The Journal of Abnormal Psychology, Vol. 10
by Unknown
Hypertext Meanings and Commentaries
from the Encyclopedia of the Self
by Mark Zimmerman
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[5] Castle and Fish, Amer. Nat., Feb., 1915.

[6] Wright, S. Amer. Nat., March, 1915.

Goddard's findings as regards feeble-mindedness fit in perfectly with this
scheme. That Goddard was unaware of it when his conclusions were reached is
all the more evidence of their soundness because it shows that they were
reached independently. Among albinos every higher grade of pigmentation
dominates all the lower grades in inheritance, and so apparently it is with
mental development; the higher grades dominate the lower. At every point
there appears to be agreement in method of inheritance between albinism and
feeble-mindedness. Each is a unit character but showing graded allelomorphic
conditions which correspond probably with different stages of arrested
development of pigmentation or mentality respectively.

The fact noted by Goddard that the feeble-minded resemble savages, that is
backward races of low mentality, has much interest to the student of
evolution. It indicates that the evolution of intelligence has occurred by
a gradual progressive advancement, stages in which reappear as the higher
grades of feeble-mindedness. Of course it is not certain that the
ontogenetic stages, at which mental development may be arrested, correspond
accurately with earlier phylogenetic stages, but the idea receives
considerable support from the observed resemblance between the mentality of
morons and that of savage peoples, if the observation may be accepted as
accurate. I do not understand however that Goddard makes any claim to
first-hand familiarity with the mental life of savages, so that no great
emphasis should be laid on the point. But the mere fact that RETROGRESSIVE
variation in mentality is GRADED favors the view that its PROGRESSIVE
evolution has been gradual, rather than the view that it has arisen by
mutation or sudden loss of inhibitors. (Bateson, Davenport).

Goddard points out that a high grade moron may be a useful and
self-supporting member of society in some environments (usually rural)
whereas he would be quite helpless in the keen competition of urban life.
This suggestion leads the reader to wonder whether many peasant and peon
populations of the old and new world represent survivals of an older and
lower grade of mental evolution than has been attained in the more advanced
nations, or whether it is merely lack of opportunity that makes these
populations backward. The fact that in every generation great men come from
the lower social levels shows that the lower classes are not entirely devoid
of capacity; nevertheless it seems probable that a low grade of intelligence
would stand a better chance of escaping elimination in the struggle for
existence when placed in a simple environment than when placed in a complex
one. Consequently, under modern conditions, we might expect a peasant or
peon population to average lower in mental capacity than a community more
advanced in civilization. Whether the peasant population would equal in
average intelligence a band of North American Indians or a tribe of native
New Zealanders is very doubtful, for in such peoples natural selection for
intelligence was undoubtedly severe because of their intense struggle with
nature and with other tribes, unaided by the accumulated knowledge and tools
of civilized communities. Among such peoples greater demands were probably
made on inborn intelligence than among modern industrial populations.

As regards the CAUSES of feeble-mindedness Goddard's findings are wholly
negative, but not less valuable on that account. His case histories
statistically studied indicate no causal relation to a number of reputed
agencies in the creation of feeble-mindedness, such as alcoholism (which he
regards as oftener a symptom than a cause), tuberculosis, sexual immorality,
insanity, syphilis, accident and consanguinity. He recognizes HEREDITY as
its principal source, i. e. he recognizes feeble-mindedness as a stage of
mentality already existing and transmissible by the ordinary mechanism of
heredity, but does not attempt further to account for it, either as a
survival or as an atavism.

That humanitarian governments by shielding and supporting the moron without
putting a limit on his naturally high reproduction will speedily increase
this class at the expense of the more intelligent classes of the community
is self-evident, if it is admitted that feeble-mindedness is hereditary, as
all who have investigated the matter carefully now declare. Goddard shows
further that a large percentage (probably more than half) of the alcoholism,
pauperism, prostitution, and crime, of the United States are directly
traceable to hereditary feeble-mindedness, another strong reason for taking
measures to reduce it.

How is this to be done? Goddard has no cure-all to offer but urges first of
all that the mental grade of each individual be accurately determined and
education and occupation be provided suited to his capacity. This will tend
to make the moron a useful and contented member of the community, not a
menace to it. Segregation is recommended so far as practicable, but in view
of the large number (estimated at 300,000 to 400,000 in the U. S.) Goddard
considers segregation of all impracticable. Nevertheless he urges further
and energetic efforts in this direction, that as many as possible may be
segregated as a safeguard against their reproduction. In individual cases
"sterilization wisely and carefully practiced" must be employed to insure
non-reproduction.

In this volume there is a pleasing absence of the rant which pervades some
eugenic literature. The author has something of importance to contribute to
science and he presents his contribution in a sober, dignified manner in
keeping with the important character of his contribution. W. E. CASTLE.

CHRISTIANITY: THE SOURCES OF ITS TEACHING AND SYMBOLISM. By J. B. Hannay.
(Francis Griffiths, London; pp. 394).

