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[*] Paper read May 6, 1914, at Albany, New York, before the American
Psychopathological Association.

Copyright 1915 by Richard G. Badger. All rights reserved.


Instructor in Neuropathology, Tufts College Medical School, In Charge Voice
Clinic, Boston State Hospital, Psychopathic Department.

THE object of this paper is to carry the analysis of stutter phenomena
deeper than before. In my last year's paper I showed that chronologically
the diagnosis of dyslalia mounted step by step from a material external
affair, up through the nerves until we came to the basal ganglia. I showed
conclusively that it was an involvement that did not exist in any of these
places. I further took steps to demonstrate and present evidence that
indicated that dyslalia was in its essence some trouble with the
personality. I mean by this: that the trouble was located in the nervous
system beyond the lower sensory areas of the sensorium; and also above the
lower motor areas on the motor side. By the broad term "personality" I mean
the total of the activities and interrelations of mental activities that
occur above our lower sensory and motor areas. The paper of last year
clearly located the trouble vaguely in this region of the personality.

Since that time I have been interested to ascertain just what the nature of
this changed personality is. In order to do so, I have carried on an
investigation that has reached interesting conclusions. To me it is new
truth. It may not be all the truth, but as far as it goes, and as for what
it is, it surely is truth and a new finding! This research is an effort to
show not only where it is but WHAT IT IS.

The method was as follows: For the purpose of finding out some of the
activities going on in the area of collaboration during speech, I asked my
stuttering patients two simple questions. I thus found that their methods of
collaboration complied to a certain mental type.

Then I carried this same method into the study of normal individuals in the
collaboration of their ideas, just before and during speech in order to
establish a norm; and to see whether or not it differed from my preliminary
test of stuttering cases just mentioned. It did, and therefore I formulated
a series of questions in order to pin the type of collaboration down to
certain fields of mental action. To make this clear, let me present an
outline of these different steps in tabular form.

1. Orientation tests on stutterers.
2. Orientation tests on normal individuals.
3. The research, its objects and methods.
4. Final detailed results.

Let us now pass to a minuter description of each of these procedures and a
tabulation of the data that resulted.


By orientation test I mean simply a vague try-out to see just where the
problem lies; an initial step to see what further steps are necessary; or in
other words enough of an investigation to know where to look next.

The orientation tests consisted in requesting a series of twenty stuttering
cases to answer two questions. Following their answers an immediate
inspection was made of the content of their consciousness before, during,
and after speech. These two questions were as follows:

1. Where do you live?
2. Say after me "The dog ran across the street."

After these questions I asked the patients to state whether there was any
picture in the content of consciousness and how long it lasted; also whether
that was detailed, intense or weak. I noted the presence of stuttering in
relation to the presence or absence of this mental imagery; and also made a
note of any other unusual data that happened. The results of the tests
indicated above can be summarized as follows:

Of the twenty stutterers examined, ten made no visualization of their homes,
some even after a residence of years; one of these twenty visualized home
very faintly; two others visualized home clearly but the picture vanished on
speaking; seven others visualized home clearly but these had been under

On repeating the dog statement, ten stutterers made no visualization
whatever; one visualized faintly; four visualized well but the picture
vanished on speaking; five others reported visualization, and four of these
had been under treatment.

At first I did not know but what this was the norm of average visualization
methods; so I tried this same series upon a number of normal individuals for
comparison; by normal individuals, I mean, at this time, merely anyone who
is free from stuttering, and chosen in a haphazard way from the hospital
community; for example, one was our executive secretary, another a
typewriter, another a telephone operator and so on.


The results of these orientation tests upon normal individuals were as

The normal individuals examined almost without exception visualized clearly
before and during speech. Sometimes this visualization was very marked in
detail and resulted in emotional responses, such as pleasures, etc.

From the above two sets of figures were thus obtained a fair norm of
visualization for ordinary individuals; and in comparison a marked variation
from this in stutterers. This data therefore warranted the tentative
conclusion that stutterers have a loss or diminished power of visualization.
This assertion may seem a little more than is warranted by such meagre data
and perhaps would be better revised pending further data into the following:
As compared with the normal, stutterers show a weakness in visualization.


These general orientation tests for a norm and its pathological variation
were the basis upon which I proceeded on broader lines with a further and
more exhaustive investigation with the following points in view:

To what extent is visualization weak?

Is it weaker in the worst cases?

Is it less and less weak as cases appear less severe?

Is it the same for past, present and future memories?

Is visualization equally at fault in all sensory areas of the cortex?

Do cases approach normal visualization processes in proportion as they
progress in their cure? and

Lastly, numerous other minor queries presented themselves.

All these questions were answered in the following research, which after
thus much orientation found a more complete and final form.

In order to answer these questions I formulated the following series of
tests to the number of twenty-four in all, and asked them in series to
nineteen stutterers, making almost four hundred tests:

1. Speech:
Say, Today is sunny.
The dog ran across the street.
Submarines will sink all the steamers.

2. Motor:
Do you dance?
Did you ever skate?
Would you sew for a living?

3. General Sensory:
How does a pinch feel?
Did you ever get hurt?
What would you like to do if it was very hot next summer?

4. Hearing: (Eyes closed)
Do you hear anything?
Did you ever hear a rooster crow?
What sounds would you like to hear next summer?

