The Journal of Abnormal PsychologyPart 5 out of 8A PSYCHOLOGICAL ANALYSIS OF STUTTERING[*] [*] Paper read May 6, 1914, at Albany, New York, before the American Psychopathological Association. Copyright 1915 by Richard G. Badger. All rights reserved. BY WALTER B. SWIFT, A.B., S.B., M.D. Instructor in Neuropathology, Tufts College Medical School, In Charge Voice Clinic, Boston State Hospital, Psychopathic Department. THE object of this paper is to carry the analysis of stutter phenomena deeper than before. In my last year's paper I showed that chronologically the diagnosis of dyslalia mounted step by step from a material external affair, up through the nerves until we came to the basal ganglia. I showed conclusively that it was an involvement that did not exist in any of these places. I further took steps to demonstrate and present evidence that indicated that dyslalia was in its essence some trouble with the personality. I mean by this: that the trouble was located in the nervous system beyond the lower sensory areas of the sensorium; and also above the lower motor areas on the motor side. By the broad term "personality" I mean the total of the activities and interrelations of mental activities that occur above our lower sensory and motor areas. The paper of last year clearly located the trouble vaguely in this region of the personality. Since that time I have been interested to ascertain just what the nature of this changed personality is. In order to do so, I have carried on an investigation that has reached interesting conclusions. To me it is new truth. It may not be all the truth, but as far as it goes, and as for what it is, it surely is truth and a new finding! This research is an effort to show not only where it is but WHAT IT IS. The method was as follows: For the purpose of finding out some of the activities going on in the area of collaboration during speech, I asked my stuttering patients two simple questions. I thus found that their methods of collaboration complied to a certain mental type. Then I carried this same method into the study of normal individuals in the collaboration of their ideas, just before and during speech in order to establish a norm; and to see whether or not it differed from my preliminary test of stuttering cases just mentioned. It did, and therefore I formulated a series of questions in order to pin the type of collaboration down to certain fields of mental action. To make this clear, let me present an outline of these different steps in tabular form. 1. Orientation tests on stutterers. 2. Orientation tests on normal individuals. 3. The research, its objects and methods. 4. Final detailed results. Let us now pass to a minuter description of each of these procedures and a tabulation of the data that resulted. 1. PSYCHOLOGICAL ORIENTATION TESTS ON STUTTERERS: By orientation test I mean simply a vague try-out to see just where the problem lies; an initial step to see what further steps are necessary; or in other words enough of an investigation to know where to look next. The orientation tests consisted in requesting a series of twenty stuttering cases to answer two questions. Following their answers an immediate inspection was made of the content of their consciousness before, during, and after speech. These two questions were as follows: 1. Where do you live? 2. Say after me "The dog ran across the street." After these questions I asked the patients to state whether there was any picture in the content of consciousness and how long it lasted; also whether that was detailed, intense or weak. I noted the presence of stuttering in relation to the presence or absence of this mental imagery; and also made a note of any other unusual data that happened. The results of the tests indicated above can be summarized as follows: Of the twenty stutterers examined, ten made no visualization of their homes, some even after a residence of years; one of these twenty visualized home very faintly; two others visualized home clearly but the picture vanished on speaking; seven others visualized home clearly but these had been under treatment. On repeating the dog statement, ten stutterers made no visualization whatever; one visualized faintly; four visualized well but the picture vanished on speaking; five others reported visualization, and four of these had been under treatment. At first I did not know but what this was the norm of average visualization methods; so I tried this same series upon a number of normal individuals for comparison; by normal individuals, I mean, at this time, merely anyone who is free from stuttering, and chosen in a haphazard way from the hospital community; for example, one was our executive secretary, another a typewriter, another a telephone operator and so on. 2. PSYCHOLOGICAL ORIENTATION TESTS ON NORMAL INDIVIDUALS The results of these orientation tests upon normal individuals were as follows: The normal individuals examined almost without exception visualized clearly before and during speech. Sometimes this visualization was very marked in detail and resulted in emotional responses, such as pleasures, etc. From the above two sets of figures were thus obtained a fair norm of visualization for ordinary individuals; and in comparison a marked variation from this in stutterers. This data therefore warranted the tentative conclusion that stutterers have a loss or diminished power of visualization. This assertion may seem a little more than is warranted by such meagre data and perhaps would be better revised pending further data into the following: As compared with the normal, stutterers show a weakness in visualization. 3. THE RESEARCH, ITS OBJECTS AND METHODS: These general orientation tests for a norm and its pathological variation were the basis upon which I proceeded on broader lines with a further and more exhaustive investigation with the following points in view: To what extent is visualization weak? Is it weaker in the worst cases? Is it less and less weak as cases appear less severe? Is it the same for past, present and future memories? Is visualization equally at fault in all sensory areas of the cortex? Do cases approach normal visualization processes in proportion as they progress in their cure? and Lastly, numerous other minor queries presented themselves. All these questions were answered in the following research, which after thus much orientation found a more complete and final form. In order to answer these questions I formulated the following series of tests to the number of twenty-four in all, and asked them in series to nineteen stutterers, making almost four hundred tests: 1. Speech: Say, Today is sunny. The dog ran across the street. Submarines will sink all the steamers. 2. Motor: Do you dance? Did you ever skate? Would you sew for a living? 3. General Sensory: How does a pinch feel? Did you ever get hurt? What would you like to do if it was very hot next summer? 4. Hearing: (Eyes closed) Do you hear anything? Did you ever hear a rooster crow? What sounds would you like to hear next summer? 5. Sight: (Eyes closed) What do you see now? What did you see yesterday? What would you like to see next summer? 6. Smell: (Eyes closed) (Pen to nose) Do you smell anything? What have you told by smell? What would you like to smell next summer? 7. Taste: (Eyes closed) Do you taste anything? What have you been able to tell by the taste? What would you like to taste next summer? 8. Muscle Sense: (Eyes closed) Put one arm up; the other like it. Put one arm up, down; the other like it. How would you hold a hand to read from it? This long series of questions with careful introspection tests upon the content of consciousness constituted then my main research in the field of stuttering. Perhaps further details in explanation of the questions chosen is unnecessary. Three or more questions on introspection were asked at each test. 4. FINAL DETAILED RESULTS are found in the following conclusions as drawn from 1440 answers. In our average conversation a visual picture is created before we begin utterance. Severe stutterers never visualize at all. In direct proportion that these cases become less severe, does visualization increase in frequency, strength and continuation in consciousness before and during utterance. When severe stutterers are free from spasms they visualize, and when they stutter they do not visualize. When mild cases are free from spasms, they visualize, and when they stutter they fail to visualize. In a word, when visualization is present stuttering is absent; when visualization is absent stuttering is present. This is true not only of EACH UTTERANCE, in most cases, but is true of severe as well as mild forms as a whole. Stutterers gain in visualization as they approach cure. For past, present and future memories: visualization is slightly more frequent for past and future. Therefore stuttering is an indication of absent or weak visualization either in isolated words, occasional stutterers, mild stutterers or the severest type, either before or during speech, or both. The slump, then, in personality which I showed last year as the main thing in stuttering as its cause and condition, is thus found by further psychological analysis, to be a slump in the power to consciously visualize. By personality I mean as mentioned above the composite of collaborative activities that lie between the low sensory repository areas and the low motor expression areas. In other words, personality includes all those collaborative processes that lie between the sensory intake areas and the motor output areas; in a word, any unexpressed use the mind makes of its intake. Conscious visualization is a part of personality processes, then. In my last year's paper([1]) the whole matter was left vague. Here something definite and constant is found. In other words the psychoanalytical method revealed no conscious subconscious cause. Granted there is room here to "interpret" (or create according to Freudian mechanisms) a definite subconscious complex, a step which I could not feel justified in taking; I leave this to better psychoanalysts than I. For me to twist stutter phenomena to comply to a theoretical complex is unscientific to say the least. But the psychological method--as represented by this paper--shows a definite constant cause for all the phenomena of stuttering. FAULTY VISUALIZATION EXPLAINS ALL PHENOMENA: Upon this basis of an involved visualization all the intricate phenomena of stuttering may be explained. Let us take some of these up in detail. THE START. Visualization processes are a matter of growth through exercise and development and use from the sensory area mostly of the eye. If these processes in their early start and evolution receive a setback through the treatment of people in the environment, such as interruptions of their early speech efforts, constant inattention of those to whom they speak, and persistent refusal by older people to answer questions propounded or the allowing of the little one to ask the same question without hopes of answer for a great number of times, these visualization processes receive a setback. This kind of treatment in the home is one of the chief causes of the slump of visualization processes. Another cause is hearing other stutterers interrupt their own visualization processes as they stutter; and still other minor causes may be almost any psychic trauma; these traumata, such as an operation, an accident or a severe illness, are sufficient to bring to the surface or intensify a growing lack of visualization that has been started by bad environment long before. THE DEVELOPMENT OF STUTTERING. When the habit of visualization is lessened, the action upon speech is the same as the withdrawal of an inhibiting or regulating reflex arc. It is thus that visualization processes act like reflex inhibition. When visualization is present a higher inhibition arc is functioning and we have a normal speech as a consequent reflex expression. When and in proportion as visualization is absent this higher inhibition arc is not functioning; and the speech thus uncontrolled flies away in spasms which we call stutter. It should be called an exaggerated or uninhibited speech reflex. The stutter, then, is merely the externalization of an exaggerated reflex of motor speech, exaggerated through the loss of the inhibitory action of a more or less weakened visualization process. Not only does this explain the phenomena at large but seems to be a satisfactory explanation for all its intricate, minute details. Some examples may, perhaps, be welcome at this point. I say to two stutterers: "Tell your first name." One of them stutters and the other one does not. On furthering questioning, it is found that the one who did not stutter visualized, and the one who did stutter did not visualize. CONCRETE: These conditions are also seen when stutterers talk about concrete and abstract matters or when they promulgate some important plea that cannot be visualized. On concrete matters that can be easily visualized the stuttering is gone; and on abstract matters where visualization is hard, the stuttering again appears. ANGER: In anger, when an intense visual picture is presented and occupies the mind, there is then no stuttering, and also in other similar situations there are periods when the individual is abandoned to some visual concept which acts in the same manner. SINGING: We all know that stutterers can sing without stuttering. The process here is a similar one; only that there is held up over the speech before utterance an auditory image of a melody in place of the visual image as held in normal speech. This auditory image may be more easily applicable as supplying the needed inhibition reflex arc than the visual because it is nearer to the speech area. PRAYER: For the same reason prayer is uttered without stuttering when there is faith enough in a God to hold an image of Him during utterance. There may also be other images held during prayer. FAMILIAR SIGHTS: Familiar sights are less stuttered upon than the detailing of situations that are less familiar and therefore can be less well visualized. This is also true of sights that have been recently