This is an attempt to expound the symbolism of the Christian religion. It is
divided into three main parts: ancient cults (phallism and sun worship);
ancient cults in the Old Testament; ancient cults in the New Testament. The
author's main thesis can be stated in a sentence: the essential constituents
of every religion, and the underlying meaning of its symbolism, are
phallicism and sun worship. Of these the former is the more important, more
primary, and more wide-spread; the latter is a superimposed layer better
adapted to more civilized and educated people, but rarely penetrating into
the hearts of the common people to the extent that the former has. "The
great branches under which all the religious systems of the past have
developed may be classed as based, on the one hand on the consideration of
our world and the continuity of life upon it, expressed in Phallic
symbolism, and on the other hand, on the Sun as the great giver and
sustainer of man, expressed in Solar symbolism." (p. 21). "As the Phallic
cult was much the older, it retained its position after the rise of the
Solar cult. It required a much higher intelligence to grasp the facts of
Solar worship, so it never entered the 'hearts' of the common people as did
the Phallic worship, but it had a much more intelligent priesthood, and was
the arbiter in all questions of dates, and regulated al) feasts; and, what
was more important to the people, fixed the time for payments of debts or
interest, and regulated the times of sowing and harvesting, so it became a
much more 'official' religion than Phallism."  In support of these
conclusions the author marshals a huge number of facts, so that the work
becomes a veritable encyclopaedia of symbolism.

Now in spite of the fact that the reviewer fully accepts the main thesis of
the book, as stated above, and therefore has no prejudice or hostility on
the score of the conclusions encunciated being distasteful, his judgment of
the book is entirely unfavourable, for the following reasons: In the first
place, any presence of the book to be a scientific, and therefore impartial,
contribution to knowledge is invalidated by the author's moral bias evident
from beginning to end, against religion in general, and Christianity in
particular, which he maintains is the most phallic of all religions. His
point of view is that of the older rationalists, to whom religion is nothing
but an unfortunate instinct for "delight in the miraculous," expressing
itself in phallic and sun worship, and fostered by the exploiting tendencies
of priests. His desire seems to be, in writing the book, to "show up"
religion and, by discrediting it, hasten its end.

In the second place, there is not a single new idea in all its closely
packed pages, and therefore no excuse for writing them, since the material
here laboriously brought together is easily accessible in other books. It
never seems to dawn on the author that pointing out the sexual basis of
religion, which countless other writers have already done, is but the
beginning of the problem, the starting-point of all sorts of complex
riddles. Having dogmatically divided all religious symbols into male and
female, he is self-satisfied enough to think that he has explained religion.
There is no inkling of the points of view suggested by such words as
determinism, significance, genesis, so familiar to the modern psychologist.

Side by side with all this goes a disorderly arrangement and very imperfect
powers of criticism. The latter feature is especially marked in the field
of etymology, where the author fairly lets himself run wild. The following
gem is a typical example (p. 110): "Bacchus became degraded into the God of
Wine, and his fetes became drunken orgies, but he was originally the
beneficent sun who ripened the fruits, and hence God of Wine, from which,
indeed, is derived the English name of all our gods, angels, prophets, or
even parsons,--"divines," "dei vini," "Gods of Wine."  Jesus was the "True
Vine."

The merits of the book are that it may direct the attention of some people
to the connection between sex and religion, if there are any who are still
unaware of this, and that it possesses a good index that may be useful to
readers with limited facilities for looking up particular symbolisms; it is
also well illustrated. ERNEST JONES.

LAUGHTER: AN ESSAY ON THE MEANING OF THE COMIC. Henri Bergson. Translated
by C. Brereton and F. Rothwell. (Macmillan, London, 1913. Pp. 200).

In this stimulating little book Professor Bergson propounds his theory of
the comic, which is shortly to the following effect. Noting first that
laughter is purely a human phenomenon, and therefore probably has a social
significance, he seeks for this by trying to define what are the essential
features of the comical. He reduces the various characteristic features in
the main to one, namely, automatism on the part of the comical person or
thing. This automatism is of a special kind; especially is it an automatism
that is out of place, that occurs at the expense of spontaneity, vitality,
and freshness. It may thus be defined as "something mechanical in something
living," "a kind of absentmindedness on the part of life."  "The comic is
that side of a person which reveals his likeness to a thing, that aspect of
human events which through its peculiar inelasticity, conveys the impression
of pure mechanism, of automatism, of movement without life."  "To imitate
anyone is to bring out the element of automatism he has allowed to creep
into his person. And as this is the very essence of the ludicrous, it is no
wonder that imitation gives rise to laughter. "This bald statement of
Bergson's conclusion is, in the reviewer's opinion, made very convincing by
the delicate analysis he proffers of numerous illustrations.