5. Sight: (Eyes closed)
What do you see now?
What did you see yesterday?
What would you like to see next summer?

6. Smell: (Eyes closed) (Pen to nose)
Do you smell anything?
What have you told by smell?
What would you like to smell next summer?

7. Taste: (Eyes closed)
Do you taste anything?
What have you been able to tell by the taste?
What would you like to taste next summer?

8. Muscle Sense: (Eyes closed)
Put one arm up; the other like it.
Put one arm up, down; the other like it.
How would you hold a hand to read from it?

This long series of questions with careful introspection tests upon the
content of consciousness constituted then my main research in the field of
stuttering. Perhaps further details in explanation of the questions chosen
is unnecessary. Three or more questions on introspection were asked at each

4. FINAL DETAILED RESULTS are found in the following conclusions as drawn
from 1440 answers.

In our average conversation a visual picture is created before we begin
utterance. Severe stutterers never visualize at all. In direct proportion
that these cases become less severe, does visualization increase in
frequency, strength and continuation in consciousness before and during

When severe stutterers are free from spasms they visualize, and when they
stutter they do not visualize.

When mild cases are free from spasms, they visualize, and when they stutter
they fail to visualize.

In a word, when visualization is present stuttering is absent; when
visualization is absent stuttering is present.

This is true not only of EACH UTTERANCE, in most cases, but is true of
severe as well as mild forms as a whole.

Stutterers gain in visualization as they approach cure.

For past, present and future memories: visualization is slightly more
frequent for past and future.

Therefore stuttering is an indication of absent or weak visualization either
in isolated words, occasional stutterers, mild stutterers or the severest
type, either before or during speech, or both.

The slump, then, in personality which I showed last year as the main thing
in stuttering as its cause and condition, is thus found by further
psychological analysis, to be a slump in the power to consciously visualize.

By personality I mean as mentioned above the composite of collaborative
activities that lie between the low sensory repository areas and the low
motor expression areas. In other words, personality includes all those
collaborative processes that lie between the sensory intake areas and the
motor output areas; in a word, any unexpressed use the mind makes of its
intake. Conscious visualization is a part of personality processes, then. In
my last year's paper([1]) the whole matter was left vague. Here something
definite and constant is found. In other words the psychoanalytical method
revealed no conscious subconscious cause. Granted there is room here to
"interpret" (or create according to Freudian mechanisms) a definite
subconscious complex, a step which I could not feel justified in taking; I
leave this to better psychoanalysts than I. For me to twist stutter
phenomena to comply to a theoretical complex is unscientific to say the
least. But the psychological method--as represented by this paper--shows a
definite constant cause for all the phenomena of stuttering.


Upon this basis of an involved visualization all the intricate phenomena of
stuttering may be explained. Let us take some of these up in detail.

THE START. Visualization processes are a matter of growth through exercise
and development and use from the sensory area mostly of the eye. If these
processes in their early start and evolution receive a setback through the
treatment of people in the environment, such as interruptions of their early
speech efforts, constant inattention of those to whom they speak, and
persistent refusal by older people to answer questions propounded or the
allowing of the little one to ask the same question without hopes of answer
for a great number of times, these visualization processes receive a
setback. This kind of treatment in the home is one of the chief causes of
the slump of visualization processes. Another cause is hearing other
stutterers interrupt their own visualization processes as they stutter; and
still other minor causes may be almost any psychic trauma; these traumata,
such as an operation, an accident or a severe illness, are sufficient to
bring to the surface or intensify a growing lack of visualization that has
been started by bad environment long before.

THE DEVELOPMENT OF STUTTERING. When the habit of visualization is lessened,
the action upon speech is the same as the withdrawal of an inhibiting or
regulating reflex arc.

It is thus that visualization processes act like reflex inhibition. When
visualization is present a higher inhibition arc is functioning and we have
a normal speech as a consequent reflex expression. When and in proportion as
visualization is absent this higher inhibition arc is not functioning; and
the speech thus uncontrolled flies away in spasms which we call stutter. It
should be called an exaggerated or uninhibited speech reflex.

The stutter, then, is merely the externalization of an exaggerated reflex of
motor speech, exaggerated through the loss of the inhibitory action of a
more or less weakened visualization process.

Not only does this explain the phenomena at large but seems to be a
satisfactory explanation for all its intricate, minute details. Some
examples may, perhaps, be welcome at this point. I say to two stutterers:
"Tell your first name." One of them stutters and the other one does not.
On furthering questioning, it is found that the one who did not stutter
visualized, and the one who did stutter did not visualize.

CONCRETE: These conditions are also seen when stutterers talk about
concrete and abstract matters or when they promulgate some important plea
that cannot be visualized. On concrete matters that can be easily visualized
the stuttering is gone; and on abstract matters where visualization is hard,
the stuttering again appears.

ANGER: In anger, when an intense visual picture is presented and occupies
the mind, there is then no stuttering, and also in other similar situations
there are periods when the individual is abandoned to some visual concept
which acts in the same manner.

SINGING: We all know that stutterers can sing without stuttering. The
process here is a similar one; only that there is held up over the speech
before utterance an auditory image of a melody in place of the visual image
as held in normal speech. This auditory image may be more easily applicable
as supplying the needed inhibition reflex arc than the visual because it is
nearer to the speech area.

