Psychiatry; a text-book for students and physicians

i

LIBRARY

THE UNIVERSITY
OF CALIFORNIA
SANTA BARBARA

PRESENTED BY

DONALD BEEKS

II

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Ak. H>

Ctbrary nf
Boliert Jaudmi Sail

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PSYCHIATRY.

A TEXT-BOOK FOR STUDENTS AND PHYSICIANS

BY

STEWART PATON, M.D.

ASSOCIATE IN PSYCHIATRY, THE JOHNS HOPKINS UNIVERSITY, BALTIMORE ; DIRECTOR Or THE
LABORATORY, THE SHEPPARD AND ENOCH PRATT HOSPITAL, TOWSON, MARYLAND

PHILADELPHIA AND LONDON

J. B. LIPPINCOTT COMPANY

1905

PREFACE

The great increase of knowledge concerning those morbid
conditions of the human body commonly but erroneously de-
scribed as mental diseases, and the resulting improvements
made in recent years in the methods employed in the investiga-
tion and treatment of them, may in part be urged as justifying
the publication of another book on Psychiatry.

No higher or more imperative duty confronts the State
and institutions of learning than that of encouraging, in every
possible manner, the prosecution of studies which promise to
result in the determination of the sources of rational thought
and action ; but it is evident that the main burden of the work
must be borne by the medical profession, from whose ranks
must come the leaders of any movement which has for its
object the prevention and cure of the diseases characterized
by defective or perverted functioning of the brain.

In writing this book I have made no attempt to compose
an exhaustive treatise; my main object has been to call atten-
tion to that aspect of the subject which is in accord with the
results of observations as they are conducted to-day at the bed-
side and in the laboratory; and while presenting the different
views of leading authorities in a manner readily to be compre-
hended by students of this important branch of medicine, to
stimulate to greater activity the interest in the investigation of
problems in the solution of which will be found the means of
increasing the brain power of the nation.

If this book shall in any way serve the purpose for which it
has been written, it will be in large part due to the encourage-
ment and advice of many friends, to whom I gratefully acknowl-
edge my indebtedness.

S. P.

CONTENTS

CHAPTER I
The importance, scope, and methods of modern psychiatry i

CHAPTER II
The nature of the disease process in alienation and its relation

to the pathological changes 16

CHAPTER III
The symptoms of alienation.

I. Impairment of the higher cortical functions as shown in

defects of judgment and intellect. Fixed or insane ideas 26
II. Anomalies in the intensity and direction of the mental

processes as shown in disorders of the attention 48

III. Disturbances of sensation, including hallucinations 51

IV. Disturbances of consciousness 67

V. Disturbances in the functions of association. Interference

with the expression of connected thought. Anomalies of

memory. Disturbances in orientation 73

VI. Disturbances in the volitional processes 87

VII. Disturbances in the emotional reactions 108

VIII. Anomalies of conduct with especial reference to the so-
called moral insanity 119

CHAPTER IV
The method of examination of patients, including examina-
tion of the cerebrospinal fluid 127

CHAPTER V
The treatment of cases of alienation 146

CHAPTER VI

The modern hospital for the insane 167

vii

FACE

viii CONTENTS

CHAPTER VII
General causes of insanity.

General considerations. Heredity. Environment. Sex. Age.
Occupation. Education. Suggestion and imitation. Fatigue.
Trauma. Marriage. Pregnancy and parturition. Intoxications.
Diseases of the internal viscera. Brain diseases. Nervous dis-
eases 178

CHAPTER VIII
The principles concerned in the provisional clinical grouping of

mental diseases 225

CHAPTER IX

Mental anomalies the result of defective development of the
central nervous system.
Idiocy. Imbecility. Mental debility 230

CHAPTER X
Psychoses which are probably in part the result of autointoxica-
tion.
Febrile deliria, including pre-febrile and post-febrile psychoses.
Acute confusional or delirious states. Acute collapse delirium.
Subacute delirious or confusional states (amentia). Korsa-
kow's syndrome 254

CHAPTER XI
Psychoses the result of chronic intoxications.

Alcoholism, including transitory disturbances of consciousness.
Delirium tremens. Acute alcoholic hallucinosis. Morphinism,
cocainism, etc 285

CHAPTER XII
Psychoses associated with imperfect functioning of the thy-
roid gland.
Myxedematous and cretinous insanity 326

CHAPTER XIII
The manic-depressive group.

States of excitement, depression, mixed and paranoioid states . . . 336

CONTENTS ix

CHAPTER XIV PAGE

The dementia precox group 372

CHAPTER XV
The dementia paralytica group 413

CHAPTER XVI
The epilepsy group 473

CHAPTER XVII
The hysteria group 494

CHAPTER XVIII
Neurasthenic and psychasthenic states 516

CHAPTER XIX
Psychoses associated with organic disease of the central ner-
vous SYSTEM.
Brain tumors. Arteriosclerosis. Cerebral hemorrhage. Throm-
bosis. Multiple sclerosis. Syphilis, etc 544

CHAPTER XX
The paranoia group 564

CHAPTER XXI
The senile group. Psychoses connected with the period of senile
involution
States of excitement and depression. Paranoioid states. Senile
dementia 575

ILLUSTRATIONS

PAGE

Handwriting of a patient suffering from dementia praecox, illustrating

her interpretation of her changed organic sensations 33. 34, 35

Diagrams illustrating consanguinity as an etiological factor in the

causation of insanity 187

Plate I. Photomicrograph of a ganglion cell 260

Plate II. Photomicrograph of a normal Betz cell 260

Plate III. Photomicrograph of a fever cell 260

Plate IV. Photomicrograph of fever cells 260

Plate V. Photomicrograph of a pyramidal cell (Bethe stain) 260

Plate VI. Photograph of a patient in a confusional state 268

Handwriting of a patient suffering from acute alcoholic halluci-
nosis, showing his interpretation of his changed organic sensa-
tions 301, 302, 303

Chart illustrating the influence of position upon the blood-pressure in

a case of manic-depressive insanity 345

Plate VII. Chart showing temperature, pulse, and respiration curves

in a case of manic-depressive insanity 346

Charts illustrating schematically the course of cases of manic-depres-
sive insanity 347, 348

Chart showing periodic forms of manic-depressive insanity 361

Chart showing the course in cases of manic-depressive insanity 362

Weight chart in a case of manic-depressive insanity 367

Plate VIII. Showing a maniacal patient in the continuous bath 370

Plate IX. Drawing made by a patient during a period of mild cata-
tonic excitement 386

Handwriting illustrating irrelevant replies in a case of dementia

praecox 389

Plate X. Photograph illustrative of cerea flexibilitas 392

Chart illustrating schematically the course of a case of dementia

praecox 403

Chart illustrating the incidence of general paralysis in women 414

Chart illustrating the incidence of general paralysis in men 415

xi

xii ILLUSTRATIONS

PAGE

Specimen of handwriting of a patient suffering from dementia para-
lytica 432

Plate XI. Photomicrograph showing thickening of pia-arachnoid and

adhesions between pia-arachnoid and cortex in a case of paresis. . 462

Plate XII. Drawings showing the normal distribution of medullated
fibres in the different cortical regions 463

Plate XIII. Drawings of sections of the cortex from a normal case
and from a case of paresis (stained with the Bielschowsky fibril
stain) 464

Plate XIV. Drawings of a normal giant cell and a giant cell from
a case of paresis (stained with the Bielschowsky fibril stain).... 464

Plate XV. Photomicrograph of giant spider-cells from a case of

paresis 466

Plate XVI. Drawing showing an increase in the number of giant
spider-cells in the cortex of a case of paresis 467

Plate XVII. Drawing showing a blood-vessel from the cortex in a
case of paresis 468

Plate XVIII. Table giving points for the differential diagnosis of the

pathological changes in paresis from those of other conditions... 470

Plate XIX. Drawing showing rod cells from a case of paresis 471

Plate XX. Photograph of a patient with senile melancholia 578

Chart showing ages of incidence in cases of senile dementia 594

PSYCHIATRY

CHAPTER I

THE IMPORTANCE, SCOPE, AND METHODS OF MODERN
PSYCHIATRY x

Psychiatry is a branch of general medicine. One of its
objects is to investigate the causes, course, and termination of
those diseases whose chief symptoms are characterized by
anomalies in the so-called mental processes. The ultimate aim
of these studies should be, first and foremost, to find and then
to apply the means best adapted to promote normal thinking;
for the actual cure of cases of alienation is a matter of sec-
ondary importance in comparison with the discovery of methods
of preventing its spread.

In view of the increasing amount of interest taken by the
public in all matters affecting its general welfare, it would
hardly seem necessary to make a special plea for the granting of
opportunities for study and investigation to those whose chief
interest is to ascertain the surest and best means of promoting
rational thought and action. If Norman Lockyer's dictum be
true, that " a struggle has begun in which science and brains are
to take the place of sword and sinews," is it not desirable that

1 Cowles, Edward : Advanced Professional Work in Hospitals for the
Insane. Am. Journ. Insan., vol. lx, 1898. Gaupp, R. : Ueber die Gren-
zen psychiatrischer Erkenntniss. Centralbl. f. Nervenheilk. u. Psych., Jan-
uar, 1903. Bawden, H. H. : Recent Tendencies in the Theory of the Psy-
chical and Physical. The Psychological Bulletin, Literary Section of
Psychol. Review, March 15, 1904. Meyer, Adolf: A Few Trends in
Modern Psychiatry. Hoch, August: A Review of Psychological and
Physiological Experiments done in Connection with the Study of Mental
Diseases. The Psychological Bulletin (Psycholog. Review), vol. i, Nos. 7
and 8, June 15, 1904.

2 PSYCHIATRY

some concerted and well-directed effort be made to find out the
most efficacious way of increasing the brain power of the
nation? If the question of the mental health of a community
is one of vital importance, how long will the investigations
relating to its preservation be carried on under such discour-
aging conditions as now exist in this country ? With the rapid
growth of modern civilization the duties of the alienist are
every day becoming more arduous and complex ; and yet at the
beginning of the present century, particularly in the United
States and England, he finds himself poorly equipped to grapple
with the problems forced upon him not only in his routine prac-
tice, but also by the State and by society at large. What is
insanity? How may the ravages of the scourge be lessened?
How far are individuals responsible for their actions? These
and other problems of equally grave import, touching the very
foundations of the social structure, are daily propounded. But
that in reality the public are wholly indifferent as to the manner
in which these questions are answered is clearly proved by the
fact that no suitable provision has yet been made in this country
for giving instruction in psychiatry, and that serious investiga-
tions concerning the nature of mental diseases have scarcely
been begun. Nor does it appear logical that in the face of this
lamentable state of affairs the opinion of the so-called expert
on insanity is daily sought for and forms the basis upon which
even the issues of life and death are decided. Fortunate would
be the community in which there was a fully equipped and well-
organized psychiatrical clinic under the control of a university
and dedicated to the solution of these and similar problems.
The mere presence of such an institution would indicate that
people were as much interested in endeavoring to increase the
public sanity as they are in the results of exploration in the
uttermost parts of the earth or in the discovery of a new star.
There is no department of medicine in which the investi-
gator needs to be in more intimate touch with the advances of
modern science than in psychiatry. The problems to be solved
by it are mainly of general, not special, interest. It not only
forms a branch of general medicine, but should be classed with

SCOPE AND METHODS 3

other biological studies. Science has demonstrated that the
anomalies in thought, action, volition, and emotion, popularly
referred to as forms of insanity, are the expression of a disor-
dered functioning of the central nervous system. Gradually we
are awakening to an appreciation of the fact that the same gen-
eral methods of investigation that are applicable in the study of
all biological sciences may be successfully adopted in attacking
the problems connected with mental diseases.

Let us consider very briefly the methods which the alienist
may employ in dealing with psychic phenomena. The problems
to be solved can be approached from several stand-points which
for the sake of convenience can be described as psychological,
clinical, chemicoTphysical, and anatomico-pathological. A word
may here be said regarding the attitude of the alienist towards
the study of mental phenomena or the functions of the cerebral
cortex. Instead of contenting himself with a naive psychology
founded upon theory and speculation, he has been taught to
rely upon the basis of steady, painstaking observation, sub-
stantiating his results whenever possible by experiment. And
by these methods alone will it become possible to attain a com-
prehensive rational understanding of the nature of insanity.
The point of view of the modern physiologist, that organic
processes are referable to physico-chemical changes, offers an-
other vantage ground, since physiology also teaches that ma-
terial changes in any organ give rise to disorders of function.
The brain is no exception to this rule. Changes in conscious-
ness, anomalies in the emotional life, impairment of volition,
are merely expressions of a disturbance in equilibrium of the
functions of the brain. In this country, particularly, the alienist
is singularly indebted to the physiologist and to the psycholo-
gist, not only for keeping alive and stimulating interest in the
study of mental phenomena, but also for valuable contributions
that have been made by both to our knowledge of the functions
of the central nervous system. So little is known, so much still
remains to be found out, and the speculative tendency in certain
quarters is so strong, that the temptation to substitute theory
for observation and experiment has to be met and resisted at

4 PSYCHIATRY

every turn. The relation of body and mind is still an enticing
theme for the philosopher, but to spend valuable time in theoriz-
ing as to the manner in which the ultimate solution of this
problem will be effected belongs only to those who live in a
realm that is far afield from the path of the clinician. New
points of view are always desirable, if they ultimately lead to
the discovery of additional facts ; but psychiatry cannot afford
to build upon shifting sands. The theories of psycho-physic
parallelism and of neo-vitalism may afford useful working
hypotheses to many investigators, but their adoption as philo-
sophical creeds should be a matter of no concern to the alienist.
The attempt to establish a " psychological basis" for the study
of mental disease is quite as undesirable as would be the attempt
to limit clinical medicine to the mere study of symptoms. The
psychological method is a useful aid to investigation, but to
consider its scope and methods as the end-all of modern psy-
chiatry shows no appreciation of the advances that have already
been made. Great as has been the stimulus derived from psy-
chological studies, the alienist fully appreciates that his line of
investigation differs essentially from that of the psychologist.

But before pointing out more in detail the positive advan-
tages derived from the new psychology a word of caution is
necessary. The facts derived from observation and experi-
ment have thwarted the attempts of those who have tried to
transform the useful working hypotheses expressed in the
theory of psycho-physic parallelism into dogmas. Even those
who were formerly the most ardent supporters of this doctrine
are now willing to admit that, while the parallelism may hold
in the case of the simpler sensations, it cannot be applied to the
more complicated psychic phenomena. Even in the analysis of
the simpler mental phenomena 2 it is impossible to correlate the
so-called mental and physical events. In all the cerebral pro-
cesses, from the simplest sensations to the most complex psychic
phenomena, there is a series of physico-chemical changes that

1 V. Kries : Ueber die materiellen Grundlagen der Bewusstseinser-
scheinungen, 1901.

SCOPE AND METHODS 5

take place, and these, so far as is known, have no immediate
correlates in the mental sphere. A series of ether vibrations
strike the ear and the individual may become conscious of a
musical note. How is each event in this physical chain to be
correlated with those comprising the psychic phenomenon?
And, in fact, do not the teachings of modern science demonstrate
the futility of such an attempt? According to the psycho-
physical theory the individual events in one place are not con-
trasted with those in the other, but what is actually attempted
is the establishment of a parallelism between a whole series of
events on the physical side with those in the mental sphere.

But it may be asked, Who shall determine exactly the two
series of events that are to be contrasted ? What is to be called
physical and what mental; and what censor shall decide the
question for us ? The careful analysis of the cerebral functions
has resulted in the destruction of the artificial barriers that were
supposed to separate them from each other. The differences
of gradation but not of quality are recognized. The power of
discrimination between violet and yellow, heat and cold, plea-
sure and pain, represents to each sentient individual important
distinctions, but by what right do we assume that in the final
analysis these differences are not referable to physical processes
that vary only in degree and intensity? For all that we know
to the contrary there are no abrupt divisions or chasms to be
crossed. The cerebral processes vary, but they do so by de-
grees, by shading off into each other without gap and without
break in continuity.

It would be superfluous to emphasize the necessity of
far more active cooperation in America between psychologist
and psychiatrist were there not abundant evidence of the lack
of communism of interests. Two facts have contributed to
this unfortunate condition. In the first place, too many stu-
dents of normal mental phenomena start with philosophical
speculation and make exact observation and the recording
of facts of merely secondary importance. This attitude in a
measure accounts for the widespread and not unjustifiable
scepticism abroad as to the true merit of many of the so-called

6 PSYCHIATRY

psychological investigations. And again, when a recognized
leader in the modern school of psychology has actually admitted
defeat and declared that his specialty never can become a
science, is it to be expected that the wares he offers for sale are
to be taken at more than their appraised value? But, happily,
although he may have succeeded in demonstrating the ineffi-
ciency of his own methods, he has failed signally in the attempt
to prove that all others are equally untrustworthy. More hopeful
investigators — and, fortunately, they represent the large major-
ity of psychologists — still have faith in the efficacy of patient
and well-directed observation. The end is not yet in view, but
a bright and brilliant page is being written, and even in the face
of what seem to be insuperable difficulties the investigator, in
the light of the advances that have been made since Herbart's
day, finds reason to take courage and begin the attack anew.
Observation, whether it be introspective in character or be
applied to the study of mental phenomena noted in others, is
being carried on with more rigorous exactitude than ever be-
fore. This is still the period of critical analysis. The period
of synthesis will come as soon as the methods of introspection,
of observation of the normal and abnormal mental processes,
and of experiment stand the crucial tests applied to them.

A few important facts have been unearthed that have given
us new points of view, and as a consequence of this extension of
the horizon many of the immediate clinical problems have
become less complex as the old riddles have been re-stated in the
language of the physiologist, thus rendering an attack with
promise of success no longer an improbability. In the analysis
of sensations Mach 3 and others have at least formulated work-
ing hypotheses of great practical value. Furthermore, it has
been demonstrated that the various muscle, joint, and complex
organic sensations not only play an important role in the physi-
ology of sensibility, but are also intimately related to the
higher mental processes. Within the last two decades the con-
stantly increasing number of publications devoted to studies

* Die Analyse der Empfindung, Jena, 1902.

SCOPE AND METHODS 7

in psycho-pathology have given a new impetus to clinical
psychiatry. These and similar studies have shown that the
methods used in the laboratory to investigate the problems of
normal brain physiology necessitate modification before they
can be adapted to meet the conditions in the ward, and as a re-
sult attempts are in progress to select for investigation methods
as simple as possible which may be applied to the study of indi-
vidual cases by the clinician at the bedside. Psycho-pathology
does not begin and end merely by measuring the promptness of
reactions; its chief service has been in an analysis of the
attention, in the study of the character of the individual reac-
tions, of the anomalies of connected thought, and in investi-
gating the sharpness and correctness, under varying conditions,
of individual judgment. One result of all this study has been
that more or less abstract terms can now be replaced by simpler
expressions which greatly facilitate the formulation of the prob-
lems to be solved. Take, for example, the analysis of the mental
symptoms of fatigue. In this connection it has been shown that
the symptomatology of fatigue can not be expressed in one con-
crete and homogeneous term, but represents an aggregate of
symptoms. Furthermore, we know that the fluctuations of the
mental functions in different persons vary not only as conditions
change, but at different times of the day in the same individual.4
The investigations that have for their aim the determina-
tion of mental capabilities and individual variations deal with
problems of vital significance, and a word may be said in refer-
ence to the important practical bearing of these studies. As
will be seen later, the exaggeration of personal reactions or
idiosyncrasies plays no small role in the pathogenesis of insan-
ity. A comprehension of the evolution of such disease pro-
cesses, therefore, calls for a more or less accurate knowledge
of mental traits and idiosyncrasies. Before he can expect to
recognize an incipient mental defect the physician must be able
to form at least an approximate estimate of what is normal, and

4 Finzi, J. : Die normalen Schwankungen der Seelenthatigkeiten.
Uebersetzt von Jentsch, Wiesbaden, 1903.

8 PSYCHIATRY

any attempt to do this necessitates the careful study of cases
and a minute and scrupulously exact differentiation of symp-
toms. In this way alone will it be possible to determine the
standards of measurements by which the mental capacity, the
intensity or incongruity of emotional reactions, the limita-
tions of the volitional processes, and other conditions can be
estimated. Undoubtedly much of the indifference exhibited by
the medical public to the study of psychiatry has arisen because
alienists have hitherto failed to enlist the sympathy of intelli-
gent physicians, inasmuch as they have not demonstrated with
sufficient care the tangible visible reactions in cases of aliena-
tion, and the possibility of provisionally grouping them accord-
ing to their intensity in some sort of orderly fashion. Most
of these phenomena are as apparent as are the physical symp-
toms of cardiac or pulmonary disease, and it is no less possible
to obtain a clue as to what constitutes the normal functioning
of the brain than to detect impairment of the respiratory or
cardiac functions. Granting the truth of this affirmation, —
and it is one that may be tested by observation, — the immediate
need of prosecuting these investigations with renewed vigor
at once becomes apparent.

One or two concrete examples will be sufficient to demon-
strate the demand for such a procedure. The opinion of an
expert is sought for in examining a new recruit who is desirous
of entering the ranks of the army or navy ; and to-day the uni-
versities have physical directors to examine into and pass upon
the physical condition of students before they are allowed to
compete in inter-collegiate sports. And yet at the same time a
heterogeneous mass of humanity, without any form of selection
and utterly regardless of its fitness, is driven through a so-called
education. Society at large must sooner or later awaken to the
realization that the indiscriminate education of the masses can
not be too strongly condemned, for excessive demands on the
brain power of a community must ultimately lower not only the
intellectual, but also the moral standards. Even with the crude
and imperfect methods now used by the alienist, if the oppor-
tunity were given to him to apply his tests, it would be possible

SCOPE AND METHODS 9

greatly to reduce the numbers of those who are seriously injured
mentally and morally by a schooling ill adapted to their indi-
vidual needs and necessities. Every one admits that it is the
duty of the physician to warn those with weak hearts or lungs
not to overtax those organs. Is it not equally important that
the mental welfare of a community be safeguarded? Only
some men are born to be educated; how many more, unfor-
tunately, have thrust upon them an education which is disas-
trous not only to themselves, but also to the community at
large! To prevent the sins of over-educated fathers and
mothers from being visited upon the children unto the third and
fourth generation is a problem of great sociological as well as
economic importance to the state. The sudden expansion of
mental powers may be quite as unfortunate as the sudden acqui-
sition of riches, and the community that heedlessly imposes
mental tasks indiscriminately upon the children in its public
schools adds greatly to the list, already appalling in length, of
those who overtax the capacities of hospitals for the insane.

Those who are familiar with the trend of modern psy-
chiatry do not need this reminder of the fact that the work of
the alienist has an important bearing on problems of the highest
ethical importance. Not only is the alienist concerned in the
attempt to throw light upon the nature and genesis of insanity,
but as these investigations necessitate on his part the careful
analysis of the higher cerebral faculties and the determination
of the source of motives for action, his work leads him to the
consideration of all problems connected with the conduct of his
fellow-creatures. Duprat 5 has emphasized the fact that " the
doctor-philosopher" of to-day, in following men like Charcot,
Ribot, and Janet, has introduced into psychology an entirely
new spirit. These authors have shown that the impulses and
vagaries of conduct in the person affected with nervous or
mental disease are only accentuations of traits common to each
individual. As. the result of this and similar investigations his

* Duprat, G. L. : Morals. A Treatise on the Psycho-sociological Bases
of Ethics. Transl. by W. J. Greenstreet. New York, 1903.

IO PSYCHIATRY

special field has so broadened that the alienist finds to-day that
he has entered the sacred precincts once occupied solely by the
metaphysician and the philosopher. The doctrine that all pro-
cesses which disturb or curtail the functions of the nervous
system are followed not only by defects in connected thought
and rational action, but with equal certainty by anomalies of
conduct in the ethical and moral spheres, is merely a statement
of facts that are self-evident to those whose eyes are trained
to observe. Those who would lead the blind must themselves
know how to walk; they must be sure of their own sight and
know whither they are going. Theories worked out in the
cloister, preconceived ideas of what ought to be, the invocation
of the categorical imperative, can no longer supply even tenta-
tive explanations of the cause and motives of our actions.
There is a preventive morality just as there is a preventive
medicine, and he who would understand the former must know
something about impulses, imperative ideas, inhibition, psycho-
motor excitement, and suggestion. Conduct is the measure of
the functional capacity of the central nervous system ; and there
may be psycho-motor excitement in the carrying out of the most
complicated as there is in the execution of the simplest acts, such
as raising an arm or taking a step. Surely he who is capable
of interpreting the simpler phenomena, without making preten-
tious claims, may rightly affirm that he is in a better position
than the mere doctrinaire to study the problems of conduct.

Not only has it become possible by simple clinical study to
analyze many of the more complex volitional processes, but
some of the fundamental facts observed have been substantiated
by experiment. The various abnormal psychic states, that are
due to the effects of alcohol, morphin, caffein, the bromides,
and other poisons upon the mental processes, have been studied
and, although the results show considerable discrepancies, a
sufficient number of data have already been brought to light to
justify further investigations in this field.6 Hoch's studies, be-

* Weygandt, W. : Die Forschungsrichtung der Psychologischen Ar-
beiten. Centralbl. f. Nervenheilk. u. Psych., 1903, Nr. 156, 158.

SCOPE AND METHODS II

gun in Kraepelin's laboratory and continued in this country,
would have received far wider recognition and would have
served to arouse the interest of alienists in America to the far-
reaching character of such investigations had there been a more
intelligent appreciation of the need of accurate and timely ob-
servation along these lines. Not only have the more elementary
mental processes been a subject of careful study, but the emo-
tions, the volitional processes, the powers of discrimination and
judgment, and the complex personality have been shown to be
composite, not single functions, and " functional psychology
has at last succeeded faculty psychology." 7

If now we turn to the consideration of what the application
of these psychological methods to the study of patients has ac-
complished, it will be found, in the first place, that a fertile field
is at once opened to investigators. In a clinical psychology such
as that exemplified in the studies of Wernicke and Ziehen the
advantages and disadvantages of this method readily become
apparent. From a purely practical stand-point alone Wernicke's
work is unique and deserves the attention of every practical
alienist. Believing as he does that the time is not yet ripe for
broad comprehensive classifications, Wernicke attempts merely
to analyze accurately the individual symptoms in different dis-
eases in the hope that some additional clue may ultimately be
obtained as to the etiology and genesis of a given disorder.
Here we have at its best the critical analysis of symptoms, and
no one who has carefully studied Wernicke's Psychiatry can
fail to appreciate the evident genius that is reflected in this
method. But the fact that the analysis of cases is so keen and
the results of the observations are presented in so clear and
cogent a manner renders the defects of a symptomatologic
grouping all the more obvious. The attempt to compare the
disturbances in the psychic functions with those of speech,
although from a psychological stand-point ingenious and one
that has unquestionably facilitated the clinical study, is a
method of investigation that can not by itself lead the alienist

7 Baldwin, J. M. : Mental Development. New York, 1897.

12 PSYCHIATRY

to the goal he strives for. Descriptive psychiatry has been
singularly enriched by this narrative of cases in terms that have
not as yet had a specific meaning assigned to them, but other no
less important factors have not been treated with equal con-
sideration. The method employed by Wernicke is a fulfilment
of a hope expressed by Kahlbaum that a careful analysis and
study of the mental phenomena of the insane would ultimately
give birth to a special scientific symptomatology, the immediate
outcome of clinical investigation and not the mere adaptation of
current psychological theories and speculations. No better
exemplification of the good that may be accomplished by these
refined methods of analysis can be brought forward than by a
reference to the studies made in connection with the various
paranoiic states. In the light of recent investigations we no
longer speak of primary intellectual defects, as if the intellect
were an isolated faculty, or compare the genesis of an insane
idea to the birth of Minerva, inasmuch as careful observation
has shown that the majority can be traced to primary changes
in organic sensations, anomalous emotional states, and dis-
turbances in the complex of sensations designated collectively
as the personality. Head 8 has shown us how subtle and evan-
escent may be these early changes in organic consciousness, and
his careful observations have shown that the genesis of the most
complex mental disturbances may ultimately be explained by
the facts brought to light by the bedside study of patients.
Although it may only be the outline sketch that he has as yet
given, even from this we can at least get some faint idea of how
the intricate paranoia-complex develops gradually and insidi-
ously from the indefinite apprehensiveness, mild suspiciousness,
ill-defined hallucinations and delusions so commonly asso-
ciated with visceral disease. A still greater refinement of the
methods employed, a greater exhibition of patience, a little
more general interest in careful bedside observation, and these
apparently illusive problems will at least be definitely formu-
lated.

8 Head, Henry : Certain Mental Changes that accompany Visceral Dis-
ease. Brain, 1901, p. 345.

SCOPE AND METHODS

13

Another excellent example of what may be accomplished
by these methods may be found in Bonhoeffer's study of the
alcoholic psychoses. Here the most painstaking methods have
been adopted in the analysis of the mental symptoms, and the
character of the reactions obtained in individual cases has been
greatly elucidated. If it is possible, for instance, in these psy-
choses of toxic origin to demonstrate the extent and nature of
the anomalies of the cerebral functions, we may in the end get
some clue as to the manner in which the poison acts.

The attitude of the modern alienist was clearly indicated by
Kahlbaum 9 in the preface to his classical work on catatonia.
The insufficiency of the psychologic method alone was clearly
pointed out, whereas the danger of restricting the study of a
disease to the minute analysis of symptoms at any given period
was shown to be an error that can not be too carefully guarded
against. The actual advances that have been made in the dif-
ferentiation of disease groups bear testimony to the necessity
of recognizing this principle. The most prominent example is
that offered by the investigations that culminated in the gradual
separation of the dementia paralytica group from a hetero-
geneous mass of symptom-complexes. This division was made
possible by the study not merely of the individual mental and
physical symptoms at one period, but by a general survey of the
whole course of the disease. The attempt to apply a similar
method to the study of other diseases resulted in the recognition
by the French of the circular insanity (folie circulaire). Iso-
lated groups of symptoms were thus shown to be related to
others that on the surface had the appearance of dissimilarity,
and Kahlbaum was able to define the catatonic symptom-com-
plex and Hecker to elucidate hebephrenia, or the so-called
adolescent insanity.

Among the apparently radical departures that have been
made in modern psychiatry, unquestionably that of Kraepelin
has attracted the most notice. This investigator believed that

* Kahlbaum, Karl : Abhandlungen iiber Psychische Krankheiten. Ka-
tatonie. Berlin, 1874.

tli&ranj of
%ahvrt Jaudnrt »»U

I4 PSYCHIATRY

the time was ripe for an attempt to sketch out in a general way
certain groups which might eventually prove to be disease enti-
ties, and numerous observations have been brought to light
which justify this position. Alienists had already emphasized
the necessity of studying the entire course of a disease and not
merely the isolated symptoms of a given period. Similar clini-
cal pictures were known to occur in a great variety of disorders,
and the analysis of these individual phenomena by themselves,
without regard for the whole, merely impeded progress.
Granted that mental diseases are not essentially different from
other diseases of the body, no less regard must be given in
psychiatry to the course and prognosis than is bestowed upon
them in other maladies.

Kraepelin's departure is, however, not so radical as many
of the more recent critics would lead us to believe. His attitude
is that of the observer who finds it essential to success that
every factor connected with the problem in question should be
taken into account and given its due valuation. The symp-
tomatology grouping may, as has already been pointed out, be
suggestive in many ways, but no definite advance can be made
by merely refining the methods for the study of symptoms.
The process of discrimination which led to the formation of the
two groups of symptoms under the heads of manic-depressive
insanity and dementia prsecox is in reality an excellent example
of a synthesis carried out along broad and comprehensive lines.

No account of modern psychiatry would be complete with-
out some mention of the work done by the French school, par-
ticularly that of Charcot and his pupils, in differentiating and
describing the chief characteristics of hysteria. Here again the
same clinical principle has been applied with equally successful
results. The study of composite, not isolated, pictures has
demonstrated that the occurrence of hysterical states does not
necessarily imply the existence of a disease entity. To compre-
hend this disorder we must frequently go back in the history of
the individual to childhood and trace the whole evolution of the
disease before a clear and comprehensive idea of the disorder
becomes possible. Hysterical traits are not born with the indi-

SCOPE AND METHODS 15

vidual, but in all probability functional defects in the nervous
system exist out of which the hysterical character develops
whenever there is sufficient provocation. Janet's recent con-
ception of psychasthenia is the result of another brilliant study
pregnant with suggestion for future investigation, although
possibly lacking in some of its details the confirmation of facts
to be obtained only after a more protracted period of clinical
observation. The advancement in psychiatry will depend
largely upon the care and accuracy with which individual cases
are studied. If generalizations are to be successfully made, they
must be based upon the scrupulously exact analyses of all the
factors concerned. Fortunately alienists in this country have at
last broken away from the conventional method of merely
recording groups of symptoms without attempting to assign the
proper valuation to the etiology, course, and termination of the
disease. Persistent and exact observation in the ward and at
the bedside is fast taking the place of the haphazard and casuis-
tic statistical methods that so long threatened to stifle the in-
tellectual life of those who were engaged in collecting these
figures. Even yet, in order to gratify the morbid curiosity of
the public, the results of imperfect observations are tabulated
and published in hospital reports, and these statistical tidbits
are made to serve as the basis of superficial generalizations.

The present is the time in which to perfect the methods for
the careful bedside study of patients. If the results from the
laboratory investigations have not equalled the expectations of
those who would reach the psychiatrical Mecca without the
toils of a long pilgrimage, a similar high standard of work may
be profitably adopted by the clinician. The present impedi-
ments that interfere with the realization of this advance will be
discussed when we come to speak of the " Modern Hospital for
the Insane." The remarkable advances that have been made in
the treatment of alienation, as well as the relation of the work
of the pathologist to the clinical problems, are of sufficient im-
portance to become the subject of separate chapters.

CHAPTER II

THE NATURE OF THE DISEASE PROCESS IN ALIENATION AND
ITS RELATION TO THE PATHOLOGICAL CHANGES

Any attempt to discuss the nature of the disease process in
cases of mental disorder necessarily brings us face to face with
a number of problems that from time immemorial have per-
plexed even the most profound thinkers. While it is a fact that
in many cases of alienation it is possible to demonstrate certain
morphological changes in the central nervous system, the exact
relation that these bear to the mental symptoms of the disease
can not even be conjectured. In spite of this lack of continuity
in our knowledge, our duty in regard to these questions is
obvious. Just as in any other department of science where the
realm of the knowable is limited in comparison with that of the
unknown, we must hold fast to the little that we actually possess
and then by observation and experiment endeavor to increase
our actual store of facts. Countless investigators in every de-
partment of science, working from many different stand-points,
are attacking the problems connected with the relations of
structure and function. But so many ideas and new rela-
tionships are being constantly proposed that, although certain
theories may from time to time be accepted as supplying a
provisional working basis, any attempt at this time to interpret
and correlate all the different views and opinions would be a
hopeless task. So many hypotheses are being advanced and the
tendency to indulge in speculation is still so prominent a char-
acteristic of the human mind that Mach's warning to the physi-
cist to beware lest he " out-philosophize the philosophers" is
equally applicable to the alienist in his research work.

The relation of structural changes to disorders of func-
tion is still a matter of speculation. Nor is this uncertainty
confined to the central nervous system, inasmuch as countless
questions of a similar nature are arising in connection with

16

NATURE OF ALIENATION

17

every organ of the body. Such being the case, it would not
be strange if the exact nature of the disease process in cases
of alienation should long remain in doubt. But, despite these
serious limitations, workers in the laboratory and clinic should
be encouraged by the fact that the little we know at least is
sufficient to show the paths along which the alienist must pur-
sue his studies. Experience has proved that the process causing
the functional anomalies is a general one, giving rise to a great
complex of symptoms and ultimately involving more or less of
the whole personality. The correctness of this view is further
substantiated if we pass from the consideration of symptoms
to that of probable causes. Here too the multiplicity of factors
of etiological importance at once becomes apparent. For ex-
ample, an individual has an attack of typhoid fever which is
followed by a psychosis. Is the fever the sole exciting agent or
are other provocative factors concerned? The latter view is
undoubtedly the correct one. In the same way dementia para-
lytica is not looked upon merely as the consequence of pro-
longed over-indulgence in alcohol or of a specific infection, but
the individual so afflicted is regarded as having been in all
probability " half born a paretic." Although definite answers
can not be given at present to these and similar questions, at
least we have learned to recognize the important fact that our
investigations of these problems must be undertaken from a
broad and comprehensive stand-point. What are especially
needed in psychiatry at present are intelligent, broad-minded
clinicians sufficiently in touch with the methods and data of
modern science to be able to differentiate between these com-
plex problems awaiting solution and decide which of them
may be attacked from the clinical stand-point and which had
better be left to the biologist or chemist.

In investigating into the nature of the process in cases of
alienation we are naturally led to inquire whether or not mental
disorders are to be classed as diseases of the brain. There can be
no doubt that, if we view them purely from the symptomato-
logical stand-point, Wernicke is correct in affirming that mental
disorders are essentially diseases of the brain, not localized but

18 PSYCHIATRY

general in character. In one sense this position is thoroughly
justifiable and is an indication that genuine advances have been
made in psychiatry. But this view can not be maintained at
present without some qualification. In the case of dementia
paralytica it is easy to demonstrate a series of more or less spe-
cific changes in the central nervous system, and with these
changes we correlate a number of functional modifications
which also, when grouped together, bear a specific stamp. It
should not be forgotten, however, that evidence adduced from
clinical and pathological studies seems to favor the current view
that dementia paralytica is the result of a toxic condition,
although we are still profoundly ignorant not only of the nature
of the poison, but also of its place of origin. But if the latter
should be located in some organ outside of the central nervous
system, from a technical stand-point this form of alienation
can not be regarded as being purely a " brain disease." An even
better illustration is seen in the study of mental disturbances
associated with myxcedema. Here it is known that the anom-
alies in the function of the brain depend upon disturbances in
the thyroid gland, and hence it would be quite unfair to classify
a myxedematous insanity as a disease of the brain alone.

Although the facts that are known in regard to the his-
tology and pathology of the central nervous system are so few
and isolated in comparison with the still unexplored territory,
the meagreness of the practical results thus far obtained by no
means justifies the criticism of those who have neither sufficient
patience nor training to enable them to attain a broad and com-
prehensive grasp of the real nature of the problems to be solved.
The many defects in our knowledge, it is true, serve to empha-
size the difficulties with which the alienist is confronted in his
attempt to gain a more comprehensive knowledge of the nature
of alienation, but they need not deter investigators from prose-
cuting with renewed vigor their researches in the realms of
physiology and anatomy. A few years ago a genuine but some-
what premature enthusiasm led not a few workers to be-
lieve that the new methods and discoveries in the histology
and pathology of the central nervous system promised an almost

NATURE OF ALIENATION

19

immediate solution of many of the problems of clinical psychia-
try. This period dates from the work of Theodor Meynert,
of Vienna, whose influence was felt so profoundly by alienists
both in Europe and this country. Earlier observers had al-
ready directed their attention to the nerve-cell, and in a gen-
eral way many of its properties and histological characteris-
tics had already been recognized. Later on a great deal of
energy was directed towards disentangling the vast complex
of fibres which were found to exist everywhere in the central
nervous system, many of the workers being imbued with the
idea that were it possible to bring order out of this chaos
great immediate benefit could be derived by the alienist from
these studies and a new association psychology could be
founded upon an anatomical basis. Unfortunately, not only
were these hopes not realized and the results obtained nega-
tive, but; on the other hand, the habit of substituting hypoth-
eses based upon incomplete anatomical studies for clinical in-
vestigations in some measure actually delayed even the proper
formulation of the really essential problems. Nevertheless,
genuine advances have been made in clinical psychiatry, thanks
to the work of men who have been thoroughly trained them-
selves and who have sought the cooperation of the pathologists.
And in the final analysis to-day the chief inspiration for the
clinician must come from those who, as Pasteur once put it,
are working in the " serene peace" of their laboratories.

Great as are the inherent difficulties of the problems that
confront the alienist, they are often still further complicated by
unwise attempts to interpret immediately clinical symptoms in
the light of the facts furnished by the anatomist and pathologist.
And the converse is equally true. Perhaps the most striking
example of this error is to be found in the attempt to assign to
the anatomical studies of Flechsig an immediate physiological
importance. All that was actually demonstrated by these in-
vestigations was that the development of medullation in the
nerves bears some general relationship to the appearance of
function, but it has by no means been established that the
former is absolutely essential for the latter. Indeed, it has been

20 PSYCHIATRY

demonstrated that definite nervous reactions may sometimes
precede the formation of the medullary sheath. Furthermore,
although Flechsig has shown that certain tracts receive their
medullation at different times, these investigations have not
thrown any light upon the great area that exists between the
point in the cortex where so many fibres begin to lose their
medullary sheath and the outermost layer, a space that is rich
in cellular elements and a specific gray substance of great mor-
phological as well as functional importance.

The essential differences in the histological structure of the
various cortical areas can not, except in a very general way, be
correlated with the functional differences. To suppose, for
example, as Wernicke has done, that the consciousness of self,
of the internal and of the external world, are represented in
separate layers is a purely hypothetical conjecture. The whole
subject of cortical localization needs revision in the light of the
facts more recently demonstrated by the biologist and physiol-
ogist. The points of discharge for efferent impulses can no
longer be considered as forming the limitations of centres, and
the application of this term itself is indefinite.

The work of Apathy, Nissl, and Bethe has clearly shown
that the relation between nerve-cells and fibres is not as simple
and clear as the earlier investigators would have led us to
believe. As soon as we are able to establish definitely the
relationship between nerve-cells, nerve-fibres, and the specific
gray substance in the cortex, a decided advance will have been
made not only of importance for the histologist, but one which
will have an immediate bearing upon certain diseases, particu-
larly dementia paralytica and certain other dementing processes.

Even from the little that is known it is justifiable to con-
clude that the so-called specific gray substance is an important
element in the central nervous system. In animals where this
morphological element is diffusely arranged, the reflex action
is simple and the movements are incoordinated ; but higher up
in the scale, when the distribution of the gray matter is limited
to certain areas, the movements become correspondingly more

NATURE OF ALIENATION 21

complex, and coordinated. This is equivalent to saying that the
increase in complexity of reflexes and coordinated movements
is dependent upon the efficiency of the receiving and elaborating
organ. Recent investigations in morphology and physiology
have shown that the ganglion-cell hypothesis is, after all, an
inadequate attempt to account for all the phenomena of reflex
action.1

As yet we have only a very imperfect knowledge regard-
ing the blood and lymph-channels of the central nervous system,
and leaving out of consideration for the moment the adventitial
lymph spaces, practically nothing is known in regard to the
passage of the blood through the brain substance. Recent in-
vestigations have clearly shown that the so-called extra- or
peri-cellular lymph-spaces are mere artefacts, and this discovery
has thrown some light upon certain pathological processes, since
it is now definitely known that the round nuclei which in certain
pathological changes are grouped about the nerve-cell are not
lymphocytes, as is even believed by some to-day, but are
neuroglia elements.

As regards the nerve-cells themselves, it will be found that,
valuable as the earlier contributions were in giving us a more
accurate knowledge of their intimate structure, later investiga-
tions have as yet failed to demonstrate the relation of the
observed changes to the general pathological processes or to the
clinical symptoms. The reaction of these structures is so deli-
cate and so many factors — such as pre-agonal changes — may
intervene, that it is almost impossible to deduce any general
conclusions from the countless number of observations that have
been made in regard to the supposed correlation of the struct-
ural changes and the clinical symptoms. Although many in-
vestigators, in despair at the slow progress that has been made
in the study of the histology of the central nervous system, seem
to discourage further investigations along this line and boldly
declare that the only hope for a possible solution of all this

1 Bethe, A. : Allg. Anatomie und Physiologie des Nervensystems.
Leipzig, 1903.

22 PSYCHIATRY

chain of problems lies in the field of physics and chemistry, a
more conservative opinion would justify the belief that im-
portant contributions still remain to be made by histologist and
anatomist. In addition to those already referred to there is
great need of the establishment of certain standards by which
an approximate and rapid estimate may be made of the number
of nerve-cells in the different areas of the cortex at different
periods of life as well as their diminution during disease. The
studies of Henschen and others in the pathology of idiocy have
shown that in these conditions the embryonal type of elements
persists, but whether there is any considerable diminution in
the number of nerve-cells is still a matter for conjecture.

What is true of the nerve-cell is equally true of the fibre.
The studies in dementia paralytica of Kaes, whose work is
referred to more in detail later, has clearly shown how im-
portant are detailed careful studies of the relative number of
fibres in the different cortical areas at different epochs of life
and their diminution in various morbid conditions.

If we turn from the more purely anatomical and physio-
logical questions to the specific bearing that certain groups of
pathological changes have upon the symptoms, it may be said
that in a few instances definite advances have been made.
Since Tuczek first accurately described the disappearance of
the tangential fibres from the cortex in general paresis, a large
body of workers all over the world have been engaged in the
study of this disease, and gradually a number of characteristics
of this pathological process have been recognized, so that in
from 80 to 90 per cent, of the cases a positive diagnosis of the
existence of the paretic process can be made directly from the
pathological findings. More recently, as will be seen later on,
Nissl, basing his observations upon the study of individual cases,
has definitely stated that it is possible to differentiate the paretic
from the syphilitic process. If these observations are generally
confirmed, it will be possible to take a decided step forward in
the clinical differentiation of the two diseases. On the other
hand, the differentiation of the protracted cases of dementia
paralytica from certain forms of the senile or alcoholic psy-

NATURE OF ALIENATION

23

choses still awaits solution. The remarkably careful and pains-
taking work of Alzheimer has demonstrated the possibility of
differentiating anatomically between a number of the arterio-
sclerotic lesions and those of general paresis. And again in
this direction the paretic process has been more definitely defined
and the boundaries have been more nearly established. Surely
even these advances are sufficient to justify the expectation that
within the next decade this important group of diseases will be
even more accurately outlined.

The problems of histopathology necessarily bring us to the
consideration of the manner in which certain toxic products act.
From the evidence at our command there can be little doubt that
the series of changes, which are noticeable in the nerve-cell in
febrile delirium and acute and sub-acute confusional states, as
well as in the terminal stages of nearly all psychoses, are the
result of the action of toxins.

As to the manner in which these poisons act or the source
from which they are derived we are still ignorant, and, indeed,
in regard to the more general subject of autointoxication
practically nothing definite is known.

It is to be hoped that gradually some light will be thrown
upon these problems, not only by the investigations made in
pathology, but by the results of experimental studies, especially
those in which the pathologist has the assistance and coopera-
tion of a well-trained chemist. The field of the experimental
production of anomalies of the cortical functions is one that as
yet has hardly been entered upon. Difficult as the problems are
which are awaiting solution, it can not be long before a large
number of investigators will have entered upon this field, in
which the harvest must eventually be so rich.

The conclusions reached by Cramer 2 deserve attention, as
they summarize the opinions entertained by the majority of in-
vestigators. This writer affirms that in all forms of psychosis
anatomical lesions are to be found, the most severe being

2 Pathologische Anatomie der Psychosen, Handbuch der patho-
logischen Anatomie des Nervensystems. Berlin, 1904.

24

PSYCHIATRY

demonstrable in cases of progressive paralysis and in certain
forms of chronic alcoholism. A condition similar to that found
in cases of dementia paralytica is frequently noticed in the
cortex of senile dements, but the lesions typical of senile de-
mentia may be differentiated from those of paresis. The
arteriosclerotic atrophy presents, as a rule, certain character-
istic changes. But frequently the localized increase in the glia
is noted in the senile psychoses, in dementia paralytica, and not
uncommonly in the so-called senile epilepsy. There is no spe-
cific change in the glia noted in any one psychosis. The simple
psychoses of the senium not complicated by paralyses and not
connected with the periods of great excitement or terminating
in dementia present the fewest alterations. It is still question-
able whether characteristic glia changes are met with in cata-
tonic states. Conditions of confusion with great excitement,
commonly referred to as acute delirium, are, as a rule, marked
by the appearance of a typical cortical encephalitis which may
or may not be of an infectious character. Delirium tremens
and other acute psychoses may be differentiated from general
paresis by the very small number of blood-elements present in
the tissues, the absence of any very marked diminution of the
fibres, and the failure to find sclerotic cells. The changes found
in the acute delirium are not seen in any other psychoses except
in dementia paralytica. Cases in which the process has not
gone so far as to give rise to cell sclerosis, disappearance of
fibres, cellular infiltration, and marked vascular changes, with
great increase in the glia, afford some hope for recovery. Spe-
cific cell changes for individual psychoses do not exist.

On the whole, then, it may be said that the hopes of those
who a decade ago saw rich rewards awaiting the investigations
of the neuro-pathologist have not been justified. But is it not
reasonable to suppose that advances towards a more compre-
hensive knowledge of the nature of mental disorders will
neither be more rapid nor more delayed than one would expect
in attempting a solution of problems equally difficult in other
branches of medicine. And while careful, painstaking investi-
gations conducted along all the different lines which the study

NATURE OF ALIENATION

25

of this subject necessitates must evidently result in an accumu-
lation of a valuable store of facts, it would be unreasonable to
expect an immediate advance of psychiatry from the casual
study of isolated portions of the central nervous system. The
pathologist at the autopsy table should conduct his investiga-
tions with the realization that mental diseases are an expression
of disordered functions of the brain, but that the causes for
these anomalies may be situated in organs outside the central
nervous system. He must further bear in mind the fact that
if a pathological process once gives rise to a disturbance in the
mental functions, the original trouble may become quiescent
and the aberration may, so to speak, become self-accumulative.

CHAPTER III

THE SYMPTOMS OF ALIENATION

All forms of alienation are to be regarded as the results
of bodily disease in which the disordered functions of the cere-
bral cortex afford the most prominent and characteristic of the
symptoms. Although, as has already been said in the opening
chapter, the clinical study of cases of insanity covers a very
wide range and implies the application of the methods employed
in clinical medicine and neurology, only the mental disturbances
can be discussed within the present compass. ' The anomalies
in the functions of the cerebral cortex may for convenience'
sake be divided into various categories. From a physiological
stand-point the student of mental processes has to consider the
reception, retention, and elaboration of sensory stimuli and
finally the discharge of the motor impulse. It is hardly neces-
sary to again emphasize the fact that all the processes represent
merely various gradations and not essential differences in qual-
ity or character.

I. IMPAIRMENT OF THE HIGHER CORTICAL FUNCTIONS

AS SHOWN IN DEFECTS OF JUDGMENT AND

INTELLECT. FIXED OR INSANE IDEAS.1

In the present section we shall not attempt to give a de-
tailed exposition of the anomalies of judgment and intellect,
but rather to indicate the manner in which they may be studied
from a clinical stand-point. Faculties which represent the most
complicated products of the cortical functions can neither be
defined nor clearly described. What has been shown to hold
true for the simpler mental phenomena — as regards their de-

1 Baldwin, J. M. : Mental Development in the Child and the Race.
New York and London, 1897. Tiling: Ueber die Entwicklung d. Wahn-
ideen u. Hallucinationen aus d. normal Geistesleben. Riga, 1897. Spiller,
Gustav : The Mind of Man. New York and London, 1902. Tiling : Zur
Paranoiafrage. Psychiat. Wchnschr., 1902, Bd. 35, 431-442.
26

DEFECTS OF JUDGMENT 27

pendence upon other functions — applies with even greater force
to the discussion of these final products of cerebral activity.
In the attempt to analyze the latter one must never lose sight
of the fact that their relationship to other functions is very
intimate, whence it follows that any anomaly of one function
will to a certain extent cause not an isolated but a general
defect. The two terms, intellection and judgment, for a time
formed a part of the stock in trade of the older psychology, but
on account of the speculative and fanciful manner in which the
discussions concerning their nature and origin were conducted
little real advance was made towards a satisfactory interpre-
tation or analysis of them. As in the case of sensation, mem-
ory, volition, or the emotions, so in a study of the intellect
and judgment it has been found possible to split these com-
plexes up into a great variety of simpler forms which merge
into each other and concerning whose nature psychologists and
alienists are gradually gaining an insight. As the character
of even the simplest mental processes is at present indefinable,
it is not to be expected that those of greater complexity can be
differentiated and labelled. There are certain manifestations,
however, of these functions that the alienist should recognize
and with the genesis of which he should show some degree of
familiarity. One of their most striking features is that they
depend upon the activity and integrity of associative memory,
so that impairment of the latter is always reflected in the
anomalies of the former. These particular mental processes
under discussion are of slow growth and only attain their maxi-
mum when the individual has reached the prime of life. In-
tellection and judgment necessarily imply the power to retain
in memory a series of events which may be compared with the
more recent facts introduced into consciousness. The com-
parison is made between the earlier and the more recent acqui-
sitions, and the individual then tries to so adjust his conduct as
to justify inferences drawn from these comparisons. If we
trace the development of mental traits in the infant, we find
that the power to form inferences or judgments only appears in
proportion as the faculty to retain and to recollect past im-

28 PSYCHIATRY

pressions becomes greater. The greater the number of the ac-
quisitions that are stored up in memory, — in other words, the
greater the power of associative memory, — the greater the indi-
vidual capacity for intellectual activity and rational thinking.
In the earliest years of life sensory impressions play a far more
important part than they do later on, and at first are the domi-
nating features in all psychic reactions. For example, when
the newborn infant takes the breast it does so in direct response
to sensory stimulation, but gradually mere sense impressions,
whether of intra- or extra-organic origin, become replaced by
more complicated acts of associative memory; and these, as
the cerebral capacity increases, may take the place of the primi-
tive unelaborated sensory impressions. In the adult a train of
associative thought which ends ultimately in the expression of
judgment may be initiated either by a sensory impression or
by a memory-picture. In the least complex reactions, such as
those referred to in the infant, the vividness of the sensory
impression is proportionately greater than the stimulus de-
rived from memory-pictures. The former is definite and con-
crete, the latter indefinite and abstract. The study of such
cases as that of Laura Bridgman, in whom both vision and
hearing were defective, would seem to justify the position that
comparatively few sensory impressions are sometimes sufficient
to stimulate complex memory and lead to the formation of
equally complex concepts and judgments.2 An individual
may be deprived of the various forms of sensory stimulation
without suffering from any serious interference with the for-
mation and retention of complex memory-pictures, and may
also be the possessor of an apparently undiminished critical
faculty. Some authors, however, who have made the phe-
nomena the subject of investigation, have failed to appreciate
how diversified and exceedingly important in the development
of the mental life of the individual are the so-called organic
sensations apart from impressions derived from the visual or
auditory areas. The important part that the muscle sense may

'Jerusalem, W. : Laura Bridgman. Vienna, Pichler, 1891.

DEFECTS OF JUDGMENT 29

play in psychic phenomena has recently been made the subject
of considerable investigation, and it would be difficult to over-
estimate the far-reaching consequences that the organic sen-
sations have upon the mental life of the individual.3 The
changes in the organic sensations and in the muscle sense may
so seriously disturb the somato-psychic consciousness as to dis-
organize connected thought and involve all the more compli-
cated cortical functions.

In abnormal mental states where the imperious and ap-
parently logical character of the ideas would at first lead the
observer to believe that the primary disturbance is an intel-
lectual defect, a more careful investigation frequently shows
that the primary change is an affective one. This is also true
in the conditions where the ideas are immobile and the sys-
tematization is marked. In children and in primitive peoples
the dominant features in the mental processes are sensations,
simple memory-pictures, and affective states. It has been
further observed that although isolated and disconnected in-
sane ideas not infrequently exist, the more complicated sys-
tematized delusions are practically never met with. A stable
elaborated systematized series of insane ideas is an impossible
occurrence in children, for, as Schultze 4 has well said, the
paranoiic must be a finished builder in the realm of thought.
It is always possible to note great variations in the affective life
of any individual who subsequently becomes the subject of
definite and systematized fixed ideas. In some instances, owing
to the change in organic sensation, the patient becomes nervous,
restless, irritable, and is thoroughly conscious of the fact that
a physical ailment has given rise to some disturbance that in-
hibits the completion of his mental processes. Gradually this
leads to mistrust of himself and then possibly of others. At

* Storch, E. : Muskelfunction und Bewusstsein. Eine Studie zum
Mechanismus der Wahrnehmungen. Wiesbaden, 1901. Kluge: Ueber den
Muskelsinn und iiber seine Darstellung bei Maupassant. Ztschr. f. Psych.,
lx, S. 414.

* Bemerkungen zur Paranoiafrage. Deutsch. med. Wchnschr., Januar
14 und 21, 1904, Nr. 3 und 4.

30 PSYCHIATRY

times we meet with cases in which a mild degree of appre-
hensiveness or anxiety is constantly present. Frequently it is
impossible to define the exact mental state of the patient except
to say that there is an indefinite sense of unrest present which
serves to fasten or tetanize the attention. Then external sen-
sory impressions, particularly those which on account of the
surrounding circumstances fall within the focus of the atten-
tion, seem to grow more vivid than normal. As a result of
this condition changes occurring in the patient's own body, or
certain events that transpire in the external world, receive from
him more than their share of attention. The individual's nor-
mal sensibility is necessarily disturbed, and as a result the origi-
nal notion in consciousness is transformed and gives birth to a
new idea which springs into being so richly colored by an
emotional setting as not to be easily displaced or corrected.
This process is naturally a progressive one. Clinical observa-
tions do not tend to confirm the view that these disturbances
in intellection only appear when there is evident a general and
uniform impairment of all the mental processes, although as the
systematization is developed such a condition may present itself.
The intimate relation that exists between the emotional tone
and the idea is shown in the occurrences of every-day life or in
discussions on political or religious questions.5 Lecky, Draper,
and others have shown how important a part these phenomena
have played in the history of the race, and every reader is doubt-
less familiar with the various outbreaks, more or less paroxys-
mal in character, of aberration which have occurred in history.
The beliefs in demoniac possession, witchcraft, and the evil
eye, so current in the middle ages, and the various manias of
modern times, — for instance, spiritualism or Christian Science,
— which at times have played an important role in the develop-
ment of nations, are familiar examples. The limitations in the
field of consciousness and the riveting of the attention upon
some one idea are phenomena that are of frequent occurrence
in women and hypersensitive men, and, as Friedman has

11 Friedman, M. : Ueber Wahnideen im Volkerleben. Wiesbaden, 1901.

DEFECTS OF JUDGMENT 3 1

pointed out, are met with even in animals ; for example, in the
antelope standing motionless and watching the approaching
caravan oblivious of danger, or the deer held spell-bound by
the flash of a lantern.

Primarily, all defects in intellect or judgment are neces-
sarily associated with defects or changes in consciousness or
in associative memory. Wernicke 6 has affirmed that in the
cases of insanity which are characterized by marked defects in
what is commonly called judgment, the content is impaired,
while the activity of consciousness is normal. Such a distinc-
tion is misleading, as it necessarily involves a debate concern-
ing the appropriate use of terms that are themselves more or
less indefinite and merely relative.

Since in all cases of alienation the personality as such
suffers, not only should the content of the insane idea be
noted, but also the attempt should always be made to study
the synchronous changes that have occurred in the complex
of sensations upon which the idea of personality depends.
The ego is never constant, varying as the elaboration of sen-
sory impressions becomes keener and the activity of asso-
ciative memory greater. For example, the belief of children
or primitive peoples in ghosts or spirits may readily be ex-
plained on the ground that the material furnished by the
senses has not been sufficiently elaborated and associative mem-
ory has not been actively stimulated to retain abstract ideas
from which comparisons and rational judgments may be
formed. As the cerebral functions develop and the child re-
ceives, retains, and, as need arises, develops these more com-
plex memory-pictures, it becomes able to correct its false im-
pressions as to the existence of such spirits. But when an
individual in the prime of life complains that he has been mal-
treated and tormented by invisible spirits, that the room is
haunted by ghosts of departed friends, that he cannot write
a letter without being assailed by unseen agencies, the cause
of the incorrigibility of these ideas must be sought for not

"Grundriss der Psychiatrie, 1900, S. 101.

32 PSYCHIATRY

only in the greater intensity of the representations, but in the
more or less complete dissociation of his entire individuality.
What psychiatry needs above all things at present is a rigid
study of cases, but without attempts to form any broad gen-
eralizations. The mere narration in a clinical history of the
content of the insane idea is an isolated fact of comparatively
small value.

Recently considerable attention has been directed to the
importance of the disturbances giving rise to anomalies of
personality. From an historical stand-point it is interesting
to note that as long ago as 1873 the significance of the changes
in organic sensations which form the basis of this depersonali-
zation was emphasized by Krishaber,7 a laryngologist and a
favorite student of Claude Bernard. More recently the work
of Janet, Head,8 and Pick 9 has forcibly redirected attention
to the great importance of these alterations of organic sen-
sibility. Unfortunately, as a rule, so few individuals afflicted
with insane ideas come under the observation of the alienist
until the systematization is more or less complete and im-
mobile, that little satisfactory progress has been made in the
study of the development of these phenomena. For this
reason the large amount of material which presents itself at
the dispensaries of any of the large city hospitals is of greater
value for study than are the cases which are admitted to our
hospitals for the insane. In practically every case of aliena-
tion which comes under observation early in the development
of the malady it will be found that the patient frequently
complains of changes in the organic sensations of such a
nature as to interfere with the integrity of the sensations upon
which the idea of individuality depends. In cases of manic-
depressive insanity, dementia praecox, and dementia paralytica,
which have early come under observation at the dispensary of

T De la Nevropathie cerebro-cardiaque, 1873. Granier : Essai sur la
Nevropathie cerebro-cardiaque ou Maladie de Krishaber, 1903.

8 Op. cit.

' Pick, A. : Neurol. Centralbl., 1903,, Nr. 1 : Zur Pathologie des Ich-
Bewusstseins. Arch. f. Psych, u. Nervenkrankh., 1904, H. I.

DEFECTS OF JUDGMENT 33

the Johns Hopkins Hospital, we have been particularly struck
with the remarkable change occurring in the organic sensa-
tions. Of this the following case affords an excellent
example :

A certain young woman who at a very early stage came under observa-
tion, and whose subsequent history showed the case to be one of dementia

praecox, frequently complained that she did not " feel herself," that " some-
thing was changing," and that there was " something the matter with the
brain." After several visits to the dispensary her sister informed the ex-
amining physician that the patient had suddenly developed suspicions, the
nature of which it was at first difficult to ascertain, but which on careful
inquiry were found to be of a sexual character. After several unsuccessful
attempts had been made to get the patient to give an account of her symp-

3

34 PSYCHIATRY

toms, the request was finally complied with and the extracts from the
autamnesis, which are given here, afford an interesting revelation of the
genesis of these ideas. The patient lived on the second floor of a small
tenement house, so that when she was lying in bed at night she heard
sounds made by the other boarders going up and down the stairs. Most
of them were men, and as the patient was kept awake by the continuous
tramping up and down the stairs she became very nervous, dreaded going

to bed, and finally became vaguely suspicious that an attempt was being
made to annoy her. One night, having experienced a feeling of suffocation,
she suddenly awoke, and immediately thought that somebody had thrown
a heavy blanket over her. During the remainder of the night she was
more nervous than usual, so that the next morning, on leaving her apart-
ment and meeting a young man who chanced to live in the same tenement,
her suspicions were at once directed against him, although later the patient
admitted that these suspicions were groundless. Although in describing

DEFECTS OF JUDGMENT 35

these ideas the patient did so in a tone which seemed to indicate embarrass-
ment and a disinclination to talk about such matters, on close examination
it at once became apparent that this emotional state was largely superficial,
and that in reality slight indifference and apathy with a more or less com-
plete change in her whole personality existed. One day, while being ques-
tioned in the clinic, the patient suddenly sprang from her chair and asked
in an excited way who was concealed behind the curtain. Although

/Acwt^ -A^o^-oL^ Arc^oL^ OlA, C 04/ CuCltiJ^

assured that no one was there, it was some time before she could be made
to go and look for herself. In a few minutes, however, she seemed to
realize that her action was foolish, and said to the examiner that she felt
some change, which she could not explain, had taken place in her head, and
that in fact her " whole person seemed to be changing." The accompanying
short account written by the patient accentuates certain of the more promi-
nent defects, such as impairment in associative memory and the vague
suspiciousness.

An important feature of these disturbances is the marked
perversion of " the sense of self-activity" which is present in
all normal individuals. According to Bryant,10 self-conscious-
ness includes all those feelings of agency or directed energy
attending every voluntary act. Undoubtedly it is a lack of
this sense which is largely responsible for the feelings that
many patients have that they are mere automatons or are no

10 Mind, 1897.

36 PSYCHIATRY

longer the masters of their own activity. Since the days of
Zeller and Griesinger, the attention of alienists has been di-
rected to what the earlier observers called psychic anaesthesias,
states intimately associated with this depersonalization, in
which there is a reduction or complete obliteration of many
of the facts of consciousness. Such conditions exist in melan-
cholias, giving color to the fixed ideas and playing an im-
portant role in the delirium of negation. The importance of
these psychic anaesthesias or paraesthesias in the development
of insane ideas is frequently well illustrated in the prodromal
period of epileptic seizures, a classic example of which is the
case of Crichton Browne, referred to in his Cavendish lecture
on Dreamy Mental States.11

The patient, a youth, said he was subject to frightful feelings asso-
ciated with a loss of personal identity, and affirmed that he frequently
seemed to lose his hold of the universe and did not know who he was.
Everything changed in a twinkling; both spatial and time relations were
completely disturbed. He was overwhelmed by a sense of terror and a
feeling that he could never become himself again. These dreadful sensa-
tions invariably came on when he was alone, and sometimes would be
induced if he looked intently at himself in a looking-glass. His sister had
similar attacks, with a temporary loss of the sense of personal identity.

The insane idea has been defined as an abnormal, incorri-
gible representation — incorrigible even when the possessor of
the idea is confronted by plain, indubitable evidence to the
contrary. As has been already pointed out, the decision regard-
ing the normal or abnormal character of the idea, particularly
if an abstract one, can not be based merely upon the content.
Mercier has said that " insanity does not consist in delusion,
but in the disorder of the thinking process which results in de-
lusion."

The transition that frequently takes place from the unreal
to the real may be gradual or may be accomplished in the
twinkling of an eye. Although there are many theories by
which the attempt is made to explain the series of changes
which result in this transformation, none of them is satisfac-

11 The Lancet, July 6, 13, 1895, Nos. 3749, 3750.

INSANE IDEAS

37

tory. The more detailed examinations made at the bedside
are necessary to throw the desired light upon these highly
complex phenomena. Much valuable information could un-
doubtedly be obtained from a closer observation of delirious
patients in the wards of general hospitals. The following
history is of interest as it shows the abrupt change that oc-
curred in a case of acute alcoholism.

The patient, a woman, was under observation at the Sheppard and
Enoch Pratt Hospital during a typical attack of delirium tremens, char-
acterized by visual and haptic hallucinations, associated with marked
apprehensiveness and fear. During the height of the attack the patient saw
a great variety of fantastic and strange figures of human beings as well as
of animals. She frequently complained of seeing enormous worms and
asked to have them removed from her bed. At first the vividness of the
representations in consciousness was very great. Gradually, however, it
became less and less, until finally the patient, although occasionally de-
claring that she still saw the same dreadful objects, did not show any
degree of emotion. After the hallucinations had entirely vanished, the
patient affirmed that she remembered distinctly the instant when the idea
came to her that the figures she had seen were not real. On being closely
questioned, she maintained that this transformation was due in part to the
decrease in the vividness of the representations. Associated with this there
was also a marked alteration in organic sensations, and she became
immediately conscious of " feeling differently."

The change that occurs in the chronic psychoses takes place
much more gradually, and the patient is frequently unable to
assign a definite time at which a sufficient insight is gained
into his own condition to enable him to differentiate the real
from the unreal.

Sometimes the sense of reality fluctuates, being now more,
now less intense as the affective state changes. For example,
in one instance, if the attention was allowed to lapse, the indi-
vidual became quite passive and the objective evidence of
suspiciousness rapidly faded away, only to be revived with
intensity whenever an incident stimulus served to awaken his
attention. At first the individual became confused, next anx-
iously expectant, and then — sometimes quickly, again more
slowly — definite suspicions crystallized and became so intense
as to dominate his conduct. The account that follows was

38 PSYCHIATRY

written by the patient while in an excited condition. A few
minutes later, when asked if his suspicions might not be with-
out foundation and merely notions that had developed as the
result of his nervousness, he admitted that such an explanation
was not improbable.

" My mental confusion becomes great if excited and this throws me
into a condition I cannot describe. I went to * * * on a visit to my
uncle's. There I was lied about in my hearing, then drugged and when I
spoke to my uncle about what I heard, I was told it was a mistake and
could not make anything of the whole business. I had had similar trouble
before this but not so great. I wished to leave but was prevailed upon not
to do so for a while. Finally my uncle came back with me himself when
I was in a drugged condition. There was all manner of talk of the most
vulgar description as well as in terms of the highest praise of which I
could make nothing. I felt incapable of doing anything for myself and my
uncle had sworn before God to act the part of a father to me. I reached
home in a dazed condition, went to bed and stayed there a while. Dr. C.
came to see me and then for the first time I began to believe that all men
were liars. My sister, Mrs. B., was a rational person and helped me out
for a few days. The rest of my family thought I was crazy or at least
unbalanced."

The evident reflex influence of the affective state in en-
abling the patient to intrench himself behind all barriers to
reason is evident even in the so-called paranoiic states that
have persisted for years.

The transition from the real to the unreal and the corre-
spondingly slow regressive changes in the critical faculties are
frequently illustrated in the clinic. The following autobio-
graphical notes, written by a patient recovering from an attack
of manic-depressive insanity, illustrate this latter type in the
evolution of the insane ideas. Many of the expressions used
by the patient give at least an inkling concerning the patho-
genesis of some of the fixed and insane ideas to which patients
similarly afflicted are subject. The patient admitted that even
in the earlier years of her life she had shown slight eccentrici-
ties in character and had had some difficulty in connected
thought. This is an important point, as it serves to emphasize
a more or less common truth to the effect that even in the more
acute psychoses the abnormalities that become marked during

INSANE IDEAS

39

the height of the disease are in reality merely accentuations of
defects which have existed in embryo for some time prior to
the acute outbreak of the malady. (The spelling and phrase-
ology used by the patient have not been changed. The great
prolixity and circumstantiality are evident.)

" I will endeavor to give a brief sketch of my whole life as I think
certain things which have happened in my life no doubt had a great deal to
do with my present illness.

" When my mind developed sufficiently to enable me to reason intelli-
gently, religion appealed to me strongly. From childhood my one desire
was to be a true Christian and naturally the habit in my childhood worried
me considerably. I was always very emotional, the most simple sermon
affecting me. I thought I had committed a great sin and at different
periods of my life producing such depression that I feared if I did not tell
my mother I would not go to Heaven when I died, but I could not tell her.
I did not want her to know she had such a bad child. During the summer
of my 14th year I remember one day feeling very much depressed over my
childhood, but it passed away and I was as happy as any other child.

" Another time very clearly I was about seventeen years old and in the
second year High School. I was taken sick with throat trouble about a
week previous to the final examinations, and I was very much worried
about losing so much time which made me very nervous. . . .

" During this time that same old thing distressed me again, I got very
much better of my nervousness and went to the seashore. When I returned
I took up school work again and whether I knew my lesson or not, I
became very nervous when I rose to recite, so I left school in October.
About a year after that I took up stenography and made a fair success of it
holding my last position for two years and a half and leaving on account of
financial difficulties in the firm, which happened in July, 1903. Previous to
this in March, 1903, my mother's mother died and I spent a great deal of
time at her bedside before her death. My mother was then taken seriously
ill in April with erysipelas being delirious most of the time and taxing
my strength to the utmost. I slept very little in the two months my
mother was sick and missed very little time from the office. My mother
began to improve in June. I went to the country the last of July and
remained there for six weeks thoroughly enjoying my long vacation, being
the first one in two years.

" When I returned home I found my mother extremely nervous and
my family thought best for me to give up stenography for a while and
relieve her of the responsibility of housekeeping, but my mother objected
to this plan as she thought I was not capable of keeping house, being the
truth no doubt, but I was willing to learn. I saw how everything was
being mismanaged, the servant drinking most of her time and neglecting
her work, and my mother too weak physically to care much yet insisted I
should not do the managing I then begged my mother to get rid of this
woman, but being almost impossible to get another one, we kept her, and

40 PSYCHIATRY

she became very much worse. I did not like to cross my mother or worry
my brothers with domestic affairs and had to bear it alone. I saw clearly
my duty and was not allowed to carry it into effect, although I felt I must
change existing conditions in some way; so I began with the servant
thinking perhaps I might help her to lead a better life, but made very little
progress in that direction; I then concluded J was neither capable nor
good enough to change anything, or help anybody. This caused me to be
very much depressed; pleasure of no kind interested me, reading did not
divert my mind and at last found it impossible to do anything until I had
reformed this servant. I thought if she became better other things would
change. In the evening I would feel better than at any other time, that is
to say, I wasn't despondent. I would wake very early in the morning,
feeling the greatest remorse about what I had done in my childhood and
almost choking with emotion, causing a very bad effect upon my bowels
and I was simply impelled to tell my mother. She gave me very good
advice and told me not to think of things which happened so long ago. I
felt a little comfortable but still very much depressed. I still could do
nothing.

" I have been a member of church since I was fourteen years old, and I
thought I had become an awful hypocrite and must make a public con-
fession of it ere I could eventually be saved, so on the next Sunday morn-
ing I broke down and told my minister I was a hypocrite, but this did not
relieve my mind, and early Monday morning when I awoke I tried to pray
and could not and went into my mother's room and told her I was bad
and hadn't surrendered and she could throw my Bible away, as it meant
nothing to me any more. In the afternoon when my father returned from
business I went to him and begged him to send me away from everybody
and I remember him saying ' Send my baby away from me' with the tears
rolling down his cheeks. At the supper table / acted so strangely that my
oldest brother immediately sent for the doctor, who pronounced it nervous-
ness, but I insisted it was only devilishness. He advised my brother either
to send me away somewhere or to his sanitarium as it was absolutely
necessary to get me away from my mother. I consented to go because I
did not want to be at home and after being there for about a week I said
I wasn't sick or nervous and / was committing an awful sin to remain
there, and I was taken away. Now my next great trouble was how to con-
vince my friends that I was not sick. There was a bazar going on at the
church at this time and I had been elected chairman of one of the tables,
but I could not serve, although when I returned from the sanitarium I
went to it feeling miserable, and when my friends inquired after my health,
I answered them one and all that I hadn't been sick. The next Sunday I
thought if I would make a public confession of everything that I had ever
done in my life and how bad I was then God would give me another
chance, but my pride would not allow me to humble myself so. I passed
and repassed the church several times that morning and would not go in,
when I then realized / was eternally lost.

" I would do nothing to please my family and as a last resort they sent
to * * * for my aunt, knowing I was devoted to both she and her little

INSANE IDEAS

41

boy, and thinking possibly they might have some effect upon me as I had
declared I had lost all love for my family. I could hardly bear to think
they had gone to so much trouble for me. It was simply impossible to
make them believe it was devilishness. My aunt after remaining in * * *
for about two days persuaded me to go back with her and being very
anxious to get away from everybody I went. I was still awfully depressed
having the vilest thoughts and thinking of Hell all the time. I thought
God could not punish me too severely for going to * * * and leaving
my mother alone. I thought nothing was too bad for me to do now.
Then the horrible hellish thought that I would eventually become a de-
graded woman took possession of me and I imagined all the men on the
street could read it on my face. I told my aunt every thought I had
almost, giving the latter delusion as a reason for not going out, and enter-
ing into her social life there. She tried to convince me it was my nerves
and I know I must have tried her patience to the utmost, especially as I
told her / felt like murdering and hated to see any of her friends call and
felt like choking them because I was so miserable and unhappy, yet she
never complained and would not write home telling them how terrible I
was, but became very cross that I didn't. I wrote one letter about myself
but she refused to send it, declaring it simply awful.

" Then the suicidal mania developed. I thought rather than disgrace
my family and friends by becoming such a person, I preferred death. Then
I thought it was only a matter of a short time before I would do some-
thing very bad and be sent to the penitentiary, and persuaded my aunt to
take me to the one in * * * and to satisfy my morbid curiosity she did.
It was simply living torture to me, as I really envided some of the poor
wretches, because I thought some of them had a chance to reform if they
wanted to, and I remember my aunt laughingly say to me, ' Well, have you
selected your cell?'

" When I read it was generally of murders, suicides and crimes of all
kinds and always come to conclusion I was just as bad as any criminal I
read about and a great deal worse than some.

" About this time / did not suffer from remorse, and it worried me as
I felt I had lost all conscience. I became indifferent to everything not
caring whether I lived or died, or was good or bad. What was so remark-
able to me that during this period of indifference I could eat and sleep and
I tried to convince my Aunt that if it were my nerves instead of the devil, I
would do neither. I went to church only once while in * * * making
me feel very badly and I refused to go after that. The Sunday before
Christmas my uncle persuaded me to go to church with him but when we
got almost there I would not go in, giving as an excuse that I felt nervous.
When I left him I intended to jump into the * * * but every time that
I seriously contemplated suicide, I was prevented from carrying out my in-
tention by that awful thought I would go to Hell, which was worse than
the terrible agony I was then enduring.

" In the meantime my family became very much alarmed as I refused
to come home, or write to them. Sometimes I would add a postscript to
aunt's letters, telling how bad I was, but never said anything of the vile

42 PSYCHIATRY

delusion which had developed in * * *, so my brother consulted Dr. X
who communicated with Dr. Z of * * * I was not cognizant of this
fact then, for had I been I would never have seen him. He came upon me
suddenly one Sunday morning, and I was compelled to talk to him. /
thought now all my finer feelings had become benumbed, while my coarser
ones predominated and were active at all times, and as I had lost all the
pride I ever had, I concluded to tell him anything that came in my mind,
especially about that devilish delusion, and it would take him but a very
short time to discover what a devil I was. He argued with me for two
hours, using his utmost efforts to impress upon me it was my nerves and
not the devil. I remember him saying to me, ' Can't you see that it is just
possible the cells of your brain might become diseased like any other part
of your body,' but having no power of discernment whatever at that time,
how could I comprehend anything? He was very kind and I remember him
taking my hands in his trying to comfort me like a father would a dis-
tressed child, telling me it was a very serious matter and he was going to
write to * * * about me. I thought this rather strange that he should
consult another doctor, as my aunt had told me he was considered a bright
man. Then the thought came to me that he would write all I had told him
and this doctor would in turn tell my family and to my horror I found I
had been caught in a trap, but I thought God was only beginning to punish
me for my terrible wickedness here on earth and expected something dread-
ful to happen at any moment, and I was not surprised to see my father walk
in on New Year's day but very much frightened. When he did not censure
me for my badness, and brought no bad news from home I was very much
relieved. He told me he had come to take me to a very pretty place outside
of * * *, and I was more glad than otherwise, as I had told my aunt to
put me away somewhere. I felt I just could not fight against them any
longer as it was useless and they believed nothing I told them, so I acqui-
esced to anything my father proposed.

" While on the train though I told him I had changed my mind and
was going home, as I felt I could not be any more trouble and expense to
my family. Knowing it would be impossible to remain in seclusion at home
any length of time before my friends became aware of it, and to their
sorrow what a vile creature I had become just by looking in my face, I
really intended to take my life by asphyxiation as soon as I got there,
believing it was my last opportunity to do so, but when I arrived at * * *
my sister and brother-in-law before I could hardly draw my breath put me
in a hack and I was brought here. Papa told me I would remain here but
a very short time and I thought how true that was, as it would be but a
very little while before you found what an impostor I was. Every morning
I woke up I expected to be the last one here, as I thought I would be sent
from this place in dire disgrace and my family would suffer for putting
me here. God would not permit me to deceive so many people, and espe-
cially those who were sick. Do you wonder that the first few weeks I
hardly spoke to any one and that I wanted to get away but I saw in a
very short time, it was impossible and / was miserable. The first month I
would do nothing at all, then I went to the other extreme working nearly

INSANE IDEAS

43

all day though doing it mechanically as my fancy work did not interest
me then in the least, feeling all the time there wasn't any use in living as
that vile delusion was constantly with me. / then became anxious to go
to the city for one reason only as I felt it gradually leaving me and I
wanted to give myself a fair test, when to my unbounded delight I found
that it had and I could look in any man's face without the slightest self-
condemnation. After I returned the thought came to me that even if I
were lost, I might be of some use and derive some pleasure in living for
others and I did not worry very much then about being lost. On Saturday
night, about five days previous to my physical collapse, or whatever you call
it, some one was playing the piano and the music impressed me to such an
extent I thought what must heavenly music be compared with this and I
expressed a wish to Miss * * * next morning I would like to go to
some church just to hear the music and shortly after that I realized I
wasn't lost. Oh! what an awakening !

" Do you wonder that I am so happy and have such a love for nature
and everything beautiful in life after such a horrible nightmare.

" I have an intense desire for knowledge, and if it is God's will that I
get real well and strong, I intend to be something.

" Accept my deepest gratitude, and may God bless you and this
institution."

What follows, in marked contrast to the preceding, was
written several days after the above description had been com-
pleted, and at a time when the patient was evidently quite
markedly exhilarated and in a very happy frame of mind.

" When I awoke yesterday morning the beauty of the day impressed me
immediately and like a bird my first inclination was to herald forth the
glory of it.

" After partaking of a very light breakfast, which after assimilation
did not have a very good effect upon my internal organs, being aware of
this by the sudden feeling of pain, though disappearing after a while, I
interested myself in various ways remaining at nothing any length of time.
I was anticipating with much pleasure the whole morning a visit from my
father in the afternoon, knowing and feeling that he is as delighted as I
at my wonderful awakening. Every day I have an increasing sympathy for
the patients here, which feeling I did not experience when I first came.

" I then ate my dinner which made me sick and feeling very tired I
rested a while after it. Being relieved by the rest my body received I
arose and dressed for an afternoon reception as I expected a number of
visitors.

" Just before they arrived, however, having the desire of pouring forth
some of the melody in my soul which I had felt all day was there but not
having the opportunity of expressing, as the only musical instrument attain-
able was in use the whole morning by one Mrs. * * * who no doubt felt
the same as I did, only I thought took an unusually long time in expressing

44 PSYCHIATRY

it, and I got very impatient but my chance came at last and taking ad-
vantage of it, I enjoyed and felt intensely the melody I made.

" When my friends arrived we went for a walk, and though going but
a very short distance I became very tired. Hereafter, I am afraid I must
limit to some extent the number of friends whom I desire to have on these
days set apart for receiving as too many excite me for I have neither the
physical strength nor the mental ability to entertain more than two or three
at one time. I remember we were over on the ' casino' porch and my
sister referred several times to something I had promised to do for her
several weeks ago and being in rather an exalted state at the present time,
material things not appealing to me in the least, I became very cross and
nervous when she persisted in it, but the thought came to me at once how
ridiculous and weak of me not to have more control of myself. I enjoyed
my evening meal and after resting a while after it, several of us strolled
over to the casino. The twilight both impressed and affected me to such
an extent that I felt a perfect peace and good-will to all man-kind that I
think one only feels when they have a deep love for God in their heart
and a reverence for His handiwork.

" When we returned, we played cards, being taught by the ladies for
the first time the game of euchre and grasping their explanation of it
readily, which would have been impossible weeks ago, and in fact my
reasoning power is better than ever in my life."

The direct dependence of insane ideas upon anomalies in
organic sensations is frequently shown in protracted cases of
manic-depressive insanity, and finds its best exemplification
in instances where there is a " crossing of symptoms," such as
psychomotor excitement with the feeling of depression and
limitations in connected thought.12 In such instances it be-
comes clearly apparent that the mere increase in intensity of
an intestinal sensation is not sufficient to account for the devel-
opment of an insane idea, but its presence indicates the latency
of other factors, such as inhibition and mental depression.
If the mere accentuation in the value of the sensation were the
sole causative factor, insane ideas would be common in those
neuroses in which there is a marked hyperesthesia in the realm
of the organic sensibility.

The clinical characteristics of the majority of insane or
fixed ideas are easily recognizable, although the basis upon

12 PfersdorfF, K. : Ueber intestinale Wahnideen in manisch-depressiven
Irresein. Centralbl. f. Nervenheilk. u. Psych., Marz, 1904.

INSANE IDEAS

45

which they are classified is purely an empirical one, adopted
with the sole idea of facilitating description. Some observers
think that they are capable of being divided into two groups,
to one of which belong all those ideas which are of a more or
less pleasant character and to the other those of an unpleasant
nature. The former, including those in which the ideas are
associated with states of exhilaration, an increased sense of
well-being and pleasurable sensations, are much less often of
forensic importance than are the latter, where suspicions, ideas
of persecution, and so on, are apt to bring the patient into
conflict with his environment. Another important point from
the clinical stand-point, and which has reference to their gene-
sis, is that some of the ideas are apparently primary in char-
acter, while others are secondary, developing as a result of
hallucinations or preexisting ideas.

The following history, accompanied by the patient's own
interpretation of his mental disorder, is a graphic illustration
of the development of certain states of suspiciousness and the
subsequent well-defined ideas of persecution. For various
reasons the history has been considerably abbreviated.

For several years the patient had exhibited symptoms of nervousness
and emotional instability. This was said to be due to a disappointment he
had experienced in not receiving a position. An indefinite history of a
somewhat similar attack was obtained, occurring six months prior to the
present illness. The causes of the present illness, as already stated, were
said to be disappointment and a tendency to brood over supposed troubles.
Later it had been noted that the patient1 was suspicious of people with whom
he came into contact, and attributed, very unjustly, certain motives to them,
such as a desire to annoy and persecute him. One day a stranger entered
the building where the patient was acting as watchman and accosted him
in a friendly manner. The patient at once became excited, and when the
stranger in a familiar way placed his hand upon his shoulder the patient
thought it was for an improper purpose and immediately assaulted his
interrogator. The patient was at once taken into custody, and after exami-
nation was transferred to the Sheppard and Enoch Pratt Hospital, where
he was admitted on September I, 1903. He was found to be in a very
emotional state, claimed that he had been the subject of conspiracy, but that
he would unearth the scheme even if violence were necessary. On Septem-
ber 6 the patient was quiet and jovial, greeting the physician and attendants
cordially and affirming that the hospital was a " grand place for rest." On
the following day he again became excited, declared that he had been

46 PSYCHIATRY

persecuted, and wished to get out a writ of habeas corpus, as he had a
" strong case against the hospital for illegal detention." He was very in-
sistent, declaring that everything had been done to annoy him and to " tear
his clothes to pieces," but that his indomitable will-power had held him
together. Furthermore, he declared that he had not slept two hours since
he had been in the institution, and that lights were flashed into his room
and kept him awake. He said that when he took a bath the attendants
squirted muddy water into the bath as soon as he got in. He refused to take
medicine after the first dose, declaring that half an hour after it had
been taken he felt everything giving way inside of him. He became greatly
excited while talking and shook his fist in the attendant's face. He admitted
that he was never suspicious before he came to the hospital, but on this
occasion he was suspicious of every movement and act and would believe
nothing that was told him. The emotional states varied, the patient some-
times complying with requests, at other times refusing absolutely to do as
he was bid. On October 10 he narrated to the examining physician the
circumstances relating to the trouble which resulted in his being brought
to the hospital. When asked who the examining physician was he at once
declared that he was the book-keeper, but would not give any reason for
maintaining this position. When pressed for an answer he was quiet for a
time, apparently absorbed in his own thoughts, and then replied, " Gentle-
men, you are interfering with my work, I must be going," and immediately
started to walk up and down the corridor. The following week, when
again visited by the same physician, the patient at once addressed him as
" Mr. X." " That is who you are ; you are the book-keeper for the
hospital." He firmly maintained that the doctor had an object in deceiving
him, but would give no reason for his belief. A few days after this he
affirmed that the questions which had been asked him by the physician the
preceding week had caused him to have " pyrotechnics," owing to which he
had been obliged to remain in bed all day.

Note of December 4. The patient has improved remarkably in the last
few weeks ; admits that all of his former delusions were foolish and laughs
at them.

From this date until his discharge (January 13) recovery was uninter-
rupted. The following account was given by the patient himself, and em-
phasizes some of the important points connected with the genesis of his
delusions. (The patient had only had a common-school education.)

" When I entered the Hospital I was for the first night and day placed
in the second ward. I slept in the Dormitory on the evening of the next
day I was transferred to the first ward and on the following morning I was
transferred to the fourth ward. I spent about five days there when I was
placed in third ward for acting in a disorderly manner and accusing Mr.
X of having evil designs on me. This was imaginary on my part as he was
simply trying to induce me to eat more; on the second day of my stay on
the third ward it suddenly struck me that I should do something to employ
my mind noticing the marks of many kinds on the walls of the room I
occupied, I commenced to count them when I reached a hundred I would
repeat. I found this helped me to a great extent or I at least thought so.

INSANE IDEAS

47

I was transferred to second ward and after spending a few days in a
despondent mood the same idea of counting up to one hundred and repeat-
ing occurred to me again; this I followed and continued for some time —
then I conceived the idea that by employing my mind and exercising my
body I could hasten my cure at this time I began to suspect all of the
attendants and some of the patients of trying to retard my recovery. This
only made me more determined than ever to get well so I continued my
exercises a short time after this I saw Dr. A for the first time he was
examining the eyes of Mr. H. To me at that time he appeared the specialist
a short time after this he again visited the ward, in the meantime I had
heard the name of * * * When I saw Dr. A the second time and was
questioned by him it suddenly entered my mind that he was Mr. F. I told
him so and that he was a book-keeper — not a doctor — the Saturday follow-
ing I again saw Dr. A but refused to believe he was such a person — I had
taken a dislike to Mr. X from the first time I saw him so when on the
night of October 18th I saw him turn off the electric light in front of
Dormitory I thought this meant my return to Dormitory to be followed by
a transfer to ward 3d — this I determined to prevent by improving my con-
dition by constant exercise so I started to walk the corridor up and down
at nine p.m. I retired to rest and slept soundly until six o'clock a.m. when
I awoke I realized after some thought that I had been suffering with
hallucinations from that morning I continued to improve both in mind and
body and at the present time I feel as well as if not better than I have felt
in three years — I want to say the feeling of resentment entertained by me
towards Mr. X has been changed to admiration and respect."

Some of the delusions in rare instances seem completely
to annihilate the idea of personality. The past is obliterated,
and the individual no longer retains any knowledge of his
former self and thus exhibits a more or less definite dual per-
sonality. Such complete changes are noticed in the wandering
mania of hysteria or epilepsy and in certain other psychoses.
Generally, however, the insane idea seems to involve only a
part of the individuality: an arm or a leg becomes glass;
the contents of the skull have been changed ; voices are located
in the abdominal cavity. Again, in other instances, the relation
of the individual to his environment becomes the subject of
mental aberration, which may assume a pleasant or an un-
pleasant character. When the former occurs, the patient's
idea of well-being,, of his personal worthiness, of his compe-
tence, are all intensified, and may become so greatly exagger-
ated that he becomes Hercules, Napoleon, or Rothschild, and
even assumes supernatural powers (megalomania).

48 PSYCHIATRY

In the antithetical states the change is of an entirely differ-
ent character. The sense of well-being is then impaired and
the consciousness of organic processes becomes painfully in-
tensified (micromania). The material wants are ill supplied.
Such patients declare they are impoverished, utterly worthless,
they have lost all their physical and mental vigor, have com-
mitted unpardonable sins, and the like.

Again, the insane ideas indicate an inimical relation of
the individual's environment to himself. Thus are formed
various suspicions, in some instances vague and general, in
others definite, well-defined, systematized, and imperious in
character. In the milder cases there is simply general distrust ;
but in the latter there are definite delusions of persecution which
drive the individual to the commission of overt acts. The
more specific characteristics of these systematized ideas are
described in the consideration of the various types of aliena-
tion.

II. ANOMALIES IN THE INTENSITY AND DIRECTION OF

THE MENTAL PROCESSES AS SHOWN IN DISORDERS

OF THE ATTENTION.

The phenomena of the attention are to be regarded not
only as the weather-vanes that indicate the direction of the
mental processes, but also as gauges by which the intensity
and volume of the latter are measured. In different indi-
viduals there is a wide latitude within which fluctuations may
occur, so that even normally there exist personal idiosyncrasies
and modifications in the stream of attention, these personal
variations being referable to distinctive dissimilarities in the
functional capacities of the nervous system. Nor is it un-
natural that inheritance and acquisition should bring about
a difference in the manner in which two given organisms will
respond to similar stimuli. In the one instance certain needs
and trends arise that do not exist in the other. One person
attends with ease to a certain subject, while a second fails
utterly in the attempt. During the waking states the brain
is constantly active and never ceases to operate; its energy

DISORDERS OF ATTENTION

49

flows first in one, then in another direction. Incident stimuli
of intra- as well as extra-organic origin are received and in
some instances retained. In one case the incident stimulus is
like the spent arrow striking the mark, but unable to penetrate
it. In another, the shaft sinks deeply beneath the surface and
a permanent impression remains. This is the beginning of a
complex train of thought that may be rich in possible con-
nections. Normally, if the energy is flowing strongly in one
direction, a new stimulus of only ordinary strength will fail
to divert the flow from a given channel. In cases of alienation,
however, the flow is often so superficial that the slightest re-
sistance interposed is sufficient to change the course of the
stream. The never-ceasing, uninterrupted activity of the cere-
bral functions is as constant as the cardiac action or the move-
ments of respiration. If the heart's action becomes irregular
or the breathing labored, there is no general rule by which the
intensity of these phenomena can be measured and no single
term by which each special occurrence can be described. Nor
is it unnatural that the same should be true for the attention.
Physiology has shown that the forces, the combination of which
is designated as attention, in reality represent the coefficient
that indicates the functional capacity of the brain. When the
activities of the higher brain centres are in abeyance, as in
sleep or states of unconsciousness, there is no such thing as
attention. Stimuli impinge upon the cerebral cortex but no
reaction follows. Impressions must be retained, elaborated,
and brought into connection with other psychic unities, so
that before they can determine the flow of attention the stimuli
must be of sufficient strength and the activity of the brain
capable of responding. In health all the conditions are favor-
able. The attention flows along certain channels which are
primarily determined by inherent qualities as well as by those
acquired through education. In various states the attention
or flow of energy is dissipated; and even if the stimuli are
of such strength that under normal conditions they would
awaken a response, they now fail to bring about any syn-
thesis or connected train of thought. This lowering of the

4

50 PSYCHIATRY

power of elaboration and of the working up of stimuli may
be temporary, as in states of drowsiness or fatigue, or may
be permanent, as, for example, in various forms of dementia.

Not only is attention necessary for thought, but it is a
factor in all volitional acts. Thought without attention is
inconceivable. The amount and intensity of the flow of en-
ergy gives character to the thought. When there is a shallow
or more or less diffuse discharge of energy our impressions
are faint; they scarcely rise above the so-called threshold
and are easily forgotten. These faint and imperfectly elabo-
rated impressions are frequently referred to as sub-conscious.
There is nothing startling or inexplicable about them. It is
the faintness of the impression which makes them elusive, and
the indefinable becomes the source of a certain degree of mys-
tery. Such expressions as unconscious mind or sub-conscious
thought are meaningless — they are simply a play upon words.
Attention is associated with every mental process. A sensa-
tion implies the existence of a certain degree of attention.
Some of the phenomena included under this term may be de-
scribed, but cannot be categorically defined. If the intra-
organic stimuli were abolished, there would be no attention,
and without this drift or set in the current sensory stimulation
would create no appreciable effect.

Although our minds are constantly flooded with a stream
of sensory impressions, all do not attain equal vividness nor
are they retained in memory. At one time this, at another
time that, object occupies the field of attention. This selection
is not volitional, but is determined for us by a variety of
causes that depend upon the physical properties of the brain.
The power to receive and retain new ideas may be termed the
recording faculty (the Merkfahigkeit of Wernicke). The
vigility of the attention is a term used by some clinicians to
indicate the fact that the direction of the stream of energy
is dirigible. The tenacity refers to the length of time during
which the current sets in a given direction. Decrease in vigil-
ity (Hypovigility) is noted in various conditions. It is a
common symptom of fatigue, as a consequence of which stim-

DISTURBANCES OF SENSATION

51

uli stronger than those normally needed are required to direct
and augment the flow. The influence of various drugs, par-
ticularly opium and the bromides, may also be productive of
similar results. The tenacity or persistence of the attention
is profoundly affected in various forms of alienation. Not
only is this true in well-marked psychoses, but frequently also
in various functional neuroses — hysteria and neurasthenia.
Not uncommonly vigility and tenacity are both affected, giving
rise to a condition called aprosexia. In this condition stimuli
produce little or no effect upon the cerebral functions ; response
is reduced to a minimum, and if under abnormally intensified
stimuli a reaction follows, it is isolated and unproductive.

In certain excited conditions the slightest stimulus pro-
duces an immediate reaction. Waves spread in all directions
as soon as the surface is broken by a ripple. This hyper-
vigility is common in neurasthenia, alcoholism, mania, and
various other conditions. As a rule, the tenacity is decreased
rather than increased. Each new impression serves to deflect
the attention. This phenomenon has been designated hyper-
prosexia. The patients in whom this symptom is marked take
everything in at a glance, pass with lightning-like rapidity
from one object to another, but are strangely deficient in the
power to carefully examine the details of any one of them.

In some conditions, particularly in cases of hallucination,
the attention seems to be firmly riveted upon the object occupy-
ing the field. The tenacity is increased while the vigility is
essentially lowered.

III. DISTURBANCES OF SENSATION, INCLUDING HALLUCI-
NATIONS.

The interest of the alienist is practically centred in three
phases of the physiology of sensation; in the first place, he
studies the facts connected with the reception and transmis-
sion of stimuli, either intra- or extra-organic in nature, from
their point of origin to the central termination of the sensory
tract ; secondly, he is directly concerned with the investigation
of the nature of the transformation of these impulses and their

52 PSYCHIATRY

elaboration and relation to the various psychical activities;
and, finally, he endeavors to correlate the relationship that
exists between the associative activities of the brain and their
objective expression in reflex or volitional acts. This three-
fold division of function is empirical. The clinician should
recognize that there is a difference of degree but not of kind
in all three, but while admitting the necessity of employing
terms to designate the phenomena of sensation, he should
never lose sight of the fact that the expressions employed are
merely relative. Clinically, the main interest is directed to
the fact that stimuli under certain conditions give rise to a
series of psychic events which are called sensations. It is
impossible to even enumerate the different steps that occur in
the transformation and elaboration of simple sensations into
the most complex of psychic phenomena. The gradations
hitherto established are purely artificial. For all that is known
to the contrary, the only form of cerebral function of which
we are cognizant is that of associative memory.13 The fact
cannot be emphasized too frequently that in describing sen-
sory phenomena terms are used merely to designate a con-
nection or series of relationships between the psychic elements
that is never constant, but is always in a state of flux. When-
ever possible it is advisable to substitute a terminology not
limited in its application and significance by special use. In
recording clinical observations a phraseology chosen from the
vocabulary of the physiologists is preferable to that in vogue
among the psychologists.

In a study of sensation three paths of investigation may
be followed : ( i ) we may content ourselves with analyzing
and recording the mental phenomena; (2) we may make the
physical processes which give rise to the sensation the subject
of special inquiry; or (3) we may employ a combination of
these two methods and thus obtain, as experience has demon-
strated, the most satisfactory results by correlating as far as

"Loeb, Jacques: The Physiology of the Brain. The Science Series,
G. P. Putnam's Sons, 1900.

DISTURBANCES OF SENSATION 53

possible the psychic and the physical processes. Every sen-
sation is made up of a certain number of elements. These
elements are physical processes — for example, sound or light
waves. Not only are our sensations formed by the union of
elements, but more complicated psychic phenomena, generally
referred to as volition, ideas, and emotions, may be similarly
analyzed. Between the physical processes or stimulus, on the
one hand, and the most complicated volitional acts, on the
other, there is an unbroken chain. A few of the links are
recognized; many are not, but the inference that the contin-
uity of this chain is unbroken is a safe and warrantable de-
duction. Sensations are the first link in the chain of mental
phenomena. It is, therefore, natural that they should first
be made the subject of investigation before considering more
complex mental processes. Sensations are the most elemen-
tary form of all our psychic activities and are the functional
elements of consciousness. The recognition of the fact that
sensations cannot be isolated from other mental processes and
studied by themselves is a matter of practical as well as of
theoretical interest. " They cannot arise in consciousness with-
out the simultaneous occurrence of thought, attention, memory,
and pleasure or pain" (Mercier). They form an integral part
of all the complicated associative cerebral activities and must
be studied in their relation to other phenomena — the attention,
feelings, emotions, etc. Not only is this true, but the con-
current variance in the physical states must also be carefully
investigated.

Under normal conditions, when a stimulus of sufficient
strength, originating either within or without the body, is
received and transmitted by the conducting nerves to the cere-
bral cortex, a sense perception is the result. Gustave Spiller 14
has justly emphasized the necessity of keeping clearly before
our minds the variety as well as the complexity of the trans-
formations that may occur in the impulse, and of which we

14 Spiller, Gustave : Mind of Man. London, Swan, Sonnenschein &
Co., Limited: New York, Macmillan & Co., 1902, p. 134.

54 PSYCHIATRY

have only the vaguest inkling. The nervous system should
be compared to a vast factory, and not to a mere telegraphic
network.

With but few exceptions, physiologists until recently have
accepted the hypothesis first enunciated by Weber, but gener-
ally associated with the name of Johannes Miiller, to the effect
that different stimuli when acting upon the same sense organ
give rise to specific sensations. Helmholtz was the first to
suggest certain modifications of this doctrine of the specific
energy of the nerve-centres in order to explain tone and light
perceptions. This investigator held that certain modifications
took place in the impulse during its transmission through the
receiving and transmitting organs. He even went so far as
to affirm that in certain cases the sensory cellular elements
in the cerebral cortex might change the character of the im-
pulse. Other workers have formulated more definite objec-
tions to this doctrine. Wundt,15 basing his belief upon the
facts known regarding the development of the sensory areas,
affirms that as these complex centres develop from simple and
similar structures, they do so only in response to external
stimuli. From this the deduction follows that as the quality
of the sensation is thus determined secondarily by the results
of external stimuli, the hypothesis that predicates belief in
the inherent specific energy of the nerve-centres is incom-
patible with the facts. The argument is carried still further,
and attention is directed to the point that great diversity in
the character of sense perceptions can not be explained merely
by a corresponding difference in the individual sensory ele-
ments. The objection of clinical importance, to the effect
that those born blind or deaf, even if the sensory nerves con-
necting the end organ and the centres are intact, are devoid
of appreciation of both auditory and visual perceptions, is a
serious drawback to the acceptance of the theory.

The intensity and quality of our sense perceptions depend

" Wundt : Grundriss der Psychologic Fiinfte Auflage. Leipzig,
1902.

DISTURBANCES OF SENSATION

55

upon several factors : ( i ) the stimulus ; ( 2 ) the receptive and
transmitting capacity of the nerve tract which joins the periph-
eral sensory organ with its central area; and (3) what Hux-
ley has called the sensifacient capacity of the cerebral cortex.

Every sensation is commonly said to have certain charac-
teristics : quality, intensity, space attributes, duration, and,
finally, a tone feeling of either pleasure or pain. These attri-
butes, singly or in combination, may be affected by disturb-
ances occurring within the body during the course of an alien-
ation. In order that a stimulus may be appreciated, it must
have a certain strength. This is generally expressed by saying
that the sensation rises above the threshold of consciousness.
In physiological terms this is equivalent to affirming that the
strength of the stimulus has been sufficient to produce in the
normal functioning nerve-centres a responsive action. In
other words, a definite connection between the different proc-
esses, called memory, feeling, and sensation, has been estab-
lished. Should the responsive action of the nerve-centres be
impaired by disease or the conduction of the impulse rendered
difficult, the connections normally established do not exist and
the sensation never rises above the threshold of consciousness.
The physiological processes which are a part of the sensation do
not cease at the instant that the threshold of consciousness is
passed, but have a tendency to persist — a phenomenon of prac-
tical importance.16

Every alienist is familiar with the fact that in certain
cases, particularly in dementia or in profound mental depres-
sion, a considerable time may elapse from the instant that the
stimulus impinges upon the peripheral receiving organ until
there is objective evidence of its appearance in consciousness.
It is not improbable that chemical changes occurring in the
tissues interpose greater resistance to the transmission of the
stimulus. A delay may also occur in the birth, elaboration,
and discharge of the afferent impulse.

" Miiller, G. E., and A. Pilzecker : Experim. Beitrage zur Lehre vora
Gedachtniss. Ztschr. f. Psych., etc., 1900, Erganzungsband I.

56 PSYCHIATRY

In the congenital defect psychoses, such as idiocy, imbe-
cility, etc., the sensifacient activity of the cortex is unquestion-
ably impaired by its incomplete development and the persist-
ence in some instances of embryonal types of the neural ele-
ments. In other cases the imperception is the result of regres-
sive cortical changes. It is not at all improbable in still other
cases that the diminished functional activity is the result of
an increased resistance to the conduction of impulses situated
in the nerves themselves. Lesions not infrequently occur dur-
ing the course of alienation that give rise to disturbances in
the sensory areas supplied by the peripheral nerves — in Kor-
sakow's psychosis, etc. The disorders of this nature are fully
treated of in the text-books on neurology.

Disturbances in sense perception occur in various forms
of alienation that are not referable to lesions in the conducting
tracts, but are psychically conditioned. These are called psycho-
anaesthesias, psycho-hyperaesthesias, and psycho-algias.17 The
cutaneous sensibility is, as a rule, intact. Impairment of con-
sciousness and the deflection of the patient's attention in a
large measure give rise to these states, which interfere with
the functioning of the sense organs and of the general organic
sensibility. Their occurrence is recognized in many instances
by careful examination and the exclusion of evidence point-
ing to the existence of peripheral lesions. In connection with
the clinical investigations of the anomalies of sense percep-
tion there are a few facts of great importance that should be
kept in mind. The stimulus and the resulting sense perception
under normal conditions bear to each other certain propor-
tional relations. When this equilibration is seriously disturbed
we have what is called an abnormal perception. The normal
relationship between the stimulus and the resulting perception
may be disturbed in several ways.

Further than this, as has already been pointed out, the

17 Bechterew : Ueber Storungen im Gebiete der Sinnesperception bei
Geisteskranken. Monatsschr. f. Psych, u. Neurol., Bd. xiii, Heft 6, 1903,

s. 590.

HALLUCINATIONS

57

state of consciousness at the time of the incidence of the
stimulus is an important factor in every sense perception. In
sleep, in stuporous states, in dementia, the visible reaction
only follows a stimulus whose intensity is far above the nor-
mal. In all conditions in which the voluntary attention is
disturbed the same lack of correspondence between the inten-
sity of the stimulus and the perception becomes apparent. The
fact that a strong stimulus may produce no reaction if a pa-
tient's attention is diverted is a matter of common observation.
On the other hand, in certain emotional states, such as excite-
ment or fear, there is often a great diminution or, it may be,
complete absence of any apparent reaction. This may be due,
as we have seen, to peripheral disturbances, or it may be cen-
trally conditioned and depend solely upon the deflection of
the attention. Disturbances of sensation which are of especial
interest to the alienist are those commonly described as hallu-
cinations or illusions. As has been said, all sensory impres-
sions when once stamped upon the neural elements as the direct
result of peripheral stimulation may be re-collected.

Sensory memory, that process which occurs in the central
nervous system as the direct result of a peripheral stimulation
and which conditions the return of sensory phenomena, may
exceptionally occur without peripheral stimulation, and then
becomes the source of fantasms or hallucinations. Every one
at times is subject to hallucinations or illusions. The cor-
rigibility or incorrigibility of these phenomena is the test
by which we judge as to whether they are or are not com-
patible with perfect sanity. The patient may suffer for years
from auditory hallucinations. He recognizes, however, the
fallacious character of the perception, and his conduct is not
in any way determined by it. No one would suppose for
an instant that an individual was insane simply because he
was subject to hallucinations, but as soon as he becomes doubt-
ful whether the false sense perception should not be permitted
to influence his conduct he may be said to be on the border-
line between sanity and insanity, and when he becomes con-
vinced that the vision or the voice, as the case may be, possesses

58 PSYCHIATRY

categorical attributes, then, unquestionably, alienation in the
legal or lay sense is present. The processes of sense percep-
tion, as has already been stated, may be both quantitatively
as well as qualitatively disturbed. The alienist is only con-
cerned with the consideration of those qualitative changes
where the power to discriminate between what is true and what
is false in perception is inhibited.

In 1832 Esquirol in his classical work18 divided abnor-
mal sense perception into two classes: (1) Illusions — sense
perceptions that are objective, false interpretations of external
objects; and (2) hallucinations, those that are purely sub-
jective. In the former case there is an external stimulus,
which in a measure is the exciting cause of the phenomenon,
but the interpretation of the sensation as it appears in conscious-
ness is a false one. Accompanying the peripheral stimulus
there is an error in judgment associated with every illusion.
Recently, Ziehen has suggested the following theory as a possi-
ble explanation for the occurrence of hallucinations. He sup-
poses that the stimulus takes its origin in the cortical cells and
is discharged in the opposite direction to the course taken by
the normal stimulus. The psychical processes referred to by
Kahlbaum as re-perception are explainable on the basis of this
theory.

In hallucinations the subjective representation may be
so exaggerated as to be indistinguishable from a true percep-
tion. The presentation, or act of associative memory, that
is normally a constituent of every perception, is reduced to a
minimum. It is questionable, however, whether this factor
is ever entirely wanting, as it is almost impossible in examin-
ing patients with hallucinations to preclude the possibility of
its existence. From a practical stand-point, however, the pre-
sentation or external stimulus in many cases may be said to
be deficient. The flies crawling over the bedclothes of the
patient suffering from delirium tremens are thought to be
angels or devils, and we are therefore justified in regarding

18 Sur les illusions des sens chez les alienes.

HALLUCINATIONS

59

these sensory phenomena as mere illusions. The fantastic
figures seen by the alcoholic at night or the voices heard by
him when in a quiet room are commonly said to be hallucina-
tions, but it is absolutely impossible to tell in each instance
whether an external stimulus does or does not enter into this
phenomenon. The sensory plainness of hallucinations is one
of their most striking characteristics. Elementary hallucina-
tions are the simplest form of these phenomena, viz., simple
sounds, akoasmata, or flashes of light, photomata. Between
these simple varieties and the extremes there are all degrees
of difference.

Baillarger distinguished two kinds of hallucinations —
psycho-sensorial and psychic. The first are the result of a
combined action of the imagination and of the organs of sense.
They are determined by an involuntary exercise of memory
and imagination to which a sensory stimulus is added. Psychic
hallucinations are said to be the result of the exercise of mem-
ory and imagination without the interposition of a sensory
stimulus. The psychic hallucinations of sound are the most
frequent. Patients describe them as " indistinct or spiritual
voices," " the communications between mind and mind,"
" thoughts coming as inspiration," " voices without sound,"
etc. These phenomena are referred to by some as pseudo-
hallucinations, by others as apperceptive hallucinations. To
distinguish sharply between the psychic and psycho-sensorial
hallucinations is impracticable. The possibility always exists
of the inability of the observer to exclude the presence of a
sensory stimulus. Lugaro19 has directed attention to what
he believes to be the distinctive characteristics of pseudo-
hallucinations. These phenomena occur, as a rule, in chronic
cases. The imagination plays an important part in their eti-
ology. They lack the distinctive characteristics, vividness, and
objectiveness of sensory phenomena. They are associated with

"Lugaro, E. : Sulle pseudo-allucinazioni (allucinazioni psichiche di
Baillarger). Riv. d. Patologia nervosa e mentale, 1903, vol. viii, fasc. I
and II.

60 PSYCHIATRY

disturbances of the psychic processes connected with hearing
and seeing or with the muscular sense. A common charac-
teristic is their coherence and the apparent antagonism to other
facts of consciousness. Synchronous disturbances in the per-
sonality are frequently noted. As a rule, they may be easily
distinguished from true hallucinations as well as from the so-
called psycho-motor disturbances of perception.

Many attempts have been made to explain the pathogene-
sis of these so-called psychic hallucinations, but as yet none
of the reasons given are entirely satisfactory. The same is
also true for that peculiar condition in which patients believe
that their thoughts become audible to those about them (Ge-
dankenlautwerden). Individuals afflicted in this way often
refuse to answer questions, declaring that their thoughts are
already known to the physician. The symptom may develop
in normal individuals, particularly during states of fatigue or
after the ingestion of certain drugs (e.g., caffein, alcohol,
hyoscin). The defects in judgment and imagination common
in mental disorders give rise on the part of the patient to false
interpretations of these phenomena. Sometimes the incidence
of either auditory or visual stimuli seems by suggestion to be
an important exciting element in their production.

In many cases in addition to audible thinking there is an
acoustic hyperesthesia. The patients complain of a whistling
or rumbling in their ears, or there may be definite audi-
tory hallucinations. One or several voices are said to repeat
the thoughts. When the individual has command of more
than one language the thoughts are repeated in the same lan-
guage in which they were first apprehended.20 There are
those who maintain that audible thinking is due entirely to
disturbances in the acoustic areas, while others affirm that
the phenomenon is caused by abnormal stimuli affecting the
centres associated with the muscular movements concerned in

20 Probst, M. : Ueber das Gedankenlautwerden und uber Halluzina-
tionen ohne Wahnideen. Monatsschr. f. Psych, u. Neurol., Bd. xiii,Ergan-
zungsheft, S. 401.

HALLUCINATIONS 6l

speech. Clinically there are two forms — one in which the
content of the hallucination is strange, and the other in which
it is more or less closely connected with the individual's train
of thought. Between " audible thinking" and the so-called
primary hallucinations there are various gradations ; in some
instances the two coexist. The ideational hallucinations, those
taking the form of actual sounds, as well as the primary forms,
are so closely associated that it is frequently difficult to differ-
entiate them. In many cases audible thinking is associated
with the occurrence of insane ideas or delusions. Exceptions
to this rule are, however, not infrequent. There may or may
not be disturbances of hearing.

The projection of the audible thoughts varies — sometimes
they are close at hand; at other times they seem to be at a
distance. At times speech diminishes, although occasionally
it increases in intensity and vividness.

In cases in which the functional activity of any sense area
has been completely destroyed by congenital structural defects,
as in those born blind or deaf, hallucinations of the corre-
sponding sense never occur. The reports to the contrary are
not reliable. The case is different in acquired blindness or
deafness. Uthoff21 reports a case in which the patient was
blind in both eyes and yet suffered from " very dazzling and
troublesome flashes of light." In this individual the peripheral
visual apparatus was absent, but there was undoubtedly some
abnormal stimulus affecting the rest of the visual tract and
giving rise to these annoying hallucinations.

Jastrow 22 has shown that if the sight is lost before the
" critical age," from five to seven, the individual does not pos-
sess any power of visualizing and never even experiences
dream visions. These interesting studies all tend to strengthen
the belief that the power of a cortical centre to function de-
pends upon the education it has received, and that if this
education has been sufficient, the power of function may per-

Monatsschr. f. Psych, u. Neurol., Bd. v, S. 372.

Jastrow: Fact and Fable in " Psychology. Houghton, Mifflin & Co.

62 PSYCHIATRY

sist for a very considerable period even without sense stimu-
lation. This view has been substantiated by the results of
clinical observations. Probst 23 reports the case of an adult
in whom both the visual centres were destroyed, and in spite
of this the patient not only was able to conceive of forms and
colors, to picture to himself the house in which he lived and
his surroundings, as well as to describe accurately the appear-
ance of his friends, but also suffered from visual hallucina-
tions. The case is of great importance, showing that the
visual centres themselves are not necessary for the production
of visual memory.

Those who are congenitally deaf have no appreciation
of sound and never are afflicted with auditory hallucinations.
The cases reported in which deaf-mutes are said to have had
auditory hallucinations can probably be explained, as some
have suggested, by the heightened perception of the arterial
pulsation. Under perfectly normal conditions hallucinations
do not follow peripheral irritation alone. Bonhoeffer, in his
very interesting study of the psychical disturbances in alco-
holics, has given the chief reasons which militate against the
acceptance of the peripheral theory as presented by Liepmann
and others. The singing in the ears which is often so dis-
tressing to anaemic patients does not by any means depend
solely upon the throbbing of the vessels. Every clinician is
familiar with the subjective sensations of light, sound, and
pain from which the neurasthenic often suffers, and these are
doubtless dependent upon the hyperexcitability of the central
nerve-centres, a condition which may result, as has frequently
been suggested, but for which no proof has yet been presented,
from an autointoxication. Similar anomalies of function are
common in many diseases: nephritis, tuberculosis, epilepsy,
as well as in poisoning due to alcohol, lead, mercury, etc. The
so-called elementary hallucinations of light, simple flashes of
light or color, may indicate lesions in the cuneus, but also
occur in various forms of alienation.

23 Probst : Monatsschr. f. Psych, u. Neurol., Bd. ix, H. i, S. 5.

HALLUCINATIONS 63

Elementary auditory hallucinations (akoasmata, acousto-
mata), simple sounds, may be the results of lesions localized
within the temporal lobe, but the visual forms may be among
the prominent symptoms of mental disease.

Anomalous taste sensations (parageusias) are not infre-
quent. Sometimes these sensations may be definitely charac-
terized as sweet, sour, etc. The hypodermic injection of mor-
phine has been known to be followed by a bitter taste which
persisted for some time. The occurrence of similar disturb-
ances has been noted in santonin poisoning. Diabetics at
times are said to have a sweet taste in their mouths. Many
other examples of this character might be given, but these
phenomena are not to be regarded as hallucinations. Frankl-
Hochwarth 24 has shown that these sensations are frequently
indefinite, and are referred to as unpleasant, nauseating, etc.
Fallacious sense perceptions of taste have been frequently ob-
served in cases of facial paralysis, middle-ear catarrh, and in
tabes, as well as in epilepsy, neurasthenia, and hysteria. The
lesions of the olfactory centres in relation to the occurrence
of hallucinations of smell have also been carefully studied.25
Frigerie's case is of great interest in this connection, as there
was an atrophy of the left pes hippocampi major.

Fallacious perceptions of smell may follow (a) toxic in-
fections, (b) structural changes due to compression of the
olfactory tract, tabetic and senile changes, or may be noted
(c) in neuroses, epilepsy, hysteria, and neurasthenia.

Hallucinations may be either unilateral or bilateral and
may occur as such in connection with any of the senses.
Seguin 26 was the first observer to call attention to the subject
of unilateral hallucinations. The auditory are more common
than any other forms. This may be due to the asymmetrical
development of the auditory centre. The unilateral visual hal-
lucinations are nearly always associated with definite lesions in

™ Die nervose Erkrank. des Geschmacks u. Geruchs, Wien, 1897.
23 Jackson and Stewart, Brain, vol. xxii, page 534. Siebert, Monats-
schr. f. Psych, u. Neurol., Bd. vi, S. 81.

M Journal of Nervous and Mental Disease, August, 1881.

64 PSYCHIATRY

either the peripheral or central part of the optic tract. The in-
ference is not justifiable that unilateral lesions in a sensory tract
always give rise to unilateral hallucinations. There have been
a number of cases reported in which a unilateral lesion of the
sensory tract was followed by a bilateral hallucination. Cases
of antagonistic auditory hallucinations occur. In one instance
recorded by Magnan the patient heard voices in one ear which
gave rise to the idea of persecution, and, later, in the other ear,
voices which became the basis of a pronounced megalomania.
Uthoff 27 has reported cases of great interest which emphasize
the causal relation that may exist in those who are subject to
visual hallucinations between the structural changes and the
functional disturbances. The evidence so far accumulated all
tends to emphasize the necessity of making an effort to deter-
mine the existence of defects in the peripheral apparatus, and
in cases of scotoma to see whether, as is so frequently the
case, the hallucinations correspond to the restricted field of
vision. Great care should also be taken in examining patients
with visual hallucinations to determine, if possible, whether
the visual field is hemianopic. One interesting case has been
reported in which a patient who was hemianopic saw in the
blind field only the halves of curious fantastic figures. Uni-
lateral visual hallucinations are more commonly associated
with peripheral disease of the eye than with lesions in the
retro-bulbar part of the optic tract. Too great emphasis
should not be attributed to the importance of peripheral ocular
disease as the immediate cause of visual hallucinations. It
has frequently been stated that the visual hallucinations of
the alcoholic are to a great extent conditioned by the variations
in the intraocular blood-pressure. The disappearance of hal-
lucinations on closing the eyes, or their movement synchronous
with that of the eye-balls, has been observed in cases of periph-
eral as well as central disturbance. The apparent movement
of the animals' faces, figures, etc., so common in many

77 Beitrage zu den Gesichtstauschungen bei Erkrankungen des Sehor-
ganes. Monatsschr. f. Psych, u. Neurol., Bd. v, S. 241.

HALLUCINATIONS 65

psychical disorders, may be due to disturbances in the nuclear
region of the ocular muscles. In one case that came under
observation the patient had external strabismus of the right
eye, and the visual hallucinations seemed to correspond with
his field of vision. The patient saw a single group of angels
when he closed one eye, but two distinct groups when both
eyes were open. The visions, according to the patient's state-
ment, were " projected upon the wall of the room," but they
did not seem to grow smaller or larger, as is often the case,
when the patient approached nearer to or went away from the
wall. This may be due to the fact that in the case referred
to there was a disturbance in the mechanism of accommoda-
tion. Although the apparent size of the hallucinatory forms
varies with their projection distance, it is still a matter of doubt
whether the patients accommodate as the distance of the fig-
ures changes.

Hallucinations of hearing are the most common form of
sense deceptions among the insane. As a rule, the sensory
vividness of auditory hallucinations is even greater than that
of the visual. A patient often describes visual hallucinations
as pictures or visions, and they seem in many cases to lack
the stamp of reality which is so characteristic of the auditory
hallucinations. One of the distinguishing features of audi-
tory as well as of other forms of hallucinations is frequently
the remarkable reflex power they exert on the whole psychic
life of the patient. The auditory or visual hallucination, char-
acterized by the most foolish or senseless content, may domi-
nate the judgment of the patient, making him commit insane
or dangerous acts. The vividness of the hallucinations does
not alone influence conduct. The emotional state and mood
of the patient are of prime importance and may even deter-
mine the character of the sensorial phenomena. Nor, on the
other hand, is the power of the hallucination or illusion in
determining conduct due simply to its persistence. Many
patients who are chronically insane hear voices for weeks or
months at a time without acting in accord with the sugges-
tions or the commands that they believe are whispered or

5

66 PSYCHIATRY

spoken in their hearing. And yet in other instances within
a few hours these same patients when dominated by the hallu-
cinations may commit insane acts.

The contents of hallucinations vary greatly, but it not
infrequently happens that the patient sees the same face, hears
the same voice, smells the same odor, etc. These false per-
ceptions, which remain the same for a considerable length of
time, are called " stabile hallucinations."

Auditory hallucinations are not uncommonly found to
be associated with disease of the ear, and may to this extent
be peripherally conditioned. Redlich and Kaufman28 ex-
amined a number of patients who suffered from auditory
hallucinations and were able to demonstrate that in the great
majority of cases there were lesions in either the middle or
inner ear that acted as sources of chronic irritation to the audi-
tory apparatus and gave rise to various elementary sounds.
These, by the agency of a hypersensitive cortex, were readily
transformed into more complex phenomena.29 The effect of
peripheral stimulation under certain conditions in the produc-
tion of visual and auditory hallucinations becomes apparent in
the cases reported by Jolly, where the latter were caused in an
insane patient by the electric stimulation of the acoustic nerve,
and by Liepmann, where slight pressure on the eyeballs in an
alcoholic patient caused visual hallucinations. It is also inter-
esting to note that removal of the peripheral exciting cause
may be followed by a disappearance of the hallucinations.

Kahlbaum30 was the first to describe the so-called reflex
hallucinations. Hallucinations of this nature are due to the
transference of a stimulus from the sensory tract upon which
it first impinges to another where it awakens a response. In
one case described by Kahlbaum, whenever the patient saw a
stranger he heard distinctly the derisive name " Uncle August."

n Ueber Ohruntersuchungen bei Gehorshalluzinanten. Wiener klin.
Wochenschr., 1897.

29 Bechterew : Ueber halluzinatorisches Irresein bei Affectionen des
Gehororgans; Monatsschrift f. Psych, u. Neurol., Bd. xiv, H. 3, 1903.

30 Die Sinnesdelirien. Allg. Ztschr. f. Psych., Bd. 23, S. 1-86.

DISTURBANCES OF CONSCIOUSNESS 67

Reflex hallucinations are not at all uncommon and are ob-
served in a great variety of conditions. They may occur
singly or be combined with disturbances of several sense areas.
Combined disturbances of sight and smell are very common,
especially where there is marked interference with the or-
ganic sensations. The combination of hallucinations of hear-
ing, sight, and touch give rise to the ideas associated with
the most serious falsifications of the patient's environment
and personality.

The importance of fixation or the direction of the atten-
tion to certain sense areas as a means of increasing the ten-
dency to the formation of hallucinations and illusions is a
well-known fact. In certain cases if the patient's attention is
directed to the points of a pair of compasses pressed against
the skin paresthesias and tactile illusions may develop. A
case of a delirious patient has been reported in which, when
the finger-tip was touched with a pair of compasses, the points
distant six millimetres from each other, two sensations were
experienced. But when the points were brought nearly to-
gether, the patient affirmed that he was touched at three or
four points. The same is true with regard to the testing of
vision. If the patient is made to read fine print, he becomes
conscious of anomalies in vision. The paralexia may develop
as the size of the print is changed. In delirium it is sometimes
noted that if a patient be permitted to look at a picture so small
that the whole can be taken in at a glance, the visual stimulus
results in a stationary vision. But if, on the other hand, he
is made to fix upon a card so large that in order to cover the
whole field a movement of the eyeballs is necessary, fallacious
sense perceptions, which appear to move, may develop.

IV. DISTURBANCES OF CONSCIOUSNESS.81

The attempts which are constantly being made to arrive
at a single accurate definition of consciousness have at present

m Von Bechterew, W. : Bewusstsein und Hirnlokalisation. Leipzig,
1898. Lipps, Theodor : Das Selbstebewusstsein ; Empfindung und Gefiihl.
Wiesbaden, 1901. Minot, C. S. : The Problem of Consciousness in its

68 PSYCHIATRY

no practical importance for the physician. From a clinical
stand-point the general description of the phenomena con-
cerned, given by Loeb, is not only sufficient, but furnishes us
with a practical working hypothesis. Associative memory or
consciousness may, according to this observer, for the present
be assumed to be the mechanism by which a stimulus brings
about not only the effects which its nature and the specific
structure of the irritable organ call for, but also those of
other stimuli which have previously acted upon the organism
or which are acting upon it simultaneously with the stimulus
in question. How far consciousness is to be considered a
factor in all animal life is a question that does not concern
the clinician, but no matter how conservative may be his view
in regard to its universality, for man at least, he is ready to
accept Minot's dictum that " consciousness stands in immediate
causal relationship with physiological processes."

If we view consciousness, in a general way, as the result
of a series of established relationships between the cortical
functions, it becomes the physician's duty to seek to determine
the factors that may derange or inhibit these processes.

The combination of the various mental elements or inte-
gers is determined by the needs of the organism. These needs
vary during different periods of life, not only at the important
epochs, but from day to day and even from hour to hour.
The equilibration of the organism when it has been disturbed
by reason of the occurrence of a new need is again restored
as soon as this need is satisfied. For example, a sensation
occurs which we call thirst; the need of water is felt. Upon
the introduction of water into the system the sensation rapidly
disappears. In a general way the duty of the alienist is simi-
lar to that imposed upon the student of the normal functions
of the brain. Both seek to determine the character and com-
plexity of the needs of the organism and to understand as

Biological Aspect. Science, 1902, vol. xvi, No. 392. Oppenheimer, Z. :
Bewusstsein-Gefuhl. Eine psycho-physiologische Untersuchung. Wies-
baden, 1903.

DISTURBANCES OF CONSCIOUSNESS 69

far as possible the manner in which it attempts to satisfy them.
When the combinations which are brought about, as the result
of cerebral activity, between the various mental integers reach
a certain volume and degree of intensity, they are collectively
designated consciousness. This term, as well as many others
in the psychological dictionary, is relative, and a separate defi-
nition must be found for each case. Roughly speaking, how-
ever, we may affirm that the various processes which we group
together under this head bear a definite relationship to each
other, so that, broadly speaking, the consciousness of one in-
dividual under normal conditions is comparable to that of
another person.

Wernicke distinguishes between the mere content (Be-
wusstseinsinhalt)and the activity of consciousness (Bewusst-
seinsthatigkeit) and has further proposed a threefold division
of groups of functions, forming three different spheres of con-
sciousness : ( 1 ) those functions upon which the ideas of self or
individuality depend — autopsychic consciousness; (2) those
which give us our knowledge regarding our own bodies —
somatopsychic consciousness; (3) the sensations through
which is revealed to us the external world — the allopsyche.

This tripartite division may be of distinct value in facili-
tating clinical descriptions. Not infrequently we meet with
forms of alienation in which the disturbances in consciousness
are limited to the first group, so that we have an autopsychic
alienation. Again, the disturbance may be largely in the group
of organic sensations — the somatopsychic psychoses; or there
may be anomalies of the sensations in the allopsychic field of
consciousness — allopsychic alienation. In the majority of
cases the symptoms are connected with more than one of the
three spheres.

The various complexes associated under the head of auto-
psychic consciousness possess only a relative stability and vary
in the same individual at different epochs of life and even
within much shorter limits of time. . In other words, the sum
total of the sensations, memories, emotions, etc., upon which
the idea of personal identity rests is never constant. In the

7o

PSYCHIATRY

normal individual there is never a complete dissolution of
all these factors at any one moment except during periods of
unconsciousness or sleep. Owing to the absence of marked
mutations it is frequently inferred that the autopsychic con-
sciousness, or knowledge of self, is comparatively stable. To
a certain limited extent, it may be said that self-consciousness
is independent of the somatopsychic and allopsychic fields of
consciousness. There are many forms of psychoses in which
the first is primarily attacked. One of the best known ex-
amples is the dissolution of the personality that occurs during
the course of dementia paralytica.

The impairment or partial inhibition of all these processes
is referred to as a dulling or clouding of consciousness. These
disorders are frequently of forensic importance. While the
cerebral activities upon which these latter functions depend
are completely inhibited, the action or actions of the individual
are performed unconsciously. From a medico-legal stand-
point the use of the term unconsciousness does not imply that
no reaction follows an external stimulus. Persons who are
subject to epilepsy may perform a series of complicated acts
during an attack. As is well known, various crimes may be
committed during the occurrence of these transitory disturb-
ances. The same is true to a limited extent of an individual
acting under the influence of certain drugs, such as alcohol
or cocain.

The disturbances in consciousness which are associated
with automatism (poromania, dromomania) are of great in-
terest to the alienist and may be of medico-legal importance.
Not infrequently during periods characterized by temporary dis-
turbances in consciousness patients undertake long journeys.
This form of attack has often been considered to be pathog-
nomonic of epilepsy, but, according to Schultz and others,32
similar automatic acts carried out during a period character-
ized by marked dulling of consciousness are met with in other

J2Ueber Krankhaften Wandertrieb. Allg. Ztschr. f. Psych., 1903, Bd.
lx, H. 6.

DISTURBANCES OF CONSCIOUSNESS

71

forms of temporary mental aberration. Such actions may
appear perfectly normal, and yet after the lapse of hours, days,
or even weeks, when the patient has fully regained conscious-
ness, the memory of events that have transpired is wanting.
The reason why a patient in this condition should undertake
a long journey is not at all clear. Somewhat similar condi-
tions have been known to be associated with alcoholism, cer-
tain forms of degeneracy, and, according to v. Krafft-Ebing,
even with neurasthenia. It is interesting to note that in many
of the cases reported the patients remember that they felt
badly just prior to starting on the journey. In some instances
there is a pronounced apprehensiveness and occasionally a
feeling of oppression in the precordial region. In others the
sensation is more general and is also accompanied by suspi-
cion, depression, and in some instances a tendency towards a
general irritability. The amnesia in these cases, as would be
expected, is nearly always marked.

Reference has already been made to the relative stability
of the content of the normal field of body consciousness
(ccensesthesia) and to some of the more important changes
which may give rise to various anomalies. Head and others
have recently called attention to the important part that diseases
of the internal viscera play in changing the normal content.33
The lower we go in the animal scale the more important the
visceral impulses seem to be in determining the actions of the
individual. But, as Head has shown, in the normal healthy
individual these are kept in the background, whereas during
disease the organic sensations may become so prominent and
insistent as to be important in determining action. These
abnormal intrusions into the field of consciousness may be the
starting-point of various moods and mental anomalies.

Changes in the organic sensibility may assume a great
variety of forms and as yet have not received sufficiently close
attention and study from physicians. Not infrequently in

** Certain Mental Changes that accompany Visceral Diseases. Brain,
1901, p. 345.

72

PSYCHIATRY

the early stages of alienation we meet with marked disturb-
ances in the ordinary sensations resulting in an abnormal sense
of fatigue. This is particularly marked in the neurasthenic
and hysterical states or in the beginning periods of depression.
The patients affirm that they cannot make the slightest effort
without experiencing a feeling of utter weariness. In other
cases, particularly the earlier stages of intoxication and in the
incipient phase of manic excitement, the patient is able to
carry through a great variety of undertakings without experi-
encing a sense of effort. An important symptom in the diag-
nosis of the early stages of mania is the apparent tirelessness
of the patients, who never seem to weary although almost
constantly in motion. Important changes in the organic sensi-
bility are further noted in connection with the feeling of thirst
or hunger. In many instances the satisfaction which follows
the drinking of fluids or the taking of food seems to be absent,
and the patient consumes large quantities of meat and drink ap-
parently without experiencing any sense either of satisfaction
or of discomfort.

Some of these points are well illustrated by the following
extracts from the histories of cases, for which I am indebted
to my friend, Dr. Cary B. Gamble, Jr.

Case I. Asthma, emphysema, impairment of attention and memory
with fear. Female, aged 50. Woman of considerable intelligence and edu-
cation. For thirty-five years has been subject to attacks of asthma, as a
result of which there is a decided amount of emphysema. Three years ago
at the time of the attacks the patient began to suffer from a considerable
amount of referred pain located anteriorly in the upper portion of the
chest and posteriorly under the left shoulder-blade. About the same time
she began to complain of an indefinite apprehensiveness without any well-
defined fear. This feeling usually precedes her asthmatic attacks. Asso-
ciated with it there is considerable diminution in the power of attention
and memory.

The following case shows a slightly greater change in
the field of body consciousness.

Case II. Female, aged 30. Mitral stenosis with failing compensa-
tion. This patient also had an area of referred pain on the left side of
her chest, which extended over the epigastrium to the hepatic region. At

DISTURBANCES OF ASSOCIATION 73

times the pain increased greatly in severity, and was associated with some
mental depression. At these periods she also became suspicious of those
about her, affirmed that the nurses neglected her, and the doctors thought
she was malingering. These moods were transitory, and the patient was
able to appreciate their significance.

Case III is of interest, as the patient showed signs not only of de-
pression, but of some exaltation. Woman, aged 35, who had suffered from
an attack of rheumatism. On admission to the hospital she was found
to be suffering from shortness of breath, cough, oedema of the extremities,
and cyanosis, with superficial pain and tenderness over the left breast and
back. Marked evidences of mitral stenosis. She was subject to attacks
of depression, followed by a marked sense of physical exaltation.

Case IV. The patient, who had signs of adherent pericardium, was
subject to alternating periods of depression and exaltation and auditory
hallucinations. For a year prior to admission to the hospital she had fre-
quently been awakened at night by hearing the sound of a bell, which
seemed to continue for about fifteen minutes. At first she thought that
the noise was real, but finally concluded that, as there were no bells in the
neighborhood, the sound was merely subjective in character. The hal-
lucinations always became more pronounced after a severe cardiac attack.
Hearing was unusually acute, and there was no evidence of thickening or
retraction of the ear-drums.

V. DISTURBANCES IN THE FUNCTIONS OF ASSOCIATION.
INTERFERENCE WITH THE EXPRESSION OF CON-
NECTED THOUGHT. ANOMALIES OF MEM-
ORY. DISTURBANCE IN ORIENTATION.

All forms of thought involve an association or connection
between the various constituent psychic elements or units.
The evidence of this synthesis becomes more apparent in what
is called connected thinking. Regarding the neural states or
processes which determine these combinations practically noth-
ing is known.

The doctrine of associationism, so frequently enunciated,
explains neither the sequences nor the variations in the thought
processes. The mere fact that certain combinations of speech
suggest mere time or spatial contiguity of ideas cannot be
regarded as an explanation of the phenomenon. The assertion
is frequently made that contiguity in place or time as well as
the factors of similarity and the law of cause and effect explain
the phenomena of the flow of thought. But the mere observa-
tion and recording of what are believed to be prominent fea-

74

PSYCHIATRY

tures of associations cannot give any real insight into the
neural conditions which are at the basis of the phenomena.

Clinical observations have shown that the character and
complexity of the synthetic processes may be essentially
changed during the course of an alienation. It may be said of
the abnormal as of the normal processes that the needs of
the organism determine the character of the association; but
it is true only in a general sense in cases of alienation, as
compared with normal states, that the complexity and char-
acter of the combinations are capable of modification. This
modification is one of degree and not of kind. The power
of association or combination is as truly a function of the
organism as is memory or the faculty of reproducing a former
impression. The expression of thoughts in speech or writing
is determined -by needs created by individual necessities, by
education, and other factors. The recollection or remembrance
of an impression once stamped upon the neural elements
awakens a train of thought or action which may have been
previously repeated countless times.

As a rule, it is only the marked deviations from these set
forms which attract the attention of the alienist. A train of
thought as well as of action in the normal individual is directed
towards a certain definite end; in other words, it is purpose-
ful. All subsidiary processes are, as a rule, repressed or in-
hibited. One of the fundamental characteristics of mental
disturbances associated with conditions of exhaustion or fa-
tigue is the undue modification of the minor processes. The
psychic activity is no longer dirigible. The subsidiary proc-
esses are intensified, and, to use an every-day expression, the
patient's mind wanders. Minor and lateral associations divert
the train of thought or action. The combinations between the
various mental elements chosen now become those that are
the simplest and easiest for the patient to form, regardless of
sense. For this reason, mere sound associations or those that
have become common through constant repetition may pre-
dominate.

Similar disturbances in association are particularly marked

DISTURBANCES OF ASSOCIATION

75

following too large doses of cocain or alcohol. They also
occur in the early stages of paresis, in dementia prsecox, and
in certain organic brain diseases. In cases of maniacal excite-
ment the disturbances in both speech and writing often present
certain characteristic anomalies. In addition to the exaggera-
tion of what in the normal individual are the subsidiary proc-
esses, the tendency to form sound associations is marked. The
patient's train of thought is not guided, as it normally should
be, by the end to be attained (Zielvorstellung). There is a
marked tendency to give verbal expression to every idea, and
his own volubility serves reflexly to divert the patient's atten-
tion. In maniacal patients the speech-compulsion exhibited
may become a dominant symptom, and is frequently, though
by no means always, increased in proportion to the degree of
psychomotor irritability present.

Aschaffenburg 34 has affirmed as a result of his observa-
tions that during the period of excitement which is character-
istic of the manic-depressive insanity there is a dissociation
of ideas. The interval of time between the incidence of the
auditory stimulus and the motor reaction is shortened, and
this is one of the reasons why the only combinations that occur
are likely to be those which are the easiest for the patient to
form, irrespective of the content or logical sequence of the
ideas.

There is also a predisposition on the part of patients
in this condition to the formation of combinations in which a
certain rhythm or cadence is present. Not infrequently this is
seen in the proneness of certain of these individuals to make
verses. In these cases there is also a marked tendency towards
pure sound association and the bringing together of senseless
syllables. From certain observations the inference has been
drawn that the tendency to sound association is indicative of
an increased psychomotor activity. Bonhoeffer, however, far

** Experimentelle Studien iiber Associationen. III. Theil. Die Ideen-
flucht. Psychologische Arbeiten. her. v. Kraepelin, Bd. iv, H. 2, Leipzig,
1902, S. 235.

76 PSYCHIATRY

from finding this tendency marked in delirious cases with
motor restlessness, noted that, on the contrary, the content of
the delirium did not differ essentially from the association in
normal individuals ; that is to say, associations determined by
the sensations preponderated. It has also been observed that
in cases of mental depression with accompanying anxiety, but
without motor agitation, there is a complete independence of
the two phenomena. The attention of the patient is, as a rule,
easily gained, but is almost as readily deflected.

It is unfortunate that the term " flight of ideas" so com-
monly used by alienists is capable of so many various inter-
pretations. Kraepelin uses the expression to describe a symp-
tom-complex which is met with in cases of manic-depressive
insanity and in certain forms of asthenic psychoses. The
absence from the speech of the patient of a definite directing
motive is characteristic of the disturbance. The prominence
of the subsidiary associations, which in normal conditions are
kept in abeyance, is noticeable, as well as the fact that external
impressions or stimuli serve to deflect the train of thought. In
this sense the typical flight of ideas consists in a combination
of symptoms which may be successfully analyzed. In the
first place, we have to do with what has been termed an ex-
ternal flight of ideas in which extra-organic stimuli give the
trend to the flight. Here the association is not determined by
the actual content. In the so-called inner flight of ideas
rhyming and association by assonance may be prominent fea-
tures. In addition, ideas keep cropping up in consciousness
and in a measure determine succeeding expressions. As a
rule, the actual rapidity with which combinations are formed
during the period of manic excitement is not increased. This,
however, is not in accordance with the opinion of those who
report a definite quickening of the association processes under
such circumstances. Ziehen contends, on the contrary, that
during the period when there is a rapid, steady flow of ideas
there is a synchronous increase in the attention which he refers
to as hyperprosexia. Closer clinical analysis reveals the fact
that there is in a large majority, if not in all, of the cases a

DISTURBANCES OF ASSOCIATION

77

propensity towards an actual splitting up of the attention. As
the manic excitement increases, the sound associations become
more and more dominant. A parallelism exists in some in-
stances between the flight of ideas and the psychomotor irri-
tation, but this feature is not constant. A typical " flight of
ideas" may, on the one hand, be associated with a general
psychomotor inhibition, while instances are not infrequent
where the motor restlessness may be present without the
" flight of ideas."

Heilbronner35 criticises Aschaffenburg's deductions, and
affirms that the phenomena noted as the result of experiments
have not been substantiated by clinical observations, and main-
tains that the rapidity of the combining processes is actually
increased. Moreover, he affirms that the flight of ideas is
independent of the speech compulsion. Wernicke attempts to
establish an intimate causal relationship between these two
symptoms and the intrapsychic hyperfunction ; the latter is
supposed to bring about an actual levelling (Nivellirung) of
ideas. Ziehen affirms that the motor agitation and the flight
of ideas are coordinated and determined merely by an abnor-
mal rapidity in the combining processes, and, further, that
there is an actual spread of the cortical irritation chiefly in-
volving the motor regions.

Liepmann36 expresses dissent from the views enunciated
by Aschaffenburg to the effect that the disturbance of con-
ceptual thought in cases of maniacal excitement is a secondary
phenomenon. He also maintains that the increase in the rap-
idity of the associative process is apparent rather than real,
and is essentially a pure motor phenomenon. Three facts,
according to Liepmann, militate against the views of Aschaf-
fenburg: (i) The patients not infrequently describe their

" Heilbronner, Karl : Ueber epileptische Manie nebst Bemerkungen
ueber die Ideenflucht. Monatsschr. f. Psych, u. Neurol., Bd. xiii, H. 3 and
4, 1903, S. 193.

M Neurolog. Centralbl., Mai 1, Nr. 9, 1903, " Ueber Ideenflucht."
Sammlungzwanglose Abhandl. aus d. Gebiete d. Nerv. u. Geisteskrankhei-
ten, Halle, 1904.