seen or that have been repeatedly seen, or that in some other way have been made intense as pictures in the visual field. AS CURE PROCEEDS: In the process of recovery where visualization is seen to increase as the stutter decreases, there is another illustration where this visualization attitude explains the whole situation. I have taken a severe stutterer and told him a story that could be well pictured, got him to work up the pictures properly by several complicated processes (which we will not consider now) and when he had them well in hand, I have seen him stand up and relate the story from beginning to end with little or no stuttering If at any point he would trip up, the inevitable confession would be that at that point he dropped the picture, or, in other words, the visualization could not be held over in its inhibitory action; and therefore the stutter came. On further request to hold it over that point, the same passage would be again expressed smoothly if he succeeded in holding the picture. This constancy, this presence and absence of the picture, its presence to make smooth talk and its absence to cause stuttering, is so constant at every turn of the situation, that I would offer it as a new interpretation of all these phenomena. I know of no other interpretation that can EXPLAIN EVERYTHING UNDER ONE HEAD as does this absence, weakness or interruption of visualization processes. TERMINOLOGY. We have found in our orientation tests that in a vague way the visualization was at fault. We have also found in normal individuals that a marked visualization was an automatic process that preceded speech, and lasted during utterance; and we have found in the long series of stutterers that visualization is entirely absent in severe cases; that it is weak in milder forms; that it is intermittent in most cases, and that on words that are smooth it always appears, and in occasional stutter it is as occasionally absent. We have also found that the form of visualization common in normal speech is the visualization of eye sensations; that in unusual situations we may have visualizations from other sense areas, such as the ear, taste or smell, but these are the RARE EXCEPTION. From all this data it would naturally follow that some sort of term is needed to designate this condition. Last year I probed to find such a term without much success. At present I see no reason why it should not be called an Asthenia; it is surely the weakening of a mental process that is strong in normal individuals. The evidence here presented shows that. I doubt whether there is any marked pathological change, since the individual may be educated out of it; but this does not necessarily follow as proven with my dog in Berlin.[2] As a general designation, then, I should consider Asthenia as apropos. One objection to this is that the weakness is by this terminology lacking in localization. Our data above has shown us that the location of the trouble is visual; that is, it is situated about a centre of sensory registration that deposits data from the eye; this must naturally then be located somewhere in or near the cuneus. We could therefore add to the terminology this idea of a minute localization and call it a Centre Asthenia. Some may prefer to carry the matter one step farther and add the name of the centre in which this weakness is located, but I fear if I take this step and complete my terminology by the word "Visual Centre Asthenia," it will, as such, not cover quite all the cases, for I find that sometimes the visualization is absent in other areas as well, and also the holding of an emotion of pleasure or pain and of other dominating mental attitudes that are sometimes visualized would not, therefore, be included. I would therefore retract the broader claim in order to place the term on a conservative basis and call the essence of the lesion simply no more or less than a Centre Asthenia. As well as visual Asthenia, the following terms might be considered as applicable: collaborative centre asthenia; imaginative centre asthenia; visual creative centre asthenia; picture producing centre asthenia. We say neurasthenia when the trouble is not in the nerves as such, so much as it is in the collaborative centres. More of this later. Here in stuttering the trouble is also collaborative, and we can be still more definite than that and say the trouble is with the collaboration of visualization. So if I were forced, however, to choose one term from all these, my choice would be "Visual Centre Asthenia." This indicates a new and rational treatment. But of this later. SUMMARY: Psychoanalysis reveals stuttering as some vague trouble in the personality[1]. Psychological Analysis shows stuttering is an absent or weak visualization at the time of speech. This new concept of stuttering as faulty visualization may be called Visual Centre Asthenia. This lack or weakness in visualization accounts for all the numerous phenomena of stuttering in severe, medium, or mild cases. A new treatment is indicated. REFERENCES [1] Swift: Walter B, A Psychoanalysis of the Stutter Complex with Results of Synthesis. [2] Swift Walter B., demonstration eines Hundes, dem beide Schafenlappen xtirpiert worden Sind. Neurologisches Centralblatt, 1910, no 13. THE ORIGIN OF SUPERNATURAL EXPLANATIONS[*] [*] Read at the 7th Annual Meeting of the American Psychopathological Association, New York, May, 1915. BY TOM A. WILLIAMS, M. B., C. M. (EDINBURGH) Corresponding Member Neurol. and Psychol. Societies of Paris, etc. Neurologist to Freedmen's Hospital and Epiphany Dispensary, Lecturer on Nervous and Mental Diseases, Howard University, Washington, D. C. THERE is a general impression that the explanations of natural phenomena, including human destinies, to which the term superstitious is given are usually attributable to the vestiges of traditional cosmogonies of our tribal ancestors handed down to children at the knees of their parents or guardians. This explanation however, is only true of a portion of the beliefs which we call superstitions. The demand for superstitious explanations depends upon psychophysiological tendencies of the human organism, the root of which is comprised in the affect which we call craving. This theorem I have tried to develop as follows:-- I Craving is a sign of physiological need. It is a sensory phenomenon, of which, however, explicit awareness cannot always be discovered. It is conspicuously noticed in cases of disturbance of the body secretions, such as occurs in over-function of the thyroid gland. It is regarded as a crude body-consciousness that something is the matter. In motorial organisms it causes visible reaction: this expresses itself in what is termed restlessness. But the unrest may show itself by a fixation more particularly in the muscles of emotional expression, although the manifestation is not confined to these; shallow respirations and restricted amplitude of movement in limbs and trunk may be observed also. In cerebrate animals the reaction of the individual is under the guidance of preceding impressions stored in the pallium and known as memories; whereas in the animals without a pallium all reaction is accomplished through stable mechanisms known as instincts. Both of these types of reaction are tropisms merely; but the former are labile, conditionable; whereas the latter cannot be modified. The science of conditionable reactions of cerebrate animals is called psychology, and the means by which the reactions are influenced are called psychogenetic, whether these are healthy or diseased. It must not be forgotten, however, that the genesis of a psychological disturbance may be purely somatic, although the manner in which the reaction shows itself is contingent mainly upon the features of the individual which have been derived from previous sensory impressions and their resultant motor reactions commonly known as experience. It is the influence of these upon the hereditary dispositions of the individual which constitute what is known as "make-up" or character; and it is this which determines the form which reaction to stimulus must take, whether the stimulus is purely psychological or somatic. Now physiological discomfort is an experience universal at one time of life or another; but the reaction to it is infinite in variety; and while part of it depends upon the congenital dispositions which are the common property of humanity, a larger part is contingent upon the psychogenetic factors which have stamped the individual. II Now an influence which has been of great significance to every human being since the traditional period, at least, has been the concept of the universe regnant at the period of that individual's life. The insistence by its protagonists upon this concept as the ultimate motive of human endeavour made its acceptance almost universal at periods when it was the custom to lean upon the dicta of authority for guidance in life even when blind obedience was not the rule. Now in natural affairs, inconvenient questionings and scepticisms towards dogmatisms would ultimately reach truth. But as inaccessibleness to verification of what was called supernatural made authority, rather than investigation, its criterion, excommunication from the tribe would still all criticism.[1] Thus every act of life became permeated by motives, originated in arbitrary interpretations of a super-nature. [1] A dramatic study of this occurrence is presented by Grant Allen in "The Story of Why-Why" in his book "The Wrong Paradise." These influences were specially conspicuous concerning the difficulties of man's almost blind struggle against the uncomprehended astronomical and geodetic phenomena marvelled at and fled from, as well as the pestilences which ravaged him. In his sociological affairs too, every act or thought became embued with relationship to an extraneous power. It is by these social and physical phenomena that the greatest appeal is made to the states of feeling termed emotions and sentiments. So that it became the custom to invoke, concerning ill states of feeling, the reference to a supernatural influence. Thus, from the cradle up, the ordering of social relationships was made dependent upon the simple expedient of the supernatural extraneous agent, rather than upon the more difficult and elaborate analysis and synthesis which would have been required for a proper investigation of each perturbing circumstance in its relation to life as a whole. The power of this influence was inversely proportional to the resiliency and tenacity as well as the general well-being of the individual. But not only is reference to the supernatural favoured by traditional cosmogony, but because of certain psychological features of the individual himself there is a tendency towards supernatural explanations of the introspective observations. The Occasions of introspection of this kind are two, and I am not speaking of the inculcated introspection of the moralists. One of these Occasions is the self-examination into his conduct which is a normal character of a thinking being. This may give rise to supernatural explanations even when the introspection is not determined by the tradition of which I have already spoken. The second kind of Occasion demanding introspection, is the autochthonous emanation of feeling of unaccustomed character. Such feelings occur at the physiological epochs;--but at these times they are readily explained in a familiar and simple way, and hence no supernatural agency is usually invoked. A similar explanation is made readily enough in cases of evident bodily disease, even where mental symptoms are prominent, for it is no longer the custom to speak of demon-possession even in the acute deliria. But even where no physiological epoch or clearly defined physical disease stands forth, unusual feelings are no uncommon phenomenon, and they demand explanation. Such occur conspicuously in the psychopathological syndrome so completely described by Janet under the term psychasthenia. Persons thus afflicted feeling an incapacity and an impediment to their free activity and not recognizing that they are sick, endeavour to interpret their feelings. Of course, the interpretation varies somewhat in accordance with the nature of the feelings, and with the person's information about the world and his psyche. But quite apart from modifications of this type, I have found it very common for patients to declare "I feel as if there was another person in me," or "I feel compelled as if by another agency to act thus." The explanation of a supernatural agent weighing upon them becomes very easy. For the purpose of this discussion, it is not important whether psychasthenia arises purely from degeneration of structure, or from faults in the chemistry of the plasma which bathes the nerve structures, or whether it is a purely psychopathological condition to which the physical phenomena are secondary, as some would have us believe. Our object is merely the setting forth of the fact that it is a diseased condition which disposes its victim towards metaphysical explanations. It is a sort of uneasiness which prevents comfort in the feelings of certainty, in the operations of the intellect and decision of action. The patient finding himself abulic, and perhaps too critical minded to accept the mundane supports in his vicinity, seeks a solace in that which to him seems powerful because incomprehensible, that is to say in something supernatural. For this, it is not essential that the victim's mind be pervaded by the infantine cosmogony which parades often as religious truth. Without anything of the sort, there may arise naive interpretations, hardly even having explicit reference to supernatural agents. For example, a patient may say "If I begin on Friday, a certain undertaking will fail," "If I do not turn my vest twice, misfortune will occur," "It is incumbent upon me to turn round in my chair, or the negotiations will fail." The enumeration of expedients would be useless. The above are from three different patients, one a boy of fourteen now completely cured; the second from the son of a prominent public man now quite restored to health; the third from a case still under care. In none of these was the bodily state of importance, the psychological reactions were the sole object of therapeutic effort, and their ordination was accomplished by purely psychological means. DATA CONCERNING DELUSIONS OF PERSONALITY WITH NOTE ON THE ASSOCIATION OF BRIGHT'S DISEASE AND UNPLEASANT DELUSIONS.