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I am grateful to Mme de Saussure for enriching my paper (Atkin, 1974) with her brilliant discussion (Saussure, 1974) of the dynamics of my case, an essential aspect which I had to forego because of space limitations. In discussing the effect of the patient's early trauma, Mme de Saussure splendidly demonstrated the effects of an impoverished narcissism and the reasons for patient's resistance to the input of love from objects. In admirable fashion she worked out the dynamics of patient's lack of trust, endowing the concept with rich and concrete meaning. She developed the psychology of 'shame'. And she gave a vivid and convincing interpretation of the patient's unique stool symptom.
I must confess, however, my disappointment in her failure to respond critically to the main thrust of my presentation, which dealt with the role of the primary constitutional factor in the defective integrative and synthetic functions of the ego in this borderline patient.
My clinical investigation of this case was an attempt to answer certain questions: is the failure of the integrative and synthetic work of the ego an outcome of a primary constitutional factor, resulting in a retardation in the maturation of her ego? Or is the failure due to the pathological effect of early traumatic emotional crises? And what is the relative contribution of each? Mme de Saussure is not alone in avoiding tackling this subject. Dealing as we do largely with mental conflicts, we analysts tend to confine the term 'genetic' imprecisely to the conflictual elements in early life. While we recognize that constitutional factors may enter into and overlap with 'genetic' factors, in general we are not inclined to deal with this forthrightly and indeed often omit it entirely.
Mme de Saussure suggests that the synthetic function can be inhibited at an early developmental stage by severe trauma. In light of the fact that this patient's serious developmental disturbances occurred in the first year of life, i