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 convulsion may be a secondary affair, and a physiological sequel to the loss of consciousness, which is psychologically determined.

L. PIERCE CLARK: For the time being I am anxious to limit my remarks to the mechanism of ESSENTIAL epilepsy, and, not to convulsive disorders in general, however closely allied to idiopathic epilepsy. At some future time I hope to take up the epileptoid convulsions and show their relationship and variation from that of the mechanism of essential epilepsy. I may say, however, that I have some data already at hand in which certain types of epileptic phenomena connected with infantile cerebral hemiplegia would show that the so-called epileptic constitution is much less marked in these cases, but is present, however, to a certain degree. As has been well known for a number of years and commented upon by such observers as Gowers, Jackson and Binswanger, the so-called hemiplegic epilepsies sooner or later develop the epileptic alteration in a character analogous to that seen in idiopathic epilepsy. I hope to show that the main roots of the so-called epileptic alteration in general necessarily lie in the primary make-up of such individuals, and that the seizure phenomena of epilepsy only intensify and make more marked the fundamental make-up when the disease has definitely fastened itself upon the individual. My next paper on this whole subject will attempt to show more conclusively that the epileptic seizures are but an unfoldment of that which has already been existent in the biological make-up of the individual epileptic.

DR. TRIGANT BURROW, Baltimore, Md., read a paper entitled "Material Illustrative of the 'principle of Primary Identification.' "[*]

[*] Reserved for publication.

DISCUSSION

DR. JAMES J. PUTNAM, Boston: I am very much interested in Dr. Burrow's paper and understand it as illustrating the argument brought forward by him last night. As I remember the situation I do not quite see why this idea is not essentially the same that has been endorsed by Freud and others. One's interest in one's self is certainly in part the basis of homosexuality, and this is intensified by the reflection from the mother.

DR. JOHN T. MAC CURDY, New York: When Dr. Burrow first brought up this subject last year it struck me as being the most original theory in psychoanalysis that had been formulated in this country and one of the most important of all the additions to our general psychoanalytic concepts. Personally, I found that it immediately solved certain problems which had been in my mind for some time. I had never been able to see how it came about that the alcoholic had a strong latent homosexuality. The ordinary interpretations of drinking as a fellatoristic substitute has always seemed unlikely, for, if this were so any liquid would serve the purpose, so why alcohol? Now it is manifest that the alcoholic is an individual who is taking a drug which dulls his sensibility. That is a way of retiring from reality, of getting away from objectivity, retiring from what Dr. Burrow calls the subjective phase. Now we understand why the patient in an acute alcoholic hallucinosis almost invariably hears voices making homosexual accusations. The unreality complex is translated into sexual terms and he is accused of unreal love. I have been struck in dream analysis by the almost constant coincidence in dreams of Mutterleib symbols in the same dream that on analysis proved to be homosexual in principle. I can quote one dream that demonstrates dramatically every point which Dr. Burrow makes in his thesis. This patient, a man who was being treated for homosexual tendencies which worried him a great deal, on one of the first days brought this dream. He was a hospital interne. Someone came to him and said a nurse had cut herself. He ran up to the surgical amphitheatre where preparations were made to fix her wound. He suddenly discovered that his was the cut and that it was on the ventral surface of the penis corresponding to the primitive subincision operation. He took up a needle, sewed it up and put on a bandage. At the end of the dream he wondered what was going to happen, whether the bandage would come off or not. Any psychoanalyst can imagine what the incision indicated, that it led directly to the idea of a vagina, also to the idea of castration which is combined with that. The bandage led to swaddling clothes. Here we have the whole situation rehearsed. The associations went to the mother. The mother changes into himself. At the same time he represents himself with a vagina and gives birth to a child, his own penis which he can fondle as his mother did him.

DR. SMITH ELY JELLIFFE, New York: It seems to me the phrase identification with the mother is very illuminating. I have no doubt that Dr. Burrow would say that the failure to develop away from this primary identification lies at the basis of what is called Narcissism. I have noted this identification with the mother, i. e., with the female, in many patients. They are, in ordinary life, after making a very hard fight with unconscious homosexual trends and are managing themselves with great difficulty. This shows particularly in the analysis of alcoholics especially of periodic types. Self-fertilization is a frequent symbol in the unconscious. In males, particularly, the identification with the mother is a frequent factor and often explains the value of the instinctively sought relief through narcosis and withdrawal from the conflict. Male hysterias also show it markedly. The aggression towards the father is a frequent female symbolization in hysteria as well.

