go away, she could not be kept there. On first seeing the patient, and bearing in mind her hallucinations, I was struck by the fact that workmen were working outside the building and had been doing a good deal of talking; that her husband had several times been to see her and, as I found by the history, had spoken once or twice to the nurse outside the door during her illness. One found one could attract the patient's attention for a moment or so, but she quickly returned to the fact that she was sure her husband was waiting to take her away. She was informed that she need not be so alarmed, that she had been ill and had been mixing up facts and unreality, that if she did not compose herself and do what she was told she would be removed to a mental hospital. From this point she appeared to recover. One was now able to demonstrate to her and to those looking after her that she was only misinterpreting external stimuli. When she said she heard her husband talking, it was the workmen talking outside her window. She heard their voices, but misinterpreted them, believing them to be that of her husband whom she so much wished to see. She said on one occasion that some woman had come to see her but was not allowed to speak to her. This was found to have been a nurse off duty, dressed in mufti, who had come up to speak to one of the other nurses. She had mentioned the patient but had not spoken directly to her. Wishing to get to the window was apparently an unconscious wish to orientate herself, to find out where she was. She afterwards admitted that this was so, and a letter from her, written after her recovery, rather emphasizes these points.

Here we have a toxaemia, affecting the cells of the brain themselves; further, we have a condition in which the person is cut off to a large extent from external stimuli because the cells are not functioning in the same way as in normal life. The consequence is that the external stimuli appear to be imperfectly recorded, but old stimuli in the way of old thoughts appear in the formation of phantasies or dreams. The dream life here is of greater force than the real, owing to the illness interfering with penetration of further stimuli, and the patient appears to live in a condition of unreality. Recovery occurs as soon as the nerve cells are so far restored that external stimuli are able to make a normal impression. The strong stimulus of pointing out to the patient the facts of the case, of making her realise that she is in a hospital and has been there a long time, and of orientating her as to the people who are dealing with her, make such an impression on what one can style her sense of reality, that the patient is able to judge between real and unreal. This patient made a complete recovery. This case again is used simply to illustrate, if

possible, the hypothesis. All cases of encephalitis, unfortunately, do not show the same good results, probably because the toxin sometimes causes such marked degeneration that the cell does not recover.

The points that are stressed in this case are:

(a) that till the toxaemia occurred the patient was well. When the external stimuli were cut off her fears about being separated from her husband reached the threshold of consciousness. It should be stated here that there were great reasons why she feared this separation from her husband, but time is too short to go into these completely.

(b) Apparently unless the patient had been treated by, so to speak, orientating her as to her position she would have been certified.

With reference to this sense of living in unreality, a case of a woman who was undoubtedly suffering from encephalitis at the mental hospital, and who also recovered and has remained perfectly well, presents an interesting phenomenon. During this patient's convalescence it happened that whenever she said she had dreamt a thing, it proved on investigation to be a real experience which she had recently been through, whereas whenever she stated that something had really happened, it turned out to be a dream! Here the normal thought processes appear actually to have been reversed. It is put forward from clinical experience of a fairly large number of cases of encephalitis with delirium, that there is always some predisposing emotional factor; in other words that delirious conditions are indicative of emotional repression, whereas in encephalitis starting with stupor the emotional factor appears to be absent.

(3) The third group. There are many organic cases in which psychotherapy can have, with our present knowledge, little curative effect. There has been an absolute break in nerve continuity and the communication of the person with external stimuli has been interfered with. Cases of aphasia are a good illustration of this point. Here, often the patient cannot understand what is said to him, nor can the medical man understand what the patient is saying. Where there is such marked disease of the brain little can be done by psychotherapy. Nevertheless psychotherapy may alleviate the emotional condition in diseases like disseminated sclerosis and tumours of the brain, and localized injuries. It will not cure the disease itself, but it often enables the patient to adjust himself to some of the disabilities arising therefrom.

This group, which I designate the organic, provides by far the greatest number of cases which are admitted to the mental hospital since the clinic has been established. It has been stated that the psychoses cannot

be treated by analysis. This may be so, but personally I doubt if the difference between a neurosis, psycho-neurosis and psychosis is not really only a matter of degree, not of essence. Our present definition of a psychosis is mainly a legal and not a medical one. I am inclined more and more to the opinion that this legal bogey has often unconsciously swayed our minds to such an extent that we behave to it in the same way as our forefathers did to the idea of witchcraft and treat it in much the same way. Witches were destroyed, imprisoned and tortured. The socalled insane have too often in the past certainly been imprisoned and perhaps even tortured (though quite unconsciously) through ignorance, and in fact will continue to be so unless the problem is approached from a psychological as well as a physiological point of view. It is Freud's genius we have to thank for giving us a line of attack that appears to have some hope of clearing up some of our problems. The paranoias, manic depressive insanity and dementia praecox groups, especially the latter, constitute a very large percentage of the so-called insane. These three groups too have been designated the true insanities. The insane show in their utterances, writings, speech etc. (Freud) irrefutable evidence of the truth of the analytic findings. This I entirely agree with from my own observations. If one examines an incoherent case by associating on the marked words in the incoherence, it will be found that these incoherent words are complex indicators and will lead back either to real or phantasy ideations in the past life of the patient, provided one can get the patient to give attention; and personally I believe that given time and patience one should always succeed in doing this. I do not mean to infer that by this alone one can always cure the patient, but as far as my own experience goes this procedure appears to have been in many cases the starting-point and has ultimately led to a recovery, and, as far as one is able to judge at present, a more permanent recovery than was obtained when this method was not used.

