KRAEPELIN Clinical Psychiatry

CLINICAL PSYCHIATRY
CLINICAL PSYCHIATRY
FOR STUDENTS AND PHYSICIANS
ABSTRACTED AND ADAPTED FROM THE SEVENTH GERMAN EDITION OF
KRAEPELIN'S "LEHRBUCH DEE PS YCHIATRIE "
BY
A.
ROSS DIEFENDORF, M.D.

IN
LECTURER
PSYCHIATRY IN YALE UNIVERSITY
MEMBER OF THE AMERICAN NEUROLOGICAL ASSOCIATION, OF THE NEW YORK NEUROLOGICAL ASSOCIATION, OF THE NEW YORK PSYCHIATRICAL SOCIETY, AND OF THE AMERICAN
MEDICO-PSYCHOLOGICAL ASSOCIATION, ETC.
NEW
EDITION, REVISED
AND AUGMENTED
gorfc
THE MACMILLAN COMPANY

LONDON: MACMILLAN &
1915
All rights reserved
CO. LTD.
COPYRIGHT, 1902, 190T,
BY
Set
THE MACMILLAN COMPANY.

Published May, 1902. Reprinted April, 1904. August, 1912; March, 1915.
up and
electrotyped.
ew edition, May,
1907
Norfooofi
J. 8.
Berwick & Smith Co. Cashing & Co. Norwood, Mass., U.S.A.
PREFACE TO THE FIRST EDITION

THE motive
for this
work was
to
make
the teachings
of Kraepelin in psychiatry accessible to American medical students and general practitioners, and, at the same time, to provide a full, but concise, text-book, not only for the
writer's
own
classes in psychiatry in the
Medical Depart-
ment
of Yale University, but as well for other American teachers who follow Kraepelin's views. Urged by the
rapidly increasing interest in Professor Kraepelin's teaching during the past five years in this country and the
constantly growing number of his disciples, it was the writer's first intention to publish a complete translation of the sixth edition of Kraepelin's " Lehrbuch der Psychiatric." It was feared, however, that a full translation
would be too large to best subserve the function of a textbook, and would have rendered impossible the adaptation
of
the Kraepelin psychiatry to our peculiar American
heeds.
The classification, terminology, and, wherever possible, the phraseology of this work are Kraepelinian, but the writer has taken the liberty of abbreviating disproportionately the description of some psychoses which are of less importance to the American physician, especially the
psychopathic states and thyroigenous insanity, and of laying more stress upon other more important forms, the description of acquired neurasthenia,
constitutional
traumatic neuroses, also the treatment in epileptic and

hysterical insanity
and acquired neurasthenia.
vi
PREFACE TO THE FIRST EDITION
The only omissions

and treatment
are the general etiology, diagnosis,
in the first volume of Kraepelin, but such as are of most importance have been added to the points etiology, diagnosis, and treatment of the different diseases.
The work has been done

duties
in the pressure of
routine
as Assistant Physician and Pathologist of the Connecticut Hospital for the Insane, and the writer begs
leave to express in this place his grateful appreciation of the generous advice and help of his colleagues in the
He is particuhospital, especially Dr. Charles W. Page. larly indebted to Dr. J. M. Keniston for a general revision of the text as well as for the arrangement of the chapter
on Epileptic Insanity, to Professor Raymond Dodge, Ph.D., of Wesleyan University, for criticism and suggestion with regard to the general symptomatology, and to Dr. August Hoch and Adolf Meyer for their continued inspiration and
critical assistance.
A.
MIDDLE-TOWN, CONNECTICUT, January 16, 1902.
EOSS DIEFENDORF.
PREFACE TO THE SECOND EDITION

THE
favorable reception of the
first
editions of Clinical
Psychiatry and its constantly increasing use as a text-book encouraged the writer to undertake a thorough revision
based on the seventh edition of Kraepelin's "Lehrbuch In accord with the present views of der Psychiatrie." Professor Kraepelin there are introduced many important
changes, both in the general symptomatology and in the For the condescription of the forms of mental disease.
venience of students the chapter on Methods of Examination is amplified by explicit practical suggestions adapted to the circumstances under which most of them will be
compelled to work, while the more elaborate procedure of the modern experimental laboratory has been omitted. In response to a general demand, an abridgment of the
chapter on the Classification of Mental Diseases is added to the present edition. Less hampered by restrictions as
to size, the present edition follows more closely the context of the "Lehrbuch." The description of the more important forms of insanity is less curtailed, while the
psychogenic neuroses and the psychopathic states which

received scant attention are
tion.
now
The chapter on Psychopathic
given fuller consideraPersonalities did not
appear in Kraepelin's earlier edition.

tried to
of his
The writer has make it clear by references wherever additions own have been made. The most important addihead of
tions without explicit references occur under the
Treatment.
vii
viii
PREFACE TO THE SECOND EDITION
in the preparation of the first edition, the work has been done under pressure of routine duties as Assistant
As
Physician and Pathologist of the Connecticut

for the Insane,
Hospital
leagues his Dr. Henry S. Noble, Superintendent, his grateful obligation for placing at his disposal the time and much of the material for the work.
Dr. J.
and the writer desires to express to his colappreciation of their help, and especially to
He
is
under special obligations to
M. Keniston
for help in reading proof
and the
arrangement of the chapter on Epileptic Insanity, and to Professor Raymond Dodge, Ph.D., of Wesleyan University,
for criticism
and suggestions with regard to the general symptomatology and the Psychopathic Personalities.
A.
MlDDLETOWN, CONNECTICUT,
April
6,
EOSS DIEFENDOKF.
1907.
CONTENTS
GENERAL SYMPTOMATOLOGY
PAGB
A. Disturbances of the Process of Perception VHallucinations and illusions, perception phantasms, repercep. .
. .
tion,
double thought, apperceptive
illusions, reflex halluci-
nations, hallucinations
and
illusions of hearing, sight, taste,
smell,
and touch.
14
Clouding of Consciousness Befogged states, disturbance of apprehension, retardation of apprehension, diminished sensibility. Disturbances of Attention Active and passive attention, blocking of attention, dulling of
.
.
.18
attention, retardation of attention, blunting of attention, passivity of attention, distractibility of attention, hyper-
prosexia.
B.
Disturbances of Mental Elaboration
......
; ;
23
Disturbances of memory, disturbances of the impressibility of memory, disturbances of the retentiveness of memory, disturbances of the accuracy of memory, fabrication of memory. Disturbances of orientation: time, place, and person disorientation; apathetic disorientation perplexity; delirious disorientation amnesic disorientation delusional disorien;
tation.
Disturbances of the Formation of Ideas and Concepts Disturbances of the Train of Thought . ., .,
29 30
External association of ideas, internal association of ideas,

paralysis of thought, retardation of thought, compulsive
ideas, simple persistent ideas, perse veration, stereotypy, cir-
cumstantiality, flight of ideas, rambling thought, desultoriness.
Disturbances of Imagination . . Simple sluggishness, retardation, indifference, excitation of the imagination, heightened suggestibility, autosuggesti. . . .
.43
bility.
Disturbances of Judgment and Reasoning
47
Knowledge and
belief, delusions,
systematized delusions, delu-
ix
CONTENTS
sions of self-depreciation, delusions of poverty, nihilistic delusions, delusions of persecution, delusions of jealousy, hypochondriacal delusions, delusions of self-aggrandize-
ment, delusions of mental soundness (absence of insight),

expansive delusions. Disturbances of the Rapidity of Thought Retardation, acceleration. Disturbances of Capacity for Mental Work
Disturbances of Self-consciousness Dual personality, double consciousness, falsifications of

consciousness.
..... .... ......

self-
56 57
58
C.
Disturbances of the Emotions Diminution and Increase of Emotional Irritability
Emotional deterioration, temporary increase of emotional irritability, change of mood.
Morbid Temperaments
irritable
Increased susceptibility to the unpleasant, apprehensiveness,

dispositions,
morbid Morbid Emotions

fanaticism,
Fear, compulsive fears, phobias, dejection, sadness with ex-
citement, morbid feeling of pleasure, wanton happiness, drunkards' humor, feeling of well-being.
Disturbances of General Feelings Ennui, fatigue, hunger, nausea, pain, feeling of shame, sexual indifference, increase of the sexual excitability, perverted
sexual feelings.
........ ... ....... .65 .......... ......

62
62
seclusiveness,
sunny
dispositions,
frivolity.
68
73
D. Disturbance of Volition and Action Diminution of Volitional Impulses

Paralysis of the will. Increase of Volitional Impulse
...... ...... .......

....
will, rigid
77 77 78 79
Motor excitement, pressure of activity, busyness. Impeded Release of the Volitional Impulse Psychomotor retardation, stupor, blocking of the
tension.
Facilitated Release of Volitional Impulses Distractibility of the will.
Heightened Susceptibility of the Will
..... .....
81
83
Weakness
of will, hypersuggestibility, catalepsy, cerea flexibilitas, echopraxia, echolalia, distractibility of the will.
Interference and Stereotypy
.......
84
Crossing of voluntary impulses, stereotypy, mannerisms, superfluous embellishment, derailment of will.
CONTENTS
Diminished Susceptibility of the Will Negativism, mutism. Compulsive Acts Impulsive Acts
xi
PAGK
88
90 90
91
Morbid Impulses
Contrary sexual instincts, sadism, masochism, fetichism, kleptomania, pyromania. Disturbances of Expression Conduct arising from a Morbid Basis
.......... .......... ........ .....

anamnesis of the
field,
93
95
97
Methods of Examination
Family
history, personal history, disease,
status prsesens, disturbances of perception, clouding of consciousness, disturbances of apprehension, disturbances of attention, disturbances of memory, orientation, train of
thought, judgment, emotional
volitional field.
FORMS OF MENTAL DISEASES

Classification of
Mental Diseases
115
115
121
Consideration of the Factors entering into a Provisional Classification

I.
Infection Psychoses
A. Fever Delirium
Etiology. Course.
121
Pathological anatomy.
Prognosis.
of
Symptomatology.
125
Treatment.
B.
Infection Deliria
Initial
Infection typhoid, of smallpox. delirium of malaria. Delirium of chorea. Deliria

deliria
of influenza, hydrophobia,
and
septic states.
Acute
131
delirium.
C.
Post-infection Psychoses
Mild Form.
II.
Second group.
.
Severe form.
J
.
'
Cerebro-
pathia psychica toxamica.
Exhaustion Psychoses A. Collapse Delirium

Etiology. Course.
.
.
.
.
.
...
136
VT*,
.
137
Pathological anatomy.
Diagnosis.
Prognosis.
Symptomatology. Treatment.
.
. B. Acute Confusional Insanity (Amentia) Course. Diagnosis. Symptomatology. Etiology. Prognosis. Treatment. C. Acquired Neurasthenia (Chronic Nervous Exhaustion) .
.
141
146
Etiology. Course.
Symptomatology.
Diagnosis.
Physical
Prognosis.
symptoms. Treatment.
xii
CONTENTS
PAGE
III.
Intoxication Psychoses 1. Acute Intoxications
........
Santonin.
159
159
Ptomaines.
2.
Chloroform.
Hasheesh.
162
Saturninia. Encephalopathia. Chronic Intoxication A. Alcoholism Acute Alcoholic Intoxication pathological and anatomical findings Chronic Alcoholism etiology, pathological anatomy, symptomatology, prognosis, diagnosis, treatment Delirium Tremens: etiology, pathological anat:
162 162
165
omy,
symptomatology,
Psychosis
:
diagnosis,
prognosis,
treatment
172
etiology,
Korssakow's
pathological
diagnosis,
anatomy, symptomatology, treatment
course,
183
etiology, symptoma-
Acute Alcoholic Hallucinosis
tology, course, diagnosis, prognosis, treatment Alcoholic Hallucinatory Dementia: symptomatology, course, diagnosis
.
189
195
197 200 201
Alcoholic
Paranoia: symptomatology, diagnosis, treatment
course,
Alcoholic Paresis
Alcoholic Pseudoparesis
J5.
Morphinism
Etiology.
..... ........
Anatomy.
Acute MorCocain
Hallucinosis.
202
Pathological
Chronic Intoxication. phine Intoxication. Course. Abstinence Symptoms. Diagnosis. Treatment. Prognosis. C. Cocainism Etiology. Acute Cocain Intoxication. Chronic
209
Cocain
IV.
Intoxication.
Prognosis.
Thyroigenous Psychoses A. Myxoedematous Insanity