Up to this point Bergson's theory of the comic fairly well coincides with
that of Freud. The latter author, it is true, summarises his conclusions in
different language. But the meaning is not very different. For him the
feeling of comicality is an "economy of ideational expenditure," and it is
evoked by the sight of another person who in a given performance displays
either a lack of mental activity or an excess of physical, i.e., who is
either stupid or clumsy. Compare this formulation with Bergson's. The latter
says that the opposite of the comic is gracefulness, rather than beauty. "It
partakes rather of the unsprightly than of the unsightly, of rigidness
rather than of ugliness."  The replacement of mental by physical activity is
insisted on in the following passage: "Any incident is comic that calls our
attention to the physical in a person, when it is the moral (i. e. mental)
that is concerned." Again, he compares a comical person to "a person
embarrassed by his body."  His automatism is essentially a lack of mental
nimbleness, a formal lack of mental elasticity, a defective capacity for
rapid adjustment, in short, a mental laziness. And especially is this defect
one of consciousness. The failure is on the part of the higher mental
activities, which should be the most alert, and what happens is a relapse
into unconscious, automatic modes of functioning, a form of absentmindness.
"The comic is that element by which the person unwittingly betrays
himself--the involuntary gesture or the unconscious remark. Absentmindedness
is always comical. Systematic absentmindedness, like that of Don Quixote,
is the most comical thing imaginable . . . . . . . No one can be comical
unless there be some aspect of his person of which he is unaware, one side
of his nature which he overlooks; on that account alone does he make us
laugh."

In substantial agreement on this general conclusion as to mental rigidity
and bodily clumsiness, the two views diverge from here. According to
Bergson, the comic presupposes "something like a momentary anaesthesia of
the heart;" "laughter is incompatible with emotion." For Freud this absence
of emotion is much more characteristic of humour than of the comic, two
matters that Bergson quite fails to distinguish. Then, whereas Freud
explains the subjective side of the comic purely on hedonic principles,
Bergson sees in it an important social function. According to him, laughter
is one of society's weapons for dealing with tendencies that threaten to
diverge from the conventional and accepted norm. It "restrains eccentricity"
and "corrects unsociability." "Any individual is comic who automatically
goes his own way without troubling himself about getting into touch with the
rest of his fellow-beings. It is the part of laughter to reprove his
absentmindness and wake him out of his dream . . . . Each member must be
ever attentive to his social surroundings; he must model himself on his
environment; in short, he must avoid shutting himself up in his own peculiar
character as a philosopher in his ivory tower. Therefore society holds
suspended over each individual member, if not the threat of correction, at
all events the prospect of a snubbing, which, although it is slight, is none
the less dreaded. Such must be the function of laughter. . . . It represses
separatist tendencies."  "Unsociability in the performer and insensibility
in the spectator--such, in a word, are the two essential conditions." This
interesting theory leaves some questions unanswered. Why, for instance,
should onlooking society remain emotionally cold in one case, and merely
laugh, and in another case adopt much graver measures? Bergson deals with
this point rather imperfectly. It is not the seriousness of the case that
decides, for "we now see that the seriousness of the case is of no
importance either: whether serious or trifling, it is still capable of
making us laugh, provided that care be taken not to arouse our emotions."
Nor is it the immoral nature of the deviation from the normal. "The comic
character may, strictly speaking, be quite in accord with stern morality.
All it has to do is to bring itself into accord with society."  "It is the
faults of others that make us laugh, provided we add that they make us laugh
by reason of their UNSOCIABILITY rather than of their IMMORALITY."  The most
specific criterion seems, in Bergson's opinion, to be that of vanity. "It
might be said that the specific remedy for vanity is laughter, and that the
one failing that is essentially laughable is vanity."

We may briefly refer to some other matters dealt with more incidentally;
wit, and the relation of the comic to art and to dreams. The discussion of
wit is perhaps the weakest part of the book. No analysis is given of the
different forms of wit, and the important subject of what may be called its
technique is quite passed by. Wit is identified in a superficial manner with
the comic in general, the fundamental differences between the two, which
Freud has dealt so exhaustively with, being altogether ignored. Bergson
gives a more interesting and profitable study of the relation of the comic
to art; especially of the nature of comedy as distinct from other forms of
drama. According to him, comedy portrays character types rather than
individual persons. He repeatedly insists on this point, adding that "it is
the ONLY one of all the arts that aims at the general; so that once this
objective has been attributed to it, we have said all that it is and all
that the rest cannot be."  Further, "comedy lies midway between art and
life. It is not disinterested as genuine art is. By organizing laughter,
comedy accepts social life as a natural environment, it even obeys an
impulse of social life. And in this respect it turns its back upon art,
which is a breaking away from society and a return to pure nature. "The
discussion of the relation of the comic to dreams is, on the other hand,
less satisfying. Comic absurdity is stated to be of the same nature as that
of dreams. The main point of resemblance seems to be that in both cases
there occurs an absence of social contact. In both there is a mental
relaxation from the effort of "seeing nothing but what is existent and
thinking nothing but what is consistent." This really applies much more to
wit than to the comic itself.