[*] [*] Presented in abstract at the Sixth Annual Meeting of the American Psychopathological Association, held in New York City, May 5, 1915. Being Contributions of the State Board of Insanity, Whole Number 47 (1915. 13). The material was derived from the Pathological Laboratory of the Danvers State Hospital, Hathorne, Massachusetts, and the clinical notes were collected by Dr. A. Warren Stearns, to whom I wish to express my indebtedness but to whom no one should ascribe the somewhat speculative character of the present conclusions. (Bibliographical Note.--The previous contribution was State Board of Insanity Contribution, Whole Number 46 (1915.12) by D. A. Thom and E. E. Southard entitled "An Anatomical Search for Idiopathic Epilepsy: Being a First Note on Idiopathic Epilepsy at Monson State Hospital, Massachusetts," accepted by Review of Neurology and Psychiatry, 1915.) E. E. SOUTHARD, M. D. Pathologist, State Board of Insanity, Massachusetts; Director, Psychopathic Hospital, Boston, Mass., and Bullard Professor of Neuropathology, Harvard Medical School, Boston, Mass. ABSTRACT Previous work on somatic delusions. Suggestion that allopsychic delusions are as a rule in some sense autopsychic. A genetic hint from general paresis (frontal site of lesions in cases with autopsychic trend.) Mental symptomatology of general paresis. Work on fifth-decade psychoses. Statistical summary. Group with pleasant (or not unpleasant) delusions. Three cases of senile dementia, delusions of grandeur, and frontal lobe changes. Three cases with religious delusions. Remainder of pleasant-delusion group. Group with unpleasant delusions. Nephrogenic group. THE suggestions here put forward concerning personal (autopsychic) delusions are based on material of the same sort as that previously analyzed for a study of somatic and of environmental (allopsychic) delusions. Our conclusions are also influenced by two analyses of the types of delusion found in general paresis. Moreover, at a period subsequent to the analysis presented here, some work on fifth-decade insanities had been completed, and the delusional features constantly found in the functional cases of insanity developing at the climacteric, entered to modify our general point of view. The situation may be summed up as follows: The accessibility to analysis of the clinical and anatomical data at the Danvers State Hospital was such as to prompt the use of its card catalogues for statistical work upon delusions. The more so, because in a period of enthusiasm over the Wernickean trilogy (autopsyche, allopsyche, somatopsyche) of conscious phenomena, the Danvers catalogue had attempted to divide the delusions recorded into the three Wernickean groups. Putting these clinical data side by side with the anatomical data, we were speedily able to single out those cases with normal or normal-looking brains and thus to secure a group approximately composed of functional cases of insanity. It shortly developed, as to the CONTENT of delusions, that somatic delusions were exceedingly prone to parallel the conditions found in the trunk-viscera and other non-nervous tissues of the subjects at autopsy.) A subsequent study has confirmed this conclusion for the distressing hypochondriacal delusions found in climacteric insanities, which delusions, however distressing, are often far less so than the true conditions found at autopsy. And it may be generally stated that the clinician can get very valuable points concerning the somatic interiors of his patients by reasoning back from the contents of their somatic delusions. But how far can we, as psychiatrists, reason back from the contents of environmental delusions, e. g. those of persecution, to the actual conditions of a given patient's environment? In a few cases it seemed that something like a close correlation did exist between such allopsychic delusions and the conditions which had surrounded the patient--the delusory fears of insane merchants ran on commercial ruin, and certain women dealt in their delusions largely with domestic debacles. But on the whole, we could NOT say that, as the somatic delusions seemed to grow out of and somewhat fairly represent the conditions of the some, so the environmental delusions would appear to grow out of or fairly represent the environment. Thus, however brilliant an idea was Wernicke's in constructing the allopsyche (or, as it were, social and environmental side of the mind) for the purpose of classification, our own analysis promised to show that for genetic purposes the allopsyche was much less valuable. These delusions having a social content pointed far more often inwards at the personality of the patient than outwards at the conditions of the world. And case after case, having apparently an almost pure display of environmental delusions, turned out to possess most obvious defects of intellect or of temperament which would forbid their owners to react properly to the most favourable of environments. Hence, we believe, it may be generally stated that the clinician is far less likely to get valuable points as to the social exteriors of his patients from the contents of their social delusions than he proved to be able to get when reasoning from somatic delusions to somatic interiors. Put briefly, the deluded patient is more apt to divine correctly the diseases of his body than his devilments by society. Our statistical analysis, therefore, set us drifting toward disorder of personality as the source of many delusions apparently derived ab extra and tended to swell the group of autopsychic cases at the expense of the allopsychic group, In the statistical analysis of a group of cases corresponding roughly with the so-called functional group of diseases, we find false beliefs about the some on a somewhat different plane from those about the patient's self and his worldly fortunes. We can even discern through the ruins of the paretic's reaction that his false beliefs concerning the body are often not so false after all, and that his damaged brain of itself is not so apt to return false ideas about his somatic interior as about his worldly importance and plight. There then seems to be more reality about somatic than about personal delusions: the contents of somatic delusions are rather more apt to correspond with demonstrable realities than the contents of personal delusions. Accordingly our analysis of delusional contents includes a hint also as to genesis. Taken naively, the facts suggest a somatic genesis for somatic delusions exactly in proportion as these delusions are not so much false beliefs as partially true ones. What genetic hint have we for the delusions concerning personality? One genetic hint was obtained from a correlation of delusions with lesions in general paresis,[2] in which disease perhaps the most profound and disastrous of all alterations of personality are found. Amidst the other alterations of personality found in paresis, autopsychic delusions are characteristic: indeed allopsychic delusions are conspicuously few in our series. And, as above, the somatic delusions, fewer in number, can be fairly easily correlated with somatic lesions, or else with lesions of the receptor apparatus (thalamus) of the brain. Now it was precisely the cases with autopsychic delusions, as well as with profound disorder of personality in general, that showed the brunt of the destructive paretic process in the frontal region. The other not-so-autopsychic cases did not show this frontal brunt, but were less markedly diseased at death and had a more diffuse process. Our genetic hint from paresis, therefore, inclines us to the conception that this disorder of the believing process is more frontal than parietal, more of the anterior association area than of the posterior association area of the brain. And if we can trust our intuitions so far, the perverted believing process is thus more a motor than a sensory process, more a disorder of expression than a disorder of impression, more a perversion of the WILL TO BELIEVE than a matter of the rationality of a particular credo. Again we may appear to burst through from an undergrowth of statistics into the clear field of truism. False beliefs are more practical than theoretical, more a matter of practical conduct than of passive experience, more a change of reagent than a reaction to change. The man on the street or even many a leading neurologist would perhaps accept this formula as his own. Certainly in general the least satisfactory of these chapters on the nature of delusions was the chapter on environmental effects,[3] and this perhaps because the results seemed so nearly negative. A further contribution to delusions of environmental nature was somewhat unexpectedly derived from a piece of work on the general mental symptomatology of general paresis.[4] Dichotomizing the paretics (all autopsied cases) into a group with substantial, i. e., encephalitic, atrophic or sclerotic lesions of the cortex and a group without such gross lesions or else with merely a leptomeningitis, I found the latter (or anatomically mild) group to be characterized by a set of symptoms which were all "contra-environmental," whereas the former (or anatomically severe) did not thus run counter to the environment. The conclusions of that paper, so far as they concern us now, are as follows:-- The "mild" cases showed a group of symptoms which might be termed contra-environmental, viz. allopsychic delusions, sicchasia (refusal of food), resistiveness, violence, destructiveness. The "severe" cases showed a group of symptoms of a quite different order, affecting personality either to a ruin of its mechanisms in confusion and incoherence, or to mental quietus involved in euphoria, exaltation, or expansiveness. The most positive results of this orienting study appear to be the unlikelihood of euphoria and allied symptoms in the "mild" or non-atrophic cases and the unlikelihood of certain symptoms, here termed contra-environmental, in the severe or atrophic cases. Perhaps these statistical facts may lay a foundation for a study of the pathogenesis of these symptoms. Meantime the pathogenesis of such symptoms as amnesia and dementia cannot be said to be nearer a structural resolution, as these symptoms appear to be approximately as common in the "mild" as in the "severe" groups. But in both papers dealing with paresis [2,4] we rest under the suspicion that the delusions are possibly of cerebral manufacture. Of course, a lesion somewhere outside the brain is not unlikely to be projected through the diseased brain, and SOMATIC delusions in the paretic are rather likely to represent something in the viscera. It was desirable to get back to normal-brain material, to learn how the INTRINSICALLY NORMAL brain[5] could perhaps produce delusions from a particular environment. Could a particularly "bad" environment actually PRODUCE delusions? By chance, at about this stage in our studies of delusions, some work on fifth-decade insanities[6] was completed. This work seemed to show that the most characteristic (non-coarsely-organic) cases of involutional origin were much given to delusions (each of 24 cases studied), somewhat more so than to the hypochondria and melancholia which we commonly ascribe to the involution period. But this result is equivocal as to the environmental (i. e. allopsychogenic) power to produce delusions, since one could not rid oneself of the suspicion that the delusions were due to the degenerating brain. To return to our former results with the normal-looking brain: Case after case of the quasi-environmental group proved to be more essentially personal than environmental, until at last it almost seemed that the environment could seldom be blamed for any important share in the process of false belief. In short, we seemed to show that environment is seldom responsible for the delusions of the insane. Be that as it may, we secured several lines of attack on the delusions of personality by our study of quasi-environmental delusions. First, we were irresistibly led to a consideration of the emotional (pleasant or unpleasant) character of the delusions. We heaped up a large number of unpleasant delusions in that (quasi-environmental, but actually) personal group. It is interesting to inquire, accordingly, whether our more obviously autopsychic cases will also be possessed of an unpleasant tone. Secondly, we came upon the curious fact that cardiac and various subdiaphragmatic diseases were correlated with unpleasant emotion as expressed in the delusions. It was therefore important to inquire whether similar conditions prevailed in the new group. Thirdly, we found ourselves inquiring whether our patients were victims of what might be termed a spreading inwards of the delusions (egocentripetal) or a spreading outwards thereof (egocentrifugal delusions). But this difference in trend, clear as it often is from the patient's point of view, remains to be defined from the outsider's point of view. Again, it remains to determine, if possible, how far delusions are dominated respectively by the intellect or the emotions, or even by the volitions. As before, I begin with a brief statistical analysis. SUMMARY Danvers autopsy series, unselected cases 1000 Cases with little or no gross brain disease 306 Cases listed as having autopsychic delusions 106 Cases listed as having only autopsychic delusions 50 Cases for various reasons improperly classified 13 Cases of general paresis in which gross brain lesions were not observed 15 Residue of autopsychic cases 22 The group of 22 cases thus sifted out can be studied from many points of view. We may recall that our former study of allopsychic delusions proved that a large proportion of delusions concerning the environment were in all probability not essentially derived from the environment. Their contents might relate to the