pain in the head, starting about four years ago. No history of a cyclothymic constitution. No hallucinations and no apparent deterioration. At this admission he was very much more depressed, anxious and apprehensive. He did not show any great fear, did not react emotionally in a fearful way.

He was able to work for only a short time after leaving the hospital the first time, and his sexual symptoms of psychic masturbation, sensuous dreams, and longing for the society of women, restrained by his fear, have continued, and were rather worse. He thought his reputation was gone; that people thought he was crazy. In the course of telling this he broke down and cried.

It appeared that he had some formed delusions, which were rather difficult to get at because of language trouble, but he thought "there was something rotten in his stomach, that perhaps he had no stomach, that his intestines were gone." He thought his brain might be gone; he was surprised that he could talk; had been thinking so for some months. This, however, was not certainly made out, and it seemed that he thought his organs were there, but that he was sick. He was having some trouble that would make him crazy.

In his first admission every one agreed in making a diagnosis of psychoneurosis, but with the second admission, and the probability of somatic delusions, it began to appear that it might represent a dementia præcox process, which had had a long incubation period during which the symptoms were those of a psychoneurosis. On the other hand, others felt that it was manicdepressive psychosis-that with the marked exacerbation of symptoms in the year that had passed, we had to do with a disorder of the cyclothymic type, which would run its course and clear up. It seemed quite clear that he had been psychoneurotic for a long time. It was not quite clear that he had somatopsychic delusions. In combination with his depression and anxiety it seemed that his condition for the last few months was more nearly that of an anxious depression than anything else.

He was committed to another institution, where he still remains.

Clearly the ideas which the patient has are the type of ideas from which many a psychoneurotic suffers. Combined with this is a well-defined psychosexual disturbance, with a very real emotional conflict between desire and fear, which has resulted in the adoption of a middle ground of psychic masturbation and this particular method of repression appears to be the main causal influence in the present state. To be sure, one could not be positive that

this is not a slowly developing dementia præcox, but certainly this is not dementia præcox in the general and more correct usage of that term; unless, indeed, we are to class all cases as dementia præcox, which would be a travesty on diagnosis.

Clearly, also, the case is not to be regarded as a usual type of manic-depressive psychosis, with its relatively clear-cut affect disorder, combined with which there may be delusions--somatic or self-accusatory, more rarely paranoid. In this case the affect disturbance is secondary, and is dependent upon a host of other factors which in general we ascribe to psychoneurosis.

CASE X.-A man of forty-one has been known to charitable organizations for over three years. Previous to that he had been employed as a car painter, earning $8 per week. His employers stated that they had never seen a man who was so anxious "to lie down on his job." He would be inactive for hours at a time, unless some one compelled him to work.

After about two years of illness, which physicians could not diagnose, he was, in 1915, sent to the North Reading Sanitarium for tuberculosis. There he improved quite rapidly, and, his family being under the care of the Associated Charities, he was examined from time to time at various outpatient departments to discover what his trouble was. One consumptive hospital found that what tuberculosis there was had been arrested. Light out-of-door employment was secured for him, driving a delivery team, but patient seemed to feel imposed upon when asked to do anything.

He was very irritable, would become displeased without provocation; his wife thought that at times he did not seem rational, that he talked queerly, believed that she had been pregnant and that she had been unfaithful to him, for all of which there was no basis. He threatened to poison the children, he threatened his wife's life, and he would wander around at night, apparently not in his right mind. Several times he threatened to jump out of a second-story window, becoming displeased over some slight matter. He brooded over pains, felt that he was a very sick man. His clergyman believed that he was just lazy, and that he had been demoralized by the state sanitarium, where he did not have to work; but it seems that he had been apathetic and unambitious for a long period before going to the sanitarium.

If any of his family became ill the patient developed a sympathetic illness, and seemed to suffer much more acutely than the one who was really ill. This was especially true at the birth of the children and during the term of pregnancy.

The patient came voluntarily to the hospital on October 27, 1917, at the suggestion of the social service department of a general hospital. Stated that he left the tubercular sanitarium because of nervousness. He could not sleep; had pains in the legs, and down the back, and in the head. These pains had been getting worse. He was too weak to work; easily fatigued;

there was a buzzing in the left ear. No hallucinations; no delusions. Somewhat depressed at time of admission. Said that he was subject to blue spells, when he did not care whether he lived or died. Not suicidal. Complained of a great deal of insomnia.

Physically, he was well developed and obese, had a red fissured tongue and red throat, and slight speech defect. Signs of some consolidation of both apices, and upper part of right lower lobe. Blood-pressure 142-108. Slight enlargement of cardiac area to the left. Deep reflexes lively. Urine negative. Spinal fluid negative. Wassermann reaction negative. Mentally, patient was accessible, somewhat depressed, wondered if he would ever get strong, and worried about his family. He had a sixth-grade education; his grasp on school and general knowledge was meager. Said that he had never been strong, and complained a great deal of pains and aches. Thought that he was of a normal make-up; spoke of blue spells, and times when he did not care whether he lived or died, but never had the nerve to kill himself, and did not think about it. No hallucinations; no delusions. Thought processes were slow and limited to his own condition, and vague sad thoughts about his family. Felt that he needed rest and out-of-door treatment. Thought that he had weakened his nervous system by over-lifting. The intelligence rating was 11.8 years on the Point Scale, a regular examination.