As may be expected, the whole book is written in Professor Bergson's
pleasing style, and is full of suggestive hints and fresh points of view.
The most significant contribution, one which pervades the book throughout,
is the view of laughter as a social censor. Even if this hypothesis is
substantiated by detailed investigation, however, it cannot rank as a
complete theory of laughter, or of the comic, until it is supplemented by
some explanation, not given by the author, of the most striking feature of
laughter, its capacity for yielding pleasure.

It only remains to say that the translation is literally excellent. ERNEST
JONES.

ADDRESSES AND PAPERS AT THE OPENING OF THE PHIPPS PSYCHIATRIC CLINIC, JOHNS
HOPKINS HOSPITAL. The American Journal of Insanity, Special Number, Vol.
LXIX, No. 5. The Johns Hopkins Press, 1915.

This special number of the American Journal of Insanity contains the
exercises and papers delivered at the opening at the Phipps Psychiatric
Clinic at the Johns Hopkins Hospital, Baltimore, Md. The contents of the
entire volume should prove to be of the greatest interest to all students
and lovers of psychiatry. The volume opens with a brief but fitting
Introduction by Dr. Adolf Meyer, Director of the Clinic, a man to whom
American psychiatry owes so much for the stimulus and inspiration which he
has injected into others. This is followed by A Word of Appreciation by
Henry D. Harland, President Trustees, The Johns Hopkins Hospital, some brief
remarks on The Psychiatric Clinic and the Community by Stewart Paton, the
heart-to-heart talk on Specialism in the General Hospital by Sir William
Osler, and a short talk on The Purpose of the Psychiatric Clinic by Prof.
Adolf Meyer. There then follow a series of fascinating and inspiring
papers, as follows: The Sources and Direction of Psychophysical Energy, by
William McDougall; Autistic Thinking by E. Bleuler; Personality and
Psychosis by August Hoch; The Personal Factor in Association Reactions by
Frederic Lyman Wells; A Study of the Neuropathic Inheritance by F. W. Mott;
On the Etiology of Pellagra and its Relation to Psychiatry by O. Rossi;
Psychic Disturbances Associated with Disorders of the Ductless Glands, by
Harvey Cushing; Primitive Mechanisms of Individual Adjustment by Stewart
Paton; Demenzprobleme by K. Heilbronner; The Inter-relation of the
Biogenetic Psychoses by Ernest Jones; Prognostic Principles in the
Biogenetic Psychoses, with Special Reference to the Katatonic Syndrome by
George H. Kirby; Anatomical Borderline between the So-called Syphilitic and
Metasyphilitic Disorders in the Brain and Spinal Cord by Charles B. Dunlap;
and Mental Disorders and Cerebral Lesions Associated with Pernicious Anemia
by Albert Moore Barrett. The number is concluded by the penetrating Closing
Remarks of Prof. Adolf Meyer.

The papers by Mott, Rossi, Cushing and Heilbronner are of the greatest
interest. The discussions by McDougall and Bleuler are fascinating and
uplifting. McDougall's paper is a masterpiece. Kirby, Jones and Hoch
present us with the modern standpoints in the conception of the psychoses.
Throughout the volume one sees the adoption of the broad biological
standpoint in mental life. The adoption of the term "biogenetic psychoses"
is indicative of the general trend. The adoption of this well-chosen phrase
is, I venture to suggest, the product of Dr. Meyer.

The reviewer regrets that the papers do not very well lend themselves for
brief reviews. Furthermore, he would not attempt to briefly present the
views which have been so lucidly and succinctly expressed by the individual
writers.

Prof. Meyer is to be commended for the very splendid program presented at
the opening exercises of the Phipps Psychiatric Clinic.

May it be a lasting inspiration for those who drink at the fountain of
psychiatry and psychopathology. MEYER SOLOMON.

BOOKS RECEIVED

SLEEP AND SLEEPLESSNESS. By H. Addington Bruce. Pp. IX + 219. Little, Brown
& Co., 1915. $1.00 net.

THE MEANING OF DREAMS. By I. H. Coriat. Pp. XIII + 194. Little, Brown &
Co. $1.00 net.

THE JOURNAL OF ABNORMAL PSYCHOLOGY

A PSYCHOLOGICAL ANALYSIS OF STUTTERING[*]

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

1915 by Richard G. Badger.

BY WALTER B. SWIFT, A.B., S.B., M.D.

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

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

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

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

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

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

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

1. PSYCHOLOGICAL ORIENTATION TESTS ON STUTTERERS:

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

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

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

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

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

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

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

2. PSYCHOLOGICAL ORIENTATION TESTS ON NORMAL INDIVIDUALS

The results of these orientation tests upon normal individuals were as
follows:

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

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

3. THE RESEARCH, ITS OBJECTS AND METHODS:

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

To what extent is visualization weak?

Is it weaker in the worst cases?

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

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

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

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

Lastly, numerous other minor queries presented themselves.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Stutterers gain in visualization as they approach cure.