environment, but their genesis could better be regarded as autopsychic (intrapersonal). In fact we really found only 6 out of 58 cases of pure allopsychic delusions, which could be safely taken as showing so much coincidence between anamnesis and delusions that a correlation could be risked. Following the method of our former work on somatic and on environmental delusions, we sought in the first instance PURE cases of autopsychic delusion-information. For a variety of reasons, more than half of the original list, namely, 28 cases, had to be excluded. Many of these exclusions were due to the strong suspicion that the cases were really cases of general paresis, despite the normality of the brains in the gross. The residue of 22 cases include, we are confident, no instance of exudative disease of the syphilitic group, though general syphilization cannot safely be ruled out in all cases. There are two groups of cases, a group of eleven cases with delusions of a generally pleasant or not unpleasant character (in which group there is a small sub-group of three cases of octogenarians with expansive delusions reminding one of those of general paresis) and a group of eleven cases with delusions of an unpleasant character. I. CASES HAVING DELUSIONS OF A NATURE PLEASING OR NOT UNPLEASING TO THE BELIEVER The true emotional nature of the beliefs placed in this group cannot fairly be stated to be pleasurable. But, if not pleasurable, they may perhaps be stated to be complacent, expansive, or of air-castle type. The criteria of their choice have been largely negative: the patients are not recorded as expressing beliefs of a painful or displeasing character: in the absence of which we may suppose the beliefs to be either indifferent or actually pleasing in character. Of the 11 cases whose delusions were supposedly of an agreeable nature or at least predominantly not unpleasant, there were 3 with delusions reminding one of general paresis. The ages of these three were 80, 84, and 87 respectively. They did not show any pathognomonic sign (e.g. plasma cells) of general paresis. They all showed in common very marked lesions of the cortex, including the frontal regions (in two instances the extent of the frontal lesions was presaged by focal overlying pial changes) .999 was a case of pseudoleukemia with marked cortical devastation but without brain foci of lymphoid cells. Two of the cases showed cell-losses more marked in suprastellate layers; in the third there was universal nerve cell destruction, with active satellitosis caught in process. Condensed notes concerning the cases with pseudoparetic delusions follow. Two of them, it will be noticed, yielded some delusions also of an unpleasant nature. CASE I. (D. S. H. 10940, Path. 999) was a clever business man, Civil War veteran, who began to lose ground at 75 and died at 84. He was given during his disease to boasting and perpetual writing about elaborate real estate schemes and said he owned a $100,000 concern for the purpose. The case was clinically unusual in that the picture of a pseudoleukemia was presented, with demonstration at autopsy of great hyperplasia of retroperitoneal lymph nodes and grossly visible islands of lymphoid hyperplasia in liver and spleen. The brain weighed 1390 grams and showed little or no gross lesion, if we except a pigmentation of the right prefrontal region under an area of old pias hemorrhage. There was also a chronic leptomeningitis, with numerous streaks and flecks along the sulci, especially in the frontal region. There was little or no sclerosis visible in the secondary arterial branches and but few patches in the larger arteries. Microscopically the cortex proved to be far from normal: every area examined showed cell-loss, perhaps more markedly in the suprastellate layers than below. CASE 2. (D. S. H. 11980, Path. 1024) was a Civil War veteran who failed in the grocery business, was alcoholic, was finally reduced to keeping a boarding-house and grew gradually queer. Mental symptoms of a pronounced character are said to have begun at 75. Death at 80. Delusions reminded one of general paresis: worth $5,000,000 a month, 108 years old, was to build a church: also, a woman was trying to poison him. Autopsy showed caseous nodules in lung, coronary and generalized arteriosclerosis (including moderate basal cerebral), mitral and aortic stenosis (the aortic valve also calcified). The frontal pia mater was greatly thickened and, although no gross lesions were noted in the cortex, the microscope brings out marked lesions in the shape of cell losses (especially in suprastellate layers) in all areas examined. There were no plasma cells in any area examined. CASE 3. (D. S. H. 12767, Path. 1185) was a widowed Irish woman, who died at 87. Previous history blank. Extravagant delusions of wealth were associated with a fear of being killed. The autopsy showed little save chronic myocarditis with brown atrophy, calcification of part of thyroid, non-united fracture of neck of left femur, moderate coronary arteriosclerosis. The brain was abnormally soft (some of the larger intracortical vessels showed plugs of leucocytes possibly indicating an early encephalitis--Bacillus cold and a Gram-staining bacillus were cultivated from the cerebrospinal fluid.) Though the convolutions were neither flattened nor atrophied and absolutely no lesion was grossly visible, the cortex cerebri and also the cerebellum were found undergoing an active satellitosis with nerve-cell destruction in all areas examined. The following three cases (IV, V, VI) present a certain identity from their delusions concerning messages from God (V thought he was God). It is very doubtful whether VI should be placed in the present group of Pleasant or Not Unpleasant Delusions, since the patient appears to have been "theomaniacal" as the French say, in a rather passive and unpleasant manner (God occasioned foolish actions!) Placed on general statistical grounds at first in the Not Unpleasant group, Case VI should be transferred to the Unpleasant group. Case V's delusion (identification with God, expression of atonement?) was in any event episodic in a septicemia. Case IV ("happiest woman in the world"), was phthisical (cf. VII) Notes follow: CASE 4. (D. S. H. 4019, Path. 218) Housewife, 37 years always cheerful, became the happiest woman in the world, hearing God's voice and being specially under God's direction. "Acute mania." Death from bilateral phthisis with numerous cavities and bilateral pleuritis. There were no other lesions except a small sacral bed-sore, a small fibromyoma of the uterine fundus, small slightly cystic ovaries, a slight dural thickening, and possibly a slight general cerebral atrophy. (wt. app. 1205 grams, marked emaciation.) CASE V. (D. S. H. 11742, Path. 852) was a victim of streptococcus septicemia (three weeks) who said he was God. Patient was a Protestant iron-worker of 59 years, who had lost an eye and had become unable to work about three months before death. Aortic, cardiac, renal lesions at autopsy. Prostatic hypertrophy. Dr. A. M. Barrett found few changes in nerve cells, except fever changes. One area in left superior frontal gyrus showed superficial gliosis. CASE VI. (D. S. H. 5345, Path. 867) was a "primary delusional insanity," a salesman of 37 years, whose beliefs concerned impressions direct from God, in consequence of which he habitually knelt and prayed. Yet many of the actions which he felt he must perform were foolish actions. The patient died of pneumococcus septicemia during a lobar pneumonia. The brain showed a few changes suggestive of fever (A. M. Barrett). There were a few flecks of atheroma in the aorta. There was an acute parenchymatous nephritis with focal plasma cell infiltrations suggesting acute interstitial nephritis. This case appears to have shown one of the most nearly normal brains in the whole Danvers series. The remainder of the Pleasant or Not Unpleasant Group as originally constituted consists of VII, a phthisical case (cf. IV), VIII, probably feeble-minded romancer, not deluded in the sense of self-deception (probably best excluded from present consideration); IX, probably not safely to be assigned to the Pleasant or Not Unpleasant Group, feeling passive in somewhat the same sense as Case VI (see above), suffering from auditory hallucinosis (superior temporal atellitosis, data of the late W. L. Worcester); X, delusion of birth to superior station, possibly the object of mixed emotions, probably not pleasant; and XI, manic-depressive exaltation with grandiose utterances, long prior to death (if there had been lung tuberculosis at the basis of the ileac ulcers, it had long since healed). Notes follow (VII-XI) and at the end a brief summary of the entire group (I-XI). CASE 7. (D. S. H. 8878, Path. 521) It is questionable whether the delusions classified in this case entitle it to inclusion in the present study. e.g. "I was baptized in the Catholic Church (patient a Protestant housewife) with holy water, ink, and Florida water." Patient was variously designated, as "dementia" and as "acute confusional insanity." Death in second attack at 26 (first attack at 22). Father also insane. Death due to bilateral ptthisis with tuberculosis of intestines and mesenteric glands, emaciation. It is noteworthy that the brain weighed but 1038 grams. Dr. W. L. Worcester's microscopic examination showed acute nerve cell changes probably of the type of axonal reactions. CASE 8 (D. S. H. 8807, Path. 556) very probably a feeble-minded subject. At all events patient had done no work in his life, had been given to spells of restlessness and excitement, and had talked disconnectedly. Symptoms were thought to have dated from the tenth year. It is questionable whether a statement that he was managing the Electric Railway and Shipbuilding Company can be regarded as delusional, that is, as believed by the patient. Death was due to (perhaps septicemia from one abscess of jaw and to hypostatic penumonia), the brain appeared normal but Dr. W. L. Worcester found, besides certain acute changes, also satellitosis. The question remains open whether the case should be regarded as defective or as belonging to the dementia praecox group. CASE 9. (D. S. H. 8605, Path. 568) had an ill-defined attack of mental disease and was in D. S. H. at 29. Thereafter, lived in Gloucester Almshouse, but at 51 became excited and was returned to D. S. H. where she died at 59. Possibly hallucinated: someone called her mother (single woman). Delusion: the spirit is here (Protestant). Patient was given to a stream of muttered, vulgar and incoherent talk. Possibly the case was residual from hebephrenia. Dr. W. L. Worcester found cell changes in the superior temporal gyri (finely granular stainable substance in practically all nerve cells) and not elsewhere. The correlation is suggestive with the probably auditory hallucinosis. The brain weighed 1190 grams. Death due to bronchopneumonia. Heart and kidneys normal. CASE 10. (D. S. H. 10145, Path. 928) a Danish fisherman possibly manic-depressive, victim of three attacks at 40, 50, and 69 years. The first attack followed loss of wife, and delusions concerning being born again developed. The last attack showed few well-defined delusions, as patient was in a bewildered and incoherent state. One statement is characteristic: if patient had remained in Denmark, he might have inherited the throne. The autopsy showed most extensive arteriosclerosis, including basal cerebral. Death from general anasarca and jaundice. (cholelithiasis). There was some question of an acute encephalitic lesion in the tissues lining the posterior half of the third ventricle. Various chronic lesions (splenitis, endocarditis, diffuse nephritis), malnutrition. CASE 11. (D. S. H. 7767, Path. 792) was a case possibly of manic-depressive type (previous attacks Hartford Retreat and Danvers State Hospital) who worked as machinist between attacks and died at 70, having been in D. S. H. 8 years. Patient was greatly emaciated and anemic from chronic ulcers of ileum. There was also cholelithiasis. There was a mild coronary atheroma and slight mitral valve edge thickening. The delusions expressed were those of great wealth. Patient also thought he was a great poet. No brain changes were found (A. M. Barrett). Having attempted on the basis of certain statistical tags to constitute a group of cases having relatively normal brains and pleasant (or not unpleasant) delusions, we are forced to reconstruct our group upon viewing several cases more attentively. Case VIII should be excluded as probably not delusional. Case X might perhaps be transferred with propriety to the unpleasant-delusion group. Certain cases of felt passivity under divine influence separate themselves out from the group; indeed VI and IX probably belong in the unpleasant-delusion group (see below). These subtractions leave seven cases to deal with. Three of these seven, viz. I, II and III, are apparently best regarded as examples of frontal lobe atrophy, and their grandiosity may resemble that of certain cases of general paresis. Of the remaining four, two, Cases IV and VII, are phthisical; one, Case VI, showed an episodic identification with God (incident in fatal septicemia), and one, Case XI, uttered manic-depressive exalted statements about wealth and poetical power. I turn to a consideration of the unpleasant-delusion group, which as first constituted was to contain eleven cases (XII-XXII) but to which must be added three more (VI, IX, X). Case XII should be at once excluded from present consideration on account of its microscopy. CASE 12. (D. S. H. 12282, Path. 942) died in a second attack of depression (manic-depressive insanity?). Catholic, always of a quiet and reserved disposition, happy in married life. Delusional attitude concerning an abortion which she said she had induced. "Soul lost," "I'll see hell." Autopsy: Death from gangrene of lung and acute fibrinous pericarditis. Erosion of cervix uteri. The edema of the brain, irregular pink mottlings of white substance, and an exudative lesion of one focus in the pia mater of the right side suggested an encephalitis more marked on the right side. Microscopically