DR. TRIGANT BURROW, Baltimore: It seems to me that the President's reference to this heterosexual instance need not necessarily be heterosexual in a psychological sense. It is important to recognize that though the object of the male in a particular case be a woman, yet psychologically this need not be a heterosexual adaptation. In the case I have cited the relation of the patient to his wife is psychologically a homosexual one. We have seen in this case the presence of a profound neurosis and coexistent with it an apparently normal sexual life. This we know from the Freudian standpoint is impossible. The heterosexual adaptation is but apparent.

DR. TRIGANT BURROW, Baltimore: In regard to Dr Putnam's comment that my thesis contains what has been said already by Freud. Undoubtedly to a large extent it has. There is, though, some modification here which seems to me of importance, if only in the way of an extension of Freud's original conception. One gets a very clear idea from Brill's excellent paper on homosexuality of Freud's essential thesis. Here the idea of homosexuality is that of a revulsion from the mother. The child is assumed to adapt itself as the mother in order to get rid of the mother as object. This first hypothesis related only to the male child. To explain homosexuality in the female, either an analogous mechanism must be assumed, according to which the female child adopts homosexuality to escape the father image, and analysis does not bear out this explanation; or, assuming the same reaction in respect to the mother in the female as in the male, the result would entail not homosexuality but a heightened heterosexuality. I think the formulation I have here advanced offers us a distinct advantage in placing the causative factor in homosexuality in either sex upon an identical genetic basis.



AFTERNOON SESSION

The meeting was called to order by the President at 2:15 P. M.

Dr. E. E. Southard, Boston, read a paper entitled, "Data Concerning Delusions of Personality."[*]

[*] Published in this number of the Journal, p. 241.

DISCUSSION

DR. SMITH ELY JELLIFFE, New York: Dr. Southard has heretofore launched us upon very large subjects. I can well recall in one of his previous communications the fascinating correlations drawn between structural changes and the character of the psychological signs. In dementia praecox particularly, he has shown us how auditory symptoms group about temporal atrophies and optical signs with the occipital and so forth and so on. He now proposes to thrust us into a larger and much more intricate sphere of activity as to the representation in the cortex of other changes which as he has described are inframicroscopical or inframacroscopical. In other words, there must be some type of correlation between the projection in the cerebral structure of the organ itself which is cerebrally represented and certain mental signs. If I see what Dr. Southard has been thinking about, we are certainly engaged in a very fascinating topic. It is well known from the standpoint of topographical cerebral correlation that the brain is nothing but a series of body symbols, as it were. Adler has entered this field and approaches the problem by saying that the inferior organ, liver, kidney, or what not, is related to a similar defective cerebral representation of the organ, thus introducing into the nemological mechanism the task of compensating for the defective structure. Dr. Southard wishes to try to map out these defects in the cerebral structures and thus reason backwards to the somatic inferiority. I confess he lifts me into ideal regions. Such stimuli are enjoyable and provocative of development.

DR. TOM A. WILLIAMS, Washington, D. C: I conceive Dr. Southard's purpose somewhat differently from Dr. Jelliffe whose thought seems to be somewhat like that of Henry Head when he published his paper in reference to hallucinations, corresponding to various head zones in correspondence with different visceral areas and with special sense organs, eye, ear and so on. I have conceived Dr. Southard as being a direct chemical in line with Folius' pathology researches. If that is the case we have a great many clinical cases which might be underlined with his central thought.