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

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

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

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

FAULTY VISUALIZATION EXPLAINS ALL PHENOMENA:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

REFERENCES

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

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

THE ORIGIN OF SUPERNATURAL EXPLANATIONS[*]

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

BY TOM A. WILLIAMS, M. B., C. M. (EDINBURGH)

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

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

I

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

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

II

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

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

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

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

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

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

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

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

DATA CONCERNING DELUSIONS OF PERSONALITY WITH NOTE ON THE ASSOCIATION OF
BRIGHT'S DISEASE AND UNPLEASANT DELUSIONS.[*]

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

E. E. SOUTHARD, M. D.

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

ABSTRACT

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

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

The situation may be summed up as follows:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

As before, I begin with a brief statistical analysis.

SUMMARY

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

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

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

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

I. CASES HAVING DELUSIONS OF A NATURE PLEASING OR NOT UNPLEASING TO THE
BELIEVER

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

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

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

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

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

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

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

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

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

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

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

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

CASE VI. (D. S. H. 5345, Path. 867) was a "primary delusional insanity," a
salesman of 37 years, whose beliefs concerned impressions direct from God,
in consequence of which he habitually knelt and prayed. Yet many of the
actions which he felt he must perform were foolish actions. The patient
died of pneumococcus septicemia during a lobar pneumonia. The brain showed
a few changes suggestive of fever (A. M. Barrett). There were a few flecks
of atheroma in the aorta. There was an acute parenchymatous nephritis with
focal plasma cell infiltrations suggesting acute interstitial nephritis.
This case appears to have shown one of the most nearly normal brains in the
whole Danvers series.

The remainder of the Pleasant or Not Unpleasant Group as originally
constituted consists of VII, a phthisical case (cf. IV), VIII, probably
feeble-minded romancer, not deluded in the sense of self-deception (probably
best excluded from present consideration); IX, probably not safely to be
assigned to the Pleasant or Not Unpleasant Group, feeling passive in
somewhat the same sense as Case VI (see above), suffering from auditory
hallucinosis (superior temporal atellitosis, data of the late W. L.
Worcester); X, delusion of birth to superior station, possibly the object of
mixed emotions, probably not pleasant; and XI, manic-depressive exaltation
with grandiose utterances, long prior to death (if there had been lung
tuberculosis at the basis of the ileac ulcers, it had long since healed).

Notes follow (VII-XI) and at the end a brief summary of the entire group
(I-XI).

CASE 7. (D. S. H. 8878, Path. 521) It is questionable whether the delusions
classified in this case entitle it to inclusion in the present study. e.g.
"I was baptized in the Catholic Church (patient a Protestant housewife) with
holy water, ink, and Florida water."  Patient was variously designated, as
"dementia" and as "acute confusional insanity." Death in second attack at 26
(first attack at 22). Father also insane. Death due to bilateral ptthisis
with tuberculosis of intestines and mesenteric glands, emaciation. It is
noteworthy that the brain weighed but 1038 grams. Dr. W. L. Worcester's
microscopic examination showed acute nerve cell changes probably of the type
of axonal reactions.

CASE 8 (D. S. H. 8807, Path. 556) very probably a feeble-minded subject. At
all events patient had done no work in his life, had been given to spells of
restlessness and excitement, and had talked disconnectedly. Symptoms were
thought to have dated from the tenth year. It is questionable whether a
statement that he was managing the Electric Railway and Shipbuilding Company
can be regarded as delusional, that is, as believed by the patient. Death
was due to (perhaps septicemia from one abscess of jaw and to hypostatic
penumonia), the brain appeared normal but Dr. W. L. Worcester found, besides
certain acute changes, also satellitosis. The question remains open whether
the case should be regarded as defective or as belonging to the dementia
praecox group.

CASE 9. (D. S. H. 8605, Path. 568) had an ill-defined attack of mental
disease and was in D. S. H. at 29. Thereafter, lived in Gloucester
Almshouse, but at 51 became excited and was returned to D. S. H. where she
died at 59. Possibly hallucinated: someone called her mother (single
woman). Delusion: the spirit is here (Protestant). Patient was given to a
stream of muttered, vulgar and incoherent talk. Possibly the case was
residual from hebephrenia. Dr. W. L. Worcester found cell changes in the
superior temporal gyri (finely granular stainable substance in practically
all nerve cells) and not elsewhere. The correlation is suggestive with the
probably auditory hallucinosis. The brain weighed 1190 grams. Death due to
bronchopneumonia. Heart and kidneys normal.

CASE 10. (D. S. H. 10145, Path. 928) a Danish fisherman possibly
manic-depressive, victim of three attacks at 40, 50, and 69 years. The first
attack followed loss of wife, and delusions concerning being born again
developed. The last attack showed few well-defined delusions, as patient
was in a bewildered and incoherent state. One statement is characteristic:
if patient had remained in Denmark, he might have inherited the throne. The
autopsy showed most extensive arteriosclerosis, including basal cerebral.
Death from general anasarca and jaundice. (cholelithiasis). There was some
question of an acute encephalitic lesion in the tissues lining the posterior
half of the third ventricle. Various chronic lesions (splenitis,
endocarditis, diffuse nephritis), malnutrition.