78 PSYCHIATRY

hallucinations in a manner which suggests a flight of ideas,
but which, on close analysis, is found to be essentially differ-
ent. This phenomenon may be unaccompanied by any motor
excitement. (2) The sound associations fail in certain cases
in which there is a definite flight of ideas. (3) In catatonic
periods intense motor excitement sometimes occurs unaccom-
panied by any flight of ideas.

The observations may be summarized as follows : Nor-
mally a train of thought is characterized by an advance or
progression of the ideas in a definite direction. In the phe-
nomenon under discussion a deflection of both the normal
sensory and associative processes occurs, so that a definite
guiding principle determining the sequence of thought is ab-
sent. There is a deflection of attention as well as impairment
of the understanding. In normal connected thought the chief
object of the attention is focussed upon independently of the
subsidiary and minor facts of consciousness. The less intense
this focussing becomes, the greater is the inclination towards
the dissolution of the train of thought. If the chance appear-
ance of a representation in the focus of consciousness is deter-
mined merely by a transitory connection or by a sensory stimu-
lus, the conditions are ripe for an excessive flight of ideas.
Liepmann affirms that in cases in which the flight of ideas is
well marked there is always a rapid change in the represen-
tations brought within the focus of the attention. This should
not be considered to be identical with an actual increase in the
rapidity of association. Although the flight of ideas is fre-
quently associated with the symptoms of psychomotor irrita-
bility, it is, nevertheless, to be regarded as an intrapsychic dis-
turbance.

The following extract from the history of a case of manic-
depressive insanity serves to illustrate the " flight of ideas."

The patient was very restless and talked excitedly as
follows (verbatim report in short-hand) :

" George A. was there. James and William as if risen from the dead.

Fort got sick. Where are you in waiting, William? Colonel X comes

up and registers. Where am I ? Jesus Christ ! I will be in time now,

DISTURBANCES OF ASSOCIATION 79

I know it. Dr. C was so good, but he did not know his business. I

forgive him. Now, there is John. I would like to see Mr. Z . I

think I understand him. That looks like John. Mother is coming. I
took the brass bead of the rosary, and I pressed it to my lips and kissed

it. Now it comes to Captain Jinks ; that's . Now, you bring me back

again — that is mother there; now there's George; and where you get to
George, he is one of the best friends I had in the world; he had an

abscess in the ear, I believe. Mr. Z came to the house, and I like

him. I got my wisdom teeth cut; now it is great. This was due to a
run-down system, and if I must say it — Tom knows all about that. Now

first comes . How many children have you got? I asked for my

brother George, who you know had an abscess in the ear. Now, it is

the first success of the Catholic Church. Now, there is Mr. N , whom

I stood for — collar buttons. And as soon as I got in there I saw George

A . Our Father who are in Heaven, hallowed be Thy name — and I

never understood what I meant. That man coming round there was in

Dr. C 's house I believe. Wait a minute, yes, that is mother with ,

and she was A-n-n-i-e. Now, there is George A and Dr. C ; he

was my friend. I took the prussic acid, and I took the brass bead, and
when we came to George A it was tally, tally."

Replies to questions:

Q. Why can't you keep still?

A. Because I am nervous, because I must. Now I am coming around
to Dr. ,

Q. Mr. C , can't you keep still?

A. I will try to keep still. Well, where is ?

Q. Tell me, Mr. C , why you can't keep still.

A. Because I had no business to behave the way I did.

Q. Can't you keep still, Mr. C ?

A. Well, I am trying.

Q. Can't you keep still without talking?

A. Yes.

Q. Let me see how long you can do so?

(Temporary silence for a few seconds; then the patient begins as
follows:)

Where is George A ?

Examiner: Can't you keep quiet?

(Silence for a longer period.)

There is George A right there. — that is , certainly it is.

Q. Mr. , why do you talk so foolishly?

A. I want to see Dr. .

Q. Who am I? (Examiner refers to himself.)

A. I do not know; is that Dr. ?

Q. Where are we?

A. Well, do the best you can.

Q. Mr. , where are we?

A. We are in the Antipodes.

Yes, what is the matter with the physician— what is the trouble?

go PSYCHIATRY

Q. What is the trouble with you, Mr. C ?

A. I am in bed sick with a run-down system.

" Now we are coming back. We are risen from the dead with Jesus,
the first success. A-n-n-i-e. Now we are getting around again. There is

the shorthand writer. Now just go to dear old and say that this

is the first success of Marconi in Jesus, and he knows of the woman,
because I did take the brass beads from mother; came to the house, and

I think Dr. he came. George A is a great friend of mine;

certainly he is."

The following is an example of a mild flight of ideas as
expressed in writing. The patient was asked to give an ac-
count of his case to the doctor.

" My Dear Doctor : I want to give you an exact statement of my case
since you left me, out of the Room yesterday morning and it will be
brief. I took a long walk with my good young attendant, ate a big din-
ner, drank 4 glasses of milk and lots of water, the trouble I reported to
you has entirely, or nearly so disappeared. I then slept for two and one
half hours so my attendant informs me, from about 2.30 to 5 P. M. then I
went out until supper time, ate a large supper, saw you later on in the
evening, after taking another rest in bed for Y* hour. Read everything I
could in a short time, walked up and down the long halls, talked to every
one that cared to open conversation, by invitation played uchre with a
man from the south with his hands done up in bandages and he beat me
hands down at the game of his choice. Then I talked until almost bed
time with him and that big fellow 220 lbs. who says he takes a glass of
beer to make him sleep. How foolish. I told him how to go to sleep with-
out any aid and he tells me this morning, although I suppose he took his
beer, that he slept splendidly. I slept soundly from about 10 until sometime
in the night when I requested the attendant to get me a glass of water and
a cup of beef tea with lots of red pepper. / awoke at 5 o'clock, my shirt is
shamefully soiled and my collar size 15 is much the worse for wear, can
I have a clean shirt and collar this morning?

" You will see from the above that I have slept from 2 P. M. yesterday
to 6 A. M. total 16 hours 2.30 ten and a half hours
2
6

10.30
any more would be very apt to give me a dull headache such as my brother
sisterinlaws and mother constantly complain of.

" I am no doubt very very mad as they all think excepting only B

and C who are both reasonable beings it is no fault of theirs :— they

were born that way and can't help it— so were you and I—' Got helf uns
wir con nicht on ders' as Martin Luther said when driven by others
to make the present remark. I have certainly written you enough to con-

m ANOMALIES OF MEMORY 8l

vince you of my crossness but they still believe me ' Mad' you don't now
help me to carry on the joke and assist me to show them ' some day' in
the far distant future that I was made but with one method without
madness.

" Please send me any old clean shirt and collar before breakfast size
15. Telephone my brother not to come to see me yet as he irritates me.
To go home and look after his own family and mind his own business.
Send me the watch he promised me, all the — papers daily all important

and social mail and see that X buys all the Farm and the tract with

the elm trees on it and do all such other things that will please me and
report progress. Then send immediately by telephone or let me do it

for the only people that fought with me until W and the dercetives

arrived.

(3) and please send for them immediately and tell them all to come to-
gether and give me all the things that will minister to my comfort and
happiness.

" Thanking you always for your kindness and that you have not
(2) given me any delays I am

" Very sincerely,
" A. B.
" Mad man behind the bars of good fortune.-

" Have my mail addressed not to the lock post-office and not to
(1) the institution for my bankers credit sake.

" To get the important features of this letter read only this many the
letter ' backwards' as all good books should in my estimation be read.
Paragraphs (1) (2) (3) (4) and then let me take a long walk with my
attendant early this morning and give me a parole later on."

ANOMALIES OF MEMORY."

The power of the organism to retain and redevelop im-
pressions is probably to be regarded as a specific function.
That so-called memories are localized in individual cells is
an hypothesis which must be abandoned, and although the
problem is one which lies within the realm of brain physiology,
it must be confessed that little is known regarding the dynam-
ics of the processes concerned in the reproduction and re-collec-
tion of past stimuli. At present it is sufficient for the clinician
to recognize that the function or functions grouped together

r Hering, E. : On Memory and the Specific Energies of the Nervous
System. 2d edition, Chicago, 1897. Loeb, J. : Comparative Physiology of
the Brain and Comparative Psychology. New York and London, 1000.
Baldwin, J. M. : Dictionary of Philosophy and Psychology (Chapter on
Memory). New York and London, 1902.

6

82 PSYCHIATRY

under the head of memory are specific characteristics of the
organism.

For convenience sake the various functions of memory
have been arbitrarily divided into three categories — those of
reproduction, recognition, and localization. But the utiliza-
tion of this division is not in any way meant to convey the
idea that these functions are separate and distinct, as it is
well-nigh impossible to conceive of one series of phenomena
taking place without the reciprocal action of a second or third.
From the clinical stand-point there is no reason why defects
in these various functions may not be considered as either
general or special in character. As an example of the first
group may be cited the general impairment in all forms of
associative memory without the existence of pronounced de-
fects in certain directions. This phenomenon is commonly
observed in a great variety of psychoses in which there is a
pronounced general mental enfeeblement. In the special or
more or less isolated defects the power of reproducing certain
images or impressions is lost while others are retained. From
the clinical stand-point and to facilitate description we may
also speak of a general amnesia — a term used to indicate the
general lack of retentiveness — or a paramnesia, in which dis-
turbance in the mechanism of associative memory causes a
distortion and false association of the retained facts. And
finally, according to some authors, there is a hypermnesia,
in which there is an apparent increase in intensity and bril-
liancy of certain mental reproductions or re-collections.

All these various psychical processes, which we collect-
ively designate as memory, may become seriously disorganized
during an attack of alienation. On account of the great com-
plexity and interaction of the processes, it is necessary that
they should be considered in their relationship to other psychi-
cal phenomena. There are, however, certain characteristics
associated with these processes which are of particular interest
to the clinician. In the first place, there is the recording fac-
ulty, or power of retaining a new impression (Wernicke's
Merkfahigkeit). Next in importance comes the capacity to

ANOMALIES OF MEMORY 83

reproduce this impression, and this is directly dependent not
upon one but upon a number of functions. And finally there
is the tendency shown by the brain to re-collect and reproduce
impressions after varying intervals of time. As has already
been pointed out, these functions are dependent upon each
other and are intimately related to other processes. In the
various disturbances which are common in the insane they do
not suffer equally. The facts bearing upon the genesis of these
functions have a clinical value. If we consider the develop-
ment of the memory in the child, it is apparent, as Spiller has
affirmed,38 that this is determined by the needs of the indi-
vidual. In the infant at birth many of the muscular move-
ments are incoordinated and performed with difficulty. Con-
stant repetition develops the power to reproduce movements
with increased ease and celerity. This exercise or muscular
memory develops rapidly in response to various intra- and
extra-organic stimuli. The return to the primitive state of
the child, where the simplest movements are reproduced with
difficulty, is not infrequently seen in certain forms of aliena-
tion, particularly in the catatonic states and in the dementias.
Next in order comes the retention memory or the feeling of
recognition. By some clinicians this form of memory or sense
of recognition is held to be a definite and distinct factor.
Vogt has affirmed that with every perception there is associated
an impression of recognition, and not only are the clearness
and plainness of the memory picture essential factors, but
coupled with them is a definite and distinct quality called the
recognition faculty (Bekanntheitsgefiihl). Pick affirms that
this factor is important in analyzing the symptoms in various
forms of alienation. He contends that the feeling of strange-
ness and the inability of individuals in certain states to recog-
nize either their surroundings or familiar faces are directly
referable to abnormalities of the recognition faculty. Rosen-
bach39 reported the case of a man who had never suffered

Op. cit.

Ellenmeyer's Centralblatt, 1886, Nr. 7.

84

PSYCHIATRY

from symptoms of alienation until one day after very severe
exertion, when he failed utterly to recognize the street in
which he had lived for years and greeted perfect strangers
as intimate friends. It was possible, however, to convince
the patient of his error. In hysterical and epileptic attacks
patients not infrequently complain of a feeling of strange-
ness and affirm that everything is far away. Although they
recognize that they are in familiar surroundings and in the
presence of friends, they are temporarily devoid of the normal
feeling of recognition. Bonhoeffer40 has described similar
sensations as occurring in epileptics. As the disturbances are
apt to be transitory in character, it is impossible to make a
complete examination of the psychical symptoms.

Somewhat different from "the mere recognition of objects
or persons is the power to re-develop the psychic processes
associated with a given stimulus or stimuli after they have
ceased to act. By this form of memory we mean that an indi-
vidual is able to retain ideas or recognize objects, persons, etc.,
provided that a sufficient number of repetitions of the original
stimuli have taken place. The face which seems strange to
us becomes familiar after being repeatedly observed. But this
faculty frequently suffers in various forms of alienation. It
is important to analyze all cases in which these disturbances
occur so as to determine, if possible, the underlying conditions.
In some instances the detention or retaining power for new
impressions is impaired. This may be tested by telling the
patient to remember three words and at the end of half a
minute asking him to repeat them, care being taken that the
cortex is not unduly stimulated by allowing the patient to say
the words aloud. In many forms of dementia the detention-
memory for even such simple tests as this is greatly lowered.
The power to retain impressions may be disturbed by the con-
stant inflow of sensory stimuli, as in the case of delirious

40 Bonhoeffer, K. : Ein Beitrag zur Kenntniss der epileptischen Be-
wusstseinsstorungen mit erhaltener Erinnerung. Centralbl. f. Nervenheilk.,
1900, S. 599.

ANOMALIES OF MEMORY 85

patients in whom a stimulus is not given sufficient time to act.
The new impression is obliterated as soon as the stimulus
which has given rise to it has ceased. The power to receive
new impressions is seriously interfered with by various drugs,
such as the bromides, morphin, etc.

The paramnesia, or tendency frequently shown by pa-
tients to distort memory, is often exemplified in the clinic. In
hysteria it is no rare thing for individuals to give the most
remarkable accounts of themselves and of their doings when
their narrative is not based upon any semblance of truth.
These cases, as a rule, are characterized by a marked increase
in the imaginative faculty. Although the suggestion has been
made that such a tendency to confabulate depends primarily
upon isolated defects in associative memory of which the
patient is only in part conscious, in Korsakow's syndrome, as
is well known, individuals show a marked tendency to freely
indulge in pseudo-reminiscences. As a rule, however, these
cases are more easily recognized than are the hysterical liars
on account of the presence of more or less impairment in all
the mental faculties. The tendency to lie and the relation that
this bears to defective memory is a theme of forensic bearing.
Unfortunately, in many cases, on account of the present limita-
tions in our knowledge, it is impossible to get at the facts in
the case. The hypermnesias are frequently exemplified not
only by patients in the clinic, but are met with in individuals
in every-day life. Under this head we may group together
those cases of phenomenal memory in certain directions,
frequently exhibited in the development of certain talents,
such as the power to calculate rapidly, to learn by rote, or in
the extraordinary feats of memory exhibited by chess players,
musicians, etc. These hypermnesias as well as the param-
nesias are frequently associated with marked disturbances in
the organic sensations. It is only necessary in this connection
to refer to the paramnestic and hypermnestic defects which fre-
quently become marked in the course of various psychoses,
such as manic-depressive insanity and dementia paralytica.

86 PSYCHIATRY

DISTURBANCES IN ORIENTATION."

By orientation is meant the power of an individual to
recognize and appreciate his environment and all that pertains
to it. This faculty is a complex one and conditioned by a great
variety of factors, chief among which is the power of re-collect-
ing and redeveloping past impressions. Disorientation is a
symptom that is frequently observed in cases of alienation and
by some clinicians is considered a fundamental anomaly in
nearly all forms. In attempting to analyze the disturbances of
orientation it should not be forgotten that the most elementary
forms- of this process are those directly associated with the
physiology of the sensory organs ; as we rise in the animal scale,
it is found that the primary sensory impressions become more
elaborate and consequently more complex and more difficult to
analyze. Clinical experience has abundantly shown that focal
lesions not infrequently give rise to disturbances in orienta-
tion. This is in part due not only to the interference with
the transmission of afferent and efferent impulses, but also
to the more general disturbances dependent upon anomalies
in the attention and in associative memory. In cases in which
focal lesions have occurred the great importance of the sen-
sory tracts for the preservation of orientation at once becomes
apparent. But the disturbances which are of particular in-
terest to the alienist are, as a rule, those in which such focal
lesions are not in evidence, although injuries to the subcortical
ganglia may give rise to a severe form of disorientation. In
the polyneuritic psychoses we frequently have an excellent ex-
ample afforded of the extreme degrees of disorientation and
indications of the important part probably played by the
peripheral tracts in the maintenance of normal relationships
between the individual and his environment. In such instances
not only the spatial but also the time orientation suffers. These
anomalies are, as a rule, not isolated, but in many instances are
complicated by considerable general impairment of all the cor-
tical functions.

" Hartmann, Fritz : Die Orientierung. Leipzig, 1902.

ANOMALIES OF VOLITION 87

That the preservation of the normal functions of the cor-
tex is essential to a perfect orientation is well demonstrated
in the early cases of general paresis. Paretics not infrequently
seem utterly unable to interpret their spatial or time relation-
ships correctly. A similar condition exists in many cases of
catatonia, and more than one observer has attempted to show
that the disorders of motility undoubtedly play an important
part in the clinical picture of this disease. . It is not at all
improbable, as Meynert, Hartmann, and others have pointed
out, that the catatonic symptom-complex, which may be char-
acterized by practically no disturbances in sensibility and by
little interference with the dynamic power of the muscle, is
in large part the result of anomalies in the so-called muscle
sense, and that this latter disturbance is referable to inter-
ference with the normal balance of the cortical functions.
Sometimes in various delirious states it is obvious that the
patient is the subject of a profound degree of disorientation.
This may, in part, be due to the influx of fallacious sense
perceptions, which create, as it were, a temporary imaginary
world in which the individual lives and to which he tries to
adjust himself. Disturbances of this character are not un-
common in delirium tremens, amentia, and a number of other
conditions. Another form of the disorder is noted in states
of depression, to a certain extent because incoming stimuli
fail to be elaborated and only serve to direct more forcibly the
patient's attention to his own symptoms. Sometimes in the
manic stupor individuals seem to completely fail to appreciate
their surroundings and have a deficient time sense. In all
forms of apathy there is a considerable degree of disorien-
tation which is also to be attributed to the disturbances in
associative memory and the inability of the individual to re-
collect past impressions and to compare them with sufficient
accuracy with other experiences.

VI. DISTURBANCES IN THE VOLITIONAL PROCESSES.

Among the more complicated of the psychic processes are
those which are commonly grouped under the head of voli-

88 PSYCHIATRY

tion. This series of phenomena belongs to the more highly
organized functions of the brain. Anomalies of volition in
the insane are not essentially different from those found in
the individual who is not the subject of mental aberration,
although the popular belief among the laity commonly assumes
that the disturbances of will which occur during the course
of alienation are the result of certain conditions and modi-
fications which do not enter into the general discussion of
the so-called problem of the will. Science affirms that all
our acts are the correlates of the associated brain processes
and that the phenomena of volition are primarily conditioned
by sensation and by variously elaborated and complex memory-
pictures, and not by the interposition of some new form of
psychical activity. The will as a specific function does not
exist. The acts of the individual, whether sane or insane, are
only the consequences of physical conditions which, if they
were fully understood, would render it possible to foretell
the character of the act. In other words, the power of voli-
tion possessed by any given individual is in direct proportion
to the functional capacity of his brain, and to assume that
he is endowed with some psychic power superior to the poten-
tial efficiency of the central nervous system is an hypothesis
that has no justification in facts.

The neural elements in the cerebral cortex are not only
responsible for the reception, retention, and modification of
sensory stimuli, but also have to do with the initiation and con-
ditioning of the efferent impulses. These impulses determine
the acts or the conduct of the individual, and between incident
motion or the stimulus, on the one hand, and the motor re-
sponse, on the other, is interposed a series of phenomena which
depend upon the structure and functional capacity of the cen-
tral nervous system. The brain determines the kind of re-
sponse and gives to a series of muscular movements a definite
stamp and character. Thus, for example, we recognize an
individual by his walk or by the character of his facial ex-
pression ; in other words, we have in a general way a definite
picture of the manner in which muscles under certain condi-

ANOMALIES OF VOLITION

89

tions respond to certain given stimuli, and these motor reac-
tions, as has already been said, are determined by the central
nervous system.

In order to obviate the difficulty of describing the voli-
tional processes in terms that, unfortunately, have a metaphysi-
cal meaning, and thus set up new stumbling-blocks that serve
to thwart the efforts of the investigator in his attempted solu-
tion of these and similar problems, some physiologists (Bethe,
Beer, and Uexhill) have proposed that only such terms shall
be employed as shall serve to indicate the immediate depend-
ence of the volitional no less than the reflex movement upon
the functional capacity of the central nervous system. With
this end in view Bethe has suggested that all forms of nervous
response should be designated as antikineses, while those re-
curring regularly and in a definite manner in response to
stimulation shall be called reflexes, whereas all the volitional
responses in which there is a variable factor due to the greater
complexity and elaboration in the physiological mechanism
shall be classed together as antiklises.42 The acts of an indi-
vidual under normal conditions vary within comparatively
narrow limits; the limitations are imposed by the functional
capacity of the higher brain-centres. Coordination and con-
tinuity of movement as well as of thought depend upon the
integrity of the neural elements in the higher brain-centres.

There is a remarkable degree of uniformity in the mech-
anism of all forms of movement. The general laws which hold
good for the simplest are applicable with certain modifications
to those of greater complexity. Reflex movements may be
defined as those following immediately upon the incidence of
a stimulus without the interposition of any cerebral process
of which we are conscious. This form of movement may be
intensified or inhibited as the direct result of sensory stimula-
tion. The same is true of movements in which there at one
time has been an element of consciousness but which, through

42 Bethe, A. : Allegemeine Anatomie und Physiologie des Nerven-
systems. Leipzig, 1903.

90

PSYCHIATRY

constant repetition, have become reflex or automatic. In the
normal individual the eyelids are quickly closed in response to
visual stimuli, and protection is thus given to the eyeballs from
injury from without. If, however, the cerebral processes are
inhibited by disease so that the reflex closure of the lids is
impossible, no response follows the stimulus. Volitional
movements differ from reflex and automatic acts in the fact
that prior to the discharge of the efferent impulse an idea of
the movement to be executed appears in consciousness, and,
as will be seen later, it is upon this phenomenon that the idea
of freedom in choice in all volitional acts depends.

Expressed in physiological terms, a volitional process may
be said to consist in the reception of the stimulus, its retention
and elaboration, brought about by the activity of the higher
brain-centres, and finally the motor discharge. The complexity
of the processes concerned in the act depends primarily upon
the response of the neural elements to the primary stimula-
tion. As has frequently been pointed out, the volitional proc-
esses, from a scientific stand-point, may be considered to
represent the totality of those conditions of which we are in
part conscious and that are directly related to a series of
movements and to whatever is contingent upon their execu-
tion (Mach). The conditions to which an individual is sub-
jected may produce disturbances of sensation or of memory,
and may also give rise to anomalies of volition. This is
equivalent to saying that just as there may be delay or resist-
ance in the reception, storing, and elaboration of stimuli, so
there may be opposition in the course of their emission. (See
tics, stereotyped movements, negativism.) The psychomotor
retardation in cases of depression and the psychomotor excita-
bility in maniacal patients afford respectively good examples
of the difficulty and of the ease with which volitional acts may
be executed. In the former case all forms of movement are
difficult, so that not only is there a delay in the reception and
actual association of the afferent, but the discharge of the
efferent impulse is impeded. In states of mania, however, the
opposite conditions prevail, and the execution of many voli-

ANOMALIES OF VOLITION gi

tional acts is carried out with greater ease and rapidity than
is normally the case.

Those who are familiar even with the elementary facts
of physiology realize that sensations and memory-pictures are
indissolubly connected; there is no sharp line dividing- them.
Disturbances in the functions we call memory may produce
anomalies in sensation, and vice versa. There is an intimate
dependence of the one series of phenomena upon the other and,
therefore, impairment of one set of functions reacts upon the
others. What is true in regard to sensation and memory is
equally true in regard to the greater complexity of functions
we call the will. Loss of vision impairs the volitional power
associated with certain movements ; for example, the blind man
stands irresolute owing to the impairment of those acquired
reactions which, in a measure, are conditioned by vision. The
impairment of volition may be the result of diminished func-
tion of the sense organs or, as in various psychoses, is caused
by the limitation and inhibition of the cortical functions. The
individual differences in the effect of a given stimulus is a
matter of everyday experience. One person may look over
the edge of a precipice without feeling a strong and almost irre-
sistible force, the consequence of certain organic sensations,
impelling him to throw himself headlong into the abyss below,
while another experiences this impulse. The differences in
the individual reactions and the degree of impairment of voli-
tion following the use of alcohol, tobacco, cocain, and other
drugs are well known. Under certain conditions stimuli
awaken in one individual a chain of impulses and desires that
in another person are either entirely absent or so feeble as
not to require any special act of will to overcome them. In
the functions of the nervous system are to be found the main-
spring of those desires that serve to attract or repel us from
certain objects, and that render one situation or event pleasant
and another painful. As the new needs spring into being, the
organism reacts in a manner determined by established trends
and inclinations that are partly the result of congenital and
partly of the acquired functions of the central nervous system.

92

PSYCHIATRY

We inherit a brain endowed with certain capacities that may-
be increased by education and the stimulating effects of our
environment. The difference in the volitional acts of two indi-
viduals is primarily determined by the disparity in the func-
tions of their nervous systems. One individual is bright, re-
sponsive, and emotional ; the other is dull and phlegmatic. In
the former the reception and elaboration of incident stimuli
are followed by a prompt and quick discharge of efferent
impulses, while in the latter the opposite condition prevails.

The alienist is interested in disturbances of volition from
two stand-points. In the first place, he considers these abnor-
mal phenomena from a clinical point of view, and, in the
second, they have an important forensic bearing. The acts
of an individual who is the subject of alienation may deviate
from the normal as a result of a number of conditions. For
this reason it is impossible to judge of the disturbances in the
volitional processes without a careful study of the individual
case. When there is a considerable impairment of all the
intellectual processes, as a result of this functional defect, the
individual may show marked impairment in his voluntary acts.
Such is the case in idiocy, imbecility, and various forms of
dementia. On the other hand, the presence of hallucinations
or illusions may condition the conduct. The crucial point in
passing judgment regarding the acts of a patient rests upon
the decision as to whether the individual who was the sub-
ject of hallucinations or illusions recognized these phenomena
as abnormal, and whether they were in any sense a factor of
importance in conditioning his act. The conduct of an indi-
vidual is not infrequently determined by the existence of an
emotional state, and emotional. excitement is primarily due to
functional changes in the central nervous system. Among the
cases where the disturbances of volition are of great moment
are those in which impulses dominate the acts of the patient.
These impulses are of great variety and of varying degrees
of intensity. (See Obsessions.) In all disturbances of con-
sciousness, so common in various psychoses, there is necessa-
rily some impairment of the volition. In various forms of

ANOMALIES OF VOLITION 93

alienation the clinician is struck by the fact that in some cases
the voluntary acts of an individual seem to be confronted with
a certain amount of opposition ; while in other cases the resist-
ance interposed between the psychical event, on the one hand,
and the physical reaction, upon the other, is below the normal,
and the patient seems to act with greater promptitude than
under ordinary conditions. As an instance of the former class
may be cited the psychomotor retardation noticeable in the
periods of mental depression, and of the latter the increased
excitability so common in states of mania as well as in the
early stages of alcoholism. In conditions of fatigue there is
also a marked diminution in the intensity and duration of the
so-called voluntary acts. The same is true in the various
forms of dementia.

The ghost of metaphysical speculation continuously con-
fronts the alienist when he attempts to deal with volitional
processes in which there is an apparent choice between one
or more motives. The doctrine of the so-called freedom of
the will is one that has long been jealously guarded from
assault by the theologian and metaphysician. There are cer-
tain obvious factors in connection with this discussion that
clearly show the problem to be one whose attempted solution
lies within the province of the alienist. It is a matter of com-
mon clinical experience that the sense of freedom associated
with volitional acts in the normal individual may be present
with even greater force in the consciousness of the patient
who is the subject of alienation. The consciousness of free-
dom accompanying all volitional acts is the result of certain
cortical functions. As has been indicated, the intensity of
this sense of freedom varies not only in different individuals,
but at different times in the same person. The feeling may
be greatly diminished in states of mental depression as well
as in fatigue or after the administration of morphin and the
bromides. This condition is in marked contrast with the ex-
travagant sense of freedom common in cases of paresis or
alcoholism and so frequently described in language that by
its exaggerated character indicates the remarkable changes in

94

PSYCHIATRY

the organic sensations upon which the feeling is based. The
consciousness of freedom that accompanies nearly all volitional
acts is a composite of sensations, emotional reactions, and
ideas. The prominence of the ideational element, dependent
as it is on the occurrence of certain organic sensations, is
greater in those instances where, subsequent to the perform-
ance of an act, there is the feeling that another motive or
line of action than the one chosen might have been selected.
The consciousness of freedom is referable not only to the act,
but also to the accompanying desire or wish. As has already
been pointed out, somatic disturbances that affect the per-
sonality or somato-psychic field of consciousness are charac-
terized by disorders of the volitional processes. The ego, or
idea of personality, represents an indefinite and variable group
of organic sensations. We are not the same to-day that we
were a year ago. When weakened by disease, exhausted by
fatigue or hunger, the limitations in our psychic personality
and volitional processes are to some extent proportional to
each other. It is important to bear in mind the fact that the
sense of freedom supposed to accompany a decision as to the
choice of motive does not occur at the instant the choice is
made, but is, in fact, a subsequent development. As Hoche 43
has affirmed, we are unable to observe and record exactly all
the processes that occur at the moment a choice is made. The
attempt to do this necessitates a recollection and redevelop-
ment on our part of all that has actually happened. The sense
of freedom is in reality an after-thought. The duty of the
alienist is to determine in individual cases the different con-
ditions that influence the thought and conduct of individuals.
Frequently it is impossible to ascertain and analyze the
facts, but we only increase and do not diminish our ignorance
by substituting for the supposed conditions an unvarying and
indescribable psychic force by and through which mountains
are supposed to be moved.

43 Die Freiheit des Willens vom Standpunkte der Psychopathologie.
Wiesbaden, 1902.

ANOMALIES OF VOLITION 95

Tics not infrequently occur during the course of the psy-
choses and seriously interfere with the prompt execution of sim-
ple volitional movements. In certain disorders, more particularly
in dementia prsecox, imbecility, and idiocy, both tonic or clonic
convulsive movements are common. These motor disturb-
ances may be secondary and connected with the appearance of
hallucinations, delusions, insane ideas, or imperative concep-
tions. The disturbance is of psychomotor origin; that is,
there are two elements which are of etiological importance —
the mental and the motor. The relative importance of these
two factors varies in different cases. The impairment of the
volitional power is dependent upon the insufficiency and ir-
regularity of the cortical functions. These phenomena seem
to indicate the incomplete development of certain psychic
functions, and the anomalies of volition which accompany va-
rious forms of tic are the result of a mental disequilibration.
In some cases the movements primarily represent responses
to external stimuli ; later, the stimuli having ceased to act, the
originally peripherally incited movement becomes automatic.
In other cases the movements may be the result of an insane
idea.

Various forms of tic are met with associated with aliena-
tion. These sudden, incoordinated, and involuntary move-
ments may be accompanied by considerable psychical disturb-
ances, as in Huntington's chorea. According to Charcot,44
"tic is a disease which is not material except in its appear-
ance;" in other words, the affection is in reality " a psychical
disease, a direct product of vesania." Brissaud has also called
attention to the abnormal mental state in patients afflicted with
tic. Meige and Feindel 45 have also emphasized the impor-
tance of the manifestations of motor storms with the asso-
ciated mental aberration. It is impossible at present to refer
in detail to the various manifestations of tic; the mental dis-
turbances associated with them are described elsewhere.

Lecons du Mardi, 1887-88, p. 124.

Les Tics et leur Traitement. Paris, 1902, p. 136.

g6 PSYCHIATRY

Stereotyped Movements. — Contrasted with these eccen-
tricities of movements is another class of motor disturbances —
stereotyped movements — which play an important part in the
symptomatology of a large group of cases. The phenomena
belonging to these are of various kinds and may be collectively
classified as stereotypies of movement or of attitude. The
former are sometimes spoken of as primary, the latter as sec-
ondary.46 Not infrequently the former are limited to the
facial muscles. The patient screws up one corner of the
mouth, closes one or both eyes, puckers up his lips to form the
curious " snouting cramp" so frequently observed. At times
these disturbances are limited to speech. There may be a
stereotyped tone of voice or character of the inflexion. In-
articulate sounds, words, or phrases are repeated (stereotyped
embolophrasia). Coprolalia may occur, but is more frequently
associated with some form of tic. Automatism is frequently
noted. The patient is told to protrude his tongue, and the
alternate protrusion and retraction is continued until he is told
to stop. When a reason for this continuation is asked for, a
senseless answer is given or the patient becomes evidently
embarrassed in attempting to find an explanation.

Stereotyped movements not infrequently resemble tics.
In character the muscular contractions do not differ essen-
tially from those of normal actions, but as the result of habit
have become involuntary. Stereotypies are never convulsive.
In clonic tic the rapidity of the muscular contraction is exag-
gerated, while in the tonic cases the duration is prolonged.
The basis of many stereotyped movements is to be found in
the acts of every-day life. The individual is characterized
by his attitude, by his manner of walking, by the personality
exhibited in his gestures, etc. These may become accentuated
during an attack of alienation. Cahen 47 pointed out that the
stereotypies of attitude or movement are coordinated and are

48 Ziehen : Psychiatrie, 2te Auflage, 1902.

47 Contribution a l'etude des stereotypies. Arch, de Neurol., Dec,
iooi, p. 474.

ANOMALIES OF VOLITION gy

not in any sense involuntary, but have the appearance of being
carried out for a purpose, at first conscious and voluntary,
but becoming through constant repetition automatic.

The incidence of stereotyped movements in insane pa-
tients is in most instances in all probability primarily due to
an insane idea. Later the idea disappears, but the movements
persist. It is sometimes difficult to distinguish between the
purely impulsive acts of the person who is the subject of a
tic and those stereotyped movements which not infrequently
are characterized by a brusque explosiveness suggesting the
former rather than the latter type of movements. The stereo-
typies of attitude may be designated as akinetic, while those
of movement are parakinetic disturbances. The latter are very
numerous, affecting various movements, the muscles concerned
in speech, gesture, mimicry, and not infrequently the writing.
The psychic correlate is shown in the expression of ideas.

The frequency with which these stereotypies are associ-
ated with insane ideas referring to movements of defence sug-
gested to Bressler that this symptom-complex was a neurosis
of self-protection due to an exaggerated excitability of the
psychomotor centres. He proposed the name " mimic-cramp
neurosis," basing his theory on the observations of Brenner
and Freud in cases of hysteria where the movements were
thought to be largely imitative.

Negativism. — Another condition not at all infrequent in
certain forms of alienation, particularly in catatonia, is the
so-called negativism. This may occasionally be mistaken for
psychomotor retardation, and is associated with considerable
impairment of the volitional processes. When negativism is
well marked there is resistance to all passive movements. Fre-
quently the patient does not wait to be touched, but turns away
his head, closes his eyes, runs into a far corner of the room,
crawls under the bed, any stimulus immediately arousing
marked antagonism. At times associated with this is the
characteristic catatonic rigidity of the muscles, but the two con-
ditions are not often found to exist synchronously. The nega-
tivism may be extreme or only transitory and of a mild degree

7

98

PSYCHIATRY

of intensity. The refusal to eat may be a marked feature in
such cases, and the urine and faeces may not be voided for long
periods of time. The attitude of the patient is silly and appa-
rently purposeless. In an aggressive or irritable patient an
hallucination or delusion will generally be found to be the
guiding motive of his conduct. Gross48 explains one form
of negativism as in part the result of psychomotor or intra-
psychic inhibition. A psychohypsesthesia limits or inhibits the
patient in his response to various stimuli, and be becomes con-
scious of the fact that he is not in harmony with his environ-
ment. Such a state is observable in the confusion which occurs
in senile psychoses where the symptoms are directly depend-
ent upon the limitation in sense perception. In another group
of cases the patient is ill at ease, dislikes interference, gives
evidence of his emotional state in his facial expression, takes
little interest in his surroundings. The more marked catatonic
symptoms are, as a rule, absent, but the patient is suspicious of
those about him. When questioned or approached he shows
plainly his disinclination to be interfered with, complains of
being disturbed, or may even become aggressive and energeti-
cally active. In this group of cases there is evidently an insane
idea as well as the consciousness of the inability to respond
promptly to external stimuli. This latter physical defect is
the basis of an emotional depression. The patient realizes that
he is unable to receive and elaborate stimuli which come to
him. The persistence of these disturbing factors may give
rise to marked anxiety which may exaggerate the psychic
defect.

The immediate cause of these phenomena cannot be re-
ferred solely to the lowering of the volitional impulses. Krae-
pelin and Sommer believe that the various catatonic disturb-
ances, such as negativism, echolalia, echopraxia, stereotypy,
mannerisms, and impulses all have a common foundation.
Two factors are intimately associated with their occurrence.

"Die Affektlage der Ablehnung. Monatsschr. f. Psych, u. Neurol.,
Bd. xii, Oct., 1902, H. 4, S. 359.

ANOMALIES OF VOLITION go

There is either a stereotypy shown by the increased tendency
of some movement or series of movements to recur after the
incidence of the initial stimulus, or the element of suggesti-
bility is nearly always present. Vogt,49 however, does not
believe that it is possible to explain the symptoms in detail
upon such a foundation. Basing his opinion upon the work
of Miiller and Pilzecker,50 as well as upon that of James, he
is inclined to believe that a representation appears in the field
of consciousness prior to every act or movement, and remains
there until displaced by an opposing reproduction. If the
latter is absent, the movement as executed does not involve the
so-called volitional processes. If more than one representation
is present in the field of consciousness, it becomes necessary
to choose, and the selection represents a voluntary choice.
When there is no abnormal psychomotor irritation, movements
resulting from choice not connected with great effort are made
half involuntarily. The result is different when there are
concurring impulses and centres whose instability is subnormal.
An additional force is then necessary to focus the attention
upon the idea of movement. This may awaken a subjective
feeling of resistance that must be overcome. Associated with
this there is a tendency of processes once initiated to persevere
in face of the increased opposition; but working against this
increased perseverance or perseveration of the process there
are a limiting and inhibition of the various associational ac-
tivities of the brain. As a result, the idea of movement or
position, once in the field of consciousness, persists there until
it is forcibly dislodged. A patient in a cataleptic state will
frequently hold his arm in an uncomfortable position even
when pricked with a pin or pinched or when another limb is
put in an equally uncomfortable position. But if he is asked
to execute a voluntary movement and is capable of responding,
as the new idea associated with changed position or with a

48 Centralb. f. Nervenheilk. u. Psych., Juli, 1902, vol. xix.
80 Experiment. Beitrage zur Lehre von Gedachtniss. Ztschr. f. Psych.,
1900, Supplement, Band i.

10o PSYCHIATRY

voluntary act rises above the threshold of consciousness, the
old idea is dislodged and the arm first elevated slowly drops.
It is claimed by some that a condition akin to this is common
after severe mental or physical fatigue. It is not definitely
proven, however, that all cases are capable of being explained
on the same basis. Patients sometimes assume attitudes or
give expression to stereotyped forms of speech as the result of
a delusion. These catatonic symptoms may be initiated as the
result of delusions, but may eventually become more or less
automatic.

Imperative Processes.51 — A train of thought may be dis-
turbed or even completely inhibited by the sudden spontaneous
appearance in consciousness of ideas which are recognized by
an individual as irrelevant and unreasonable. The occurrence
of these ideas may be merely temporary or they may persist
for so long a time as to harass and even terrify the person.
One of their distinguishing characteristics is the inability of
the individual to banish them from consciousness. These phe-
nomena have received various names — obsessions, imperative
ideas, perceptions, conceptions, or reproductions.

Closely allied to the imperative ideas is another group of
phenomena in which the compulsion to perform certain acts
seems to be the essential factor in their pathogenesis. Recently
Bianchi 52 has suggested the possibility of roughly grouping
these phenomena into (i) obsessional emotions, (2) obses-
sional ideas, and (3) obsessional impulses.

Westphal's 53 description of these processes was the one
which for a long time was generally accepted by alienists.
This author called attention to the fact that at least four fac-
tors were characteristic of them :

( 1 ) The normal intelligence ;

(2) Absence of any primary emotional disturbance;

(3) The imperative manner in which they force them-
selves into the foreground of consciousness;

01 Loewenfeld, L. : Die psychischen Zwangsercheinungen. Wiesba-
den, 1904.

" Clinica Moderna, 1899.
"Arch. f. Psych., Bd. ii.

ANOMALIES OF VOLITION IOi

(4) Their recognition by the patient as foreign and ab-
normal.

In 1869 von Krafft-Ebing pointed out the frequency with
which obsessions occur in certain forms of alienation. In fact,
the relative importance of these phenomena was considered to
be so great that certain psychoses in which they seemed to be
the chief symptom were grouped together under the head of
the imperative-process psychoses (die Zwangsvorstellungen-
psychosen). Various conditions, such as fatigue, hunger, pro-
longed mental or physical exertion, seem to favor the develop-
ment of these phenomena.

Friedmann 54 has recently called attention to the fact that
the genetic conditions which give rise to these dominating
conceptions are not well understood, and consequently any
attempt to adjust our present knowledge regarding them so
as to satisfy a purely clinical conception may lead to confusion.
The difficulty of differentiating obsessions from various other
phenomena which are associated with marked emotional dis-
turbances is often very great. The same is true in regard to
the difficulty of distinguishing the imperative conceptions
which frequently occur during the course of various psychoses
from the fixed ideas which often interfere with and domi-
nate the reasoning powers of a patient. In order to facilitate
the differentiation of these phenomena Friedmann has endeav-
ored to explain the occurrence of the imperative idea on a
different basis from the one given by Westphal. The latter's
explanation may account for the simpler, compulsory repro-
ductions, but this definition is inapplicable to the imperative
ideas, impulses, or the imperative thinking so frequently ob-
served in cases where the whole emotional and intellectual life
of the patient is dominated by the obsession. Westphal's defi-
nition simply refers to the manner which characterizes the
appearance of the perception in consciousness. It takes no
account of the fact that the actual content of the reproduction
may be a factor of considerable importance. Unquestionably

M Centralb. f. Nervenheilk. u. Psych., Nr. 144, 1902.

I02 PSYCHIATRY

in some cases the enthralling power of the obsession may be
due to the fact that the appearance in consciousness is so sud-
den and so distressing that all other psychical processes are
inhibited. In other cases the agency of chance external stimuli
may be admitted as an etiological factor. In these latter cases
an obsession takes the form of an echo-like reproduction, as
in echolalia. In conditions of fatigue or exhaustion patients
frequently complain of the constant and annoying recurrence
of certain tunes, melodies, phrases, verses of poetry, etc., which
they have heard. The more aggravated forms, on account of
their sudden startling appearance in consciousness, are in many
ways analogous to muscular cramps. Certain authorities have
spoken of them as " reproduction" or " memory cramps."
Ribot has referred to them as characterized by a semi-tetanized
attention (Aufmerksamkeit). As already stated, the forms
which may be included under this head are comparatively few.
Another factor is prominent in their pathogenesis. The simple
memory of a past event does not form by itself the basis of
an obsession, but the recollection of an unpleasant occurrence
may awaken in the patient a degree of expectancy or fear,
and this emotional state becomes, as it were, the nucleus around
which obsessions may develop. In the majority of the im-
perative processes the element of futurity is always present.
Theoretically, the difference between the fixed idea and the
imperative idea is that the latter, more or less suddenly and
without any relation to what has gone before, overwhelms
consciousness, whereas the former develops more gradually
and is, in a measure, a result of associative thinking. The
fixed idea, granting the truth of the premise upon which it is
based, is characterized by a logical development, the impera-
tive idea is abrupt and illogical.

Wernicke attempts to differentiate autochthonous from
exaggerated (iiberwertig) ideas. The latter, he thinks, are
distinguishable from the former in never being recognized by
the patient as strange and inexplicable intrusions into con-
sciousness. Although they are frequently most annoying and
persistent, patients do not recognize them as abnormal. Ac-

ANOMALIES OF VOLITION IC>3

cording to the same view, in exaggerated ideas the pathologi-
cal element in their genesis and in their content is not admitted
by the patient, as it frequently is in imperative ideas or repre-
sentations. It may be admitted that occasionally patients are
capable of distinguishing autochthonous thoughts, whose
content is strange and mystifying, from obsessions whose
sudden and inexplicable appearance in itself emphasizes to
the patient their abnormality. In many cases it is impossible
to adopt such a rigid classification of these phenomena. Wer-
nicke affirms that autochthonous ideas are distinguishable
from obsessions in that the former are recognized as foreign
to, and arising outside of, the individual personality, and on
this account are believed to dominate more than do the latter
the whole of the psychic life.

It has already been noted that the content of the obsession,
although it frequently exerts an important influence upon the
patient, has practically no relation to the ideas that have im-
mediately preceded it in consciousness. Instead of being an
active impulse which diverts and transforms a train of thought,
it is more analogous to an inhibitory impulse which delays and
disorganizes associative thinking. It is an obstacle to pro-
gressive thinking. The idea can not be banished from con-
sciousness, and, as a result of this phenomenon, fear, expec-
tancy, doubt, and isolated incomprehensible representations
overwhelm and cloud the intellectual processes. The effect
of the obsession upon the other psychological processes is not
only irritating, but paralyzing. This is particularly true in
the case of individuals where the normal associative thinking
is defective.

Arnaud 55 calls attention to the . fact that an obsession
is in reality an extremely complicated phenomenon. It is
characterized by a series of actions and reactions which pro-
foundly affect the whole mental life as well as the organic
functions causing disorder in the dynamics of the associative

65 Arch, de Neurologic Sur la Theorie de l'Obsession. Avril, 1902,
P- 257-

104 PSYCHIATRY

mechanism of the brain. This is seen in the disturbance of
some or all of the voluntary processes, including the higher
intellectual functions. An imperative representation may be
defined as a deficient mental synthesis, — an abulia. Arnaud
affirms that the emotional as well as the purely intellectual
element, the idea, both play an important but, nevertheless,
secondary part in its pathogenesis. According to this theory,
the emotional element is measured by the intensity as well as
by the character of the " crises angoissantes" which accompany
the obsession, but it is never the causative factor. Patients
subject to these phenomena are conscious of their inability to
banish the obsession from their consciousness. They live in
apprehension of its return and this fact conditions their emo-
tional state. The idea, in a measure, determines the formal
character of the obsession. But the influence exerted by the
idea itself is directly proportional to the degree to which voli-
tion is impaired. When the voluntary impairment is marked,
the obsession attains greater significance. Especially is this
true if the idea or representation is the immediate incentive to
action. If it is, the case becomes of forensic importance. The
compulsive acts which depend upon imperative representations
or ideas must be carefully distinguished from those that are
motiveless and the result of pure impulse. According to
Ziehen,56 the latter are also compulsory, but are motiveless and
do not depend directly upon pathological emotional states,
sensory anomalies, or representations. The impulsive act
has no corresponding state of consciousness in which an idea
of its abnormality is present. After its completion there is an
intact memory and an undiminished power of retrospection.

Considerable attention has been devoted by some clinicians
to the evolution of the obsession and to a discussion of the
part played by these phenomena in the genesis of various forms
of alienation. Falret and Menier affirm that an obsession is
never so transformed as to become an important factor in the

M Monatsschr. f. Psych, u. Neurol., Bd. xi, Heft i.

ANOMALIES OF VOLITION I05

clinical picture of delirious states. This observation has not
been generally confirmed.57

Cases not infrequently come under observation where the
delirious state seems to be a direct evolution from the obses-
sions. There is reason to believe that obsessions are of prime
importance in the evolution of certain forms of melancholia,
mental confusion, the delire onirique, and in certain system-
atized deliria. Again there are cases where the persistence for
a considerable period of time of these obsessions has given
rise to states of mental depression of varying degree. For
example, a patient, who was much prostrated physically by
long-continued nursing of a member of her family afflicted with
cancer, gradually began to notice that the impulse to wash her
hands came to her at short intervals. The foolishness of these
repeated acts was recognized by the patient, but the obsession
continued and was a source of great annoyance to her. She
became greatly depressed as a result of this impulse and feared
that if it continued she would lose her mind. Although admit-
ting that the frequent repetition of these washings was absurd,
she affirmed that she was unable to resist the impulse. Ob-
servers have directed attention to the part played by similar
obsessions in the disorganizing of associative thinking. The
probable part played by obsessions in the development of para-
noia is discussed under that head.

The following provisional grouping of these phenomena
by Loewenfeld 58 forms a satisfactory clinical basis for their
study :

A. Those in the intellectual sphere, which may be divided
into two categories :

( I ) More or less isolated and independent obsessions

including imperative ideas, in the narrower sense of the

" Seglas, J. : Soc. med.-psych., seance du 26 fevrier, 1901 ; note sur
revolution des obsessions et leur passage au delire. Arch, de Neurol., vol.
xv, 2e serie, 1903, No. 85 (Janvier).

88 Loewenfeld, L. : Die psychischen Zwangserscheinungen. Wiesbaden,
1904.

io6 PSYCHIATRY

word, imperative sensations, and imperative hallucina-
tions.

(2) The obsessive ideas of a more complicated form
of mental activity, such as the forced questioning, folie du
doute, imperative remembrances, compulsory thinking, ex-
cessive introspection.

B. The imperative processes which are chiefly character-
ized by anomalous emotional reactions, apprehensiveness with
or without definite fears, imperative emotional states and
moods.

C. The imperative phenomena associated with the motor
discharge, impulses, a great variety of simpler movements as
well as more complicated acts, and inhibitory processes.

Impulsivity. — The normal behavior of an individual may
be profoundly disturbed as the result of impulses which may
assume a great variety of forms and give rise to complications,
many of which are of forensic importance. The mechanism of
these impulses is not essentially different from that occurring
in the normal individual. All grades exist, varying from those
which can scarcely be called abnormal to those which are asso-
ciated with the commission of the most brutal and disgusting
crimes. From a clinical stand-point these impulses may be
divided into those with disparate and those with coinciding
motives. In speaking of the disturbances that occur in organic
sensibility, it was shown how the ordinary sensations attending
hunger, thirst, rest, and activity are sometimes perverted during
the course of an alienation, and this change in the ccensesthesia
may be the basis of impulsivity. These forced acts may pro-
duce results of a more or less indifferent character or they may
be attended by danger either to the individual or to others.
An illustration of the former class is the impulse to keep in
motion noted in nervous individuals and so frequently mistaken
for normal healthy activity. These abnormal impulses of a
more or less harmless character occur in a great variety of
conditions, in hysteria as well as in the initial stages of various
other psychoses. Frequently in the prodromal period of manic-
depressive insanity there is a marked tendency for the indi-

ANOMALIES OF VOLITION 10y

vidual to be continually on the move. Again, some of these
individuals, apparently without any good and sufficient motive,
will sit down and write page after page. Reference has been
made to the various other impulses in the consideration of the
psychasthenic states. Among the many acts which are asso-
ciated with danger to the individual or those who surround
him only a few of the more important need be mentioned here.
For instance, certain individuals show a tendency to steal at
any and all times — kleptomania — or to set fire to property —
pyromania. Both of these vices are common in the large class
of individuals who are broadly designated as degenerates, as
well as in epilepsy, senile conditions, and a variety of other
forms of alienation. Suicidal impulses are not infrequent, and,
as a rule, are much more common than the homicidal forms.
In a consideration of the former we have to distinguish be-
tween those which are and those which are not the result of
deliberation. The former are not infrequently met with, par-
ticularly in cases of hysteria and in the very early stages of
alienation, at a time when the patient is particularly susceptible
to suggestion. The impulse is closely related to a tendency
shown by nervous individuals to jump from high places. As
a rule, the suicidal tendency in these instances is a matter of
purely momentary suggestion. Cases are on record where the
mere sight of a sharp instrument, of a hammer, or of fire-arms
has been sufficient to prompt the individual to attempt violence
upon himself. The homicidal impulse, as has already been
said, is relatively less common. In all probability Loewenfeld's
view is correct that the homicidal impulse is never preceded
by a fear frequently expressed by nervous individuals that
they may do bodily harm to those about them, but comes sud-
denly and with overwhelming force. It may be suggested, just
as in the case of the suicidal impulse, by the sight of fire-arms,
sharp instruments, an exposed part of the body, such as the
throat or the neck. Undoubtedly the mental pictures evoked by
the revolting details of murder trials, as published in the daily
press, have occasionally been sufficient to drive ill-balanced indi-
viduals to commit suicide, and less frequently homicide.

io8 PSYCHIATRY

The sexual impulses assume a great variety of different
forms and may play an important part in the symptomatology
of several forms of alienation. Exhibitionism is frequently
noted, particularly in the early stages of senile and paralytic
dementia. Vices due to perverted sexual sensation — paeder-
asty, nekrophilia, zoophilia, sadismus, and masochismus — the
latter two designated collectively as algolagnia (v. Schrenk-
Notzing) — have been carefully investigated by a large number
of alienists 59 and are frequently of forensic importance.

VII. DISTURBANCES IN THE EMOTIONAL REACTIONS."

Accurately to define an emotion in a single phrase is as
impossible as to give an exact definition of the phenomena of
consciousness, intellect, or, in fact, of any expression that is
used in a relative sense. The emotions are singularly complex
compounds that derive their importance largely from the ac-
companying neural disturbances. They consist of a complex
series of phenomena which give rise to symptoms that only
in a general way are distinctive ; and for this reason the alien-
ist should be exceedingly guarded in attempting to describe
their characteristics in general terms. Each case must be
studied on its own merits, and few, if any, rules can be laid
down as guiding principles. An incident stimulus gives rise
to a certain feeling, and this in turn to a desire, an act, and
a subsequent sense of satisfaction or dissatisfaction, according
as the wish is gratified or not; and to this complex of sen-
sations others may be added until the links in the chain of
mental processes become too numerous to analyze.61 When a
stimulus acting under normal conditions impinges upon the
cerebral cortex with sufficient intensity for us to become con-

"* Eulenberg, A. : Sadismus und Masochismus.

80 Morel : Du delire emotif nerveux du systeme nerveux ganglionnaire
visceral. Archiv gener. de med., 1866. Ribot: The Psychology of the
Emotions, 1897. Sergi : Dolore e Piacere, Les Emotions, 1901. Finzi:
Die normale Schwankungen der Seelenthatigkeiten (Deutsch von Jentsch),
1900.

41 Die Laune — Eine Aerztliche-psychologische Studie. Jentsch, Wies-
baden, 1902.

ANOMALIES OF EMOTION IOg

scious of it, a concomitant series of phenomena can be noted.
To facilitate description, for the sake of convenience, these
may be divided into two groups — mental and physical. If,
for example, the ringer is pricked with a needle, there are cer-
tain objective facts that may become obvious. There may be
a change in the facial expression indicative of pain, accom-
panied or followed by a series of complicated muscular con-
tractions resulting in the drawing away of the hand. Con-
nected with these objective phenomena are those that are com-
monly described as subjective in character.

These two classes of phenomena — psychic and physical —
are always present in emotional reactions, although the rela-
tive importance of the two is never constant and has been
variously estimated by different observers. A series of optic
stimuli may give birth to a definite and well-defined sense of
fear. Here the primary visual stimulus has associated with
it memory-pictures, sensations, and a chain of neural disturb-
ances, all of which we refer to collectively as fear. The bodily
changes are a cold and clammy skin, blanching of the counte-
nance, increase in the rapidity of the pulse, and, it may be,
a marked tremor. The psychic concomitants are manifold.
There may be only an indefinite sense of anxiety or fear; or
it may be that the possible effects of some supposedly imminent
disaster are pictured in rapid succession and with considerable
detail. These phenomena vary in individuals, and their inten-
sity and extent are not constant, but fluctuate at different times
in the same person.

Not only is it important that the physician should study
the changes in the organic reactions, both mental and physical,
that are to be observed in cases of alienation, but he must first
familiarize himself with the fluctuations that occur in the life
of the normal individual. In this way alone will he be able
to understand many of the changes which occur during the
course of alienation. In many instances the latter are simply
to be regarded as representing an intensification of those re-
actions which have persisted during the whole life of the
individual. Take, for example, the periods of depression to

HO PSYCHIATRY

which so many persons are subject.62 One person may endure
a series of misfortunes without any marked tendency to be-
come really depressed, whereas in another every trifle serves
to disturb the mental equilibrium. These varying moods are
of such frequent occurrence in nearly every individual that
they cannot be considered as abnormal. Thus in patients who
for a considerable time have been subjected to severe discom-
fort or even pain, we shall often find that on the cessation of
the irritation a reaction characterized by excitement and a
certain sense of exhilaration follows. These reactive phases
are not infrequently met with in convalescents from some pro-
tracted disease, such as typhoid fever. As has frequently been
suggested, the slight exaltation that exists in cases of phthisis
may be referable to some form of autointoxication. The
anomalous emotional states that follow protracted mental and
physical fatigue are well known. In many instances the
fatigue causes paresthesias in the field of body consciousness
which are at the basis of the irritability and discomfort ex-
hibited by many individuals.

The affective disorders are sometimes aggravated by
anomalous mental states, more especially following hallucina-
tions. The objective signs of anxiety or fear exhibited by
patients who are the subject of delusions are of this class.
The opposite condition is not infrequently met with. There
may be a gradual or, at times, a sudden and spontaneous change
in the physical condition of the patient. As a result of this
state the power of connected thinking is limited or for the
time completely inhibited. In both instances the extent of
the reaction depends upon the functional capacity of the cen-
tral nervous system. In the former case the neural disturb-
ances predominate, while in the latter the disorganization and
dissociation of thought become the more important feature.
The physical changes upon which both series of phenomena
depend disorganize or inhibit the cortical functions. Whether

82 Lange, C. : Periodische Depressionszustande und ihre Pathogenesis.
Deutsch von H. Kurella, 1896.

ANOMALIES OF EMOTION IXI

the so-called psychic or the neural disturbances dominate, the
clinical picture depends upon individual idiosyncrasies.

As has repeatedly been pointed out, our emotions are
highly developed compounds, which it is frequently impossible,
in view of the few facts at our command, to analyze clinically
in their entirety. In the case of certain emotional disturbances
it is sometimes possible to trace their rise from a sensation or
feeling comparatively simple in origin. About this feeling
as a nucleus are clustered other sensations, or it may be groups
of sensations, which vary in character. All of these may be
united into one symptom-complex. The complexity, no less
than the intensity, of these highly organized reactions depends
directly upon the functional capacity of the central nervous
system. The same idea may be differently expressed by say-
ing that the emotional display of an individual is conditioned
by that series of events which has directly affected the develop-
ment of the central nervous system. The child at birth can-
not be said to be an emotional creature. It is true that it
cries in response to a stimulus, but this cry expresses neither
pleasure nor pain. The physical phenomena are present, but
the ideational part of the emotional display is absent. In the
adult the conditions are different. As the nerve-cells and
fibres in the cerebral cortex become functionally active, a series
of phenomena are noted in the child that are the result of the
greater elaboration and working up of the stimulus by the
cortical elements prior to its discharge as an efferent impulse,
and gradually in the course of development he becomes accus-
tomed to respond in a definite manner to different forms of
stimuli. Certain neural inclinations are established, and in
time the growing brain responds more easily to one kind of
a stimulus than it does to another. Finally, when the prime
of life is reached, it is seen that the functional capacity of the
central nervous system of one individual differs essentially
from that of other persons. Certain neural inclinations have
been established and the power of inhibiting or initiating the
cortical functions has received a definite trend. One of the
chief aims of education should be to adapt the emotional reac-

112 PSYCHIATRY

tions of an individual to his environment. These reactions
must not be excessive nor incongruous. The nervous system
must be trained to ignore the action of certain irritating
stimuli. Hypersensitiveness and misery are, in a measure,
synonymous terms. The proper development through edu-
cation of the nervous system of neural inclinations or dis-
inclinations is a matter of prime importance.

In the adult the mental processes have different shades
and degrees of coloring. This is commonly expressed by
saying that each thought and act has its accompanying mood.
These moods or states are the qualifying factors in sensations
due either to intra- or extra-organic stimuli. A given sensa-
tion may be attended by a sense of pleasure, but if its intensity
is increased and its duration prolonged, a definite sense of
pain develops, thought is disorganized, and, as a result, doubt,
instability, or anger may result.

The manner in which the organism reacts to stimuli con-
ditions the appearance of the mood. The reactions are in part
the result of congenital factors and in part of trends acquired
through education and environment. In normal thought and
action there is deliberateness, no incongruity, no sudden ces-
sation or break in the physiological processes. In alienation
the reverse is true. Thus impulses, imperative conceptions,
or strange organic sensations break in upon and inhibit or
repress a line of thought or action. The dominant note of
the mood is frequently characterized by great permanence and
a marked tendency to reiteration. All forms of stimuli seem
to intensify but not to alter its form. The patient who suf-
fers from mental depression sinks deeper into his gloom when-
ever he is stimulated; it matters little what the character of
the sensation may be. A waltz or a comic song is quite as
apt to increase the intensity of mental pain as the sound of
a dirge or funeral anthem. The same principle holds in cases
of exaltation. Everything serves to magnify the sense of well-
being and to add to the feeling of exhilaration. No event is
too solemn, no situation too serious, to detract from the levity
and buffoonery of some maniacal patients.

ANOMALIES OF EMOTION 1 13

Mood is a collective term used to express the mental tone
accompanying a thought or act. It indicates the existence of
modifications that have taken place in the process of the work-
ing up and elaboration of stimuli. Moods tend to persist,
since the equilibrium is only gradually restored to the normal.
In cases of disease this persistence of definite mental tones
is often exaggerated. The mood once established becomes in
a measure permanent. It gives direction to the whole train
of thought. Out of the various organic needs pressing for
satisfaction develops the mood, and this in turn dominates for
the time the whole field of psychic activity. To-day all forms
of stimuli seem to give rise to disagreeable ideas. The whole
mental attitude is one of depression, but a night's rest changes
the whole character of our mentality. By common consent
certain moods are designated by definite terms, such as pleas-
urable, painful, etc.

Some observers maintain that a sensory impression, as it
appears in consciousness, is associated either with a sense of
pleasure or pain, but such a view exaggerates the importance
of these two tonal elements. It is possible that as the result
of our environment and education our nervous system re-
sponds without effort to certain kinds of stimuli. A mental
reaction which in one individual may be accompanied by a
distinct sensation of pleasure or pain in another is neutral.
From this it is not justifiable to draw the inference that nor-
mal thought or action is completely unaccompanied by neural
disturbance, but rather that a stimulus which in one individual
is attended by a series of complicated psychic and physical
reactions, a sense of conscious effort, and a needless expendi-
ture of energy may in another person fail to elicit evidences
of great neural disturbance.

The diminution or impairment of the objective emotional
reactions is frequently noted in cases of alienation. In im-
beciles or idiots an imperfect development of the cerebral cor-
tex may be responsible for the persistence of a less complicated
psychic and yet more intense physical reaction. The imper-
fections and intensity of the emotional displays of childhood

8

literary of

114

PSYCHIATRY

are well known. In children the defect in the mental elabo-
ration of the stimulus is characteristic. What may be termed
the neural reactions are well developed, but the psychic are in
abeyance. Those who suffer from congenital or acquired de-
fects of the central nervous system are particularly liable to
emotional storms of great intensity, owing to the decreased
power of inhibition. On the other hand, the so-called higher
or intellectual emotions are only developed to a limited extent.

In the earlier stages of dementia praecox there is marked
impairment in the intellectual side of the emotional reactions.
In fact, the essential characteristic of this disease is said by
Stransky to be the dissociation between the idea and the corre-
sponding emotional reaction — an intrapsychic incoordination.
In some cases any form of sensory stimulation may give rise
to incongruous and intense reactions. Thus some patients
while sobbing will nevertheless affirm that they feel in the best
of spirits or laugh when there is absolutely no occasion for
any display of mirth. Their attitude towards their surround-
ings changes ; they become unsociable and appear to have lost
all affection for their friends and even for members of their
family. As the disease progresses they become more and more
emotionally indifferent, until finally only those reactions are
retained that are the immediate expression of the physical
needs of the organism.

In some cases the patient is conscious of his limitations,
and recognizes that his emotional state is anomalous. This
is more apt to be the case in hysterical or neurasthenic indi-
viduals than in the earlier stages of a condition that even-
tually is to develop into a pure psychosis. In the latter an
apathy often comes on synchronously with the change in the
emotional tone, whereas a neurasthenic patient not infre-
quently affirms that he has lost interest in his surroundings
and friends ; that his ideals are things of the past; and he is apt
to be depressed mentally by the consciousness of this subjective
disorder. The defects in the emotional life of individuals are
often associated with a tendency to an exaggeration of the
reactions that are retained.

ANOMALIES OF EMOTION

115

An increase in the intensity and volume of the physical
reactions in the emotional display is characteristic of various
forms of mental disturbances. On the other hand, the imme-
diate effect of a stimulus upon an over-susceptible nervous
system may be almost a complete inhibition of the associated
functions of the brain. The individual may even lose con-
sciousness or the cortical functions may be only partially in-
hibited, giving rise to a state of confusion. Intense emotional
reactions are not uncommon in neurasthenics. These indi-
viduals, by their environment and training, have little capa-
bility for ignoring irritants. They are hypersensitive and
exhibit to a marked degree the evils of interpreting pleasure
and pain merely in terms of sensation. The slightest external
stimulus serves to direct their attention to themselves, and
there it remains fixed until diverted by a stronger irritant.
Their lack of mental equilibrium is often characterized by in-
tense anxiety, grief, pleasure, and pain, which succeed each
other with great rapidity. Emotional instability and its con-
comitant reactions are exhibited by many epileptics, who on
the slightest provocation are intensely pleased or greatly dis-
pleased. Again, the epileptic is apt to be capricious, and not
uncommonly is the subject of sudden and inexplicable out-
bursts of temper.

The excessive volume and intensity of the emotional re-
actions in the insane are not infrequently associated with
psycho-anaesthesias. Thus in many maniacal patients a psycho-
analgesia is readily demonstrable, the patients throwing them-
selves about the bed or the room and often inflicting serious
injuries upon themselves without giving any objective evidence
that they have the slightest appreciation of painful sensations.
Even when the actual conduction of sensory impulses from the
periphery is not impaired, the patient's attention is sometimes
so firmly riveted upon certain objects or upon the execution
of certain muscular movements that peripheral irritation is
ignored. This fact doubtless explains the cases of insane per-
sons who, being impressed with the delusion that they are
superhuman, inflict severe bodily injury upon themselves. The

n6 PSYCHIATRY

spirit of exaltation, the tetanization of the attention, and the
resulting psychic analgesia explain the deeds of many self-
torturers, not only among those who are clearly insane, but in
certain border-line cases — for instance, those of fanatics and
many so-called martyrs.63 In these cases stimuli that under
normal conditions would produce marked neural disturbances
fail to do so and the individual remains indifferent, experi-
encing neither pleasure nor pain.

The study of the objective evidence of neural disturb-
ances in the emotional reactions is important. Thus in states
of exaltation the rhythm of the breathing, as well as the
character of the cardiac action, is altered. The secretion of
sweat or urine is often interfered with, and there may be
marked disturbances of function of the voluntary and invol-
untary musculature. Exaltation may in a measure be consid-
ered antithetical to depression, and the physiognomy in the
two states is essentially different. In the former the skin over
the forehead is smooth or thrown into slight horizontal wrin-
kles, the eyebrows are elevated, and the eyes show an increase
in the secretion of tears. The corners of the mouth are raised.
In states of depression the condition is reversed. In young
children, idiots, and in some forms of dementia the neural
disturbances accompanying states of depression and exaltation
are, in a measure, similar. The effects of an outburst of anger
may influence the whole musculature. If the reactions are
greatly exaggerated, there may be a complete inhibition of
certain motor functions followed by an increase in the inten-
sity and volume of others. The statement that in the former
condition there is a high intracranial tension, while in the
latter it is subnormal, is a pure hypothesis. Unquestionably,
in many instances the depression is associated with increased
tension in the peripheral arteries and exaltation with the oppo-
site condition, but from these observations alone deductions
regarding the state of the cerebral circulation are not justifi-
able. As a rule, those emotional displays may be said to be

m Mercier : Psychology, Normal and Morbid, 1901.

ANOMALIES OF EMOTION

117

abnormal in which there is evidence of marked dissociation
of the cortical functions.

Considerable variation in the emotional display in patients
who are the subjects of the same form of alienation is not
infrequent. For example, in one case of maniacal excitement
there may be marked motor restlessness, a rapid pulse, tremor,
and all the objective evidences of considerable neural disturb-
ance, and accompanying the physical symptoms the character-
istic rapid flow of ideas indicative of psychic hyperesthesia.
In another patient there may be a marked disproportionate-
ness between the physical and mental concomitants of the emo-
tional instability, sometimes the former, and again the latter
predominating.

Closely associated with the neural disturbances in the
anomalies of emotion are the feelings or groups of sensations
which are designated moods or feeling-tones. In certain in-
stances, as has already been said, these moods are devoid of
color, and no one feeling dominates the clinical picture. The
patient may be indifferent or apathetic. In certain delirious
states the apathy is broken only by the performance of acts
that are apparently the result of various impulses depending
upon changes in the organic sensations. In other cases marked
anxiety is the dominating symptom. This is frequently indefi-
nite in character, the patient not being able to assign any cause
for his mental distress. Some clinicians affirm that this anx-
iety, so often a prominent symptom in mental disease, pos-
sesses the characteristics of a distinct emotion and is attended
by a definite sense of mental pain. In the majority of in-
stances, however, the ideation associated with the neural dis-
turbance is ill-defined. Patients in this state frequently declare
that they cannot describe their feelings. The investigations
of Kornfeld 64 are of interest in connection with the determi-
nation of objective evidences of neural disturbances in cases
in which anxiety is a prominent symptom. Not only is there
marked alteration in the tone and functional capacity of the

M Zur Pathologie der Angst. Jahrbiicher f. Psychiatrie, Bd. xxii.

u8 PSYCHIATRY

skeletal muscles, but this functional derangement involves the
muscular elements in the walls of the blood-vessels. This is
shown by the rise of blood-pressure and the variations in char-
acter of the pulse-wave. The anomalies of glandular secre-
tion are particularly noteworthy. The rapid rise in blood-
pressure which occurs as the emotional storm gathers is fol-
lowed by an equally rapid drop, beginning when the patient
breaks out into a profuse sweat.

The anxiety of cortical origin that is met with in cases
of alienation, according to Souque,65 should be sharply dis-
tinguished from the precordial anxiety, which is a bulbar
symptom. The latter is a definite symptom-complex, charac-
terized by a sense of depression or suffocation, while the for-
mer, equally intense, is characterized by vague apprehensive-
ness.66 The two states may appear independently in the same
case. The objectless, indefinite feeling of anxiety so common
in various forms of alienation not infrequently crystallizes
into fear. This change may be due to the occurrence of hallu-
cinations or delusions. Lowenfeld has suggested the follow-
ing classification of the various states of anxiety.

(i) Those relating to the health of the individual. (2)
Those in which there is excessive apprehensiveness in regard
to questions connected with ethics and morality. (3) Those
relating to the health of members of the immediate family
or friends. (4) Numerous others connected with the indi-
vidual's profession or particular view of life.

The indefinite crystallized fears are most noticeable in
cases in which there are marked hallucinatory disturbances,
such as those due to alcohol, cocain, and various drug intoxi-
cations. The phobias associated with obsessions, though com-
mon in neurasthenics and hysterical individuals, never give
rise in these patients to severe emotional, storms as sudden in
their onset and incongruous in their nature as those found in

M Societe de Neurologie de Paris, Decembre 4, 1902.
86 The difference between these two phenomena is indicated by French
writers, who distinguish between angoisse and anxiete.

ANOMALIES OF CONDUCT IIO_

various psychoses. In cases of depression the feeling-tone
varies from the mildest to the most intense psychic pain. The
feeling of mental depression may be secondary, depending
upon the occurrence of hallucinations or delusions, as is the
case in the early stages of melancholia or the manic-depressive
insanity. The mildest forms, those without motive or domi-
nant idea, and on this account called primary, are met with
in various forms of nervous and mental disease as well as in
childhood and old age.

VIII. ANOMALIES OF CONDUCT WITH ESPECIAL REFERENCE
TO THE SO-CALLED MORAL INSANITY.

Somewhat analogous to the anomalies of connected
thought which have been shown to be related to the develop-
ment of insane ideas are the various disturbances of the so-
called moral and ethical sense. In 1835 Pritchard in England
first suggested the term " moral insanity" to designate a not
very uncommon group of cases in which the acts of the pa-
tients are characterized at times by startling moral obliquities.
For some time these cases were regarded as forming a group
by themselves owing to the belief that they possessed many
characteristics in common. Long before Pritchard's time, how-
ever, this type of aberration had already attracted the atten-
tion of alienists, and excellent descriptions of it are to be
found in Pinel's writings under the head of mania without
delirium, or, as Esquirol called it, the affective or instinctive
monomania. The attitude of the English alienist in the study
of the problems suggested by these cases was largely the
result of the psychology of the day, which taught that the
division of the brain functions was tripartite, and that each
of these was characterized by more or less independence, so
that one group of phenomena in the realm of thought, feeling,
or volition might be seriously interfered with without causing
a disturbance of the others. The Scotch and French schools
of philosophy had also inculcated the belief in the existence
of a definite and distinct " moral sense" that was capable of
distinguishing between good and bad, just as the touch differ-

120 PSYCHIATRY

entiates between heat and cold or the eye between black and
white. Owing to the study of cases en masse and the influence
of this scholastic type of psychology, it became customary to
speak of the ethical and moral lapses of individuals as if they
were to be regarded as isolated defects of the higher cortical
functions. Gradually, however, physiologists not only suc-
ceeded in analyzing the sensorial processes, but were also able
to show that all the cerebral functions were composite. In
the light of these investigations, the term " moral insanity"
came to be looked' upon merely as satisfying a provisional
requirement to designate a certain large group of heterogene-
ous cases. At the same time, its introduction into psychiatrical
literature was of historical significance, inasmuch as it
amounted to a tacit assent to the proposition that the behavior
of an individual was merely an expression of the functional
activity of the central nervous system, and that in the ultimate
analysis it could be shown that " men's characters must be in
part determined by their visceral structure."

The phenomena concerned in the study of human conduct
cannot be thought out by the metaphysician, nor is any reason-
able person willing to admit that the categorical imperative,
or " the still, small voice of conscience," are any longer to be
regarded as satisfactory explanations for the behavior of an
individual. Only as the result of patient, painstaking obser-
vation are we gradually getting some clue to the motives and
agencies which are at work in determining the simplest acts
of an individual, and a few guiding principles have already
been laid down that are of use in directing the inquiry con-
cerning the more complicated volitional processes. These in-
quiries necessarily relate to the nature and development of
individual character and by the laity are supposed to deal with
the cases which are referred to as occupying the boundary line
between sanity and insanity. As a matter of fact, such inter-
mediate stages never exist. An individual is either normal
or abnormal, well or ill; and to suppose that intermediate
stages exist is merely playing upon words.

As certain phases of this problem are considered else-

ANOMALIES OF CONDUCT

121

where in this book, we propose to confine the present discus-
sion to those cases in which the element of choice and delib-
eration seems to be an important factor in conditioning the
behavior of an individual. We may, therefore, exclude at
once all those cases in which the acts of an individual are
merely the result of chance impulses or obsessions, such as
the impulsivity that is so common in the dream states of
hysterical or epileptic conditions, in the early stages of de-
mentia prsecox, or in other psychoses. It is a curious com-
ment upon the looseness and illogical character of human
reasoning, that while an individual is exculpated for a crime
when it is proved beyond doubt that he has been acting merely
as the result of a blind impulse, the plea of insanity may not
be entered when an act is the result of an apparent deliberation
or choice. Suppose, for example, that a crime has been com-
mitted by a man who possibly for months has deliberated upon
a plan of action and has finally selected the one best adapted
to some foul end and where no evidence will be left behind
which will incriminate him. Such an individual undoubtedly,
in a certain sense, indicates more plainly than does the person
who is actuated by mere impulse that his cerebral processes
are deficient and that he can neither think nor act up to the
current standards by which conduct is judged. For physiology
teaches us that only individuals possessing the most complete
functioning of the higher centres are capable of successfully
inhibiting many morbid tendencies of thought or action.

One duty of the alienist, therefore, is to attempt by the
aid of careful investigation to throw light upon the biological
factors conditioning the determinism upon which the conduct
of individuals depends. Here we have to distinguish between
the influence exerted by personal characteristics, inherent ten-
dencies and traits, and the determinism that is the product of
environmental agents. A sharp distinction can not, however,
always be drawn between the two, and, furthermore, this
problem necessarily involves the discussion of those complex
phenomena of heredity to which reference is made elsewhere.
In addition to the more remote factors that determine the

I22 PSYCHIATRY

behavior of individuals, the clinician has to consider those
that act more directly and that for want of a better term may
be called the immediate provocative agents. Such, for exam-
ple, are the physical changes that occur daily, or even hourly,
in the individual, so that he becomes responsive to certain
forms of stimuli which at another time would produce little,
if any, positive reaction. At present investigations carried on
in the clinic with a view to attempting the solution of this and
similar problems are largely casuistical in form. Neverthe-
less, much important information may be gathered from stud-
ies of this nature.

In taking up the question of individual behavior, then, we
have from a purely practical stand-point to consider all the
events or conditions that influence connected thinking, delib-
eration, choice, and finally the act or series of acts which may
be regarded as the culmination of these processes. Of course,
they are not to be regarded as separate and distinct, but are
merely designated empirically by the terms referred to in
order to facilitate description. Certain phases of this question
have already been discussed when dealing with the volitional
processes. Naturally, each case must be studied on its merits ;
but, broadly speaking, the higher the intellectual type, the more
complicated the processes of conception, deliberation, and
choice.

In order to arrive at any real understanding of the be-
havior of individuals it is essential to become familiar with
the slight anomalies in conduct which so frequently come under
the observation of the physician and in which the complexity
of the phenomena concerned is not so great as to baffle analy-
sis. Let us consider for an instant the possible approaches
that may be made to the study of the conduct of an individual
who is imbued with the spirit of pessimism. Under this term
may be grouped together all those philosophical views which
affirm that suffering and pain more than counterbalance the
sum total of life's pleasures and happinesses. Certain forms of
pessimism find their immediate expression not only in the
countenance but also in the acts of an individual. If we at-

ANOMALIES OF CONDUCT I23

tempt to analyze the physical condition which underlies this
view of life, it is possible to bring to light a number of facts
which will have an important bearing upon the mental atti-
tude of the individual who entertains these ideas. In certain
forms of pessimism it is at once noticeable that there is con-
siderable impairment of the volitional processes, and individ-
uals so afflicted give expression in one way or another to the
subjective sense of insufficiency and abulia. They not infre-
quently spend their time in lamentation. It is easier for them
to cry out that " all is vanity and vexation of the spirit" than
it is to act. Kowalewsky 67 has gone so far as to affirm that
the asymmetry in the relation of the pleasure and pain func-
tions that exists in pessimistic individuals is the underlying
cause which determines their views. Such observations can
frequently be confirmed in the clinic by the study of the large
group of neurasthenic individuals who, when subjected to any
additional strain, are immediately thrown into a state in which
anxiety, apprehensiveness, and mental depression become dom-
inant factors in the symptomatology. In the more severe
cases a more or less complete change in the whole personality
follows. Another important factor in the genesis of these
conditions, where the volitional processes seem to be more
or less interfered with, is the tendency exhibited by such indi-
viduals to excessive mental rumination.68 Up to a certain
point the judgment and critical faculties are well preserved,
but, as Maudsley long ago pointed out, action seems to be
blocked by the tendency exhibited by men even of great intel-
lectual capacity to expend their energies in introspection or
in the minute analyses of certain trains of thought. A classic
example of such a type is that portrayed in Hamlet. In the
transition from the socially disposed pessimist to the misan-
thrope we can trace a gradual unbroken line, as we can be-
tween the latter and the extreme anarchist. The different links
in the chain may be filled in by careful clinical study.

07 Kowalewsky : Studien zur Psychologie des Pessimismus. Wiesbaden,
1904.

88 La Logique morbide. L'analyse mentale. N. Vaschide, Paris, 1903.

124

PSYCHIATRY

Similar methods of investigation are also applicable to
a variety of other conditions. In a study of criminality, just
as in a study of psychiatry, progress has undoubtedly been
delayed at times by the excessive zeal exhibited by a few
observers in their desire to pick out and formulate definite
types which they would judge by purely arbitrary standards.
Imbued with this idea, Lombroso attempted to create a special
class, as it were, which was to comprise all the various types
of criminals. In a measure these delinquents were supposed
to be fundamentally different from the normal man, and were
remarkable not only for their vices but for the anomalies in
physical structure which were supposed to be more or less
distinctive. Undoubtedly, such a view is too extreme to be
accepted literally. In studying these delinquents such a great
variety of factors must be taken into account that it becomes
impossible, except in a very general way, to find characteristics
that in the main are distinctive. Nevertheless, alienists and leg-
islators have come to recognize a class of individuals — incor-
rigible recidivists, predestined to lead lives of violence and
crime — as presenting the characteristics of Lombroso's de-
linquent. As a rule, these unfortunates present considerable
mental impairment along certain lines; they are subject to
vicious impulses and are apt to be completely deficient in sym-
pathy and altruistic qualities. Ferri has divided them into
the following categories : ( i ) those with impaired intelligence
and bad congenital tendencies; (2) those in whom the in-
tellectual faculties are less involved, but who are signally ad-
dicted to debauchery, vagabondage, and crime; (3) those
who are unable to persevere in any serious occupation during
life, who show deliberateness in the manner in which they
act, but who seem incapable of resisting the vicious impulses
to which they are frequently subject.

Nacke 69 has suggested the following provisional classifi-
cation of individuals in whom anomalies of conduct are pro-
nounced: (1) imbeciles; (2) those in whom the moral and

" Nacke, P. : Ueber die sogenannte Moral Insanity. Wiesbaden, 1902.

ANOMALIES OF CONDUCT I2c

ethical defects appear cyclically; (3) the so-called psychic
degenerates (in the sense in which Magnan employs the
term). Koch70 affirms that the moral defects are a sign of
congenital psychopathic degeneracy, and would differentiate an
active and a passive form. Brunet recognizes three grades :
moral idiocy, moral imbecility, and moral debility. The classi-
fication, however, is of relatively less importance than the
study of the symptomatology of the individual cases and the
methods to be adopted in studying such individuals.

Whether cases of so-called moral insanity occur without
accompanying intellectual defects is a much debated question.
Some observers affirm positively that cases of marked defects
in the ethical and moral sense are frequently noted without
demonstrable changes in the intellectual spheres, but an equal
number hold a contrary view. The difficulty arises in deter-
mining what type of anomaly shall be classified under the
head of an intellectual defect. The whole controversy, un-
doubtedly, is a survival of the idea that the functions of the
brain were more or less isolated and that one field might be
invaded without seriously interfering with the mental phe-
nomena of another. It would scarcely exist if the merely
relative character of the phraseology were more generally
recognized and greater attention were paid to the study of
individual cases. Unquestionably, instances occur in which the
most prominent anomalies are in the emotional reactions and
where impulsivity may be marked, although a casual investi-
gation fails to demonstrate the existence of any mental im-
pairment. Such cases should be described sufficiently at length
to permit whoever reads the record, and has sufficient medical
knowledge, to form his own opinion.

Schultze sees in these cases no evidence of general mental
impairment or feeble-mindedness, but attempts to explain the
phenomena as an evidence of a psychic degeneracy which
renders the individual unable to modify the automatic ego-
istic instincts sufficiently to permit of the development of any

70 Die psychopatischen Minderwerthigkeiten. Ravensburg, 1893.

126 PSYCHIATRY

altruistic feelings. According to this view, the personal in-
terests are so strong that the individual is unable to detach
himself sufficiently from what immediately concerns himself
to develop an interest in any action with which he himself is
not more or less directly connected. Such an hypothesis,
however, assumes that the disturbances of function must be
exceedingly complex and accompanied by serious interference
with the more complicated forms of associative memory.
Others find in the emotional instability belonging to moral
insanity an exemplification of the condition which Wernicke
describes as the levelling off of ideas. Such individuals are
more or less neurotic, exhibit some degree of unrest as well
as an instability of the emotional life. In dealing with these
cases, as in other forms of alienation, it must not be forgotten
that the original defect in function, although sometimes com-
paratively slight, may give rise to a disturbance which is to
be regarded as a cumulative one. Numerous observers have
demonstrated that a relatively insignificant mental defect may
be followed by a considerable degree of so-called moral de-
generacy. According to Thulie, most of the youthful crimi-
nals may be classed among the " higher degenerates" —
desequilibres, or those described as being instinctively vicious.

CHAPTER IV

THE METHOD OF EXAMINATION OF PATIENTS, INCLUDING
EXAMINATION OF THE CEREBROSPINAL FLUID 1

Whenever the alienist is called upon to examine a patient
he has a three-fold duty to perform. In the first place, to
determine whether or not the individual is suffering from any
form of illness. If this question is decided in the affirmative, it
then becomes necessary to find out if possible the causes which
have been instrumental in bringing about the illness or that
favor its development and continuance, as well as all other
factors bearing upon the case, in order to determine upon a
thoroughly rational course of treatment. And, finally, he
must endeavor to study every case that comes under his obser-
vation with such care and accuracy as to bring to light any
new facts, no matter how trivial they may at first sight appear,
that will lead to a more comprehensive knowledge of mental
disorders. These results can only be obtained by adopting those
measures which are necessary to cultivate and train the facul-
ties of patient and accurate observation. Those who appreciate
how difficult it is to obtain careful records in the cases of so-
called physical disorders will appreciate the still greater difficul-
ties which exist in the examination of those who are afflicted
with alienation. The reasons for this are, in the first place, the
absence of symptoms which can in any sense be regarded as
pathognomonic and the fact that the alienist at present is deal-
ing not with definite disease entities, but simply with groups of
symptoms. One of the first difficulties to the more complete
and thorough examination of patients will be removed when
we possess a supply of men who are not only trained in clinical
observation, but who are capable of recording the results of
their investigations in simple, direct expression. Unfortu-

1 Sommer, R. : Lehrbuch der psychopatholog. Untersuchungsme-
thoden. Berlin, Wien, 1899. Fuhrmann, M. : Diagnostik u. Geisteskrank-
heiten. Leipzig, 1903.

127

128 PSYCHIATRY

nately, a great deal of the clinical phraseology has a specific
meaning attached to it, and clinicians have too frequently
yielded to the temptation to abbreviate and to substitute terms
which have a relative significance for simple detailed descrip-
tions of cases. The taking of records on especially constructed
charts on which a list of symptoms is printed, the observer being
expected to state categorically whether such a given symptom
is or is not present, is a most pernicious practice, because, other
things being equal, the employment of such charts generally
indicates that those who are to take the clinical histories have
not been sufficiently drilled in the methodical examination of
patients. Psychiatry has passed through the era when it was con-
sidered sufficient to study cases en masse, and everything should
be done in order to encourage the careful, detailed observation
of every individual patient. During the conduct of the clinical
examination it should always be borne in mind that the whole
personality of the individual is more or less involved. Mental
disorders are not merely brain diseases with localized disturb-
ances of function, and we must be continually on our guard lest
we gradually fall into the habit of seizing upon certain symp-
toms or certain phases of the disease, while others are ignored.
In cases of mental disorder more than in others there always
exists a strong tendency, which must be continually combated,
to make the clinical picture fit some arbitrarily constructed
frame.

Anamnesis. — Family History. — Only very rarely is it
possible to obtain from the family history sufficient data to
justify any deductions that have any immediate bearing upon
the problems of heredity. Nevertheless, in the majority of
cases we shall be able to gain from such an inquiry a fairly
good idea with regard to the environment in which the indi-
vidual has been living. If alienation is found to have existed
in a patient's family, we should find out whether it was a
progenitor, a descendant, or a collateral that was affected, what
was the probable cause of the trouble, and the age and environ-
ment of the individual in whom the disorder made its appear-
ance. If possible, a sufficient number of facts should be recorded

EXAMINATION OF PATIENTS 1 29

to enable any one who subsequently reads the history to form
his own opinion as to the medical character of the malady. If
the occurrence of pronounced mental alienation is not admitted,
we should search for any symptoms of mental deterioration or
degeneracy — suicide, alcoholism, eccentricities of character, and
the like — that would indicate the existence of functional dis-
orders. Some light may also be obtained from definite data
concerning the causes of death in the cases of various members
of the family — apoplexy, convulsions, tuberculosis, Bright's
disease, etc.

Regarding the parents of the individual, it is important to
note whether they were blood relatives; whether one or both
were alcoholics ; whether there was any marked discrepancy in
their ages, and so on. The question of lues in the parents must
always be kept in mind, but of necessity, although searching, our
inquiries must be made cautiously. When direct questions can
not be put, or when put can not be answered, we should try to
find out whether there has been a history of skin eruptions, sore
throat, falling out of the hair, rheumatic pains, bone diseases,
frequent miscarriages on the part of the mother, etc., as such
points, even when not conclusive, have always a certain signifi-
cance, the importance of which should be carefully weighed.
Information regarding the social and intellectual status of the
family and whether there have been any sudden changes in
these conditions is also of importance. As has already been
pointed out, a sudden change in the social status of a family,
such as that following the sudden acquirement of great wealth,
or the sudden transformation that sometimes follows the relin-
quishing of manual for intellectual pursuits, is often, particu-
larly in this country, accompanied by the appearance of nervous
or mental disease.

Personal History: Infancy and Childhood. — This should
begin with questions regarding the condition of the mother
during pregnancy, especially, did she suffer from nephritis, any
acute infectious disease, trauma, mental shock, or sudden change
in her mode of life? Following this an attempt should be made
to ascertain the conditions under which birth occurred — whether

9

130

PSYCHIATRY

at full term or prematurely, whether it was normal, protracted,
or instrumental, and the apparent effects upon the child. What
infectious diseases or trauma occurred during the early years
of infancy? Such incidents should be noted, and we should
attempt to determine whether or no there was any subsequent
impairment in the mental or physical development of the child.
If a history of convulsions be obtained, their probable cause,
duration, and frequency should be recorded as well as the na-
ture of any paralyses that may have followed. At what age
teething began and whether the process was accompanied by
any unfavorable signs ; at what age the child learned to walk
or speak; the severity, duration, and sequelae of the so-called
children's diseases, should all be made the subject of particular
inquiry. The signs of rickets should be carefully distinguished,
and a full note be made, if possible, upon the mental traits of
the child — as to its impressionability, nervousness, fears, way-
wardness, temper, and whether it had to be treated differently
from other children. The age at which schooling began and
the progress made should be stated.

Puberty. — The mental and physical state of the patient
prior to the onset of puberty having been recorded with as great
detail as possible, a note of contrast as to the changes that may
have taken place at this critical epoch- should follow. Was the
mental and physical development precocious, delayed, or in any
way abnormal? Particularly important at this stage are the
eccentricities of character. In girls the age at which the menses
appeared should be noted, as well as such attendant circum-
stances as anaemia, nervousness, pain, signs of mental depres-
sion, hypochondriasis, and an excessive exhibition of religious
conviction.

Continuing, the development of the individual, both physi-
cal and mental, should be traced, and any instances of impair-
ment of the physical vigor should be cited, particularly the
occurrence of an attack of any infectious disease — such as
typhoid fever, pneumonia, malaria, meningitis, gastro-intestinal
disturbances, — as well as of any constitutional diseases —
syphilis, tuberculosis, — and any of the various functional dis-

EXAMINATION OF PATIENTS I3I

orders — hysteria, hypochondriasis, epilepsy. What were ap-
parently the immediate and remote effects upon the individual ?
In febrile disorders the occurrence of delirium or convulsions
or mental disorders may have an important bearing on the sub-
sequent history. If trauma or an attack of some disease is
recorded, the facts should be given with sufficient detail in the
history to enable a reader to determine for himself whether this
factor is to be considered of importance in relation to subse-
quent events in the life of the individual. Personal idiosyn-
crasies, the evidences of a neuropathic constitution, — such as
marked fluctuations in the emotional life, a tendency towards
excessive blushing, palpitation, attacks of nervousness with
apprehension and fear, excessive morbidity, intolerance for
alcoholic beverages, mental irritability, as well as an inability
to bear pain or mental distress, — should be recorded.

The emotional life of the individual should be carefully
investigated and the attempt made to determine whether fluc-
tuations in it apparently became more or less marked after
puberty or whether a marked indifference to higher interests
and a loss of an altruistic spirit developed. Was there any
tendency shown towards the formation of marked antipathies
either for persons or objects? Was such a condition dependent
upon the result of chance impulses or did it develop slowly
from what were first groundless and fleeting suspicions but
later were transformed into definitely crystallized and fixed
ideas ? The individual's general view of life, characterized by
excessive optimism or pessimism, and any apparent lack of
ability to adapt himself to his surroundings should be explicitly
described. As the individual became older the cropping up
of personal eccentricities, an exaggerated egotism, and an
abnormal tenacity of personal views on social, political, or
religious questions, the quality of temperament indicative of a
phlegmatic, apathetic, excessively ambitious, or jealous nature,
deserve attention. An attempt should be made to determine
whether all the faculties were developed harmoniously or
whether intellectual progress took place along certain limited
lines. If the individual showed remarkable attainments in one

132

PSYCHIATRY

direction, were there corresponding defects in others? Of
what nature were his social relationships, particularly regard-
ing- the members of the immediate family ? In the examination
of women particular attention should be paid to the slight
anomalies of the mental functions that may be associated with
the menses. Was there an increase of nervousness, or any
degree of mental depression? The same points are of im-
portance in connection with pregnancy and the climacterium.
At what period did the mental anomalies first make their
appearance, and what was their character?

Present Illness. — Causes. — When possible it is desirable
to establish a more or less definite date at which the patient was
last said to have been in " good health," and then to trace, as
logically and connectedly as possible, the development of the
symptoms from that time on until the moment that he first came
under observation. From the information obtained it will be
noted whether the present illness is the first attack of alienation
or represents merely a recurrence of symptoms that have been
noted in other periods of life.

The primary operative causes must be sought for and the
character of the symptoms, their course and development, de-
termined, as well as the sudden or gradual appearance of the
alienation. All the physical ailments should be carefully noted
in as minute detail as if an examination were being made in a
case of typhoid fever or pneumonia, after which particular
attention should be paid to all the mental symptoms, anomalies
of memory, impaired intellectual capacity, a diminished or ex-
cessive feeling of fatigue, fluctuations in the emotional life,
changes of character, moral defects, psychic painful states or
depression, fear, intellectual and physical disquietude, pes-
simism, excessive optimism, reticence or loquaciousness, dream
states, the " wandering manias," any tendency towards extrava-
gance and a reckless plunging into new undertakings without
waiting to count the cost, and any other evidences of mental
peculiarities. The appearance of imperative processes, halluci-
nations, delusions, ideas of reference, insane ideas and their
apparent influence upon the conduct of the individual, should be

EXAMINATION OF PATIENTS I33

recorded. The apparent relationships between the mental and
physical disturbances should be sought for and noted. What
effect did these anomalies in mental activity have upon sleep,
upon the weight of the individual, upon the secretory or the
excretory functions? When a full history of the individual
symptoms has been obtained the attempt must be made to show
whether the course of the malady has been continuous, inter-
mittent, or remittent, and if the relation of the various symp-
toms to each other has been constant or changing.

Status Prcesens. — When the individual is not greatly ex-
cited the physical examination is usually undertaken as soon as
the history has been completed. But when the motor restless-
ness is very great, or if for some other reason a thorough exami-
nation is contraindicated at the time of admission, it is always
not only possible but most important to make a careful note
upon the mental state of the patient according to the methods
to be referred to presently. The physical examination should
be as complete as that made upon patients in the best general
hospitals, into the details of which it is not necessary to go at
present. In regard to the observation of the physical symptoms
the following points should be noted, although no hard and fast
scheme should be adopted (vide Lehrbuch der Psychiatrie, v.
Krafft-Ebing, Wien, 1904, p. 243). The measurement of the
skull along a line just above the external occipital protuberance
and glabella should always be taken. Although the normal for
men is 55 centimetres, and for women 53 centimetres, variations
within certain limits are not uncommon, and for practical pur-
poses all skulls whose circumference does not fall below 48 or
exceed 56 may be considered normal. The ordinary distance
between the extreme lateral points of the skull measured by
means of the calipers is between 14 and 15 centimetres. Other
signs of physical degeneracy are to be looked for in connection
with the

( 1 ) Eyes: Rhombo-, lepto-, and clino-cephalus. Retinitis
pigmentosa, coloboma iridis, albinism, unequal pigmentation
of the iris, congenital strabismus.

(2) Nose: Any unusual prominence or malformation of

134

PSYCHIATRY

the nose; e.g., the thickening of the lateral roots noted in
myxcedema and cretinism.

(3) Ears: Morel's ear, smooth helix ; the Darwinian ear,
satyr-shaped with prominent tubercles; Wildermuth's ear, in
which the antihelix is proportionately much larger than the
helix.

(4) Teeth: Total or partial defect in secondary dentition ;
abnormal position of the teeth.

(5) Mouth and gums: Excessively small or large gums,
as well as anomalies of the hard and soft palate.

(6) Skeleton and extremities: Signs of dwarfism, club-
foot, club-hand, unequal development of the hand, supernumer-
ary hand, unequal development of the fingers and toes.

(7) Genitalia : Cryptorchia, epispadias, hypospadias or
hermaphrodism, uterus infantilis, uterus bicornis, phimosis or
lengthening and hypertrophy of the fore-skin.

(8) Hair: Sparsity or occurrence of hair in abnormal
locations.

After this follows the examination of the higher sensory
organs, the eye and ear, for which the ophthalmoscope and
otoscope render important aid.

Sensibility: Hyperesthesias, anaesthesias, and paresthe-
sias, neuralgias, reactions to the assthesiometer needle, electrical
current, heat and cold.

Cutaneous and deep reflexes.

Motor functions: Facial innervation, mydriasis, myosis,
unevenness of the pupils, reaction of the iris to atropin or
cocain, nystagmus, strabismus, paralysis of the eye muscles,
ptosis, speech, aphasia, ataxia, glossoplegia, tremor, paresis, dis-
turbances of sphincters, catalepsy, and muscular contractions.

Secretory functions: Salivation, excessive sweating, uni-
lateral or general. Examination of urine.

Trophic disturbances of the skin: Perforating ulcers, etc.

Testing the Mental State. — The method of examination
of the mental faculties that should be employed in whole or in
part as soon as the patient enters the hospital will now be de-
scribed. In a private household it is often impossible to con-

EXAMINATION OF PATIENTS 135

duct an examination which is thorough and satisfactory, and
even in institutions the method employed must be frequently
modified to meet the exigencies of the case.

As soon as the patient is brought to the hospital he should
at once be taken in charge by one of the resident physicians,
and as complete a record as possible of all objective symptoms
should be made within an hour or two after his admission.
Unfortunately, a failure to appreciate the necessity of recording
the symptoms as they arise often leaves us with a report that
the patient was in too excited a condition to be examined, and
as a consequence no notes are made upon the case until the
individual has become somewhat accustomed to his surround-
ings and has quieted down. When such a course is followed
many valuable details may be overlooked and forgotten, and
it must be insisted that in many instances the manner in which
the individual reacts to his new environment — especially the
presence or absence of any attempt to try to adjust his conduct
so as to meet the new conditions — is of vital importance. To
facilitate the description of the examination the patients will
be divided into two main classes, — (A) those who can not or
will not respond to questions; (B) those who are able and
willing to do so.

(A) In dream-like and stuporous states the examiner
should make an accurate record of the effect produced by ex-
ternal stimulation. Although consciousness may be so dull
that all evidences of mentality are absent, if the individual is
pricked with a needle or touched with a hot or cold object, a
visible reaction, such as a slight change of position or of the
facial expression, an increase of the rapidity of the pulse or
respiration, not infrequently follows.

In many instances the failure to respond to questions is
due to excitement. This is true for the various manic states
such as occur in alcoholism, manic-depressive insanity, dementia
prsecox, epilepsy, and a variety of other conditions. When such
is the case the examiner should describe as accurately but as
tersely as possible the general appearance and conduct of the
individual. The effects of external stimulation should be

136 PSYCHIATRY

noted : whether it tends or does not tend to increase the excite-
ment, or whether the patient is so absorbed in his own acts and
thoughts that he is utterly oblivious to his surroundings. Not in-
frequently at first sight an individual fails to respond to external
stimuli, and yet on a more careful examination it will be noticed
that when he is spoken to or stimulated in any way there is an
increase in the excitement, although there may be no evidence
of distractibility. In such instances the individual, if he be
talking or shouting, when addressed only talks and shouts the
louder, and the intensity of the general motor restlessness is
increased. In some stages of catatonic excitement, however,
although the individual may be exceedingly uproarious and
boisterous, external stimulation seems to have little, if any,
effect in increasing the intensity of the reactions. In noting
the general appearance and character of the actions it is very
important to determine whether there is any correspondence
between the ideas which flash through the patient's mind and
the visible facial, gestural, or postural reactions. Thus, in an
individual who is aggressive, uproarious, or furious, does the
facial expression or what the patient says in any measure corre-
spond with the visible reaction, or does each act seem to be the
result of purely dissociated and fleeting impulses? In this, as
in all other descriptions, the use of technical terms should be
scrupulously avoided in the main text, although they may be
retained as marginal notes or in a summary of a detailed
description.

If the individual is able to utter intelligent sounds, the
character of the speech should be carefully noted : (a) Its neu-
rological features. Is there a tendency towards the slurring of
syllables, any dropping of words or scanning? (b) The con-
tent of what is said may either be taken down in shorthand by a
stenographer or, better yet, by means of a large phonograph,
from which transcription can be made later. In some in-
stances, however, the excitement of the individual is so great
that by neither method is it possible to get a full report of what
is said. If the speech is incoherent, particular attention should
be paid to the expressions used, to determine ( I ) whether cer-

EXAMINATION OF PATIENTS 137

tain words or syllables are constantly repeated (stereotyped
iteration) ; (2) whether the patient uses a great variety of
new words (neologismus) or whether there is an evident in-
clination to resort to diminutives, doubling of the words, onoma-
topoietic expressions and disfigurement of speech.2 Sometimes
when the stereotypy of speech is marked many words begin
with a prolonged hissing sound, as if the patient were about to
stammer, and the word is then pronounced with a marked ex-
plosiveness. (3) Notes should be made upon the apparent rela-
tion of the words used to the ideas expressed. Patients
afflicted with dementia praecox will frequently give utterance
to several sentences grammatically formed and logically ex-
pressed, and then several words which bear no reference to
what has preceded are suddenly interjected. The rhetoric should
be described, especially if the patient has any tendency to express
himself in a bombastic or egotistical manner. In excited
patients it is important to determine whether the flight of ideas
(Ideenflucht, Fuite des idees) is present, in which case the asso-
ciation of ideas is clearly merely superficial, indicating that the
patient has little selective or critical power left, and the flow of
words has no definite end in view, being merely the result of
hap-hazard impulses due to internal or external stimulation.
The words used apparently suggest sound associations or
alliterations, and when the true manic condition exists the ideas
expressed indicate exhilaration and exaltation.

As regards the content of what is said, it is important to
note (1) whether there is any suggestion made as to the ex-
istence of hallucinations or insane ideas; (2) any tendency to
confabulate or indulge in pseudoreminiscences (pseudologia
fantastica).

It is further important to determine whether the logor-
rhcea is affected by external sensory stimuli or whether it is
merely the product of ideas which keep flashing through the
patient's mind. In the former case it will be noted that sensory

1 Sante de Sanctis. Intorno alia psicopatologia dei neologismi. An-
nali di nevrologia, xx, p. 597.

138 PSYCHIATRY

impressions, visual, auditory, or others, immediately deflect or
disturb the patient's attention. When the excitement is greatest
this effect may only be manifested by an increase in the intensity
of the speech reaction without any deviation in the flow of ideas.
In other cases, however, the effect of the incident visual and
auditory stimuli becomes at once apparent, since the patient
refers directly or indirectly to what has been heard or seen.
In many instances the attention is so riveted upon the delusions
or hallucinations of which he is the subject that the patient is
unable to respond to questions. In many cases the effects that
these phenomena have are immediately reflected in the physiog-
nomy or general action of the patient. Hence an accurate
description of the facial expression is of great importance. Is
the individual sad, depressed, and, if so, is it shown by the
wrinkling of the forehead, the glassy appearance of the eyes, the
absence of tears, the drooping of the corners of the mouth ? Or
if anxiety, apprehensiveness, mistrust or actual suspicion, list-
lessness and apathy, exhilaration and exaltation, pride or arro-
gance, are present, what objective expressions of these are
reflected in the facial reactions or general attitude of the
individual? In addition to the physiognomy and actions of
the patient attention should be paid to the character of his dress
or toilet, both of which frequently throw some light upon the
mental state, the maniacal patient frequently exhibiting a ten-
dency to deck himself in gaudy colors, to exhibit theatrical
mannerisms and eccentricities in dress, whereas other indi-
viduals are unmindful and neglectful of their personal attire as
well as their individual needs. The mannerisms of the indi-
vidual are important, and any tendency towards the repetition
of stereotyped movements or phrases should at once be noted.
If the patient shows a tendency to strike dramatic attitudes or to
pose, the attempt should at once be made to ascertain whether
there is a definite motive in consciousness for such an act, or
whether it is merely the result of chance impulse or stereotyped
repetitions.

The occurrence of negativism is an important symptom.
When well marked it may be easily recognized, but it is often

EXAMINATION OF PATIENTS 139

very difficult to positively affirm that the individual is nega-
tivistic and not actuated by the presence of fallacious sense per-
ceptions or insane ideas. The negativistic patient does just the
opposite of what a rational individual would do under the
same circumstances. The appearance of an emotional storm
would indicate that the conduct is actuated by the appearance
in consciousness of some idea and that the case is not one of
pure negativism. In extreme cases the patient refuses food,
and any form of external stimulation seems to start up reflexly
this silly, unmotived resistance. Patients in this condition
seldom, if ever, speak, or their speech is monosyllabic or limited
to a few disconnected words. If an attempt is made to flex or
extend a limb, to turn the head or open the eyes, the patient at
once becomes resistive. Where the symptoms are not so in-
tense, it will be noticed that a request to raise an arm or a leg
or to close one eye may result in some movement, but generally
not the one asked for (parapraxia). The so-called flexibilitas
cerea is seen in a variety of conditions.

If automatism is present, when passive movements are
made as soon as the examiner relaxes his hold of the patient's
limb the movements are continued automatically. To be dis-
tinguished from simple automatism is command automatism,
in which a patient is compelled to execute unpleasant or un-
welcome movements or is prevented from making normal de-
fensive movements when variously threatened. This condition
is probably the result of a paresis of volition occurring largely
in catatonics. These conditions are frequently noted in cata-
tonic as well as in hypnotic dream states. The general appear-
ance of patients who are in this cataleptic condition is more or
less characteristic and should be described. The face is ex-
pressionless, the eyes have a vacant stare. Mutism exists and
the volitional movements are reduced to a minimum. The
tendency for movements, when once initiated, to persevere may
be noted in cases of catatonia. If the patient is asked to touch
the tip of his nose with the finger, several seconds may elapse
before the request is complied with, but when the movement
has once been begun it continues whenever the patient is stimu-

140

PSYCHIATRY

lated, no matter if a totally different request has been made.
The stereotyped automatic movements of the catatonic indi-
vidual are highly characteristic and essentially different from
those of the patients who are actuated by definite ideas. Some
catatonic patients will never enter a room without walking along
one line in the carpet, or will sit and play solitaire by the hour in
an automatic way, making the same mistakes and always going
through the same movements. The mannerisms are particu-
larly noticeable when such individuals feed themselves or make
the attempt to dress. Some patients will sit by the hour turning
their heads from side to side in a rhythmic, stereotyped manner.
Even the movements of respiration seem to be affected, and at
intervals of a few seconds the patient will take a long breath
followed by sighing expiration. Sometimes echopraxia corre-
sponding with echolalia occurs.

(B) When the individual is both able and willing to reply
to questions, after the objective symptoms which are apparent
on superficial examination have been noted, a more detailed
examination of the mental condition is made. The manner in
which the patient replies to questions should be described. In
the first place, a considerable interval may elapse from the time
the question is put before any visible reaction signifies that the
sense of the interrogation has been apprehended. Such a delay
frequently occurs in states of depression, whereas in excitement
the reply is given with lightning-like rapidity. Sometimes, how-
ever, although the sense of the question seems to be quickly
apprehended, there may still be a pause — the result of delayed
reaction or psychomotor retardation. If the patient is under
the influence of an hallucination or an insane idea, the delay
may be purposeful. In many instances the patient must be very
carefully studied and all the evidence carefully weighed before
it is possible to determine with which one of the two conditions
we are dealing. The content of what is said should be recorded
as carefully as possible, and we should note whether or not the
patient has a tendency to be garrulous, to enter into great detail
in all his statements (circumstantiality), and whether or not
any marked degree of irrelevancy is present.

EXAMINATION OF PATIENTS

141

The emotional state, as reflected in the facial expression as
well as in other reactions, may be an important feature in the
case. The examiner should describe the facial expression,
whether it is apathetic, depressed, elated, etc., and then an at-
tempt should be made to determine if the visible reactions are or
are not in accord with the idea that occupies the patient's field of
consciousness. In stages of manic excitement the patient may be
angry, depressed, or joyful, and at once gives evidence of what
is passing before his mind. But it is eminently characteristic of
certain conditions that a marked dissociation between the idea
(noopsyche) and the visible reaction (thymopsyche) exists.

Many of the psychological tests suggested are too com-
plicated to be of value in the clinic. As a rule, we begin with a
note upon the patient's attention. Is it easily gained and, if so,
is it well maintained, or does it easily lapse and is there a great
degree of distractibility? If distractibility is present, it is well
to note whether it is produced by all incident stimuli or only
follows certain kinds. A very good simple clinical test for the
attention of educated individuals is the so-called " one-hundred
test." The individual who is being examined is asked to sub-
tract six or seven from one hundred and to continue the sub-
traction down to zero. Evidences of mental fatigue and dis-
tractibility can often be easily demonstrated by this simple
method. The functions of associative memory should then be
tested. This includes the power of picking up and retaining
impressions and the faculty of re-collecting and redeveloping
memory pictures referring to a more remote period in the past.
An excellent idea of the power of associative memory is ob-
tained by asking the patient to give an account of his present
illness and of the events in his past life which have any bearing
upon the condition. The tendency to indulge in pseudoreminis-
cences or to confabulate may become noticeable. In many
cases, although there is no positive defect in memory, a note
should be made as to whether the patient does or does not com-
plain of a subjective defect in recollection. In connection with
memory it is important to note whether the orientation of the
patient is impaired either in its spatial or time relations. Such

142

PSYCHIATRY

defects, as a rule, quickly become apparent when the individual
is asked a number of simple questions. How long have you
been in the hospital ? How long have you been ill ? Where is
the hospital situated? Where is your home? Closely associ-
ated with the sense of orientation is the so-called sense of
recognition, disturbances of which are not infrequently noted.
These may be transitory, as in conditions of neurasthenia and
epilepsy, or may be more permanent and occur in the states of
excitement in certain psychoses. The disorientation of the
patient may still further be conditioned by the occurrence of
either hallucinations or insane ideas and affect either the
somatopsychic, autopsychic, or allopsychic field of conscious-
ness.

The power of the individual to associate ideas may be
tested, either in reply to questions or by his voluntary conversa-
tion as well as by the writing, obtained. Simple tests may also
be used, such a one, for example, as that proposed by Fuhr-
mann. One hundred test words are printed on a slip and the
patient is told, as soon as a word is called off to him, to describe
the quality of the object named. The length of time that elapses
between the calling off of the word and the reply is noted. In
intelligent individuals it is estimated that from 95 to 100 per
cent, of the associations are correctly given. But when there
is a marked diminution in the intelligence or when the reactions
are greatly impaired the number falls below 70 per cent. ; and
when it is as low as 60 per cent, there can be no doubt that
a pathological condition exists. The quickness of the reaction
may be tested in a variety of different ways, by the chromo-
scope, for instance, although for all practical purposes the
various forms of apparatus, all of which are more or less com-
plicated, have little advantage over the simpler clinical tests.

The examiner should attempt to ascertain whether the
disturbances of the association are merely of a negative char-
acter or due to the cropping up in consciousness of autochtho-
nous ideas which are recognized by the individual as having
developed in some strange and unaccountable fashion. In
ideas of reference the individual often attributes to his own

EXAMINATION OF PATIENTS

H3

words or actions as well as to those of others an exaggerated
importance and tries to establish a relationship which does not
really exist. In dominant ideas the imperious character of the
idea overriding all other processes of association is a most
marked feature.

The examination in regard to the occurrence of hallucina-
tions or illusions is frequently beset with many difficulties, par-
ticularly as many patients are extremely sensitive and refuse to
admit their occurrence. Not uncommonly the examiner by
watching the actions of the patient may be led to infer that
definite hallucinations occur, and if such is the case, it is im-
portant to determine their nature: whether they are primary
or secondary in character and whether they seem to bear any
relation to defects in the sensory apparatus; whether their
subjectivity is marked and whether they are stable or mobile,
unilateral or bilateral. For the points to be noted in connection
with insane ideas and the other phenomena of alienation the
reader is referred to Chapter III.

Examination of the Cerebrospinal Fluid. — A complete ex-
amination of the cerebrospinal fluid includes a determination of
the character of the cellular and bacterial elements present as
well as of the physical and chemical qualities. Numerous
methods have been suggested for obtaining specimens, and
inasmuch as so many varying factors must be taken into account
in the examination of the fluid, it is essential that no precau-
tions should be omitted to prevent the occurrence of discrepan-
cies in the results of the observation. Recently Meyer 3 has
redirected attention to the necessity not only of carrying out
the procedure with the strictest aseptic precautions, but also of
observing certain rules in the examination of the fluid after its
withdrawal. He recommends the technique employed by
Sicard.4 At least 3 or 4 centimetres of the spinal fluid
are drawn off into a sterile tube and at once centrifugalized.

8 Meyer, Ernst : Ueber Cytodiagnostik. Untersuchung des Liquor
Cerebrospinalis. Berl. klin. Wchnschr., 1904, Feb. 1, Nr. 5, S. 105.

* Sicard and Monod : Examen histologique du liquide cephalo-
rachidien dans les meningo-myelites. Bull, de la soc. med. des Hop., 1901.

144

PSYCHIATRY

The French writers prefer to employ a centrifuge capable of
making 3000 revolutions and the process is completed in ten
minutes, but when the rotation is slower (2500 to the minute)
at least half an hour is necessary. The technique has been
described in detail by Nissl.5 After centrifugation is com-
pleted the fluid is carefully poured off into a reagent glass. A
glass pipette is then introduced into the tube so as not to touch
the sides and the substances on the bottom are carefully sucked
up. The contents of the pipette are then blown out again so
that a better mixture of all the elements may be obtained. The
second time the contents of the pipette are carefully blown out
on to three glass slides, care being taken that the drops be
equal in size. The slides after being allowed to dry in the air
are brought for half an hour into equal parts of absolute alcohol
and ether. For staining Unna's polychrome methylene-blue
solution is used, a few drops being allowed to remain on the
specimen for ten minutes, being then washed off with distilled
water; the slides are then passed through alcohol and xylol,
and the specimen is mounted in balsam with a thin cover-glass.
Ravaut 6 differentiates between a decided reaction (grosse
reaction) when from 20 to 150 cell elements are found in the
field of the oil immersion, a moderate reaction (reaction moy-
enne) when from 7 to 20, a suggestive reaction (reaction dis-
crete) when from 4 to 6, and a negative reaction (reaction
nulle) when only 2 or 3 lymphocytes occur in each field. Ac-
cording to Sicard, with a Leitz objective No. 7, giving a mag-
nification of from 300 to 400 times, the presence of 3 or 4
lymphocytes in the field may be regarded as normal. In some
pathological cases, however, a great increase in their number
is observed. In many instances the cells having a pale-blue
nucleus somewhat larger than that of the lymphocyte, with
granular masses in the body and showing a tendency to stain a
reddish tinge, are noted. Morphologically these elements re-

5 Die Bedeutung der Lumbalpunktion fur die Psychiatric Centralbl.
f. Nervenheilk. u. Psych., April, 1904.

* Le Liquide cephalorachidien des syphilitiques en periode secondaire.
Annales de Dermatologie et de Syphiligraphie, 4 serie, tome iv, p. 537.

EXAMINATION OF PATIENTS

145

semble mast-cells, and Meyer is inclined to regard them as
small mononuclear leucocytes. A lymphocytosis of varying
degrees has been noted in dementia paralytica, tabes, tuber-
culous meningitis, chronic alcoholism, and in all diseases in
which there is an involvement of the meninges. In some of
Nissl's cases polynuclear leucocytes were seen, but their signif-
icance is not clear. It is important to note that the cellular ele-
ments in the spinal fluid vary considerably, and that at the first
and second puncture it may be impossible to demonstrate the
presence of lymphocytes, whereas on a third occasion a num-
ber of cells may be found. The procedure is indicated in all
doubtful cases, especially when it is necessary to differ-
entiate between functional and organic disorders, although the
exact significance of the findings cannot as yet be clearly de-
fined.

For the estimation of the pressure of the spinal fluid many
methods of procedure have been employed, but the results
so far obtained do not permit of the formation of a definite
opinion. Considerable differences have been frequently noted
depending upon whether the patient occupies the recumbent
or the sitting posture. At present very little is known regard-
ing the secretion or circulation of the spinal fluid. As regards
the importance of the results to be obtained from chemical
analyses opinions vary widely. Thus Schaeffer holds that the
increase of albuminous constituents, so frequently noted, is
directly due to inflammatory changes in the meninges and not,
as others believe, the result of similar changes in the nervous
system in other parts of the body. For a detailed account of
the results of the chemical analyses the reader is referred to the
work of Guillain and Parant 7 as well as that of Coriat.8

7 Sur la presence d'albumines coagulables par la chaleur dans de liquide
cephalorachidien des paralytiques generaux. Revue Neurologique, No. 5,
30 Avril, 1903.

8 The Chemical Findings in the Cerebrospinal Fluid and Central Ner-
vous System in Various Mental Diseases. The American Journ. of In-
sanity, 1904, vol. lx, No. 4.

CHAPTER V

THE TREATMENT OF CASES OF ALIENATION 1

During the nineteenth century marvellous changes took
place in the methods of caring for and treating cases of
alienation. The removal of the insane from dungeons, through
the exertions of Pinel, marked the beginning of a new epoch
in psychiatry; but no less important was the second era, her-
alded by the introduction into psychiatry of modern clinical
methods and the establishment on the Continent of Europe, par-
ticularly in Germany, of fully equipped hospitals for the insane
closely affiliated with the universities. In the older institutions
the dominant idea in the plan of organization had regard merely
to the detention of the patients, and it is in this respect that the
modern hospital for the insane shows a radical divergence.
Within the last thirty years as remarkable a change has taken
place in the treatment of the insane as in the improvement of
surgical methods. Unfortunately, in institutions in the United
States, with few exceptions, the detention character is still
primary, and opportunities for successfully treating patients are
still few and incomplete, inasmuch as the existing organization
and imperfect equipment do not make it possible to give them
the benefit of the best medical skill. Nor will this defect be
remedied until we in this country have learned to appreciate that
proficiency in psychiatry can be obtained only in institutions in
which the interest of the alienist in his profession is kept alive
by abundant facilities for study and his energy is stimulated by
the presence of students for whose training he is responsible.
The establishment of psychiatrical hospitals in close proximity
to other university clinics affords the only possible solution of
the fundamental problems with which we are now confronted.

1 A System of Physiologic Therapeutics, vol. viii — Rest ; Mental
Therapeutics — Suggestion, by Francis X. Dercum. Phila., 1903. Gastpar,
A. : Die Behandlung Geisteskranker. Stuttgart, 1903.

146

GENERAL TREATMENT I47

Among the manifold advantages to be obtained in this way-
two are deserving of special mention here: (i) only in this
way can we command a supply of alienists thoroughly com-
petent to practise and teach their specialty; (2) only when
every medical student is given the opportunity under competent
supervision to observe and become acquainted with the various
clinical phases of insanity can we hope that the general prac-
titioner will finally become sufficiently educated along these
lines to recognize the development of alienation in its earliest
stages, — the period when the best results may be hoped for in
combating the ravages of this scourge. There is no branch of
medicine in which the ounce of prevention is of greater value.
Many cases which now become hopelessly chronic, if the diag-
nosis were made earlier in the disease and the proper condi-
tions for treating the patient were provided, might readily be
cured.

Prophylactic Measures. — In the section devoted to the
discussion of the etiology of insanity sufficient has been said to
indicate what measures may be instituted to prevent the spread
of alienation. Although various factors concerned in the trans-
mission of normal or abnormal mental qualities are still very
imperfectly understood, common-sense and experience justify
us in maintaining that in the vast majority of cases it is better
that individuals who have shown signs of mental aberration
should not marry. Hence it follows that one of the most im-
portant reasons for making ample provision in every com-
munity for the care of the insane is to deprive individuals who
are bereft of reason of the opportunity to propagate their kind.
The actual encouragement sometimes given by physicians to
those who are physically and mentally unfit to marry and the
public indifference to the necessity of restraining epileptics and
those who are mentally defective from having children are a
serious menace to society. Only those who are familiar with
the conditions that prevail in the higher as well as in the lower
classes fully realize the important sociologic bearing of this
problem. As has been pointed out, many of the vagabonds and
tramps who are prone to indulge their sexual impulses pro-

I48 PSYCHIATRY

miscuously are subject to various forms of alienation, it having
been estimated that in Germany at least 15 per cent, of this
class were insane.2 But although it is desirable for the good of
the community that only individuals who are mentally sound
should propagate their kind, it is scarcely to be expected that
the passage of laws similar to the one enacted in Minnesota will
to any degree regulate or do away with the possibility of mar-
riages among those who are mentally defective. Hence we are
left with only two methods by which these dangers can be met,
— namely, ample provision for these poor unfortunates in in-
stitutions or, if they be left at large, castration.

Whenever an individual presents symptoms that in any
way suggest the possible outbreak of an attack of alienation
which might be fraught with danger to himself or the com-
munity, he should immediately be kept under constant observa-
tion until the physician has been able to establish at least a ten-
tative diagnosis; but this can be satisfactorily and quickly
accomplished only in cities where reception hospitals have been
established. In communities where such institutions do not
exist, it remains for us to do the next best thing, and at once
remove him to an asylum, where he can be under constant
observation until further developments occur. Not only is this
step necessary to prevent any disastrous results to others, but
it is the one which will best serve the interests of the patient.
In properly constructed and fully equipped hospitals for the
insane even the milder cases of alienation have a far better
chance for a rapid recovery, and experience has shown that
mental depression always tends to deepen and excitement to be
exaggerated when the patient is surrounded by individuals or
by objects with which he has been familiar. Unfortunately, a
misguided sense of kindness and the fear of damaging the
reputation of a respectable family often lead to a temporizing
policy, and the patient is kept at home until all hope of recovery
has vanished, while in the end the family in no wise escapes the

3 Wilmanns, Karl : Die Psychosen der Landstreicher. Centralbl. f.
Nervenheilk. u. Psych., 1902, Bd. xii, xxv. Jahrgang.

GENERAL TREATMENT I49

terrible slur. Against such sentimentality the physician who
understands anything about insanity and who has the real in-
terest of his client at heart will sternly set his face. Not but
what we must confess that the prejudices which we have to
overcome are not wholly unjustifiable, inasmuch as the majority
of institutions in the United States are poorly adapted to care
for the incipient and curable types of alienation. And although
we may be convinced that even an imperfect institution can
offer better results than the home in the majority of these cases,
we should never rest until the public has been convinced that
the best will in the end prove not only to be the most humane,
but also the most economical.

As soon as the patient is within the hospital, if the symp-
toms are acute or subacute in character, the bed treatment
should at once be instituted. This rule applies also to the
acute exacerbations occurring during the course of a chronic
psychosis. This method of treatment, to be successful, necessi-
tates all the adjuncts of the modern hospital, — trained nurses,
facilities for bathing and other hydrotherapeutic measures,
massage, electricity, diet, etc., — and the apparent lack of success
derived from it must often be attributed to the fact that it is
attempted in institutions that are in the transition pe/iod be-
tween the asylum and the hospital and therefore are ill adapted
to carry out all the various procedures necessary. The means
used to quiet excited patients next demand consideration.
In the modern hospital for the insane the strait- jacket and
camisole, except in very rare cases, " belong in the garret,"
and the frequent resort to these mechanical forms of restraint
is an indication of the existence of two pernicious conditions :
(i) a lack of proper bathing facilities; (2) an insufficient
number of nurses. In institutions which are not properly
equipped for the carrying out of hydrotherapy mechanical
restraint often becomes a necessity. The sheet or camisole may
then be employed with considerable advantage to the sufferer,
as nearly every insane patient soon realizes that it is useless to
attempt to free himself and get out of bed. On the other hand,
if the excited patient is simply allowed to go on struggling

ISO

PSYCHIATRY

with two or even three nurses, violent motor restlessness may
be kept up uninterruptedly for hours until both patient and
nurses are utterly exhausted.

The importance of the continuous rest in bed for patients
suffering from acute or subacute forms of alienation can hardly
be overestimated. This measure, however, cannot be success-
fully carried out without the aid of physicians and nurses who
have been specially trained not only in the care of the insane, but
also in the wards of a general hospital, and have a thorough
practical knowledge of the details of the so-called rest-cure.
In the first place, unless the patient is carefully tended by a
skilful nurse, bed-sores are apt to develop. This complication
can be obviated by bathing, strict attention to cleanliness, the
removal of all possible sources of pressure, by change of posi-
tion, and by immediate attention to small excoriations as soon
as they appear. In nearly all instances the monotony may be
broken by the institution of various hydrotherapeutic measures.

No definite time can be dogmatically prescribed during
which the patient should be kept in bed. The physician's com-
mon-sense and experience must be the guide in all such matters.
As a rule, patients who have lost weight and are anaemic should
be kept in bed until they have shown a very decided improvement
in their general condition. In the milder cases it is sufficient to
keep the patient in bed for a week or ten days ; whereas in the
severer cases two or three months are necessary in order to
derive the most satisfactory results from the treatment. When
the proper time comes the bed treatment may be gradually
broken by short periods during which the patient is allowed to
sit up. Gradually various forms of exercise, such as are re-
ferred to later, may be introduced. For a more detailed descrip-
tion of the rest-cure the reader is referred to the publications of
Weir Mitchell, which created a new epoch in the treatment of
nervous and mental diseases, as well as to Dercum's excellent
account of the methods.3 Under no circumstances should the

s A System of Physiologic Therapeutics, vol. viii. Edited by Solis
Cohen. Phila., 19x13.

GENERAL TREATMENT X5I

patient be kept continuously in bed unless he can be under the
constant supervision of a well-trained nurse. The monotony of
the rest in bed should be relieved by baths, packs, massage,
passive or active movements, and in the milder cases or during
the periods of convalescence by the nurse reading aloud or
occupying the patient's attention by some pleasant and not too
stimulating form of mental occupation.

Hydrotherapy.4 — The good effects to be derived from
appropriate hydrotherapeutic measures in the treatment of cases
of alienation are becoming more and more appreciated every
day. Among the more important of these procedures is the
warm bath. The water should be at a temperature of from 340
to 360 C. The tub should be placed in a room in the isolating
ward especially prepared for the purpose, or a portable tub
which can be moved about from one room to another may be
employed. There should be sufficient water in it to afford a
considerable degree of buoyancy, so that there is little, if any,
pressure upon the various parts of the body and limbs. If nec-
essary, one or more rubber air-cushions may be introduced to
help to sustain the weight. A canvas sheet may be stretched
over the tub, great care being taken in cases of excitement or of
marked mental depression that the patient shall have no chance
of strangling himself by means of the edge of the sheet. In-
gress and egress of the water supply for the portable tubs may
be secured by means of a long hose carried to the nearest bath-
room. As a rule, the first bath should last from fifteen minutes
to one hour. In many cases this will be sufficient to lessen
motor restlessness and to exert a beneficial reflex influence upon
the states of anxiety, but the submersion may be prolonged for
several hours or the patient kept continuously in the tub for one
or more days. Many excited patients become quickly accus-
tomed to the water and after a few minutes do not offer any
objection to the continuance of the bath. In each case it is

* Ueber die Anwendung der physikalischen Heilmethoden bei Nerven-
krankh. in der Praxis. Hoffman, 1898. Hydrotherapy. A System of
Physiologic Therapeutics. Phila., 1903.

152 PSYCHIATRY

better that a physician should be present while the first bath is
being given in order that the effects upon the mental and
physical state of the patient may be carefully noted. After the
patient is taken from the tub he should be carefully dried and
put to bed, and in the majority of acute cases kept there until the
next bath is given. When for various reasons it is impossible
or inadvisable on account of a weak heart, cerebral hemor-
rhage, etc., to give a tub-bath, warm packs may be tried. This
procedure is carried out as follows: A rubber blanket having
been placed under the patient, he is wrapped in a warm wet
sheet and then covered over with a woollen blanket. At
intervals the blanket is removed for a few moments and the
sheet moistened with warm water. This method of treatment
will often be found to be very beneficial in cases of acute
alcoholic delirium as well as the mild forms of insomnia and
hypomaniacal states. Sometimes it is advisable to give only
one tub-bath in the twenty- four hours and supplement this with
warm packs every four or six hours. Cold baths and cold packs,
as a rule, are of no service or even may be very deleterious in
states of excitement, but later may be used with considerable
advantage in hypochondriasis and mild states of depression.
The prolonged warm baths are particularly useful in the ex-
cited stage of paresis as well as in that of manic-depressive
insanity, collapse delirium, amentia, and Korsakow's syndrome.
Alter has given an interesting account of the beneficial effects
of baths in the treatment of protracted cases of maniacal excite-
ment as compared with those obtained from the use of drugs.5
It can not be denied that any properly conducted hydrothera-
peutic regime makes very considerable demands upon the time
and energies of the nurses and attendants, but so far as its
value in the treatment of various mental conditions is concerned
experience has shown that from its employment many patients
will derive benefits which it has not been found possible to
obtain by any other means at our disposal.

6 Alter, W. : Versuche mit zellenloser Behandlung und hydrothera-
peutischen Massnahmen. Centraibl. f. Nervenheilk. u. Psych., 1902,
Marz, N. F., Bd. xv, xxv. Jahrgang.

GENERAL TREATMENT I53

Massage is a very important adjunct in the treatment of
certain forms of alienation, such as psychasthenia, neuras-
thenia, hysteria, the milder stages of manic-depressive insanity,
particularly the period of depression, and during convalescence
from all the more acute psychoses. Not only is it indicated
during periods of mental depression, but it often proves dis-
tinctly beneficial in certain of the very mild maniacal states.
Instead of forcing patients who are mentally depressed to
exert themselves or to expend any little energy they may have
accumulated in getting out of bed and taking walks, it is far
better that they should be kept flat on their backs and exercise
administered to them in the form of massage or passive move-
ments. This may be given once or twice a day according to
the indications in the particular case. The reactions of patients
vary considerably, and sometimes it is found desirable to give
the massage in the morning, at other times at night, while many
patients can take it twice a day, morning and night, with bene-
fit. In any case the degree of force used and the duration of
each treatment depend very largely upon the condition of the
patient.

Various gymnastic exercises in the form of the so-called
German or Swedish movements can often be employed with
great benefit. The former are generally a variety of simple
active movements somewhat similar to those frequently taught
in the schools. In some cases the patients may be allowed to
hold in their hands sticks or light dumb-bells while carrying out
the exercises. The latter are a variety of more complicated
movements, a description of which will be found in special
hand-books. Many of these forms of exercise are indicated
when the patient is up and about the wards, and some of the
milder forms may be tried while he is still in bed. They are
particularly valuable when the individual is just entering upon
the stage of convalescence and when it is desirable that only a
certain amount of physical exercise should be taken without
materially increasing his sense of effort. Under supervision
the patient is allowed to execute a number of movements, such
as raising and elevating the arms or legs, care being taken

154

PSYCHIATRY

not to overtax his strength. In this way many of the muscles
are brought into play before the time comes at which walking
should be attempted. V. Bechterew 6 for several years has
successfully carried out this practice of having patients who
were feeble or who were afflicted with various forms of
paralyses taught to execute a series of movements while
in the full-bath. In some instances where the active move-
ments can not be successfully carried out, the nurse or
attendant may use the various passive movements. Such
practices are of great use not only for the physical effect that
they have upon the patient in stimulating the circulation, but
also for the influence exerted upon the mental condition, since
they aid in distracting the patient's attention from himself and
in keeping his mind more or less occupied. As an adjunct to
the means already indicated a plentiful supply of fresh air is all-
important. Nothing can be worse for patients than the tem-
perature of the wards through which one frequently has to pass,
particularly in the institutions where steam heat is employed.
In fact, in not a few of our insane asylums not only the patients
themselves, but the attendants and members of the medical staff,
have been known to suffer severely from the close, impure, and
overheated atmosphere in which they have to spend so large
a portion of their time. For a certain part of every day, par-
ticularly when the sun is shining, even in cold weather, bed
patients should be well protected with a sufficiency of coverings
and two or three times a day the windows in the ward should
be opened wide for several minutes. Patients suffering from
mental depression, when the motor restlessness is not marked, —
or, in fact, in a variety of other conditions where there is little
or no excitement, — may be wheeled out-of-doors in bed and left
there under the supervision of an attendant for several hours.
It is much to be regretted that whereas the facilities for such
treatment exists in some of our general medical hospitals, they
are for the most part lacking in the institutions to which acute

8 Heilgymnastiche Behandlung im Bade. Centralbl. f. Nervenheilk.
u. Psych., Marz 15, 1904.

GENERAL TREATMENT jee

mental cases are consigned. Nothing can be more strongly
condemned than the practice of allowing anaemic, sallow-look-
ing patients to remain seated in their rooms or in the corridors
for hours at a time without a breath of fresh air, whereas, if
proper provision were made, even when in bed, they might be
kept practically out-of-doors, and when able could be kept occu-
pied by massage, gymnastics, and the amusements indicated in
each individual case. In every institution for the insane, before
it becomes worthy to be called a hospital, in addition to a
corps of thoroughly trained nurses there should be ample fa-
cilities for carrying out the rest-cure and hydrotherapy in
all its details. Moreover, certain of the attendants should be
skilled in giving massage, and there should be at least one
capable of giving instruction to the patients, under the direc-
tion of the physician, in various gymnastic exercises. The
apparatus employed need not be elaborate and the exercises
could be carried out in some airy, cheerful room set apart for
that purpose, where a few patients could be taken at one time.
As has been said, for acute conditions a complete or some modi-
fied form of the rest-cure is generally indicated, but not a few
patients, particularly those afflicted with dementia praecox, seem
to be greatly benefited by more or less severe exercise in the
open air.

Mental Treatment. — Not so very long ago many
articles were published dealing with what was termed the " men-
tal treatment" of different forms of alienation. Undoubtedly
many insane patients are particularly susceptible to suggestion,
and we have already pointed out that much of the benefit to be
derived from massage, hydrotherapy, and gymnastics is largely
due to the fact that the patient's attention is diverted by what
is being done for him, and in this way his mind is stimulated
gradually to more normal action. Undoubtedly a few cases of
alienation, particularly certain hysterical states, are temporarily
improved by an artificially obtained hypnotism, but that per-
manent beneficial results are ever brought about by this form of
treatment is highly improbable, and the general consensus of
opinion is against its employment in institutions.

I56 PSYCHIATRY

The attitude of the alienist towards his patients is very
important. He should always tell them the truth and should
convince them that his conduct towards them is always straight-
forward. If the physician is once found to have practised any
form of deception, no matter how excellent the motive, the
patient will never regain the confidence in him which is abso-
lutely necessary for the accomplishment of any good results.
The higher the intellectual state of the patient previous to the
attack of alienation, the more necessary does it become that the
medical attendant should be interested even to the point of
enthusiasm in all that pertains to his profession. Practical ex-
perience has shown that many of the more intelligent patients
are quick to note the mental inertia and lack of scientific interest
on the part of medical officers of hospitals for the insane. Dur-
ing convalescence the patient should be very carefully watched
by the nurses and physicians in order that the first signs of a
relapse may be detected and met by proper treatment. Only
exceptionally should he be permitted to see members of his own
family or friends, as such interviews are frequently followed by
a renewal of the symptoms. The physical condition should be
carefully noted, and in all hospitals regular charts of the bodily
weight should be kept in such a manner that they may be readily
consulted by the physician on his daily rounds. In manic-
depressive insanity, or the acute psychoses more particularly,
the rise or fall in bodily weight is of very great significance in
the prognosis.

A few more specific suggestions regarding the treatment
of cases of acute or subacute excitement as well as of depression
may not be out of place here. When individuals are maniacal
it is nothing less than inhuman to merely confine them in a
single room about which they are allowed to roam like wild
animals. They should be kept either in bed or in the prolonged
bath. The latter may be given immediately upon admission,
if the patient is not too excited or in too exhausted a condition.
In all forms of excitement the patients are frequently consti-
pated— a condition that may be relieved by the administration
of various remedies, preferably calomel, castor oil, or croton oil

GENERAL TREATMENT

157

given by the mouth. Unless some contraindication exists,
the bowels should be moved as soon as the patient comes to the
hospital. Steps should also be taken against too long a reten-
tion of the urine. When the water is not passed at the proper
intervals, warm wet cloths should be applied over the region of
the bladder, or warm sitz-baths should be tried. Sometimes
the urine may be gently expressed from the bladder by means
of an abdominal manipulation similar to that employed in the
removal of the placenta. On account of the danger of septic
infection catheterization should be employed only as a last
resort. If instrumental relief becomes necessary, the strictest
aseptic precautions should always be taken, and if it becomes
necessary to frequently repeat the operation, urotropin, 0.5
gramme two or three times a day, or from three to ten drops
of turpentine may be given.7

Isolation is indicated not only in cases of acute excitement,
but also in profound mental depression. Nothing is more un-
fortunate than the method of treatment of mental depression
so often adopted in our institutions, which allows the patients
during the periods of deepest depression to associate with other
insane individuals, and. instead of keeping them in bed often
compels them to get up and walk about the wards. This is
quite analogous to the treatment of such cases so often pre-
scribed through ignorance by the general practitioner, who
advises patients afflicted with mental depression to travel. On
the contrary, all such patients should be isolated and kept in bed,
and they should be seen only by the physician and nurses and
not allowed to interview members of their family. In many
of the French hospitals hysterical and other excited patients
frequently have their beds completely surrounded by a canopy
or tent formed of sheets supported by an iron framework. The
patient is permitted to raise the sheet only upon the approach
of the physician or nurse, and in this way can be kept com-
pletely isolated for days at a time. Intelligent patients who

T Pfister, H. : Die Anwendung von Beruhigungsmitteln bei Geistes-
kranken. Halle a/S., 1903.

158 PSYCHIATRY

have passed through periods of severe mental depression dur-
ing convalescence frequently complain that nothing intensified
their suffering so much as to be urged to occupy themselves
or to be driven to try and divert their attention from their
own troubles, or in any way to contrast their condition with
that of people about them. In fact, they feel that to expend
what little energy they may have possessed in trying to re-
spond to external stimuli could only result in harm. Thus,
for example, one of our patients declared that whereas the
most detailed and elaborate observation of the physician in
no way fatigued or annoyed him, inasmuch as it made him feel
more certain that every effort was being made to restore him
to health, at the same time his feelings of depression were
rendered much worse by any attempt to force him to exert him-
self. The more acute the mental depression the more impera-
tive the indication for perfect rest in bed.

In all forms of acute alienation the diet is of great im-
portance, and in every hospital there must be a diet kitchen and
an instructor thoroughly trained in the preparation of food.
Until the physician becomes acquainted with a case and sees
how the patient will respond to treatment a fluid diet is indi-
cated. As a rule, about six ounces of milk every two or three
hours will be sufficient; but in some rare instances where the
digestive disturbances are marked very small quantities should
be given every hour for a short time. If the milk is not well
tolerated, eggs, bouillon, broths, gruels, the various wheat
preparations, or rice may be tried. It is of great importance that
patients should drink plenty of water, either plain or aerated.
Even when only fluid substances are being administered it is
important that several glasses of water be taken every day. In
many instances the patient, particularly the sufferer from hallu-
cinations or illusions, will refuse nourishment in all forms, but
by dint of tact and kindness the nurse or attendant will often
be able to overcome his objections. Whenever it can possibly
be avoided, it is undesirable to arouse the antagonism of the
patient by peremptory commands. In some instances where
nourishment is not immediately indicated the patient may be

GENERAL TREATMENT

159

allowed to go for several hours, after which it will often be
found that his objections have disappeared and some form of
food is taken gladly. In some cases when the patient can be
trusted, if the food is put within his reach and the nurse leaves
the room, he will take it when he finds himself unobserved.
Great caution, however, should be exercised in leaving patients
alone. Either the motor restlessness or psychomotor retarda-
tion may be great enough to interfere with the taking of food.
In these cases, as well as in those in which the refusal to take
food is the result of some delusion, forced feeding must be
resorted to. When this procedure is necessary the patient is
made to sit up in bed in order to avoid regurgitation or vomit-
ing. The instruments necessary are a soft rubber sound of
about 70 centimetres in length and from .8 to 1.5 centimetres
thick, similar to a Nelaton's catheter. For various reasons it is
preferable that the outlet of the sound should be in the end and
not in the sides, but if one with lateral openings is used care
should be taken that their edges are smooth In the majority of
the excited states as well as in the stuporous cases it is impossi-
ble to introduce the sound through the mouth without the use of
considerable force, which is always undesirable. In these cases
the passage through one or other of the nostrils can be utilized.
Only mild pressure should be used and the sound should never
be rotated, as the nasal mucous membrane is delicate and can
very readily be injured. As the sound passes the pharynx reflex
gagging, coughing, or an excessive flow of saliva and disturb-
ances in respiration often result. Intense reflex coughing, cya-
nosis, and difficult breathing usually indicate that the instrument
has been passed into the trachea, and in such cases it should be
at once withdrawn. If the patient be made to bend his head
slightly forward, not only the flow of saliva from the mouth, but
also the opening of the pharyngeal passage will be facilitated.
If too great haste is not used, the reflexes become less active and
permit of the further advancement of the sound. Very ob-
streporous patients are sometimes able to temporarily prevent
the sound from passing the pharynx, in which case the instru-
ment is withdrawn and then carefully reintroduced. When

jfa PSYCHIATRY

the sound finally reaches the stomach the outer end is attached
to a glass tube, which is in turn connected with the rubber
inflator (Politzer bag) or Davidson's syringe. The glass tube
and syringe should be filled with the fluid nourishment, so that
as little air as possible may be injected into the stomach when
the bulb is squeezed. As soon as the food has been introduced
into the stomach the sound and glass tube are disconnected, and
the former is withdrawn slowly until the end is through the
pharynx, when it may be more quickly removed from the nose.
In unconscious patients, if regurgitation of the fluid threatens,
the tube should at once be withdrawn. When there is much
tendency to vomiting after forced feeding, subcutaneous in-
jections of morphin or the admixture of a small amount of
opium with the fluid introduced through the catheter gives
satisfactory results. Various forms of fluid nourishment may
be administered in this way, and experience has shown that
patients may be kept alive in this manner for considerable
periods of time. Some such formula as the following: Milk,
750 cubic centimetres; eggs, 3; sugar, 150 grammes, may be
given two or three times a day. In some instances small quan-
tities of lemon- juice or the drugs indicated for the particular
case may be mixed with the fluid. In cases of haemophilia,
haemoptysis, weak heart, or where vomiting might prove to be a
source of danger in itself, this form of feeding is contra-
indicated. Nutritive enemata either alone or as an adjunct to
other forms of feeding are at times of great service. These are
best preceded by a rectal injection of lukewarm water to which,
when necessary, glycerin or olive oil has been added. After
the lower bowel is thoroughly cleansed an opium suppository
may be introduced, and in fifteen minutes or half an hour later
the nutritive enema.