a few small vessels showed plugs of polynuclear leucocytes. The nerve cells were affected by various acute changes. The visuo-psychic portion of an occipital section (right) showed suprastellate cell-losses of a somewhat focal character Of the remaining ten (XIII-XXII), one, Case XIII is another of mixed emotions ("am Eve and have to suffer;" "in Purgatory;" etc) of a religious type. It is the only case in the unpleasant group with phthisis pulmonalis, (combined, however, with abdominal tuberculosis and nephritis). CASE 13. (D. S. H. 7361, Path. 499) was a somewhat defective Catholic woman (mother insane) always of a melancholy and reserved temperament. She had been ill-treated by husband, child had died, another had followed soon. She developed a belief that she was Eve and had to suffer. At hospital decided that she was in purgatory and expressed a variety of other religious beliefs. She also thought she was ill-treated at hospital. Her head was asymmetrical: skull thick and eburnated. Brain (1130 grams described as normal). Chronic interstitial nephritis. Pulmonary and mesenteric tuberculosis. Of the remaining nine (XIV-XXII) all had grossly evident kidney lesions except two (XIV and XV). Of these two, XIV probably had renal arteriosclerosis and was in any case very gravely arteriosclerotic in general and suffered from cystitis. Case XV died apparently of starvation with hepatic atrophy; it is a question whether "poverty" was or was not a delusion. Notes of XIV and XV follow: CASE 14. (D. S. H. 8741, Path. 500) was a German teacher, college-bred, of a reserved and melancholy turn of mind (mother insane). An attack at 39, another at 70. "Both poor wife and son will starve." "Perhaps they should be put out of reach of poverty," later felt he "had caused death of wife and son on account of his expensive living." Autopsy: chronic internal hydrocephalus, cerebral arteriosclerosis. Brain weight 1180 grams. Coronary sclerosis with calcification throughout, aortic and pulmonary valvular calcification hypertrophy of heart. Cystitis. CASE 15. (D. S. H. 4454, Path. 237) was presumably a manic-depressive case, had in all four attacks, and died in the fourth attack (66 years). The day he arrived at the hospital, having not eaten for several days at the end of several months of delusions of poverty the case was called "acute melancholia," and the cause of death assigned was starvation. The liver weighed 1102 grams and was fatty. There was a diffuse thickening and clouding of the pia mater, and the dura was firmly adherent everywhere to the skull. Notes follow of seven cases (XVII-XXII) which show many lesions, are in a number of instances cardiorenal and in all instances renal. If it is permitted to count XIV also as renal, a list of eight cases out of the original list of eleven unpleasant-delusion cases is obtained in which nephritis of some type has been found. Case XIII, nephritis and phthisis, belongs also in the renal group. CASE 16. (D. S. H. 4168, Path. 226) feared death and refused food on the ground that she should not eat. Patient had always been of a despondent and reserved nature (sister also insane) and, after her husband's death, when she was 53, grew unable to carry on her house, dwelt constantly on griefs, entered hospital at 61, and died at 64 ("chronic melancholia"). Death from internal hemorrhagic pachymeningitis. The liver of this case weighed 1074 grams and was fatty. There was chronic interstitial nephritis. CASE 17. (D. S. H. 4707, Path. 498) originally cheerful and frank, lost her situation as companion, grew despondent at failure to get employment, had a "hysterical" attack at 52. It is doubtful whether her beliefs were delusional: "can never be better," "will not be taken care of," "no place for her." "Subacute melancholia. "The autopsy showed gastric dilation (over 3000 cc.), and an atrophic liver and pancreas, and slightly contracted kidneys. The heart was normal. Death from ileocolitis. Moderate chronic internal hydrocephalus. Dr. W. L. Worcester's microscopic examination showed rather unusual degrees of nerve cell pigmentation (precentral and paracentral). CASE 18. (D. S. H. 8898, Path. 570) was an unmarried daughter of a fire insurance company president. Both her mother and she developed mental disease after the company failed (Boston and Chicago fires). Both mother and father died, and patient was in several hospitals after 36, obscene, denudative, onanist. Delusions concerning crimes committed. Satyriasis. Could hear fire kindled to burn her. Diagnosis, "secondary dementia." Death at 54 from bilateral bronchopneumonia. Atrophic uterus. Cystic right ovary with twisted pedicle: atrophic left ovary: contracted kidneys. The brain was not abnormal in the gross-- but showed (Dr. W. L. Worcester) some acute changes (also larger cells pigmented). CASE 19. (D. S. H. 10106, Path. 663) a cheerful Irish house-wife (mannerism of drawling words) underwent a maniacal attack at 41, and another at 44. Delusions: "sorry she had lived": "broken her religion" Given to self recrimination. Autopsy: Death from hypostatic penumonia. Healed gastric ulcer. Moderate arteriosclerosis, slight cardial hypertrophy. Granular cystic kidneys. Mucous polyp and subperitoneal fibromyoma of uterus. The brain was macroscopically normal, but showed superficial gliosis (frontal and precentral) and thinning out of medullated fibers superficially (frontal). CASE 20. (D. S. H. 8963, Path. 679) an epileptic shoe-maker, 50 years, was of the belief that he was sent to Hospital for hitting a boy and was to be executed. Autopsy: Aortic and innominate aneurysm, hypertrophy and dilatation of heart. Interstitial nephritis. The brain, normal macroscopically, proved microscopically to show, in all areas examined, superficial gliosis. There was gliosis in parts of the cornu ammonis, but no demonstrable nerve cell loss (interesting in relation to the epilepsy). CASE 21. (D. S. H. 4584, Path. 861) cabinet-maker of melancholy temperament, Civil War veteran. Said to have been feeble-minded after six months in rebel prison. Violent at times for twenty years. Did no work, thought "soul lost." Death from pneumococcus and streptococcus septicemia. Chronic diffuse nephritis. The brain was described grossly as normal: but microscopically there was marked superficial gliosis in all areas examined and considerable cell loss in suprastellate layers of precentral cortex. The calcarine sections show little or no cell-loss. But one section from the frontal region is available (right superior frontal). This shows little cell-loss except in the layer of medium-sized pyramids. CASE 22. (D. S. H. 8250, Path. 909) an unmarried woman without occupation, two attacks of "melancholia" at 36, and 40. Always of a retiring and shy disposition. Mental disease began after father's death. Delusions (if such): has been selfish and wicked. Constant self condemnation. Suicidal. Exophthalmic goiter. Autopsy: Thyroid glandular hyperplasia. Mitral sclerosis. Aortic sclerosis with ulceration. Chronic endocarditis. Chronic diffuse nephritis. Scars of both apices of lungs, with small abscess of left apex. Emaciation. Brain weight 1050 grams. No gross lesions described; microscopically profound alterations; extreme or maximal cell-losses in small and medium-sized pyramids in both superior frontal regions. Smaller somewhat less marked cell-losses elsewhere. Upon reviewing the unpleasant-delusion group, then, we exclude one (XII) altogether. It is questionable whether XV actually exhibited delusions at all. We then discover that eight (in all probability all) of our nine remaining cases are renal in the sense of grossly evident lesions at autopsy. But it will be remembered that we transferred three cases originally thought to entertain "not-unpleasant" delusions to the unpleasant group, because their constraint, although conceived to be of divine origin, seemed to be unpleasant (VI, IX, X). Of these VI and X were renal cases; but IX is expressly stated by a reliable observer (the late Dr. W. L. Worcester) to have had normal kidneys as well as heart. In point of fact, however, Case IV had hallucinations and religious delusions ("spirit is here") probably derived therefrom, and Dr. Worcester found an isolated brain lesion correlatable with the hallucinosis; and in any event the emotional state of the patient is in grave doubt. Accordingly if we take the unpleasant-delusion group to be constituted of Cases VI and X (transfers from the first group), XIII, XIV, and XIV to XXII, that is eleven cases, we come upon the striking fact that virtually all of them are renal cases. Of course, as (with Canavan) I have been at some expense of time to prove, virtually ALL cases of psychosis (as autopsied) are in a microscopic sense abnormal as to kidneys.[7] But only about a third exhibit GROSS interstitial nephritis, arguing a certain severity of process. The above cases, it will be observed, fall into the GROSS class in respect to renal lesions. Without laying too much stress on such results, it is worth while to say that, whereas most workers might be willing to surmise that metabolic or catabolic disorder must affect the sense of well-being, I must confess that the discovery of so much gross kidney disease in a group selected on other grounds filled me with a certain surprise. The literature is not without suggestions as to the possible correlation of renal and mental disorder. Ziehen,[8] for example, remarks that nephritis brings about mental disease in two ways,--through vascular changes which very frequently accompany chronic nephritis and other uremic changes in the blood. Inasmuch as we know that creatin, creatinin and potassium salts irritate the animal cortex, Ziehen notes that psychopathic phenomena may occur in man as a result of slight uremic changes. According to Ziehen, most of these nephritic psychoses run the course of what he calls hallucinatory paranoia (it may be remembered that Ziehen counts among paranoias a number of acute diseases and even so-called Meynert's amentia). Chronic nephritis, as well as acute diabetes and Addison's disease are thought by Ziehen to produce certain chronic forms of mental defect which he terms autotoxic dementia, but he regards most of these cases as really cases of arteriosclerotic dementia. It does not appear that Wernicke[9] has considered renal correlations systematically. Kraepelin[10] mentions the epileptiform convulsions of uremia as well as delirious and comatose conditions, especially those in advanced pregnancy. These uremic conditions may be both acute and chronic. But Kraepelin has not been able to convince himself of the existence of a clearly defined uremic insanity unless the delirious condition just mentioned may be regarded as such Binswanger[11] states that the mental disorders occurring in acute and chronic nephritis are either toxemic psychoses on uremic bases, or due to arteriosclerosis. In the latter cases, he states that the disease pictures are as a rule characterized by grave disturbances of emotions, chiefly of a depressive character. He adds that these are all too frequently the forerunners of arteriosclerotic brain degeneration. A brief mention of renal disease in the general etiology of mental disease is made by Ballet.[12] Ballet states that Griesinger's opinion that renal disease had little importance in the etiology of mental disease and that no one would count the cerebral symptoms of Bright's disease as mental is no longer held. Ballet enumerates a number of works upon so-called folie brightique which tend to prove that acute or chronic Bright's disease gives rise either to melancholic disorder or alternately to maniacal and melancholic disorder. How the mental disease is produced is doubtful. Ballet holds that all the various psychopathic disorders resulting from Bright's disease are autotoxic. Renal disease like heart disease is only capable of awakening a latent predisposition or liberating a constitutional psychosis, unless it is merely effecting a species of intoxication. It cannot be doubted that the relation of kidney disorder to mental disorder is worth intensive study, of which the present communication is merely a fragment. Progress will be of course impeded by the fact that upon microscopic examination, practically all cases of mental disease coming to autopsy show renal disease of one or other degree; in fact, it is perhaps possible to show a higher correlation of renal disease with mental disease than of brain disease to mental disease. Perhaps something can be obtained if we limit ourselves to a study of cases with pronounced somatic renal symptoms and signs, cases with the renal facies and the like. As to the question of phthisis and mental disease, Ziehen remarks that the tuberculous are often observed to be optimistic but that other cases show a hypochondriacal depression with egocentric narrowing of interests. He speaks of a sort of rudimentary delusional disorder looking in the direction of jealousy in certain cases. Pronounced mental disorder occurs rarely in tuberculosis, according to Ziehen, and leads either to melancholia or to hallucinatory states of excitement, resembling the deliria of exhaustion or inanition. Acute miliary tuberculosis may produce the impression of a general paresis or of an amentia in Meynert's sense. The inanition delirium of tuberculosis resembles that of carcinosis and malaria. Kraepelin regards tuberculosis as of very slight significance in the causation of insanity, despite the fact that slight changes in mood and in voluntary actions frequently accompany the course of the disease. Irritability, depression and sensitiveness, incomprehensible confidence and desire to undertake various tasks, pronounced selfishness, sexual excitement and jealousy are the traits of mental disorder in tuberculosis. Kraepelin states that many cases of tuberculosis show traits of alcoholic disease and says that the occurrence of polyneuritic forms of alcoholic mental disorder is favored by the association of tuberculosis with alcoholism. Wernicke does not systematically consider the topic. Binswanger states that tuberculosis, aside from miliary tuberculosis or meningitis, produces