The symptom complex here is that which is ordinarily ascribed to neurasthenia, namely, pains, weakness, easy fatigue, and fixation of ideas upon the physical condition. During the patient's ten days in the hospital he did not improve. Because of the low mental rating he was regarded as a primarily subnormal person, who had neurasthenia ; without, however, any very definite history of severe nerve exhaustion previous to the onset of symptoms.

On December 20th, the patient was returned to the hospital by the police because of an attempt at suicide. Patient, however, denied this, but said that he might have made a bluff. Claimed that his head was better than when he was here two months before, but his nerves and stomach, and a burning feeling around his genitals and frequency of micturition bothered him.

It appears that he ran out on a third-story porch and threatened to jump off, and this was his bluff at suicide. At another time, when he was feeling very blue and depressed, he picked a knife off the table and drew it across his throat; his wife thought he meant it. He remained accessible, with fixation of ideas upon himself. He developed several times the idea of impending death, when he was very much agitated. Most of the time he was worried and depressed. On one occasion he made an attempt to escape because he wished to go home. His condition of agitation varied somewhat, but, as a rule, he was rather uneasy; was continually questioning the doctors about his condition, and about going home, insisting that he was

perfectly all right. Analysis of the gastric contents revealed nothing abnormal, although it cleared up the patient's idea that his stomach was out of order. He would beg for one more chance to prove that he was not insane, and could go to work and support his family. There were several periods when he thought he was going to die. Continued restless, depressed, and worried until transferred on January 29th, 1918. During this period he lost about twenty pounds in weight.

From the descriptions obtained, and from the examination of the patient, it appears that he had always been a subnormal person and of the psychoneurotic type throughout life; with a fixation of ideas upon physical ailments at about the age of thirty-eight; since which time, and because of this complex, he had been unable to work. A very important point is the high diastolic bloodpressure, ranging from 98 to 106. This, in general, means capillary fibrosis, and this in turn may give rise to pains in various locations. Because of his mental state, and the depression associated with it, he made attempts at suicide, or at least made threats of suicide as a means of obtaining sympathy. His temperament may be described as that of the cyclothymic, although his upper level was never one of great activity.

A case of this type really goes beyond the ordinary neurasthenic, chiefly because of the lack of a real appreciation of the situation. It is not typical of manic-depressive psychosis; he does show an anxious depression, although the depression is perhaps more subjective than objective. There were not at any time any selfaccusatory ideas, nor any definitely formed somatic delusions. The ideas present are much vaguer than the ordinary somatic delusion, and definitely of the psychoneurotic type.

Because of the capillary fibrosis, of the original low level of the individual and the possible concomitance of involutional factors, the prognosis is not particularly good.

This patient is obviously insane, in the legal sense, and so needs to be committed in order to prevent the possible success of his suicidal attempts. So, although his psychosis is of the psychoneurotic type, he is insane and as such committable.

In March, 1918, he is agitated, apprehensive, self-accusatory and restless. The case is regarded as one of manic-depressive at the institution to which he was transferred.

SUMMARY.

The first point of interest lies in the differentiation of psychoneurotic from psychotic states. In almost all of the cases presented the diagnosis is rather perturbing. Indeed, in some it appears rather clearly to be other than psychoneurosis. Yet in most cases the state seems to be what we call psychogenetic in origin, and there are many symptoms of a psychoneurotic nature. It is very difficult to define simply and accurately the differences between psychoneurosis and psychosis. In both the symptoms may be of the same type-pains, somatic ideas, emotional and ideational difficulties. The great outstanding difference seems to be that the psychoneurotic resist the ideas, where the psychotic accept the ideas, incorporate them into the personality and elaborate them. There are also fatigability, sensitiveness and worrying as symptoms of the psychoneurotic state, which are not usual in the psychoses. It is readily seen that the border line is tenuous and decision often difficult. In such cases the reaction to suggestion and explanation may be very important in determining the true diagnosis. Such suggestion is often only temporarily accepted even by the psychoneurotic, so that this is not an infallible guide to correct diagnosis.

Most of these patients are obviously insane in the sense earlier given. Such patients as Case I (suicidal attempt); Case II (successful suicide); Case III (dementia præcox type of incorporation of ideas); Case IV (depression causing inability to care for self); Case VII (seclusion, suicidal attempts); Case IX (somatic delusions, psychosexual disturbance); Case X (attempts at suicide, agitation); are clearly in need of mental hospital care and treatment, for their own protection and in the attempt to alleviate the condition. Such cases are not suitable for out-patient treatment. Yet with the exception of Case III, Case VII and Case X, the symptoms are certainly those of a psychoneurosis.

Neurotic persons are especially likely to be thrown off balance under external stress and strain. This was true in Cases II, III (?), IV, V, VI (?), VIII, IX (?). In Case III the cause possibly lay in the distasteful work and the reaction to masturbation. In Case VI the external stress seemed to be related to a cause for depression, usually the death of a loved one—which brought up the vicious circle of ideas regarding her own death. In Case IX