Electrotherapy. — In the treatment of mental cases
electricity is not of very great value. In the milder forms of
depression, neurasthenia, or hypochondriasis, the Holz machine
may be used with some benefit. Occasionally where the patient
is open to suggestion temporary beneficial effects follow the use
of the faradic current. The local paralyses that are relieved

GENERAL TREATMENT I6I

by the use of galvanism are of neurological rather than psy-
chiatrical interest.

Medicinal Therapy. — With the exception of mercury and
the iodides for the amelioration of some of the milder mental
disturbances dependent upon syphilis, or of quinine in cutting
short the acute delirium associated with malaria, and the thy-
roid extract in myxcedema and cretinism, we possess no specific
drugs for the treatment of alienation.

Opium may be administered in various forms to quiet ex-
cited patients or lessen pain. As a rule, it is best to begin with
small doses, given three or four times a day and gradually in-
creased if necessary. Many of the mild forms of excitement or
anxiety quickly respond to this form of treatment.

Comparatively large doses of opium have been recom-
mended by Flechsig in the treatment of mental depression. In
the more chronic cases, however, great caution is necessary in
order to guard against ill effects from the drug upon the gastro-
intestinal tract. Morphin in the form of Magendie's solu-
tion in doses of 5 to 10 drops may be substituted for opium,
especially when subcutaneous injections are employed. Great
care must be taken that during the stage of convalescence the
patient does not become an habitue of the drug.

Hyoscin is serviceable in various forms of acute excite-
ment, although many authors object to its use when the mania-
cal symptoms are very marked. Where it is necessary to quiet
the patient quickly, so that the transportation to the hospital
may be effected at once and with as little disturbance as possible,
this drug is very useful. Hyoscin may be given in combination
with morphin.

Scopolamin (hydrobromate) may be administered by the
mouth in doses of from one-two-hundredth to one-one-hun-
dredth of a grain (.0003 to .0006 gramme), or hypodermically
in doses of one-four-hundredth to one-two-hundredth of a
grain (.00015 to .0003 gramme). In acute stormy deliriums
this drug, if given with great care, is particularly useful in
quieting the patients. Many authors have reported instances
of delirium following the use of hyoscin and scopolamin, but

n

162 PSYCHIATRY

such results have not been observed at the Sheppard and Enoch
Pratt Hospital.8 As a rule, after an interval of half an hour
following the administration of scopolamin the patient falls
into a quiet sleep, which is occasionally preceded by a dryness
in the throat, an increased sense of fatigue, and more rarely by
slight disturbances in coordination of movement. If the first
dose is not successful, another may be administered after one or
two hours, but a third dose is not, as a rule, either indicated or
necessary. This drug has been very successfully used in all
forms of acute excitement, particularly the excited periods
belonging to manic-depressive insanity, paresis, epilepsy, acute
delirium due to alcohol or other causes, and catatonia. Some-
times the combination of scopolamin with morphin seems to
exert a beneficial effect. The drug is contraindicated in the
presence of any marked cardiac complication, feeble pulse, or
very advanced arteriosclerotic conditions. No cumulative
effects have been noticed. Various other hypnotics are often
useful; amylene hydrate in doses of from I to 3 cubic centi-
metres (15 to 45 minims), sulfonal 1 to 2 grammes (15 to 30
grains), trional 1 to 2 grammes (15 to 30 grains).

Just recently veronal has attracted considerable attention.
A single dose of 0.5 to 1.0, or exceptionally 1.5 to 2 grammes,
may be given in hot water, tea, or coffee. It is said to
act within from thirty minutes to one hour. No bad after-
effects have been noted except in seven cases reported by
Fischer,9 in which there was an unpleasant feeling in the head,
somnolence, and in one case nausea and vomiting. Abraham,10
who tried the drug extensively in the excited periods of de-
mentia paralytica, was not favorably impressed with the results

8 Bumke : Skopolaminum hydrobromicum. Monatsschr. f. Psych, u.
Neurol., xiii, 1 u. 2. Van Vleuten, C. F. : Ein Delirium in Anschluss
an Hyoscinmissbrauch. Centralbl. f. Nervenheilk u. Psych., 1904, Nr.
168, Jahrg. xxvii, S. 19.

' Ueber die Wirkung des Veronal. Therapeut. Monatsheft, 1903,
Jahrg. xvii, August 3, 393.

10 Ueber Versuche mit Veronal bei Erregungszustanden der Paralytiker
Centralbl. f. Nervenheilk. u. Psych., Marz 15, 1904.

GENERAL TREATMENT 163

obtained. Its use has been highly recommended by many com-
petent observers in the treatment of simple insomnia.

Paraldehyde, in spite of its nauseous taste, is extensively
used. It seems to have no unpleasant after-effects and has been
strongly recommended in all forms of alcoholism and in various
types of mania. It is supposed to be of special value in the
senile and arterio-sclerotic forms of alienation. Cumulative
action and idiosyncrasies for the drug have not been noted even
when its use has been continued for a long time. The dose
is from 15 to 60 minims (1 to 4 cubic centimetres) largely
diluted with syrup and flavored with tincture of orange peel
or some aromatic. Cases of the paraldehyde habit are not
uncommon.

The bromides are still considered of great value. They
are particularly useful in cases of excitement with sexual mani-
festations as well as in the forms associated with epilepsy.
They are sometimes very efficient in cases of insomnia due to
the milder forms of maniacal excitement. The potassium and
sodium salts as well as bromipin are most commonly employed.
Their continuous use, however, in large doses, is apt to set up
gastro-intestinal disturbances and occasionally severe toxic
symptoms, and patients who have been taking them for a long
time often show considerable disturbances in associative
memory, acne, loss of appetite, and foul breath. Individual
idiosyncrasies are not uncommon.

Within the past decade chloral hydrate, in doses from 5
to 20 grains (.3 to 1.3 grammes), has been less frequently
employed on account of various toxic symptoms, such as slow-
ing of the heart's action, irregular pulse, and various dis-
turbances of the gastro-intestinal tract, which sometimes follow
its use. A certain degre of tolerance for its action is soon
established and if continued the drug has to be given in in-
creasing doses. In all cases of cardiac disease it is contra-
indicated.

Sulfonal is often useful in the treatment of cases of aliena-
tion. The disadvantages attending its use are that it is slowly
absorbed and the hypnotic effect is delayed. In spite of these

1 64 PSYCHIATRY

objections, it may be most successfully used for the treatment
of insomnia, and may also be administered in many of the
milder forms of excitement. The dose varies from 10 to 30
grains. A number of observers have reported haematopor-
phyrinuria as well as excessive mental cloudiness and occasional
attacks of prostration with slight irregularity in the heart's
action. Trional given in doses of from 10 to 25 grains (1 to
2 grammes) is often efficacious in the same class of cases in
which the administration of sulfonal is indicated. The hyp-
notic effect is less delayed, but undesirable symptoms similar to
those mentioned in connection with sulfonal have been re-
corded.

Choralamide has frequently been recommended, but has
no advantages over the drugs already mentioned.

With the single exception of the thyroid extract in cases
of myxoedema and cretinism, to which reference is made later
on, the various organic extracts have not proved efficacious.
Among other therapeutic procedures that have been tried and
found wanting is the use of various substances which normally
set up a febrile reaction, in the form of strong inunctions,
blisters, and injections. These measures were based on the
theory that the occurrence of fever frequently seemed to be
followed by a disappearance of some, if not all, of the mental
symptoms. Without going so far as to say that they never do
good, mention may be made of the fact that many persons
suffering from alienation not infrequently have high tempera-
tures without deriving any apparent benefit, and even at times
show an actual increase in the severity of their former symp-
toms. Equally unsatisfactory have been the results obtained
by Binswanger and others who injected the toxins formed
by certain bacteria, the colon bacillus, typhoid bacillus, etc.

Saline infusions, however, have proved to be of definite
value in the treatment of various psychoses, particularly the
marked toxaemia associated with febrile forms, acute delirium,
amentia, and the more acute phases of general paresis. n They

11 Donath, Julius : Die Behandlung der progressiven Paralyse, sowie
toxischer und infectioser Psychosen mit Salzinfusionen. Allg. Ztschr. f.

GENERAL TREATMENT j^

were first recommended in 1890 by Sahli in cases of uraemia
and in collapse. Various formulae have been used, but the one
most generally employed is the 0.7 per cent, physiological salt
solution. If necessary, duboisin, hyoscin, or other medica-
ments may be added to it. From 400 to 800 cubic centimetres
are generally given, according to the indications, at intervals of
from 36 or 48 hours. Some clinicians give even larger quan-
tities, as much as 1000 cubic centimetres, and at shorter in-
tervals. Donath highly recommends the following formula:

Potassii sulphat, 0.25 gm. (gr. iv) ;

Potassii chloridi, 1.00 (gr. xvi) ;

Natrii chloridi, 6.75 (gr. ex) ;

Potassii carbonat. pur. sice, 0.40 (gr. vi) ;

Natrii phosphat. crys., 3.10 (gr. 1) ;

Aq. destillat, 1000 (1 quart).

The following method of administration is recommended :
The fluid is sterilized in a two-litre glass vessel placed inside
a second larger vessel full of water, which is then boiled for
from half to three-quarters of an hour and allowed to cool to
400 C. The injection, under strict aseptic precautions, is made
into the subcutaneous tissues in the neighborhood of the breast,
hypochondrium, or beneath the skin of the abdomen, or, as
other authorities prefer, directly into the venous circulation,
although it would not appear that there exist any special indica-
tions for the latter procedure. Not infrequently a considerable
rise in temperature is noted, but further than this, if the injec-
tion is properly given, there are no untoward results. A dif-
ference of opinion still exists regarding the class of cases in
which saline infusions do the most good. They are strongly
indicated in all toxic conditions where there is motor restless-
ness, but conditions in which mental depression is marked do
not seem to be benefited by this procedure, and in some instances
it has been followed by a temporary increase in the severity of

psych, gericht. Med., Bd. 60, H. 4, Berlin, 1903. Di Gaspero, H. : Ueber
die Kochsalzinfusionstherapie bei Geisteskranken. Therap. d. Gegenw.,
1902, S. 397 ff. Wickel, C. : Kochsalzinfusionen in der Therapie der Psy-
chosen. Psych. -Neurol. Wchnschr., 1903, 18, 19.

166 PSYCHIATRY

the mental symptoms. Soon after the injection of the fluid
there is a marked increase in the quantity of urine excreted.
When, for various reasons, it does not seem advisable to give
the fluid hypodermically, high rectal injections of salt solution
may be substituted.

What has been said so far in regard to treatment applies
chiefly to what may be done for patients in modern hospitals
reserved for the more acute types of mental alienation. As
soon as the chronic stage of the disorder is reached, such indi-
viduals are better off in an asylum situated at some distance
from the city. Here the patients can find better opportunities
for employment both indoors and out, and at the same time
they are not brought into contact with the more acute forms
of alienation — a matter of great importance for both classes
of patients. Much has been written about the home treat-
ment of cases of alienation. Provided the patients have first
been under the observation of a thoroughly competent alienist
for a time sufficient to allow him to make a diagnosis and
determine that the sufferer may, with safety to himself and
his relatives, be given a considerable amount of freedom, it
is possible to carry out the treatment along certain lines at
home, particularly if the general practitioner under whose
charge the patient falls is willing to utilize the various sugges-
tions which should be given him. But until a positive diagnosis
has been arrived at, no case of alienation should be treated out-
side of an institution. During the remissions that occur in
cases of dementia praecox and general paresis and in a few
instances during the period of convalescence from the acute
psychoses the patient may be allowed to remain at home, pro-
vided that a suitable environment can be maintained for him
there

CHAPTER VI

THE MODERN HOSPITAL FOR THE INSANE1

The rapid increase in insanity that has followed the fever-
ish activity in the last few decades is ever bringing up for
solution new problems dealing with the adequate provision of
suitable institutions for persons who have been unable to bear
up against the stress, and who have consequently become inca-
pable of caring for themselves, or, still worse, who are a men-
ace to the peace and welfare of those about them. Nor can
we sit down with folded hands and point with pride to what
has already been accomplished. It is true that among our pre-
decessors, and even among those who are still living, it is not
hard to find " makers of history," men preeminent in sterling
character and energy, single-hearted, with one ruling idea and
aim in life — to rescue the insane and feeble-minded from
neglect or even cruelty; nor can we ever forget the debt of
gratitude we owe them. But with changed times come changed
conditions, and progress is ever calling for renewed and steady
effort until we shall have come much nearer to perfection than
we are at present.

Broadly speaking, the insane for whom public care has to
be provided may be divided into three classes, of which, how-
ever, numerous subdivisions are possible:

I. Those requiring constant care, supervision, and the
best possible medical treatment, either because (a) they are in
an acute stage of mental disease and are violent and dangerous

1 Griesinger : Archiv f. Psych., Berlin, 1868-9. Transl. by Frank R.
Smith, Am. Journ. Insan., 1903, vol. lx. Kraepelin : The Duties of the
State in the Care of the Insane. Transl. by Stewart Paton, Am. Journ.
Insan., vol. lvii, 1901. Peterson, F. : A Visit to the Newest Psychopathic
Hospital. Med. News, vol. lxxvi, 1900. Mitchell, S. Weir: Address be-
fore the fiftieth annual meeting of the Am. Med.-Psychol. Association.
Proc. of Am. Med.-Psychol. Association, Phila., 1894.

167

j68 PSYCHIATRY

to themselves or their fellowmen, or (b) they are in an incipi-
ent and presumably curable stage of insanity and require special
and immediate attention in order that their chances for recov-
ery may be materially increased.

II. Those requiring less constant care and supervision,
but who, nevertheless, are fitted only for institution life (in
asylums or sanitaria.)

III. Those who, although not capable of taking care of
themselves, are able to live in farm colonies or in private fami-
lies.

The progress referred to above has mainly affected the
last two classes. To a large extent these patients are insured
a comfortable existence, and recoveries among them — at least,
sufficient to warrant a return to their homes — are happily not
so very rare. But in order that we may be able to strike at
the root of the matter we must devote our best efforts ( I ) to
curing all recoverable cases — and this can be done only by
taking them in hand at the earliest possible moment, when the
disorder is still in its incipient stage; and (2) to giving to as
many physicians as possible the chance of receiving a thorough
training in psychiatry, in order that cases of insanity may be
recognized by the general practitioner before it is too late, and
that the importance of preventive psychiatry may be fully
realized by the leaders of thought in every community. •

These two fundamental needs, then, since they can not be
satisfied by the asylum, the farm colony, and the boarding-out
system, call for the establishment of special institutions which
have been variously designated as hospitals for the insane,
psychiatrical clinics, or psychopathic hospitals; and these will
form the subject of the present chapter.

Unfortunately, institutions that promise the realization
of these ideals are too rarely found either in Great Britain or
the United States. That the need for them has been felt is
evident from the efforts that have been made to transform
some of the smaller asylums into psychiatrical clinics. Nor
is it to be wondered at that such endeavors have proved only
partially successful, inasmuch as the former had been planned

PSYCHIATRICAL HOSPITALS 169

at a time when the present exigencies in the care of the insane
either did not exist or were unrecognized. As a result, these
transformed institutions — situated for the most part far from
the centres of population and hampered by a general arrange-
ment that worked against the ready admission of patients,
while rendering instruction to students in psychiatry impossi-
ble— could never represent anything more than a transition
stage — a compromise between the asylum proper and the real
hospital. The former, placed at some distance from the city
and with accommodations for a relatively large number of
patients — from 200 to 1000 or even 2500 — can with proper
forethought afford the best care possible for the chronic in-
sane — the indications for progress being along the lines of
improvement in hygienic surroundings and facilities for light
employment in shops or in the open air. In these communities,
however, hospital treatment must necessarily always be a sec-
ondary consideration, nor should they be hampered by having
thrust upon them burdens and responsibilities which they are
not adapted to meet.

To restate the proposition, then, the psychiatrical clinic
or hospital is intended to satisfy two fundamental needs : ( 1 )
Better provision for the care and cure, if possible, of cases of
acute and incipient insanity; (2) adequate provision for in-
struction in treatment and for investigation into problems
upon the solution of which depend the arrest of the develop-
ment of insanity in the State. But in order to fulfil these ob-
jects, its structure and organization must be planned so that
the following conditions will be satisfied :

( 1 ) Ease of access. The institution should be near to
or within the limits of a city.

(2) A limited capacity, in order that every individual
patient may be made the subject of special study.

(3) Perfect construction, equipment, and organization, in
order that a thorough and energetic treatment can be under-
taken for all patients for whom there is hope of recovery.

(4) A relatively large staff of physicians and nurses.

(5) Ample provision not only for the teaching of stu-

170

PSYCHIATRY

dents, but also for the prosecution of post-graduate investi-
gations and research in clinical psychiatry, psycho-pathology,
and in the anatomy and pathology of the nervous system.

(6) The ready admission of patients and their speedy
transference, when necessary, to other more appropriate insti-
tutions. Provision "for out-door and voluntary patients.

The manner in which, so far as our present experience has
taught us, these conditions may best be met and fulfilled will
now be briefly discussed.

( i ) Location. — If the institution be located at some dis-
tance from a centre of population, the commitment of cases of
incipient insanity will be rendered more difficult and not a few
patients will lose the opportunity for speedy treatment — which
in some cases is equivalent to missing their only chance for
recovery.

Of course, ideal conditions can not always be realized, but,
if possible, the psychiatrical hospital should be within the city
limits or quite near them. The extensive grounds, large gar-
dens or farm, so essential for the asylum or the convalescent
home, are not needed for the hospital, although a certain area
of ground — from one to three acres — is indispensable. This
would supply sufficient space for a small garden where the con-
valescent patients could sit or walk in the open air. Again,
the easier of access the institution is to a fairly large cen-
tre of population, the less will be the antipathy of patients
towards a residence there, since they will feel that they are
not shut up in some remote asylum away from the world and
all their friends; and, moreover, they will be spared a long
and tedious journey, which is distressing alike to patients and
relatives.

Such an institution, when situated in a city, will afford
the medical profession an opportunity of becoming as inti-
mately acquainted with its organization, its methods, and its
results as is the case with the medical hospital; while at the
same time the medical staff will not be isolated and will have
every chance of keeping in touch with the advances that are
being made in general medicine, of which their own is a most

PSYCHIATRICAL HOSPITALS

171

important branch. Again, the mere enumeration of the prob-
lems to be solved, involving questions in heredity, the psycho-
logical analyses of symptoms, the chemical study of secretions
and excretions, improvements in methods of physical diagnosis,
ought to be sufficient to emphasize the necessity of placing
these psychiatrical hospitals in immediate proximity not only
to other medical clinics, but also to the non-medical parts of
the university. The highest types of clinical and laboratory
investigation can only be accomplished in hospitals that are
sufficiently close to a good university for the medical officers
to feel the stimulating effect of the encouragement and aid
given to all forms of investigation ; nor is it probable that high
ideals in the character of the work to be accomplished will be
as readily sustained under other conditions.

(2) A Limited Capacity. — The capacity of the hospital
must naturally depend much upon the demands of the com-
munity in which it is situated. It is advisable, however, that
it should be relatively small, so that each individual case can
be studied carefully in a reasonably short time. In asylums for
chronic patients there is much less urgency in this matter, but
in a case of acute insanity a speedy and as far as possible a
correct diagnosis is most important, inasmuch as the future
of these patients is in the balance. Roughly speaking, insti-
tutions varying in capacity from 80 to 100 beds represent
the size which best lends itself to an efficient organization.
Furthermore, the fact that the accomm'odations are limited
will serve to prevent the accumulation of chronic cases which
belong elsewhere.

(3) Construction, Equipment, and Organization. — The
problems dealing with the construction of such hospitals for
the insane have not as yet received much attention in English-
speaking countries. Many of these institutions in Germany
are admirably adapted to meet the needs of the several com-
munities in which they have been established. But in America
and England conditions are so different that the German ideas
could not be accepted without considerable modifications in
the general plans. With us most of the details have yet to

172

PSYCHIATRY

be worked out, but even at the present time a few axiomatic
propositions are permissible.

In the first place, from a technical stand-point, in all mat-
ters of construction, equipment, and organization such an
institution must partake of the character of a hospital as fully
as any of the best institutions provided for the care and treat-
ment of the so-called bodily disorders. This at once necessi-
tates the provision for the treatment in bed of a large percen-
tage of the patients. Experience has taught us that many suf-
ferers from acute psychoses or exacerbations of the more
chronic mental disorders do far better when confined to bed
until the acute symptoms have passed off. Physicians con-
nected with out-patient departments every day meet with indi-
viduals suffering from incipient insanity, whom they are unable
to benefit at their homes because facilities for putting the
patients to bed, isolating them, and employing the other neces-
sary procedures are lacking. In addition to the various forms of
apparatus which naturally belong to a general hospital, the
institution should be well provided with all the appliances
necessary for carrying out hydrotherapeutic measures. It
should also be possible to give Turkish baths, the various
sprays and douches, and also the prolonged or continuous
bath.

The institution should contain two small reception de-
partments (with separate accommodations in each for men
and women), where new-comers may stay for a few hours,
until they have been carefully examined and a rational course
of treatment has been outlined for each case. One department
should be set apart for maniacal or delirious patients and the
other reserved for individuals who are less noisy and are not
apt to disturb their companions. It is very inadvisable to put
quiet patients with those who are violent, especially as many
individuals suffering from incipient insanity retain a fair in-
sight into their own condition, and nothing can have a worse
mental effect upon them than to be brought into close asso-
ciation with pronounced forms of insanity.

(4) (a) The Medical Staff. — With regard to the organi-

PSYCHIATRICAL HOSPITALS

173

zation of the medical staff, it is quite evident that the number
of physicians required will be relatively greater than that
deemed necessary for a general hospital. The fact that the
examination of an average insane patient takes two or three
times as long as when one has to deal with an ordinary sick
man means that a much larger staff of physicians can find full
employment.

In this connection it may be pointed out that if the psycho-
pathic hospital is established in close proximity to a medical
school a great many advantages, not only to the medical staff
but also to the patients, may be obtained from the employment
of " voluntary assistants." Young graduates or medical stu-
dents accepting these positions and working for a few hours
every day can easily be trained in taking histories and assisting
in examinations with great benefit to themselves, while at the
same time they can relieve the members of the medical staff
from much of the dull routine which otherwise would fall on
them and become so burdensome that it might deaden their
interests in the higher problems connected with their pro-
fession.

The sole responsibility of the clinic must rest upon the
medical director, who should be in absolute control of all medi-
cal matters, and who should have a continuous and not an inter-
rupted service. The inferior character of the work accom-
plished in the general medical hospital, where one physician
attends for a few months and is then followed by another, as
compared with that done where a single head is responsible for
the whole service year in and year out, should be a sufficient
argument against the establishment of the rotation method in
connection with our hospitals for the insane.

It is advisable that the management of the institution
should be under the ultimate control of the university authori-
ties, the director being a member of the medical faculty.

The department of psychiatry may justly be considered
one of the most important in a university, and the directorship
of the hospital and the professorship of psychiatry should be
held by one and the same man, who should receive a remunera-

174

PSYCHIATRY

tion sufficiently large to entirely relieve him of the necessity
of seeking outside practice.

The examination of the patients, the general direction of
the medical work, the supervision of investigations carried on
by competent assistants in the laboratory, and the training of
students — undergraduates and postgraduates — will be more
than sufficient to occupy the attention of the chief medical
officer. If the medical work is to be successfully organized
and carried on, it is essential that the assistants and students
be stimulated and encouraged by the example set by the direc-
tor in undertaking and carrying out original investigation, and
in view of the difficulties connected with the clinical and labo-
ratory problems with which he has to grapple, sufficient time
for study and investigation should be allowed him.

It is far better that the director should not live in the
hospital. During the night and for the few hours of the day
during which he is absent his place can perfectly well be taken
by the first assistant. This officer, whose duties should be
regulated by the director, whenever it is possible, should be a
comparatively young man, who is thoroughly interested in
his subject and for the sake of the valuable experience that
such a position carries with it is willing to spend at least two
years in the service of the institution. It is readily seen that
too many changes would be unjust not only to the patients,
but also to the director, since the resident, when he has once
become familiarized with his duties, can not only take better
care of the former, but can also relieve the latter of many of
the responsibilities connected with the clinic and the supervision
of the work that is being done in the laboratory.

It would be an ideal arrangement if the interests of the
first assistant were directed along lines different from those
of the second assistant, in order that the whole field of psychi-
atry might as far as possible be represented, at least in the
interests of the staff. Thus, if one assistant shows a preference
for the pathological problems, it would be well if one or more
of the others were to take up more especially psychological,
physiological, and chemical studies.

PSYCHIATRICAL HOSPITALS 175

On the whole, it would seem better that the responsibility
for the male and female wards should rest upon one individual
and that two assistants should never have equal authority. In
a hospital with accommodations for 100 patients, in addition
to two resident physicians, it would be advisable to have one
or more graduates as clinical assistants, who could receive
their board and lodging but would be willing to work without
a salary. Again, as has been said before, much of the routine
work could be done by students.

(b) The Nursing Staff. — As in the case of the medical
staff, the conditions existing in a general hospital are not to
be taken as an index of the number of nurses that is necessary
for the psychiatrical clinic. For several reasons a relatively
much larger number is required in the latter. In the first
place, very few of the patients are capable of aiding in the
carrying out of the treatment, and others, actively or passively,
resist any form of interference. Besides this, more particu-
larly in a hospital for cases of acute insanity, a large majority
of the patients have to be carefully watched every moment,
lest a sudden impulse should lead them to commit some act of
violence and to inflict an injury either upon themselves or upon
those around them. When these facts are taken into considera-
tion, it becomes at once apparent with what great mental, in
addition to physical, strain the duties of the nurse are associ-
ated. Moreover, for the same reason, the hours of duty in
the wards should undoubtedly be short, otherwise the nurse
cannot fail to lose much of the mental freshness and vigor so
essential in dealing properly with the insane.

The organization of the nursing staff could be safely in-
trusted to a superintendent who has already had some practice
in the education and training of nurses in a good general hos-
pital and has afterwards had some practical experience in the
care of the insane. The latter would also be highly desirable
in the case of a certain proportion, at least, of the head nurses.

(5) Facilities for Teaching and Investigation. — It is
always a matter of surprise to visiting Americans to see the
large sums of money that have been and are being expended in

I76 PSYCHIATRY

Germany for building and equipping laboratories — patholog-
ical, physiological, and chemical — in connection with psychi-
atrical clinics. The amount of expenditure justifiable in the
several cases necessarily depends upon a variety of conditions.
For example, if the psychiatrical clinic is in close proximity to
some good medical school or university, the laboratory space
can be readily confined to two or three medium-sized rooms,
in which a few students can work, since abundant facilities
can be afforded to the members of the staff and special investi-
gators in some of the other buildings — the anatomical, patho-
logical, or physiological laboratories. If, however, the insti-
tution is situated at some distance from a centre, so that these
conveniences are not available, much larger sums will have to
be spent in providing separate and commodious laboratories.

(6) The Admission and Transfer of Patients. — For the
benefit of the patients, admission into these hospitals should
be made as easy as possible, and there should be a minimum
amount of formality and red tape. Elaborate legal procedures
can not fail to deter many patients from availing themselves in
time of the immense benefits offered to them and their families
by such institutions. In our day and generation the argument
that, if certain long-established forms are done away with,
many sane persons will be liable to detention in institutions
against their will, is too ridiculous to deserve serious consid-
eration. To render such an outrage possible, the conspiracy —
between the medical officers and nurses, and even servants of
the institution, who would have to be in league with the com-
mitting physicians and the patient's friends — would be so com-
plicated and require such wide ramifications that it would only
be a matter of a few hours or days before the news of the de-
tention would be spread abroad and reach the ears of the mem-
bers of the State Board of Lunacy and the public.

Voluntary Patients. — An individual who is conscious that
his mental condition renders it unsafe for him to remain at
large should readily be able to obtain admission into the hos-
pital until a careful examination can be made into his condi-
tion. If, however, on mature consideration it becomes apparent

PSYCHIATRICAL HOSPITALS

177

to the medical officer that the patient can not be trusted or that
he will probably later object to remain until he has sufficiently-
recovered to warrant his discharge, the friends should at once
be advised of the matter, so that a formal commitment can be
made.

Out-Door Patients. — In connection with the hospital a
well-organized dispensary or department for out-door patients
is an essential supplement to the hospital proper. In all our
large cities patients come every day to the neurological clinics
who are on the border line of insanity, although their closest
relatives may never have suspected the existence of any mental
defect. Such patients could be kept under observation in the
out-door clinic and could at once be committed, if necessity
arose, to the hospital itself. Moreover, on being discharged
from the hospital, patients could be told to report at the dis-
pensary at stated intervals, and thus be kept under observation
for a length of time sufficient to satisfy the physician how far
the recovery has proceeded.

It is evident that all patients who, after careful exami-
nation, are found not to be of the class for which the psychi-
atrical hospitals have been established or who are evidently
passing into a chronic stage of insanity should immediately be
transferred to other more appropriate institutions.

Briefly, then, the economic advantages to a community
of a psychiatrical hospital with a well-organized out-patient
department may be summed up as follows :

( 1 ) A large number of patients would receive the benefit
of skilled medical care at a stage of the disease at which there
is great hope of either aborting or cutting short an attack of
insanity. Thus there would be an actual decrease in the num-
ber of insane individuals.

(2) Numerous fatalities — suicides and homicides — would
be prevented by the timely commitment of individuals suffer-
ing from acute attacks of insanity.

(3) The asylums proper, in contradistinction to psychiat-
rical hospitals, would be relieved of many of the more trouble-
some cases and would, therefore, be much better fitted to carry
out their appropriate work.

CHAPTER VII

GENERAL CAUSES OF INSANITY

The study of the etiology of mental disease is bound up
with that of the most difficult problems in medicine. The in-
vestigator, as a rule, does not have to deal with causes which
are immediately operative, but rather with those whose action
is delayed and prolonged, it may be, over a number of years.
Frequently the individual does not come under observation
until the original cause has ceased to operate and a condition
so complex has developed that it is impossible to determine the
essential factor or factors in the etiology. Unfortunately, the
study of the mental functions of the normal individual has not
been of the character to be of great aid to the alienist in
attempting to analyze the disturbances grouped as insanity.
As has frequently been pointed out, clinical observations have
been largely isolated and disconnected, so that no standards
exist by which comparison can be made and early deviations
from the normal mentality detected. Furthermore, the transi-
tion from the normal to the abnormal in the mental life, except
in isolated cases, is slow in its progression ; and even in these
latter instances it is still a matter of* doubt whether a given
individual, who has been perfectly normal mentally, as a result
of some accident can suddenly become afflicted with a definite
alienation. In the etiology of mental diseases, then, we have
to do with an exaggeration of personal idiosyncrasies, with
the accentuation of abnormal traits in character, and with a
more or less complete dissociation of the entire personality.
How far the modifications which take place in the individual
in alienation are due to external and how far to internal causes
it is well-nigh impossible to say. To be able to determine the
operative cause in any case of alienation implies the possession
of some knowledge regarding the exact nature of the transition

178

CAUSES OF INSANITY

179

that takes place in the patient when he passes from the actual
world to the world of imagination in which the insane person
lives.1 Concerning the nature of this change we have no
knowledge. This one fact, however, is obvious, that the vari-
ety of fluctuations in the normal mental life is strongly con-
trasted with the more or less monotonous character of the men-
tal processes in those who are insane.

Again, in many instances, to attain a comprehensive knowl-
edge of the development of a case of alienation would neces-
sitate not only a study of causes, but an insight into the char-
acter and temperament of the individual prior to the appearance
of the mental symptoms. Every psychosis begins with a
change in sensation, temperament, or representation that af-
fects the relation of the individual to his environment. What
the earliest changes are can as yet be only vaguely conjectured.
A rich reward awaits the clinician who will patiently study
the earliest symptoms of imperfect functioning of the cerebral
cortex as they appear in connection with the slight changes in
function of many of the internal organs. As we are still in
ignorance as to the precise manner in which causes operate,
the view of Mobius, that mental diseases should be classed as
endogenous or exogenous, or that of Kraepelin, that we should
speak of internal or external causes, although suggestive, does
not aid materially in the solution of the problems.

Heredity. — There is so much glib talk about the prob-
lems of heredity that the uninitiated are led to believe that a
great deal is definitely known regarding the transmission of
normal and abnormal mental traits; indeed, many alienists
fail to appreciate our limitations in this respect. At present
we do not possess an accumulation of carefully collected clini-
cal data from which it is justifiable to draw any really valuable
deductions, nor can the meagre facts recorded in the average
clinical history be analyzed in such a way as to make clear
their bearing upon the biological problems under discussion.

1 Tiling, Th. : Zur Aetiologie der Geistesstorungen. Centralbl. f. Ner-
venheilk. u. Psych., 1903, September, Bd. xiv.

180 PSYCHIATRY

Moreover, a little practical experience will readily convince
the investigator that the data connected with the supposed
transmission of mental traits, that can be gleaned by the alien-
ist, are generally far too vague to merit serious consideration.
No doubt, inquiries concerning the mental traits and charac-
teristics of the ancestors of those afflicted with alienation often
bring to light interesting information about the environment
in which the patient has been born and brought up, but any
attempt to deduce therefrom conclusions as to the quality or
quantity of natural mental capacity that may be said to be
transmitted from the individuals of one generation to those of
the next will at once prove unsatisfactory. Such an investi-
gation must necessarily deal with a number of indefinite fac-
tors. What is born with the individual? What happens to
him after birth ? 2 These are the two main problems, in-
volving many others, which call for immediate solution, and
to obtain a satisfactory answer to each of these careful in-
vestigations along many different lines are necessary. Broadly
speaking, then, we distinguish between the so-called original
traits or inherent qualities, that are the result of influences
which have acted prior to birth, and the secondary or post-
natal characteristics that result more immediately from en-
vironment and education. It is readily seen that essential
points in the discussion of the first question are hard to arrive
at, and the little information obtainable frequently comes to
us second-hand and is obscured by so many other factors that
it becomes almost impossible to form even a conjecture as to
what mental characteristics can be attributed to transmission
from the ancestral line. Koller 3 examined the family histories
of 370 perfectly sane individuals and found evidence of mental
deterioration among the progenitors in 59 per cent, of the
cases, whereas for 370 insane persons the hereditary factor was
present in 76.8 per cent. The mere citation of these figures is

2 Thorndike, Edward L. : Educational Psychology. New York, 1903.

3 Koller, Jenny : Beitrag zur Erblichkeitsstatistik der Geisteskranken
im Kanton Zurich, etc., Arch. f. Psych., xxviii.

CAUSES OF INSANITY 181

sufficient to show how careful investigators should be in basing
deductions as to the relative importance of " a bad family his-
tory" upon any series of figures which have not been subjected
to the severest form of critical analysis. Again, the difficulties
involved in the discussion of the problems relating to the in-
heritance of mental traits are far more complex than those
encountered in dealing with the transmission of mere physical
qualities ; and they are still further increased when an attempt
is made to determine the relation of these questions to clinical
problems, since in order to arrive at any sound conclusions it
is first necessary to have a clear understanding of the patho-
genesis of the various forms of insanity, and, as has been
pointed out elsewhere, this latter field is still unexplored.

Perhaps a concrete example may serve to bring out some
of these difficulties. Morgan 4 has referred to the classical ex-
periments of Brown-Sequard in which epilepsy appeared in
animals born of parents rendered epileptic by an injury to the
spinal cord or by section of the sciatic nerve. At first thought
this evidence might seem to support the Lamarckian hypothesis
of the inheritance of acquired characteristics, but, as Morgan
has pointed out, so little is actually known about the nature of
the disease in question that it is not justifiable to indulge in
any speculation as to the deductions that are warranted from
experiments of this character. During uterine life so many
possible factors may be operative that the appearance of post-
natal epilepsy can not as yet in any sense be considered evidence
of the immediate transmission of an acquired defect. Epi-
lepsy, which may very properly be taken as a prototype of
alienation, is not in any sense an entity, but a condition or
symptom-complex, and may be the result of a great variety of
causes, and the same is true in regard to all the various psy-
choses which represent more or less indefinite complexes and
in which the possible effects of a multiplicity of etiological
factors have to be taken into consideration. In the description
of physical conditions we possess standards of measurement

4 Evolution and Adaptation. New York and London, 1903.

1 82 PSYCHIATRY

which are exact and which may be stated in figures ; whereas,
in the consideration of mental traits comparative estimates vary
greatly, as the result not only of the personal equation, but
also of the conditions under which the observations are carried
on. Even if it were possible to establish certain standards by
which the mental capacity of the members of a family could
be measured, the departures from that standard could be the
result of so many different conditions that in the final analysis
the observer would be practically unable to put his finger upon
the particular facts or factors concerned. Take, for example,
a family which for several generations has resided in a small
country town and in which, as each new generation has ap-
peared, the same factors have been operative in moulding the
mental and physical development along certain lines. If now at
the end of a given time this family removes to a large city, or if
in any way the immediate environment is suddenly changed, so
many exigencies arise and so many new conditions at once be-
come operative that it is impossible to enumerate the agencies
which maybe potent in affecting the development of the children
born in the new environment. The same difficulties arise even
when the transmission of traits, not from remote ancestors
but directly from the mother to the child, are under discus-
sion. The action of environmental influences — anaemias, toxic
agents, and the like — can not always be recognized and defi-
nitely distinguished from the other forces affecting the life
of the organism. At present the majority of biologists declare
that we have no direct indubitable evidence that substantiates
the Lamarckian view. It only remains, then, for us to confess
our practical ignorance concerning the immediate problems con-
nected with the acquisition of mental traits and their trans-
mission to a line of descendants, and our inability to measure
with any precision how far acquired conditions of general
health produce changes in the germ plasm and to what degree
such changes influence mental qualities in the offspring.

The so-called personal predisposition of certain indi-
viduals towards mental disease is of great practical interest.
As we have already seen, this tendency seems to be the result

. CAUSES OF INSANITY 183

of a number of factors which at present can not be successfully-
interpreted, although the opportunities for studying such phe-
nomena are numerous. In pronounced types of the so-called
cumulative or convergent hereditary predisposition the physical
or mental degeneracy is said by some observers to be found in
both the paternal and the maternal ancestry. In the unilateral
type the degeneracy appears either on the maternal or the pa-
ternal side.

Atavistic Heredity. — Tanzi and Riva affirm that an ata-
vistic tendency is very important in certain forms of degen-
eracy, and becomes apparent in a marked predisposition shown
by members of a family to outbreaks of alienation. According
to these observers, in this form certain signs of nervous or
psychopathic degeneracy have apparently persisted through a
number of generations and have finally become so accentuated
that the individual concerned seems to be reduced to the primi-
tive state from which the race has shown a slow evolution.
This form of heredity has been particularly emphasized by the
anthropologists, — Lombroso and others, — and this so-called
cumulative tendency is supposed to satisfactorily account for
the ferocity of certain criminals, as well as for the fact that
many of these low instincts have a tendency to become perma-
nent in certain families. Another important feature lies in the
fact that the reappearance of morbid traits in the line of the
descendants may be either simple or transformed (homomor-
phous or heteromorphous). Thus when the same form of
degeneracy or psychosis appears it has a tendency to recur
practically unchanged in the descendants, whereas the trans-
formed type is characterized by a complete change in the form
of the degeneracy or psychosis. Since the days of Morel 5 the
importance of the so-called hereditary degeneracy has been
emphasized by numerous investigators. Morel himself holds
that the law of transmitted degeneracy is more or less definite
and is capable of being formulated somewhat as follows: In

5 Traite des degenerescences physiques, morales et intellectuelles de
l'espece humaine, 1857.

^ psychiatry

the first generation we have a nervous temperament and ethical
and moral defects ; in the second a tendency towards apoplec-
tiform seizures, severe neuroses, or alcoholism; in the third,
marked psychic disturbances, suicidal manias, and intellectual
defects; in the fourth, idiocy, imbecility, and other anomalies
in development are noted. Nevertheless, it must be said that
in view of the great complexity of the problems involved such
a definite formulation must necessarily be merely conjectural.
Piercani 6 examined the family histories of 1958 persons, — 1064
males and 894 females, representing 889 families, — and came
to the following conclusions : The occurrence of disease in the
father or mother seemed to have a more serious effect upon the
male than upon the female descendants. The " cross-heredity"
is apparently more marked between mother and son than be-
tween father and daughter. Wiglesworth 7 examined 2445
cases of mental disease with a special view to determining the
relative importance of the hereditary factor, and concluded that
it was present in 28 per cent, of all the cases, but was less fre-
quent in men than in women. Where the mother had suffered
from alienation, and where there were both sons and daughters
among the descendants, the latter were more commonly af-
fected than the former. Our own observations do not confirm
the experience of other alienists that the daughters are less
prone than the sons to show signs of mental aberration when
the father has been insane.

Consanguineous marriages are said to be often followed
by anomalies in the children. Thus, in a family observed by
Mathieu,8 which consisted of 43 descendants of parents who
were blood relatives, 10 were described as " peculiar," 3 as
fools or idiots, 3 were deaf-mutes, and 1 committed suicide.
Howe studied 95 children, the issue of consanguineous mar-

8 Ulteriore contributo alio studio delle leggi che regolano la ereditaria
psicopatica. Atti dell' XI Congresso freniatr., Ancona, 1004.

7 The Presidential Address delivered at the Sixty-first Annual Meeting
of the Medico-Psychological Association, held at Liverpool on July 24, 1902.
The Journ. of Ment. Science, xlviii, p. 611.

* Gaz. des Hop., 1890, p. 1260.

CAUSES OF INSANITY

185

riages, and found that 44 were idiots. The world's history-
affords interesting examples of the importance of the unfor-
tunate results that follow too close and frequent intermarriages
between relatives.

The importance of the hereditary factor varies, not only
in different countries, but also in different races and in different
social states. Thus, for example, its significance is undoubted
in aristocratic circles, in classes where the marriages are largely
confined to individuals of the same social and intellectual stand-
ing, and among certain races or sects, such as the Jews or
Quakers. In this connection, however, it has been questioned
whether the mere inbreeding of families in itself necessarily
gives rise to deterioration, provided there is no sign of degen-
eracy in either of the parents.

The evidence respecting heredity as a factor varies greatly,
but its influence would appear to be very pronounced in certain
psychoses, such as alcoholism, manic-depressive insanity, and
epilepsy, whereas in other maladies, such as the arterio-
sclerotic insanities and the senile psychoses, it is likely to be
comparatively unimportant. As regards the so-called signs of
degeneracy, it is probable that alienists, have gone too far and
have drawn too sweeping deductions, and we are now begin-
ning to see that the use of the term needs to be qualified in each
individual case. Broadly speaking, the signs of degeneracy
may be grouped under two heads : ( 1 ) the somatic and (2) the
psychical. In the first group we meet with a variety of mani-
festations which indicate interference with development, and
are most marked in the defect psychoses. Among these may
be mentioned epileptiform seizures, attacks of severe neuralgia,
a tendency to sexual and alcoholic excesses, anomalies of den-
tition, intolerance for alcohol, and various forms of paralysis,
either limited or more or less general in character. The vari-
ous forms of psychic degeneration are manifold. They include
an excessive impressionability, a tendency towards the develop-
ment of hallucinations and delusions whenever the bodily re-
sistance is at all lowered, anomalous affective states, excessive
development of the imagination, a tendency to lie, and not in-

jS6 psychiatry

frequently the various imperative processes, impulses, phobias,
and so on, all of which symptoms are generally characterized
by a certain degree of periodicity, becoming more marked when
the individual is obliged to live in an atmosphere which throws
too great a strain upon his nervous organism.

What is greatly needed in the investigation of the ques-
tion of the hereditary transmission of mental diseases are care-
fully planned and executed studies of the family histories of
those suffering from alienation, carried through not one but
over several generations. As the question of environment is
such a difficult one to eliminate, it is better that for the present
only those patients be selected who have come from communi-
ties in which there has been comparatively little change in the
habits of life or general social conditions in which they have
been born and brought up.

The family histories on the following page, tabulated by
Dunton, while giving an important clue as to the previous
environment in which the patients were born and bred, do not
offer sufficient data upon which to base any theory in regard
to the direct transmission of alienation.

Environment. — In this connection a great variety of
different factors directly or indirectly provocative of alienation
may be referred to. It is a matter of common observation that
mental disorders show marked variations in type among indi-
viduals of different nationalities. An excellent example can
be obtained from a study of the various forms of alcoholism.
Thus, in southern Italy acute alcoholism is practically un-
known, and it is only as one travels northward and the climatic
conditions change that there is a notable increase in the num-
ber of the acute psychoses resulting from this form of intoxi-
cation. Again, general paresis is found much less frequently
in warm climates than in those in which the changes of tem-
perature are greater. In certain countries, such as Abyssinia,
even where the percentage of syphilis among the natives is
very high, cases of general paresis are almost unknown. More
than one observer has called attention to the fact that there are

CAUSES OF INSANITY

187

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essential differences to be noted in regard to the various types
of mental diseases which are found in America as compared
with those in Europe. Thus White 9 has recently shown that
the types of alienation vary in different parts of the United
States; and the observations made by members of the staff
at the Sheppard and Enoch Pratt Hospital would seem to indi-
cate that the incidence of cases which resemble Meynert's
amentia is greater than that noted in certain clinics abroad,
particularly at Heidelberg, where this symptom-complex seems
to be comparatively infrequent. Again, the statistics of
Vienna, when compared with those of Heidelberg, show a more
frequent occurrence of this form of alienation in the Austrian
capital. The several mental disorders which are the result of
drug intoxications other than alcoholism naturally vary in
different localities. Thus, for example, it is not surprising to
find that cocainism is more prevalent in the countries in which
the drug is indigenous or that the psychoses associated with the
eating and smoking of opium and the indulgence in the use of
hashish are more common in the East. The frequency with
which purely functional disorders, such as psychasthenia and
epilepsy, are met with varies greatly in different parts of the
world, while certain curious symptoms, such as Latah, or the
phenomena of " running Amok," as found among the Malays,
are almost entirely confined to certain localities.

Not only are different environments productive of certain
more or less specific forms of alienation, but the change from
one to another may be followed by equally unfortunate results,
causing outbreaks of insanity among those who are mentally
or physically unable to properly adjust their lives to the new
surroundings. Instances of this influence are often noted in
connection with persons who have left their homes to take
up their residence in foreign countries. Mental disturbances
of a more or less peculiar character are noted in the English
people who spend portions of their lives in India, as well as in

* Geographical Distribution of Insanity in the United States. Journal
of Nervous and Mental Diseases, May, 1903.

CAUSES OF INSANITY 189

Americans who migrate to tropical climates. The outbreaks
of insanity among our soldiers in the Philippine Islands present
problems that deserve careful consideration.

The subject of environment also necessitates the discus-
sion of local differences as well as the more immediate sur-
roundings which an individual creates for himself. The types
of alienation differ even among individuals who live in the
same locality. Thus the negroes and the whites living in the
same State will show certain differences in the types of mental
disorders from which they suffer. Again, members of the Jew-
ish race, no matter where they live, are generally thought to
be particularly susceptible to nervous and mental diseases.

Sudden changes in environment occurring to individuals
or whole races are frequently followed by an outbreak of alien-
ation. Statistics show a great increase in the number of men-
tal diseases following the sudden acquisition of wealth either
by individuals or by communities. It is true that the excep-
tional man may be able to withstand sudden changes in his
environment, but for the mentally unstable individual any
marked and rapid alteration in his surroundings, whether it
be in the nature of an elevation or lowering, is unquestionably
associated with great danger. These undoubted facts demand
the earnest consideration of those who are striving for the
so-called elevation of the masses. To " hasten slowly" may
in the end prove to be the kindest method.

Another important element in the causation of alienation
is the great tendency shown to leave the country and congre-
gate in cities. But while the dangers of too great centralization
can hardly be overrated, it should not be forgotten that
many persons who live in the country create for themselves an
artificial environment and live in a manner which is quite as
detrimental to their mental welfare as is the life of the indi-
vidual in a crowded city. Monotony as well as over-excitement
is provocative of mental disorders. There can be little doubt,
however, that every social movement which tends to check the
enormous increase in the population of the cities and to send
many back to a rural life deserves to be encouraged.

190

PSYCHIATRY

The various conditions associated with the individual's
daily life and work are also of importance in this connection.
Here we find a great variety of causes operative which pre-
dispose towards alienation. As has been mentioned elsewhere,
it has long been a matter of observation that workers in lead
and various other toxic substances show a marked tendency
towards the development of alienation.10 In fact, nearly every
form of occupation has its own especial dangers for the indi-
vidual who is weakly and who has inherited or developed a
tendency to succumb to nervous or mental strain.

As far as the professions are concerned, it has long been
generally recognized that those which tend to develop the emo-
tional life at the expense of the other faculties have special
dangers of their own. Thus artists and musicians, who have
allowed their lives to become too one-sided, are often found
to possess an unstable mental equilibrium.

The effects of environment in the production of fatigue
are considered elsewhere. Provided the individual is placed in
hygienic surroundings and receives proper nutrition, it may
be said that hard work — if anxiety and worry are eliminated
— never results in alienation. On the other hand, individuals
who have no regular work and no incentive in life readily be-
come a prey to nervous and mental disorders ; nor need we go
far to seek for an explanation for the great prevalence of men-
tal disturbances among the tramp class, as well as among the
well-to-do members of society who are without definite occu-
pation.

Imitation and Suggestion.11 — In the history of the
human race the phenomena included under these two terms
have played a most important part, but here only their relation
to mental disorders will be discussed. The so-called epidemic
psychoses that were of so frequent occurrence during the Mid-

10 Meillere, G. : Le Saturnisme. Etude historique, physiologique,
clinique et prophylatique. Paris, 1903.

11 V. Bechterew : Suggestion u. ihre sociale Bedeutung. Deutsch von
Weinberg. Leipzig, 1899.

CAUSES OF INSANITY

191

die Ages have deservedly attracted the attention of physicians
as well as the laity. These manifestations develop in connec-
tion with the social, religious, and political life of peoples, and
at a time when the true nature of mental disorders was not
understood, it was thought that a direct transmission of thought
and energy through the agency of unseen powers took place.
But even as early as the fifteenth or sixteenth centuries there
were a few intelligent physicians who recognized that the pro-
nounced psychoses, such as melancholia and mania, never ap-
peared in epidemic form, and to-day it is generally agreed that
alienation is not capable of being spread by mere imitation or
suggestion.

The folie a deux is occasionally seen, two or three, but
never more, members of the same family being afflicted. These
rare cases of so-called psychic infection are only observed
where individuals are in constant communication with insane
patients. Thus, two friends occupying the same room, two
members of the same family, more especially two brothers or
two sisters or a brother and a sister, sometimes become insane
almost at the same time. A similar misfortune has occasion-
ally been known to afflict both husband and wife. Such forms
of mental disturbance never occur except in hereditarily pre-
disposed individuals, and the alienation which results is usually
one of the more chronic types. Probably the majority of cases
reported as instances of psychic infection are erroneously clas-
sified, since in reality no transmission of the disorder has
occurred, but it has merely happened that the same etiological
factor has been active in both cases. Certainly, the cases of
so-called conjugal dementia paralytica are not to be classified
in this category.

As the etiology of mental disorders has become a subject
for more exact study and investigation, it has been found neces-
sary to define as nearly as possible in each individual case a
series of phenomena that are designated as suggestive. As the
clinical facts have gradually been gathered together, it has been
discovered that not one, but a great variety of conditions may
give rise to the manifestations belonging to what is termed

192 PSYCHIATRY

suggestion. To Charcot and his scholars we owe a great debt
of gratitude for first taking the investigation of these phe-
nomena out of the hands of those who were actuated by super-
stition and fear or guided by a merely speculative philosophy.
As a result of the influence of the French school, psychologists
and alienists began to give this subject the attention it de-
served. Unquestionably, many of the great movements in
religion, politics, and sociology have been the immediate result
of the suggestibility among races, nations, or sects. The per-
secutions in the Middle Ages of those who were supposed to
be possessed, the burning of witches, and in more modern times
Mahdism, Dowieism, Christian Science, the remarkable ser-
vices and revival meetings of certain religious sects, anarchism,
and a host of other social and political fads can be traced to
this origin. Friedmann believes that the fundamental psycho-
logical defect is not an affective one, but that the character of
the representation or the idea in consciousness is the essential
dynamic force. Hellpacht 12 affirms that suggestibility may
be regarded as an evidence of quantitative disproportion be-
tween the emotional state and its expression, the latter being
more or less impaired. This disparity is eminently character-
istic of the hysterical individual.

In attempting to determine whether a given case is one
of so-called induced insanity we have to distinguish between
a variety of different conditions. In the first place, induced
insanity, in the sense in which the term is often used, may be
said to be present when alienation develops in an individual
who has been for a more or less prolonged period of time in
close contact with a patient suffering from insanity. The alien-
ation is of the same type in the second as in the first patient,
and continues after the two individuals have been separated.
Such examples, however, are but rarely met with.

Much more frequent in occurrence is the second form, in

" Hellpacht, Willy : Analytische Untersuchungen zur Psychologie der
Hysteric Centralbl. f. Nervenheilk. u. Psych , 1903, Dezember, N. F., Bd.
xiv, S. 737.

CAUSES OF INSANITY 193

which an individual who has exhibited a marked predisposition
towards nervous or mental disease shows symptoms of insanity
immediately after having been brought into contact with a
well-defined case of insanity. This type is well represented in
many forms of hysteria or the paranoioid states, as well as in
the so-called conjugal insanity where both man and wife suffer
from mental depression.

In a third form individuals who have already shown signs
of insanity imitate the symptoms of the patients with whom
they are brought into contact. This is particularly noticeable
in cases of hysteria and dementia praecox.

Finally, normal individuals who have been continuously
associated with persons suffering from mental disease occa-
sionally acquire certain idiosyncrasies of character and tem-
perament. Instances of this are not uncommon among asylum
attendants and care-takers of insane patients.

Sex.13 — Difference in sex is generally supposed to play
an important part in the pathogenesis of alienation. In the
consideration of this question it is essential to distinguish be-
tween what may be called the innate differences between the
male and female and those that are the result of environment
and education. Although a great deal has been written regard-
ing the so-called primary distinctions, very little is definitely
known about them, and the problem is one which needs to be
much more carefully investigated. Until the years of puberty,
however, it may be said that no very marked differences as
regards innate mental qualities exist between boys and girls.
The fact that from time immemorial it has been the cus-
tom to treat the two sexes differently makes it still more
difficult to decide what has been inborn in either sex and what
has resulted from environment; nor can we expect that the
work so far done by the psychologists will give us much aid
towards solving the problem. Nevertheless, some little might
be learned from a long series of observations, conducted by

" Ellis, H. : Man and Woman. London, 1894. Mobius, P. J. : Gesch-
lecht u. Krankheit — Geschlecht u. Entartung. Halle, 1903.

13

194

PSYCHIATRY

carefully trained observers, upon the development of normal
children, under such conditions that the factor of environment
could be reduced to the minimum. After puberty, however,
in normal types easily recognizable differences in the mental
powers of the two sexes develop, but how far these changes
are the result of innate qualities and how far the result of
environment and training it is impossible to say. The impor-
tant part that puberty plays in mental development has been
recognized by the laity as well as by scientific investigators.14
Although many important facts have already been brought to
light regarding the physical and mental changes which occur
in males and females at this period, there are still many points
which need further elucidation. Differences in climate, in
race, and in social conditions, and a great number of other
important factors must be taken into account before it is pos-
sible to make any very broad generalizations. The premature
onset of puberty, which frequently happens in the Southern
races, is certainly of significance in the pathogenesis of various
nervous and mental disturbances. On the other hand, the delay
of puberty points to retarded development, and inasmuch as
the growth of the individual depends upon so many various
factors, it becomes apparent that the discussion of this whole
question involves the consideration of a series of complex prob-
lems, for the solution of which the mere appearance or absence
of certain sexual characteristics offers nothing final. The
physical changes that are associated with puberty are largely
influenced by the general nutrition of the individual boy or
girl, and any deficiencies in metabolism are apt to be followed
by retarded or faulty development. Nothing is more common
in anaemic girls than to find that the period of puberty has been
delayed. Unfortunately, the laity and even physicians too
often attribute the various forms of nervous breakdown which
occur at this time solely to the absence of the menses, whereas

" Marro, A. : La puberte chez l'homme et chez la femme, etudiee dans
ses rapports avec l'anthropologie, la psychiatrie, la pedagogie et la sociol-
ogie. Traduit sur la deuxieme edition italienne par J. P. Medici. Biblio-
theque des sciences anthropologiques, i. Paris, 1902.

CAUSES OF INSANITY

195

in reality the amenorrhcea is merely one of the symptoms of
a general constitutional disturbance.

At this period, when the diverging sexual characteristics
are becoming fully developed, the influence of heredity, alco-
holism in the parents, of poverty, malnutrition, and affective
disturbances become of even greater importance than they have
been before, especially as regards the development of the men-
tal functions. We not infrequently meet with emotional dis-
turbances of varying degree which may ultimately give rise to
nervous and mental symptoms of considerable significance.
The exact causes of these anomalies are not definitely known,
but alienists have long been accustomed to speak of the puberty
psychoses or of the insanity of adolescence as if there were
specific forms of alienation occurring at this period.

Between the years of puberty and the time when the
woman is no longer capable of bearing children she is much
more predisposed to mental disturbances than the average man.
This condition of affairs naturally depends upon the nervous
and mental disturbances associated with pregnancy and par-
turition, or, on the other hand, with sterility and its underlying
causes. A similar predisposition also becomes manifest at the
approach of the menopause, although it must be insisted that
the real tendencies towards mental breakdown that exist at this
time are greatly intensified by the promulgation of popular be-
liefs and superstitions which have little foundation in fact. It
is a matter of clinical experience that, as a rule, a woman is
more predisposed towards mental depression than a man.
Nor is this unnatural when we take into consideration the fact
that she has less independence, and if obliged to earn her living
has greater difficulties to overcome. This explanation, how-
ever, offers only a partial solution of the phenomena.

In cases of manic-depressive insanity, as a rule, it may
be said that the periods of depression are longer and more
intense in the female than in the male, whereas the symptoms
of excitement and exhilaration are less frequently met with.
In other psychoses we also encounter certain differences in
the type of the disease which seem to bear some relation to

196 PSYCHIATRY

sexual differences. For example, in dementia paralytica the
classical type of the disease is almost never met with in women,
in whom it appears almost always in the depressed form. As
a matter of fact, this disorder is comparatively infrequent in
women, especially those of the higher classes, the majority of
female paretics coming altogether from the lowest elements
of society.

Age. — The great majority of cases of alienation come on
during the prime of life at a period when the individual is
exposed to the greatest stress and strain. Nevertheless, besides
the defect psychoses, various acute, subacute, and chronic men-
tal disorders are sometimes met with even in very young chil-
dren. Thus, hysteria is not very uncommon in the very early
years of childhood, and competent observers have reported de-
lirious states occurring during infancy. Every teacher in the
public schools meets with children, even among the very .young,
who show marked anomalies in conduct, and who are generally
regarded as bad characters or as more or less incorrigible de-
linquents and a menace to their fellow-scholars. These chil-
dren are sometimes referred to by medical writers as degener-
ates or mentally ill-balanced.

In addition to the hysterical states the psychic epilepsies
are not at all uncommon in young children. Thus, Pick 15 has
recently called attention to an important psychoneurosis occur-
ring in the earlier years of life which has certain characteristics
suggestive of epilepsy, and says that the children afflicted in
this way show symptoms of so-called wandering mania (poro-
mania or dromomania) associated with signs of episodic emo-
tional irritability, mental dulness, wilfulness, and impulsivity.
In addition to states characterized by the more pronounced
symptoms of alienation we meet with a variety of manifesta-
tions which should at once lead the physician to suspect the
existence of anomalies in the functioning of the central ner-
vous system. We are often told that an individual, who later

15 Pick, A. : Ueber einige bedeutsame Psycho-Neurosen des Kindes-
alters. Halle a/S., 1904.

CAUSES OF INSANITY

197

has shown symptoms of alienation, was unusually bright dur-
ing the earlier years of life, whereas, as a matter of fact, ob-
servations which have been made upon this point in nowise
confirm the correctness of this popular opinion. Healthy boys
and girls are far more apt to show exceptional mental qualities
than those who later in their careers break down mentally
(Thorndike).

From the onset of puberty until the first symptoms of old
age begin to make their appearance the number and variety of
mental diseases increase greatly, largely because during the
prime of life the individual is subjected to the severest tax
upon his mental as well as upon his physical powers. The
conditions which in women during this period are particularly
apt to give rise to mental breakdowns are referred to in an-
other section. In males we find a great difference in the inci-
dence of the several types of alienation. Thus, men from
about 35 to 50 are much more subject to general paresis than
at any other period of life. As old age comes on the types of
mental disorders are different from those in earlier life, since
they are associated with certain degenerative changes in the
central nervous system that are apt to lead to the production
of a more or less characteristic group of clinical symptoms
belonging more particularly to forms of the so-called senile
alienation. The relative frequency of incidence at the various
ages will be considered in fuller detail in the discussion of the
several groups of mental diseases.

Education. — If a training in pedagogics gave teachers
a clearer and more practical insight into actual life as well as
some appreciation of the beginning pathological tendencies of
humanity, many failures would be avoided and many difficul-
ties would be overcome (Von Krafft-Ebing). The instances
in which a profession ill adapted to the individual capabilities
is chosen would be less frequent, and thus the mental life of
numbers would be preserved intact. There is probably no
greater fallacy than to regard the education given in our public
schools as a cure-all for the many deficiencies of our social and
political system. Unquestionably, much good may be accom-

198 PSYCHIATRY

plished in the attempt to educate the masses, provided some
selection is made in the choice of those who are to be given the
advantages of a school training. That the enormous increase
of nervous and mental diseases, one of the most serious men-
aces to the public welfare, is the immediate result of trying to
educate numbers of individuals whose central nervous systems
are functionally unable to withstand the strain imposed upon
them, is obvious to all those who are competent to judge of
such matters. If the aid of intelligent physicians were sought
in determining the question as to what children were fitted to
receive a public school education, unquestionably many cases
of insanity which develop later in life would never occur. It
is a curious comment upon popular government that so little
effort is being made along these lines, and that, while the pub-
lic has the right to prevent the spread of measles or scarlet
fever, it assumes no authority in matters relating to the pre-
vention of alienation. Only in certain Continental cities is
any effort being made to limit the advantages and risks of edu-
cation in the public schools to those who have sound bodies
and sound minds, and nowhere have these questions received
the attention they deserve.

The first duty of the educator should be to determine the
latent capacity of the individual and then adapt the training
as far as possible to meet the needs of the developing nervous
system. To render it possible for an individual who is physi-
cally and mentally unfitted for the stress associated with the
effort to undertake the acquirement of what is termed a liberal
education should be regarded as an offence against the public
health and morality no less culpable than if one were to deliber-
ately place him in an environment where he is exposed to an
infectious disease. What particular form of education is best
adapted to the average child? How far should the negro be
carried in his schooling? Of what degree of mental activity
is woman capable without impairing her physical vigor ? These
are not questions that can be solved by mere amateurs, but
involve problems calling for the earnest consideration of those
who are at least familiar with the methods of investigating the

CAUSES OF INSANITY

199

difficulties connected with the functional activity of the cen-
tral nervous system.

It is much to be regretted that some of the ill-directed zeal
which seeks to impose needless restrictions upon proper experi-
mentation upon the lower animals cannot be directed into chan-
nels where it will serve to prevent educational faddists from
inflicting irreparable injury upon the brains of those who are
intrusted to their care. Quite as much technical skill and ex-
perience is required to form a correct estimate of the functional
capacity of the brain as to determine whether the heart or lungs
are normal ; and the ignorance upon these topics displayed by
those who are supposed to be authorities upon questions of
education is greatly to be deplored.

Fatigue.16 — Recent investigations have shown that the
manifestations grouped under this term are varied and ex-
ceedingly complex. The mental and physical anomalies com-
monly described as evidences of fatigue are only in part the
result of long-continued activity, since other factors are almost
always present. These symptoms vary considerably, not only
in different persons, but in the same individual under different
circumstances. The mental symptoms of fatigue may be de-
scribed as a weakening of the attention, a lowering in the proc-
esses of associative memory, and disturbances in organic sen-
sibility of an anaesthetic or more generally of a paresthetic
nature. The work of Weygandt17 as well as that of Aschaf-
fenburg, of Patrick and Gilbert,18 of Mosso,19 of Binnet and
Henri,20 Joteyko,21 Mainzer,22 as well as of other investigators,

" Fatigue, Mental and Physical, with Bibliography. Dictionary of
Philosophy and Psychology. Baldwin. New York and London, 1901, vol.

i, P- 374-

" Psychologische Arbeiten, 4, 45.

18 Psychological Review, September, 1896.

"La fattica, 1891.

30 La fatigue intellectuelle, 1898.

21 Joteyko, I. : Fatigue. Dictionn. Physiol., Charles Richet, Paris, 1003.

M Stoffwechselstudien iiber den Einfluss geistiger Thatigkeit und pro-
trahierten Wachens. Monatsschr. f. Psych, u. Neurol., 1903, Bd. xiv, H.
6, S. 442.

200 PSYCHIATRY

has already thrown considerable light upon the genesis of this
somewhat complex group of phenomena. In the light of these
investigations an attempt has been made to study the devel-
opment of the symptoms in various psychoses in which fatigue
is supposed to be an important etiological factor. So far, how-
ever, the results obtained have not been entirely satisfactory,
as it has been impossible to analyze all the various factors
which must be taken into account before any trustworthy de-
ductions are drawn, and consequently any attempt to differen-
tiate the fatigue psychoses from other forms of alienation can
not at present be satisfactory. The work of Hodge and others
showed that after excessive fatigue it was possible to demon-
strate in the ganglion cells of the central nervous system
changes which were supposed to be more or less specific. More
recent investigations, however, seem to render it highly proba-
ble that the effect of fatigue upon the nerve-elements is, largely
at least, indirect, and comes about through the production of
an autointoxication. Not a few investigators have made an
attempt to determine exactly the character of the toxins formed
during the fatigue process, but as yet the results are meagre
and unsatisfactory. Rauke, as long ago as 1865, suggested
that the change in the character of the muscular contractions
might be due to the heaping up in the system of toxic products,
a view which more recently has again been advocated by
Mosso, Schiff, and others. Weichardt 23 conducted a number
of experiments upon mice to determine, if possible, the exist-
ence of a blood-serum containing toxic products the result of
fatigue. He found that no definite results follow the intra-
peritoneal injections of the blood-serum of fatigued mice as
compared with the injection of that taken from normal ani-
mals. In both series of cases fatal results followed the injec-
tion. Practically the same results followed intravenous injec-
tions except that after the normal as well as the serum from the
fatigued animals fat embolism resulted. These results were

23 Ueber Ermiidungstoxine und deren Antitoxine. Munch, med.
Wchnschr., 1904, Januar, Nr. 1, 51. Jahrg., Erste Mitteilung.

CAUSES OF INSANITY 201

still further confirmed by observations upon rabbits and guinea-
pigs. After considerable difficulty somewhat more positive
results were obtained by experimenting with the muscle of
animals which had been previously subjected to fatigue. Here
it was found that if the muscle-plasma of very much fatigued
animals was injected subcutaneously, death resulted after a
period varying from twenty to forty hours. It was further
noted that no fatal results followed when the plasma, before
being injected, was placed in a thermostat for two hours at
a temperature of 560 C, whereas the plasma which was not
warmed but was allowed to stand for forty-eight hours in-
creased greatly in its toxicity. Nevertheless, after being pre-
served for eight days in the ice-chest with the addition of toluol
it had practically lost its toxicity. Weichardt was further able
to demonstrate that by intraperitoneal injections of the toxic
muscle-plasma obtained from fatigued andimals an antitoxic
serum could be derived which apparently neutralized the toxins
produced by fatigue.

Trauma. — The importance of trauma as an etiological
factor in the production of alienation has long been recognized,
although physicians have differed essentially in regard to the
relation of the injury to any special type of psychosis. Grad-
ually it has been generally concluded that there is no specific
psychosis resulting from trauma, although a few clinicians still
describe a symptom-complex which they call a post-traumatic
dementia. About all that can be said upon this point is that
trauma is a predisposing factor to alienation, and that as a
result of a blow upon the skull the brain may become a locus
minoris resistentice. The difficulty of determining the exact
importance of trauma is greatly increased in the case of an
individual who previously has shown a marked predisposition
towards mental disorder or where a history of lues or alcohol
is obtained.

As has often been pointed out, the effect of trauma upon
the cerebral functions is essentially different in infants or chil-
dren from that in adult life. During intra-uterine life or at
the time of labor the skull may be subjected to mechanical

202 PSYCHIATRY

injuries, as a consequence of which hemorrhages from the
cerebral vessels may result with destruction of the cortical
tissue and the production of porencephalic areas, atrophy of
the hemispheres, or irregular development of the cerebral gyri.
Fletcher Beach, in examining 810 idiots, found that in 35 cases
the injury to the central nervous system could be directly re-
ferred to the use of instruments at birth, but also noted that in
216 cases impairment of the psychical functions had followed
difficult labor without instrumental delivery. Kuntzel in 500
cases of idiocy estimated that in 8.9 per cent, forceps had been
used; whereas in 4.5 per cent, a difficult but non-instrumental
delivery was a factor of importance.

Wulff 24 called attention to the impairment of the intellec-
tual faculties following trauma occurring either during intra-
uterine life or at the time of birth, and has traced an imme-
diate connection, in 1436 idiotic children, between the injury
inflicted and the following conditions: microcephalus, adhe-
sions between the dura and skull, between the dura and pia,
between the pia and brain, pachymeningitis chronica, lepto-
meningitis, hydrocephalus externus, hydrocephalus internus,
atrophy, cerebral sclerosis, and porencephalus.

Sperking and Kronthal 25 were among the first to describe
definite histological changes following trauma, consisting in
marked sclerosis with local hyaline and fatty degeneration in
the entire arterial system, particularly in the spinal cord and
brain. In 1897 Koeppen26 referred to the microscopical
changes in the central nervous system following severe trauma
and described a clinical symptom-complex characterized by
memory defects, irritability, and seizures similar to those of
dementia paralytica. This observer believed that these trau-
matic psychoses could be differentiated from dementia para-
lytica by the lesser degree of impairment of the intelligence and
interference with the functions of speech and a retained pupil-

** Allg. Ztschr. f. Psych., Bd. xlix, 1893.
"Neurolog. Centralbl., 1888.

** Koeppen : Ueber Gehirnveranderungen nach Trauma. Ref. im Neu-
rolog. Centralbl., 1897.

CAUSES OF INSANITY

203

lary reflex. Bruns affirmed that the presence of a pupillary
light reflex was pathognomonic of the traumatic cases. Studies
of experimental lesions produced by trauma in animals showed
that marked changes were present in the nerve-cells. Muralt
has described catatonic changes following trauma. Viedenz 27
has carefully reviewed the whole subject, and comes to the
following conclusions:

Injuries to the skull in children are often followed by de-
mentia complicated with convulsive seizures. In some cases in
which the intelligence is well preserved there may be a degener-
ation of the moral sense. Injuries directly affecting the central
nervous system may produce psychoses in adults who have
never shown any predisposition to mental disease; but the
more marked the predisposing factor, the greater the tendency
towards the development of alienation. The mental dis-
turbances may develop immediately after the injury or after
the lapse of an intervening period, during which prodromal
symptoms can usually be detected. A specific post-traumatic
insanity does not exist, although some of the psychoses follow-
ing trauma have certain features in common — changes in
character, irritability, memory defects, and intolerance for alco-
hol. Various types of alienation may be referred to this as the
inciting cause. There is a remarkable similarity between the
clinical pictures of some of the psychic disturbances following
injuries to the skull and certain forms which are? attributable to
alcohol. The pathological changes are rarely characterized by
gross lesions. The changes in the smaller blood-vessels are
marked. No specific alteration in the ganglion cells has been
noted. Rosenfeld 28 has reported 48 cases of hypochondriasis
secondary to trauma, and as a result of his investigation affirms
that the character and severity of the trauma are not the only
factors which determine the clinical features of a post-trau-
matic psychosis. Psychical abnormalities, such as feeble-
mindedness of various degrees or a predisposition to hypo-
chondriacal states, are factors of great importance in the

"Arch. f. Psych, u. Nervenkrankh., Bd. xxxvi, H. 3, p. 863.
^Centralbl. f. Nervenheilk. u. Psych., Bd. xxvi, Nr. 156, 1903.

204 PSYCHIATRY

etiology. The trauma may merely intensify a previously ex-
isting mental deterioration.

Adolf Meyer 29 has suggested the following provisional
classification of the cases of alienation following trauma :

(i) The direct post-traumatic deliria with febrile reac-
tions, the delirium nervosum of Dupuytren, which is not essen-
tially different from the mental aberration following operations
or injuries, and a condition characterized by coma developing
in alcoholic as well as non-alcoholic subjects. And, finally, a
more protracted delirious state, with marked tendency to con-
fabulate, which may or may not be associated with alcoholism
or senility.

(2) The post-traumatic constitution, characterized by the
excessive reaction of the individual to the toxic effects of
alcohol, influenza, etc., a certain type of vasomotor neurosis,
the explosive diathesis, hysterioid or epileptoid episodes, with
or without convulsions, and, finally, a paranoioid state.

(3) Traumatic defect conditions — aphasias, mental de-
terioration with epilepsy and a terminal deterioration due to
progressive alterations of the primarily injured parts, either
with or without arteriosclerosis.

(4) Psychoses in which trauma is merely a contributory
factor — dementia paralytica, manic-depressive insanity, cata-
tonic deterioration.

(5) A grouP °f traumatic psychoses following injuries
not directly affecting the head.

Operations. — Psychoses not infrequently develop in in-
dividuals who have been subjected to surgical operations.
These post-operative alienations present a great variety of
clinical forms, none of which can be regarded as in any sense
specific. An interesting study of these cases from a clinical
stand-point has been made by Picque and Briand.30 In a large
percentage of instances, especially in patients who have been
operated upon while in a weak physical condition, symptoms

29 Anatomical Facts and Clinical Varieties of Traumatic Insanity.
Am. Journ. of Insan., 1004, January, vol. lx, No. 30.
*° Archives de Neurologie, Mars, 1903, No. 87.

CAUSES OF INSANITY

205

of neurasthenia develop, but these forms must be carefully dis-
tinguished from those in which the symptoms of alienation
are marked. To another distinct class belong the deliria which
develop soon after an operation and result from septic intoxi-
cation. Sometimes, however, symptoms of alienation appear
in patients who have recovered from the immediate effects of
the operation, and which cannot therefore be referred directly
to a toxaemia. In such cases the transitory delirium has to be
regarded as an epiphenomenon, the operation, however, being
a factor of some considerable etiological importance. Many
authorities believe that a post-operative psychosis never de-
velops in an individual who has not previously shown some
predisposition to alienation. As a general rule, it may be
assumed that the variability in the mentality of an individual
and his predisposition to insanity are factors of the greatest
importance.

Marriage. — The effects of marriage upon individuals
who are mentally unsound are usually far from good. In the
more chronic cases, it is true, there is sometimes no material
change, but in the great majority of instances marriage is fol-
lowed by a marked exacerbation of the symptoms, culminating
either in an acute outbreak of mania or a profound deepening
of the depression, as the case may be. There is an ill-founded
and utterly unjustifiable belief current among the laity that
many forms of alienation are likely to be benefited by mar-
riage, and, unfortunately, not a few members of the medical
profession have been known to recommend this step in the hope
that some improvement might follow. Such a procedure can
not be too strongly condemned. The literature contains not a
few references to outbreaks of alienation immediately follow-
ing marriage — the so-called nuptial insanity; and Kraepelin
in his text-book has classed the majority of such cases either
among the manic-depressive insanities or the amentias. Ober-
steiner 31 distinguishes two groups of cases : ( 1 ) Those in

11 Ueber Psychoses in unmittelbarem Anschluss an die Verheiratung
(Nuptiales Irresein), Jahrb. f. Psych, u. Neurol., Leipzig u. Wien, 1902.

206 PSYCHIATRY

which a previous existing alienation is made more pronounced
and first becomes recognized by the physician immediately after
marriage. (2) A group of cases in which the symptoms ap-
parently develop primarily. Most of the cases in the second
group occur in nervous run-down females, nearly always be-
tween the ages of 19 and 27. The immediate cause is undoubt-
edly in part due to the sexual excitement following marriage,
although Obersteiner rightly says that several other factors
must also be taken into account. Although the majority of
these cases have been noted in women, nuptial insanity
occasionally occurs in men. Thus in one of our male patients,
whose history is given later on, marriage preceded the outbreak
of an attack of dementia prsecox. In the clinical examination
of these cases it is important to determine whether symptoms
of alienation have not existed in a mild form before the actual
outbreak of the more acute manifestations. The forms of
alienation are varied. In one or two instances acute or sub-
acute confusional delirious states have been reported from
which the patient recovered completely.

Pregnancy and Parturition.32 — The old writers were
in the habit of speaking of puerperal manias and puerperal
melancholias, as if these mental disturbances were in a sense
to be regarded as entities. Recent clinical investigations, how-
ever, have clearly shown that while pregnancy, parturition, and
lactation may be regarded as inciting causes, they are in no
sense to be associated with a specific form of alienation, and
that the mental disturbances cannot be differentiated by any
specific symptoms from those of other psychoses. It is now
generally conceded that practically any form of alienation may
begin during pregnancy, the puerperium, or the period of lacta-
tion. As regards their relative incidence during these three
periods the authorities are not fully agreed, but, making allow-
ance for small differences in percentages, there is a singular
unanimity of opinion among both older and later writers that

n Klix : Ueber die Geistesstorungen in der Schwangerschaft und im
Wochenbett. Halle a/S., 1904. Williams, J. Whitridge : Obstetrics. New
York, 1903.

CAUSES OF INSANITY

207

mental disorders make their appearance more frequently dur-
ing the puerperium than during the period of lactation, and
are still more rare during pregnancy. The following statistics
cited by Klix may be taken as fairly indicative of these views :

_ Puerperium (within T . ..

Pregnancy . , ,. , . . Lactation

six weeks after labor)

Schmidt 17.6 49.3 33.0

Hoche 11.38 46.4 42.18

That normal pregnancy is to be considered a factor of
eminent importance in the etiology of alienation is shown by
the large number of psychoses which appear in association with
childbirth in patients with a bad family history, in the more
recent statistics the figures varying from 47 to 32 per cent.
Moreover, where a marked predisposition towards alienation
exists, the mental break-down is most apt to occur early in
pregnancy, less often at full term or within six weeks of
parturition, and least frequently during the period of lactation.

As regards the age of the patients, it will be seen that
symptoms of alienation appear somewhat rarely in pregnant
women before the twenty-fifth year, but then begin to be en-
countered with increasing frequency, reaching their maximum
incidence between the thirtieth and fortieth years. Of the
cases developing before parturition the majority come on dur-
ing the latter half of pregnancy; and as a general rule the
earlier the alienation becomes apparent during pregnancy the
worse is the prognosis. Most of the post-partum psychoses
come on within the first fourteen days after labor, generally
between the fourth and the sixth day. Regarding the character
of these psychoses and their etiology there is still some di-
vergence of opinion. Some authorities maintain that every
form of alienation occurring during labor or the puerperium is
immediately the result of an infection, but this sweeping state-
ment must be received with caution. In support of this view
is the fact that the psychoses that make their appearance at
this time are almost always accompanied with a rise of tem-
perature and various somatic symptoms, which indicate the

208 PSYCHIATRY

existence of an infectious process ; and, moreover, there is often
a concomitant mastitis, parametritis, pneumonia, etc. But
admitting that many of the cases are referable to some form of
septic infection, it is a noteworthy fact that some psychoses
continue long after the subsidence of the temperature and gen-
eral somatic symptoms. Fiirstner 33 years ago described an
acute hallucinatory insanity of parturition, a form of aliena-
tion which began with a prodromal period of short duration
and was followed by a period of active hallucinosis. Reference
is made to this subject under the head of acute delirium and
amentia, and under these two groups undoubtedly may be
classed a number of the more acute forms of mental disturb-
ance which occur at these periods. The connection of septic
processes with the mental disturbances occurring during the
period of lactation is a subject which needs to be further in-
vestigated. Whenever signs of alienation appear, the possi-
bility of an infection should always be remembered and every
effort should be made either to identify or exclude this factor.
Moreover, it should not be forgotten that fever and the local
septic processes are not always parallel phenomena with the
psychic disturbances, and this fact often increases the diffi-
culty of making a diagnosis. As Klix has pointed out. pro-
found disturbances in consciousness appearing at the beginning
of labor should at once arouse the suspicion of the existence
of a severe septic process or an oncoming eclamptic seizure.
The mental disturbances which occur subsequent to the period
of lactation do not materially differ from other forms of
psychoses and need not be dealt with in detail here.

Anaemias. — In cases of protracted anaemia we meet with
changes in the peripheral as well as in the central nervous sys-
tem. Recently these lesions have been studied in detail for the
spinal cord, and similar alterations are said to exist in the
brain. Not uncommonly anaemic patients evince a marked
irritability, associated with more or less indifference to their

83 Ueber Schwangerschafts- und Puerperalpsychosen. Arch, f . Psych.,
1875, Bd. v, H. 2, S. 505.

CAUSES OF INSANITY

209

surroundings; and although they are apparently hypersensi-
tive for certain stimuli, they fail to respond to others. These
patients are apt to be unsympathetic, to take pessimistic views,
are decidedly anti-sociable in their inclinations, and nearly all
show subjective defects in memory. The cases that have been
reported in which pronounced somatic disturbances, such as an
unilateral facial paralysis, transitory hemiplegic attacks,
aphasic symptoms, the Argyll-Robertson pupil, and disturb-
ances of speech, indicate the action of some etiologic factor
other than anaemia.

The recent literature is full of reports of mental disturb-
ances occurring during the course of pernicious anaemias. The
psychical symptoms are general impairment of the intellectual
faculties characterized by a slight apathy and delay in the
motor reactions. In addition to these defects irritability and
exaltation have occasionally been mentioned.34

The importance of severe anaemia as an etiologic factor
in various forms of alienation, as, for example, in certain con-
fusional states, the so-called collapse delirium and amentia, has
been frequently emphasized. Pontoppidan 35 and Petren,36 in
addition to the symptoms already enumerated, mention deliri-
ous and confusional states which develop in cases of pernicious
anaemia just prior to death. Marcus 37 reports a case in which
the symptoms consisted in a marked irritability with some ex-
altation, followed by depression, diminution of the intellectual
activities, and, finally, marked somnolence. Later the patient
developed symptoms that were similar to those observed in the
classical type of paresis. It is probable that these last mentioned
manifestations are largely referable to the personal predisposi-
tion of the patient towards this particular form of alienation.
It is not at all unlikely that the mental symptoms developing in

** Marcus, Henry : Psychose bei pernicioser Anamie. Neurolog. Cen-
tralbl., 1903, 16 Mai, Nr. io, S. 453.

" Psychiatr. forelaesn. Kjobenhagen, 1892.

88 Ryggmargs forandringar vid pernicios Anami. Dissert., Stockholm,

1895.

"Op. cit.

14

2io PSYCHIATRY

cases of anaemia depend upon some toxin that acts directly
upon the central nervous system.38

Fevers and Infectious Processes. — The part played by
infectious diseases in the etiology of alienation has been dis-
cussed in connection with the fever deliria, and need not be
referred to again in the present chapter. The relation of the
general constitutional diseases, especially tuberculosis, to alien-
ation is also considered elsewhere more in detail. The mental
state of tuberculous patients is one that has received careful
attention from numerous observers. The old belief to the
effect that there is a general euphoria present in certain stages
of tuberculosis is an hypothesis which has not been confirmed
by careful clinical investigation.39 The manner of life and a
great variety of other conditions in a measure determine the
mental state of many tuberculous patients, although a certain
degree of hopefulness even in the face of death is not uncom-
mon. On the other hand, it has been frequently shown that
various forms of alienation — states of confusion with or with-
out hallucinations, insane ideas, exaltation and depression,
motor restlessness, etc. — may be associated with this disease.

The occurrence of tuberculosis in the insane is a matter
of very great importance. Fortunately, the hygienic conditions
which now prevail in many hospitals for the insane and the
introduction of proper clinical methods have resulted in a per-
ceptible reduction of morbidity and mortality from this disease.
The attempts that are being made in our asylums to isolate
tuberculous patients and to keep them as much as possible in
the open air cannot be too highly commended. The great prev-
alence of tuberculosis among patients suffering from certain
forms of alienation — particularly dementia prsecox — has at-
tracted special attention.

The relation of syphilis to mental disease is more fully dis-
cussed in the chapter on alienation associated with organic
diseases of the brain. The importance of this etiological factor

1 Grawitz : Berliner klin. Wchnschr., 1901, Nr. 24.
Letulle : Etude sur la psychologie du phtisique. Arch, de med., 1901.

CAUSES OF INSANITY 211

can hardly be overestimated. It is commonly supposed that
the luetic poison brings about the formation of toxins which
have a markedly deleterious effect upon the central nervous
system. Individual predisposition also seems to be an im-
portant factor in determining the character of the clinical
picture. That the ultimate effects of the poison may be long
delayed becomes evident in such forms of alienation as demen-
tia paralytica, where the first symptoms are noted, on an aver-
age, about ten years after the primary infection.

Although it is highly probable that defective metabolism
plays an important part in the pathogenesis of alienation, little
is known upon the subject. It is only necessary to mention in
this connection the forms of alienation following diseases of
the thyroid gland, the mental conditions associated with Addi-
son's disease, or the various delirious states following disturb-
ances in the gastro-intestinal tract. Further references to this
subject will be found in connection with the discussion of dia-
betes, gout, and changes in the blood in their relation to abnor-
mal mental states.

The important part played by toxic substances introduced
into the organism from without — such as alcohol, morphin,
and lead — and the relation that diseases of the spinal cord and
peripheral nervous system bear to alienation have been more
fully discussed elsewhere under separate heads.

Gout. — Various forms of mental aberration are not infre-
quent in families whose members are sufferers from gout.
Minkowski's40 studies, however, do not bear out the view that
the toxic action of the uric acid, a diminution in the oxidation
processes, or an alteration in the alkalescence of the blood is
the cause of these symptoms. In fact, he states that all the
explanations hitherto advanced are purely hypothetical. The
symptomatology of the milder cases is in a measure character-
istic. The patients, unless their work is done in the open air,
are apt to be irritable and easily fatigued mentally and physi-

40 Die Gicht. Nothnagel's Specielle Pathologie und Therapie. Bd. vii,
Theil III.

212 PSYCHIATRY

cally. In addition to the milder neurasthenic states in gouty
families we not infrequently meet with cases of mental depres-
sion generally associated with neurasthenic or hysterical mani-
festations. More marked psychical disturbances, periods of
excitement, delirious states associated with marked rises of
temperature, have frequently been reported. Of particular
interest are the transitory forms of alienation which follow
an attack of gout. Berthier 41 collected a number of instances
of psychoses in gouty individuals. It is not improbable, how-
ever, as Crichton Brown maintains, that psychoses only occur
in such gouty individuals as have previously shown a predispo-
sition towards alienation. Some of the psychoses which follow
an attack may be either the results of alcoholic or lead ence-
phalopathy or represent true ursemic disturbances. The in-
clination of certain patients to periods of depression or hypo-
chondriasis associated with their gouty attacks does not
necessarily mean that the mental symptoms are specific, since
it is evident that the mere presence of pain or disablement
might be sufficient to account for these so-called gouty depres-
sions. It should always be borne in mind that gout, no less
than any other disease, may be an important factor in the
etiology of insanity without being the sole specific cause.

Diabetes and Glycosuria. — The intimate association
that exists between diabetes and various disturbances in the
peripheral and central nervous system has long been recog-
nized, and nearly all the text-books on medicine give somewhat
full descriptions of the many nervous and mental symptoms
which may be encountered in diabetic patients. That these
disturbances are in part the result of an autointoxication there
seems to be little doubt, but the various theories advanced to
explain the character of the changes in the tissues are by no
means satisfactory. Kussmaul's opinion that the symptoms
might be the result of an autointoxication due to acetone has
not been confirmed either by clinical observation or by experi-
ments upon animals. Equally unsatisfactory has been the

41 Annales Medico-psychologiques, Paris, 1869.

CAUSES OF INSANITY

213

hypothesis that /5-oxybutyric acid, and not acetone, is the
cause of the disturbance. The supposed acidity of the blood,
which was regarded as the immediate cause of the symptoms,
has been practically negatived by the observations of Klemp-
erer and others.

The disturbances of the functions of the brain which may
occur during diabetes are manifold. A mild form of depres-
sion with lack of initiative, extreme mental and physical
fatigue following slight exertion, and a considerable degree of
intellectual torpor are not infrequently noted. The condition
known as narcolepsy — the patient showing a marked tendency
to fall asleep at all times — should also be mentioned. Some-
times the periods of depression are broken by states of motor
restlessness and some degree of exhilaration, and occasionally
we meet with periods of delirium, such as that recorded in the
following history, to which my attention was called by Dr.
Futcher. This patient suffered from active fallacious sense
perceptions, and his case is also of interest in that it shows the
difficulty that sometimes exists in the diagnosis of these con-
ditions.

Johns Hopkins Hospital, Medical No. 9326. General No. 24,955. Male,
aged 48. German. Clerk in commission house. Admitted December 10,
1898. Discharged January 16, 1899. Improved. Diagnosis : Diabetes
mellitus.

Family History. — Negative.

Personal History. — On account of the patient's mental state the history-
was obtained from his friends and was, therefore, somewhat unsatisfactory.
No history of previous severe illness was obtained, except of a malarial
attack lasting two months, a year before admission. As a young man he
was somewhat dissipated, but during the last three or four years he has been
more temperate. There is a history of chancre, but that of a secondary
eruption is indefinite. Recently the patient has been suspicious of his wife
receiving attention from other persons ; but whether any grounds for these
ideas existed is not known.

Present Illness. — In January, 1898, the patient had an attack similar to
the present one and has never been quite well since. At that time a diag-
nosis of Bright's disease was made by his physician. Eight days prior to
his admission to the hospital the patient began to complain of headache and
dizziness. These symptoms were soon followed by disturbances in con-
sciousness and on the day before admission by illusions. For three or four
days prior to admission the patient was very drowsy and slept a great deal
of the time.

214

PSYCHIATRY

Condition on admission: Well built man. Respiration slow and
labored, very irregular in rhythm and fulness. Face quite blue, cyanosis
also marked in hands and fingers. Pulse ioo to the minute ; of small vol-
ume ; tension higher than normal. Eyes : Pupils react equally and readily
to light and accommodation. Lungs : Nothing abnormal. Heart : Area
of cardiac dulness diminished. The second aortic sound is accentuated.
While the patient was being conveyed from the dispensary to the ward he
fell asleep in a chair and could not be aroused. Later, on the same day,
his appearance was suggestive of diabetic coma. A specimen of urine
drawn through the catheter was very acid, specific gravity 1037, showed a
faint trace of albumin, 6 per cent, of sugar, and an abundance of urates.
On December 13 the patient became actively delirious, boisterous, and had
illusions relating, as a rule, to his former profession. Diacetic acid and
acetone were found in the urine. There was no /J-oxybutyric acid in
the fermented urine.

On December 16 the patient was less delirious, but on the 17th it was
necessary to place him again under restraint. On the 21st it was noted that
his condition still remained unchanged.

January 1 : The patient became much more tractable and was able to
talk slowly and fairly rationally. January 2 : The urine was free from
sugar and acetone, but at midnight he became wildly delirious, jumping
up in bed, talking irrationally, and at times being very maniacal. Next
morning (January 3) the patient was again quiet. January 4: Sugar had
reappeared in the urine. January 6 : The patient was perfectly docile and
tractable. On January 9 he had an attack of violent excitement. On
January 14 there was a sudden rise of temperature to 103.20 F. On the
16th he was somewhat quieter and was removed at the request of his
friends to his home. No further notes on the condition of the patient could
be obtained, but it was discovered that he died at some date (not known)
previous to January, 1903.

Another important group of mental cases, sometimes
noted in connection with diabetes, are those described by Lau-
denheimer 42 as instances of pseudo-paresis. In these forms
the disturbances in the attention, defects in associative memory,
occasional interference with the functions of speech and loco-
motion, various peripheral paralyses, and impairment of the
light reflexes render the differential diagnosis from true pare-
sis exceedingly difficult. Generally, however, they can be iden-
tified on account of the improvement in the symptoms follow-
ing the disappearance of the sugar from the urine.

Arch. f. Psych., xxix, 2. Berl. klin. Wchnschr., 1898, 21.

CAUSES OF INSANITY 215

Cardiac and Vascular Disease.43 — Disturbances in the
circulation are not uncommonly followed by or associated with
anomalies in the mental life. Maudsley long ago advanced the
interesting speculation that were the heart of one man placed
in the body of another the exchange would probably not seri-
ously interfere with the circulation of their blood, but might
make a real difference in the temper of their minds; and this
hypothesis would seem to receive daily confirmation from the
observations in the clinic. As Head 44 has shown, the mental
changes associated with anomalies in the heart's action may
be caused by variations in the cerebral blood supply, since we
often encounter a delirious condition associated with cardiac
insufficiency or with changes due to altered vascular condi-
tions. Mental disturbances may be the immediate result of the
anomalies in circulation, or may develop secondarily by lower-
ing the resistance of the organism so that the effects of such
toxic substances, as alcohol or the products of autointoxication,
are less easily combated.

These abnormal mental states connected with disturbances
in the cardiac functions vary greatly in severity as well as in
character. In the milder forms they are limited to slight
changes in the organic sensibility, and the patient merely be-
comes aware of the increased or irregular cardiac action, his
consciousness of it rendering him depressed and restless. In
other states the depression is more marked; the individual

43 D' Astros : Etude sur l'etat mentale et les troubles psychiques des
cardiaques. These de Paris, 1881. Mickle, J. : On Insanity in its relation
to Cardiac and Aortic Disease. London, 1888. Fauconneau : De la folie
d'origine cardiaque. These de Paris, 1900. Huchard : Le cerveau car-
diaque. Bull, med., 1891. Dobrotsworski, S. : Les maladies du cceur
comme cause des psychoses. Conference a la clin. neurol. de Petersbourg,
10 Decembre, Vratch, 1899, p. 318. Fischer, J. : Ueber Psychosen bei Herz-
kranken. Allg. Ztschr. f. Psych., Bd. liv, H. 6, S. 1060. Eichhorst:
Deutsche med. Wchnschr., 28 Juni, 1898. Langdon, F. W. : Cardio-
vascular and Blood States as Factors in Nervous and Mental Disease. Cin-
cinnati Lancet-Clinic, May 7, 1904. Gamble, Cary B. : Johns Hopkins
Hosp. Bull., vol. xv, 1904.

44 Certain Mental Changes that accompany Visceral Disease. Brain,
Part III, 1901, p. 346.

2l6 PSYCHIATRY

begins to be suspicious, sometimes only of certain individuals,
although in other cases this feeling is more general. Not infre-
quently hallucinations are noted in the milder cases, which,
however, are generally recognized by the patient as fallacious
sense perceptions. At first they are apt to be vague in char-
acter and ill-defined, but as the trouble increases or as the ideas
become more persistent, the appreciation of their fallaciousness
may be lost. In some cases, instead of depression, a state of
exaltation or exhilaration is met with. The importance of
these circulatory anomalies in cases of mental depression and
apprehensiveness has been more fully investigated by Rein-
hold,45 and the subject will be again referred to when we come
to discuss senile melancholia. Acute dilatation of the heart
has often been noted in several of the more acute psychoses,
particularly the febrile deliria and the acute delirium and amen-
tia. Recent observations go to show that cardiac changes of
some importance may take place during the acute onset of some
of the chronic psychoses, such as dementia prsecox, manic-
depressive insanity, and dementia paralytica. In the last, as
well as in other conditions, marked changes in the cardiac
muscle are relatively common. The mental disturbances con-
nected with disorders of the vascular system are referred to
more in detail in the discussion of arterio-sclerosis as well as
of certain other morbid conditions — alcoholism, general pare-
sis, the senile psychoses, and others — which are often com-
plicated by marked arterial changes. Evidences of changes
in the superficial circulation are frequently met with in insane
patients. Thus, in cases of dementia praecox the patients have
a peculiar pasty appearance and at times a more or less pro-
nounced degree of cyanosis. In the maniacal states we en-
counter manifestations pointing to the existence of a relaxed
vasomotor condition. Thus a pronounced degree of der-
matographia is not uncommon. The relation of the blood-
pressure to the various mental states has lately been the sub-
ject of painstaking study, but the results thus far published are

45 Munch, med. Wchnschr., 1894, 16.

CAUSES OF INSANITY

217

still open to criticism, and all of these observations must as yet
be accepted with caution. Dunton,46 who conducted his experi-
ments on the changes of blood-pressure in relation to states of
depression and excitement with the greatest possible care, ad-
mits that the instrument with which the observations were
made did not give results which he could regard as entirely
reliable. Indeed, the data obtained are so uncertain that the
blood-pressure records can not, as a rule, be accepted as afford-
ing any definite indications for treatment. In a general way,
however, it may be said that the evidence so far accumulated
points to the existence of a subnormal blood-pressure in states
of excitement and an increase in states of mental depression.
Of course, where other additional factors have to be taken into
account the results are even more unsatisfactory.

Mental Disturbances in Hepatic Disease. — Disturb-
ances in the hepatic functions are not rarely associated with or
followed by aberration.47 A full review of this subject by Bal-
let,48 with bibliography, has recently appeared. The recorded
mental symptoms furnish a great variety of clinical pictures, of
particular importance being the states of somnolence and
stupor that not infrequently develop during the terminal stage
of hepatic disease. In the milder cases the faculty of attention
becomes defective ; actual distractibility, the result of increased
sensory impressionability, is not marked, but the patient seems
unable to direct his mental energies persistently for any given
length of time in one direction. In other words, the attention
is not actively diverted, but as the result of the lethargic condi-
tion simply lapses. In another group of cases where marked
disturbances in the hepatic functions were noted, the patients
were more or less excited and showed evidences of speech com-
pulsion, psychomotor excitability, auditory and visual hallu-
cinations, and more or less indefinite and unstable insane ideas.

** Some Observations upon Blood-Pressure in the Insane. Trans, of
American Medico-Psychological Association, 1903.

" Delaye and Foville: Nouveau Journ. de med., 1821, Septembre.
48 Ballet : Traite de la pathologie Mentale, Paris, 1903, p. 478.

2l8 PSYCHIATRY

Such cases are not to be regarded as the result of hepatic dis-
ease by itself, but of a series of complications. After a period
of brief excitement the patient may pass more or less rapidly
into a state of stupor which generally ends in death (delirium,
coma hepaticum). The hepatic stupor or coma is far less apt
than the uraemic or diabetic form to show evidence of remis-
sion, and a complete recovery seldom, if ever, occurs.49 When
the excitement is of a mild grade and deep stupor does not
intervene, the psychic anomalies may persist for weeks or
months, after which the patients may gradually recover.

Temporary mental disturbances are not infrequently noted
after operations upon the common bile-duct. Dr. J. M. T.
Finney informs me that in the records of ioo operations
upon the biliary passages the occurrence of a peculiar tran-
sitory delirium has been noted in about 10 per cent, of the
cases. These mental disturbances develop during the course
of convalescence after the bile-passages have been drained, and
are apt to run rather a characteristic course, frequently lasting
a fortnight and then disappearing without leaving any re-
siduary mental disturbances. The severity of the condition
varies from a mild temporary aberration, accompanied by diz-
ziness and peculiar sensations in the head, to a wild delirium.
As a rule, the nocturnal exacerbations are marked. The first
symptoms of mental aberration generally appear about the end
of the first week after the operation, and consist in a slight
dizziness or dull feeling, frequently accompanied by mental
depression, confusion of ideas, hallucinations, both visual and
auditory, and various forms of delusions. The symptoms
often develop at the time at which the bile begins to leak
around the drainage-tube and flow over the surface of the
wound, at this time unprotected by granulations. It may be
said that the development of the mental anomalies seems to
bear some definite relationship to the activity of the kidneys,
inasmuch as at the time of the delirium some diminution in

48 Quincke u. Hoppe-Seyler. Die Krankheiten der Leber. Nothnagel's
Spec. Pathol, u. TFerap., Wien, 1899.

CAUSES OF INSANITY

219

the amount of urine passed and the presence of albumin and
tube-casts have generally been noted.

Finney believes that the following conditions play an im-
portant part in the pathogenesis of the delirium :

(1) An abnormal condition of the bile due to derange-
ment of the hepatic functions.

(2) A possible absorption of toxic products from the
presence of bacteria.

(3) A predisposition to nervous and mental disturbances,
causing an increased susceptibility in the abnormal reactions
for certain toxic products.

Undoubtedly many of these symptoms referred to are the
result of an intoxication due to the accumulation in the system
of substances the result of imperfect metabolism. It is diffi-
cult to differentiate the pure, uncomplicated cases of hepatic
disorder from those in which such etiological factors as alco-
holism, syphilis, or tuberculosis are added.

The prognosis depends in a measure upon the nature and
extent of the disease. The toxic products that cause the symp-
toms may be derived from more than one source, and are either
manufactured directly by the liver or absorbed from the intes-
tinal tract. Pathological changes in the liver are noted in
many of the psychoses.

Nephritis.50 — Disturbances in the functioning of the
kidneys are frequently found complicating the course of vari-
ous psychoses and have been made the subject of a special
study by numerous investigators. Although some authors
maintain that there is a specific form of alienation associated
with Bright's disease, the evidence adduced is far from con-
clusive. The abnormalities in the urinary secretion, found

50 Hagen : Des maladies des reins considerees comme causes d'alienation
mentale. Allg. Ztschr. f. Psych, u. psych.-gericht. Medizin, xxxviii, 1.
Bouvat : Essa'i sur l'uremie delirante. Th. de Lyon, 1883. Dieulafoy : De
la folie brightique. Soc. med. d. hop., 10 Juin, 1883. Contrib. a l'etude
clin. et experim. de la maladie de Bright sans albuminuric Soc. med. d.
hop., 11 Juin, 22 Octobre, 1886. Raymond: Sur certains delires simulants
la folie survenus dans le cours des nephrites chroniques. Arch. gen. de
med., Mars, 1882.

220 PSYCHIATRY

associated with psychoses, in the vast majority of cases are to
be regarded as the result rather than the cause of the aliena-
tion. The delirium that occurs in uraemia has certain specific
characteristics which are fairly distinctive, but even in this
connection it is scarcely permissible to speak, as do certain of
the French writers, of a specific ursemic delirium. Although
the urine has been carefully examined in a great variety of
psychoses, no very definite results have been obtained. After
careful analyses in a large number of cases of recurrent mania
and melancholia Pilcz was able to arrive at the following not
very satisfactory conclusions : In many individuals, who dur-
ing the period of remission showed no abnormal condition of
renal secretion, at the time of the attack the urine contained a
variety of abnormal chemical constituents, but the results of
the analyses did not in any sense show anything specific of the
condition. It was, however, found that the characteristics of
the urine during a given period of either excitement or depres-
sion were fairly constant for the same individual.

Gastro-intestinal Disturbances. — Regarding the dis-
turbances in the gastro-intestinal tract and their relation to
forms of alienation very little is known. That the former are
frequently associated with various forms of mental disorders is
a matter of common clinical experience, but the relation that
they bear to the alienation is a matter of conjecture. Von
Wagner51 assumed that in certain forms of acute mental dis-
ease there was an autointoxication due to defective metab-
olism; and the same observer was able to demonstrate the
increase in the urine of indican as well as of acetone. In the
case reported by Raimann 52 the symptom-complex resembling
Korsakow's syndrome was noted in a patient who died and in
whom at autopsy were found multiple lymphosarcomata of the
small intestine. A few other cases somewhat similar in char-

51 Ueber Psychosen durch Autointoxication vom Darm aus. Jahrb. f.
Psych., 1002, xxii, 177.

" Raimann, Emil : Ein Fall von Cerebropathia psychica toxaemica
(Korsakow) Gastrointestinalen Ursprunges. Monatsschr. f. Psych, u.
Neurol., 1002, October, Bd. xii, H. 4, S. 329.

CAUSES OF INSANITY 221

acter have been reported in the literature. That there is a
marked defect in the functions of the stomach and intestines
in very many cases of alienation is a matter of common clinical
experience, as, for example, in cases of dementia prsecox and
manic-depressive insanity. Moreover, milder forms of mental
depression, such as hypochondriasis, are not uncommonly
noted in connection with gastro-intestinal disturbances.

Migraine. — Not infrequently attacks of migraine are
complicated by elementary psychic disturbances.53 In such
cases it is not improbable that the symptoms of mental aberra-
tion are indicative of the existence of a complicating neurosis,
such as epilepsy or hysteria gravis, and are not in any sense
specific. Von Krafft-Ebing, referring to the occurrence of at-
tacks of migraine in individuals who are subject to epilepsy,
says that in these cases we have to do with an ophthalmic or
sensory disturbance of the Jacksonian type, in which the visual
aurae precede the attack. These cases are not infrequently
referred to as instances of epileptic migraine or migrainous
epilepsy. The psychical disturbances are usually transitory.
In some instances attacks of migraine seem to be associated
with hysterical seizures, and, as von Krafft-Ebing has pointed
out, the converse may also be true. In rare cases, together
with the pain, definite visual hallucinations are present. The
amnesic aphasia, that frequently occurs, may last from a
few seconds to half an hour. Paresthesias associated with
hemicrania are sometimes met with. During the attack
there is some disturbance of speech and a diminution in the
pupillary reflexes. Severe psychoses, however, are not com-
mon, a fact which von Krafft-Ebing thinks is indicative of
their etiological complexity, although Mingazzini and Pacetti
hold a contrary opinion 54 and believe that the hysterical symp-
toms in all cases are to be regarded merely as complications.

"V. Krafft-Ebing: Arbeiten aus dem Gesammtgebiet der Psychiatrie
tind Neuropathologie, Heft i. Ueber Migranepsychosen. Jahrbiicher f.
Psych, u. Neurol., Bd. xxi, H. I u. 2, 1902.

M Riv. sper. d. freniatria, 25, fasc, 2, 3, 4.

222 PSYCHIATRY

The defects in memory vary in intensity from the milder to
the more severe amnesias.

Mental Disturbances in Chorea. — Not infrequently
in cases of Sydenham's chorea symptoms of mental aberration
appear and are characterized by emotional irritability and rapid
changes in the mood. Attention was originally directed in de-
tail to these disturbances by Marcel,55 although references to
the subject of even an earlier date 56 are found in the literature.

In addition to the above-mentioned psychic anomalies,
choreic patients frequently suffer from various kinds of obses-
sions, while in the protracted cases the various forms of psy-
chic tic are apt to develop. This latter symptom shows itself in
an uncontrollable impulse to perform certain acts, to touch ob-
jects, to count, etc. The mental aberration in these cases is of
all gradations, from the milder forms of psychasthenia to much
more profound disturbances. These patients are, as a rule,
markedly impressionable and exceedingly capricious, being
turned about by every whim. They become moody, morose,
exceedingly depressed mentally, and on little or no provocation
change with great rapidity, becoming nervously animated and
unduly elated. The defects in the intellectual functions, except
in the delirious states, as a rule, depend upon the lapse in mem-
ory and attention. The consciousness of their nervousness
makes these patients at times appear indolent and lazy. In
some cases 57 there is a marked transitory state of confusion,
associated with great motor restlessness, and during this period
fallacious sense perceptions are common. Visual hallucina-
tions not infrequently occur, particularly just before the patient
falls asleep, and are apt to be more or less terrifying in char-
acter, the forms assumed being those of horrible-looking ani-
mals, people, etc. These may persist, and during sleep the
patient may suffer from nocturnal terrors. Visual hallucina-
tions are the most common, but the visual, haptic, and erotic

05 Memories de l'Acad. de Medecine, 1859.
M Plat, 1614.

57 Mobius : Neurolog. Beitrage, H. 2, S. 129 ff. Munch, med.
Wchnschr., 1892, Nr. 51 u. 52.

CAUSES OF INSANITY 223

forms also occur. In a few cases the patients pass into a stupor-
ous state. Ziehen, under the head of choreic psychic changes,
describes these milder forms of aberration as typical. Cases
occurring during pregnancy (chorea gravidarum) are charac-
terized by great severity of the motor disturbances and by
periods of intense excitement and exhaustion. In some in-
stances the disease is complicated by hysterical symptoms and
not rarely is a complication of epilepsy.

Bradley 58 has reported a case of chorea insaniens with
pathological findings at autopsy. There were marked degenera-
tion of the ganglion cells, " organized mitral vegetations, con-
gested hemolymph glands, arterial hypoplasia, an apparently
actively functioning, persistent thymus, and mesenteric lym-
phatic hyperplasia."

The treatment for these cases is that indicated for chorea,
in addition to the employment of means for the relief of the
mental disturbances : a fluid diet, rest in bed, and warm baths
or packs. In cases in which the motor unrest or aberration is
very marked sedatives may be employed — paraldehyde, amy-
lene hydrate, trional, etc. These drugs, however, should be
used with great caution.

Huntington's Chorea. — In the so-called degenerative
chorea the mental changes, as a rule, are much more marked
than in the ordinary type. Not infrequently the patients
are subject to attacks of depression, which gradually become
more frequent, until finally there are no lucid intervals, and in
addition the sufferers show a marked degree of mental reduc-
tion, becoming apathetic and indifferent. Despite the apathy
and intellectual impairment, however, such individuals often
show a considerable degree of emotional instability, which
manifests itself in frequent outbursts of temper. The memory,
as a rule, is greatly impaired. The intellectual defect becomes
apparent early in the disease. The rapidity with which it pro-
gresses varies considerably. In some cases ideas of persecu-
tion, alternating with varying degrees of euphoria, may de-

58 Am. Journ. Insan., vol. lx, No. 4, 1904.

224 PSYCHIATRY

velop. As Wollenberg 59 has stated, there is no exact
parallelism between the mental and the physical symptoms. In
cases in which the motor symptoms are greatly exaggerated it
does not necessarily follow that the mental impairment is pro-
found. In the case reported by Rusk,60 which is important on
account of the detailed history, choreiform movements had
been noted for seven years prior to the appearance of the men-
tal symptoms. Gradually both the physical and the mental
symptoms became worse and the patient finally died from an
intercurrent complication. Recent autopsies have not con-
firmed the views formerly entertained that a diffuse interstitial
encephalitis exists in such cases. As Rusk points out, there is
not sufficient evidence for assuming the existence of an inflam-
matory condition. The organic lesion consists chiefly in a
marked increase of the neuroglia.

The disease, as is well known, has a marked tendency to
recur in families. Although it has been said that it generally
makes its appearance about middle life, Heilbronner 61 main-
tains that it shows a tendency to recur in every generation at
an earlier period than in the one preceding. The treatment is
purely symptomatic.

w Wollenberg : Chorea. Nothnagel's Spec. Pathologie und Therapie,
Bd. xii, Theil II, Abth. 3.

80 Rusk, Glanville Y. : A Case of Huntington's Chorea with Autopsy.
Am. Journ. Insan., 1902, lix, No. 1.

81 Heilbronner : Ueber eine Art progressiver Hereditat bei Hunting-
ton'scher Chorea. Arch. f. Psych, u. Nervenkrankh., Berlin, 1003, Bd.
xxxvi, H. 3.

CHAPTER VIII

THE PRINCIPLES CONCERNED IN A PROVISIONAL CLINICAL
GROUPING OF MENTAL DISEASES 1

Any attempt to form a provisional grouping of mental
disorders, to be successful, must be based upon the considera-
tion of a number of different factors. In the first place, it is
of prime importance for physicians to realize that in a study of
alienation we are not dealing with definite disease entities, such
as typhoid fever or pneumonia, where a direct causal relation-
ship between the exciting etiological factor and the symptoms
of the disease is demonstrable. In typhoid fever or meningitis
the nature of the morbid process is more or less definite, and
the natural history of these and similar disorders has been
clearly and accurately described. In a consideration of even
the simplest forms of alienation, however, there are so many
indefinite and ill-defined factors to be considered that the prob-
lems connected with the differentiation of disease types at once
become difficult and complex. Before considering definitely the
basis upon which an attempt may be made to classify the vari-
ous forms of mental disorder we shall first point out certain
errors to be guarded against. For unless a considerable degree
of caution is exercised there is danger lest we not only fail in
the attempt to delineate the chief characteristics of the various
symptom-complexes in a manner that will be useful in stimu-
lating further study, but also tend to foster the spirit of de-
preciation and pessimism which renders real progress impos-
sible.

In the introductory chapter attention was called to the fact

1 Paton, S. : The Classification of Mental Diseases. Reference Hand-
book of the Medical Sciences. William Wood & Co., New York, 1902, vol.
v, p. 25. Nissl, F. : Kritische Bemerkungen zu Ziehen's Aufsatz ; Ueber
einige Liicken u. Schwerigkeiten d. Gruppierung des Geisteskrankheiten.
Centralbl. f. Nervenheilk. u. Psych., 1904, Marz 15.

IS 225

226 PSYCHIATRY

that the purely symptomalogic study of the cases, however ad-
mirable it may be in certain respects, can never supply a suffi-
cient basis upon which to attempt a grouping of the various
forms of alienation. Such a method of investigation assumes
as a necessary postulate that the observation of symptoms is the
only important factor in a study of clinical psychiatry. More-
over, it was pointed out that, so little being known with regard
to the anatomy and physiology of the brain, any endeavor to
form a pathological basis upon which the cases of alienation
may be grouped would be equally futile. In this connection
should be mentioned the attempt that has been made by Wer-
nicke to differentiate the several disease pictures according to
the supposed localization of the anatomical processes in the cen-
tral nervous system. The fundamental assumption, however,
on which this opinion rests — that a similar disease process un-
derlies all forms of mental disturbances in which there are ana-
tomical lesions — amounts to no more than a pure hypothesis.
Such a view does not take into account, for example, the de-
monstrable differences, pathological as well as clinical, that exist
between syphilitic lesions in the central nervous system and the
changes observed in dementia paralytica, nor between the latter
and those belonging to various forms of the senile psychoses
In these instances we have to deal with essentially different
disease processes. Unfortunately, however, as yet the alienist
has been able to recognize only a few lesions that have certain
distinctive characteristics, so that the pathological findings
alone cannot supply a basis for classification. Until it is de-
monstrable beyond peradventure that certain factors in the
study of cases of alienation are of specific importance, the only
rational and comprehensive method to be adopted is that which
takes into consideration all the possible facts bearing upon the
case ; for the present at least, therefore, this must be regarded
as the most natural and the simplest method of grouping the
various complexes. Take, for example, the study of dementia
paralytica. Here we have a variety of clinical symptoms which
in their totality have come to be regarded as more or less spe-
cific and are associated with a process running a fairly definite

GROUPING OF MENTAL DISEASES

227

course, passing into a peculiarly characteristic dementia and
ending sooner or later in death. On the pathological side these
clinical changes may generally be correlated with certain ana-
tomical lesions. When all these factors are taken into account,
we are able to recognize a disease group with certain definite
clinical characteristics more or less intimately dependent upon
certain changes in the central nervous system.

Such a method of grouping as that which has been indi-
cated can hardly be antagonistic to progress, and is useful in
aiding the alienist to formulate his views and to bring into
greater prominence many of the problems which need solution.
The first group of disorders which will be discussed are those
classed as the defect psychoses — idiocy, imbecility, and other de-
grees of mental debility. The ill-defined character of this group
and the empiricism which associates under the same head such
a variety of disorders will at once be recognized. Although the
severer cases are always associated with marked structural
changes of the nervous system, it has been customary to dis-
cuss these disorders not with those due to organic brain disease,
but to look upon them as forming a group by themselves.

The second group of mental disorders which are consid-
ered are designated acute and subacute, confusional and deliri-
ous states, in part the result of autointoxication. These include
the febrile deliria, the acute collapse delirium, the so-called
amentia (Meynert), and Korsakow's syndrome. Although the
evidence which favors the autointoxication theory is meagre
and more or less indefinite, the possible influence in these cases of
toxic products has not been lost sight of, and this grouping,
therefore, seems to be one which offers a reasonable working
hypothesis. The next chapter deals with certain forms oi
chronic intoxication caused by various poisons — alcohol, mor-
phin, cocain, lead, etc.

Following this are the groups of manic-depressive insanity
and dementia praecox, in which the grouping is based merely
on the symptomatology, course, prognosis, and termination,
without regard to the pathological findings, which are too in-
definite to be considered of any present value.

228 PSYCHIATRY

Then follows the large group of cases of dementia par-
alytica in which the same factors are taken into account, but
here, inasmuch as the changes in the central nervous system are
of more or less specific importance, they are given their due
valuation. The senile psychoses, including states of depression
and excitement, mixed states and dementia, are next consid-
ered.

Under the head of epilepsy and hysteria a variety of symp-
tom-complexes are discussed which in the main possess certain
distinctive characteristics, but frequently show so many simi-
larities that it is impossible to differentiate the two conditions.
In the chapter dealing with neurasthenia and the psychasthenic
states we have attempted merely to sketch out, as it were, the
outlines of a group which as yet can not be definitely filled in.
Here the term neurasthenia is reserved for the pure cases of
chronic nervous exhaustion, while the term psychasthenia is
applied to the conditions variously designated as the " fear" or
" anxiety" psychoses and impulsive insanity, in which, in addi-
tion to the ordinary symptoms of nervous fatigue, abnormal
impulses, phobias, and various other psychical disturbances
form part of the clinical picture.

A separate chapter has been devoted to the consideration
of the various forms of mental disorder associated with organic
brain lesions, while under the head of the paranoia group are
brought together certain chronic conditions which cannot be as
yet definitely assigned to any of the symptom-complexes de-
scribed.

In view of what has already been said, the possibility of the
occurrence of combined psychoses may readily be inferred. If,
however, the subject of insanity is discussed purely from a
symptomalogic stand-point it would be impossible to speak of
combined psychoses, as such a conception does not take into
account the origin, course, or termination of any of the symp-
tom-complexes nor recognize fundamental differences in the
various clinical pictures. Even to the casual observer, however,
it at once becomes apparent that in adopting a clinical grouping
of disease there is no valid reason why a patient may not pre-
sent symptoms which point to the possible association of more

GROUPING OF MENTAL DISEASES

229

than one disease process. There is plenty of evidence to show
that hysterical symptoms not infrequently complicate a number
of other psychoses : for example, manic-depressive insanity, de-
mentia praecox, general paresis. Apparently v. Krafft-Ebing
was the first to use the term " combined psychoses," but as
Gaupp 2 has pointed out, a distinction must be made between
the combined and the composite (zusammengesetzte) psycho-
ses. The latter, according to Ziehen and Wernicke, are to be
regarded as composite conditions entirely void of fundamental
distinctive traits. Among the more important of the combined
forms is the reported association of manic-depressive insanity
with dementia paralytica. Whether or not the former may also
complicate dementia praecox cannot be decided positively, as
our knowledge of both disorders is largely casuistical. The
same is true in regard to the possible association of true manic
excitement with various confusional states. Here the difficulty
of diagnosis is very great. There can be little doubt, however,
that such a process as dementia praecox not infrequently com-
plicates the defect psychoses, idiocy and imbecility, and to ob-
servations of this association may be traced the belief enter-
tained by some clinicians that the dementing process is closely
related to certain forms of idiocy. The occurrence of hysterical
symptoms during the course of alienation following syphilitic
infection is not infrequent, and some cases are on record in
which it is more than probable that the ordinary course of de-
mentia praecox has been markedly changed by a complicating
specific infection. The fact that many of the different forms of
alienation do not correspond with the typical pictures may in a
measure be accounted for not only by the difference in individ-
ual reaction, but also by the possible addition of one mental dis-
ease to another. V. Krafft-Ebing and others have called atten-
tion to the development of dementia paralytica during the
course of paranoia. The senile psychoses and the associated
changes in the central nervous system not improbably compli-
cate many other forms of alienation.

2 Gaupp, R. : Zur Frage der kombinierten Psychosen. Centralbl. f.
Nervenheilk. u. Psych., 1903, 15 December, xxvi. Jahrg., Nr. 167, S. 766.

CHAPTER IX

MENTAL ANOMALIES THE RESULT OF DEFECTIVE DEVELOP-
MENT OF THE CENTRAL NERVOUS SYSTEM *

Idiocy, imbecility, and mental debility represent the three
different grades into which these disorders may be divided.
This classification, however, is purely empirical. The causes
are either congenital or acquired, and are as widely diversified
in character as in degree of intensity. In cases of the first cate-
gory macroscopic as well as microscopic lesions are demonstra-
ble in the central nervous system, while for the second and
third group, on account of our limited and imperfect knowl-
edge, there is nothing in the pathology that is tangible.

Idiocy. — From a purely practical stand-point cases of
idiocy may be divided into three groups, (a) To the first be-
long the cases in which the defect in the central nervous system
is so great that after birth the child lives only for a short period
of time and its existence is a purely vegetative one. The study
of such cases furnishes a field of fruitful exploration for the
physiologist, and an important chapter yet remains to be writ-
ten by any one who has the opportunity and inclination to make
a careful analysis of the functionings of the central nervous
system of which such monsters are capable and of correlating
the physiological responses with the structural conditions.2 Al-
ready there are a considerable number of observations on record
which tend to show that life may persist for a considerable
period of time even when all the higher brain-centres are lack-

1 Ireland, W. W. : The Mental Affections of Children ; Idiocy, Im-
becility, and Insanity. Phila., 2d ed., 1900. Bailey, Pearce : Reference
Hand-book of the Medical Sciences, vol. v, p. 145, 1902. Starr, M. Allen :
The Cerebral Atrophies of Childhood. Organic Nervous Diseases. New
York, 1904.

2 Vaschide : Essai sur la psycho-physiologie des monstres humains.
Paris, 1903.

230

IDIOCY

231

ing. For example, anencephalic monsters not possessing a cere-
brum or basal ganglia have been known to survive for more
than a week.3 Spontaneous or mimetic movements in such cases
did not occur, although external stimulation was followed in
one instance by a bizarre and indescribable reaction of the facial
muscles. Cases in which one cerebral hemisphere or the cere-
bellum and corpus callosum have been entirely absent, and in
which life has persisted for some time, have been reported.

(b) Of more immediate interest to the alienist are those
cases in which the defects in the central nervous system are less
extensive. To this second class belong idiots in whom there is
almost a complete inability to utter articulate sounds, but who
manifest greater complexity and more coordination of move-
ments than is found in those of the first group, and, moreover,
give evidence that they possess sensation and some associative
memory. Such individuals, however, practically never show a
functional development of the central nervous system higher
than that seen in infants at the end of the first year of life. As
a rule, the diagnosis of such conditions can be made soon after
birth. The first evidence may be that an infant shows no desire
to take the breast ; or about the time when in the normal infant
there is some evidence of reaction to a bright light (from the
first to the third day) no effect is produced by the incident
stimulus. The degree of impressionability to sensory stimula-
tion attained by such individuals varies within considerable
latitudes.

The especial symptomatology of individual cases deserves
further careful and painstaking study.4 As a rule, it can be
decided that the disturbances in sensation are complex and not
dependent upon mere interference with function in the peri-
pheral tract. Although in some instances the latter exists, its
presence cannot be made to explain all the sensory disturbances,
since it is obvious that there is also a considerable defect in the
reception, elaboration, and retention of sensory impressions. As

* Anton, G. : Anencephalie und Hemicephalie. Handbuch der Path,
des Nervensystems. BQrlin, 1904.

4 Sollier : Psychologie de l'idiot et de l'imbecile. Paris, 1891.

232

PSYCHIATRY

would be expected, all forms of associative memory seem to be
affected, and taste, smell, touch, sight, and hearing are more or
less seriously disturbed. Sometimes mentally defective infants
seem to lack the most elementary organic sensations and are
deficient in even the purely animal instincts. Although they
may react to both visual and auditory stimuli, the reaction has
no meaning for them ; they fail to recognize their parents, and
never appear to become familiar with the objects with which
they are almost continually brought into contact. Their capac-
ity for attention is at a very low ebb. Bright objects held be-
fore the infant fail to attract its gaze, and even if the eyes are
turned in the direction of the stimulus, one observes only a
vacant stare without any objective evidence of association be-
tween the sensory impressionability and the visible reaction.
The associative processes are very limited. Even the most ele-
mentary— those necessary for the development of orientation —
are deficient, and such creatures often seem to be unable to
appreciate the direction of sounds, rolling their heads about
vaguely and seldom turning their eyes in the direction from
which these have emanated. Even the elementary emotional
reactions — smiling or other expressions of pleasure — may be
completely absent. In some instances the power of movement
becomes more extensive and incoordination does not develop.
In other cases the ataxia becomes less marked, but the move-
ments are clumsy and at times almost choreiform in character.

(c) The third group of cases consists of those which up
to the present time have received the most careful study and are
characterized by a limited power of speech, comprehension, and
articulation.5 In some instances the attempts at articulation
are restricted to a few guttural sounds more suggestive of the
grunting of an animal than of human speech. But even in cases
where neither spontaneous speech nor the comprehension of

5 Emminghaus : Die psychischen Storungen des Kindesalters. Tubin-
gen, 1887. Sollier : Op. cit. Voisin, J. : L'Idiotie. Paris, 1893. Ham-
marberg : Studien iiber Klinik und Pathologie der Idiotie. Deutsch von
Berger, 1895. Storring, Gustav : Vorlesungen iiber Psychopathologie in
ihrer Bedeutung fur die normale Psychologic Leipzig, 1900.

IDIOCY 233

spoken language is developed, one must be careful to look for
the existence of other forms of association, since not infre-
quently these may have reached a relatively much greater devel-
opment, which can be detected by observing the movements, the
power of expression, and the apprehension of visual stimuli,
such as the recognition of cards, pictures, and so on.

In another group of cases, although articulation is re-
stricted to a few words or syllables, the comprehension of signs
or spoken words may attain a still higher development, so that
the characteristics of simple objects, the nature of the environ-
ment, and familiar faces are recognized better than one would
at first be led to suspect. In such cases there may be a marked
appreciation of physical qualities, — the difference between heat
and cold, — of a sense of comfort or discomfort, and even a com-
prehension of the nature and uses of a variety of ordinary ob-
jects. In still another class of cases speech comprehension and
articulation have advanced still further. Associative memory is
much better developed and the patients are able to pick out dif-
ferent letters or cards ; they acquire a wider vocabulary and can
associate names with objects. The organic sensations seem to be
more complex, the associative qualities concerned in taste and
smell are more highly developed. Elementary feelings of pleas-
ure, discomfort, or pain are associated with certain persons, ob-
jects, or phenomena. These patients differentiate to some ex-
tent between those who are kind to them and those who are not
friendly. The dissociation between emotional reaction and idea-
tion is less marked. A slight appreciation of time may develop
and an evident familiarity with the environment is often a
prominent feature. As a rule, these patients need to be care-
fully watched. They may be subject to impulsive acts or sud-
den outbursts of temper. The simple organic sensations
predominate, and whatever interest develops is usually that
associated purely with the personal needs.

Certain observers have divided their cases into two groups
— the anergetic or apathetic form and the erethic or versatile
type. In the former the power of directing the attention is in
some cases almost absent, and all forms of emotional reactions

234

PSYCHIATRY

are deficient or merely embryonic in character. In patients of
the latter group it is possible to attract the attention and affect-
ive reactions often follow. To this category belong the indi-
viduals who are capable of being trained up to a certain point,
and can be taught to some extent to administer to their own
wants, to feed, dress, and wash themselves and perform other
light duties.

The power of attention may be variously estimated by test-
ing the power to remember cards, pictures, colors, and the more
simple characteristics of objects and persons. As Storring has
pointed out, the speech development is not proportional to the
amount of mentality. Some idiots show a considerable ability
to express themselves audibly and name familiar objects cor-
rectly, and yet at the same time possess an intellectual capacity
much below that of others whose speech is far less developed.
Certain of these individuals even attain to the mental status of
the ordinary child between the ages of six and eight years —
about the time it begins to go to school.

The physical manifestations in idiocy are varied and nu-
merous. Those which pertain to the skull and nervous system
will be described when we come to speak of the pathology. The
disproportionateness in the development of the head, extremi-
ties and trunk is often well marked. The teeth are nearly al-
ways irregular. Not infrequently the sensory organs show gross
anatomical defects. It has been estimated that from 6 to 8
per cent, of these unfortunates are either born blind or become
so early in life, while in other cases the peripheral visual tract
is intact. Paralyses of the ocular muscles are common. Hear-
ing is sometimes defective, but this is not so frequent an occur-
rence as the impairment of sight. Disturbances in taste and
smell, other than those of psychical origin, are rare. The
organic sensibility is depressed, and these defects may give rise
to various complications. Thus, some idiots never experience a
sense of satiety and will keep on eating or drinking until com-
pelled to stop. Owing to the feebleness in somatic sensation,
the patient may not know when to defecate or urinate, so that
incontinence or retention may result. The great variety of de-

IMBECILITY

235

fects of the bony system, among- the most common of which is
caries, need not be described in detail here. Idiots are particu-
larly susceptible to pulmonary disorders, especially tubercu-
losis. Again, the lack of cleanliness may give rise to various
complications.

The sexual organs, as a rule, show marked defects. Unde-
scended or poorly developed testes, hypospadias, and phimosis
are some of the most common abnormalities. The sexual func-
tions are either absent or perverted.

The motor disturbances are usually well marked, and the
limbs may be small. In some cases, particularly in the acquired
forms due to the cerebral palsies, paralyses exist — paraplegias,
monoplegias, and diplegias. Atrophies may be present. The
reflexes are sometimes exaggerated, in other cases deficient or
absent. Anomalies in the salivary secretions, digestive disturb-
ances, regurgitation, nausea, and vomiting are not uncommon.

Semi-Idiocy, or Imbecility. — In the semi-idiot, or imbecile,
all. forms of associative memory reach a higher complexity than
in the idiot. Sense memories, above all those associated with
vision and less commonly those concerned with hearing, show
much more stability, and the patient possesses much greater
facility in re-collecting and redeveloping them ; so that as a rule
imbeciles become familiar with a great variety of objects, par-
ticularly those with which they are most frequently brought
into contact. Again, such individuals have the power of appre-
hending and appreciating to some extent the quality of objects.
They are capable of differentiating between the simpler colors,
are able to remember names, particularly those of members of
their own family, although they are usually unable to appreciate
the finer differences involved in comparison and contrasts.
Their vocabulary is generally limited to naming objects, and
frequently the interrogative is simply expressed by giving utter-
ance to the name of the object concerning which their curiosity
is aroused. Adjectives are used more frequently than adverbs
and prepositions, and the more complicated associations are apt
to be feeble or entirely deficient. These deficiencies in the asso-
ciative memory are largely dependent upon lapses in the atten-

236 PSYCHIATRY

tion. Imbeciles never possess the power of making any pro-
longed mental effort or of keeping any object for more than a
few seconds within the focus of the attention.

The emotional displays of the imbecile, although not as
crude nor characterized by the dissociation that is so marked in
those of the real idiot, are still incomplete, monotonous, and
largely confined to the expression of pleasure or pain. These
individuals are practically never able to appreciate anything
which does not immediately concern their own interests. The
power of differentiating between right and wrong is purely ele-
mentary, and none of the affective states shows any altruistic
tendencies. The acts are largely the result of transitory im-
pulses, and a volitional movement, the result of deliberate choice
and judgment, is scarcely ever witnessed. At times the impulses
and motives are replaced by attempts to copy, and this power
of imitation is the one important clue to the future training of
the patient. Imbeciles are particularly prone to be the subject
of sexual impulses; these defectives are very apt to wander
away from home and thus form a very considerable percentage
of the vagabonds and unemployed poor. Their excessive emo-
tional outbreaks not infrequently lead them to resort to vindic-
tive and brutal acts. Hatred in the true meaning of the word,
however, cannot be said to exist in their minds, inasmuch as
their actions are dictated by impulse. Nevertheless, under the
spur of a sudden provocation they sometimes attempt to damage
property, set fire to houses, or attack members of the family of
those who have irritated them.

Again, the movements of the imbecile are far more pur-
poseful and coordinated than those of the idiot, and the physi-
cal symptoms are much less pronounced. Speech comprehen-
sion and articulation are far better developed, although more or
less defect is generally present — lisping, stammering, and the
like. Sometimes these patients have difficulty in the pronuncia-
tion of certain consonants — G and ;K, G and T, S, R, or L. At
times all the movements concerned in the articulation of speech
seem to be hampered. The movements of the tongue are more
or less limited. The disturbances of speech in mentally im-

MENTAL DEBILITY

237

paired children have been carefully studied by Liebmann,6 who
divides them according to their etiology as follows : ( 1 ) The
so-called secondary troubles, including mutism and agramma-
tism, stuttering, and lisping. (2) Primary troubles in which
the speech, though present, is indistinct. The latter are depend-
ent either upon organic or functional causes. Among the causes
of the former are malformations or paralyses of the palate, nar-
rowing of the pharynx caused by local obstructions, and dis-
turbances of hearing.

The movements of the tongue are always somewhat lim-
ited. The other motor defects are generally more obvious in
connection with the finer and more coordinated forms, such as
those necessary in grasping a pen or holding a fork. The man-
ners and gait of such individuals may be coarse and clownish,
and immediately suggest the decided mental impairment that
exists.

Mental Debility or Enfeeblement. — Under this category
belong a large group of individuals who never attain the mental
development of the average normal adult. All forms of grada-
tion and transition exist between this and the preceding group,
and no sharp line of demarcation can be drawn. As a rule,
such individuals show no deficiency in the mere reception and
retention of sensory impressions. Indeed, certain forms of
memory may be developed even abnormally.7 This is particu-
larly true in regard to figures, and individuals are occasionally
met with who in many ways show a deficient mentality, but
have the most remarkable power of calculating and of remem-
bering figures. Many of the arithmetical or calculating " won-
ders" belong to this class. As a rule, the memories which relate
to the individual's home, the names of the various members of

• Die Sprachstorungen geistig zuruckgebliebener Kinder. Samml. von
Abhandl. a. d. Gebiete der pad. Psych., iv, 3. Berlin, 1901. Stotternde
Kinder. Ibid., 1903. Liebmann u. Edel. Die Sprache der Geisteskranken.
Halle a/S., Marhold, 1003.

7 Peterson, F. : Idiot Savants. Popular Science Monthly. New York,
December, 1896. Wizel, Adam : Ein Fall von phanomenalem Rechnen-
talent bei einem Imbecillen. Arch. f. Psych, u. Nervenkrankh., 1904, Bd.
xxxviii, H. 1, S. 122.

238 PSYCHIATRY

his family, of his immediate friends, and all those with whom
he is brought into daily contact are well preserved. Deficien-
cies only become apparent when the associative forms of mem-
ory necessary for the re-collecting of abstract ideas are carefully
studied. The imagination in such individuals is apt to be well
developed, so that not infrequently the actual defects in the
higher forms of memory are concealed by the vivid play of their
fantasy, which in many instances resembles that seen in cases of
hysteria. As has been said, the simpler forms of associative
memory, particularly those connected with the senses, show
comparatively few defects, but the mental impairment that ex-
ists is frequently brought out by an attempt on the part of the
individual to concentrate his attention for a certain length of
time. Furthermore, the judgment of such individuals, except
concerning the simplest things and the most ordinary events of
life, shows considerable deficiency. Not uncommonly these
deficiencies are first noticeable at the time when the child first
goes to school. An attempt at manual training brings these out
far less than the study of books. The emotional life, although
at first normal, is apt to show anomalies, particularly in regard
to the feelings connected with the aesthetic and ethical senses.
The egotism of these individuals is usually striking and may be
the most dominating feature in the symptomatology. As they
are brought more into contact with the world they begin to
exhibit eccentricities of character.

In the apathetic type the symptoms are those of indiffer-
ence, frequently mistaken for pure laziness, the absence of any
high aim or ideals, the desire to lead a life as uninterrupted and
placid as possible without regard for the welfare of those about
them. In the earlier years of childhood these anomalies become
apparent in the disinclination shown to associate with other
children, in the frequent desire expressed to be left alone. With
the years of puberty the defects may become more apparent, or,
instead of the apathy, fluctuations in the emotional life may be-
come more and more marked. Such children show a marked
tendency to lie and steal and are very likely to become a care
and burden to their family. Later, sexual and alcoholic

MORAL INSANITY

239

excesses become more and more common and are lacking only
in a very few of these individuals.

Moral Insanity. — The very mildest cases of mental impair-
ment are frequently to be found among the large group of cases
commonly referred to as instances of moral insanity. In these
forms the defects are largely in the ethical spheres and are the
result of impulses, lack of inhibition, and a variety of other
causes which are often very difficult to recognize. Many of
these cases, developing as they do in individuals who show a
marked hereditary predisposition, may be easily confused with
the various psychopathic states. At times they are complicated
with hysterical symptoms and in other patients they are asso-
ciated with epileptiform attacks. The imperative processes are
often noted in idiocy as well as in imbecility.

The early recognition of these cases, as has already been
pointed out, is of great importance, inasmuch as the existence of
mental defects in children should call for their removal from the
public schools and their relegation to institutions especially
adapted to their peculiar needs. Recently Consoni 8 has called
attention to the importance of careful study of the anomalies of
attention that occur in feeble-minded children as one of the best
means for the early recognition of the existing defect. In
psychasthenic children a certain degree of static conative atten-
tion is always present. Furthermore, the degree of the general
capacity for attention is in direct proportion to the affective
state and their power of inhibition. In normal children the
capacity for the conative dynamic attention is more developed,
and is an indication of the activity of the cerebral processes.

Etiology. — The estimation of the number of imbeciles in
the community with any degree of accuracy is practically impos-
sible, as a large number, particularly those in the lower classes
of society, never come under medical supervision. On account
of the impaired physical state of this class of individuals the
death-rate is particularly high in the earlier years of life, so that

8 Consoni, F. : La Mesure de l'attention chez les enfants faibles d'esprit
(Phrenastheniques). Arch, de Psych., 1903, No. 7, t. ii, fasc. 3, p. 209.

240

PSYCHIATRY

for adults the proportion is comparatively much less. The
cases, as a rule, may be divided into (i) congenital and ^2)
acquired forms.

( 1 ) Of prime importance is the so-called neuropathic de-
generation of the parents. If the family histories are carefully
examined it will be found that probably one and sometimes both
parents have been the subjects of nervous or mental disorders.
This is somewhat more commonly observed on the mother's
than on the father's side. The next most important factor is
alcohol. According to the classical researches of Bourneville,9
in 1000 cases of imbecility alcoholism in the father was noted
471 times, in the mother 84 times, and in both parents 65 times.
Demme found that the occurrence of alcoholism was noted in
81.9 per cent, of the parents, and that in ten families of alco-
holics normal children were noted in only 17.5 per cent.

Without question syphilis in the parents very often pro-
duces mental defects in the children, although some of the Eng-
lish statistics, particularly those of Piper, would seem to indi-
cate that its significance has been somewhat overestimated.
This point, however, has not as yet been satisfactorily settled,
and the whole subject needs fuller investigation, particularly as
in many cases, for various reasons, it is impossible to obtain
definite data with regard to the presence or absence of luetic
infection in the parents. A remarkable contrast is noticeable be-
tween these figures and those given in regard to the importance
of tuberculosis as an etiological factor. Here the proportion
varies from those of Piper — 23 per cent. — to those of Kalin —
56 per cent. But here again figures are apt to be misleading,
and it should not be forgotten that tuberculosis is said to occur
in 1 5 per cent, of the parents of healthy children. Again, it is
also worthy of note that in scrofulous children imbecility does
not occur more frequently than in the non-scrofulous. The im-
portance of lead and various other toxic substances, as well as
severe illnesses, protracted fevers and trauma, have been vari-
ously emphasized as important factors in the parents in the pro-

8 Progres med., 1897, No. 2. Recherches cliniques et therapeutiques
sur l'epilepsie, l'hysterie et l'idiotie. Paris, 1902.

ETIOLOGY OF IDIOCY

241

duction of idiocy in the children. The marriage between blood
relatives, where a neuropathic family taint exists, undoubtedly
emphasizes such a tendency, and the children are liable to be
defective.

Some observers have taken occasion to emphasize the fact
that imbecility is somewhat more common among the firstborn
than it is among second and third children. This may be due
to the greater difficulty attending the first as compared with
subsequent labors.

(2) Among the more important of the causes of acquired
idiocy are all the injurious factors which may affect the embryo
through the mother. Among the laity it is generally supposed
that severe mental shocks, frights, and the like are very apt to
exert a detrimental effect upon the mental as well as upon the
physical powers of the child. This may be in certain cases due
to disturbances in the uterine circulation, but in all probability
the importance of psychic shock in this connection has been ex-
aggerated. The occurrence of nervous diseases during the
months of pregnancy is particularly apt to give rise to mental
defects in the child. Premature birth is also another cause, but
in this connection it must not be forgotten that certain of these
cases are due to syphilitic infection in the parent. The various
kinds of trauma that may befall the mother are also of great
importance in the etiology.

In about one-third of the cases of acquired mental impair-
ment diseases occurring during the earliest years of life are of
the greatest etiologic significance, and not a few children, born
healthy, after a severe attack of diphtheria, influenza, measles,
scarlet fever, typhoid fever, or meningitis, are left mentally de-
ficient. This is also true for those who have had rickets, ence-
phalitis, hydrocephalus, and various forms of convulsions.
Epilepsy by itself is seldom the cause of the defect, but mental
impairment is frequently associated with the seizures and forms
an integral part of the same complex.

Koenig10 affirms that a complete chain may be traced be-

10 Koenig, W. : Ueber cerebralbedingte Komplikationen welche den cere-
bralen Kinderlahmungen wie der einfachen Idiotie gemeinsam sind, sowie

16

242 PSYCHIATRY

tween the cerebral palsies on one side, in which there is a nor-
mal mentality, to the cases of pronounced idiocy without any
evidence of impaired motility.

The following table from his second paper represents an
attempt to compare the etiological factors in 260 cases of idiocy
with those in 70 cases of cerebral palsy :

Cerebral Simple

Palsy. Idiocy.

1. Mental or nervous diseases in the as-

cendants about 28.5% 32 %

2. Phthisis in the ascendants about 14-4% about 13.8%

3. Father markedly alcoholic 23 % about 15 %

4. Mental shock to mother during preg-

nancy 23 % about 12.5%

5. Physical trauma to mother during

pregnancy about 2.9% about 3 %

6. Relationship between the father and

mother 1.4% about 1.1%

7. First birth 27.1% about 17.6%

8. Premature birth 10 % 3.8%

9. Born in wedlock 10 % 6.5%

10. Child always sickly 157% 10 %

11. Child last of family or last of a num-

ber of children 10 % 16.9%

12. Nervous or mental disturbances in

brothers or sisters 7-1% 30.7%

13. Phthisis or scrofula in brothers and

sisters 57% 2.3%

14. Death of brothers or sisters in early

years, or suspected abortions .... 357% about 16.8%

15. Difficult birth or asphyxia 11.4% (14% ?) 10 %

16. Trauma 57% 2.6% (2.5% ?)

17. Infectious diseases 7-1% 3-4% (2.3% ?)

18. Lues 4 % certainly 6.5% surely

3 % probably 4.2% probably

Non-myxcedematons Infantilism. — In the consideration of
these defect psychoses a brief mention may be made of cases of
infantilism not associated with disturbances in the function of
the thyroid gland, but more or less directly dependent upon pul-

iiber die abortiven Formen der ersteren. Ztschr. f. Nervenheilk., Bd. xi.
Die Aetiologie der einfachen Idiotie verglichen mit derjenigen der cere-
bralen Kinderlahmungen. Allg. Ztschr. f. Psych, u. psych. -gericht. Med-
izin, 1904, Bd. lxi, H. 1 and 2, S. 133.