no mental disorder except phenomena of the amentia of exhaustion. Ballet states that there exists a peculiar mental state in the tuberculous. It is compounded as rule of sadness, of looking on the dark side and of profound egoism. This readily leads to mistrust and suspicion which may be pronounced enough to constitute a sort of persecutory delusional state or a state of melancholic depression (Clouston, Ball). More rarely there are phenomena of excitation explained in part by fever. In its slightest degree this phenomenon of excitation is characterized by a feeling of well-being, of euphoria, which even at the point of death may give the patient the illusion of a return to health, or there may be a more pronounced excitation with impulsive sexual and alcoholic tendencies. Autointoxication may lead to the usual train of confusional symptoms. If we compare the accounts in the literature of the two conditions here in question, namely, nephritis and phthisis, we must be convinced, that aside from so-called autotoxic phenomena, renal disorder seems to be marked by a tendency to depressive emotions but that phthisis shows not only depressive emotion but also euphoric and hyperkinetic phenomena. So far as these results thus hastily reviewed are concerned, they are consistent with the appearances in the present group of cases. Both the nephritic and phthisical groups need further intensive study. As to the question of the spreading inwards or outwards of delusions from the standpoint of the patient, no analysis is here attempted. It is plain, however, that the theopaths, as James calls them, or victims of theomania, to use the French phrase, will be of importance in this analysis because of the equivocal character of the emotions felt in cases of religious delusion. SUMMARY AND CONCLUSIONS The paper deals with delusions of a personal (autopsychic) nature and is one of a series based upon certain statistics of Danvers State Hospital cases (previous work published on somatic, environmental (allopsychic) delusions and those characteristic of General Paresis). The previous work had suggested that somatic delusions are perhaps more of the nature of illusions in the sense that somatic bases for somatic false beliefs are as a rule found. On the other hand, delusions respecting the environment (allopsychic delusions) had appeared to be more related to essential disorder of personality than to actual environmental factors. The fact that cases of paresis with delusions were found to have their lesions in the frontal lobe, whereas non-delusional cases showed no such marked lesions, is of interest in the light of the present paper because three cases of senile psychosis were found to have delusions of grandeur and, although they are demonstrably not paretic, they also show mild frontal lobe changes supported by microscopic study. The Danvers autopsied series, containing 1000 unselected cases, was found to show 306 instances with little or no gross brain disease. Of these, 106 had autopsychic delusions and of these 106, 50 cases had delusions of no other sort. 15 of these 50 cases appeared to have been cases of General Paresis in which gross brain lesions were not observed at autopsy, and upon investigation 13 other cases were found to be, for various reasons, improperly classified. The residue of 22 cases was subject to analysis and readily divides itself into two groups of 11 cases each, or two groups of normal-looking brain cases having autopsychic delusions and these only are cases which may be termed the "pleasant" and "unpleasant" groups, in the sense that the delusions in the first group were either pleasant or not unpleasant, whereas the delusions in the second group were of clearly unpleasant character. Three of the "pleasant" delusion group were the three cases of grandeur and delusions in the senium above mentioned. Three others were cases of "theomania" in the sense that their delusions concerned messages from God. It is not clear that these three religious cases should be regarded as belonging in the group of "pleasant" delusions on account of the sense of constraint felt by the patients. The remainder of the "pleasant group," as the delusions were originally defined, turned out for the most part to show either doubtful delusions or delusions involving a sense of constraint rather than of pleasure. An endeavor was made to learn the relations of pulmonary phthisis to the emotional tone of the delusions. The few available cases in this series seem consistent with the hypothesis of phthisical euphoria (IV, "happiest woman in the world," hearing God's voice, VII and possibly XI). The problems of the "pleasant" delusion group, as superficially defined, turned out to be a. the problem of a group of senile psychoses with grandiose delusions and frontal lobe atrophy; b. the problem of felt passivity under divine influence; c. the problem of phthisical euphoria. The group of "unpleasant" delusions in the normal-looking brain group should be diminished by one on account of its positive microscopy (encephalitis). One case (XIII) is a case of mixed emotions of religious type, showing phthisis pulmonalis together with abdominal tuberculosis and nephritis. One case (XV) is doubtful as to delusions; the remainder are subject to renal disease, as a rule associated with cardiac lesions. Two cases which were transferred from the "pleasant" to the "unpleasant" group on account of constraint feelings, were also renal cases,--VII and IX. The only exception to the universality of renal lesions in this group is the case in which religious delusions were probably based upon hallucinations for which hallucinations an isolated brain lesion was found, very probably correlatable with the hallucinosis. Virtually all of the eleven cases determined to belong in the "unpleasant" group are cases with severe renal disease as studied at autopsy. Whether the unpleasant emotional tone in these cases of delusion formation is in any sense nephrogenic and whether particular types of renal disease have to do with the unpleasant emotion, must remain doubtful. A still more doubtful claim may be made concerning the relation of euphoria to phthisis. The renal correlation is much more striking as well as statistically better based. A further communication will attack the problem from the side of the kidneys in a larger series of cases. REFERENCES [1] Southard. On the Somatic Sources of Somatic Delusions. Journal of Abnormal Psychology, December, 1912-January, 1913. [2] Southard and Tepper. The Possible Correlation between Delusions and Cortex Lesions in General Paresis. Journal of Abnormal Psychology, October-November 1913. [3] Southard and Stearns. How far is the Environment Responsible for Delusions? Journal of Abnormal Psychology, June-July, 1913. [4] Southard. A Comparison of the Mental Symptoms Found in Cases of General Paresis with and without Coarse Brain Atrophy. Submitted to Journal of Nervous and Mental Disease, 1915. [5] Southard. A Series of Normal-Looking Brains in Psychopathic Subjects, American Journal of Insanity, No. 4, April 1913. [6] Southard and Bond. Clinical and Anatomical Analysis of 25 Cases of Mental Disease Arising in the Fifth Decade, with remarks on the Melancholia Question and Further Observations on the Distribution of Cortical Pigments. [7] Southard and Canavan. On the Nature and Importance of Kidney Lesions in Psychopathic Subjects: A Study of One Hundred Cases Autopsied at the Boston State Hospital. Journal of Medical Research, No. 2, November, 1914. [8] Ziehen. Psychiatrie, Vierte Auflage, 1911. [9] Wernicke. Grundriss der Psychiatrie, 2 Auflage, 1906. [10] Kraepelin. Psychiatrie, Achte Auflage, I Band, 1909. [11] Binswanger. Lehrbuch der Psychiatrie, Dritte Auflage, 1911. [12] Ballet. Traite de Pathologie Mentale, 1903. SIXTH ANNUAL MEETING OF THE AMERICAN PSYCHOPATHOLOGICAL ASSOCIATION New York, N. Y., May 5, 1915 PROGRAM ADDRESS BY DR. ALFRED REGINALD ALLEN, President, Philadelphia, Pa. 1. "The Necessity of Metaphysics," Dr. James J. Putnam, of Boston, Mass. 2. "Anger as a primary Emotion, and the Application of Freudian Mechanisms to its Phenomena," President G. Stanley Hall, of Worcester, Mass. 3. "The Theory of 'Settings' and the Psychoneuroses," Dr. Morton Prince, of Boston, Mass. 4. "The Mechanisms of Essential Epilepsy," Dr. L. Pierce Clark, of New York, N. Y. 5. "Material Illustrative of the 'Principle of Primary Identification,' " Dr. Trigant Burrow, of Baltimore, Md 6. "Psychoneuroses Among Primitive Tribes," Dr. Isador H. Coriat, of Boston, Mass. 7. Data Concerning Delusions of Personality," Dr. E. E. Southard, of Boston, Mass. 8. "Dyslalia Viewed as a Centre-Asthenia." Dr. Walter B. Swift, of Boston, Mass. 9. "Constructive Delusions, " Dr. John T. MacCurdy and Dr. W. T. Treadway, of New York, N. Y. 10. "Narcissism," Dr. J. S. Van Teslaar, of Boston, Mass. 11. "The Origin of Supernatural Explanations," Dr. Tom A. Williams, of Washington, D. C. 12. "The Psychoanalytic Treatment of Hystero-Epilepsy, " L. E. Emerson, Ph. D., of Boston, Mass. The meeting was called to order by the President, Dr. Alfred Reginald Allen, at 9:30 A. M., in Parlor E, Hotel McAlpin. Dr. Allen delivered The Presidential Address. Dr. James J. Putnam, of Boston, read a paper entitled, "The Necessity of Metaphysics."[1] [1] Published in the June-July number, p. 88, of this Journal. DISCUSSION DR. MORTON PRINCE, Boston: I sympathize with Dr. Putnam in his interest in philosophical problems, my only conflict with his point of view being with what I conceive to be a mixing of problems. I suppose that if we want an explanation of the universe it must be in terms of philosophy or metaphysics. The only alternative is to accept it as a phenomenal universe, as it is. You will remember that when it was reported to Carlisle that Margaret Fuller said she "accepted the universe," he replied "Gad! I think she had better!". So we have got either to explain the universe in terms of philosophy or accept it as it is. I have no objection to introducing philosophical problems if we do not confuse those problems with our psychological problems. They are entirely distinct. This distinction between philosophy and science the physicists and chemists clearly recognize. One of their problems is the ultimate nature of matter, but it is not a problem of practical physics and chemistry. These deal, let us say, with phenomenal atoms and molecules, with their attractions and repulsions, etc. In dealing with the problem of the ultimate nature of matter the chemist analyzes matter and finds that it can be reduced to atoms, and then analyzes the atoms and finds them composed of electrons flying about within the circumscribed space of an atom. Then he analyzes the electron and reduces it to negative electricity, and when asked what negative electricity is he says it is a form of the energy of the universe, and stops there and says--"I don't know," when asked to explain energy. Here the problem of the ultimate nature of matter becomes a question of philosophy and metaphysics. It is a field of research by itself. The chemist never confuses that problem with the specific problems of his particular science. These deal with empirical atoms and molecules as he finds them. No chemist would undertake to give the chemical formula of the union of sulphuric acid and zinc by a formula which expressed the ultimate nature of atoms or negative electricity. If he did so he would confuse his problems. And so I think we confuse our problems when we attempt to explain empirical psychological phenomena in philosophical or ultimate terms. We must treat our psychological elements--ideas, wishes, emotions, etc,--as the chemist treats atoms and molecules. But, just as the latter may take up ultimate problems as a special field of investigation so may we do, if we like, but we must not treat them as psychological problems. This confusion of problems is, I think, the fundamental error of Jung and others in treating of the libido when he and they attempt to explain specific phenomena as empirically observed. Jung undertakes to resolve libido into the energy of the universe. Of course this is possible. All forces can be ultimately so resolved, including the forces of mind and body. Emotions such as anger and fear are forces and each of these forces, with great probability, can be reduced in the ultimate analysis to a form of energy. But this is not to admit that we are justified in explaining specific concrete psychological phenomena, with which we are dealing, in philosophical terms. We must explain them in terms of the phenomena themselves. As a monist and pan-psychist, for example, I may believe that conscious processes can be reduced to, or be identified with the ultimate nature of matter, the thing-in-itself. And conversely atoms and electrons may be reduced to a force which may be identified with psychic force, but I would not attempt to explain psychological behaviour in terms of such a philosophical concept but only through phenomenal psychological forces, let us say, wishes. In other words, I would not undertake to introduce pan-psychism into the problem at all as an explanation of a particular phobia. I think, therefore, that when Jung and others attempt to explain phobias and other psychological phenomena through a philosophical concept of the libido as analyzed into an elan vitale or the energy of the universe, they not only confuse their problems but introduce such a mixing up of terms that the resulting explanation becomes little more than nonsense. The libido, whatever it may be, must be treated as a psychophysiological force just like any of the other emotions. Otherwise psychology ceases to be a science. Now one word about conflicts. Undoubtedly conflicts play a most important part in such psychological disturbances as we have to deal with in the psycho-neuroses, but I cannot agree that psychological conflicts conform only to, or are synonymous with ethical conflicts. Undoubtedly there are a large number of conflicts between ideas and sentiments which we have all agreed to label as ethical, but there are also a large number of conflicts between sentiments which cannot