PRESIDENT HALL: It is almost too good to be true if Dr. Southard has really made connections between delusions of personality and the great topic of character. It illustrates the old Hippocratic saw, "God-like is the man who is also a philosopher." Character might almost be called a name for all the mysteries of psychology, and from Mill's ethology and the old phrenologies of temperament that Wundt adopts with slight modifications, we have really made little progress. It seems to me very significant that Dr. Southard should interest himself, as his paper leads one to judge he does, in such problems as Shand's somewhat abstract work, and should seek correlations with legal characterology like that of Roscoe Pound. It would be of great interest to know whether Dr. Southard obtained his differentiations purely from pathological cases or whether, accepting Shand or Pound or both, using their distinctions as apperceptive organs, he unconsciously reads their distinctions into his cases. His paper, at any rate, is a genuine contribution as well as an encouragement to those who seek to correlate the normal with the abnormal.

DR. JAMES J. PUTNAM, Boston: I only want to express my warm sympathy with Dr. Southard's scheme. This careful working out of correlations one would say is a good method of scientific research and must lead to something. I think Dr. Southard would rather avoid the suggestion of CAUSES for the results that he found, but the METHOD appears safe and profitable.

DR. JOHN T. MACCURDY, New York: As another psychoanalyst it gives me pleasure to hear this paper. As a psychoanalyst, and one who has done most of his work with the delusions. of the insane, I must say that I have felt all along that psychoanalysis fails utterly when it tries to account for the manifest content of a delusion. We can trace the psychological stages from the manifest content in varying delusions back to a more or less constant unconscious striving— the latent content. The tendency of this latent content to appear as delusions depends on a defect of adaptation, which must have a physical basis probably of a general nature. The delusions, in many cases, are symbols of the latent content. From a psycho-analytic standpoint, the problem presented in Dr. Southard's paper is "Why is a certain symbol chosen in one case and another in another individual?" It may well be that specific organic factors operate here. One could imagine that the mechanism is purely psychological. In a hepatic condition, for instance, the attention of the patient may be directed to that part of the body which is affected by the pathological process in the liver and that for this reason the ideas which appear refer to generations in that region. At least we may hope for definite and interesting results from elaboration of the method outlined by Dr. Southard's statistics.

DR. SOUTHARD: I am rather astonished and well pleased at the cordial reception of my little statistical work on delusions and upon the elaborate discussion. As to Dr. Hall's question whether my data were collected to prove the a priori contention concerning the correlation of unpleasantness with lesions below the diaphragm, I would say that I expressed a suspicion of this correlation in my paper on "How Far is the Environment Responsible for Delusions," (Journal of Abnormal Psychology, June-July, 1913). I was stimulated to finish my article by the appearance of Shand's book on "The Foundations of Character" and the articles on "Personality" by Prof. Roscoe Pound which have been appearing in the Harvard Law Review.

"Dyslalia Viewed as a Centre Asthenia" was the title of a paper read by Dr. Walter B. Swift, Boston.[1]

[1] Reserved for Publication.

NO DISCUSSION

DR. JOHN T. MACCURDY, New York, read a joint paper (with DR. W. T. TREADWAY) entitled "Constructive Delusions."[2]

[2] Published in the August-September number, p. 153, of this Journal.

DISCUSSION.

DR. WILLIAM A. WHITE, Washington, D. C., spoke of his interest in the paper and his agreement with it. He suggested that it might be quite proper to use the term "archaic" in speaking of this type of delusions. He also commented on the recurrence of the excitement in the case of the last patient quoted which, he suggested, might represent a physical periodicity as the individual had a homosexual component in his make-up, so that it might be reasonable to suppose that this was fundamentally sex periodicity.