Etiology.
........
Treatment.
Course.
214 214 216
Symptomatology.
Treatment.
B.
Cretinism
Etiology.
Pathological Anatomy.
Symptomatology.
.
Treatment.
V.
Dementia Praecox
Etiology
219 219
221
Pathology
CONTENTS
General Symptomatology: disturbances of apprehension,
disturbances of orientation, hallucinations, disturbance of consciousness, disturbance of attention, disturbance of memory, disturbance of the train of thought, dis-
xiii
turbance of judgment, disturbance of the emotional field, disturbances in the volitional field
. . .
Symptoms Hebephrenic Form: symptomatology,

Physical
course
222 229
physical symptoms,
230
Catatonic
pathological anatomy, physical symptoms, course

:
Form:
symptomatology,
241
Paranoid Forms Dementia Paranoides: symptomatology, physical symptoms, course

:
Second Group symptomatology, course Diagnosis of Dementia Prsecox Treatment of Dementia Prsecox
......... ....
.
257
260 265 272

276
VL
Dementia Paralytica
Etiology (juvenile paresis)
Pathology
Pathological
276 279
Anatomy
:
280
General Symptomatology
disturbances of apprehension, disturbances of memory, disturbances of the train of

.
thought, disturbances of judgment, disturbances of the . . . . . . emotions, conduct
285
Physical Symptoms sensory symptoms, paralytic attacks, disturbances of speech, ataxia, reflexes, vasomotor dis:
turbances
Demented Form
Expansive Form (megalomania)
......
.
290 299
301
Form (galloping Depressed Form

Agitated
paresis)
307 310
Course of Dementia Paralytica Diagnosis of Dementia Paralytica

Prognosis (arrested paresis)
314 315
318
319
VH.
Treatment Organic Dementias

Gliosis of Cortex (diffused cerebral sclerosis)
.
323
. .
323 323
326
Huntingdon's Chorea: physical symptoms, course, diagnosis, pathological anatomy Multiple Sclerosis Cerebral Syphilis: simple syphilitic dementia, syphilitic
......
pseudoparesis
326
xiv
CONTENTS
PAGB
Tabetic Psychoses
Arteriosclerotic Insanity: pathological anatomy, symptomatology, severe progressive form, diagnosis, treatment
332
333
341
Cerebral
Tumor
Brain Abscess
Cerebral Apoplexy Cerebral Trauma traumatic delirium, traumatic dementia Involution Psychoses
:
343
343 344 348
VIII.
A. Melancholia
Etiology. Pathological anatomy. Symptomatology delusions of self-accusation, hypochondriacal delusions,
:
348
hallucinations,
disturbances
of
nihilistic delusions.
B.
Diagnosis. Presenile Delusional Insanity

Etiology.
Physical symptoms. Prognosis. Treatment.
thought, Course.
.....
Diagnosis.
364
Symptomatology. nosis. Treatment. C. Senile Dementia

Etiology.
Prog-
369
Pathological anatomy. Symptomatology. Physical symptoms. Severer grade of senile deSenile Delirium. Sementia. Presbyophrenia.
nile Delusional Insanity.
IX.
Manic-depressive Insanity
Etiology
.......
Diagnosis.
Treatment.
381
381
Symptomatology: disturbances
of apprehension, disturbances of perception, disturbances of memory, disturbances of judgment, disturbances of thought, disturbances of the emotional and volitional fields
....
382
Manic States
390
:
Hypomania Mania (Tobsucht)

course
Delirious
..........
:
symptomatology, physical symptoms, course
390 394
symptomatology, physical symptoms,
Mania: symptomatology, physical symptoms,

397 400 400 402
course
Depressive States
Simple Retardation
Delusional
Form
Stuporous States
symptomatology, course symptomatology physical symptoms, course

:
Mixed
States
405 407
Irascible mania.
Depressive excitement.
Unproductive
stupor. Depression with a flight of ideas. Depressive state with flight of ideas and emotional ela-
mania.
tion.
Manic
CONTENTS
Course
of
xv
lucid
Manic-depressive
intervals, transition states
Diagnosis
Prognosis
Treatment
X.
Paranoia
nosis.
Etiology.
Querulent Insanity
XI.
Epileptic Insanity
.......... .......... ........... ........ .........

Symptomatology. Treatment.
Course.
Diagnosis.
insanity,
post-epileptic
epileptic
...... ..........
Insanity
:
duration,
412
415
417 419 423
Prog432
434
Etiology. Pathology. Symptomatology. Physical sympPeriodical ill-humor. toms. Befogged states: preepileptic
insanity,
-psychic
epilepsy,
deliria,
somnambulism,
conscious
stupor,
anxious
delirium,
dipsomania.
Diagnosis.
Prognosis.
Treatment.
XII.
The Psychogenic Neuroses

A. Hysterical Insanity
Etiology.
driasis.
....... .......
:
457
457
Pathology.
cal personality, changes in character,
Symptomatology: hysterihypochonBefogged states Physical symptoms.

states,
delirious
hysterical lethargy,
somnambuProg. .
lism, silly excitement. nosis. Treatment.
Course.
Diagnosis.
B.
Traumatic Neurosis (traumatic hysteria) Etiology. Symptomatology. Diagnosis. Treatment. C. Dread Neurosis
Symptomatology.
Course.
475
Prognosis.
XIII.
Constitutional Psychopathic States.

eracy.)
A. Nervousness
Symptomatology. Course. B. Constitutional Despondency Symptomatology. Course. C. Constitutional Excitement
Symptomatology. Diagnosis. Treatment. D. Compulsive Insanity Tormenting Ideas: onomatomania, arithmomania, Griibelsucht, folie du doute, erythrophobia. Phobias
:
........ .......... ......... ...... ...... .......

Diagnosis.
480
Treatment.
(Insanity of Degen-
485
485 492
495 498
Diagnosis.
Treatment.
Treatment.
agoraphobia, mysophobia, delire du toucher.
Crises. Impulsions. Course. Prognosis.
Treatment.
xvi
CONTENTS
PAGR
E. Impulsive Insanity
507
The impulse
F.
to
tramp.
Pyromania.
Impulse to kill. Course. Contrary Sexual Instincts Etiology. Symptomatology. Treatment.
Kleptomania. Diagnosis. Treatment.

510
Diagnosis.
Prognosis.
XIV.
Psychopathic Personalities A. Born criminals (moral insanity, "delinquente nato,"
515
XV.
moral imbecility). Etiology. Symptomatology. Diagnosis. Treatment B. The Unstable Symptomatology. Diagnosis. Treatment. C. The Morbid Liar and Swindler Symptomatology. Prognosis. Treatment. D. The Pseudoquerulants Diagnosis. Treatment. Defective Mental Development A. Imbecility stupid form, lighter grades, energetic type. Course. Diagnosis. Treatment B. Idiocy
:
515
521 526 531 536
536 544
....
:
}/
Etiology.
Pathology.
Symptomatology
severe
cases, light cases.
Diagnosis.
Prognosis.
Treat-
ment.
ILLUSTRATIONS
FACING PAGK
PLATE
1.
Muscular tension in catatonic stupor

Muscular tension in catatonic stupor
Cerea
flexibilitas in catatonic stupor
246
PLATE
PLATE
FIG.
2. 3.
1.
248
Catatonic writing showing verbigeration
....
.
250
251
PLATE
PLATE
4. Illustrates the normal pyramidal cell of the cerebral cortex and the cytological changes occurring in dementia paralytica
282
5. The normal cerebral cortex cerebral cortex in idiocy and dementia paralytica also the glia in the normal cortex, the presence of spider cells in dementia paralytica and their relation with
; ;
the blood-vessels
284
paretics, illustrating the lack of expression in
PLATE PLATE
FIG.
6.
group of
the countenance and the inelastic attitude

7.
1.
294
296
Paretic handwriting
Paretic handwriting
Paretic handwriting showing partial agraphia
.
296
.
.
FIG. FIG.
2.
296 296
3.
8.
Paretic handwriting showing complete agraphia .

Paretic handwriting
all of
PLATE
PLATE
298
9. Group of three cases of Huntingdon's chorea, were trying to look at the photographer
whom
324 334 396
PLATE PLATE
10.
Arteriosclerotic cortex
normal cortex
....
11.
Self-decorated
.
manic patient
PLATE
FIG.
12
1.
398
398
.
Macrocephaly
Microcephaly.
. .
FIG. 2.
398
398
.
FIG.
3.
Representing asymmetry of cranium and face Representing asymmetry of cranium and face
.
.
FIG. 4.
398
A.
DISTURBANCES OF THE PROCESS OF PERCEPTION
perception of external sensory stimuli depends two conditions: the adequate stimulation of the upon sensory end organ and the elaboration of this stimulation
;
THE
by the central nervous system. The loss of one or more of the senses modifies mental
development in proportion to the importance of the sensory material lost and the possibility of substituting other
sensory experience.
Loss of sight is relatively unimportant, but loss of hearing, on account of its relation to
language, is of great importance indeed, unless specially trained, deaf mutes remain mentally weak through life.
;
Illusions and Hallucinations. More important than the mere absence of sensory experience is its falsification.
Inadequate stimulation of the sense organ produces " of impressions corresponding to the "specific energy that sense for instance, an electric current may produce a sound, a taste, a tactual or a visual sensation, according
;
as
it
stimulates the corresponding sense organ.
Such sen-
sations are real illusions, but they do no harm because they are immediately recognized as illusions. In conditions of mental disturbance,
on the contrary, especially
where there
is great clouding of consciousness, the subsensations of light as the result of congestion of jective
fire
the eye, or a roaring in the ear, may be interpreted as or torrents of water, giving rise to genuine deceptions
This sort of peripherally conditioned sense deception has been called elementary, on account of its origin in that part of the sensory apparatus which receives the stimulus.
States of consciousness similar to sensory perceptions may be produced by the excitation of the so-called cortical
which are not corrected.
naturally referred to an external object, and results in an illusion as to the real source of the stimulus. This group of hallucinations may be
sensory areas.
This
is
called perception phantasms.
They may occur
in
normal
individuals, particularly at the onset of sleep, as hypnogogic hallucinations. In abnormal conditions, they are
extremely vivid and misleading. They usually bear no relation to the content of thought, and, conseoften
quently, seem to the patient to belong to the external world. They have a fairly uniform content, subject only to slight modification (stable hallucinations of Kahlbaum),
and consist of senseless words, noises, figures, and the like, which are repeated over and over again. Because of their
central origin, they
may
occur after destruction both of
the peripheral sense organ and the afferent nerve. The cases of hemilateral disturbance of the field of vision, in
which the gaps produced by the disordered perception are

filled
out by the patient, point clearly to central origin in that portion of the cortex which has to do with visual
perception. There are some cases in which sense deceptions have prevailed in the normal half of the field of vision, where the cortex in both occipital lobes has been
diseased.
of the bilateral cortical blindness there has
Again, coincident with the rapid development been observed

of active perception of light.
sudden development
Peripheral influences may also produce, directly or indirectly, conditions of excitation in the higher portions of the sensory tracts, which lead to sense deceptions, particuthe general irritability of these parts is increased. In morbid conditions, ordinary organic stimuli suffice to
larly
if
produce such falsification. In other cases, these hallucinations may appear if attention is merely directed to that sensory field, or if an emotional condition temporarily
increases the general susceptibility to stimulation. It disappears, on the other hand, as soon as the patient
becomes quiet or directs