PRAYER: For the same reason prayer is uttered without stuttering when there
is faith enough in a God to hold an image of Him during utterance. There may
also be other images held during prayer.

FAMILIAR SIGHTS: Familiar sights are less stuttered upon than the detailing
of situations that are less familiar and therefore can be less well
visualized. This is also true of sights that have been recently seen or
that have been repeatedly seen, or that in some other way have been made
intense as pictures in the visual field.

AS CURE PROCEEDS: In the process of recovery where visualization is seen to
increase as the stutter decreases, there is another illustration where this
visualization attitude explains the whole situation. I have taken a severe
stutterer and told him a story that could be well pictured, got him to work
up the pictures properly by several complicated processes (which we will not
consider now) and when he had them well in hand, I have seen him stand up
and relate the story from beginning to end with little or no stuttering If
at any point he would trip up, the inevitable confession would be that at
that point he dropped the picture, or, in other words, the visualization
could not be held over in its inhibitory action; and therefore the stutter
came. On further request to hold it over that point, the same passage would
be again expressed smoothly if he succeeded in holding the picture.

This constancy, this presence and absence of the picture, its presence to
make smooth talk and its absence to cause stuttering, is so constant at
every turn of the situation, that I would offer it as a new interpretation
of all these phenomena. I know of no other interpretation that can EXPLAIN
EVERYTHING UNDER ONE HEAD as does this absence, weakness or interruption of
visualization processes.

TERMINOLOGY. We have found in our orientation tests that in a vague way the
visualization was at fault. We have also found in normal individuals that a
marked visualization was an automatic process that preceded speech, and
lasted during utterance; and we have found in the long series of stutterers
that visualization is entirely absent in severe cases; that it is weak in
milder forms; that it is intermittent in most cases, and that on words that
are smooth it always appears, and in occasional stutter it is as
occasionally absent.

We have also found that the form of visualization common in normal speech is
the visualization of eye sensations; that in unusual situations we may have
visualizations from other sense areas, such as the ear, taste or smell, but
these are the RARE EXCEPTION.

From all this data it would naturally follow that some sort of term is
needed to designate this condition. Last year I probed to find such a term
without much success.

At present I see no reason why it should not be called an Asthenia; it is
surely the weakening of a mental process that is strong in normal
individuals. The evidence here presented shows that. I doubt whether there
is any marked pathological change, since the individual may be educated out
of it; but this does not necessarily follow as proven with my dog in
Berlin.[2] As a general designation, then, I should consider Asthenia as

One objection to this is that the weakness is by this terminology lacking in
localization. Our data above has shown us that the location of the trouble
is visual; that is, it is situated about a centre of sensory registration
that deposits data from the eye; this must naturally then be located
somewhere in or near the cuneus. We could therefore add to the terminology
this idea of a minute localization and call it a Centre Asthenia.

Some may prefer to carry the matter one step farther and add the name of the
centre in which this weakness is located, but I fear if I take this step and
complete my terminology by the word "Visual Centre Asthenia," it will, as
such, not cover quite all the cases, for I find that sometimes the
visualization is absent in other areas as well, and also the holding of an
emotion of pleasure or pain and of other dominating mental attitudes that
are sometimes visualized would not, therefore, be included. I would
therefore retract the broader claim in order to place the term on a
conservative basis and call the essence of the lesion simply no more or less
than a Centre Asthenia. As well as visual Asthenia, the following terms
might be considered as applicable: collaborative centre asthenia;
imaginative centre asthenia; visual creative centre asthenia; picture
producing centre asthenia. We say neurasthenia when the trouble is not in
the nerves as such, so much as it is in the collaborative centres. More of
this later. Here in stuttering the trouble is also collaborative, and we
can be still more definite than that and say the trouble is with the
collaboration of visualization. So if I were forced, however, to choose one
term from all these, my choice would be "Visual Centre Asthenia." This
indicates a new and rational treatment. But of this later.

SUMMARY: Psychoanalysis reveals stuttering as some vague trouble in the
personality[1]. Psychological Analysis shows stuttering is an absent or weak
visualization at the time of speech. This new concept of stuttering as
faulty visualization may be called Visual Centre Asthenia. This lack or
weakness in visualization accounts for all the numerous phenomena of
stuttering in severe, medium, or mild cases. A new treatment is indicated.


[1] Swift: Walter B, A Psychoanalysis of the Stutter Complex with Results
of Synthesis.

[2] Swift Walter B., demonstration eines Hundes, dem beide Schafenlappen
xtirpiert worden Sind. Neurologisches Centralblatt, 1910, no 13.


[*] Read at the 7th Annual Meeting of the American Psychopathological
Association, New York, May, 1915.


Corresponding Member Neurol. and Psychol. Societies of Paris, etc.
Neurologist to Freedmen's Hospital and Epiphany Dispensary, Lecturer on
Nervous and Mental Diseases, Howard University, Washington, D. C.