CASE 11. (D. S. H. 7767, Path. 792) was a case possibly of manic-depressive
type (previous attacks Hartford Retreat and Danvers State Hospital) who
worked as machinist between attacks and died at 70, having been in D. S. H.
8 years. Patient was greatly emaciated and anemic from chronic ulcers of
ileum. There was also cholelithiasis. There was a mild coronary atheroma
and slight mitral valve edge thickening.

The delusions expressed were those of great wealth. Patient also thought he
was a great poet. No brain changes were found (A. M. Barrett).

Having attempted on the basis of certain statistical tags to constitute a
group of cases having relatively normal brains and pleasant (or not
unpleasant) delusions, we are forced to reconstruct our group upon viewing
several cases more attentively.

Case VIII should be excluded as probably not delusional.

Case X might perhaps be transferred with propriety to the
unpleasant-delusion group.

Certain cases of felt passivity under divine influence separate themselves
out from the group; indeed VI and IX probably belong in the
unpleasant-delusion group (see below).

These subtractions leave seven cases to deal with. Three of these seven,
viz. I, II and III, are apparently best regarded as examples of frontal lobe
atrophy, and their grandiosity may resemble that of certain cases of general
paresis.

Of the remaining four, two, Cases IV and VII, are phthisical; one, Case VI,
showed an episodic identification with God (incident in fatal septicemia),
and one, Case XI, uttered manic-depressive exalted statements about wealth
and poetical power.

I turn to a consideration of the unpleasant-delusion group, which as first
constituted was to contain eleven cases (XII-XXII) but to which must be
added three more (VI, IX, X).

Case XII should be at once excluded from present consideration on account of
its microscopy.

CASE 12. (D. S. H. 12282, Path. 942) died in a second attack of depression
(manic-depressive insanity?). Catholic, always of a quiet and reserved
disposition, happy in married life. Delusional attitude concerning an
abortion which she said she had induced. "Soul lost," "I'll see hell."

Autopsy: Death from gangrene of lung and acute fibrinous pericarditis.
Erosion of cervix uteri. The edema of the brain, irregular pink mottlings
of white substance, and an exudative lesion of one focus in the pia mater of
the right side suggested an encephalitis more marked on the right side.
Microscopically a few small vessels showed plugs of polynuclear leucocytes.
The nerve cells were affected by various acute changes. The visuo-psychic
portion of an occipital section (right) showed suprastellate cell-losses of
a somewhat focal character

Of the remaining ten (XIII-XXII), one, Case XIII is another of mixed
emotions ("am Eve and have to suffer;" "in Purgatory;" etc) of a religious
type. It is the only case in the unpleasant group with phthisis pulmonalis,
(combined, however, with abdominal tuberculosis and nephritis).

CASE 13. (D. S. H. 7361, Path. 499) was a somewhat defective Catholic woman
(mother insane) always of a melancholy and reserved temperament. She had
been ill-treated by husband, child had died, another had followed soon. She
developed a belief that she was Eve and had to suffer. At hospital decided
that she was in purgatory and expressed a variety of other religious
beliefs. She also thought she was ill-treated at hospital. Her head was
asymmetrical: skull thick and eburnated. Brain (1130 grams described as
normal). Chronic interstitial nephritis. Pulmonary and mesenteric
tuberculosis.

Of the remaining nine (XIV-XXII) all had grossly evident kidney lesions
except two (XIV and XV). Of these two, XIV probably had renal
arteriosclerosis and was in any case very gravely arteriosclerotic in
general and suffered from cystitis. Case XV died apparently of starvation
with hepatic atrophy; it is a question whether "poverty" was or was not a
delusion. Notes of XIV and XV follow:

CASE 14. (D. S. H. 8741, Path. 500) was a German teacher, college-bred, of
a reserved and melancholy turn of mind (mother insane). An attack at 39,
another at 70. "Both poor wife and son will starve." "Perhaps they should
be put out of reach of poverty," later felt he "had caused death of wife and
son on account of his expensive living."  Autopsy: chronic internal
hydrocephalus, cerebral arteriosclerosis. Brain weight 1180 grams. Coronary
sclerosis with calcification throughout, aortic and pulmonary valvular
calcification hypertrophy of heart. Cystitis.

CASE 15. (D. S. H. 4454, Path. 237) was presumably a manic-depressive case,
had in all four attacks, and died in the fourth attack (66 years). The day
he arrived at the hospital, having not eaten for several days at the end of
several months of delusions of poverty the case was called "acute
melancholia," and the cause of death assigned was starvation. The liver
weighed 1102 grams and was fatty. There was a diffuse thickening and
clouding of the pia mater, and the dura was firmly adherent everywhere to
the skull.