conversation,
of environment, etc.
his attention elsewhere, as in
manual or mental employment, change
Further evidence of cooperation of conditions of stimulation in the sense organ is found in the occasional occurrence of one-sided hallucinations, the
frequent association of chronic middle ear disease with hallucinations of long standing, and the production of
hallucinations of sight in alcoholic delirium by gentle pressure on the eyeball. Usually these sense deceptions appear only in a single sensory field, and are frequent in the fields of hearing and sight.
tions
most
Sense deceptions are divided clinically into hallucina-
and
illusions.
In
the the
former there are no recoglatter
nizable
external stimuli;
real percepts.
ficult to
In some
are falsifications of cases this distinction may be dif-
carry out on account of internal stimulation of the sense organs, such as occurs in phosphenes, entotic
noises, etc.
In other cases the distinction
is clear.
The
perception of ghosts in moving clouds and limbs of trees, curses and threats in ringing bells, are evidently illusions. But the well-known visual disturbance of the alcoholic,
and the voices which torture the condemned
in his prison,
when everything
is
quiet, are pure hallucinations.
The universal
characteristic of the entire group of sense
deceptions
is
their sensory vividness.
They depend on the
same sort of cerebral processes as does normal perception, and the false perception takes its place in consciousness among the normal sensory impressions without any disThe patients do not merely tinguishing characteristic. believe that they see, hear, and feel, but they really see, hear, and feel. In morbid conditions very vivid ideas or memory images may assume the form of hallucinations, being regarded by
the patients as real perceptions of a peculiar kind. Many investigators hold that all false perceptions should be regarded as ideas of imagination of extraordinary sensory
vividness.
But
in order that
an idea attain the
clearness
This special cause must be present. is indicated by the fact that in patients suffering from hallucinations, not all, but only certain groups of ideas
of a perception,
some
seem to play a role in the sense deceptions, and besides these there are usually ideas of the ordinary, faded, and formless The element which makes a hallucination out of type.
a vivid idea
tral
probably a reflex excitation of those censensory tracts, through which alone normal stimuli
is
come
to
consciousness
.
(the so-called
"reperception" of
If it is really these areas of the brain through Kahlbaum) whose excitation perception acquires its peculiar sensory
marks,
sions.
lies
it is
easy to see
how they may
participate in vary-
ing degrees in the active process of
renewing previous impresthere
A view of this sort would explain the fact that
ness
between the sense deception of pronounced sensory vividand the most faded memory image an unbroken series
It is possible that during the ordinary
this reflex excitation or reperception
is
of transition stages.
thought processes
always present in a very slight degree, but that only when
the process becomes morbid, or the sensory areas themselves are in a condition of increased excitability, does the vividness
of the
tion.
memory
picture approach that of true sense percepProbably there is, moreover, a definite relation beirritability
tween the strength of the reperception and the

of the sensory areas
;
the greater their irritability, the more easily will the memory images attain sensory vividness, the lighter the reflex excitation need be to release them, and the
more independent they are of the current of thought. The extreme case would be found in the sense deceptions depending upon local excitation, which seem to the patient to be something quite foreign and external. The extreme case in the other direction would be those instances which are
not true sense deceptions at
sible to
all,
but merely ideas of great
sensory vividness. By careful investigation it is often posanalyze the data given by the patient, which apparently indicated hallucinations, and to discover that the patient does not regard the impression as objectively real,
but
merely differentiates
the reperception
is
it
from
of its forceful vividness.
his ordinary ideas on account In these cases it is probable that
special sensory tracts
strongly developed, while irritability of This seems to be is not increased.
borne out by the fact that this group of hallucinations, which has been variously designated as psychic hallucinations
(Baillarger), pseudohallucinations (Hagen),
and apprehen-
sion hallucinations (Kahlbaum), involves several or all of the sensory fields, and that it always stands in close relation to the other contents of consciousness
fications of perception,
;
while the true
falsi-
a single sensory tract,

thought.
on the other hand, usually belong to and are independent of the train of
A striking illustration of this type of hallucinations is found in a condition called "double thought." Immediately
of
upon the appearance
any idea, the patient has another distinctly subsequent idea of the same thing i.e. every idea This double is followed by a distinct sensory after-image. thought occurs most frequently when the patients are reading, sometimes when writing, and occasionally, also, when The sensory linguistic ideas come vividly to consciousness. if the words are actually spoken. after-image disappears
;
Other hallucinations of hearing universally accompany

condition.
this
Apperceptive illusions are those in which subjective elements unite with the objective sensory data, giving rise to a distorted and falsified impression. They are of very fre-
quent occurrence in normal life prejudice, expectation, and the emotions continually influence our perceptions even in Even the most transpite of our earnest effort to be neutral.
;
quil scientific observer is never quite certain that his per-
ceptions do not unconsciously suit themselves to the views with which he approaches his investigation while in reading
;
we
unconsciously correct the errors of the type-setter from the residua of our experience. In mental disturball
for this falsification of apprehension.
ances the conditions are often extraordinarily favorable Marked emotional
excitement, great activity of the imagination, and finally, the inability to sift and correct experience by reason, all are favorable to its development. Thus, it frequently hap-
pens that the sensory impressions of patients take on fantastic forms and become the basis of a thoroughly falsified apprehension of the external world, even when there are
no true hallucinations. This phenomenon naturally occurs most frequently, both in normal and abnormal states, when the sensory impressions are confused and indefinite, and not
readily differentiated.
There
is
an
allied
group of disturbances which consists

in the release of a false perception in
one sensory
field
through a real impression received by another, constituting the so-called "reflex hallucinations of Kahlbaum." sensory stimulus may produce conditions of excitation,
which, transferred to an over-excited sensory area, occasion the development of an hallucination. Similar conditions
are daily encountered in the so-called sympathetic sensations, like the unpleasant sensation of an inexperienced onlooker at a painful surgical operation. In morbid conditions these may be very marked. Especially sensations of
movement which
frequently
accompany sense impressions
seem way. There are patients who feel on their tongues the words spoken by others; a glance from some one may excite a sensation of strain.
to rise in this
which
very important characteristic of sense deceptions, in one way points to their origin and in another to
their importance as a disease

irresistible influence
symptom, is the powerful and which they exert over the entire thought
It is true that occasionally
;
and
activity of the patient.
sound and, pronounced also, that at the beginning, as well as at the end, of a mental
illusion
appears in persons mentally
disease the illusions are often recognized as such, because of their improbable content, but usually persistent illusions and
hallucinations overpower the judgment, and ultimately the patients invent the most foolish and fantastic explanations
to account for them.
The
tions
basis for this irresistible influence
is
not to be found
in the sensory vividness of the illusion, since real sensa-
and
definite evidence are useless as correctives.
Its
explanation is found rather in the intimate connection between the illusions and the patient's innermost thought, morbid
fears,
and desires. The emotional states and the feelings color the illusions in a peculiarly high degree, as one might
10
expect from their influence in normal life. It is frequently observed, especially in the end stages of dementia praecox,
that illusions appear only in connection with the periodical vacillations of the emotional state, while they completely disappear in the interval. This influence of the emotional
life
upon the thought and actions only disappears with recovery, or when progressive deterioration obliterates emoIn both cases the illusions
tional activity.
may
continue,
but the patients do not react upon them. These facts manifestly disprove the general view that
real
sense deceptions regularly, or even frequently, act as the causes of delusions. To be sure, patients point to their hallucinations as the basis of their symptoms, but
there can be no doubt that the sense deceptions have a common source of origin with the other disturbances of the
In reality the patient's attitude toward his illusions and hallucinations is not the same as his attimental equilibrium.
tude toward his actual perceptions. No healthy individual would refer to himself such words as "That is the president,"
and then immediately believe he must be the president. But when these words form the keystone of a long chain of secret misgivings, an hallucination of that sort makes the most profound impression, and immediately there arises a firm conviction, not only that the words were really spoken,
but that they express the truth. In view of these facts we see no special practical value in distinguishing in single cases whether the delusion, the
emotional state, or the corresponding sense deceptions appear first. In the vast majority of cases, and especially where the sense deceptions appear with persistent delusions, all of these disease
symptoms
result of
one and the same
common
are certainly only the cause.

large
Illusions
and hallucinations present a
number
of

clinical types in the different sensory fields.
11
fre-
The most
quent sense deceptions of sight are those which occur at night, the so-called visions; God, angels, dead persons, The less distorted figures, wild animals, and the like.
sense deceptions of sight which appear in daylight along with the normal impressions are much more like
common
normal perceptions and consequently more deceptive.
The
sense deceptions of the alcoholics are of this type (see The objects of the surroundings may take on an p. 176).
entirely different appearance;
vice
patients mistake strangers
for relatives and versa, and believe that the same persons are taking on different forms and faces, are making
grimaces, etc.
The most important sense deceptions

so-called voices,
of hearing are the
by The basis for their importance lies in the fundamental significance of language in our psychic life. The
is
a term which
usually well understood
the patient.
voices usually have
an intimate relation to the content
of
consciousness;
for
in fact, they are the linguistic expressions
of the patient's inmost thought,
and
for this reason

all
have
him a
far greater convincing
power than
other sense
deceptions, more even than real speech. The voices mock the patient, threaten him, and tell his secrets. They are heard in the scratching of a pen, in the barking of dogs, etc. Sometimes there are several distinct "voices" with characteristic differences.
Usually they are low, as if coming from a distance, though occasionally they are loud enough to drown all other noises. It rarely happens that the "voices" speak long sentences. Usually they consist of short, interrupted remarks. The hallucinations in fever delirium and in greatly bewildered patients are changeable and confused.
Auditory sense deceptions are seldom indifferent to the
12
almost always accompanied by strong emotional disturbances and wield a powerful influence over the patients' actions. They make them distrustful, excited,
patients, but are
and even drive them

tormentors.
to angry attacks
on
their imaginary
The
so-called
"internal
voices"
etc.,
"suggestions,"
"tele-
phoning," "telegraphing,"
form a special group of
hallucinations of hearing. These naturally are not regarded by the patients as sensory in their origin. They may occur
monologue or as a conversation with distant persons; sometimes the voices of conscience seem to critias a kind of
the patient or spur him on. In all these cases the patient develops the delusion that his thoughts are known to every one, or that they are produced and influenced by outcise
side forces.
Sense deceptions in the other senses are of much less importance. False perceptions of taste, smell, dermal,
muscular, and general senses, so far as they derive their the origin from the thoughts of the patient, and not from
disturbance of the sense organs, point to a profound change of the whole psychical personality.
Where
delusions of electrical influence, of position, of
incasement of different organs of the body, the disappearance of the ears, mouth, etc., are present we no longer have simple illusions and hallucinations, but almost always a
severe disturbance of the higher psychical processes. Hallucinations develop differently. One might judge The type of the hallucination this from their great variety.
may
be determined in a measure by the form of the mental In fever delirium and infection psychoses the disease.
hallucinations
and
illusions are variable
curring in all the different fields of sensation
and dreamlike, ocand producing

Similar hallu-
a most confused and fantastic experience.

cinations
13
and
illusions exist in the alcoholic delirium,
but
here they present a peculiar sensory vividness and they combine so that the separate experiences are much more definite.
Indeed, they combine so intimately with each other that they offer a good foundation for the development of " an occupation delirium." Another characteristic of these alcoholic hallucinations and illusions is that they are very
numerous and change rapidly. These sense deceptions, originating as they do from imperfectly perceived impressions, can even be created and influenced by mere suggestion. The hallucinations in cocainism which appear in the visual and auditory fields and in the field of general sensibility " are closely related. The microscopic" hallucinations of
the perception of numerous minute objects, little animals, or holes in the wall On the other hand in the epileptic delirium or little points.
sight are particularly characteristic;
i.e.
the hallucinations are accompanied by a peculiarly intense tone of feeling; for instance, the sight of blood, of fire, objects of fear, the hearing of threats, the noise of shooting,
In all of these conditions it is or the music of angels. an extensive involvement of the corprobable that there is
tex by the disease process. This seems the more probable as clouding of consciousness regularly accompanies these
states.
tory delirious states

ferent senses:
Other disease processes present even more transiwith hallucinations involving the dif-
such as manic-depressive insanity, senile dementia praecox, and occasionally paresis. In dementia, the bewildered and excited stages of dementia praecox hal-
lucinations of hearing predominate, while in similar states in manic-depressive insanity hallucinations of sight are more prominent, and particularly hallucinations of the general sensibility.
In paresis illusions are
much more
evident
infre-
than hallucinations, although both are comparatively
14
quent. There is only a small group of cases in which the sense deceptions involve only a single sensation ; as, for instance, in
most cases
of acute alcoholic hallucinosis,
some
cases of alcoholic hallucinatory dementia, in there are very striking hallucinations of hearing. Also in some epileptic states, hallucinations of hearing only appear.
and which
Hallucinations of hearing alone are by far most frequent in dementia prsecox. They are rarely absent long. Usually
they represent one of the

tinue as the only
hallucinations
first
symptom
for
symptoms and often they consome time. In the delirious

It
is
states of dementia prsecox they are usually associated with
and
illusions of the other senses.
also in
dementia praecox that the peculiar disturbance called " The content of the haldouble thought" mostly occurs. lucinations is of a fearful or disturbing nature only at the beginning, while later it becomes more or less indifferent and
senseless,
which
is
in
marked contrast
to the other forms of
mental diseases mentioned above.