PRESIDENT HALL: Sex periodicity in males is very interesting. A student of mine many years ago kept his own record for some years and published it anonymously in my journal, as did another some ten years ago, and the twenty-eight day cycle seemed very marked in the first and somewhat so in the last of these papers. They are certainly interesting to the geneticist. We now often speak of dreams as protectors of sleep. I am inclined to think that a good many delusions are protectors of sanity in much the same way, and I am not at all sure that we cannot say that we shall ere long see that this is to a great extent true for the imagination. If this patient had a less vivid fancy perhaps his delusions would have been kept less fluid and his sanity would have been better protected. Is there not a relation between floridness of fancy which passes easily over to delusions (just as creative geniuses are allied to artists), but may there not be an inverse correlation between great liveliness and activity of fancy and liability to fixed delusions? At any rate, from the normal standpoint we are seeing more and more that man lives on a genetic scale. This might be illustrated by the many cases, some of them pretty well analyzed, of cat-phobias. The greatest enemies of mankind were once the felidae, and the theory now is that this type is made up of very definite elements, viz., sharp claws, stealthy tread, eyes that shine in the dark, power to leap far and suddenly, a uniquely developed voice, etc. Now the cat-phobiacs generally focus on some one of these traits in consciousness, but analysis seems to show that the rest of them reinforce the one that experience happens to thrust forward into the center of the field of consciousness. In general it seems to me that it is a great educational advantage to keep open the experiences that connect us with the past of the race, and it may have a psychotherapeutic value which we do not now dream. Years ago a New York paper investigated, with the aid of many of its reporters, and found hundreds of people fishing off the wharves of New York on Sunday, very few of whom caught any fish, and many who did threw them back. They were reverting to the old piscatorial stage, feeling again the old thrill of a nibble on the hook, and went home refreshed, even if they had not had a bite, because they had been able to drop back into an ancient stratum of the soul which was sound, so that they came back to the hard reality of the next day refreshed. Play in general, too, we now regard as reversionary, and I cannot but believe that many delusions are precisely the same.

DR. TOM A. WILLIAMS, Washington, D. C: Dr. Hall has cited the cat-phobia in illustration that the belief that Dr. MacCurdy developed may be one in which there may be philogenetic reasons for the phenomena. It seems to me that before we use such data we need analyses more complete than has been given for any of them. His citation brought to my mind a case I am working with now, a cat-phobia. The cat does not represent sharp eyes and claws. The cat is a definite symbol of definite sexual occurrences in childhood. I should like to ask whether it would be here desired to draw philogenetic conclusions. I think not without the further analysis which would be necessary. I have a very strong distrust of the efforts which Jung and Abrahams have made, followed by some of us, to draw analogy between the morphological changes and the psychological experiences of the race as reproductions in the life history of the individual.

DR. E. E. SOUTHARD: I should be inclined to feel that much of the disturbance in the constructive delusion group would be structurally founded upon normal or abnormal conditions in the parietal lobe. At any rate cases with hyperphantasia in my recent Dementia Praecox series (American Journal of Insanity, 1914-15) appear to be correlated with parietal lobe anomalies and atrophies. It is a curious thing that such subjects with hyperphantastic delusions are very often good institutional workers. Although a delusion of persecution by poison is an exceedingly simple delusion, it is in a sense far more harmful to the organism and may be often far more productive of motor results in a patient than an elaborate psuedo-scientific theory such as constructed by Dr. MacCurdy's patient. It is obvious that the degree of disease does not vary directly with the simplicity of the delusion.

It seems to me that Dr. MacCurdy's work has not only theoretical interest but also practical importance from the standpoint of prognosis.

DR. WALTER B. SWIFT, Boston: I often wonder if we are not a little inclined to go too far back for explanations. In football it is recognized that the men on the field have two sets of reflexes out of which they play under different circumstances. One is a set that they have learned in the lower schools; and the other is the reflex circle that they use after they have been trained differently in college. When these men get tired it is a psychological observation that they go back to those first learned reflex mechanisms. That is, when tired, they play the football of the secondary schools. Something similar occurs in stammering. When a case is trained to have a higher reflex vocalization, and they learn to vocalize spontaneously, it inhibits their stammering. But when they get tired they revert again. In the subject under discussion are we not reaching too far back for sources? Should we not go to infancy or early childhood (to the old reflex circle there) rather than to ones we suppose are inherited?

DR. TOM A. WILLIAMS, Washington, D. C.: My remarks do not apply to the contents of the delusions, of course, but to the cerebral capacities merely which were susceptible of the formation of such delusions.

DR. SMITH ELY JELLIFFE, New York: Dr. MacCurdy's paper fascinated me a great deal. There is so much material that one is in a maze. I am sorry, moreover, that he had to mutilate his conclusions by being forced by lack of time to condense them. It strikes me he gives us a very important contribution to the mechanism of the cure of some psychoses. That mechanism of cure, may be stated as follows: How can one take the split off libido which results from the analytic technique and apply it to a better constructive synthesis? It would seem that these constructive delusions really correspond to interpretative schemes whereby a certain amount of the split off libido becomes synthesized. In that sense these delusions are constructive and are, therefore, helpful to the patient. They represent partial curative processes.