NON-MYXCEDEMATOUS INFANTILISM

243

monary and cardiac lesions or upon malaria. Andral and Tar-
dieu, as well as others among the older writers, had directed at-
tention to this subject, but it remained for Hirtz to point out
the close relationship that seemed to exist between certain forms
of infantilism and tuberculosis. In 1871 Lorain described
a degenerative infantilism characterized by physical anomalies
and a persistence of many of the youthful qualities during life.
In this type it was noticed that the afflicted individuals were be-
low the normal height, did not have hair on the parts of the body
where it appears in the normal adult, and that the sexual organs
were incompletely developed. The intelligence in these individ-
uals, however, was not greatly impaired. Mitral or pulmonary
stenosis was often present. These cases are capable of being
differentiated from those of myxedematous infantilism. At
the time of puberty it is found that the physical and mental
changes do not take place. In girls menstruation is absent, the
breasts do not develop, and the whole appearance of the indi-
vidual retains the infantile characteristics. It has been definitely
shown that the imperfect development is not due to the anoma-
lies in the sexual organs, since in other cases it has happened
that after castration normal development has followed. In the
production of this form of infantilism tuberculosis and malaria
are undoubtedly factors of importance. Associated with the
cardiac and cardio-vascular disturbances we not infrequently
find a delayed and impaired development of the whole body
characterized by smallness of stature, lack of development in the
limbs, absence of hair in the axilla and about the genitals, asso-
ciated with a deficiency of the sexual sense and a certain degree
of mental enfeeblement. Such individuals are very often consid-
ered lazy; they are subject to emotional anomalies and phobias;
they are greatly troubled by excessive blushing and show slight
eccentricities in character. In the case examined by Fer-
ranini n there was found a deficient intestinal absorption, a
quantitative insufficiency of the albuminous derivatives in the

11 Ueber von der Schilddriise unabhangigen Infantilismus. Arch.
Psych, u. Nervenkrankh., 1904, Bd. xxxviii, H. I, p. 206.

244

PSYCHIATRY

urine, a moderate increase in the elimination of the alloxuric
bases, a deficiency in the excretion of uric acid, and an increase
of ammonia. The chlorides, the quantity of the urine, and its
acidity were subnormal.

Pathology. — The pathology of the defect psychoses is ex-
tensive and includes a variety of macroscopic as well as micro-
scopic lesions, the result of the action of injurious agencies
which directly inhibit the development of the central nervous
system.12 In the severer cases not only are defects found in the
brain, but accompanying lesions are noted in other parts of the
nervous system. The alienist is more particularly concerned
with those cases in which structural imperfections are not so
sufficiently extensive as to preclude the existence of all men-
tality, so that to him the cases of acephalic or anencephalic mon-
sters are not of special interest. The description of the various
malformations of the skull and their relation to the brain is a
subject that cannot be discussed in detail in this book.13 Co-
existing and related defects of the skull and brain are sometimes
found, but these are not constant, nor is there always apparent
in the skull any external evidence of the intracranial lesion.

Premature ossification frequently takes place in cases of
idiocy, but although a diminution in the volume of the brain is
sometimes associated with decreased capacity in that of the
skull, these two conditions are not always coincident. Disturb-
ances occurring during intra-uterine life — rhachitis fcetalis,
chondrodystrophia fcetalis, or the osteogenesis imperfecta of the
newborn — may be the cause of curious structural anomalies,
such as partial or general craniostenosis. There may be a
hyperplastic condition of the brain with a marked hyperostosis
at the base of the skull, and instead of being premature the ossi-

12 Hammarberg : Studium iiber Klinik u. Pathol, der Idiotic Upsala,
1895. Bourneville : Recherches cliniques et therapeutiques sur l'epilepsie,
l'hysterie et l'idiotie, vol. i et seq. Paris, 1900. Spiller, W. G. : A Contri-
bution to the Pathology of Imbecility and Idiocy, Phil. Med. Journal,
March 12, 1898.

13 See Anton : Entwickelungsanomalien des Gehirns. Handbuch der
patholog. Anat. des Nervensystems. Herausgegeben v. Flatau, Jacobsohn
u. Minor, Berlin, 1903.

MICROGYRIA

245

fication of the cranial bones may be delayed. This latter con-
dition has been noted in cases of congenital syphilis. The
defects involving actual loss of the substance of the brain are
manifold. Among the more important are those in which there
is complete or partial absence of the commissural fibres, particu-
larly of the corpus callosum and of the anterior commissure.
In some of these cases there is a corresponding change in the
shape and size of the convolutions, particularly those on the
mesial surface of the brain, where the convolutions are irregu-
larly developed. In some instances the gray matter is relatively
intact, the greater loss of substance being found in the white
matter. Duret has called attention to the fact that the compli-
cated vascular system in the pia does not develop before the
fourth fetal month and that, as branches from these vessels pen-
etrate the cortical substance, marked disturbances during the
process of development become possible. According to
Anton 14 the anomalies in development of the cerebral cortex
itself are frequently noted, and according to Hammar-
berg three types of cortical defects occur. First, there may
be a persistence of the embryonal arrangement of the cellular
elements, both as regards their distribution and individual char-
acter, cells as well as fibres retaining their primitive type. The
zonal fibres are few in number, occasionally only traces of them
being found. Second, in the less severe cases the embryonal
type of the elements is lost, but their arrangement and number
correspond to the development noticed in children at the end of
the first year. The third class represents a slightly more ad-
vanced stage of development. Sachs15 has called attention to
similar conditions in cases of the so-called amaurotic family
idiocy.

Microgyria.16 — This condition may be the result of a pri-

14 Anton, G. : Hydrocephalies Entwickelungsstorungen des Gehirns.
Handb. der Patholog. Anatomie des Nervensystems. II Abth., Berlin,
1903.

"Journal of Nervous and Mental Diseases, 1887, 1892.

19 Probst, M. : Zur Lehre von der Mikrocephalie u. Mikrogyrie. Arch,
f. Psych, u. Nervenheilk., Bd. xxxviii, H. I, 1904.

246 PSYCHIATRY

mary disturbance in the development of the brain (true micro-
gyria), or may be caused by an active disease process directly
affecting the cortical tissues during fetal life. This category
also includes congenital defects of the cortex, in which there is
a striking diminution in the size of the convolutions as well as
of the cortical substance. The histological examination of the
sections through the cortex in these cases reveals a variety of
changes. In some instances the neuroglia layer is increased in
breadth ; the number of nerve-cells is diminished and their posi-
tion and arrangement are irregular. The vessels and mem-
branes in cases of true microgyria are seldom affected, but
where there has been a superficial inflammation the existence of
the usual changes may be demonstrated.

Heterotopia. — An abnormal distribution of the gray sub-
stance— although due to developmental anomalies in the fetus —
may occasionally exist even in adults without giving rise to
signs of alienation. The gray substance may contain ele-
ments similar to those seen in the normal cortex or basal
ganglia, or may be completely changed by a preexisting hydro-
cephalus (Virchow).

Porencephalus, or loss of brain tissue, represents a great
variety of lesions, for a full description of which the reader is
referred to the text-books on pathology and to the monographs
of Shirras and others.

The majority of these lesions occur in the beginning of
intra-uterine life. In a comparatively large number of cases,
however, the porencephalic defects are acquired during life, par-
ticularly in the earlier years, and have been found in the mesial
or basal surface of the hemispheres, in the central island, in the
temporal, parietal, frontal, and occipital convolutions, while in
a comparatively large number of cases the basal ganglia were
also affected.

Hydrocephalus. — Under this category are included the
cases in which there is a marked increase in the quantity of the
cerebrospinal fluid. The quantity normally contained in the
brain is supposed to vary from 60 to 150 cubic centimetres. In
the mild cases of hydrocephalus it varies from 200 to 400 cubic

HYDROCEPHALUS AND MICROCEPHALUS

247

centimetres, but cases are reported in the literature in which the
total quantity was more than five litres. A great variety of
changes are noted in this condition. The ventricles are dilated,
and as a result of the pressure various lesions are noted in the
brain substance in the cortex, basal ganglia, cerebellum, spinal
cord, and medulla.

The terms micro encephalus and microcephalas include all
the disturbances in the development of the nervous system
which result in such a diminution in the size of the brain and
skull as to cause a marked disproportion between these and the
other portions of the body. An abnormal smallness of the brain
and skull which occurs in dwarfs — nanocephalus — inasmuch as
it is a symmetrical diminution, is a condition that is different
from the one under discussion. The cases of microcephalus
proper may be grouped in two categories : ( 1 ) The simple cases
in which there has been a marked impairment in the develop-
ment of the brain without a residuary pathological process.
Associated with this there is a corresponding proportional lack
of development in the bony covering. (2) Cases in which the
proportional relations between the brain and skull are markedly
disturbed. This type was described by Giacomini as pseudo-
microcephalus. This form of the microcephalic brain does not
represent merely a miniature of the normal condition, for there
is often a considerable asymmetry noticeable in the development
of various convolutions. The histological changes have been
studied by a number of observers and have been shown to in-
clude a variety of lesions. In some cases the number of the
nerve-cells is markedly decreased. Frequently there is an irreg-
ularity in the arrangement of the elements.

The causes of hydrocephalus and microcephalus are too
complex and varied to be discussed in the present chapter. Of
the various monographs on this subject the most comprehensive
is probably the one by Anton,17 which also contains a review of
the literature.

From what has been already said, it will be seen that the

Op cit.

248 PSYCHIATRY

pathology of the defect psychoses cannot be comprehensively
treated in a text-book on psychiatry. The various complica-
tions in the nervous system associated with the lesions to which
reference has been made cannot even be enumerated. Under the
head of acquired idiocy or imbecility are grouped a number of
cases which are due to lesions occurring during the earlier years
of life — organic brain disease, meningitis, trauma, etc. Refer-
ence is also made to this same subject in the discussion of or-
ganic brain diseases and their relation to alienation.

The diagnosis of idiocy, except during the earlier stages of
infancy, is, as a rule, not difficult.

The following table, based by Church and Peterson upon
the observations of Preyer with some slight modifications, is of
use as an aid to diagnosis :

Circumference of skull in both sexes at birth, 36 cm. Transverse
diameter, 22 cm. Naso-occipital, 22 cm.

At the end of the first year the circumference is increased by from
8 to 10 cm. ; the transverse by from 4 to 5 cm. ; the naso-occipital by from
8 to 10 cm.

Ireland considers that the term microcephalic is applicable to all heads
of adults below 17 inches, or 431 mm., in circumference. In hydro-
cephalic skulls examined by Humphrey the greatest circumference was
from 23.5 to 25.5 inches.

Normal child :

1st to 3d day. — Sensitive to light.

2d to 3d day. — Reaction to touch.

4th day. — Evidences of audition.

7th day. — Sensibility to taste.

nth day. — Notices candle, facial reaction suggesting pleasure.

23d day. — Tears.

26th day. — Smiles.

30th day. — Vowel sounds.

1st month. — Taste, smell, touch, sight, hearing. Sleeps two hours at a
time, 16 hours out of 24.

2d month. — Occasional strabismus. Recognizes human voice. Turns
head towards sound. Pleased with music and with human faces. Laughs
at tickling and clasps with its four fingers at the 8th week. First con-
sonants, 43d to 51st days.

3d month. — Cries of joy at sight of mother or father. Eyelids not
completely raised when the child looks up. Knows sound of watch at
9th week ; listens with attention.

4th month. — Eye movements perfect. Sees objects move towards

DEFECT PSYCHOSES

249

the eye. Joy at seeing itself in mirror. Poses thumb. Head held up per-
manently. Able to sit up with support to back.

14th week. — Beginning to imitate.

5th month. — Discriminates strangers. Pleasure of crumpling and
tearing newspapers, pulling hair, or ringing bell. Sleeps 10 or 11 hours
without food. Consonants 1 and k. Seizes and carries objects to mouth.

6th month. — Raises itself to sitting posture. Laughs, raises and drops
arms when pleasure is great.

7th month. — Astonishment shown by open mouth and eyes. Turns
head as sign of refusal.

8th month. — Astonished at new sounds and sights.

9th month. — Stands on feet without support. Claps hands for joy.
Fear of dog. Turns over when laid face down. Turns head to light
when asked where it is. Questions understood before child can speak.
Voice more modulated.

10th month. — First attempts at walking.

nth month. — Sitting has become habit of life. Stands without sup-
port; whispering begins.

12th month. — Pushes chair. Obeys command " Give the hand."

13th month. — Says " papa" and " mamma."

14th month. — Raises itself by chair; imitates coughing and swinging
of arms.

15th month. — Walks without support. Understands ten words.

16th month. — Runs alone.

17, 18th, 19th months. — Sleeps 10 hours at a time; associates words
with objects and movements. Blows horn, strikes with hand or foot;
waters flowers ; tries to wash hands, to comb and brush hair, and to
execute other imitative movements.

20th to 24th months. — Marks with pencil on paper; executes orders
with surprising accuracy.

25th to 30th months. — Distinguishes colors. Makes sentences of several
words. Begins to climb and jump and to ask questions.

30th to 40th months. — Goes upstairs without help. Clauses formed,
words distinctly spoken. Influence of dialect appears. Much questioning.

Frequently the occurrence of hydrocephalus, micro-
cephalus, or some other physical deformity directs the attention
of the parents to certain deficiencies in reactions of the child to
the simpler forms of stimulation. Failure to take the breast,
inability to fix its eyes upon objects or to follow them may be
noted early.. Only gradually, however, in the majority of
cases do the defects in intelligence become apparent. Anoma-
lies of dentition are often very marked, and it has been calcu-
lated that some degree of abnormality in this respect is found
in over 90 per cent, of the cases. The primary dentition is

250

PSYCHIATRY

greatly delayed. The teeth are irregular in form and fre-
quently appear with marked intervals. Diminution in the num-
ber is not uncommon. Erosions which are commonly attributed
to syphilis are noted. The presence of any of the physical de-
fects to which reference has already been made, particularly
those affecting the skull, may be of great aid in establishing a
diagnosis during the early period of infancy. This is particu-
larly true in regard to the failure of the fontanelles to close or
the premature ossification of the bones of the skull.

The diagnosis in the acquired defect psychoses is fre-
quently more difficult than is the case in the congenital types. In
children the recognition of the milder forms depends largely
upon the history obtained. It is not necessary to repeat what
has already been said in regard to the various symptoms. In
the milder cases the defects in intelligence first become marked
when the children go to school. It is then found that they are
unable to keep up with their classes, that their attention lapses
easily, that they fail to take a normal interest either in their
studies or companions. In addition to the psychic degeneration
there may be evidences of ethical defects or emotional anoma-
lies. Many of these symptoms may occur, especially at the time
of puberty, in other conditions, but in the defect psychoses the
individual simply fails to develop intellectually, emotionally, and
ethically, and there are no progressive signs of marked aliena-
tion. As dementia prsecox sometimes occurs in feeble-minded
children, this combination may give rise to difficulties in diag-
nosis. But the appearance of stereotypy, mannerisms, the cat-
atonic excitement — which is essentially different from that seen
in excited idiots or imbeciles — are all features that are in a
measure characteristic of the progressive psychosis. The occur-
rence of physical symptoms — the Argyll-Robertson pupil, the
absence of knee-jerks and disturbances of speech — serve to dis-
tinguish the youthful cases of dementia paralytica from idiocy
and imbecility.

The following scheme, slightly modified from one pro-
posed by Heller, could be used to good advantage in schools in
endeavoring to determine the number of pupils present who

DEFECT PSYCHOSES . 25 1

show mental deficiencies sufficiently marked to warrant their
removal to special institutions :

Name.

Age.

Religion.

Profession or occupation of parents.

Residence. Location in city. If in a house, the number of rooms and
occupants.

General surroundings.

Evidences of poor heredity. Alcoholism, mental diseases, suicide,
criminality, relationship of parents ; lues, tuberculosis.

Brothers and sisters. Ages, occupations, any facts bearing upon their
mental and physical characteristics.

Development of the child. At what age did it begin to walk and
speak? Evidences of rhachitis.

State of nutrition. Height. Weight. Circumference of skull.

History of illnesses. Convulsions. St. Vitus' dance. Brain diseases.
Injury to the skull or nervous system.

Physical anomalies and signs of degeneracy. Paralyses, headaches,
defects in speech, hearing, or vision ; mouth breathing.

Traits. Cleanliness, dirtiness, truthfulness, lying, a tendency to steal,
apathy, irritability, hypersensitiveness, imaginativeness, forgetfulness, su-
perficiality, sexual anomalies.

Particular inclinations and capabilities. Music. Manual dexterity.
Character of writing, and power to calculate.

Treatment.18 — The treatment of the defect psychoses can
not be entered upon in detail in a general text-book. Broadly
speaking, idiotic children are much better off in an institution
than they are at home. Those who exhibit some capability of
being trained should be placed in an institution where there are
especially appointed teachers. As regards the excited type of
idiocy, it is particularly desirable that these defectives should be
removed from their surroundings, especially if there are other
children in the family, as they are frequently subject to impulses
and anomalous emotional states which may be a source of great
danger, not only to themselves but to those about them. Fur-
thermore, their condition is rendered worse by the petty annoy-
ances and teasing to which they are too often exposed. Again,

18 Weygandt, W. : Die Behandlung idiotischer u. imbeciller Kinder in
arztlich. u. padagog. Beziehung. Wurzburg, 1900. Heller, T. : Grundriss
der Heilpadagogik. Leipzig, 1004.

252

PSYCHIATRY

it is not uncommon for these children to be given to excessive
masturbation, and generally speaking they are unfit associates
for other children. The most appropriate training is usually
one in which manual traits are cultivated and pedagogy plays
an altogether minor part. Not infrequently the results that may
be obtained from skilful training are remarkable in the milder
grades of idiocy and imbecility. Many of these unfortunates
can be taught not only to take care of themselves, to feed and
dress themselves, but also to undertake various of the simpler
forms of employment, such as light work about the farm or in
the house. Imbeciles, particularly those of the higher grades,
can be rendered capable of gaining, if not a livelihood, at least
some recompense for their labors — which, among the poorer
classes of society, is highly desirable. As these children learn
largely from imitation, great care should be taken that the exam-
ples put before them to imitate should be the most appropriate
possible. All forms of overexertion, physical or mental, should
be prohibited ; the children should live as much as possible out-
of-doors ; the diet should be carefully regulated and proper pre-
cautions taken against the various accidents to which their con-
dition exposes them. Gastro-intestinal disturbances are not un-
common, inasmuch as such individuals are apt to bolt their food
without masticating it, and frequently eat whatever is put be-
fore them without exercising the slightest judgment as to qual-
ity or quantity. Obstinate constipation is not infrequent. On
account of the general lowering in the mental and physical
faculties these unfortunates are particularly susceptible to vari-
ous forms of infection — tuberculosis, pneumonia, and the exan-
themata— and their vitality is, as a rule, far lower than that of
normal children.

Operative interference in cases of microcephalus has
proved barren of results. Nor is this surprising, since it has
been shown that the condition is not due solely to the early
ossification and too rapid closing of the sutures, the changes
in the bony vault being only a part of the whole disease process.
The milder grades of congenital mental defects are not uncom-
monly found among children attending the public schools.

DEFECT PSYCHOSES

253

These individuals suffer from a method of education for which
they^ are not adapted ; nor is it desirable that they should be
allowed to associate with other children. Unfortunately, up to
the present time only in Germany is any serious attempt being
made to remove these mentally deficient children from the
public schools and place them in institutions where they can be
properly cared for. When there is any reason to believe that
syphilis has been an important etiologic factor, the children
may be given mercury or the iodides. Not infrequently the
administration of calomel is followed by slight temporary im-
provement. In rachitic imbeciles careful attention should be
paid to the diet. It should be nutritious but plain, made up
largely of milk, eggs, fish, and green vegetables, with only a
little meat. Life in the open air and gymnastics under medical
direction are also indicated. Cod-liver oil, the syrup of the
iodide of iron, arsenic, and phosphorus often prove beneficial.

CHAPTER X

PSYCHOSES WHICH ARE PROBABLY IN PART THE RESULT OF
AN AUTOINTOXICATION a

These may be conveniently considered under the follow-
ing headings: A. The so-called infectious or fever deliria.
This category includes all forms of mental aberration asso-
ciated with febrile diseases and not forming an integral part
of other psychoses. B. The acute or collapse delirium. C.
The subacute delirious or confusional states variously described
as amentia, acute hallucinosis, delirious mania, acute confu-
sional insanity, and, finally, Korsakow's symptom-complex.

A. The Fever Deliria. In a description of the fever
epidemic of 1836 Schweich cites a reference from the obser-
vations made by an eye-witness of a somewhat similar condi-
tion in the year 1580 to the effect that "some had a severe
bleeding, some were out of their heads and babbled, but such
was only a sweating delirium" Sydenham and others of the
earlier writers directed attention to the not infrequent associa-
tion of fever with mental disturbances, and Esquirol tried to
establish a definite causal relation between these occurrences.
Schlager, in 1857, described many of the features of the
typhoid psychoses,2 and Weber,3 in 1865, directed the attention
of physicians more especially to the forms of alienation asso-
ciated with acute diseases. Mental aberration of varying de-

1 For the bibliography see Adler : Ztschr. f. Psych., Bd. liii, p. 740,
and Ballet, Traite de la Pathologie Mentale. Paris, 1903, p. 330.

2 See also Farrar, Clarence B. : On the Typhoid Psychoses. Medical
Reports of the Sheppard and Enoch Pratt Hospital, 1903, vol. i, No. 1,
p. 42. Friedlander, A. : Ueber den Einfluss des Typhus abdominalis auf
das Nervensystem. Berlin, 1901. Siemerling : Ueber Psychosen nach
akuten u. chronisch. Infektionskrankheiten. Allg. Ztschr. f. Psych, u.
psych. -gericht. Medizin, Bd. lxi, H. 1 and 2.

8 Weber, Hermann : On Delirium or Acute Insanity during the De-
cline of Acute Diseases, etc. Med.-Chirurg. Trans. 1867, xlviii, p. 135.

254

FEVER PSYCHOSES 255

grees of intensity and of length of duration has been reported
in connection with practically all the febrile diseases. The
frequency of these psychic manifestations depends upon a
number of conditions, such as the nature of the disease,
the severity of the epidemic, the time of life at which the in-
dividual is affected. It has been estimated that from 2 to 4
per cent, of all mental disorders are referable to an attack
of some acute infectious disease. In some countries at' least
3.5 per cent, of the cases of insanity are attributed to typhoid
fever. Physicians have long recognized the fact that the
severer epidemics of influenza were in a comparatively large
percentage of the cases particularly apt to be followed by men-
tal trouble. The character of the alienation was variously de-
scribed as mania, hypochondriasis, melancholia, or depression
associated with suicidal tendencies. Berkley and Jelliffe 4 are
among those who have more recently directed the attention of
physicians in this country to the importance of this disease as
productive of various forms of alienation. The latter par-
ticularly has emphasized the fact that a great increase in the
number of suicides occurred during the decade in which in-
fluenza was prevalent as compared with that prior to the
appearance of this malady. Although this increase can not be
attributed solely to the appearance of influenza, the fact can not
be doubted that this disease has been instrumental in adding
materially not only to the number of cases of alienation, but to
the severer forms in which the impulse to self-destruction is a
common symptom. Women who suffer from an acute infec-
tious disease are somewhat more prone to show signs of aliena-
tion than are men, and the greatest number of cases are noted
in both sexes during the prime of life. Nevertheless, even
very young children are by no means exempt.5 This group
may be subdivided into: (a) The prefebrile delirium, a con-

* Jelliffe, Smith Ely: Influenza and the Nervous System. Phila. Med.
Journal, 1902, Dec. 27, p. 1041.

° Heinemann, M. : Ueber Psychosen u. Sprachstorungen nach acut.
fieberhaften Erkrankungen in Kinderalter. Arch. f. Kinderheilkunde, Bd.
xxxvi, p. 173-195.

256 PSYCHIATRY

dition that frequently gives rise to serious errors in diagnosis;
(b) the more common delirious state developing during the
height of the fever; (c) the post-febrile psychoses. These
last, properly speaking, begin at varying intervals after the
temperature has begun to subside and their main clinical char-
acteristics— if they are not a part of other psychoses such as
manic-depressive insanity or dementia prsecox — are not essen-
tially different from those of collapse delirium or amentia. Ab-
normal psychic states may develop during the course of any
febrile disease, and, furthermore, it is important to note that a
fever may be an important etiological factor, not only in these
but also in other forms of alienation.

(a) In the first subdivision the dominant symptoms,
according to Farrar, are ( 1 ) impaired associative activity ; (2)
disorientation; (3) psychomotor excitement; (4) fallacious
sense perceptions with developing delusions ; ( 5 ) anxious affec-
tive states. As a rule, for some time prior to the onset of the
mental malady the patient has been in poor health, has been
nervous, sleeping poorly, showing considerable motor restless-
ness, more marked, probably, at night. There is an inability
to focus the attention and considerable impairment in associa-
tive memory. Symptoms of a general psychomotor restless-
ness, not limited to the functions of speech, are more common
in these cases than in those in which there are psychomotor
retardation and depression. This slight psychic aberration de-
velops several days before the more acute symptoms, but occa-
sionally, when the toxaemia seems to be more intense, the pro-
dromal period may be absent, or, if it exist at all, is only of a
few hours' duration and then immediately passes over into the
stage of acute delirium. Such a condition is sometimes met
with in the exanthemata, typhoid fever, pneumonia, influenza.
The patient after feeling sick for a few hours or days sud-
denly becomes wildly maniacal. Such cases carry with them a
grave prognosis and occur generally, though not always, in in-
dividuals who have an hereditary predisposition. In addition
to the symptoms already referred to, it is important to note
that there is apt to be considerable disturbance in the reception

FEVER PSYCHOSES 257

and elaboration of sensory stimuli, which in most cases gives
rise to illusions which are generally of a disagreeable or terri-
fying character. The sound of voices, of people walking in the
wards, and all ordinary forms of auditory stimuli are at once
misinterpreted by the patient and render him unduly apprehen-
sive and anxious. Associated with the illusions there are, as a
rule, very vivid hallucinations which constantly change in
character. This combination of symptoms may give rise to a
disorientation and incoherence so complete as to amount to
asymbolism. The increase in the number of illusions and
hallucinations is generally associated with still greater motor
restlessness, the refusal of food, and the exaggeration of all
the somatic symptoms. In some instances there is a continuous
and rapid progression in all the symptoms and the patient dies
without the occurrence of any break in the delirium. In other
cases lucid intervals intervene and persist for several hours at
a time, so that the patient to a certain degree becomes rational,
appreciative of what is going on about him, and shows a fair
degree of orientation. In some cases the initial delirium passes
over directly into an abnormal mental state, which persists not
only during the acme but after the subsidence of the febrile
symptoms, only disappearing long after the drop in tempera-
ture has occurred. In rare instances the delirious stage is not
accompanied by any fever and the mental symptoms subside
as the temperature rises.

The prognosis in these cases of initial delirium is generally
more unfavorable than in those in which the mental aberration
makes its appearance later on in the disease. Not only is there
a greater danger that the alienation may persist for a con-
siderable period of time or end in a paranoiic state, but the
gravity of the prognosis, so far as the disease itself is con-
cerned, is generally worse. The severe forms of initial delirium
in typhoid fever and acute articular rheumatism with a high
temperature (41 ° to 44 ° C.) are particularly dangerous. The
percentage of mortality in all cases varies somewhat according
to different observers, but the average of all available statistics
is between 40 and 50 per cent.

17

258 PSYCHIATRY

(b) The great majority of delirious states, since they de-
velop during the height of the disease, belong to this second
subdivision. This is particularly true in regard to typhoid
fever, pneumonia, influenza, acute rheumatism, meningitis, and
the various exanthemata. The symptoms may not differ essen-
tially from those already described as belonging to the pre-
febrile deliria, except that in the majority of cases the onset is
more gradual. There is nearly always considerable inter-
ference with the transmission of sensory impulses, psychic
anaesthesias, paresthesias, or hyperesthesias sometimes appear-
ing, generally associated with hallucinations and delusions.
Consciousness is almost never unclouded. The degree of motor
restlessness varies greatly in different individuals, sometimes
being so intense that the patient can be restrained only with the
greatest difficulty, while in other instances it is limited to
spasmodic twitchings or incoordinated choreiform-like move-
ments of the extremities. At times there develop twitchings
of the facial muscles and some interference with the muscles of
speech, more rarely with those of deglutition. These cases,
according to the severity of their symptoms, may be subdivided
into four groups (Kraepelin). (i) Those in which the cloud-
ing of consciousness is most marked, but in which strange
organic sensations are present. The motor restlessness varies
from a mere fidgetiness to more pronounced forms. The
patient complains of headache and various feelings of discom-
fort. His sleep is broken and he is apt to suffer from un-
pleasant dreams. (2) The symptoms are somewhat increased
in intensity, and hallucinations and delusions, particularly those
of a dream-like character, begin to make their appearance.
These latter, as a rule, are strange and grotesque, and are
both visual and auditory in character. (3) Here we meet with
a marked increase in the number of the symptoms, more or
less complete disorientation, and a diminution or entire loss
of appreciation by the patient that he is ill, a marked exag-
geration of the motor restlessness, varying emotional states
characterized by great intensity as regards their expression.
Furthermore, there is an exaggerated tendency to talk and a

FEVER PSYCHOSES 259

sensory flight of ideas. (4) In the severest cases there is com-
plete disorientation, consciousness is very markedly affected,
external impressions produce practically no reaction; the pa-
tient, when not comatose, talks continuously in a low, mum-
bling tone, and periods of coma vigil and lethargy are of
frequent occurrence.

The symptoms generally continue as long as the fever
lasts, and may then disappear after the defervescence; on
the other hand, they may persist for a considerable period of
time, until finally one of two things happens, — either the patient
gets well or else he passes over into a paranoiic condition.
The intensity of the mental symptoms does not seem to bear
any definite relation to the height of the fever or the rapidity
of the pulse. The mental disturbances occurring during
typhoid fever are supposed to be more or less specific, and
yet a careful study would show that they do not differ essen-
tially from those which may occur in other febrile disorders
of equal duration. The intensity of the febrile delirium varies
greatly in different cases.

The diagnosis of these conditions is not difficult. The
prognosis is always grave, and becomes more so when the men-
tal symptoms persist after the fall in the temperature.

The treatment in the prefebrile as well as in the febrile
deliria is largely symptomatic. If the patient is not too excited,
the cold pack may be used with great benefit. Ice-bags may be
kept applied to the head. If the patient is not too weak, the
full bath is often very efficacious. Sometimes it is advisable
in dealing with very excited patients to begin with water at
about blood-heat and then gradually reduce the temperature.
The nursing of these patients is all-important. In well-
equipped hospitals, where there are plenty of skilful nurses and
abundant opportunity for carrying out hydrotherapeutic meas-
ures, the camisole and other artificial means of restraint are
practically never indicated. Moreover, hydrotherapy will gen-
erally render unnecessary the administration of hypnotics and
sedatives of various kinds which are often detrimental in these
cases. Saline infusions are often very effective.

2<5o PSYCHIATRY

(c) The post- febrile psychoses may for the sake of con-
venience be divided into two groups : ( I ) those occurring
coincidently with or soon after the subsidence of the tem-
perature; (2) those developing more slowly and after a
longer lapse of time. As has already been pointed out, fever
in itself may be an etiologic factor of great importance in
the development of almost any form of alienation, such as
dementia praecox, manic-depressive insanity, etc., although it
can never be regarded as a causative agent specific for any one
type. After the drop in temperature has occurred or during
the period of convalescence acute delirious or confusional con-
ditions may develop, a description of which is given in the
following section. At present it is the general consensus of
opinion 6 that the pathological changes which occur in the
central nervous system as the result of elevations of the bodily
temperature are to be regarded as the results of autointoxica-
tions ; but the manner in which the toxines act is still a mys-
tery, and as yet no definite relationship can be established
between the lesions and the clinical symptoms. Formerly
considerable importance was erroneously attached to the sup-
posed hyperaemic or anaemic condition of the cerebral vessels.
Such conditions may be the result merely of preagonal or post-
mortem changes, or due to the alterations in the position of
the body. Nevertheless it is always possible to say, from in-
spection of the central nervous system, particularly in sections
treated with the Nissl stain, that the individual previous to
death has suffered from pyrexia. In the nerve-cells, as a rule,
very marked changes are demonstrable. They show a ten-
dency to stain diffusely, this feature probably being the result
of the dissolution of the chromatic substance and its diffusion
throughout the cell. The nucleus is sometimes swollen and
eccentric; the processes, particularly the axis cylinder, show
a strong tendency to stain deeply. Some observers have re-
ported fragmentation, particularly of the apical processes and
axis cylinders.7

8 Friedlander, Goldscheider, Aschaffenburg.
7 Meyer, E. : Orth's Festschrift.

PLATE I

Ganglion cell. Nissl stain. X 750. Spencer, }., hom. immers. obj. (Cramer isoch. plate.)

PLATE II

I

<r

«

I

\*

Normal Betz cell. Nissl stain. X 750. Spencer, {„ horn, immers. obj. (Cramer isoch. plate.)

platp: hi

*>

Fever cell. ,< 750. Diffuse staining of cell-body, nucleus, and processes. The intercellular
substance is also stained. Spencer, £ horn, immers. obj. (Cramer isoch. plate.)

Fever cells showing diffuse staining of cell-body, nucleus, and processes. X 750. Spencer,
^ hom. immers, obj. (Cramer isoch. plate.)

PLATE V

Large pyramidal cell, ant. cent, convolution (Bethe stain). X iooo. A, axis cylinder;
L, lateral basal processes. The intercellular substatice, which is not stained in I and II, and
is indicated in III, in this preparation is easily recognizable.

THE ACUTE DELIRIUM 26l

In some of the acute intoxication psychoses mitotic figures
are demonstrable in the glia.

The nerve-fibres are sometimes affected in the severer
cases, showing degeneration of the myelin sheaths and the for-
mation of small globular masses. In the protracted cases,
particularly the typhoid psychoses, fatty degenerations are
noted in various parts of the nervous system. Micro-organisms
— the typhoid, influenza, and tubercle bacillus, the pneumo-
coccus and various other forms, as well as the parasite of
malaria — are often found in the central nervous system. What
relations these organisms bear to the pathological changes and
to the clinical symptoms is not clear, but it is generally supposed
that, in the majority of instances at any rate, they are of only
secondary importance and that the invasion has often taken
place just before death.

B. The Acute Delirium. Collapse Delirium. Delirium
Grave. Phrenomania. Bell's Disease. — Frequent references,
more or less definite in character, occur throughout medi-
cal literature 8 to a form of aberration bearing a striking
similarity in certain particulars to the type seen in infectious
diseases and characterized by an acute onset with severe
somatic disturbances. Calmeil 9 first suggested the name of
the acute delirium, but it remained for Weber,10 under the
title of collapse delirium, to give a detailed and accurate clini-
cal account of this group of symptoms. The unity of the
various clinical pictures was first emphasized by certain French
clinicians (Chaslin), but great credit is due to the Heidel-
berg school for recognizing a similar origin and develop-
ment for these cases, despite the fact that at first sight their
symptoms are strikingly dissimilar. Nor does this union upon
a common basis have any reference to the supposed bacillary
factor in the etiology, — a theory advocated principally by the
Italians, — but. is derived from the fundamental analysis of these

8 Hippocrates : Ccelius Aurelianus. Thomas Willis.

8 Traite des mal. inflam. du cerveau. t. i, p. 142.

10 Med. Chir. Trans., vol. xlvii, p. 135. London, 1865.

262 PSYCHIATRY

conditions, the result of experimental studies made by Krae-
pelin and others into the nature of fatigue.

The malady is characterized by a marked interference with
the mental functions, disturbances of sensation and motion,
and in from 40 or 50 per cent, .of the cases a favorable
termination after a period varying from several days to two
or three weeks. It makes its appearance in neurotic individ-
uals who have been subjected to severe psychic shocks or during
the period of defervescence after febrile diseases — such as the
exanthemata, typhoid fever, pneumonia, erysipelas, influenza —
or after severe trauma, parturition, or surgical operations.
Generally, after the prodromal period, which may vary from a
few hours to several days, the patient begins to suffer from
motor anomalies of the hyperkinetic, parakinetic, or akinetic
type, with accompanying psychic anaesthesias, paresthesias, or
hyperesthesias, and various kinds of hallucinations, which
are particularly apt to take on a fantastic and bizarre character,
the patients complaining that they see various animals, angels,
or devils. In the earlier stages these hallucinations are likely
to be dream-like in character and seldom dominate the actions
of the individual, but gradually the sensory plainness becomes
exaggerated and their reflex power greatly increased. Soon
states of apprehensiveness and marked anxiety develop. The
patient is distracted or frenzied by the apparitions which seem
to hover about his bed, and may even attempt to escape from
them by covering his head with the bedclothes or frequently,
if not watched, by resorting to other and more desperate means,
in his blind fury attacking nurses or physicians. As the dis-
order progresses, disorientation becomes more and more com-
plete and he becomes unable to recognize his surroundings,
declaring at one moment that he is in heaven, or again affirm-
ing with equal emphasis that he is in prison or in the depths
of hell. The identity of those about him is frequently con-
fused; the nurse or the physician is claimed as an intimate
friend or, when the emotional state has changed, is regarded
with suspicion or terror. As the irritability increases, the
speech-centres are almost never left unaffected and the inco-

THE ACUTE DELIRIUM 263

herence increases. The motor disturbances may be so exag-
gerated that all coordinated movements are seriously impaired.
Consciousness is greatly clouded. The affective state is one
in which inexplicable impulses dominate the cerebral activity
and all forms of associative memory are greatly impaired. In
some instances the reactions of the patient and the content of
the ideas expressed may at times suggest the typical flight of
ideas of the maniacal patient. But as a rule the incoherence
becomes greater, the individual is less responsive to external
stimuli, and disorientation is frequently more marked and con-
sciousness more clouded. In some cases the character of the
delirium is less boisterous, the motor restlessness not promi-
nent, and the patient's appearance suggests the low muttering
delirious state of typhoid fever. In still another type of the
disease the individual hallucinations are not as dominant and
those that exist are less evanescent in character, while certain
forms of auditory or visual hallucinations seem to be more or
less constantly in the field of the patient's attention and an
explanation or systematization of these phenomena may be
attempted by him. Periods of mental depression may alternate
with those of excitement or stupor. These cases are extremely
difficult to differentiate from the other psychoses, particularly
amentia.

The physical symptoms which occur during the course of
the acute delirium are manifold, although none are specific.
On this point, however, certain writers hold a different view.11
During the prodromal period we meet with anorexia, nausea,
vomiting. In some cases, in addition to the psychic hyperes-
thesias alluded to, there are peripheral disturbances in sensa-
tion. At other times there are painful areas over the site of
some internal organ, particularly in the cardiac and epigastric
regions. As the disease develops, there may be a rise in tem-
perature, 390 to 41 ° C. not being uncommon, and a more or
less sudden drop just prior to death is sometimes noted. Cases

11 Pritchard, W. B. : Delirium Grave. The Journ. of Nerv. and Merit.
Diseases, vol. xxxi, March, 1904, No. 3.

264 PSYCHIATRY

are observed in which there is no febrile rise, and even sub-
normal .temperatures occur quite frequently. During the acme
of the delirium the patient gives every appearance of an indi-
vidual suffering from a severe toxaemia. The face has a pecu-
liar drawn appearance, the complexion is sallow, the eyes are
somewhat sunken, the tongue is thick and coated, and, as the
motor restlessness becomes greater, there seems to be consid-
erable difficulty in articulation. The loss of weight is marked,
and a rise in the curve, even if the mental state is unchanged,
generally indicates a more favorable prognosis. Sometimes
a patient will gain several pounds in two or three days.

The gastro-intestinal disturbances are generally pro-
nounced. Sometimes the nausea and vomiting are so obsti-
nate that no food can be retained and a resort to artificial
feeding becomes necessary. In other instances the refusal to
take food is the result of delusions. The breath, as a rule, is
fetid and constipation is marked, although at times a watery
diarrhoea supervenes. The urine is often scanty, of high spe-
cific gravity, and, according to numerous observers, is very-
toxic in its qualities, a statement, however, that does not
always hold good. The chlorides are frequently diminished
and traces of albumin and sugar are not uncommon. Cer-
tain investigators have found an increase in the quantity of
indican and uric acid. At times there may be an unusual
flow of saliva. The skin in the cases with a high temperature
is dry, but in the asthenic types of the disease is moist and
covered with a cold, clammy sweat. The latter is particularly
noticeable in fatal cases. Not uncommonly the patients,
particularly in the severe types of the disease, suffer from
epileptiform or mild apoplectiform attacks, the occurrence
of which has sometimes been responsible for a diagnosis of
general paresis. In rare instances disturbances in the eye-
muscles and in the reflexes to light are noted. As would natu-
rally be expected, the skin and tendon reflexes show no essen-
tial difference from those belonging to all stages of excitement
and are, as a rule, markedly increased.

Termination.' — At least 50 per cent, of the patients sue-

THE ACUTE DELIRIUM 265

cumb. In venturing a prognosis the character of the physical
symptoms should always be allowed great weight. The out-
look is generally worse where the motor restlessness is excessive
or the patient shows signs of collapse, the pulse becoming
small and rapid and the stomach rejecting nourishment. The
delirium runs its course within a few hours or several days,
and, when a favorable outcome is to be expected, usually ter-
minates, as do many of the cases of delirium tremens, the
patient falling into a prolonged sleep.

Much can be accomplished in the way of treatment. A
great deal depends on the nursing, and these individuals are
far better off in a good general hospital than in any asylum
imperfectly equipped in this respect. Moreover, in view of
the difficulties attending the nursing of such patients in pri-
vate houses, any attempt to care for them at home is usually
unjustifiable. One or more nurses must be in constant at-
tendance, so that everything possible may be done to relieve
the symptoms as speedily as possible. Although such patients
frequently struggle furiously to get away from their attend-
ants, trying to jump out of the window or to injure themselves
in various ways, mechanical restraint should not be resorted
to until appropriate hydrotherapeutic measures have been tried
and failed. In practically all cases, if the warm continuous
bath is properly given, being supplemented, if necessary, by
small doses of some hypnotic, it will have the desired effect.
The bath should be given with great care, and at first one of
the resident physicians should keep within call for some time
in order to note the effects.

The methods of procedure are described in detail in the
chapter on Treatment. (Cf. page 151.) When the patient
is once in the tub he is better off than in bed. The duration
of the bath may be varied according to circumstances, — from
five minutes to several hours, if necessary. When the tem-
perature is high or the patient shows evidences of marked
toxaemia, saline infusions are often useful. A tendency to
collapse may be combated by the administration of alcohol,
coffee, camphor, digitalis, or strychnine. The administration

266 PSYCHIATRY

of narcotics should be resorted to only when the bath has failed
to quiet the restlessness, but, if it becomes necessary, small
doses of bromide, sulfonal, trional, and in exceptional cases
scopolamin may be given. Every means should be employed
to keep up the nutrition. Small quantities of milk should be
given regularly every two hours combined with raw eggs or
bouillon. If the stomach rejects nourishment, nutritive ene-
mata — from two to three in twenty-four hours — are indicated.
Sometimes high rectal injections of normal saline solution at
body temperature are of great value in preventing collapse.

The pathology of this condition, as far as it is known,
will be described in the following chapter.

C. Subacute States of Delirium and Mental Con-
fusion. Amentia (Meynert).12 Acute Confusional In-
sanity, Delirious Mania, Hallucinatory Insanity.
Hallucinatory Confusion, Paranoia Dissociativa
(Ziehen). — The distinguishing features in the forms of alien-
ation to be described under this head are clouded consciousness,
interference with associative memory, hallucinations and de-
lusions, as well as anomalous emotional states, such as appre-
hensiveness and fear. No sharp line divides this from the
group of cases just described. The malady, when uncompli-
cated, runs its course in from six or eight weeks to several
months, and does not include any conditions that are to be
regarded as belonging to other forms of alienation. The line
between the more protracted cases of the acute delirium and
these clinical forms can only be drawn arbitrarily, as there
are no distinctive features. Although individuals may suffer
from more than one attack, many of the so-called recurrent
cases not improbably represent phases in other psychoses, such
as manic-depressive insanity, dementia praecox, dementia para-
lytica. A great many of these confusional states can only be
differentiated from the acute delirium by their more prolonged

" Meynert, Die acut. hallucin. Formen des Wahnsinns u. ihre Verlauf.
Allgemein. Ztschr. f. Psych., xxxviii. Jahrbuch f. Psych., 1881. Chaslin:
La confusion mentale primitive, 1895. Del. Greco : Sulle varie forme die
confusione mentale. II Manicomio moderno, 1897 and 1898.

AMENTIA

267

duration. The older authors, particularly Pinel, Esquirol,
Georget, Griesinger, Kahlbaum, described a variety of con-
ditions, the majority of which may be included under this
head; but it was not until Meynert studied this syndrome
that the probable unity of the various clinical pictures became
apparent. This conclusion has been more recently extended
and confirmed by the investigations carried on concerning the
nature of fatigue and the possibility that exhaustion is a factor
of specific and fundamental importance in this group of psycho-
ses. Wernicke,13 however, still emphasizes what he considers
to be essential dissimilarities in the varieties of cases forming
this group.

The onset of the disease in many cases is not essentially
different from that of the acute delirium, especially in those
instances in which the malady runs a somewhat prolonged
course. After the prodromal period, following one of the
causes to which reference will be made later, the patient shows
signs of restlessness, slight dissociation in connected thought,
mild apprehensiveness, and fear of being left alone, and not
infrequently complains of being troubled by unpleasant
thoughts or by frightful dreams when he gets to sleep.
Sometimes gradually, at other times within a short space
of time, the disturbances in associative memory become more
marked, the distractibility increasing so that the attention is
constantly wandering. Even when asked a simple question,
the patient may say a few words and then, becoming oblivious
of what was uppermost in his mind, pass to another topic.
Distractibility, however, is not the chief feature, as it is in
maniacal excitement, in which sensory impressionability is
apt to be very great. Sensory impressions easily deflect the
patient's attention, but, on account of the clouded conscious-
ness, they do not give a definite trend to the subsequent re-
actions. On account of the rapid deflections in the attention,
memory suffers greatly and, since all sense impressions are
evanescent, the patient forgets in a few minutes the events

18 Grundriss der Psychiatrie, 406.

268 PSYCHIATRY

that have just transpired. The face sometimes assumes an
anxious expression; marked tremor may develop and often
slightly incoordinated and involuntary contractions of the
facial muscles are present. If the patient is asked to fix the
eyes upon an object, the request is not complied with for
more than an instant. The disturbances in sensibility, as
a rule, are similar to those in the acute delirium and may
be considered to be of psychic origin. Gradually the halluci-
nations become more marked. At first they are generally of
a primary character, — flashes of light, sounds of bells or of
running water. But soon the ordinary noises about the wards
begin to be misinterpreted. The sighing of the wind is evi-
dence of the passing of unseen spirits; the sounds made by
patients in other parts of the ward become the voices of friends
calling for help. Frequently the patient complains of an un-
pleasant taste in the mouth, which is regarded as a sign that
his food has been poisoned. Shapes of curious animals —
snakes, lizards, horrid monsters — are seen. Not infrequently
these fallacious sense perceptions result in insane ideas of
persecution, and the patient affirms that the nurses and physi-
cians are trying hard to kill him. Sometimes the grotesque
phantasms or frightful apparitions suggest the mental disturb-
ances in epilepsy. In the earlier stages the hallucinations are
constantly changing. Each new impulse seems to start up a
sensory flight of ideas. At times the motor restlessness, which
is nearly always present early in the disease, is associated with
considerable garrulity, and the content of what is said and
the character of the speech reaction may suggest the flight
of ideas. But the dulling of consciousness, the lack of agree-
ment between the external surroundings and what is said, as
well as the absence of other symptoms, help to distinguish
the conversation of these patients from that of the typical
maniac. As the disease progresses, the rapid change in the
character of the hallucinations and illusions becomes less
marked. Certain forms show a tendency to persist, and to
these the patient is constantly referring. As the flightiness
diminishes, there is a greater tendency shown towards the

PLATE VI

At the time this photograph was taken the patient was in a stale of great mental confusion.

AMENTIA 2g9

development of definite ideas of persecution or self-accusation ;
patients refer to themselves as lost souls without hope and
eternally damned. If any form of external stimulation affects
them, it is apt to increase the states of apprehensiveness or
anxiety, so that the dominating force of the hallucinations and
illusions becomes overwhelming. The motor restlessness
varies from a mild uneasiness to the wildest, most incoordinated
and excessive movements. At times the incoordination and
the explosiveness of certain acts suggest exaggerated forms of
chorea.

The consciousness of the individual is, as a rule, greatly
disturbed, although moments of apparent quiet and lucidity
may come and go.

The physical symptoms of amentia during the earlier and
more acute stages do not differ essentially from those of the
acute delirium, although the loss of weight is not usually so
rapid and the physical signs are less prominent. During the
excited period the pulse frequently becomes rapid and small;
at times during the course collapse symptoms may develop.
The reflexes are nearly always increased ; the temperature may
rise during the periods of greatest excitement or less commonly
falls below the normal.

Course. — The clinical course of the disease varies greatly
and is associated with a variety of mental symptoms. The
two principal types of the disease are similar to those described
under the head of the acute delirium, — an asthenic type and
one in which the confusional state is more boisterous and the
general motor restlessness greater. To the former belongs
the confusional or stuporous amentia of Meynert; to the
latter, the hallucinatory confusion, delirious amentia, and the
so-called acute hallucinatory paranoia of other writers. The
following table, taken from Ballet,14 gives some idea of the
variety of mental states which are temporarily grouped to-
gether under this head :

14 Traite de la Pathologie Mentale.

270 PSYCHIATRY

Asthenic mental confusion Cerebral torpor

Stupidity
Acute dementia

Hallucinatory mental confusion Depressed form

Mixed form
Systematized delirium

Unquestionably many of the states frequently grouped
under this head in reality represent stages of other psychoses.
Great confusion in grouping has arisen from the fact that
many of the clinical records mention merely the symptoms of
a single attack, without giving any information as to the
previous history of the individual or as to his condition after
leaving the institution.

Termination. — In a large number of cases recovery takes
place, although, more particularly in the asthenic types, not
a few of the patients die during the earlier stages in collapse.
In the former the manifestations suggest a protracted acute
delirium. The duration for the most part is between three
and six months. Some cases undoubtedly pass over into a
chronic paranoiic state which may persist for months and
sometimes never entirely clears up.

The prognosis depends upon a variety of factors, largely
upon the physical condition of the patient. In the asthenic
types constant and recurrent attacks of heart weakness are
to be regarded as ominous. The persistence of the insane
ideas, more particularly when they are well systematized, gen-
erally means that the case will run a long course, and the prog-
nosis for ultimate recovery is correspondingly worse. Not
uncommonly patients die from some intercurrent trouble. On
account of their lowered vitality and poor nutrition, they are
particularly susceptible to pneumonia, infections of various
kinds, tuberculosis, and so on. A more or less rapid increase
in the bodily weight is nearly always a favorable sign.

Incidence. — As happens also in the acute delirium, females
are attacked more often than males. Although abroad the
disease seems to be of comparative infrequency, according to
Kraepelin representing only one-half per cent, of all the cases

AMENTIA 27j

of alienation, it is probable that a comparatively large number
of cases occur in this country. The same opinion has recently
been expressed in regard to the frequency of its incidence in
Vienna.

The history of the following case is of interest on account
of the occurrence of catatonic symptoms. When the patient
was first seen, a provisional diagnosis was made of dementia
praecox, but, as the mental confusion and hallucinations gradu-
ally disappeared, and a complete recovery without any signs
of mental reduction followed, a revised diagnosis of amentia
was substituted :

Miss X, aged 32. Nationality, U. S. A. Admitted November 9, 1903 ;
discharged February 15, 1904. Patient confused. History obtained from
mother, sister, and nurse.

Family History. — Mother living, rather delicate. Father died of pneu-
monia at 63. Four brothers living and well. One brother died of " abscess
of the brain." Two sisters living, one delicate. Both sisters and brothers
are nervous.

Personal History. — Measles, chicken-pox, whooping-cough, and scarlet
fever in childhood. No other acute diseases. Strong and well until about
16, when she began to have some menstrual trouble, which has continued
off and on ever since. At this time she nursed her grandmother for some
months during a severe illness, and this strain was followed by " nervous
prostration." She blamed herself for not having done more, but the sister
affirms that the patient worried without cause, as there was no reason for
self-reproach. Some years after her health was tolerable. For eleven
years she was in " ill health." Cause not known. Ten years ago she
went to a hospital as a probationer nurse, but she found that she worried
excessively and always feared that she had not done things correctly.
Eight years ago two brothers had typhoid fever. She nursed them and
worried greatly over their condition. One brother died from abscess of
the brain following middle-ear disease, and the patient reproached herself
greatly, as she thought she could have done something to prevent this.
Since then she has never been quite well and has had one nervous attack
after the other. Has travelled about a good deal and seen many physi-
cians. Some of them made a diagnosis of hysteria. No especial features
were noted beyond these until October, 1901, when she had an attack of
sciatica, together with severe pain and loss of power in the arms. She
became weak and helpless and her condition caused much alarm. She
gradually recovered from the sciatica and spent some months in bed.
In the spring of 1902 she was able to be up, but was very nervous. The
appetite has usually been poor. She has been subject to headaches for
several years. Average weight, 108 pounds.

272 PSYCHIATRY

Present illness began September 20, 1903. She complained of weakness
in both arms and apparently was unable to feed herself. In about two
weeks this disappeared and the power in her hands returned. When the
question came up as to where she would pass the winter, she began again
to complain of weakness in her arms. She went to bed and was prescribed
for by a physician. Later it was noticed that she was dull mentally and
did not seem to comprehend clearly what was said to her about business
affairs. She had difficulty in counting money. At this time there were
no hallucinations or delusions. Four or five days later, when seen by
her mother and sister, a great change was noticed. She seemed to recog-
nize people about her, but talked in a rambling way. She was then
brought to Baltimore. While on the train she was restless and hard
to control and had an idea that people were being killed.

October 21, 1903 : There were some hallucinations of sight and hearing.
The fixed ideas relating to certain individuals whom she supposed to have
been killed became more pronounced and persistent. When admitted to
the hospital, she declared that her father and brother were dead and their
bodies were in the next room. She then began to talk about a hansom cab
and an instant later spoke about an epigram and later of a monogram. She
was able to give her name and age correctly, but was not oriented for
place.

November 9, 1903 : At night she talked excessively in a loud tone of
voice. There was no sense in what she said. Marked distractibility.
Pupils large but equal. Tongue heavily furred. On the 10th she was in an
apparent stupor, and could not be aroused when spoken to in a loud tone
of voice. Haemoglobin, 60 per cent.

November 13, 1903 : The patient was lying in bed on her back with the
eyes partly closed and mouth open, snoring slightly. Face expressionless.
No marked mechanical irritability of the facial nerve. Patient could be
tickled and pressure made over the supraorbital branch without much
effect. The toes and fingers could be pinched without any apparent
reaction. When the arms were raised, there was a slight tendency for
them to remain in the position in which they were placed. No response
to passive movement. It was difficult, though possible, to get a response
to questions. The voice was very feeble. When the second question
was asked, the reply was nearly always a repetition of that given to the
first. For a few days following there were periods of restlessness and
the patient tried to get out of bed. On one occasion the face, neck, and
hands suddenly became cyanotic. There were slight convulsive move-
ments of the face, neck, and extremities. The movements were not
violent nor extensive. The patient seemed perfectly unconscious for
about fifteen minutes. On the 20th there was slight resistance to passive
movement. No attitudinizing. There was disorientation for time and
space. She mistook the identity of those about her, talked a good deal,
but had no typical flight of ideas. The emotional state was one of more
or less indifference. She obeyed simple commands promptly. Distracti-
bility was not very great.

A note made on December 8 states that the patient had had an ex-

AMENTIA 273

cellent week : remained quiet nearly all the time ; seemed perfectly normal ;
memory excellent.

The treatment consisted in injections of normal salt solution, 400 c.c.
being given on November 15, after which the procedure was repeated at
varying intervals until she became rational. In addition to this she was kept
on a strict rest-cure and given wet packs. On February 15, 1904, the patient
was discharged cured. Careful examination failed to demonstrate the
presence of any mental impairment. Weight on admission, 90 pounds ; on
discharge, 104^ pounds. Two months after her discharge the patient was
reported to be in excellent health.

Age. — The disorder is apt to occur in individuals in the
prime of life. Cases have been reported as occurring as early
as the ninth or tenth year and some as late as the fifth or sixth
decade of life. Nevertheless it must be said that in the latter
instances the symptoms were atypical, and on account of the
age of the patient it is almost impossible to say that the re-
corded confusional state was not a part of some senile dis-
order.

. Etiology. — As a rule, the family history in individuals
who are afflicted with these acute confusional states is bad,
and the fact can be elicited that one or both parents have suf-
fered from neuroses or definite psychoses. Even as regards
cases which seem to be of very acute onset, in the majority
it will be found that the individual prior to the onset of
the disease had been subject to some form of nervous or men-
tal disorder. Not uncommonly we find that such individuals
have always been more or less delicate, that as children they
have required to be more carefully guarded than other mem-
bers of the family, and after puberty have been subject to
anomalous emotional states, attacks of so-called nervous pros-
tration, and a great variety of symptoms which could belong
only to the possessor of an unstable nervous system.

The exciting causes of confusional insanity are in a meas-
ure identical with those provocative of the acute delirium. Par-
turition is not infrequently the starting-point of the disorder
in the predisposed, and gastro-intestinal disorders seem to be
intimately connected with not a few of the cases.15 For a long

15 Wagner : Wien. klin. Wchnschr., 1895.
18

274 PSYCHIATRY ,

time prior to the outbreak of the malady the patients frequently
suffer from poor digestion, anorexia, nausea, constipation
alternating with attacks of diarrhoea, and a great variety of
disturbances. Next in importance are the acute diseases, par-
ticularly the exanthemata, as well as typhoid fever and influ-
enza. Mental and physical shock also play an important role,
while all forms of trauma seem to favor the development of
this psychosis.

Differential Diagnosis. — The recognition of amentia is
frequently beset with many difficulties. In the earlier stages
of the disease the character of the excitement, the appearance
of certain stereotyped mannerisms, the tendency to repeat cer-
tain words, and the general mentality of the patient are sug-
gestive of the catatonia of dementia precox. The difficulty
in differentiating the two conditions is greatly increased when
we remember that these, as well as other catatonic symptoms,
may occur during the course of amentia, although they are far
less definite and noticeable than in cases of dementia prsecox.
In amentia there are, as a rule, a greater impairment of con-
sciousness and a more general defect in associative memory.
The patient is more confused, less impulsive, and shows con-
siderable difficulty not only in the elaboration but also in the
reception of sensory impressions. From cases of manic-
depressive insanity the differentiation is often difficult, but in
genuine cases of mania the flight of ideas has certain specific
qualities, described more fully elsewhere, and the interference
with consciousness or with the reception of all forms of sen-
sory impressions is less marked. Occasionally amentia may
be mistaken for dementia paralytica, but the diagnosis is soon
settled if on careful physical examination somatic symptoms
are detected. As regards chronic alcoholism, the history as
well as the general features of the two diseases seldom leave
the physician in doubt as to the real condition.

The treatment of amentia does not differ essentially from
that of the acute psychoses. During the periods of excitement
hydrotherapeutic measures — full baths, warm packs — saline
infusions, careful nursing, forced feeding, and protection of

AMENTIA 275

the patient from self-inflicted injury should be employed.
The drugs which may be helpful are the same as those used in
other excited conditions.

Pathology}* — Practically little is known regarding the
pathology of these two forms of alienation. At various times
observers have attempted to prove that the acute delirium was
a cerebral malady of an infectious nature, while others main-
tain that it develops purely as the result of an exhaustion of the
central nervous system. Bianchi and Piccinino 17 thought they
had demonstrated that a special bacillus found by them in the
blood and meninges in cases of the acute delirium played an
important role in the etiology. These observations, however,
have not been confirmed by other investigators. Ceni 18 showed
that in the early stages of the delirium no micro-organisms
were present, and that in other instances where they appeared
later in the disease they were of various forms. At present
it is generally believed that these micro-organisms do not
bear any definite relationship to the mental symptoms, although
it is not improbable that they may give rise to secondary in-
fections of a grave character. The nerve elements, as a rule,
show considerable alteration. In some instances we meet with
a peripheral chromatolysis, more marked in the larger elements,
but generally the central or perinuclear disintegration of the
chromatic substance involves most of the cell. None of the
changes recorded are in any sense specific, and it is question-
able how closely related they are to the mental symptoms.
Where the patient has suffered from a hyperpyrexia, the

16 Camia, Florenz : Ueber Veranderungen an den Nervenzellen bei
acuten Psychosen. Rivista di pat. nervos. e ment, fasc. 9, 1900. Bins-
wanger, O. ; Berger, H. : Zur Klinik u. patholog. Anat. d. post-infect.-
u. Intoxicationpsychosen. Archiv. f. Psych, u. Nervenkrankh., Bd. xxxiv,
H. 1, 1901. Hoch, August: On Changes in the Nerve-cells of the Cortex
in a Case of Acute Delirium and a Case of Delirium Tremens. Am.
Journ. Insan. Tomlinson, H. A. : The Pathology of Acute Delirium.
Am. Journ. Insan., 1903, vol. lx, No. 9.

17 Sulla origine infettiva d'una forma di delirio acuto. Ann. di Nevrol.,
1893, xi.

18 Riv. sper. di Fren., fasc. i, 1900.

276 PSYCHIATRY

changes due to the fever per se are pronounced. Some investi-
gators have emphasized a homogeneous atrophy of the nu-
cleus of the larger nerve-cells. This is important not as having
any direct bearing upon the specificity of the change, but rather
as an indication that cells thus affected can never return to
their normal state. The cells in the spinal ganglion and
throughout the sympathetic nervous system are nearly always
affected. Orr19 and others have called attention to the fact
that there may be marked alteration of the myelin sheath and
axis-cylinder, the myelin breaking up into little droplets or
oval globules, or in other instances the axis-cylinder being
denuded. Personally I am inclined to believe that these changes
are more directly the result of the terminal pyrexia than of
the alienation. In addition to the changes in the cortex, a
variety of lesions in the cord have been described. Turner 20
and Camiar directed attention to the degeneration in the
pyramidal columns in many of the acute insanities. Lesions
are frequently noted in the kidneys, liver, and heart. These
include fatty degenerations of the cells, of the convoluted
tubules or the glomeruli of the kidney, of the hepatic cells,
and also a degeneration involving the muscular fibres of the
heart. It is not at all improbable, as the Italian observers
have suggested, that the mental symptoms are the result of an
autointoxication induced by a variety of conditions, and that
this primary toxaemia so lowers the vitality of the individual
that secondary intoxications due to the presence of micro-
organisms may result.21 There are so many doubtful points
involved in a discussion of the pathology of these cases that
dogmatic statements are out of place. Orr is right in saying
that only by attacking the problems concerned from every
possible vantage ground can a better comprehension of the
nature of the disease be attained.

19 Orr, David : A Contribution to the Pathology of Acute Insanity.
Brain, Summer, 1902, part xcviii, p. 240.

MJourn. of Mental Science, Oct., 1900.

21 D'Abundo, Agostini : Rivista sperimentale di Freniatria, fasc. iv,
1900.

KORSAKOW'S SYNDROME 277

Regarding the nature of the pathological changes in
amentia, practically nothing is known. Lesions similar to
those described as existing in the febrile psychoses or the acute
deliriums are frequently met with, but these bear little, if any,
relationship to the symptoms.

D. Cerebropathia Psychica Tox^mica. Korsakow's
Syndrome. Polyneuritic Psychosis. Neurocerebrite
Toxique.22 — Mention occurs in the literature, as early as the
middle of the last century,23 of the mental disturbances met
with in alcoholics with accompanying lesions in the peripheral
nerves. In this country the subject was referred to by Mills
in 1886 and by M. Allen Starr24 in 1887, but this syndrome
was first described in detail by Korsakow,25 whose name is
now commonly associated with this clinical picture. The work
of Soukhanoff,26 Babinski, and others has shown that similar
mental disturbances may occur in cases in which alcohol does
not enter as an etiologic factor.

The psychic aberration may be briefly summarized as con-
sisting in defects in associative memory, confusion with a
marked tendency to confabulate and indulge in pseudo-remin-

22 Tiling, Th. : Ueber alkoholische Paralyse und infektiose Neuritis
multiplex. Halle a/S., 1897. Meyer, E., u. Raecke, J. : Zur Lehre vom
Korsakow's Symptomcomplex. Archiv f. Psych., 1903, Bd. 37, H. 1.
Turner, John : Twelve Cases of Korsakoff's Psychosis in Women. Journ.
of Mental Science, October, 1903. Miller, Harry W. : Korsakow's Psy-
chosis. Report of Cases. Am. Journ. Insan., lx, No. 4, 1904. E. Dubre :
Ballet's. Traite de la pathologie mentale, 1903, p. 1122.

23 Magnus Hiiss, 1849-52.

24 Middleton Goldsmith Lectures, 1887. Medical News, March, 1887.

23 Trouble mentale dans la paralysie alcoolique et son rapport avec la
derangement de la sphere psychique dans la nevrite multiple d'origine non-
alcoolique. Moniteur russe de la psychiatrie et de la neuropathologie, 1887,
t. iv, fasc. 2. Plusieurs cas de cerebropathie originale combinee avec la
nevrite multiple (cerebropathia psychica toxaemica) : Gazette russe heb-
domadaire clinique, 1889, Nos. 5-7. Du trouble mental combine avec la
nevrite multiple (cerebropathia psychica toxaemica) : Revue russe de
medecine, 1889, No. 13, pp. 3-18.

29 Revue russe de medecine, 1896, No. 14, and Revue de med., Mai,
1897.

278 PSYCHIATRY

iscences, hallucinations, and delusions, whose character will
be presently described, and marked fluctuation in the affective
life. In many of the alcoholic cases the syndrome bears a
striking resemblance to certain forms of delirium tremens,
and for this reason, as well as because alcohol was a causative
factor in so many cases, Bonhoeffer and others have referred
to the condition as a form of chronic alcoholic delirium. In
the instances, which frequently come under observation, where
there is a marked disturbance in the functions of the peripheral
nerves, we meet with anaesthesias, paresthesias, or hyperes-
thesias more or less directly referred to the distribution of
the peripheral nerves, at times an ataxic incoordination, an
atrophy of muscles (amyotrophies), a diminution or com-
plete abolition of the deep reflexes, contractures, permanent
deformities due to paralysis and disturbances of the cranial
nerves, ophthalmoplegias, etc. These neuritic disturbances
may or may not precede the development of the mental
symptoms. In almost all of the cases there is a prodromal
period during which the patients show signs of some mental
aberration, irritability, at times sleeplessness, at other times
a marked drowsiness or even stupor from which they are
aroused only with the greatest difficulty. After the lapse of a
varying interval of time, the characteristic delirium makes its
appearance. As a rule, memory for the immediate past is
markedly defective, although the individual may retain a rela-
tively exact knowledge of the earlier periods of his life. The
attention of such patients is easily gained, but is kept with diffi-
culty and only imperfectly. The tendency to confabulate and
indulge in pseudo-reminiscences is extraordinary and is one of
the most characteristic features in the majority of the cases.
Such patients will frequently narrate long tales having every
semblance of truth, and yet upon investigation it will be found
that they have no substantiation in fact. The sense of recogni-
tion may be greatly impaired ; the patients do not know those
about them, forget the faces of members of their own family
and friends, and not infrequently show marked deficiencies in
spatial and time orientation. Not infrequently cases are met

KORSAKOW'S SYNDROME 279

with in which the lacunae in memory do not seem to follow
any rule, the patient remembering, without any particular rea-
son being evident, certain events and situations while apparently
completely oblivious of others. The confusion which exists
and is characteristic of a large number of the cases depends
upon a great variety of causes, a great part of it being in all
likelihood referable to the disturbances in the peripheral tracts
and sense organs. The hallucinations and delusions in a
measure resemble those present in other toxic states. Those
connected with the visual, tactile, and more rarely the auditory
sense are met with. Frequently the first assume the form of
visions. In the beginning these come to the patient only at
night, but as the disease progresses they become more intense
and are present also during the day. They may or may not
be of a terrifying character, giving rise to states of great ap-
prehensiveness or anxiety, and sometimes assume fantastic,
bizarre characteristics so commonly met with in the toxic
and alcoholic deliria. The mental enfeeblement is more or
less marked. As a rule, this impairment is general and not
limited to any specific function. In opposition to the view
maintained by certain writers, I am inclined to believe that the
critical faculties are always impaired, and for this reason the
patients are more or less credulous and open to suggestion.
Except in the severest forms the patients retain some degree
of insight into and appreciation of their own condition, not in-
frequently affirming that the defects in memory and percep-
tion incapacitate them for the performance of all ordinary
duties.

The emotional states vary. Sometimes the patient is ex-
hilarated and the condition may simulate the so-called classical
type of paresis. In others there is depression, although there
is an absence 27 of the self-accusation noticed in true melan-
cholia.

The clinical forms of the disease vary considerably, and

" Starr, M. Allen : Organic Nervous Diseases. Lea Brothers & Co.,
New York and Phila., 1903, p. 124.

28o PSYCHIATRY

in making an attempt to differentiate them we must bear
in mind the fact that certain syndromes now included under
this head may eventually be found to belong in another cate-
gory. Ballet describes the following clinical types : ( i ) An
amnestic form, in which the chief feature is the pronounced
disturbance of memory. Individuals so afflicted show scarcely
any power of recollecting or redeveloping events that have
transpired only a few minutes before. The conversation
gives evidence of the extraordinary tendency to indulge in
pseudo-reminiscence. (2) The confusional type. There is a
greater interference with consciousness, and the patient is more
or less apathetic and indifferent to his surroundings, responding
feebly, or at times not at all, to stimulation. ( 3 ) The delirious
form. Here the psychosensorial super-production is marked.
Hallucinations are varied and, although evanescent, at times
possess great sensory plainness. In the more protracted cases
the fallacious sense perceptions give way to organized and more
or less systematized ideas of persecution or negation and a
systematized delirious state develops. (4) The emotional
type, in which the apprehensiveness, anxiety, phobias, and ex-
aggerated emotional reactions give a decided coloring to the
whole clinical picture and in which the symptoms come and
go in an episodic form. (5) The dementing type, in which
there is a still greater interference with all forms of associative
activity and less reaction to external stimuli. These conditions
bear a striking resemblance to the stuporous states in typhoid
fever, meningitis, etc. This asthenic dementing form may
terminate more or less rapidly in death.

Duration. — The duration of the disorder varies within
wide limits, — from a few weeks to several months. Certain
writers hold that complete recovery sometimes takes place, an
affirmation which I am at present unprepared either to accept
or reject. Unfortunately, many of these patients, who have
been treated in general hospitals or institutions devoted to the
care of the insane, have not been carefully examined prior to
their discharge, and the entry "discharged cured" is frequently
made on the history without any details of the examination

KORSAKOW'S SYNDROME 281

being recorded. Although on superficial examination these
patients may be apparently well, it is probable that a more
detailed examination would reveal the persistence of some slight
psychic defect in the majority of cases. Patients not infre-
quently die during the delirium from some intercurrent com-
plication.

Etiology. — A great variety of opinion is still entertained
regarding the causation. The disease undoubtedly is more
common during the prime of life, but it may occur in children
as well as in old people. Some writers affirm with great posi-
tiveness that women are more susceptible than are men (Chot-
zen), whereas Soukhanoff and Boutenko 28 in a total number
of 192 patients found 112 males and 80 females. That the
syndrome is undoubtedly the result of a toxaemia is generally
conceded,29 but the nature of the poison, which in some in-
stances affects the central nervous system and in others also
the peripheral nerves, has not yet been determined. Although
at first alcohol was supposed to be an etiologic factor in all
the cases, it is now known that a similar if not an identical com-
plex of symptoms can develop as the result of other causative
agents. Nevertheless, although the condition comes on occa-
sionally after typhoid fever, tuberculosis, gastro-enteritis, and
toxic conditions due to lead, arsenic, etc., the majority of cases
are noted in alcoholics. Within the past decade numerous
observers have called attention to the importance of tubercu-
losis, not only as a causative factor in polyneuritis, but also
as giving rise to mental symptoms similar to those just de-
scribed. Diabetes and various disturbances in the functions
of the kidney and liver are also known to be associated with
a similar group of symptoms. The work of Klippel, Ballet,
Gilbert, and others has added particular emphasis to the im-
portance of hepatic insufficiency as a factor in the etiology of
similar conditions.

28 Serge Soukhanoff and Andre Boutenko : A Study of Korsakow's
Disease. Journ. of Ment. Pathol., 1903, vol. iv. pp. 1-33.

29 Miller, Harry W. : Am. Journ. Insan., lx, No. 4, 1904.

282 PSYCHIATRY

Differential Diagnosis. — It is often impossible in cases
where there is a marked alcoholic history to distinguish this
condition from the more protracted forms of delirium tremens,
but sufficient has already been said to indicate the differences
in the clinical picture between these and the typical cases of
alcoholic delirium. As many of the cases present symptoms —
such as impaired tendon reflexes, a diminished or absent light
reflex, speech disturbances, and others — which suggest general
paresis, the differentiation of these two conditions is frequently
beset with many difficulties, but the disorientation, confusion^
interference with consciousness, more or less evanescent char-
acter of the hallucinations, and the typical defects in memory
are significant. The disturbance of the mental faculties in
Korsakow's psychosis is apt to be more or less episodic, and
not steadily progressive as in dementia paralytica. Protracted
remissions and the apparent cure, with a disappearance of the
prominent physical and mental symptoms, speak strongly in
favor of the former condition.

The features that distinguish it from manic-depressive in-
sanity and functional psychoses are, as a rule, fairly character-
istic, as in Korsakow's syndrome there is a greater interference
with consciousness, a more specific defect in memory, greater
confusion, and more marked physical symptoms. An exami-
nation of the cerebrospinal fluid often gives negative results,
but in certain instances, particularly where there was consid-
erable disturbance in the functions of the liver, the fluid was
decidedly colored and in cases reported by Castaigne and Gil-
bert biliary pigments were found to be present.

Treatment. — The treatment of these cases is largely symp-
tomatic. As soon as the diagnosis is made, the patient should
be at once isolated and kept in bed. The diet should be restricted
to milk or other liquid nourishment. If the neuritic complica-
tions are marked, they may be combated by the use of ice-bags
or hot applications, the physician being guided by the comfort
of the patient. If these measures do not relieve the pains, the
administration of bromides or chloral or injections of mor-
phin may be resorted to. The warm packs and continuous

KORSAKOW'S SYNDROME

283

bath frequently give most satisfactory results in relieving
symptoms. Great care must be taken to see that the'bowels
are kept well regulated and the urine should be carefully ex-
amined and any evidence of beginning nephritic complications
should be watched for. In the asthenic types of the disease it
is necessary to resort to stimulation and forced feeding. Alco-
hol, caffein, or strychnin may be administered according to indi-
cations. During the period of convalescence the patient should
be kept as much as possible in the open air, and even during
the height of the disease, if he is reasonably quiet, his bed
should be moved out on the porch. All forms of physical or
mental exertion should be carefully avoided during convales-
cence. As soon as the mental condition of the patient permits,
massage may be given. After he is well enough to be dis-
charged from the hospital, the patient should be strongly urged
to take a prolonged vacation. A sea-voyage, or a residence in
a locality where the climate is not too stimulating, or subject
to too great variations in temperature, will generally do much
towards preventing a relapse and strengthening the physical
and mental powers.

Pathology. — Where lesions in the peripheral nerves have
been present, we find the histological conditions which belong
to a neuritis. According to Gombault, the primary lesions
consist in a segmental periaxial neuritis. Parenchymatous
changes — multiplication of the nuclei, swelling of the proto-
plasm, fragmentation, degeneration of the myelin — have been
reported by numerous observers. For a more detailed descrip-
tion of these the reader is referred to the various monographs
upon the subject. In some cases the membranes, especially the
dura, are markedly affected. A great variety of changes have
been described as occurring in the cerebral cortex, basal ganglia,
and cerebellum. In some instances in the cortical cells there is
a peripheral chromatolysis, but in most of the larger cells there
seems to be a tendency towards a central disintegration of the
Nissl bodies ; in fact, both of these changes are almost always
found. In the more chronic cases there are alterations in the
neuroglia. In the more acute forms, those which simulate

284 PSYCHIATRY

general paresis, there may be evidence of mitosis in the nuclei,
with swollen cell bodies, but, as a rule, the changes are more
chronic in character and are largely restricted to an increase
of the neuroglia fibres. There may be some disappearance of
the fibres in the cortex, particularly of those in the tangential
layer, but this is not nearly as marked as in general paresis
and other psychoses. In addition to the changes in the cen-
tral nervous system, lesions occur in nearly all the internal
organs, so that the general picture of the pathological changes
strengthens the view derived from clinical observation that
the symptoms are a result of a general intoxication.

CHAPTER XI

PSYCHOSES THE RESULT OF CHRONIC INTOXICATIONS

Various substances, after being taken into the system for
a considerable length of time, are apt to bring about a chronic
poisoning or intoxication, which manifests itself in somatic or
less often in psychical disturbances. Occasionally, however,
we meet with instances in which the ordinary bodily functions
do not suffer any marked disturbance, while the central nervous
system seems to bear the brunt of the degenerative process. In
a large percentage of the cases that come under the care of the
alienist the abuse of alcohol has been the main etiological fac-
tor. Hence in view of its great frequency and importance alco-
holism will be discussed somewhat at length, while the re-
mainder of the toxic substances which sometimes cause psychi-
cal disorders will be dealt with much more briefly.

ALCOHOLISM.1

General Considerations. — The effect of alcohol upon
the functions of the central nervous system is not always
constant, for not only are there individual idiosyncrasies, but
at different times in the same person the reactions are subject
to considerable variations. Although some discrepancy still
exists regarding the results of recorded observations after the
ingestion of small amounts, there is a marked degree of una-
nimity in regard to the symptoms produced by large doses.2

1 Hirt, Edward : Der Einfluss des Alkohols auf das Nerven- und
Seelen-leben., Miinchen, 1904. Abderhalden, E. : Bibliographic der gesam-
ten wissenschaftlichen Literatur iiber den Alcohol u. den Alcoholismus.
Berlin, Wien, 1904.

J Kraepelin : Ueber die Beeinflussung einfacher psychischer Vorgange
durch einige Arzneimittel, 1892.

285

286 PSYCHIATRY

Excellent reviews of the whole subject are given by Hoppe3
and Abel.4

The facts obtained from experimental work tend to con-
firm clinical experience regarding the effects of this drug when
taken in fairly large quantities. At first there is a limitation
of the intellectual activity, with an increased tendency to motor
restlessness. The earlier mental symptoms may be said to
consist in a characteristic disorganization of thought, with a
more or less complete loss of the power to focus the attention.
These symptoms depend in a measure upon diminished inhibi-
tion, so that every new sensory stimulus, instead of being re-
pressed, receives more than its due valuation, a fact that be-
comes apparent in thejllogical and foolish conversation so fre-
quently noted in alcoholics. The incTTnatioTY shown Dy patients
who are under the influence of alcohol to translate all sensory
impressions and ideas into immediate action is a form of psy-
chomotor excitement that may occasionally be limited to the
speech-centres, but more frequently is general. All muscular
movements are in a measure incoordinated, and to a certain
degree involuntary. Motives for speech and action are fre-
quently replaced by impulses of a temporary and evanescent
character. V The attention may be easily gained, but is, as a
rule, maintained with difficulty. I Although the views enter-
tained in regard to the action of small doses of alcohol upon
the form and persistence of voluntary muscular movements
are conflicting, this does not hold true for the effects of large
amounts. Clinicians generally accept Kraepelin's affirmation
that severe muscular effort is made more difficult and does
not become easier after the administration of alcohol. Frey's
experiments (1896), which seemed to show that following
small doses (thirty grammes of whiskey) the capacity of the

* Hoppe : Neuere Arbeiten ueber Alkoholismus. Centralbl. f. Ner-
venheilk. u. Psych., November 15, 1902, Nr. 154, xxv. Jahrgang, S. 681.

' Abel : A Critical Review of the Pharmacological Action of Ethyl
Alcohol, with a Statement of the Relative Toxicity of the Constituents of
Alcoholic Beverages. Physiological Aspects of the Liquor Problem, vol.
ii, 1903.

ALCOHOLISM

287

non-fatigued muscle to react was decreased, while that of the
fatigued muscle was increased, have not been generally con-
firmed. Oseretzkowski and Gluck maintain that after doses
of from fifteen to fifty grammes of absolute alcohol there is
in general a slight but temporary increase of the functional
capacity of the muscle; but this apparent increase is attrib-
uted by Kraepelin merely to the disappearance of normal in-
hibition. More recent investigations seem to indicate that the
effect of alcohol is more deleterious to the fatigued than to
the non-fatigued muscle. At all events, there is little or no
evidence to prove that alcohol in small doses does not in-
crease the dynamic power of the muscle in single spasmodic
efforts.5

Regarding the action of alcohol upon the psychic activ-
ities there is still some discrepancy among observers. It may
be said, however, that the higher the intellectual processes
undertaken by a person who has been given a certain amount
of alcohol the more apparent does the immediate effect of the
dose become. In all cases there is a disturbance in the atten-
tion. Although the results so far obtained in the psychological
laboratories are of great interest in this connection, they have
not been sufficiently numerous to permit of any wide generali-
zations concerning the clinical effects of comparatively small
doses of alcohol. As has already been stated, the individual
reaction to the effects of the drug varies within wide limits.
In many forms of mental disease intolerance for alcohol is an
early symptom. This is particularly noticeable in cases of
epilepsy, in neurasthenia, and in hysterical individuals, as well
as in persons who have been subjected to severe trauma. Fol-
lowing a blow upon the head patients may develop in a com-
paratively short time a very marked degree of intolerance to
the drug. This symptom is particularly noticeable in the early
stages of paresis as well as in certain cases of dementia prsecox

s Chaveau : La production du travail musculaire utilise-t-elle comme
potentiel energique l'alcool substitue a une partie de la ration alimen-
taire? Compt. rend., t. 132, No. 2; and Alcool et travail musculaire.
Academie des Sciences, 21 Janv., 1901.

288 PSYCHIATRY

and arteriosclerosis. The importance from a practical stand-
point of determining the existence in an individual of an
abnormal intolerance for alcohol is not only of clinical but also
of forensic importance. In the courts a distinction is frequently
made between what may be termed ordinary intoxication and
states which are supposed to be distinctly pathological. Such
a discrimination, however, is as impracticable as it is unscien-
tific.

The question is frequently asked : How far are the voli-
tional powers of the individual diminished by the use of alco-
hol? and, further, if volition is impaired, to what degree does
the affected individual become the subject of uncontrollable im-
pulses? In the milder degrees of intoxication it is frequently
necessary to decide how far memory is affected, so as to de-
termine whether certain acts committed during a given period
may or may not have been remembered. It is generally ad-
mitted that alcohol, particularly in large doses, may produce
marked disturbances in the field of consciousness, and that
certain acts or events that have transpired during these lapses
may be either completely forgotten or remembered only in
part by the patient. Not infrequently persons who are addicted
to the excessive use of alcohol give evidence of consider-
able intellectual activity without subsequently retaining in
memory the slightest trace of what has transpired during a
given period of time. In some individuals the physical dis-
turbances associated with this degree of intoxication are
marked, while in others they are almost entirely absent. In
degenerates, during the period of intoxication the motor dis-
turbances, as exhibited in speech and gait, may not be greatly
exaggerated.6 During a period of intoxication, especially
during the prodromal and middle stage, the knee-jerks are
increased, while later they are diminished. Gudden 7 affirms
that in more than half of the intoxicated persons who were

8 Forel in Kolle : Gerichtlich-psychiatrische Gutachten. Stuttgart, 1899,
S. 216.

1 Gudden, Hans : Ueber die Pupillenreaktion bei Rauschzustanden
und ihre forens. Bedeutung. Neurol. Centralbl., 1900, Nr. 23.

ALCOHOLISM 289

admitted to the psychiatrical division of the General Hospital
in Munich, during the period of exaltation, there was either
a marked impairment or a complete absence of the light reflex.
This phenomenon disappeared after the patients had slept off
the effects of the intoxication. In some individuals, in whom
antecedent to the stage of intoxication there was a certain
degree of mental impairment, diminution in the light reflex
persisted for several hours after the individual had awakened
from sleep. It is important to note that a temporary impair-
ment of the light reflex may occur during periods of prolonged
intoxication, whereas after a period of abstinence this symptom
disappears.

Various forms of sensory paralysis may occur during a
period of intoxication, and these are accompanied by a nar-
rowing of the field of consciousness with amnesia. None of
the physical symptoms can be considered pathognomonic.8

Cases of intoxication in which there are extreme motor
restlessness and mental confusion, followed by a more or less
sudden cessation of the symptoms with a tendency to sleep for
several hours, may in a measure be considered characteristic
of a degree of intoxication that is usually accompanied by
considerable mental aberration. It is important from a foren-
sic stand-point to bear in mind the fact that mere intolerance
to alcohol is not sufficient evidence of mental disease to justify
the generalization that if this condition exists the acts of an
individual are necessarily beyond volitional control. The dis-
turbances in consciousness due to the effects of alcohol have
been the subject of considerable investigation. Two groups
of cases essentially different from the ordinary form of intoxi-
cation may be separated : ( 1 ) those in which the character
and duration of the symptoms are merely those of the ordinary
drunken person, but increased in intensity and duration; (2)
cases, generally occurring in eccentric individuals or in degen-

8 Cramer : Ueber die forensische Bedeutung des normalen und path-
ologischen Rausches. Monatsschr. f. Psych, u. Neurol., Bd. xiii, Jan.,
1003, H. 1, S. 36.

2Q0 PSYCHIATRY

erates, in which emotional instability, insomnia, and amnesia
develop. In some instances a period of maniacal excitement
may be added to the other symptoms. A transitory delirious
state may form the connecting link between intoxication and
a well-developed psychosis. Somnambulism and convulsive
seizures are characteristic of other forms. The transitory
mental disturbances frequently observed during periods of
intoxication have also been made the subject of special inves-
tigation by Moeli.9 This investigator affirms that cases occur
in which the acts executed during the disturbances in the field
of consciousness caused by the alcohol are prompted by ideas
which have already existed for some time. For example, an
individual who for many years had been in comparatively poor
physical health, and later had been subject to vague suspicions
regarding his wife's fidelity, during a period of intoxication
became so suspicious and enraged as to attack and seriously
injure his wife. Not only was no memory of the act retained,
but there was no recollection of any event that had transpired
during the period of intoxication.

Cases of individuals who have shown none of the signs
of epilepsy, but who have committed crimes the sole motive
for which has developed only just prior to the acute change
in the content of consciousness, are not uncommon. Thus,
for example, a certain man shot a woman. There was no
recollection of the act, although the patient remembered dis-
tinctly having met her, but on the following day, after the
effects of the intoxication had subsided, he was able to recall
some disconnected events that had occurred during the period
of temporary abolition of consciousness. This, as well as
similar cases, in many respects suggest an epileptiform attack.
The stupor and disorientation characteristic of many cases
of epilepsy are absent. Partial or complete amnesia, however,

8 Ueber die voriibergehenden Zustande abnormal Bewusstseins infolge
von Alkoholvergiftung u. uber deren forensische Bedeutung. Allg. Ztschr.
f. Psych., iooo, Bd. 57, H. 2 und 3.

DELIRIUM TREMENS

291

may occur in both instances. Bregmann10 believes that the
most dangerous form of alcoholism occurs in individuals whose
nervous systems present a considerable power of resistance for
the toxic action of the drug, and, instead of the development of
multiple neuritis, delirium tremens or other psychoses, only
lapses in morality and intellection are noted.

Confusion still exists in regard to the identity of many of
the symptom-complexes which are classed as alcoholic psy-
choses. At present the clinical forms of the disease may be
considered under the following heads:

(1) Delirium Tremens. — This condition is character-
ized by an acute course and by a group of symptoms essentially
different in many respects from those occurring in other de-
lirious states. There is an impairment of the associational
activities of the brain, with accompanying fallacious sense per-
ceptions, motor restlessness of varying degree, and a tremor
which is in a measure characteristic. During the prodromal
period certain initial symptoms are often observable several
days before the outbreak of the delirium. The physical mani-
festations of chronic alcoholism, such as nausea or vomiting,
are frequently present. As a rule, some slight motor restless-
ness, more pronounced at night, is noted, while during the day
the patient may complain of feeling ill at ease, of being excess-
ively nervous, and show himself abnormally responsive to
external stimulation. In some cases only a vague feeling of
apprehension is present or there may be an ill-defined fore-
boding of some unpleasant occurrence. In the majority of
cases the visual stimuli are followed by more intense reactions
and are much more apt to give rise to anxious states than
those affecting the auditory mechanism. If the patients sleep
at all at night, they are very apt to be excited and extremely
restless, thrashing about in their beds, talking in their sleep,
and sometimes being victims to somnambulism. In place of
the feeling of depression during the prodromal period, at

10 Die Behandlung der Trinker u. der Kampf mit dem Alkoholismus.
Sdrowie, 1902.

292 PSYCHIATRY

times a slight hypomaniacal condition may develop, that is
apt to persist and continue during the height of the delirium.
The transition from the prodromal to the second stage
of the disorder can not always be sharply differentiated. In
most of the cases the above-mentioned symptoms precede the
acute outbreak by only a few days, or they may develop more
gradually, culminating in the delirious condition only at the
end of two or three weeks. As a rule, the restlessness, the dis-
turbances of consciousness, and anomalies of sensation become
greatly accentuated as soon as the second or delirious stage
begins. During this period the disturbances of sensation are
in a measure characteristic. The patients, as a rule, suffer
from visual, haptic, and auditory hallucinations. The occur-
rence of the last-named variety always indicates a graver prog-
nosis. Although the bizarre, grotesque, or fantastic character
of these disturbances is of great importance, the nature of
the hallucinations may to some extent be determined by the
daily life of the patient prior to the outbreak of the disease;
the coachman drives his horses, the butcher is busy in his
shop, the artist paints imaginary pictures. On the other hand,
his immediate environment may exert little influence in this
regard; the patient, while lying in bed in a state of marked
delirium, although restrained by the camisole, may consider
himself at home and carry on conversations with imaginary
friends. Any stimulus of sufficient strength impinging upon
the cerebral cortex serves to awaken a chain of memory pic-
tures and suggests situations or events in his former daily
life. Not uncommonly there is a tendency on the part of the
patients to associate their hallucinations with forms of move-
ment,— they say they are flying in the air, swimming, rising
in water, or the like; but, according to Liepmann, these will
disappear if the sufferers are kept absolutely quiet. The vis-
ual hallucinations may be colored or may be shadow-like
visions. As a rule, the forms of rats, snakes, insects, fish, or
other animals are prominent features. Not infrequently the
visual hallucinations are recognized as unreal. The belief in
the subjectivity of these phenomena varies during the height

DELIRIUM TREMENS

293

of the delirium. Very commonly the anaesthesias, hyperes-
thesias, and paresthesias are attributed to unseen agencies, —
to spirits or devils.

The cutaneous hallucinations are of various forms, and
movement is again a prominent feature of them. Formication
— the sensation as of insects crawling over the limbs, body,
etc. — is often complained of. The haptic hallucinations are
frequently referred to the hands, the face, or the inside of the
mouth. The sensory disturbances may suggest to the patient
the use of familiar objects. Thus, smokers affirm that they
have a cigar or pipe between their lips. Auditory hallucina-
tions, although less prominent, vary greatly in complexity,
from simple elementary akoasmata to the more complicated
sounds of voices engaged in conversation. Bonhoeffer refers
to the fact that auditory hallucinations characterized by a
monotone are never observed in delirious patients, but, as a
rule, possess a definite rhythmic character. Hallucinations of
taste have been reported by some observers.

As has already been mentioned in the chapter dealing with
disturbances of sensation, clinicians are almost unanimous in
emphasizing the importance of the role played by definite
lesions in the peripheral nerves in determining the occurrence
of hallucinations and illusions. Magnan, Galezowsky, Rose,
Kruckenberg, and others have affirmed that elementary dis-
turbances in perception occur during the delirium, but the
difficulties that beset the solution of this question are very
great. In many cases of delirium it is impossible definitely to
prove or disprove the existence of disturbances in the cutaneous
sensibility. Bonhoeffer believes that hearing is not impaired ;
that in most of the cases the anaesthesias are of psychic origin,
due to the deflection of the patient's attention; and less fre-
quently are the result of lesions in the peripheral nerves.

These investigations of Bonhoeffer do not corroborate
those of Magnan, which tended to prove that amblyopia fre-
quently occurs during the delirious process. Kruckenberg be-
lieves that there is often a narrowing in the field of vision, an
observation, however, which needs further confirmation. Bon-

294 PSYCHIATRY

hoeffer affirms that as yet there exists little evidence which
is indicative of the existence of great impairment in the sharp-
ness of perception. If the latter's observations are correct, it
would seem improbable that the localization of the hallucinations
is determined solely by lesions occurring in the peripheral
organs. The attention during the height of the delirium is seri-
ously impaired, but it not infrequently happens that for a very
short period the power of focussing the mental faculties upon
a given object is surprisingly great. The disturbances in speech
are often well marked. If a patient is made to read aloud,
the psychical defects frequently become much more promi-
nent. Paralexia is not uncommon. Slight disturbances in
the ocular muscles may increase the difficulty in reading, but
when this is the case, with one eye covered the patient is able
to proceed with greater rapidity and with fewer mistakes. The
rapid flow of ideas which frequently occurs is in a measure,
pathognomonic. The patients ramble along in their conver-
sation without any apparent definite aim in view. Each new
impulse, either intra- or extra-organic, suggests a new idea,
which is rapidly replaced by another. This symptom has been
referred to as a sensory flight of ideas. Kraepelin and Aschaf-
fenburg have pointed out that external stimuli play a very
important role in determining the character of the deliria and
that the tendency to rhyme and to form sound associations is
usually well marked. The suggestibility of the patients, as
would be expected, is very great, being generally more pro-
nounced in this than in any other psychosis. The memory
for occurrences long antedating the onset of the delirium may
be relatively intact, while for the more immediate past it
is often a blank. The time sense is seriously disorganized.
The tendency to confabulate is decided, but this symptom is
also common to other psychoses in which the attention is greatly
impaired. The loss of orientation, which is frequently pro-
nounced, in a measure depends upon the patient's falsification
of the representation of the external world as well as upon the
protean and evanescent character of the sensory impressions;
but, as Wernicke has suggested, this is not the sole cause of

DELIRIUM TREMENS

295

the disorientation. In nearly all cases the dissociation of
thought is so great that the judgment becomes very defective,
although now and again a patient, even during the height of
the delirium, will attempt to explain and correlate the isolated
and irrelevant ideas which seem to spring into consciousness,
thus showing the existence of a suggestion of coordination in
the thought processes. The sej unction of the personality
varies in degree. Wernicke holds that the falsifications of
the external world, or allopsychic consciousness, are very
great, while the preservation of the autopsychic is equally
distinctive.

In cases in which megalomania is present, there is reason
for suspecting the existence of an incipient paresis or some
other form of psychosis as a complication. The emotional
disturbances in these patients are essentially characteristic.
The anxiety, which is frequently intense, may be localized
in the chest, but, as a rule, it is much more general in char-
acter and dominates all the actions of the patient. The emo-
tional disturbance is apt to fluctuate markedly, particularly
in the earlier stages ; it often reaches such a degree that any-
thing approaching to a thorough examination is not possible,
although not uncommonly the patient may be temporarily
pacified. On the other hand, in the later stage of the delir-
ium a well-marked complacency may develop. General psycho-
motor restlessness is nearly always a prominent symptom,
but at times does not affect the speech-centres, so that the pa-
tients may not be unduly garrulous, and the field of attention
seems to be greatly narrowed. In some instances a patient
will sit for hours without uttering a word; while in others
the speech compulsion is quite as marked as the general motor
restlessness. The tremor — which gives its name to the de-
lirium— appears, as a rule, in the extremities, tongue, and not
infrequently in the facial muscles, particularly those connected
with speech. It may become so intense that the patient is
hardly able to stand or to give audible expression to his
thoughts, and under these conditions the speech disturbance
is readily recognized as a purely motor disorder and thus may
be easily distinguished from that of general paresis.

296 PSYCHIATRY

The period of the delirium is nearly always associated
with some elevation of temperature, the origin of which has
not been satisfactorily explained, although it may be said that
high fever generally indicates the existence of some compli-
cation. The pulse varies during the height of the delirium;
it may be almost imperceptible and so rapid as to be counted
with difficulty. An acute cardiac dilatation may develop dur-
ing this stage.

During the prodromal period, when the symptoms are
vague and indefinite, — somewhat resembling those occurring
in the initial stage of any acute infectious disease, — there is
at first active skin hyperemia, which lasts from eight to ten
hours and is then followed by a contraction of the superficial
blood-vessels. The blood-pressure also increases after the ini-
tial hyperaemic stage has passed, and is said to remain high
as long as the delirious symptoms persist. Following the
rapid pulse of the acute stage, there is a period during which
bradycardia is pronounced, the rate falling to 50 beats or less
per minute. According to Dollken,11 this symptom is refer-
able to the exhaustion.

The other physical symptoms are not essentially different
from those which occur during any form of delirium. The
urine shows no specific changes. Albumin and casts are not
infrequently found. The blood examinations are practically
negative, although during the period of the most intense ex-
citement Elsholz was unable to find any eosinophiles. For-
merly clinicians regarded the symptoms as being merely de-
pendent upon hyperexcitation of the cerebral cortex, but
Wernicke and others have recently called attention to the fact
that actual psychic paralyses exist.

The course of the disease varies in different cases. The
prodromal period, although practically never absent, is re-
duced to a minimum in the cases complicating acute disease.
For example, a certain man who for years had been a hard

11 Die korperlichen Erscheinungen ties Delirium tremens. Leipzig.
1901.

DELIRIUM TREMENS 297

drinker, while at work in a factory suffered a severe wrench
of his arm, necessitating removal to a hospital, where almost
immediately symptoms of delirium tremens developed, al-
though prior to the injury he had not shown any marked
nervous disturbance. In the so-called abortive forms, the
patient, after a period of prolonged anxiety, breaks out into
a profuse sweat, and after a few days the symptoms gradu-
ally subside, the second stage being absent. In some instances
the initial stage is succeeded by one in which all, particularly
the psychic, symptoms become accentuated. This period ends
after from four to eight days in convalescence. In these cases
the first or prodromal stage — characterized by nervousness,
slight motor restlessness, tremor, sleeplessness, etc. — is fol-
lowed by the period in which most of the psychical symptoms
attain their maximum, and then gradually subside until the
stage of convalescence is finally established.

As a rule, the first signs of improvement consist in the
gradual subsidence of the hallucinations and delusions and the
disappearance of the affective disorders. The motor restless-
ness disappears; the patient now lies quietly in bed, and sooner
or later falls into a deep sleep which may persist for twenty-
four or forty-eight hours. After the acute symptoms have
completely disappeared, some slight disorientation and dis-
sociation in thought may persist for several days. The pa-
tient's actual insight into his condition varies considerably.
In some instances the period of delirium is a blank. Other
patients remember that they have been ill and not infrequently
are able to recall certain of the hallucinations from which they
have suffered.

In the so-called adynamic form of the disease, that is
occasionally met with, the pulse is compressible and small, the
patient is more or less stuporous, sweats profusely, and pre-
sents a clinical picture in which it is difficult to recognize any
of the specific signs of delirium tremens.

The final outcome of the majority of cases is in recovery,
the mortality in the uncomplicated cases being 3 or 4 per cent.
In those in which complications exist the death-rate is much

298 PSYCHIATRY

higher, — from 10 to 15 per cent. Pneumonia is most often
responsible for the fatal ending. In other instances the chronic
gastro-intestinal disturbances become prominent and greatly
increase the danger in the disease. Patients suffering from
delirium tremens are peculiarly susceptible to infection.

Pathogenesis. — The delirium develops on the basis of
chronic alcoholism, so that it may in a measure be regarded
as an acute exacerbation of a chronic process. Jacobson 12
has studied 247 cases of delirium tremens with a view of de-
termining certain important points in the pathogenesis. In
every instance the patients were found to have presented symp-
toms of chronic alcoholism for periods varying from one to
seven years prior to the outbreak of the delirium. The great
majority of these individuals were habitual drinkers; 60 per
cent, partook of whiskey, 30 per cent, of beer and whiskey, and
6 per cent, of beer alone. In 14 cases the outbreak of the
delirium followed trauma. Elmergreen 13 and Pritchard 14 de-
scribe a mild form of the disease, seen in moderate drinkers,
and an exaggerated type, or forme fondroyante, in those indi-
viduals who are addicted to marked alcoholic excesses.

Certain predisposing factors favor the outbreak of the
delirium. Among the most important are those that in a
measure lower the resistance of the organism, — trauma, fever,
particularly pneumonia, operations, marked emotional disturb-
ances or excitement, profound anaemia, conditions of life which
lead to states of physical or mental exhaustion, — anything, in
fact, that overtaxes the functions of the central nervous sys-
tem. It is a common experience in general hospitals that
patients suffering from delirium tremens are particularly lia-
ble to develop pneumonia. Jacobson has affirmed that cer-

12 Jacobson, E. : Ueber die Pathogenese des Delirium tremens. Allg.
Ztschr. f. Psych., Bd. 54, H. 1 u. 2.

u Elmergreen : Delirium Tremens in Moderate Consumers of Alcohol,
with Report of Four Cases. Med. Times, July, 1899. The Delirium Tre-
mens in Moderate Drinkers. Journ. Am. Med. Assoc, November, 1900.

14 Pritchard : Delirium Tremens in Moderate Consumers of Alcohol.
Med. Times, 1809, No. 8.

DELIRIUM TREMENS 299

tain symptoms — fever, albuminuria, enlarged spleen — suggest
the striking resemblance between delirium tremens and the
acute infectious diseases, and he sought to establish a causal
relationship between the pneumococcus and the outbreak of
the delirium. Similar views have been advocated by Villers,15
who maintained that in the majority of cases of delirium the
pneumococcus was the factor of greatest etiologic importance.
Hertz has affirmed that delirium tremens is an intoxication
psychosis due to the impairment of the function of the kid-
neys. In 15 cases of uncomplicated delirium tremens Nonne18
proved that the cultures taken from the blood were sterile and
thinks this sufficient reason for not regarding the delirium as
the result of an infectious process.

The peculiarity characteristic of the disease is attributable
to the fact that the symptoms occur only in those who have
suffered from the effects of chronic alcoholism. It is gener-
ally held that the delirium may develop in chronic drinkers
when alcohol is suddenly withdrawn, but this view has recently
been called into question. Weygandt, while admitting such
a possibility, maintains that if they do occur all such cases
present very mild forms of the disease.

Most of the recorded clinical observations of cases of
delirium tremens have been made during the height of the
delirium. The periods of development and decline, during
which symptoms may arise that would furnish important clues
as to the pathogenesis of this state, have not until recently
been studied with sufficient accuracy.

Delirium tremens is generally seen in individuals in the
prime of life; it is more frequent in men than in women, but
in rare instances children have been known to suffer from it.
It is impossible to say, even approximately, the amount of
alcohol which will give rise to this group of symptoms, as
the individual idiosyncrasies are so varied. As would be sup-

" Pathogenie et pronostic du delirium tremens. Bulletin de la soc. de
med. ment. de Belgique, 1898, p. 142.

18 Allg. Ztschr. f. Psych, u. psych. -gericht. Medizin, 1904, Feb. 15, Bd.
61, H. 1 u. 2.

300 PSYCHIATRY

posed, the disease is more common in countries in which whis-
key and brandy are taken in large quantities than in the south-
ern parts of the globe where wine is the chief beverage.

(2) Acute Alcoholic Hallucinosis (Wernicke, Bon-
hoeffer). — The chief characteristic of this group of cases is
anxiety associated with comparatively mild disturbances in
the somatopsychic and allopsychic fields of consciousness. Fur-
thermore, in addition to hallucinations (similar in character
to those occurring in delirium tremens), there can be noted
a manifest attempt on the part of the patient to explain and
establish some sort of relationship between the various iso-
lated and incongruous facts existing in his consciousness.
For this latter reason, the condition is referred to by some
authors as acute alcoholic paranoia.

In some instances the intense affective disorders are ref-
erable to auditory hallucinations of a threatening or terrifying
character. Some patients affirm that every person that enters
the room has maligned them or has attempted to subject them
to sinister influences, and not infrequently declare that the
thoughts of the individuals who wish to do them harm are
communicated through the medium of the air or by unseen
spirits. The complaint is not infrequently made by the pa-
tients that they can keep nothing secret, as their every thought
is audible to those about them.

The history of the following case illustrates this clinical
type.

Male, single; aged 36. Had been accustomed to take alcohol for a
number of years in considerable quantities, and has also smoked ex-
cessively. For some six months prior to admission he had been drinking
more heavily and constantly, frequently taking thirty or forty drinks of
whiskey a day. For about six weeks his friends and relatives noticed that
he was becoming very nervous. He expressed fear of bodily harm, and
had periods of combativeness alternating with others of marked docility.
He began to be subject to optical hallucinations, usually of a pleasant type,
and to auditory hallucinations. He imagined that he heard all sorts of
noises, and occasionally thought that people were plotting to do him harm.
After his admission to the hospital these symptoms persisted. His con-
versation was confused and irrelevant and he showed marked disorienta-
tion for time and place. The anxiety was not as great as that noticed in

ALCOHOLIC HALLUCINOSIS

301

cases of delirium tremens. He recognized objects, but mistook persons.
He was able to do simple multiplication rapidly. At times he obeyed
orders only slowly, as if confused, but at other times quickly and intelli-
gently. He affirmed that he had died eighteen years before and had been
dug up three weeks prior to his admission to the hospital. He said he had
felt the snails crawling over him, and that he was " nicely packed in a
coffin with straw." He knew who he was ; showed little, if any, dis-
turbance in autopsychic consciousness ; and responded correctly to a
three-word test. After these symptoms had persisted for several weeks,
the patient began to have periods during which the hallucinations were less
marked. Gradually, but at first for only brief intervals, he recognized the
fact that he had been ill, and was extremely nervous and was willing to
admit that he was not responsible for what he said or did. After such
ameliorations the old symptoms would return again. Gradually the lucid
intervals became longer; his bodily weight increased, and finally, after
being under observation for three months, he was discharged.

This was written by patient during the period of acute delirium. Disturbances in the
functions of the peripheral nerves were the basis for the ideas in regard to death, burial, and
resurrection. The patient constantly complained of feeling snails crawling over his legs.

Although the majority of patients make some attempt to
explain the hallucinations and delusions, systematization is by
no means equally developed in all cases. States of anxiety are
frequently a prominent symptom. Sometimes megalomania
is present, but this is not characterized by the exaggerated
self-complacency that appears in paretics. In marked con-
trast to what is encountered in cases of delirium tremens.

302 PSYCHIATRY

these patients show relatively little impairment in connected
thought. There is less tendency to reckless confabulation, and
the power of picking up and retaining new impressions is
much less impaired than it is in the delirious cases. Concern-
ing the preservation of the powers of orientation, clinicians
differ; they are agreed, however, that neither space nor time
sense is intact. The degree of impairment varies in different
cases. The hallucinatory disturbances apparently come and
go. The patients have periods, lasting a few hours, during
which the voices or visions become unusually prominent and
then gradually subside. The somatic disturbances are the
same as those noted in other forms of alcoholism.17

-/'-//

^*^Ce ^cst^~- •6u*J^—*tZ*^*

K

Insight into his condition partially regained. Interval of several weeks had elapsed.

The more the clinical picture corresponds to that of de-
lirium tremens the more favorable is the prognosis. Some
clinicians affirm that the occurrence of hallucinations other
than auditory is more apt to be associated with the severer
and more protracted forms of the disease; while those in
which there is marked disturbance in the organic sensations
are looked upon as particularly unfavorable. It is not at all

11 Illberg : Der Akute hallucinatorische Alkoholwahnsinn. Festschrift
zum 50-jahr. Bestehen des Stadtkrankenhauses zu Dresden.

ALCOHOLIC HALLUCINOSIS

303

improbable that some of the incurable forms of chronic alco-
holism begin with a period in which the symptoms resemble
those of acute hallucinosis.

l(*C4t *£4£r>-1s/p~> lO&s&Zba^C &C***—*~y „

Complete insight. Written just prior to discharge from hospital.

Pathogenesis. — It is interesting to note that, whereas in
delirium tremens optic and tactile hallucinations are prominent,
in the acute hallucinosis those of the acoustic type predominate.
The essential difference in the two clinical pictures has been
referred by some clinicians to the individual differences exist-
ing in regard to the functional importance of the auditory
centres. Such an attempted explanation, however, is unsatis-
factory, inasmuch as cases have been reported in which delirium

3o4 PSYCHIATRY

tremens and hallucinosis have occurred in the same individual.
The differential diagnosis in typical cases is not difficult. The
alcoholic amnesia, the more or less sudden occurrence of audi-
tory hallucinations, the comparatively slight disturbances in
associated thinking, the delusions bound together with more
or less systematization, are the essential points to be kept in
mind. Although the clinical picture described is most fre-
quently associated with alcoholism, it is not improbable that
it occasionally occurs in other diseases.

The prognosis in many of the cases is favorable. The
majority of the patients recover completely. Relapses are,
however, not infrequent.

The duration of the disease varies from six or eight weeks
for the milder cases to three or four months for the severer
types.

(3) Paranoiic and Dementing States. — The para-
noic states which develop during chronic alcoholism are often
divided into two categories : ( 1 ) Those which may be looked
upon as sequelae of either delirium tremens or acute hallucino-
sis; and (2) the so-called primary forms, which are less fre-
quent and have a more unfavorable outcome. Raecke 18 be-
lieves that the true chronic alcoholic paranoiic state may be still
further differentiated from those cases in which there are long
remissions and a relatively favorable outlook. Patients may
pass through an attack of delirium tremens and improve men-
tally and physically in every way except that they are harassed
by one or more persistent delusions. As a rule, the insane
ideas retain the same stamp of grotesqueness which charac-
terizes them in the course of the other alcoholic psychoses, and
at the same time defects in the social and ethical conscience
of the patient are nearly always well marked. The patient
may affirm that his body is to be burned or that he has been
dead and buried. A few of the persistent ideas may be accom-
panied by others that are transitory in character. Although
on superficial examination judgment and memory seem to be

" Neurolog. Centralis., 1903, Nr. 21, Nov. 1, S. 1032.

PARANOIIC STATES 305

intact, a more careful analysis of the symptoms will seldom
fail to reveal the existence of considerable intellectual weak-
ness. Some patients pass directly from the acute stages of
delirium tremens or the acute hallucinosis into the chronic
paranoiic state. Particularly characteristic of the latter form
of chronic alcoholism are the ideas of suspiciousness and jeal-
ousy, which may almost be regarded as specific and are fre-
quently directed against the members of the patient's own
family. Individuals in this state affirm that an attempt is
being made by members of their family to get rid of them, —
that, for example, poison is introduced into their food, — and
the paresthesias or anaesthesias to which they may be subject
become to them signs of unseen agencies which are being
employed for their torture or destruction. In a comparatively
large number of these cases the delusions are sexual in char-
acter. V. Krafft-Ebing affirms that the insane ideas of perse-
cution in about 80 per cent, of the male alcoholics are of this
character. Not uncommonly there is an hyperesthesia sexu-
alis. The failure to satisfy this passion frequently enrages
the patient, and the wife is often accused of infidelity in its
most disgusting and revolting forms. As a rule, these insane
ideas are accompanied by great emotional instability, which
often expresses itself in violent outbreaks of temper, while in
the intervals the patient may be sullen and morose. The
erotic excitement is liable to be most intense early in the dis-
ease. The hyperesthesia is followed by the stage in which
sexual desire is partially or completely absent. Hallucinations
only occasionally occur during this paranoiic stage. The emo-
tional equilibrium of the patients varies. At times there
is considerable apathy, or again mild depression alternates
with periods of excitement. During the latter stage the so-
called " alcoholic humor" becomes noticeable. At times the
patient may become excited, particularly when surrounded by
members of his family. If these individuals are kept in an
institution where they do not have access to any form of alco-
hol, there may be considerable improvement after several
months or a year; the hallucinations may disappear entirely

306

PSYCHIATRY

and the defects in memory become less marked. Sometimes
the insane ideas gradually diminish, until the patient gains
considerable insight into his own condition. As a rule, how-
ever, there is a marked feeling of complacency, and the patient
fails to show by any emotional reaction an exact appreciation
of his condition. Individuals may remain in this stage for
years, periods of remission not infrequently alternating with
states characterized by an increase in the number of insane
ideas or in more intense periods of depression. The intel-
lectual defects continue, so that these patients are never capa-
ble of undertaking any task which involves the expenditure
of any considerable mental effort. Occasionally individuals re-
cover sufficiently to leave the institution and to engage in
some form of occupation free from any great degree of re-
sponsibility. After the lapse of a period of years the dementia
may become much more pronounced. As a rule, it is compli-
cated by symptoms which suggest the existence of arterio-
sclerosis as well as of cerebral softening. Not infrequently
cases are met with in which the diagnosis from general de-
mentia paralytica is very difficult. In these instances the
motor symptoms — tremor, disturbances of speech, incoordi-
nated muscular movements — are marked. For the most part
the Argyll-Robertson pupil and the disturbances of the bladder
and rectum, depending upon lesions in the spinal cord, render
the diagnosis of dementia paralytica probable. This latter dis-
ease is characterized by remissions which are only transitory,
while in the pure alcoholic psychoses they may extend over
a period of years, so that not uncommonly the disease process
is apparently stationary. In some few cases recovery has
been reported, but it is highly probable that if a thorough
examination were made some psychic defect could be noted.

Alcoholism. Paranoioid State with Partially Retained Insight
into Condition.— Johns Hopkins Hospital Dispensary. Male, aged 38.
United States. Married. Painter. Admitted April 26, 1904. Complains
of nervousness and that the people with whom he used to live do not treat
him well.

Family History. — Negative for nervous and mental diseases.

PARANOIIC STATES

307

Personal History. — Measles, whooping-cough, chills and fever at about
15. Gonorrhoea at 19. No definite luetic history. When he was 20 years
old he began to indulge in alcoholic excesses. Every three or four months
he would go on a spree. This continued up to five years ago, when he
stopped these excesses because he thought they were doing him harm.
Has never had delirium tremens. One day he fell in the street and lost
consciousness ; had a slight " spell." Was taken home by a friend, and
has had no similar attack. Married two years ago. Wife well and strong.
The patient has not touched any liquor for a year and a half. Smokes a
good deal, — twelve pipes a day. It is impossible to obtain a definite his-
tory as to whether he was sometimes neurotic, although he himself thinks
that he was. He has never had any symptoms of lead poisoning.

Present Illness. — His wife says that about two years ago her husband
after a period of abstinence drank excessively and became very nervous
and suspicious. He thought that the people he noticed talking to each
other on the street were directing their remarks against him. When ques-
tioned about this, the patient says that at the time he was not sure that
they were talking against him, but now he is confident that they were. The
reason for this positive affirmation is that he has so frequently heard what
they said and the voices have been so plain that he can no longer doubt.
About a year ago he supposed that a number of lodgers at the big boarding-
house in which he lived annoyed him. The patient affirms that he fre-
quently overheard these former companions say, " We will lay for him on
his way to work and we'll kill him." He knows of no reason for their
doing this except that they were patrons of the boarding-house of which
he was janitor and, as they were all excessive drinkers, they took great
exception to the patient's interference with their sprees. No actual violence
was ever attempted by them. Frequently at night, when the patient was
lying awake, he would hear them talking in the next room and threatening
violence. A curious thing about it all was that the patient at this time
never saw his supposed enemies, but only heard them speaking outside of
his door. These suspicions have continued pretty constantly, and within
the past two years the patient and his wife have changed their place of
residence three times in order to escape from his supposed persecutors.
The patient is sometimes afraid to go out, as he fears that these enemies
will pounce upon him. Occasionally, when he is walking along the street,
he first experiences a curious sensation that somebody is following him and
then turns to look, when his fears are confirmed by actually seeing some
one. The patient's wife, who is a very sensible, phlegmatic person, says
that there is no truth in the statements made by the patient. At night he is
frequently sleepless and asks his wife if she hears the voices in the adjoin-
ing room. He cannot be made to believe that nobody is speaking. When
the patient is asked if he will not admit that his present condition might
be the result of his former habits, he is quite willing to agree that his
nervousness and sleeplessness and generally run-down condition are the
result of his excessive indulgence in alcohol, but says that the voices are
too real and too constant for him to believe that they too are the result
merely of his disordered nervous system.

3o8 PSYCHIATRY '

The patient was well oriented in time and space, wa? not emotional,
gave a connected account of himself, although apparently he had little
interest in matters outside of his own immediate condition. He was in-
different to the fact that his wife worried considerably about his present
condition, being quite self-centred and somewhat egotistical. As the
somatic symptoms have no immediate bearing upon the mental state, they
have been omitted from this abstract. When last heard of, the patient had
left his home and his wife had no knowledge of his whereabouts.

Complications of various kinds may occur during the
course of delirium tremens and the alcoholic psychoses, the
acute as well as the more chronic forms. Epileptiform con-
vulsions not infrequently occur. At times the attacks of petit
or grand mal follow excessive alcoholic indulgence, but in these
cases alcohol is the exciting factor, not the main cause. It
has already been pointed out that epileptics are markedly sus-
ceptible to the effects of alcohol. On account of their emo-
tional instability such patients not infrequently resort to
liquor, for the reason that they sometimes feel the need of a
stimulant, more especially during the periods of depression
either preceding or following the attacks. Many cases of peri-
odic drinking, or dipsomania, may be attributed to epilepsy.
In a large number of chronic drinkers a history of fainting
spells, temporary attacks of amnesia, mild degrees of aphasia,
etc., as well as the severer forms of epilepsy, can be elicited.
The association of hysterical symptoms with alcoholism has
not infrequently been noted.

It should be borne in mind that alcoholism may be com-
plicated by various diseases. The variety of lesions caused
by the action of the drug is very great, and these may in turn
give rise to symptoms. In the vascular system we find fatty
and atheromatous degeneration; at least one-fourth of all
the cases of arteriosclerosis are said by some clinicians to be
due to alcoholism. Nor should it be forgotten that arterio-
sclerosis gives rise to an intolerance of even small quantities
of the drug and that this may be one of the earliest symptoms
of vascular disease.

Myocarditis and a dilated heart are frequently observed.
Various forms of nephritis are met with, particularly the con-

ALCOHOLISM 309

tracted kidney and fatty degeneration of the renal cells. The
liver, as well as the gastro-intestinal tract, is nearly always af-
fected. The relationship of gout to chronic alcoholism has been
referred to by many authors. Sugar is not infrequently found
in the urine of patients suffering from delirium tremens.
Rosenberger and Arndt noted the occurrence of glycosuria in
the initial stages of the disease,19 but Reuter found that if the
patients were put on a restricted diet the sugar disappeared,
and from this inferred that the ingestion of alcohol with an
excess of carbohydrates predisposed individuals to glycosuria.
The development of a true diabetes from these transitory gly-
cosurias has never been reported. As has been said before, the
susceptibility of alcoholics to infection is well known. Re-
cently considerable attention has been directed to the relation
of many cases of alcoholism and tuberculosis.20 The effects of
the drug in disturbing the functions of the circulation, respi-
ration, and digestion so lower the resistance of the organism
as to make the individual particularly liable to tuberculous in-
fection. This theory receives still further confirmation in the
tendency shown by the children of alcoholic parents to fall a
prey to the latter disease.

Etiology and Treatment. — As the successful treatment
of alcoholism in all forms necessitates a knowledge of the
causes that have given rise to the disorder, these two topics
may be conjointly discussed. The most important factor of
all is the attempt to prevent the spread of alcoholism. Al-
though this is supposed to be a sociological question, its ulti-
mate solution rests largely with the medical profession. As
White 21 has well said, " The causes of drinking are infinitely
varied and intimately bound up in the heart of man, — at once
an expression of his strength and his weakness, his successes
and his failures." In a country in which every attempt is

19 Reuter, K. : Ueber Alkoholglykosurie. Mitteilungen aus dem Ham-
burger Staatskrankenhause. 1901.

20 Stein-Orvosi, Hetilap., 1903, No. 45.

21 White : Alcoholic and Drug Intoxication. Reference Handbook of
Medical Sciences, vol. v, p. 81.

3io PSYCHIATRY

being made to educate the masses, it should not be forgotten
that the elevation of an individual out of the sphere into which
he was born may impose a tax upon the functions of his ner-
vous system which may eventually expose him to serious temp-
tations. The frequency with which neuroses and psychoses
appear in families in which there has been a sudden and rapid
change in environment — for example, a removal from country
to city life — is a factor of great importance and should re-
ceive most careful consideration. The addiction to alcohol
is a symptom of a functionally unstable nervous system, and
the contrary view entertained by the laity is not justified by
clinical observation or experience. Under the stress of the
conditions created by modern civilization, many individuals
in the social organism, in attempting, as they suppose, to better
their condition, are thrown out of sympathy with their sur-
roundings and thus become subjected to excessive nervous
strain. Alcoholism, the various drug habits, and the tendency
shown by the public to indulge in quack medicines may simply
be regarded as different phases of this general mental and phy-
sical instability. A great deal can unquestionably be done by
physicians in educating the public to mitigate these evils.
Careful instruction should be given in the public schools re-
garding the effects of alcohol; but, unfortunately, much that
is now given is based upon imperfect observation, and the facts
are so distorted by fanatical enthusiasm that, to say the least,
little good has thus far been done. Greater care should be
taken in regard to the expression of generalizations in relation
to the causes of alcoholism and the best methods of preventing
its spread. There is no question of public interest that is in
greater need of being studied by sober-minded individuals.
The causes are in many instances so complex and so far-reach-
ing in their consequences that a very careful analysis of the
facts is desirable before this question can be successfully dealt
with.22

" Helenius, Matti : Die Alkoholfrage. Eine soziologisch-statische Un-
tersuchung. Jena. Gustav Fischer.

ALCOHOLISM

311

Therapeutic measures in all forms of acute alcoholism can
be directed merely to combating the individual symptoms. In
the acute delirious states the drug should be withdrawn with
the greatest care. To withhold it completely at once in some
instances causes an intensification of the symptoms and gives
rise to serious interference with the action of the heart. With
care, however, caffein, camphor, and other forms of cardiac
stimulants may be substituted as occasion requires. The pa-
tient during the acute stages should be kept in bed, preferably
isolated so that he may be removed from all forms of external
stimulation. The motor restlessness, when present, is best
treated by the prolonged bath given under careful supervision ;
or, if this procedure is not well tolerated, the warm pack may
be tried. If the restlessness is not quieted by means of the
bath, various sedatives may be used with care, — morphin, the
bromides, chloral, and hyoscin. The complications must be
treated symptomatically as they arise. In cases in which there
is a complicating nephritis, it may be necessary to give the
patient hot-air baths. The diet should consist of fluids, pref-
erably milk, given in small quantities frequently repeated.
At times the gastric disturbances are so marked that patients
will not retain any nourishment, and feeding by enemata must
be resorted to. As the patient improves, feeding should be
forced as much as possible. As a rule, food is better tolerated
when given in small quantities and repeated at intervals of
two or three hours. Strychnin, administered either by the
mouth or subcutaneously, has been highly recommended. In
some cases the drug certainly seems to prove of considerable
benefit, but it should not be looked upon in any sense as a
specific.

In the more chronic forms it is of prime importance that
the patient be made to realize the importance of total absti-
nence, not only from alcohol but from all forms of stimulants.
Each case must be studied upon its own merits, and the exciting
causes that have given rise to the tendency to excesses in alco-
hol must be combated. This frequently necessitates a change
in the individual's mode of life and in his environment. Emo-

jI2 PSYCHIATRY

tional disturbances of any form should as far as possible be
avoided. The impulses to take alcohol are as much the out-
come of excessive pleasurable feelings as they are of dis-
comfort or actual pain. The majority of patients, when they
have recovered from the acute stages, are better off in a mild
climate not subject to great variations of temperature than
in one in which the changes are excessive and sudden. Much
has been written about the use of hypnotic suggestion in the
treatment of these cases, and it can not be denied that in some
hysterical patients satisfactory results have been obtained, and
to its influence must largely be attributed many of the adver-
tised cures, — only a small minority of which, however, are
genuine. The alcoholic is a neurotic individual and is par-
ticularly open to suggestion. But it should not be forgotten
that the use of mental suggestion not infrequently makes the
case worse rather than better. The individual should be shown
how to successfully cultivate and train his volitional powers
and should not be taught to rely upon quack cures. What are
particularly needed in this country are small sanitaria, under
the direction of thoroughly competent and well-trained medi-
cal men, situated in the country within easy reach of cities,
where patients of this class may be sent for treatment. The
patient should be under constant supervision, should have
enough but not too severe exercise; all forms of amusement
as well as of mental occupation should be definitely prescribed,
and as far as possible these individuals should be taught how
to live. Such patients should be kept under observation for
a considerable period of time after the symptoms of alienation
have subsided. At least a year under medical supervision is
necessary before the individual has regained sufficient nerve
force to enable him to resist a return to his former habits.

Pathological Anatomy. — For a full description of the
changes that occur in the internal viscera in chronic alcohol-
ism the reader is referred to the text-books on clinical medi-
cine and general pathology.

Of the lesions in the central nervous system due to the

ALCOHOLISM 3!3

action of alcohol none is specific.23 In the observations made
upon animals which have been given repeated doses of the drug
extending over long periods of time, in addition to inflamma-
tory changes in the pia, fatty degenerations in the connective-
tissue substance and the blood-vessels, and vacuolization, with
atrophy of the cortex, have been frequently noted. The opin-
ion is steadily gaining ground that the effect of alcohol alone
does not produce a psychosis, but rather gives rise to certain
tendencies which are of etiological importance. It is as yet
unknown why the drug should affect different portions of the
central nervous system in different individuals.-' As has fre-
quently been pointed out, the locus minoris resistentiae is
sometimes in the vascular system and again in the meninges,
the latter being found affected in nearly every case. Gener-
ally there are a marked opacity and thickening of the pia over
the convexity and not infrequently an ependymitis. Pachy-
meningitis hemorrhagica is met with and adhesions between
the dura and the skull of inflammatory origin are common.
The vessels, as a rule, are affected, although Cramer reports
two cases of chronic alcoholism, in both of which during life
there had been evidences of considerable dementia but in which
there were no sclerotic changes noticeable in the larger arteries.
These findings do not substantiate the views of those who
maintain that the changes in chronic alcoholism are always
associated with marked vascular lesions. In one case reported
there was a dilatation of the medium-sized and large arteries
and veins with hyaline degeneration of the walls. In some
instances the lumina of vessels were narrowed and obliterated.
Red and white blood-cells were found between the different
layers of the walls of these vessels. The lymph-spaces were
dilated, the glia was increased, and many monster spider-
cells were found, particularly in the neighborhood of the ves-

23 Cole : Changes in the Central Nervous System in the Neuritic Dis-
orders of Chronic Alcoholism. Brain, Autumn, 1902. Systematic Exam-
ination of the Central and Peripheral Nervous System and Muscles in a
Case of Acute Alcoholic Paralysis with Mental Symptoms. Archives of
Neurology, ii, p. 835.

3,4 PSYCHIATRY

sels. In the cases which run an acute course and where the
mental disturbances are very severe, the changes in the glia,
as a rule, are well marked. In some instances there is atrophy
of the convolutions with a disappearance of the medullated
fibres.

In cases of delirium tremens Bonhoeffer24 and Troem-
ner23 failed to find any specific changes. The former noted
a dissolution of the chromatic substance, particularly in the
large giant cells of the central convolution. This was asso-
ciated with granular degeneration and change in the contour
of the cell, which argued the existence of a pathological
process of great severity. In some instances the nucleus was
eccentric; in others it was in its normal position, although
frequently shrunken in appearance. The Purkinje cells were
normal. Troemner affirmed that the pathological process due
to alcohol is more or less diffuse. In the sections examined
the lesions in the occipital region, however, were less exten-
sive than in other areas. The subpial glia felting was in-
creased in quantity. The vessels were thickened and there
were fatty degeneration of the intima and small-celled infil-
tration of the media. The inclination to hemorrhages was
marked, particularly in the central and frontal convolutions.
A spot of predilection was the gray substance about the third
ventricle and the aqueduct of Sylvius.

Ether. — Although in some countries, particularly Ireland
and certain parts of Prussia, this drug is habitually taken in the
form of inhalations, such cases are not common in America,
although they are occasionally met with, more particularly
among the higher social classes. For a detailed description of
the acute ether intoxication the reader is referred to the various
text-books which deal fully with the subject. As would be ex-
pected, the continued use of the drug has a marked effect not

14 Pathologisch-anatomische Untersuchungen an Alkoholdeliranten.
Monatsschr. f. Psych., Bd. x, S. 265.

* Pathologisch-anatomische Befunde bei Delirium tremens nebst
Bemerkungen zur Struktur der Ganglienzellen. Arch. f. Psych., Bd. xxxi,
H. 3.

CHLOROFORM 3!5

only upon the kidneys, liver, and heart, but also upon the mental
faculties, giving rise to hysterical states or hallucinatory dis-
turbances which are apt to be combined with impulsive acts.

Chloroform. — Psychoses occasionally follow the admin-
istration of chloroform, but instances in which mental aberra-
tion persists for a considerable length of time after the with-
drawal of the drug are rare. That such are not unknown, how-
ever, is evident from certain references that appear throughout
the medical literature.26 Thus in one instance, after only 15
cubic centimetres of the drug had been taken by inhalation,
marked mental aberration occurred lasting for half an hour
after the cessation of the anaesthesia. The patient was greatly
excited and, although able to leave the room, failed to recognize
those about him, mistook the physician for a comrade, and
showed marked disorientation for time and place. The delir-
ium lasted for over half an hour and then gradually cleared
up. In some cases the tendency to pseudoreminiscence is very
marked and disorientation for time and place is nearly always
present. A few cases have been recorded in which the confu-
sion lasted for from two to five days. Although delirious states
are more common, cases have been reported in which the pa-
tients sank into a deep stupor, in one instance lasting for three
days. Somewhat similar conditions have been reported after
the administration of other drugs, such as ether, ethyl bromide,
iodoform.27 These mental disturbances are supposed to be
caused indirectly by an autointoxication resulting from the
administration of the drug, but in all probability the predis-
position of the individual is a very important factor.

Inasmuch as the manner in which chloroform and allied
drugs act is not understood, it is not surprising that nothing
definite is known regarding the pathology of these conditions.
Heger thought that in profound anaesthesia there was a con-

26 Scheuerer, Franz : Beitrage zur Frage der Chloroformpsychose.
Psych. Neurol. Wchnschr., 1904, Nr. 46 und 47.

27 Schlesinger : Die bei der Behandlung mit Iodoform auftretenden
Psychischen Storungen. Allg. Ztschr f. Psych., Bd. liv, H. 6. Nach.
Deut. med. Wchnschr., 1898, Litt. Beil., Nr. 18, S. 120.

3i6

PSYCHIATRY

traction of the cell-body and a moniliform condition of the den-
drites, a change demonstrable in animals to whom ether, chloro-
form, chloral, or morphin had been given. Binswanger has
advanced the hypothesis that a temporary disturbance in the
function of the nerve-cell is caused by the loss of nutritive
material due to the molecular changes in the Nissl granules.
As a result of these simple disturbances of nutrition, which may
occur in states of exhaustion, inhibitory processes are supposed
to be initiated which are an expression of an irregularity in the
functions of the cell, and the synthetic processes in the cell are
thus hindered. Cloetta,28 following Meyer and Overton, affirms
that all narcotic drugs have a common characteristic of going
into solution in oil to a degree proportional to their narcotic
power; but as the nervous system is particularly rich in sub-
stances which are closely allied to the fats, instead of an actual
chemical change one of a more purely physical character takes
place. They think that the liver has a great affinity for the
chloroform circulating in the blood and that this organ, rich in
such fatty substances as cholesterin and lecithin, has the power
of combining physically with chloroform, ether, and other nar-
cotics of the aliphatic series, such as sulphonal, chloral, and
paraldehyde.

Paraldehyde. — As this drug was largely used a few
years ago in the treatment of alcoholism and morphinism, it
should not be a matter of surprise that the original habit was
often exchanged for the more novel vice. The effects of paral-
dehyde in comparatively large doses are very similar to those
of alcohol, but the immediate manifestations are much more
quickly observed. Cases are on record in which the continued
use of the drug resulted in marked impairment of the nutrition,
great loss of weight, and auditory hallucinations, this more or
less chronic state being superseded by an acute exacerbation,
the symptoms of which were remarkably similar to those of
delirium tremens. Visual and auditory hallucinations, as well as

n Cloetta, M. : Ueber den Unterricht in der Arzneimittellehre. Munch,
med. Wchnsch., 1902, Nr. 1, S. 25, ff.

MORPHINISM 3I7

those of smell and touch, predominate, accompanied by marked
tremor, obstinate insomnia, some difficulty in speech, and dimi-
nution in the power of orientation.29 Nevertheless, some ob-
servers believe that considering the great frequency with which
the drug is administered the cases which present the foregoing
symptoms form a very small minority.30

Morphinism.31 — In this country patients become addicted
to morphin more commonly than to other forms of opiates,
although opium-eating and opium-smoking, unfortunately, are
not very rare in America. The development of this habit de-
pends upon a great variety of conditions and each case needs to
be studied by itself. Not a few patients gradually become
habituated to the vice from the fact that the drug is too often
prescribed for long periods of time by physicians for the relief
of pain in chronic neuralgia, sciatica, insomnia, and nervous-
ness, or in women for dysmenorrhea. In many patients, par-
ticularly among the wealthier classes, subcutaneous injections
are resorted to. As a rule, those who begin by taking opium
later on become addicted to the alkaloid.

The mental symptoms of morphinists are varied and in the
main have certain general characteristics which aid in the
recognition of the disease. In the earlier stages, and before the
patient has become a thorough slave to the habit, he is apt to
show marked symptoms of hysteria. At times states of appre-
hensiveness and anxiety develop ; the patient readily becomes
flustered, often develops mild suspicions, is decidedly pessi-
mistic and hypersensitive, affirms that old friends are forsaking
him, that all his actions are misinterpreted. Soon ethical de-
fects become more or less pronounced. A tendency to lie, par-
ticularly when questioned in regard to his failing, is developed,
and as action becomes more difficult the fabrications increase in

29 Behr, A. : Beitrag zur Kasuistik der Paraldehyddelirien. St.
Petersb. med. Wchnschr., 1902, Nr. 14.

30 Bemke : Paraldehyd als Schlafmittel. Monatsschr. f. Psych, u. Neu-
rol., Bd. xii, Dezr., 1902, H. 6.

31 Schutze : Zur Casuistik des chronischen Morphinismus. Charite-
Annalen, xxvi. 1902.

3i8 PSYCHIATRY

scope and variety. The sense of duty becomes more and more
blunted till it finally disappears. The patient becomes decidedly
apathetic, is lacking in all altruistic qualities, and shows himself
regardless of all duties except those connected with his own
energies. The whole character deteriorates and the defects are
in many respects similar to those belonging to certain stages in
alcoholism although they altogether differ from others. These
individuals will resort to any kind of subterfuge in order to
obtain a supply of the drug, and if they have any in their pos-
session, whenever they expect a visit from attendants or physi-
cians, they find various hiding-places for it or conceal it about
their persons. The ingenuity shown by some patients in this
respect is extraordinary. As would naturally be inferred, all
association processes are seriously interfered with, the degree
of the disturbance depending largely upon individual idiosyn-
crasies and the amount of the poison taken. Thus every grade
is encountered from slight inhibition or incoherence to deep
somnolence or stupor. In the earlier stages and in certain in-
dividuals, even when large doses are taken, there may be an
abnormal irritability and a tendency to talk, the apparent
flight of ideas and general motor restlessness being very sug-
gestive of alcoholism. Hallucinations and delusions may
develop, although they are not usually present unless the mor-
phinism is complicated by alcoholism or the effects of some
other drug. The visual as well as the auditory hallucinations,
as a rule, are of a definite elementary character — bright or
colored flashes of lightning, sparks, sounds, the ringing of
bells, etc. Moreover, these patients are not uncommonly suf-
ferers from psychsesthesias, parsesthesias, or less frequently
hyperesthesias.

The physical symptoms of these cases in a measure depend
upon the individual reaction to a variety of conditions. When
the habit has existed for any length of time the patients show
an obstinate aversion to food and an utter disinclination for
any form of exercise; as a result they become anaemic, and
develop a more or less marked cachexia. Furunculosis is not
uncommon, particularly in those who use the drug hypo-

MORPHINISM 3I9

dermically. The breath is generally foul, the teeth show signs
of neglect, the hair becomes dry and shows a tendency to fall
out. As would naturally be expected, there are marked dis-
turbances in the circulation. The extremities are apt to be
cold; the superficial circulation is poor; the heart is rapid
and becomes more or less irregular. Disturbances of vary-
ing intensity in the gastro-intestinal tract are constant, and
the patients usually suffer from anorexia, flatulence, and at-
tacks of diarrhoea alternating with obstinate constipation.
Even in the earlier stages the pupils of the eyes are contracted
and are sometimes reduced almost to the size of pin-points.
The reactions for light and accommodation are usually im-
paired.

Anomalies in the muscular power are generally well
marked and are more or less dependent upon the psychic state.
The disinclination to exercise or to make any effort is reflected
in the general character of the patient. The muscles become
flaccid, the gait is hesitating, and all volitional movements are
more or less impaired. Quite commonly a pronounced inten-
tion tremor and in some cases very marked incoordination
of all muscular movements and Romberg's symptom develop.
In such cases, however, it always becomes necessary to exclude
some complication. The disturbances in sensation are varied
and are largely of central origin. The sexual functions are
usually diminished, although in rare instances a condition of
excitability has been reported. In addition to the symptoms
already described a few observers have called attention to the
occurrence of epileptiform attacks as well as those suggestive
of pseudo-angina. Variations in temperature, with occasional
rises even to 390 or 400 C, are not uncommon in morphino-
maniacs, but since experiments on animals would indicate that
injections of morphin are followed by a lowering of the tem-
perature, we must infer that in some cases at least such rises are
due to a localized infection following a careless injection.
Nevertheless, in other cases the febrile disturbances must prob-
ably be regarded as the result of secondary intoxications due to
the gastro-intestinal disturbances. These individuals usually in

320

PSYCHIATRY

the end die of some intercurrent trouble, the cachexia being
often a very important factor.

Delirious states, particularly a form closely resembling
delirium tremens, may develop. Sometimes late in the disease
coma or convulsions supervene. During the period of absti-
nence, particularly if the individual has been addicted to the
use of the drug for any length of time, the untoward symptoms
are temporarily liable to be greatly exaggerated. The patient
beomes excessively irritable and gives vent to outbursts of tem-
per; the gastro-intestinal disturbances increase and in some
cases there develop visual and auditory hallucinations with
marked delirious states, accompanied by suicidal and homicidal
impulsions.

The treatment of these cases is very difficult and frequently
is a severe tax upon the patience and ingenuity of the physician
and the nurse. When the insidious effects of the drug upon
the mental and physical state of the patient are remembered, it
becomes clear that a cure cannot be accomplished except after
a long time. When large quantities of the drug have been
taken daily, in private practice the gradual, and not the sudden,
withdrawal is indicated, since the latter is apt to be accompanied
by severe and at times dangerous effects. If, however, it is
possible to place the patient in a hospital before beginning the
treatment the morphin may be stopped at once.32 Isolation is
absolutely necessary. If he remains at home, the patient must
be secluded, if possible, from all members of his family and
from his friends and placed in charge of thoroughly competent
nurses who must be fully impressed with the importance of the
fact that such individuals will resort to every possible subter-
fuge in order to obtain the drug. In what may be termed the
expectant treatment, while the drug is being gradually with-
drawn, the various symptoms must be dealt with as they arise.
A milk diet — small quantities being given every two hours —
is at first preferable. If the milk is not well borne by the

" Halleck, M. S. : Cases of Morphinism in which the drug was im-
mediately withdrawn. Medical Record. 1903, vol. lxiii, No. 15, p. 572.

MORPHINISM 321

stomach, broths, albumen, and plain soups may be substituted.
The bowels must be carefully regulated and any attacks of
diarrhoea, which may occur, must be checked as soon as pos-
sible, inasmuch as they soon bring about a weakening of the
patient. All forms of stimulants except in emergencies, such as
weakness or irregularity of the heart or an imminent collapse,
are contraindicated. In the very severe cases, however, caffein,
digitalis, whiskey, and strychnin are sometimes beneficial. The
restlessness and delirium may be combated by the warm pack
or the continuous bath given with great care. Occasionally the
administration of sedatives becomes necessary, but these should
be withdrawn at the earliest possible moment. As the nutrition
of the skin is generally seriously impaired, care should be taken
that bed-sores do not develop.

During the early stages of the treatment, particularly in
the severer cases, in addition to isolation and rest in bed, forced
feeding becomes imperative. Gradually, as the patients gain
mentally as well as physically, they may be allowed to get up,
at first for short periods of time. At this period the cold pack,
cold sprays, massage, or gymnastics under medical supervision
are of great advantage. As soon as the patient is able to go
about, it is desirable that he should be sent to some small sani-
tarium in the country, where he may have a restful life, good
food, plenty of fresh air, and strict medical supervision. In
this connection, however, a careful choice is necessary, since
not every institution which receives these patients supplies suffi-
cient medical care, and in some cases the environment of the
patient is anything but satisfactory. Under no condition should
the physician permit a return to the ordinary surroundings and
avocation until a very considerable period of time has elapsed
after the giving up of the habit. If it is necessary that the
patient should return to a life where there is mental and physi-
cal strain, to speak of a complete recovery until at least a year
has elapsed is utterly ridiculous. If, however, it is possible to
surround him with conditions which will allow him to lead a
healthy life, in an environment which does not impose too great
a tax upon his physical or mental reserve force, he may be per-

$22

PSYCHIATRY

mitted to do so at an earlier time provided it is possible to con-
tinue the medical supervision of the case.

Recently the administration of hyoscin has been highly
recommended in the treatment of morphinism, but even small
doses cause alarming symptoms in some patients.83 Camphor
has also been given as a substitute with varying results.34 Liv-
ingston 35 recommends ergot very highly in the treatment of
alcoholism and morphinism.

Cocainism. — The conditions which lead to the develop-
ment of the cocain habit are as complex and varied as those
which give rise to morphinism. When cocain was first intro-
duced, it was sometimes prescribed as a remedy for the mor-
phin habit, and the result in a large number of cases was that
the patient gave up the former to acquire the latter vice. As
a rule, the cocainism is not generally accompanied in the
early stages with the pronounced symptoms that mark the
addiction to morphin. We do, however, meet with restless-
ness, irritability, a certain degree of insomnia, loss of appetite,
and, if the habit is persisted in for any length of time, the indi-
vidual may become subject to choreiform movements, anomal-
ous emotional states characterized by outbreaks of temper and,
in the severer cases, transitory delirious states with auditory
and visual hallucinations. On the other hand, if addiction to
the drug continues, the manifestations increase in intensity with
more rapidity than in the morphin habit.

The physical symptoms accompanying the mental disturb-
ances usually consist in marked tremor, sometimes great pallor,
profuse sweating, cold extremities, and most commonly a rapid
and small pulse. The pupils are usually dilated. At times these
patients are subject to attacks of syncope and in some instances

" Pettey : Drug Habit. Med. News, 1902. Crothers, T. D. : Hyoscine
in the Treatment of Morphinism. The Quarterly Journal of Inebriety,
1903, vol. xxv, No. 3, July. Rosenberger, C. : The Hyoscine Treatment
of a Morphine Habitue. The Medical News, November 29, 1902.

