University of Virginia Library

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

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.[1] 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 debâcles. 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 naïvely, 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 producedelusions?

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. CaseIV ("happiest woman in the world"), was phthisical (cf. VII) Notes follow:
10 pt here.

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 lencocytes. 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 adherenteverywhere to the skull.

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

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

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

showed rather unusual degrees of nerve cell pigmentation (precentral and paracentral).

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

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

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

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

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

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

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

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

CASE 22. (D. S. H. 8250, Path. 909) an unmarried woman without occupation, two attacks of "melancholia" at 36, and 40. Always of a retiring and shy disposition. Mental disease began

after father's death. Delusions (if such): has been selfish and wicked. Constant self condemnation. Suicidal. Exophthalmic goiter.

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

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

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

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

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

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

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

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

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

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

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

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

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

Kraepelin regards tuberculosis as of very slight significance

in the causation of insanity, despite the fact that slight changes in mood and in voluntary actions frequently accompany the course of the disease. Irritability, depression and sensitiveness, incomprehensible confidence and desire to undertake various tasks, pronounced selfishness, sexual excitement and jealousy are the traits of mental disorder in tuberculosis.

Kraepelin states that many cases of tuberculosis show traits of alcoholic disease and says that the occurrence of polyneuritic forms of alcoholic mental disorder is favored by the association of tuberculosis with alcoholism.

Wernicke does not systematically consider the topic.

Binswanger states that tuberculosis, aside from miliary tuberculosis or meningitis, produces no mental disorder except phenomena of the amentia of exhaustion.

Ballet states that there exists a peculiar mental state in the tuberculous. It is compounded as rule of sadness, of looking on the dark side and of profound egoism. This readily leads to mistrust and suspicion which may be pronounced enough to constitute a sort of persecutory delusional state or a state of melancholic depression (Clouston, Ball). More rarely there are phenomena of excitation explained in part by fever. In its slightest degree this phenomenon of excitation is characterized by a feeling of well-being, of euphoria, which even at the point of death may give the patient the illusion of a return to health, or there may be a more pronounced excitation with impulsive sexual and alcoholic tendencies. Autointoxication may lead to the usual train of confusional symptoms.

If we compare the accounts in the literature of the two conditions here in question, namely, nephritis and phthisis, we must be convinced, that aside from so-called autotoxic phenomena, renal disorder seems to be marked by a tendency to depressive emotions but that phthisis shows not only depressive emotion but also euphoric and hyperkinetic phenomena.

So far as these results thus hastily reviewed are concerned, they are consistent with the appearances in the present group of cases. Both the nephritic and phthisical groups need further intensive study.

As to the question of the spreading inwards or outwards of delusions from the standpoint of the patient, no analysis is here attempted. It is plain, however, that the theopaths, as James calls them, or victims of theomania, to use the French phrase, will be of importance in this analysis because of the equivocal character of the emotions felt in cases of religious delusion.

SUMMARY AND CONCLUSIONS

The paper deals with delusions of a personal (autopsychic) nature and is one of a series based upon certain statistics of Danvers State Hospital cases (previous work published on somatic, environmental (allopsychic) delusions and those characteristic of General Paresis). The previous work had suggested that somatic delusions are perhaps more of the nature of illusions in the sense that somatic bases for somatic false beliefs are as a rule found. On the other hand, delusions respecting the environment (allopsychic delusions) had appeared to be more related to essential disorder of personality than to actual environmental factors.

The fact that cases of paresis with delusions were found to have their lesions in the frontal lobe, whereas non-delusional cases showed no such marked lesions, is of interest in the light of the present paper because three cases of senile psychosis were found to have delusions of grandeur and, although they are demonstrably not paretic, they also show mild frontal lobe changes supported by microscopic study.

The Danvers autopsied series, containing 1000 unselected cases, was found to show 306 instances with little or no gross brain disease. Of these, 106 had autopsychic delusions and of these 106, 50 cases had delusions of no other sort. 15 of these 50 cases appeared to have been cases of General Paresis in which gross brain lesions were not observed at autopsy, and upon investigation 13 other cases were found to be, for various reasons, improperly classified. The residue of 22 cases was subject to analysis and readily divides itself into two groups of 11 cases each, or two groups of normal-looking brain cases having autopsychic delusions and these only are cases which may be termed the "pleasant" and

"unpleasant" groups, in the sense that the delusions in the first group were either pleasant or not unpleasant, whereas the delusions in the second group were of clearly unpleasant character.

Three of the "pleasant" delusion group were the three cases of grandeur and delusions in the senium above mentioned. Three others were cases of "theomania" in the sense that their delusions concerned messages from God. It is not clear that these three religious cases should be regarded as belonging in the group of "pleasant" delusions on account of the sense of constraint felt by the patients.

The remainder of the "pleasant group," as the delusions were originally defined, turned out for the most part to show either doubtful delusions or delusions involving a sense of constraint rather than of pleasure.

An endeavor was made to learn the relations of pulmonary phthisis to the emotional tone of the delusions. The few available cases in this series seem consistent with the hypothesis of phthisical euphoria (IV, "happiest woman in the world," hearing God's voice, VII and possibly XI).

The problems of the "pleasant" delusion group, as superficially defined, turned out to be a. the problem of a group of senile psychoses with grandiose delusions and frontal lobe atrophy; b. the problem of felt passivity under divine influence; c. the problem of phthisical euphoria.

The group of "unpleasant" delusions in the normal-looking brain group should be diminished by one on account of its positive microscopy (encephalitis). One case (XIII) is a case of mixed emotions of religious type, showing phthisis pulmonalis together with abdominal tuberculosis and nephritis. One case (XV) is doubtful as to delusions; the remainder are subject to renal disease, as a rule associated with cardiac lesions.

Two cases which were transferred from the "pleasant" to the "unpleasant" group on account of constraint feelings, were also renal cases,—VII and IX. The only exception to the universality of renal lesions in this group is the case in which religious delusions were probably based upon hallucinations for which hallucinations an isolated brain

lesion was found, very probably correlatable with the hallucinosis.

Virtually all of the eleven cases determined to belong in the "unpleasant" group are cases with severe renal disease as studied at autopsy.

Whether the unpleasant emotional tone in these cases of delusion formation is in any sense nephrogenic and whether particular types of renal disease have to do with the unpleasant emotion, must remain doubtful. A still more doubtful claim may be made concerning the relation of euphoria to phthisis. The renal correlation is much more striking as well as statistically better based. A further communication will attack the problem from the side of the kidneys in a larger series of cases.

REFERENCES