DR. JOHN T. MACCURDY, New York: I would like to refer briefly, first, to the point made by Dr. White to the effect that these ideas were interesting in so far as they were archaic. That is true and it is one of the profoundest truths we have to offer. At the same time it is of psychological and not strictly speaking of psychiatric value. The purpose of my paper was essentially psychiatric, to point out that there is a prognostic value in such delusion as I have tried to outline. Now one can get archaic delusions in patients very much deteriorated. The point of this paper is rather to show, as the discussion brought out, that it is the constructive tendency operating in the insane as it has historically in the race. The second point as to the cycle in his attacks, to follow the inference of Dr. White, I presume he meant to imply that there may have been some organic swing corresponding to the psychotic swing. That of course is quite possible. At the same time the analysis of this case showed that purely psychic factors had a great deal to do with it. His monthly attacks seemed to represent a break in the balance. He was always in unstable equilibrium and the factor that seemed to decide the issue finally between relative sanity and a markedly deteriorated state, was a purely psychological one. When his father died, when he was released from that bondage, the relief seemed just enough to decide the issue. So the organic factors here seem to be the general, underlying inability to adapt himself. One of the hardest situations to adapt himself to was his relations with his father. If he could not free himself he was going to be very insane. When that factor was removed he became relatively insane.

DR. TOM A. WILLIAMS, Washington, D. C., read a paper entitled, "The origin of Supernatural Explanations."[*]

[*] Published in this number of the Journal, p. 236.

DISCUSSION

DR. E. E. SOUTHARD, Boston: Are all these somatic explanations of metaphysics?

DR. WILLIAMS: Largely.

DR. SMITH ELY JELLIFFE, New York: I recall a note in one of Dr. Jones' papers in which he says "that in the future our reason will be used to explain things. Heretofore it has been used to explain them away."

DR. TOM A. WILLIAMS, Washington, D. C.: I am not prepared to make any predictions about a thousand years from now, that is in the air. I mention not the levels at all, nor do I speak of "decerebrate metaphysics." Nor do I speak of metaphysics at all unless one would imply that what I have called supernatural explanations needs must be metaphysical. I do not speak of cerebral functions per se. I was simply speaking of states of feelings. The source and origin I did not go into. I simply made an attempt to imply that such states of feeling were responsible for the discomfort and feeling of inadequacy of the patient, and as Dr. Jelliffe has well repeated that the victim attempts to rationalize this in supernatural fashion and that this may be not at all dependent upon the notion of the supernatural universe he has imbibed as a child. It is a construing of natural means for getting out of a difficulty.

Dr. L. E. Emerson, Boston, read a paper entitled "The Psycho-Analytic Treatment of Hystero-Epilepsy."[*]

[*] Reserved for publication.

DISCUSSION

DR. JOHN T. MACCURDY, New York: I have been very much interested in this paper by Dr. Emerson and the part that has interested me most in it has been the therapeutic side. I cannot feel, however, that it adds a great deal to our knowledge of epilepsy, that is, of idiopathic epilepsy. That, of course, is a tremendously difficult problem to tackle. If we are to regard it as a psychosis then we expect it to show other reactions, just as dementia praecox shows manic depressive symptoms. If we are to find out what the epileptic reaction is, we must study it in those who are typically epileptic and nothing else. Or else we may examine those with transitional states grading over into hysteria, for example, excluding from our formulations everything in them that is hysteric. This last case which Dr. Emerson brought forward seemed to me to represent what is essentially an hysteric reaction. The convulsive movements this man went through were symbolic. It is difficult to regard these movements in epilepsy as symbolic because in the true epileptic there is as typical unconsciousness as we know. How can anything going on in almost absolute unconsciousness represent something symbolic to the individual? This is possible however, when the condition grades off from the hysteric side into the epileptic. The fundamental epileptic phenomenon is the disturbance of consciousness, and that is what must be explained.