** Erlenmeyer : Therapeut. Monatsh., 1903, Februar. Hofmann:
Therapeut. Monatsh., 1903, April.

" Medical News, March 5, 1904.

BROMISM 323

epileptiform convulsions supervene. Confirmed habitues, when
under the immediate influence of the drug, seem to be imper-
vious to any sense of fatigue and to have a craving for the dis-
charge of nervous energy, which is exhibited both mentally and
physically. Not uncommonly we meet with various disturbances
of sensation, generally anaesthesias, although paresthesias and
hyperesthesias are not rare. At times, in addition to the audi-
tory and visual hallucinations, to which reference has been
made, the patients are subject to psychomotor hallucinations
and curious disturbances in the organic sensations, so that they
feel as if they were floating in the air, balancing on the edge
of a precipice, and so on.

As regards treatment, what has already been said in regard
to morphinism holds good with appropriate modifications for
the cocain habit.

Bromism. — Not infrequently the alienist has opportunities
of observing the symptoms produced as the result of the ex-
cessive administration of some form of the bromides. In fact,
the somewhat reckless manner in which these drugs are given in
all forms of nervous excitement or depression makes this group
of cases comparatively large. As a rule, the mental disturb-
ances are characterized by a delay in the elaboration of incident
stimuli and an impairment of all of the more complicated voli-
tional acts. When the symptoms are pronounced, the patient
often speaks in a low, monotonous tone, only replying to ques-
tions after a considerable delay. When asked to exert himself
in any way, he shows a marked inhibition in connection with
the execution of the muscular movements. At times these more
elementary symptoms are complicated by marked defects in
memory amounting at times to more or less complete disorien-
tation, confusion, sleepiness, or stupor, while associated with
these are certain physical symptoms, such as vertigo, ataxia,
epileptiform attacks, and various signs of disturbances in the
gastro-intestinal tract.

Tobacco Intoxication. — At the present time we under-
stand very little about the nature of tobacco poisoning, and it is
probable that many of the deleterious effects attributed to nico-

3^4

PSYCHIATRY

tin are clue to one or more of the various derivatives of the
plant. Although it is frequently stated in text-books that the
excessive use of tobacco may give rise to marked mental dis-
turbances, such as delirious states and subacute or chronic hal-
lucinatory paranoiic conditions, it is doubtful whether the drug
is ever the sole cause of a definite protracted mental aberration.
The conditions which result from the excessive use of tobacco
in any form are well known. They vary in different individuals
from mild gastro-intestinal disturbances to more severe symp-
toms, with loss of appetite, nausea, vomiting, associated with
disturbances in the circulation, such as a weak and rapid, irreg-
ular, or intermittent heart. Individual idiosyncrasies for to-
bacco are not uncommon. In some cases the smoking of a
single cigar renders certain people markedly depressed mentally
for several hours.

Ergotism. — The chronic intoxication the result of the
ingestion of ergot, although observed in Europe, particularly
in South Germany and Italy, is practically unknown in the
United States. The symptoms induced by continued doses of
this poison may resemble those encountered in tabo-paresis.

Lead Poisoning; Saturnism. — As long ago as 1771,
Dehane 36 called attention to the fact that mental disturbances
sometimes appear in individuals who have been poisoned by
lead. The first definite attempt, however, to establish a causal
relationship between the disturbances in nervous functions and
lead intoxication was made by Tanquerel des Planches.37
Since that time investigators have discovered many interesting
facts which have an important bearing on this question. The
peripheral forms of paralysis will not be discussed here. The
alienist is more particularly interested in the mental disturb-
ances, which are generally spoken of under the head of lead
encephalopathy and in the main present certain characteristics
in common. Sometimes the mental symptoms are ushered in by

Ratio Medendi. Paris, 1771.

Traite des Maladies du Plomb ou Saturnisme. Paris, 1840.

SATURNISM

325

epileptiform attacks (Judd,38 Oliver39). In some instances
the epileptiform attacks are followed by apoplectiform seizures,
which may have a rapidly fatal ending. Another group of cases
belonging to the delirious form are characterized by a more or
less acute onset. The prodromal symptoms are apt to be those
usually associated with lead poisoning — constipation, lead colic,
etc. Later the patient begins to complain of severe headache,
loss of sleep, disturbances of vision, and still later of more or
less active hallucinations. In the cases characterized by a
slower course paresthesias precede the more acute period of de-
lirium. During these attacks periods of profound coma may or
may not occur. Another form of lead paralysis is represented
in the types either associated or identical with cases of dementia
paralytica.

The manner in which the poison acts has not as yet been
satisfactorily explained, although a variety of hypotheses have
been advanced. By some investigators it is supposed that the
lead produces a true cerebral ansemia giving rise to headaches,
vertigo, sensorial troubles, delirium, etc. Jaccoud believed that
this poison showed a particular affinity for the brain. The
general consensus of opinion favors the view that the lead may
simply be regarded as an inciting factor, generally in those who
have already shown some predisposition to alienation.

38 Judd, W. R. : A Case of Lead Encephalopathy. Brit. Med. Journ.,
1904, April 16.

39 Clifford Allbutt's System of Medicine, vol. ii, p. 988.

CHAPTER XII

PSYCHOSES ASSOCIATED WITH IMPERFECT FUNCTIONING OF
THE THYROID GLAND 1

The mental disturbances associated with disordered func-
tions of the thyroid may be divided into two groups: (i)
Those due to diminished function, — myxcedema and cretinism.
(2) Those due to hyperf unction, — exophthalmic goitre.

Myxcedema. — Gull in 1873 first called attention to cer-
tain physical and mental symptoms occurring in women in
association with disturbances of function in the thyroid gland.
These observations were extended to male patients by Ord,
who proposed the term myxcedema to designate this condition.
Several years later Charcot and Ballet added greatly to the
clinical knowledge of this disorder; but it was not until the
operative experience of Reverdin in 1882,2 of Kocher in 1883,
and the important experimental work upon animals of Scruff,
Horsley, and others appeared, that its true nature was made
clear. From the facts gathered from these various sources it
became evident that any marked deficiency in the functions
of the thyroid may give rise to symptoms of myxcedema. All
these studies were verified and extended by further experience
with cases of operative myxcedema or the cachexia strumi-
priva.

The physical symptoms of myxcedema need not be dwelt
upon here at length, as they are fully described in the various

1 Church and Peterson : Myxcedema. Nervous and Mental Diseases.
Philadelphia. New York, and London, 1903. Roubinovitch, J. : Troubles
mentaux par insuffisance thyroidienne. Traite de la pathol. mentale.
Paris, 1903. Osier, W. : Practice of Medicine. Fifth Edition. New York,
1903. Also Sporadic Cretinism in America. Trans, of the Congress of
American Physicians and Surgeons, vol. iv.

In 1867 Sick had called attention to a form of psychic degeneracy
occurring in a ten-year-old boy following operation on the thyroid.
326

MYXEDEMATOUS INSANITY 327

text-books on clinical medicine. Peculiar changes in the skin
early attract attention. A mucoid infiltration makes its ap-
pearance in the integument of the face, extremities, abdomen,
nose, ears, and eyelids, as well as in certain other localities.
There are well-marked changes in the hair, teeth, and nails,
as well as in the buccal, lingual, and pharyngeal mucous mem-
branes. Glandular activity is interfered with. The thyroid
is diminished in size in most of the cases, although it is occa-
sionally larger than normal. Sensory disturbances also occur,
and areas where the infiltration is marked are apt to be anaes-
thetic or hypersesthetic. The pulse is irregular and weak.
The patient soon presents the peculiar cachectic appearance
more or less characteristic of the disease.

Myxedematous Alienation. — Mental anomalies are to be
found in nearly all cases of myxoedema and are chiefly charac-
terized by marked impairment in connected thinking. Among
the milder forms of mental defect usually noticeable are diffi-
culty in thinking, apathy, memory defects, and a tendency to
excessive drowsiness. As a rule, the patients become indiffer-
ent to their surroundings, do not respond to the action of nor-
mal stimuli, and as the disease advances show great impair-
ment of the power of recollection as well as in the elaboration
and working up of new stimuli. Wolseley 3 maintains that
in cases of myxcedema the spontaneous attention or instinctive
selection of some stimuli in preference to others is impaired.
Contrary to the general opinion entertained by physicians,
this observer thinks that the retentiveness of memory is well
preserved while its impressionability is diminished. The chief
characteristic of the mental state is the retardation of thought
without any impairment in judgment. If the attention of the
patient is once aroused and sustained, there is no evident dis-
sociation of the mental processes, while the diminution in the
volitional impulses is the cause of the lack of initiative as well

' Wolseley, Lewis : The Mental State in Myxoedema. Lancet, April
23, 1904.

328 PSYCHIATRY

as of the striking immobility of face and body so characteristic
of the disease. In a comparatively large number of cases hal-
lucinations and insane ideas of varying degrees of intensity
may be present. Pilcz 4 has called attention to the fact that
the mental manifestations at times are dependent upon the
myxcedema and are then symptoms of the disease; in other
instances they are merely the expression of a complicating
psychosis. That different types of alienation may compli-
cate myxcedema has also been shown by numerous authorities,
particularly Berkley, and for this reason the great variety of
the mental symptoms which have been observed during the
course of myxcedema and which have been said to be specific
of the disease is open to doubt. Nevertheless, the fact that
certain types of insanity occurring during the course of myx-
cedema recover completely after the administration of the thy-
roid extract renders it in the highest degree probable that
a specific myxedematous insanity exists, and therefore not
all cases are to be regarded merely as a combination of
myxcedema and an independent psychosis. Instances of
pronounced myxedematous insanity are not very rare and
have been reported by a large number of clinicians. Accord-
ing to Clouston, the primary changes are delay in the asso-
ciational processes, vague suspiciousness, and varying degrees
of mental depression. In some cases a period of euphoria
or maniacal exaltation intervenes, while some writers have
reported symptoms of negativism, verbigeration, and various
forms of dementia. These last must be accepted with great
caution, as the further histories of the cases are not given
and their occurrence would suggest a possible dementia praecox
complicating myxcedema.

A convenient clinical classification into two categories
may be made. In the first, progressive somnolence, torpor,
intellectual defects, and not infrequently various forms of

4 Pilcz, Alexander : Zur Frage des myxodematosen Irreseins und der
Schilddrvisentherapie bei Psychosen uberhaupt. Jahrb. f. Psych, u. Neurol.,
1901, Bd. xx, S. -7.

CRETINISM 329

convulsions and coma, ending in death, form the clinical pic-
ture. To the second belong hallucinations of the senses, par-
ticularly anomalies of the various organic sensations, as well
as disturbances of taste, smell, and hearing. The attacks of
mental depression may alternate with those of maniacal ex-
citement, and, in addition to these, states of anxiety associated
with visual hallucinations of a very vivid and terrifying char-
acter have been noted. One instance has been reported in
which there were symptoms of marked mental depression with
hypochondriasis and ideas of persecution. The majority of
cases in which periods of exaltation and depression occur not
improbably are complicated by a manic-depressive insanity.
In many of these cases found in the literature the records
are too incomplete to justify a positive declaration as to
whether the psychosis was an expression of the primary dis-
ease or merely represented a combination of two totally dif-
ferent processes. Unfortunately, not a few patients have been
under observation only in the wards of a general hospital,
whence, upon the subsidence of all symptoms, they have been
discharged and reported as cured; but, on account of the lack
of further information, it is impossible to say that no recur-
rence of the mental trouble occurred later on.

In the treatment of myxcedema the thyroid extract is,
as is well known, a specific. Various preparations may be ad-
ministered. Concerning the relative merits of these the reader
is referred to the text-books on general medicine. In regard
to the treatment of the special mental symptoms to which ref-
erence has been made, the indications are the same as those
laid down for similar conditions. (See Chapter V.)

Cretinism. — By some the word cretinism is said to have
been derived from Chretien, Christian, and referred to the
supposed inability of these imbeciles to commit sin. A more
probable derivation is from cretira (creatura), a term used
to designate an individual whose physical impairment was such
as to make him an object of pity.5 Cretinism is more or less

° Ackermann : Ueber die Kretinen, eine besondere Menschenart in
den Alpen. Gotha, 1790.

330 PSYCHIATRY

endemic in parts of Switzerland, Italy, France, Sweden, Great
Britain, and in a few places in North America (Minnesota,
Ontario). Sporadic cases are met with in all countries.6

This congenital condition is characterized by mental and
physical anomalies which in their totality alone are distinctive.
Prominent among the former is the general impairment in
all the mental faculties, and among the latter are the changes
in the skeleton and the skin and deficiencies in the sexual appa-
ratus. All these changes are more or less directly related to
the disturbances in the function of the thyroid gland. The
operative causes are largely endemic.

Physical Symptoms. — Among those which have received
the most notice from clinicians are the defects in the thyroid
gland. In many cases, however, it is extremely difficult to tell
from palpation whether there is an actual change in the struct-
ure of this organ. This is largely due to the fact that it
develops behind the sternum and therefore can be examined
only with great difficulty. The general consensus of opinion is
that only a certain proportion of these defectives show any
abnormalities of 'the thyroid. Thus, out of 3600 cretins ex-
amined in Lombardy only 1125 showed an enlargement.

Among the most striking features are the remarkable de-
fects in the development of the bony skeleton. As a rule, these
are not noticed at birth, but become apparent only after the
lapse of several months. The disproportionateness in develop-
ment of the skeleton is not nearly as marked as in the cases of
idiots, although sometimes the abnormality of the skull is at
once noticeable. Cretins are met with in whom the skull seems
to be proportionately smaller. The delay in the ossification
and the persistence of the cartilaginous epiphyses in the bones
are frequently so marked that the limb of an adult may re-
semble that of an infant of one or two years. The physiog-
nomy of these patients is very striking, and here again the
changes in the bones are very apparent. The nose is usually

• Weygandt, W. : Der heutige Stand der Lehre vom Kretinismus.
Halle a/ S., 1904.

CRETINISM 33 !

flat and broad, the orbital cavities are far apart, and the jaws
protrude. The skin is less affected than in cases of myxcedema,
and this fact has led certain observers to believe that the ab-
sence of myxcedematous changes was specific of the typical
cretins. More careful investigation, however, has failed to
substantiate this view. The hair is somewhat sparse and falls
out easily. The nails are defective and, as in myxcedema, there
is considerable interference with the function of the sweat-
glands. The surface temperature is apt to be below that of
the normal individual. The skin has a wrinkled appearance,
so that even when quite young cretins may look like old peo-
ple. Various anomalies are found in connection with 'the mus-
cles and their mechanical irritability is said to be increased.
As would be expected, the internal organs are nearly always
affected, particularly the heart and lungs. Anomalies occur-
ring in the sexual organs are common. In some cases even
after the thirtieth year no development of the genitals has
taken place. In women the breasts are apt to be poorly devel-
oped and pigmentation as well as glandular tissue is almost
completely absent.

Mental Symptoms. — The primary perceptions are often
impaired. This impairment may or may not be due to local
causes. Thus, defects of hearing are not infrequently due to
the existence of a catarrh or enlarged tonsils, and those con-
nected with taste and smell to pathological conditions of the
mucous membranes. The disturbances in the associative mem-
ory, as well as in the more complicated mental processes, vary
greatly according to the individual case. As yet a satisfactory
grouping of the cases is impossible, and the best is probably
an empirical division into the apathetic or anergetic and the
excitable or erethic form. All degrees from the severest to
the mildest type are encountered. In the worst cases the
individual never develops mentally beyond the condition be-
longing to earliest infancy. There is a marked inhibition of
all the psychical activities, of the attention, the power of re-
taining and elaborating impressions, etc. Sometimes there is
great interference with the understanding of speech, and the

332

PSYCHIATRY

patients are capable of learning the meaning of only a few
of the simplest words and signs. The existence of such indi-
viduals, as in the case of the worst type of idiots, is largely
vegetative. Only occasionally are inarticulate sounds produced.
In rare instances the involuntary rhythmic movements some-
times noted in idiots are encountered.

In milder cases the individual reaches the stage when he
is able to a certain extent to appreciate his surroundings and
is capable of being taught to feed and dress himself, but devel-
opment further than this does not take place. Some difficulty
in articulation is present in nearly all the cases. Certain indi-
viduals show sufficient mental capacity to go to special schools
where they are able to acquire the rudiments of an education.
The acquisition of manual dexterity is usually easier than of
knowledge acquired from books.

According to Weygandt, the patients may be divided into :
( i ) dwarf cretins and those of the infantile type, in which the
skeletal and mental development do not advance beyond the
stage of a child of three or four years; (2) half-cretins, who
correspond to the anergetic type but are still capable of being
educated; the dwarf features are marked and, as a rule, the
patients average about four feet in height; (3) the cretinoids,
who still show the habitus, the lack of development, the cretin
physiognomy, and the changes in the skin, as well as the men-
tal insufficiency. In all these cases it must be remembered that
the disturbances which occur in the various organs are not
always of equal degree of intensity, so that the anomalies in the
skeleton, skin, and central nervous system may show consid-
erable variations.7

Pathology. — The work of Langhans 8 undoubtedly
formed the basis for many later investigations into the patho-
logical anatomy of cretinism. In some cases the thyroid shows

' Weygandt, W. : Ueber Virchow's Cretinentheorie. Neurol. Cen-
tralbl., Nr. 7-8, 1904.

'Anatomische Beitrage zur Kenntniss der Cretinen (Knochen, Ge-
schlechtsdriisen, Muskeln und Muskelspindeln nebst Bemerkungen iiber
die Bedeutung der letzteren). Virchow's Archiv, 1897, Bd. cxlix, S. 155.

EXOPHTHALMIC GOITRE 333

marked atrophy of its epithelium, while in one instance there
was a decided hypertrophy of one portion. Tumors have been
reported situated to one side of the trachea. The medulla of
many of the bones resembles that found during infancy. The
ovaries show cystic degeneration. The testicles are atrophic.
According to Hofmeister, in animals whose thyroid has been
removed no spermatozoa are found. The myxedematous
changes have already been described. The heart and lungs
show changes. The spleen, liver, and kidneys are also abnor-
mal. In the cerebral cortex, in specimens prepared with the
Nissl stain the nerve-cells seemed to be small and did not stain
deeply. The apical processes showed considerable change,
being somewhat attenuated and visible for long distances. All
the various theories entertained regarding the origin of cre-
tinism cannot be mentioned here. According to one view, it
is not at all improbable that through the drinking-water some
deleterious organism is introduced into the system which has
a particular affinity for the thyroid gland.

As regards the differential diagnosis, it is necessary to dis-
tinguish between cretins, individuals suffering from other
diseases of the thyroid, cases of dwarfism due to other causes,
and congenital idiots or feeble-minded persons. In this country
this differentiation becomes unnecessary, as only the sporadic
cases of cretinism ever develop.

In the treatment, removal from unhygienic surroundings
and change in the water-supply are important. The brilliant
results obtained from the administration of thyroid extract are
too well known to need detailed mention here.

Mental Disorders associated with Hyperfunction
of the Gland: Exophthalmic Goitre, Graves' Dis-
ease, Basedow's Disease. — It has long been recognized that
mental disturbances are apt to occur during exophthalmic
goitre (Basedow, 1840). The milder forms consist in emo-
tional instability, attacks of more or less depression or ex-
citement with accompanying states of apprehensiveness and
mild phobias. The attention is also markedly disturbed, and,
on account of the nervousness, it is apparently impossible for

334 PSYCHIATRY

these patients to concentrate their minds long upon any one
subject. Another group of cases is met with in which the
symptoms are episodic in character, states of depression or
excitement alternating; and during these periods obsessions,
impulses, and phobias may develop. The hallucinations that
have been reported in cases are, as a rule, visual in character
and generally of a disturbing or terrifying nature. Ballet 9
recorded cases in which the visual were followed by audi-
torv hallucinations and eventually systematized persecutory
ideas developed. Statistics go to show that, although periods of
depression may occur, the maniacal symptoms seem to be much
more frequent. Jacobs 10 was able to find the records of ten
cases in which an acute mania terminating fatally complicated
the course of Graves' disease. Hirschl n extracted from the
literature — from 1862 to the present date — 43 cases of in-
sanity complicating Basedow's disease. Of these the ma-
jority showed maniacal symptoms, only 6 recovered from
the alienation, while 18 of the patients died. Certain French
writers, however, particularly Dutil, hold that the occur-
rence of these psychoses in the course of goitre is somewhat
commoner than the above statement would lead us to infer.
It should not, however, be forgotten that in a certain propor-
tion they are in reality phases of some independent psychosis,
so that after the cases of alcoholism, manic-depressive insanity,
and dementia praecox have been eliminated there remains a
comparatively small group which definitely belongs to this cate-
gory. Whether we are at present justified in classifying these
forms of alienation as in a measure characteristic of the dis-
turbances of the thyroid gland we are unable to say. The
question needs to be more fully investigated, and, unfortu-
nately, the majority of records in the literature are too in-
complete to warrant a positive conclusion.

* Des idees de persecution dans le goitre exophthalmique. Soc. med.
des hop., 1890.

10 Jacobs, Henry Barton: The Am. Journ. Insan., vol. lv, No. 1,
1808.

11 Krafrt-Ebing: Lehrbuch der Psych., Stuttgart, 1903.

EXOPHTHALMIC GOITRE

335

The treatment is largely symptomatic. As a rule, the pa-
tients if they have become at all excited should be at once
transferred to a hospital. There they can be kept in bed on
a fluid diet. The administration of sodium phosphate, as rec-
ommended by Mobius and others, may be tried, as well as the
effects of belladonna. The thyroid extract has been frequently
given in these cases, but, although its use has occasionally
seemed to be beneficial, it usually makes the condition worse.
As a rule, during the periods of marked depression or excite-
ment the patient is much better off in bed, and the diet should
be restricted to nutritious and easily digested forms of food.
The bowels should be carefully regulated. Warm packs or
prolonged baths are often efficacious.

CHAPTER XIII

THE MANIC-DEPRESSIVE GROUP 1

For a long time alienists have recognized the fact that
there are psychoses characterized by maniacal outbreaks re-
curring with well-marked periodicity and broken by inter-
vening lucid intervals. Moreover, clinical experience has
shown that patients afflicted with melancholia later in the
course of this disease not infrequently develop maniacal symp-
toms. But although these two phenomena have been recog-
nized as belonging to a large number of cases of alienation,
the interpretations of their clinical significance have not always
been in accord.2 The older clinicians were inclined to attrib-
ute too much importance to the mere periodicity which char-
acterized the return of certain psychoses, and even recently
Hitzig, Jolly, and Pilcz have maintained that for practical
reasons in a number of forms of insanity it is still necessary
to consider this as the most distinctive element in their symp-
tomatology. But gradually alienists are awakening to an
appreciation of the futility of attempting to establish the ex-
istence of a disease entity upon such insufficient grounds as
the apparent prominence of some symptoms and the conjec-
tural unimportance of others, and are learning to recognize
that to attach too great significance to the more periodic re-
currence of individual symptoms is equally unscientific.

A new epoch began in 1 85 1 when Falret 3 described a
periodic mental disturbance which he designated as folic cir-
culaire. Again, after Baillarger and Falret in 1854, indepen-
dently of each other, had affirmed that the so-called circular

1 Hoch, August : Manic-Depressive Insanity. Reference Handbook
of the Medical Sciences. William Wood & Co., New York, 1902.

= Pilcz, Alexander : Die periodischen Geistesstorungen. Jena, 1901.
'Gazette des Hopitaux, 1851.
336

MANIC-DEPRESSIVE INSANITY

337

insanity was a disease entity, it became evident that hitherto
sufficient care had not been exercised in estimating the relative
importance of all factors pertaining to the etiology, symptoma-
tology, course, prognosis, and termination of these periods of
mental aberration. Moreover, clinical experience had demon-
strated that the only logical and scientific method of studying
disease was from this broader and far more comprehensive
stand-point, and, as a result of these changes of view, less stress
was laid upon individual and isolated symptoms, and an at-
tempt was made to give to each event in the disease its just
valuation. But as soon as the truth of these underlying prin-
ciples had been recognized it was found that many cases of so-
called simple mania or melancholia, as well as of the mixed
forms, have many features in common, and on closer investi-
gation it also became apparent that pure cases of mania or
melancholia practically never occur. Kraepelin,4 imbued with
these ideas, grouped together under one head diseases having
a common symptomatology with a certain more or less well-
marked tendency to recurrence and a similar outcome. One of
the fundamental facts that served to direct investigations along
this line was that in many forms of alienation a group of
symptoms are in the foreground of the clinical picture which
formerly had been considered specifically characteristic of the
so-called circulary insanities. The presence of a marked de-
gree of mental deterioration in some cases and its absence in
others was also an important consideration that influenced the
genesis of the views entertained by the Heidelberg school in
the formulation of the conceptions of the manic-depressive
insanity.

Dementia prsecox, including all cases in which there is a
characteristic mental reduction, affords a strong contrast to
those cases in which the symptoms of excitement or depression,
with a tendency to recurrent attacks, may occur, but without
the development of any well-marked specific deterioration of
the mental faculties during the lucid intervals or as a terminal

4 Lehrbuch der Psychiatric 1896.
22

338 PSYCHIATRY

dementia. The expression " specific deterioration" must be
used with certain qualifications. In the present state of our
knowledge we are not justified in assuming that no mental
reduction is noticeable in those cases of manic-depressive in-
sanity in which the attacks have recurred at short intervals
or have lasted for long periods of time. Not infrequently
patients pass through an attack of alienation that in all par-
ticulars, except its very protracted duration, resembles manic-
depressive insanity. At the end of such a period, when the
patients are discharged " recovered," we are frequently un-
able to say that the mental faculties are quite as vigorous
as they were prior to the onset of the disease, and yet if a
deterioration does exist it does not bear any resemblance to
that occurring in cases of dementia praecox, nor does it have
any specific signs by which it may be recognized. In some
cases neither the frequency of the occurrence nor the pro-
tracted character of the attacks can be considered responsible
for the existing mental changes. Cases of the latter group
vary greatly, in the intensity of the symptoms as well as in
the duration of the lucid intervals. They may be complicated
by other forms of psychoses, but in the main it is possible
to pick out certain points in the symptomatology and clinical
course of the disease which suggest a common basis. It is
advisable for the present, in the consideration of dementia
praecox as well as in the description of the manic-depressive
psychoses, to refrain from designating these two groups as
definite disease entities. The present differentiation of these
cases is in a measure temporary, but the principles on which
it is made are consistent with and not antagonistic to progress.

Before attempting to study the clinical course of the cases
which are brought together under the head of manic-depressive
insanity, it is essential that there should be as clear and defi-
nite a conception as possible of the individual symptoms and of
the relation they bear to each other in the clinical course of the
disease.

I. Maniacal Phase. Motor Symptoms. — In this period
the majority of patients exhibit motor symptoms which are

MANIC-DEPRESSIVE INSANITY 330

definite and in a measure specific. The one most apparent to
the casual observer is the general restlessness. The majority
of maniacal patients are never still. In the incipient stages
every thought and new idea is immediately translated into
action; there is a psychomotor excitability; movement is
easy ; rest is impossible. The initial symptoms are often char-
acterized by a tendency to have many irons in the fire, to
engage in new undertakings, to become unusually strenuous,
to be always bustling or seeking for some new outlet for the
discharge of excessive energy. Frequently an individual, who
has been seclusive or quiet in demeanor, becomes vivacious,
never has a moment to spare, is obtrusively animated, plunges
into society, is meddlesome, insists on beginning new under-
takings without waiting to count the cost. Every psychic
impulse, however vague and indefinite, seems to suggest new
fields of activity. The excitability is ideational as well as
motor in character. In some instances the former in others
the latter type predominates. Occasionally cases are observed
in which the motor irritability, although excessive, does not
seem to affect the speech centres. In other instances the con-
verse is true, and in the absence of other motor symptoms the
patient keeps up a steady, uninterrupted chatter. This motor
excitability varies greatly in different cases. Sometimes, in
the early stages, it may be hardly perceptible, and gradually
increases only after a considerable lapse of time to its maxi-
mum intensity, whereas in other instances it reaches its full
development within a few hours. It may become so intense
and diffuse as to implicate all the muscles of the body and in-
capacitate the individual for the performance of coordinated
muscular movements, so that he is unable to leave his bed.
Accompanying the incoordinated and involuntary movements
there are marked tremulousness and an unsteadiness .which
occasionally becomes choreiform in type, although, as a rule,
the movements are less jerky and impulsive. The tremor in
the milder cases is only perceptible in the extremities and
tongue and may scarcely be noticeable in the facial muscles.
As the intensity of the motor symptoms increases the tremor

34Q

PSYCHIATRY

becomes more and more marked until the excursions may be-
come so exaggerated as to give rise to considerable uncertainty
in all volitional acts. During a maniacal attack the actual
muscular strength of patients sometimes seems to be increased,
but this phenomenon is referable to the insensitiveness to pain
and the absolute indifference to injury whicrT characterizes
the conduct of so many individuals during this stage. The
exaggeration of the functional power of the muscles is apparent
rather than real and depends upon the absence of inhibition
no less than upon the recklessness of the individual. During
the periods of wildest excitement the patients rush heedlessly
about the wards, striking or attacking whoever chances to
come in their way, throwing themselves blindly against the
furniture or walls, and exhibiting homicidal as well as sui-
cidal tendencies. Associated with these displays of brute force
there is nearly always a diminution of the pain sense which is
centrally, not peripherally, conditioned.5 The patients inflict
upon themselves all manner of injury without evincing the
slightest appreciation of pain. One case is on record in which
a patient actually tore his tongue loose from its attachments
during a period of maniacal excitement. Even in the rela-
tively mild grades the speech of the patient pretty constantly
shows certain definite changes. The compulsion to talk be-
comes noticeable. The individual who has been more or less
reticent and restrained is voluble, flippant, and a mere driv-
eller. Not only is this change noticeable, but the emotional
state also fluctuates. An individual who prior to the attack
has been more or less stupid becomes witty, sharp at repartee,
or a mere buffoon. The tendency to joke, to pun, to form
sound associations and alliterations are features that become
more prominent as the case develops. In the majority of cases
there is the so-called flight of ideas, a symptom which has
been described more in detail in the introductory chapters.
It is important to note that the steady, uninterrupted flow of

" Paton, Stewart : The American Journal of Insanity, vol. lviii, No. 4,
1902.

MANIC-DEPRESSIVE INSANITY 34I

words is the result of both intra- and extra-organic stimuli.
Not only do the words used suggest to the patient new ideas,
to which immediate expression is given, but the sound and
rhyme associations are also eminently characteristic. Exter-
nal stimuli serve to deflect and give a definite trend to what
the patient says. The actual rapidity in the association of ideas
is not increased; the flight of ideas is indicative of mental
insufficiency rather than over-productiveness.

Hoch has made the suggestion that the use of the term
" flight of ideas" to characterize all forms of rapid psychic
discharges is in some instances inappropriate on account of the
disconnected and irrational character of the conversation. In
each case the complex should be analyzed as far as possible,
as the causes as well as the variations in this combination of
symptoms are not well understood.

In some cases the inordinate desire to write is no less
marked than the speech compulsion. The quantity of notes
and letters that these persons indite is frequently astounding.
The way in which they express themselves and the character
of the association of ideas bear a striking similarity to the
mannerisms and idiosyncrasies of speech. Kraepelin has made
a number of interesting studies to determine the essential
characteristics of the writing of these patients. By means
of a special apparatus (Schriftwage) the force and the dura-
tion of the muscular movements were graphically recorded
and measured, and it was found that the rapidity with which
the penstrokes were made and the amount of pressure expended
in their execution during this stage were exaggerated. Even
in mild cases the contrasts that exist in the character of the
writing during the periods of depression and excitement are
striking.

The facial expression during the period of excitement
corresponds with the prevailing emotional tone, and by rapid
and exaggerated changes often reveals the affective instability.
Occasionally there seems to be an asymmetrical play of the fa-
cial muscles. The action of the muscles of speech and degluti-
tion is impaired only in the severer forms of the disease.

342

PSYCHIATRY

Sensations. — Except in mild cases it is extremely diffi-
cult to make a careful examination of the sensations. As a
rule, however, no marked disturbances in the functions of the
peripheral nerves are found. As the excitement increases the
attention of the patient lapses more and more, at times being
riveted upon certain portions of his own field of consciousness.
If the peripheral sensation is tested at such times the ob-
server may be led to believe that touch or pain sensation is
greatly impaired, inasmuch as there is no apparent response
to stimuli, whereas, as a matter of fact, this condition depends
purely upon the psychical state of the individual. The min-
ute the patient's attention is directed to that portion of the
body in which sensation is being tested it will become appa-
rent that the slightest touch or pin prick is at once appre-
hended. Not infrequently in the early stages the patients are
hyperaesthetic for different forms of peripheral stimulation.
Vague hallucinations of the various sensations are not uncom-
mon; particularly the elementary forms such as indefinite
sounds, lights, etc. Well-defined persistent hallucinations do
not occur in the majority of cases. Those that are met with,
as a rule, vary greatly in form and change with remarkable
rapidity. On account of the marked fluctuations in the atten-
tion and the excited condition of the patient illusions are even
more frequent than definite hallucinations. The voices of
patients or attendants are mistaken for those of intimate
friends. Sounds heard in the wards are immediately associated
with scenes directly connected with the patient's own per-
sonality or environment at home. Psychic hallucinations are
not frequently observed. Occasionally, however, patients af-
firm that they are subject to visions which, as a rule, are asso-
ciated with motion and only temporarily invade the field of
consciousness. The objectivity as well as the time and spatial
relations of these fallacious sense perceptions may be very
indefinite.

The associative functions of the brain are generally more
or less seriously disorganized. In the milder cases this defect
does not at once become apparent. The patient's power of

MANIC-DEPRESSIVE INSANITY 343

orientation may be well preserved, the disturbances in con-
sciousness becoming marked only when the symptoms have
reached a certain degree of intensity and the motor restlessness
and flight of ideas have become important factors. The first
change in the psychic process is the absence of normal inhibi-
tion and the consequent tendency towards the overvaluation
of the minor processes in associative thought. There is a
temporary abolition, as it were, of the selective and critical
faculties due primarily to the absence of inhibition. Every
idea that flashes into the patient's mind instantly becomes of
equal importance with the one that has immediately preceded
it. It is not improbable that in cases of maniacal excitement
two essentially different factors, (i) a loosening of the asso-
ciative mechanism and (2) a psycho-sensorial super-produc-
tion, are concerned in the symptomatology. As has frequently
been suggested, the clinical picture is composite and may be
considered to be caused by incident stimuli with exaggerated
reactions as well as by the effects of certain paralyzing agents.
The relationship that exists between these two factors is best
expressed in the law of psychic antagonism enunciated by
Friedmann, who affirms that no psychic function is increased
without impairment of others. The power of directing the
attention is seriously impaired. At times, however, there may
be what might be termed a semi-tetanization, the patient con-
centrating for an instant all his faculties upon certain objects.
It is this phenomenon which has led some observers to believe
that there is an actual increase in the power to focus the
attention (hyperprosexia). The impairment of the critical
faculties is marked in nearly all cases of maniacal excitement.
The incident stimuli seem to spread in all directions and the
result may be a temporary but complete transformation in
an individual, so that he becomes unusually vivacious, humor-
ous, sprightly, witty, and displays what to the casual observer
appears to be an intellectual super-productiveness. During the
stages of greatest excitement the patients become oblivious
to the environment in which they belong and become utterly
unconscious of their own physical as well as their intellectual

344

PSYCHIATRY

limitations. They affirm that they are as strong as Hercules,
as rich as Croesus; the poorly dressed and poverty-stricken
woman becomes a queen, etc. These insane ideas vary often
from those characterized by a moderate degree of complacency
and exaltation to the wildest exaggerations and extravagances.
Inconstancy and capriciousness are eminently characteristic of
the mental state of the maniacal patient. The systematization
of the insane ideas, if it exists at all, is apt to be merely tran-
sitory.

The power to pick up and retain new impressions is di-
minished in proportion to the increase in the amount of energy
expended in the focussing of the attention. In the earlier
stages or in the milder cases the patients not infrequently re-
tain only those impressions of their surroundings or of cur-
rent events that can be taken in at a glance. The more com-
plicated memories are seriously impaired.

Anomalies of the Emotions. — The anomalies of emotion
are frequent and varied in character. In nearly all cases dur-
ing the earlier stages a marked feeling of exaltation is present.
The patients are pleased, self-complacent, and in the best of
humors. Unquestionably, changes in the organic sensations,
such as absence of the ordinary sense of fatigue, may in a
measure be responsible for this mental attitude. As the mani-
acal stage advances this exaltation increases rapidly. The indi-
vidual becomes vivacious, elated, hilarious, is thrown into
transports of delight or ecstasy ; later he is boastful, gives vent
to the wildest statements, and becomes a mere blusterer. The
correlative emotional expressions are all exaggerated. The
patient laughs loudly and long on the slightest provocation,
throwing his head back, opening his mouth wide, and giving
vent to his feelings in a preposterous manner. In some cases,
instead of the feeling of exaltation, excessive irritation is noted
and the individual becomes domineering and subject to violent
outbursts of temper. The slightest interference with what is
his will may result in an emotional storm of great intensity,
which, however, often ends as abruptly as it has begun. On
the other hand, some patients become most affectionate. They

MANIC-DEPRESSIVE INSANITY

345

claim every one as their intimate friend. Accompanying these
emotional changes, not infrequently there is marked sexual
excitement. This may be limited to a mere expression of satis-
faction at being in the presence of the opposite sex, or erotic
impulses may lead to sexual perversion — masturbation, exces-
sive intercourse, attempts at rape, etc. During this period men
as well as women may become vulgar, obscene, lose all sense of
decency, and exhibit an inordinate fondness to converse on
topics relating to the question of the sexes and marriage. The
development of these symptoms in many instances, if the pa-
tients are not under restraint, gives rise to complications of
medico-legal importance.

Blood
Press.

Mar.

12

16

19

23

26

Pulse

R

S

R

S

R

S

R

S

R

S

no

110

P ^

160

115

/

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/

1

/

1

/

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/

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//

,

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■ Pulse R, reclining S, sitting up in bed

Case of Manic-Depressive Insanity. Depression with anxiety. To illustrate differences
in rapidity of pulse and in blood-pressure in the sitting and reclining postures respectively.
Variations are greater than normal.

The physical symptoms of mania are those common to
most of the forms of mental excitement accompanied with
motor restlessness. The pulse, as a rule, is accelerated, the
rapidity rising as the motor restlessness increases. The blood-

346 PSYCHIATRY

pressure in most of the uncomplicated cases is low during the
period of excitement. Slight causes — a person entering the
room, a sudden noise, or anything which attracts the attention
— frequently produces wide variations in pulse and in blood-
pressure. The accompanying chart graphically shows how in
one of our cases a change of posture produced a wide variation
when the patient was in an agitated condition and a less wide
variation when the patient was somewhat stuporous.

Other observations tend to confirm those of Dawson,6
who affirms that " the characteristic feature of the general
circulation in excitement and probably in exaltation is low
arterial tension which helps to maintain, if it does not cause,
the mental state." But " here again there is no direct evidence
of the state of the cerebral circulation."

Pilcz has called attention to the marked correspondence
which exists between the pressure, frequency, and sphygmo-
graphic tracings of the pulse in cases during the stage of ex-
citement as contrasted with the results of similar observations
made during the period of depression. From this it must not
be inferred that there are pulse-curves characteristic of the
manic and of the melancholic periods. The personal variation,
however, must be considered in each individual case. The
examination of the blood during the maniacal stage reveals
no characteristic changes. Fisher,7 after a careful examination
of the blood in a number of cases, has come to the following
conclusions : ( i ) there is no pathognomonic blood change dur-
ing the maniacal phase; (2) anaemia is not a causative nor a
constant factor; (3) the haemoglobin and red cells are fre-
quently increased in number during the attack, and (4) leuco-
cytosis is almost a constant accompaniment and apparently a
result of psychomotor activity. The reported variations in its
alkalinity have not been confirmed.8 The breathing during the

* The Role of the Blood Supply in Mental Pleasure and Pain. Dublin
Journal of Medical Science, February, 1900.

T Fisher, Jessie Weston : The Blood in Manic-depressive Insanity.
Am. Journ. Insan., 1903, vol. lix, No. 4.

' Lambranzi : Rivista di patologia nervos. e mentale, 1899, fasc. vii.

PLATE VII

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Chart showing temperature, pulse, and respiration curves in a case of manic-depressive
insanity. On admission the patient was excited, but soon became more quiet (A). After
two weeks the excitement returned (/>) and became more marked than it had been at the
time of admission.

MANIC-DEPRESSIVE INSANITY

347

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(I.) Case of manic-depressive insanity showing loss and gain of weight, increase in aver-
age hours of sleep, and indicating schematically changes in emotional and motor spheres. In-
tellectually, prior to attack, patient was slightly deficient. Dotted lines indicate condition
before admission to hospital.

34«

PSYCHIATRY

periods of greatest excitement is, as a rule, somewhat shallower
and increased in rapidity as compared with the normal. Some
observers have reported a rise in the temperature varying from
0.50 to 2° C. The bodily weight nearly always falls during

Lbs. !

1 IV

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(II.) Case of manic-depressive insanity of short duration. Chart shows loss and gain of
weight, increase in average hours of sleep, and indicates schematically the changes in intel-
lectual, emotional, and motor spheres.

the period of excitement. (Charts.) Sometimes there is a
rapid drop of several pounds. At other times the loss is more
gradual and is in a measure proportional to the motor excite-
ment.

The changes in the chemical constituents of the urine are
not characteristic. During the height of the attack peptone

MANIC-DEPRESSIVE INSANITY 340

and albumin are not infrequently present, but these disappear,
as a rule, as the excitement diminishes.

Symptoms indicating the existence of destructive lesions
in the central nervous system are not infrequently reported.
The instances in which hemiplegias occur are due to compli-
cating focal lesions. The same is true of the facial paralyses
as well as those implicating the ocular muscles. Occasionally
convulsions take place during the period of excitement. When
these are noted they are extremely suggestive of the existence
of epilepsy. The various symptoms arising from over-stimu-
lation or paralysis of the sympathetic are not infrequent dur-
ing the attacks. In some instances it has been possible to con-
firm the observations of Schott, Ball, Regis, von Wagner, Men-
del, and others regarding the occurrence during the period of
excitement of pupillary differences. As a rule, the pupils are
widely dilated and react to light. The superficial and deep
reflexes are generally increased. The occurrence of ankle-
clonus during the period of greatest excitement has occasion-
ally been noted.

Disturbances in the gastro-intestinal tract, giving rise to
anorexia, nausea, vomiting, and constipation, are nearly always
present. The disorders are not improbably due in a majority
of the cases to functional disturbances involving the internal
secretions. In many cases there is a marked salivation and
diminished sweat secretion. In some cases, if given an op-
portunity, patients bolt large quantities of food, — bulimia, —
but frequently, on account of the motor restlessness, it is ex-
tremely difficult to feed them.

II. The State of Depression. — By. some this condition
has been regarded as the antithesis of the period of maniacal
excitement. This is true, however, only in a very limited sense.
In nearly all cases of depression certain symptoms occur which
are also to. be met with during the cycle of greatest mental per-
turbation. Not only is this a fact, but the gradations which
exist between marked manic excitement, on the one hand, and
deep depression, upon the other, are so gradual that it is sel-
dom justifiable to consider the two states as fundamentally

35o

PSYCHIATRY

antithetical. As motor restlessness is a prominent symptom
of mania, so the psychomotor retardation may be equally char-
acteristic of the state of depression.

The motor anomalies occurring during the period of de-
pression are referred to by Wernicke as the expression of an
intra-psychic akinesis. The appearance of the patient suggests
a general diminution in the ideomotor activities of the cere-
bral cortex. All movements are slow and made with difficulty.
As has been pointed out, the reactive are less interfered with
than the so-called initiative movements. This is particularly
true for speech. The reply to a simple question is given only
after the lapse of a considerable interval of time, the tone and
pitch of the voice are lowered, the intensity of all movements
of the lips and tongue is greatly diminished. The same limi-
tations are noticeable in many cases in the facial innervation.
The intensity of all voluntary movements, not only of the face,
but of the extremities and trunk, is generally impaired. Asso-
ciated with the delay in the muscular reaction and decrease
of the intensity of movements in many cases there is an accom-
panying emotional depression as well as a retardation in the
processes concerned in thought. These symptoms vary greatly.
In the mild cases psychomotor retardation and the psychical
feeling of depression are sometimes made out only with diffi-
culty. The antecedent motor restlessness and slight exaltation
may serve to bring these symptoms into sharp contrast and
thus facilitate their recognition as abnormalities, and not the
mere expression of a personal idiosyncrasy.

In other cases the retardation of thought and action is
well marked, and associated with this there is considerable emo-
tional depression. The emotional instability so characteristic
of the maniacal state, as a rule, disappears during the period
of depression, and is replaced by an unbroken and stable af-
fective tone. On account of the retardation that exists, the
examiner may be led to believe that the primary sensations
are not intact, but the difficulty of testing patients in this con-
dition is so great that, as a rule, definite conclusions cannot
be drawn. The reaction time during the period of depression

MANIC-DEPRESSIVE INSANITY 35 j

is greatly lengthened. The pulse generally becomes slower.
The blood-pressure, which was low during the period of manic
excitement, other things being equal, rises during the de-
pression. The changes in the handwriting, as would be
expected from the retardation of all voluntary movements, are
characteristic. Reference has already been made to this point
in discussing the symptoms of the manic excitement. In some
cases the retardation of thought and action is less marked
than the emotional depression. This will be discussed in con-
sidering the mixed forms. In the milder cases time and spa-
tial orientation are well preserved, but in the severer types
there may be marked confusion. Sometimes the patients are
conscious of the subjective difficulty in the associative proc-
esses. They not infrequently affirm that they are unable to
speak or to think; they appreciate the difficulties, but are
unable to assign any definite reason for them. The somato-
psychic consciousness is markedly affected. As a rule, it may
be said that the patients are simply depressed mentally, while
in some cases there is superadded a feeling of vague appre-
hension, which later develops into marked anxiety. The emo-
tional depression deepens as the patients become more or less
conscious of their inability to think or act. Everything is
difficult for them. This emotional state may be intensified by
the appearance in consciousness of anomalous sensations, anx-
iety, fear of impending death, and various painful states which
in cases of extreme rarity are peripherally conditioned, but, as
a rule, are merely symptoms of psychic pain. Imperative con-
ceptions sometimes dominate the field of consciousness, and
these may give rise to more complicated phenomena, especially
if they persist for any length of time. In some instances the
cropping up of imperative ideas may be the basis for a sys-
tematized micromania. In the milder cases this may be absent
and merely a feeling of insufficiency exists. The patients affirm
that they once were able to do their work, but the increased
difficulty in thinking and in the execution of voluntary acts
incapacitates them. In the extreme cases a marked akinesis
may result.

35^

PSYCHIATRY

Not infrequently insane ideas develop. In some instances,
particularly in the uncomplicated forms, they represent an
attempt on the part of the patient to interpret the change in
the organic sensations. Such a condition may seriously dis-
turb the individual's ideas of his own personality or may alter
his apparent relationships to his environment. On the former
basis we have the development of the ideas of self-insufficiency
and personal unworthiness or the commission of unpardonable
sins for which there is an immediate and awful retribution.
Thus a patient will frequently assume that he is the most
wicked person God ever created, and the like. Various hypo-
chondriacal symptoms may also be superadded. In the latter
instances the dissociation in the consciousness of the external
world culminates in ideas of persecution, etc. The develop-
ment of insane ideas out of obsessional impulses and hallu-
cinations is considered by some clinicians as indicating the
occurrence of complications. Heller 9 has affirmed that hallu-
cinations are comparatively infrequent during the course of
melancholia. According to Ziehen in depression they only
occur in one out of ten cases. Schott,10 who examined 250
patients suffering from melancholia with this special point in
view, reported the occurrence of hallucinations in only 28.8 per
cent., hypochondriacal ideas in 27.6, and imperative concep-
tions in 8 per cent, of the cases.

The inhibition of the psychical faculties may become so
marked that the patients pass into a stuporous condition. To
all outward appearances they seem to lead a merely vegetative
existence. External stimuli fail to produce any evident reac-
tion ; or, at most, a simple reflex movement follows. There
is no elaboration or working up of incident stimuli. The
patients, as a rule, remain in bed. They do not refuse to
take food, but they have to be fed. Occasionally a slight
swallowing movement is made; at other times the fluid runs

9 Heller, E. : Die Wahnideen der Melancholiker. Inaug. Diss. Mar-
burg, 1898.

Beitrag zur Lehre von der Melancholic

MANIC-DEPRESSIVE INSANITY

353

from the mouth. x\fter the patient has recovered, generally
the memory for that period during which the psychic inhibi-
tion and retardation were at their maximum is a mere blank ;
at other times there are islands in memory — some events being
plainly recollected, while others are completely forgotten.

The physical symptoms in this stage, with the exception
of those already noted, do not differ essentially nor specificallv
from those recorded during the period of the motor excite-
ment.

Clinical Course. — The course of the disease is character-
ized by the appearance of symptoms that give to the clinical
picture now the signs of maniacal exaltation or again that of
mental depression with their correlative physical attributes.
The syndrome of exaltation and motor restlessness may alter-
nate with that of depression and psychomotor retardation. In
other cases the dominant emotional tone and concomitant physi-
cal state ushering in the symptoms may persist with slight
modification until the end of the attack, a temporary sugges-
tion of the so-called antithetical state only occasionally coming
into view. Not infrequently there is an intermixture of symp-
toms so that the emotional tone characteristic of one state is
attended by the physical signs generally associated with the
other condition. The tendency of the attacks to recur at longer
or shorter intervals is another distinctive feature of the dis-
ease. The lucid intervals, which are essentially characteristic,
are not marked by the development of other forms of mental
aberration, such as paranoiic states or dementing processes.

This group includes simple and recurrent manias and mel-
ancholias as well as the various forms of circular insanity and
the so-called recurrent paranoias that do not exhibit symptoms
of a specific mental reduction in the lucid intervals. The dis-
cussion of the features characteristic of the different clinical
groups will be taken up under the following heads :

(i) States in which the dominant symptoms are exhila-
ration and motor restlessness. This form may rightly be said
to include all cases of the typical or classical type of mania as
well as the milder forms, such as hypomania, mania without

23

354

PSYCHIATRY

delirium, some of the delirious manias, as well as some forms
in which the motor restlessness and exaltation show a tendency
to run a protracted course and the insane ideas become more
or less systematized. The cases which were formerly de-
scribed as instances of pure mania are very infrequent.11 They
include only from one to three per cent, of all the cases. As
a rule, this type is met with more often in the earlier than in
the later years of life, although some clinicians affirm that it
not infrequently appears in young children in the atypical form.
Many, if not all, of the so-called cases of simple mania, if
studied with sufficient care, show at some time during their
course the symptoms which are commonly associated with the
period of depression, — viz., the psychomotor retardation, the
limitation and delay in the functions of association, mental
depression, etc.

These symptoms may be only transitory in character
and easily escape the notice of the physician. As a rule,
the disease begins with an initial stage of longer or shorter
duration in which the patient becomes nervous, irritable, un-
duly responsive to all forms of stimuli. There may be marked
sleeplessness of which the patient does not, as a rule, com-
plain. The motor excitement may be general or in some in-
stances limited to the speech centres. If stimulated, the pa-
tient becomes voluble, and the function of the inhibitory
centres is apparently temporarily abolished. It is not infre-
quently the case that this so-called prodromal period repre-
sents a depressed stage. If such a state exists, the patient
speaks little, becomes seclusive; or, if he does speak, he may
be thought to be hypochondriacal on account of the numerous
complaints expressed concerning his bodily state. Gastro-
intestinal disturbances are not infrequent. Headaches occur,
and in place of actual depression there may be merely an in-
definite feeling of insufficiency or marked anxiety. This
initial stage, which in some instances is a true prodromal

11 Hinrichsen : Allg. Ztschr. f. Psych., Bd. liv. Mayser: Neurol.
Centralbl., 1898, Nr. 11.

MANIC-DEPRESSIVE INSANITY

355

period, merely ushering in the maniacal outbreak, in other
instances is more prolonged, marking a true period of depres-
sion and varying in duration from a few days to several weeks.
The second stage is one in which the maniacal symptoms of
motor restlessness, exaltation, emotional anxiety, etc., attain
their maximum intensity. In these cases the diagnosis is not
difficult, the patients presenting most, if not all, of the symp-
toms which have already been described under the head of the
maniacal phase. In the mania gravis, the motor agitation is
excessive. The emotional storms that come and go are intense
in their severity. Marked exaltation may alternate with or
be replaced by periods of intense anger. The flight of ideas
may become masked by a complete incoherence and disasso-
ciation. In the type of cases described by Weygandt 12 as
unproductive mania there is marked motor restlessness, with
considerable impairment in the associative processes, and a
marked deficiency of expression amounting at times to mutism.
In some of the severer forms of the disease disorientation and
general mental confusion may persist for days or even weeks.
Death may occur during this period, if the patient is not care-
fully guarded from self-inflicted injury, or the disease is com-
plicated by pneumonia, nephritis, etc. The terminal stage,
as a rule, marks a gradual transition from the second period
of the disease. The symptoms, one by one, become less and
less marked, and the patient finally enters the stage of con-
valescence. The symptoms of mania not infrequently persist
for several months or even a year. Death occurs in about
5 per cent, of the cases. The symptoms characteristic of
depression may not become apparent until the stage of con-
valescence is reached. The mild cases — mania mitissima or
hypomania — only occasionally come under treatment in hos-
pitals, and frequently present considerable difficulty in the
establishment of a diagnosis. The following history is typical
of these milder forms of the disease :

" Ueber die Mischzustande des manisch-depress. Irreseins. Miinchen,.
1899-

356 PSYCHIATRY

Male; single; aged 23. Described as young man of high moral char-
acter ; of regular habits, studious and industrious. Never had any serious
illness. About two months before admission to the hospital there was
a change noticed in the patient's disposition. There was slight exalta-
tion and excitement : " he became unduly elated at his business pros-
pects." Some garrulity was noted. The language was characterized by
slight extravagances in expression. Later he became slightly suspicious
of some ot his friends, whom he accused of having maligned his character.
Shortly after this he acquired a passionate desire for dancing ; showed
no signs of violence, and was apparently rational, although he always
seemed excited and acted as if he were in a hurry. One day prior to
admission to the hospital he became confused and wandered aimlessly
about for several hours. Was reckless in the expenditure of his money.
Went into a strange store and told the clerks that he was prepared to
take charge of the business. Had to be forcibly ejected. During the
month that the patient was under observation in the hospital he improved
rapidly. The motor restlessness became less marked, the confusion in
speech and garrulity disappeared. His weight, which at first had dropped,
increased, and the patient was finally discharged recovered.

During the period that the patient was in the hospital a diagnosis
of manic-depressive insanity was made. Motor restlessness, flight of ideas,
and exaltation were the dominant symptoms. Since the patient's discharge
he has had two mild attacks of mental depression.

When the symptoms of depression occur in the terminal
stage they are not infrequently looked upon as mere reactive
phases of the acute stage. Many cases of the aggravated forms
of neurasthenia in which there is a well-marked periodicity
present are unquestionably to be classed among these mild
cases of manic-depressive insanity.13 During the period of ex-
citement the patients become fidgety, eccentric, somewhat ex-
hilarated, always in a flurry, slightly officious, meddlesome,
showing a desire to talk on the slightest provocation. Asso-
ciated with these mental disturbances, the bodily weight drops
slightly and the rapidity of the pulse may be somewhat in-
creased. The emotional instability is often pronounced.

In cases typified by the history given, the garrulity of the
patients is frequently the dominant feature. The value of this

11 Hecker : Die Cyclothymia cine circulare Gemiitserkrankung. Ztschr.
f. Praktische Aerzte, 1897. Nr. 1, p. 6. Die milder verlaufenden Arten d.
circularen Irreseins. 22 Wanderversammlung der sudwestdeutschen Irren-
arzte zu Baden. 2 Sitzung 22, 23 Mai. 1897.

MANIC-DEPRESSIVE INSANITY 357

symptom necessarily depends upon the knowledge the observer
has of the character of the patient prior to the attack. There
may be no gross dissociation of thought, so that the patients,
on casual observation, may not be considered incapacitated
for work. The diagnosis of mild manic excitement in a great
measure depends upon the motor restlessness. The flight of
ideas is not necessarily characterized by incoherence, even if a
tendency is shown to translate ideas into some form of action.
While the excitement persists, the interests of the patients seem
to enlarge. Little escapes their attention. They plan new
enterprises, enter with zest into new undertakings. The judg-
ment, as a rule, is not markedly impaired. The conduct of
the patient, in a measure the result of impulses which quickly
come and go, is accompanied by considerable emotional in-
stability. There are not, however, the same irrelevancy and dis-
connectedness which characterize the conduct of patients af-
flicted with dementia prsecox. The emotional instability of
the patient suffering from manic-depressive insanity, as a rule,
is in response to external stimuli and may have the appearance
of being purposeful. The emotional changes are rapid, fluc-
tuating, and the varying tones or shades of feeling are
strangely antithetical. Not infrequently the patients them-
selves notice this anomalous state; thoughts are said to gal-
lop through their heads with unusual rapidity ; they complain
that they have no rest, that they cannot free their minds
from the various schemes which continually present them-
selves. Not infrequently digestive disturbances occur during
these attacks of mild maniacal excitement, and in some cases
there is a marked increase in the rapidity of the pulse. The
patients often come under observation when it is impossible
to determine the existence of maniacal symptoms without a
most careful study not only of one but of several attacks.
These cases were referred to formerly by the French observers
as instances of folic raisonnantc. After carefully studying
the symptoms, it may be possible to determine that the increased
intellectual activity of the patient is apparent rather than real.
This is shown in the rapidity with which patients pass from one

358 PSYCHIATRY

subject to another; the fact being that they are the most im-
pressed by the ideas that at a given moment occupy the focus
of their attention, never suspending judgment until they are
able to form an accurate comparative estimate and thus to de-
termine the best course of action. Frequently the conversation,
if carefully noted, brings to light peculiarities which are, in
a measure, distinctive, such as preponderance of alliterations,
etc. The absence of tact and the dulling of the more deli-
cate sensibilities are not infrequently striking. During this
period of mild excitement symptoms of fatigue are generally
absent; the patients sleep but little; the appetite, as a rule, is
somewhat diminished, though at times the food may be bolted
in fairly large quantities.

Between these cases and the severest forms of mania all
grades are found. In some instances insane ideas predomi-
nate. The differential diagnosis between these cases and those
of general paresis in its early stages is frequently difficult,
especially when occurring in comparatively young people.

The maniacal stage in some cases is characterized by an
absence of general motor excitement, the symptoms noted
being more purely psychical. In women the periods of greatest
excitement may coincide with the menstrual epochs. The so-
called periodic psychopathia sexualis is in many instances a
mild recurrent type. The mere periodicity of the recurrence
is not in any sense a point of great diagnostic importance.
The forensic importance of these cases is referred to under
the chapter dealing with the questions of legal responsibility.
Occasionally we meet with cases in which there is marked mo-
tor restlessness as well as the compulsion to act, but the limita-
tion and retardation of the associative faculties are prominent
features in the symptomatology. These patients represent the
examples of mania with limited and delayed thought — the un-
productive mania. The emotional state may be one of evident
pleasure or exaltation. This group of symptoms in some cases
may take the place of the period of true maniacal excitement.
In others it merely follows it, representing the stage of sub-
sidence of the acute symptoms (Stadium dementiae or morise).

MANIC-DEPRESSIVE INSANITY 359

(2) States in which the dominant symptoms are psycho-
motor inhibition, mental depression, and retardation in the
association of ideas. — The milder cases, hypo-melancholias,
are not infrequently diagnosed as neurasthenia. As a rule, it
is impossible to say when the prodromal period begins. The
symptoms are not specific. For a long time the patient may
be considered to be merely a hypochondriac, and it is only
when the subsequent stage occurs in which the antecedent
psychic inhibition is contrasted with the motor restlessness
and exaltation that a diagnosis can be made. In some cases
the prodromal period is one in which the dominant features
are slight motor restlessness and a group of physical symptoms
which suggest the very mildest form of maniacal excitement.

Anaesthesias, more frequently paresthesias, occur. As the
period of depression develops, the psychomotor retardation
becomes evident, and the patient passes into a stuporous state
in which the retardation is excessive. At times the patient
may become subject to hallucinations. In the milder cases, as
a rule, these are evanescent in character.

The occurrence of cases of pure mental depression with-
out any of the accompanying symptoms of excitement are
exceedingly rare, if, indeed, they ever occur. The following
case abstract shows that, even although symptoms of excite-
ment may be slight, they are never completely absent :

Patient, female, single, aged 39. Two years prior to admission she
had a nervous breakdown due to worry. Six months before coming to
hospital there was a period of improvement followed by nervousness and
insomnia. Religious fears and anxiety developed. On admission to the
hospital she was very nervous, slightly confused ; there was loss of appe-
tite and insomnia. Self-accusation was noted. The patient affirmed that
she was a very wicked woman and that she expected Almighty God to
strike her dead. The facial expression was one of depression. The asso-
ciation of ideas was slow. The tone of voice was low and monotonous.
There was considerable motor retardation. She retained insight into her
own condition. The power of fixation and concentration was poor. Sus-
piciousness and fear were at times marked. She was decidedly intro-
spective, and explained the evolution of her insane ideas as follows :

(1) That she was an unconscious hypocrite, doing evil without know-
ing it.

(2) That consciousness of innate evil had led her to believe that she
was an exceptional person, that no one ever had been created so bad as
herself.

360 PSYCHIATRY

(3) That as a consequence of this unusual wickedness she had reve-
lations of the devil, visual and auditory.

(4) That she recognized that she was a lost soul ; that she was
haunted by the awfulness of her prospect in the presence of the evil spirit,
as well as the ideas of future torment.

(5) She affirmed that all these were spiritual phenomena (auditory and
visual hallucinations).

Weight on admission, February 13, 1901, 134 pounds. June I, 125
pounds. In the early part of February motor restlessness was very marked.
It gradually decreased until April, when it passed away. All the symptoms
subsided, and the patient was discharged November 23, greatly improved ;
weight 133 pounds.

The period of excitement may occur either in the prodro-
mal period or in the period of convalescence, and is not infre-
quently in the latter stage referred to merely as a reactive
hyperemia. The duration of the depression varies. Instances
have been reported in which it recurred every few days with
great regularity. Clinically, the majority of cases may be
grouped into those with psychomotor retardation and depres-
sion accompanied by more or less stupor. Some of the pa-
tients who show signs of melancholia with motor restlessness
(melancholia agitata) belong in this group, while other cases
are instances of dementia prsecox or the involutional melan-
cholias.

(3) States in which the symptoms of excitement and of
depression occur with some degree of regularity and ivith an
inclination to alternate.1* The charts X and Y, taken from
Weygandt, give a graphic indication of the character and se-
quence of the recurrences in the cases commonly referred to as
instances of circular insanity. The curve below the horizontal
line indicates depression, and the one above the period of ex-
citement. Weygandt affirms that in 150 cases with marked
recurrences 20 per cent, had attacks in which the mixed char-
acter of the symptoms predominated. In 33 per cent, this
was merely transitory, and was most marked during the tran-

14 Dewey : A Case of Circular Insanity studied from Clinical Differ-
entia] and Forensic Stand-points. Journ. Amer. Med. Assoc, April 30,
May 7, 1904.

MANIC-DEPRESSIVE INSANITY

361

sition stages. Marked deviations from this type of the disease
were noted in 14 per cent, of the cases.

Folie, a double forme.

Continuous type.

With irregular intervals.

Q W Q ^

Alternating form.

1 I M 1 I l<|sM>'T [ I I I I I I I >iNM[M> I I I I 1 I <Tj7>i^mjJ> I I

1895 1896 1897 1898

From an observed case.
Chart X, showing periodic forms of manic-depressive insanity. (From Weygandt.)

(4) States in which the affective fluctuations become
less marked and the patient shows a tendency to develop a
more or less immobile systematized paranoiic condition}* —
The diagnosis in these cases can frequently he made only with
considerahle difficulty and after much time has elapsed. This
category includes some, if not all, of the so-called recurrent
paranoias in which during the lucid intervals there is no

"Weygandt: Ueber die Mischzustande des manisch-depressiven Irre-
seins. Miinchen, 1899. Sollier: Stir une forme circulaire de la neuras-
thenic Revue de Medecine, 1893, p. 1909. Pferdsdorff: Ueber intestinale
Wahnideen im manisch-depressiven Irresein. Central!)!, f. Nervenheilk.
u. Psych., 1904, Marz, Nr. 170.

362

PSYCHIATRY

specific reduction. In the United States alienists are particu-
larly indebted to August Hoch for his study of this type of
the disease. These cases may be divided into two categories :
(a) those which develop out of one of the conditions de-

W*

+H

^ftfo'wkr"

Chart Y, showing course in cases of manic-depressive insanity.

In the above diagrams the black horizontal line indicates the period of psychomotor re-
tardation, the open horizontal line the period of psychomotor irritability or excitability. The
curve below the line indicates emotional depression, and above the line indicates emotional

excitement. For example :

tional depression.

indicates psychomotor retardation and emo-

indicates psychomotor irritability and emotional

excitement. The short vertical lines divide the curves into weekly periods. (From Weygandt.)

scribed as depressed, excited, or mixed states, and (b) rare
instances in which the paranoiic condition is marked at the out-
break of the alienation.

Etiology. — Nothing is known in regard to the dominant
causes which determine the character of the attacks. There is
no satisfactory hypothesis that attempts to explain the reason
why motor restlessness and exaltation are the dominant feat-
ures in one case and in another psychomotor retardation and

MANIC-DEPRESSIVE INSANITY

363

depression. Lambranzi 16 examined, between 1895 and 1901,
173 cases in which the diagnosis of mania had been made. Of
these individuals 99 were women and 74 men ; 48 had already-
been under treatment; 37 had a recurrence of the attack during
the period of observation; 15 had several attacks, and their
cases were diagnosed as periodic psychoses; 5 had recurrent
attacks of melancholia, and were regarded as suffering from
circular insanity. Of the remainder, after the elimination of
the doubtful cases in which alcoholism, epilepsy, or hysteria
played an important role in the pathogenesis, there were 12
which gave the clinical picture of mania. In 157 patients in
whom the diagnosis of melancholia was made 27 had been
under treatment for a similar trouble; 34 had single recur-
rences; 5 a periodic, and 4 a typical circular insanity. The
remaining 19 cases had symptoms of mental depression. More
recently Soukanoff and Gannouchkine 17 have examined all
patients suffering from mania admitted to the Psychiatrical
Clinic in the University of Moscow, carefully excluding all
cases in which there were any symptoms of depression as well
as all forms of the circular insanity. From these observations
they came to the conclusion that every acute psychosis, whether
it be amentia, melancholia, mania, etc., always has a tendency
to recur at shorter or longer intervals. Out of 4434 patients
admitted to the clinic between November, 1887, and Septem-
ber, 1902, only 40 cases, 16 in men and 24 in women, were diag-
nosed as mania. It was found after a further analysis of
these statistics that the symptoms of motor restlessness and
exaltation were more apt to dominate the clinical picture in
women than in men in the proportion of 2 to 1. Although the
number of maniacal patients was less than 1 to 100, the per-
centage of cases of mental depression was almost seven times
as great. Although the pure maniacal symptoms according

10 Lambranzi, Ruggiero : Contributo alio studio della " frenosi maniaco-
depressiva" e della melancolia da involuzione (Giorn. de psichatr. clin.,
xxx, No. 2, 3.

17 £tude sur la manie. Archives de Neurologie, t. xv, Mai, 1903, No.
89, p. 401.

364 PSYCHIATRY

to these statistics are comparatively rare in both men and
women, the mental depression is one of the most frequent
psychical disturbances in women.

According to Kirn and Pick,18 in the so-called circular
form of the disease the character of the first attack seldom
corresponds with that of the later recurrences. Generally the
patient has an attack of mania followed by a period in which
motor restlessness and exaltation are the dominating symp-
toms; then a lucid interval followed by an attack of mania or
melancholia. Some clinicians affirm that the circular forms
always begin with an attack of melancholia. Clouston, how-
ever, maintains that the symptoms of excitement most fre-
quently occur in the initial seizure. When the attacks of de-
pression and excitement are associated and have reached a
maximum intensity they tend to recur at frequent intervals
during the rest of the patient's life.

The prognosis is, as a rule, bad in all forms of periodic
insanity in which the individual attacks are severe and pro-
longed. It is somewhat more favorable where the attacks are
shorter in duration and come in groups. The duration of the
attacks may vary greatly from a few hours to one or two years.
Cases have been reported in which the attacks lasted for six to
seven years.

The mental condition of the patients during the lucid
intervals varies. Cases have been recorded in which frequent
attacks have occurred during the life of the patient, and in
the intervals between the attacks the intelligence seemed to
be unimpaired. One author mentions a patient who died at
the age of 78 and who had suffered from recurrent attacks
for forty-four years, and yet during the remissions had ex-
hibited no trace of intellectual impairment. The lowering
of the cortical functions, most frequently noted in these indi-
viduals during a remission, does not, as a rule, show itself

"Die periodischen Psychosen. Stuttgart, 1878. Pick: Eulenberg's
Realencyclopadie d. gesammten Heilkunde, III. Aufl., Bd. iv, p. 665.
" Circulares Irresein."

MANIC-DEPRESSIVE INSANITY 365

in the intellectual sphere. Generally there is a certain degree
of emotional irritability, a capriciousness, marked egotism, and
perhaps an impairment of the ethical sense. In some instances
a chronic state develops which bears the marks either of mani-
acal excitement or the period of depression. Tne former is
occasionally interspersed by periods in which the motor rest-
lessness alternates temporarily with a brief period of psycho-
motor retardation. In the prolonged cases of mental depres-
sion the periods of depression alternate with those of motor
restlessness. These chronic cases need to be studied more in
detail. The occurrence of well-systematized insane ideas with a
lessening of affective fluctuations is generally an indication that
the attack will be a protracted one. It is not always possible
to say from the intense character of the excitement or the mere
depth of the depression that the patient will be a long time in
convalescing. In all forms of this disease it is very important
that a careful record should be kept of the weight of the indi-
vidual. As long as this falls, either in the period of depression
or excitement, a favorable prognosis cannot be given even
if the mental state of the patient seems to show some improve-
ment. As soon, however, as the weight curve begins to rise
a favorable prognosis may be given, even if the mental status
is apparently unchanged. An example illustrating the im-
portance of this last point is given in the history of the fol-
lowing case : .

The patient, a man aged 20, was admitted to the Sheppard and Enoch
Pratt Hospital November 28, 1903.

Family History. — Negative for nervous and mental diseases.

Personal History. — No peculiarity in mental development. Good stu-
dent. History and mathematics favorite topics of study at school. Whoop-
ing-cough and measles when a child. At the age of 15 was thrown from a
wagon ; was unconscious for an hour, but made a rapid recovery and no
after-effects were noted. " Has been treated for kidney trouble since age
of 18, and has frequently had attacks of chills and fever, during which he
was often delirious." Character previous to onset of present illness has
been described as at times vacillating and impulsive.

Present Illness. — Relatives noticed that he had acted queerly for about
a year. At times would seem to be absent-minded and dreaming. In the
spring of 1903 he suffered from loss of appetite, a general feeling of malaise,

366 PSYCHIATRY

and some mental depression. These symptoms continued off and on until
October, 1903, when he became restless with periods of reticence, seclusive-
ness, and irritability. He was easily confused and occasionally self-accusa-
tory. A few days prior to admission to the hospital he began to talk a great
deal, and " preached on everything he had seen or heard." Later became
very violent, wanted to put his father and mother out of the house. This
period of aggressiveness was followed by one of the depressed spells, which
lasted only a few hours, when he again became excited, indulged in a great
deal of profanity, and tried to whip one of his uncles. Patient was first
taken to the city almshouse, and transferred from there on November 28
to the Sheppard and Enoch Pratt Hospital. On admission to the latter
institution it was noted that he was apparently dazed, confused, and
showed considerable motor restlessness, but towards evening this disap-
peared. On the following day while under examination he made no
objection to being undressed, merely submitting passively without offer-
ing in any way to help. The general character of the motor reactions
indicated the 'existence of slight psychomotor retardation. Attention
easily gained, but little power of concentration. Voluntary conversation
at times limited. Once or twice without any apparent reason began to
cry and complain of having been cursed by some one whose name he did
not give. Admitted that his memory was somewhat defective, but other-
wise he was " quite bright in his mind," " although sick of trying to save
people," and did not want anyone to send him to prison. On December 3
the patient was more communicative. His attention was easily gained but
still lacked concentration. He would begin to describe an object or to
give expression to some ideas, but distractibility was very marked, and
apparently he had no goal in view. Emotional tone corresponded with
mental state. Weight, 113 pounds. Blood-pressure, 130. On this date,.
December 4, patient began to show signs of increasing motor restlessness
and compulsory speech, insisting upon declaiming before patients and
attendants.

December 5. Markedly depressed, with tendency, to cry. Affirmed
that his thoughts are audible so that other people could hear them. Even
God had heard them, otherwise the patient would have been dead long
ago. Remembered having been noisy during the night. Said he could
not help this, as he saw some one rising from the dead. Declared that
unpleasant thoughts made him cry.

December 10. Motor restlessness more marked, considerable exuber-
ance of spirits. Danced and cut capers, tore his clothes, and was mark-
edly impulsive. At the end of December the patient had gained four
pounds in weight, but there was no improvement in the mental condition.
On January 21, although there was some general motor restlessness
present, the patient's emotional tone was evidently one of depression.
While being examined, he showed no tendency to talk, but when asked to
write gave evidence of the existence of a sensory flight of ideas. Patient's
condition has gradually improved, and with the exception of the two slight
drops in weight indicated on the chart there has been a steady and un-

MANIC-DEPRESSIVE INSANITY

367

interrupted gain. The slight loss of weight between February 5 and 12
was accompanied by a change in the mental attitude of the patient, as
he was angered and depressed by what he thought was an apparent in-
attention and lack of sympathy exhibited in his case by a relative.

Lbs.
150

140

130

120
110

srtsiss-.^rr.s

B

>

A

/

/

/

/

^

Weight chart in a case of manic-depressive insanity. At A and B the patient was more
depressed than usual.

Pathogenesis. — Nothing is known regarding the imme-
diate causes of this disease. There is no other form, however,
of mental aberration in which the hereditary factor plays a
more important role. In from 80 per cent, to 90 per cent,
of the cases of manic-depressive insanity the history of insan-
ity afflicting the ascendants is well marked. SoukhanofT and
Gannouchkine,19 as the result of their observations, affirm that
women are more inclined to suffer from depression than are
men (3:1), and that the hereditary factor plays a less impor-
tant role in the former than in the latter. The disease when it
once makes its appearance in a family shows a remarkable ten-
dency to reappear in the descendants. Even when a history
of definite symptoms of alienation cannot be obtained as having
occurred in the progenitors, " strong family idiosyncrasies"
are nearly always noted. As a rule, the majority of patients

11 £tude sur la melancholic Annales medico-psychologiques, Sept-
Oct., 1903.

368 PSYCHIATRY

who suffer from this disease are delicate. From their earliest
years they have exhibited eccentricities of character referable
to an unstable nervous system — hypochondriasis, " attacks of
the blues," sexual irregularities, more or less egotism, a ten-
dency to lie, etc., being some of the more common defects. The
importance of trauma, the acute infectious diseases, meningitis,
encephalitis, parturition, excessive and prolonged physical and
mental strain have all been emphasized as etiological factors.

Sufficient has already been said to show that the differen-
tial (iiag)iosis in these cases is frequently beset with many diffi-
culties. This is particularly true in the excited stage. The
motor restlessness and exaltation in this condition, as a rule,
differ essentially from those observed in cases of dementia
prsecox. In manic-depressive insanity the patient is more re-
sponsive to external stimuli, he is easily deflected and may to
a certain extent be led. Each new impression as it is stamped
upon the cortex gives birth to an idea expressed either in speech
or action that is the result of the incident stimulus. The flight
of ideas may be distinguished from a mere hotch-potch, inas-
much as the latter by its extreme silliness, irrelevancy, numer-
ous repetitions, and reiterations, is more suggestive of mere
automatism. The actions of the patients during the stage of
maniacal excitement are, as a rule, conditioned by the effect of
extra-organic stimuli. In the earliest stages of the excitement
the diagnosis is frequently extremely difficult, as it depends
largely upon the intimate knowledge possessed by the observer
of the patient's idiosyncrasies. The maniacal excitement may
be mistaken for the earliest toxic symptoms produced by cocain,
alcohol, and other drugs which give rise to motor restlessness
and a limited flight of ideas. In the pronounced cases the
mental exhilaration of the patient may simulate the incipient
euphoria of general paresis, but in the latter instance the ideas
are apt to be more insistent and the self-complacency of the
patient is more exaggerated. The recognition of the depression
in the early stages or in the milder forms of the disease is even
more difficult than that of manic excitement. Not infrequently
it is extremely difficult to determine whether an actual psycho-

MANIC-DEPRESSIVE INSANITY

369

motor retardation exists. The diagnosis is rendered even more
difficult if, as is often the case, depression is associated with
motor excitement. The subjective sense of insufficiency of
which the patients may complain is an important sign during
the period of depression. Individuals so afflicted may regret
that they are unable to work, or to exert themselves in any
way, and may complain bitterly of the retardation and inhibi-
tion of their mental processes.

The involutional melancholias are, as a rule, to be distin-
guished by the greater tendency shown for the development
of the systematized delusions and the absence of marked
psychomotor retardation and delay in all forms of thought.
In these cases the insane ideas are more stable. The outbursts
of anxiety which accompany the pre-senile or senile depressions
are important factors in the differential diagnosis of these dis-
orders. Dementia precox is to be distinguished from manic-
depressive insanity by the occurrence of mannerisms, motor
symptoms, verbigeration, isolated impulsive acts, etc. The
milder cases described as cyclothemia are not infrequently
difficult to differentiate from neurasthenic states in which not
infrequently there is a mixed state of mild excitement with
subsequent depression. Occasionally, it is impossible to decide
for some time whether a case is one of epileptic mania or of
manic-depressive insanity. In the former instance the out-
breaks are apt to be more violent, the patient is much more
dangerous, and the typical flight of ideas in the broadest sense
is, as a rule, not present. The occurrence of epileptiform at-
tacks is distinctive.

The treatment of these cases is symptomatic. What has
already been said in a general way in reference to the treat-
ment of states of mania or depression may be applied to the
care of patients during the attacks of manic-depressive insanity.
In the case of a young person it is the duty of the physician to
inform the parents or guardians that the tendency of the disease
to recur is very great. The life of the afflicted individual must
be so ordered that all forms of excitement, physical or men-
tal, are reduced to a minimum. If the circumstances permit

24

3/0

PSYCHIATRY

an out-of-door life in the country, it is to be recommended.
Great care should be exercised during the onset of puberty.
If the patient becomes conscious of too great supervision of
all the minor details of his or her life, the periods of mild
depression are augmented or the development of a marked
hypochondriasis may be generated. During the period of
excitement care should be taken to guard against the occur-
rence of sexual irregularities. The mildest cases may be treated
at home provided the physician fully comprehends the nature
of the disorder and is fully alive to the exigencies of the case.
The severer cases can be handled much better in an institution,
where a rest-cure in bed with massage, hydrotherapy, and a
light and nutritious diet can be provided.

As the tendency of manic-depressive insanity to recur in
families is very marked, marriage in the case of individuals who
have once suffered from this form of alienation is contra-
indicated. During the periods of excitement the prolonged or
continuous baths are often efficacious in cutting short an at-
tack. During the periods of depression as well as during the
excitement the patient should be kept constantly in bed. Dur-
ing the former phase as well as during the milder attacks of
manic excitement, in moderate weather, the bed may be
wheeled out on the porch or balcony and the patient kept in
the open air. This is particularly desirable in cases of anaemic
individuals. Where such a procedure is not possible the win-
dows in the room may be opened wide for several hours a day,
so that the patient in this way may be given plenty of fresh
air. During the period of depression the patient may be put
in a warm bath, and if there is no contraindication, the tem-
perature of the water may be gradually cooled, the patient
being carefully watched to see that no ill effect follows this
procedure. After the bath massage and passive movements
are frequently of great value in stimulating the superficial cir-
culation. In many cases tonics, such as iron, strychnin, and
arsenic, are indicated. In the cases of manic-depressive in-
sanity which occur in plethoric individuals it is advisable that
the diet should be carefully restricted. The patient must be

MANIC-DEPRESSIVE INSANITY 37I

closely watched, as such individuals, although apparently
very robust, are physically below the standard and frequently
show a marked anaemia.

Pathology. — The pathological findings in cases of manic-
depressive insanity do not throw any light upon the nature
of this disease. Patients do not die from the immediate effects
of the disorder itself, but from some intercurrent affection.
The histological changes in the neural elements of the central
nervous system are those found in other chronic or acute dis-
eases. Turner has described alterations in the nerve-cell which
were affirmed to be in a measure specific for the so-called deli-
rious manias, but on more careful investigation similar changes
were found to be present in other conditions. Great care
should be exercised in examining the central nervous system
and in basing deductions as to the pathogenesis of the disease
upon the occurrence at autopsy of cerebral hyperaemias. Not
infrequently the marked injection of the vessels of the mem-
branes and cortex is merely an agonal or post-mortem change,
the result of alterations in the blood-supply due to the position
of the body. It is true that the maniacal stage is very often
associated with low blood-pressure in the peripheral arteries,
while in the stage of depression the reverse holds good; but
that the intracranial tension is either increased or lowered
can not be decided from the condition of the peripheral circu-
lation. Pilcz 20 affirms that in ten cases reported there were
no marked pathological changes found in the central nervous
system. In seven cases scar tissue was reported, and in ten
instances other changes were noted. The findings in the cen-
tral nervous system in two cases reported by the author were
practically negative. Stoddart 21 has formulated the hypothesis
that in mania an irritating product is formed within the cor-
tical cells, while in melancholia the effect of the toxic agent
is paralyzing. This same observer thinks that in a few cases
of mania, in addition to the poison originating within the
nerve-cell, a toxic substance also occurs in the plasma.

20 Op. cit, and Beitrage zur Klinik der period. Psychosen. Monatsschr.
f. Psych, u. Neurol., December, 1903.

21 Stoddart, W. H. B., Lancet, London, March 5, 1904.

CHAPTER XIV

THE DEMENTIA PRECOX GROUP *

Although the various forms of alienation recognized
under this head present a symptomatology with definite and
distinctive features and in a majority of instances a terminal
dementia that is essentially characteristic, it is not improbable
that dementia prsecox does not form a disease entity. The
clinical conceptions that have resulted in this assignment of
cases have been of comparatively slow growth.1 As will be
seen later, this group of symptom-complexes is formed by the
union of several clinical types of alienation that have hitherto
been considered distinct. Among the more important of these
are the cases originally described by Kahlbaum as instances of
catatonia, a psychosis considered by him from a diagnostic and
prognostic stand-point to be a disease entity.2

In his classical monograph catatonia was defined as a
brain disease characterized by cyclic, alternating periods of
melancholia, mania, stupor, confusion, with associated motor
disturbances, and terminating in dementia. From this clinical
picture one or more of these symptoms may be absent. The
prognosis was admitted to be favorable in some cases ; in others
death might occur during attacks of catatonic rigidity and ex-
citement. Remissions were infrequent and the hereditary
factor was considered unimportant. Kahlbaum called particu-
lar attention to what he considered to be distinctive features of
the catatonic symptoms. Neisser 3 emphasized the necessity
of considering the clinical picture as a whole as definitely char-

'Arndt : Ueber die Geschichte der Katatonie. Centralbl. f. Nerven-
heilk. u. Psych., 1902, p. 81.

" Kahlbaum : Ueber das Spannungsirresein. Vortrag auf der Natur-
forscherversammlung. Ref. Archiv. f. Psych., ii, 1875. Kahlbaum:
Die Katatonie. 1869.

'Neisser, C. : Die Katatonie, 1887.
372

DEMENTIA PRECOX 373

acteristic, and did not lay great stress upon the diagnostic value
of individual symptoms. Prior to the appearance of Kahl-
baum's monograph on catatonia, Hecker4 had described a
group of cases in which the mental symptoms developed about
the time of puberty in individuals hereditarily predisposed
towards insanity. The outcome in these cases was a termina-
tion in a similar characteristic dementia. These observations
were confirmed by Hack Tuke 5 and Fink.6 In 1886 Schiile
affirmed in words that have become classic that of those heredi-
tarily predisposed individuals who are " wrecked on the cliffs
of puberty," some become hebephrenics, while others are
afflicted with an acute dementia. For this latter group he
suggested the name dementia precox.

In 1890 A. Pick, basing his observations upon those of
Kahlbaum, came to the conclusion that hebephrenia was a form
of dementia prsecox. Under this latter term Pick included the
class of diseases beginning at puberty with a quiet onset and
ending in a progressive dementia.

In 1892 Daraszkiewicz, under the influence of Tschisch
and Kraepelin, broadened the conception of hebephrenia so that
the severe and protracted cases were grouped together with the
shorter and milder instances described by Hecker. Thus the
bridge was formed between the two groups. It was affirmed
that the marked apathetic dementia developed either insidiously
or followed periods of acute excitement. It is thus apparent
that the genesis of the present views regarding hebephrenia was
in a measure determined by the increased emphasis placed upon
the prognosis. The possibility of uniting the two disease
groups was first definitely suggested by Kraepelin, who in the
sixth edition of his text-book brought together the various
forms of alienation which will be described under this head.

4 Hecker: Hebephrenic Virchow's Archiv. f. path. Anat., 1871,
Bd. lii.

5 Hack Tuke : A Manual of Psychological Medicine, 1879, p. 345-

6 Fink : Ein Beitrag zur Kenntniss des Jugendirreseins. Allgem.
Ztschr. fur Psych., 1881, Bd. xxxvii, S. 498.

374 PSYCHIATRY

He admits that other names, such as the demenza primitiva of
the Italians or the dementia simplex of Riger, may have cer-
tain advantages. Quite recently 7 the objections to the use of
the name dementia prsecox as a general term have been more
definitely formulated.

The fact that within the near future certain types of cases
now described as dementia prsecox may be taken out of this
group does not detract from the importance in clinical psy-
chiatry of the formulation of those conceptions upon which the
present clinical analysis is based. The fact cannot be too
strongly emphasized that in studying this psychosis too much
stress should not be laid upon the individual symptoms pre-
sented by a patient at any one period of the disease. It is the
study of the condition as a whole, including the onset, course,
termination, and general symptomatology, which promises the
best practical results. Little progress was made in the study of
dementia paralytica so long as clinicians were satisfied with
simply grouping together the symptoms which occurred at any
given period of the disease without an equal regard for the
known facts connected with the etiology, termination, and
prognosis as well as with the clinical course.

The triple clinical division suggested by Kraepelin —
namely, the hebephrenic, catatonic, and paranoiic forms of the
disease — is fairly satisfactory if the attempt at differentiation
is not pushed to the extreme. Little is to be gained by the
efforts sometimes made to distinguish too sharply between
these groups, as many of the symptoms are common to all three
forms. Until more is known regarding the natural history of
this disease it is ill-advised to try to adhere to a too rigid
clinical classification.

The majority of the cases develop between the twentieth
and thirty-eighth years, although competent observers have re-
ported the outbreak of the symptoms before the fifteenth and
as late as the fiftieth year. The periods of puberty and

7 Sommer, Robert : Beitrage zur Psychiatrische Klinik. Marburg, Bd.
i, Heft 4.

DEMENTIA PRECOX 375

adolescence are unquestionably the times at which the majority
of the cases develop. But it leads to unnecessary confusion if
the possibility of the occurrence of cases at later periods of life
is denied. The importance of this fact is more generally recog-
nized by Continental writers than by English and American
alienists. The onset of the disease is frequently insidious, owing
to the so commonly slow progression in the earlier stages of its
development no less than to the protean character of the symp-
toms. There is no other form of alienation in which an
intimate knowledge of the individual is of greater importance
as an aid in establishing the diagnosis at an early period of the
disease than in dementia prsecox. While it is incumbent upon
the alienist to recognize the malady early in its course, the fact
should never be lost sight of that the continual striving to dis-
cover symptoms supposed to be of specific diagnostic value may
be carried to an extreme. In many instances the signs of
mental aberration may be obvious for a considerable period
of time prior to the appearance of symptoms now generally
recognized as distinctive of this psychosis.

Cases with an acute onset are not infrequently reported,
but it is extremely doubtful whether such actually occur. In
many instances the apparently sudden onset is found on closer
examination to be merely an exacerbation of previously exist-
ing symptoms.

For example, a young man came under observation in the dispensary
of the Johns Hopkins Hospital giving the following history: The patient
affirmed that he had felt perfectly well until a few days before his mar-
riage, but had then become excessively nervous. The day following this
event he went off with several friends and drank to excess, although he did
not become intoxicated. He came home that night, complained of not
sleeping well, and the next morning on awakening suddenly sprang out of
bed, seized his wife by the throat, and almost choked her to death. He
threatened to kill several members of the family who tried to quiet him.
Although conscious of what he had done, he was unable to assign any
motive for his acts of violence and was willing to admit that they might
be considered those of an insane person. The overwhelming power of
the impulses was recognized by the patient. Gradually these obsessional
acts ceased, but the conduct of the patient was so eccentric that he was
advised to come to the Sheppard and Enoch Pratt Hospital for treatment.

3;6 PSYCHIATRY

Although the history of the case given by the family at first suggested the
possibility of an acute onset, more careful inquiry elicited the fact that the
patient had exhibited mental aberration for a considerable period of time
prior to this outbreak. The subsequent development of the case proved
it to be one of dementia praecox.

Another instance was that of a young woman 24 years of age who was
said to have been perfectly sane until she had an acute outbreak of mania.
Later it was discovered that the patient for years had been decidedly neu-
rotic. She had always been painfully shy and over-particular regarding
her dress. She was described as being impulsive at times and emotionally
unstable.

In the early stages, particularly in young girls, attacks of
migraine may precede or usher in the symptoms. Either prior
or subsequent to these attacks of pain there is some mental
depression. Occasionally the early symptoms are referred to
an acute attack of some disease, such as influenza, typhoid
fever, scarlet fever, etc. Although it is probable, then, that
dementia praecox does occur in individuals who until the time
of onset have shown no sign of mental deterioration, too great
emphasis can not be put upon the necessity of careful inquiry,
not only regarding the patient's personal peculiarities or idio-
syncrasies, but also as to the nature of the environment and
antecedents prior to the onset of the attack.

The prodromal symptoms usually extend over a period of
years. Children who have given every promise of a normal
mental development may in the first years of adolescence show
evidences of a gradual progressive mental decline. This de-
terioration may be so slow and yet so widespread that it is
difficult for a long time to recognize special defects involving
separate functions. Irregularities in the emotional life nearly
always accompany the intellectual decay. Individuals who have
never displayed marked emotional disturbances until the onset
of neurasthenic symptoms and then without apparent cause
give evidence of constantly recurring outbreaks of temper on
little or no provocation should be kept under close supervision.
Such patients not infrequently resort to unprovoked violence,
and then after the act is committed express regret for their
conduct, but, nevertheless, true penitence is not observed. The
development of these symptoms should at once awaken sus-

DEMENTIA PRECOX 377

picion. Cases not infrequently come under observation in
which impulses seem to replace all motives. The emotional
storms which are occasionally exhibited early in the develop-
ment of these cases are essentially different from those common
to cases of hysteria or neurasthenia. In the former there is
an explosive violence entirely without motive and the event
may be isolated and soon forgotten ; whereas in the latter
group of cases an apparent motive for the excitation of feeling
may almost always be found and is generally associated with
a period of hypochondriacal depression. The acts of violence-
due to an emotional storm awaken in the neurasthenic a feeling
of repentance, but the sense of contrition in patients suffering
from dementia prsecox is entirely superficial. The emotional
impulses, having the character of obsessions, which not infre-
quently crop up during the prodromal period, are apt to be
transitory and evanescent. A young woman without the
slightest reason to fear such an event hears a step on the stairs,
fears that an intruder will force himself into her room, gives
vent to an apparent emotional outbreak, which passes away
as quickly as it came and the incident is promptly forgotten.
Every sensory stimulus at times seems to awaken the starting-
point for a new chain of disconnected heterogeneous ideas.
There is an apparent incoordination as well as disorganiza-
tion of thought. Local systematized delusions seldom develop
early in the disease except in the paranoiic form. Not infre-
quently, however, various disturbances of sensation may occur.
Early in the disease patients complain of singing in the ears,
" strange sounds" in the head, pistol shots, bright flashes of
light, or the like. Olfactory hallucinations, particularly of an
unpleasant character, are not infrequent. One meets with
psycho-anaesthesias having the character and distribution of
purely functional disorders. Paresthesias are less common.
At first the disturbances in sensation may be practically un-
noticed by the patient until his attention is directed to them.
Gradually the tendency to explain their occurrence becomes
more apparent. Psychic hallucinations frequently occur. Their
importance in the early stages of the disease has recently been

i7S PSYCHIATRY

emphasized by Lugaro.8 This observer affirms that in cases of
dementia prsecox, particularly in the paranoiic forms of the
disease, the pseudo-hallucinations are frequently met with.
Real hallucinations are either very infrequent or do not occur
at all. The memory is well preserved. The power of ideation
is unimpaired, although there is a marked disturbance in the
sequence and relationship of the products of thought. The
disturbed mental action consists largely in the abnormal elabora-
tion of the voluntary impulses. Arrested impulses dominate,
, as it were, the field of psychic activity. The psycho-pathology
of these cases may be reduced fundamentally to a disturbance in
the primary elaboration of stimuli, volitional impulses, etc., of
which pseudo-hallucinations are correlative phenomena. The
anomalies in the organic sensations, particularly the visceral,
are noticeable in the very earliest stages and are frequently
associated with the occurrence of the epigastric voices, etc.

In addition to psychic hallucinations insane ideas are fre-
quently met with. Except in the paranoiic forms of the disease,
systematization is, as a rule, not well marked. The ideas, as ex-
pressed by the patient, show plainly the marked disorganization
in connected thinking. The emotional tone of the patient when
describing these ideas is, as a rule, one of apathy, broken only
by acts which are more frequently the result of mere impulse
than the consequence of the dominating force of the ideas. In
some cases, particularly those in which the disease progresses
slowly, hypochondriacal ideas are present. The patients affirm
that changes have taken place in their internal organs, that
they are losing their minds, that their energy is fast disappear-
ing, that they are unable to arouse themselves to action. At
times megalomania may develop ; the type, however, is essen-
tially different from that seen in dementia paralytica. The
silly exaggerations are prominent. The ideas expressed are
grotesque, bizarre, and sometimes suggested by the environ-
ment. An event or an object is mentioned by a patient, and

* Lugaro, E. : Sulle pseudo-allucinazioni (allucinazioni psichiche di
Baillarger). Riv. d. Patologia nervosa e mentale, vol. viii, fasc. I and 2.

DEMENTIA PRECOX 379

coupled with this there is an insane idea entirely irrelevant, its
presence having apparently been suggested by mere spatial or
time contiguity.

Sometimes patients complain of receiving electric shocks
concerning the nature of which they may develop vague sus-
picions, affirming that they have been given to them by certain
individuals. In the early stages these phenomena are recog-
nized as abnormal. Occasionally to the imperative conceptions
exaggerated ideas may be added. The patients complain that
they can not get rid of these feelings, although occasionally they
admit their inability to reason logically concerning the occur-
rence of these phenomena. Some affirm that the repetition of
these sensations or the persistence in the field of consciousness
of an imperative conception will in time compel them to do or
say things of which they will be ashamed. The majority of
the patients do not suffer great mental anguish. This is in a
measure characteristic. There is more or less apathy. Emo-
tional storms may gather, break, and disappear, leaving the
patient in a state of apparent indifference.

Among the cases of dementia prsecox which are found
among dispensary patients a number give a history of attacks
of mental depression occurring early in the disease. As a rule,
these periods of depression are not accompanied with hypo-
chondriacal symptoms. The patients, when they are asked to,
assign a reason for their depression, but if left to themselves
are listless and apathetic. A conscientious, hard-working
student becomes mentally depressed. He affirms that he has
been derelict in the performance of his duties, is most persistent
in his declaration that his only chance to succeed in life has
been thrown away. The affirmation is made and persistently
adhered to, but the statement lacks any of the earnestness that
carries conviction with it.

In nearly all cases there is a general blunting of the
emotional tone. This is very characteristic. The patients be-
come indifferent to their most intimate friends as well as to
members of their family. Occasionally in the earlier stages of
the malady appreciation of this change is noted by the patients

380 PSYCHIATRY

themselves. Not only is there marked impairment of the
patient's sympathies and affections, but at times a paradoxical
reaction in the objective expression of the feeling tone occurs.
Stransky ° has emphasized the importance of the incongruity
in the affective state between the ideation and the emotional
reaction (thymopsyche and noopsyche). This symptom is in-
dicative of dissociative incoordination of the cortical functions
— an intrapsychic ataxia. Patients not infrequently indulge
in buffoonery even while they affirm that they feel depressed
and sad. The exaltation which occurs is essentially different
from that of the maniacal patient. The individual is silly,
" mad as a March hare," and gives outward expression to the
intellectual as well as emotional impairment. The humor, wit,
and vivacity sometimes noticeable in cases of excitement due to
alcohol or marking the early stages of manic-depressive in-
sanity are lacking. The precocious dement is indifferent, lack-
adaisical, and at times singularly impulsive and impetuous with-
out being passionate.

The synchronous appearance of a slow psychical reaction,
very difficult to distinguish from the psychomotor retardation
in the period of depression in manic-depressive insanity with
mental apathy, when taken in conjunction with other symptoms,
is of diagnostic importance. This phenomenon, recently de-
scribed by Dunton,10 has been noted during the early stages of
the disease in a comparatively large number of cases. There
seems to be little, if any, difficulty in the transference of either
afferent or efferent stimuli, but the working up and elaboration
of impulses after their reception is apparently more difficult than
normal. If a patient in this state is questioned, not infrequently
two or three seconds elapse before there is any objective evi-
dence of an attempt to respond. Then the reply is given, gen-
erally in a low, monotonous tone. By careful examination

* Stransky : Zur Kenntniss gewisser erworbener Blodsinnformen.
Jahrbikher f. Psych, u. Neurol., Bd. xxiv, Heft i.
10 Am. Journ. Insan., vol. lix, No. I, 1902.

DEMENTIA PRECOX

38l

evidence may be obtained that there is no delay in the trans-
mission of the impulse to the cerebral cortex, and there is no
subjective sense of deficiency such as occurs in the period of
depression when the phychomotor retardation is marked. This
preservation of the so-called primary sensations is character-
istic of nearly all cases of dementia praecox in the earlier as well
as in the advanced stages of the disease. The fact that the
conduction of sensory impulses from the periphery to the centre
is rapid and apparently normal favors the occurrence of various
forms of hallucination. The orientation, as a rule, both for
time and place, is not seriously affected, although patients may
affirm that they do not know where they are. In some cases
this is due to the apathy which exists, but in others it is merely
an expression of the patient's desire to be left alone. Another
cause for the apparent disorientation occasionally met with is
the consciousness the patient has of subjective difficulties in
formulating his ideas. This gives rise to a marked disinclina-
tion to speak. Patients realize their inability to carry through
to its logical conclusion a train of thought and therefore refuse
to talk. This disinclination is, as a rule, in the early stages due
to two factors : first, an appreciation of the subjective difficulty
in the association of ideas ; and, second, the emotional state
engendered by hallucinations or illusions gives birth to sus-
piciousness and a consequent reticence. This symptom is not
infrequently met with in the earlier stages, but becomes much
more marked as the disease progresses. The antagonism
aroused bv interference from without varies in different cases.
In the catatonic form of the disease this so-called negativism
is well marked. The passive resistance to all forms of inter-
ference offered by the patient in the later stages is motiveless
and purely capricious, although at first it may be the result of
an insane idea. The genesis of these refractory states has been
discussed in the first part of the book. The absence of a well-
defined motive, the disorganization of connected thinking, and
the anomalous emotional state are the factors that are respon-
sible for the actions of the patient. In the earlier stages not

382 PSYCHIATRY

infrequently a motive is given by the patient for his actions.
Gradually this vanishes and his conduct becomes aggressively
resistive in response to all stimuli. He refuses to speak or, if
he does, gives audible expression to his feelings in as few words
as possible. He refuses to look the examiner in the face, closes
his eyes, and may struggle violently to get away from the
physician or attendants. In the exaggerated cases the patients
cover themselves up with blankets, or hide under the bed, in
the closets, in out-of-the-way nooks and corners, even refusing
nourishment and refraining from voiding urine or evacuating
their bowels until actually compelled to do so.

In addition to negativism, stereotypies of attitude and
action are in a measure characteristic. As has already been
said in Section I, a motive or an insane idea is primarily the
inciting factor. Gradually this idea disappears and the move-
ments crystallize and remain permanent. The limitations in
the field of consciousness and the tendency of physiological
processes, when once initiated, to persist are the factors which
give rise to these symptoms. In the earlier stages the stereo-
typies are sometimes difficult to differentiate from tics. An
example of this was seen in the case of a man who came under
observation in the Johns Hopkins Hospital Dispensary and
proved to be suffering from one of the slowly dementing forms.
He was accustomed at every few steps, as he walked, to rub
the calf of the right leg with the toes of the left foot. When
asked why he did this the patient affirmed that his leg itched,
but it was obvious that while a paresthesia might originally
have been the cause of this stereotyped movement, later it had
become automatic. The stereotypies of movement may affect
the extremities and the face. Not infrequently patients make
curious grimaces, grin in a stereotyped manner, pucker up their
lips (the snouting cramp), make kissing sounds, etc. The
habits of the patient prior to the onset of the disease in a
measure determine the character of the stereotypies, the move-
ments which are the most familiar to him showing the greatest
tendency to recur. The muscles of the trunk may be similarly

DEMENTIA PRECOX 383

affected. Patients gesticulate or assume strange theatrical
attitudes. Their gait becomes stiff, pantomimic, in a measure
pathognomonic. The speech is changed, but at first only occa-
sional eccentricities attract attention. The vocabulary is limited.
The words used show a remarkable degree of precocity, are
strange and outlandish. There is a tendency to repeat certain
words and phrases. In the advanced stages of the disease the
repetition of senseless syllables is more or less habitual. There
is no difficulty in the mechanism, but merely in the forms of
expression. These are stilted, quixotic, fantastic, incoherent,
and often extremely silly. At times the patients interject a
few senseless syllables and then return for an instant to the
conversation only to relapse again into utter foolishness. As
the disease progresses the incoherence and silliness become
more and more marked, and we often have merely a verbal
hotch-potch or, as Forel has termed it, a word-salad (Wort-
salat).

The eccentricities and mannerisms of speech are dupli-
cated in writing; the tendency to repeat words, syllables, and
phrases is very marked. The example given in Chapter III,
page 33, shows an attempt made by the patient to write out
an account of her physical condition.

Not infrequently cases of mirror writing are reported.
Patients not infrequently give expression to their thoughts
either audibly or in writing in the form of doggerel. The
style of the verse is stilted, bombastic, or inordinately foolish.
In the later stages of the disease the speech may be limited to
the mere repetition of a few words or senseless syllables.

Another important symptom which frequently occurs,
sometimes in the earlier as well as in the later stages of the
disease, is the grotesque irrelevancy exhibited in replying to
questions (Paralogia, Vorbeireden). This symptom-complex
was first described by Ganser11 and consists in the apparent

11 Ueber einen eigenartigen hysterischen Dammerzustand. Vortrag ge-
halten am 23. October, 1897, in der Vers, der mitteldeutschen Psychiatr. u.
Neurologen in Halle. Arch. f. Psych, u. Nervenkrankh., xxx, S. 633.

384 PSYCHIATRY

inability of the patient to answer directly or satisfactorily the
simplest questions. With the exercise of a little care it is pos-
sible to elicit the fact that patients frequently retain a fair
degree of comprehension of what is asked them, but the reply
is disconnected and inapposite to a degree. Although an ap-
parent effort is spasmodically made to answer the question, the
patient seems unable to focus directly upon the essential point
in his reply.

Example. — Female, single, aged 28. The first symptoms of alienation
were noted several years ago. The present attack began in 1900. She felt
the attack coming on and tried to fight against it. There were alternating
periods of depression and excitement, impulsive acts and marked dementia.
The patient's present condition is such that she has to be carefully watched ;
she is very impulsive and erratic ; will suddenly jump up from her chair and
walk in an aimless way up and down the wards. She has struck patients
and attendants and is unable to feed herself. The primary sensations are
well preserved. When questioned she occasionally gives a prompt reply,
showing that there is no obstruction in the afferent tract. At other times
the question has to be repeated several times before it is apprehended.
She makes an occasional low whining sound, is continually smacking her
lips as if kissing some invisible person. Some of the questions and answers
are as follows: Q. How are you? A. I am tolerable, I am sick, I need a
care, I need to go to heaven. Q. Where do you think you are? A. I do
not know. Oh, yes, I am here, I am here on the bed. Q. How long have
you been here? A. I have been here a long time — already — I want the
Bible in my hands. Q. What do you want in your hands? A. I guess it
would be lilies. Oh, no, she must not ; oh, yes, the Bible. Hand me the
paper and the pencil, let me write, write the other way. Won't you please
send for a watermelon? That would do me good. I want some water.
The patient was asked why she behaved in such an extremely foolish man-
ner. To this she replied, " Because it is that girl that causes me the
nightmare. Oh, please send some food." Q. Are you hungry? A. Yes;
I want something in my stomach, I want some one to kiss me. She recog-
nizes a pencil and an eyeglass when shown to her. She begins to cry when
shown a penknife, but cannot assign any reason for this emotional dis-
turbance. She suddenly shouted out, " Keep on writing down things, send
some things, I want to go to town. This is me, this is me." Q. What is
your name? A. You kiss me, you kiss me, then it will be all right. You
kiss me, you kiss me, you feed that child on the right food. Q. Whom do
you want to kiss? A. I do not know. Did you bring me any c-a-k. Oh,
don't go, mother.

The patient frequently makes mistakes concerning the identity of
persons. Refers to one patient as " little blind boy." Sometimes calls the
nurse mother, at other times Aunt Betsy.

DEMENTIA PRECOX 3gs

This grotesque irrelevancy has more recently been made
the subject of careful study.12 On account of the fact that
this symptom is not infrequently associated with verbigeration,
mild cataleptic states, negativism, echopraxia, and echolalia,
Nissl affirms that in the large majority of cases it is diag-
nostic of dementia praecox rather than of hysteria. Quite re-
cently attention has been called to another symptom that may
be referred to causes similar to those upon which the irrele-
vancy of speech depends. It is well illustrated in the manner in
which patients comply with the request to shake hands, doing
so in an irresolute, more or less indifferent manner, as if the
command were only feebly comprehended. Frequently during
the period of catatonic excitement there are verbigeration and
the rhythmic repetition of numbers, syllables, and words which
are indirectly related either to the content of the question or
to the sound of the word. According to some authors, the
essential characteristic of the complexity of the manifestations
in this form of mental disorder is the evident lack of corre-
spondence between the motor symptoms.13 This statement,
however, needs to be qualified. The movements are frequently
characterized by an absence of unity of purpose and of
coordination which contrasts strikingly with certain phases
of the mental state of the patient. For example, patients
not infrequently exhibit stereotypies, catatonic rigidity, inco-
ordinated and involuntary spasms, while the mental examina-
tion shows that they are well oriented and that there is com-
paratively little disturbance in the power of recollection. But
this dissociation between the mental and motor disturbance is
apparent rather than real. A careful study of a case shows

12 Racke : Beitrag zur Kenntniss des hysterischen Dammerzustandes.
Ztschr. f. Psych., lviii, S. 115. Hysterischer Stupor bei Strafgefangenen.
Ibid., S. 408. Nissl : Hysterische Symptome bei einfachen Seelenstor-
ungen. Centralbl. f. Nervenheilk. u. Psych., Nr. 144, S. 2. Wesphal:
Ueber hysterische Dammerzustande und das Symrtom des Vorbeiredens.
Neurol. Centralb., 1003, Januar 1, Nr. 1, S. 7.

13 Paul Masoin : Observations sur la demence precoce et la catatonic
Bull, de la Societe de Medecine Mentale, Decembre, 1902, No. 107, p. 366.

25

386 PSYCHIATRY

that there is a functional inhibition affecting the motor as
well as the psychical powers. In dementia prsecox the cere-
brum seems to have lost the faculty of responding coordi-
nate^ to external stimulation, while a purposeless inexplicable
inhibition dominates all the cortical functions with tyrannical
power.14

Hebephrenic Form. — This division includes two groups of
cases of which the first represents the type of disease originally
described by Hecker. Here we have to do with a chronic
slowly progressive form of dementia with few evidences of
negativism, stereotypy, motor excitement, or impulsivity. The
apathy and progressive dementia are the prominent symptoms.
For these cases Weygandt has proposed that the term dementia
simplex or heboidophrenia (the latter originally suggested by
Kahlbaum) should be retained. He reserves the name hebe-
phrenia for a group of cases which exhibit marked emotional
disturbances, periods of excitement and of depression, fre-
quently accompanied by active hallucinations and illusions,
while a terminal dementia is common to both forms. The
characteristic catatonic symptoms, such as mannerisms, cata-
lepsy, negativism, stupor, and marked motor disturbances, do
not become pronounced features. The essential difference in
symptomatology, according to Weygandt, between dementia
simplex and hebephrenia lies in the fact that the former runs a
more chronic course than does the latter group. Wernicke 15
affirms that heboidophrenia or heboid possesses more of the
characteristics of a specific psychosis than does hebephrenia.
Although clinically an attempt to establish distinctions between
the two groups of cases may possess certain advantages, it is
impossible to draw sharp and definite lines in all cases. The
tendency to adhere to too rigid a classification may retard

11 The motor symptoms play a very important part in the clinical picture
of the disease. The observations of Bernstein are of great interest in this
connection. He has called particular attention to the increase in the
mechanical irritability of the muscles and the formation of the so-called
idiomuscular swelling or tumor. (A. Bernstein: Ueber die klinische Be-
deutung der Muskelwulst bei Geisteskranken (Russisch), Moskau, 1900.)

" Grundriss der Psychiatrie, 1900, S. 518.

PLATE IX

*.gx 1^-f^p^^^ Vf

2 ='
S *?
S p

2 o

» a

3 £

2. o

51 f">

DEMENTIA PRECOX

387

progress by emphasizing differences which are apparent rather
than real ; and for this reason at the present it is inadvisable to
subdivide this group of cases.

The onset in this form of the disease is not essentially
different from that already described as characteristic of all
forms of dementia prsecox. As a rule, there is less probability
of the onset being acute than in the catatonic cases. If a care-
ful history is obtained it is generally possible to show that the
patients for years prior to the onset of the more definite symp-
toms of alienation have exhibited eccentricities of character.
They are said by their parents to be seclusive, to shun other
children, to be jealous, over-particular in matters of dress, and
generally hypercritical. Up to a certain period, generally about
the time of puberty, these patients may develop rapidly intel-
lectually, but show marked capriciousness and general emo-
tional instability. They may be very proficient in certain sub-
jects but exceedingly deficient in others. Their psychical as
well as their physical resistance is frequently lowered. As a
rule, the patients are described by those who have known them
as always having been pale, thin, and nervous children. The
emotional disturbances are characterized by sudden and ex-
plosive outbursts of temper. Not infrequently the children
who later become hebephrenics are said by their parents or
friends to have been even in early life at times over-pious or
excessively conscientious. At times they are given to brooding
long upon subjects which generally do not interest children of
their age. When the period of puberty approaches these indi-
vidual idiosyncrasies become more marked ; the patients grow
more seclusive, more irritable, and markedly emotional. The
eccentricities of character begin to crystallize. It is noted by
their friends that they rapidly become singularly unconven-
tional and are looked upon as " queer fish." When perchance
an acute infectious disease, such as scarlet fever or influenza,
intervenes, or they suffer- some injury or some psychical shock,
they convalesce but slowly from the effects. The eccentricities
of character now become exaggerated and the emotional apathy
becomes a prominent symptom, taking the place of the exces-

388 PSYCHIATRY

sive enthusiasm, transports of love, and foolish infatuations that
have occurred during the earlier stages. The memory may or
may not be greatly impaired. Vague suspiciousness develops.
The patient becomes self-centred, gives expression to indefinite
fears, is distrustful of the members of his immediate family.
If transitory emotional storms develop, it is noticed that the
depth of feeling is not commensurate with the display. This is
a factor of great importance. Even during the period of great-
est storm and stress evidences of this apathy may be detected.
At times the sense of well-being is apparently intensified. The
patient smiles in a foolish way, says that he never felt better,
is perfectly satisfied with himself and the world in general. This
state of complacency is not persistent and differs essentially in
this respect from the euphoria of paresis and other conditions.
When the disease has developed the disturbances in associative
thinking are generally marked. Some patients rarely take the
initiative in conversation, while in others there may be a typical
disorganized ataxic expression of ideas with considerable
speech compulsion, differing essentially, however, from that
seen in the maniacal states. The complaints made by the pa-
tients are frequently numerous and varied. They affirm that
something is queer in their heads, deplore their state of mental
depression, complain of insomnia, of disturbances in the various
organic sensations, that they are subject to paresthesias or
neuralgias. But even these lamentations are devoid of emo-
tional feeling. In the milder cases the hallucinations and
delusions are lacking in vividness and sensory plainness. They
are sometimes referred to as simple light or color sensations
or indefinite sounds. At other times the patients affirm that
they see grotesque and bizarre figures or hear voices. In a
comparatively large number of cases these disturbances of sen-
sation seldom reach any degree of severity.

There is marked disturbance in the volitional acts. The
patients lounge about the house or the wards. The facial ex-
pression is apathetic. When asked why they do not occupy
themselves, they reply that they are unable to do so or refuse
to assign any reason. At times they sit motionless for hours,

DEMENTIA PRECOX

389

taking little interest in their surroundings. The dull expression
of the face may occasionally be broken by the sudden inexplica-
ble appearance of a silly smile which flits across the countenance
and rapidly vanishes. The changes in expression are purely
impulsive. The orientation in the milder cases is fairly well
preserved. Not infrequently in testing the memory it is ob-
served that many patients give correct answers to a number of
questions and then suddenly the replies become irrelevant,
farcical, and puerile. The breaks in memory are frequently
startling. The patients remember coming to the hospital, give

e O.e. s^z^ j

This is a facsimile of the handwriting of a case of dementia precox (terminal stage).
The patient was asked to give a short resume1 of a monograph he had once written upon a
certain tribe of Indians. The request had to be constantly repeated by the examiner, as the
patient, after writing one or two words, would suddenly break off and attempt to leave'the
room.

the year correctly, the day of the week and month, and then
fail utterly to recall their own names. The grotesque irrele-
vancy in their replies, to which allusion has already been made,
is not infrequent in this form of the disease.

As the dementia progresses many of these patients exhibit
occasional signs of negativism, stereotypy, and automatism, but
there are cases in which these symptoms are more or less marked
from the beginning to the end of the disease. In the latter the
diagnosis is frequently very difficult and can only be made after

39o PSYCHIATRY

the patient has been under observation for a considerable period
of time. This simple dementing form is of great practical and
forensic importance.10 The onset is very insidious. The defects
in intelligence and anomalies of emotions may be very slight.
The specific symptoms do not develop. The progress is exceed-
ingly slow and the course may be masked by long periods during
which the patient's condition remains unchanged. In the lower
classes of society these patients are frequently found among
the tramps and vagabonds. On superficial examination it is
impossible to demonstrate any marked mental defect. Thought
that does not require much concentration or protracted effort is
unimpaired. If, however, the patient's attention is long riveted
upon one theme spasmodic irrelevancy and a tendency to jump
from one topic to another may become apparent. Written as
well as spoken language may be formally correct. Orientation
and the power of picking up and retaining new impressions is
fairly well preserved. Ethical defects sooner or later become
obvious. These are apt to be noticeable first about the time
of adolescence. Individuals resent discipline, become antisocial,
addicted to drugs, particularly to alcohol, but do not give such
marked evidences of sexual excesses or irregularities as are
met with in the other forms of the disease. The same is true in
regard to the commission of actual crimes. These are common
in the severer types of the disease if the patient's liberty is not
restricted, but vagabondage and the commission of minor
offences characterize many cases of this slow dementing type.
The intolerance for alcohol is marked. This symptom alone
may be the means of bringing the patients to hospitals f<3r
observation and treatment. As the disease progresses the in-
dividuals may be thought to be merely very eccentric or ethically
deficient, but the true character of the disorder is seldom recog-
nized. Very gradually, it may be after the lapse of years and
without the occurrence of acute exacerbations, the signs of
dementia praecox appear.

16 Diem, Otto : Die einfach demente Form der Dementia Pracox.
Archiv f. Psych, u. Nervenk., Bd. xxxvii, Heft I.

DEMENTIA PRECOX 39I

Catatonic Form. — The most prominent symptoms in this
form of the disease are cyclic alternating periods of depression,
mania with characteristic motor disturbances, stupor, and con-
fusion. Their relative prominence in individual cases varies
considerably. In some instances the depression and stupor are
more marked, in others the excitement and motor symptoms.
The affirmation made by some observers to the effect that char-
acteristic motor symptoms may be entirely absent during the
whole course of the disease is not confirmed by the clinical evi-
dence. On the contrary, careful routine examinations made at
different stages in the disease show that they are always present.
Patients whose symptoms are so obscure that it is at first im-
possible to recognize them as catatonic are frequently admitted
to hospitals. More frequently even than in the other forms of
the disease a history may be obtained from the relatives or
friends which at first suggests the possibility of an acute onset.
We find that after an acute attack of illness the patient had
convalesced but slowly and during this period, while subjected
to some unexpected physical or mental strain, the symptoms of
catatonia developed. As a rule, the signs of mental depression
are the first to appear. This type of melancholy is often difficult
to differentiate from that occurring in manic-depressive insan-
ity. At times the patients pass from depression into a period of
mutism which may persist for days, weeks, or even months.
Generally at some time during this interval there are well-
marked symptoms of negativism. If the patient is in bed,
immediately on the approach of the physician the bedclothes
are drawn over the head, the slightest touch is resented, and
every attempt is made to get beyond the reach as well as out of
the sight of the examiner. Patients who are so afflicted and are
walking about the wards run to a far corner, hide behind the
door, in the closets, under the bed. If restrained, they often
resist actively. If the head is held, they refuse to look at the
physician. To the casual observer the negativistic symptoms
seem to develop without rhyme or reason. All forms of ex-
ternal stimuli seem to arouse an aimless, capricious, silly resist-
iveness. Frequently such patients struggle violently, without

392

PSYCHIATRY

uttering a sound, to get away from the nurse or attendant or
may burst out into a silly laugh. Sometimes they become very
angry, but this emotional display generally indicates the pres-
ence of some delusion. The negativism may persist for weeks
at a time. During this period patients frequently refuse all
nourishment, so that forced feeding has to be resorted to. There
may also be a voluntary retention of the urine and faeces. In
addition to negativism marked stereotypy of word and action
may become a prominent feature. The patients will stand for
hours in one spot. If the condition known as cerea Uexibilitas is
present they maintain for long intervals of time any attitude in
which they are placed. At times catatonics seem to have a very
restricted capacity for holding idiomotor images in conscious-
ness. If the arm is elevated and placed in an uncomfortable
position there is no tendency to allow it to fall either in response
to various forms of pain stimuli or when the other arm or a leg
is put in an equally uncomfortable position ; but the moment the
attention is directed to carrying out some voluntary act, such as
protruding the tongue, closing one eye ,or flexing and extending
the fingers, the arm which has been elevated slowly drops to the
side. During the earlier stages of this depression, which is more
apparent than real, a condition suggesting psychomotor retar-
dation develops. The more carefully the patients are stud-
ied the less obvious becomes the actual change in the emotional
tone. What was at first taken for depression is found in reality
to be apathy. If the patient during the period of depression tells
us of certain hypochondriacal feelings, a marked incongruity
between the objective expression and the emotional tone can
be detected. In the very earliest stages this apathy is evidenced
by a certain degree of listlessness, lack of interest in the sur-
roundings, and an evident embarrassment which is increased
when the patient is conscious of being watched. This state is
evanescent in character. During this period patients not infre-
quently are very impulsive and may show marked suicidal ten-
dencies. Acts are not performed with any degree of deliberation
and seem to be the result of pure impulse. When the depression
deepens a catatonic stupor may intervene. To all outward ap-

PLATE X

Cerea flexibilitas in a slowly developing case of dementia praecox. When this patient first
came under observation at the Johns Hopkins Dispensary there was only a very mild degree
of dementia present.

DEMENTIA PRECOX 393

pearances the patient leads a purely vegetative existence; the
face is apathetic, expressionless ; extra-organic stimuli, as a rule,
produce little or no evidence of reaction. The muscular rigidity
on passive movement is usually well marked. In some instances
all the muscles of the trunk and extremities are involved, while
in others only certain groups seem to be affected. The rigidity
may be more or less limited to the movements of flexion or
extension ; at times pronation and supination are also involved.
Occasionally the face shows involvement, and in exceptional
instances the muscles of mastication may become so rigid that
the jaws are tightly closed. All passive movements, as a rule,
awaken antagonism in the opposing muscles. In the catatonic
contraction there is a marked hypertonia of the muscles. This
may frequently be so intense that it is impossible to alter the
position of the limb in a catatonic without using great force.
The antagonistic action of muscles may be quickly recognized
when the examiner attempts to flex or extend passively the limb
of the patient. Observers differ essentially in regard to the
specific importance of the symptom known as cerea flexibilitas.
Some clinicians affirm that this condition may frequently be
met with in the manic stupor of manic-depressive insanity as
well as in other psychoses. Pain stimuli are usually not fol-
lowed by an apparent reaction. The skin may be pricked with
a needle or stimulated with a strong galvanic or faradic current
without any evidences of sensation. The conduction of the
nerves for electrical stimuli has been investigated, but the re-
sults so far obtained are conflicting. The patient makes few,
if any, movements. Attempts at passive movements may evoke
considerable rigidity. A patient will often keep his hands so
tightly flexed, the finger-tips and nails pressing deeply into the
palms of the hands, that it is necessary to forcibly open the
hands and give him something to grip upon, in order to prevent
maceration of the palms of the hands and fingers. Frequently
the eyes are kept tightly closed, or again they are partly or wide
open. The eyeballs may be touched without any evident reac-
tion. During the continuance of this state external stimuli
neither increase nor diminish the rapidity of the pulse nor the

394

PSYCHIATRY

rhythm of the respiration. But in spite of the presence of these
symptoms the psychical functions are not completely inhibited.
Days or weeks afterwards when the patient has emerged from
this condition it is found that events that have occurred during
this stuporous state are sometimes recalled in such detail as to
show a remarkable degree of memory. The transition from this
stage may be gradual or in some instances sudden. Occasion-
ally a patient who has been in a deep stupor for weeks in a few
hours becomes completely changed, is able to answer questions,
to walk about the ward, and give a rational account of every-
thing that is transpiring. It may be weeks, however, before
the transformation is complete. In some cases the period of
stupor is not well marked and the depression may be followed
immediately by a maniacal condition. During this time the
acts of the patient may suggest the frenzied state of epileptics.
Every stimulus is unduly magnified and there seems to be no
power of inhibition present. If given their liberty, the patients
rush wildly about the wards, assaulting other patients, nurses,
or whoever happens to come in their way, throwing themselves
against the wall, on the floor, striking and breaking pieces of
furniture, etc.

Hallucinations and delusions may be associated with the
impulses. The patients see fantastic figures, devils, spirits. As
a rule, they affirm that these phantoms are of a hostile character
and are trying to injure or kill them. At times these delusions
have a sexual basis. The patients affirm that evil spirits are
trying to outrage them or that they are forced to do unclean
things against their will. When interrogated as to their physi-
cal condition a whole chain of delusions suddenly springs into
the foreground of consciousness. Any and all questions ac-
tively initiate and arouse anger. The physician is peremptorily
told to get out of the room, and if the request is not at once
complied with summary vengeance is threatened. On being
left to himself the patient may at once become quiet, sitting
down and relapsing into an apathetic state, but on the approach
of any one he suddenly springs up again and becomes aggres-
sively offensive. The excited catatonic patient is a source of

DEMENTIA PRECOX 3o5

great danger to himself as well as those about him. The change
from the state of apparent apathy to one of the wildest excite-
ment is instantaneous. The duration of these periods of excite-
ment, as well as of those of depression or stupor, vary greatly
in duration. The paroxysms are characterized by greater im-
pulsivity, more explosive emotional gusts, in which the acts are
more unpremeditated and more inexplicable than those occur-
ring during the motor excitement in the manic-depressive
insanity. The actions as well as the speech of the excited
catatonic are either monotonous and iterative or are startling,
inapposite, and bear no relation to the incident stimuli. The
tendency to harp on one theme, the inane jargon that is appar-
ently not conditioned, nor deflected by extra-organic stimuli, is
in marked contrast to the typical flightiness of the maniacal pa-
tient. The expressions used by catatonics are sometimes only
senseless syllables, stereotyped expressions repeated, it may be,
for hours at a time. If an attempt is made to deflect or to
stop these babblings, the patients only shout the louder. During
the excitement catatonics often refuse food. If unrestrained,
they dash dishes on the floor, fling them across the ward, strug-
gle violently while being fed, or tear their clothes to pieces.
Certain individuals show only a limited motor excitability,
while in others there is a general restlessness ; they skip, hop,
run, jump, and keep up an incessant motion, not infrequently
carrying on these antics with a silly smile on their faces. They
bump heedlessly into the furniture, shove any one out of the
way who happens to be near, if they do not actually strike or
kick him. Although considerable force may be coupled with
these actions, the patients often are not deliberately aggressive
and will not try to injure any one unless interfered with.

Psycho-anesthesias are not uncommon. Some patients
fling themselves about, caring little how or where they strike,
and frequently inflict severe injuries upon themselves. Even
these coarse, unpremeditated movements, as a rule, show some
evidence of stereotypy. There is no marked incoordination, but
the patients are decidedly clumsy, and any appearance of grace
and ease is absent.

396 PSYCHIATRY

This form of the disease varies within wide limits. The
degrees of intensity and duration of individual symptoms can
not be foretold. The stuporous condition may last for months
and the relative prominence of the mannerisms, tics, nega-
tivism, command automatism, is different in each case that
comes under observation. The catatonic excitement may show
occasional remissions or exacerbations, or may continue un-
changed for months, or in extreme cases for even two or three
years.

Paranoiic Form. — This type of the disease is represented
in part by cases in which catatonic symptoms first appear and
are followed later by the development of fixed systematized
insane ideas. These cases end, as do the other forms, in a
terminal dementia. Many of them, until recently, were gen-
erally classified under paranoia. On account of the chronic and
frequently stable character of the paranoiic symptoms it is
often impossible to make a diagnosis unless a complete history
of the case is obtained. In the early stages periods of depres-
sion, of excitement, of stupor, and the characteristic catatonic
motor disturbances — rigidity, negativism, stereotypy, and ver-
bigeration— occur. Many observers in discussing the subject of
paranoia attempt to distinguish between chronic simple par-
anoia and the hallucinatory form. If these paranoiic states are
carefully studied, symptoms characteristic of dementia praecox
can frequently be noted at some time during their course. Ac-
cording to Weygandt 17 this group of cases, in which in the
earlier stages hallucinations are a prominent symptom followed
later by stable organized insane ideas, represents a definite
clinical type of the disease. The hallucinations are frequently
strange, fantastic, and seem to exert a remarkable influence
over all volitional acts. One patient under observation in the
hospital refused to work, as he affirmed that the birds in the
trees talked to him and he was obliged to listen to what they
said. He also told us that at times voices repeated things to
him, generally of a pleasant character. Frequently hallucina-

" Weygandt: Op. cit.

DEMENTIA PRECOX ^7

tions and the insane ideas are combined in such a way as to
give the picture of a well-ordered systematized persecutory
paranoia. The patients affirm that they are being chased about
by devils, receive electric shocks, are being communicated with
by spirits; the room is full of invisible forms who are con-
stantly harassing them. These ideas may persist for years,
gradually becoming more foolish and absurd, and the disor-
ganization of associated memory becomes more and more
marked. Not infrequently hypochondriacal symptoms are
present. When asked why they do not work, the patients affirm
that they are unable to do so, that the heart has been displaced,
that certain organs are wanting, that they lack the power to
concentrate their attention. Sometimes they express a willing-
ness to work, but contend that they are prevented from doing
so by the action of spirits, devils, fiends. One patient for months
at a time complained of stomach trouble. He would stand for
hours kneading his abdomen and trying to belch up wind.
Occasionally impulsive acts appear, at other times mannerisms ;
again the speech suggests the word hotch-potch or verbigeration,
or the patients may show plainly command automatism. The
auditory are more common than visual hallucinations, although
the latter sometimes occur. Not infrequently olfactory hallu-
cinations are present. Patients affirm that dead animals have
purposely been left outside their door and that the unpleasant
odors are a continual source of annoyance.

Another group of cases are those described by Kraepelin
under the term dementia paranoides. Here the hallucinations
are less in evidence, but the insane ideas of persecution and
megalomania become more prominent. At times, early in the
disease, the hallucinations have great sensory vividness, but this
is soon lost and instead the chronic systematized delusions de-
ficient in objective plainness occur. The delusions are protean
in character. Sooner or later during the course of the disorder
symptoms described as characteristic of dementia praecox are
sure to appear. At times patients are so disputatious and
querulous as to justify their classification among the cases of
so-called litigious insanity. Again, it may be very difficult to

398 PSYCHIATRY

differentiate them from the true paranoiics, and this can only
be done when it is possible to obtain from competent observers
a full history of the case. Instances are reported in which pa-
tients have been so specious and plausible in the statement of
their supposed grounds for controversy and wrangling that the
affairs have been carried to court. In the more pronounced
cases there is marked dissociation of thought as well as impair-
ment of volition and emotional apathy. The stories told by
the precocious dements are, as a rule, illogical and lack the con-
tinuity of those of the paranoiic. The patients sometimes give
an account of the manner in which they have been ill-treated by
their friends. Up to a certain point the tale is logical and to
all intents and purposes truthful; then unexpectedly some
unseen agency is introduced without rhyme or reason, and they
confess that certain acts committed have been due to the ad-
monitions of spirits or of departed souls. Occasionally the
character of the megalomania is pathognomonic for this type
of the disease. The same fantastic unreal elements enter into
its composition. The patients affirm that they are in league
with spirits, receive information from them; that they have
the power of second sight; have communication with other
worlds; that they are princes or princesses of the Pole Star.
While affirming this in one breath they complain of their help-
lessness in another ; that they are powerless and unable to help
themselves.

Associated with the megalomania there is frequently a
slight emotional depression. The hypochondriacal complaints
are characterized by an apparent lack of emotional feeling. In
some instances, as has already been said, the continuity and
logical character of the insane ideas are well maintained, while
in others the aid of mysticism, clairvoyance, spiritualism, and
Christian Science is invoked to explain anomalies of thought
and action. In these latter cases the ideas, as a rule, are more
incoherent, and the strangest, weirdest, and most extravagant
forms of speech are employed. These patients are excessively
capricious, full of fads, crotchety, inconsistent, and erratic to
an extreme degree. Their conduct is in a measure conditioned

DEMENTIA PRECOX 399

by the insane ideas. Impulsivity is marked at times, at others
there are frequent mannerisms and displays of arrogant ego-
tism, ostentatiousness, and priggishness. The stereotypies vary
greatly in character. Some individuals never leave the ward
without walking along a certain line on the carpet. Others
sit in one place, half automatically play games of cards — soli-
taire— for hours, shuffling the cards in the same stereotyped
way, playing game after game correctly but in a mechanical
manner, yet apparently taking little or no interest in what they
are doing. Voluntary conversation is sometimes limited, at
other times there is a tendency to be garrulous. The inability
to divert and direct the patient's train of thought is singularly
noticeable. These individuals become irresponsive to external
stimuli although the primary sensations are exceedingly well
preserved.

Dementia Paranoides. — Admitted to hospital December 15, 1896.
Male, aged 34, single.

Family History. — Mother nervous. Rest of family history negative.

Personal History. — Early history of patient somewhat indefinite. Al-
though said to have been unusually bright at school and college and always
ranking well in his favorite studies, he showed no aptitude for others.
Was a close and hard-working student. Manner diffident, disposition
retiring. While abroad in 1892 he broke down from overwork and was in
a hospital for some time undergoing treatment. Was brought home in
1894. While living at home he worked for some time in a desultory way,
was very reticent, secluded himself from others, was inclined to take
violent dislikes towards members of his family, but was never violent.
Became suspicious of his friends without cause and refused to be con-
trolled. Came to the hospital willingly when told he had been committed.
Upon admission he was quiet and reticent, answered questions in mono-
syllables, but quite coherently, and said he would remain quietly here.

Physical Condition. — Spare in flesh. Movements nervous and awk-
ward, head ill-shapen, forehead flat. Complained of dyspepsia of intestinal
type. Remained in hospital until January 10, 1896, when he was discharged
and left for home. During stay at home he was diffident and seclusive, ate
and slept fairly well, improved somewhat in weight and strength. Several
attempts were made to employ him, but he showed no power of attention.

Readmitted December 15, 1896. Condition about the same as when
in hospital, except he had gained somewhat in flesh and strength. During
1897 his general condition remained the same. Returned to the hospital and
was allowed to go home for a day or two at a time. Expressed the delusion
that a battery was being worked on him. Once he left the dinner-table very

4QO

PSYCHIATRY

suddenly, tipping over his chair in doing so. When asked why he had done
so, he said that a galvanic battery had been applied to him and that the doc-
tors knew all about it. Occasionally was somewhat agitated and markedly
discontented and often asked to be allowed to go home. At other times
would sit for long periods staring vacantly into space. Ate and slept well.
Would read newspapers and medical journals to some extent, but gradu-
ally lost interest. At one time he helped with the urinary analyses in the
laboratory, but was erratic in the work and not to be depended upon.
During 1898 kept a great deal to his room, came late to meals, was easily
disturbed by the noises in the adjoining room, moved away from people
because he thought " they wish to say things they do not want me to hear."
Swore considerably, sometimes at the doctor. Always late in going out for
exercise, irritable, seldom smoked. He thought the nurses were trained to
keep food away from him. Tiptoed around in a suspicious manner ; thought
he heard noises coming from the register and these frightened him. Com-
plained of chirping of birds and kept his window closed. Was apt to wan-
der from the walking-party " to look for bones of dead animals." One
day he suddenly became impulsive, and without provocation threw a cup
at a nurse. Very slow in dressing. Would pick up his collar and shirt
and blow them off as if trying to get them clean.

In 1901 he exhibited the following peculiarities : Excessive washing of
hands. Would bathe from one to two hours. His manner and position
were decidedly awkward. Would not look at observer straight in the eye,
simply glanced at him and then immediately looked away as if embarrassed.
Replied to questions put to him in as few words as possible. Did not volun-
teer any information. Objected to examination on the grounds that this
procedure, as conducted by the doctors, was unfair and that the information
thus obtained might be used to identify him if he escaped. He said the
doctors maligned him and made fun of his gait and other peculiarities.
Very suspicious and thought that people were trying to injure him and
accounted in this way for his confinement in the institution.

Physical Examination. — No defect in speech. Thorax shows noth-
ing remarkably abnormal. Reflexes slightly exaggerated. Memory for
past events accurate and correct. Mental reactions quick. Patient has an
exaggerated sense of modesty. Orientation normal. Has a number of
auditory delusions.

December, 1903. The mental reduction is gradually becoming more
pronounced.

The So-called Lucid Intervals and Terminal Stage. — A
great many of the cases of dementia praecox end in a specifically
characteristic dementia, in which the emotional anomalies and
intellectual impairment give color to the clinical picture. The
limitation and inhibition of volitional acts are also marked.
Sense perception, as a rule, is singularly well preserved. Man-
nerisms, stereotypies of thought and act, impulsivity, negativ-

DEMENTIA PRECOX 40I

ism, command automatism, stuporous and cataleptic states, may-
persist during the dementia and recur at varying intervals with
a greater or lesser degree of severity. All forms of the disease
may end in the severer grades of dementia, nor are there any
known signs by which in any given case the degree of severity
can be foretold. In a general way, however, it may be said that
the paranoiic forms are less liable to show an abatement in the
intensity of the symptoms than are the hebephrenic or catatonic
types. No instances on record can be adduced to prove con-
clusively that there is ever a restitutio ad integrum after the
disease has developed far enough to permit an accurate diag-
nosis to be made.18 In the lowest classes of society the perma-
nent defects in the volitional, emotional, and intellectual spheres
may escape notice owing to failure to recognize them as distinct
from mere idiosyncrasies the result of the low social status of
the individual. According to Kraepelin 8 per cent, of the
heboid and hebephrenic and 13 per cent, of the catatonic patients
recover sufficiently to resume their ordinary occupations at
home. It is always possible, however, to demonstrate in these
individuals residuary psychical defects. Meyer,19 basing his
observation on the study of 46 cases of catatonia ad-
mitted to the Tubingen clinic, affirms that the prognosis is
relatively more favorable in the cases where the onset is sudden
and the stupor an early symptom than it is when the disease
begins more gradually and the stereotypies are pronounced.

This phase is in contrast to the retained intellectuality in
the lucid intervals of many, but not all, of the cases of manic-
depressive insanity. The periods of improvement frequently
recorded during an attack of dementia praecox may be inter-
rupted at any time by an acute exacerbation of the disease.

The physical symptoms of dementia praecox are multiform,
but individually none is specifically characteristic. A muddy
complexion, is frequently noted in patients in whom mental

18 A contrary opinion has recently been entertained by Karl Kahlbaum.
Monatsschr. f. Psych, u. Neurol., Bd. xii, Juli, 1902, Heft 1, S. 58.

19 Meyer, E. : Zur prognostischen Bedeutung der katatonischen Er-
scheinungen. Munch, med. Wchnschr., 1903, Nr. 32.

26

402

PSYCHIATRY

depression is a prominent symptom and acne vulgaris is quite
common. In the more chronic cases the sufferers have a
peculiar pasty appearance, the features not infrequently sug-
gesting the changes which occur in myxcedema. Sometimes
the patients look younger than they really are, but this ex-
pression would strike the careful observer as not due to the
preservation of functions seen in normal individuals, but rather
as suggesting the juvenile appearance of one whose mental
development has lagged behind. In one patient that came
under observation during the attack of depression which pre-
ceded the excitement there was a marked acneiform eruption
limited to the forehead. This was associated with gastro-
intestinal disturbances, and persisted through the period of
depression, but passed away before the end of each maniacal
outbreak.

Vasomotor disturbances are common. There may be
marked dermatographia. The skin is apt to be dry or it may
have a greasy appearance. At times there may be a tremor of
the tongue and extremities, and a weakness and temporary
spastic condition of the latter have been described in some cases.
Not uncommonly there is a marked increase in the mechanical
irritability of the muscles supplied by the facial nerve. Tapping
over this region elicits a short, sharp, quick contraction, and this
hyper-excitability sometimes involves not only the muscles
directly stimulated, but also those on one side of the face. The
eyes at times are affected with cramp-like contractions of the
muscles which suggest a nystagmus. The pupils in the early
stages react immoderately to light; not infrequently a hippus
is present. The tendon reflexes are frequently very active, in
some cases exaggerated. At times a slight ankle clonus may
be present. There may be cyanosis, profuse salivation, and
sweating. The rate of the pulse is sometimes quickened, par-
ticularly during the excited periods, and the blood-pressure may
be low, as is usually seen in cases where the motor restlessness
is excessive. Abnormally low temperatures have been reported,
especially during the period of depression. An increase of tem-
perature, if it persists for any length of time, should at once

DEMENTIA PRECOX

403

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Chart to illustrate course of case of dementia praecox. The chart shows characteristic
gain and loss of weight, average hours of sleep, and schematically indicates the changes in
the intellectual, emotional, and motor spheres. The patient died December 21, 1902.

404

PSYCHIATRY

arouse suspicions of tuberculosis, a disease to which these
patients are very prone (Kiernan). In the acute cases the
bodily weight not infrequently falls rapidly below the normal.
In the more chronic, particularly in the hebephrenic type of the
disease, the patients may become quite plump and fat.

Etiology. — The hereditary factor would appear to be of
great importance in the genesis of this disease. Some observers
have noted evidences of alienation in the progenitors in at least
75 per cent, of their cases and were able to show that the dis-
ease was endogenous in many families ; Bianchini 20 found that
hereditary predisposition was present in nearly all of his cases.
Mucha affirms that among the ascendants the disease was of
such a type that the account of the symptoms given was suffi-
ciently definite to justify the diagnosis of dementia praecox.
Confinement in an institution was not considered essential for
proving the existence of some degree of this form of mental
aberration. Thus the father, mother, brother, or sisters were
found to have exhibited abnormal mental characteristics, such
as apathy, a singular lack of initiative, combined with the occur-
rence of mannerisms, stereotypies, etc. Burr 21 affirms that
" only he who is preordained can acquire the disease."

Apart from the hereditary basis the environment of the
patient is of the greatest importance. Rapid change in the social
condition of families is unquestionably a factor of great etio-
logical importance. The children of families who were formerly
poor and have suddenly come into the possession of wealth are
particularly prone to fall victims to this malady. The same is
equally true of individuals who have been accustomed to a
quiet country life and then have moved to large cities, where
they have been suddenly subjected to new and entirely altered
surroundings. In the discussion of catatonia Kahlbaum called
attention to the fact that the disease was particularly apt to

" Sull eta compersa e sull' influenza dell' ereditaria nella natogenesi
della demenza primitive o precoce. Riv. sperim. di Freniatria, vol. xxix,
fasc. 3, 1003.

21 Burr, Charles W. : University of Pennsylvania Med. Bull., March,
1003-

DEMENTIA PRECOX 40c

break out in the families of those who were engaged in certain
professions or trades, and affirmed that ministers, teachers, and
their children were particularly liable to suffer from this disease.
Its frequency in other professions has also been noted ; and, in
fact, any occupation which gives rise to conditions which lower
the physical activities of the individual while unduly stimulating
the functions of the central nervous system is preparing the
soil for this form of alienation. According to Bianchini and
other observers the mental and physical development of those
afflicted with the disease prior to the outbreak of the malady,
except the catatonic form, has been normal. All physical dis-
orders which cause a profound anaemia, disorders of digestion,
and those occupations which cut the patient off entirely from
exercise in the fresh air, long periods of work uninterrupted by
holidays, trauma, excesses of various kinds, infectious diseases,
particularly influenza, may become the starting-point of this
disease. As far as we know there does not seem to be any
great difference in the frequency with which the malady affects
the two sexes. Instances of this form of mental aberration
are said to have followed certain surgical operations.22 But
although this statement can not be categorically denied, the
present evidence upon which it rests is too limited to warrant its
acceptance. That operative interference has merely precipitated
an attack of catatonia must first be positively excluded before it
is possible to affirm that catatonic symptoms are the direct result
of injuries inflicted upon the central nervous system.

The differential diagnosis 23 when the disease is well de-
veloped is not particularly difficult, especially if stereotypies,
mannerisms, verbigeration, and negativism are present. In the
early stages, however, it is often impossible to make a positive
diagnosis of dementia praecox until the patient has been under
observation for some time. At first the protean forms of

22 Bonhoffer, K. : Ueber ein eigenartiges operativ beseitigtes kata-
tonisches Zustandbild. Centralbl. f. Nervenheilk. u. Psych., Nr. 156,
Januar, 1903.