THERE is a general impression that the explanations of natural phenomena,
including human destinies, to which the term superstitious is given are
usually attributable to the vestiges of traditional cosmogonies of our
tribal ancestors handed down to children at the knees of their parents or
guardians. This explanation however, is only true of a portion of the
beliefs which we call superstitions. The demand for superstitious
explanations depends upon psychophysiological tendencies of the human
organism, the root of which is comprised in the affect which we call
craving. This theorem I have tried to develop as follows:--


Craving is a sign of physiological need. It is a sensory phenomenon, of
which, however, explicit awareness cannot always be discovered. It is
conspicuously noticed in cases of disturbance of the body secretions, such
as occurs in over-function of the thyroid gland. It is regarded as a crude
body-consciousness that something is the matter. In motorial organisms it
causes visible reaction: this expresses itself in what is termed
restlessness. But the unrest may show itself by a fixation more particularly
in the muscles of emotional expression, although the manifestation is not
confined to these; shallow respirations and restricted amplitude of movement
in limbs and trunk may be observed also. In cerebrate animals the reaction
of the individual is under the guidance of preceding impressions stored in
the pallium and known as memories; whereas in the animals without a pallium
all reaction is accomplished through stable mechanisms known as instincts.
Both of these types of reaction are tropisms merely; but the former are
labile, conditionable; whereas the latter cannot be modified. The science of
conditionable reactions of cerebrate animals is called psychology, and the
means by which the reactions are influenced are called psychogenetic,
whether these are healthy or diseased. It must not be forgotten, however,
that the genesis of a psychological disturbance may be purely somatic,
although the manner in which the reaction shows itself is contingent mainly
upon the features of the individual which have been derived from previous
sensory impressions and their resultant motor reactions commonly known as
experience. It is the influence of these upon the hereditary dispositions of
the individual which constitute what is known as "make-up" or character; and
it is this which determines the form which reaction to stimulus must take,
whether the stimulus is purely psychological or somatic.

Now physiological discomfort is an experience universal at one time of life
or another; but the reaction to it is infinite in variety; and while part of
it depends upon the congenital dispositions which are the common property of
humanity, a larger part is contingent upon the psychogenetic factors which
have stamped the individual.


Now an influence which has been of great significance to every human being
since the traditional period, at least, has been the concept of the universe
regnant at the period of that individual's life. The insistence by its
protagonists upon this concept as the ultimate motive of human endeavour
made its acceptance almost universal at periods when it was the custom to
lean upon the dicta of authority for guidance in life even when blind
obedience was not the rule. Now in natural affairs, inconvenient
questionings and scepticisms towards dogmatisms would ultimately reach
truth. But as inaccessibleness to verification of what was called
supernatural made authority, rather than investigation, its criterion,
excommunication from the tribe would still all criticism.[1] Thus every act
of life became permeated by motives, originated in arbitrary interpretations
of a super-nature.

[1] A dramatic study of this occurrence is presented by Grant Allen in "The
Story of Why-Why" in his book "The Wrong Paradise."

These influences were specially conspicuous concerning the difficulties of
man's almost blind struggle against the uncomprehended astronomical and
geodetic phenomena marvelled at and fled from, as well as the pestilences
which ravaged him. In his sociological affairs too, every act or thought
became embued with relationship to an extraneous power.

It is by these social and physical phenomena that the greatest appeal is
made to the states of feeling termed emotions and sentiments. So that it
became the custom to invoke, concerning ill states of feeling, the reference
to a supernatural influence. Thus, from the cradle up, the ordering of
social relationships was made dependent upon the simple expedient of the
supernatural extraneous agent, rather than upon the more difficult and
elaborate analysis and synthesis which would have been required for a proper
investigation of each perturbing circumstance in its relation to life as a
whole. The power of this influence was inversely proportional to the
resiliency and tenacity as well as the general well-being of the individual.

But not only is reference to the supernatural favoured by traditional
cosmogony, but because of certain psychological features of the individual
himself there is a tendency towards supernatural explanations of the
introspective observations. The Occasions of introspection of this kind are
two, and I am not speaking of the inculcated introspection of the moralists.
One of these Occasions is the self-examination into his conduct which is a
normal character of a thinking being. This may give rise to supernatural
explanations even when the introspection is not determined by the tradition
of which I have already spoken.

The second kind of Occasion demanding introspection, is the autochthonous
emanation of feeling of unaccustomed character. Such feelings occur at the
physiological epochs;--but at these times they are readily explained in a
familiar and simple way, and hence no supernatural agency is usually
invoked. A similar explanation is made readily enough in cases of evident
bodily disease, even where mental symptoms are prominent, for it is no
longer the custom to speak of demon-possession even in the acute deliria.
But even where no physiological epoch or clearly defined physical disease
stands forth, unusual feelings are no uncommon phenomenon, and they demand
explanation. Such occur conspicuously in the psychopathological syndrome so
completely described by Janet under the term psychasthenia. Persons thus
afflicted feeling an incapacity and an impediment to their free activity and
not recognizing that they are sick, endeavour to interpret their feelings.
Of course, the interpretation varies somewhat in accordance with the nature
of the feelings, and with the person's information about the world and his
psyche. But quite apart from modifications of this type, I have found it
very common for patients to declare "I feel as if there was another person
in me," or "I feel compelled as if by another agency to act thus." The
explanation of a supernatural agent weighing upon them becomes very easy.
For the purpose of this discussion, it is not important whether
psychasthenia arises purely from degeneration of structure, or from faults
in the chemistry of the plasma which bathes the nerve structures, or whether
it is a purely psychopathological condition to which the physical phenomena
are secondary, as some would have us believe. Our object is merely the
setting forth of the fact that it is a diseased condition which disposes its
victim towards metaphysical explanations.

