individual organ, since this is really a problem clearly enough set forth in general pathology. Only the lack of satisfactory etiology will be emphasized in this connection. On the other hand, the question which is raised in this paper, and which we are trying to solve, asks rather, what reasons there are for the fact that certain diseases attack just a certain organ. The solution accepted by us, which takes a primary inferiority of this organ as a basis of the disease, is at one with the opinions and researches of many authors. In this question we can, perchance, only claim to have undertaken the study of organ inferiority more comprehensively, and to have considered its significance of greater import. A greater objection might however be raised against the further declaration that other diseases, too, not considered true diseases, such as infectious diseases, and “adventitious ” diseases, often require, or at least are dependent upon, the assumption of organ inferiority in their course. A still greater number of diseases might be mentioned at this point, as, for instance, tuberculosis, which is probably always localized in the inferior organ, an assumption which, if conclusively established would bring many of the doubtful questions relating to heredity, place of entry, and paths of infection, immunity and therapy, nearer to a solution... The colonization of Loffler’s bacillus and other microérganisms in the pharyngeal space, of the Frankl-Weichselbaum diplococci in the lungs, the agents of typhoid, cholera and dysentery at definite spots in the intestine, and many other infections, likewise, fall under this head.

At the same time the part that bacterial invasion has played should not be denied. But the acceptance of an inferiority of the diseased organs seems particularly assured, since thg presence of many pathogenic microdrganisms can be demonstrated in well people. To be sure, one can often expect only obscure signs of inferiority, in fact in a number of these diseases the illness itself and its course must be considered, for the time being, as evidence of inferiority. This causes us to drop the conception of “absolute” inferiority for these widely spread diseases, and to introduce the term “ relative” inferiority, which is of value, be it temporarily or only in regard to certain causes of disease. As regards tuberculosis, to be sure, the proofs of primary inferiority of the lung, or of other attacked organs, seem to be abundantly present. The very appearance of heredity makes this more easily acceptable. Likewise the frequently typical localization in the lungs, kidneys, joints and brain. As a matter of fact, citations may be quoted which give information in regard to certain arrests of development, as those of Frankl, Schick and Sorgo, statements which we can without further ado classify with the signs of degeneration which are emphasized later on.

With reference to diabetes, epilepsy, tumors, chronic alcoholism, obesity, cretinism, and a few other diseases, I undertake to determine, after looking through a considerable amount of material, their position with reference to the study of organ inferiority. A little series of observations has suggested to me to consider these diseases, also, as built upon a foundation of organ inferiority.

The role of chance in diseases of inferior organs is surely not as great as is commonly thought. One comes in contact, at least, with cases that strike one so remarkably that a greater number of them succeed in convincing one that their determination has been differerently and more strictly given than by mere chance. One of these cases I will present in the following. Ladislaus F., 8 years old, was injured in August of the year 1905, by a pen which went into the outer upper quadrant of the left eyeball, and reached through the conjuctiva bulbi into the sclera. The patient had come too close to a schoolmate who was brandishing a pen, yet neither of the boys could be accused of malevolence or particular inattention. The wound healed with slight reactions. In October of the year 1905, the boy again presented himself with a coal-splinter, which a gust of wind had blown into his eye, imbedded in the cornea of his left eye. After extracting the foreign body the wound soon healed. In January, 1906, the patient again received a prick in the left eye, which was caused, just as on the first occasion, by a schoolmate with a pen he was using, and which was about 1 cm. below and inside the first punctured wound. This wound also healed like the first, in a short time, leaving an ink-tinged scar. One might think that all this was purely bad luck. I was able to ascertain the following: The maternal grandfather suffered from diabetic iritis and was for a long time under the care of an oculist. The mother had convergent strabismus, likewise the patient’s younger brother, and both had hypermetropia and diminished acuteness of vision, which could not be accurately demonstrated owing to the inattention and lack of intelligence of the boy. One of the mother’s brothers was troubled by numerous recurrences of conjunctival eczema, and had convergent strabismus. Our patient had full acuteness of vision, hypermetropia to a slight degree, but showed a lack of the conjunctival reflex in both eyes.