Clouding of Consciousness. within us characteristic mental
External stimuli occasion
phenomena which we appre-
hend immediately and distinguish as presentations, feelThis experience is designated as conings, and volitions. which is present whenever physiological stimuli sciousness,
are converted into psychic processes.
sciousness
eral
is
The nature
of con-
obscure, yet we know not only that it in gendepends upon the functioning of the cerebral cortex, but also that its individual phenomena are connected with definite, but as yet undetermined, physiological processes
in the
nervous system.
Just as the transition of the external
stimuli into sensory excitations depends upon the nature of the sensory organ, so the condition of the cerebral cortex
is
cal into conscious processes.
the determining factor in the transformation of physiologiWhether such transformation

takes place in individual cases
is
15
mine, since
we have no immediate
often very difficult to deterinsight into the inner
experience of others and are compelled to draw our conclusions from their behavior.
The condition
in
which the transformation
of physio-
logical into psychical processes is completely suspended, is designated unconsciousness. Every stimulus which crosses
the threshold of consciousness, thereby arousing a psychic process, must possess a certain intensity which cannot sink
below a definite
limit.
This limit
is
called the threshold
value and varies greatly according to the condition of the While it is lowest in strained attention, the threshcortex.
old value reaches infinity in the deepest coma. It is thus possible to distinguish different degrees of the clearness of consciousness according to the character of the threshold
But even when conscious processes are no longer aroused by external stimuli, consciousness in the form of obscure presentations and general feelings may still
value.
exist.
the clearness of consciousness decreases sufficiently, befogged consciousness results (Dammerzustand) during
If
,
which neither the external nor internal stimuli can create These befogged states are clear and distinct presentations.
encountered in epileptic and hysterical insanities, as transitory states contrasting sharply with the normal life of the
Prolonged befogged states are also found in mental processes are rendered difficult and the which
individual.
psychophysical threshold is considerably raised. Sometimes the threshold value may be so altered that it is different for external
and
internal stimuli
that
is,
while
external stimuli have
little effect,
vivid conscious processes. The opposite condition obtains in states.
internal stimuli produce This is what occurs in delirious
demented
states,
16
where not infrequently external stimuli easily produce sensations, while internal have little effect in consciousness. What occurs here is not an increase of the threshold value,
but a prolonged sinking of the psychophysical excitation. Indeed, this is the distinction between dementia and the
befogged states. Disturbance of Apprehension. The full effect of an external stimulus takes time. Experiment demonstrates that our sense perceptions reach the point of greatest clearness only after a period of
some seconds.
be retarded.
Under some
Stimuli of
all,
circumstances this process

incompletely, although no
is
may
short duration are either not apprehended at

If
or only
real difficulty of apprehension
the retardation in the development of sensory impressions is considerable, the impressions fade away before they are really perceived. Some very strong
present.
impressions may be apprehended, but they are more or less incoherent because the connecting links and the
accompanying events reach consciousness only in an incoherent and confused form. This disturbance of apprehension in its pronounced form is encountered in senile dementia (presbyophrenia) and Korrsakow's psychosis, but exists in a much less marked degree in many other
psychoses, particularly of the delirious type. The apprehension of external impression requires not only the development of a percept of sufficient strength,
absorption into the systematic interconnections of our experience. The vast majority of our impressions Presenat any given moment are obscure and confused.
its
but also
tations only become clear of past experience in the
and distinct when they find residua " memory, resonators," as it were,
through whose sympathetic vibration the sensory stimuIt is through this process, which lation is intensified.
17
apperception," that each percept becomes united with our past experience, through which alone it can
calls
Wundt
"
be understood.
by memory
of perception.
This supplementing the given impression images greatly increases the delicacy of our
it
apprehension, but brings with
the danger of a falsification
The most frequent type

hension
stimuli.
is
apprethe increase of the threshold value for external

intense the stimuli
of the disturbance of
must be in order to produce an impression, the more confused and defective will be the picture of the external world. The patients
apprehend only a small part of the impressions which they receive. They fail to note and to understand their
environment.
The more
We
call
this
diminished sensibility.
The
gradual development
is
of this disturbance of apprehension
found in simple fatigue and its transitions into sleep, but also in the morbid states of extreme mental exhaustion. Ether and chloroform isolate our consciousness from
number
hol,
the external world most completely and rapidly, but a of narcotics act in a similar way ; such as, alco-
paraldehyde, and trional. Diminished sensibility

in fever,
is
also
found
it is
and intoxication
deleria, as well as in the
clouded consciousness of epilepsy and hysteria. Oftentimes also found in the various phases of manic-depressive
insanity, especially in the depressive and manic stupor, but also in the more intense maniacal excitement.
The
tal
entire sensory experience in the first stages of mendevelopment remains on the plain of simple perception.
of the external world have left no memory residue there is no network of psychological associations through which new experience may be related to the past. In the severest forms of arrested mental
As long as the impressions
development
this condition persists,
and there
is
no possi-
18
bility of the
gradual clearing of the clouded consciousness. It remains forever a confused medley of vague isolated
is
presentations and feelings, in which there hension or order.
no clear appre-
Disturbances of Attention.
is
of mental
is
present in our inner field of This limitation of consciousness phenomena.

called the
At any one moment there view only a limited number

"
Since the entire
limitations
"span
of consciousness.
life
chain of our psychical of this span, our inner
must pass under the
life presents a constant coming and mental processes. One experience after another appears and disappears ; each approaches from the dark-
going of
ness of the unconscious, at first being indistinct and weak, after a short time reaching the climax of its clearness and
strength, another.
and then sinking from
sight to give place to
within the
This development of a mental phenomenon field of consciousness is coincident with that
inner activity of the will which we call attention. Our sense organs turn to the forceful impressions, and those presentations appear which strengthen the process that
claims our attention.
The
strain of attention
It is
may have
cer-
various degrees and directions. tain physical phenomena ; such as,

alterations in breathing, pulse,
accompanied by
pressure.
movements
of the body,
and blood
Attention not only strengthens a developing impression, but without doubt it retards its fading. In this way each
impression exerts an influence on
its
successors.
Their retheir devel-
lation to their predecessor inhibits or promotes
opment.
attention becomes active
In this manner the primitive passive and aimless and selective. It is not the force
of the external impressions,
but rather the attention, which
determines our inner experience. Experience is determined not so much by the strength of external impressions as by
19
In a child the favoring or inhibiting effect of attention. the content of consciousness is helplessly dependent upon accidental circumstances it perceives only the most strik;
ing stimuli.
perception
cies
is
In adults, on the other hand, the process of more and more dominated by personal tenden-
which gradually develop out of the experiences of the
individual.
We train ourselves to notice certain impressions
in preference to others, so that some stimuli, however faint, have decided advantage over others. On the other hand,
we accustom
ourselves to be inattentive to regularly recurring stimuli, yielding them no influence over our psychic This development of definite "points of view," processes.
definite
interest, leads to an extraordinary the threshold of consciousness, so that at the variability of
directions of
same moment when strong

in
stimuli pass quite unnoticed,
we
apprehend with greatest acuteness the slightest alterations

affected in different psychoses. In the first place, in all conditions of advancing dementia there is a blunting of attention. Perceptions arouse no cor-
some special object. The attention is variously
responding
They are not united with the and they fail to incite him to patient's past experience pursue them further on his own initiative. In the case of a deteriorated paretic the most striking occurrences may take
memory
images.
place without creating any impression, although he may be In dementia prsecox a able to comprehend questions. striking disorder of the attention is present from almost the
Particularly in the stuporous inception of the disease. states, all attempts to arouse the attention are unsuccessful, even prodding with a needle, or touching the cornea, fails
to create
any voluntary movement.

but a suppression
This
is
not a blunting
of the attention
of the attention.
The
patients perceive well enough
what takes place about them,
20
but they involuntarily prevent the perception influencing their thought or action. Even all the external expressions that accompany attention, such as the turning of the head
and eyes, and apparently also the alteration of the pulse and breathing, are absent. This disorder corresponds
with the negativistic processes found in disturbances of volition and may be called a blocking (Sperrung) of the
attention.
In some stuporous states of manic-depressive insanity a

retardation of the attention occurs.
Here
also
it is difficult
to get into touch with the patient, but only because he lacks that internal process which connects his external impressions
and
his past experience,
of the attention.
difficult,
and incites the The development of
selective activity
ideas
is
rendered
life,
not on account of deterioration in the mental
but through the process of retardation which prevents the perceptions from gaining any extensive influence over the
internal
life.
In manic-depressive insanity the external
expressions accompanying attention are usually preserved, the patients look around inquiringly, although not understandingly. They look at objects placed before them and
turn the head at a noise.
An
immediate result of these disturbances of attention,

is
both blunting and retardation,

influence
the loss of their determining
upon new
perceptions.
single impression
may
be able to arouse the attention and be strengthened by it, but the persistent continuance of this psychical process,
with
its
resulting choice of
the incoming perceptions,
is
lacking.
but
it
An impression once aroused may last some time, can always be displaced by a new stimulus, provided
which
This is passivity of the strong enough. observed particularly in paresis and senile It also occurs in the stuporous forms of manicis is
only the latter

attention
dementia.

depressive insanity
21
and
in
many
of the
demented states
following infectious diseases.

patients resemble children who have never had experience, therefore have no ideas or memory pictures that
The
can be awakened to direct the attention. In those forms of mental weakness, in which mentality does not develop be-
yond the grade of childhood, the attention throughout life remains passive and lacks independence. Distractibility of attention is the domination of the atten-
by accidental, external, and internal influences. Limitation of the attention arises through the want of ideas that
tion
have strength enough to influence the process of apprehension is a greater flightiness of the mental The attention leaps from one impression to processes. in spite of the fact that an endeavor is made to another,
;
in distractibility there
direct the attention.
This disturbance regularly accompa-
nies those mental states that exhibit increased irritability. It is probable that in increased distractibility of the atten-
tion the separate impressions fade so rapidly that they have no dominating influence upon the incoming percep-
Details are apprehended without a comprehensive view of their relations, and the entire apprehension is
tions.
superficial.
The
is
lightest
form
of distractibility
is
found in the absentit
mindedness of fatigue.
In chronic nervous exhaustion

also the case in convalescence
more
persistent, as
is
from
severe physical or mental disease. It appears to a marked degree hi the excited stages of paresis, sometimes also in
catatonia, collapse delirium, and in the infection psychoses, but particularly in the manic forms of manic-depressive
insanity.
In these conditions a single word or the most

is
casual stimuli suffice to distract the attention.

Distractibility of attention
continuously present in some
22
forms of constitutional psychopathic states, where it exerts a very powerful influence upon the mental development. The more distractible a man is, the less perception is controlled
by inner motives
is
is
arising
from experience, and the
less
coherent and uniform

Distractibility
the conception of the external world.
not to be confounded with hyperprosexia, which consists in the total absorption of the attention by a
examples of which are found in the so-called absent-mindedness of scholars and the complete absorption
single process,
of the melancholiac in his sad ideas.
B.
DISTURBANCES OF MENTAL ELABORATION
The material of experience, received through the different and clarified by attention, forms a basis for all further mental elaboration, and it is self-evident that both disturbances of apprehension, and the inability to make a systematic choice in the impressions, must affect to a marked
senses
degree the character of all intellectual processes. All higher mental activity deDisturbances of Memory.
pends largely upon memory. Every impression which has once entered consciousness leaves behind it a gradually fad" ing disposition" to its recall, which may be accomplished
either through
an accidental association
of ideas or
through
an exertion
This disposition to recollection is really identical with the residua which each new perception contributes to the store of experience and to the resources of
of the will.
memory.
The residua are strong and permanent
in direct
proportion to the clearness of the original impression, and to the multiplicity of its relations to other processes, i.e. to the interest it arouses and to the frequency of its repetition.
The vast majority
of our ideas
and the greater part
of the
association complexes with which we have to do daily, are so accessible to us that they appear of themselves under the
least provocation
and without any
effort.
dependent on impressieach of which may be disturbed retentiveness, bility independently of the other.
Memory
is
really a dual process
and on
Impressibility
is
the faculty for receiving a more or less
permanent impression made by new experience.