It is a sort of uneasiness which prevents comfort in the feelings of
certainty, in the operations of the intellect and decision of action. The
patient finding himself abulic, and perhaps too critical minded to accept
the mundane supports in his vicinity, seeks a solace in that which to him
seems powerful because incomprehensible, that is to say in something

For this, it is not essential that the victim's mind be pervaded by the
infantine cosmogony which parades often as religious truth. Without anything
of the sort, there may arise naive interpretations, hardly even having
explicit reference to supernatural agents. For example, a patient may say
"If I begin on Friday, a certain undertaking will fail," "If I do not turn
my vest twice, misfortune will occur," "It is incumbent upon me to turn
round in my chair, or the negotiations will fail." The enumeration of
expedients would be useless. The above are from three different patients,
one a boy of fourteen now completely cured; the second from the son of a
prominent public man now quite restored to health; the third from a case
still under care. In none of these was the bodily state of importance, the
psychological reactions were the sole object of therapeutic effort, and
their ordination was accomplished by purely psychological means.


[*] Presented in abstract at the Sixth Annual Meeting of the American
Psychopathological Association, held in New York City, May 5, 1915. Being
Contributions of the State Board of Insanity, Whole Number 47 (1915. 13).
The material was derived from the Pathological Laboratory of the Danvers
State Hospital, Hathorne, Massachusetts, and the clinical notes were
collected by Dr. A. Warren Stearns, to whom I wish to express my
indebtedness but to whom no one should ascribe the somewhat speculative
character of the present conclusions. (Bibliographical Note.--The previous
contribution was State Board of Insanity Contribution, Whole Number 46
(1915.12) by D. A. Thom and E. E. Southard entitled "An Anatomical Search
for Idiopathic Epilepsy: Being a First Note on Idiopathic Epilepsy at
Monson State Hospital, Massachusetts," accepted by Review of Neurology and
Psychiatry, 1915.)


Pathologist, State Board of Insanity, Massachusetts; Director, Psychopathic
Hospital, Boston, Mass., and Bullard Professor of Neuropathology, Harvard
Medical School, Boston, Mass.


Previous work on somatic delusions. Suggestion that allopsychic delusions
are as a rule in some sense autopsychic. A genetic hint from general
paresis (frontal site of lesions in cases with autopsychic trend.) Mental
symptomatology of general paresis. Work on fifth-decade psychoses.
Statistical summary. Group with pleasant (or not unpleasant) delusions.
Three cases of senile dementia, delusions of grandeur, and frontal lobe
changes. Three cases with religious delusions. Remainder of
pleasant-delusion group. Group with unpleasant delusions. Nephrogenic

THE suggestions here put forward concerning personal (autopsychic) delusions
are based on material of the same sort as that previously analyzed for a
study of somatic and of environmental (allopsychic) delusions. Our
conclusions are also influenced by two analyses of the types of delusion
found in general paresis. Moreover, at a period subsequent to the analysis
presented here, some work on fifth-decade insanities had been completed, and
the delusional features constantly found in the functional cases of insanity
developing at the climacteric, entered to modify our general point of view.

The situation may be summed up as follows:

The accessibility to analysis of the clinical and anatomical data at the
Danvers State Hospital was such as to prompt the use of its card catalogues
for statistical work upon delusions. The more so, because in a period of
enthusiasm over the Wernickean trilogy (autopsyche, allopsyche,
somatopsyche) of conscious phenomena, the Danvers catalogue had attempted to
divide the delusions recorded into the three Wernickean groups. Putting
these clinical data side by side with the anatomical data, we were speedily
able to single out those cases with normal or normal-looking brains and thus
to secure a group approximately composed of functional cases of insanity.

It shortly developed, as to the CONTENT of delusions, that somatic delusions
were exceedingly prone to parallel the conditions found in the trunk-viscera
and other non-nervous tissues of the subjects at autopsy.) A subsequent
study has confirmed this conclusion for the distressing hypochondriacal
delusions found in climacteric insanities, which delusions, however
distressing, are often far less so than the true conditions found at
autopsy. And it may be generally stated that the clinician can get very
valuable points concerning the somatic interiors of his patients by
reasoning back from the contents of their somatic delusions.

But how far can we, as psychiatrists, reason back from the contents of
environmental delusions, e. g. those of persecution, to the actual
conditions of a given patient's environment? In a few cases it seemed that
something like a close correlation did exist between such allopsychic
delusions and the conditions which had surrounded the patient--the delusory
fears of insane merchants ran on commercial ruin, and certain women dealt in
their delusions largely with domestic debacles. But on the whole, we could
NOT say that, as the somatic delusions seemed to grow out of and somewhat
fairly represent the conditions of the some, so the environmental delusions
would appear to grow out of or fairly represent the environment.