23 Pritchard, W. H. : Observations on Dementia Praecox. Cleveland
Med. Journ., January, 1904, p. 18.

4o6 PSYCHIATRY

neurasthenia have to be considered. The occurrence of im-
pulsive acts, mental depression with slight apathy, slow psy-
chical reaction, the appearance of mannerisms and the like,
however, render it probable that the case is one of dementia
praecox and not a purely functional disorder. Not infrequently
hysterical symptoms complicate the question and increase the
difficulties in diagnosis, since they often are met with during
the early stages of dementia praecox. Occasionally we have
to do with the so-called hysterical insanity, but it must always
be remembered that this form of alienation is comparatively
rare and many of the cases formerly classed under this head
are now known to be dementia praecox. Hysterical symptoms
•do not necessarily mean an hysterical insanity.

The initial stages of manic-depressive insanity and de-
mentia praecox frequently have many symptoms in common.
The motor restlessness of the former presents essential differ-
ences that distinguish it from the quixotic, volcanic, emotional
explosions of the precocious dement. In the latter group of
cases the acts seem to be the result of an inexplicable im-
pulsivity. The motor agitation is not so constant; there are
moments of quiet and apathy. The patients, if they talk at all,
give expression to their ideas in a bizarre, grotesque manner.
Frequently the hotch-potch of words is apparent. In the ma-
niacal cases, on the other hand, there is the typical flight of
ideas characterized by an uninterrupted flow of language. The
train of thought deviates rapidly in response to various stimuli.
In the dementing cases the dissociation is the prominent fea-
ture in the anomalous physical state. The typical flight of ideas
is absent, although there may be the stereotyped repetition of
certain words and phrases. Another essential difference is that
in the maniacal cases the emotional no less than the intellectual
state is in a measure determined by the patient's environment.
Maniacal patients see something that pleases them or arouses
their suspicions, and the appropriate emotional tone and the
corresponding objective expression of the same are instanta-
neously reflected in thought and act.

In the dements there is an apparent incongruity or dis-

DEMENTIA PRECOX 407

sociation between the expression of the mood and the incident
stimulus ; the emotional change is frequently foolish, purpose-
less, silly. One is never quite sure how these cases will respond
to stimuli. In those afflicted with manic-depressive insanity
the physician is frequently able to say in advance what effect
a given stimulus will have.

The differentiation from paresis is sometimes difficult,
particularly in the juvenile forms of the disease. The speech
and action of the paretic may at times become decidedly stereo-
typed, but never to the same degree commonly noticed in cases
of dementia prsecox. The condition of the pupils, the diminu-
tion in the reaction for light, the involvement of the cranial
nerves, and the speech disturbances are important diagnostic
signs of paresis. During the course of epileptic mania we fre-
quently meet with impulsive acts associated with great violence.
The disorientation of the epileptic is more apt to be complete.
The precocious dement, on the other hand, frequently retains
a fairly accurate knowledge of his environment and identity.
Meyer 24 affirms that the appearance of catatonic symptoms,
while unfavorable, does not necessarily imply that the case is
absolutely incurable, as in his experience from 20 to 25 per
cent, of his patients who have shown these symptoms after a
considerable period of time have completely recovered. The
hereditary factor is an important element in at least 54 per
cent, of all cases. The period of depression in the dementing
cases may be distinguished from the senile melancholias by
the occurrence of stereotypies, negativism, etc. This psychosis
is, as a rule, distinguished from amentia by the more sudden
onset of the latter, the history of a period of marked physi-
cal exhaustion, the number as well as the dominating force of
hallucinations and illusions, and the marked disturbance in
the perceptive processes as well as in orientation. The differ-
ential diagnosis, however, between this disorder and other sub-
acute delirious or confusional states, such as amentia, is fre-

14 Zur prognostisch. Bedeut. der katatonisch. Erschein. Munch, med.
Wchnschr., 1903, Nr. 32.

4o8 PSYCHIATRY

quently one of the most difficult that the alienist is called upon
to make. There is little doubt that isolated catatonic symptoms,
such as verbigeration, cerea flexibilitas, and impulsivity are not
infrequently observed in the latter condition. We are inclined
to agree with Stransky 25 that amentia is not as uncommon a
disease as the Heidelberg statistics seem to indicate, it having
been met with only six times in 1500 cases. In two instances
which within the past year have fallen under our observation
the patients although showing catatonic symptoms ultimately
recovered, and after a careful examination no residual mental
defect was noted. From these and similar observations we
are led to believe that the occurrence of isolated catatonic symp-
toms does not necessarily imply the existence of dementia
praecox.

The juvenile cases of dementia praecox bear a striking simi-
larity to cases of imbecility. The diagnosis depends upon the
history of the patient and the occurrence of those symptoms to
which reference has so frequently been made. The difficulties
are increased in cases in which the dementia seems to be en-
grafted upon a preexisting state of feeble-mindedness.

Some clinicians have attempted to establish the identity
of the pathological processes concerned in the production of
imbecility and certain cases of dementia praecox. This error
depends in a measure upon the failure to recognize the fact that
dementia praecox not infrequently occurs at a comparatively
early period of life. These juvenile cases dement rapidly and
give rise to a chronic state which presents many of the symp-
toms common to imbeciles. The greatest difficulty in diagnosis
is sometimes met with in the more protracted cases. As Jahr-
marker 2,i has pointed out, there is need for a more careful study
of the type of cases now grouped under the head of dementia
paranoides. Only after the lapse of months, or it may be of
years, is it possible to determine whether the disease in question

'* Stransky, Erwin : Zur Lehre von der Dementia Praecox. Centralbl.
f. Nervenheilk. u. Psych., 1904, Januar, xvii. Jahrg., N. F., Bd. xv.

28 Jahrmarker, Max: Zur Frage der Dementia Pracox. Eine Studie.
Verlag von Carl Marhold. Halle a/S., 1903.

DEMENTIA PR/ECOX 409

should be grouped under the head of paranoia or whether there
are any symptoms which suggest catatonic dementia. In regard
to these cases it must also be kept in mind that a paranoiic state
does not warrant the diagnosis of paranoia.

The occurrence of isolated catatonic symptoms during the
course of other psychoses has been frequently observed. Jahr-
marker 27 has noted them in dementia paralytica and reference
has already been made to their appearance in amentia. In one
case that came under observation the patient presented a typical
series of catatonic symptoms and in addition Argyll- Robert-
son pupils, absence of the patellar tendon-reflex, characteristic
paretic disturbances of speech, and a definite history of luetic
infection were noted. Such a combination of symptoms, how-
ever, naturally suggests the possibility of a complication. In the
majority of cases with diminished reflexes, unequal pupils, and
a sluggish reflex for light we are justified in assuming the
presence of two distinct disease processes. Although it may
be admitted that isolated catatonic symptoms occur during the
course of other psychoses, this does not justify the assumption
that the simultaneous or consecutive appearance of several of
these symptoms is not specific of catatonia. As far as we are
able to judge, there is no reason for believing that the cata-
tonic form of dementia prsecox may not complicate other
forms of insanity. If this be true, the catatonic symptoms are
not an integral part of the clinical picture of other forms of
alienation. The nervous manifestations which are in a measure
characteristic of the earlier cases of catatonia are increased
tendon-reflexes and sometimes widely dilated pupils.

Pathology. — The pathological changes noted at autopsy in
the internal viscera of patients who have died during an attack
of dementia praecox are, as a rule, extensive, but neither indi-
vidually nor collectively are they specific. Kiernan was the
first observer to call attention to the fact that cases of catatonia
are very apt to have tuberculous infections.

Dunton, as a result of his very careful studies, reports that

"Op. cit.

4io

PSYCHIATRY

there is a general but not excessive series of alterations in the
neural elements. The nerve-cells show slight central chromo-
lysis, more marked, as a rule, in the deeper layers of the cortex.
Some of the nuclei are swollen and there is a folding of the
nuclear membrane. Pale yellowish pigment in greater amount
than occurs in the nerve-cells of individuals of a similar age
and who have not suffered from alienation is found. These
changes are also noted in the nerve-cells of the basal ganglia.
Dunton 28 expresses himself very conservatively in regard to the
supposed diminution in the number of nerve-cells in the cortex.
In some instances there is an increase in the number of neu-
roglia cells which also occasionally give evidence of mitotic
division (Alzheimer). Neurophagocytosis is fairly well
marked. In one case Dunton observed " decrease in the num-
ber of Purkinje cells, and those present were distorted, atro-
phied, and showed the condition described as ghost cells."
The vascular changes, if they exist at all, are unimportant.
The membranes are normal. The hypophysis is not increased
in size.29

Zacher in a case of chronic paranoia terminating in de-
mentia reported a moderate degree of disappearance of the
medullated fibres in the cerebral cortex. Analogous conditions
were found by Cramer in two cases. In the first case the de-
menting process followed melancholia and in the second a
chronic paranoia.

Alzheimer maintains that the glia changes are in a measure
specific and that the severity of the symptoms is in a measure
proportional to the extent of the changes in these elements.
The intensity of the lesions in the nerve-cells runs parallel with
the changes in the neuroglia elements. Vogt has reported the
pathological findings in five cases of dementia prsecox and cata-
tonia. In one case the cell changes were scarcely noticeable,
but in the others the chronic cell change was well marked.

M Report of a second case of dementia praecox with autopsy. The
Am. Journ. Insan., 1904, lx, No. 4.

"Dunton, William Rush, Jr.: Medical Reports of the Sheppard and
Enoch Pratt Hospital, 1903, vol. i, No. 1.

DEMENTIA PRyECOX 4II

There was an increase of the glia throughout the outer cortical
layer as well as about the vessels. In one of the cases the vessel
wall was somewhat thickened. In the adventitia there was a
diminution of the nuclei and a considerable amount of pigmen-
tation. Practically the same conditions have been reported by
others. The investigations of Dunton in this country have
added materially to the importance of the above-mentioned
findings by confirming these observations in cases in which
careful detailed histories were given. The clinical histories, as
well as the general pathological findings, all tend to support the
hypothesis that the disease, at least in its incipiency, is an auto-
intoxication.

Bernstein 30 has recently emphasized certain facts in the
clinical picture which seem to tend to strengthen this view. On
account of the increased mechanical irritability of the muscles in
the catatonic state he infers that the hypertonia is due in part
to the action of certain toxic agents upon the neural elements in
the central nervous system. The muscular phenomenon is
looked upon as purely psychomotor. So characteristic are these
motor symptoms supposed to be that the name of dementia
paratonita progressiva or paratonia progressiva has been sug-
gested as preferable to dementia prsecox.

Patini and Madia 31 as a result of their investigations con-
clude that the catatonic symptom-complex is the product of an
abnormal psychosomatic state appearing episodically and
standing in more or less definite genetic relationship to the
stupor. According to the same view the catatonic condition
has many points in common with provoked catalepsy as well as
with the phenomena noted in somnambulism. The three con-
ditions of catatonia, catalepsy, and somnambulism indicate a
lowering of certain functions of the brain with an over-activity
of others, and as a result of this there are a disequilibration
and a dissociation of the cerebral activity.

80 Bernstein, Alexander : Ueber die Dementia Pracox. Allg. Ztschr. f.
Psych, und psych. -gericht. Medizin, Bd. lx, Heft 4, Berlin, 1903.

81 Annali di Nevrologia, 1903, anno xxi, fasc. v, vi.

412

PSYCHIATRY

Treatment. — When the diagnosis of dementia praecox is
established the afflicted individual, if possible, should be trans-
ferred to a hospital for the insane so as to be for a time under
constant medical supervision. The symptoms should be studied
with a view to determining the degree of liberty that may with
safety be given to the sufferer. In the milder forms of the
disease there is sufficient intellectuality left to render it possible
for him to be employed, preferably out-of-doors in work about
a farm or garden. Hard physical exercise in the fresh air
seems to lessen the tendency to impulsivity and acute exacer-
bations of the disease. These mild forms of the disease are
peculiarly well adapted for treatment in the colony system.
The severer types are best off either in a hospital or an asylum
where they can be carefully watched. The treatment of the
symptoms, as they arise, is purely symptomatic. As this form
of alienation is very common according to some observers, ex-
clusive of idiocy and imbecility, making up about one-fifth to
one-sixth of the cases admitted to hospitals for the insane
(although this is probably much too high a figure), it is de-
sirable that the characteristic symptoms should be recognized as
early as possible by the general practitioner. A comparatively
large number of cases are to be found among the children in the
public schools. The tendency to emotional outbreaks, intellec-
tual impairment, looseness in morals, should be sufficient rea-
sons for the immediate removal of these children from contact
with others.

CHAPTER XV

THE DEMENTIA PARALYTICA GROUP. ( PARESIS. PROGRESSIVE
GENERAL PARALYSIS OF THE INSANE ) l

Except for occasional remissions this disorder is char-
acterized by a group of mental and physical symptoms which
tend to become more and more aggravated until a peculiarly
characteristic dementia supervenes, to be followed by death after
a period varying from one to ten or more years from the onset.
The psychic anomalies are the result of a more or less general
progressive paralysis of the cortical functions combined with
occasional evidences of focal lesions. Pathological changes in
the brain, medulla, spinal cord, peripheral nerves, and sympa-
thetic system are common and frequently extensive, but the
totality of these alterations is alone distinctive. The beginnings
of our knowledge regarding dementia paralytica are supposed
to date back to the time of Thomas Willis, although in all prob-
ability the earliest authentic descriptions are those of Haslam in
1798. The characteristic speech disturbance was first noted by
Esquirol, but the first definite attempt to differentiate dementia
paralytica as a disease entity was made by Bayle in 1822, and
the first monograph upon this subject was written by Calmeil
in 1826. Since that time, both in the clinic and laboratory, a
large body of investigators have added materially to our knowl-
edge of this disease, so that at present it has probably been the
subject of more extended study than any other form of aliena-
tion. For the sake of clearness brief mention will first be made
of the various individual symptoms, but the discussion of their

'V. Krafft-Ebing: Die Progressive allgemeine Paralyse. Holder,
Wien, 1894. Bannister, H. M. : Reference Handbook of the Medical
Sciences, vol. v. New York, 1902. Dupre, E. : Paralysie Generale Pro-
gressive. In Ballet's Traite de Pathologie Mentale, Paris, 1903, pp. 884-

1057-

4i3

4H

PSYCHIATRY

relative importance and the different ways in which they are
apt to occur will be reserved until we come to deal more in
detail with the course of the disease.

Although the clinical symptoms of general paresis which
have attracted the most attention are those developing in con-
nection with lesions in the central nervous system, clinicians are
gradually becoming convinced that more care should be be-
stowed upon the study of disturbances referable to disorders in
the internal viscera even in the earliest stage of the disease.
The clinical picture is the result of a chronic progressive change
in the nerve-elements, and although this deterioration may on
superficial examination seem to be more marked in some one
part of the nervous system, the disease process, as a rule, is not
localized, so that symptoms suggesting focal lesions are most
commonly to be regarded as the result of complications. The
malady progressively affects the whole psychic life of the indi-
vidual, but its onset may be most insidious. During its course
anomalous emotional states characterized by excitement, de-
pression, or apathy may appear with accompanying hallucina-

9
8
7
6
5
4
3
2
1

■

f

':V

'■''■

ill

■ >

j

'//' j i ; {

\

25 30 35 40 45 50 55 6

0

Chart I. General paralysis in women. 36 cases. (After Pickett.)
The figures at the bottom represent the ages ; those at the side the number of cases.

tions and delusions, but later on there develops, more or less
rapidly, a terminal dementia with a specific stamp and distinc-
tive physical manifestations.

DEMENTIA PARALYTICA

415

Incidence and Etiology.2 — In the great majority of
cases the disease makes its appearance in the third and fourth
decades of life at the time when the intellectual faculties are

Chart II. General paralysis in men. 113 cases. (After Pickett.)
The figures at the bottom represent the ages ; those at the side the number of cases.

supposed to be at their highest stage of development and the
individual is. subjected to the greatest stress and strain of life.
Undoubted cases occurring as early as the first or second and as

2 Die Aetiologie der progress. Paralyse.
Wchnschr., 1904, Nr. 43.

Raecke. Psychiat. Neurol.

4i6 PSYCHIATRY

late as the fifth or sixth decades are on record, but are relatively
rare. In the so-called infantile type of the disease hereditary
syphilis is apparently the chief factor and boys and girls are
about equally affected, but during adult life it is six or seven
times more common in men than in women.3 Undoubtedly the
disease is now recognized more frequently in women than for-
merly, but it is probable that, owing to the marked variations
presented in the disorder as it affects females and the rare
occurrence of a marked euphoria, its true nature was not
infrequently overlooked. V. Kiss 4 gives the incidence in
women as compared with men as i : 30.3, while Ringe5 found
it much more frequent, 1 15,6.

As regards the etiology of paresis in general two anti-
thetical views are entertained, some authorities holding that
syphilis is the sole cause of nearly all the cases, while others
minimize the significance of this factor and assume that in
at least half of the cases the hereditary predisposition is all-
important. In any case the latter should never be under-
estimated. Nacke 6 has referred to the frequency with which
stigmata of degeneration are observed. The general con-
sensus of opinion favors the view that the family history
indicates the existence of nervous or mental trouble in the
ancestors in at least 45 per cent, of all cases. According to
Ziehen signs of degeneracy, while more common in paretics than
in the sane, are less frequently met with in this malady than in
other forms of alienation. Other observers have called attention
to the relative infrequency with which degenerates are afflicted
with paresis. The occurrence of the disease in the descend-
ants of those who have suffered from paresis is not infrequently
reported, although they are more particularly apt to suffer
from various functional disturbances of the nervous system,

* Hoch, August : General Paralysis in Two Sisters. Journ. Nervous
and Mental Disease, 1806.

4 Orvosi Hetilap., 1904, No. 7.
6 Idem., 1903, No. 45.

* Die sogenannten ausseren Degenerationszeichen bei der p. P. der
Manner. Allg. Ztschr. f. Psych., Feb., 1899.

DEMENTIA PARALYTICA 4!7

such as impaired development, alcoholism, epilepsy, etc.7 Since
the observations of Esmarch and Jensen 8 it is obvious that in
the great majority of cases syphilis is an important etiological
factor, but it is impossible to substantiate the view that all others
are necessarily of secondary importance. The statistics upon
this point vary considerably. Gudden maintained that there
was a definite luetic history in 35.7 per cent., Hirsch in 56 per
cent, Jolly in 69 per cent., Mendel in 75 per cent., and Alz-
heimer in 90 per cent, of the paretics examined ; nor is it at all
improbable that in a varying proportion of the remaining cases
it may play an important role, although it is impossible to either
affirm or deny its existence. Between the initial sore and the
outbreak of dementia paralytica a long period may intervene —
on an average from ten to fifteen years. Hirschl gives the
extreme limits at from two to thirty and v. Kiss at from one to
thirty-two years. It is, furthermore, important to bear in mind
the fact that in many cases it is impossible to say that the
patient has not previously suffered from syphilis, although there
may be complete absence of positive evidences of a specific in-
fection. Some alienists affirm that neither a neuropathic pre-
disposition nor the syphilitic infection is sufficient to account
for all the symptoms that develop in the course of general
paresis.9 The observations of Scheube 10 are of considerable
importance as showing the relative frequency of syphilis as an
etiologic factor. From all the available data it is obvious that
paresis is relatively rare in tropical and subtropical countries
and among half-civilized peoples, whereas syphilis is very com-
mon. In Abyssinia Holzinger was unable to discover a single
case of paresis among 12,000 cases of syphilis. Rothschuh

7 Vallon et Wahl : La famille des paralytiques generaux. Congres
de Paris, 1900. Arnauld: La descendance des paralytiques generaux.
Soc. med. -psych., 1899.

* Syphilis U- Geistesstorung. Ztschr. f. Psych., Bd. xiv, S. 20.

* Coulon, E. : Nature et pathogenie de la paralyse generate. Revue de
Psych., 1902, Nr. 10. Hurd : Etiology of Paresis. Am. Journ. Insan., vol.
lviii, No. 4.

10 Scheube, R. : Die venerischen Krankheiten in den warmen Lan-
dern. Arch. f. Schiffs und Tropen Hygiene, 1902, Bd. vi, Nr. 5-7.

27

4i8 PSYCHIATRY

did not meet with any case of the disease among the Nicara-
guans, although it was estimated that at least 70 per cent, of the
men and 50 per cent, of the women were syphilitic. Similar
conditions are said to exist in Cashmere, Siam, Algiers,
Egypt, Southern California, and Brazil. The same is true in
regard to the negroes in countries where syphilis is common
and general paresis a great rarity. Berkley n and Tschisch 12
maintain that progressive paralysis is merely a late form of
syphilis and that if hereditary lues is taken into account this
factor covers the whole field of the etiology. In other aliena-
tions it is estimated that lues is an etiological factor in from 12
per cent, to 18 per cent, of all the cases.

Instances are occasionally reported of a so-called con-
jugal paresis.13

Chronic alcoholism is a factor of considerable etiologic
significance and is probably present in at least 10 or 15 per
cent, of all the cases that come under observation, although
some authors think it occurs much more frequently. Care must
be taken, however, to distinguish between the drink habit which
develops as a result of the disease from that form of over-
indulgence which precedes and is essentially of primary causal
importance.

Trauma is supposed by some to be solely responsible in
a very few cases for the development of dementia paralytica,
but although it may properly be regarded as an occasional ex-
citing agent, it is not in any sense the only one. A majority
of the cases preceded by trauma seem to develop into the simple
dementing type of the disease.

The importance of fatigue as a provocative agent in the
genesis of the disease has been repeatedly pointed out, but there

11 Berkley, Henry J. : A Treatise on Mental Diseases. D. Appleton &
Co., 1900.

12 Tschisch, W. : Definition of Progressive Paralysis ; its differentia-
tion from similar forms of disease. The Journ. of Mental Pathology,
July, 1902.

13 Ferenczi, A. : Budapester konigl. Aerzte-Gesellschaft, Bd. xvi, 1903.
Cullerre, A.: Arch, de neurol., 1004, Fevrier.

DEMENTIA PARALYTICA 4!9

are some observers who seriously question this position and
maintain that this factor alone, uncomplicated by other con-
tingencies, never gives rise to symptoms that are suggestive of
general paresis.

Insolation has been reckoned of considerable etiologic
importance, Regis and others holding that it first gives rise to
a toxaemia, which process is the starting-point of the disease.
The influence of chronic lead poisoning has long been recog-
nized, but it must always be borne in mind that many of the
cases reported as instances of paresis are in reality not to be
distinguished from Korsakow's psychosis. In Italy pellagra
has often been known to precede paresis. As a rule, the social
position and daily life of the individual are not without in-
fluence. The disease is uncommon in those who are able to
lead a regular, orderly life, but is very frequent among soldiers,
travellers, journalists, physicians, and those whose manner of
life is more or less irregular. Paresis is particularly apt to
develop among men in the higher classes of society, although
women in the same grade are singularly exempt. Any severe
disease which lowers the vitality of the individual may be the
exciting cause. Recently English observers have maintained
that gastro-intestinal disturbances play an important role in
the development of the disease.14 The statement of Bruce and
Robertson that the disease is an intoxication caused by bacterial
toxins as yet can not be substantiated, and there is little evi-
dence to warrant the belief that B. coli is an important etio-
logical factor. Bruce's theory that the normal blood-serum
causes an agglutination of B. coli more readily than does the
serum of the paretic has not yet been generally substantiated.

The sweeping condemnations sometimes put forth by cer-
tain writers against the evils of modern civilization and their
supposed relation to the marked increase in the number of
paretics are, in view of the paucity of facts, of little scientific
value. The more general recognition of the disease by the

14 Raimann, E. : Zur Aetiologie der progressiven Paralyse. Wien.
klin. Wchnschr., 1903, Nr. 13.

420

PSYCHIATRY

medical profession is a potent factor in bringing about this
apparent, but not necessarily actual, increase in the spread of
the disease.

Mental Symptoms. — The cardinal defects in the mental
functions that appear early in the disease and in nearly all
cases form the basis upon which the more complicated psychic
anomalies develop are : ( i ) disturbances in the power of atten-
tion; (2) amnesias; (3) defects in the associative processes
largely shown in the inability of the individual to form mental
syntheses; (4) changes in sensibility and in the so-called
organic sensations.

( 1 ) The inability to direct the attention may be the very
first symptom of the disease. At first the patient may be con-
scious of this abnormality and lament the fact that he is unable
to keep his thoughts focussed upon any one subject. His mind
wanders, and every attempt to focus for any length of time
upon one object or subject is accompanied by an abnormal sense
of effort. The more intellectual the individual the sooner does
this defect become apparent. The business man finds that he is
unable to conduct his own affairs or to concentrate his energies
upon the accomplishment of a single aim, inasmuch as he is
disturbed by the constant influx of new stimuli to such an ex-
tent that he soon loses track of the goal towards which he has
set out. This distractibility can be readily demonstrated by
various simple tests. For example, if the patient is asked to
add up a long column of figures, it not infrequently happens
that before the addition is completed the attention is deflected
from the problem either by the cropping into consciousness of
some new idea or by some external stimulus.

(2) As a result of this defect in the attention the memory
early shows signs of being seriously disturbed. These amnesic
defects become apparent in many ways. Thus individuals who
in both conversation and writing have before had command of
a large and varied vocabulary become greatly restricted in their
use of words, and for this reason may complain that it is a
great effort for them to express themselves. These disturb-
ances in composition, to which more detailed reference will be

DEMENTIA PARALYTICA 42I

made later on, closely resemble those seen in conditions of great
physical fatigue, and it is only when they are associated with
other symptoms that they become of diagnostic importance.
On account of the great distractibility of the individual, new
impressions are evanescent and are seldom retained. The more
complicated the process necessary for the re-collection and re-
development of sensory images the more readily does the dis-
sociation become evident. Such individuals frequently retain
a fairly accurate knowledge of events that have occurred in their
past life, while the present is more or less of a blank. The
memory for faces seen only once or twice is generally soon
blotted out. In the very earliest stages patients are often
greatly distressed by this defect, since they realize that it unfits
them for the successful performance of their ordinary duties.
The lapses of memory, as a rule, are progressive, and it is not
rare to find patients who forget the street in which they live or
are unable to recall the names of the various members of their
own family. Although in the earlier stages the patient gen-
erally retains some idea as to the importance of these defects,
and either tries to conceal them or in some way or other to
divert the attention of the observer, later on the consciousness
of their existence is much less likely to awaken a very great
degree of emotional disturbance.

Aphasic symptoms may intervene but are indicative of
complications, such as hemorrhage, softening, etc. The mem-
ory defect is more or less general, involving not only the visual
images but also including sounds. The memory for events also
suffers, and frequently the patient is unable to give any con-
nected account of what he has done on the preceding day or even
in the past hour. In spite of the great defect in recent mem-
ories there is often a remarkable recollection of events that
have occurred in the remote past.

(3) As would naturally be expected, time and space
orientation are also seriously interfered with, so that pa-
tients find themselves unable to recall the year, month, and
day of the week, and may be equally unoriented as to their
environment. At first such individuals may complain that their

422

PSYCHIATRY

surroundings seem strange to them, but cannot give any defi-
nite idea of just how they have changed except that per-
sons no less than familiar objects look unnatural. Gradually
these symptoms increase in intensity until orientation is com-
pletely destroyed and the patients fail to recognize where they
are, have no recollection of their places of business, do not re-
member being brought to the hospital, etc. In addition, all the
memories necessary for the preservation of the personal identity
are apt to be lost. In the terminal stages associative thought is
so completely disorganized that even the memories of events
long past are more or less completely obliterated. These anom-
alies in the connection of ideas appear early in the disease, and,
as has been said before, there is often a subjective recogni-
tion of this by the patient, who is himself conscious that every
mental process, particularly if it is at all complex, is only accom-
plished by the expenditure of an abnormal amount of energy.
To the observer the actual association of ideas is evidently
slow and imperfect. The higher the intellectual status of the
individual the more pronounced does this defect in association
become. Partly owing to the distractibility and partly to the
difficulty in association the amount of time required for the
completion of each mental process is very greatly increased.
The patients complain that what they were once able to do in a
few minutes now may take them an hour or more. They can not
assign a definite reason for this mental change, although they
may be fully conscious of the fact that it is abnormal. As the
disease advances the defects in association, which are at first
demonstrable only in connection with the more complicated
processes, may modify even the simplest mental effort. For ex-
ample, if a series of words is written down on a paper and the
individual is asked to give the antithetical word or phrase, it will
be noted, as a rule, that, if done at all, this is accomplished only
with the greatest difficulty. Gradually the patient becomes un-
able to control even the simpler associations, and practically all
forms of connected or associated thought are finally abolished.
Frequently, however, defects in the ordinary forms of associa-
tion as well as the anomalies in the mental synthesis and in the

DEMENTIA PARALYTICA 423

re-collection and redevelopment of past events are in part hidden
by an endeavor on the part of the patient to supply the breaks
in continuity of thought by flights of fancy. Thus, we often
encounter individuals who, although recognizing the attendants
or their immediate environment, endeavor to fill up the gaps in
memory by drawing upon their imaginations in order to find a
plausible explanation for circumstances which they feel to be
unsatisfactory. As the dissociation of thought continues,
marked confusion and a true primary incoherence may result.
(4) Anomalies of sensation are not uncommon in all stages
of paresis, but on account of the mental state of the patient it
is frequently impossible to make a satisfactory demonstration
of their existence. Sensation for touch, temperature, and pain
is not often seriously disturbed. Marandon de Montyel,15
after making careful examinations of the sensibility in a com-
paratively large number of paretics, has come to the conclusion
that whereas touch is comparatively normal in the majority of
cases during the whole course of the disease, the pain sense is
disturbed in at least one-fourth of all the cases. Somewhat
rarely hypsesthesias or analgesias depending upon peripheral
lesions are encountered, whereas hyperesthesias are said to
be of even less frequent occurrence.16 Nevertheless, it is prob-
able that the psycho-anaesthesias, psycho-paraesthesias, and psy-
cho-hypsesthesias are of far more frequent occurrence than is
commonly believed. The so-called coenesthetic euphoria re-
ferred to by the French writers undoubtedly depends upon these
psychic disturbances, and in the more advanced stages of the
disease the patients not infrequently pound themselves with
their fists or purposely inflict some injury upon themselves,
actuated by the mere spirit of bravado or to show the observer
the truth of their claims that they possess qualities superior to
those of the ordinary individual. To one particular form of
analgesia — an anaesthesia for pain on pressure over the ulnar

15 De 1'evolution comparee de la sensibilite etudiee chez les memes
maladies aux trois periodes de la paralyse generale. Bull, de la societe
de med. ment., Sept., 1902.

18 Ballet : Traite de Pathologie Mentale. 1903.

424

PSYCHIATRY

nerve as it passes the olecranon process — first noted by Biernaki
in 1894 some specific diagnostic importance has been assigned
by some authorities, but the same condition has been noticed in
a variety of other forms of alienation.

Psycho-parsesthesias are not uncommonly met with, the
patients complaining of vague disturbances in various portions
of the body — formications and other extremely annoying sen-
sations. At times unpleasant sensations are referred to the
internal viscera, and when these occur in the later stages of the
disease the patients endeavor to interpret their importance in
various ways. The special sense organs may be affected, and
hyperesthesias as well as paresthesias of the retina, of the
auditory apparatus, of the olfactory tract, are not rarely met
with.

In the earlier stages the hallucinations are very apt to
belong to the elementary forms and may be associated with
touch, sight, hearing, taste, or smell; when, as occasionally
occurs, they are unilateral in character, they are generally con-
nected with disturbances in the peripheral tracts. Recently
attention has been called to the fact that hallucinations, par-
ticularly the haptic forms, are somewhat more common, and
Serieux affirms that they play a more important role in the
genesis of the delirious states than was originally supposed.
They are probably most common in cases complicated by alco-
holism and other toxic conditions. The occurrence of psycho-
motor hallucinations has been referred to by Seglas and other
observers. The occurrence of these as well as the auditory
forms is not infrequently associated with certain localized dis-
turbances in the corresponding sense area. Not infrequently
during the course of the disease periods occur which are char-
acterized by a great exaggeration in the intensity of the hallu-
cinations, so that there develops a true hallucinatory mania.

Marked changes in the organic sensations usually develop
early in the disease. This is particularly true in regard to the
increased sense of fatigue; in fact, in a number of cases the
presence of this symptom alone in the absence of more specific
somatic changes may render it impossible to determine whether

DEMENTIA PARALYTICA

425

we are dealing with a neurasthenia or a dementia paralytica.
This sense of fatigue is common not only after mental exertion,
but is also frequently noticed after any severe physical effort.
On the other hand, at a still later stage some patients instead of
complaining of fatigue seem to be entirely devoid of this sensa-
tion. Effort costs nothing, and the tireless and unremitting
activity of such individuals is strongly suggestive of the similar
condition which ushers in an attack of manic-depressive insan-
ity. Such individuals are never still, constantly planning and
undertaking; they are living examples of perpetual motion.
Occasionally cases are met with, particularly those following
trauma, in which apathy is among the first of the mental symp-
toms. Often the period of depression or exaltation is ushered
in by one characterized by an excessive irritability. The patient
is unable to perform his daily duties, since every trifle is a
source of great annoyance, and every form of stimulation seems
to evoke an abnormal reaction. The simplest interrogation
arouses an immediate sense of antagonism and may provoke
an explosion x>f temper accompanied by tremor, reddening or
blanching of the face, and all the visible signs of great anger.
Such individuals, if their purposes are crossed, are very apt to
resort to violence. Not infrequently the emotional anomalies
are characterized also by outbreaks of apprehensiveness and
marked anxiety. Sometimes the unpleasant sensations are
referred to the head or chest, more particularly when there are
marked signs of disturbances in the cranial nerves or in the
circulation. Frequently, however, the anxiety and appre-
hensiveness is general in character and may be directly asso-
ciated with and apparently induced by one of the explosive
outbursts of temper. These emotional disturbances may persist
for some time and may then be followed by the depression or
exaltation.

These more or less primary defects in the mental facul-
ties give rise to a great variety of changes in the character,
which vary somewhat with the social as well as the intellectual
status of the individual ; hence the ability of the physician to
recognize the condition will depend to some extent on a knowl-

426 PSYCHIATRY

edge of the individual prior to the onset of the disease. The
primary disturbances in the personality are characterized by a
lack of judgment. The patient begins to lose his sense of pro-
portion, of the relative value of things in general ; his higher
moral sense becomes blunted ; the sense of duty is diminished or
entirely absent; business interests, professional engagements,
social and family ties, are ignored. As a rule, the earliest dis-
turbances are confined to the autopsychic consciousness. There
is a change in the conditions which determine the personality of
the individual. Such patients are apt to become egotistical.
They are self-centred, but except in a certain set of cases there
is an absence of hypochondriacal sensations. The sense of well-
being is exaggerated, and in contrast with hypomania is apt
to be persistently and consistently magnified. The patients are
intent on carrying out some new plan or scheme connected with
their business. They affirm that the great opportunity in life,
for which they have long waited, has at last come. For years
they have been getting ready to meet such an emergency, and
they undertake any extravagant scheme without considering the
probability of failure and with indomitable assurance that the
ultimate success of their ventures is merely a question of time.
At first this abnormal self-reliance becomes apparent only in
certain directions, generally along the lines in which the
patient's activities have been most prominently directed prior to
the onset of the disease.

Not uncommonly the apparent increase of energy in an
individual is a source of wonder to his friends or business asso-
ciates. At first the abnormality characterizing the acts or
physical processes of the individual does not become apparent,
and the failure on the part of the medical attendant to recognize
an incipient case of paresis frequently gives rise to serious
results financially, particularly if the individual has been able
to impress trusting associates with the apparent practicability
and ease with which his countless schemes can be successfully
carried through. Not infrequently in these earlier stages, asso-
ciated with the defects already enumerated, such individuals
show a marked tendency towards alcoholism, and, as a rule,

DEMENTIA PARALYTICA 427

are particularly susceptible to the toxic effects of the drug.
In most of the cases various sexual irregularities make their
appearance — urinating in public before women, exhibitionism,
the loss of all sense of decency, uncontrollable erotic impulses
that may result in assaults upon young women or children,
and sexual perversity. Later the period of excess is followed
by a marked diminution of the sexual appetite and impotence.
The insane ideas that occur during the course of the disease
are very varied in character and some have long been regarded
as being in a sense specific. This is particularly true of the
forms which will be described later when dealing with the ex-
pansive type of the disease. These ideas are apt to be largely
colored by the emotional tone of the individual. For example,
in the states of depression the individual is possessed by hypo-
chondriacal ideas, by curious notions regarding his own per-
sonal identity, or more or less typical nihilistic ideas ; while in
the expansive stage the euphoria is accompanied by ideas which
equally reflect the delirium. Their genesis has been studied by
numerous authors, but considerable discrepancy still exists as to
the exact manner in which they develop.17 Wizel as a result of
a careful study has come to the conclusion that the disorien-
tation in time and space, to which reference has been made,
is in part responsible for the development of the more or less
characteristic insane ideas. Another important factor in their
pathogenesis, according to the same author, is the anomaly
in the stereometric sense as well as the defects in memory.
These defects give rise secondarily to exaggerations of the time
and space sense that become evident in the extraordinary char-
acter of the delirium. As a result of these mental anomalies
the paretic suffers from a general dissociation of both abstract
and concrete ideas. Gross,18 on the other hand, maintains that

17 Storrung, Gustav : Vorlesungen iiber Psychopathologie in ihrer Be-
deutung fur die normale Psychologic Leipzig, 1900. Wizel, Adam :
Ueber die Pathogenese des specifischen Wahns bei Paralytikern. Ein
Beitrag zu psychologisch experimentellen Untersuchungen iiber die De-
mentia paralytica. Neurol. Centralbl., 1903, August 1, Nr. 15, S. 723.

18 Gross, Otto : Ueber die Pathogenese des specifischen Wahns bei
Paralytikern. Neurolog. Centralbl., 1903, September 1, Nr. 17, S. 843.

428 PSYCHIATRY

the mode of development of these ideas is essentially different
from that in other forms of mental disturbance. This delirium
is not in any respect an attempt on the part of the patient to
explain the strange ideas which are forced into his conscious-
ness, but is to be regarded as the result of a process similar
to that occurring in hysterical individuals who narrate the
most extraordinary adventures without any foundation of
truth. -Both phenomena are merely the product of the im-
agination. In addition to these insane ideas which are char-
acterized by their strangeness and incoherency we frequently
meet with other forms similar to those developing in para-
noic states, these latter being the result of an attempt at
explanation on the part of the patient of the isolated facts in
his consciousness.

Somatic Symptoms. Disturbances of Motility. —
Among the abnormal motor manifestations are tremor and
incoordination of the muscles of the trunk, extremities, face,
tongue, and those connected with speech and deglutition. The
disturbances are very varied and depend in great measure upon
the localization of the disease process. The cases in which the
pathological changes affect the spinal cord naturally afford a
great variety of neurological symptoms. Closely associated
with the cortical changes in all cases of paresis a slight inco-
ordination of all muscular movements not uncommonly de-
velops. This is particularly apt to first make itself noticeable
in connection with the more complicated procedures, such as
the finer movements of the fingers, the contraction of the facial
muscles, and those concerned in the coordination of the move-
ments of the eye. The tremor, which is present in a large num-
ber of cases, is, as a rule, fairly rapid — from four to six or
more oscillations in a second. It may be easily demonstrated
by making the patient extend his arms, stretch out his fingers,
or protrude the tongue ; and even if not at first apparent in the
muscles supplied by the facial nerve, it may be brought out by
asking the patient to show his teeth, not allowing him to
actually touch them with his lips and thus steady his move-
ments. This method is frequently sufficient to demonstrate

DEMENTIA PARALYTICA 429

the existence of a marked tremor in the region of the labionasal
fold, and may also be observed in the lips and when more intense
in the muscles about the eyes, particularly in the lids; occa-
sionally it is well marked in the region of the frontalis. Fibril-
lary tremors in the muscles sometimes exist. Generally the con-
tractions are slow, but this apparent interference with function
is apt to be largely superficial and does not seem to involve the
deeper layers of the musculature. The tremor of the tongue is
frequently so marked as to be a source of great annoyance to
the patients, and they will often try to conceal it when talking
by opening the mouth very widely and protruding the tongue,
their attempts to steady it giving rise to the most curious gri-
maces, which should readily excite our suspicions. It is a matter
of common experience that the tremor is not always constant
but varies considerably, its extent depending more or less
directly upon the general physical condition. At certain times
movements of incoordination seem to be more marked, and
frequently one can notice slight spasmodic disturbances in the
musculature which assume a more or less clonic character.

The gait of the paretic is, as a rule, characterized by some
uncertainty, the degree depending largely upon the extent of
involvement of the cord centres. As a rule, all grace and
delicacy of movement seem to be lost early, and the individual
who prior to the onset of the disease showed refinement and
good social breeding becomes awkward and clownish in his
manners and appears ill at ease.

The electrical response of the muscles in cases of general
paresis uncomplicated by disturbances in the peripheral nerves
as a rule show no marked or specific change.19 Lenzi20 and
other observers have noticed a partial reaction of degeneration
in the terminal stages.

Not infrequently a spasmodic contraction can be noticed
in various parts of the body, and it is probable that this phe-

18 Pilcz, A. : Ueber Ergebnisse elektrisch Untersuch. bei Paralys.
Progress u. Dement, senilis. Jahrbucher f. Psych, u. Neurol., 1903.

10 Delia reazione eletrica nerv. e musculare nelle paralisi generale
progressiva degli alienati. Ann. di Nevrol, 1899.

430

PSYCHIATRY

nomenon is not always confined to the musculature of the
trunk and extremities, but occasionally implicates the muscles
of the bladder and other internal organs. Occasional instances
of catatonic rigidity have been reported, but the histories of
the cases in which this is said to have occurred are not given
in sufficient detail to warrant the deduction that the typical
form is ever noticed in the course of general paresis.

Disturbances in Speech. — The anomalies of movement are
particularly liable to implicate the musculature of the organs
concerned in speech and manifest themselves mainly in diffi-
culty in articulation and enunciation (dyslaliae). They must
not be confused with the dysphasias or dyslogias which have
to do with impairment of the sensory functions of speech.
These disturbances are unquestionably due in part to the
interference with the functions of the cerebral cortex. The
dyslalia, or dysarthria, at first is merely an exaggeration of the
muscular disturbances resulting from fatigue. The patient
when asked to pronounce long words, such as Rappahannock
River, parallelopiped, finds considerable difficulty in enunciating
clearly and distinctly. As a result there is a marked tendency
to drop certain syllables and slur others. The difficulties are
frequently increased if the patient has been previously fatigued
as the result of mental or physical effort. When the disturb-
ance in speech is marked, the attempt to enunciate is accom-
panied by an increase of the tremor of the lips and marked
incoordination of the muscles concerned. The patient not in-
frequently affirms that his tongue feels thick or that the attempt
to enunciate clearly is accompanied by a definite sense of
fatigue. The dysphasias are analogous to many of the disturb-
ances noted in sensory aphasia. The occurrence of motor
aphasia generally indicates the presence of a complication. The
dyslogias are shown in the manner of speech; for example,
during the period of marked euphoria the enunciation is apt to
be slow and special emphasis is laid on certain words. The
speech is not accompanied by refinement of manner or gesture,
while in the periods of depression it is even more monotonous
and may be replaced by periods of mutism. Many authors have

DEMENTIA PARALYTICA

431

called attention more particularly to the peculiar intonation of
paretics. Marandon de Montyel 21 has recently made this the
subject of special investigation. Only in a small proportion of
the cases, about one-third, is the character of the voice un-
changed. In some cases the alteration is permanent, while in
others there are periods of exacerbations and remissions in the
defects, the former, as a rule, being much longer than the latter.
According to the same observer these vocal disturbances are
much more apt to occur in the second than in the first period,
while in the final stage motor troubles become extreme. The
phonograph has proved of great service in recording the char-
acter of the speech disturbances.

Disturbances in Writing. — These are similar to those
noticed in connection with speech, and as a French observer has
aptly said, " the style is the man." The purely cortical disturb-
ances cause dissociation of thought, so that attempts on the part
of the patient to write, aside from the mere mechanical execu-
tion, necessitate marked effort. Furthermore, the modifications
in the method of expression reflect the emotional and mental
state of the individual. Marked exaggeration or hyperbole is
characteristic of the period of expansiveness, while the reverse
is true for the state of depression. The movements in holding
the pen as well as in the actual execution of the letters are
coarse and incoordinated, and in the severe cases these defects
become so exaggerated that the writing is illegible. The same
tendency shown towards the omission of syllables becomes
noticeable in the writing. Defects in spelling and orthography
may become pronounced. The example of handwriting which
follows illustrates the character of the changes.

In addition to the disturbances in motility, already noted,
we not infrequently meet with a slight paresis of the muscles
supplied by the facial nerve. This is generally unilateral and
gives rise to marked facial asymmetry. The space between the

21 Contribution a l'etude des alterations de la voix dans les premieres
periodes de la paralysie generate. Journal de Neurologie, 1903, Nov. 5,
No. 21.

432 PSYCHIATRY

lids is often increased, owing either to a paresis of the orbicu-
laris or to a drooping of the under lid. Sometimes the uni-
lateral asymmetry becomes noticeable only when the patient
attempts to speak or pucker his lips, to whistle, or to protrude

THE JOHNS HOPKINS HOSPITA
DISPENSARY.

Ho. Date, „

Handwriting from case of dementia paralytica to illustrate excessive tremor.

the tongue. Disturbances of the ocular muscles are not infre-
quent, and temporary paresis of those supplied by the third
and sixth nerves is of considerable diagnostic importance
(Hiram Woods).22 The paralyses that occur as the result of
complications will not be described in full here, a comprehensive
account being available in the various articles and text-books
on neurology. The general muscular power, as a rule, is
diminished, although single muscles or groups are more affected
than others. It may be said, however, that a definite mono-
plegia or hemiplegia is to be regarded as an evidence of a
focal lesion.

Disturbances of Vision. — The disturbances of vision that
occur during the course of paresis are frequent and varied in
character. Frequently in the early stages we meet with disturb-
ances in the mental processes connected with the visual pro-
cesses that are suggestive of the functional disorders noticed in

" Schmidt-Rimpler, H. : Die Erkrankungen des Auges im Zusammen-
hang mit anderen Krankheiten. Wien, 1898.

DEMENTIA PARALYTICA 433

neurasthenia and hysteria. Associated with attacks of mi-
graine, which are not uncommon, are encountered a great
variety of visual anomalies which are ordinarily associated with
these attacks and are probably caused by the action of certain
toxic substances upon the visual cortex.

Inequality of the pupils is frequently noted and when well
marked is of considerable diagnostic importance when taken
in conjunction with other symptoms. Not only is an inequality
frequently noticeable, but the outlines of the pupil are also
irregular. In the earliest stages of the disease, particularly at
the time when the neurasthenic symptoms are marked, the light
reflex is often very active and sometimes a definite hippus is
present. Following this period the reflexes for light may grad-
ually become more and more sluggish, until at last, after vary-
ing intervals of time, the light reflex may disappear altogether
although accommodation is retained. The typical Argyll-
Robertson pupil, however, seldom appears except in the cases
which begin with tabetic symptoms. An inequality and irregu-
larity of the pupils with a diminished light and accommodation
reflex probably form the most common combination of symp-
toms. The so-called paradoxical light reflex — the pupil not
contracting when suddenly exposed to a bright light but dilating
shortly afterwards — has been noted in some instances. This
whole subject has been reviewed by Piltz,23 who affirms that the
true paradoxical light reflex is a very exceptional symptom and
occurs only in association with severe organic lesions of the
central nervous system. It may easily be confused with the
change that occurs in the pupils on convergence, divergence,
or with the hippus, as well as with the effect produced by heat
stimulation of the sympathetic and the so-called orbicular reac-
tion.

Atrophy of the optic nerve occasionally occurs, but is not
nearly as common as it is in tabes. It should, however, be stated
that some observers have reported its occurrence with much

Neurolog. Centralbl., 1902, Nov. 1, Nr. 21, and Nov. 16, Nr. 22.

28

434

PSYCHIATRY

greater frequency. Keraval and Raviart 24 maintain that the
sclerosis of the optic nerve, when it does occur, may be either
insular or annular in character. In all probability it is more
common in patients who have not come under medical treat-
ment until late in the disease. This conclusion is based upon
the fact that it is much more commonly observed in public insti-
tutions where the patients are only received after the disease is
well along in the second stage than in private hospitals where
patients are accepted at a much earlier period. These same
observers 25 affirm that the fundus is normal in 38 per cent, of
the paretics that have come under their observation.

Reflexes. — The reflexes in general paresis have been
studied by numerous observers, and the character of the dis-
turbance noted has been found to depend largely upon the char-
acter and extent of the spinal cord lesions. In the cases compli-
cated by tabetic changes the deeper reflexes may be diminished
or abolished in the later stages, although before they may have
been increased. Not infrequently the deep reflexes are tempo-
rarily abolished. This is particularly apt to be the case when
sugar appears temporarily in the urine — in the so-called pseudo-
pareses of diabetic origin. The statistics regarding the num-
ber of cases in which the deep reflexes are impaired or abolished
vary considerably, a difference that depends largely upon the
stage of the disease at which the observation is made as well as
upon a number of other conditions, such as the variations in the
type of the disease in different localities. In fully one-half of
the cases the reflexes are increased or exaggerated. This is in
part due to the absence of the ordinary cortical inhibition as
well as to the lesions in the lateral pyramidal tracts. The super-
ficial reflexes — more especially the pharyngeal and cremasteric
— are frequently altered, so that early in the disease it is not
uncommon to find them greatly exaggerated. The Babinski
reflex may or may not be demonstrable.

24 Keraval et Raviart : Etat du fond de l'ceil chez les paralytiques
generaux et les lesions anatomiques initiales et terminales. Archives de
Neurol., 1903, Janvier.

25 Arch, de Neurol., 1904, Mars, No. 99.

DEMENTIA PARALYTICA 435

Vasomotor and trophic disturbances are present in nearly
all cases and are very varied in character. Disturbances of the
circulation, most marked, as a rule, in the head, face, and ex-
tremities, are relatively common. Sometimes there is a slight
cyanosis of the face and associated with it an oedema of the eye-
lids not infrequently resulting in an apparent ptosis. It is true
that similar disturbances are found in other psychoses, never-
theless, their importance should not be underestimated as an
aid to diagnosis in the very early stages of the disease. The
occurrence of these congestions and localized cedemas is ex-
plained by a number of observers as the result of a paresis
affecting the vasomotor system.26 Not infrequently a diffuse
sweating may be noticed, which is particularly apt to occur after
the subsidence of an emotional outbreak. The sweating in
some cases is localized, being confined to certain portions of the
body, but occasionally a marked unilateral hyperidrosis is noted.
Numerous writers have referred to the importance of hsema-
toma auris in paresis as well as in other psychoses, but, as
Robertson has shown,27 the occurrence of these othaematomata
is wrongly attributed to vasomotor disturbances, observations
having shown this phenomenon to be the result of degeneration
in the cartilaginous substance of the ear. Sometimes an ab-
normal dryness of the skin is noted, while other patients suffer
from seborrhcea, purpura, or herpes; again, when lesions of
the posterior columns of the cord are present, perforating ulcers
are apt to occur.

The arthropathies are not uncommon in the cases in which
the tabetic symptoms are prominent, and even spontaneous frac-
tures are sometimes met with. Among the trophic disturbances
which play an important role are those associated with decubi-
tus. During the terminal stage, unless the patient is kept
scrupulously clean and the skin frequently bathed and all points
of continuous pressure are relieved as frequently as possible,
bed-sores are apt to develop which are exceedingly difficult to

m E. v. Niessel : Ueber Stauungserscheinungen im Bereiche der Gesichts-

venen bei der progressiven Paralyse. Berl. klin. Wchnschr., 1902, Nr. 35.

27 Robertson, Ford : Pathology of Mental Diseases. Edinburgh, 1000.

436 PSYCHIATRY

treat and may eventually prove the starting-points of a general
infection. Some patients are annoyed by a profuse flow of
saliva.28

Febrile disturbances are of common occurrence, and prac-
tically a case never comes under observation in which at some
time during the course of the disease, particularly in the ter-
minal stage, abnormal temperatures are not noted. Slight
daily variations are found even when no marked complication
exists. The curve is generally irregular and the rises may or
may not be associated with an exacerbation of the gastro-
intestinal disturbances, constipation, retention of urine, or some
lesion in the respiratory tract. Furthermore, it is probable that
febrile movements are sometimes due to central lesions. As a
rule, there is a marked rise (to 400 C. or over) accompanying
the so-called paretic attacks. Subnormal temperatures are
sometimes noted, particularly in the terminal stage, and are not
infrequently associated with symptoms of collapse.

Vagaries in the action of the heart are frequently noted.
The rhythm is sometimes irregular, the rate is usually increased,
but when a meningitis exists or the paretic process progresses
towards the lower centres (vagus) there may be a marked
bradycardia. The vascular disturbances frequently give rise to
secondary disturbances in the action of the heart. In the periods
of depression, as a rule, there is a rise in the arterial tension,
whereas during the excitement a fall may or may not be noted.
The respiratory changes, unless they are the result of complica-
tions, are purely of a functional nature. On account of their
lowered resistance such patients are particularly liable to bron-
chitis and pneumonia, or even pulmonary abscess.

The general nutrition of the paretic, as a rule, suffers, the
deterioration becoming more noticeable with the greater acute-
ness of the symptoms. In the galloping cases, as a rule, the
weight drops and remains low, the patient sometimes losing ten,
fifteen, or even twenty pounds in a few weeks. In the more

28 Marandon de Montyel : Contribution a l'etude de la sialorrhee dans
la paralysie generale. Gazette des hopitaux, 1902, pp. 1087 et 1095.

DEMENTIA PARALYTICA 437

chronic forms of the disease, especially when the patient is under
proper treatment in a hospital, the apparent subsidence of the
acute symptoms is generally associated with a gain in the bodily
weight. The disturbances in the function of the liver are various.
It is not rare to find an increase in the hepatic dulness. The se-
cretory functions of the stomach, as a rule, are materially al-
tered. There is sometimes a diminution in the hydrochloric acid
or even a complete achlorhydria. Constipation often alternates
with severe attacks of diarrhoea. As would be expected from
the pathological changes, the urine is seldom normal and in the
majority of cases shows more or less marked anomalies. Prob-
ably the most common of these is an intermittent albuminuria
with or without the presence of hyaline casts. Peptonuria is
said to be more frequent in this than in any other form of
alienation. The quantity of these abnormal constituents is
likely to reach its highest point during the attacks of excitement.
Acetonuria and glycosuria are often noted, and, as has already
been pointed out, the appearance of these constituents in some
cases seems to bear a close relationship to the symptoms
(pseudo-paresis of diabetic origin). Polyuria is sometimes
noted, particularly in the early stages of the disease.

The course of the disease may be broadly divided into
three periods; (i) the prodromal (stadium prodromorum) ;
(2) the second, in which the mental and physical symptoms
become fully developed (stadium conclamatum) ; and (3) the
terminal stage, during which the dementia becomes more
marked and finally terminates in death (stadium terminale).

The first period may extend over a number of years, and
in many cases the earliest symptoms cannot be distinguished
definitely from those of neurasthenia or the psychasthenic
states.29 In this first period, except in the acute cases, the
disease is almost always slowly progressive, and the neuras-
thenic manifestations, when not associated with the specific
mental anomalies or the bodily symptoms to which reference

28 Schaffer, Karl : Anatomisch-klinische Vortrage aus dem Gebiete
der Nervenpathologie. Jena, 1901. Zehner: Vortrag iiber cerebrale
Neurasthenie und deren Verhaltniss zur progressiva! Paralyse, S. 259.

438 PSYCHIATRY

has been made, can only be distinguished from those of a
true nervous exhaustion or psychasthenia by this steadily pro-
gressive tendency. The recognition of the paresis is even
more difficult in this early stage in individuals who would
naturally be classed among the so-called degenerative neur-
asthenics, in whom there is a marked family predisposition
towards nervous and mental disease and who all their lives have
been nervous and subject to various psychasthenic manifesta-
tions, such as defects in the intellectual and moral spheres, and
who may or may not have presented a variety of episodic
symptoms.

In the second period the mental and physical symptoms
already described become more prominently developed, while
in the final stage the dementia attains its maximum develop-
ment, the physical symptoms are greatly accentuated, and some
intercurrent trouble generally hastens death.

The different clinical forms of the disease may con-
veniently be described under five heads : ( i ) the acute or so-
called galloping paresis — forme fondroyante; (2) the de-
pressed or melancholic type; (3) the expansive or classical
type; (4) the simple dementing form; (5) the atypical cases.

Acute or Galloping Paresis, Forme Foudroyante. — Con-
siderable confusion exists in regard to the propriety of in-
cluding certain cases under this category. As long ago as 1852
Beau 30 described a series of cases which were characterized by
febrile symptoms, incoordination of movements, and various
forms of delirium, ending in death within two or three weeks
after the onset. A majority, if not all, of these cases not im-
probably belong in the category of the acute deliria. Forms,
however, certainly occur which run their course in from six to
twelve months and on post-mortem examination reveal a series
of changes identical with those described as characteristic of
general paresis. As Buchholtz 31 has shown, we must exclude
from this group such cases as begin with a slowly progressive

' Paralyse generate aigue. Archives generates de medecine, 1852.
Arch. f. Psych, u. Nervenkrankh., Bd. xxxvi, H. 2.

DEMENTIA PARALYTICA 439

prodromal period culminating in an acute outbreak with a fatal
termination. Furthermore, there must be excluded from this
group of cases those which begin with acute symptoms but are
complicated by some intercurrent trouble, such as tuberculosis,
sepsis, etc., not the immediate result of the disease process.
Some observers would have this category still further restricted
to those cases which terminate rapidly in death after delirious
or coma-like states with severe seizures, the result of an exhaus-
tion of the nerve-centres (Heilbronner). Weber32 maintains
that the group of symptoms frequently described as occurring
only in galloping paresis is not above suspicion, as the proof has
not yet been given that this particular symptom-complex is
specific for the disease, and, further, that the clinical picture
drawn by Buchholz by no means forms an entity, but rather
represents an accident determined by secondary factors, such as
the anatomical localization of the disease process in certain
areas, accidental injuries, the result of faulty nutrition, exhaus-
tion, and so on.

There is, however, a class of cases that begin with a very
acute onset. The patient may for several days or one or two
weeks have shown signs of nervousness, irritability, depression,
slight excitement, insomnia, and loss of appetite, but none of the
physical symptoms characteristic of paresis need be present.
Then suddenly an acute outbreak occurs characterized by
marked disturbance in orientation, a tendency to confuse the
identity of friends and members of the family, these manifesta-
tions being sometimes accompanied by exhilaration or exalta-
tion which may or may not progress to a marked megalomania.
Generally such patients are very excited, aggressive ; they lose
all sense of decency, are overwhelmed by hallucinations both
auditory and visual, which for a time seem to dominate their
actions. During these periods of excitement these individuals
are exceedingly dangerous, not only to themselves, but also to
those about them. The emotional instability is often quite

32 Ueber die galoppierende Paralyse nebst einigen Bemerkungen iiber
Symptomatologie und pathologische Anatomie dieser Erkrankung. Mo-
natsschr. f. Psych, u. Neurol., Bd. xiv, November, 1903, H. 5, S. 374.

44Q

PSYCHIATRY

marked. For a short time the patient is hilarious and excited,
or, again, there may be intervals of depression and weakness.
In the earlier stage of the delirium the physical symptoms of
paresis may be practically absent, but gradually the somatic
changes make their appearance. There is generally consider-
able difficulty in making the proper tests, but when this is pos-
sible it is often found that the consensual reflex is becoming less
and less active for light. There are apt to be slight facial in-
equalities due to paresis of the nerve and mild disturbances of
speech. As a rule, the incoordination of movements becomes
marked and may develop into a pronounced ataxia. Weygandt
affirms that the bodily symptoms develop rapidly, and always
keep pace with the mental deterioration, but our own experience
has by no means confirmed this view. At times the excitement
amounts to a frenzy, rivalling that of the epileptic psychoses.
If left to themselves, the patients rush up and down the room,
gesticulating and threatening attendants and physicians with
vengeance; they refuse food and will not allow themselves to
be touched. Occasionally the mental symptoms may on super-
ficial examination resemble those of manic-depressive insanity,
but the apparent flight of ideas in which sound association and
alliterations predominate is in reality not so marked as in the
latter class of cases. The distractibility of such patients is
pronounced. Each new stimulus, as it impinges upon the cere-
bral cortex, produces an immediate reaction at once reflected in
the speech or action.

Remissions are not infrequent, and the greatest excitement,
associated with an hallucinatory mania, incoherence, and me-
galomania, may alternate with periods of calm characterized by
a remarkable disappearance of both mental and physical symp-
toms. If death does not follow as the result of some accident
or intercurrent trouble, such as pneumonia, infection, Bright's
disease, etc., the patient may sink rapidly during one of the
periods of excitement from pure exhaustion. The history of
the following case illustrates this type of the disease :

Male, aged 37, married. Admitted to the Sheppard and Enoch Pratt
Hospital October 29, 1901. Died March 2, 1902.

DEMENTIA PARALYTICA

441

Family History. — Negative.

Personal History. — No history of severe illness. No previous aliena-
tion. History of probable luetic infection several years ago, for which he
was treated.

Present Illness. — During September, 1901, patient began to lose interest
in his work. He became quite nervous and worried about his work and
complained of digestive disturbances, for which he consulted a physician.
Two weeks prior to his admission to the hospital he stopped work, became
markedly apathetic, and at times hypochondriacal. Marked insomnia de-
veloped and vague suspicions. He feared that persons were coming into
the house at night and was also troubled with auditory hallucinations.

Examination in Hospital, October 30. — Lying in bed, apparently com-
fortable; takes no notice of persons entering the room; gives name cor-
rectly and year of his birth, although unable to give his age in years. Has
slight subjective appreciation of defect in memory. When he tries to
speak his tongue becomes tremulous and immovable, as if the muscles were
easily fatigued. At times the deeper muscles are thrown into play and
the lower jaw is frequently moved to the right. The lips are puckered
and the words come with an explosive force. There is some slight slurring
and a tendency to drop syllables, but the defect is not sufficiently marked
to be regarded as characteristic of a typical case of paresis. The patient
is distractible and emotional. He talks a great deal about having con-
tracted syphilis, and fears that he has given the disease to his wife. He
has marked religious fears and is anxious to know whether he can be
saved. He occasionally complains of hearing voices which tell him disa-
greeable things. There is marked incoherence. At times he is slightly im-
pulsive, springing up in bed and pointing to the electric light fixtures,
which he wishes to have removed. Once during the examination he
jumped up in bed, threw off the coverings, and went through the motions
of taking a bath. When he became quiet he did not seem to remember
what he had done. He would give no reason for his actions except once
to say " It's putrid."

Physical Examination. — Strong frame, poorly nourished. Takes an
occasional interest in what is going on about him and follows the move-
ments of persons in the room. The pupils are equal, dilated; direct and
consensual reactions for light normal ; accommodation also normal. Re-
flexes : Dermatographia well marked. Abdominal skin reflexes scarcely
perceptible. Cremasteric reflexes present on both sides. Muscles : No
apparent insufficiency in the eye muscles. No nystagmus. The grip of the
two hands is markedly different. The greater force at first is in the
right hand.

Heart : No marked enlargement. Sounds clear at apex. Second
sound at base slightly accentuated. Arteries slightly sclerotic. Inguinal
glands slightly enlarged on either side, firm, but showing no shotty con-
sistence. No nodes on the tibia.

Urine : 800 cc. in 24 hours. Specific gravity, 1025 ; distinct trace of
albumin, urea 1.34, indican diminished. No casts.

A few days after the first examination the patient became much more

442

PSYCHIATRY

restless and emotional. The distractibility was increased. In a few days
the incoordination of the muscles of the face, eyes, and tongue became
much more marked. The speech was low and muttering. When his arms
were held out the involuntary and incoordinated movements became much
more marked, and at times were choreiform in character. At times the
patient would be in a very good humor, and his conversation would
become slightly more connected and logical. He affirmed that he loved
every one and wanted to be loved by every one. He claimed to have made
several excursions to Heaven and described meeting persons as tall as the
room. Occasionally he had attacks in which the motor restlessness and
general excitement became very intense, and on a few occasions he was
aggressively violent, threatening to kill any one who came near him. The
speech disturbances became more marked. The condition did not change
materially, until February, when he had several epileptiform convulsions,
accompanied by complete loss of consciousness and general sweating; the
tongue was bloody from having been bitten, and the respirations were shal-
low. The eyes, as a rule, were fixed towards the right and upward. At
times there was a slight oscillation of the eyeballs, somewhat rhythmic, and
suggesting nystagmus. Towards the middle of the month the excitement
became more intense and his ideas and delusions first became definitely
expansive. At the end of the month the patient became distinctly worse
and very drowsy. There was no evidence of any pulmonary lesion. The
heart sounds were rapid, the first impure at the apex. The urine showed
a few casts, but no blood. The patient sank rapidly and died March 2,
1902.

The pathological findings have been described at length,33 and it is
not necessary to repeat them here except to say that they were all indicative
of general paresis.

The Depressed Type. — This form is not infrequent,
although the exact proportion can not be accurately expressed in
figures. In Europe competent observers affirm that it includes
from a fourth to a third of all the cases of general paresis ; as
a rule, it is characterized by few remissions and terminates
fatally in from two to three years. In the prodromal period we
meet with a variety of psychasthenic symptoms. Gradually
hypochondriacal ideas begin to make their appearance, the
patient's insight into his own condition being usually retained
longer than in the other forms of the disease. Such individuals
not infrequently complain that " something is wrong with

31 Paton, Stewart, and G. Y. Rusk : Acute Paresis, with Report of a
Case ; the Clinical History and Pathological Findings. Am. Journ. Insan.,
1903, vol. lix, No. 3.

DEMENTIA PARALYTICA 443

them ;" they are conscious of defects in memory and begin to feel
that they can not trust themselves in the performance of their
ordinary routine duties. They notice their inability to focus the
attention, to make any prolonged mental or physical effort, and
not infrequently affirm that they are going to lose their minds ;
that there is no hope for their recovery. At times they suffer
from severe attacks of migraine, or again they may be subject
to headaches so persistent and of such a localized character as
to suggest the existence of a neoplasm. As a rule, such patients,
particularly in the earlier stages, are very irritable. This affec-
tive state becomes the more noticeable if the genuineness of
their complaints is for a moment called into question. Not in-
frequently the depression is interrupted by intervals of appre-
hensiveness and anxiety during which the motor restlessness
increases and the patient becomes greatly excited. Frequently
insane ideas characterized by marked oddities and absurdities
make their appearance. These are liable to become even more
persistent when the disease reaches the highest stage of its de-
velopment. The patients hear voices, sometimes referred to the
chest, abdomen, or to other parts of the body ; or, again, they
are projected and seem to come from various corners of the
room, from under the bed, or from outside of the windows.
Occasionally the voices are far away, lack subjectivity, and have
some of the characteristics of psychic hallucinations. As a rule,
they say unpleasant or obscene things, scold, threaten, or terrify.
The specific character of the hallucinations reveals an existing
dementia. Now and again the patient may apparently be con-
vinced of their subjectivity for a time, but in the great majority
of cases the power of recognition is entirely lost. Sometimes
patients will sit and indulge in a monotonous, uninterrupted
wail, lamenting their condition or their inability to comply with
the demands made by the voices. As a rule, the visual hallucina-
tions are less dominating and less insistent than the auditory
forms, and occasionally are associated with definite individuals.
The haptic forms are not infrequent and are usually associated
by the patient with external agencies. Spells are supposed to be
thrown over them, and the tingling in their extremities to which

444

PSYCHIATRY

they are subject becomes in their eyes a sign that they have been
poisoned by unseen powers. All the devils in Hell are con-
spiring to make them unhappy and kill them by slow torture.
The incongruity displayed by the patients is sometimes remark-
able. An individual who affirms that he is Prince Louis of the
Pole Star and for hundreds of years has been flying from one
world to the other, the possessor of universal power, in the next
breath will admit that he is kept a prisoner in the hospital and
is unable to get away. Although true remissions in this form
are infrequent, exacerbations are not uncommon, at times cul-
minating in a period of hallucinatory mania, during which the
patients become very violent and need to be most carefully
guarded.

Although these acute exacerbations with the intensification
of the hallucinations are more liable to occur in patients who
have a marked alcoholic history, they sometimes are met with
in those who have always been temperate. The danger from
such patients is greatly increased when the ideas of persecu-
tion become prominent and render them suspicious of all about
them. The physician and nurses become spies, the hospital is a
prison or a Hell, the food is poisoned, their sickness is a result
of a conspiracy. Every sound is misinterpreted and becomes
a sign of some one approaching with some sinister motive or
bent on disturbing their peace. Even when these insane ideas
are at their height evidences of dementia are nearly always
present, and on account of the existing distractibility the patient
may be temporarily diverted. Although many of the cases on
superficial examination may resemble paranoiic states, such indi-
viduals seldom refuse to eat, and if tactfully handled, can, as a
rule, be persuaded to do as the nurse desires, except, of course,
during the period of greatest excitement. Occasionally the
patient passes from the depression into a period of stupor,
which, however, can not be regarded in the light of a remission.
Personally I have never observed a case in which a genuine
remission occurred. This form seems to be relatively more
frequent in women than in men, and on account of its com-
paratively short duration it may be classed next to the galloping

DEMENTIA PARALYTICA 445

cases as the most severe type of the disease. Such patients are
particularly difficult to nurse on account of their suicidal ten-
dencies, and if not restrained frequently resort to violence upon
others in order to accomplish their end. If no intercurrent
complication develops, they die as a result of exhaustion.

The Expansive Form. — Until recently this was supposed
to include the majority of all cases, and on that account was
regarded as the classical type of the disease. It is now known,
however, that the percentage of the expansive forms is much
smaller than that representing the depressed type, only about
from one-tenth to one-fifth of all the cases coming under obser-
vation belonging to the former category. After the prodromal
period the course may not differ essentially from that observed
in other types of the disease. The patient gradually begins to
lose an insight into his own condition. Although at first he
may have been somewhat hypochondriacal and conscious of his
mental and physical defects, he now becomes more or less in-
different or apathetic. It is worth remembering that in an indi-
vidual who belongs to the lower classes of society this change
may on casual examination be mistaken for actual improvement
instead of a deeper clouding of the intellect. Formerly de-
pressed, the patient now ceases to be hypochondriacal and
often appears to be in the best of humors. He is readily elated.
The attacks of mild apprehensiveness, as a rule, give way to
states of exhilaration, during which the sense of well-being is
more or less exaggerated. The patient forgets all his ailments,
no longer complains of headache. If he refers at all to his own
case, it is in a spirit of the utmost hopefulness, and he affirms
that members of his family or his physician exaggerate his
symptoms. There is no reason, he maintains, why he can not
return to business and the ordinary routine of life. Gradually
the self-confidence increases until the word failure is left out of
his lexicon. The business man becomes so elated that he is
ready and willing to plunge into any new undertaking, to de-
velop his business along new lines ; he becomes restless unless
there are numerous channels for the discharge of his surplus
activity. Any rebuff that is met with is either viewed in a spirit

446 PSYCHIATRY

of utter indifference or only serves to intensify his self-com-
placency. The sober-minded, phlegmatic individual is puffed
up with his own conceit, becomes a braggart, his speech is de-
cidedly bombastic. The affective state is usually one of jubi-
lance or undue elation. The speech is characterized by extrava-
gance, and the individual exhibits many eccentricities of
character that are absolutely foreign to him.

The changes in the organic sensations produce an entire
absence of fatigue. Such individuals are always ready for any
new undertaking and delight in the opportunity to show their
supposed mental and physical superiority. Gradually the sense
of personal vanity increases until it knows no bounds and is
beyond competition. The exuberance of spirit is often shown
by the actions — singing, laughing, or dancing. The motor rest-
lessness increases, and with it, as a rule, there is an exaggera-
tion of the tremor, of the incoordination, and clumsiness of
movement. The patient displays a still more boisterous ag-
gressiveness and is continually referring to his deeds of prowess
or harping upon his supposed physical superiority. The insane
ideas are fanciful, extremely grotesque, at times obscene. Not
infrequently the delusions are colored by memories of the daily
occupation of the individual prior to the onset of the illness.
The business man is occupied in devising schemes to extend his
business, in making long journeys. The professional man is
busy in his profession. As the dementia develops the extrava-
gance of these ideas increases rapidly. Such individuals do not
confine their plans and schemes to this world, but often would
have them embrace Heaven, Hell, and the whole universe.
Nothing can exceed in extravagance the ideas entertained by
these patients when the megalomania is at its height. As the
disease progresses, the defects in intelligence become more and
more marked, and at times periods of great excitement may
intervene, during which the patients are liable to tear their
clothes or inflict severe injuries upon themselves unless closely
watched. The times of excitement sometimes give way to
periods of depression and the disorder may take on a circular
form. As may be inferred, time and space orientation are

DEMENTIA PARALYTICA 447

seriously disturbed. The patients seem to retain only in a
vague way any appreciation of their surroundings. They are
so self-centred in their own delusions that they are absolutely
indifferent to the interests of those about them. The emotional
reactions correspond with the ideas in consciousness. The sense
of power, of well-being, is reflected in all that the patient does
and says.

As a rule, the course of these cases is somewhat longer than
that belonging to the depressed types. Not infrequently in
institutions these patients live for quite a long while — as much
as eight or ten years, and some observers have reported cases
of much longer duration. There are decided remissions, and
although these individuals still refer to their insane ideas and
delusions, the intensity of these is diminished and does not seem
to dominate the patients unless they are provoked or unduly
disturbed. This form of the disease seems to be less frequent
in women than in men. Competent observers have concluded
that this type is much rarer now than it was twenty years ago,
but the question is one that is exceedingly difficult to determine,
inasmuch as many of the cases which are now recognized as
instances of general paresis at that time were classed in other
categories. No form was included unless it was characterized
by grandiose ideas and exhilaration. The recognition of so
many of the other forms of the disease would, therefore, have a
tendency to make the expansive type appear relatively less
frequent.

A transition from the second to the terminal stage of the
disease is more gradual, as a rule, than in the depressed form,
and it is frequently impossible to sharply differentiate these two
epochs. As in the other forms, the patient may succumb to
various complications. During periods of remission it not in-
frequently happens that the physical condition improves very
markedly and some patients increase quite rapidly in weight.

As a rule, the hallucinations in this form do not play a very
important role. The auditory are more apt to occur than are
the visual forms, but these hallucinatory states are somewhat
rare, and when they occur are apt to be only transitory.

448 PSYCHIATRY

The Dementing Form. — According to some observers the
so-called dementing type of paresis is becoming more frequent.
This view, however, needs further confirmation, and it can
readily be conceived that the apparent increase in frequency is
due to the fact that these cases, which were formerly overlooked
and classed among the various forms of dementia, are now
recognized as instances of dementia paralytica. Indifference
and apathy are the chief characteristics of individuals afflicted
by this form of the disease. In the prodromal period we may
meet with periods of depression, but gradually the affective state
is replaced by one of apathy. At first the patients show a dis-
inclination to work or to exert themselves, and although for a
time retaining some appreciation of their condition, gradually
lose it entirely. They sit about the house, taking but little in-
terest in anything that goes on about them ; they neglect their
work, their families, and become utterly devoid of any sense of
duty. When asked to explain their apathy they may make a
feeble attempt to do so, but, as a rule, are unable to offer a sat-
isfactory explanation for their conduct. The hypochondriacal
complaints which have been more or less pronounced in the
prodromal period disappear. The patients, when spoken to,
reply in rather a low, monotonous voice, not infrequently in
monosyllables, and are unable to give any satisfactory account
of themselves or the onset of their disease.

The lapses in attention are more passive than active. The
distractibility is not excessive ; the instant the patient is left to
himself he immediately lapses into this apathetic condition. As
a rule, the impairment of the general sensibility seems to be
more marked than in the other types of the disease. The patient
can be pricked with a needle, pinched, or made to suffer quite a
severe injury without any corresponding emotional reaction.
As the disease progresses the apathy becomes more and more
profound and may, as a rule, be easily distinguished from that
characterizing the other forms of dementia. The primary sen-
sations are apt to be greatly impaired, and it is almost impos-
sible to stimulate the patient sufficiently to evoke an emotional
reaction of any degree of intensity.

DEMENTIA PARALYTICA

449

Atypical Cases. — In this category are included a variety
of cases which run an atypical course, at least 10 or 15 per
cent, of all the various forms, (a) Among the more common
are those occurring in individuals at a more advanced period
of life than is common in cases of dementia paralytica. In
some the symptoms are largely local — sensory or motor
aphasia, alexia, agraphia, hemianopsia, and loss of certain cor-
tical functions. The general dementia becomes noticeable only
in the later stages. In others the course as well as the ana-
tomical changes are of such a nature that it is impossible to
differentiate this type of the disease from a senile dementia
(Lissauer). (b) Among the atypical cases those in which the
spinal lesions play an important role are not infrequent and
include the tabetic, amyotrophic, and spastic forms. In addi-
tion to the mental symptoms of paresis, such as have already
been described, we have those of the complicating cord lesions ;
but for a detailed description of these the reader is referred to
the various text-books on neurology.

The course of the so-called tabo-paresis, occurring in only
about 6 per cent, of the cases, in certain particulars is essentially
different from that of the other types of the malady.34 Lues
seems to be even a more important etiological factor in these
than in other forms. Optic atrophy, paralysis of the external
muscles of the eye, an impaired pain sense, relatively little dis-
turbance in speech, severe crises with marked disturbances of
the bladder and rectum and prolonged remissions are, as a rule,
the most pronounced features in the clinical picture. Occa-
sionally in such cases we meet with peculiar delirious states
with vivid and varied hallucinations. The pathological lesions
in the cord are closely akin to, if not identical with, the pure
degenerative sclerosis of the posterior columns. In a second
division the lateral columns are also affected and give rise to

** Torkel, K. E. F. : Besteht eine gesetzmassige Verschiedenheit in
Verlaufsart und Dauer der progressiven Paralyse je nach dem Charaktcr
der begleitenden Ruckenmarksaffection ? Psych. Klinik in Marburg.
Inaug. Dissert., 1903.

29

450

PSYCHIATRY

spastic symptoms, while in the third group there is a combina-
tion of both forms of the lesions.

We are particularly indebted to Dr. H. A. Cotton for the
following note on the much-mooted point as to the relation of
tabes and paresis.

Among the supporters of the theory of the identity of the two diseases
may be mentioned Raymond, Nagotte, Fournier, Schaffer, and Mott, who
base their opinion upon the following facts: (i) That tabes complicates
general paresis in at least two-thirds of the cases. (2) The occurrence of
symptoms in both diseases which show both as to their onset and develop-
ment a marked similarity. (3) The identity of the etiology. (4) A simi-
larity in the pathological changes although a different anatomical location.
Those who are opposed to this doctrine, Joffroy, Ballet, Fuerstner, Nissl,
and others, maintain that the two diseases are entirely distinct and that
when they are associated it is merely a coincidence. The tendency, how-
ever, of the two processes to be associated in the same subject is con-
sidered by some to be an important point in favor of the former view.
This concurrence may occur in one of the three following ways: (1) The
initial tabetic symptoms may later in the disease be complicated by
those of general paresis; or (2) the converse of this is true; (3) the
two disorders appear about the same time and run a parallel course. Those
who from a pathological basis maintain that the two processes are not
identical affirm that general paresis is a chronic inflammatory process and
tabes a degenerative one, while those who dissent from this view affirm
that in cases of tabes where no paretic symptoms were noticed during
life, after death the lesions characteristic of general paresis were demon-
strated in the brain ; and, furthermore, that in cases of paresis uncom-
plicated by tabetic lesions degenerations were found at autopsy in the
posterior columns. The question needs still further investigation before
a definite conclusion can be reached.

The Cerebellar Form. — Although it has been shown by a
number of observers that the cerebellum is regularly affected in
a large majority of cases, we meet with a very small number
in which it has undergone any marked degree of atrophy.
Cases have been described in which the diagnosis of cerebellar
tumor has been made. As a rule, later in the disease the symp-
toms of general paresis develop so that the differentiation be-
comes possible. Buder 3ri has described a case of general
paralysis in which the physical symptoms were an Argyll-

36 Buder: Allg. Ztschr. f. Psych., Bd. lx, H. 4.

DEMENTIA PARALYTICA 45 1

Robertson pupil, absence of knee-jerk, fairly characteristic
speech disturbance and a hemiplegia, and associated with them
considerable dementia; this same patient was also subject to
apoplectiform attacks. At autopsy it was found that the left
hemisphere was 32 per cent, lighter in weight than the right
£154 grammes) and that there was a marked cerebellar atrophy
on the opposite side. It is by no means clear, however, that
such cases are not to be regarded as instances of paresis com-
plicated by localized lesions not in any sense immediately re-
lated to the case, but merely accidental. In still other very
rare cases the degeneration seems to be more or less confined
to the thalamic regions, but what is the nature of the symp-
toms is as yet only very imperfectly understood. Adolf Meyer,
among others, has more recently called attention to the im-
portance of these cases in which the atrophy is excessive on
one side of the brain and only slight on the other.

Seizures. — These are frequently the result of cortical irri-
tation and are generally described as apoplectiform or epilepti-
form in character. They may or may not be accompanied by a
rise of temperature. As a rule, the changes in consciousness vary
from a slight dulling to temporary abolition. In the latter case
the patients fail to react to any form of external stimulation, but
lie in a stupor, frequently retaining no control over the bladder
or rectum. Necessarily in all instances speech is seriously inter-
fered with. In the milder attacks the patient is able to produce
sounds, occasionally words, while in the severer forms with
marked loss of consciousness there is, of course, no attempt at
speech. The pulse becomes irregular and sometimes dicrotic.
As a rule, there is considerable difficulty in swallowing. In some
cases various groups of muscles are affected by a clonic spasm,
while in other instances there are varying degrees of paresis and
occasionally one observes in the non-paralyzed group of muscles
a hypertonicity. Sometimes the clonic seizure is replaced by a
tonic convulsion. Whenever a permanent monoplegia or hemi-
plegia develops it may usually be considered as an evidence of
the existence of a complication. Not infrequently during the
attacks the eye-muscles, particularly those supplied by the third

452

PSYCHIATRY

and sixth nerves, are very apt to be affected. Nystagmus may
also be noted. Prior to and following the attacks one not infre-
quently meets with the so-called trigeminus symptom, when the
patient sits and grinds his teeth. Frequently there is a marked
difference in the surface temperature between the paralyzed and
non-paralyzed areas. During these attacks the seizures not
infrequently begin with an epileptiform attack, the patient
suddenly sinking to the ground and losing consciousness,
after which the symptoms referred to above develop. The
reflexes are wont to be interfered with, being sometimes di-
minished but seldom totally absent except in the severest cases.
On the non-paralyzed side the tendon reflexes are often in-
creased. On account 'of the disturbance in consciousness it
is impossible to test the touch and pain sensation with any
degree of accuracy. As a rule, the primary sensations are
seriously interfered with. There may be temporary blindness
or deafness. Not infrequently auditory and visual hallucina-
tions precede the attack. When the motor centres are in-
volved there is motor aphasia and in other cases the sensory-
aphasia is present. The duration and intensity of the attacks
vary greatly. In some cases there is a slight vertigo lasting a
few seconds with temporary interference with motility and
disturbance of speech; in others there are severe seizures
which last for two or three days.

Remissions. — During the course of the disease, particu-
larly in the chronic forms, remissions frequently occur. They
are chiefly met with in the slowly progressive cases which begin
with tabetic symptoms. Some well-authenticated instances
have been recorded in which there was considerable improve-
ment in the disturbances of speech, in the tremor, in the gen-
eral incoordination of muscular movements and an actual sub-
sidence of the mental symptoms, and such phases may extend
over long periods of time. For example, Schafer35 reports a
case which ran a course of twenty-three years and was charac-

** Schafer, Gerhard: Zur Casuistik der progressiven Paralyse. Lange
Dauer und erhebliche Remission. Ztschr. f. Psych., lx.

DEMENTIA PARALYTICA

453

terized by the remarkable length of the remission. The diag-
nosis was ultimately verified by the pathological findings. In
another case reported by the same author after the disease had
progressed steadily for two years a remission almost equal to
that in the first case was noted. In the latter instance the
patient convalesced so far as to be able to take up again his
work as a stenographer, and after examination by the military
authorities was said to be entirely well. It is not at all im-
probable that the remissions are much more apt to occur in
cases which come under treatment early in the disease than in
those who only come to the hospital after the symptoms are
well developed. The remissions in the acute cases are only
temporary, while in the expansive and dementing forms they
are much more apt to be of considerable duration than in the
melancholic cases.

Termination. — In spite of occasional references in the liter-
ature to a favorable outcome, the evidence to the contrary at
present is so convincing that it may be taken for granted that
progressive paralysis always terminates fatally. The supposed
cures recorded by Schule, Schafer, Tuczek, Svetlin, on account
of the incompleteness of the records, cannot with certainty be
differentiated from instances representing certain phases of
manic-depressive insanity, alcoholism, catatonia, or hysterical
degeneracy. And even for those cases in which the disappear-
ance of all the symptoms undoubtedly occurred we unfor-
tunately have no positive proof that a restitutio ad integrum took
place. Thus in one of Alzheimer's patients who died from an
intercurrent trouble during a remission, at autopsy the changes
characteristic of dementia paralytica were demonstrable
throughout the central nervous system. Sufficient has already
been said to show that a great majority of the patients die from
some complication, as, for instance, a lobar or catarrhal pneu-
monia, or an infection, such as cystitis or pyelonephritis, or from
pure exhaustion generally described as the paretic marasmus.
The course of the disease is progressive and is characterized
by the fact that no true — i.e., anatomical — remissions actually
occur, and, as has been said, even where all the symptoms have

454 PSYCHIATRY

disappeared the contention that all the histological changes in
the central nervous system have been obliterated so that the
nervous and other elements are restored to their normal con-
dition is not capable of demonstration, inasmuch as we possess
no observations which would substantiate this view. Arnaud 37
reports that seventy-three cases of dementia paralytica who
died at the Maison de Sante Vauves did not, during the ter-
minal period of the malady, show any evidence of motor im-
potence, and in sixteen instances an intercurrent disease was
the immediate cause of death. The same observer affirms that
severe trophic disturbances are much less common than is
generally supposed.

Differential Diagnosis.38 — The early diagnosis in
many cases of dementia paralytica is exceedingly difficult and
yet is one that is frequently of momentous importance. The
symptoms of paresis may be grafted upon those of neuras-
thenia, and if such a condition exists it is almost impossible in
the prodromal period to recognize the onset of the graver dis-
order. A diagnosis based solely upon the analysis of the mental
symptoms is very apt to be erroneous, although, broadly speak-
ing, the limitations in connected thinking in the neurasthenic
are less progressive as contrasted with those in the paretic, and
in the former are not commonly associated with flagrant defects
in the aesthetic and moral sense.

In paresis the symptoms of which the patient complains are
apt to be less evanescent, but more incongruous, or even bizarre,
than are those in neurasthenia. The general practitioner is often
greatly embarrassed when forced to decide whether or not a
patient who during the prime of life begins to suffer from
gastric disturbances, a disinclination to work, an inability to
focus the attention, slight lapses in memory, restlessness, an
abulia of which there may be subjective appreciation without
accompanying physical signs, is entering upon the first stage of

17 Sur la periode terminale de la paralysie generate et sur la mort des
paralytiques generaux. Rev. Neurol., Aout 31, 1903.

38 Hoche : Die Friihdiagnose der progressiven Paralyse. Halle a/S.,
1896. Klippel : Les Paralyses Generates progressives. Paris, 1898.

DEMENTIA PARALYTICA

455

this form of alienation. In the functional as well as in the
organic disorder we may have signs of mental depression of
which the patient is at first fully conscious, and in both cases
obsessions as well as phobias may play an important role. The
gravity of the prognosis assumes a more serious aspect when
in the face of a definite history of alcoholism the mental symp-
toms become markedly progressive. In such instances not only
one, but several careful physical examinations should be made
at short intervals in order that the first positive symptom of
paresis may be recognized. It is in just such doubtful condi-
tions that the method of cytodiagnosis, first introduced by
Widal,39 offers an important adjunct in the differentiation,
since the occurrence of lymphocytes in the spinal fluid would
indicate the existence not necessarily of paresis, but, at any rate,
of some organic lesion. In regard to the mental symptoms the
appearance of a mild degree of apathy and indifference, or even
the suggestion of a general impairment of all the psychic func-
tions, no matter how slight this involvement may be, is a danger
signal of more significance than even great and rapid varia-
tions in the emotional life, as these latter are not uncommon in
psychasthenia. In the classical type of the disease the conduct
of the paretic contrasts strongly with the general bearing of the
psychasthenic. The latter seldom becomes active, strenuous,
determined, or bumptious, but is indolent, resigned, never litig-
ious, and is evidently a person whose volitional movements
are more or less inhibited and restrained through doubt or fear,
a description which certainly does not apply to the paretic,
except, perhaps, in the early stages of the depressed type of the
disease. On the contrary, paretics are prone to translate their
ideas into action and to go ahead without waiting to count the
cost. Again, the insight of the psychasthenic into his own
condition is better preserved.

The diminution in the consensual light reflex or the ten-
dency to slur syllables as well as a general incoordination of
the muscular movements, when taken in connection with the

i9 Widal et Ravaut : Soc. de Biologie, Juin 30, 1900.

456 PSYCHIATRY

mental symptoms, the slight lapses in consciousness, the tem-
porary epileptiform or apoplectiform attacks, disturbances in
articulation, the ophthalmic migraine, and the temporary
aphasias or pareses of the extrinsic muscles of the eye, are
signs of positive value. The mental activity of the paretic
is, as a rule, considerably impaired, while the neurasthenic
may retain much of his normal mentality, although attempts
to exercise it are accompanied by an increased sense of effort
and fatigue.

The differentiation from hysteria which sometimes com-
plicates and at other times simulates dementia paralytica is
frequently beset with many difficulties, and in the absence of
the somatic symptoms, particularly in men, a positive opinion
should not be advanced.40

It must not be forgotten that even in hysterical seizures
there may be a temporary inhibition in the light reflex, and in
all doubtful cases judgment should be suspended until the
patient has recovered from the immediate effects of the seizure,
so that a careful examination is possible. The persistence of
an impaired light reflex, the occurrence of difficulties in the
enunciation of words, and, above all, the presence of lympho-
cytes in the cerebrospinal fluid, are factors that should be con-
sidered of great weight in the establishment of the diagnosis
of paresis.

At times epileptic attacks may give rise to difficulties in
diagnosis, and it is frequently necessary to keep the patient
under observation for some time before the final decision can
be made. The sudden appearance of mania with excessive
apprehensiveness, exaggerated fears, varied and constant hallu-
cinations which dominate the whole conduct of the individual
are, as a rule, much more apt to be indicative of the existence
of the functional neurosis. Even in the most acute cases of
paresis there is apt to be a prodromal period of one or two
weeks prior to the outbreak of the graver symptoms.

Multiple sclerosis, particularly in its early stages and when

*° Babinski : Verhandlungen der Societe med. Hopitaux de Paris. 1892.

DEMENTIA PARALYTICA 457

occurring at the prime of life, may be mistaken for general
paresis. The emotional conditions in the two disorders, how-
ever, are apt to be somewhat different. In the sclerotic pro-
cesses the patient frequently suffers from sudden and inex-
plicable outbursts of temper of which he generally retains a
fairly accurate knowledge, while at the same time he is con-
scious of the fact that such anomalous emotional states are
decidedly abnormal. Nor is there, as a rule, any marked evi-
dence of any general mental impairment. The paretic, on the
other hand, may be subject to such outbreaks, but these are
more or less constantly followed by apathy or an indifference as
to their consequences. The appearance of the scanning speech
and the intention tremor are, of course, of diagnostic impor-
tance.

But the greatest difficulty in making a decision arises in
those rare cases of paresis that begin with a sudden onset and
in many respects resemble instances of delirium acutum. The
history of some direct exciting cause, such as a protracted ill-
ness, trauma, some severe mental shock, hemorrhage, the pres-
ence of a normal light reflex, the absence of a protracted neur-
asthenic stage, disturbances in articulation, and paretic seizures,
taken together, are factors that are indicative rather of the acute
delirious states than of a galloping paresis.

Reference has already been made, when speaking of the
atypical forms, to the fact that it is frequently impossible to
differentiate a paresis coming on late in life from a senile de-
mentia. The clinical symptomatology of chronic alcoholism or
Korsakow's syndrome may bear a striking resemblance to that
of dementia paralytica, and frequent references to these so-
called pseudoparetics are found in the literature. As a rule,
the speech disturbances of alcoholism are distinguishable from
those of the paretic, the former being characterized by greater
tremulousness and less difficulty in articulation than the latter.41
An important point in establishing the diagnosis in doubtful
cases is that an alcoholic frequently recovers to quite a remark-

41 See Alcoholism, Korsakow's Syndrome.

458 PSYCHIATRY

able extent, provided that the toxic agent be withdrawn,
whereas paresis is apt to be markedly progressive.

The differentiation from cerebral syphilis is frequently dif-
ficult. Although the luetic infection may give rise to cerebral
disturbances characterized by more or less localized motor
symptoms combined with incoherence, disorientation, and an
hallucinatory delirium with insane ideas, a general mental im-
pairment equal to that which exists in the cases of dementia
paralytica is not observed. In lues the speech disturbance is
less pronounced and far less characteristic than in paresis. The
tendency of the syphilitic process to become more or less local-
ized is an important factor that should always be kept in mind.
We not infrequently meet with disturbances in the course of
syphilis which may give rise to suspicion of a beginning de-
mentia paralytica, particularly when the Argyll-Robertson pupil
is present, together with a marked tendency to mental and phy-
sical fatigue, impairment of memory, and slight disturbances in
speech.

The excited or depressed states occurring during the
course of dementia paralytica may be mistaken for somewhat
similar periods in manic-depressive insanity. The essential
points in the diagnosis have been fully discussed in considering
the latter psychosis.

Treatment. — Reference has already been made to the
factors that must be regarded as of etiologic importance, and it
is unnecessary to repeat here what has already been said in
regard to prophylaxis. As soon as a positive diagnosis of gen-
eral paresis has been arrived at the alienist should at once ex-
plain the gravity of the prognosis to members of the family or
friends and advise the immediate removal to an institution
where the patient can be under constant supervision. Among
the wealthier classes, where it is possible to secure the services
of trained nurses, so that constant intelligent supervision can be
guaranteed, and if the family is willing to take the full responsi-
bility of possible accidents in the earlier stages, the patient may
be treated at home. But the fact should be emphasized by the
physician that such a course is, as a rule, inadvisable, as such

DEMENTIA PARALYTICA

459

patients can receive much better care in an appropriate institu-
tion. Patients suffering from the classic type of the disease
while in the hospital, except during the excited periods, do not
need to be as closely watched as those afflicted with the de-
pressed form, as the latter are much more prone to mutilate
themselves or commit suicide. In the prodromal period or
the early part of the second stage nearly all patients should
receive the possible advantages of anti-syphilitic treatment.
This may be given either in the form of inunctions or by the
internal administration of mercury either alone or combined
with the iodides, according to the indications in each case. The
results obtained, however, are seldom gratifying. In the later
stages of the disease the symptoms, as they arise, are treated
purely symptomatically. At all stages hydrotherapeutic meas-
ures, either in the form of packs or prolonged baths, as the indi-
cations arise, are distinctly beneficial. As a rule, such patients
are much better off without alcohol in any form, although in
cases of collapse or in the terminal stages it is frequently neces-
sary to resort to small doses of the drug. In cases of sexual
excitability, in addition to the baths, small doses of the bromides
are frequently of great value. Insomnia is frequently distress-
ing, particularly during the periods of greatest excitement, and
may be combated by the ordinary hydrotherapeutic measures
or by the administration of chloralamid. hyoscin, sulfonal, mor-
phin, or bromides, as well as by the application of cold com-
presses to the head, while the patient is kept in a continuous
warm bath for three to four hours. During the paralytic attacks
it is frequently impossible to feed the patient except by rectum.
At such times benefit may be derived from salt injections either
alone or combined with the various substances mentioned in the
first section of the book. In retention of urine great care must
be taken in the catheterization that no infection is carried to the
bladder, since in the weakened condition of the patient a cystitis
will surely form a complication and may result fatally. When
the mentality is greatly impaired care should be taken that the
patients do not choke themselves to death by swallowing their
food without mastication. So far as drugs are concerned, ergot

46o PSYCHIATRY

injections have been recommended, and the withdrawal of
cerebrospinal fluid under careful aseptic precautions has been
said to be followed by amelioration or cessation of the para-
lytic attacks.

At all times skilled nursing is absolutely essential, adding
greatly to the comfort of the patient, preventing complications,
and prolonging life. As such patients are at times very dirty
in their habits great care must be taken to avoid bed-sores, as
the most simple localized infection may prove a menace to life.
All points of pressure should be relieved as far as possible by
bathing with soap and warm water or a mixture of water and
alcohol, by the support of rubber cushions, and by hardening the
skin with zinc ointment. The bowels must be carefully regu-
lated, and if marked constipation is present small doses of
calomel frequently repeated at intervals are of great value.
During the remissions the patient may be allowed to return to
his home provided that he can still be kept under constant
medical supervision.

The injections of salt solution have been tried with favor-
able results in a number of cases. The saline infusions were
first used in 1890 by Stahli in various forms of intoxications.
Recently they have been tried in cases of dementia paralytica.42
The method of procedure has been described in detail in the
first section of the book, in which the formula for the fluid which
seems to afford the best results has also been given. In addition
to the infusions rectal injections of salt solution are frequently
beneficial. During this treatment the patient should be kept
quietly in bed and preferably on a fluid diet.

Pathological Anatomy. — In general paralysis of the
insane lesions are found in nearly all the internal organs, and
even in patients who die early in the disease the changes are not
by any means confined to the central nervous system. The
visceral lesions have been extensively studied and may be classi-

0 Donath, Julius : Die Behandlung der progressiven Paralyse, sowie
toxischer und infectioser Psychosen mit Salzinfusionen. Allg. Ztschr. f.
Psych, u. psych.-gericht. Med., 1903, Bd. lx, H. 4.

DEMENTIA PARALYTICA 46i

fied as follows : 43 ( i ) those preceding the development of the
malady, such as alcoholic cirrhoses, tuberculous processes; (2)
lesions that are more directly related to the disease process, —
chronic congestions, visceral hemorrhages ; (3) passive conges-
tions; (4) secondary infections (pneumococcus, streptococcus,
bacillus coli). Among the pulmonary lesions we not infre-
quently meet with congestions, catarrhal or lobar pneumonias,
emphysema, gangrene, and tuberculous infections. The heart is
nearly always affected, myocarditis or endocarditis being often
found. The liver, stomach, and pancreas are the seat of chronic
as well as acute pathological processes, and the kidneys are
practically never normal. Generally vascular lesions are almost
always present in varying degrees of intensity. The widespread
character of the changes gives rise to a marked cachexia, which
is at once apparent in nearly every case.

The bones of the skull are frequently altered. Robertson 44
affirms that there is a condensation of the bones, sometimes
but not always accompanied by a thickening, while the diploe
is frequently thinner and the bony substance may be replaced
by cancellous material. In other instances the bones may be
greatly thickened and increased in weight, and along the inner
surface of the skull bony protrusions of considerable size are
often found. Fraenkel's 45 investigations led him to believe
that the weight of the skull in general paresis is greater than in
any other form of mental disease, but this observation has not
been generally substantiated.

Membranes. — The dura may have a normal appearance,
but frequently is thicker than in other psychoses and gives
evidence of a pachymeningitis externa. The statement that a
pachymeningitis haemorrhagica interna exists in fully half the
cases, however, needs confirmation, although it cannot be denied
that such a condition is sometimes present. In the more recent
cases one is apt to find a fibrinous exudate which in places may

Klippel : Arch, de med. experiment., Juillet, 1892.
Pathology of Mental Diseases. Edinburgh, 1900, p. 68.
Riv. sperimentale di Freniatria, vol. i.

462 PSYCHIATRY

show signs of organization. It was formerly believed that
localized hemorrhages of considerable size were not un-
common, but true haematomata are rare, and Gross in 124
autopsies on patients dead of paresis found them in only
5 instances. A similar conclusion as to their rarity has
more recently been expressed by Fiirstner.46 When haema-
tomata do exist, however, they are found either over one or
both hemispheres and in rare instances may attain quite a con-
siderable size. Extensive adhesions between the dura and pia
are common, but over the convexity the latter is usually opaque
and thickened, the change being first apparent along the course
of the vessels. Over the basal portion of the pia they are less
marked. Frequently when the pia is stripped off from the brain
a marked decortication takes place, showing the existence of a
leptomeningitis chronica profunda. The increase in the con-
nective tissue of the pia and subarachnoid tissue is frequently
noticeable even in the early stages of the disease, although it is
not uncommon at this period to find the pia-arachnoid tissue
filled with leucocytes. The ependymal lining of the ventricles
is often thickened, presenting a granular appearance, and its
epithelial layer is degenerated.

The changes in the blood-vessels of the membranes fre-
quently apparent on macroscopic examination are not specific
of the disease, inasmuch as similar conditions are seen in alco-
holics and various forms of chronic dementia.

The weight of the brain is generally diminished (Jen-
sen).47 The weight of the brain of paretics is about 150
grammes below the average of those individuals who have
not suffered from mental disorders. This question, however,
is one that can not be settled offhand, as the discrepancies in
the various recorded observations are too great to be easily
explained. Marchand gives the average weight of the brain
of the normal man, between 40 and 49, as 1403 grammes,

48 Fiirstner : Monatsschr. f. Psych, u. Neurol., November, 1902.

47 Arch. f. Psych., 1888, Bd. xx. Ilberg, Georg : Gewicht d. Gehirns u.
seines Theiles, v. 102 an Dement. Paralyt. verstorb. mannlichen Sachsen.
Allg. Ztschr. f. Psych, u. psych. -gericht. Medizin, Bd. xl, H. 3.

PLATE XI

M*~~

, _ -

Section of cortex from a case of paresis, showing thickening of pia arachnoid and adhesions
between pia arachnoid and cortex. X 50. Zeiss planar, 20 mm. (Cramer isochr. plate.)

PLATE XII a

mmmM

XM.K.

X.11

Gyrus occipitalis.

Gyrus pnecentralis.

The four drawings ( Plates XII a and XII b) were made from sections of the cerebral
cortex of a man aged 30. Thickness of section, 40/01. Stained by original VVeigert method.
No recorded history of mental disease.)

PLATE., XII b

I

K.3A..K.

Gyrus postcentrals.

Gyrus frontalis (superior).

DEMENTIA PARALYTICA 463

but the extreme limits of this so-called normal weight may
vary between 1250 and 1550 grammes. The specific gravity
of the cerebral cortex is said to be diminished in the more
chronic cases. The ventricles are often dilated and there is
a marked atrophy of the cortex most noticeable, as a rule, in
the frontal and parietal areas. This can be seen in freshly
cut sections, the atrophy being usually more marked at the
base than at the summit of the convolution.

Two main views are held in regard to the disappearance of
the fibres from the cerebral cortex in cases of paresis. The
earlier investigations, particularly those of Tuczek, render it
probable that in certain cortical areas, particularly in the cen-
tral and occipital convolutions, the fibres are not severely
affected. This same view has been more recently advocated by
Schaeffer.48 Lawrence,49 after a series of very careful and de-
tailed studies, concludes that in the brains which he has studied
the pathological process was more severe in the central and
frontal regions. Nevertheless, Kaes,50 after very extended ob-
servations, arrives at a different conclusion. Instead of the
localized disappearance of fibres the latter finds that the paretic
process is a general atrophy, not only of the zonal fibres, but
of those in the second and third Meynert layers, as well as in
the Baillarger-Gennari stripes. The disappearance of the fibres
is essentially diffuse. In the areas where the fibres are not so
densely packed a complete absorption may occur, but in the
deeper areas of the cortex, where the fibres are thicker, this
rarely takes place. The necessity of further careful compara-
tive studies of all the different cortical areas is essential. The
relationship between the extent of the disappearance of the
fibres and the duration of the disease seems to be more or less

48 Schaeffer, Karl : Ueber Markfasergehalt eines normalen und eines
paralytischen Gehirns. Neurolog. Centralbl., 1903, September 1, Nr. 17,
S. 802.

" Studies upon the Cerebral Cortex in the Normal Human Brain
and in Dementia Paralytica. Journ. of Nerv. and Ment. Disease, Nos. 10,
11, 12, 1903.

60 Monatsschr. f. Psych, u. Neurol., Bd. xii, H. 5.

464 PSYCHIATRY

definite. The general consensus of opinion is against the view
that any direct relationship exists between the meningeal
changes and the atrophy of the fibres. Frequently the nerve-
fibres in the cortex appear to be swollen and not infrequently
show marked varicosities, being at times broken up into little
balls. Some observers have reported the occurrence of hyper-
trophied axis-cylinders in nearly all cases of paresis. Not only
are the fibres in the various cortical areas affected, but marked
changes have been observed in the basal ganglia as well as in
the medulla and spinal cord. Not infrequently areas of de-
generation may be found in the optic thalamus and in some
cases in the gray matter surrounding the third ventricle. Lis-
sauer states that in a few of the atypical cases the pathological
changes are most marked in this subcortical centre.

Nerve-Cell Changes?1 — Inspection of the cortex with a
low-power lens in stained specimens often shows a notable dis-
appearance of cells. Where the atrophy is marked, if the sec-
tion is studied under the low power of the microscope the nor-
mal columnar arrangement of the cells in rows is seen to be
broken up, while practically all conceivable changes are observed
in the cells. These have been described in detail by Hoch.82

The nerve-cell changes may be described as (1) acute,
characterized by swelling of the cell-body, which tends to stain
diffusely, and an increase in the size of the nucleus, and finally
a more or less disintegration of the whole; (2) a chronic form,
in which the axis-cylinders show a marked tendency to stain
more or less deeply, and a granular appearance of the body,
with a tendency to stain faintly; (3) a cell sclerosis, another
chronic change frequently met with, in which the processes be-
come tortuous, stain deeply; the cell-bodies have a shrunken

51 Binswanger : Die pathologische Histologic der Grosshirnrinden-
Erkrankungen bei der allgemeinen progressiven Paralyse, 1893. Nissl:
Archiv f. Psych., Bd. xxviii, S. 989. Heilbronner: Allgem. Ztschr. £.
Psych., Bd. liii, S. 172.

" Hoch, A. : On Changes in the Nerve-Cells of the Cortex in a Case
of Acute Delirium and a Case of Delirium Tremens. Am. Journ. Insan.,
vol. liv, 1898.

DESCRIPTION OF PLATE XIII.

Fig. i.— Cross-section cerebral cortex (gyrus centralis posterior, culmen).
Normal adult male.

Fig. 2.— Same area from a case of dementia paralytica. The drawings
include four external layers of cortex : I, Lamina zonalis. II, Lamina
granulans externa. Ill, Lamina pyramidalis. IV, Lamina granulans in-
terna.

The nerve-cells in Fig. i show plainly the fibrillary structure and great
numbers of finely branching dendrites. The very long pointed processes
are particularly prominent in the large pyramidal cell layer. The nucleus is
not stained. The portion of field not occupied by cells is filled in by a felt-
ing (Filz) of very fine medullated and non-medullated nerve-fibres and
branching dendrites.

In Fig. 2 it will be noticed that the nerve-cells are much closer together,
while the cell bodies have an homogeneous dark appearance with only an
occasional suggestion of the normal fibrillary structure. The dendrites are
either absent or are shortened, tortuous, and swollen. The extracellular
felting, particularly in layer I, is markedly thinner. The disappearance of
elements from the field includes the finest structures. If this section is com-
pared with one stained by the Weigert method, the appearance in the field
of the large number of fibres in spite of the severe affection of the cellular
elements is very striking.

PLATE Xril

Fig. i.

Fig. 2.

PLATE XIV

Fig. 3. — Normal giant or Betz cell in the gyrus centralis anterior.
Fi<;. 4. — Giant cell from same area. Case of dementia paralytica.

The above drawings were made from original preparations kindly loaned by Drs. Biel-
schowsk\ and Brodmann of the N'eurobiological Institute, Berlin. The sections were stained
by the Bielschowsky lil>ril stain. Figs. 1 and 2, Zeiss, oc. 4. Figs. 3 and 4, homogen.
immers. r», oc. 2.

DEMENTIA PARALYTICA 465

appearance, and many of them seem to be partially filled with
a bright yellow pigment.

Whether the acute changes stand in direct relationship to
the paretic process, or whether they develop in the terminal
stage, as the result of infections or of the acute symptoms aris-
ing from complications developing in connection with the kid-
neys, heart, lungs, or other internal viscera, it is difficult to say.
It may be laid down as a general rule that in other diseases
where similar cell changes are observed — in senile dementia
and epilepsy — they are frequently so widespread as to render
it improbable that the disease process is cortical in origin. In
addition to these changes, it is not uncommon to find small or,
more rarely, large areas of sclerosis scattered through the cen-
tral nervous system.

The Neuroglia Changes. — Anomalies in the structure of
the neuroglia are met with in every case of dementia paralytica.
The findings in the acute and chronic cases differ essentially.
Generally there is a proliferation of the fibres, which is much
more marked in the latter than in the former. As a rule, there
is an increase in the subpial felting, not uniform, but more
marked in some places than in others. Bands of fibres may
be noticed along the blood-vessels. The abnormal growth of
fibres is frequently excessive along the ependymal lining of
the central gray masses. In the acute cases the cells appear
as if they were reacting to some stimulus; there is a marked
increase of the protoplasm surrounding the nucleus, so that
not infrequently the cell-body reaches large dimensions. In
the case from which the illustration was taken quantities
of large spider-cells were found in the molecular layer, being
most numerous in the outer half. A few were found along the
inner portions of the layer, where it comes into contact with the
small pyramidal cells. These monster cells vary in size. Not
only is the protoplasm surrounding the nucleus hypertrophic,
but in many instances the nuclei themselves are larger and paler
in color than normal. The nuclei are altered in shape, some are
oval, others present a notched appearance, while still others
are sausage-shaped or have a dumb-bell form. Great numbers

30

466 PSYCHIATRY

of these large cells may be present, and under this condition the
increase of the neuroglia fibres is not well marked. The forma-
tion of fibres belongs to a later stage. Many authorities hold
that the hypertrophic glia-cells separate themselves from the
fibres, and that the former, under the influence of a chemotactic
stimulus, wander towards the source of greatest irritation. In
the acute stages evidences of cell mitosis are frequently ob-
served. The neuroglia cells not infrequently surround the
nerve-elements (the so-called accompanying or " Trabant"
cells). In some sections the appearance of an actual encroach-
ment of the glia upon the nerve-cells is met with. These are
the factors which suggested to Marinesco the term neurono-
phagia. Occasionally a monster cell shows a double nucleus.
The terminal stage in the transformation of the cell is appar-
ently the production of fibres. In the more chronic cases, as has
already been said, the increase of fibres is the most noticeable
finding in connection with the neuroglia changes. Here we find
few, if any, of the large cells. The subpial felting is, as a rule,
greatly increased. The fibres in the earlier stages are some-
times thick and have a swollen appearance. In some instances
we meet with amyloid bodies. Redlich believes that these are
formed in the glia-cells. In the case described 53 by Rusk and
the author, the former referred to the presence of certain spher-
ical bodies with regular outlines and of a homogeneous nature,
which stained indifferently with any acid or basic stain and
readily decolorized, but did not give the reaction for amyloid or
fat. The unusually important role played by the neuroglia
nuclei has been pointed out by Nissl.54

Lesions in the sympathetic probably occur in all the cases,
and unquestionably give rise to many of the symptoms that
occur. Recently the solar plexus has been carefully studied in
a number of cases by Laignel and Lavastine,65 who have de-
scribed a variety of lesions which were more or less constant.

M Op. cit.

" Arch f. Psych., Bd. xxxii, H. 2.

u Histol. Pathologie du Plexus Solaire chez les paralytiques generaux.
Revue Neurologique, 1903, Aout, p. 827.

PLATE XV

Giant spider-cells, cerebral cortex (Eenda stain). X 1000. (From a case of galloping paresis.)

PLATE XVI

Outer
spider-cells

aver of cerebral cortex. Case of acute paresis. Great increase in number of giant
. Benda's neuroglia stain (Zeiss comp. oc. No. 6, obj. 2 mm.)

DEMENTIA PARALYTICA 467

Among the more noticeable were a pigmented atrophy and an
interstitial sclerosis. The cellular changes seemed to be sec-
ondary to the sclerotic processes.

The Vascular Changes. — The vascular changes are, as a
rule, pronounced, particularly in the smaller blood-vessels. Ac-
cording to certain observers changes occur in the arteries and
veins preceding the lesions in the lymph-channels. The thick-
ening of the membranes, due to chronic inflammatory processes,
causes a dilatation of the subarachnoidal lymph-spaces and a
damming up of the venous blood supply, so that His's epicerebral
space is obliterated and marked changes in the pial vessels, as
well as in the small arterioles entering the superficial layer of
the cortex, follow. There may be a marked increase in the
nuclei of the adventitia. The changes are not confined to the
arteries, but are also noticeable in the veins. There is a dilata-
tion of the intra- and extra-vascular lymph-spaces. Warda56
has found that the hyaline degeneration extends even to the
capillaries of the cortex, and associated with this change there
is a marked increase of the adventitial nuclei as well as of the
cells forming the endothelial lining. In many instances there is
a marked perivascular infiltration of the tissues. The adventi-
tial spaces are dilated, red and white blood-cells being found in
the perivascular spaces. Nonne holds that the vascular changes
of paresis do not correspond with the picture of Heubner's
endarteritis, which is considered by many the crucial pathologi-
cal test of the existence of syphilis. In the acute cases it is ex-
tremely difficult to say whether the vascular changes precede or
are secondary to the alterations in the neural elements. In a
few cases there is an increase in the intimal constituents that
may go on to a complete occlusion of the vessel. Not infre-
quently the vessels show small aneurysmal dilatations, while the
evidences of the formation of new vessels is, as a rule, fairly
well marked and more striking in the outer layer of the cortex.
Vogt and Nissl have called attention to the occurrence of
epithelioid Marschalko plasma-cells in the vessels. This finding

MZtschr. f. Nervenheilk., Bd. vii.

468 PSYCHIATRY

is represented in the accompanying illustration. The appear-
ance of these cells indicates the existence of chronic inflamma-
tory changes, so that to a limited extent they afford us im-
portant aid in distinguishing the paretic processes from the
cortical changes observed in certain psychoses. Of course, this
does not apply to the brain diseases which are commonly re-
ferred to as organic. Havet 57 does not believe that the plasma-
cells are in any sense pathognomonic of the paretic process.
Sections obtained from the cerebral cortex in the various
autopsies performed at the Sheppard and Enoch Pratt Hos-
pital were examined by Rusk and Dunton with a view to
this point, and their results tend to confirm the observations
of Vogt. Plasma-cells were found in the cortical vessels in
cases which ran an acute or subacute course, but in material
from protracted cases they were not demonstrable. They
have not been observed in cases of dementia prsecox or manic-
depressive insanity, but were seen in one case of a young boy
who had been subject to epileptiform attacks for a number
of years, although the history did not permit a positive clinical
diagnosis. Weber believes that the plasma-cells spring from
the connective tissue, and that their presence indicates a more
extensive inflammatory process than when they are absent.
Mahaim found in certain cases numerous cells having a round
nucleus and irregular structure, the protoplasm containing vac-
uoles, the body being sometimes large, in other instances small,
and containing granulations of different sizes which stained
deeply.

As was mentioned when discussing the clinical symptoms,
cases of paresis are not rare in which the paretic process is much
more pronounced in certain areas of the cortical surface, and
this localization may give rise to focal symptoms. Adolf Meyer
has reported the case of a man forty-two years of age, who had
difficulty in the use of the left arm, and at the same time men-
tally showed slight expansiveness. As the case progressed an

07 Bulletin de l'Acad. de Medecine de Belgique, IV. serie, tome xvi,
No. 7, Seance du 26 Juillet, 1002.

PLATE XVII

Blood-vessel from cerebral cortex of a case of galloping paresis, a, plasma cells.

DEMENTIA PARALYTICA 469

anaesthesia of central origin of the left arm was found to be
present. Associated with these symptoms there were slow, in-
coordinated, and involuntary movements in this arm, a gradual
development of rigidity of the musculature on the whole left
side, and a left hemiplegia. At autopsy the posterior part of
the right hemisphere was found to be the seat of the paretic
process. No focal lesions were present. There was marked
atrophy of the cortex and a distention of the ventricles with
gliosis of the left portion of the cerebellum. Similar cases have
been described by Hoch. In this connection Bleuler 58 has re-
ported an instance of unilateral delirium occurring during the
course of general paresis.

These cases are thought by some observers to be essentially
different from those in which the paralytic process is compli-
cated by a focal lesion. In view of the more recent investiga-
tions of Kaes 59 and others, which indicate that in at least a
majority of the cases the pathological process is generalized
and not local, we are unable to explain the occurrence and sig-
nificance of these atypical forms. Probably, however, certain
of the supposed atypical unilateral cases of general paresis are
complicated by arterio-sclerosis. The apparent localization of
the paretic process to one cortical area is explicable on the
ground that there is a vascular lesion similar to that described
by Alzheimer, giving rise to an atrophy and reaction in the
nerve and neuroglia tissue difficult to differentiate from the
changes occurring during paresis. These arterio-sclerotic le-
sions may precede the development of the paretic process. Fur-
ther investigation is needed in relation to these points.

For the exact nature of the pathological process different
explanations have been offered. Nissl 60 affirms that paresis is
a chronic inflammation of the central nervous system, and that
the facts justify the attempted differentiation between this dis-
order and other psychoses on a histo-pathological basis. The

M Halbseitiges Delirium. Psych, neurol. Wchnschr., 1902, 34.

M Op. cit.

*° Neurolog. Centralbl., 1902, December 16, Nr. 24.

47Q

PSYCHIATRY

lesions present indicate an inflammation, which is character-
ized by a marked infiltration of the adventitial sheaths, with
the occurrence of the plasma-cells. From these findings the
deduction is made that an inflammatory process is the basis
of the changes, and that the latter can not be the result of a
simple degeneration.

As the result of two hundred autopsies performed by Vig-
ouroux and Laignel-Lavastine 61 on patients who had died
from dementia paralytica, these observers concluded that the
pathological processes could be divided into three categories:
( i ) cases in which there was a general cellular infiltration of
the meninges and cortex not accompanied with marked degen-
erative lesions of the arteries; (2) instances of marked hyaline
degeneration and pigmentation in addition to the infiltration,
and (3) cases characterized by marked degeneration of the
arteries with or without a discrete infiltration.

More recently Nissl 62 has attempted to draw even sharper
lines between the histo-pathological changes of cerebral lues
and those that occur in paresis. As has already been mentioned,
the important point in the differentiation is to be sought not in
single lesions, but in the totality of the findings. The paretic
process may be regarded as diffuse in the sense that changes are
present throughout the whole cortical region, but those which
are specific of paresis need not show an equal intensity in all
the different areas, but are in a sense localized. This idea ren-
ders it possible to draw a distinction between the typical and
atypical cases. A resume of the changes which may be regarded
as specific of general paresis is as follows :

( 1 ) A marked disappearance of the tangential and supra-
radiary fibres.

(2) An increase and thickening of the glia fibres, particu-
larly the subpial felting, as well as of the bands of fibres around
the blood-vessels ; a considerable increase in the number of cells

0 Revue Neurol., Aout 31, 1903.

82 Nissl : Zur Lehre von der Hirnlues. Centralbl. f. Nervenheilk. u.
Psych., 1903, December 15, Nr. 167, S. 788.

PLATE XVIII

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Rod cells from the cortex in paresis.

Fig. i.— Isolated forms. In the one to the right is shown a pigmentary deposit in the protoplasm
of the longer polar process.

Fig. 2. — Capillary containing plasma cells. A mural element (adventitial) lies alongside of, but
entirely separated from, the vessel wall. This element has the morphological characteristics of the
rod cells which are scattered through the grey matter.

Fig. 3. — Mural element separating itself from the vessel wall, but not yet entirely free.

Drawings from sections stained with polychrome methylene-blue. Zeiss, homog. immers. 1-30.
Ocular iv.

DEMENTIA PARALYTICA

471

with progressive changes in the nuclei and a synchronous thick-
ening and increase in the size of the cell-body, and a differentia-
tion particularly of thick glia fibres out of the protoplasm.

(3) The appearance of various lesions in the nerve-cell.

(4) The adventitial spaces, particularly of the middle-
sized vessels, contain plasma-cells, lymphocytes, and occasion-
ally mast-cells. In the adventitial sheath there is nearly always
pigmentation.

(5) A formation of new vessels with numerous connec-
tions between the glia protoplasm and the vessel walls.

(6) The so-called Rods (Stabchenzellen) are not so nu-
merous in any other process.

(7) The characteristic changes in the spinal cord.
The syphilitic process may be differentiated as follows :

( 1 ) A relatively slight disappearance of the tangential and
supra-radiary fibres.

(2) A different character in the glia changes from that
noticed in general paresis. The throwing-off of the glia fibres
is less marked, and the large, thick fibres are not common. The
bands of fibres about the vessel walls are less prominent, but
the thick processes connecting the cells with the vessel walls are
more numerous. The nuclei are enormously increased and
reach a colossal size. The so-called typical glia (gemastete)
cells are absent, and the cells themselves show more frequent
regressive changes.

(3) The nerve-cells, as a rule, show a greater tendency
towards swelling and disintegration of the cell-body.

(4) There is at the most only a very slight suggestion of
the adventitial infiltration, with only an occasional mast-cell.

(5) A marked proliferation of the cells of the intima,
which show an inclination to form small vascular lumina inside
of the original vessel. The elastic fibres split into two or even
four or five layers. The formation of new vessels is the most
characteristic feature in the picture. The cells in the vessel
walls do not show any fat pigment. The capillaries frequently
bore through the glia protoplasm.

(6) Rods (Stabchenzellen) are rare.

472

PSYCHIATRY

(7) The spinal cord shows no typical degeneration.

A careful analysis and comparison of all the facts seems
to justify the view that dementia paralytica is a diffuse toxic
process affecting nearly all the organs in the body, but showing
a marked predilection for the central nervous system. In fact,
we have a series of phenomena somewhat analogous, as some
observers have suggested, to the cachexias following the de-
struction of the thyroid or suprarenal bodies.

It is interesting to note that Watson,63 in studying the
central nervous system of cases of juvenile general paralysis,
comes to the conclusion that the lesions are not merely the
result of impaired development, but of some active process.

85 The Pathology and Morbid Histology of Juvenile General Paralysis.
Arch, of Neurol., ii, 1903.

CHAPTER XVI

THE EPILEPSY GROUP1

Epilepsy is a disease characterized by disturbances in
consciousness of varying degrees of intensity, with or without
convulsive seizures. In the majority of cases the changes in
the character of the individual noticeable between the attacks
are almost specific and may manifest themselves in either a
temporary or a permanent mental aberration. As Binswanger
has shown,2 in the narrower sense only those cases may with
certainty be called epilepsy in which the symptoms are charac-
terized by chronicity and are indicative of an interference with
the general functions of the central nervous system. At the
outset a difficulty in regard to the use of the word epilepsy is
experienced, as the study of the condition to which the term
" psychic epilepsy" has been applied includes a variety of symp-
toms. The stable epileptic manifestations are referred to as
changes in character or disposition, while the episodic forms are
associated with the attacks or their equivalents. Hoffmann, who,
in 1862, was the first to use this expression, affirmed that it was
possible to recognize the disorder in cases in which the charac-
teristic motor anomalies were altogether absent. On the other
hand, a reaction has taken place, and the general consensus of
opinion now favors the view that in the absence of the specific
motor symptoms the diagnosis of epilepsy shall be made with a
considerable degree of mental reservation. The observations
of Hoche 3 and others have served to emphasize the extreme

1 Gowers : Epilepsy and Other Chronic Convulsive Diseases. London,
1901. Dutil, A. : Troubles mentaux dans l'epilepsie. Ballet, Traite de
pathol. mentale. Paris, 1903. Starr, M. Allen : Is Epilepsy a Functional
Disease? Journ. Nerv. and Ment. Dis., March, 1904.

2 Die Epilepsie. Specielle Pathologie und Therapie. Nothnagel,
Wien, 1899.

' Hoche, A. : Die Differentialdiagnose zwischen Epilepsie und Hys-
teric Berlin, 1902, A. Hirschwald.

473

474 PSYCHIATRY

difficulty that frequently exists in differentiating cases of severe
hysteria from epilepsy, and Aschaffenburg has recently care-
fully examined a number of cases with the view of determining
whether in many of the presumed instances of psychic epilepsy
a positive diagnosis is justifiable. The latter, although admit-
ting the relative diagnostic importance of such symptoms as
headache, profuse sweating, dilatation of the pupils, impaired
reactions, the increase in the rapidity of the pulse, the marked
tremor, blanching or reddening of the face, the severe attacks
of diarrhoea, etc., maintains that on account of the present lim-
itations of our knowledge the question cannot by any means
always be answered positively in the affirmative. After these
qualifying statements we may proceed to the consideration of
the clinical forms of alienation associated with this neurosis.

The mental disturbances may be conveniently arranged in
four main groups : ( I ) those that precede the attacks, — the
aurse; (2) those that develop during the height of the seiz-
ure,— the psychic equivalents of the motor symptoms; (3) the
sequelae, or post-epileptic phenomena; these three groups in-
clude the symptoms that are episodic; (4) those that are more
or less constant during the intervals between the attacks and
bring about anomalies in thought and action that in a measure
show themselves in the character of the individual. These per-
manent changes vary in degree from mere eccentricities of char-
acter to the most pronounced forms of dementia.

Before proceeding to the discussion of the different groups,
a word may be said in passing as to the general character of
the mental symptoms. Thus we may have forms characterized
by periods of (a) excitement, (&) depression, and (c) mixed
forms, in all of which impulses may play an important role.
The excitement may take the form of simple mania lasting for
only a few minutes or in some instances for months or even
years, or it may be of extreme violence (manie furieuse).

The impulsions are characterized by their sudden, in-
explicable appearance and their independence of external
circumstances. They are very varied in character, — suicidal,
homicidal, dipsomaniacal, pyromaniacal, poriomaniacal,-

THE EPILEPSY GROUP

475

they may be associated with various forms of automatism and
exhibitionism.

( i ) Aura may be classified as psychic, sensorial, motor,
and vasomotor (Reynolds). Among the more important of the
disturbances in the mental activities are the anomalies of emo-
tion. A patient may be overwhelmed by states of anxiety
which are intimately associated with changes in the organic
sensations. Frequently he is able to localize the accompanying
disturbances in the head, breast, or abdomen. Not infrequently
the onset of the anxiety is sudden and to the patient inexplica-
ble, and at times this sensation develops into a definite fear.
The former may be accounted for in the majority of cases by
the comparatively short duration of the phenomenon, while in
the cases in which the aurae last longer anxiety may crystallize
into a definite, well-defined phobia, and when this is the case,
in addition to the changes in the organic sensations, hallucina-
tions and delusions may occur, which often form the basis of
an anomalous affective state. Not uncommonly the first
symptom of an approaching epileptic seizure is a profound
mental depression, the patients sinking deeper and deeper into
the slough of despond until they are overwhelmed by the seiz-
ure. Binswanger reports an instance in which the period of
depression was followed by one of marked exaltation amount-
ing to euphoria. As a rule, during the prodromal stage the
patient is apt to be excessively irritable, brooks no interference;
he is subject to violent outbursts of temper and shows a high
degree of emotional instability. The disturbances of the intel-
lectual faculties are either the result of marked inhibition, in
which case there is complete interference with certain of the
mental processes, or there may be an apparent increase in the
intensity and rapidity of the psychical reflexes. In the former
case there is retardation and a marked delay in the working up
and elaboration of every stimulus that impinges upon the cere-
bral cortex, not only in the sense areas, but the defects are even
more general, including the functions of associative memory.
Sometimes the amnesia amounts to a general impairment of
memory, while in other instances it is more localized, the defects

476 PSYCHIATRY

being checkered in character and certain islands of memory
remaining intact. The patients frequently describe this tem-
porary mental enfeeblement by declaring that they have diffi-
culty in thinking, that their thoughts become obscure, that they
are unable to direct their attention, and in many ways appar-
ently recognize the general sluggishness of all the cerebral pro-
cesses. The delay in the association of ideas may be easily
shown by means of the simple clinical tests to which allusion
is made in the first section of the book. In the antithetical state
the mental reflexes sometimes seem to be short-circuited as it
were, and there is such a quick response to any and every
stimulus that there seems to be an increase in the mentality;
nevertheless, on careful examination the field of consciousness
is found to be limited, the apparent augmentation in the psychic
activity being merely due to the promptness of the simpler
psychic reaction and not to any greater elaboration in the work-
ing up of the stimulus.

Among the psychic aurae imperative ideas and obsessions
play an important role. Patients not infrequently complain that
during a certain period preceding the attack they are distressed
by the rapidity and intensity with which their brain seems to
act. Certain obsessions shoot up into the field of consciousness
and serve to increase their nervousness, sometimes giving rise
to definite states of anxiety or fear. The aurae connected with
the special senses are frequent and varied in character (Gow-
ers). In the visual field patients frequently suffer from ele-
mentary hallucinations: they see bright lights, occasionally
colored, particularly red. Associated with these elementary
hallucinations are those of a more complex character, — visions
of animals or human figures. Not infrequently patients de-
scribe these phenomena with great accuracy and minuteness.
As a rule, the hallucinations and delusions are grotesque and
bizarre in character. The elementary auditory hallucinations
belong rather to the more complex forms, which are less fre-
quently encountered.

(2) Mental Symptoms occurring during the Height of the
Attack. — Instead of the convulsive seizures characterized by

THE EPILEPSY GROUP 477

tonic or clonic spasms with marked disturbances in conscious-
ness, there may occur what are termed psychic equivalent at-
tacks. These may be divided categorically into three groups :
(a) transitory disturbances in consciousness, lasting for a few
seconds or minutes; (b) the same psychical defect associated
with slight motor involvement, such as turning of the head,
temporary squint, etc.; (c) clouding of consciousness asso-
ciated with affective emotional disorders, accompanied by
anomalous automatic impulsive acts.4

Frequently it is impossible to recognize with certainty
these transitory disturbances as epileptiform, and it is only after
their recurrence and when the probability of the existence of
some organic brain lesion has been eliminated that the diag-
nosis can be determined. There is no form of mental aberra-
tion which is more commonly ignored or not recognized than
the milder types of the psychoses which belong to latent epi-
lepsy, as it is termed (larvirte epilepsie). In the less severe
forms of the disease — petit mal intellectuel — the patients not
infrequently pass from a period of depression to one of anxiety,
in which they become irritable and impulsive. Not infrequently
during these attacks the sufferer may even become so desperate
that he attempts suicide. As a rule, the subjects of these at-
tacks retain some insight into their condition, and often rec-
ognize that they are the subjects of obsessions or insane ideas,
or wander about aimlessly, overwhelmed by anxiety. The
attack itself lasts from a few seconds to several minutes.

The more severe attack — grand mal intellectuel — may
be preceded by a period during which the motor discharge is
replaced by severe emotional storms, marked mental depres-
sion, intense anger, or great anxiety, associated with hallucina-
tions of various forms. Aschaffenburg noted the occurrence of
attacks of mental depression in 78 per cent, of the cases of psy-
chic epilepsy, This symptom was practically uncomplicated in
some cases, while in others it was associated with anxiety, optic
hallucinations, motor restlessness, and boisterous aggressive-

* V. Krafft-Ebing : Lehrbuch der Psychiatrie, 7te Auflage, 1903, S. 486.

478

PSYCHIATRY

ness. Frequently the diagnosis is only possible when the attack
has passed and the patient falls into a deep sleep. Often
there is a period preceding the acme which is characterized
by primary incoherence and marked dissociation of thought,
while in other instances there may be stupor, broken by periods
of intense excitement, during which the conduct of the patient
is dictated by obsessions and impulses of such a dominating
character that the individual brooks no interference, destroys
his clothing, breaks the furniture, rushes heedlessly about, in-
jures those who come across his path, and becomes a source
of the greatest danger not only to himself, but to those about
him. It is not improbable that a symptom-complex that in
some measure suggests the typical flight of ideas as seen in
manic excitement may be occasionally noted in these transitory
periods of aberration occurring in epileptics.5 As a rule, the
excessive narrowing in the field of consciousness with the ten-
dency to verbigeration, as well as the boisterous rage of the
epileptic, serve to distinguish this apparent fictitious flight from
that seen in manic-depressive states. It is only in those cases
of epileptic mania in which the motor restlessness is excessive
and the emotional storm is very intense that this apparent flight
really resembles the true maniacal type.

In some instances speech compulsion and verbigeration rap-
idly alternate with periods of mutism, a combination of symp-
toms that is somewhat analogous to conditions that are marked
in hysteria and in precocious dements.

Orientation, as would be expected, is markedly impaired.
The hallucinations vary greatly in number and intensity. As
a rule, the visual and auditory predominate, but the functions
of touch, taste, and smell may be similarly affected. The pa-
tient's relation to the external world is almost completely sev-
ered, and definite motives for action are replaced by obsessions
and fallacious sense perceptions, which, as a rule, take on great
sensory vividness and a variety of forms.

6 Heilbronner : Ueber epileptische Manie nebst Bemerkungen iiber die
Ideenflucht.

THE EPILEPSY GROUP 479

Especially common are grotesque or frightful apparitions,
whose approach overwhelms the patient with fear and intense
anxiety, — curious animals, monsters of all sorts, devils, fright-
ful-looking personages, who attempt murder, rape, etc. Not
infrequently the fallacious sense perceptions are so vivid and
of such a gruesome and terrifying character as to give rise to
states of intense mental anguish. Patients are threatened by
some dreadful incubus, are confronted by the tortures of hell,
see visions and dream dreams more terrible in their content
than the sights described in the Inferno. Sometimes the visions
are of a different character. Devils are replaced by angels,
the patients have communication with heaven, and, as a result
of these pleasant revelations, marked euphoria may be present,
the patients giving expression to their feelings by jubilant
shouts or by decking themselves in fancy dress. The allopsy-
chic disorientation of the patient in cases of this character may
in part be referable to hallucinations and delusions, but there
are others where this sensory vividness is less intense, and then
the disorientation is due to other causes.

As a rule, the number of representations in consciousness
is decidedly limited. This in a measure undoubtedly explains
the intensity of certain retained sensations and the reflex effect
which they seem to exert on the conduct of the individual. In
these severe cases the memory, as may be inferred, is markedly
impaired, although occasionally single and isolated events that
occur during the attack are remembered.

Essentially characteristic of psychic epilepsy is the so-
called dream state, in which we see evidences of considerable
interference with the cortical functions, and this in turn is a
potent factor in the production of the allopsychic disorientation.
As Wernicke has pointed out,6 the disorientation may be so
excessive as to amount to asymbolism.

A second important characteristic of the dream state is
the tendency shown by certain cortical functions when once
initiated to persevere (perseveration). Patients repeat the

"Op. cit.

48o PSYCHIATRY

same words in reply to widely different questions, and it is fre-
quently necessary to greatly increase the intensity of the audi-
tory stimulus before a change in the reply is given. This ten-
dency is also shown in the repetition of certain acts and in the
recurrence and persistence of certain ideas or groups of ideas.

(3) The post-epileptic mental disturbances may in a meas-
ure resemble those which precede the attack. In some instances
they may be regarded as merely protracted aurae or as ante-
cedents of the stuporous state. Just as in the period preceding
the attack, so following it, we may have marked emotional
disturbances, pronounced anxiety, psychomotor retardation,
periods characterized by hallucinosis and the cropping up of im-
perative ideas and obsessions. In this period there may also
be various degrees of mental apathy, with or without the au-
tomatic and impulsive acts. At times there occur the well-
known dream-like states, lasting from a few seconds to several
hours, days, or even weeks, or periods of marked excitement,
with vivid and persistent hallucinations and very great incoher-
ence, similar to those already described may intervene. The
protracted stuporous states are much more common at this
time than in the initial stage or during the so-called equivalent
period. Associated with the impaired mentality there may at
times be marked mutism during which the loss of consciousness
is only partial. Not infrequently cataleptic phenomena are
noted, and these may give rise to great difficulty in differentiat-
ing the case from one of dementia prsecox. It should not be
forgotten that the post-epileptic mental disturbance sometimes
follows single and ill-defined attacks or recurs only after the
lapse of long intervals. When this is the case there is naturally
great difficulty in establishing the diagnosis. Occasionally an
abortive epileptiform attack is followed by marked disturbances
in consciousness and considerable amnesia, a condition that
may give rise to questions of great forensic importance. The
duration of unconsciousness, both during the attack itself and
in the terminal stage, varies greatly. In some instances the
period of total amnesia is synchronous with that of the stupor
or coma, while in others the patient's memory may be so de-

THE EPILEPSY GROUP 48i

fective as to be a perfect blank, not only for all events during
the height of the attack, but for a considerable period prior
to the onset of the first pronounced symptoms. In these cases
the post-epileptic stage can not be well differentiated from the
equivalent period. Thus one of my patients remembered dis-
tinctly leaving his home on a certain morning to go to his place
of business. He had not proceeded far when he suddenly lost
consciousness, and when he regained it he found himself under
arrest, accused of having broken a large plate-glass window in
a store at some distance from the spot where he lost conscious-
ness.

The forensic importance of similar attacks is very great.
Patients often become violent, brutal, and, on account of their
recklessness and apparent indifference to pain, can be restrained
only by the exercise of great force. Siemerling reports the
case of a patient who, during an attack characterized by great
excitement and confusion, with marked automatic impulsive
acts, had once been confined in a hospital for the insane. Three
years later, without any apparent motive, this same man killed
a woman. Witnesses to the act immediately took the man into
custody. During the examination that followed the patient
remained perfectly quiet, showed no appreciation of the deed,
and made no attempt to escape. Gradually he awakened from
the dream-like state into which he had fallen, and at first
affirmed that he had not committed any crime, but finally ad-
mitted the commission of the deed, justifying it, however, on
the ground that it was done in response to a command of God.
During the six weeks in which he was under observation in the
Charite the patient suffered from transitory disturbances of
consciousness, with hallucinations associated with marked
periods of anxiety. The memory was exceedingly defective.
When the attack finally subsided the patient affirmed that on the
day on which he had committed the murder he remembered
having had a severe headache and the sudden and inexplicable
appearance of the idea that he must immediately buy a razor.
On the evening of the same day he went to Berlin to visit his
brother. Soon after arriving in the city his memory became a

3i

482 PSYCHIATRY

perfect blank, with the exception that he vaguely remembered
attacking some person, being actuated only by a blind impulse.
This is an example of a group of cases that not infrequently
come under observation. Patients of this class during these
periods of unconsciousness (ambulatory automatism) have
been known to go on long journeys, to commit theft, arson, or
assault, and display a marked tendency to exhibitionism and
vagabondage.

Buchholtz called attention to a comparatively small group
of cases in which the insane ideas develop during the equivalent
period, become systematized, and persist for long periods of
time. These are the instances referred to in the literature as
paranoiic states developing upon an epileptic basis.

(4) In the majority of cases? after the epilepsy has existed
for a considerable period of time a more or less pronounced
form of dementia makes its appearance. Gradually the interests
of the individual become more or less limited and monotonous.
The mental processes are considerably delayed, marked length-
ening in the reaction time taking place. The defects in memory
become more noticeable, and the intellectual and ethical deficien-
cies are so intensified that finally in the severest forms of the
disease the patients are unable to show any evidence of cerebra-
tion. In these cases the articulation of speech may be seriously
impaired, and the individual is reduced to a state which is com-
parable to some of the lowest forms of idiocy. The earlier in
life the epileptic attacks appear, the more apt is the dementia to
become of a pronounced character.

Differential Diagnosis. — As has already been pointed
out, there is often great difficulty in distinguishing mental dis-
orders associated with epilepsy from those occurring during
the course of other psychoses. This is particularly true in re-
gard to the various forms of hysteria. It should also be
remembered that hysterical symptoms may obscure those of
genuine epilepsy.7 Sufficient has already been said in the

7 Hermann, J. S. : Ueber spatauftretende hysterische Anfalle bei Epi-
leptikern. Monatsschr. f. Psych, u. Neurol., xiii. Bratz u. Falkenberg:
Hysterie und Epilepsie. Archiv f. Psych., Bd. xxxviii, Hft. 2, 1904.

THE EPILEPSY GROUP 483

chapter on hysteria to point out the symptoms that may be
considered of importance in differentiating the two diseases.
The vertigo without disturbances in consciousness, which fre-
quently occurs in patients suffering from gastric or cardiac dis-
ease, is easily differentiated from true attacks of epilepsy. In
the prodromal stage of dementia paralytica, the senile psy-
choses, or during the onset of the acute delirium, we not
infrequently meet with states of apprehensiveness, motor rest-
lessness, irritability associated with visual and auditory hallu-
cinations, combined with outbreaks of anger and suicidal or
homicidal attempts, which may temporarily resemble epilepti-
form attacks. The subsequent development of the case, as well
as the characteristic visual symptoms in a case of paresis, aid
in establishing a diagnosis. Not infrequently in individuals
who are afflicted with gout we meet with epileptiform attacks
which present many difficulties in the differentiation from true
epilepsy, but in the former the prognosis is very much better
than in cases in which we have the hallucinations, the impulsive
acts, and the memory disturbances described as characteristic
of the confusional states occurring during epilepsy. Some
observers affirm that the more or less sudden onset and disap-
pearance of alienation, the peculiar type of the hallucinations,
the impulsive acts, and the memory defects should at once
arouse suspicions as to the existence of this malady. Others
.maintain that if epilepsy is present the insane ideas are either
of a persecutory or boastful character and that the hallucina-
tions generally refer to religious subjects. Kraepelin, on the
other hand, has emphasized the apprehensive, angry character
of the patients suffering from epileptic mania, while Bon-
hoeffer thinks that a hypochondriacal coloring of the insane
ideas with marked disturbances of organic sensations and
hallucinations of smell and taste are alone specific. The
attempt to establish a safe criterion based upon the analysis of
the physical symptoms is equally unsatisfactory. The absence
of the light reflex, which sometimes occurs and may persist for
twenty-four hours, is frequently noticed in other conditions.
Probably somewhat more important are the dilated pupils with

484

PSYCHIATRY

a sluggish reaction for light. It is not improbable, as Raecke
and others have pointed out, that the drunken character of the
walk, the general tremor and irregular incoordinated move-
ments, reminding one of chorea or myoclonia, deserve more
careful attention. The speech disturbances, including either
marked disturbance of articulation with a tendency to scan and
stammer, and in other instances pronounced aphasic symptoms,
with echolalia and verbigeration, have received careful study.
Pick8 has indicated the sequence of what he calls the re-evolu-
' tion of speech following the epileptic attack. At first there is
complete word deafness, and then, although the patient is
unable to comprehend the sense of the words, he can repeat
them mechanically. This period is followed at varying
intervals by the return of spontaneous speech.

Frequently, if no history of the patient has been obtained,
there is some difficulty in deciding whether a case is one of
manic-depressive insanity or the mania of epilepsy. Formerly
it was believed that the typical flight of ideas was charac-
teristic solely of the excited periods of manic-depressive in-
sanity, but recently Heilbronner 9 has called attention to the
fact that a syndrome closely resembling this may occur in true
epileptic mania. The differential diagnosis may be still further
complicated by the appearance of euphoria, distractibility, mo-
tor restlessness, and speech compulsion. We believe, however,
that this combination of symptoms is of comparatively infre~
quent occurrence, and such a condition is apt to persist only in
cases of true mania. The differential diagnosis is sometimes
difficult to make from cases of true mania where the patient
is exceedingly aggressive, boisterous, and brutal. As a rule,
the epileptic characteristics, such as marked apprehensiveness,
states of ecstasy, and acts which are the result of blind im-
pulses, sooner or later become so prominent in the clinical

8 Ueber die sogen. Reevolution (H. Jackson) nach epileptischen An-
fallen nebst Bemerkungen uber transitorische Worttaubheit. Arch. f.
Psych., xxii, S. 756.