23
The
clear
24
apprehension of events, especially when aided by active

attention, increases this impressibility, while it is lessened by difficulty of apprehension, by distractibility and indifference.
It,
therefore,
is
diminished wherever there
is
cloudi-
ness of consciousness, as in amentia, to a less extent in the absent-mindedness of fatigue, and in the states of deterioration in dementia prsecox, paresis, and in epileptic insanity,
which are characterized by stupid indifference to the environment. The most marked disturbance of impressibility occurs in Korssakow's psychosis and senile dementia, especially presbyophrenia,
although the
assimilated.
moment
impressions are
In these patients the process of perception develops very slowly, so that with those stimuli which act quickly the process of apprehension
well
apprehended and
becomes
distinctly impaired
and at the same time the pro-
cesses of consciousness fade very quickly.
In normal life it is the greatly diminished impressibility which renders it difficult to recall our dreams. This demonstrates that psychic
exist
life,
and therefore consciousness, can
without
consciousness,
activity,
with
memory. Similar conditions of clouded undoubted evidences of a psychic
but yet without memory, occur in epilepsy,
many
profound intoxications, and hypnotism. "Retrograde amnesia," in which memory is more or less
delirious conditions,
permanently destroyed without clouding of consciousness, occurs in epileptic, hysterical, and paralytic attacks, head
injury,
and some attempts at suicide, in which patients cannot remember the events which immediately precede the
attack.
Memory
for this period
may
return.
Retentiveness of
memory
for past events
depends upon the
previous impressibility, upon repetition and the native tenacity of the individual memory. Its disturbance is
manifested by an inability to accurately recall former knowl-

edge and important personal events.
25
Lack
of impressibility
usually accompanies lack of retentiveness, but the converse is not necessarily true, as impressibility is affected by cloudIn senility ing of consciousness, while retentiveness is not.
the former
is
far
more disturbed than the
latter;
recent
events leave no residua, while remote events recur in memory with ease and accuracy. This is even more striking in
senile
dementia and
may
psychosis the weakness of memory a definite period of the life.
occur in paresis. In Korssakow's may extend back to cover

disturbed.
The accuracy
of
memory may be
is
Even
in
normal conditions, accuracy
change of personality or the emotions,
ment
of delusions, the past is Vivid imagination and pronounced egoism imperceptibly modify the memory of past experience even in normal life
stories are embellished
self
In morbid and in the developalways more or less falsified.

only relative.
details, while the becomes a more and more important factor. This is
with interesting
always exaggerated in disease, while in melancholia, persecutory and expansive delusions often color the of the past until it seems like pure invention.
memory
is
mixture of invention and real experience " paramnesia. There also exist hallucinations of
(Sully),
called
memory"
found especially in paresis, paranoid dementia, and sometimes also in maniacal forms of manic-depressive insanity. It also
of pure fabrications, being
which consist
occasionally occurs hi epileptic and hysterical befogged states. But fabrications are particularly characteristic of
Korssakow's psychosis, and presbyophrenia, in which states the gaps produced by disordered perception are filled in with
falsifications of
memory, including even incidents of youth. These are often fantastic accounts of wonderful adventures ;
they
may
be modified by suggestion and are frequently
self-
26
contradictory (see p. 186). The delusion of a double existence may be produced by confusing present experience with indistinct memory images of the past, so that every
event seems like a duplicate of a former experience. This sometimes occurs transiently in normal life; in disease
it
may
last
for
months, and
is
found particularly
is
in
epilepsy.
Disturbances of Orientation.
Orientation
its
is
the
clear
comprehension
of the
environment in
and personal
relations.
Our present
temporal, spacial, related to our past
experience in a temporal series through the function of memory. Only recent events are remembered with the
greatest distinctness ; while the rest is grouped around more or less isolated points, which form the basis for the general chronological arrangement of our experience. In Spacial orientation is partly dependent on memory.
the
first place,
memory
enables us to recognize immediately
parts of our present environment, while
even an unknown
environment
may be comprehended
when the
former.
latter includes the
through our experience motives or conditions for the
in place orientation.
But apprehension may also play an essential role In any unknown environment into
which one happens to be placed, the process

regularly clears
of perception the real situation by bringing about a up connection between the immediate impressions and our This often involves more than a mere past experience.
identification of the present with the past.
It
may
result
from a more or
reasoning.
arises
less
complicated process of reflection
and
In the same manner, orientation as to persons from the cooperation of memory, perception, and judgment. Thus it becomes apparent that lack of orientation or disorientation may arise from disorder of memory, from dis-
27
order of apprehension, and from disorder of judgment. In many cases two or more of these causes are combined.
Further, the disorder may involve all the fields of orientation or it may be limited to a single field, so we may dif-
between total and partial disorientation. The apprehension of the environment may be prevented by
ferentiate
the fact that the patients cannot elaborate their external impressions, or by an inhibition of thought, or by a
clouding of consciousness with or without falsification of The first case is very common in dementia perception.
pracox, where the disorientation usually results from the lack of mental activity, and may be called an apathetic
disorientation.
is no difficulty in perception. The lack the inclination to understand the patients simply meaning of what they see and hear, so that for weeks at a
There
time they
they are, In the depressive phases of manic-depressive insanity the apprehension of the environment is rendered difficult
may give themselves no concern as to where how long they have been there, or whom they see.
through the presence of retardation and there develops The patients perceive details a condition of perpkxity.
The diswell enough, but they fail to synthesize them. orientation in the most pronounced manic states may
perhaps be similarly accounted for, as there accompanies it a marked difficulty in the apprehension and elaboration
of external impressions.
The
different forms of clouding
of consciousness in focal lesions of the brain, in epilepsy,
and
in alcoholics cause a
of orientation.
pronounced disorder In the delirious states found in infection

less
more or
and intoxication psychoses,
also in hysteria
and
epilepsy,
there exist, besides the lack of clearness of apprehension, also sense deceptions, both of which cloud and falsify the
picture of the environment.
28
Iii
Korssakow's psychosis there is an amnesic disorientation which depends neither upon disturbances of apprehension nor of perception.
orientation
is
While in
this condition place
usually well retained, the patients are absolutely helpless as regards time. They do not know when they came into the institution, when they were last visited
by
relatives,
when they
last dined, etc.
Events
of a
month
ago may be referred to as occurring yesterday, and again an occurrence of yesterday may be mentioned as happening months ago. This amnesic form of disorientation may occur even more strikingly in presbyophrenia, where on account of the marked
disturbance of perception in connection with the difficulty of apprehension, mental elaboration of external impressions
is
almost impossible, hence patients
fail
to get
any idea
of
their environment, although details are understood without

difficulty.
The amnesic form
of disorientation also occurs

is
in paresis,
where time orientation
most often at
fault.
Amnesic disorientation occurs in other psychoses, indeed, wherever the disorder arises from faults of memory. One's own experience in orienting himself upon awakening from
a sleep or after fainting indicates how difficult it is to regain time orientation after a severe clouding of consciousness.
The delusional form of disorientation is quite different. Here we have to do with a faulty mental elaboration of impressions which are correctly perceived and apprehended,
leading to a false opinion as to the environment in its temporal and spacial relations. The patients are not clouded,
but they maintain delusional ideas as to the time, place, and persons. Illusions or hallucinations may be the basis
mistaken personalities and the assertions of paranoid patients that they are in prison, in a bad
for such beliefs, as in
house, etc.
29
Disturbances of the Formation of Ideas and Concepts. Most of the complex ideas of normal life are composed of
heterogeneous elements, furnished by the various senses. In these complexes the importance of the material furnished by
any one sense depends upon the peculiarities of the individual. For some, vision is the most important sense, for others
audition; but both of these senses
may
be entirely lacking
without preventing a high development of ideation.
On the
other hand, lack of permanence of sensory impressions and imperfect assimilation always interfere with the formation
of
complex
ideas.
This
is
illustrated
in congenital
and
acquired imbecility.
The formation
fullest
of concepts is the necessary condition for the
development of ideation. In normal life those elements of experience which are often repeated impress themselves
more and more
strongly, while the accidental varia-
tions of each individual experience are driven
more
into the background.
more and The concepts thus developed
are a sort of
experience.
composite photograph or generalization of
These concepts are the most permanent and most easily reproduced of all our ideational processes. But even these
may
are
not be reproduced in totality. More and more in the developed consciousness single elements of these concepts
made
to stand for the whole.

is
The exact form
of this
often accidental, as when some The single image comes to stand for the total concept. form of this development is found in the abbreviahighest tion of thought by the use of linguistic symbols, i.e. when a
abbreviation of thought
word stands for the idea. In morbid conditions, especially

this
in congenital imbecility,
development
may
stop at
any
point.
The patients
may
cling to individual experience
without being able to
30
sift
out the general characteristics of different impressions They are unable to find concise ex-
of a similar nature.
pressions for more extended experience; the essential is not distinguished from the unessential, the general from the
particular.
it
This not only prevents the development of thought, but also retards the assimilation of new material. New im-
pressions find no point of attachment in the mental life; they cannot be arranged or systematized, and pass rapidly In acquired imbecility the residua of earlier into oblivion.
experience
may
partly conceal the inability to receive
new
impressions and to form new ideas. Later, however, this defect gradually becomes more evident. Similarly in paresis, dementia praecox, and senile dementia, the circle
and general ideas and concepts are gradually replaced by the specific, the immediate, and the tangible. New impressions are no longer elaborated and the most
of ideas narrows,
recent experience is quickly forgotten, while the memory of the past is still fairly constant. In direct contrast to this is the disturbance produced by
morbid
similar
excitability of the imagination,
which correlates
dis-
and even contradictory
ideas.
Such forced and
arbitrary combinations naturally interfere with the normal development of concepts. Thus the foundation of all higher
mental activity becomes a mass of confused and indistinct psychic structures, which can give rise ojnly to one-sided
and mistaken judgments as soon
as the patients
leave
the region of immediate sensory experience. The tendency to reveries and dreams, lack of appreciation of facts, impossible plans and chimeras, so often found in imbecility,
paresis,
and paranoid dementia, are
clinical
forms of
this
disturbance.
Disturbances of the Train of Thought.
The
association of

ideas
31
may be
divided into two groups
external
and internal
associations, the former being effected by purely external or accidental relations, while the latter arise from a real
coherence in the content of the ideas.

External associations usually arise through the customary connection of ideas in time or space, of which thunder and
an example; or through habits of speech, in which a definite association of words becomes so fixed by frequent repetition that one word always calls up the others, Sound associaas in quotations and stereotyped phrases. an important and extreme form of this type, are based tions, either upon similarity of sound or of the movements of the vocal organs, as seen, for example, in a morbid tendency to rhyme. This disturbance may be so marked that the
lightning
is
associated sounds are altogether meaningless. Internal associations depend upon the logical arrangement of our ideas according to their meaning. The association
between
different individuals of the

is
same
species,
or different species of the same class, instance, the association of boy with
of this kind;
for
man and man
with
The special form animal, which emphasize some particular

etc.
of
internal
associations,
characteristics of a con-
cept, usually attributes, states of being, or activities,
means
is
of
which a preceding idea

predicative
is
called
association.
by more closely defined, That the dog is an
animal belongs to the first class of internal associations; that he is dark-colored, or that he runs, belongs to the
second.
Paralysis of thought, the simplest form of disturbance of the train of thought, is characterized by complete absence of all associations. It begins as a more or less marked retardation,
and develops
into characteristic
It occurs in
monotony and
distractibility of thought.
a moderate degree
32
in fatigue.
is
Narcotic poisoning presents severer forms.
It
a fundamental symptom in the psychoses accompanied by deterioration paresis, dementia praecox, and senile de:
mentia.
Retardation of thought is manifested by difficulty in the elaboration of external impressions ; the train of thought is
markedly retarded, and the control of the store of ideas is incomplete. It may bring the train of thought to a complete In contrast to the paralysis of thought, to which standstill.
it
presents a
superficial
similarity,
this
inhibition
may
suddenly disappear under certain conditions, as fear. The they are not, like the patients do not lack mental ability
;
weak-minded or deteriorated, obtuse and indifferent, but they are unable to overcome this restraint which they themThe most pronounced form of selves very often realize. this disturbance is seen in the depressed and mixed forms of manic-depressive insanity, and perhaps, also, in the disturbance of thought in epileptic stupor.
disturbances of the content of thought are best understood as a faulty arrangement of the individual links of our
The
thought with relation to the goal ideas.

is
usually directed
by
definite goal ideas,
Normal thought and of the ideas
which appear in consciousness, those elements are specially favored which stand in closest relation to these controlling
goal ideas. Out of the large number of possible associations those only really occur which lie in the direction determined by the general goal of the thought process.
In morbid conditions the train of thought

rupted by
may
be inter-
individual ideas, or other trains of thought with
an
especially
p. 355).
may
prominent emotional tone (cf. Melancholia, of some sad experience or a fright so dominate us that our thoughts in spite of all effort
The memory
return to the same channel.
33
Compulsive ideas are those ideas which irresistibly force themselves into consciousness. These are usually accompanied by a disagreeable feeling of subjection to some overwhelming external compulsion. The mere fear of their
them into consciouson a basis of emotional disThey usually develop turbance, and, therefore, accompany melancholia and derecurrence
is
often sufficient to bring
ness.
pressed phases of manic-depressive insanity, also sometimes the depressive states of dementia praecox. The content of
these impulsive ideas is unpleasant and harassing. The patients are compelled to think constantly of some shocking experience, which they have had, or to depict some mis-
which may befall them. The profound emotional despondency which serves as a basis for these thoughts and at the same time furnishes a good soil for their development has associated with it a feeling of compulsion. As the disease develops, despondency becomes more predominant,
fortune,
the resistance of the patient to the ideas is gradually weakened, so that the feeling of subjection vanIn this way the original compulsive ideas are transishes.
particularly
if
formed into delusions.