Thus, however brilliant an idea was Wernicke's in constructing the
allopsyche (or, as it were, social and environmental side of the mind) for
the purpose of classification, our own analysis promised to show that for
genetic purposes the allopsyche was much less valuable. These delusions
having a social content pointed far more often inwards at the personality of
the patient than outwards at the conditions of the world. And case after
case, having apparently an almost pure display of environmental delusions,
turned out to possess most obvious defects of intellect or of temperament
which would forbid their owners to react properly to the most favourable of
environments. Hence, we believe, it may be generally stated that the
clinician is far less likely to get valuable points as to the social
exteriors of his patients from the contents of their social delusions than
he proved to be able to get when reasoning from somatic delusions to somatic
interiors. Put briefly, the deluded patient is more apt to divine correctly
the diseases of his body than his devilments by society.

Our statistical analysis, therefore, set us drifting toward disorder of
personality as the source of many delusions apparently derived ab extra and
tended to swell the group of autopsychic cases at the expense of the
allopsychic group,

In the statistical analysis of a group of cases corresponding roughly with
the so-called functional group of diseases, we find false beliefs about the
some on a somewhat different plane from those about the patient's self and
his worldly fortunes. We can even discern through the ruins of the paretic's
reaction that his false beliefs concerning the body are often not so false
after all, and that his damaged brain of itself is not so apt to return
false ideas about his somatic interior as about his worldly importance and
plight. There then seems to be more reality about somatic than about
personal delusions: the contents of somatic delusions are rather more apt to
correspond with demonstrable realities than the contents of personal
delusions. Accordingly our analysis of delusional contents includes a hint
also as to genesis. Taken naively, the facts suggest a somatic genesis for
somatic delusions exactly in proportion as these delusions are not so much
false beliefs as partially true ones.

What genetic hint have we for the delusions concerning personality? One
genetic hint was obtained from a correlation of delusions with lesions in
general paresis,[2] in which disease perhaps the most profound and
disastrous of all alterations of personality are found. Amidst the other
alterations of personality found in paresis, autopsychic delusions are
characteristic: indeed allopsychic delusions are conspicuously few in our
series. And, as above, the somatic delusions, fewer in number, can be
fairly easily correlated with somatic lesions, or else with lesions of the
receptor apparatus (thalamus) of the brain.

Now it was precisely the cases with autopsychic delusions, as well as with
profound disorder of personality in general, that showed the brunt of the
destructive paretic process in the frontal region. The other
not-so-autopsychic cases did not show this frontal brunt, but were less
markedly diseased at death and had a more diffuse process.

Our genetic hint from paresis, therefore, inclines us to the conception that
this disorder of the believing process is more frontal than parietal, more
of the anterior association area than of the posterior association area of
the brain. And if we can trust our intuitions so far, the perverted
believing process is thus more a motor than a sensory process, more a
disorder of expression than a disorder of impression, more a perversion of
the WILL TO BELIEVE than a matter of the rationality of a particular credo.

Again we may appear to burst through from an undergrowth of statistics into
the clear field of truism. False beliefs are more practical than
theoretical, more a matter of practical conduct than of passive experience,
more a change of reagent than a reaction to change. The man on the street or
even many a leading neurologist would perhaps accept this formula as his

Certainly in general the least satisfactory of these chapters on the nature
of delusions was the chapter on environmental effects,[3] and this perhaps
because the results seemed so nearly negative.

A further contribution to delusions of environmental nature was somewhat
unexpectedly derived from a piece of work on the general mental
symptomatology of general paresis.[4] Dichotomizing the paretics (all
autopsied cases) into a group with substantial, i. e., encephalitic,
atrophic or sclerotic lesions of the cortex and a group without such gross
lesions or else with merely a leptomeningitis, I found the latter (or
anatomically mild) group to be characterized by a set of symptoms which were
all "contra-environmental," whereas the former (or anatomically severe) did
not thus run counter to the environment. The conclusions of that paper, so
far as they concern us now, are as follows:--

The "mild" cases showed a group of symptoms which might be termed
contra-environmental, viz. allopsychic delusions, sicchasia (refusal of
food), resistiveness, violence, destructiveness.

The "severe" cases showed a group of symptoms of a quite different order,
affecting personality either to a ruin of its mechanisms in confusion and
incoherence, or to mental quietus involved in euphoria, exaltation, or

The most positive results of this orienting study appear to be the
unlikelihood of euphoria and allied symptoms in the "mild" or non-atrophic
cases and the unlikelihood of certain symptoms, here termed
contra-environmental, in the severe or atrophic cases. Perhaps these
statistical facts may lay a foundation for a study of the pathogenesis of
these symptoms. Meantime the pathogenesis of such symptoms as amnesia and
dementia cannot be said to be nearer a structural resolution, as these
symptoms appear to be approximately as common in the "mild" as in the
"severe" groups.

But in both papers dealing with paresis [2,4] we rest under the suspicion
that the delusions are possibly of cerebral manufacture. Of course, a lesion
somewhere outside the brain is not unlikely to be projected through the
diseased brain, and SOMATIC delusions in the paretic are rather likely to
represent something in the viscera.

It was desirable to get back to normal-brain material, to learn how the
INTRINSICALLY NORMAL brain[5] could perhaps produce delusions from a
particular environment. Could a particularly "bad" environment actually
PRODUCE delusions?

By chance, at about this stage in our studies of delusions, some work on
fifth-decade insanities[6] was completed. This work seemed to show that the
most characteristic (non-coarsely-organic) cases of involutional origin were
much given to delusions (each of 24 cases studied), somewhat more so than to
the hypochondria and melancholia which we commonly ascribe to the involution
period. But this result is equivocal as to the environmental (i. e.
allopsychogenic) power to produce delusions, since one could not rid oneself
of the suspicion that the delusions were due to the degenerating brain.