be pigeon-holed as ethical. For example, the mother whose child is threatened with danger and who herself would incur danger in rescuing her child, undergoes a conflict between her fear instinct, on the one hand, and her love on the other, exciting also her anger emotion. The anger and love conflict with the fear, down and repress it. There you have a conflict but I think it could not be classed as an ethical conflict. It is a general law, whenever one instinct antagonizes another instinct there is a conflict. It is a conflict which has its prototype in the lower organic processes. Thus Sherrington's spinal reflexes, that he has worked out so beautifully, involve conflicts between opposing organic impulses. In the scratch reflex, for instance, the impulse which excites the flexor muscles inhibits the excitation of the extensor muscles. I believe this principle underlies the higher processes and upon it is built up the whole of the psycho-physiological mechanisms. DR. TOM A. WILLIAMS, Washington, D. C.: I want Dr. Putnam to reply to two objections to his position. One, the manifestations of functional capacities which are themselves dependent upon structural differences. I am not talking now of psychogenetic determinants, but alone of the trends of which Dr. Putnam has spoken. Is he not assuming the contrary to Darwin when he says that function precedes structure? Are not the potentials dependent upon the variation which has determined this function? I am speaking now in the broadest possible terms and not confining myself to the cerebrum. Do we not find it in the tadpole who is prepared for breathing not because he wants to breathe, but because he is going to have a new kind of breathing apparatus and the duck who takes to the water because he has the mechanism to swim? Two, in regard to Hegel and the appeal to the ethical as being of a different type from the motive of biological satisfaction. Is not that difficulty only apparent, and is it not answered by Dr. Putnam's own appeal that these matters should be settled independently, and is not it the case that the average sexual man would settle it very differently from Dr. Putnam himself and most of us; and is not it true that, though the ethical determinants of behaviour are not auspicious for the average sexual satisfactions of man, yet are they not themselves forms of hedonistic satisfactions? For a man who would behave unethically would be miserable in doing so by the loss of his own self-respect. So that he already has a hedonistic determinant for his own conduct which is in harmony with the biological concepts of Aristotle. DR. JAMES J. PUTNAM, Boston: I should be very sorry to be taken as wishing to put myself in the sort of adverse position which Dr. Prince and Dr. Williams believe me to assume. I accept, of course, the proposition that there are conflicts which are not ethical, and, as Dr. Williams says, the average man would naturally come to different conclusions from those of the trained man in ethical matters. I want to make a slight movement towards restoring a balance which it seemed to me had become tipped too far one way. Psychoanalysts, for example, actually deal with metaphysics and yet they do not really study out what this involves. If we were nothing but scientific men we could say, "very well, let metaphysics go." But we are not. We are dealing with individuals who are thrilling with desires, hopes and fears, the movements of which cannot be expressed in scientific formulae. Dr. Williams speaks of Darwin. It can be asserted with justice, however, that the genetic method of investigation which is exemplified by Darwin's study of evolution is an imperfect method for discovering the aims of human beings. I refer to the interesting book of Prince Kropotkin in which he studies mutual aid as a factor in evolution, mutual aid being something not adequately contemplated by Darwin, who considers conflict as the essential influence in evolution. Prof. Judd showed in a paper a few years ago the change which has taken place in the attitude of a good many students of economics through the introduction of human intelligence and desires as something quite distinct from the conflicts of interests, and similar arguments have been brought forward by students of evolution. Among others Prof. Cope, the distinguished Zoologist of Philadelphia and Prof. Hyatt of Boston, showed very clearly how the course of evolution becomes materially changed when desires and will become prominent as factors. I agree that, as a partial motive, structure does limit and determine function. There is no question about that. I merely want to say that logically function precedes structure, inasmuch as the wish and desire to do a thing precedes the means by which we secure for ourselves the power to do it. But of course all energies must work through structural media. In regard to hedonism, one must recognize that pleasure counts as a partial motive, but when it comes to taking it as the final motive it fails utterly. Our lives contain determinants which we cannot range under the category of pleasure. We act in certain ways because our structure and our functions and our wills are what they are, and not exclusively by our temporary wishes. Our "meanings," when thoroughly studied are found to coincide with the meaning of the universe as a whole. It is only through getting hold of the entire scheme that you have something that you can use as a criteria. The nearest approach to this is obtained through the study of the most broadly developed, public spirited men, and such men do not work in accordance with hedonistic principles. President G. Stanley Hall, of Worcester, Mass., read a paper entitled, "The Application of Freudian Mechanisms to Other Emotions."[*] [*] Published in the June-July number, p. 81, of this Journal. DISCUSSION DR. JOHN T. MAC CURDY, New York City: I have been so interested in the paper by Dr. Hall that I have been distinctly delighted by it and with your permission I will refer to a point in Dr. Putnam's paper directly pertinent to the issues raised by Dr. Hall. Dr. Putnam has spoken of the necessity for metaphysics by which I presume he means the necessity for formulation. Yesterday there was some antagonism in a discussion on formulation. We cannot avoid formulating. Our advance in knowledge is purely empiric unless it is directly dependent on formulation. We have not formulated enough. We have stuck too much to our empiric data, have not made the necessary deductions from it. What formulations there are have been based on therapeutic data and explain the productions of symptoms. No attention has been paid to the general psychoneurotic or psychotic Anlage. When this is done I am sure that it will be found that there are just such primordial reactions as President Hall has been talking about lying back of all the sexual impulses. Sexual reactions have in the course of development come to be the vehicle for more primitive ones. We know by observation that the infant demonstrates anger in a much greater degree, and long before he gives evidence of things sexual, in anything approaching the adult sense of that term. The temporary formulation of psychoanalysts who attempt to explain anger or temper by sadism are really ridiculous. President Hall rightly says that sadism must be explained by anger. That is one of the primitive emotions. Sex is merely a vehicle. The importance of this transference is that the sex emotions are peculiarly adapted to repression and when once unconscious, continue to operate all through the life of the individual. This is less likely to occur in the sudden reaction of anger, which is much more apt to be blown off at the time. DR. SMITH ELY JELLIFFE, New York, N. Y: I cannot quote the line, but in Shaw's "Doctor's Dilemma," recently presented in New York, there is an exchange of words during which the heroine tells the surgeon that she is tempted to pass from loving him to hating him. He replied that one is surprised after all what an amazing little difference there is between the two different attitudes of mind. Dr. Jelliffe said he was quite in sympathy with what Dr. MacCurdy had been saying, with reference to the need for formulation: We all know how these formulations have grown and how they are utilized practically. For instance, we formulate an attitude towards space. We wish to handle space and say 3 ft. or 7 ft. in order to handle space relations. In other words, to handle space we utilize a formulation which we call a measure of space. In the same manner in order to handle time we make a hypothetical unit to be pragmatic. In handling the phenomena of electricity, we formulate other units. In my own mind there has grown up therefore the analogy that in order to handle psychological phenomena we have formulated the Oedipus by hypothesis. This hypothesis I would define as the unconscious biological directing of the energy of the child towards the parent of the opposite sex and away from that of the same sex. This is the unconscious basis of what in consciousness we call love and hate. The boy is unconsciously directed away from the parent of the same sex. He develops according to the Oedipus hypothesis the desire to get away from the father or the father image. All other men are patterned after the father image and if this strong biological direction fails to take place, his interest not being directed in an opposite direction, he fails to mate and thus fails in his reproductive function. The reproductive function cannot go on without this biological thrust towards the proper object. By Narcissism is meant the formulation that a new development is taking place in the infantile Oedipus fantasy. The child cannot hold on to the mother image. He passes it to others nearer his own age. He does it first through his own identification with the female. His bisexuality permits this. Similarly the infantile father protest must be supplanted by an evolved brotherly love. The competition with the father image must take a new form. It must be a mutual competition with mutual productivity. Any contact between man and man that does not ensue to the value of both in some degree, therefore, registers a failure to sublimate the unconscious gather hatred of the infantile stage of development. Sublimated hatred of the father image is brotherly love. Sublimated love of the mother image is taking one's place in the world as a father for the continuance of the race. In the unconscious the formula of direction against same sex and towards opposite sex, means therefore that in the unconscious love and hate are the same; one cannot give them these names however. Thus I would enlarge the Oedipus formula and say that it is useful not only in understanding the neurotic, but it can be used to measure up all psychological situations. DR. JAMES J. PUTNAM, Boston: I deeply appreciated and enjoyed what Dr. Hall said and I have no question whatever that we all who are so interested in psychological work profit by arguments of this sort being brought before our notice. I think it is an unfortunate thing that Adler, who was on that line and did such good work in it, coupled his statements with a sort of denunciation of Freud's views. It seems to me to have been entirely unnecessary. One of the remarkable stories of O. Henry, who was a keen observer of human nature, deals with a frontier army officer who exposed continually himself to danger, desiring to work out in an indirect way this feeling of conquering one person by another, only it was himself, his own cowardice, that he wished eventually to conquer. I would ask Dr. Hall if the notion of which Royce has made so much, namely, the social concept, is not one which perhaps would act as the common denominator in these cases. We cannot assert ourselves and get angry without virtually having reference to other persons, neither can we have sex feelings without such reference. It seems that the social instinct or imagination which is carried around by every individual and which determines his acts is as natural and as invariably present as the existence of a desire to live, not to speak of the desire to conquer. DR. MORTON PRINCE, Boston: I feel extremely thankful to Dr. Hall for his very interesting and satisfying presentation of the thesis which he has given us. I remember an old gentleman once saying to me, in speaking of another man with whom he had been conversing, "He is a very intelligent man. He thinks just as I do." So I think Dr. Hall is a very intelligent man; he thinks just as I do. I am entirely in accord with his views which he has so well expressed. What he has said is in principle the basis of the paper which I intended to present this morning but which, in view of the length of our programme, I have decided to withdraw. The principle underlying the large number of concrete facts which he has given is that besides the sexual instinct there are a large number of other instincts--one of which is anger--which have a very important place and play important parts in personality. Some of these instincts play not only as important a part as the sexual instinct but even a more important part. And, as Dr. Hall has said, the Freudian mechanisms can be applied to them just as well and just as logically. If an analysis is fully carried out along the directions of these instincts we find, according to my observations, the same disturbances that we find from conflicts with the sexual instinct and effected by the same mechanisms. Amongst these instincts besides anger there is the parental instinct, containing, if we follow Mr. McDougall's terminology, tender feeling or love. At any rate love is an instinct entirely distinct from the sexual instinct. There are also the instinct of self-assertion and, fully as important as any, that of self-abasement. This last, according to my observations and interpretations plays a very important part in many cases of psycho-neurosis and leads through conflicts to the same disturbances of personality that one finds brought about by conflicts between the other instincts. That love may be something entirely separate and distinct from the sexual instinct is a view which is