If the fundamental emotional state is independent of morbid changes of the emotions, as encountered in various
psychoses, the disturbing factor in the compulsive ideas does not reside so much in their content as in the fact of their
The most striking forms of these comideas develop in the states of hereditary degeneracy pulsive Increased emotional sus(cf. Compulsive Insanity, p. 498).
constant recurrence.
ceptibility, as well as
a tendency to morbid introspection, are
the fundamental states from which these compulsive ideas In the very lightest forms there develop ideas develop.
which are unpleasant. There is still another group of cases
in
which some
34
simple
common
ideas
of every train of thought, later gaining mastery;
the compulsion to recall become so prominent that the patient makes out a long list of names, and finally indexes the names of every person
development such as the name of some one, which may
interfere
with
the
whom
sort
he meets.
The compulsion
is
to count
is
of the
same
and again there
the compulsion to ask of them-
selves all sorts of questions (Gruebelsucht) (cf. p. 500). There is here a feeling of uncertainty which incites the
patient to a distinct
effort,
which
feeling
can never be
quite satisfied, because every suggestion leads to still another series. There is no end to the names, the numbers,
and the questions to be asked. The

is,
real basis for these ideas
therefore, a feeling of discomfort, identical with that

incites all of
which
us to seek for clearness and truth ;
but in the case of the patient these ideas are no longer the servants, but are masters of the psychical personality, because he has not the power to suppress them when they
hinder the train of thought. Distinguished from the compulsive ideas are the simple
persistent ideas,
ings of
unaccompanied by marked unpleasant feelcompulsion. This phenomenon is probably due to

of
definite
the absence
or
fixed
goals in
the train of
a view which is borne out by our experience thought with the persistence of some of our own ideas, whenever we give free rein to our thoughts. Rhyme, verses, and melo-
sometimes cling to us even in spite of our throw them off.

dies
efforts to
In gross brain lesions there
is
often found a
peculiar
Words persistency of linguistic expressions. used shortly before are repeated by mistake.
naming objects use words which they have
spoken.
and phrases
Patients in
just heard or
it is
Fatigue
may
so aggravate this disorder that
35
impossible to secure a correct answer, as one gets only a monotonous repetition of previous statements.
In another phase of the disorder, more or less motor to be sure, patients use an indicated object in the same way
previously and correctly used another. In Neisser happily names this disturbance perseveration.
they have just

cases
some
of senile
dementia with pronounced
persist-
ency of ideas, Schneider has pointed out that ideas once aroused develop very slowly. In fact, in perseveration,
one often has the impression that the patients fail to understand the new perceptions and when forced simply repeat
themselves.
Patients only
named a
picture right after one
is
If this hypothesis or two other pictures had been shown. the disorder is conditioned not so much by the correct,
peculiar stubbornness of a particular idea, but rather by the difficulty of releasing other ideas to displace it.
One should
distinguish carefully from perseveration the
tendency "to run to death the same ideas" so often occurIt is but ring in dementia praecox in a pronounced form.
another expression of stereotypy of the will. Examples of this condition may occasionally be encountered in children.
It
consists of
an impulsive, often
limitless repetition of
similar expressions, sometimes alone and sometimes interwoven in other more or less incoherent trains of thought.
The content and is not,
of these stereotyped ideas
is
quite accidental
as in simple persistent ideas, determined by that which has preceded. In morbid conditions, even when the collection and
prevented by mental disease, there remain some residual ideas of the normal This results in a state, fixed by constant repetition. monotonous content of consciousness with a marked imelaboration of
new
impressions
is
poverishment of the store of ideas.
This occurs in senility,
36
paresis,
and other deterioration
processes, in which the to a few phrases, or even repeated over and over. These
train of ideas
may
shrink
down
a few words which are
phrases, in contrast to the persistent ideas of the catatonic, are not senseless, but actually express the content of the The following is an example: patient's consciousness.
Frazier went away this morning, will be back soon. Didn't ask him what time he'd come home. Frazier is working up in the lot I was up in the lot yesterday. I forget what I at something.
"
went what
for.
Frazier
is
it.
cared about
He asked me talking of selling the place. Father is going over there to-day. Father
;
don't care for the farm.
He didn't speak to me he is downhearted. should bring up his boys to work upon it. Frazier don't have time to work. He don't stay home much. I would advise them He
to
have a place and keep
it.
If I get well I will
keep
it, if
I can.
The boys would like to have some farm. They won't stay in a place. Frazier don't like to work on the farm. [Patient hears a woman coming up the hall.] Some woman I hear coming. If she was on
a farm, she wouldn't handle much money. If they sell the place, the children will starve for hunger. [Patient looks at her hand.]
I
If
am
he
all
sells
blacked up. I have been out on the farm a good deal. the place, the little children will starve for hunger," etc.
Circumstantiality is the interruption of the course of ideas by the introduction of a great multitude of nonessential accessory ideas,
which both obscure and delay the
train of thought. The disturbance depends upon a defective estimation of the importance of the individual ideas in relation to the goal ideas. The goal may, indeed, be
ultimately obtained, showing some real coherence, but only after many detours. The simplest form of circumstantiality
appears in the prolixity of the uneducated, who are unable to arrange their general ideas in accordance with their importance, and show a tendency to adhere
to
details.
Some even have
difficulty
in distinguishing

sharply what
is
37
The
actually seen from what is simply imagined. circumstantiality of the senile is probably due to the
disappearance of the general ideas and concepts. Circumstantiality is also present to a marked degree in epileptic
which the following passage taken from the bibliography of an epileptic is an example
insanity, of
:
Before one believes what others have told him or what he has read in the almanacs he must be convinced and examine himself before one can say and believe that a thing is beautiful or that a thing
is
it,
"
not beautiful ;
it
first
investigate, go through
it
yourself,
and examine
and then, when

is
through
thing
has investigated everything and has gone himself and examined it, then man can at once say the
man
is not beautiful or not good ; therefore, I myself say, if one will make a statement about a thing, or will sufficiently establish something or will speak in conformity with the truth, the thing is right or is not right, so must every man likewise examine
beautiful or
the thing as he believes himself responsible before the tribune God, and before his Majesty the King of Prussia, William the Second,
and the Emperor of Germany. " soldiers have done to me.
I will
now
relate further
what the
or incomplete development of goal ideas gives rise clinically to two important forms of disturbance of the train of thought: (1) flight of ideas, (2) desultoriness.
The absence
The
is
first effect
of a defective control over the train
of ideas
a frequent and abrupt change of direction.
The
train of thought will not proceed systematically to a definite aim, but constantly falls into new pathways which
are immediately abandoned again. The impetus for such changes of direction can arise from both external stimuli
and from
internal processes. In flight of ideas the instability of goal ideas produces a condition in which the successive links of the chain of
thought stand in fairly definite connection with each other, but the whole course of thought presents a most varied
38
change of direction. The patient is unable to give long answers to questions, and cannot be held to a problem
requiring much mental work, because ideas once aroused are immediately forced into the background by others. This is a fundamental symptom of the manic form of
manic-depressive insanity, and also occurs in acute exhaustion psychoses, infection deliria, paresis, occasionally also in It may fatigue of normal life and especially in dreams.
appear in alcoholic intoxication. There is no great wealth of ideas, but on the contrary it is often accompanied by
a conspicuous poverty of thought. Moreover, the rapidity of the association of ideas is not at all increased, but
patient's incoherence, therefore, depends simply on the lack of that unitary control of the association of ideas which represses all secondary ideas and permits progress only in a definite
on the other hand
is
usually diminished.
The
any accidental idea which would normally inhibit the goal idea may assume importance. It is not, then, the rapid succession of ideas which
direction.
As the
result of this,
warrants the designation of a

bility of single ideas
flight of ideas, but the which are unable to exert any
instainflu-
ence over the course of the train of thought. In flight of ideas the direction of the train of thought is determined by external impressions, chance ideas, or
finally
by simple
associations, external or internal.

is
The
influence of chance ideas
well demonstrated in intoxica-
tion deliria, and especially in opium intoxication, in which vivid ideas of the imagination follow each other in a varie-
gated series, giving rise to an incoherent progression of unrelated fancies, to which experience offers no key. This
might be called the
delirious
form
of flight of ideas.
The rambling
thought of the
another form of the flight
hypomaniacal patient is of ideas in which the patients

are
39
diverted
by unimportant
is
incidents,
ject.
and
left
reminiscences, and need to be frequently led back to their subideas,
The
following
an example (the patient being asked

:
when she
"
the Hartford Retreat)

January.
bazine of Aunt Jane's.
She had on a black bomown and got another from neighbor Jenkins. She lives in a little white house Come up with an old green umbrella 'cause kitty corner of our'n. You know it can rain in January when there is a thaw. it rained. Snow wasn't more than half an inch deep, hog killing time, they
My mother came for me in

One
shoestring of her
butchered eight that winter, made their own sausages, cured hams, and tried out their lard. They had a smoke house. [But how about your leaving Hartford?] She got up to Hartford on the Dr. half-past eleven train and it was raining like all get out.
Catholic, just sat with his
Butler was having dinner, codfish, twasn't Friday, he ain't no back to the door and talked and laughed
and talked."
Here, in spite of many diversions, we see a fairly good sequence in the content of thought which centers around a
the patient's mother. In the following example, on the other hand, the predominance of motor speech ideas has led to a massing
visit of
of habitual speech associations, combinations of
common
words, and finally to simple sound associations. It might be called an external flight of ideas in contrast to an internal
flight of ideas characterized
"
I
by
internal associations.
was looking
soap. ness of feet don't win feet, but feet win the neatness of men. Run don't run west, but west runs east. I like west strawberries " best. Rebels don't shoot devils at night.
You always work Harvard
at you, the sweet boy, that does not want sweet Neatfor the hardware store.
The
train of thought is supplanted by fixed and familiar phrases, in which the influence of linguistic ideas clearly
40
outweighs that of the content of thought; while sound

associations, rhymes, associations.
ance of ^this
and quotations, etc., stifle all internal The most favorable condition for the appearform is an increased motor excitability and
type of incoherent to characterize, as it is not well
this
alcoholic intoxication.
Desultoriness, the second
form of
speech,
is
more
In
difficult
it
the external form of speech is fairly well retained, but there seems to be a complete loss of goal ideas, while an incoordinate mass of ideas follow each
understood.
other aimlessly and abruptly. In the flight of ideas we were able to discover some connection, if only the most external,
between the separate links of
ideas,
which gradually
led to a
new
chain, until the original standpoint
was en-
In desultoriness there is no recogsight of. nizable association between the successive ideas, while the
tirely lost
move along for some time in simiare confused and contradictory. In phrases. They flight of ideas the course always tends toward changing
trains of thought often
lar
and hence never attained
goals,
entering new circles; train of thought does not progress at all in

in this form,
tion,
and is, therefore, always on the other hand, the
any one direcbut only wanders with numerous and bewildering

is
digressions in
which
the same general paths, the following of an example

:
MIDDLETOWN, Dec.
15, 1901.
DEAR SISTER
I received
your box in perfect shape and money as well. Do you wish to see me. If you care or somebody else will. Do. Awful lonesome. A new suit and fair words. This time give me a little money if you will (tell her to use slang my front yard). Give me a punch for fun. You are read that way) leave (Give her a drop
of
your poison).
Latest song attendant.
(Give her a wife she
is