* Heilbronner, Karl : Ueber epileptische Mania nebst Bemerkungen
uber die Ideenflucht. Monatsschr. f. Psych, u. Neurol., xiii.

THE EPILEPSY GROUP 485

picture as to be easily recognized. Sometimes patients suffer-
ing from catatonic excitement may suggest the various forms
of epileptic mania. The differentiation is frequently compli-
cated by the appearance of perseveration. This symptom,
which frequently occurs in cases of dementia praecox, is also
common in epilepsy. Bonhoeffer10 has shown that the capa-
city of epileptics for association is particularly limited, and
that in addition to this they show a marked inclination to re-
peat certain words. On this account the speech of patients
may be particularly monotonous, and they may repeat for
hours at a time certain phrases or words. The importance
of these senseless repetitions in epileptic states has been em-
phasized by Siemerling.11 But the appearance of mannerisms,
stereotypies, negativism, as a rule, establish the diagnosis.

Recently Raecke 12 has carefully studied the transitory
disturbances in consciousness in epileptics with a view to de-
termining, if possible, whether any causal relationship exists
between these and the convulsive seizures. As the result of
his observations, he has come to the conclusion that the ethical
and intellectual defects in epilepsy do not develop in proportion
to the severity and duration of the attacks, although both
phenomena are undoubtedly the result of similar disturbances in
the cortical functions. The variety of the attacks may be differ-
entiated according to their severity as follows :

(1) The severe convulsive attacks; (2) the rudimentary
and atypical seizures; (3) petit mal; (4) states of confusion;
(5) paranoiic conditions; (6) the dream states, and finally the
periods of depression or exaltation. Gradually clinicians have
come to realize that the amnesia is not a safe criterion in the
absence of other symptoms upon which the diagnosis of psychic
epilepsy may be made. Amnesic defects may be absent in epi-
leptiform attacks, but when they exist may present a variety

10 Die akuten Geistesstorungen der Gewohnheitstrinker. Jena, 1901.

11 Ueber die transitorischen Bewusstseinsstorungen der Epileptiker in
forensischer Beziehung. Berl. klin. Wchnschr., 1895, Nr. 12.

12 Die transitorischen Bewusstseinsstorungen der Epileptiker. Halle
a/S., 1903.

486 PSYCHIATRY

of forms. The onset is sudden, and the return of the power
to re-collect and redevelop past impressions may be equally
abrupt. The amnesic defect, as a rule, has the following
characteristics: It may be simple, retrograde, anterograde,
transitory or permanent, complete or incomplete, or may be
entirely absent. Its presence may justify the suspicion of the
existence of epilepsy, but its absence is not proof positive that
the disease does not exist. The simple and retrograde am-
nesia may not render an individual irresponsible for all his acts,
and in this way is essentially different from the anterograde
form.13

Pathogenesis. — The so-called hereditary factor in cases
of epilepsy is of great etiological importance. Griesinger was
among the first to call attention to the neuropathic or psycho-
pathic predisposition that exists in many cases, and clinical
observation has shown that in individuals in whom this
psychopathy is marked there is an apparent lowering of the
resistance of the central nervous system for both physiological
and pathological stimuli. As yet nothing definite is known
in regard to the primary changes in function which form
the basis upon which this condition develops. As the result
of clinical study, we know that the causes producing this pre-
disposition may act through one or both parents upon the
child ; they may be acquired during intra-uterine life, or after
birth.

In the first category may be grouped all the agencies which
have such a deleterious effect upon the ancestry as to give rise
to anomalies of function in the nervous system of the descend-
ants. Chief among these is alcohol. It is affirmed that in at
least one-quarter of the cases of epilepsy the history of alcohol-
ism in one or both parents may be obtained, and not only is
this poison responsible for many of the cases of pure functional
epilepsy, but it is also an etiological factor of great importance
in cases of imbecility and idiocy with epileptiform seizures.

u Maxwell, J. : L'amnesie et les troubles de la conscience dans l'epi-
lepsie. Leipzig, 1903.

THE EPILEPSY GROUP 487

Robinovitch 14 has endeavored to demonstrate the apparent
definite causal connection that exists between this psychosis and
various forms of ancestral alcoholism. Nevertheless, while it
is only right to be exceedingly cautious in minimizing the im-
portance of this drug as an etiological factor, the fact must be
kept in mind that the existing evidence does not fully justify
the statements so frequently made to the effect that there is an
immediate causal connection between the occurrence of alco-
holism in a remote ancestor and of epilepsy in the individuals
of a later generation. Many of the agencies that interfere
with normal conception and pregnancy may result in the birth
of epileptic children. In this category may be enumerated psy-
chic shocks, trauma, as well as the various accidents incident to
pregnancy and parturition.

In addition to the deleterious effects upon the offspring of
chronic alcoholism in the parents, it is well known that lead,
morphin, etc., may be equally important factors in the produc-
tion of epileptic children. A similar tendency exists if the par-
ents suffer from general constitutional diseases, such as
tuberculosis, syphilis, as well as profound anaemia, leukaemia,
diabetes, gout. In such cases the children may suffer from a
general impairment of the functions of the central nervous sys-
tem or from marked developmental anomalies of structure and
subsequent impairment in function.

The deductions derived from careful clinical observation
all tend to support the view that epilepsy is to be considered not
as the immediate effect of the deleterious action of the agencies
already described, but rather as an expression of a certain es-
tablished predisposition, and the same factors which may have
been potent in the production of the tendency of an individual
to nervous or mental disease may also become important etio-
logical factors immediately operative during his life. This is
particularly true in regard to the various forms of intoxication
to which reference has already been made. Alcohol, lead, mor-

11 Robinovitch, Louise G. : The Genesis of Epilepsy. The Journal of
Mental Pathology, 1902.

488 PSYCHIATRY

phin, may all play an important role. The same is true in
regard to the effect of exhaustion. Excessive mental or physi-
cal strain may have an injurious influence upon the central
nervous system. The chronic constitutional diseases of child-
hood, such as rachitis and scrofula, are also of importance, as
well as the diseases which develop later in life, particularly at
the time of puberty, such as the severe forms of anaemia, the
hemorrhagic diathesis, scurvy, hemophilia, gout, arthritis de-
formans, diabetes mellitus. The relation of the acute infectious
diseases to this psychosis has been repeatedly emphasized by
clinicians — measles, diphtheria, typhoid, as well as whooping-
cough, scarlet fever, and malaria.

That a connection exists between syphilis and epilepsy has
long been recognized. The cases of functional epilepsy which
develop in individuals who have had a syphilitic affection are
to be differentiated from those in which the convulsive seizures
are merely the early symptoms of marked structural lesions due
to the specific toxin. Long ago Fournier called attention to
the fact that the primary infection might become an etiologic
factor of great importance in the pathogenesis of cases of epi-
lepsy. Parasyphilitic epilepsy often occurs in individuals in
whom the primary infection has taken place years before the ap-
pearance of the convulsive disease.15 The attacks, as a rule, ap-
pear less often than in the so-called idiopathic forms of the dis-
ease, but the dream-like states are comparatively more frequent,
while the intellectual defects are less common. The fact should
be borne in mind that the specific infection cannot be justly re-
garded as the prime cause of epilepsy if a definite history of the
action of other injurious agencies, such, for example, as
trauma, alcoholism, severe attacks of the acute infectious dis-
eases, cardiac lesions, arterio-sclerosis, diabetes mellitus, has
been obtained. The causal relationship between epilepsy and
syphilitic infection has been referred by some clinicians to the
so-called dyscrasia, by others to the changes in metabolism
caused by the action of the syphilitic poison, or, finally, to the

15 Syphilis und Nervensystem. Max Nonne. Berlin, 1902.

THE EPILEPSY GROUP

489

lesions in the central nervous system analogous to those that
occur early in the infection in the mucous membranes and skin.

Paris 16 has suggested the following purely hypothetical
explanation of the malady : A hyperactivity of the central ner-
vous system due primarily to an increase in the secretion of the
thyroid and genital organs develops, and associated with this
there is an accumulation of toxins in the blood due to a
diminution in the excretive activity. The basis for such an
assumption rests largely on those observations which tend to
show that epilepsy is more common in women than in men, and
also that many cases of this disorder frequently seem to be
temporarily benefited by marriage and pregnancy. The indi-
cations for treatment based upon this theory are : ( 1 ) to at-
tempt to diminish the general sensibility; (2) to try to limit
the functional activity of the thyroid and genital glands; (3)
to secure elimination of the secretions, and, finally, to prevent
as far as possible the accumulation in the organism of all tox-
ins which may serve to increase the meningo-encephalitic ex-
citement.

Treatment. — The prevention of the spread of this dis-
ease is of the greatest importance. In addition to the attempt
to mitigate or remove the causes referred to as of etiological
value, the physician should do all in his power to prevent the
marriage of an individual who has been afHicted with genu-
ine epilepsy. There is no form of mental disease in which
there is greater danger of either the recurrence of this malady
or of the appearance of a new psychosis in the descendants.

During the periods of depression and excitement the pa-
tients are much better off in an institution, where they can be
under constant medical supervision and receive careful nursing.
Sufficient has been said to show that these individuals may be a
source of great danger, not only to themselves but to the com-
munity, and therefore for their own sakes, as well as for the
well-being of others, they should be placed in a hospital as soon
as the first symptoms of marked alienation are recognized. Fre-

18 Arch, de Neurologie, 1904, Nos. 98-99.

49o

PSYCHIATRY

quently a great deal may be accomplished by the dietetic treat-
ment. The patient should be taught to eat slowly, and in order
that he may not overburden his stomach should be allowed to
take small quantities of food repeated at intervals of three or
four hours instead of three meals a day. All forms of stimu-
lants are prohibited. Alcohol in any form is a poison, and the
same is true to a less extent of tea and coffee. Tobacco should
also be withdrawn. As a general rule, the amount of butcher's
meat should be restricted, chicken, fish, oysters, and milk tak-
ing its place. Fresh bread, pastry, and sweets are strongly
contraindicated. In the severer cases an exclusively milk
diet continued for some time will prove satisfactory. Not
infrequently if the dementia is not marked and the periods
of excitement and depression are not excessive the patients
do exceedingly well in country homes under medical super-
vision where they can be cared for under the colony system.
Although the use of the bromides is generally indicated dur-
ing the periods of excitement, much may be done to quiet
the patient by restricting the diet and by giving wet packs or
the continuous bath. Sedative drugs are far less efficacious
in the treatment of the various forms of aberration associated
with epilepsy than they are in controlling the attacks associated
with convulsive seizures. The bromides may be administered
in the form of the sodium, potassium, or ammonium salt, pre-
ferably alone or in combination. Care should be exercised to
avoid bromism, which is generally accompanied by marked loss
of appetite, disturbances in the gastro-intestinal tract, acne,
diminution in the reflexes, impairment of memory, and apathy.
Arsenic is frequently of use in combating these symptoms, and
in addition is an excellent tonic. Bromalin (Merck), bromo-
pin, and bromocol have been recommended by various author-
ities. Flechsig advises the bromide-opium treatment. He gives
extract of opium, beginning with small doses, the quantity
being gradually increased until the end of the sixth or seventh
week, when the opium is suddenly withdrawn and is replaced
by bromide. Toulouse and Richet have endeavored to bring
about what they term a " hypochlorization" of the body in

THE EPILEPSY GROUP 4QI

order to facilitate the absorption of the bromide. The daily diet
is as follows : i to i y2 litres of milk, 40 to 50 grammes of butter,
3 eggs without salt, fruit, 300 to 400 grammes of white bread.
Instead of common salt the patient is given three grammes of
sodium bromide a day. This procedure seems to have been fol-
lowed with some success. Ceni 17 believed that he had isolated
two specific substances in the blood of epileptics and that he
had obtained beneficial results in the line of treatment by em-
ploying an artificial serum in which one of these substances was
present. These results have not been generally confirmed.18
Decided improvement has been noted in some cases after the
employment of hydrotherapeutic measures. Cool applications
to the head and back as well as half-baths (at 300 — 260) given
for six to ten minutes are the means employed. This treat-
ment makes it possible to greatly reduce the quantity of
bromide. It is also desirable that patients should drink plenty
of water so as to aid in diuresis.

The Pathology of Epilepsy. — In many of the cases of
epilepsy, particularly those in which the mental symptoms are
more prominent than the localized motor disturbances, it is im-
possible to discover any changes in the brain tissue which are in
any sense pathognomonic. The cases of Jacksonian epilepsy
which depend upon the existence of a local lesion are rather of
neurological than of psychiatrical interest. These include the
cases secondary to cerebral hemorrhage, trauma, brain abscess,
tumors, embolism, thrombosis, etc. The importance of the scar
tissue in the brain as a source of local irritation, which may
give rise to periods of mental aberration, offers a problem that
has not as yet passed the hypothetical stage, and sufficient ref-
erence to this subject has already been made in the chapter on

17 Del siero di sangue degli epilettici. Riv. sper. freniatr., vol. xxvii,
fasc iii-iv. Specifische Autocytotoxine u. Antiautocytotoxine im Blute
der Epileptiker. Neurolog. Centralblatt, April 16, 1903.

18 Roncoroni : La sierterapia dell' epilepsia. Archiv du psichiat.
scienze penali ed antropol. crim., vol. xxiii, fasc. 4/5, 1902. Sala u. Rossi:
Zur Frage iiber einige angebliche toxische u. therapeutische Eigenschaften
des Blut-serums vom Epileptikern. Neurolog. Centralblatt, Sept. 15, 1903.

492 PSYCHIATRY

manic-depressive insanity. That more diffuse lesions in the
central nervous system are apt to give rise to epileptic seizures
is generally recognized. The various clinical forms of epilepsy
may follow the acute meningitides, both the purulent and also
the serous varieties, while not infrequently epilepsy, compli-
cated by a slow progressive dementia, develops as a sequel to
these inflammations of the membranes.

Not infrequently various sclerosed areas, which indicate
the occurrence of encephalitides, are found in the brains of
epileptics. These are frequently met with in the hippocampus,
and considerable importance has been attached by certain au-
thorities to this finding. Recently attention has been called to
the fact that this change is in reality a hypoplasia referable to
defects in the development of the brain. In some cases also
there is a marked gliosis of the hippocampus with disappear-
ance of ganglion cells from certain portions of the lobe.

Chronic meningitis plays an important role in cases of
idiocy associated with epilepsy. Nor should it be forgotten
that even when local cerebral lesions are known to exist in cases
of epilepsy in the majority of cases it is impossible to establish
a direct connection between their existence and the occurrence
of the attacks. The same is true in regard to the hyperemias
'and stases in the cerebral vessels, inasmuch as these are of sec-
ondary and not primary importance.19 For a long time the
changes in the blood-vessels in the brain of epileptics have re-
ceived careful attention from investigators, and a dilatation of
the fine cortical arterioles, veins, and capillaries, as well as the
formation of new ones, have been reported. In most of the
cases the vascular changes are plainly the result and not the
cause of epilepsy.

Hydrocephalus, either congenital or acquired, is not infre-
quently noted, and in cases of epilepsy which have extended
over a considerable period of time there is a marked increase of

10 Jolly, F. : Pathologische Anatomie der Epilepsie und Eklampsie.
Handbuch der pathol. Anatomie der Nervensystems. Abt. iv. (Bog. 61-
81), Berlin, 1903, S. 1276.

THE EPILEPSY GROUP 493

the subpial felting, as well as in the number of the superficial
cortical vessels. Weber 20 has shown that in other cases there is
a localized irregular increase of the perivascular glia fibres,
both coarse and fine, that in some places fills up the whole of the
outer layer of the cortex and completely obliterates the vessels.
There is also an increase in the number of glia nuclei, and the
presence of large spider-cells with coarse processes is noted in
cases where there is a localized encephalitic inflammation. The
increase in the glia is in all probability secondary rather than
primary in character. Often there is a heaping up of small
round cells, probably neuroglia elements, about the larger
nerve-cells, and the latter when closely examined may show an
excentric position of the nucleus and considerable degeneration
of the granules. These changes, however, are not in any sense
specific.

20 Weber, L. W. : Beitrage zur Pathogenese und patholog. Anatomie
der Epilepsie. Jena, 1901.

CHAPTER XVII

THE HYSTERIA GROUP *

Although a perfectly satisfactory definition of this dis-
order cannot be given, its chief manifestations are easily recog-
nizable and are capable of analysis and description. According
to our present views, hysteria is now held to be a disease which,
to a greater or lesser extent, affects the entire organism,2 and
the mental anomalies associated with it are sufficiently marked
to justify its inclusion among the psychoses. Sydenham was
the first to describe hysteria as a disease of the nervous sys-
tem, but it remained for Charcot to affirm that hysteria was
a psychic malady par excellence and for Janet3 to see in this
disorder " a form of mental disintegration characterized by
a tendency towards the permanent and complete dissociation
of the personality. The symptoms are both primary and sec-
ondary. The former are capable of being reproduced by sug-
gestion ; the latter are more subordinate in character.

The psychic abnormalities of hysterical individuals may
be roughly divided into the following categories : 4 ( I ) The
ideas or representations of the patient's own body, the so-called
organic sensations, appear in consciousness with an abnormal
degree of intensity. (2) The emotional reactions directly and
indirectly connected with this complex of sensations may be
so intensified as to interfere with both sensory and motor func-
tions.

For a full description of the physical symptoms of hysteria

1 Preston, George J. : Hysteria and Certain Allied Conditions, 1897.
Binswanger : Die Hysteric A. Holder. Wien, 1904. Hellpach, W. : An-
alytische Untersuchungen zur Psychologie der Hysteric Centralbl. f.
Nervenheilk. u. Psych., Bd. xv, 1003, p. 736.

'Briquet: Traite de l'hysterie, 1859, p. 517.

s Janet : The Mental State of Hystericals. Translated by Corson. G.
P. Putnam's Sons, 1901.

* Weygandt : Psychiatrie, Muenchen, 1902.
494

HYSTERIA 495

the reader is referred to the various text-books of neurology
as well as to the monographs on this subject. The more com-
plex mental phenomena of this disease are largely conditioned
by (i) disturbances of the attention; (2) anomalies of emo-
tion; and finally, (3) a general interference with the normal
mental functions, particularly noticeable in the disturbances of
memory and in the vivid play of the imagination. As these
primary symptoms may give rise to a variety of disturbances
of the mental processes the latter may be advantageously
studied from many different stand-points. Briefly stated, then,
the mental stigmata consist in anaesthesias, amnesias, and abu-
lias. The normal sense perception is not infrequently inter-
fered with and patients frequently suffer from anaesthesias,
paresthesias, hyperesthesias, and disorders of sensation, so
distributed as not to correspond with the peripheral distribution
of any one nerve, and which for this reason are more properly
described as psychic anaesthesias, psychic paraesthesias, and
psychic hyperaesthesias.

The anaesthesias or hyperaesthesias are sometimes limited
to one-half of the body — hemianaesthesias, hemihyperaesthesias
— or occur in areas forming plaques or geometrical figures.5
As has been said above, the disturbances in sensation bear no
relation to the distribution of the peripheral nerves and may
be general, localized, or selective in character. For example,
there may be insensibility to pain and heat or only to the un-
comfortable sensations produced by forcible movements of the
limbs. Another important characteristic of these disturbances
is their tendency to become systematized. Thus, some patients
affirm that they are able to see certain objects or certain per-
sons and not others. The selection in these cases seems to be
determined by the mental state of the individual. General
anaesthesias are occasionally noted. The hyperaesthesias or
hyperalgesias are associated with various organs and take the
form of myalgias, cephalalgias, pleuralgias, etc. In all proba-
bility, however, thev are much rarer occurrences than is com-

" Charcot : Lecons sur les maladies du systeme nerveux.

496 PSYCHIATRY

monly supposed. In regard to these phenomena one must be
careful to distinguish between the cases in which there is an
apparent and a real accentuation in the sense acuity. Moreover,
there exist certain phenomena, commonly referred to as hyper-
esthesias, that are of purely psychic origin and are referable
to the presence of certain fixed ideas. In such cases the patient
is not only extremely sensitive to all forms of external stimu-
lation, touch, heat, cold, etc., but is also affected by a general
mental hyperesthesia frequently shown by the fact that he
complains of suffering acutely before any cause, has been oper-
ative ; and again, these psychic hyperesthesias or hyperalgesias
are often combined with actual anesthesias. Thus, one of
Janet's patients would shriek with pain as soon as the exam-
iner's hand approached her abdomen, but immediately her
attention was distracted, it was observed that there was ah
actual diminution of sensation. The fixed ideas not only have
a remarkable effect upon general cutaneous sensibility, but also
upon the special organs, such as vision and hearing.

The contradictory characteristics of the sensory anomalies
are more particularly of diagnostic importance. They often
change with great rapidity and are largely influenced by sug-
gestion. Not infrequently the sense organs seem to be in a
state of hyperexcitation, so that in the visual sphere we may
meet with hallucinations and illusions. The former are more
apt to be elementary, although at times patients affirm that they
see visions of the character to be described later. Elementary
auditory hallucinations occur, but are less common. Some-
times these phenomena seem to be purely subjective and appear
even in the absence of any well-defined external stimulus, while
at other times they are evidently illusions.

As a rule, these disturbances are associated with marked
emotional anomalies and are accompanied in many cases by
attacks of pain — headache, intercostal neuralgias, etc. Their
duration varies from a few minutes to several hours, seldom
longer. Their subjective character is usually recognized by
the patients, who appreciate the fact that they are abnormal,
and their conduct, with the exceptions referred to later, is sel-

HYSTERIA . 497

dom actuated or dominated by these fallacious sense percep-
tions. Micropsia and macropsia are not infrequently noted,
and in many instances it is possible to produce hallucinations
by mere suggestion. The taste and smell are affected in a
large percentage of the cases. Hysterical patients generally
show idiosyncrasies in their sensory predilections, expressing
preference for unusual dishes, taking pleasure in such odors
as that of asafcetida or valerian — odors that are wont to be
particularly objectionable to the normal individual. The atten-
tion of these patients is readily gained, but quickly lapses, and
can only be sustained with great effort. These fluctuations un-
questionably form the basis of many of the amnesic defects to
which reference will presently be made. This condition — the
so-called aprosexia — was first described by Guge in referring
to the lapse of attention noticeable in patients suffering from
some obstruction in the nasal passages. The symptom can
often be readily demonstrated. If the patients are made to
read either to themselves or out aloud, although the words may
be pronounced correctly and without delay, it is quite evident
that the sense of the sentence is not apprehended. Whole
paragraphs may be read without the individual being able to
recollect any of the words. If the patient is forced to stimulate
the attention to the utmost, there is often to be noted a reflex
series of phenomena, such as headache, vertigo, various indefi-
nite pains, and more or less nervousness which may lead to
emotional outbreaks. On account of the marked distractibility
hysterical patients are frequently led to errors in interpretation
of a great variety of phenomena and events, and this fact is
fundamentally responsible for many of the apparent inconsis-
tencies and contradictions in their character that are commented
upon by the laity. The defects in memory are characterized
by a considerable degree of capriciousness, and not uncom-
monly may be increased or diminished by suggestion.

The systematization, frequently characteristic of the sen-
sory disturbances, is also noticeable in regard to the amnesias.
Many hysterical patients forget only certain facts connected
with the train of thought, while retaining a logical and uninter-

32

498 PSYCHIATRY

rupted recollection of others. Such forms of amnesia occur
not only for events, but in regard to persons and particularly
for language. This last defect may be so pronounced as to
give rise to difficulties in differentiating the case from one of
aphasia. The loss of memory may be restricted not only in
this way, but may also include the muscular movements, being
sometimes limited to those concerned with articulation or with
the performance of certain definite acts ; or in severer types it
may be much more extensive and involve the muscles of the
limbs and trunk, as in astasia abasia.

Among the more complicated forms of hysterical amnesia
are disturbances in the sense of recognition, an anomaly which
has recently been described by a number of observers.6 Pa-
tients who are afflicted in this way not infrequently affirm that
there has come about a marked change in their sensations, so
that they are unable to recognize their surroundings and famil-
iar objects. The feeling is common in hysteria, but may also
occur in epilepsy as well as in other neuroses. Thus a patient
will often affirm that he is more or less suddenly " overwhelmed
by an indescribable sensation that makes everything seem
strange and far away."

As has frequently been pointed out, the disturbances of
volition are characterized by a series of changes similar to those
noted in connection with sensation and memory. The abulias
may be both local and general as well as characterized by more
or less systematization. The intellectual forms seem to be in
a measure dependent upon the patient's inability to think cor-
rectly, but when a synthesis has once been established — for ex-
ample, when a new idea has given direction to a train of
thought — this not infrequently persists.

What has been said in regard to the mental abulias is
equally true of those with which emotional reactions are ordi-
narily associated. A hysterical patient will always hesitate
about beginning a new series of movements, and when told to

6 Pick : Neurol. Centralbl., Jan. I, 1903. Alter, W. : Ueber eine
seltenere Form geistiger Storung. Monatsschr. f. Psych, u. Neurol., 1903,
Bd. xiv, H. 4, S. 246.

HYSTERIA 499

do a certain thing he may make the attempt, but the effort is
feeble, spasmodic, and soon fails. Such individuals give one
the impression of being unable to gather up sufficient force at
the outset to overcome an initial resistance, and for this reason
an act when once committed is frequently repeated and becomes
in time partially automatic.

These abulias in hysteria exert a marked reflex effect upon
the whole mental attitude of the patient. The totality of the
emotional reactions in hysteria is reduced as compared with
those occurring in the healthy normal individual. Only a com-
paratively few stimuli — the insistent ideas — serve to awaken
an emotional response. The hysterical individual can hardly
be regarded as a person with broad interests; he usually be-
comes cynical and narrow-minded in regard to everything that
does not immediately pertain to himself. On the surface he
may be apparently generous and disinterested, but when his
character is closely studied it will seem that there has come
about a great narrowing of the intellectual horizon. These
anomalous emotional states are often well marked and explain
both the general attitude of the hysterical patient to his imme-
diate environment as well as his general loss of interest, as a
consequence of which he is usually found to be devoid of altru-
ism and markedly deficient in many social instincts, so that he
frequently expresses a longing to be left alone and seems de-
sirous of becoming more or less isolated. Nevertheless, on
account of his impressionability, a paradoxical state develops
in which noble sentiments, such as those of gratitude or sym-
pathy, are passionately expressed, but as promptly forgotten.

The hysterical modifications in character, to which allusion
has already been made, are very varied and incongruous, and
the disturbances in sensation, attention, and memory in turn
give rise to a dissociation of the personality. No single feature
of these anomalies of character is as constant as their incon-
stancy (Sydenham). Hysterical individuals are incapable of
any prolonged effort, for the reason that they lack the power
of concentration and because the focus of their attention is
constantly changing. It is true that individuals belonging to

5oo PSYCHIATRY

the highly intellectual class may be easily interested and are at
times vivacious and animated, but the intelligence, far from
being progressive, is frequently retrograde. The knowledge
accumulated by these persons is, as a rule, superficial, although
it may cover a great variety of subjects. The countless lapses
in attention and the accompanying amnesia often render it im-
possible for such individuals to add materially to their store
of knowledge, inasmuch as each new stimulus from without
seems to divert and disorganize the train of thought. When
their attention is obtained, the observer is particularly struck
not only by the ease with which it lapses, but by the fact that
it can be only partially diverted to subjects that lie outside the
patient's own individuality. If the patient is aroused from an
apparent revery, momentary attention is given to what is being
said, but not infrequently the conversation is broken by the
interjection by the patient of some quite irrelevant idea that has
evidently just at that instant crossed the field of attention.

In addition to the changes already noted, hysterical pa-
tients are apt to be exceedingly selfish, this trait manifesting
itself in a great many different ways and being the direct result
of the dissociation which occurs in personality. Such individ-
uals seem so absorbed in their own tiny world that they fail
to grasp in any sense their relationship to their immediate fam-
ily and friends. This symptom is the result of the general
mental impairment as well as of the diminution in the number
of the emotional reactions. Hence it is not surprising that
hysterical individuals show remarkable inconsistencies in char-
acter, and these in their turn are dependent upon the physical
defects in function to which reference has already been made.
Prominent among the mental idiosyncrasies of these patients
is a tendency to lie. This failing is often referable to the same
cause as that which engenders untruthfulness in children —
namely, fear. In many instances hysterical individuals have
a strong tendency to deceive on account of a desire to conceal
their defects combined with a craving for sympathy from
others. The abnormal activity of the imagination in hysterical
patients is another fertile source of their lack of veracity. Not

HYSTERIA 50I

infrequently these individuals tell about the most extraordinary
adventures that they affirm have happened to them, but which,
upon investigation, are shown not to be based upon a single
fact. These Munchausen-like narratives not infrequently refer
to extraordinary scenes through which the individual has
passed or to events that have occurred in his daily life. The
history of the following case affords an excellent illustration
of this type of hysterical liar:

Male, aged 24, admitted to the Sheppard and Enoch Pratt Hospital.

Family History. — Maternal uncle insane. No other history of ner-
vous or mental disease.

Personal History. — Born at full term. Paralyzed at the age of 3
on the right side, and did not recover for several months. Otherwise
growth and development were normal. He walked and talked at the
usual age. Began school at 6. He was more or less nervous as a child,
but submitted fairly well to disappointments and gave up without giving
expression to his own desires. He did not care for study, but showed
a great desire to travel and read books on such subjects. His memory
was good.* There is no history of definite disease. In character he has
been excitable, rambling, vacillating, impulsive. He has been a regular
and sound sleeper until a short time ago. He affirms that he has never
taken a drink in his life, and has never used tobacco. For some time he
has had nervous spells, during which he has taken occasional doses of
morphin, prescribed by a physician.

The present illness is attributed to overwork, ill-health, and disappoint-
ment. Eighteen months ago he insisted on going upon the stage against
the wishes of his family, though they finally consented. He began to study
in a dramatic school, but was not successful. He then travelled about with
a company. Three weeks prior to his admission the patient had written
to his father, asking for a sum of money as a ransom, which was to be
paid to persons living in the boarding-house where he was staying. This
boarding-house, of questionable character, was in a town over one hun-
dred miles distant from the city in which the patient had lived. On being
questioned the patient affirmed that he had walked to this town from the
city in company with a young man ; but he either could not or would not
give any further explanation. His condition at this time was described as
weak, and the patient seemed apathetic, although at times he complained
a good deal of pain about his heart. When admitted to the hospital he
had attacks of apparent unconsciousness. At times he was violent, and
had to be restrained, although he had offered no objection to being brought
to the hospital and seemed perfectly rational. He spent a good deal of
his time in reading or walking, and enjoyed bowling and playing games.

Physical Examination. — Well developed, not very muscular. Tongue
protruded in middle line, straight, not tremulous.

Eyes: Pupils well dilated, react fairly to accommodation.

502 PSYCHIATRY

Heart : No enlargement ; sounds normal. Dermatographia very rapid
and diffuse. (During the examination the patient said that he had had a
number of nervous attacks during the past few months. He could tell
when the attacks were coming on. He said that a pain started in his
heart and extended down to his hip ; later he could feel this from his head
to the tips of his toes. The sensation he experienced was as if a knife
were sticking into his heart and there was red-hot blood in his veins.
When overwhelmed by these attacks he was very nervous and could not
sit still.)

His attention is easily obtained and well maintained. He gives a
disconnected account of his experiences, and does not seem to understand
that his story must fail to impress others as being truthful. He gives
utterance to a great many inconsistencies, some of which he recognizes.
His own account of his conduct prior to his appearance in the boarding-
house referred to is as follows : He was in the company for two-and-a-
half years and was getting on very well, although others may not have
thought so. He proposed to a friend that they form a company of their
own. This they were unable to-do through lack of funds. Following this,
he was engaged to play in a stock company. While on his way to join
it with a friend he was waylaid in an unfrequented street by two men,
who chloroformed him. He did not entirely lose consciousness, and felt
a revolver in the pocket of one of his captors, and thus realized that re-
sistance was useless. He and his friend were confined in a room in the
city until finally they made their escape. During the time that he was tied
he lost from a pint to a quart of blood.

The story is altogether improbable, and, as the patient narrates it,
full of inconsistencies.

While in the hospital he has had nervous attacks, preceded by pain in
the region of the heart, with some motor restlessness, during which he
walks up and down the room wringing his hands and crying aloud. The
attacks can be quieted by a hypodermic injection of distilled water.

Another factor of importance in the hysterical stigmata is
supplied by the over-valuation and persistence of certain ideas.
Reference has already been made to this point, and it has long
been known that this phenomenon is important not only in the
production of the disturbances in sensation and motility, but
also dominates all the mental processes of the hysterical per-
son. It frequently happens that this remarkable play of the
imagination is associated with an abnormal emotional state,
during which the subsequent acts of the individual seem to
be guided purely by an intense egotism or by Impulses which
are the result of a passionate outbreak. As a rule, such indi-
viduals show a remarkable deftness and great ingenuity in

HYSTERIA 503

concealing all the consequences of the unlawful acts which they
may have committed. Examples of this are occasionally met
with in the law courts, where an attempt at poisoning or
murder has been completely covered up by the patient.

The suggestibility of hysterical patients is very great, and,
as has already been said, anaesthesias, amnesias, paralyses, and
abulias may be induced by this agency in the form of a single
idea or a complex train of thought that occupies the entire field
of consciousness. Sometimes single sensations may be inter-
posed to form a link in the chain of thought ; for example, an
attack of pain in any part of the body may be associated with
the idea of injury. The train of thought may be so compli-
cated as to completely occupy the field of attention, and while
this lasts may completely transform the individual. In some
instances a condition occurs which has been described as delire
ecmnesique? In this state individuals are completely preoccu-
pied by events which have happened at a period long antedating
the attack, and both by their conduct as well as by their whole
mental state reveal the fact that they live in the past. It is
important to note that under the influence of suggestion, if any
train of thought is once diverted by an external stimulus, this
serves as a starting-point about which new ideas cluster. This
frequently means that a complete series of visual and auditory
as well as kinesthetic representations are re-collected and re-
developed, this growth in mental elaboration being more or
less automatic and depending upon a repetition of ideas and
memory pictures which have once been stamped upon con-
sciousness. During this process the sensations upon which the
idea of individuality depends are reduced to a minimum ; per-
ception becomes altered in character, and, as a rule, the repre-
sentations are but faintly stamped upon the memory, a fact
which, more than any other, serves to differentiate the thoughts
and acts of hysterical patients from those of normal indi-
viduals.

The dream states which occur during the course of hysteri-

7 Pitres : Legons cliniques sur l'hysterie, ii, p. 293.

504

PSYCHIATRY

cal attacks are not at all uncommon and present many qualities
that are striking and, in a measure, characteristic. According
to Sollier,8 hysterical patients are always in a pathological state
of dreaminess, and this drowsiness and the anaesthesias are
practically one and the same, so that it suffices to completely
arouse the hysterical person in order to entirely restore sensa-
tion. Such individuals, if left undisturbed, easily lapse into a
state of revery, so that it may easily be said of them that " they
are not content to dream constantly at night; they dream all
day long."

In these conditions the patient, while under observation,
seems to be wool-gathering, is confused, falls into a state of
dream-like revery. Speech may be limited to monosyllables,
is sometimes incoherent, and, although the patient may seem
to be emotional and apparently desirous of describing his sen-
sations, he is unable to do so. Not infrequently the speech is
characterized by marked irrelevancy (Vorbeireden).9 During
these states there is a very marked narrowing of the field of
consciousness and a temporary suspension of many of the func-
tions of association. The acts that have the appearance of
volition are, in a measure, influenced by the idea which at the
time happens to occupy the field of consciousness. This point
is well illustrated in the cases that are influenced by hypnotiza-
tion, and for this reason have been described as hypnoid states
(Breuer). During these dream states individuals may per-
form curious and inexplicable acts, in some instances commit-
ting crimes, such as theft or arson ; or at other times their
conduct seems to be purposeless and without any apparent ap-
preciation of its real significance.10 Sometimes these dream

8 Genese et nature de l'hysterie. Paris, Alcan, 1897.

9 Ganser : Ueber einen eigenartigen hysterischen Dammerzustand.
Arch. f. Psych, u. Nervenkrankh., xxx, S. 633. Zur Lehre von hysteri-
schen Dammerzustande. Arch. f. Psych, u. Nervenkrankh. xxxviii, Hft. 1,
1904. Nissl : Hysterische Symptome bei einfachen Seelenstorungen. Cen-
tralbl. f. Nervenheilk. u. Psych., xxv. Jahrg., Jan., 1902. Westphal, A.:
Ueber hysterische Dammerzustande und das Symptom des Vorbeiredens.
Neurolog. Centralbl., Jan. 1 and 16, 1903.

10 Wollenberg : Handbuch der gerichtlichen Psychiatric Berlin, 1901.

HYSTERIA

505

states are interrupted by impulsive acts which, in a measure,
resemble those committed by patients in the early stages of
dementia prsecox.

The following abstract serves to indicate many of the hys-
terical traits :

Female, aged 25. Single.

Family History. — Father nervous. Two brothers of the patient are
also nervous. Otherwise the family history is negative for any nervous or
mental disease.

Personal History. — No serious illness except scarlatina and diphtheria.
Her health in childhood was good. She received a severe fright when 5
years old. The patient affirms that she can never remember the time
when her mind was not morbid. The catamenia began at 14, and
were preceded by attacks of great nervousness. The lack of sympathy
between herself and her mother and her own hypersensitiveness gave rise
(she affirms) to untruthfulness. Even as a child she expressed a desire
to become a trained nurse. Apparently the periods of depression ante-
dated puberty by a long time, and she affirms that the idea of suicide has
been in her mind for a great part of her life. After her fourth menses
the patient disappeared from home and was absent long enough to oc-
casion some anxiety. She returned later in the day, and from the account
given had apparently been wandering about aimlessly. As a rule, she is
very nervous and fussy during the menstrual period. Her first marked
nervous breakdown occurred when she was about 16 years of age. She
began to study nursing at 18, but was unable to stand the strain. She
suffered from some flow recurring every week or two, and was operated
upon for retroflexion. She says that she went a good deal into
society, and being very nervous she felt the need of stimulants, so that she
took small amounts of whiskey. She did not form the whiskey habit, but
began the use of coffee instead. Later, she drank a great deal of tea. In
1900 she complained of constant fatigue. Being threatened with the rest-
cure she relinquished the idea of spending most of the time in bed.
She had a number of hysterical attacks. She often assumed a theatrical
manner and affected not to know her friends. She was found one day
by her mother inhaling chloroform. Once when visiting a friend she left
the house, saying she was bored and that she would return when she got
ready. Between five o'clock one afternoon and the next morning at eight
she wandered about in the woods. The recollection of this event seems
to be somewhat defective. Soon after this she declared that she intended to
get some poison and go to a deserted house, after having gotten rid of all
her jewelry and clothing which could identify her, melting the jewelry and
burning the clothing, and then swallowing the poison. Of that night she
only remembers "the woods and the wind." She has been very emotional
and talkative at times, and at others depressed and much given to talking
about suicide. She has had several attacks in which she flings herself about

5o6 PSYCHIATRY

the bed, but soon becomes quiet and lucid. She is very self-centred, feels
compelled to constant activity, but at the same time overcome by a sense of
fatigue. She has made several dramatic attempts at suicide, once trying to
tie a shoe-string tightly about her neck. She occasionally discusses her
mental state, and at times affirms that she expects to become a raving
maniac.

The physical examination was practically negative. Vision good.
Visual field unimpaired. Pupils moderately dilated and very active to
both consensual and direct light reflexes.

Urine, slightly acid, specific gravity 1029. Very faint trace of albumin.
Dense cloud of phosphates thrown down on heating. No sugar. The
bodily weight is said to vary from 97 to 107 pounds.

The patient was discharged somewhat improved after being two
months in the hospital. She went to a private sanitarium, from which
she escaped, and went to live in a large city, as she thought it would be
necessary for her to become a working girl. She was there for nearly two
years before her whereabouts became known to her family, and was finally
found only by the merest accident.

The duration of the dream periods may last from several
minutes to weeks or even months. They are said to bear some
relation to the hysterical convulsions preceding- or following
them, or to form the so-called psychic equivalents. During this
period of limitation in the field of consciousness, ideas and im-
pulses that have been prominent during the lucid intervals
dominate the individual. The diagnosis of the hysterical dream
state, as a rule, depends upon the sudden appearance of the
disturbance, which is generally caused by some immediate and
discoverable motive; or it may be the final stage of an emo-
tional outbreak.

Hysterical patients are frequently given to somnambulism.
This phenomenon presents itself under a great variety of forms
which within the present limits cannot be described in detail,
but are dealt with fully in the works of Janet, Gilles de la
Tourette, and Hack Tuke. Many writers maintain that the
somnambulism of children is one of the earliest symptoms of
hysteria, as is shown by the development of other symptoms.
The somnambulist, as a rule, has a set expression, the pupils
are more or less immobile; obstacles placed in the way are
generally avoided, and the patients usually do not injure them-
selves.

HYSTERIA 5o7

In addition to the clinical pictures already described, quite
a number of delirious states may occur which have been divided
by Colin into the following categories : X1 ( i ) Delirious mani-
festations in ordinary hysteria; (2) an hysterical mental state
associated with definite alienation. Pitres 12 describes three
types of delirium: (1) hysterical mania; (2) an hallucinatory
delirium; (3) delire ecmnesique. At present such a sharp dif-
ferentiation does not seem to be practical. The delirium is
characterized by a great number of different symptoms. There
may be marked depression, the patient being hypochondriacal,
self-centred, and giving expression to countless complaints;
or, on the other hand, there may be excitement with a feel-
ing of exaltation, during which the patient may perform
numerous silly acts. In some instances during the delirium
the patient raves about religious subjects or becomes profane
and obscene. The visual and auditory hallucinations pre-
dominate and in many cases are so vivid as to suggest stages
of acute alcoholism. The irritability of these patients, as may
be inferred, is very great, but is not characterized by the offen-
sive aggressiveness seen in true manic states. Their emotional
instability is one of the most characteristic features, the phases
in the delirium changing sometimes with almost lightning-like
rapidity. During these states the patient may show a great
tendency to an exaggerated play of phantasy, depicting situa-
tions which are unreal, so that it is frequently difficult to find
any basis for their bizarre ideas. In some cases the delirium
is colored by marked sexual irritation, which in others, how-
ever, is absent. Occasionally patients are apparently over-
whelmed by periods of profound anxiety, which seems to de-
pend upon the existence of definite phobias, the fear of losing
the mind, of committing crimes, of death, etc., which may be
more or less vague in their genesis. In these states of anxiety
the patients not infrequently wander about, affirming that all

11 Colin : Etat mentale des hysteriques. Ballet's Traite de pathologie
mentale. Paris, 1903.

12 Pitres : Legons sur l'hysterie et l'hypnotisme. Paris, 1891.

5o8 PSYCHIATRY

hope is gone from them, that they are to be destroyed, that they
are past all help.

According to Krafft-Ebing, these delirious states may be
divided into those of short and those of long duration. In the
former condition one not infrequently meets with states of
marked ecstatic exaltation alternating with periods of anxious-
ness, while the more protracted states are characterized by a
greater variety of hallucinations and a moderate dulling of
consciousness with considerable systematization in the various
representations that appear before consciousness. These are
the cases described in the literature under the head of hysterical
hallucinatory insanity. The attacks may begin suddenly and
last for weeks or months and be characterized by periods of
remission or intervals when there is a relative degree of lucid-
ity. These delirious states not infrequently develop after great
mental or physical fatigue and are particularly frequent in
women after severe menorrhagias as well as during the puer-
perium and climacterium. The systematization is sometimes
marked; ideas, of persecution, of having committed sins, erotic
desires and impulses, as well as religious excesses, are promi-
nent. Great care must be exercised in differentiating these
cases from those of manic-depressive insanity. Some writers
mention a more protracted form of the malady in which the
various disturbances of sensation and consciousness are more
persistent and the ideas more definitely systematized. These
are not infrequently described as hysterical paranoioid states,
and may be ushered in by periods of depression or excitement
characterized by marked hysterical symptoms. Although some
of them are unquestionably instances of pure hysteria, the fact
should never be lost sight of that others mark the initial stage
of various psychoses.

As a rule, hysterical mania is characterized by incessant
movement without marked incoordinated agitation. The pa-
tients throw themselves about, roll on the floor, but are not
apt to injure themselves, a fact that is partly accounted for
by the presence of considerable lucidity, in marked contrast
to the mental state in mania. The conduct is capricious and

HYSTERIA 5o9

menacing; the actions are frequently eminently contradic-
tory.13

Age. — Hysterical symptoms may occur in children, and
descriptions of outbreaks of this psychosis in young persons are
not infrequently found in the literature — the chorea major, the
dance rage, etc. Since Briquet's work in 1859 many other
excellent clinical pictures of the disease have been recorded, and
it is now admitted that when the disorder occurs in young
people in at least one-fifth of the patients it appears before the
twelfth year. As von Striimpell has said, " If hysteria did not
exist in children, there would be no ' wonder cures' and no
' wonder doctors.' " When the disease makes its appearance
before puberty it comes on, as a rule, between the seventh and
fourteenth years.14

Sex. — The disorder is more common among women than
among men. In the latter, however, the symptoms are far more
apt to assume a serious aspect and, as a rule, are characterized
by greater tenacity and a more intense depression. After the
prime of life has passed the clinical picture in both sexes corre-
sponds more to the male type — hysterie douloureuse a manifes-
tation splanchnique.15

Etiology. — The etiology of the disease is very imper-
fectly understood, although, generally speaking, the majority
of the cases occur in individuals with a psychopathic consti-
tution. Not uncommonly the symptoms first make their ap-
pearance after mental shock or following trauma. Cases
belonging to the latter group are frequently of considerable
forensic importance. Hysterical symptoms are often noted
in the early stages of various forms of alienation, such as
mania, dementia prsecox, dementia paralytica, and are not
uncommon in all forms of toxaemia, particularly those due
to alcohol, lead, morphin, cocain, and other poisons. Great
care should be observed, however, in affirming that the symp-

" Sollier : Guide pratique des maladies mentales. Paris, 1893.
" Brims, L. : Die Hysterie im Kindesalter. Halle, 1897.
15 De Fleury. Contributions a l'etude de l'hysterie senile. Bordeaux,
1890.

5io

PSYCHIATRY

toms are always the result and not the cause of the addiction
to alcohol. This fact is of great importance in connection
with the genesis of the various drug habits which not infre-
quently develop in individuals upon an hysterical basis.

Differential Diagnosis. — The hysterical states not in-
frequently develop during the prodromal periods of various
psychoses. When this is the case the positive diagnosis can
be established only after the other more specific symptoms have
become more prominent. These cases must be carefully distin-
guished from those in which the hysterical symptoms are more
or less stable and which are not complicated by those of other
forms of alienation. The differentiation of hysteria from neu-
rasthenia is frequently difficult. As a rule, the occurrence of
the hysterical anaesthesias or the various forms of paralyses
gives important indications. The same painful points on
pressure may be found in both instances, but in hysterical
states they are apt to preponderate on one side of the body
and bear some definite relationship to the changes in the cuta-
neous sensation. The essential difference in the mental states
in the two diseases has been discussed at length not only in
the present chapter, but also in the one dealing with neuras-
thenic states.

In the early stages of dementia prcecox we not infrequently
meet with a series of hysterical symptoms, and it is only when
certain distinctive manifestations — such as catatonic periods of
excitement and depression, the stereotypies, mannerisms, or
negativism — make their appearance that the diagnosis can be
arrived at with certainty. The importance of the so-called ir-
relevancy in dementia prsecox (Vorbeireden, Danebenantwor-
ten 16 ) has been alluded to elsewhere. When this symptom is
pronounced the patients are unable to answer correctly ques-
tions of the simplest character, although they generally give
indications that the sense is rightly apprehended. Nissl's
view that the occurrence of irrelevancy always indicates the
existence of dementia praecox needs further substantiation,

J° Ganser : Loc. cit. Moeli : Ueber irre Verbrecher. Berlin, 1888.

HYSTERIA 5II

inasmuch as a number of competent observers have recorded
its presence in the severer forms of hysteria and particularly
in the hysterical disturbances of consciousness following
trauma. Frequently the hysterical dream states or periods of
hallucinatory mania give rise to great difficulties in differen-
tiation. Here the past history of the patient is of the greatest
importance, particularly the occurrence of paroxysmal attacks
of crying, the characteristic emotional disturbances, as well as
the appearance of anaesthesias, various forms of paralyses, and,
finally, the sudden clearing up of the symptoms after they have
existed for a considerable period of time. A comparatively
large number of cases of manic-depressive insanity have been
mistaken for various hysterical states. Here a previous knowl-
edge of the patient's history is of the greatest importance. The
diagnosis is more difficult in the milder forms where the motor
restlessness, the flight of ideas, and general exhilaration char-
acteristic of the manic state are not well developed. Such
individuals not infrequently present a variety of manifestations,
such as painful points on pressure, psychic anaesthesias, and dis-
turbances in the mental faculties, which to the casual observer
seem to correspond with those of the maniacal stage. The
diagnosis depends somewhat on the manner in which the symp-
toms progress. The absence of definite hysterical manifesta-
tions, such as paralyses or hysterical convulsions, are of con-
siderable significance. The flight of ideas in the mild cases,
influenced as it is by both external and internal stimulation,
is decidedly different from the psychical symptoms of the hys-
terical individual, in which the vivid play of the imagination
is far more striking than the immediate response of the patient
to the various kinds of stimuli. The depression in the manic-
depressive psychoses is essentially different from the hypo-
chondriacal egocentric character of the depressed hysterical in-
dividual. The marked emotional outbreaks of the latter usu-
ally stand in direct contrast to the state of the patient in whom
the objective symptoms of depression are more striking and
are unaccompanied by any evidence of a more general anoma-
lous emotional state. The occurrence of marked psychomotor

512

PSYCHIATRY

retardation is more or less specific of the depressed stage of the
recurrent psychosis.

The diagnosis between the hysterical states and epilepsy
is often beset with many difficulties. In the present chapter
reference can only be made to the signs that are of diagnostic
importance in attempting to differentiate between the psychic
equivalents in the two disorders. The history of the onset of
the attack is of considerable importance. In hysteria the prod-
romal symptoms are apt to be much more intense and well de-
fined, and the so-called abdominal aurse are more prominent
than in epilepsy. The loss of consciousness in epilepsy is much
more apt to be sudden and complete, and during this period the
patient is frequently insensitive towards external stimulation.
The hysterical symptoms during the attack may be intensified
by additional stimuli from without, and such patients are open
to various forms of suggestion. The memory defect in hysteria
is much more apt to be only partial, and the events which have
occurred during the attack may frequently be recalled to the
hysterical patient, particularly under the influence of sugges-
tion.

A few cases are reported in the literature in which in the
early stages of the disease symptoms of paresis were masked
by various hysterical manifestations. Thus, one writer noted
the occurrence of astasia, anaesthesia of the left leg, loss of
smell and taste. These symptoms were greatly improved by
the use of the faradic current, but later others specific for pare-
sis made their appearance. Sometimes there is difficulty in
distinguishing the hysterical attacks from those of an apoplec-
tiform character occurring in the earlier stages of general
paresis. The appearance of symptoms which are dependent
upon the existence of organic lesions, such as impairment in
the light reflex, speech disturbances, etc., at once establishes the
diagnosis.

Treatment. — The suggestions that have already been
made with reference to the education of neuropathic children
apply with equal force to those in whom symptoms of hysteria
make their appearance early in life. • Although it is necessary

HYSTERIA 5I3

that all forms of coddling should be scrupulously avoided, there
is no indication for going to the other extreme and attempting
under the present conditions of life to train children according
to Spartan methods. The giving of very cold baths to nervous
children, dressing them with insufficient clothing, making them
go about with bare legs and feet, or not allowing them to wear
hats in cold weather are injurious fads. Such children need a
regular life free from the excitement that follows either mental
or physical over-exertion. It should never be forgotten that
too severe physical exercise occasionally produces results as
unfortunate as those following mental excesses. No definite
rules can be laid down, but the most important principle to
inculcate upon parents and teachers is that the education of
nervous children should be entrusted only to those who them-
selves possess a sound mind in a sound body. Great care
should be exercised in the training of the mental faculties of
children who show an excessive development of the imagina-
tion, for although this faculty plays an important role in edu-
cation no less than in the maintenance of mental and physical
vigor, an abnormal tendency to read only fairy tales, ghost
stories, etc., should be as far as possible discouraged.

The treatment of hysterical symptoms in the adult is an
undertaking which frequently taxes the ingenuity and patience
of the physician. In the first place, the latter should recognize
the importance of the fact, to which Dercum and others have
called attention, that in a large number of cases there is marked
evidence of a general disturbance of health. The necessity
of isolating patients who are suffering from attacks of hysteria
and placing them in some institution where they will be under
the immediate care of a competent physician and well-trained
nurses can not be too strenuously urged. In some few instances
among patients in the wealthier classes the isolation and rest-
cure may be carried out at home, although not as successfully
as in a first-class hospital. In the examination of the patient
it is of great importance for the physician not to dilate too
much at length upon the individual symptoms, as such indi-
viduals are so open to suggestion that not infrequently the ex-

33

514

PSYCHIATRY

amination, unless carefully conducted, may lead to an intensi-
fication of the pain in certain sensitive areas or an increase in
the extent of an existing paralysis.

Patients suffering from the severer forms of hysteria, as
soon as the examination has been completed, should be at once
put to bed and completely isolated, being visited only by the
physician in charge and the nurses. On no account is it advisa-
ble to permit members of the family to see the patient. The
rest in bed should be at first continuous, broken only by the
time that the patient spends in the bath-tub or in changing
from one bed to another. Various hydrotherapeutic measures
are of great use in the treatment of hysteria, sometimes the
pack being used either warm or cold, and in other instances the
prolonged bath (see Chapter V). The physician's common-
sense and judgment must tell him which line of treatment is
the most efficacious, as individuals vary exceedingly. The
depression may be greatly benefited by the cool bath or pack,
whereas insomnia may be combated by the use of warm water.
Electricity may be used not only to stimulate the muscles in
cases of paralysis, but also to relieve pain. Frequently the
faradic current or static electricity is of some benefit. Com-
bined with the rest in bed the patient is given massage, at first
once, and then later twice or even three times a day. Care
must be taken not to increase the extent of any painful points,
but as the patient becomes less sensitive these areas also may
be rubbed. As improvement continues, instead of massage
various forms of exercise, especially passive movements, may
be added. The exact period of time during which the patient
should remain in bed can not be dogmatically prescribed, but,
as a rule, in the absence of other contraindications, it is well
to persist in this procedure until the emotional instability be-
comes less marked and the general tone of the system is im-
proved. Various means may be used to abort the hysterical
paroxysms — sometimes a dash of cold water in the face, the
administration of valerianates, asafoetida, or hypodermic injec-
tions of distilled water may be resorted to. On no account
should either the nurse or the physician seem to attribute too

HYSTERIA 5X5

much importance to the seizures, and gradually the patient may
be taught to control them. In the cases of individuals who are
unable to go to a hospital and where the paroxysms are only
of a mild character, a modified rest-cure may be instituted at
home, provided there is some sufficiently intelligent member
of the family who is able to aid the physician in carrying out
the directions.

CHAPTER XVIII

NEURASTHENIC AND PSYCHASTHENIC STATES x

Since Beard first described neurasthenia the groups of
symptoms included under this head have provided a field for
numerous investigations by alienists and neurologists. The
disease is described by many clinicians as a psychopathic con-
dition characterized by (i) abnormal mental and physical fa-
tigue, (2) impairment of the associative memory, and (3)
sensory disturbances of psychic origin. The individual symp-
toms are liable to considerable variation, and those to be de-
scribed seldom present an equal prominence in any one case.
Dutil 2 and others maintain that it is possible to distinguish
between the more or less stable mental states in which the neu-
rasthenic symptoms of fatigue, instability, abulia, and depres-
sion are more or less constant and a variable, episodic state,
folie neurasthenique, in which impulsivity, obsessions, and pho-
bias recurring with some degree of periodicity dominate the
clinical picture. Certain writers, more particularly Janet and
Raymond, would regard both series of symptoms as represent-
ing one and the same disease, and include under the head of
psychasthenia a large group of cases characterized by the ordi-
nary neurasthenic symptoms, as well as the various forms of
obsessions, impulses, phobias, tics, mild deliriums, states of
apprehensiveness, and the subsequent defects in character which
develop as a result of these phenomena. According to this
classification, therefore, psychasthenia would, as a result of

1 Von Krafft-Ebing: Nervositat u. neurasthenische Zustande. Wien,
1895. Binswanger : Pathologie u. Therapie der Neurasthenic Jena, 1896.
Ganser : Die neurasthenische Geistesstorung. 1899. I. Janet, II. Janet et
Raymond : Les Obsessions et la Psychasthenic Paris, 1903. Loewenfeld :
Die psychischen Zwangserscheinungen. Wiesbaden, 1904. Wollenberg:
Die Hypochondric Wien, 1904. Dubois : Les psychonevroses et leur
traitement moral. Paris, 1904.

1 Dutil, A. : In Ballet's Traite de Pathologie Mentalc Paris, 1903.
516

NEURASTHENIC STATES

517

these phenomena, comprise a very large number of heteroge-
neous cases, including such complexes as the " degenerative
psychoses," characterized by the prominence of obsessional
ideas and fears (Zwangsvorstellungpsychosis), the impulsive
insanity, the fright psychoses, as well as the milder forms of
the paranoiic states — the paranoia rudimentaria of Morselli.
Moebius and Dejerine hold that the neurasthenic state may
properly be regarded as merely an initial stage out of which
various other disturbances develop, while Kowalewsky, as
long ago as 1887, maintained that chronic exhaustion or neu-
rasthenia is a disease of the nervous system that in its milder
forms affects chiefly the visceral centres, but when the malady
becomes more severe gives rise to the clinical picture now re-
ferred to as psychasthenia. Janet thinks that psychasthenia has
many features in common with epilepsy, and the former is re-
ferred to as if it were merely a mild but chronic representation
of the latter. Clinically, psychasthenia occupies a median posi-
tion between epilepsy on the one side and hysteria on the
other. According to Janet, the representations in consciousness
in the psychasthenic are endogenous and relate to persons or
objects in the patient's environment, while in hysteria the no-
tions that occupy the attention are exogenous in origin and
the result of suggestion or emotional disturbances.

As this classification in a measure facilitates description,
it has been adopted here, although with the evidence at hand
it must be regarded only as a strictly provisional expedient. In
the first category falls the group of cases commonly described
as chronic nervous exhaustions, and in the second those in
which the symptoms have a tendency to change and recur with
some degree of periodicity. For the sake of convenience we
shall here designate the former condition as neurasthenia and
the latter as psychasthenia.

A sharp differentiation between chronic nervous exhaus-
tion— the secondary or acquired form — from the so-called con-
genital type of the disease, although possible in many instances,
is in others met by serious difficulties. It must be borne in
mind that the two groups of cases frequently blend and that

5i8 PSYCHIATRY

the distinction is made more as an aid to description than be-
cause of the existence of any fundamental reason which would
justify this division. Levillain directed attention to the neu-
rasthenic states occurring in hereditarily predisposed individ-
uals and which make their appearance early in life, becoming
accentuated at or about puberty and characterized by a variety
of mental stigmata principally in the emotional and intellectual
spheres, the patients belonging to the large group of individuals
referred to by Magnan as " desequilibres."

In passing, it is well to note that a clinical distinction may
reasonably be drawn between the cases of cerebral neurasthenia,
or cerebrasthenia, which have a progressive tendency and in
reality represent the prodromal period of certain organic dis-
eases,— e.g., dementia paralytica, senile dementia, dementia
praecox, — and the uncomplicated and more or less stable neu-
rasthenic states.3

Clinical Symptoms. — These will be described under two
separate groups: (i) Those that are more or less stable; (2)
those that have a tendency to become variable and episodic.

A. Neurasthenic States. — As has already been stated,
fatigue, both mental and physical, is a cardinal symptom in
neurasthenia. This is shown in many ways. Neurasthenics
are wont to complain that every effort gives rise to a sense
of fatigue, the expression of which is largely subjective, inas-
much as such individuals may under sufficient stimulus be made
to exercise considerable effort, although as soon as the inciting
factor is withdrawn they return immediately to their former
condition. This sense of weariness not only limits the execu-
tion of volitional acts, but also impairs the intellectual proc-
esses, any attempt to continue a line of connected thought
being accompanied by an abnormal sense of effort. Moreover,
the patients frequently affirm that the more they struggle to
throw off this mental inertia the more rapidly does the feeling
of fatigue become intensified.

1 Schaffer : Anatomisch-klinische Vortrage aus dem Gebiete der Ner-
venpathologie. Jena, 1901.

NEURASTHENIC STATES

519

An excellent method of demonstrating this fatigue in
neurasthenics has been proposed by Weygandt. The patients
are asked to add up columns of figures and give their results
within a certain time limit. In normal individuals during the
second or fourth quarter of an hour during which the experi-
ment is carried on there is a definite increase in the facility
with which the additions are made, whereas in the neuras-
thenic the inability to focus the attention, shown by the increase
in the number of errors in the additions, rapidly makes its
appearance. By this method we may construct two curves rep-
resenting graphically the contrast between the normal and the
abnormal individual.

For sudden and spasmodic effort there is no diminution
in the dynamic power of the muscles, but this quickly falls if
the strain is prolonged. The ease with which these patients
are tired out is revealed in the limitation of the volitional proc-
esses, and the more complicated the chain of muscular move-
ments undertaken the more evident does this become. In very
exaggerated cases the patients complain that they are unable
even to raise a limb, and remain for days and weeks in bed
unless compelled to exert themselves. The mere thought of
being placed in a position where the expenditure of effort is un-
avoidable frequently causes great mental distress. In addition
to the subjective sense of fatigue accompanying physical and
mental effort, we meet with a variety of sensory disturbances
that may also condition the inertia, for it is not improbable, as
Ziehen has suggested, that the evident disinclination to move
is referable in part to hyperalgesias or hyperesthesias. Neu-
rasthenic patients, as a rule, seem abnormally sensitive to all
forms of stimuli, each new stimulus causing an apparent
radiation. For example, a bright light impinging on the retina,
in addition to the immediate discomfort, sometimes gives rise
to photophobia or to a whole chain of nervous symptoms. As
a rule, the patients show a hyperesthesia of one or more senses,
resembling those noted in hysteria — hyperesthesia retinae,
hyperacusis, and hyperosmia. Closely associated with these
psychic hyperesthesias is the fear of pain which is frequently

520

PSYCHIATRY

so characteristic and may give rise to states of mental anguish
similar to those described by Mobius under the head of akinesia
algera. Such patients frequently express themselves as being
unable to tolerate the mildest irritant without becoming ex-
cessively nervous and emotional. On actual pressure various
parts of the body frequently seem to be the seat of pain.

The psychic hyperesthesias in neurasthenics are referred
to by Blocq 4 as topoalgias, and are characterized, according
to him, by the persistence of a painful sensory memory, a
phenomenon that bears to the sensory functions a relation anal-
ogous to that of the fixed idea to the intellectual processes.
Not infrequently these pains are referred to the head and neck,
to various regions in the chest — particularly the precordial or
epigastric — as well as to the extremities. The pain seems to
appear spontaneously, and when occurring in the head is de-
scribed not as a definite headache, but rather as a more or less
indescribable feeling of an unpleasant nature. Various unpleas-
ant cutaneous sensations often appear which may be associated
with emotional anomalies, such as the so-called acarophobia
and other forms that will be described later on. The pains
may be either diffuse or localized, and are more apt to be sym-
metrical in their distribution than is the case in hysteria.

Sensory disturbances in connection with the sexual organs
are not uncommon. These give rise to para- or hyperesthe-
sias that play an important part as causes of masturbation, ex-
cessive intercourse, and the production of the whole chain of
subsequent nervous and mental symptoms belonging to the
so-called sexual neurasthenias. Sexual pollutions frequently
occur in neurasthenics and may aggravate the already existing
mental symptoms, but these are never to be considered of
primary etiologic importance, being the result and not the
cause of the disease. Such painful sensations in women are
apt to be of greater importance than in men, as they may lead
the patient to insist upon the removal of the ovaries, uterus,
or clitoris.

4 Gaz. hebd. de med. et de chir., Mai, 1891.

NEURASTHENIC STATES

521

In addition to the hyperesthesias, we frequently meet with
a great variety of paresthesias. Many patients complain of
curious sensations in the extremities, of seeing flashes of light,
of hearing indefinite sounds. Various forms of pruritus may
develop and cause excessive annoyance. As a rule, the dis-
turbances in the cortical centres give rise to only elementary
hallucinations except in the case of the visual centre. Neuras-
thenics sometimes complain of seeing visions and faces when
the eyes are closed, but these disappear when the eyes are
opened and the subjective character of the phenomena is at
once recognized by the patient. Numerous observers main-
tain that the hallucinations in neurasthenia, as contrasted with
those in hysterical crises, never develop completely, since the
mental representations remain imperfect and therefore do not
dominate the subsequent acts of the patients. Further refer-
ence will be made to this subject later on when the episodic
symptoms are described.

The mental characteristics of the neurasthenic are very
varied. As has already been pointed out, distractibility is
usually somewhat marked, so that the focus of attention is con-
stantly changing, and any attempt on the part of an individual
to fix it for a given length of time is accompanied by an ab-
normal sense of effort. These fluctuations are largely account-
able for the amnesias. The patients complain that they cannot
recollect even the simplest occurrences or events of their daily
life — a fact that often distresses them exceedingly and gives
rise to marked emotional disturbances, as well as increasing
their sense of insufficiency. Frequently, when an extra effort
is made to remember certain ideas or events, there is not only
the immediate discomfort caused by the increased expenditure
of energy, but the failure intensifies the emotional outbreak,
so that the patients are apt to become very despondent and
possessed by various hypochondriacal ideas. The irritability
of the neurasthenic has already been referred to. External
stimuli of all forms seem at times to be an acute annoyance.
Occasionally, without apparent provocation, such individuals
become angry or morose, and the exaggerated sense of con-

522

PSYCHIATRY

trition and penitence that follows is almost sure to be super-
seded by mental depression. Although neurasthenics may at
times find an excessive enjoyment in objects or events of a
pleasurable nature, they are prone to become easily depressed,
a feeling which is intensified as soon as any effort meets with
opposition.

Under the head of chronic nervous exhaustion may be
included the group of cases described by some authors as in-
stances of constitutional depression (constitutionelle Verstim-
mung). This condition is more apt to occur in individuals
who show a remarkable mental development along certain lines
but a deficiency in others. Such persons not infrequently are
enthusiastic and earnest in beginning any new work, but are
easily fatigued and discouraged. As a rule, they suffer from
a variety of symptoms, and are particularly subject to hypo-
chondriacal attacks. They are frequently more or less cynical,
seldom finding anything in life from which to derive much
encouragement, and continually looking upon the dark side of
every question. In the higher classes of society these individ-
uals are generally recognized as cynics and pessimists, are
much given to reflection, and are, as a rule, excessively in-
trospective.5 As Maudsley has pointed out, this group of
cases not infrequently includes individuals of great intellectual
attainments but who, on account of their mental state, are none
the less deficient in the power of leadership or organization.
The psychic tonus of these individuals is altered, and this de-
terioration is reflected in their whole emotional life.6 Many
of these cases were formerly described under the head of
melancholia, but are to be differentiated by the absence of
insane ideas, self-accusation, as well as by the sudden changes
in the affective display. In many of these individuals the ap-
pearance in consciousness of an unpleasant thought gives rise
to a feeling of depression which may persist for several hours.

8 Kowalewski, Arnold : Studien zur Psychologie des Pessimismus.
Wiesbaden, 1904.

* Pick, A. : Zur Psychopathologie der Neurasthenic Arch. f. Psych,
u. Nervenkrankheiten, Bd. xxxv, 1902.

PSYCHASTHENIC STATES

523

In the neurasthenic, as distinguished from the patient suffering
from true melancholia, we find that the conditions of irrita-
bility associated with apprehensiveness are largely influenced
by external impressions and ideas.

The emotional state may vary from one in which there
is merely a vague sense of discomfort to one in which there
is an exaggerated sense of mental depression or anguish. As
a result of these tendencies, all of which centralize, the patient's
interests become more and more egotistical. In some instances
there is marked hypochondriasis and an elimination from con-
sciousness of all ideas not relating to the individual needs and
interests. Such patients can only talk and think about them-
selves or about matters in which they have an immediate in-
terest, and eventually become incapable of any degree of
altruism.

B. Psychasthenic States. — Prominent among the episodic
syndromes are the various forms of obsessional ideas and im-
pulses. As was pointed out in the introductory section, these
ideas are frequently abstract in nature and exceedingly com-
plicated in their pathogenesis. They include many different
forms, of which only the more common types will be referred
to here. Chief among these are the hypochondriacal obses-
sions, all of which tend to make the individuals self-centred and
abnormally sensitive in regard to their physical ailments.
Sometimes their attention seems to be riveted upon certain
organs. A slight palpitation suggests the idea that they have
organic heart disease, and in spite of repeated assurances to
the contrary from competent physicians they adhere most tena-
ciously to their autodiagnosis. In other instances the obses-
sions are referred to the genital organs. A slight herpes or
eczema is sufficient ground for believing that they are infected
with syphilis. Ideas regarding impending death or the onset
of various chronic maladies — such as phthisis or blindness —
are repeatedly forced upon their attention. A slight cough is
regarded as a sure sign of pulmonary tuberculosis; pains in
the legs become the initial symptoms of locomotor ataxia; a
mild degree of nausea and vomiting carries with it a premoni-

524

PSYCHIATRY

tion of gastric carcinoma, etc. Frequently these fixed ideas
are related not only to the personality of the individual, but to
his environment, as well as to his social relationships. Fre-
quently neurasthenics suffer from an excessive form of shy-
ness shown in attacks of recurrent and excessive embarrass-
ment. Such individuals are continually plagued by the idea
that whatever they do or say is regarded as improper. They
affirm continually that when among strangers they are ill at
ease, unable to carry on a conversation, that their wits leave
them, so that all forms of social duties pall upon them.

The imperative ideas or obsessions (Zwangsvorstel-
lungen) are associated with the so-called imperative processes,
of which there is a large variety. The mental states in which
these are the dominating symptom have been described by
Donath, of Budapest,7 as anarchasma. The intrusion of these
irrepressible ideas into consciousness often gives rise to a great
variety of mental, motor, and emotional anomalies. Among
the first are the various questions which the patient frequently
feels impelled to ask (folie du pourquoi). These in a great
many cases refer to the patient's own condition, but not infre-
quently relate to objects quite outside of the personality. The
absence of motive renders it not at all improbable that these
interrogations are similar to the " whys and wherefores" of
children. Not uncommonly, especially in the intellectual class
of patients, this interrogatory mood drives them to the dis-
cussion of abstruse themes. They feel themselves compelled
to spend much time in debating why God made the world,
why they were put on the earth, the origin of right and wrong,
and various other metaphysical inquiries. It is not at all im-
probable, as Royce has pointed out, that John Bunyan suffered
from this form of mental agitation; and Rousseau in his
" Confessions" admits that he was often greatly troubled by
speculations as to the nature of Hell. These types are closely
akin to those described by Legrand du Saule and other French
writers as " mental rumination." In such cases a long train

7 Arch. f. Psych., 1896.

PSYCHASTHENIC STATES

525

of connected ideas occupies the field of attention, so that the
individual can not break away from them and is frequently-
obliged to continue a particular line of thought to the bitter
end. Not infrequently phenomena of this character are most
insistent at night and form one of the important causes of in-
somnia, from which neurasthenics so frequently suffer. The
same is true of the so-called forced reveries into which neuras-
thenics are frequently thrown and from which they have the
greatest difficulty in freeing themselves.

Frequently psychasthenics give objective expression to
their impellent ideas by eccentricities of manner and character.
Such individuals not infrequently waste a great deal of time
in " putting things in order." Rest is impossible if a book or
any object about the room is out of its proper place. The
mania for the preservation of order is particularly noticeable
in young neurasthenic mothers, who cannot bear to see their
children's clothing disarranged or their hands or faces dirty
even while at play. The first idea that strikes their attention
is not the comfort and health of the child, but rather that they
must always be scrupulously clean and well dressed. Fre-
quently neurasthenics feel obliged to count or to work out
problems — arithmomania — or express their preference for cer-
tain numbers which they feel obliged to repeat, sometimes to
pronounce aloud. Similar conditions are noticeable in the
states of fatigue following exhaustion, after fevers, trauma,
etc., when the sufferers will tell us that they are impelled to
count the figures on the wall, the books in the book-case, ob-
jects about the room, and to continue this operation until ex-
hausted. In the condition described by Charcot and Magnan
as onomatomania 8 the patient feels obliged to recall a certain
name or names which have once been noticed, not infrequently
spending considerable time and energy in going to some out-
of-the-way street to find a certain board once casually noticed
in passing. Sometimes patients affirm that without cause they
are compelled to swear and blaspheme. This sometimes occurs

8 Arch, de Neurologie, September, 1885.

526 PSYCHIATRY

in young girls or in individuals in whom the phenomenon is
equally extraordinary.

In many of the psychasthenic states we meet with a variety
of tics. These anomalies of movement, as Charcot pointed
out,9 are the caricature of natural acts. These various move-
ments may be provisionally classified, not according to the
groups of muscles affected, but rather by the act of which the
tic is the caricature; for example, tics of the mouth, of the
eyelids, respiratory tics, tics of attitude, etc.10

The emotional disturbances associated with anomalies of
ideation and motion are also varied. Various classifications
of the fears to which the psychasthenic individuals are subject
have been attempted. Freud makes three categories : ( I )
the traumatic phobias (more common in hysteria) ; (2) an
exaggeration of ideas entertained regarding events in ordinary
life, such as fear of night, solitude, or sickness; (3) fears of
place — agoraphobia, etc. Janet, on the other hand, prefers a
four- fold division : ( 1 ) fears relating to the body and deter-
mined by anomalies of sense perception; (2) those relating
to objects outside of the body; (3) those of situation which
are not determined merely by the perception of single objects,
but rather by a combination of circumstances; (4) the fears
pertaining to various ideas. Many of the fears in the somato-
psychic field of consciousness have already been shown to be
dependent upon the psychic hyperesthesias. This is in a meas-
ure true in regard to the so-called fears of function, fears of
movement, — akinesia algera, — and the acathisia described by
Haskovec.11

Instances have been reported in which the person has had
a fear of speaking. Psychasthenic individuals not infrequently
are greatly perturbed by the various phobias associated with
the processes of digestion. They believe that everything that
they eat disagrees with them, that their food does not nourish

' Lecons du Mardi, 1888-89, P- 464.

10 Les tics et leur traitement. Meige et Feindel, Paris, 1902.

"Haskovec: L'akathisie. Revue neurologique, 30 Nov., 1901.

PSYCHASTHENIC STATES

527

them. Sometimes the phobias are referred to various internal
organs or are not infrequently excited by various sensations,
odors, sounds, etc. Photophobia is not an uncommon symp-
tom. In this as well as the other phobias connected with the
senses the peripheral tract is intact, and in individuals who
for considerable periods of time have been afraid to venture
into the light, examination has shown the eyes to be in every
way normal. Somewhat more complicated are the fears of
touching certain objects, — delire du contact, — a series of phe-
nomena to which Esquirol first directed attention. These in-
clude the cases of mysophobia and rupophobia.

The persistence of these ideas and the remarkable reflex
power which they may exert over the conduct of the patient
are well shown in the following history :

Female, aged 33 years. Married. Came to Out-patient Department,
Johns Hopkins Hospital, complaining of nervousness.

Family History. — Mother extremely neurotic, paralyzed before she
was married, also hypochondriacal. Father dead; was said to have been
a cripple.

Personal History. — Strong and healthy baby. When 3 years old
she had scarlet fever; has been nervous ever since. Pneumonia at 16.
Married at 19. One child, 13 years old. For a great many years
the patient has been getting more and more nervous. She has been
troubled with headaches, cold feet and hands, hot flushes ; indefinite pains
first on one, then on the other side of the body. " Sometimes the toes of
the right foot were stiff and paralyzed." Several years ago she affirms
that she was deaf in the right ear. Also complains of poor eyesight. The
family physician says that the patient has had several attacks which in a
measure suggested epilepsy, but she has never injured herself during an
attack and never passed her urine involuntarily, although after the last
attack the quantity was greatly increased. Ten years ago the patient began
to be greatly disturbed by the presence of dust in her room. She affirmed
that she was always busy cleaning. She used to dust and sweep until she
was worn out. She recognized that this excessive cleanliness was fool-
ish, but said that ever since she was a girl in school she has been over-
particular about her personal appearance and dress. At first she did not
think that her efforts at excessive neatness and tidiness were foolish, but
this idea gradually dawned upon her. While in the Johns Hopkins Hos-
pital for operation — repair of laceration following labor — she began to feel
a constant craving for water to wash her hands in, and used to beg to be
allowed to hold wet rags in her hands. After leaving the hospital she fre-
quently felt obliged to hold her hands under the tap in the kitchen. At first
this sufficed, but soon she began to think that this flow of water was not

528 PSYCHIATRY

large enough. This impulse to wash her hands has become so strong
that when the patient tries to resist it she frequently breaks down and
cries. She never uses warm water, but always cold. The symptoms have
become so distressing that the patient is willing to do anything to be
cured, as she says the impulses at present are so strong that she cannot
possibly resist them. She also declares that her heart gives her a great
deal of trouble — " It feels as big as my head" and beats very rapidly.
She is exceedingly sensitive to noise and excitement and has even been
obliged to have the door-bell of her house disconnected, particularly dur-
ing the period of menstruation. Her appetite is markedly capricious.
Sometimes there is polyphagia, when she bolts her food. This is particu-
larly marked during the week before menstruation. At other times the
patient eats very little.

Physical Examination. — Medium height, poorly nourished, mucous
membranes somewhat pale, exceedingly neurotic, manner unstable, restless.
At first she was somewhat reserved in answering questions, but as soon
as the ice was broken she became loquacious and then talked a perfect
stream about herself. No defects in associative memory were demonstra-
ble. The reflexes were all slightly exaggerated. There was slight ten-
derness in the right iliac fossa.

Thorax : The lungs and heart were normal.

There was no typical flight of ideas, no marked impulsivity. The
patient was very emotional and solicitous about her future, feared that
she would never recover, became depressed, and cried easily when her
thoughts were directed along this line. She was sent to the Sheppard
Hospital, and after remaining there for several months was discharged
unimproved.

Agoraphobia, — the so-called fear of open places, — an-
other not uncommon symptom, was first described by West-
phal.12 Practically speaking, the term is applied not to an
actual fear of open places, as the name would indicate, but
rather to a complex series of phenomena due to the strange,
indefinable sensations that overwhelm nervous individuals
when brought into surroundings with which they are unac-
quainted and where they feel the lack of that physical and
moral support to which they are generally accustomed.

Claustrophobia — the fear of closed places — is exhibited in
various ways. Thus some patients are conscious of a vague
sense of oppression and apprehensiveness as soon as they enter
a public building. In the mild cases this does not become so

"Arch. f. Psych., H. 3, 1872.

PSYCHASTHENIC STATES 529

apparent, provided that the sufferer does not feel that he is
placed in a position whence exit is difficult. A distressing ten-
dency to blush is noted in many psychasthenics, and is often
sufficiently pronounced to make the patient averse to going
into society. In the exaggerated cases it is excited whenever
the patient encounters a stranger— eurotophobia. This term
must be carefully distinguished from erythrophobia, or the fear
of a red color.

Taphophobia — the fear of being buried alive — is also not
uncommon. A great variety of other phobias have been de-
scribed, but need not be mentioned here, since details can be
found in the various special works upon the subject.

The so-called diffused emotional disturbances are of fre-
quent occurrence and some patients continue in a state of anx-
ious expectancy for considerable periods of time without being
able to assign any definite cause for the condition or to control
it. This symptom varies in intensity from mere timidity to
pronounced apprehensiveness and anxious expectancy accom-
panied by tremor ; it is associated with disturbances in the cir-
culation and respiration, and in some instances with nausea,
vomiting, and attacks of diarrhoea. The physiological symp-
toms noted in these affective disorders have been referred to
more in detail in the first section of the book.

The phobias, obsessive ideas, and impulses are particularly
apt to recur in the form of crises in which the emotional dis-
turbances are greatly accentuated and the dominating influ-
ence of the anomalous condition in some instances becomes
overwhelming.

The obsessional ideas and obsessional impulses cannot be
sharply differentiated. Although in all cases in which a domi-
nant idea is present there is a marked tendency towards move-
ment of some kind, the exact instant at which the translation
of thought into action takes place cannot always be deter-
mined by the observer. For example, in cases in which the
impellant idea is one that arouses a sense of fear, there is a
marked tendency on the part of the patient to show this in his
actions. This driving power is dominant in all forms of ob-

34

53Q

PSYCHIATRY

sessions, so that in the majority of cases it is impossible to
affirm that an idea which harasses and torments the patient is
not sufficiently tyrannical to cause some kind of movement, al-
though the act may be apparently purposeless and not directly
related to any motive. The obsessive ideas of suicide, so
common in pure psychasthenic states, are seldom, if ever, fol-
lowed by actual self-destruction. From the forensic stand-
point these patients may be considered as only standing on the
border-line of insanity. In order that the impulsion may be
sufficiently strong to drive the individual to the commission
of definite crimes, as a general rule there must be superadded
another psychosis complicating the -psychasthenic state. The
dominating motive force of these impulses is materially less
than in hysterical states, with the exception of those of genital
origin, which are considered by most authorities to be capable
of dominating the volitional processes. Not infrequently ob-
sessions of this nature are the cause of masturbation, both in
males and females. In some instances these ideas so persist-
ently annoy and distress the patients as to give rise to anoma-
lous emotional states of depression which in women some-
times become so strong that they demand the removal of the
ovaries. Many of the cases of sexual perversion which come
under observation are referable to these impulses. Although
obsessions of genital origin are among the most common forms,
there exists a great variety of others. For example, some
patients affirm that they feel compelled to lie and are greatly
worried by the fear that they will be unable to tell the truth.
Occasionally we meet with instances in which individuals are
seriously disturbed by the appearance in consciousness of an
impulse to steal. The obsessions which give rise to addiction
to drugs, such as morphinomania or dipsomania, often entirely
nullify the will power of the patient, despite the fact that indi-
viduals afflicted in this way may do their very best and resort
to a variety of means to resist the obsession, trying hard to
divert their attention or to extricate themselves from all situa-
tions which seem to favor the development of the impulse.
After the morphin or alcohol has been taken, in all probability

PSYCHASTHENIC STATES

531

the case becomes further complicated owing to the toxic action
exerted by the drugs themselves.

Reference has already been made to the occurrence of
hallucinations in psychasthenic states. These anomalous sen-
sations possess many of the characteristics referred to in de-
scribing other phenomena, and lack the stamp of reality to such
an extent that French writers believe they represent an
hallucinatory mania and not real hallucinations. The hallu-
cinations very frequently occur as visions. In patients of a
low intellectual status these are very apt to be associated with
current superstitions and regarded as " signs from Heaven"
or " portents of the future." The visual forms are among
the most common, and may be associated with sexual ideas.
For example, one of our patients used to affirm that she saw
a naked man appear before her. Auditory hallucinations are
much less frequent, although at times patients are annoyed by
queer sounds, the cropping up of certain tunes in their mem-
ories, the endless reiteration becoming a source of intense
worry.

These phenomena are supposed to have a symbolic rela-
tionship to certain objects. At times they seem to the patient
to be projected, but are to be regarded rather as the reproduc-
tion of memory pictures characterized by incompleteness and
cloudiness and not possessing the attributes, such as the form
and color, of a real object. Belief in the reality of these phe-
nomena is never marked except at certain critical epochs in
their development; during the lucid intervals the patient is
thoroughly conscious of their subjectivity. The mental state
which may develop as a result of the obsessive ideas and hallu-
cinations is one of doubt, the so-called delire du doute. These
sentiments of doubt frequently develop, but at first only in
reference to obscure or abstract subjects. Such individuals are
particularly worried by religious questions, and the fact that
they can not carry through to its conclusion a train of thought
is to them most distressing and serves to intensify this un-
certainty. This feeling is not, as some writers have held, a
special symptom, but is rather the expression of the intellect-

532

PSYCHIATRY

ual state generated by the incompleteness of the mental opera-
tions.

It would appear, however, that most writers have spoken
too dogmatically in holding that the integrity of consciousness
is preserved during the crises, although it is an undoubted fact
that even at these times the patients may struggle to free them-
selves from the thraldom of various obsessions. With regard
to this point the psychological phenomena need to be studied
more in detail before any sweeping generalizations can be made.
Disturbances of consciousness, if they exist, are more difficult
of demonstration than is the case in hysterical subjects.

The defects in orientation, that occur and are referable
principally to slight disturbances in the sense of recognition,
would seem to lend additional color to the view that conscious-
ness is not as intact as has been commonly supposed. Again,
it is a noteworthy fact that some of these individuals seem to
have a double personality. Patients may affirm that they feel
as if they were in another world, that all around them is
strange and foreign.

The symptoms already referred to give rise to secondary
mental disturbances which are exhibited in anomalies of char-
acter and action. Chief among these is the vacillation so char-
acteristic of the psychasthenic when forced to exert himself.
Such individuals feel uncertain and are perplexed by their vari-
ous doubts, so that in addition to the mental or physical fa-
tigue, which so commonly annoys and harasses them, they are
deterred from action by the development of an anomalous men-
tal state or are enthralled by a fixed idea relating to their own
physical and mental incapacity. Psychasthenics never form a
definite resolution, and therefore are unable to act spon-
taneously; when finally driven by the force of circumstances
to exert themselves, they frequently refer to what they do
as the mere expression of an automaton or a machine. Con-
scious that their volitional movements are inhibited, they
affirm that they are dominated by a strange and inexplicable
power, and many of them are painfully aware of the incom-
pleteness of their intellectual acts, are harassed by their ina-

PSYCHASTHENIC STATES

533

bility to direct their attention, and become extremely sensitive
about their subjective deficiency of perception. The emo-
tional disturbances blend with and color the intellectual and
volitional defects, to which reference has already been made.
Such individuals frequently affirm that they do not experi-
ence the ordinary pleasures of life, that there is little that
arouses in them a sense of gratification or pleasure. Fre-
quently they are subject to attacks of mental as well as physical
restlessness. Not only is this common during their waking
hours, but patients frequently complain that their sleep is dis-
turbed and that they cannot rest well at night. This restless-
ness gives rise to certain indefinite needs which the patient
feels must be gratified. Unquestionably this slight motor rest-
lessness with the accompanying apprehensiveness, as well as the
obsessions, plays an important role in the cases of individuals
who seek for relief in alcohol, morphin, or cocain ; these con-
ditions are also favorable for the development of erotic im-
pulses. As an antithetical state we frequently meet with an
exaggerated indolence, the patients becoming utterly indifferent
to all high aims and ambitions. Another important change
which is frequently noticed is the tendency shown towards the
development of a misanthropic spirit, which will often explain
the so-called social abulia, or disinclination to go into society.
Such an individual is inclined to become more or less isolated
from his surroundings and lead the life of a recluse. On the
other hand, these patients may show an excessive need of the
society of others and an abnormal craving for the sympathy
of their friends and relatives.

Although there are many theories regarding the cause of
these psychasthenic states, there is practically nothing that is
definitely known regarding their development. Some ob-
servers affirm that the various episodic symptoms, particularly
the obsessive. impulses, are really secondary, the result of the
reaction of the impellent idea upon the emotional life of the
individual. The emotional theories are referred to under the
section dealing with obsessions. The hypothesis of greatest
value in regard to the genesis of the disease is undoubtedly that

534

PSYCHIATRY

recently proposed by Janet and Raymond, in which the appa-
rent unity of the phenomena described in this chapter has been
pointed out and the chief factor in the pathogenesis of the
mental state is held to be the subjective sense of incompleteness
of the mental activity. The lowering of the psychic and ner-
vous tension is assumed to be the fundamental cause under-
lying all these conditions. The various fluctuations that occur
give rise to the differences in symptomatology. The observa-
tions of Janet and Raymond have added greatly to our clinical
knowledge of this disease. Their studies, as well as those of
Freud, have supplied us for the present with working hypothe-
ses which greatly facilitate further investigations.

The course of the disorder varies greatly. In the milder
forms, characterized by the symptoms of nervous exhaustion,
the condition lasts for a few months, while in the severe or
more protracted types, especially in those in which the heredi-
tary predisposition is marked, it persists with more or less
variation during the greater part of life. The latter develop,
as a rule, in individuals in whom the hereditary factor is pres-
ent, and follow some exciting cause, such as injury, a severe
attack of illness, mental shock, etc. Magnan holds that these
psychasthenic states are always to be regarded as stigmata of
degeneration. The various manifestations may be considered
under the head of the intermittent, remittent, and continuous
forms. The last was described by Roubinovitch in 1893, but
can not be sharply distinguished from the others.

The intermittent form is characterized by the various epi-
sodic symptoms to which reference has already been made.
They generally develop whenever some exciting cause, such as
increased mental or physical fatigue, intervenes, or follow emo-
tional disturbances. Not infrequently long remissions may
occur in the forms in which the obsessions and phobias have
for a considerable period of time seemed to dominate every
thought, while in other cases the disturbed and more lucid
periods alternate rapidly. Exacerbations may occur daily,
weekly, or at much longer intervals. The temporary improve-
ment noted in these cases may be very remarkable, and close

PSYCHASTHENIC STATES 535

study of a given case occasionally renders us able to predict
an amelioration. For example, Janet calls attention to the
interesting fact that the psychasthenic symptoms frequently
disappear during pregnancy.

In the remittent forms, although the symptoms already
enumerated show a marked tendency to remit, they never en-
tirely disappear. Quite frequently the color or form of the
obsession, as well as the other psychic abnormalities, may
change, but the emotional state of the patient can never be said
to be quite normal. Even when the episodic symptoms have
practically subsided there are left behind a certain degree of
listlessness, a general impairment of the volitional processes, a
lack of initiative, and a lowering of the whole psychic tone.

Apart from the physical complications to which reference
has been made, the mental symptoms may terminate in one of
several ways : ( I ) The neurasthenic state may become chronic
and extend over a long period of years. (2) The more or less
stable symptoms of chronic nervous exhaustion may be compli-
cated by the appearance of the episodic symptoms. (3) The
hypochondriacal and other obsessions may become chronic and
systematized so that we have conditions resembling some of the
elementary paranoiic states. In certain cases the symptoms
may entirely disappear, and the patient is said to be cured.
The disease may be slowly progressive, but after a certain point
is reached the symptoms may never become much worse, and
remissions may frequently occur. In rare cases the obsessions
and impulses become exaggerated, and late in the disease other
psychoses complicate the clinical picture.

The prognosis in the episodic forms is much more un-
favorable than in the other types; in fact, it may be said that
a cure is seldom, if ever, effected. There are competent ob-
servers who maintain that the forms connecting this with other
forms of alienation practically never occur, but the general
consensus of opinion favors the view that transitional states
between the chronic nervous exhaustion and true melancholia
are found in about 2 or 3 per cent, of the cases. In these
we have a neurasthenic complex of symptoms with considerable

536 PSYCHIATRY

irritability, and, in addition, imperative ideas and a marked
tendency on the part of the patient to try and establish rela-
tionships between the various abnormal sensations.18

Attention has been called to the fact that some cases, par-
ticularly those in which the abnormal scrupulosity (delire du
scruple) is well marked, may end in states of exaltation which
are closely akin to, if not identical with, the mystic delirium
common in hysterical individuals.

Various other forms of disturbances in the field of con-
sciousness with and without more definite symptoms of alien-
ation have been described by numerous observers. Cases in
which marked mental confusion and deep stupor have been
reported must be regarded with suspicion, as in all probability
these form a part of other psychoses. .

Physical Symptoms. — A great variety of objective
symptoms have been noted, but the exact relative importance
of these phenomena can not be accurately estimated. They are,
however, so frequent and of such intensity as to warrant the
affirmation that these psychasthenic states should no longer be
looked upon as instances of purely mental disturbance, in the
ordinary sense of the word. The mental anomalies, such as
the obsessions, states of apprehensiveness, and so on, are nearly
always accompanied by a variety of symptoms which seem to
indicate the existence of some impairment of the nervous func-
tions. In the more chronic cases we meet with various forms
of neuralgias and other painful conditions. The attempt has
frequently been made to bring these anomalies of sensation into
relationship with the supposed disturbances in the circulation.
In view of the present limitations in our knowledge, however,
such an hypothesis may be regarded as scarcely plausible. It
is interesting to note in passing that some observers have at-
tempted to demonstrate the existence in neurasthenics of a
definite rise of temperature associated with the attacks of
severe headache, but the patients usually exaggerate the

53 Friedmann : Ueber Neurasthenische Melancholic Neurol. Cen-
tralbl., 1903, Nr. 2, S. 1155.

PSYCHASTHENIC STATES

537

trouble. Insomnia is not infrequent. On the other hand, now
and again we meet with markedly neurasthenic individuals,
more especially among those that have a gouty or rheumatic
diathesis, who never seem to be able to get enough sleep;
who are victims of a marked degree of somnolence and who
often sleep for ten or twelve hours at night, with occasional
naps during the day. These prolonged periods of sleep, how-
ever, may be broken by dreams of a disturbing character,
giving rise to many unpleasant sensations. In nearly all
neurasthenic or psychasthenic states, all the reflexes, more
particularly the superficial, are apt to be increased in in-
tensity. Dermatographia is commonly a prominent symp-
tom. Cases are reported in which the ankle and patellar clonus
have been elicited, but these should be viewed with suspicion,
and the possible existence of a cord lesion must always be
remembered. The pupillary reflexes are, as a rule, very active,
at times a marked hippus being present. In the states of
chronic nervous exhaustion the pupils are apt to be quite widely
dilated. The nutrition of these patients generally suffers con-
siderably. A great many of them are poorly nourished and
more or less anaemic. Nevertheless, others show an excess of
adipose tissue and may become exceedingly stout. As a rule,
the haemoglobin is somewhat reduced in quantity. The appe-
tite, in states of hysteria, is often very capricious. At times
these individuals eat practically nothing, while again they may
exhibit an abnormal craving for food and remarkable idiosyn-
crasies of taste. Some observers maintain that the digestive
disturbances of the neurasthenic are dependent upon deficient
secretion of the gastric glands, and still more often motor
insufficiency of the gastric muscle, as a consequence of which
the contents of the stomach are not discharged within the nor-
mal time and gastric fermentation and certain forms of auto-
intoxication result. Undoubtedly many cases of nervous dys-
pepsia are quite amenable to suggestion, and the emotional
state of the patient at the time that the food is taken is a very
important factor in digestion. Moreover, with the gastric dis-
turbances are associated others of intestinal origin, the most

538 PSYCHIATRY

important being diarrhoea and constipation, which often alter-
nate.

The nutritional defects become more evident in the cases
in which there is a lithsemic or a gouty diathesis. The urine
of these patients, however, is not at all characteristic, and anal-
yses furnish no clues which would serve to explain the ac-
companying mental conditions. Even the observations regard-
ing the general diminution of the urea and the increase of
uric and phosphoric acids are questionable. The same may
be said regarding the presence of indican and skatol.

Abnormalities in the circulation in neurasthenics are very
common. Associated with the vasomotor disturbances, to
which reference has already been made, we not infrequently
find a tachycardia. Bradycardia is sometimes noted, but when
this sign is marked and persistent, it can usually be accounted
for by the existence of some complication. The pulse is often
irregular, both in force and rhythm. Some observers, par-
ticularly De Fleury, affirm that in a large number of neuras-
thenics there is a hypertension, and look upon the symptoms
of the disorder as evidences of an autointoxication.

The changes in the circulation occurring during the epi-
sodic symptoms have been spoken of in the introductory sec-
tion. There are no marked abnormalities affecting the respi-
ration excepting during the periods of excitement or anxiety.
Certain observers have called attention to the frequency of
cutaneous lesions in cases of psychasthenia, more particularly
various forms of eczema, and not uncommonly seborrhoea, ab-
sence of tears, and rhinorrhcea. In women disturbances of the
menstrual functions are common.

As has already been pointed out, there is no disturbance
in the muscular power for sudden spasmodic effort, but the
symptoms of fatigue appear very early, and the sudden fall
in the curve representing the dynamic power of the muscle is
nearly always a constant symptom.

Differential Diagnosis. — The recognition of neuras-
thenia is frequently beset with many difficulties. Neurasthenic
states are encountered in the early stages of the more acute

PSYCHASTHENIC STATES 539

psychoses, as well as of dementia prsecox, dementia paralytica,
hysteria, and manic-depressive insanity. In hysteria, as a rule,
the occurrence of the typical attacks, the motor spasms, the
paralyses, and the fairly characteristic disturbances of sensa-
tion are differential points. Again, the hysterical states are
more apt to be characterized by a number of definite symptoms
and a more or less complete obliteration of certain functions
with an exaggeration of others. In psychasthenia there are
no complete lacunae in sensation, memory, or in the motor
functions. It is this characteristic of the hysterical manifes-
tations which stamps the phenomena as automatic, and gives
to the motor disturbances, impulsions, and other motor symp-
toms a regularity in rhythm, which is not noted in other dis-
eases (Janet). The cases in which obsessional ideas and
impulses are present may frequently give rise to considerable
difficulty in differentiation, and the absence of true hysterical
stigmata is frequently the only means of arriving at a positive
diagnosis.

Not uncommonly the initial stages of dementia precox
are characterized by the appearance of psychasthenic symptoms
which may last for a considerable period of time before the
development of the stereotypies, mannerisms, and explosive-
like impulses. Cases strongly suggestive of neurasthenia, but
developing in young persons, particularly girls, at or about the
time of puberty, and accompanied by very severe attacks of
migraine, with a tendency at times to a mild degree of emo-
tional apathy, should at once give rise to suspicions regarding
the existence of dementia praecox. The psychasthenic states,
in which the impulses are prominent, are usually characterized
by a certain degree of emotional instability, but the idea in
consciousness and the objective expressions of the emotion are
likely to correspond. The dissociation of these two factors, as
has already been pointed out elsewhere, is characteristic of
dementia. Furthermore, in psychasthenia, the condition is
more stable and psychic hallucinations are absent.

Not infrequently, for a short period of time, in the very
early stages of an attack of manic-depressive insanity, the

540

PSYCHIATRY

symptoms may be suggestive of psychasthenic states. The dif-
ferentiation, however, should hardly prove to be very difficult
if the patient is kept under close observation for several days,
except in the very mild cases and during the period of de-
pression. But even here it will be helpful to remember that
the neurasthenic usually retains a much clearer insight into
his own condition and shows no evidence of psychomotor re-
tardation. The physical state in psychasthenics remains prac-
tically unchanged, whereas in the manic-depressive conditions
the patient is apt to show a more or less sudden loss of weight
and not infrequently considerable disturbances in the gastro-
intestinal tract.

It often happens that the initial stages of paresis can be
distinguished from psychasthenic states only with the greatest
difficulty. Here a complete history of the patient is of the
greatest possible value. In individuals who prior to middle
life have never experienced any nervous breakdowns and who
have enjoyed good health, the appearance of a psychasthenic
condition, especially if there does not seem to be any immediate
cause for it and if it be protracted, should at once make us sus-
pect a developing dementia paralytica. This suspicion becomes
stronger if, in addition to the symptoms of chronic nervous
exhaustion, signs of ethical and social defects in character be-
come at all prominent. The appearance of temporary paralyses
of the eye-muscles, of incoordination in the facial movements,
of some difficulty in speech, or a slight impairment of the light
reflexes are frequently sufficient grounds for leading the physi-
cian to believe that he is dealing with a case of paresis, and
not one of psychasthenia. The same is true in regard to the
occurrence of attacks of vertigo associated with temporary
aphasia and an increase in the difficulty of speech. In psychas-
thenia the clinical memory tests are much less apt to reveal
the existence of positive defects than is the case in dementia
paralytica.

Disturbances in the emotional life of the individual in
psychasthenia are much more apt to be the result of excessive
reaction to stimuli from without or of mere transitory im-

PSYCHASTHENIC STATES 54I

pulses than of actual defects in judgment, as is so frequently
the case in dementia paralytica. Agam, insane ideas are much
more characteristic of the latter than of the former condition.

In the early stages of various acute psychoses we not infre-
quently meet with symptoms which also belong to chronic ner-
vous exhaustion or the typical psychasthenic states, but in the
former these usually give way in a few days to the more pro-
nounced manifestations of alienation.

Etiology. — The inciting causes of the majority of cases
of neurasthenia are too numerous to receive mention here. In re-
gard to the factors that primarily give rise to the episodic symp-
toms little definite can be said. Loewenfeld cites the following
causes as provocative of states of apprehensiveness, and these
same agents doubtless play an important part in the genesis
of the episodic symptoms : ( i ) A predisposition, the result of
abnormal heredity, which serves to accentuate the effect of
inciting agencies. (2) Essential or more immediately opera-
tive causes, either somatic or psychical. Among the former are
classed the sexual, and among the latter the emotional dis-
turbances. (3) Accessory causes that may temporarily inter-
fere with the functions of the central nervous system.

Treatment. — In the treatment of neurasthenia a great
deal of good may be accomplished by the complete or modified
rest-cure (see chapter on Treatment), but in the episodic forms
an amelioration of the symptoms is practically all that can be
hoped for. As has already been pointed out, the hereditary
factor is so dominant that prophylaxis becomes a question of
vital importance. Unfortunately, psychasthenics may be the
product, not of one, but of several generations ; and although
in an advanced state of society it might be possible to eliminate
many of the hereditarily predisposed individuals by requiring
a medical certificate permitting parties to marry, this desider-
atum could not be attained until the procedure had been in
force for many years. The danger of consanguineous mar-
riages has been frequently emphasized, as the children of such
parents are particularly apt to develop marked psychasthenic
states, particularly if there have been anomalous traits of char-

542

PSYCHIATRY

acter in the family. Another important danger noted by
numerous observers is the' fact that marriage, not only between
members of an undesirable family, but between the members
of families who have for several generations been devoted to
the same pursuits, is fraught with danger. Thus, in the case
of marriages of individuals belonging to highly intellectual
circles, particularly the university sets, the children seem to
exhibit an exaggeration of mental idiosyncrasies and traits
similar to those possessed by the parents. This fact provides
one of the strongest arguments against the excessive education
of women, particularly in this country. There can be little
question that when the women have the same intellectual aims
and ambitions as the men the tendency towards the develop-
ment of peculiarities of character, anomalies of emotion, and
mental tics is strongly accentuated in the children. As has
frequently been noted, there is a remarkable tendency shown
in the families in whom gout is present to the development of
psychasthenic states in the children. Prophylaxis in these cases
would necessitate more simple nourishment on the part of the
parents, the giving up of alcohol in any form, and a more
rational out-door life. In families in which the parents are
devoted to purely intellectual pursuits it is important that the
children should be removed as far as possible from the ten-
dency to what the French call " mental rumination." From
an early age they should be accustomed to interest themselves
in manual labor, in out-door sports, but not to excess; they
should never be forced at school, nor should any mental exer-
cises be encouraged if the child shows a tendency to become
isolated from its companions or to indulge in flights of fancy
or speculation. Everything should be done to encourage in
the child a healthy social character. On the appearance of
abnormal symptoms — excessive embarrassment, precocious -
ness, or a tendency to hold aloof from companions — the child
should be removed from its surroundings, and, if possible,
sent to the country or to some boarding-school where the
mental regime is less strenuous and every opportunity is given
for the cultivation of a healthy nervous system. Above all

PSYCHASTHENIC STATES

543

things, the children should not be taught to interpret pleasure
merely as being the absence of pain or discomfort. Particu-
larly harmful are all the tendencies which encourage in chil-
dren introspection, and equally undesirable are the various
forms of so-called religious instruction which are frequently
inflicted upon young people. Coming, as they do, at a time
when there is need of self-restraint and the exercise of the nor-
mal reasoning powers, they tend to substitute the play of the
emotions and to inculcate the dangerous principle of being
guided by impulse and by what the individual without reflection
believes to be the proper course.

CHAPTER XIX

PSYCHOSES ASSOCIATED WITH ORGANIC DISEASE OF THE CEN-
TRAL NERVOUS SYSTEM.1

Disturbances in the mental functions associated with
organic lesions in the central nervous system are not very un-
common, prominent among them being the psychical anomalies
described in connection with the following disorders :

Multiple Sclerosis. — With the earlier stages of this dis-
ease are sometimes associated a variety of neurasthenic symp-
toms which give rise to difficulties in diagnosis. At times these
manifestations of fatigue, both mental and physical, are present
for a considerable period of time before the tremor, disturb-
ances of speech, or other more or less distinctive signs make
their appearance. Occasionally marked disturbances in the
affective life of the individual are noted and the patient is
subject to ungovernable outbursts of temper, which sweep over
him with little provocation and which, after they have passed,
may occasion a genuine sense of remorse. As a rule, the pa-
tient retains an insight into his own condition ; he appreciates
that he is ill and that the nervous and mental disturbances are
the result of the disordered functioning of his nervous system.
In some instances these symptoms are slowly progressive, in
others they are remittent, and the patient may show a tem-
porary improvement sufficiently marked to excite general com-
ment among his friends. The mental disturbances and the
physical signs are not proportional, sometimes the former, in
other cases the latter, predominating, and they seem to bear no
definite relationship to each other. As a rule, in the early
stages, when the neurasthenic symptoms are marked and when

1 Hunt, J. Ramsay : Multiple Sclerosis with Dementia : A Contribu-
tion to the Combination Form of Multiple Sclerosis and Dementia Par-
alytica. Am. Journ. of Med. Sci., December, 1903. Dupre, E. : Psycho-
pathies organiques. In Ballet's Traite de Pathologie Mentale, Paris, 1003.
544

MULTIPLE SCLEROSIS S4S

the insight is well retained, the emotional tone is one of depres-
sion, but later on this may be lost, and the patient, becoming
more or less unconscious of his abnormal state, shows evi-
dences of some slight euphoria, a condition that is characterized
by an increased sense of well-being and a certain boastfulness
which in a measure are suggestive of dementia paralytica.2
In addition to the defects already noted, impairment of asso-
ciative memory is frequently a prominent symptom, and this
may give rise to slight disturbances in orientation, the latter,
as a rule, being less pronounced than in general paresis. The
mental symptoms, as has already been pointed out, generally
develop more or less irregularly, although in some cases con-
siderable impairment of the various faculties is noted. As a
rule, certain functions remain unaffected, and in this respect
the mental condition in multiple sclerosis differs essentially
from that observed in dementia paralytica, where practically
there is an involvement of all the psychic functions. The
multiplicity of the symptoms which may occur in the sclerotic
process and the frequent difficulty that is experienced in estab-
lishing a positive diagnosis have been particularly emphasized
by a number of investigators.3

The pathological changes in the central nervous system
can not be discussed in detail here. Although the sclerotic areas
are occasionally noted in the cerebral cortex, they are much
more common in the white matter as well as in the basal gan-
glia and cerebellum.4 When, as sometimes happens, sclerotic
changes are present in the corpus callosum, many authorities
hold that they are of great significance in the pathogenesis
of the mental symptoms. Nevertheless, other factors, such as
autointoxication, must be considered, and it is improbable that
these areas are the sole cause of the dementia, since the study

2 Starr, M. Allen : Organic Nervous Diseases. New York and Phila-
delphia, 1903, p. 701.

* Philippe, CI., et Castan : Memoire depose pour le prix civrieux a
l'Academie de Medecine. Daunenberger : Inaug. Dissertation, Giessen,
1901.

4 Philippe and Jones: Etude anatomo-pathologique de l'ecorce cere-
brate dans la sclerose en plaques. Soc. d. Neurol., 1899.

35

546 PSYCHIATRY

of the cellular elements in these cases has brought to light a
more or less general involvement of all the cortical cells, in
some instances amounting to a pigmented atrophy.

Amyotrophic Lateral Sclerosis. — Mental disturbances
in this disease have been reported by a number of writers.
Mott, Spiller,5 and other investigators have called attention to
the fact that in these cases there may be demonstrable changes
in the cerebral cortex. The mental symptoms are not in any
sense specific, and, as a rule, develop after those depending
upon the lesions have become so pronounced that the former
may be regarded as secondary in importance.

Apoplexy. — Mental anomalies may either precede or
follow a cerebral hemorrhage. When they occur as pro-
droma they often consist merely in nervousness, considerable
emotional irritability, and varied disturbances in ^associative
memory. Sometimes the patients become unusually irritable;
they are subject to outbursts of temper or may be markedly
hysterical, laughing and crying apparently without any provo-
cation. Following the attack, various manifestations are noted.
The extent and severity of these are not at all proportional to
the physical symptoms, nor, with a few exceptions, do they
seem to be influenced by the location of the lesion. Starr's 6
experience agrees with that of Seguin and Brissaud, that when
the lesion is in the right temporal lobe the loss of emotional
control seems to be more marked than when located elsewhere.
The intensity of the symptoms varies greatly, from a mild
degree of apathy to attacks of maniacal excitement with im-
pulsive acts of various kinds. Then, as is often the case, the
changes are progressive; the mental enfeeblement becomes
more and more pronounced until a profound dementia super-
venes. But it must be remembered that the mere local lesion
is not in any sense the immediate cause of this general mental
impairment, but unquestionably other causes, such as arterial

8 A case of amyotrophic lateral sclerosis. A contribution from the
Pepper Laboratory of Clinical Medicine. Philadelphia, 1900.
6Op. cit.

MENINGITIS 547

changes or areas of softening, are subsidiary factors. The at-
tacks characterized by hysterical symptoms are not at all in-
frequent ; the patients burst into laughter or tears without any
or on very slight provocation, and are unable to control their
emotions. Associative memory is nearly always impaired, the
defect being sometimes general and at other times isolated,
certain functions being well preserved while others are more
or less completely lost. The insight retained by the patient
into his own condition varies greatly and depends upon a num-
ber of circumstances. In some instances the individual appre-
ciates to a remarkable extent the nature of his trouble, in others
not at all. The character of the dementia that frequently de-
velops in these cases can not be distinguished from that occur-
ring in the arteriosclerotic or in the senile forms of alienation.

The relation of tabes to dementia paralytica and the occur-
rence of mental symptoms during the course of the former dis-
ease are subjects that are discussed in Chapter XV.

Meningitis. — Mental symptoms are frequently observed
in cases of meningitis. In the first place, there may be merely
the clouding of the consciousness or the disturbances in organic
sensibility which are common in any febrile disease. In other
cases, particularly in epidemic cerebrospinal meningitis, as well
as in the septic, tuberculous, and syphilitic forms, there may
be all grades of deliria varying from the mildest type already
referred to to the most pronounced maniacal excitement in
which the patient is kept in bed only with the greatest diffi-
culty. In these severe cases, in addition to the clouding of
consciousness, fallacious sense perceptions, which vary greatly
in character, are quite common. Sometimes the visual forms
predominate ; at other times they are associated with auditory
and somatic hallucinations. The degree of fever and the men-
tal aberration are by no means always parallel. Even with a
relatively low temperature certain patients show a marked ten-
dency to become wildly delirious, whereas in other cases, despite
a marked degree of hyperpyrexia, the mental faculties are re-
markably well preserved. In some instances early in the dis-
ease there are evidences of well-defined local lesions, whereas

548 PSYCHIATRY

in others the infection seems to be of a more general type and
the mental symptoms predominate. Clinically, we have to
distinguish between the meningitis which occurs as a primary
uncomplicated disease and those forms which complicate other
disorders, such as dementia paralytica, senile psychoses, alco-
holism, etc.

Brain Abscess. — Localized collections of pus in the brain,
in addition to the physical signs, are not infrequently attended
by a variety of mental symptoms, none of which, however, are
in any sense to be regarded as specifically characteristic. In
some instances there is merely a mild degree of motor restless-
ness or the patient becomes excessively irritable, while in other
cases there are varying degrees of apathy or stupor. Cases
have been recorded in which the abscess was attended by symp-
toms of marked depression or by degrees of motor restlessness
and exhilaration which simulated a true mania. In the in-
stances in which the history of infection is obtained and where
there are localizing symptoms as well as febrile disturbances
the diagnosis is not difficult, but in the more protracted cases,
where the abscess becomes encapsulated and the mental symp-
toms are the most dominant clinical feature, a diagnosis fre-
quently can only be made with the greatest difficulty, and in
some instances the real cause can not be recognized without an
autopsy.

The mental disturbances associated with thrombi or em-
boli in the cerebral vessels do not, as a rule, depend upon the
local disturbances, but are referable to a number of factors
that cannot be appropriately discussed here.

Brain Tumors.7 — Not all tumors of the brain cause
symptoms of a sufficiently pronounced character to render their
recognition easy. As can readily be gathered from the litera-
ture, even large tumors have been found at autopsy in the cen-
tral nervous system which during life had caused no note-
worthy manifestations. On the other hand, relatively small

7 Schuster, Paul : Psychische Storungen bei Hirntumoren. Stuttgart,
1902.

BRAIN TUMORS 549

neoplasms may give rise to marked local disturbances as well
as to a more or less general impairment of all the mental fac-
ulties. In the face of these apparently contradictory facts, as
well as for other reasons, it is often impossible to determine
how far the symptoms of alienation are directly due to the
presence of a tumor, and in the majority of cases the mental
defects must doubtless be regarded as secondary manifesta-
tions. It would be interesting and of great practical impor-
tance to determine in what percentage of cases a well-marked
alienation develops directly as the result of a neoplasm in indi-
viduals who are not hereditarily predisposed towards aliena-
tion. Thus in 73 patients Schuster affirms that in only 10
per cent, were there evidences of a marked predisposition
shown by the occurrence of mental abnormalities — particularly
nervousness and a tendency to alcoholism — prior to the devel-
opment of the tumor. As has already been pointed out, the
growth of the tumor is not so uncommonly accompanied by
a marked degree of mental aberration. In some cases this
amounts merely to disturbances in the affective life. The pa-
tients become easily fatigued and display a considerable degree
of distractibility. They are easily irritated and may be sub-
ject to violent outbursts of temper. In younger individuals,
on the other hand, apathy, distractibility, and in some instances
lethargy and somnolence are more likely to occur. Outbreaks
of delirium are sometimes noted, but when these occur the
possibility that the tumor is complicated by the development of
some independent psychosis should not be lost sight of. Schus-
ter and others have shown that the tumor may simply be a
factor of secondary importance when it precedes an attack of
manic-depressive insanity, dementia prsecox, amentia, etc.
Sometimes, however, it may in a way precipitate the alienation
by lowering the mental and physical resistance of the patient,
and because its presence may cause an actual circulation in
the blood of toxins which may give rise to certain delirious
states.8 As a rule, except in the case of the frontal lobe tu-

8 Wollenburg : Centralbl. f. Nervenheilk. u. Psych., 1903, Bd. xxvi, Nr.
i56.

55o

PSYCHIATRY

mors, the location of the neoplasm does not give a specific
stamp to the mental symptoms. The great variety of recorded
mental disturbances observed in cases of brain tumor will
appear from the following table from Schuster's work :

Predis-

Total Heredity position Alcoholism

Excitement 95 5 4 8

Melancholia 57 3 5

Delirium and confusion.. 52 2 2

Dementia paralytica 29 5 1 5

An abnormal tendency to

jest 23 . . 1 2

Paranoiic states 19 4 2 2

Neurasthenic states 15 2 3

Mania 13 2 3

Moral insanity 7 3 3 2

Circular insanity 5 I I

Simple mental weakness.. 423 725

Mental Disturbances Associated with Arterio-
sclerosis.9— Not only have recent investigations added ma-
terially to our knowledge regarding the pathological changes
taking place in the central nervous system as the result of
vascular sclerosis, but considerable advance has also been made
in establishing a closer relationship between some of the lesions
and the symptoms. For this reason it has been considered
advisable to change the order hitherto followed in the descrip-
tion of other diseases, so as to emphasize as much as possible
the importance of the alterations in the central nervous system
as the determining factor in the development of the clinical
picture.

Meyer has called attention to the fact that the nervous
system may suffer in three ways as the result of arteriosclero-
sis: ( 1 ) there is a reduction or marked change of metabolism

"Koppen: Arch. f. Psych., Bd. xx, S. 891. Binswanger: Berl. klin.
Wchnschr., 1894. Alzheimer : Allg. Ztschr. f. Psych., 1895, Bd. li, S. 809.
Monatsschr. f. Psych, u. Neurol., Bd. iii. Centralbl. f. Nervenheilk. u.
Psych., xxv. Jahrg., Nr. 149, Juni 15, 1902, S. 399. Noison et Coyne,
Union med., 1869. Meyer, Adolf: Albany Medical Annals, vol. xxiv,
No. 3, 1903.

ARTERIOSCLEROSIS 551

due to the arteriosclerotic disease in one or more organs; (2)
the changes in the nervous system are directly the result of
disturbances in the vascular mechanism; or (3) there may be
a lowered metabolism due to a state of exhaustion caused by
the action of toxic substances.

The forms of alienation associated with this disease are
more common after the fiftieth year of life, but they are not
infrequently present at the fortieth year or even earlier.

An example of mental disturbance with arteriosclerosis,
as it is sometimes seen in young people, is given in the follow-
ing abstract from the history of a case, for which I am indebted
to Dr. Cary B. Gamble, Jr. :

Patient, white; male; aged 22.

Family history good, except that the patient's father died of tuber-
culosis.

Personal History. — Denies lues and has no scar or enlarged glands.
Five years ago the patient had a moderately severe attack of typhoid fever,
from which he convalesced rather slowly. For the past two years he
has been unable to fasten his attention long upon any one subject and fre-
quently becomes greatly depressed, and fears that he is going insane.
Memory for past events is well preserved, and there is no evident dis-
sociation in thought. About a year ago the patient began to complain of
unpleasant dreams, always occurring when he was half awake. The con-
tent of the dream always had reference to the same subject; he thought
he was fighting with a gigantic snake, and always experienced a sense of
great relief when he awoke. Within the past two or three months this
idea has persisted after waking, and the patient fears that the snake may be
real, and that it is concealed under his bed or somewhere about the
room. On being assured that the idea about the snake was merely the
product of his imagination, he at first assented, but later said that he was
unable to get rid of the idea. With the exception of the marked depres-
sion he has shown no other mental symptoms. On examination his
arteries were found to be in a remarkable condition of sclerosis, being
uniformly thickened, and traceable high up in his arm. The cardiac
impulse was in the anterior nipple line, and there was a marked accentua-
tion of both sounds. Blood-pressure 200. Urine negative.

In the great majority of cases that come under observa-
tion, particularly in hospitals, the general disease is so far
advanced and affects so many organs that there is little diffi-
culty in referring any symptoms of alienation that may be
present to these changes. At such a time it is difficult to

552

PSYCHIATRY

accomplish much in the way of treatment, and for this reason
the need for making a diagnosis at a much earlier period is evi-
dent. Hence it follows that a more general appreciation of
the premonitory signs on the part of the family physician
would unquestionably avert serious disaster in not a few
instances.

In cases in which there are evidences of nephritis, diabetes,
enlargement of the heart, or changes in the arterial walls, the
existence of a concomitant sclerotic process in the central ner-
vous system is probable. On the other hand, when the sclerosis
is limited to the central nervous system its recognition is far
more difficult. Some of the more important of the clinical
signs of the malady are seen in the milder types of the disease,
generally referred to as " the nervous forms." These cases
are not uncommon in both men and women after the fortieth
year. The patients complain of fatigue, both mental and
physical; they recognize the fact that they can not fix their
minds long upon one subject; they are subject to neuralgias
of various forms, which occasionally suggest attacks of mi-
graine. In many instances there is a singular subjective feel-
ing, nearly always present, of loss of memory. The patients
complain that they can not remember well, but on careful exam-
ination it may be impossible to prove the existence of a positive
defect. This subjective sense of difficulty in recalling past
events is nearly always present. Sometimes positive defects
in memory, particularly for figures and names, may be demon-
strated. Cramer has called attention to the fact that in many
instances associated with these initial symptoms at times there
is a marked intolerance for alcohol. Patients complain of
an inability to understand what is said to them. This is par-
ticularly true if the subject is at all involved and not clearly
stated. Slight temporary motor or sensory aphasias may be
present. The patients, as a rule, show some irritability; they
do not like to be crossed, to have people differ from them. At
times they develop even a vague suspiciousness. They feel
that their old freinds are leaving them. They lose confidence
in themselves, are oversensitive in many ways, think that their

ARTERIOSCLEROSIS 553

acts are noted and criticised adversely by friends as well as
by strangers. In some instances there is a marked dulling of
the moral sense. This gives rise to sexual irregularities, —
masturbation, assaults upon children, etc. Again, the finer
sensibilities may be lost or there may be a tendency to become
obtrusively egotistical. The one symptom which is very char-
acteristic of all this group of cases consists in the remarkable
insight that such patients have regarding their own condition.
Up to a certain degree they are able to appreciate and estimate
the value of their symptoms. They recognize the psychical
hyperesthesias as abnormal. Personal characteristics in a
measure determine the clinical picture. The patients frequently
complain that if the symptoms persist they will lose their minds.
Up to a certain point they are rational. They are willing to
admit that they are not bereft of will power, they express the
desire of doing everything in order to recover, but they con-
tinually harp upon the fact that if their disorder does not abate
they will be driven insane. Individuals displaying these symp-
toms are met with in private practice, but in these early stages
are seldom found in institutions.

The diagnosis is frequently difficult, as the evidence of
general sclerotic changes may be absent, although sometimes
the finding of sugar in the urine may indicate their presence
in the central nervous system. The process in some cases may
progress slowly and pass on into the second stage. The pa-
tients not infrequently die of some intercurrent trouble or there
may be a long period when the symptoms are more or less
stable. In other cases the onset is followed by a greater rap-
idity of progression, the emotional disturbances are more prom-
inent, positive defects in memory are present, the attention is
greatly impaired, and the subjective sensations are, as a rule,
intensified. Hallucinations and insane ideas may complicate
the clinical picture. Observers differ regarding the occurrence
of megalomania. Periods of intercurrent excitement may
come and go. Sometimes mental depression is the chief fea-
ture in the case. The patients have a woe-begone appearance,
sit in a far corner of the ward with the eyes fixed upon the

554 PSYCHIATRY

ground and the corners of the mouth often slightly drooping.
They complain of being ruined, of having committed flagrant
sins for which they can not be forgiven. They affirm that it is
wrong for them to be in the hospital, that they do not deserve
such good treatment, that they should be killed, even tortured,
on account of their wrong-doing. In some cases they adhere
to these ideas with great tenacity, while in others they can be
diverted temporarily. Emotional instability is often present
and fits of laughing and crying often alternate. In some cases
interest may be suddenly aroused by the visit of a friend or
by the occurrence of a sudden and unexpected event, but this
change is only transitory. There may be marked motor rest-
lessness, which displays itself in various ways. Sometimes
the patient will wander aimlessly about in a fairly good-humor
until an attempt is made to restrain him, but then he becomes
violent. Such persons not infrequently exhibit a curious ten-
dency to collect various articles or objects lying about the
wards or that have been gathered by them on their walks about
the hospital grounds. Transitory delirious states are not at
all infrequent. At first these are of short duration, but as the
disease progresses they become longer and the delirium is
more constant. The focal lesions which may occur during the
course of the cases are not, as a rule, responsible for the mental
symptoms. This fact is particularly important, and should be
borne in mind more especially in connection with the post-
apoplectic dementias. In reality the symptoms of alienation
are referable to the accompanying arterial changes. In these
severer cases the patients still preserve a remarkable insight
into their own condition.

In some instances the symptoms displayed during the
course of the disease are of forensic importance. Patients suf-
fering from a mild degree of arteriosclerosis, with symptoms
of alienation that are apparently out of proportion to the physi-
cal changes, not infrequently are brought before the courts for
having committed acts of violence. Various forms of assault,
theft, arson, the infliction of injury upon members of the family
or friends without any provocation, etc., have been reported.

ARTERIOSCLEROSIS 555

Our knowledge regarding the mental diseases associated
with arteriosclerosis practically dates from the early attempts
made to differentiate the spurious from the typical cases of
dementia paralytica.10 Klippel, in 1891, described his pseudo-
paralyse generate arthritique, a condition essentially the same
as cerebral atrophy due to arteriosclerosis. In 1894 Binswan-
ger described the cerebral cortical atrophy associated with vas-
cular disease, and pointed out in this connection certain facts
which were supposed to be important in the differential diag-
nosis of the two conditions. In reporting these investigations
he referred to the occurrence of a diffuse chronic subcortical
encephalitis. About the same time Alzheimer described a con-
dition to which he gave the name of perivascular sclerosis. In
these studies he emphasized the important clinical fact that
although there might be marked sclerotic changes in the vessels
of the central nervous system, the process was absent or only
present to a limited degree in other organs. This important
fact renders the diagnosis in many instances extremely difficult.

In the milder cases one finds occasionally small areas of
softening with general dilatation of the perivascular spaces
and an increase of the glia. The ganglion cells show marked
pigmentation, but, as a rule, the medullated fibres are intact.
The vessels show the characteristic arteriosclerotic changes. In
the glia a few spider-cells are found, but compound granular
corpuscles are, as a rule, absent.

In the second group of cases there is generally a marked
diminution in the weight of the brain and dilatation of the
ventricles ; the white substance has a curious gray appearance,
and not infrequently many miliary aneurysms are found. The
ganglion cells as well as the fibres are little altered. The
arteriosclerotic areas may be numerous; there is marked in-
crease in the spider-cells; compound granular corpuscles are

"Alzheimer: Centralblatt f. Nervenheilk. u. Psych., xxv. Jahrgang,
Nr. 149, 15 Juni, 1902, S. 399. Idem: Histologische Studien zur Differen-
tialdiagnose der progressive Paralyse. Nissl, Franz : Zur Histopathologic
der paralytischer Rindenerkrankung. Histolog. u. Histopatholog. Arbeit,
iiber die Grosshirnrinde, Herausgeg. von Fr. Nissl, Bd. i, Jena, 1904.

556 PSYCHIATRY

generally present. Alzheimer distinguishes the following con-
ditions:

(i) A chronic subcortical encephalitis first described by
Binswanger. Only the deeper fibre tracts are affected, and the
cortex proper is practically intact. In these cases, in addition to
the psychical symptoms noted, as a rule, various disturbances
occur that point to local lesions. The differential diagnosis
between these and certain atypical cases of dementia paralytica
is frequently difficult. With the exercise of great care and a
careful study Alzheimer believes that it is possible to diagnose
such cases during life. In the cases of atypical paresis, as a
rule, there are evidences which point to the existence of a more
general destructive process than is the case in patients affected
with arteriosclerosis. In this latter group of cases the lesions
may be limited to one or more convolutions and the process
may be more intense in one area than in the other, but the
tendency is for the symptoms referable to focal lesions to be-
come prominent in the clinical picture. This is equally true
in regard to the psychical anomalies. In the senile dementias
as well as in the cases of dementia paralytica there is a general
impairment of the intellectual faculties. In the cases of arterio-
sclerosis, on the other hand, some psychical functions may be
intact, while others are markedly disturbed. As has been
pointed out, cases of arteriosclerosis by their symptoms sug-
gest the occurrence of focal lesions and to the casual observer
are more plainly indicative of organic brain disease than are
many cases of senile or paralytic dementia. The cases of senile
dementia with focal lesions are frequently as difficult to dis-
tinguish from true arteriosclerosis as are some of the atypical
cases of paresis. In the former group of cases, as Alzheimer
affirms, it is possible to obtain glimpses, as it were, of con-
ditions which are more or less characteristic of senile dementia
and which indicate the presence of a general rather than a
localized cortical lesion.

(2) A destructive process more or less limited to the cor-
tex. The focal areas are wedge-shaped with the base of the
wedge external. These areas are occupied almost exclusively

ARTERIOSCLEROSIS ccy

by a thick glia network. The longer association tracts are
intact. Along some of the capillaries there are evidences of
beginning softening.

(3) Here we have to do with a perivascular gliosis. In
the cortex, as well as in the deeper portions of the convolutions,
we meet with circumscribed areas in which the nerve-cells have
been destroyed and replaced by a marked increase in the glia.
These areas usually correspond with the regional distribution
of the affected arteries. An important symptom in differen-
tiating these cases from the dementias is the so-called senile
epilepsy. The clinical forms recognized are generally two —
one in which the psychical aberration during or following the
attack is not great and the symptoms are apparently due merely
to local disturbances in the cortical circulation; in the other
group of cases evidences of marked focal lesions are more
prominent. Following an attack there are evidences of paraly-
sis, narrowing of the field of vision, etc.

In these milder forms of the disease the diagnosis rests
largely upon the nervousness, the psychical and physical fa-
tigue, headache, the subjective disturbances of memory, attacks
of vertigo, and the tendency to remissions. The period at
which the sclerotic process begins varies in different individuals
and depends upon many causes. A general discussion of this
subject can not be entered upon here. Suffice it to say that
aside from the ordinary factors enumerated, such as syphilis,
alcohol, etc., there seems to be in certain families a marked
predisposition to these diseases of the vascular system. More-
over, in certain localities the disease is more common than it
is elsewhere.

The severer cases, especially when the symptoms of aliena-
tion are at all marked, are much better off in an institution
where they can be properly cared for. The bodily weight
should be carefully watched. If there is a marked decrease, the
patient is better off in bed. The diet should consist largely of
milk. The periods of excitement may be benefited by pro-
longed baths. The administration of as few drugs as possible
is indicated. Insomnia may sometimes be relieved by giving

558 PSYCHIATRY

the patient a lukewarm pack when the bath is not indicated.
This may be followed by some light nourishment, such as a
glass of milk. The severer and more temporary forms of
excitement are best treated by the use of sulphonal, bromides,
chloral, morphin, or hyoscyamin in small doses.

The general treatment of these cases is largely sympto-
matic. In the earlier stages, as soon as there is any suspicion
of a sclerosis of the vessels in the central nervous system, the
patients must be removed as far as possible from all responsi-
bilities. They should be advised to give up everything which
will subject them to unnecessary strain, either mental or physi-
cal. Life in the country is preferable to that in the city. The
diet must be light and nourishing; plenty of exercise, not
severe, in the open air is indicated. If the sense of fatigue is
well marked, the patients may do well to undergo for a short
time a rest-cure, during which time they are confined to bed,
kept on a fluid diet, given massage, and allowed to have an oc-
casional Turkish bath, best given under medical supervision.
Stimulants of all kinds must be avoided. The bowels must be
kept well regulated. In the poorer class of patients who come
to the dispensaries and hospitals a great deal can be done by
regulating the diet and by advising the patient to carefully
avoid all excesses. The number of meals should be increased
to five or six in the twenty-four hours instead of three. This,
as a rule, obviates the possibility of a patient overtaxing his
digestion at any one time.

Syphilis.11 — Since the middle of the last century the
question as to whether syphilis gives rise to psychoses which
can in any sense be characterized as distinctive of this disease
has been much debated. Although no satisfactory solution has
as yet been arrived at, much of the work of recent investigators
has at least been beneficial in re-formulating the problems to
be solved. As has already been said, it is now possible in a

u Rumpf : Die syphilitischen Erkrankungen des Nervensystems, 1887.
Kowalewsky : Arch. f. Psych., xxvi, 2. Nonne : Syphilis und Nerven-
system. Berlin, 1902.

SYPHILIS 559

great number, if not in all, of the cases to differentiate the
syphilitic from the paretic process, and the arteriosclerotic from
the senile group ; and at the same time we have arrived at more
definite ideas about certain other conditions. In 1877 Erlen-
meyer affirmed that the mental anomalies occurring during
syphilis might be divided into the so-called simple psychoses
and those in which disturbances of motility and sensibility are
met with, the condition then bearing a striking resemblance in
many of its phases to general paresis. Fournier speaks of a
chronic depressed state in which there is a general intellectual
impairment, and a second more acute type characterized by
definite periods of excitement and delirium, which he holds
are directly attributable to the action of irritating stimuli upon
the cerebral cortex. Heubner 12 differentiates three distinct
forms of aberration associated with cerebral syphilis : ( 1 ) In
the first the pathological process is more or less localized, gum-
mata being present in the convexity of the brain associated
with conditions of depression or excitement with accompany-
ing defect in memory, intelligence, and in the whole person-
ality. In this form aphasia, various local paralyses, and epi-
leptiform attacks are often encountered. (2) In the second,
where the arteritis is confined to the basal portions of the brain,
the symptoms are those of a simple dementia. ( 3 ) In the third
form, where the vascular changes are more pronounced in the
cortex, the most prominent manifestations are delirium, partial
loss of consciousness, together with impulsive acts of various
kinds. These investigations were carried still further by Kowa-
lewsky.13 The relation of the syphilitic infection to neuras-
thenic and hysterical states was studied by Charcot and his
pupils. A convenient clinical division of the aberrations asso-

12 Von Ziemssen's Handbuch, Bd. xi, 1.

" Syphilis und Neurasthenic Centralbl. f. Nervenheilk., 1893, iii.
Zur Lehre von der syphilitischen Spinalparalyse von Erb. Neurol. Cen-
tralbl., 1893, Nr. 12. Die functionellen Nervenkrankheiten und die Syph-
ilis. Arch. f. Psych., Bd. xxvi. Geistesstorungen bei Syphilis. Allg.
Ztschr. f. Psych., Bd. 1, 1894. Syphilitische Epilepsie. Berl. klin. Wchn-
schr., 1894, Nr. 4.

56o PSYCHIATRY

ciated with syphilis corresponding with the three periods is as
follows: (i) Those occurring after the arrest in development
of the chancre. (2) Those encountered during the efflores-
cence, this period extending to the time when in cases which
have not been promptly treated the arterial and meningeal le-
sions make their appearance. (3) Those belonging to the
period during which the gummatous growths develop and the
arterial disease becomes marked.

During the first period the mental symptoms are those
belonging to an acute infectious disease. Among the milder
disturbances noted are various manifestations of hysteria and
neurasthenia. These may or may not be associated with
marked mental depression, the individual being greatly per-
turbed on account of the character of the disease from which
he is suffering, and being unable to divert his mind from the
possible terrible effects of the malady which he is continually
picturing to himself. These cases are frequently described as
instances of syphilophobia. Occasionally in neurasthenic sub-
jects these fears are so intense that a hypochondriacal state
supervenes from which it is almost impossible to arouse the
patient. In other instances, instead of depression, we meet
with marked maniacal excitement. In all probability, how-
ever, in such cases the infection acts merely as a provocative
agent in precipitating an attack of manic-depressive insanity,
amentia, or some other psychosis.

States of depression or excitement are much more apt to
occur during the period of efflorescence, and here a symptom-
complex may develop which suggests the acute delirium asso-
ciated with a rise of temperature followed by indications of
more or less complete collapse, convulsive seizures, and symp-
toms of meningeal invasion.

In the third stage the onset of the mental symptoms is,
as a rule, more gradual. In many instances there is apparently
a general impairment of the mental and physical vigor. At
first there may be some confusion, although in the early stages
the patient retains a fairly accurate insight into his own con-
dition. Some authors are inclined to distinguish between

SYPHILIS 56X

simple luetic dementia and the so-called pseudoparesis of luetic
origin. As these two groups of cases are apt to resemble each
other in many ways, it is impossible to differentiate clearly be-
tween them. In some instances, however, we meet with indi-
viduals who show an insidious and progressive blunting of all
their mental faculties with marked loss of insight and defect
in memory, and who ultimately develop an apathetic dementia.
During the course of the disease epileptiform or apoplectiform
attacks may or may not occur. In other instances variations
in the affective state are noted; the individual is sometimes
depressed, at other times markedly exhilarated, so much so that
it is frequently impossible to differentiate this mental condition
from that which occurs in general paresis. In some instances
ideas of persecution develop, the individual becoming markedly
suspicious, not only of members of his own family, but of all
with whom he is brought into contact. As a rule, however,
these ideas are more or less transient and are seldom persistent
or intense enough to supply more than a temporary motive for
conduct. Such individuals, particularly in the early stages, are
apt to show marked intolerance for alcohol as well as a loss
of the power of concentrating the attention or energies. They
neglect their work, no longer care for their families, and exhibit
an indifference to all but the immediate necessities connected
with their own existence. In the cases which simulate general
paresis we may have impairment of the light reflexes, some
difference in the facial innervation, marked tremor in the mus-
cles of the face, tongue, and extremities, and a complex of
symptoms which it is frequently impossible at the moment to
differentiate from those of general paresis. These pseudo-
pareses of syphilitic origin may, however, be recognized by
the slow progressiveness of the clinical features, the tendency
to long remissions, and sometimes by the definite benefit de-
rived from antisyphilitic treatment. In some cases a euphoria
similar to that described under the expansive type of general
paresis develops. In these dementing cases the course is, as
a rule, protracted, death intervening only after a period of
from ten to twenty years from the onset. As a rule, when the

36

562 PSYCHIATRY

dementia is marked, little can be expected from treatment, and
permanent mental defects are nearly always noted, although
the cases may be differentiated from those of genuine dementia
paralytica by the apparent cessation of the disease process and
the remissions extending over several years. The epileptiform
attacks in these cases are apt to be much more frequent than
in general paresis. The so-called juvenile paretics, as far as
the present evidence indicates, should be classed as hereditary
syphilitica, as they usually present more of the symptoms of
cerebral syphilis than of general paresis.

Treatment — In the group of cases described under the
first and second heads an energetic antisyphilitic treatment
often brings about recovery. Particularly desirable in these
early cases is the use of inunctions. If any nervous symptoms
develop it is better that the patient be isolated for a time, kept
quietly in bed, given frequent baths or packs, and a diet re-
stricted principally to milk. In the more acute cases, where
maniacal symptoms appear, the individual should be trans-
ferred at once to a hospital where he can be carefully watched
and the administration of mercury and iodides pursued rapidly
to the point of tolerance. In the group of symptoms which
develop later in the infection, the therapy is apt to be less satis-
factory, although excellent results often follow the administra-
tion of large doses of the iodides. It is better to begin with
small doses of a saturated solution and rapidly increase, add-
ing one drop to the amount three times a day. In this way the
patient can soon be made to take from ioo to 200 grains daily.
After large doses have been given for four or six weeks the
drug should be withdrawn and the patient allowed to go with-
out any medication for a week or ten days, after which another
period of treatment, lasting a month or six weeks, should be
begun. In many of these mental abnormalities occurring in
neurotic and debilitated individuals tonics — iron, arsenic, and
strychnin — prove valuable adjuncts. The diet should be light
but nourishing, and in the absence of too acute symptoms a
life in the open air is all-important.

Pathology. — A great variety of pathological changes are

SYPHILIS

563

demonstrable in the central nervous system as a result of syphi-
litic infection. The characteristic lesions in the blood-vessels
(see chapter on Dementia Paralytica) are nearly always pres-
ent, but, as has been pointed out elsewhere, the marked infil-
tration does not, as a rule, affect the adventitial sheath. We
meet with frequent evidence of the formation of new vessels,
and, according to Nissl, the hypertrophy of the endothelial
lining of the vessels is also a source for the new vessel forma-
tion, small capillaries penetrating the cells. In not a few syphi-
litic cases many of the localizing symptoms — for instance, vari-
ous forms of paresis — are to be explained by the occurrence of
areas of softening, whereas in the cases of paretic dementia
they are more apt to be associated with changes in the minute
structure of the cortex. The nerve-elements themselves are
often swollen, and if a section of the cortex from a case of
syphilitic disease is compared with one taken from the normal
brain an apparent increase, not only in the size of the nerve-
elements, but also in the formation of new vessels, can be
detected. The size as well as the number of glia-elements is
often greatly increased, and in certain places where the nerve-
elements have been destroyed we have a thick matting of the
glia-fibres (Nissl's Gliarasen). The diminution in the num-
ber of the nerve-fibres is not nearly as' striking as in the cases
of general paresis. For a full description of the various gum-
matous formations the reader is referred to the various text-
books on general pathology.

CHAPTER XX

THE PARANOIA GROUP *

The term paranoia was formerly used to designate cases
of alienation in which the insane ideas were expressed in such
a way as to suggest a certain degree of systematization or con-
nection, being also developed with a semblance of logical se-
quence and marked by stability. Such cases were referred to
as partial or systematized deliria, and were supposed to stand
in sharp contrast to the so-called general deliria of mania or
melancholia. Furthermore, it was thought that paranoia was
more common in individuals who prior to the onset of the
alienation had shown some predisposition towards nervous or
mental disorders.

For a long time in the history of psychiatry paranoia was
regarded as one of the stable symptom-complexes concerning
whose origin and development it was impossible to gain any
very clear conception, and alienists were apparently content
with a merely casuistical study of cases and a series of cata-
logues of symptoms, so that each new phase in the social life
seemed to be represented by a special type of paranoia. The
text-books on psychiatry abounded in such titles as the per-
secutory, religious, hypochondriacal, sexual, or hysterical types
of paranoia, and every slight variation in the clinical picture
was accepted as sufficient justification for the immediate for-
mation of a new group. Gradually, however, it became ap-
parent, as has been shown in the chapter dealing with insane
ideas, that the mere systematization and persistence of insane
ideas could not be taken as specific characteristics of a disease
entity. As soon as alienists began to study the development,

1 Berze : Ueber das Primarsymptom der Paranoia. Halle, 1903. Mc-
Donald, W. : The Present Status of Paranoia. Am. Journ. Insan.,
1904, January, vol. lx, No. 3. Schultze : Bemerkungen zur Paranoia f rage.
Deutsch. med. Wchnschr., 1904, Januar 14-21, Nr. 3-4.

564

PARANOIA

565

course, and termination of the various symptom-complexes, it
was noted that clinical pictures remarkably similar in many
respects could develop out of what were primarily essentially
different conditions, and that neither the logical sequence nor
the persistence of the ideas, with the retention of a fair degree
of intellectual power, could be justly regarded as a dominant
characteristic any more than the temperature curve could be
considered the sole specific means of differentiating febrile dis-
orders. As soon as the clinical method of investigation was
given a fair trial it was found that it was possible to remove
from this group a variety of paranoioid states which were
found to be merely transitional phases belonging to other psy-
choses. Formerly it had been the custom to distinguish be-
tween the so-called acute and chronic cases of paranoia, the
curability of the former being a matter of common observation.
But the recognition of such a distinction soon led investigators
to inquire whether the acute process with merely transitory
paranoioid conditions might not be fundamentally different
from the chronic states. It was noted, for example, that many
of the more protracted cases of delirium tremens in which the
insane ideas were arranged with some degree of logical se-
quence persisted for a considerable length of time unchanged,
eventually clearing up and disappearing, and that finally the
patient recovered completely. Gradually, as it became clear
that the same mental state was observable in a variety of other
conditions — for example, in the acute confusional insanity of
the English writers and in the amentia of Meynert — alienists
awakened to an appreciation of the fact that the grouping of
these acute forms with the chronic systematized insanities was
based merely upon the existence of certain superficial simi-
larities. Thus, in connection with the study of a large group
of cases which led to the present formulation of ideas in regard
to dementia prsecox, it became apparent that a great variety
of chronic systematized forms of alienation characterized by
a terminal dementing process with many specific symptoms in
common, such as stereotypies, negativism, etc., bore only a su-
perficial resemblance to paranoia. More recently the attention

566 PSYCHIATRY

of alienists has been directed to the occurrence of paranoioid
forms of manic-depressive insanity, and here again it has
been shown that in addition to the mental condition of the
patient there are symptoms of a more purely physical charac-
ter which serve to differentiate these cases from the so-called
paranoia group. Whether the majority of the chronic cases
develop out of an acute paranoiic condition is still question-
able.