generally recognized and accepted by psychological writers but entirely ignored, as a rule, by Freudian writers. A criticism which I would make of the work of the Freudians is that while they recognize these instincts they do not give them their full value nor study them as completely and thoroughly--nor do they carry their studies to the final logical conclusion--as they do with the sexual instinct. So far as they may do so they subordinate these instinctive emotions entirely to the sexual instinct so that these latter simply make use of them. When the psycho-neuroses are completely studied we will find the same repression of the various instinctive dispositions and impulses to which I have referred in the one case as in the other, and of ideas organized with these disposition. We find the same conflicts and resulting disturbances. The sexual instinct has no hegemony. To my mind each occupies precisely the same position and may play the same part in personality. When you bear in mind that psychologically it is a fact, as I believe, that sentiments are formed by the organization of emotional instincts with ideas, with the memories of experiences, as Shand has pointed out, and when you remember that it is through the force of emotional instincts thus organized that an idea, i e., a sentiment, acquires its driving force which tends to carry the idea to fulfilment, and when you bear in mind that sentiments thus formed are derived from antecedent experiences sometimes dating back to childhood and sometimes persisting through life, we can understand how conflicts arise between antagonistic sentiments and the part which the different instincts, through the force of their impulses, play in these conflicts. Furthermore when we bear in mind that sentiments thus originating and organized are conserved in the subconscious forming what I call the "setting" which gives idea meaning, the meaning being the most important component of any idea, and when we bear in mind that this subconscious setting is an integral part of the total mechanism of thought--each sentiment in the setting striving to carry itself to completion, and for this purpose repressing every conflicting sentiment--I think we find a satisfactory explanation of the disturbances due to conflict in the psycho-neuroses. Such a mechanism gives full value to any one and all of the emotional instincts without giving primacy to any one. DR. WALTER B. SWIFT, Boston: In regard to the origin of emotions: I understood Dr. Hall to say that they were not instinct. Of late I have been observing two young children develop certain emotions. The starting point of that development has seemed to be in the imitation of motions seen in others. It is plain to see that this is along the line of the James-Lange hypothesis. So that before these motions were seen there was no emotion in the child. If these motions were observed and imitated by the children then the emotions developed. I would, therefore, like to ask President Hall whether he would consider imitation of motion seen in another as the starting point of the development of emotion. DR. TOM WILLIAMS, Washington, D. C.: The value of formulation we know. It has been well illustrated by Dr. Hall's paper that he has by definite concept followed out by investigation of this. The disadvantage of formulation is very well shown by over-formulation by the scholastics in the Middle Ages. I think Dr. Hall's wonderful contribution to our psychological researches should be kept in mind by those who have excessively formulated in a certain direction in order that some of us at least may apply to some of the other emotions what others have attempted concerning libido. Dr. Prince has long appealed for other methods than those which have been applied so exclusively to the sexuality. In reference to the manifestation of the anger trend, for instance, it may be not only a definitely conscious manifestation, but it may perhaps produce a crisis even in dream-thought. I am speaking of a case. A young boy at boarding school who was a musical genius had been very much bullied. He suffered a great deal from this, but did not retaliate until one night in the dormitory with eight boys while asleep, he being badgered by neighbors, got up while asleep and attacked these larger boys and discomfited them. It was the subject of conversation in the dormitory, whether he was really asleep or not. The boy became so terrible in his anger on future occasions and so successful as a fighter that his bullying thereafter ceased, and his status in the school thereafter was different. Whether this really occurred in a dream state or was mere simulation I cannot say. DR. A. A. BRILL, New York City: I must say that the mechanisms described so interestingly by Pres. Hall are found in our patients during analysis and I believe that almost all of them belong to the love and hate principles. This may not seem so on superficial examination, thus, I have on record nine cases of women who were suffering from various forms of psychoneurosis, one of whose symptoms was screaming. Every once in a while they had to scream. It was an obsessive screaming. Questioning elicited that the screaming always occurred when they were thinking of some terrible or painful thought. For instance, one woman went through fancies of killing her husband and when she came to the idea of shooting him, she began to scream. Here one might think that it was an ethical struggle which had nothing to do with sex, but if one considers that it was against her husband that her anger was directed, that she wished to kill him because he abused her and that there was another man in the case, it becomes quite clear that the anger had a sexual motive. Concerning new formulations, I feel that there is nothing against promulgating new attitudes and theories, provided one has sufficient cause for doing so. Formulations based on insufficient data and hastily constructed are dangerous, to say the least. Prof. Freud is most careful in formulating new theories. He gathers his material for years before he puts it forth in the form of tentative theories and does not hesitate to modify them if occasion demands. Nor is it true that the Freudians ignore the work done by others. Freud and his followers give due credit to other observers, but as the Freudian mechanisms have opened up so many new fields for investigation, we naturally give most of our time to this work. That does not at all signify that we ignore everything else, as some believe. Freud himself continually urges that the psychoanalytic problems should be taken up by observers in other fields than medicine and I was, therefore, extremely pleased to hear Prof. Hall's formulations of anger. I do not believe, however, that his paper shows that we are overestimating the sexual impulse. Basically, all his mechanisms come under the heading of "Sex," as we understand it. DR. L. E. EMERSON, Boston, Mass: I wish to express my delight in President Hall's paper. It seems to me what he has done has been to show the breadth of the Freudian conception of sex. The word sex as the Freudians use it, includes all personal relations and even personality; and it is apparently in question only as to whether one is going to draw a line at one place and say everything on this side is sex and the other side personality, or whether one is going to enlarge the concept of sex to include personality. That as I understand it, is what Dr. White has also said. It seems to me the value of the sex conception lies in the fact that while it can be expanded, and is illimitable, at the same time it focuses, it does come to a point. Personalities as talked of ordinarily have no point, they are too vague. On the other hand, a man who has a mind no bigger than a pinhole is too circumscribed to be capable of understanding any very broad generalization. If one can grasp a conception that does have a center, even though no circumference, he has got hold of a very valuable generalization. DR. E. E. SOUTHARD, Boston: Dr. Jelliffe has just brought into ridicule what he terms "pinhole psychiatry;" but as I remember it, there is a technical method in psychology whereby things may be more clearly visible through a pin-hole! The valuable thing about President Hall's communication is that the fundamental distinction is brought out between two groups of workers in psychopathology. I should be inclined to divide the people in this room into what might be termed emotional monists and emotional pluralists. The Freudian theory is in general a theory of emotional monism and therefore fundamentally must satisfy a great many of the Hegelian tenets. Hence, perhaps Dr. Putnam's adherence to both Hegel and Freud. Now as I understand it, what Dr. Prince wants is an emotional pluralism such as might well be founded upon the data in MacDougall's "Social Psychology" and in Shand's work on "The Foundations of Character." This view of emotional pluralism is one which I should myself be compelled to hold. We must remember, however, that the work of Cannon on various types of emotion may possibly show that different emotions which look vastly unlike (e. g. fear and rage) may be in some sense equivalents. Fear may be equivalent to rage much as different types of energy in the physical universe are equivalent to one another. The emotions may be interchangeable in some sense so that it might be possible that sex emotion and the emotion of fear are translatable. In this way there might be constructed a fundamental monism of emotion in the same sense that energetics is a science which unifies electricity, heat, magnetism, etc. It would not seem to me, however, appropriate to identify all kinds of emotion with the sexual. PRESIDENT HALL: It would take an encylopedia and an omniscient mind. and many hours and days to exhaust such a topic as this. Dr. Southard has said some of the things I would have said. I supposed this society was primarily interested in pragmatic discussions. At any rate, I left the American Philosophical Society some years ago and entered this to get rid of metaphysics and arid abstractions. As to what Dr. Swift says, it seems to me imitation plays a great but is by no means the sole role. It is of course purely instinctive, and the social instinct comes in everywhere, so much so that discussion on almost any topic is liable to raise the question of the individual versus the social forces in the world. As to Dr. Jelliffe's opinion whether after all hate and love are at bottom the same, he perhaps bottoms on the recent discussions of what I might call the expanded theory of ambivalence, as represented by Weissfeld. But I do not interpret this to mean that there is any sense whatever that has any pragmatic value in the statement that love and hate are the same. If you assume this, one is dizzy and the world seems to spin around. Hegel showed a sense in which being and not being are the same but that is a most abstract and purely methodological statement. What in the world is more opposite than love and hate, from every practical and truly psychological point of view? We must not be credulous about the unconscious and ascribe to it absurdities, nor must we lose our orientation for surely up and down, right and left, light and dark, do differ. If the unconscious can be used to cause a darkness in which everything loses its identity and fuses into a general menstrum, as Hegel said all cows were black in the dark, it seems to me we can get nowhere. Ought we not to start by admitting that there are certain immense differences in the emotions, whether conscious or unconscious, and that the tendency to find a common background or identify them is a matter largely of speculative interest? DR. MORTON PRINCE, Boston, read by title a paper entitled "The Theory of 'Settings' and the Psychoneuroses." DR. L. PIERCE CLARK, New York, N. Y., read a paper entitled, 'The Mechanism of Essential Epilepsy."[*] [*] Reserved for publication. DISCUSSION DR. E. E. SOUTHARD, Boston: Idiopathic epilepsy as found in Massachusetts material and estimated from the appearances in the gross anatomy of the brain occurs in about one of every three cases. There are accordingly more idiopathic epilepsies than there are idiopathic or "functional" psychoses, if the data of gross anatomy form a reliable index. It was a somewhat curious thing that in a series of cases investigated by Dr. Thom and myself, that the more frequent the attacks of epilepsy the less there seemed to be to show for them in the autopsied brains. In certain cases with daily attacks the brains were strictly normal in gross appearances. It was the frankly organic cases with large focal lesions that had the occasional attacks. These frankly organic cases rarely had high frequency attacks. DR. TOM A. WILLIAMS, Washington, D. C.: Will Dr. Clark explain the eccentric convulsions such as when there is uraemia, on similar grounds? Also, if he will postulate in such cases as recover with metabolic treatment. I have published cases in which recurrent attacks of some years duration were removed by means which considered only the metebolesia. (See Journal of Neurology and Psychiatry, March, 1915.) DR. JOHN T. MACCURDY, New York: I have held the opinion for some years that the study of epilepsy was going to be of greater psychiatric moment than that of any other condition. I feel that this promise has been very largely fulfilled by the work Dr. Clark has been doing for the last two years. We have found, I think, from that work that we can really shell out what we may term an epileptic reaction, which is really the most primitive of all psychiatric reaction. It corresponds to a flight from reality. It is a return to the subjective phase, which, in the psychoses, is no vague but a very real thing. In epilepsy we get it in pure culture as a lapse of consciousness, expressed either in completeness as in a grand mal attack or partially when consciousness is merely clouded. Sleep probably represents an analogous condition. We go to sleep to repair the body while psychologically we are seeking that flight from reality which we all long for. The
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