lonesome).
Hill St.
I
41
suppose
Tom
Kellhams Pete whair Fitch.
Will Eddy. I strong don't you know he passed it to the other young from Newark but he could not start it. He did not know where it came from. He
Right
tell
me
give over
Pa Ma
Nell Har.
I got McKingleys Son over me at times he works on sleeps under. the stylish horse. He is a black strong. I am a red. You know the Pres. Brokerage and drink cigars and walks, speeches. He is
37 Port Rhoda he served 10 years at his trade he is working 14 good mack. Tell Burnie he is liked by him but not strong enough they live 9,000 miles in the air over the three miles you read in school. ... Pa Pa you know the stove he carried. 1,700 Ib. trunk strong nature, hard life when I got to let him know how on
for sense
pipe here through the converser the head electro gave and they don't speak and it was a corn sense.
by.
me
I
a dime
am
bed
now good
Yours
Aff.
Distractibility through internal

also
and external
influences
be present to a marked degree, but the newly may aroused ideas do not serve as bases for others, but simply intrude into the desultory train of thought in an incoherent
manner.
their
In this
way
it is
incoherent
jumble,
to
often possible, in the midst of obtain coherent replies to
following is an example of this (the physician's questions are enclosed in brackets)

questions.
:
The
[Why are you here ?] Because I am the empress. The dear parents were already there and everything was already there and had given me permission. I have also learned stenography. Why,
David, how are you? Even a member of the reserve, megalomania, empress. [Do you feel well ?] Oh, thanks, very well, since the government has given me permission we will be good friends.
"
Oh, God
my
brother Carl David the
first
write something.
[Why
are
you here?]
all.
and Olga. Ah, let me Insane. Megalomania.
[What
is
that?]
[Will
Nothing, nothing, at
[How
old are you?]
22-7-1872.
you come again ?] I do not know. When he comes I will not run after him (laughs). I must always be close I have nothing (grasps at the watch chain. (clasps her hands). But the chain is nothing. How I will at once see what time it is. "
42
This example does not show, however, the repetition of single words or phrases which so frequently occur in the
catatonic productions,
and
is
shown
in the following
"You don't own this building, I know that. The Hartford pigpen never supported, never confirmed food, therefore are not supported and this building will pay for that and food which conWhite immortal eternal receipt for that food. The war I have the white immortal eternal receipt. Mars planet Mars. war planet, or war world Mars. The war world or the war planet Mars. White immortal eternal receipt for its existence and confirmation receipt. The Hartford pigpen is not supported or has
firmed
it.
not confirmed food or the laws of food, therefore will not be supported by those who have confirmed food. The white immortal
eternal receipt."
In extreme desultoriness the speech consists of a mere series of letters, syllables, or sounds, while in the severest
always some goal idea even though it rapidly changes, and the majority of the expressions consist of actual words; here there is a perfectly senseless repetition of the same sounds with only insignififorms of
flight of ideas there is
cant modifications, like the following:

"
Ellio, ellio, ellio altomellio-altomellio,
selo, eloo,
devo, heloo
f . f . f.
f. f. f.
f. f.
dear father,
f. f. f.
dear father,
e. e. f .
old and
new
Catholic Church,"
and so on in monotonous repetition. Sound associations seem to play an important role here, but the train of thought does not advance through it to new ideas. These disturbances which destroy or interrupt the internal coherence of thought gives rise to what is called confusion of thought, which is a prominent symptom of mental
disease.
This
symptom develops
variously.
If
the inter-
ference with the coherence of thought arises from flightiness of the goal ideas, then we have a form of confusion charac-

terized
43
by
flight of ideas
with
its
tendency to external and
verbal associations.
The abrupt development of many differ-
ent ideas without order, and not leading to any definite goal There may also idea, gives rise to the desultory confusion.
be differentiated
confusion, which
this
still
is
characteristic of delirious states.
another form of confusion, dreamy In
type there exists besides the disturbance of apprehension and the rapid fading away of the perceptions, a marked prominence of sensory elements in thought. There
is
also a combined
form
of confusion, in
which there
is
new trains of thought each other incoherently. The head fairly swims following because there is not an opportunity to marshal or survey
transitory appearance of abundant,
the rapidly appearing ideas. This type of confusion characterizes those forms of mental disease in which the rapidly appearing thoughts are elaborated into a permanent
delusion formation, in the
same way that
in
normal
life
a person gradually works into his train of thought a new idea that at first was confused. Also the presence of many
be regarded as a cause of an hallucinatory confusion, just as a normal person sometimes loses his orientation if he is suddenly placed in an inextricable
hallucinations
may
environment with new and puzzling impressions. Mental retardation can also produce a form of confusion of thought, through the slowing of the process of comprehension and mental elaboration. This has been designated stuporvus confusion. In it one sometimes encounters
a combination with a genuine flight of ideas. Finally the emotional attitude may play a very important role in the development of different forms of confusion of thought.
In some diseased mental states with marked disturbances

of the emotions, this element is of great importance.
Disturbances of Imagination.
The fund
of our earlier
44
experience becomes of most value to us when we are able to bring from it into consciousness voluntary ideas and mem-
ory images.
tion.
This ability is provisionally named imaginaIt requires on the one hand reproducible residua of
former mental processes, and on the other hand that process which enables us to formulate new mental pictures out of
the simple residua of memory and make it possible to elevate ourselves above our simple sensory experience and
perform original mental work.

of imagination may be seriously disturbed in In some degree this is observed in simple mental fatigue, also in poisoning with narcotic and hypnotic drugs, but more especially in the severe grades of deterioration
disease.
The power
found in
eases.
paresis, senile dementia, and other mental disIn these latter disturbances the atrophy of the
is
imagination
The
usually combined with defective memory. ideas are not only not at one's disposal, but they may
also in large
numbers disappear.
Where
this loss is less
extensive, as, for instance, often in epileptic insanity; there
These patients still have some command of their store of ideas, but they require a very long time and considerable stimulation.
develops a simple sluggishness (Schwerfalligkeit).
The retardation which is encountered in the depressive and mixed phases of manic-depressive insanity is to all external appearances similar to sluggishness. The disturbance of thought processes of the befogged states of epileptic and hysterical insanities probably also belong here. Retardation differs from sluggishness in that it is a transitory Retardation is state, while the latter is a permanent one.
usually accompanied ground which exert
by alterations in the emotional backsome influence over the function of

life.
imagination even in normal
In
is
it
one finds that the

difficult;
elaboration of external impressions
rendered

indeed,
it
45
may
even be so
much impaired
as to cause
com-
plete perplexity, owing to the lack of memory pictures; the patients cannot think of anything, they lose all connec-
tion with their earlier experience, and sometimes cannot even give the names of their nearest relatives. Nothing
Thought seems to come to a standstill. Such patients may present the external appearance of profound dementia but the fact that all of these severe disturbances suddenly disappear indicates retardation, moreoccurs to them.
;
over the patients suffering with retardation themselves recognize the resistance against which they have to struggle.
indifferent as demented patients are simply unable, in spite of great effort, to are; they overcome the constraint of thought.
They are not stupid or
In the indifference so characteristic of dementia praecox there is no resistance offered to the activity of thought,
but there
is
a more or
less
complete lack of motive for
mental work.
If these patients are sufficiently stimulated,
they are able to call up some of their favorite ideas, but they are never forced to mental work of their own accord.
of what happens to them, and they have no thought of the future. Mental activity stagnates more and more, and there gradually develops a shrinking a sort of atrophy from disuse. In of the store of ideas contrast to the paretic they often surprise one by the occasional display of a much greater wealth of ideas than This very rarely it was supposed they actually possessed. in the deteriorated stages of dementia paralytica. happens This observation confirms the belief that in dementia praecox there is a real loss of mental activity. Morbid excitation of the imagination is evidenced by a special vividness of the memory images, which under cer-
They take no account
tain
circumstances acquire the strength of sensory im-
46
pressions.
states,
This occurs particularly in the different delirious is almost always present a pronounced
where there
disturbance of apprehension. Another example is found in of the anxious states of melancholia, manic-depressive insanity, and of the psychopathic states, in which the
some
patients detail their fears with painstaking clearness
and
completeness. In the excited stages of manic phases of manic-depressive insanity, of paresis and of catatonia, it is a question
whether there really is an increase of the imaginative power. One might judge that there was no question as to this in the manic phases of manic-depressive insanity,
but really the realm of ideas here is barely, while it very often is even diminished.
patients assert that they
if
at
all,
Some
enlarged, of these
in the
abound
in ideas,
and even
circular depressive phases patients

assertion, in spite of retardation.
may make
the same
is, however, good reason to believe that there really exists more of an increased distractibility and flightiness of the internal
There
processes than an increased production of ideas. persistent increase in the activity of the imagination is found in a considerable group of psychopathic individuals,
such as the morbid adventurer and inventor, who in the

the realities of
results,
pursuit of their extravagant plans completely lose sight of life, keeping their gaze fixed only upon the
difficulties
while they never take into serious consideration the and insufficiencies of their methods. Then there
the dreamer, who gives himself up to reveries. Finally there are the morbid liar and swindler, who take the greatest satisfaction in the variegated pictures of their busy imaginais
tion.
Great activity of the imagination regularly accompanies an increased susceptibility of thought to external and inter-

nal causes.
in children
tibility
to
47
In normal individuals this trait is exhibited and women. Morbid suggestibility and suscepautosuggestion are regular accompaniments of
psychopathic states, especially the hysterical conditions. They are manifest here not only in the accessibility of
many
thought and feeling to striking impressions and persuasion, but also in the appearance of all kinds of physical symptoms which are released through the medium of emotional
states.
Judgment and Reasoning. Judgment and inference are the most complex products of the intellect. Since perception, memory, the formation of concepts, and
Disturbances
of
the association of ideas are their necessary preconditions,
they
will
be more or
less affected
by every imperfection
of
these processes.
But
this is not the only source of their
derangement.
Human
free
knowledge has two sources

of
experience,
and the
Neither
action
is
the
mind
itself
(imagination).
of
source
knowledge
tion,
independent empirical never free from preconception and expectawhile even the wildest imagination employs material
entirely
is
the other;
which originally came from experience.

sharply differentiate empirical knowledge
Nevertheless,
we
from pure
belief,
which
arises
from the recasting and interpretation of
draw this distinction. Their and traditions are as credible mythological interpretations to them as direct experience. Even in children invention and experience are sometimes only partially differentiated. Whenever invention can be easily tested by direct experience the line between the two becomes more and more
sharply defined; but even here the natural incompleteness of our apprehension or our habits of thought may lead us
experience. Primitive people do not
48
into error.
If the
or unreliable, imagination
data furnished by experience is scanty is free to fill the field with its
own
creations.
[Empirical science has slowly supplanted many of the misconceptions of primitive thought, but superstition still survives among the uncultured; while even among the
cultured there are beliefs which no experience or arguments can shake. The essential characteristic of these beliefs
is
their emotional significance for the individual.
Dog-
matic opinions, ideas firmly fixed by tradition, education, and habit, acquire an overwhelming emotional value, and
not only persist in spite of experience, but even mould experience into conformity with themselves (cf. the force
of prejudice). The emotional significance of such beliefs has its basis in their relation to vital interest. feeling of helpless dependence and insecurity in the presence of the
unknown and mysterious in primitive races. Even
is
the
fertile soil of superstition
in most highly cultured persons and religious convictions, although more or less political dependent on the rational elaboration of experience for
their content, are characteristically inaccessible to opposi-
tion
and argument/}
Delusions
These peculiarities of normal thought help us to understand the delusions of diseased consciousness.
or
are morbidly falsified beliefs which cannot be corrected either
by
argument
or
experience.
They do not
but from
belief.
arise
from
perceptions (hallucinations or illusions), they are always due to a morbid interpretation of the events arising in the patient's own imagination. The tendency so often encountered in health,
to
deliberation, experience often associated with actual
Although
and
falsified
draw sweeping conclusions from insufficient data or to assume a causal relationship between purely accidental
49
occurrences, becomes an important factor in morbid conditions; the most innocent events are construed as mystic
symbols of secret occurrences, and simplest facts are full of mystery. The flight of a bird is an omen of good fortune;
an accidental gesture reveals sudden danger.