To return to our former results with the normal-looking brain:

Case after case of the quasi-environmental group proved to be more
essentially personal than environmental, until at last it almost seemed that
the environment could seldom be blamed for any important share in the
process of false belief. In short, we seemed to show that environment is
seldom responsible for the delusions of the insane.

Be that as it may, we secured several lines of attack on the delusions of
personality by our study of quasi-environmental delusions. First, we were
irresistibly led to a consideration of the emotional (pleasant or
unpleasant) character of the delusions. We heaped up a large number of
unpleasant delusions in that (quasi-environmental, but actually) personal
group. It is interesting to inquire, accordingly, whether our more obviously
autopsychic cases will also be possessed of an unpleasant tone. Secondly, we
came upon the curious fact that cardiac and various subdiaphragmatic
diseases were correlated with unpleasant emotion as expressed in the
delusions. It was therefore important to inquire whether similar conditions
prevailed in the new group. Thirdly, we found ourselves inquiring whether
our patients were victims of what might be termed a spreading inwards of the
delusions (egocentripetal) or a spreading outwards thereof (egocentrifugal
delusions). But this difference in trend, clear as it often is from the
patient's point of view, remains to be defined from the outsider's point of

Again, it remains to determine, if possible, how far delusions are dominated
respectively by the intellect or the emotions, or even by the volitions.

As before, I begin with a brief statistical analysis.


Danvers autopsy series, unselected cases 1000
Cases with little or no gross brain disease 306
Cases listed as having autopsychic delusions 106
Cases listed as having only autopsychic delusions 50
Cases for various reasons improperly classified 13
Cases of general paresis in which gross brain lesions were not observed 15
Residue of autopsychic cases 22

The group of 22 cases thus sifted out can be studied from many points of
view. We may recall that our former study of allopsychic delusions proved
that a large proportion of delusions concerning the environment were in all
probability not essentially derived from the environment. Their contents
might relate to the environment, but their genesis could better be regarded
as autopsychic (intrapersonal). In fact we really found only 6 out of 58
cases of pure allopsychic delusions, which could be safely taken as showing
so much coincidence between anamnesis and delusions that a correlation could
be risked.

Following the method of our former work on somatic and on environmental
delusions, we sought in the first instance PURE cases of autopsychic
delusion-information. For a variety of reasons, more than half of the
original list, namely, 28 cases, had to be excluded. Many of these
exclusions were due to the strong suspicion that the cases were really cases
of general paresis, despite the normality of the brains in the gross. The
residue of 22 cases include, we are confident, no instance of exudative
disease of the syphilitic group, though general syphilization cannot safely
be ruled out in all cases.

There are two groups of cases, a group of eleven cases with delusions of a
generally pleasant or not unpleasant character (in which group there is a
small sub-group of three cases of octogenarians with expansive delusions
reminding one of those of general paresis) and a group of eleven cases with
delusions of an unpleasant character.


The true emotional nature of the beliefs placed in this group cannot fairly
be stated to be pleasurable. But, if not pleasurable, they may perhaps be
stated to be complacent, expansive, or of air-castle type. The criteria of
their choice have been largely negative: the patients are not recorded as
expressing beliefs of a painful or displeasing character: in the absence of
which we may suppose the beliefs to be either indifferent or actually
pleasing in character.

Of the 11 cases whose delusions were supposedly of an agreeable nature or at
least predominantly not unpleasant, there were 3 with delusions reminding
one of general paresis. The ages of these three were 80, 84, and 87
respectively. They did not show any pathognomonic sign (e.g. plasma cells)
of general paresis. They all showed in common very marked lesions of the
cortex, including the frontal regions (in two instances the extent of the
frontal lesions was presaged by focal overlying pial changes) .999 was a
case of pseudoleukemia with marked cortical devastation but without brain
foci of lymphoid cells. Two of the cases showed cell-losses more marked in
suprastellate layers; in the third there was universal nerve cell
destruction, with active satellitosis caught in process.

Condensed notes concerning the cases with pseudoparetic delusions follow.
Two of them, it will be noticed, yielded some delusions also of an
unpleasant nature.

CASE I. (D. S. H. 10940, Path. 999) was a clever business man, Civil War
veteran, who began to lose ground at 75 and died at 84. He was given during
his disease to boasting and perpetual writing about elaborate real estate
schemes and said he owned a $100,000 concern for the purpose.

The case was clinically unusual in that the picture of a pseudoleukemia was
presented, with demonstration at autopsy of great hyperplasia of
retroperitoneal lymph nodes and grossly visible islands of lymphoid
hyperplasia in liver and spleen. The brain weighed 1390 grams and showed
little or no gross lesion, if we except a pigmentation of the right
prefrontal region under an area of old pias hemorrhage. There was also a
chronic leptomeningitis, with numerous streaks and flecks along the sulci,
especially in the frontal region. There was little or no sclerosis visible
in the secondary arterial branches and but few patches in the larger
arteries. Microscopically the cortex proved to be far from normal: every
area examined showed cell-loss, perhaps more markedly in the suprastellate
layers than below.