After all these deductions have been made we are still left
with a small residual group of cases which can not as yet be
definitely assigned to any of the psychoses hitherto described.
And it is to this more or less indefinite assemblage of cases,
representatives of which constantly fall under the observation
of the physician, that attention will be briefly directed in the
present chapter. Wernicke has defined the characteristics of
this group of cases as consisting in a falsification of the con-
tent in conjunction with a normal activity of consciousness.
As the acute forms of paranoia are variously classified under
the different psychoses of which they form an integral part, it
only remains to consider the so-called residual forms in which
the active disease process has either run its course and become
stationary or continues to develop only slowly and insidiously.
Whether a clinical differentiation upon this basis can be main-
tained depends altogether upon the facts which the histories
of cases, followed through long periods of time, bring to light.
Reference has already been made in the earlier sections to the
necessity of studying carefully the pathogenesis of the various
forms of paranoia. Admitting that in the acme of the disease
the main features of many of the cases consist in an essential
absence of disturbances in the affective life and a predominance
of more purely intellectual defects, too sweeping conclusions
based upon a partial truth are still unjustifiable. For the earlier
that we see many of the cases in which the intellectual defects
are prominent, the more convincing is the evidence that among
the first disturbances in the mental life the affective anomalies
play an important part. For this reason the former attempts
to bring the paranoioid states, as representing purely intellec-

PARANOIA

567

tual defects, into such sharp contrast with mania and melan-
cholia are not supported by our present knowledge. Berze
refers the primary disturbance in paranoia neither to an intel-
lectual nor to an emotional state, but to an anomaly in apper-
ception of such a character that the process of bringing the
psychic content into the field of consciousness is impaired.
This anomaly of function results in the impairment of the ap-
perception, and upon this derangement depends the lack of
judgment and defective critical power of the paranoiic. Fur-
thermore, this defect in function retards the departure of the
idea from the field of consciousness when the representation
has once gained access to it, and this anomaly in turn gives
rise to a tendency to establish forced relationships between the
various ideas in consciousness. These mental defects, of which
the patient himself is in part subjectively appreciative, are in
all probability the basis of the subsequent ideas of persecution.
Hallucinations, when they occur, are neither primary nor essen-
tial factors in the development of paranoia. As a further
result of his observations Berze concludes that the individual
who is the subject of paranoia suffers from a psychic defect
which can not be designated as an evidence of feeble-minded-
ness in the ordinary sense of the word, and that the primary
disturbances are not in any sense affective. This point of view,
although extremely suggestive, can not be considered as more
than an interesting and possibly helpful hypothesis.

Specht 2 affirms that in studying cases of paranoia atten-
tion must be paid to several factors, such as the direction and
form of the insane ideas as well as the material out of which
they are developed. According to this same observer, the
psychogenetic factor of greatest importance is the direction
or trend given by the idea as determined by the individuality
of the patient. Thus the ego becomes the centre of any false
system of thought, and as yet clinicians have failed to empha-
size sufficiently the importance of the egocentric character of

2Ueber den pathologischen Effekt in der chronischen Paranoia. Er-
langen und Leipzig, 1001.

568 PSYCHIATRY

every insane idea. The importance of the affective disturbances
and the fact that these ideas are born of emotional states in
part explain their incorrigibility. The genesis of the ideas
may be attributed not to the preponderance of one pronounced
emotional state, but rather to a mixture of factors. Pure de-
pression concentrates the patient's attention too minutely,
while exaltation or exhilaration diffuses it. The systematized
insane idea springs from a complex emotional state in which
no one tone is alone dominant. The clinical proof for this is
found in the paranoioid states which frequently develop in
association with manic-depressive insanity.

With our present knowledge the ultimate solution of the
whole question can not be derived from a study of comparative
symptomatology, but must depend upon the perfection and
elaboration of clinical histories to such an extent that the de-
velopment, course, and termination of the doubtful cases,
extending over long periods of years, can readily and minutely
be investigated. The mere refinement of the psychological
analysis, however admirable it may be, cannot give us any real
insight into the natural history of the disease with which we
are dealing; neither can the protracted duration of certain
cases be looked upon as a safe criterion in differentiation.. It
is not at all improbable that whereas a disease process in one
individual may run its course in a few months, in another
person, under different surroundings and a stronger mental
resistiveness, it may be prolonged for a period of years.

The remarkable confusion that results from the mere
epochal study of paranoiic states, without any genuine and
steady attempt to trace the connection between apparently dis-
similar conditions, is well exemplified in the study of the so-
called original paranoia. According to Sander,3 who first used
the term, this form of chronic systematized insanity develops
in individuals who early in life have shown certain abnormali-
ties in character with a marked inclination to indulge in con-

3 Sander, W. : Ueber eine spezielle Form der primaren Verriicktheit
Arch. f. Psych., Bd. i.

PARANOIA 569

fabulation and dream-like revery. In the acme of the disease
these individuals, on account of the character of their insane
ideas, are classed among the most dangerous lunatics. Other
observers think that the clinical course of the disease is one
in which periods of vivid hallucinosis occur. The character
of the fallacious sense perception determines the mood until
eventually mental deterioration develops. The symptomatic
features of these cases were considered by Neisser to be a
varied combination of fallacious sense perceptions with an
elaboration of the ideas, particularly those relating to the per-
sonality, and in the second place an excessive tendency towards
the falsification of memory. A number of writers, particularly
Meynert, were inclined to believe that such individuals had
been the subjects of insane ideas for the greater part of their
lives. Other clinicians have endeavored to find points of dif-
ferential importance between this and other forms in the
manner of the development of the malady.

The importance of periods of hallucinosis has been vari-
ously estimated, some writers holding that they are more or
less constant, others that they are only occasional and episodic.
Kraepelin, in the last edition of his book, dissents from the
view that it is possible to trace the genesis of the insane idea
back to an early period in youth, but thinks that the so-called
original paranoiics in whom the disease is said to have begun
at an early period of life with a progressive development,
broken by acute periods or exacerbations with marked hallu-
cinosis, should be classified among the hebephrenics.

One of Schott's 4 patients has been under medical sur-
veillance for twenty-five years. On account of the detailed
history given the case is one of considerable importance in
throwing light upon certain disputed points in the pathogenesis
of this and similar conditions. Prior to the period at which
this patient entered the asylum in 1879 marked eccentricities

4 Schott, A. : Beitrag zur Lehre von der sogenannten originaren
Paranoia. Monatsschr. f. Psych, u. Neurol., 1904, Mai, Bd. xv, H. 5,
S. 321.

57o

PSYCHIATRY

of character had already been noted and a more or less indefi-
nite history of the occurrence of insane ideas, even in earliest
childhood, was given. The evidence upon this latter point,
however, is believed by Schott to be too uncertain to justify
its recognition. While the patient was under observation
periods of definite hallucinosis occurred. In 1891 the patient
began to show signs of megalomania, and the ideas which then
presented themselves persisted with remarkable stability. Al-
though the systematization and persistence of the insane ideas,
together with a certain degree of intactness of memory and
the power of intellectual effort, are still noted, the occurrence
of disturbances in the motor functions during the attack would
naturally suggest the idea that the case is one of hebephrenia
and not true paranoia. Schott himself is of the opinion that
the form of alienation is to be regarded as a chronic hallu-
cinatory paranoia.

In the careful scrutiny and analysis of symptoms the clini-
cian should avoid the error of assuming that the presence or
absence of slight mental deterioration without other specific
symptoms can be accepted as a means of differentiating between
the typical cases of paranoia and other forms of alienation. As
has been pointed out in Chapter III, it is more than probable
that in every case in which an insane idea develops a certain
amount of mental impairment exists. Frequently in the clinics
individuals are met with who show a series of stable systema-
tized insane ideas while still retaining considerable ability in
reasoning, and in whom there can be noted but little inter-
ference in the volitional processes except when a certain line
of conduct brings these into conflict with their delusions. The
history of such individuals is that gradually, over a period of
years, they become more or less nervous and irritable and
nearly always show a tendency to be more and more self-
centred. This latter phenomenon generally shows itself in a
certain degree of distrust and inability to adapt themselves to
their surroundings; they fail to get along with friends or
relatives and begin to display a certain queerness and eccen-
tricity of manner which is sooner or later recognized as ab-

LITIGIOUS INSANITY 57I

normal even by the laity. Frequently the friends will tell us
that these individuals have always been queer, have always
shown marked eccentricities of character, have always been
easily prejudiced and possessed by fixed ideas. Gradually the
insane ideas become more and more crystallized, and, as a rule,
first one or two make their appearance, and later others de-
velop secondarily. In tracing the evolution of the symptoms
it may be found that what could at first properly be described
as irritability later becomes mistrust or suspiciousness. The
conduct of those about them is misinterpreted ; everything that
is done, according to these patients, is directed against their
welfare; poison is put into their food; they are followed on
the street ; if confined in an institution, they complain that they
have been illegally committed and spend their days brooding
over this fact. Frequently symptoms of definite hallucinations
are present, and although the individual may not admit that
such is the case, if carefully observed he will often be noticed
apparently listening to the sound of voices, his lips moving as
if attempts were being made to reply; in short, his conduct
will in many ways justify the belief that he is influenced by
fallacious sense perceptions.

Not infrequently, in addition to the auditory hallucina-
tions, visual and particularly haptic forms seem to affect the
conduct. As a rule, associative memory is to some extent
impaired, but it often happens that memories immediately af-
fecting the life of the individual are fairly well preserved,
whereas those connected with his relationship to those about
him are either defective or falsified. The emotional tone of
such individuals is conditioned largely by the occurrence of
hallucinations, being either one of suspicion or fear, or of
aggressiveness, according to the nature of the fallacious
sense perception. The higher faculties are more or less in-
terfered with. These defects become more apparent when
the symptoms of the patient are the immediate subject of
discussion.

Litigious Insanity. — Another important class of cases
to which the attention of alienists was especially directed by

572

PSYCHIATRY

the writings of Hitzig 5 is the so-called litigious insanity. As
a rule, these individuals are characterized by the remarkable
pertinacity with which they adhere to their ideas. They have
a singular disregard for the rights of others with whom they
are brought into contact and seem utterly unable to appreciate
that a question may have two sides. All they seek for is
to establish what they regard as their own rights without
any deference for the feelings or rights of others. It is fre-
quently very difficult, particularly for the laity or for physicians
who have had no experience in psychiatry, to determine the
existence of a marked mental defect in these individuals. They
are generally regarded by members of the community as lim-
ited in their interests, excessively egotistical, and stubborn;
but apart from these apparent eccentricities of character they
are considered normal. The more one is brought into contact
with them the narrower does their range of interest appear.
Their conversation is limited to a perpetual harping upon af-
fairs which are of immediate interest only to themselves, and
in action as well as in word they show an utter lack of the
power of dissociating themselves from the very small world
in which they live. As a rule, they have an exaggerated sense
of self-consciousness and egotism. Whatever goes on about
them is immediately supposed by them to have some relation
either to their conduct or to matters which pertain to them-
selves. Generally the mental disturbance first makes its ap-
pearance in connection with some real or fancied grievance,
which they harbor in their minds and brood over continuously.
They are unable to recognize that other persons may have
rights, and their own individuality is the centre of the world
in which they live. They are utterly uncompromising in their
actions as well as in the expression of their own individual
opinions, and brook no interference. An opposing opinion
seems to stimulate them to greater obstinacy and make their

'Hitzig: Ueber den Querulantenwahnsinn, 1895. Pfister: Ueber
Paranoia chronica querulatoria. Allgem. Ztschr. f. Psych., lix, p. 589. See
also Lane, E. B. : Litigious Insanity with Report of a Case. Am. Journ.
Insan., vol. lix, No. 2, 1902.

LITIGIOUS INSANITY ry-y

argumentative aggressiveness even more noticeable and more
unpleasant. Any attempt to hold them back merely drives
them to even greater lengths in attempting to establish their
fancied rights. Their time is often spent in writing lengthy
appeals to friends or officials and in setting forth their side
of the case with the greatest minuteness of detail, and without
admitting in any way that the person with whom they have
been brought into controversy can possibly have any rights
in the matter. Persons affected by forms of litigious insanity
are great nuisances to the community. A failure to convince
one set of officials of the merits of their case only serves to
increase their pertinacity; they become even more set in their
determination to establish their claims, and immediately go
to others in authority, reiterating their grievances and clamor-
ing for justice. As the mental symptoms in these cases usually
become pronounced during the prime of life and develop in-
sidiously, a great deal of annoyance is often suffered by mem-
bers of their family and friends before the fact is recognized
that these individuals are really insane. Not infrequently they
are conspicuous litigants in the courts, and, as the mental de-
terioration is not a prominent symptom, their supposed griev-
ances often excite the sympathy and compassion of those who
are unacquainted with all the facts.

Gradually, as the disorder progresses, the argumentative-
ness and aggressiveness become so intense as to estrange the
individual from members of his own family. Even at this
stage the intellectual capacity, although limited in certain di-
rections, may be retained to such a degree that there may be
little or no evidence of deterioration that can be appreciated
by those who are not experts. Frequently the litigious para-
noic, if he has failed to accomplish his ends by fair methods
and by legal procedures, will adopt foul means, contriving all
sorts of plots, often most ingeniously constructed, and some-
times in this way securing the aid of innocent persons in the
perpetration of some crime. Cases are on record in which
individuals who were under the delusion that they had suf-
fered the loss of funds through the action of friends either

574 PSYCHIATRY

themselves perpetrated thefts, or incited others to do so in
order to acquire the money which, as they claimed, had been
lost or had been taken from them by legal procedures. These
patients will not stop short of any means to accomplish their
ends, and even deliberate murders not so very rarely have to
be looked upon as having been committed by individuals suffer-
ing from this form of insanity.

CHAPTER XXI

THE SENILE GROUP. PSYCHOSES CONNECTED WITH THE
PERIOD OF SENILE INVOLUTION

In the following chapter we propose to give an account
of the mental disturbances which come on first during the period
of senile involution and are not recurrent attacks of alienation
that have appeared prior to this epoch of life. In order to
facilitate the discussion of these disorders, it may be well to
refer to the mental, physical, and histological changes which
are characteristic of the period of senescence. The mental
changes occurring in normal old age are in a measure specific.
It may be said in a general way that there is marked inter-
ference with the synthetic processes ; in other words, although
the critical faculties are well retained, the productivity or
mental output, as compared with that of the preceding period
in life, is limited. Of course, the inference is not to be drawn
that this happens in all cases, for history contains brilliant
examples of remarkable retention of intellectual capacity, even
into the eighth and ninth decades (Virchow, Gladstone). But,
generally speaking, the acquisition of new facts and intellectual
expansion in the normal individual do not continue after the
fiftieth year. Not only does this enfeeblement in the associa-
tive mechanism become gradually more and more marked,
but there is also a narrowing in the emotional life. In ad-
vancing years the individual becomes more and more centred
in his own affairs and in his own immediate environment,
so that only with considerable difficulty are his interests ex-
tended beyond the range of persons, objects, and things with
which he has long been familiar. Associative memory, as a
rule, is one of the first functions to suffer. Recent impressions
fade, and the individual shows a tendency to revert more and
more to the times of his early manhood and youth. For this
reason, as a rule, there is an apparent indifference and lack

575

576 PSYCHIATRY

of interest in the affairs of the present, and the " good old
times" are referred to with constantly increasing- frequency.
As may be inferred, the habits and customs of the life of an
individual play an important part in bringing out at this period
eccentricities of character.

The bodily manifestations in the period of senescence are
very varied and prominent. Among these, as a rule, are the
changes in the facial expression, the increase in the number of
wrinkles and deepening of those that already exist, together
with a general wasting of the musculature, the disappearance
of subcutaneous fat, and considerable impairment in the motor
activities. The senile tremor is commonly noted. The hair, as
a rule, is white and sparse, the arcus senilis is marked, and other
senile changes in the eye become apparent. In some instances
the pupils are uneven, but the reactions for light are not, as
a rule, greatly impaired except in the cases which suggest
dementia paralytica. Various neurotic disturbances, the result
of arterial changes, are also noted, while imperfect functioning
of the heart, liver, and other organs is common.

The changes that occur in the central nervous system in
senility have been the subject of considerable investigation.
Redlich x regards all the changes found in the brains of indi-
viduals who have died at an advanced age as marks of senility.
Nevertheless, it would seem far better to use the term not as
meaning a normal aging, but in a pathological sense, and to
class under this category only those alterations which do not
occur in the majority of old people.

Chief among the changes in the brain is the marked de-
crease in its weight, as shown by the following statistics of
Parchappe :

30-39 yrs. 60-69 yrs-

Man 1413 grm. 1334 grm.

Woman 1246 1 175

1 Redlich, E. : Beitrag zur Kenntniss der pathologischen Anatomie der
Paralysis agitans und deren Beziehungen zu gewissen Nervenkrankheiten
des Greisenalters. Arbeiten aus d. Inst. f. Anat. u. Physiol, d. Nerven-
systems. H. Obersteiner, Wien, 1894.

SENILE PSYCHOSES 577

In nearly all cases of advanced senility there is also consid-
erable atrophy of the convolutions, with a deepening and broad-
ening of the fissures. In the interior of the brain we meet with
a dilatation of the ventricles and canals and a mild grade of se-
nile hydrocephalus. In the cortex we not infrequently meet with
the etat crible and in the central ganglia the foyers lacunaires
de disintegration described by Marie. Accompanying these
gross lesions are changes in the nerve-cell, a granular degen-
eration of the Nissl bodies, with a chromatolysis. In many of
the cells there is a marked increase in the pigmentation, inter-
preted by some authors as pigment degeneration of the cells.

In the vascular system we meet with dilatation of the ves-
sels, particularly of the intra- and extra-adventitial spaces
(spaces of Virchow-Robin and His), with considerable pig-
mentation in the adventitial coat. The neuroglia is usually
increased in quantity, both the cells and the fibres, but particu-
larly the latter, participating in the process. Colloid degener-
ation of the vessels has been noted by Alzheimer, and its oc-
currence is said not to be always indicative of a pathological
lesion. Associated with the over-development of the neuroglia
tissue there is an increase in the number of amyloid bodies, the
origin of which, according to Obersteiner, is probably in round
yellow bodies found in the glia-cells.

In a certain number of individuals the physical changes
incident to old age are associated with marked symptoms of
mental aberration during life, the clinical picture as well as
the post-mortem alterations supplying evidence of pathological
lesions in the central nervous system. The senile psychoses
may, from a pathological stand-point, be divided into three
classes: (1) Cases of simple senile mental disturbances, dur-
ing which no evidence of marked organic lesions are to be
found. In patients dying of some intercurrent malady and
coming to autopsy the only pathological change which bears
any relation to the alienation is a very slight accentuation of
the senescent changes already described. (2) Cases in which
the symptoms point to the existence of definite organic lesions
in the central nervous system and which in many instances, in

37

578 PSYCHIATRY

the clinical picture as well as in the post-mortem findings,
simulate cases of general paresis. (3) The senile dementias.

Besides the fact that this grouping is very convenient, it
offers the possibility of a classification upon a clinical as well
as a pathological basis.2 But, nevertheless, it must always be
borne in mind that the cases can not always be sharply differ-
entiated, and the groups may merge into each other. In order
not to repeat what has already been said in Chapter XV upon
the subject of the clinical and pathological differentiation be-
tween the atypical cases of dementia paralytica and certain
forms of the senile psychoses, only two clinical groups, corre-
sponding to (1) and (3), will be discussed in the present
chapter.

(1) The first group includes states of (a) mental depres-
sion, ( b ) excitement. Under the former are included the cases
which are characterized by mental depression, generally asso-
ciated with some anxiety and apprehensiveness, but which do
not form a part of other psychoses.3 These cases are among
the most common of all the forms of alienation which develop
at this period of life. The duration of the disease varies from
several weeks to one or two years, and in a large percentage of
the cases there is an ultimate recovery. The onset, as a rule,
is insidious and slowly progressive. In the majority of cases
there is at first a slight accentuation of the senile mental
changes to which reference has already been made; but after
some one of various exciting causes has intervened, the patient
shows a tendency to become more and more egocentric. The
outside world contains less of interest for him and he becomes
absorbed entirely in his own immediate environment. The
initial symptoms as well as the later stages of the disease have
a strong individualistic stamp. Personal idiosyncrasies are
accentuated, and the patient becomes hypochondriacal, more
or less indifferent, or introspective, in accordance with the

2 Cramer, A. : Die senile Seelenstorung. Patholog. Anatomie des
Nervensystems, 1904, Bd. ii, S. 1504.

* Kraepelin : Psychiatrie, Siebente Auflage.

PLATE XX

Senile melancholia.

SENILE PSYCHOSES 579

traits of character exhibited during his former life. Not only-
do the personal qualities become exaggerated in the early stages
of the disease, but the daily life of the individual, to which he
has become accustomed for years, becomes reflected in this
stage. Thus, the business man first loses pleasure and interest
in his daily occupation and begins to worry about trifles. He
is easily confused, complains that every mental effort causes
him too great an output of energy, every new undertaking
immediately gives rise to apprehensiveness, and the fear of
failure may be so great as to cause marked emotional disturb-
ances. Early in the disease, as a rule, the subjective feeling
of insufficiency develops ; in fact, this is one of the most char-
acteristic symptoms of the disease and plays an important part
in its further development. This sensation varies in intensity
from one of mere dejection to a feeling of anguish, and when
unassociated with the fixed ideas is in a measure proportional
to the intrapsychic akinesis. As the disease progresses the
akinetic disturbances become more and more marked, until
finally they are evident in the impairment of connected thought
as well as in the diminution in extent and energy of all voli-
tional movements. The mental inertness is shown in a great
variety of ways, and may in part be attributed to the alteration
in those psychic sensations which are so immediately depend-
ent upon the general organic sensations.4 That series of com-
plex affective states which we refer to commonly as pleasure,
love, hate, and so forth, is in the ultimate analysis dependent
upon the preservation of the normal organic sensations, and
when there is any interference with these, there is a correspond-
ing change in the emotional reactions. For this reason the
progressive feeling of insufficiency and depression is accom-
panied by a corresponding decrease in the number of emotional
reactions, a deficiency that becomes more apparent the more
highly organized and sensitive the character of the patient
prior to the attack.

Although there is a diminution in some of the organic sen-

4 Wernicke. Op. cit., 345-

58o PSYCHIATRY

sations, others become intensely exaggerated, and these un-
doubtedly form the basis upon which many of the hypochon-
driacal states develop. In many cases the patient becomes more
or less rapidly self-centred, evincing little or no interest even
in the immediate members of the family, so occupied is he
by his own symptoms and the course of the disease. In the
hypochondriacal form the individual frequently affirms that
the disease with which he is afflicted is incurable and that
medical aid can be of no avail. The deepening mental gloom
is broken only by renewed expressions of hopelessness and
dismal laments regarding his poor physical condition. In
some instances the patient's attention is mainly centred in his
thoracic or abdominal organs, and he not uncommonly affirms
that his viscera have been transposed, injured, or even removed.
A good example of these delusions is afforded by the following
case:

Male, aged 63, married. Admitted to the Sheppard and Enoch Pratt
Hospital June 27, 1901.

Family History. — One sister insane.

Personal History. — The patient has had no illness since childhood
except occasional attacks of indigestion. Has never used tobacco nor
alcohol. Has been married 35 years ; his wife and several children are
living. While he has always done hard mental work he has had no nervous
breakdown.

Present Illness. — In the summer of 1900 the patient became greatly
worried about his work, and by October had become extremely nervous.
He was troubled with insomnia and was in a state of continued depression,
which increased to absolute hopelessness about himself. He had fixed
ideas relating exclusively to his own person. He thought that his food
was not being properly assimilated, and, although his appetite was good,
he constantly affirmed that he had no desire to eat. In December he
expressed the fear that he was losing his mind and would not be able to
attend to his daily occupation. In January, 1001, the patient weighed 75
pounds, a loss of 50 pounds from his normal. He complained of a throb-
bing sensation in his brain and of increasing worry concerning his digestive
troubles. He soon felt obliged to give up his work and went to an institu-
tion for treatment. The insomnia and mental depression increased. He
had the fixed idea that his digestive organs were drying up, that his body
was disintegrating, and that to take food would be fatal. These symptoms
continued pretty much the same until June, when he expressed his inten-
tion of starving himself to death and thus ending his suffering.

Present Condition. — On admission the following note was made: The

SENILE PSYCHOSES

581

patient remains in bed, makes no effort to assist himself, and relies entirely
upon the nurse. The facial expression is fixed and indicates a depressed
mood. There are horizontal furrows on the forehead and two slight per-
pendicular grooves between the eyes. He shows no marked aversion to
talk and answers questions, but is markedly egocentric and convinced of
the truth of the ideas regarding his physical and mental condition. He
affirms that his present condition is due to overwork and insomnia and
that the latter has led to insanity. He says that prior to the onset of the
disease his organs functioned normally, but now their action has become
vitiated and everything about his physical economy has gone wrong. He
is not self-accusatory, but is constantly brooding over his condition, mani-
festing many and varied hypochondriacal symptoms. He says that he has
no appetite and does not wish to eat, that everything tastes alike, and
that when his eyes are closed he can not tell one article of food from
another. He declares that every mouthful he takes, instead of digesting,
remains inside of him and ferments, and that his bowels are never moved
naturally. Speech is slow and somewhat hesitating; the tone of the voice
is low, with falling cadences. There are no aphasic symptoms. He de-
clares that his hearing is failing; that he is unable to recognize familiar
sounds. He has shown no delusions regarding his personality and has not
mistaken the identity of other persons.

Physically he is anaemic and emaciated. Tongue clean and moist.

Audition : Hears watch at a distance of five or six inches from the
right and one or two inches from the left ear.

The eyes show nothing abnormal.

The tendon reflexes are all diminished. Epigastric active, cremasteric
fair.

Heart sounds extremely weak. No apex beat localized on inspection
or palpation.

Blood : Haemoglobin, 65 per cent. Red blood-cells, 4,900,000 ; leuco-
cytes, 8000.

Several months later it is noted that the patient's mood has not changed
and he is still depressed and introspective. He has had some slight trouble
with his nose and thinks that the mucous membrane is gone. He says his
nose is closing up, that his nasal passages will soon be entirely closed, and
that he will be unable to breathe through them. December, 1001. The
somatic delusions persist. Suspects that he is losing his speech. Main-
tains that his food does not digest, but merely piles up inside of him. Has
been under the impression that the respiratory passages are becoming
occluded. He does not cleanse his nostrils properly and will not allow
his face to be touched while being bathed, fearing that water will get into
his nose and thus suffocate him.

November, 1902. Still insistent upon the " disorganization of the body,
principally the intestinal tract." Does not initiate conversation ; remains
seated quietly ; does not pay any attention to conversation between others ;
watches the movements of patients and nurses, but does not enter into con-
versation. Occasionally walks over to the window and looks out at the
view. The improvement during 1902 has been very slow. Patient admits

582 PSYCHIATRY

that he sleeps better than formerly, although he still maintains some of
his ideas about his digestive tract.

As in this case, the patients seem to show considerable
appreciation of the fact that they are the subjects of mental
aberration. They express the fear that they are losing their
minds, and in proof of the truth of their declarations refer
to the mental confusion, vertigo, and other abnormal sensations
with which they are affected.

In addition to the hypochondriacal feelings, many patients
show a marked tendency to brood over sins of omission as
well as of commission of which they affirm they have been
guilty. Utterly disconsolate, they dwell upon acts committed
in their youth, and mere peccadilloes are now looked upon as
heinous offences. They remember on a certain occasion having
told a lie and affirm that the memory of this sin has persisted
all their lives, and now Providence has burned its imprint
upon the brain and sent the disease as a just retribution. Fre-
quently the observer is struck by the fact that the causes as-
signed by the patients as reasons for their despondency are
wholly insufficient and out of all proportion to the excessive
affective disorder. In addition to the ideas of culpability and
criminality, we frequently meet with those of persecution, which
are very apt to be colored by the emotional tone of the patient.
Or, again, a patient may affirm that life has been too happy,
that he has been too selfish, and has lived in the present, taking
no thought for the morrow; that as the result of this frame
of mind he has given little attention to matters of religion,
and consequently God wishes to direct his thoughts to less
worldly affairs, and so torments the body in order that his mind
may be set on higher things. Not infrequently the ideas are
associated with a human agency and, if this is the case, the
illness is regarded as the result of poison which has been put
into his food. At other times the ideas of being persecuted
and of having sinned are combined. Patients express a fear
that they are to be brought before a court of justice to be tried
for crimes, and in spite of their innocence are to be convicted.

SENILE PSYCHOSES

583

They are firm in their declaration that no reason exists why
this calamity should overwhelm them and they be cast upon
such a sea of trouble. Life has become a hell upon earth, owing
to the supposed faithlessness of family and friends, and they
alone and unaided must wander through a slough of despond.
Not infrequently such individuals complain of great annoy-
ance from being, as they suppose, under continual observation.
Nothing that they do can remain hidden ; their acts and even
their thoughts are known to those about them ; they long for
some degree of privacy and dread the publicity to which they
think they are exposed.

In many cases extreme poverty is complained of. Even
well-to-do individuals affirm that they have lost every cent;
that, as a result, they have been sent to what was represented
to them as a hospital but is in reality a poor-house; that not
only they but their family and friends are in absolute need;
that nobody knows of this fact but themselves, and that noth-
ing remains for them but to die before the disgrace becomes
public, and they long for death in the hope that the misery of
seeing relatives and friends in great want may be spared to
them. Sometimes patients in this state affirm that they have
accumulated enormous debts which can not be paid, and this
delinquency may be referred to their deficient business capacity
or to the improper use they have made of funds entrusted to
their care.

In some instances the ideas are nihilistic in quality. The

whole world is changed. The air that the patients breathe is

becoming less; the food supply is at an end; there is no

possible help, not only for themselves, but for those about

them. All are dying or are actually dead, and they alone

survive. Not only is the world about to be destroyed, but

the whole universe is rapidly disappearing; nothing remains

but chaos. The following extract from the letter of a patient

illustrates these nihilistic ideas as well as the dissociation of

thought :

" Were the whole world mine or the wealth of it, I would give it for
one moment of life. Dr. X said, ' You can live if you want.' Dr. Y said

584 PSYCHIATRY

put her at , but time, place, position, nor people can have effect on this

that was not allowed what the smallest insect has or the vilest beast. No
heart with the pulsations of life, no brain with a sensation of feeling, no
body to ache or decay, but when an infant robbed of all that belongs to
mortals."

In a comparatively few cases we find that the individual
has the idea that he is possessed by evil spirits or that he is
transformed. On account of the awfulness of his supposed
crimes he has been turned into an animal, a dog or a cat, and
as a consequence of early delinquencies is destined to an un-
broken metempsychosis.

In regard to the genesis of the insane ideas a great variety
of opinions have been advanced by different authors. Heller 5
maintains that in the uncomplicated cases they are an attempt
on the part of the patient to interpret the abnormal feelings
that depend upon the disturbances in the complex of organic
sensations. As a result of these anomalies the patient develops
strange ideas, not only in regard to his own personality, physi-
cally as well as mentally, but also to his relationship with
the external world. From the former spring the ideas of self-
depreciation, accusation, and hypochondriasis, while from the
latter arise those ideas of reference that culminate in a well-
developed belief of persecution, etc. The same author believes
that the development of the insane ideas out of obsessions, fal-
lacious sense perceptions, and " audible thoughts" indicates
the existence of a complicating psychosis. According to
Ziehen, the hallucinations are met with in about one-tenth of
all the cases, and auditory forms, when they occur, generally
consist of elementary sounds localized in the head, chest, or
abdomen, or may resemble psychic hallucinations. Systema-
tization of the insane ideas is not at all infrequent, and is par-
ticularly noticeable at the height of the disease. Schott 6 has
affirmed that its presence does not by any means justify the

"Heller: Die Wahnideen der Melancholiker. Inaug. Diss., Marburg,
1898.

8 Schott : Beitrag zur Lehre von der Melancholie, Arch, f . Psych, u.
Nervenkrankh., Bd. xxxvi, H. 3.

SENILE PSYCHOSES

585

statement that the prognosis is unfavorable. In the cases
where the mental depression is the dominating feature the
facial expression is essentially characteristic. As a rule, the
skin over the forehead is wrinkled, owing to contraction of
the frontalis muscle. The wrinkles are horizontal, except just
between the two eyes, where frequently there are several short
perpendicular furrows. When the anxiety and apprehensive-
ness are not great, the corners of the mouth are usually de-
pressed, the lips tightly closed, the eyes often have a glassy
and vacant look. The attention of these patients varies some-
what with the degree of depression. In the milder cases it
is easily gained, but retained with difficulty, as the patient
constantly tends to revert to himself and his complaints. Asso-
ciative memory is not apt to be greatly impaired except in
so far as it is affected by the depression and insane ideas, to
which reference has already been made. Frequently the pa-
tients are well oriented for time and place, and, except in the
very severe forms, there is no marked disturbance in con-
sciousness. In a comparatively large number of the cases
the emotional disturbances play a very important part, and
chief among these is the state characterized by great anxiety
and apprehensiveness — the Angst of the Germans.

Although it is not improbable that cases of mental de-
pression with marked apprehensiveness and anxiety may de-
velop relatively early, it cannot be denied that the majority
are first noted after the prime of life has passed. The appre-
hensiveness may at first be definitely localized in the chest or
abdominal cavity or even more sharply limited to the precordial
region. The dependence of this symptom upon cardiac lesions
has already been referred to in the chapter on Anomalies of
Emotion. Unquestionably, in many cases the mental symp-
toms already referred to are complicated by the appearance
of periods of great anxiety and apprehensiveness. The pri-
mary sensation, as has been stated, may at first be localized,
but rapidly becomes more general, and not only intensifies
the depression and furnishes a new basis for the further de-
velopment of the insane ideas, but is also reflexly affected by

586 PSYCHIATRY

the presence of other symptoms. When the apprehensive-
ness is marked, the motor restlessness, as a rule, becomes very
great. Such patients pull at their clothes, scratch themselves,
bite their fingers, wander aimlessly about the wards, complain
of a great variety of indefinite fears, and act as if they were
under the shadow of some impending evil, concerning the na-
ture of which they have only a faint inkling. Frequently they
barely have time to give expression to one fear before this idea
seems to be forgotten and a new one takes its place in con-
sciousness. In some cases the apprehensiveness is associated
with hypochondriacal ideas, while in others those of self-abase-
ment, of persecution, and the other forms already mentioned
frequently make their appearance and exert a dominating in-
fluence on the patient. The history of the following case
shows clearly the genesis of some of the symptoms and is in
many respects characteristic:

Male, aged 52. Farmer.

Family History. — Father died of " cardiac dropsy." Mother died at
68 of heart trouble. No nervous or mental disease.

Personal History. — Ordinary diseases of childhood. Sunstroke at the
age of 32. Very severe attack. Unconscious for two and a half hours.
Convalescence slow. Typhoid fever three years ago. Very delirious
during the attack. Influenza last winter followed by heart trouble. The
patient has always been rather excitable and slightly impulsive. Other-
wise no anomalies of character. Steady worker. No history of alcohol or
narcotics. No venereal disease.

Present Illness. — Following the attack of grippe last winter the patient
began to brood a good deal over his ailments. For two or three months he
had periods of mental depression, occurring about once a week, which
gradually increased in frequency until they recurred every day. For a
month prior to admission to the hospital he had shown symptoms of motor
restlessness and would tear his clothes and hair, pray in a loud tone of
voice, sing, etc. The excitement was most marked during the afternoon
and night. The patient declared that he was ruptured, had spinal trouble,
that people were cutting holes in the back of his neck, that he had dropsy
and other bodily ills. At times he affirmed that he himself was to blame
for these injuries and would repeat for hours at a time, " Why did I do
that?" Since the attack began he has been unable to write. The day he
was admitted to the hospital he tried to sign a cheque for his wife but
could not do it. Although greatly excited during the last month he has
shown considerable appreciation of his mental condition and referred fre-
quently to the fact that he was going to the hospital. Just prior to admis-

SENILE PSYCHOSES 587

sion to the hospital he shot at his wife and then attempted to commit
suicide.

Physical Examination. — October 31. Patient lying in bed on his back.
On the approach of the examiner he glares at him in a wild way, but almost
immediately turns his eyes away. Well nourished, muscular development
good. No excess of fat. At times shows no tendency to change posture of
body in bed, retaining uncomfortable position for several minutes. Occa-
sionally he moves the bedclothes and looks under them as if he were seek-
ing for something, and then begins to pick at the skin over the abdomen
as if there were some paresthesia. At intervals of two or three minutes he
starts up as if he were actuated by sudden impulses. His expression at
this time is one of anxiety and apprehensiveness, and he almost imme-
diately lapses into his former slightly apathetic state. Noises made by
tapping on the bed or the tick of a watch held close to his ear seem to
make little if any impression upon him. Occasionally he looks in the direc-
tion of the person addressing him. The majority of his volitional reactions
do not seem to be the result of external stimulation, with the possible ex-
ception that he occasionally promptly shows some resentment on being
touched, but the repetition of this stimulation fails to induce similar results.
The sound of voices makes little if any impression. He does not attempt
to answer questions. At one time he smacked his lips as if he wanted to
drink, but when water was brought to him he made no attempt to help
himself. Occasionally he seems to be bothered by flies and makes an
attempt to catch them. When the mouth is forcibly opened by a spoon or a
tongue-depressor no gagging follows, but as soon as the spoon is with-
drawn the patient rapidly protrudes and retracts the tongue. These move-
ments are kept up for several seconds. The eyes show nothing abnormal
beyond injection of the corneal vessels and a very slight irregularity of the
left pupil.

Heart : Cardiac dulness begins at the third interspace, extends beyond
the nipple to P. M. I., which is located with the stethoscope in the fifth
interspace outside the nipple. The heart's action shows marked irregu-
larity, noticeable at the apex as well as in the radial pulse. Five or six
beats in rapid succession are followed by two or three slow ones separated
by long intervals. There is a systolic murmur at the apex. The second
sound is snapping in character. In the pulmonic area the first sound is
murmurish. The second sound is stronger. Lungs normal on auscultation
and percussion.

Reflexes: Knee-jerks exaggerated. Cremasteric reflexes present.
Neither McCarthy's reflexes nor the abdominal skin reflexes obtained.
Dermatographia is slow in appearing. No rigidity on passive movement.
No paralyses.

Four days after admission a slight improvement was noted. The
patient apprehended and answered some questions. At night he was very
much disturbed. He spent a good deal of his time praying that he might
die and go to Heaven. For the next ten days the patient was in a state
characterized by great apprehensiveness and anxiety. He moaned and
groaned a great deal of the time, and would run up and down the ward,

58S PSYCHIATRY

wringing his hands and crying " My God !" at the top of his voice. When
spoken to sharply he would reply intelligently, giving his age, name, and so
on, but almost immediately would begin to ramble again. Blood-pressure,
190 millimetres. One month after admission there was marked self-accusa-
tion. No psychomotor retardation, but a constant expression of hypochon-
driacal ideas. He began to show some slight anxiety about his family and
to take notice of the objects and things about him. Towards the end of
the second month there was considerable improvement. He appreciated his
condition — that he had been ill and that he was recovering — although the
hypochondriacal ideas were still marked.

The urine showed nothing abnormal. Indican, sulphates, phosphates,
and chlorides were practically normal. No albumin, no sugar.

In this and in similar cases the consciousness is much
more markedly affected than in the pure types of affective
melancholia, and not infrequently associative memory is also
considerably disturbed. This may, in a measure, be dependent
upon the fluctuations of the attention, which seem to become
more noticeable the greater the anxiety and apprehensiveness.
In both classes of cases, as may be inferred, there is great dan-
ger of the patient committing suicide, and where the emotional
disturbances are marked the attempt may be made to inflict
injury upon others. These patients should be under constant
observation and never left alone. As a rule, from the begin-
ning until the end of the disease insomnia is common, and even
when sleep is obtained it is apt to be restless and broken by
unpleasant and terrifying dreams. The appetite is poor, and
forced feeding must frequently be resorted to.

Gastro-intestinal disturbances and obstinate constipation
are common. The surface temperature is not infrequently
lowered, the extremities being cool and sometimes slightly
cyanotic. The pulse, as may be inferred, is frequently abnor-
mal and gives evidence of the presence of arterial changes.
The pressure is, as a rule, high. Cardiac lesions are common.
The skin is usually dry and shows evidence of nutritional
changes.

In addition to the physical symptoms already noted, in at
least one-half of the cases there is a marked increase in the
deep reflexes. In a comparatively few cases a diminution is
noted which often is associated with the appearance of sugar

SENILE PSYCHOSES 58q

in the urine. The vasomotor disturbances are frequently
marked. Dermatographia, as a rule, is easily obtained and
persists for a considerable length of time. Schott has estimated
that in at least 12 per cent, of the cases there is a marked
increase in the mechanical irritability of the muscles, particu-
larly at the period when there is considerable impairment in
the nutrition. The disturbances in sensation are largely psychic
in origin. The bodily weight falls and remains low. As a
rule, the rise in the curve is the first indication of improve-
ment.

Course and Prognosis. — The disease pursues a chronic
course, varying from a few weeks to two or more years. In
the milder cases the ups and downs are more marked than in
the severer forms, in which the mental state of the patient
frequently remains stationary for long periods of time. As
the bodily weight increases and the general physical condi-
tion improves, the mental symptoms gradually begin to dis-
appear. The systematization becomes less marked. The
patients express doubt as to the truth of the fixed ideas and
are willing to admit that their mental depression as well as
their feeling of insufficiency and the fixed ideas are the result
of physical ailments. Sometimes a period characterized by
irritability and varying degrees of motor restlessness inter-
venes, and associated with this there are marked fluctuations
in the emotional life. Naturally the longer the duration the
more unfavorable is the prognosis, but cases of complete re-
covery have been reported after the disease had lasted for four
or five years. As a rule, the tendency for the insane ideas to
become systematized is more marked in the cases which begin
at a very advanced period of life than in the earlier ones.

The prognosis in a large number of cases is favorable.
Kraepelin reports that 32 per cent, of his patients recovered,
while in 23 per cent, a marked improvement took place. Ac-
cording to Schott,7 there was a complete recovery in 35.2
per cent, of the cases which occurred in the fifth decade, and

TOp. cit.

59°

PSYCHIATRY

in 22.2 per cent, of those which came on during the sixth
decade. The prognosis becomes more unfavorable when there
is evidence of marked mental reduction ; for example, in cases
where the signs of mental depression and apprehensiveness or
anxiety give place to apathy and indifference. As has already
been said, the earlier the systematization of the insane ideas
the longer will be the duration of the case. In cases where
the physical state becomes rapidly worse, the refusal of food
marked, and the changes in circulation assume an ominous
character, death may follow from pure exhaustion. The oc-
currence of various disorders, such as Bright's disease, an en-
docarditis, or pneumonia, increases the gravity of the prognosis.
The disease is much more frequent in women than in men, the
proportion being as two to one. It is much more common in
the married than in the unmarried, and in at least one-half of
the cases there seems to be a predisposition to alienation, shown
either by the occurrence of mental disease in the parents or
in the brothers and sisters, or by the tendency shown by the
patient earlier in life to become the subject of " nervous break-
downs," etc. The tendency to recurrence is marked, being
present in at least 1 5 or 20 per cent, of the cases. When com-
plete recovery does not ensue the disease either progresses
until the symptoms of senile dementia become well marked or
the patient recovers sufficiently to be discharged from the insti-
tution, although a considerable degree of mental enfeeblement
remains.

The differential diagnosis is often difficult. Cases occur-
ring towards the end of the fourth or the beginning of the
fifth decade may very easily be mistaken for instances of manic-
depressive insanity, in which the psychomotor retardation is not
well marked and the insane ideas are not well developed. The
diagnosis can often be established after careful observation of
the development of the disease. The marked emotional indif-
ference characteristic of patients suffering from dementia prae-
cox, as a rule, serves to differentiate this disorder from the
involutional melancholias, as well as the disturbances in asso-
ciative thinking and the presence of obsessions and impulsive

SENILE PSYCHOSES em

acts. The depressed form of general paresis is, as a rule, char-
acterized by a considerable defect in associative memory and
a marked general mental impairment, as well as by the occur-
rence of physical symptoms.

Treatment. — When the disease is well developed, unques-
tionably the patient is better off in bed and under the constant
supervision of a well-trained nurse and not merely of an at-
tendant. He should be carefully isolated from all disturbing
influences, even the members of the family not having access
to him. At the beginning of the treatment it is always better
to restrict the diet to fluids — milk given regularly at intervals
of from two to three hours or raw eggs beaten up, either alone
or in milk; later, soups, toast, raw or stewed oysters may be
added. If there is any motor restlessness or any marked de-
gree of apprehensiveness or anxiety present, it may be neces-
sary to administer sedatives; trional, sulphonal, the bromides
may be given in small quantities, but not, however, until the
effect of the bath given in a tub at the bedside or, if the patient
does not stand this well, of warm packs, has been tried. As
the case progresses gentle massage may be given, either once
or twice a day. The manner in which the patient reacts to this
procedure should be carefully noted, as in some instances it
excites him so that sleep is interfered with. The effect of the
hydrotherapeutic measures is, as a rule, satisfactory. If the
bathing and massage are well borne, the patient may be given
cold sprays, but as this procedure is apt to be very stimu-
lating it is best employed only in the morning hours. The
mental effect of a good nurse cannot be overestimated, and
her intelligence should be of such a character as to be capable
of arousing and stimulating the patient's attention. The care-
ful selection and reading out loud of good literature by the
nurse, especially such as serves to amuse, is useful during the
period of convalescence.

The period of convalescence is apt to be somewhat pro-
tracted and the patient needs to be carefully guarded against
the danger of relapse. Not infrequently a change of air, a long
voyage, or a quiet life in the country, if possible under medical

592

PSYCHIATRY

supervision and the care of a trained nurse, is indicated. No
form of treatment can properly be condemned as severely as
that frequently advised by many practitioners, who send their
patients during the onset or height of the disease on long jour-
neys or prescribe forced occupation as the best means of in-
suring recovery. This form of treatment, if it does not end
fatally, owing to suicide of the patient or some intercurrent
complication, is sure to add greatly to the duration of the
disease, even although the proper therapeutic measures may be
finally instituted.

In addition to the symptoms of agitated melancholia char-
acterized by motor restlessness, great anxiety, and appre-
hensiveness, there is a group of other symptoms deserving
special mention which occasionally occur in senile cases. The
majority of these, however, probably represent either the early
stages of alienation developing on an arteriosclerotic basis or
the prodromal symptoms of senile dementia. This is particu-
larly true in regard to the cases in which the hallucinations
become marked and the mania resembles that of the excited
stage of dementia paralytica. There is the same expansive-
ness, mental exaltation, tendency to engage in new occupa-
tions, to form new plans, to act without counting the cost.
Wernicke has described a group of cases which he thinks occur
quite frequently at this period and bear a marked resemblance
to Korsakow's symptom-complex. This group of cases was
described by the older writers as presbyophrenia (Arndt).
The power of the patient to comprehend the questions ad-
dressed to him, the fact that it is possible to attract the atten-
tion, and the evident response to external stimulation, as well
as the ultimate recovery, are supposed by some to differentiate
them from those terminating in senile dementia. In general,
these cases bear a marked resemblance to those of mental de-
pression with anxiety and apprehensiveness which have been
described. There is marked allopsychic disorientation with
a great tendency to confabulate, and, as a rule, the retro-
active amnesia is present. The emotional changes may be
characterized as either an euphoria or as a condition in which

SENILE PSYCHOSES 593

the patient is exceedingly irritable and given to outbursts of
anger. The disturbances in the power of apprehension, ac-
cording to Wernicke, do not depend entirely upon the allo-
psychic disorientation. These cases are apt to run an acute
course, lasting from four to eight weeks, although in some
instances they are more chronic. In a large number the
prognosis for recovery is favorable, but some end in senile
dementia.

In addition to the cases already mentioned, Kraepelin has
described certain pre-senile paranoiic states of suspiciousness in
which the judgment is markedly impaired (pre-senile Beein-
trachtigungswahn), the onset of the disease being slow and
insidious and characterized by the appearance of hypochon-
driacal and persecutory ideas. The latter are particularly
directed against the members of the family and have a sex-
ual coloring. Associated with these insane ideas there are
various nervous pains, spasms, etc. In a few instances the
hallucinations play an important part. The connected think-
ing, apart from the appearance of the insane ideas, is not
greatly disturbed. The moods are those of depression and
apprehension, or sometimes irritability and excitement. The
volitional acts are at times replaced by marked impulsivity,
and the insane ideas generally exert a dominating force. It
is not improbable that some of these cases represent examples
of dementia prsecox developing late in life. The group is ill-
defined and cannot be described as in any sense containing cases
that are specifically characteristic of this period. In some in-
stances the symptoms are characterized by a slow progression
ending in the typical senile dementia.

(2) Senile Dementia.8 — A sharp line of distinction be-
tween this and the preceding group of cases can not be drawn.
As has already been said, cases of involutional melancholia may
terminate in. dementia in either one of the following ways :

8 Pickett, William. Senile Dementia ; a Clinical Study of Two Hun-
dred Cases, with particular Regard to Types of the Disease. The Journal
of Nervous and Mental Disease, No. 2, 1904.

38

594

PSYCHIATRY

In the first place, the dementing process may follow the attack
of mental depression without any break in the continuity of
the morbid process; a condition that is particularly apt to be
met with when the disease runs a protracted course and where
the systematization of the insane ideas begins early and re-
mains more or less stable. Again, patients may pass through

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

1 1 1 1 1 1

34

32
30
28
26
24

Lxj

12
10
8
6
4"
2

..1 . 1

H

V i

h

1 It

20

■ ;l V

; I" .:

16
14
'12
10
8

1 1

:{■:'{

i. ):1 f ]

••■

■'■•

\ 1

■\ i

— I 1 .]

1

'. •■•■

.

*

.

—

L1TJ.;L.L,

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|60|65I70J75'80!85:90! |60 i 65 i70|76l80t85 190| |65|70|76I80|85| |60|65|70|75l80|85l

Simple confusion.il,
143 cases.

Excited (maniacal),
17 cases.

Depressed (melan-
cholic), 14 cases.

Paranoioid,
36 cases.

Chart to show the ages of patients belonging to the several types of senile dementia.
The figures at the bottom represent the ages by hemidecades ; those at the side, the number
of cases (Pickett).

one period of depression, apparently recover, then after an
interval of time there is a second or third attack, during which
the mental reduction so characteristic of the group under dis-
cussion makes its appearance. Many of the excited forms
merely represent the precursory symptoms of this stage.
Again, dementia may intervene in a second type of cases that
cannot be distinguished clinically from those described under
the arteriosclerotic forms. To avoid repetition, the initial
symptoms of the dementing cases will not be referred to again
in detail, as they do not justify the attempt to establish more
definite distinctions. The existence of dementia is to be sus-

SENILE PSYCHOSES 595

pected in those cases where the symptoms which have been
described persist and where there are evidences of permanent
mental impairment, often distinguishable by the greater lower-
ing of the faculty of attention and the consequent defects in
associative memory. Such patients are able to retain few, if
any, recent impressions, and at the end of even a few seconds
test words or phrases can not be recalled. As might be ex-
pected, orientation in time and place frequently suffers greatly,
and some patients cannot tell the hour of the day and may
even be unable to remember whether it is early morning or
late in the evening. In spite of this marked inability to recol-
lect recent events, those which have occurred in the long past
are frequently well remembered, so that circumstances con-
nected with youth may be related with considerable accuracy
and with some degree of detail.

The power not only of picking up but also of elaborating
new impressions becomes less and less. Hallucinations, par-
ticularly the auditory forms, as a rule, become somewhat more
frequent, and the patients complain of hearing strange voices
which frequently have a threatening and unpleasant character.
The stability of the hallucinations is not, as a rule, constant,
since they frequently change with great rapidity.

In addition to the auditory and visual forms, we often
meet with marked disturbances in all the organic sensations,
giving rise to new or intensifying the already existing insane
ideas of suspicion and persecution. The patients lose faith in
all those with whom they are brought into contact — nurses and
physicians alike are accused of attempts to poison them, of
being the instruments of unseen spirits, of the devil, and
strange and supernatural powers or influences are attributed
to them.

The emotional instability is frequently very marked; the
patients often become excessively irritable and dislike intensely
to be disturbed in any way. A simple question as to how they
feel may give rise to an extraordinary outburst of temper, when
they will struggle hard to get away from the examiner. When
left alone they may sit still for hours and only occasionally

596 PSYCHIATRY

seem to evince any interest in what is going on about them.
At times the facial expression shows apprehensiveness, anxiety,
or even marked depression, but, as a rule, in the terminal
stages is characterized by a considerable degree of apathy.
In other cases, particularly in those which, clinically as well
as histologically, bear a resemblance to dementia paralytica,
there is some exhilaration and exaltation present. The pa-
tients may converse freely, may be markedly egocentric and
indulge in excessive confabulation — giving accounts of ex-
traordinary journeys, of remarkable deeds they have per-
formed, boasting of their superhuman powers and of their
great mental attainments. In these cases the speech compul-
sion may be marked and the patients give expression to their
thoughts in a way that may suggest an inner flight of ideas.
As a rule, they are far less amenable to external stimuli than
are individuals suffering from pure mania. In the later stages
the compulsion and flight of ideas disappear and the patients
may remain silent for long periods of time, only occasionally
giving expression to a few ill-defined and senseless syllables.
The articulation, as a rule, is much less impaired than in cases
of dementia paralytica. In addition to the symptoms already
referred to, there is marked impulsivity, which not infrequently
shows itself in various ways which are of great forensic impor-
tance— theft, arson, attempts at murder, exhibitionism, or
assaults upon children. The last two, in nearly all instances,
are the results of impulses of a sexual nature.9

The symptoms already referred to not infrequently show
a marked tendency towards exacerbations with remissions and
occasional transitory delirious states. During such periods the
hallucinations, insane ideas, as well as the motor restlessness and
disturbances of speech, become much more marked. As the dis-
ease progresses the exacerbations are less acute and the men-
tal reduction becomes more pronounced until the life of the
individual amounts to an almost purely vegetative existence.

* Hoche, A. : Dementia Senilis. Handbuch der gerichtlichen Psy-
chiatric Hirschwald, Berlin, 1901.

SENILE PSYCHOSES 597

No attempt is made to eat, and such patients seldom give ex-
pression to any feeling. In point of fact, they seem to be
reduced to a condition in which there is a great deficiency in
the appreciation of all organic sensations.

The complications that may occur, as would be expected,
are very varied and not infrequent — attacks of vertigo, stu-
porous states, epileptiform attacks, symptoms pointing to focal
lesions, paralyses, etc.

Death usually intervenes after some cerebral complication,
such as hemorrhage; or these patients are particularly apt to
develop pneumonia, exacerbations of an existing nephritis,
gastro-intestinal disturbances, diarrhoeas, and not infrequently,
unless the greatest care is taken, a general infection, the result
of a bed-sore.

The differential diagnosis in the typical cases is not diffi-
cult. But in some of the atypical forms there may be inequality
of the pupils, impairment of the light reflex with disturbances
of speech, and euphoria, so that the clinical differentiation from
cases of dementia paralytica is exceedingly difficult and, in
fact, frequently impossible. Cases of manic-depressive insan-
ity which develop late in life may give rise to considerable
difficulty. Frequently it is necessary to wait until the termina-
tion of the attack before a positive opinion may be ventured.
As a rule, the dementing process seldom makes its appearance
before the middle of the seventh decade. If the history of the
case shows that the patient has not been subject to any form
of mental aberration prior to this period of life, the occurrence
of the symptoms of senile dementia may be more easily recog-
nized than in persons who have suffered from other psychoses,
particularly when little or nothing is known in regard to the
factors of immediate etiological importance. The general con-
sensus of opinion among clinicians is that the hereditary factor
is not one. of great importance. The baneful influences due
to the stress and strain of social conditions, and such factors in
the environment of the patient as tend to prevent the enjoy-
ment of old age with ease and dignity, may be considered as
provocative.

598 PSYCHIATRY

The pathological changes in senile dementia vary in inten-
sity and extent from those described as occurring during the
period of old age. There is a general rarefaction of the tissues
with marked chronic cell changes and some increase in the glia.
In typical cases the vascular changes, although present, are
relatively so trivial that they can not be the sole cause of the
other lesions in the cortex.

It is not possible as yet to refer the variations in individual
clinical pictures to fundamental differences in structural lesions.
Meyer 10 has described changes occurring in the brain in a
number of cases, particularly in the end stages of depressive
disorders, near or after the climacteric period. These lesions
he attributes to a central neuritis, using the term as an equiva-
lent of parenchymatous neuritis mainly of central distribution.
The symptoms, as a rule, are vague, consisting chiefly in diffi-
culty in locomotion and in the coordination of movements,
jactitation of the limbs, febrile disturbances, attacks of diar-
rhoea, followed by a terminal period in which the mental state
is one of apprehensiveness, delirium, or stupor.

The forensic importance of these cases is considerable,
a fact that may be referred in part to the amnesias, the occur-
rence of insane ideas, to the occasional impulsivity of the
patients, and the marked emotional anomalies.

The treatment is purely symptomatic. As a rule, patients
are better off in an institution where they can have the benefit
of careful medical supervision, trained nursing, hydrotherapy,
massage, etc. Such persons are particularly prone to show
great animosity and to become much more intractable when
surrounded by the members of their own family.

10 Meyer, Adolf : On Parenchymatous Systemic Degenerations. Brain,
vol. xxiv (1901), p. 47.

INDEX

Abulia, 123, 454; in hysteria, 495,
498, 503; in neurasthenia, 516,
533-

Acarophobia, 520.

Acathisia, 526.

Acute alcoholic hallucinosis, 300;
Pathogenesis of, 303.

Acute confusional insanity, 266.

Acute delirium, 261 ; Physical
symptoms of, 263; Termination
of, 264; Treatment of, 265.

Age as a cause of insanity, 196.

Agoraphobia, 526, 528.

Akinesia algera, 520, 526; in manic-
depressive insanity, 351 ; in senile
psychoses, 579.

Akoasmata, 59, 63, 293.

Alcohol, 17, 62, 91, 215, 240, 542,
557-

Alcohol, Abnormal psychic states
due to, 10, 13, 304; Action of,
upon psychic activities, 287 ; Ef-
fect of, upon muscles, 286.

Alcohol, Intolerance for, 287; in
arteriosclerosis, 288, 552; in epi-
lepsy, 287; in hysteria, 287; in
neurasthenia, 287 ; in paresis, 287,
427; in dementia praecox, 287,
390 ; following trauma, 287 ; in
syphilitic psychoses, 561.

Alcoholic humor, 305.

Alcoholic intoxication, Unusual
forms of, 289.

Alcoholics, Psychical disturbances
in, 62.

Alcoholism, 37, 71, 129, 135, 186, 188,
204, 219, 285, 334, 363, 453, 455,
487, 488, 507, 548, 549; Compli-
cations during, 308; Emotional
anomalies in, 290; Etiology of,
309; in epilepsy, 486; in paresis,
418, 424, 426, 444; Pathological
anatomy of, 312; Psychomotor
excitability in, 93 ; Treatment of,

309-
Alcoholism, Chronic, 24, 274, 457 ;
Differential diagnosis from Amen-
tia, 274; Paranoiic and dement-
ing states developing during,

304-
Algolagnia, 108.

Amaurotic family idiocy, 245.

Amentia (Meynert), 188, 205, 209,
216, 227, 256, 263, 266, 363, 407,
549, 560, 565; Catatonic symp-
toms in, 408, 409; Course of,
269; Differential diagnosis of,
274; Disorientation in, 87, 268,
407; Dissociation in, 267; Eti-
ology of, 273; Fear in, 267;
Forms of, 269; Incidence of, 270,
273; Pathology of, 275; Physi-
cal symptoms of, 269; Prog-
nosis in, 270; Termination of,
270; Treatment of, 274.

Amnesia, 82, 308, 485; in alcohol-
ism, 290; in epilepsy, 475, 480;
in hysteria, 495, 497, 498, 500, 503 ;
in neurasthenic states, 521 ; in
paresis, 420; in post-epileptic
mental disturbances, 480.

Amyotrophic lateral sclerosis, 546.

Anaemias, 130, 208, 298, 487, 488;
Apathy in, 209; Exaltation in,
209; Irritability in, 208; Psycho-
motor retardation in, 209.

Anaesthesias, in alcoholic paranoiic
states, 305; in hysteria, 495, 496,
503, 511 ; in Korsakow's syn-
drome, 278.

Analgesias in paresis, 423.

Anarchasma, 524.

Anencephalic monsters, 231.

Angst, 585.

Antikineses, 89.

Antiklises, 89.

Anxiety, 109, 117, 123, 138, 269;
Blood-pressure in states of, 118;
Classification of states of, 118;
Neural disturbances in states of,
117; in acute alcoholic halluci-
nosis, 300, 301 ; in delirium acu-
tum, 262 ; in delirium tremens,
295 ; in epilepsy, 475, 476, 477, 479.
480; in hysteria, 507, 508; in
Korsakow's syndrome, 280; in
manic-depressive insanity, 351,
354. 355; in morphinism, 317; in
myxoedematous alienation, 329 ;
in paresis, 425, 443 ; in senile psy-
choses, 369, 578, 585, 588, 500, 591,
592, 596.

599

6oo

INDEX

Anxiety of cortical origin as dis-
tinguished from praecordial anx-
iety, 118.

Anxiety psychoses, 228, 585.

Apathy, 131, 138, 238; associated
with brain abscess, 548; asso-
ciated with brain tumors, 549;
Disorientation in, 87; following
apoplexy, 546; in anaemia, 209;
in delirious states, 117; in de-
mentia paranoides, 308; in de-
mentia praecox, 378, 379, 380, 381,
386, 387, 388, 392, 395, 406; in
epilepsy, 480; in Huntington's
chorea, 223; in morphinism, 318;
in myxedematous alienation, 327 ;
in paresis, 414, 425, 445. 448, 455,
457; in post-epileptic mental dis-
turbances, 480; in senile psy-
choses, 590.

Aphasia, 204, 308, 559; in arterio-
sclerotic psychoses, 552 ; in pare-
sis, 421, 449, 452, 456; Amnesic,
in migraine, 221.

Apoplexy, 129; Mental anomalies
associated with, 546.

Apoplectiform attacks, 264, 451,
456; in syphilitic psychoses, 561.

Apperception in paranoia, 567.

Apprehensiveness, 12, 123, 138, 216,

266, 483, 484, 541 ; and praecor-
dial oppression, 71 ; in amentia,

267, 269; in delirium acutum,
262 ; in delirium tremens, 291 ; in
epilepsy, 456; in Graves' dis-
ease, 333 ; in Korsakow's syn-
drome, 280; in manic-depressive
insanity, 351 ; in melancholia,
523; in morphinism, 317; in neu-
rasthenia, 516; in paresis, 425,
443» 445 ; m psychasthenic states,
533, 536 ; in senile psychoses, 578,
579, 585, 586, 588, 590, 591, 592,
593, 596.

Aprosexia, 51, 497.

Argyll-Robertson pupil in paresis,
250, 409, 433, 458.

Arithmomania, 525.

Arteriosclerosis, 23, 204, 216, 306,
308, 547, 550.

Arteriosclerotic atrophy, 24.

Arteriosclerotic changes in paresis,
469.

Arteriosclerotic psychoses, 550; Di-
agnosis of, 553 ; Grouping of, 556;
Incidence of, 551 ; Pathological
changes in, 555; Treatment of,
558..

Association, see also Memory, Asso-
ciative.

Association, Disturbances of, 73;
in acute alcoholic hallucinosis,
304; in dementia praecox, 381,
388; in hysteria, 504; in manic-
depressive insanity, 342, 343, 351,
354, 355 ; in myxcedematous
alienation, 328; in paresis, 420,
422.

Associationism, Doctrine of, 73.

Associative activities of the brain
and reflex and volitional acts, 52.

Associative thinking, 102, 103, 105.

Astasia abasia, 498.

Asymbolism in epilepsy, 479.

Ataxia in bromism, 323 ; in paresis,
440.

Atrophy, Cortical, in senescence,
577-

Attention, 7, 30, 48, 53, 57, 67, 76,
77, 115, 294, 561; Disorders of,
48; in alcoholism, 51, 286; in
amentia, 267; in chorea, 222; in
cretinism, 331 ; in delirium tre-
mens, 294; in fatigue, 199; in
flight of ideas, 76; in Graves'
disease, 333 ; in hepatic disease,
217; in hypomania, 357; in hys-
teria, 495, 496, 497, 500, 503; in
idiocy, 232, 234, 239; in manic-
depressive insanity, 342, 343 ; in
myxcedematous alienation, 327 ;
in neurasthenic states, 519, 521 ;
in paranoia, 568; in paresis, 420,
443, 448, 454; in pseudo-paresis,
214; in senile psychoses, 585,
588, 595; in syphilitic psychoses,
561; in volitional acts, 50; Te-
nacity of, 50; Tetanization of,
30, 102, 116, 343; Virgility of, 50.

Audible thinking, 60, 61, 584.

Auditory hallucinations, 57, 60, 62,
64, 65, 66; in acute alcoholic
hallucinosis, 300, 303, 304; in
acute delirium, 263 ; in cocain-
ism, 322, 323 ; in delirium tre-
mens, 292, 293 ; in dementia prae-
cox, 397 ; in epilepsy, 476, 478 ;
in fever deliria, 258; in Graves'
disease, 334; in hepatic disease,
217; in hysteria, 496, 507; in
Korsakow's syndrome, 279; in
meningitis, 547; in morphinism,
318, 320; in paraldehyde intoxi-
cation, 316; in paranoia, 571; in
paresis, 439, 443, 447, 452 ; in psy-
chasthenic states, 531 ; in senile
psychoses, 584, 595.
Aufmerksamkeit, 102.
Aurae, in epilepsy, 475, 476, 480;
Visual, in epileptic migraine, 221.

INDEX

601

Autointoxication, 23, no, 212, 215,
220, 227, 254, 260, 276, 315, 411,
537, 545-

Automatism, 70, 90, 96, 139; in .de-
mentia praecox, 368, 389, 396, 397,
401 ; in epilepsy, 475, 480, 482 ;
in hysteria, 499.

Baillarger's division of hallucina-
tions, 59.

Basedow's disease, Mental disor-
ders associated with, 333.

Bekanntheitsgefuhl, 83.

Bell's disease, 261.

Bile-ducts, Mental disturbances
after operations upon the, 218.

Blood and lymph channels of the
central nervous system, 21.

Blood, in delirium tremens, 296, 299 ;
in manic-depressive insanity, 346.

Blood-pressure, in anxiety, 118; in
delirium tremens, 296; in de-
mentia praecox, 402; in depres-
sion, 116; in emotional storms,
118; in manic-depressive insan-
ity, 345, 3SI« 371 • in senile psy-
choses, 588; Intraocular, condi-
tioning visual hallucinations, 64;
Relation of, to mental states, 216.

Brain abscess, Psychoses associated
with, 548.

Brain tumors, Psychoses associated
with, 548.

Bridgman, Laura, Case of, 28.

Bromism, 323.

Bulimia in manic-depressive insan-
ity, 349-

Caffein, Abnormal psychic states
due to, 10.

Cardiac and vascular disease as
causes of insanity, 215.

Cardiac and vascular disturbances
in non-myxoedematous infantil-
ism, 243.

Catalepsy, 411.

Cataleptic phenomena in post-epi-
leptic mental disturbances, 480.

Cataleptic state, 99, 385, 401.

Catatonia, 204, 373, 401, 404, 411,
453 ; Orientation in, 87.

Catatonic, excitement, 250, 394, 485 ;
form of dementia praecox, 391 ;
rigidity in paresis, 409, 430;
states, 24, 98 ; stupor, 392 ; symp-
tom-complex, 13, 87 ; symptoms
in psychoses other than dementia
praecox, 409.

Cerea flexibilitas in catatonic form
of dementia praecox, 392, 393, 408.

Cerebrasthenia, 518.

Cerebropathia psychica toxaemica,
277.

Cerebrospinal fluid, Examination
of, 143.

Chloroform, Psychoses following
the administration of, 315.

Chondrodystrophia foetalis, 244.

Chorea, 269, 509 ; and epilepsy, 223 ;
gravidarum, 223; Huntington's,
95, 223, 224; insaniens, 222, 223.

Christian Science, 30, 398.

Circular Insanity, 336, 353, 360.

Circumstantiality, 140.

Clairvoyance, 398.

Claustrophobia, 528.

Cocainism, 322.

Coenaesthesia, 71, 106.

Ccenaesthetic euphoria in paresis,
423-

Collapse delirium, 261.

Collectionism in arteriosclerotic
psychoses, 554.

Coma, 204, 439 ; hepaticum, 218 ; in
lead-poisoning, 325 ; in morphin-
ism, 320; in myxcedematous
alienation, 329; vigil, 259.

Combined psychoses, 228.

Composite psychoses, 229.

Conduct, Anomalies of, 119, 196.

Confabulation, 137, 141, 277, 278,
294, 302, 596.

Confusion, 24, 105, 271, $72, 536,
560 ; after operations on the bile-
ducts, 218; in bromism, 323; in
chorea, 222 ; in dementia praecox,
391 ; in Korsakow's syndrome,
277, 279, 282 ; in manic-depres-
sive insanity, 351.

Confusional insanity, 266.

Confusional states, 23, 209, 210, 227,
260, 266, 273, 407.

Consciousness, 12, 30, 31, 53, 55, 56,
57, 67, 76, 78, 99, 100, 101, 104,
no, 113, us, 135, 142, 266, 522;
Allopsychic, 69, 70, 142; Auto-
psychic, 69, 70, 142, 426; in
alcoholism, 289, 292, 295, 300;
in amentia, 267, 268 ; in de-
lirium acutum, 263 ; in dementia
praecox, 382; in epilepsy, 476, 477,
478, 479, 480, 485, 512; in fever
deliria, 258, 259; in hysteria, 503,
504, 506, 511; in hysterical de-
lirious states, 508; in Korsakow's
syndrome, 280, 282 ; in manic-
depressive insanity, 343 ; in men-
ingitis, 547; in paranoia, 566,
567; in paresis, 451, 452, 456; in
psychasthenic states, 532; in

602

INDEX

senile psychoses, 585, 588; So-
matopyschic, 69, 70, 94, 142,
351 ; Transitory disturbances of,

485.

Convulsions, 129; in morphinism,
320; in myxedematous aliena-
tion, 329.

Coprolalia, 96.

Craniostenosis, 244.

Cretinism, 329; Differential diag-
nosis of, 333; Grouping of, 332;
Mental symptoms of, 331 ; Path-
ology of, 332; Physical symp-
toms of, 330; Treatment of, 333.

Crises angoissantes, 104.

" Critical age," 61.

Cyclothemia, 369.

Cytodiagnosis in paresis, 455.

Daily life and paresis, 419.

Defect psychoses, see also Idiocy
and Imbecility.

Defect psychoses, 185, 227, 229;
Diagnosis in the acquired, 250;
Pathology of, 244; Treatment
of, 251.

Defence movements, 97.

Degeneracy, Signs of, 185; Stig-
mata of, in paresis, 416.

Degenerates, 107, 125, 416; Ferri's
grouping of, 124.

Degenerative psychoses, 517.

Delire, ecmnesique, 503, 507; du
contact, 527 ; du doute, 531 ; du
scruple, 536; onirique, 105.

Delira, Diagnosis in, 259; Fever,
23, 210, 216, 227, 254; Grouping
of, 255, 258; in meningitis, 547;
Prognosis in, 259; Systematized,
105 ; Treatment of, 259.

Delirious mania, 266.

Delirious states, 196, 206, 209, 227,
254, 280, 290, 407, 449, 559, 596;
in arteriosclerotic psychoses, 554 ;
in chorea, 222; in chloroform
psychoses, 315; in cocainism,
322; in heart disease, 215; in
hysteria, 507; in morphinism,
320; in tobacco intoxication, 324;
Apathy in, 117; disorientation
in, 87.

Delirium, 67, 84, 205, 213, 427, 428,
438, 439, 440.

Delirium acutum, 24, 216, 261, 266,
267, 268, 269, 457, 483; Physical
symptoms of, 263 ; Termination
of, 264 ; Treatment of, 265.

Delirium, Collapse, 209, 227, 256,
261 ; grave, 261 ; in cases of
brain tumor, 549; in lead-poi-

soning, 325; in neurasthenia, 516;
Initial, 255 ; of negation, 36.

Delirium, Subacute states of, and
mental confusion, 266.

Delirium tremens, 24, 58, 265, 282,
291, 565 ; Abortive form of,
297; Adynamic form of, 297;
Course of, 296 ; Disorientation in,
87; Hallucinations in, 292; Inci-
dence of, 299; Pathogenesis of,
298; Physical symptoms of, 296;
Speech disturbances in, 294;
Tremor in, 295, 297.

Delirium, Uraemic, 220.

Delusions, 12, 61, 95, 100, no, 118,
119, 132, 138, 258, 264, 266; after
operation on the bile-ducts, 218;
in acute alcoholic hallucinosis,
301, 304; in alcoholic paranoiic
states, 304, 305 ; in delirium tre-
mens, 297; in dementia para-
noides, 397; in dementia praecox,

377, 388, 392, 394 ; in epilepsy, 475,
476, 479; in Korsakow's syn-
drome, 278, 279; in morphinism,
318; in paranoia, 570; in paresis,
414, 446, 447 ; in senile psychoses,
580; systematized, in involutional
melancholia, 369.

Demence Precoce des jeunes gens,

372.
Dementia, 55, 57, 84, 92, 93, 116,

228, 372, 373, 449, 559, 562 ; after
apoplexy, 546, 547, 554 ; Epileptic,
474, 482, 492; in multiple sclero-
sis, 545 ; in myxoedematous alien-
ation, 328; in paresis, 438, 443,
444, 446, 449; Luetic, 561.

Dementia paralytica, see also Pare-
sis.

Dementia paralytica, 17, 18, 20, 22,
24, 32, 85, 196, 202, 204, 216, 226,

229, 250, 266, 274, 282, 306, 374,

378, 413, 483, 509, 518, 539. 54i,
545- 548, 562, 576, 578, 592, 596,
597; group, 13.

Dementia paranoides, 397; Apathy
in, 398 ; Delusions in, 397 ; De-
pression in, 398; Dissociation in,
398; Disturbances of volition in,
308 ; Hallucinations in, 397 ;
ideas of persecution in, 397 ; Im-
pulsivity in, 399; Insane ideas in,
397. 398; Megalomania in, 397,
308; Stereotypies in, 399.

Dementia, Post-traumatic, 201.

Dementia praecox, 14, 32, 75, 121,
T35» 137, 187, 193, 206, 216, 221,
227, 229, 250, 256, 260, 266, 271,
274, 328, 334. 337, 338, 357, 360,

INDEX

603

368, 369, 468, 478, 480, 485. 509,
5io, 518, 539, 549, 565, 590, 593;
Apathy in, 378, 379, 380, 381, 386,
387, 406 ; Association in, 381 ;
Automatism in, 368, 389, 396, 397,
400 ; Blood-pressure in, 402 ; Com-
plexion in, 401 ; Consciousness
in, 382; Cyanosis in, 216, 402;
Delusions in, 377; Depression in,
379, 396, 402, 406; Differential
diagnosis of, 405 ; Dissociation
in, 380, 385, 392, 406; Emotional
anomalies in, 376, 378, 379, 387,
400 ; Emotional storms in, 377,
379. 388, 395 ; Environment in,
404 ; Etiology of, 404 ; Gait in,
383 ; Grouping of, 374 ; Halluci-
nations in, 377, 381 ; Heredity in,
404 ; Hypochondriasis in, 378 ;
Ideas of persecution in, 397; Il-
lusions in, 381 ; Imperative con-
ceptions in, 379; Impulsivity in,

369, 377, 392, 395, 397, 400, 406,
408 ; Incidence of, 375 ; Inhibi-
tion in, 386, 400; Insane ideas in,
378, 381 ; Intellectual anomalies
in, 376, 380; Intrapsychic inco-
ordination in, 114; Irrelevancy
in, 368, 383, 510; Lucid intervals
in, 400; Mannerisms in, 369, 386,
396, 397, 400, 404, 405, 5io; Me-
galomania in, 378; Memory in,
378 ; Mirror writing in, 383 ;
Motor anomalies in, 369, 386;
Muscular irritability in, 402, 411;
Negativism in, 381, 386, 389, 396,
400, 405, 407 ; Obsessions in, 2,77 ',
Orientation in, 381 ; Paresthesias
in, 377, 382; Pathology of, 409;
Physical symptoms of, 401 ; Pro-
dromal symptoms of, 376;
Pseudo-hallucinations in, 378;
Psychic hallucinations in, 378;
Psychical reaction in, 380; Psy-
cho-anaesthesias in, 277 ', Pulse in,
402 ; Pupils in, 402 ; Reflexes in,
402 ; Reticence in, 381 ; Saliva-
tion in, 402 ; Sensations in, 377,
378, 381 ; Sense of deficiency in,
381 ; Speech in, 383, 385 ; Stereo-
typies in, 382, 385, 386, 389, 392,
395, 396, 400, 404, 405, 407 ; Stupor
in, 386, 396, 401 ; Suspiciousness
in, 379, 381; Sweating in, 402;
Temperature in, 402 ; Terminal
stage of, 400 ; Tics in, 95 ; Train
of thought in, 381 ; Treatment of,
412; Tremor in, 402; Tubercu-
losis in, 210; Vasomotor dis-
turbances in, 216, 402 ; Verbigera-

tion in, 369, 385, 396, 397, 405;
Weight in, 404; Writing in, 383.

Dementia praecox, Catatonic form
of, 391 ; Apathy in, 392, 395 ;
Cerea flexibilitas in, 392, 393, 408 ;
Confusion in, 391 ; Course of,
396; Delusions in, 392, 394; De-
pression in, 391, 392, 394, 395,
510; Dissociation in, 392; Ex-
citement in, 391, 394, 510; Facial
expression in, 393; Hallucina-
tions in, 394; Hypochondriasis
in, 392 ; Impulsivity in, 392, 395 ;
Inhibition in, 394; Memory in,
394 ; Motor disturbances in, 391 ;
Muscular rigidity in, 393 ; Mutism
in, 391; Negativism in, 391, 510;
Respiration in, 394; Sensory dis-
turbances in, 395 ; Speech in,
395 ; Stupor in, 391, 392, 394, 395.

Dementia praecox, Hebephrenic
form of, 386; Apathy in, 388;
Association in, 388; Delusions
in, 388 ; Depression in, 386, 388 ;
Emotional storms in, 388; Ethi-
cal defects in, 390; Facial ex-
pression in, 388; Hallucinations
in, 386, 388; Illusions in, 386; In-
somnia in, 388; Irrelevancy in,
389, 390; Irritability in, 387;
Memory in, 388, 389; Onset of,
387 ; Orientation in, 389, 390 ;
Paresthesias in, 388; Sensations
in, 388 ; Speech compulsion in,
388 ; Suspiciousness in, 388 ;
Volitional disturbances in, 388.

Dementia praecox, Paranoiic form
of, 396; Hallucinations in, 396;
Hypochondriasis in, 397 ; Im-
pulsivity in, 397 : Insane ideas in,
396, 397; Speech in, 397.

Dementia praecox, Simple dement-
ing form of, 390.

Dementia praecox complicated by
syphilitic infection, 229.

Dementia praecox group, 372.

Dementia, Senile, 457, 518, 556, 578,
592, 593 ; Differential diagnosis in,
597 ; Forensic importance of,
598; Pathological changes in,
598; Treatment of, 598.

Dementia simplex, 372, 374, 386.

Dementing and paranoiic states due
to alcohol, 304.

Dementing processes, 353.

Demcnza primitiva, 372, 374.

Demoniac possession, 30.

Depression, 44, 55, 72, 76, 08, 109.
112, 116, 119, 123, 130, 132, 138,
140, 141, 193- 195, 205, 210, 213,

604

INDEX

215, 216, 221, 228, 308, 323, 353,
359. 363, 364, 365» 369, 379, 402,
455 ; after operation on the bile-
ducts, 218; associated with brain
abscess, 548; associated with
gout, 212 ; in alcoholic paranoiic
states, 306; in arteriosclerotic
psychoses, 553 ; in chorea, 222 ; in
delirium tremens, 291 ; in demen-
tia paranoides, 398; in dementia
praecox, 379, 386, 388, 391, 392,
394, 395, 396, 402, 406, 510; in
epilepsy, 474, 475, 477, 489; in
Graves' disease, 333, 334, 335;
in Huntington's chorea, 223 ;
in hysteria, 507, 508, 514; in
manic-depressive insanity, 350,
351, 354, 368, 511; in multiple
sclerosis, 545 ; in myxedematous
alienation, 328, 329; in neuras-
thenia, 516, 522, 523 ; in paranoia,
568; in paresis, 414, 425, 427,
431, 436, 439, 440, 444, 446; in
psychasthenic states, 530 ; in senile
psychoses, 578, 579, 585, 590, 593,
594, 596; in syphilitic psychoses,
559, 560, 561 ; in tobacco intoxi-
cation, 324.

Depression, Disorientation in, 87;
Isolation in treatment of, 157 ;
Psychomotor retardation in, 93.

Depressive phase of manic-depres-
sive insanity, 349.

Dermatographia in neurasthenic
states, 537; in senile psychoses,
589.

Desequilibres, 518.

Diabetes and glycosuria, 212, 487,
488, 552.

Diet, 158; in alcoholism, 310; in
arteriosclerotic psychoses, 557,
558; in senile psychoses, 591.

Dipsomania, 530.

Dipsomaniacal impulses in epilepsy,
474-.

Disorientation, see also Orientation.

Disorientation, 86, 295, 297 ; in
acute delirium, 262, 263 ; in
amentia, 87, 268, 407; in brom-
ism, 323 ; in cerebral syphilis,
458; in chloroform psychoses,
315; in epilepsy, 200, 407, 479;
in fever deliria, 258, 259; in
initial delirium, 257; in Korsa-
kow's syndrome, 282 ; in manic
stupor, 87 ; in unproductive
mania, 355.

Dissociation, no, 411; in amentia,
267; in dementia paranoides, 398;
in dementia praecox, 380, 385, 392 ;

in epilepsy, 478; in hysteria, 499,
500; in manic-depressive insan-
ity, 75, 352, 355, 357J in paresis,
.423, 427- .

Distractibility, 141 ; associated with
brain tumors, 549; in amentia,
267; in hepatic disease, 217; in
hysteria, 497 ; in neurasthenia,
521 ; in paresis, 420, 422, 440, 444,
448.

Dreams in senile psychoses, 588.

Dream states, 36, 132, 135; epilep-
tic, 479, 488; hysterical, 503.

Dromomania, 70, 196.

Drugs, Abnormal psychic states
due to, 10, 285.

Dysarthria, 430.

Dyslalia, 430.

Dyslogia, 430.

Dysphasia, 430.

Echolalia, 98, 102, 385, 484.

Echopraxia, 98, 385.

Education and insanity, 197.

Egotism, in manic-depressive in-
sanity, 365, 368; in mental de-
bility, 238.

Electrotherapy, 160.

Embolophrasia, 96.

Emotion, 12, 27, 30, 53, 57, 69, 108,
132, 258, 273.

Emotional anomalies, 101, 195, 311;
in alcoholism, 290; in arterio-
sclerotic psychoses, 553 ; in co-
cainism, 322 ; in delirium tremens,
295 ; in dementia praecox, 376,

378, 379, 387, 400; in epilepsy,
115, 475, 477; in Huntington's
chorea, 223 ; in hypomania, 356,
357; in imbecility, 236; in Kor-
sakow's syndrome, 279; in manic-
depressive insanity, 344, 350, 351,
354; in neurasthenia, 114, 115,
521, 523 ; in non-myxcedema-
tous infantilism, 243 ; in para-
noia, 568, 571 ; in paresis, 425,
427, 439,. 455; in post-epileptic
mental disturbances, 480; in psy-
chasthenic states, 526, 529, 540;
in senile psychoses, 579, 595.

Emotional reactions, 94; Disturb-
ances in the, 108, 125; Objective
evidence of neural disturbance in
the, 116.

Emotional storms, Blood-pressure
in, 118; in dementia praecox, 377,

379, 388, 395; in epilepsy, 477,
478; in manic-depressive insan-
ity, 355-

Encephalitis, Cortical, 24, 241, 368.

INDEX

605

Endarteritis, Heubner's, 467.

Environment as a cause of insanity,
186, 310.

Epilepsia larvata, 471.

Epilepsy, 62, 63, 70, 84, 107, 121,
I3i, 135, 142, 181, 188, 204, 221,
228, 241, 308, 363, 394, 473, 512,
517; Amnesia in, 475, 480; Anx-
iety in, 475, 476, 477, 479, 480;
Apathy in, 480; Apprehensiveness
in, 456; Auras in, 475, 476, 480;
Automatism in, 475, 480, 482 ; Con-
sciousness in, 476, 477, 478, 479,
480, 485, 512; Delusions in, 475,
476, 479; Dementia in, 482, 492;
Depression in, 474, 475, 477, 489;
Dietetic treatment of, 490; Dif-
ferential diagnosis of, 482; Dis-
orientation in, 290, 407, 479; Dis-
sociation in, 478; Dream states
in, 479, 488; Emotional anom-
alies in, 115, 475, 477! Emotional
storms in, 477, 478; Euphoria in,
475, 479 ; Excitement in, 474, 478,
489; Flight of ideas in, 478; Gait
in, 484; Hallucinations in, 456,

475, 476, 477, 478, 479, 480; He-
redity in, 486; Ideas of persecu-
tion in, 483 ; Imperative ideas in,

476, 480 ; Impulsivity in, 407, 474,

477, 478, 480, 481 ; Inhibition in,
475 ; Insane ideas in, 477 ; In-
sight in, 477; Intellectual dis-
turbances in, 475 ; Irritability in,
475, 4775 Latent, 477; Memory
in, 475, 479, 482 ; Mental disturb-
ances resulting frorn^ 480; Mental
symptoms in, 474, 476, 477;
Motor restlessness in, 477, 478;
Mutism in, 478, 480; Obsessions
in, 476, 477, 478, 480; Orientation
in, 478 ; Paranoiic states in, 482 ;
Pathogenesis of, 486; Pathology
of, 491 ; Phobias in, 475 ; Psychic,
*96, 473, 477 ; Psychomotor re-
tardation in, 480; Senile, 557;
Speech in, 482, 484 ; Speech
compulsion in, 478; Stupor in,
200, 480; Treatment of, 489;
Tremor in, 484 ; Verbigeration
in, 478, 484.

Epilepsy and chorea, 223, 484.

Epileptic attacks, Grouping of, 485.

Epileptic, mania, 407, 440, 478 ; mi-
graine, 221.

Epileptiform attacks, 264, 290, 308,
369, 468 ; in bromism, 323 ; in
paresis, 451, 452, 456; in senile
psychoses, 597 ; in syphilitic psy-
choses, 561, 562.

Ergotism as a cause of insanity,
324-

Erythrophobia, 529.

Esquirol, 58, 119.

Etat crible, 577.

Ether intoxication, 314.

Euphoria, in epilepsy, 475, 479; in
Huntington's chorea, 223; in
multiple sclerosis, 545 ; in paresis,
368, 388, 423, 427, 430 ; in pseudo-
paresis of syphilitic origin, 561 ;
in senile dementia, 597; in tuber-
culosis, 210.

Eurotophobia, 529.

Evil eye, 30.

Exaltation, 116, 138, 210, 216, 289,
353, 362, 364, 368, 596 ; in anaemia,
209 ; in hysterical delirious states,
508; in manic-depressive insan-
ity, 355 ; in myxoedematous alien-
ation, 328, 329; in paranoia, 568;
in paresis, 425, 439.

Examination, of patients, 127; of
the cerebrospinal fluid, 143.

Exanthemata, 256, 258, 262, 274.

Excitement, 57, 72, 76, 78, no, 195,
228, 323, 364, 368, 369, 385, 386,
396, 402 ; after apoplexy, 546 ; in
acute delirium, 263 ; in alcohol-
ism, 290; in arteriosclerotic psy-
choses, 557; in chorea gravi-
darum, 223; in catatonic demen-
tia prsecox, 391, 394, 510; in epi-
lepsy, 474, 478, 489; in Graves'
disease, 333, 334, 335; in hepatic
disease, 217; in hysterical para-
noioid states, 508 ; in meningitis,
547; in myxoedematous aliena-
tion, 329; in paresis, 414, 436,
439, 444, 446 ; in senile psychoses,
578, 593; in syphilitic psychoses,
559, 560.

Exhaustion, Chronic nervous, 228,
517, 522, 535-

Exhaustion in chorea gravidarum,
223.

Exhibitionism, 427, 475; in senile
dementia, 108, 596.

Exhilaration, 138, 195, 213, 216, 353,
445, 511, 596; associated with
brain abscess, 548; in paranoia,
568.

Exophthalmic goitre, Mental dis-
orders associated with, 333.

Facial expression, in arteriosclerotic
psychoses, 553 ; in dementia pre-
cox, 388, 393; in depression, 116;
in exaltation, 116; in manic-de-
pressive insanity, 341 ; in series-

6o6

INDEX

cence, 576; in senile psychoses,
585, 596; indicating emotion,
109, 141

Fanatics, 116.

Fatigue, 7, 60, 100, no, 132, 199;
Associative memory in, 199; At-
tention in, 109; in arteriosclerotic
psychoses, 552; in cases of brain
tumor, 549; in hysterical de-
lirious states, 508; in multiple
sclerosis, 544; in neurasthenia,
516, 518, 519, 538; in paresis, 418,
424, 446, 458; Sensibility in, 199;
Toxic products the result of, 200.

Fatigue, Absence of, 358; in cocain-
ism, 323 ; in maniacal states, 344 ;
in paresis, 446.

Fatigue, Effect of, on ganglion
cells, 200.

Fear, 57, 109, 118, 228, 526; in
amentia, 266, 267; of impend-
ing death in manic-depressive
insanity, 351 ; Pulse in, 109;
Tremor in, 109.

Feeding, Forced, 159; in amentia,
274; in catatonic dementia prae-
cox, 392; in Korsakow's syn-
drome, 283 ; in morphinism, 321 ;
in senile psychoses, 588.

Feelings, 53, 55.

Fever-change in nerve-cells, 260.

Fevers and infectious processes as
causes of insanity, 210.

Flechsig, Anatomical studies of, 19;
on treatment of epilepsy, 490.

Flight of ideas, 76, 78, 117, 137,259,
274, 484, 596 ; in amentia, 268 ;
in epilepsy, 478; in hypomania,
357 ; in manic-depressive insanity,
340, 355, 368, 406, 511 ; in morphin-
ism, 318; in paresis, 440; Ficti-
tious, in epileptic mania, 478;
Sensory, in delirium tremens,
294.

Folie, a deux, 191 ; circulaire, 13,
336 ; de la puberte, 372 ; du pour-
quoi, 524; neurasthenique, 516;
raisonnante, 357.

Forensic importance, of arterio-
sclerotic psychoses, 554 ; of cloud-
ing of consciousness, 70; of dis-
turbance in the volitional pro-
cesses, 92 ; of impulsive acts in
epilepsy, 481 ; of intolerance for
alcohol, 288, 289; of senile psy-
choses, 596, 598; of the simple
dementing form of dementia prae-
cox, 390.

Formication in delirium tremens,
293-

Foyers lacunaires de disintegra-
tion, 577.

Gait, in dementia praecox, 383 ; in
epilepsy, 484; in morphinism,
319; in paresis, 429.

Ganglion-cell hypothesis, 21.

Gastro-intestinal disturbances, as
causes of insanity, 130, 220, 273 ;
in acute delirium, 264; in brom-
ism, 323 ; in manic-depressive in-
sanity, 349, 354, 540; in morphin-
ism, 319, 320; in neurasthenic
states, 537; in paresis, 419, 436,
437. 454 5 »n senile psychoses, 588,
597 ; in tobacco intoxication, 324.

Gedankenlautwerden, 60.

Glia changes, 24, 261 ; in alcohol-
ism, 314; in defect psychoses,
246; in dementia praecox, 410;
in epilepsy, 493 ; in paresis, 465 ;
in senescence, 577.

Gliarasen, 563.

Gout, 309, 483 ; as a cause of in-
sanity, 211, 487, 488.

Grand Mai Intellectuel, 477.

Graves' disease, Mental disorders
associated with, 333.

Gray substance, Importance of, 20.

Gymnastic exercises, 153.

Haematoma auris, 435.

Hallucinations, see also Auditory,
Haptic, Tactile, and Visual hal-
lucinations, respectively.

Hallucinations, 12, 45, 51, 57, 67,
92, 95, no, 118, 119, 132, 137, 138,
140, 142, 143, 210, 216, 258, 266,
271, 359. 449, 483; after opera-
tions on the bile-ducts, 218; in
acute alcoholic hallucinosis, 300,
301, 302, 303, 304; in alcoholic
paranoiic states, 305 ; in amentia,
268, 269, 407 ; in arteriosclerotic
psychoses, 553 ; in cocainism,
322 ; in delirium acutum, 262 ;
in delirium tremens, 292, 297 ; in
dementia paranoides, 397; in de-
mentia praecox, 377, 381, 386, 388,
394, 396; in epilepsy, 456, 475,
476, 477, 478, 479, 480; in fever
delirium, 257 ; in Graves' dis-
ease, 334; in hysteria, 496; in
hysterical delirious states, 508;
in initial delirium, 257; in Kor-
sakow's syndrome, 278, 279, 280,
282 ; in lead-poisoning, 325 ; in
manic-depressive insanity, 342,
352 ; in meningitis, 547 ; in mor-
phinism, 318, 320; in myxcedema-

INDEX

607

tous alienation, 328, 329; in neu-
rasthenia, 521 ; in paraldehyde in-
toxication, 316; in paranoia, 567,
569, 570, 57i; in paresis, 414,
424. 439, 443, 447; in post-epi-
leptic mental disturbances, 480;
in psychasthenic states, 531 ; in
senile psychoses, 584, 592, 593,
595, 596.

Hallucinations, Apperceptive, 59 ;
Attention in, 51 ; Baillarger's di-
vision of, 59; Bilateral, 63; Ele-
mentary, 59; Elementary audi-
tory, 63; Elementary, of light, 62;
Erotic, in chorea, 222; Idea-
tional, 61 ; of hearing, 65 ; of
smell, 63 ; of taste, in delirium
tremens, 293; Peripheral theory
of, 62, 293 ; Pseudo-, 59 ; Psychic,
59, 60; Psychomotor, in cocain-
ism, 323; Psycho-sensorial, 59;
Reflex, 66; Stabile, 66; Uni-
lateral, 63, 424; Ziehen's theory
explaining, 58.

Hallucinatory, confusion, 266; de-
lirium in cerebral syphilis, 458;
disturbances, 315 ; insanity, 208,
266; paranoiic conditions in to-
bacco intoxication, 324.

Haptic hallucinations, in chorea,
222 ; in delirium tremens, 292,
293 ; in paranoia, 571 ; in pare-
sis, 424, 443.

Hebephrenia, 13, 372, 386, 569, 570.

Hebephrenic form of dementia piae
cox, 386.

Heboidophrenia, 386.

Henschen's studies in the pathology
of idiocy, 22.

Hepatic disease, Mental disturb-
ances in, 217.

Heredity, 121, 179, 541; Atavistic,
183 ; in dementia praecox, 404 ; in
epilepsy, 486; in manic-depres-
sive insanity, 367; in paresis, 416;
in psychoses associated with brain
tumors, 549; in senile dementia,
597-

Heteropia, 246.

Heubner's, endarteritis, 467; group-
ing of syphilitic psychoses, 559.

Homicidal impulse, 107 ; in epilepsy,
474 ; in morphinism, 320.

Hospitals for the insane, 167.

Hydrocephalus, 202, 241, 246.

Hydrotherapy, 151 ; in acute de-
lirium, 265; in alcoholism, 311;
in amentia, 274; in arterioscler-
otic psychoses, 557; in epilepsy,
491; in fever deliria, 259; in

Graves' disease, 335; in hysteria,
514; in manic-depressive insanity,
370 ; in morphinism, 321 ; in pa-
resis, 459; in senile psychoses,
591-

Hyperacusis, 519.

Hyperesthesia, Acoustic, 60 ;
Psychic, 117.

Hyperesthesia retinae, 519.

Hyperesthesias in hysteria, 495,
496; in Korsakow's syndrome,
278; in morphinism, 318; in neu-
rasthenic states, 519, 520; in pa-
resis, 423.

Hyperalgesias, 495, 496; in neuras-
thenic states, 519.

Hypermnesia, 82, 85.

Hyperosmia, 519.

Hyperprosexia, 51, 76; in maniacal
phase of manic-depressive insan-
ity, 343-

Hypertonia, Muscular, in catatonic
form of dementia praecox, 393,
411.

Hypervigility of the attention, 51.

Hypochondriacal depression, 377.

Hypochondriasis, 130, 131, 212, 221,
370; in dementia praecox, 378,
392, 397; in gout, 212; in manic-
depressive insanity, 352, 354, 359,
368; in myxoedematous aliena-
tion, 329; in neurasthenic states,
521, 523 ; in paresis, 426, 427, 442,
445, 448; in psychasthenic states,
523, 535 ; in senile psychoses, 578,
580, 582, 584, 586, 593 ; traumatic,
203.

Hypomania, 353, 355, 426.

Hypomelancholia, 359.

Hypovigility of the attention, 50.

Hysteria, 14, 63, 72, 84, 85, 97, 118,

121, 131, 193, I96, 204, 221, 228,

238, 363, 377, 385, 406, 433, 453,
456, 474, 478, 482, 517, 526, 539,
560; Abulia in, 495, 498, 503;
Amnesia in, 495, 497, 500; Anaes-
thesias in, 495, 496, 503, 511;
Anxiety in, 507, 508; Associa-
tion in, 504 ; Attention in, 495,
496, 497, 500, 503; Automatism
in, 499; Consciousness in, 503,
504, 506, 511 ; Delirious states in,
507; Depression in, 507, 508, 514;
Differential diagnosis of, 510;
Dissociation in, 499, 500; Dis-
tractibility in, 497; Dream states
in, 503: Emotions in, 114, 494,
495, 496, 511; Etiology of, 509;
Hallucinations in, 496; Hyper-
aesthesias in, 495, 496; Illusions

6o8

INDEX

in, 496; Impulsivity in, 106, 502;
Insomnia in, 514; Irrelevancy in,
504, 510; Mania in, 507, 508;
Memory in, 498, 512; Motor dis-
turbances in, 502; Paresthesias
in, 495 ; Phobias in, 507 ; Psychic
abnormalities of, Grouping of,
494; Sensory disturbances in,
495. S02; Sex in, 509; Somnam-
bulism in, 506; Speech in, 504;
Suggestibility in, 503 ; Suicidal
impulses in, 107; Treatment of,
512; Volitional disturbances in,
498.

Hysteria Group, 494.

Hysterical hallucinatory insanity,
508.

Hysterical liars, 85, 428, 500.

Hysterical paranoioid states, 508.

Hysterical seizures in migraine,
221.

Hysterical states, 315, 530, 559.

Hysterical symptoms, in alcoholism,
308; following apoplexy, 547;
following syphilitic infection, 229 ;
in chorea, 223; in morphinism,

317.
Hysterie douloureuse a manifesta-
tion splanchnique, 509.

Ideas, S3, 94; Autochthonous, 142;
Exaggerated, 102 ; Exaggerated,
in dementia praecox, 379.

Ideas, Fixed, 101, 496, 520, 579, 589.

Ideas, Flight of, see Flight of ideas.

Ideas, Imperative, see Imperative
ideas.

Ideas, Insane, see Insane ideas.

Ideas, Levelling off of, 77, 126; Ni-
hilistic, in senile psychoses, 583 ;
Obsessional, 529; of negation in
Korsakow's syndrome, 280.

Ideas of persecution, 45, 64; in
amentia, 269; in dementia prae-
cox, 397 ; in epilepsy, 483 ; in
Graves' disease, 334; in Hunt-
ington's chorea, 223; in hysteri-
cal delirious states, 508; in Kor-
sakow's syndrome, 280; in myx-
edematous alienation, 329; in
paranoia, 567 ; in paresis, 444 ;
in senile psychoses, 582, 593, 595 ;
in syphilitic psychoses, 561.

Ideas of personality, 69, 569; Anni-
hilation of, 47.

Ideas of reference, 132 ; in senile
psychoses, 584.

Ideas, Systematization of, in acute
alcoholic hallucinosis, 301 ; in
hysterical delirious states, 508;

in paranoia, 568, 570; in senile
psychoses, 584, 589, 590, 594.
Idiocy, 56, 92, 113, 116, 227, 229,
230, 412, 482, 486; Acquired, 372;
Amaurotic family, 245 ; Anerge-
tic or apathetic form of, 233 ;
Associative memory in, 232, 233;
Attention in, 232, 234, 239 ; Diag-
nosis of, 248; Dissociation in,
233 ; Erethic or versatile form of,
233; Grouping of, 230; Impul-
sivity in, 233; Motor anomalies
in, 235 ; Orientation in, 232 ;
Pathology of, 22 ; Physical mani-
festations in, 234 ; Speech in, 232 ;
Sensations in, 233, 234; Tics in,

95-

Illusions, 57, 58, 59, 67, 92, 257, 268,
269; in amentia, 407; in demen-
tia praecox, 381, 386; in hysteria,
496; in manic-depressive insan-
ity, 342.

Imagination, 60.

Imbecile children in schools, 239.

Imbecilitas tarda, 372.

Imbecility, 56, 92, 113, 227, 229, 230,
235, 408, 412, 486; Etiology of,

239-

Imitation and suggestion, 190.

Imperative ideas, 95, 100, 102, 112,
132; in dementia praecox, 379;
in epilepsy, 476; in manic-depres-
sive insanity, 351 ; in psychas-
thenic states, 524.

Imperative process psychoses, 101.

Impulses, 92, 98, 112, 121, 228; Sex-
ual, 108.

Impulsive insanity, 228.

Impulsivity, 97, 104, 106, 121, 125,
196, 315, 386, 483, 559; in apo-
plexy, 546; in dementia para-
noides, 399; in dementia praecox,
369, 377, 392, 395, 397, 400, 406,
408; in epilepsy, 407, 474, 477,
478, 480, 481 ; in hysteria, 106, 502 ;
in idiocy, 233 ; in manic-depres-
sive insanity, 106; in neuras-
thenia, 516; in senile psychoses,
593, 596.

Infantilism and tuberculosis, 243.

Infantilism, Non-myxcedematous,
242.

Influenza, 255, 256, 258, 262, 274,
376, 387-

Inhibition, 44, 115, 340; in alco-
holism, 286 ; in bromism, 323 ; in
epilepsy, 475 ; in dementia prae-
cox, 386, 394, 400; in manic-de-
pressive insanity, 343, 352, 369.

Initial delirium, 256.

INDEX

609

Insane ideas, 36, 61, 95, 97, 119, 132,
137, 140, 142, 210, 483, 541; and
anomalies in organic sensations,
44; in alcoholic paranoiic states,
306; in arteriosclerotic psycho-
ses» 5S3J in cerebral syphilis,
458; in dementia paranoides, 399 ;
in dementia praecox, 378, 381, 396,
397; in epilepsy, 477; in hepatic
disease, 217; in manic-depressive
insanity, 352, 354, 522; in myx-
cedematous alienation, 328; in
paranoia, 567, 569, 570, 571; in
paresis, 427, 443, 446, 447; in
senile psychoses, 584, 585, 589,
593, 596.

Insanity, Conjugal, 191, 193; Gen-
eral causes of, 178; Induced, 192;
of puberty and adolescence, 372;
of pubescence, 372 ; Nuptial, 205 ;
Pathogenesis of, 7.

Insight, following apoplexy, 547;
in arteriosclerotic psychoses, 553;
in delirium tremens, 297; in epi-
lepsy, 477; in multiple sclerosis,
544, S4S ; in neurasthenic states,
540 ; in paresis, 442, 445 ; in psy-
chasthenic states, 455 ; in senile
psychoses, 582; in syphilitic psy-
choses, 560.

Insomnia, in alcoholism, 290; in
arteriosclerotic psychoses, 557 ;
in cocainism, 322; in dementia
praecox, 388; in hysteria, 514; in
manic-depressive insanity, 354 ;
in neurasthenia, 525 ; in paralde-
hyde intoxication, 317; in pare-
sis, 439, 459; in senile psychoses,
588.

Instability in neurasthenia, 516.

Insufficiency, Feeling or Sense of,
123 ; in manic-depressive insan-
ity, 35i, 352, 354, 369; in senile
psychoses, 579, 589.

Intellect, 12; Defects of, 26; in
chorea, 222; in dementia prae-
cox, 376, 380; in epilepsy, 475:
in Huntington's chorea, 223.

Intoxication, Ether, 314; Paralde-
hyde, 316; Tobacco, 323.

Intoxications, Drug, 188, 227; Fear
in, 118; Psychoses the result of
chronic, 285.

Intrapsychic incoordination in de-
mentia praecox, 114.

Irrelevancy, 140; in dementia prae-
cox, 368, 383, 389, 390, 5io; in
hysteria, 504; in hysterical dis-
turbances of consciousness fol-
lowing trauma, 511.

39

Irritability, 131; associated with
brain abscess, 548 ; associated with
brain tumors, 549; in anaemia,
208 ; in apoplexy, 546 ; in arterio-
sclerotic psychoses, 552; in
chorea, 222; in cocainism, 322;
in dementia praecox, 387; in epi-
lepsy, 477; in manic-depressive
insanity, 365; in melancholia,
523; in morphinism, 318, 320; in
multiple sclerosis, 544 ; in neuras-
thenic states, 521 ; in paranoia,
571 ; in paresis, 425, 439, 443 ; in
senile psychoses, 593, 595.

Isolation, as a cause of insanity,
157; in the treatment of insanity,
157.

Judgment, 7, 26, 60, 123, 541; in
alcoholic paranoiic states, 304 ; in
hypomania, 357, 358; in mental
debility, 238; in myxoedematous
alienation, 327; in paranoia, 567;
in paresis, 426.

Kleptomania, 107.

Korsakow's syndrome, 56, 85, 220,
227, 277, 419, 457, 592; Clinical
forms of, 279; Differential diag-
nosis of, 282; Duration of, 280;
Etiology of, 281 ; Pathology of,
283 ; Treatment of, 282.

Kraepelin's, division of febrile de-
liria, 258; method of investiga-
tion, 13.

Krishaber's work on organic sensa-
tions, 32.

Larvirte epilepsie, 477.

Lead poisoning, 324; in paresis,
4x9.

Leptomeningitis, 202; chronica pro-
funda in paresis, 462.

Lie, Tendency to, 368; in hysteria,
500; in morphinism, 317.

Litigious insanity, 397, 571.

Localization, Cortical, 20.

Lucid intervals, in dementia prae-
cox, 400 ; in Huntington's chorea,
223 ; in hysterical dream states,
506; in manic-depressive insanity,
353, 361, 364-

Macropsia, 497.

Malaria, 130; as a cause of non-
myxoedematous infantilism, 243.

Mania, 206, 336, 363, 364, 372, 509,
564; Attention in, 51 ; Delirious,
266; Epileptic, 369, 478; gravis,
355; Hysterical, 507, 508, 511;

6io

INDEX

mitissima, 355; Mood in, 112;
Psychoanalgesia in, 115; Psycho-
motor Excitability in, 93; Recur-
rent, 353 ; Unproductive, 355, 358 ;
Wandering, 47, 132, 106; without
delirium, 119, 354.

Manic-depressive group, 336.

Manic-depressive insanity, 14, 32,
38, 44, 76, 119, 135, 195, 204, 205,
216, 221, 227, 229, 256, 260, 266,
274, 282, 329, 334, 380, 393, 401,
406, 425, 440, 453, 458, 468, 478,
484, 492, 508, 51 1, 539, 549, 56o,
566, 590, 597 ; Clinical course of,
353; Differential diagnosis of,
368 ; Dissociation in, 75 ; Eti-
ology of, 362 ; Gastro-intestinal
disturbances in, 349, 540; Group-
ing of forms of, 353 ; Heredity in,
367; Impulsivity in, 106; Initial
stage of, 354; Insane ideas in,
522 ; Irritability in, 365 ; Memory
defects in, 85 ; Mortality in, 355 ;
Pathogenesis of, 367; Pathology
of, 371 ; Prognosis in, 364 ; Psy-
chomotor retardation in, 359, 360,
362, 365, 368, 511; Second stage
of, 355; Terminal stage of, 355;
Treatment of, 369; Weight in,
348, 365, 540.

Manic-depressive insanity, Depres-
sive phase of, 349, 354; Akinesis
in, 351 ; Anxiety in, 351, 354, 355;
Apprehension in, 351 ; Associa-
tion in, 351, 354, 355; Blood-
pressure in, 345, 351, 371 ; Con-
fusion in, 351 ; Dissociation in,
352; Emotion in, 350, 351, 354;
Feeling of insufficiency in, 351,
352; Hallucinations in, 352; Hy-
pochondriasis in, 352, 354, 359,
368; Imperative ideas in, 351;
Inhibition in, 352; Insane ideas
in, 352, 354; Insomnia in, 354;
Micromania in, 351 ; Motor anom-
alies in, 350, 354, 355; Obses-
sional impulses in, 352; Orienta-
tion in, 351 ; Physical symptoms
of, 353 ; Pulse in, 351 ; Pupils in,
349 ; Psychomotor retardation
in, 35o, 353, 354; Reaction time
in, 350; Reflexes in, 349; Soma-
topsychic consciousness in, 351 ;
Speech in, 350; Stupor in, 87,
352; Writing in, 351.

Manic-depressive insanity, Maniacal
phase of, 338 ; Absence of fatigue
in, 344 ; Association in, 342, 343 ;
Attention in, 342, 343 ; Blood in,
346 ; Blood-pressure in, 345, 371 ;

Bulimia in, 349; Consciousness
in, 343; Dermatographia in, 216;
Emotional anomalies in, 344;
Facial expression in, 341 ; Flight
of ideas in, 340, 355, 368, 408, 511 ;
Gastro-intestinal disturbances in,
354 ; Hallucinations in, 342 ; Hy-
perprosexia in, 343 ; Illusions in,
342 ; Inhibition in, 343 ; Motor
symptoms of, 117, 338, 339; Mus-
cular power in, 340; Orientation
in, 343 ; Pain sense in, 340 ; Phy-
sical symptoms of, 345 ; Pulse in,
»7. 345, 346, 356, 357; Pupils
in, 349 ; Reflexes in, 349 ; Respira-
tion in, 346; Sensations in, 342,
344 ; Sexual excitement in, 345 ;
Speech compulsion in, 75, 340;
Temperature in, 348; Tremor in,
117, 339,' Urine in, 348; Weight
in, 348; Writing in, 341.

Mannerisms, 250, 274, 485 ; in de-
mentia praecox, 369, 386, 396, 397,
400, 404, 405, 406, 510.

Marriage, 147, 184, 205.

Martyrs, 116.

Masochismus, 108.

Massage, 153.

Medicinal therapy, 161.

Medullation, in the nerves, 19; of
nerve tracts, 20.

Megalomania, 47, 64 ; in acute alco-
holic hallucinosis, 301 ; in arterio-
sclerotic psychoses, 553 ; in de-
lirium tremens, 295 ; in dementia
paranoides, 397, 398; in dementia
praecox, 378; in paresis, 439, 440,
446.

Melancholia, see also Depression,
and Manic-depressive insanity,
Depressive phase of,

Melancholia, 36, 105, 119, 206, 279,
336, 363, 364, 372, 522, 535, 564,
588 ; agitata, 360, 592 ; Involu-
tional, 360, 369, 590, 593 ; Recur-
rent, 353 ; Senile, 216, 407, 578.

Memories, Sense, in imbecility, 235 ;
in neurasthenic states, 520.

Memory, 27, 53, 55, 69, 81, 91, 104,
132; in alcoholic paranoiic states,
304 ; in amentia, 267 ; in arterio-
sclerotic psychoses, 552, 553 ; in
chorea, 222; in delirium tremens,
294 ; in dementia praecox, 378, 388,
389, 394: in epilepsy, 475, 479,
482 ; in Huntington's chorea, 223 ;
in hysteria, 498, 512; in paranoia,
569, 570, 571 ; in paresis, 85, 420,
427, 454, 458 ; in senile psychoses,
575 ; in syphilitic psychoses, 561.

INDEX

6il

Memory, Abnormal, in mental de-
bility, 237.

Memory, Associative, see also Asso-
ciation.

Memory, Associative, 27, 28, 31, 52,
58, 68, 82, 87, 141, 266; in amen-
tia, 267; in apoplexy, 546, 547;
in cretinism, 331 ; in dementia
praecox, 397 ; in epilepsy, 475 ; in
fatigue, 199 ; in idiocy, 232, 233 ;
in imbecility, 235 ; in Korsakow's
syndrome, 277, 278, 279, 282; in
mental debility, 237; in migraine,
222 ; in multiple sclerosis, 545 ;
in myxcedematous alienation, 327 ;
in paranoia, 571 ; in pseudo-
paresis, 214 ; in senescence, 575 ;
in senile psychoses, 585, 588, 595-

" Memory Cramps," 102.

Memory, Detention, 84; Develop-
ment of, 83 ; Division of func-
tions of, 82 ; Muscular, 83 ; Re-
tention, 83.

Memory pictures, 88, 91, 109.

Meningitis, 130, 225, 241, 258, 280,
368, 436, 492 ; Psychoses asso-
ciated with, 547.

Mental anomalies the result of de-
fective development, 230.

Mental capabilities, Importance of
determination of, 7.

Mental debility or enfeeblement,
230, 237; Apathetic type of, 238.

Mental development, Preyer's table
indicating normal, 248.

Mental diseases, Grouping of, 225.

Mental disorders, associated with
cardiac and vascular disease, 215;
with chorea, 222 ; with anomalies
in the function of the thyroid
gland, 326; with gastro-intestinal
disturbances, 220; with hepatic
disease, 217 ; with hyperfunction
of the thyroid gland, 333 ; with
migraine, 221 ; with nephritis,
219; with operations upon the
common bile-duct, 218; Treat-
ment of, 335.

Mental processes in children and
primitive peoples, 29.

Mental rumination, 123, 542.

Mental treatment, 155.

Merkfahigkeit, .50, 82.

Metabolism, Defective, in relation
to mental disease, 211.

Microcephalus, 202, 247; Operative
interference in, 252.

Microgyria, 245.

Micromania, 48; in manic-depres-
sive insanity, 351.

Micropsia, 497.

Migraine, Mental disorders asso-
ciated with, 221.

Migrainous epilepsy, 221.

Mimic-cramp neurosis, 97.

Mirror writing in dementia praecox,
383.

Monomania, Affective, 119; In-
stinctive, 119.

Monsters, 244.

Mood, 112, 113, 117, 569.

Moral insanity, 119, 125, 239.

Moral sense, 119; in arteriosclero-
tic psychoses, 553 ; in paresis, 426,
454-

Morphinism, 10, 317, 530; Physical
symptoms of, 318; Treatment of,
320.

Motor anomalies, in acute delirium,
262, 263; in chorea gravidarum,
223 ; in dementia praecox, 369, 386,
391; in hysteria, 502; in idiocy,
235 ; in manic-depressive insanity,
338, 339, 350, 354 ; in paresis, 428,
431 ; in senescence, 576.

Motor restlessness, 210, 213, 258,
265, 349, 353, 359, 362, 363, 364,
365, 368, 483, 484 ; associated with
brain abscess, 548; in alcoholism,
286 ; in amentia, 267, 268, 269 ; tn
arteriosclerotic psychoses, 554; in
chorea, 222 ; in delirium tremens,
291, 295, 297; in epilepsy, 477,
478 ; in hypomania, 357 ; in manic-
depressive insanity, 355 ; in mor-
phinism, 318; in paresis, 446; in
psychasthenic states, 533 ; in
senile psychoses, 586, 589, 591,
592, 596.

Multiple sclerosis, 456, 544.

Muscle sense, 28, 29, 87.

Muscles, Electrical response of, in
paresis, 429; Exaggeration of
functional power of, in manic-
depressive insanity, 340; Inco-
ordination of, in paresis, 428, 451,
452 ; Mechanical irritability of,
in dementia praecox, 402, 41 1 ;
Mechanical irritability of, in
senile psychoses, 589; Power of,
in the neurasthenic states, 519,

538- . . r

Muscular rigidity in catatonic form
of dementia praecox, 393.

Mutism, 139; in dementia praecox,
391 ; in epileptic mania, 478, 480 ;
in imbecility, 237; in unproduc-
tive mania, 355.

Mysophobia, 527.

Mysticism, 398.

6l2

INDEX

Myxoedema, 18, 326, 402 ; Physical
symptoms of, 326; Treatment of,

329-

Myxcedematous alienation, 327.

Myxoedematous infantilism differ-
entiated from non-myxoedematous
infantilism, 243.

Nanocephalus, 247.

Narcolepsy, 213.

Negativism, 97, 138, 385 ; in de-
mentia praecox, 381, 386, 389, 391,
396, 400, 407, 485, 510; in myxce-
dematous alienation, 328.

Nekrophilia, 108.

Nephritis, 62, 129, 552, 590, 597 ;
Mental disorders associated with,
219.

Nerve-cell changes in acute de-
lirium, 275; in alcoholism, 314;
in amentia, 275 ; in chloroform
psychoses, 315 ; in cretinism, 333 ;
in defect psychoses, 246, 247 ; in
delirious mania, 371 ; in dementia
praecox, 410; in paresis, 464; in
senescence, 577.

Nerve-cells, Effect of fatigue on,
200 ; Fever-change in, 260 ; Sig-
nificance of pathological changes
in, 21.

Nerve-fibres, 19, 20, 261 ; Signifi-
cance of pathological changes in,
22.

Nervous system, Blood and lymph
channels of the central, 21 ; in
senescence, 576; Mental symp-
toms associated with organic
changes in the, 544; Pathology
of, 18.

Neurasthenia, 63, 71, 72, 118, 123,
228, 356, 359, 377, 406, 433. ^7,
454, 510, 516, 518, 560; see also
Neurasthenic states.

Neurasthenic states, 369, 516, 518,
559; Apprehensiveness in, 516;
Attention in, 51, 519, 521 ; Char-
acteristics of, 516; Depression in,
516, 522, 523 ; Differential diag-
nosis of, 538 ; Distractibility in,
521; Emotional anomalies in, 114,
115, 521, 523; Etiology of, 541;
Fatigue in, 516, 518, 519, 538;
Hallucinations in, 521 ; Hypo-
chondriasis in, 521, 523 ; Im-
pulsivity in, 516; Insight in,
540 ; Insomnia in, 525 ; Irritabil-
ity in, 521 ; Paresthesias in, 521 ;
Phobias in, 516; Physical symp-
toms of, 536 ; Sensory disturb-
ances in, 519; Treatment of, 541.

Neurasthenic and psychasthenic

states, 516.
Nenrocerebrite toxique, 277.
Neuronophagia in paresis, 466.

Obsessions, 100, 103, 121, 455, 517,
529 ; Grouping of, 105 ; in chorea,
222 ; in epilepsy, 476 477, 478,
480 ; in manic-depressive insanity,
352; in neurasthenia, 516; in psy-
chasthenic states, 523, 534, 535,
536.

Onomatomania, 525.

Operations, Psychoses developing
after, 204.

Organic brain diseases, 75, 227.

Orientation, see also Disorientation.

Orientation, 86, 141 ; in acute alco-
holic hallucinosis, 302; in de-
lirium tremens, 294; in dementia
praecox, 381, 389, 390; in epileptic
mania, 478 ; in idiocy, 232 ; in
manic-depressive insanity, 343,
351; in multiple sclerosis, 545; in
paraldehyde intoxication, 317; in
paresis, 87, 421, 439, 446; in psy-
chasthenic states, 532; in senile
psychoses, 585, 593, 595.

Osteogenesis imperfecta of the
newborn, 244.

Out-door patients, 177.

Pachymeningitis chronica, 202; in
paresis, 461.

Psederasty, 108.

Pain, 53, 109, 130, 131, 233, 393, 495,
496, 519, 543; in neurasthenia,
62.

Pain sense in maniacal phase of
manic-depressive insanity, 340; in
paresis, 423.

Paradoxical light reflex, 433.

Paraesthesia, 67, no; in alcoholic
paranoiic states, 305 ; in dementia
praecox, 377, 382, 388 ; in hysteria,
495 ; in Korsakow's syndrome,
278 ; in lead poisoning, 325 ; in
migraine, 221 ; in morphinism,
318; in neurasthenic states, 521.

Parageusias, 63.

Paraldehyde, Intoxication from,
316.

Paralexia, 67; in delirium tremens,
294.

Paralogia, 383.

Paramnesia, 82, 85.

Paranoia, 105, 228, 229, 396, 397,
564; Acute alcoholic, 300;
Chronic hallucinatory, 570; Orig-

INDEX

613

inal, 568, 569; Pathogenesis of,
566, 569.
Paranoia, dissociativa, 266; Re-
current, 353, 361 ; rudimentaria,

Paranoiic form of dementia prae-
cox, 396.

Paranoiic states, 12, 193, 204, 353,
444, 482, 508, 517; and dementing
states developing during chronic
alcoholism, 304; after amentia,
270 ; following fever deliria, 259 ;
in epilepsy, 482; in manic-de-
pressive insanity, 566, 568.

Parapraxia, 139.

Paratonia progressiva, 372, 411.

Paresis, 22, 23, 24, 75, 186, 209, 229,
279, 295, 407, 413, 512, 540, 556,
561, 591 ; Acute, 438, 453 ; Alco-
holism in, 418; Amnesias in, 420;
Amyloid bodies in, 466; Amyo-
tropic forms of, 449; Anxiety in,
425, 443 ; Apathy in, 414, 425, 445,

448, 455. 457; Aphasia in, 421,

449, 452, 456; Apprehensiveness
in, 425, 443, 445; Argyll-Robert-
son pupil in, 250, 409, 433, 458;
Arteriosclerotic changes in, 469;
Arthropathies in, 435; Associa-
tion in, 420, 422; Ataxia in, 440;
Attention in, 420, 443, 448, 454;
Atypical cases of, 449; Brain
weight in, 462; Cardiac disturb-
ances in, 436; Catatonic symp-
toms in, 409, 430; Cerebellar
form of, 450; Clinical forms' of,
438; Conjugal, 418; Conscious-
ness in, 426, 451, 452, 456; Cor-
tical atrophy in, 463; Course of,
437; Cyanosis in, 435; Cytodiag-
nosis in, 455; Daily life and, 419;
Delusions in, 414, 446, 447; De-
mentia in, 438, 443, 444, 446, 449;
Dementing form of, 448, 453;
Depression in, 414, 425, 427, 431,
436, 439, 440, 444, 446; Differ-
ential diagnosis of, 454; Dissocia-
tion in, 423, 427; Dissolution of
the personality in, 70; Distracti-
bility in, 420, 422, 440, 444, 448;
Dural changes in, 461 ; Emo-
tional anomalies in, 425, 427, 439,
455 ; Ependymal changes in, 462 ;
Etiology of, 416; Euphoria in,
368, 388, 423, 427, 430 ; Exaltation
in, 425, 439; Excitement in, 414,
436, 439, 444, 446; Exhibitionism
in, 108, 427 ; Facial asymmetry in,
431, 440; Fatigue in, 418, 424,
446, 458; Febrile disturbances in,

436 ; Fibre changes in, 463 ; Final
stages of, 438; First period of,
437; Flight of ideas in, 440;
Focal symptoms in, 468; Gait in,
429; Galloping, 438; Gastro-in-
testinal disturbances in, 419, 436,
437, 454; Glia changes in, 465;
Haematomata in, 462 ; Hallu-
cinations in, 414, 424, 439; He-
redity in, 416; Hydrotherapy in,
459; Hypaesthesias in, 423; Hy-
peresthesias in, 423 ; Hypochon-
driasis in, 426, 427, 442, 445, 448;
Ideas of persecution in, 444; In-
cidence of, 415 ; Inco-ordination
of muscles in, 428; Insane ideas
in, 427, 446, 447; Insight in, 442,
445 ; Insolation in, 419 ; Insom-
nia in, 439, 459; Irritability in,
425,. 439 ; Judgment in, 426 ; Ju-
venile, 562; Lead poisoning in,
419; Megalomania in, 439, 440,
446 ; Memory in, 85, 420, 427, 454,
458 ; Mental symptoms of, 420 ;
Migraine in, 443 ; Moral sense in,
426, 454; Motility, Disturbances
of, 428, 431 ; Muscular disturb-
ances in, 428, 455 : Nerve-cell
changes in, 464; Neuronopha-
gia in, 466; Optic atrophy in,
433 I Orientation in, 87, 421, 439,
446 ; Pain sense in, 423 ; Patho-
logical anatomy of, 460, 470;
Personality in, 426; Pial changes
in, 462; Plasma cells in, 467;
Prodromal stage of, 437; Psycho-
anaesthesias in, 423 ; Psycho-
hypaesthesias in, 423 ; Psycho-
hyperaesthesias in, 423 ; Pupils in,
407, 433, 455; Reflexes in, 434,
452; Remissions in, 440, 444, 447,
452, 460; Respiration in, 436;
Rod cells in, 471 ; Saline in-
fusions in, 459, 460; Second
period of, 438; Seizures in, 451;
Sensation in, 420, 423, 446, 448;
Sense of duty in, 426, 448 ; Sense
of power in, 447; Sense of pro-
portion in, 426; Sense of well-
being in, 447; Sexual irregulari-
ties in, 427, 459; Skull changes
in, 461 ; Social position and, 419 ;
Somatic symptoms of, 428, 440;
Spastic forms of, 449; Speech in,
250, 407, 409, 413, 430, 451, 452,
455, 458 : Stereometric sense in,
427 ; Stigmata of degeneration
in, 416; Stupor in, 444, 451 ; Sus-
piciousness in, 444; Sweating in,
435 ; Sympathetic, Changes in the.

614

INDEX

in, 466; Syphilis in, 417; Tabes
and, 450; Tabetic forms, 449;
Termination of, 453 ; Trauma in,
418, 425; Treatment of, 458;
Tremor in, 428, 446, 452 ; Trigem-
inus symptom in, 452; Trophic
disturbances in, 435, 454; Urine
in, 436, 437 ; Vascular changes in,
24, 467; Vasomotor disturbances
in. 435 1 Visceral changes in, 461 ;
Visual disturbances in, 432;
Volition in, 93 ; Weight in, 436 ;
Writing in, 431.
Paresis, Depressed form of, 442 ;
Attention in, 443 ; Hallucina-
tions in, 443 ; Insane ideas in,
443; Irritability in, 443; Motor-
restlessness in, 443 ; Suicidal ten-
dencies in, 445.

Paresis, Expansive form of, 427,
431, 445, 453 ; Course of, 447 ; Ex-
hilaration in, 445 ; Hallucinations
in, 447 ; Insight in, 445 ; Motor
restlessness in, 446.

Paretic marasmus, 453.

Parturition, 262, 368.

Passive movements, Resistance to,
in catatonic form of dementia
praecox, 393.

Pathology of central nervous sys-
tem, 18; in multiple sclerosis, 545.

Perception, 100 ; in amentia, 407 ;
in delirium tremens, 294 ; in
Korsakow's syndrome, 279.

Periodic insanity, 360; Prognosis
in, 364.

Perseveration, 99, 485 ; in epileptic
dream states, 479.

Personality, 12 ; Anomalies of, 32 ;
Anomalies of, in paresis, 426;
Double, 532.

Pessimism, 122, 131, 132.

Petit mal intellectuel, 477.

Phobias, 228, 455 ; in epilepsy, 475 ;
in Graves' disease, 333, 334 ; in
hysteria, 507 ; in Korsakow's syn-
drome, 280; in neurasthenia, 516:
in non-myxoedematous infantil-
ism, 243 ; in psychasthenic states,
526, 529, 534.

Photomata, 59.

Photophobia, 519, 527.

Phrenomania, 261.

Plasma cells in paresis, 467.

Pleasure, 53, 232, 233, 543, 579.

Pneumonia, 130, 256, 258, 262, 270,
298, 355. 436, 440, 453. 590, 597-

Polyneuritic psychoses, 86, 277.

Porencephalus, 202, 246.

Poromania, 70, 196, 474.

Post-febrile psychoses, 260.
Pregnancy and parturition as causes

of insanity, 206, 487.
Presbyophrenia, 592.
Presenile Beeintrachtigungswahn,

593-

Progressive general paralysis of the
insane, 413.

Pseudo-hallucinations in dementia
praecox, 378.

Pseudo-microcephalus, 247.

Pseudo-paresis, of diabetic origin,
214, 434, 437; of syphilitic origin,
561.

Pseudo-reminiscences, 85, 137, 141 ;
in chloroform psychoses, 315; in
Korsakow's syndrome, 277, 278,
280.

Psychaesthesias in morphinism, 318.

Psychasthenia, 188, 222, 228, 438, 455,
516.

Psychasthenic states, 228, 437, 523 ;
Apprehensiveness in, 533, 536;
Cause of, 533 ; Consciousness in,
532; Course of, 534; Depression
in> 530; Emotional disturbances
in, 526, 529, 540; Hallucinations
in, 531; Imperative ideas in, 524;
Insight in, 455 ; Intermittent
form of, 534; Motor restless-
ness in, 533 ; Obsessions in,
523, 535; Orientation in, 532;
Phobias in, 526, 529, 534; Prog-
nosis in episodic forms of, 535 ;
Remittent forms of, 535 ; Ter-
mination of, 535 ; Tics in, 526 ;
Tremor in, 529.

Psychiatrical hospitals, 146, 167.

Psychiatry, in relation to physi-
ology, 3 ; in relation to psychol-
ogy, 5 ; Scope and methods of,
1 ; Work of the French school
in, 14.

Psychic anaesthesias, 36, 258, 262,

495,. Si 1.

Psychic antagonism, Law of, 343.

Psychic epilepsy, 473.

Psychic hallucinations, in dementia
praecox, 377 ; in manic-depressive
insanity, 342 ; in paresis, 443 : in
senile psychoses, 584.

Psychic hyperaesthesias, 258, 262,
263, 495, 496, 519, 526, 553.

Psychic paraesthesias, 258, 262, 495.

Psychic phenomena, Methods of-
investigating, 3.

Psycho-algia, 56.

Psycho-anaesthesia, 56 ; in demen-
tia praecox, 377, 395 ; in paresis,
423-

INDEX

615

Psycho-analgesia in fanatics and
martyrs, 116; in maniacal pa-
tients, 115.

Psycho-hypsesthesia, 98; in paresis,
423.

Psycho-hypersesthesia, 56.

Psychomotor excitability, 44, 90,
93; in hepatic disease, 217; in
manic-depressive insanity, 339.

Psychomotor hallucinations in pa-
resis, 424.

Psychomotor inhibition, 77.

Psychomotor irritability, 75, 78, 99.

Psychomotor retardation, 90, 93,
97, 98, 140, 369; in anaemia, 209;
in epilepsy, 480; in manic-de-
pressive insanity, 350, 353, 354,
359, 360, 362, 365, 368, 5ii.

Psycho-pathology, Functions of, 7.

Psycho-physic parallelism, Theory
of, 4.

Puberty, 193, 273, 370, 373, 374,
387.

Pulse, in cocainism, 322 ; in de-;
lirium tremens, 296; in demen-
tia praecox, 402; in fear, 109; in
manic-depressive insanity, 117,
345, 346, 351, 356, 357; in myx-
edema, 327; in neurasthenic
states, 538; in paretic seizures,
451 ; in senile psychoses, 588.

Pupils, in alcoholism, 289; in co-
cainism, 322 ; in dementia prae-
cox, 402 ; in manic-depressive
insanity, 349 ; in migraine, 221 ;
in morphinism, 319; in paresis,
407, 433, 455 ; in senescence, 576,
597-

Pyrexia, Effects of, on nerve-cells,
260, 276.

Pyromania, 107, 474.

Reaction time in manic-depressive
insanity, 350.

Recognition faculty, 83.

Recording faculty, 50, 82.

Reflex acts, and the associative ac-
tivities of the brain, 52.

Reflex movements, 90.

Reflexes, in amentia, 269 ; in de-
lirium acutum, 264 ; in Korsa-
kow's syndrome, 278, 282 ; in
manic-depressive insanity, 349; in
neurasthenic states, 537; in pa-
resis, 434 ; in paretic seizures,
452 ; in senile psychoses, 588.

Re-perception, 58.

Reproductions, 100.

Rest treatment, 150, 541.

Rhachitis fetalis, 244.

Rheumatism, Acute articular, 257,

258.
Rickets, 241.
Rupophobia, 527.

Sadismus, 108.

Saline infusions, 164; in acute de-
lirium, 265 ; in amentia, 274 ; in
paresis, 459, 460.

Saturnism, 324.

Scarlet fever, 376, 387, 488.

Schriftwage, 341.

Self-accusation, in amentia, 269; in
melancholia, 522.

Self-consciousness, 35.

Semi-idiocy, 235.

Senescence, Mental symptoms of,
575-

Senile dementia, 24, 593 ; Differ-
ential diagnosis of, 597 ; Forensic
importance of, 598; Heredity in,
590, 597; Pathological changes
in, 598 ; Treatment of, 598.

Senile epilepsy, 24.

Senile psychoses, 24, 216, 228,
273, 483, 547, 548, 575; Anxiety
in, 369, 578, 585, 588, 590, 591,
592, 596; Apathy in, 590; Appre-
hensiveness in, 578, 579, 585, 586,
588, 590, 501, 592, 593, 596; At-
tention in, 585, 588, 595 ; Blood-
pressure in, 588; Consciousness
in, 585, 588 ; Course of, 589 ; De-
lusions in, 580; Depression in,
57.8, 579,. 585, 590, 593, 594, 596;
Differential diagnosis in, 590;
Emotional anomalies in, 579, 595 ;
Excitement in, 578, 593 ; Facial
expression in, 585, 596; Feeling
of insufficiency in, 579, 589; Gas-
trointestinal disturbances in,
588, 597 ; Grouping of, 577 ; Hal-
lucinations in, 584, 592, 593, 595,
596; Hypochondriasis in, 578
580, 582, 584, 586, 593; Impul-
sivity in, 593, 596; Insane ideas
in, 584, 585, 589, 593,. 5?6; In-
sight in, 582 ; Insomnia in, 588 ;
Irritability in, 593, 595 ; Memory
in, 575, 585. 588, 595: Motor
restlessness in, 586, 589, 591, 592,
596; Orientation in, 585, 593,595.:
Physical symptoms of, 588 ; Prog-
nosis in, 589; Speech in, 596;
Suspiciousness in, 595 ; Treat-
ment of, 591.

Senility, 107, 204, 575, 576.

Sensation, 27, 69, 88, 91, 94, 109, III,
112.

6i6

INDEX

Sensation, Anomalies of, 12, 29,
5i» 72, 73, 91 ; in acute alcoholic
hallucinosis, 302; in cocainism,
323 ; in delirium tremens, 292 ;
in dementia praecox, 378, 381, 388,
395; in epileptic mania, 479; in
hysterical delirious states, 508 ; in
idiocy, 232, 234 ; in manic-depres-
sive insanity, 342, 344; in myx-
edematous alienation, 329; in
neurasthenic states, 519; in pa-
resis, 420, 423, 446, 448; in pa-
retic seizures, 452; Significance
of, 32.

Sensation, Characteristics of, 55;
Methods of study of, 52.

Sensations, Analysis of, 6; Sub-
jective, 62.

Sense of deficiency in dementia
praecox, 381.

Sense of duty in paresis, 426, 448.

Sense of proportion in paresis, 426.

Sense of reality, 37.

Sense of recognition in hysteria,
498.

Sense of self-activity, Perversion
of, 35-

Sense of self-consciousness, Exag-
geration of, in litigious insanity,
572.

Sense of well-being, 47.

Sense perception, 54, 57; Disturb-
ances in, 56, 58; Intensity of, 54.

Sense, Stereometric, in paresis, 427.

Sensibility, Changes in organic, 71,
199

Sensory impressions, 28, 30, 31, 50,
"3-

Serum treatment of epilepsy, 491.

Sex as a cause of insanity, 193.

Sexual impulses, 108; in alcoholic
paranoiic states, 305; in arterio-
sclerotic psychoses, 553; in pa-
resis, 427, 459; in senile psy-
choses, 596.

Sexual organs, Sensory disturb-
ances of, in neurasthenic states,
520.

Sexual perversion, 530.

Skin in acute delirium, 264.

Sleep, 49.

" Snouting cramp," 96, 382.

Social position and paresis, 419.

Somnambulism, 411 ; in alcoholism,
290 ; in delirium tremens, 291 ;
in hysteria, 506.

Sound association, 75, yy, 78.

Speech, in alcoholic paranoiic states,
306; in cerebral syphilis, 458; in
cretinism, 331 ; in delirium tre-

mens, 294, 295 ; in dementia prae-
cox, 383, 385, 397 ; in epilepsy, 482,
484; in hysteria, 504; in idiocy,
232 ; in imbecility, 236 ; in Korsa-
kow's syndrome, 282; in manic-
depressive insanity, 350; in mi-
graine, 221 ; in multiple sclerosis,
457, 544; m paraldehyde intoxica-
tion, 317; in paresis, 250, 407, 409,
413, 430, 452, 455, 458; in paretic
seizures, 451 ; in senile psychoses,
596.

Speech compulsion, in delirium tre-
mens, 295; in dementia praecox,
388; in epileptic mania, 478; in
hepatic disease, 217; in manic-
depressive insanity, 75, 340.

Spiritualism, 30, 398.

Stdbchenzellen in paresis, 471.

Stadium dementiae, 358.

Stereotypies in dementia paranoides,
399; in dementia praecox, 382,
385, 386, 392, 395, 396, 400, 404,
405, 407, 485, 5io.

Stereotypy, 96, 138, 140, 250.

Strain, 368.

Structural changes and disorders of
function, 16.

Stupor, 372, 536; associated with
brain abscess, 548 ; in bromism,
323 ; in chloroform psychoses,
315 ; in delirium acutum, 263 ; in
dementia praecox, 386, 391, 392,
394, 395, 396, 401; in epilepsy,
290, 480; in hepatic disease, 217;
in manic-depressive insanity, 87,
352; in morphinism, 318; in pa-
resis, 444; in paretic seizures,

451-

Subacute states of delirium and
mental confusion, 266.

Subconscious impressions, 50.

Suggestibility, in delirium tremens,
294; in hysteria, 503.

Suicidal impulses, 107, 530; in
epilepsy, 474, 477; in morphinism,
320; in paresis, 445.

Suspiciousness, 12, zy, 45, 48, 98,
216; in alcoholic paranoiic states,
305 ; in arteriosclerotic psychoses,
552; in dementia praecox, 379,
381, 388; in myxedematous
alienation, 328 ; in paranoia, 571 ;
in paresis, 444; in senile psycho-
ses, 595.

Sydenham's chorea, 222.

Syphilis, 130, 219, 240, 241, 253, 487,
557; Cerebral, 458; complicating
dementia praecox, 229; in epi-
lepsy, 488; in paresis, 417; in

INDEX

617

relation to mental disease, 210,
559-

Syphilitic infection followed by
hysterical symptoms, 229.

Syphilitic psychoses, 558; Group-
ing of, 559; Pathology of, 562;
Treatment of, 562.

Syphilophobia, 560.

Tabes, Relation of, to paresis, 450.

Tabo-paresis, 324, 449.

Taphophobia, 529.

Temperature, in amentia, 269; in
dementia praecox, 402; in manic-
depressive insanity, 348; in mor-
phinism, 319; in paretic seizures,
451 ; in senile psychoses, 588.

Tenacity of the attention, 50.

Thought, 53.

Tic, Psychic, in chorea, 222.

Tics, 95; in dementia praecox, 396;
in imbecility, 95 ; in neuras-
thenia, 516; in psychasthenic
states, 526.

Time sense in delirium tremens,
294.

Tobacco intoxication, 323.

Topoalgias, 520.'

Toxic products, Manner of action
of, 23.

Train of thought, 49; in dementia
praecox, 381 ; in hysteria, 497,
503 ; in manic-depressive insanity,
406.

Trauma, 129, 130, 131, 201, 240, 241,
262, 274, 298, 368, 457, 487, 488;
Classification of cases of aliena-
tion following, 204; Forensic im-
portance of hysterical symptoms
following, 502 ; Histological
changes following, 202; Hypo-
chondriasis following, 203 ; Irrel-
evancy in hysterical disturbances
of consciousness following, 511;
in paresis, 418, 425.

Traumatic psychoses, Differentia-
tion of, from dementia paralyt-
ica, 202.

Treatment of mental cases, 146.

Tremor, in alcoholic paranoiic
states, 306; in cocainism, 322; in
dementia praecox, 402 ; in de-
lirium tremens, 295 ; in epi-
lepsy, 484; in fear, 109; in ma-
nic-depressive insanity, 117, 339;
in morphinism, 319; in multiple
sclerosis, 457, 544; in paralde-
hyde intoxication, 317; in pa-
resis, 428, 446, 452; in psychas-

thenic states, 529; in senescence,
576; in syphilitic psychoses, 561.

Trophic disturbances in paresis, 435,
454-

Tuberculosis, 62, no, 129, 130, 219,
240, 252, 270, 281, 309, 439, 487;
and infantilism, 243; and insan-
ity, 210; Euphoria in, 210.

Tuczek's fibre studies in paresis, 22.

Typhoid fever, 17, no, 130, 225, 241,
256, 257, 258, 262, 263, 274, 280,
281, 376, 488.

Unconsciousness, 70.

Uraemic delirium, 220.

Urine, in acute delirium, 264; in
arteriosclerotic psychoses, 553 ;
in delirium tremens, 296; in
manic-depressive insanity, 348; in
neurasthenic states, 538; in non-
myxoedematous infantilism, 244;
in paresis, 436, 437; in recurrent
mania and melancholia, 220; in
senile psychoses, 589.

Vascular changes, 24; in sene-
scence, 577.

Vaso-motor disturbances, in demen-
tia praecox, 402 ; in paresis, 435 ;
in neurasthenic states, 538.

Verbigeration, in dementia praecox,
369, 385, 396, 397. 40S, 408; in
epileptic mania, 478, 484; in myx-
edematous alienation, 328.

Vertigo, in bromism, 323 ; in lead
poisoning, 325 ; in senile psy-
choses, 597.

Vigility of the attention, 50, 51.

Visual disturbances in paresis, 432.

Visual hallucinations, 62, 65, 66;
and ocular disease, 64; in acute
delirium, 263; in chorea, 222; in
cocainism, 322, 323 ; in delirium
tremens, 292 ; in dementia prae-
cox, 397; in epileptic mania, 478;
in fever deliria, 258; in Graves'
disease, 334 ; in hepatic disease,
217 ; in hysteria, 496, 507 ; in
Korsakow's syndrome, 279; in
meningitis, 547; in migraine, 221;
in morphinism, 318, 320; in myx-
cedematous alienation, 329; in
paraldehyde intoxication, 316; in
paranoia, 571 ; in paresis, 439,
443, 447, 452 ; in psychasthenic
states, 531 ; Unilateral, 63.

Volition, Disturbances of, 87; For-
ensic importance of, 92; in de-
mentia paranoides, 398; in de-

6i8

INDEX

mentia praecox, 388; in hysteria,

498; in neurasthenic states, 519;

in paranoia, 570.
Volitional processes, 10, 52, 53, 120,

123 ; Definition of, 90.
Voluntary patients, 176.
Vorbeireden, see Irrelevancy.

Wandering mania, 47, 132, 196.

Weber's hypothesis, 54.

Weight, in acute delirium, 264; in
amentia, 270; in arteriosclerotic
psychoses, 557 ; in dementia prae-
cox, 404; in hypomania, 356; in
manic-depressive insanity, 348,
365, 540; in paraldehyde intoxi-

cation, 316; in paresis, 436; in
senile psychoses, 589.

Will, Freedom of, 93.

Witchcraft, Belief in, 30.

" Wonders," Arithmetical or Cal-
culating, 237.

Wort-salat, 383.

Writing, in dementia praecox, 383 ;
in manic-depressive insanity, 341,
351 ; in paresis, 431.

Zielvorstellung, 75.
Zoophilia, 108.

Zwangsvorstellungenpsy chosen, 101,
517.

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