Notes follow of seven cases (XVII-XXII) which show many lesions, are in a
number of instances cardiorenal and in all instances renal. If it is
permitted to count XIV also as renal, a list of eight cases out of the
original list of eleven unpleasant-delusion cases is obtained in which
nephritis of some type has been found. Case XIII, nephritis and phthisis,
belongs also in the renal group.

CASE 16. (D. S. H. 4168, Path. 226) feared death and refused food on the
ground that she should not eat. Patient had always been of a despondent and
reserved nature (sister also insane) and, after her husband's death, when
she was 53, grew unable to carry on her house, dwelt constantly on griefs,
entered hospital at 61, and died at 64 ("chronic melancholia"). Death from
internal hemorrhagic pachymeningitis. The liver of this case weighed 1074
grams and was fatty. There was chronic interstitial nephritis.

CASE 17. (D. S. H. 4707, Path. 498) originally cheerful and frank, lost her
situation as companion, grew despondent at failure to get employment, had a
"hysterical" attack at 52. It is doubtful whether her beliefs were
delusional: "can never be better," "will not be taken care of," "no place
for her." "Subacute melancholia. "The autopsy showed gastric dilation (over
3000 cc.), and an atrophic liver and pancreas, and slightly contracted
kidneys. The heart was normal. Death from ileocolitis. Moderate chronic
internal hydrocephalus. Dr. W. L. Worcester's microscopic examination showed
rather unusual degrees of nerve cell pigmentation (precentral and
paracentral).

CASE 18. (D. S. H. 8898, Path. 570) was an unmarried daughter of a fire
insurance company president. Both her mother and she developed mental
disease after the company failed (Boston and Chicago fires). Both mother and
father died, and patient was in several hospitals after 36, obscene,
denudative, onanist. Delusions concerning crimes committed. Satyriasis.
Could hear fire kindled to burn her. Diagnosis, "secondary dementia."

Death at 54 from bilateral bronchopneumonia. Atrophic uterus. Cystic right
ovary with twisted pedicle: atrophic left ovary: contracted kidneys. The
brain was not abnormal in the gross-- but showed (Dr. W. L. Worcester) some
acute changes (also larger cells pigmented).

CASE 19. (D. S. H. 10106, Path. 663) a cheerful Irish house-wife (mannerism
of drawling words) underwent a maniacal attack at 41, and another at 44.
Delusions: "sorry she had lived": "broken her religion" Given to self
recrimination.

Autopsy: Death from hypostatic penumonia. Healed gastric ulcer. Moderate
arteriosclerosis, slight cardial hypertrophy. Granular cystic kidneys.
Mucous polyp and subperitoneal fibromyoma of uterus. The brain was
macroscopically normal, but showed superficial gliosis (frontal and
precentral) and thinning out of medullated fibers superficially (frontal).

CASE 20. (D. S. H. 8963, Path. 679) an epileptic shoe-maker, 50 years, was
of the belief that he was sent to Hospital for hitting a boy and was to be
executed.

Autopsy: Aortic and innominate aneurysm, hypertrophy and dilatation of
heart. Interstitial nephritis. The brain, normal macroscopically, proved
microscopically to show, in all areas examined, superficial gliosis. There
was gliosis in parts of the cornu ammonis, but no demonstrable nerve cell
loss (interesting in relation to the epilepsy).

CASE 21. (D. S. H. 4584, Path. 861) cabinet-maker of melancholy
temperament, Civil War veteran. Said to have been feeble-minded after six
months in rebel prison. Violent at times for twenty years. Did no work,
thought "soul lost."

Death from pneumococcus and streptococcus septicemia. Chronic diffuse
nephritis. The brain was described grossly as normal: but microscopically
there was marked superficial gliosis in all areas examined and considerable
cell loss in suprastellate layers of precentral cortex. The calcarine
sections show little or no cell-loss. But one section from the frontal
region is available (right superior frontal). This shows little cell-loss
except in the layer of medium-sized pyramids.

CASE 22. (D. S. H. 8250, Path. 909) an unmarried woman without occupation,
two attacks of "melancholia" at 36, and 40. Always of a retiring and shy
disposition. Mental disease began after father's death. Delusions (if
such): has been selfish and wicked. Constant self condemnation. Suicidal.
Exophthalmic goiter.

Autopsy: Thyroid glandular hyperplasia. Mitral sclerosis. Aortic sclerosis
with ulceration. Chronic endocarditis. Chronic diffuse nephritis. Scars of
both apices of lungs, with small abscess of left apex. Emaciation. Brain
weight 1050 grams. No gross lesions described; microscopically profound
alterations; extreme or maximal cell-losses in small and medium-sized
pyramids in both superior frontal regions. Smaller somewhat less marked
cell-losses elsewhere.

Upon reviewing the unpleasant-delusion group, then, we exclude one (XII)
altogether. It is questionable whether XV actually exhibited delusions at
all. We then discover that eight (in all probability all) of our nine
remaining cases are renal in the sense of grossly evident lesions at
autopsy.