CASE 2. (D. S. H. 11980, Path. 1024) was a Civil War veteran who failed in
the grocery business, was alcoholic, was finally reduced to keeping a
boarding-house and grew gradually queer. Mental symptoms of a pronounced
character are said to have begun at 75. Death at 80. Delusions reminded one
of general paresis: worth $5,000,000 a month, 108 years old, was to build a
church: also, a woman was trying to poison him.

Autopsy showed caseous nodules in lung, coronary and generalized
arteriosclerosis (including moderate basal cerebral), mitral and aortic
stenosis (the aortic valve also calcified). The frontal pia mater was
greatly thickened and, although no gross lesions were noted in the cortex,
the microscope brings out marked lesions in the shape of cell losses
(especially in suprastellate layers) in all areas examined. There were no
plasma cells in any area examined.

CASE 3. (D. S. H. 12767, Path. 1185) was a widowed Irish woman, who died at
87. Previous history blank. Extravagant delusions of wealth were
associated with a fear of being killed.

The autopsy showed little save chronic myocarditis with brown atrophy,
calcification of part of thyroid, non-united fracture of neck of left femur,
moderate coronary arteriosclerosis. The brain was abnormally soft (some of
the larger intracortical vessels showed plugs of leucocytes possibly
indicating an early encephalitis--Bacillus cold and a Gram-staining bacillus
were cultivated from the cerebrospinal fluid.) Though the convolutions were
neither flattened nor atrophied and absolutely no lesion was grossly
visible, the cortex cerebri and also the cerebellum were found undergoing an
active satellitosis with nerve-cell destruction in all areas examined.

The following three cases (IV, V, VI) present a certain identity from their
delusions concerning messages from God (V thought he was God). It is very
doubtful whether VI should be placed in the present group of Pleasant or Not
Unpleasant Delusions, since the patient appears to have been "theomaniacal"
as the French say, in a rather passive and unpleasant manner (God occasioned
foolish actions!) Placed on general statistical grounds at first in the Not
Unpleasant group, Case VI should be transferred to the Unpleasant group.
Case V's delusion (identification with God, expression of atonement?) was in
any event episodic in a septicemia. Case IV ("happiest woman in the
world"), was phthisical (cf. VII) Notes follow:

CASE 4. (D. S. H. 4019, Path. 218) Housewife, 37 years always cheerful,
became the happiest woman in the world, hearing God's voice and being
specially under God's direction. "Acute mania." Death from bilateral
phthisis with numerous cavities and bilateral pleuritis. There were no
other lesions except a small sacral bed-sore, a small fibromyoma of the
uterine fundus, small slightly cystic ovaries, a slight dural thickening,
and possibly a slight general cerebral atrophy. (wt. app. 1205 grams,
marked emaciation.)

CASE V. (D. S. H. 11742, Path. 852) was a victim of streptococcus septicemia
(three weeks) who said he was God. Patient was a Protestant iron-worker of
59 years, who had lost an eye and had become unable to work about three
months before death. Aortic, cardiac, renal lesions at autopsy. Prostatic
hypertrophy. Dr. A. M. Barrett found few changes in nerve cells, except
fever changes. One area in left superior frontal gyrus showed superficial

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

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

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

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

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

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

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

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

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

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

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.


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.


[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.


New York, N. Y., May 5, 1915


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,

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

[1] Published in the June-July number, p. 88, of this Journal.


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

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

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.


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

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

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.


DR. E. E. SOUTHARD, Boston: Idiopathic epilepsy as found in Massachusetts
material and estimated from the appearances in the gross anatomy of the
brain occurs in about one of every three cases. There are accordingly more
idiopathic epilepsies than there are idiopathic or "functional" psychoses,
if the data of gross anatomy form a reliable index.

It was a somewhat curious thing that in a series of cases investigated by
Dr. Thom and myself, that the more frequent the attacks of epilepsy the less
there seemed to be to show for them in the autopsied brains. In certain
cases with daily attacks the brains were strictly normal in gross
appearances. It was the frankly organic cases with large focal lesions that
had the occasional attacks. These frankly organic cases rarely had high
frequency attacks.

DR. TOM A. WILLIAMS, Washington, D. C.: Will Dr. Clark explain the eccentric
convulsions such as when there is uraemia, on similar grounds? Also, if he
will postulate in such cases as recover with metabolic treatment. I have
published cases in which recurrent attacks of some years duration were
removed by means which considered only the metebolesia. (See Journal of
Neurology and Psychiatry, March, 1915.)

DR. JOHN T. MACCURDY, New York: I have held the opinion for some years that
the study of epilepsy was going to be of greater psychiatric moment than
that of any other condition. I feel that this promise has been very largely
fulfilled by the work Dr. Clark has been doing for the last two years. We
have found, I think, from that work that we can really shell out what we may
term an epileptic reaction, which is really the most primitive of all
psychiatric reaction. It corresponds to a flight from reality. It is a
return to the subjective phase, which, in the psychoses, is no vague but a
very real thing. In epilepsy we get it in pure culture as a lapse of
consciousness, expressed either in completeness as in a grand mal attack or
partially when consciousness is merely clouded. Sleep probably represents an
analogous condition. We go to sleep to repair the body while psychologically
we are seeking that flight from reality which we all long for. The

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