and so on. She would eat the most curious things, such as stove polish, etc. Her first act on being brought to the asylum was to smash a window pane with a chair.

On examination the patient was seen to be still in this excited condition. She was in continual movement, made frequent attempts to climb out of the window, constantly flourished her arms and declaimed at a high voice. Her hands, when she was not gesticulating, were busy crumpling or tearing fragments of paper. At times exacerbations of great violence occurred in which she needed restraint. Her hair was dishevelled, and her personal appearance neglected. Her expression was distinctly lascivious, though her behavior was never indecent.

Oh yes,

The

On studying her logorrhoea one found that it consisted of a series of rapidly uttered words and short phrases, mostly related one to another by sound associations. The following are examples: "What a pretty tie. I wish I were tied to someone who was pure, and had pretty eyes. I'm fond of pretty eyes. Fond of lies. Not fond of the kind of lies I've been accused of. I was. There are different kinds of lies, lie up, lie down." significance of the last words will be seen later. "I don't trust him. New York trusts. Roosevelt is all right. Except when he talks about race suicide. Bearing children is all very well when you have no bearing-down pains. There are too many panes in this window; I should like to open one." We see how prominent is the impulsive and rapid transition, along the most superficial associations, from idea to idea, so characteristic of the manic flight of ideas.

The patient was perfectly oriented in time, place and personality. She retained insight into her condition, knew exactly why she had been confined, and that she would soon be better and about again. After the early stage no hallucinations occurred, except of smell. Her delusions have been mentioned above, and will be discussed in the course of the analysis. Her memory was unimpaired, as was so far as could be tested-her power of retention. There was no sense deficiency, no contraction of the visual fields or disturbance of sensibility, and no other stigmata of hysteria. Her judgment in everyday matters was sound, and there was no evidence of intellectual deterioration. No mannerisms, catalepsy or stereotypies were ever noted.

There was but little sleep for the first few days. The tongue was furred and rather dry. The pulse rate and temperature were slightly raised. There was much constipation and the appetite was at first very deficient. There were no abnormal physical signs in the nervous system.

Course. The excitement gradually subsided, and in a couple of weeks had practically disappeared. Synchronously with this the delusions became less prominent, and the patient gradually realized the falsity of them. In January, 1909, she was allowed to go out on probation, and did so for a couple of days at a time at frequent intervals until her final discharge in April. Further details of the course of the case will be given in the analysis.

Diagnosis.-There are only three diagnoses that come into serious consideration, manic-depressive insanity, dementia paranoides, and hysteria. The last-named can with the greatest probability be excluded, on account of the absence of physical signs or symptoms of this malady, and the non-correspondence of the mental condition, either clinically or psychologically, with that characteristic of hysteria. The reactions were never infantile, there were no amnesias, aboulias or phobias, and the word-associations were not of the kind found in hysteria.

To exclude the diagnosis of dementia præcox is more difficult, especially as the thought of this malady is especially raised by the fact of the history extending so far back, by the chronicity of the symptoms with their occasional exacerbations, and by certain features of the delusions present. However, on the one hand there was none of the peculiar "shut-offness," or loss of contact with the immediate environment, that is the most constant accompaniment of dementia præcox, nor were there any somatopsychic perversions, stereotypies, verbigerations or mannerisms such as we might expect to find by the time the case had developed so far; on the other hand the alternation of depression and excitement, the vehemence of the latter manifestation, the logorrhoea, the suggestibility during the excited period, the retained insight into the condition, the morbidly sharp definition of the subsequent recollection of all the events in the illness, the form of association reactions, and the typical manic flight of ideas, all strongly go to show that we are dealing with a case of manic-depressive insanity.

As will presently be shown, the delusions that occurred bore a distinctly paranoid stamp. This feature may be found in a variety of psychoses, in general paralysis, dementia præcox, alcoholic "dementia," etc. It is becoming more and more doubtful whether true paranoia exists as a separate entity, and Specht' has recently advanced excellent reasons to show that a large number of cases in which this diagnosis has been made are really cases of chronic mania, i. e., of manic-depressive insanity.

Psycho-Analytic Observations.-Up to this point the case has been considered on strictly Kraepelinian lines, and the diagnosis arrived at by observing and weighing the import of the external objective manifestations of the malady. Of fundamental importance as this route is in teaching us so much about our cases, the grouping of them, the separation of one form from another, the outlook on prognosis and the general review of the disease, yet in its very merits lie its limitations. It definitely aims at giving us a conception of the disease as seen from the outside, in other words from the point of view of the clinical observer. It does not pretend to lead us to an appreciation of the morbid phenomena as seen from the inside. We thus never reach the patient's point of view, never realize what a given external manifestation represents to him, and thus never approach a true understanding of the meaning and significance of that manifestation.

It is precisely here that Freud's psycho-analytic methods supplement the usual modes of study, and thanks to them we are for the first time beginning actually to penetrate into the patient's mind, and to learn something about the pathogenetic mechanisms by means of which the different symptoms of the disorder are brought about. The psycho-analysis of an individual case of any psychosis is so difficult that it is rarely complete. In the present case only a certain number of indications were obtained, which, however, yielded clues of considerable value to the interpretation of the most prominent symptoms. We may begin by noting the results of a few association tests.

'G. Specht: Ueber die klinische Kardinalfrage der Paranoia. Zentralbl. f. Nervenheilk. u. Psychiatr. 1908. S. 817.

y= correct reproduction.

0=nothing reproduced.

00= memory even for stimulus word forgotten.

In these associations the following points are noteworthy: the high percentage of "complex" indicators; the high percentage of superficial associations, particularly of clang and motor-speech forms; the markedly erotic assimilation shown in regard to most of the stimulus words; and the striking similarity between the results of the two examinations, although a month apart.

They may be contrasted with the following associations, made on January 21. In these the number of superficial associations is

much fewer, and approximates to the normal. The erotic trends are, however, still marked, and the number of "complex" indicators is almost as great as before (about 50% of the tests).

Reproduction.

γ

poor.

walk.

snow.

པཅསཔཙྪིཾནཿཊྛསཝིËན༥ པཔཱ་ྩསསརཔ་པཎྞཾ་་་་་་་་་་་་

= correct reproduction.

0= nothing reproduced.

00= memory even for stimulus word forgotten.

On studying the patient's logorrhoeic utterances, and certain clues which will presently be mentioned, obtained from her association reactions, one of the first groups of ideas that impressed itself on the observer was that concerning the "impurity" of her