But it will be remembered that we transferred three cases originally thought
to entertain "not-unpleasant" delusions to the unpleasant group, because
their constraint, although conceived to be of divine origin, seemed to be
unpleasant (VI, IX, X). Of these VI and X were renal cases; but IX is
expressly stated by a reliable observer (the late Dr. W. L. Worcester) to
have had normal kidneys as well as heart. In point of fact, however, Case IV
had hallucinations and religious delusions ("spirit is here") probably
derived therefrom, and Dr. Worcester found an isolated brain lesion
correlatable with the hallucinosis; and in any event the emotional state of
the patient is in grave doubt.

Accordingly if we take the unpleasant-delusion group to be constituted of
Cases VI and X (transfers from the first group), XIII, XIV, and XIV to XXII,
that is eleven cases, we come upon the striking fact that virtually all of
them are renal cases.

Of course, as (with Canavan) I have been at some expense of time to prove,
virtually ALL cases of psychosis (as autopsied) are in a microscopic sense
abnormal as to kidneys.[7] But only about a third exhibit GROSS interstitial
nephritis, arguing a certain severity of process. The above cases, it will
be observed, fall into the GROSS class in respect to renal lesions.

Without laying too much stress on such results, it is worth while to say
that, whereas most workers might be willing to surmise that metabolic or
catabolic disorder must affect the sense of well-being, I must confess that
the discovery of so much gross kidney disease in a group selected on other
grounds filled me with a certain surprise.

The literature is not without suggestions as to the possible correlation of
renal and mental disorder. Ziehen,[8] for example, remarks that nephritis
brings about mental disease in two ways,--through vascular changes which
very frequently accompany chronic nephritis and other uremic changes in the
blood. Inasmuch as we know that creatin, creatinin and potassium salts
irritate the animal cortex, Ziehen notes that psychopathic phenomena may
occur in man as a result of slight uremic changes. According to Ziehen, most
of these nephritic psychoses run the course of what he calls hallucinatory
paranoia (it may be remembered that Ziehen counts among paranoias a number
of acute diseases and even so-called Meynert's amentia). Chronic nephritis,
as well as acute diabetes and Addison's disease are thought by Ziehen to
produce certain chronic forms of mental defect which he terms autotoxic
dementia, but he regards most of these cases as really cases of
arteriosclerotic dementia.

It does not appear that Wernicke[9] has considered renal correlations
systematically.

Kraepelin[10] mentions the epileptiform convulsions of uremia as well as
delirious and comatose conditions, especially those in advanced pregnancy.
These uremic conditions may be both acute and chronic. But Kraepelin has
not been able to convince himself of the existence of a clearly defined
uremic insanity unless the delirious condition just mentioned may be
regarded as such

Binswanger[11] states that the mental disorders occurring in acute and
chronic nephritis are either toxemic psychoses on uremic bases, or due to
arteriosclerosis. In the latter cases, he states that the disease pictures
are as a rule characterized by grave disturbances of emotions, chiefly of a
depressive character. He adds that these are all too frequently the
forerunners of arteriosclerotic brain degeneration.

A brief mention of renal disease in the general etiology of mental disease
is made by Ballet.[12] Ballet states that Griesinger's opinion that renal
disease had little importance in the etiology of mental disease and that no
one would count the cerebral symptoms of Bright's disease as mental is no
longer held. Ballet enumerates a number of works upon so-called folie
brightique which tend to prove that acute or chronic Bright's disease gives
rise either to melancholic disorder or alternately to maniacal and
melancholic disorder. How the mental disease is produced is doubtful.
Ballet holds that all the various psychopathic disorders resulting from
Bright's disease are autotoxic. Renal disease like heart disease is only
capable of awakening a latent predisposition or liberating a constitutional
psychosis, unless it is merely effecting a species of intoxication.

It cannot be doubted that the relation of kidney disorder to mental disorder
is worth intensive study, of which the present communication is merely a
fragment. Progress will be of course impeded by the fact that upon
microscopic examination, practically all cases of mental disease coming to
autopsy show renal disease of one or other degree; in fact, it is perhaps
possible to show a higher correlation of renal disease with mental disease
than of brain disease to mental disease. Perhaps something can be obtained
if we limit ourselves to a study of cases with pronounced somatic renal
symptoms and signs, cases with the renal facies and the like.

As to the question of phthisis and mental disease, Ziehen remarks that the
tuberculous are often observed to be optimistic but that other cases show a
hypochondriacal depression with egocentric narrowing of interests. He
speaks of a sort of rudimentary delusional disorder looking in the direction
of jealousy in certain cases. Pronounced mental disorder occurs rarely in
tuberculosis, according to Ziehen, and leads either to melancholia or to
hallucinatory states of excitement, resembling the deliria of exhaustion or
inanition. Acute miliary tuberculosis may produce the impression of a
general paresis or of an amentia in Meynert's sense. The inanition delirium
of tuberculosis resembles that of carcinosis and malaria.

Kraepelin regards tuberculosis as of very slight significance in the
causation of