To illustrate, a patient who was admitted to the hospital, resistive, negative, incoherent; urinated in his bed; destroyed his clothes; at times stuperose; used to sit in a chair and appear to be picking aimlessly at nothing; impulsive at times; would not converse at all; at times his negativism was so great that he always did the opposite to what he was told. Physically, low blood-pressure; cyanosed extremities; given to frequent masturbation, and if he did not masturbate he had eneuresis. There was a history of a similar attack.

The treatment was first directed mainly to improving his general physical condition. The patient suffered from severe and chronic consti

pation. This was treated with very little permanent result at first, that is to say that until psychological methods were employed no marked improvement took place.

Many attempts were made to influence him by suggestion and at times he appeared to improve. The suggestions made were active attempts by my colleague and myself, and passive, if one may use that term for the device of acting on his mental processes by entirely objective methods, such as altering his ward, trying the ward where the worse cases were both troublesome ones from a refractory point of view and degraded ones from a demented and dirty point of view, the object being to try to affect his obviously egoistic and narcissistic tendencies by thrusting very strong external stimuli upon him. He was always told that if he would behave himself he would be put in a better ward. The only observed effect of this was that in the worst wards he was quieter than in better ones, and this was interpreted as a clue to the fact that in the worst wards his narcissism received a reinforcement from the fact that he felt or said to himself "anyway I am better than these others" and therefore his libido was less in conflict with the ego or his inferiority feeling ego trends were less at variance with his sexual or love trends. He now, however, developed a habit, or perhaps one should say it was noticed that whenever he sat in a chair stuffed with horsehair he pulled it to pieces and played with the horsehair, throwing it all over the room, and that he always tore the mattress. At this time he was very hostile to me personally. I repeatedly pressed him by questioning him as to why he did this; usually he simply grinned, but one day he replied "Hitchy Koo." I repeatedly asked him what this made him think of, always making the suggestion that he could get well if he tried. After repeated attempts of the same nature, one day in reply to the question "what does Hitchy Koo make you think of?" he replied "horsehair, sneezing, school." Time is too short to give the further associations, but what he eventually gave as the full statement of the position was that whilst at school he was much lauded by his head master, who reminded him of his father, to whom he was always in opposition. He was afraid of his father, and also his schoolmaster. The boys at school he despised in one sense because he was cleverer than they, but envied in another because they played games which he could not manage. He was too proud to learn, but hid it under a cloak of superiority. He had been made a prefect by the head master and thus felt his responsibility. Another master who was unpopular with the boys and with him had a plot made against him by them, of which the patient was cognisant, but he would not tell the

Head, nor would he dissuade the boys, in fact he himself supplied a packet of 'Hitchy Koo Powder' which he had found, to one boy who he admitted he knew was in the plot and who he further guessed would use it on this master, which was exactly what happened. The master complained to the Head and the Head questioned the patient who denied having anything to do with the matter. This preyed on his mind and he began to justify himself and eventually repressed the episode. He was angry with the Head for lauding him as a good boy and an example. He considered the Head foolish, as he had considered his father foolish. There were various episodes to do with his father's attitude towards himself, unduly strict in some matters, especially over certain habits, eneuresis being one, and undue laudation of his intellect to others. His mother absolutely spoiled him, but deferred to his father in all things. The habit of picking horsehair stopped from this date, that is from the time the whole episode was narrated, and it did not recur. The picking of the horsehair symbolized his conflict, and also was a partial compensation, that is he threw it away, which he had often wished he had done with the Hitchy Koo Powder. He improved also and began to employ himself, and though the analysis did not run too smoothly, he eventually became quite normal and was discharged. After two years a report from a relative states that he is doing well in New Zealand, and also states that everyone likes him because he is so different from other young men. This case I mention as it appeared from the clinical symptoms to be one of that group we designate dementia praecox. Of course, the diagnosis is open to doubt, as he recovered, and it may be that the term fixation hysteria would be better. One other interesting point is that on his gradual mental recovery his physical health improved with no further alteration in his medication. His grey pills and enemas were gradually discontinued and his bowels became normal. It may be argued, of course, that they did so when he got moving about and doing things, but against this is the fact that he did a good deal of moving about when he was ill, and it was not till the psychological side was clear that he remained well.

In connection with the incoherence of the insane, I could give many instances, but time forbids. All I would add is that as far as I have been able to observe, if the associations were able to be proceeded with, the symptoms improved, though there might not be complete recovery, and further the incoherent word was always a key to a real episode or phantasy in the past loaded with a strong affect.

It appears to me possible that the only difference between a psychoneurosis and a psychosis is a physical one, and that unless we find