I thought it would be fun to ‘dig up’ a historical paper and have a look at it. I recently bought a book on Winnicott entitled ‘Through Paediatrics to Psycho-Analysis’ which contains a number of Winnicott’s classic papers. Winnicott was a paediatrician who developed a unique psychoanalytic approach and body of theory. Winnicott has now passed into psychiatric folkelore and some of his concepts such as the ‘good-enough mother’ are widely recognised.
However this was not always the case. In Masud Khan’s introduction, he writes
‘Winnicott was to run into a special sort of difficulty with his analytic colleagues from the start – that of being politely disregarded’.
Khan goes on to write that despite presenting his paper on the Manic Defence in 1935 at a scientific meeting, this paper was not republished for another 20 years anywhere. While Winnicott developed insights from his clinical practice, Khan is quick to dismiss Winnicott’s theories as a simple conversion of clinical acumen into theory.
‘Only to dogmatise his abstractions from clinical experiences to the status of concepts is to distort his style of thinking. They are more exactly and wilfully, what Nietzsche calls, ‘regulative fictions’…..none has received such instant acclaim as that of the transitional object’
So the paper i’m looking at today is ‘A Note on Normality and Anxiety’ – originally published in ‘Clinical Notes on Disorders of Childhood’ in 1931.
In an age where there are so many randomised controlled trials with significant p values and equally significant kudos, this paper (actually a chapter in a book) is cut from a different cloth. In the 19 pages of this paper, there are no references! However, there are numerous cases described – a two year old girl who is screaming, a one-year old with a cough, a nine-year old girl with cyclical vomiting and so on. There is not even a debate here about the difference between quantitative and qualitative methodology. It is partly instead the basis of the apprenticeship model of learning – that the wise teacher disseminates their knowledge accumulated through years of practice and reflection so as to let the apprentice make more sense of the complex world they are in.
As written above, however it is much more, because material is chosen which provokes debate. The paper is organised broadly into sections on physical symptoms of anxiety, physical changes due to emotions, physical causes of nervousness and anxiety masking physical disease. Winnicott writes that
‘One physical effect of anxiety is the tendency to produce thinness….such a combination of thinness, pallor, liability to feverishness….makes the doctor suspect physical illness…..whereas a few years ago these children were classed as ‘pre-tuberculous’ they are now considered ‘pre-rheumatic by those who do not recognise the anxiety factor’.
Perhaps here we see some of Winnicott’s strengths, the authority to speak as both a paediatrician and psychoanalyst and the ability to look circumspectly at evolving medical culture to gain insights into illness. Winnicott writes of physical changes due to emotional causes affecting..
The Eyes: ‘Obsessional blinking, another method of dealing with the sense of guilt over seeing’
The Nose: ‘Usually associated with congestion is increased sensitivity of the nasal mucous membrane and nose-picking’ and that the congestion results from continual excitement.
The Throat: ‘An anxious situation increases this tiresome throat, and it seems clear that much unconscious hostility is dealt with by the symptoms’. Winnicott talks of the ‘anxious throat’!
On physical causes of nervousness, Winnicott writes ‘Latent rheumatism is not, however, a common cause of nervousness’. Finally Winnicott also writes of anxiety which masks an underlying physical illness.
Winnicott’s writing is simple, clear and insightful and his writings in general have become extremely influential.
Winnicott D. Through Paediatrics to Psycho-analysis. The Hogarth Press and the Institute of Psycho-analysis. 1978.
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