I do not wish to deduce too much from this case. Nevertheless it seems certain to me that one must accept an inferiority of the organ of vision in this boy, which is pretty well established by heredity, the different varieties of illness in his relatives, partly of inflammatory, partly of functional nature, and the deficiency of the reflex function of the conjunctiva and the poor protection of the eyes, a fact which seems to me to be related in some not yet wholly explained way to the deficient reflex action. At this point I must also add that under adequate psychical conditions, by means of greater activity on the part of the psyche, the above mentioned inferiority of the eyes may be made good. The boy can learn by experience and can hide the partly organic defect by psychical exertion. The transition between organic inferiority and psychical compensation becomes comprehensible in such cases. But there can also be no question that from the nature of the psychical compensation the traces of the redeemed organic inferiority remain unobliterated, and that, for example, in the above-mentioned case, the protection of the eyes must have moved into the field of conscious awareness, and in this manner the visual character of the individual experienced a particular strengthening. But more of this later.

Meanwhile permit me to add, in this connection, the following about the nature of organ inferiority, which seems already to have been elucidated here and there: For the purpose of a simple and distinct arrangement, we shall name only two forms in which the inferiority of an organ expresses itself, morphologic and functional inferiority. Both are present at the same time in the majority of cases. I should like to designate as “relative” inferiority, a third form, upon which I shall lay little stress. This declares itself only in the case of illness and becomes recognizable only under increased demands or following upon systematic tests.

2. Morphologic Inferiority: One can point out as deficient the development of the shape of an organ, its size, its individual portions of tissue, individual cell complexes, of the whole apparatus or of limited parts of the same. A certain probability, which is in accord with biological conditions, would have it appear that fundamentally just the most highly developed, differentiated cells and cellcomplexes have come out the worst, while the tissues of lesser capacity, which owe their development to an earlier embryologic epoch, may be normally or -even super-normally developed. The deficiency will concern first of all those portions of tissue which as secretory, nervous elements, protective tissue, excretory ducts or supply channels, guarantee the full development of the function. When life activity begins and with it the innumerable sources of stimulus of energy and metabolism, the remaining fetal or postembryonic tissues will experience a great demand and a sufficient sudden impulse to growth. Their final formation will, to be sure, not be that of normal fetal development, but will be enough to insure the functions necessary to life. In relation to the life and health of the individual, the consideration is, that one of his organs has to perform the functions necessary to the economy of the organism with a lesser stock of tissues or one less capable of resistance. With satisfactory structural material and sufficient provisions it is often possible to master the work. But just as often, perhaps, the hour comes when the insufficiency of the organ is revealed, when the external and internal hindrances can no longer be controlled. The normal structure and wear and tear of the organ give place to regressive phenomena, which are just as much determined in their nature by the morphologic inferiority of the organ, as by the special causes setting the disease in action. The moment at which the function necessary to life fails is relative. It is accordingly not at all surprising to find that at times inferior organs suffice for a complete lifetime.

From the conditions of morphologic inferiority of an organ the cause of which is always fetal defect of development, the following conclusions may be positively drawn:

1. Since the fetal defect in development is brought about by inherited or acquired properties of the spermatozoon or ovum the hereditary character of organ inferiority must stand out in a particular fashion. The heredity may not always be exhausted in the morphologic inferiority of one and the same organ, it can, as will be later shown, be proved by functional deficiency, by inferiority of a second organ, as was pointed out before, or by cases of illness [‘‘ relative” inferiority] among relatives.

2. Since the greater number of organs are withdrawn from direct observation we are often compelled to infer possible inferiorities from anomalies in their size, form, and position. An extremely important makeshift is presented in the functional anomalies which should be considered in conjunction with other characteristics of organ inferiority as authorized signs of inferiority. Directly perceivable to the eye and sense of touch are the organic inferiorities lying close to the outer integument and often standing in relation to it. These have passed up to the present day under the name of external signs of degeneration, or stigmata. They represent for the greater part nothing more than the visible expression of the inferiority of the related organ, whereupon in the individual cases, at all events, the question always arises as to how far into the deeper part of the organ the inferiority extends.

3. From the fetal character of the morphologic organ inferiority, from the embryonic lack of material which we think causes this, it follows that frequently manifold organ inferiority must occur which can be explained either by local difficulties or by deficiency of material extending through several organs. The relation of different organs to each other has to play a part in this, a part which began likewise in the embryonic stage. In these cases also, a fact which is confirmed by experience, a morphologic anomaly can be replaced by a functional defect.