Further proof of the subjective origin of delusions is found in the close relation which they maintain to the Just as in health the self forms the ego of the patient. of reference for our thoughts and feelings, so in disease point
the mysterious creations of the imagination are most intimately connected with the patient's own welfare. The
delusions are, consequently, never indifferent to the patient except in cases of advanced deterioration. They are not
only referred to the self, but they exercise a marked influence over the patient's emotional attitude to ward his environment.
Delusions are inaccessible
to
not originate in experience.

able to correct
argument, because they do Experience, therefore, is un-
them
as long as they remain delusions.
Only
in convalescence,
when they become a mere memory
of delusions, can they be recognized as false. At the height of the disease they are as firmly established as reason herself.
So long as the morbid conditions which give

persist,
rise to
them
the delusions are unchanged. If they are relinquished or modified, the change is not due to argument, but to a change in the morbid condition. Our argument
drive the patient to admit non-essential points, but the delusion serenely reasserts itself, notwithstanding the
may
most evident
is
self-contradiction.
nal object of reference or
Even when the extersupport is destroyed, a new one
quickly found. The delusion needs no other support than the absolute conviction of the deluded.
Vivid emotional
states,
such as
and enthusiasm are important
fear, sorrow, anger, joy, factors in the origin of
50
delusions.
Even
in health, anxiety and enthusiasm create the consideration of any subject, fears and
for
us,
in
hopes which really have nothing to do with the subject matter. In morbid conditions, sorrow and fear exert the
strongest influence on the falsifications of ideas. Clouding of consciousness is sometimes a factor in the
development of delusions, especially in delirious states. Delirium tremens and fever delirium, for instance, present a host of fantastic delusions with but very little emotional disturbance.
believed one day
Moreover, delusions which are firmly may be recognized as false the next,
clearly indicating a morbid condition of consciousness, which rendered their correction impossible. We have an example of this in dreams, where we are unable to detect or correct those contradictions which are perfectly clear Without doubt, therefore, we must to us on awakening. the clouding of consciousness as an essential preregard
liminary condition for the development of delusions.
In paresis, senile dementia, and dementia prsecox, delusions appear in which neither emotions nor disturbances of
consciousness play a prominent role.
The
ness, which is a prominent symptom seems to favor the development of delusions. But congenital mental weakness shows only a slight tendency to the development of delusions, and likewise many cases of senile, paralytic, and precocious dementia run their
psychic weakin these diseases,
course without delusions.

cannot, therefore,
lie
The
real cause for the delusions
in the psychic
weakness of
itself,
but only in the accompanying conditions of excitation, which permit all sorts of delusional fancies to spring up in
the patient's mind.
delusions originate
It can
be
easily
demonstrated that
most
freely during heightened or de-
pressed moods.

Another source of delusions
51
may
perhaps be found in
those peculiar ideas which in health are accustomed to

occasionally "pop" into our heads, and whose origin we are unable to account for. While they have no power over us, for the patient, on the other hand, they bear the
even though soon changed for others. They often intrench themselves firmly in his thoughts and dominate experience, feeling, and
stamp
of absolute certainty,
conduct.
After this
preliminary
consideration
of
all
the facts
relative to the origin of delusions,
we
are led to the as-
sumption that the essential factor is an inadequate functioning of judgment and reason. In health we are accustomed
to judge all our fancies according to the standard of our own past experience, and to regard as invention that which
does not conform to our knowledge. The patient either does not perceive the contradictions between his fancies
and his former experience, or he disregards it and hides it under assumptions which are even more fanciful. Clearly the patient has lost, not only the impulse, but the power,
to oppose, correct, or suppress his delusions. The cause of this disability was formerly sought in the peculiar attributes of the individual ideas. The doctrine of "mono-
mania," which held that the "fixed idea" was only a

circumscribed disturbance of an otherwise healthy psychic
life,
was based upon this assumption. The development of delusions is thus seen to be based on the general disturbance of the entire psychic life. They are probably incited by emotional fluctuations which transform slumbering hopes and fears into imaginary ideas. But the fact that these ideas become delusions and acquire
a power which even
the senses cannot destroy,
can only be
explained by an inadequate functioning of judgment, depend-
52
ent
of con-
on impassioned emotional excitement, clouding sciousness, and weakness of the reasoning power.
The character and duration of delusions differ according to their mode of origin. Those which originate in
change with the patient's mood, and usually disappear with the emotional disturbance. Delusions of delirium, which are determined both by
emotional
disturbances
clouding of consciousness and emotional disturbances, are variegated fantastic pictures recurring in manifold forms,
with
little
or no mental elaboration or coherence.
They
likewise disappear with the clearing of consciousness and the subsidence of the emotional disturbance. Delusions de-
pending both upon mental deterioration and upon emotional disturbances do not vanish with the fading of the emotional
states.
rected
They are gradually forgotten, but are never corby reason. Such delusions occur in paresis, dementia
and
senile
prsecox,
dementia.
In these psychoses the
forgotten delusions may reappear for short periods durWith continued moderate ing emotional exacerbations.
may be firmly held and even elaborated, as in the paranoid forms of dementia
emotional excitement delusions
prsecox.
Persistent delusions are of
two types, the systematized
and the unsystematized. If systematized, the individual delusions form a part of a system i.e. they all center or more definite objects, and whenever new about some one
;
develop they are absorbed into this system. delusions are usually expressed in a logical manner. Such The unsystematized delusions may ultimately disappear, as in dementia prsecox, end stages of chronic alcoholdelusions
ism, paresis,
they may become permanent through frequent repetitions, without systematization, as in the paranoid form of dementia prsecox. The
senile psychoses, or
and
53
progressive and uniform systematization of the delusions without marked mental deterioration constitutes paranoia
in the strict sense of the word.
In this form the delusions
basis of a thoroughly elaborated, but falsified, apprehension of self and the environment; but even here
become the
a decided weakness of judgment

monstrable.
is
probably always de-
system of coherent delusions, sometimes found in paresis and dementia praesimilar
The somewhat
cox, are always of shorter duration.
Practically all
delusions
center in the
self,
either as
self-depreciation (depressive delusions) or as self-aggrandize-
ment (expansive delusions). Among depressive delusions, those of self-accusation stand closest to the normal life.
Many normal
persons torment themselves with the belief
that they are unlucky. In states of morbid depression the idea of guilt may be associated with the patient's
every action.
He
believes that he
is
and deceiving others;

of abominable deeds
his past appears to
constantly injuring him as a series
and
terrible crimes.
He
is
an
irre-
creature, repudiated consequently about to suffer a fitting punishment, arrest, the scaffold, the stake, or whatever else his ingenuity can invent.
deemable,
unfeeling
is
by God and
damned, and
Related to these delusions are the general fears of poverty, loss of work, or some other misfortune about to befall
themselves
this
or
relatives.
In progressing mental weakness
form of delusions
may become
is
thing, the patient included,
nihilistic, when everynon-existent or less than
nothing. large group of depressive delusions are those of persecution. They originate during periods of indisposition, discomfort, or anxiety.
excited
marks.
Mistrust and suspicion are by peculiar coincidences and misinterpreted reNewspaper articles and popular songs contain
54
references
and even
indirect
insults.
All
assertions
of
and friendship are disbelieved. At this time, also, there usually appear hallucinations, especially auditory. The patient sees himself involved in a network of secret
love
and imminent dangers which he cannot escape. All are joined against him and gloat over his misery. Men call after him, whisper to each other, shun him, spit in front of him, etc. Food and drink have a peculiar taste, as if
hostilities
poisoned, etc. Delusions of jealousy also play a prominent rSle. The patient notices a coolness in marital relations, detects
fond glances and secret signs, finds in letters arrangements for secret meetings. The wife is embarrassed by
his
unexpected return home, tries to conceal something, coughs in a significant manner, the room is darkened.
Outside some one pounds on the door, a form scurries by the window, the last child does not resemble its father,
Indeed, these delusions as cited by the patient are sometimes presented with such good foundation that it is
etc.
difficult to distinguish
them from
ideas of infidelity that are
actually justified. Delusions of infidelity occur principally in chronic alcoholism and cocainism, but also in senile
mental disorder. In advanced mental weakness the persecutory ideas often assume a very fantastic form. Absurd somatic delusions of transformation and witchery, such as telepathy,
magical, electrical, or hypnotic influences, are common forms. Sexual delusions are especially common, varying from mysterious sexual excitation to imagined childbirth
during stupor. All these evils may be attributed to any individual or group of individuals from the neighbor or
husband, to fraternal or political societies. In hypochondriacal delusions the object
is
some
alleged

incurable disease.
55
Harmless physical symptoms are reas signs of syphilis, sexual excess, paresis, etc. garded With the onset of deterioration the delusions become
absurd and fantastic.
Expansive ideas
may
also
be referred to a somatic
basis.
Thus, feeble paretics extol their beautiful voice, their
gym-
nastic dexterity, although they cannot produce a single musical tone or even stand on their feet. Closely con-
nected with the hypochondriacal ideas are such expansive ideas as that the excretions are gold, Rhine wine, etc.
Sometimes delusions with a depressive content acquire the

Patients state that they significance of expansive ideas. will die at once in order to be translated to heaven ; they
send invitations to their
own
execution, which
is
to be con-
ducted with great pomp. The delusion of mental soundness, in spite of deep-seated mental disease, constitutes an absence of insight into the
disease.
morbid states
This absence of insight is almost universal in ; many patients not only consider themselves
and paranoia.
perfectly sane, but remarkably intelligent, as in paresis The external relations of the patients, the
social position
expansive delusions.
and property, are similarly transformed by Noble descent, close relation to the
temporal and spiritual authorities, even association with supernatural powers, are among the most frequent forms.
With further development the patient becomes the
Presi-
On the other hand, patients dent, the Pope, Christ, or God. boast of their untold wealth and vast estates, including
whole continents or the world
gigantic undertakings
fill
itself,
while vague plans of
their minds.
Depressive and expansive delusions are by no means mutually exclusive. They may co-exist or follow one another very closely. The victim of persecutory delusions
56
discovers an adequate cause
of this persecution in exnatural right to great possession or ceptional ability, high positions. His detention is the result of jealousy or These relations are not the result of logical intrigues.
elaboration, but rather spontaneous and independent conIn sequences of the internal condition of the patient.
dementia prsecox the appearance of expansive ideas following delusions of persecution indicates a decided progress
of
mental weakness.
Disturbances of the Rapidity of Thought. The normal of the association of ideas and concepts varies so rapidity
greatly in different individuals, and sometimes even in the same individual, that it has been impossible to establish a
standard by which morbid deviations can be accurately estimated. We are, however, able to recognize two disturbances
namely, retardation and acceleration of the train of thought. Retardation occurs even in healthy individuals as the
result of physical
and mental fatigue. Some unpleasant It also occurs emotional states produce the same result. during the intoxication produced by alcohol, ether, chloro-
form, chloral, and to a moderate degree after the use of tobacco. This disturbance is characteristic of the depres-
and mixed forms of manic-depressive insanity, is found in the end stages of dementia praecox and paresis, and in congenital imbecility. Moderate retardation apsive
pears also in melancholia. Acceleration is less frequent than retardation.
In nor-
mal
produced only by some forms of emotional excitement, and by such drugs as morphine, caffeine, and ethereal oil of tea. In morbid states genuine acceleration
life
it is
probably never found. In flight of ideas the thought may appear accelerated, but even here real delay can usually be demonstrated.
is
57
The capacDisturbances of Capacity for Mental Work. ity for mental work is independent of the rapidity of
thought.
It is scarcely to
mentation, although it In normal of mental disease.
be measured by direct experiforms a most important symptom

the capacity for mental the residua of past efforts. These
life
work
is
determined by
residua condition the increase of capacity, which we call In morbid states the effects of practice are practice.
usually lessened and rapidly disappear, particularly in

congenital imbecility.
The capacity
for mental
work stands
in inverse ratio to
Increased susceptibility to fatigw susceptibility to fatigue. is very general in most forms of insanity. find it in
We
exhaustion psychoses, dementia prsecox, congenital imbecility, and paresis, where it is often the first striking
symptom of the disease. In neurasthenia it is often masked by increased nervous irritability. Recovery from fatigue is effected by relaxation and
especially
by
sleep.
Melancholiacs and neurastheniacs
recover very slowly from the effects of mental, emotional, and physical activity. This is the result, in part of diseased mental tone, in part also it results from disturb-
ances of sleep, not only in amount but depth. It has been shown that in conditions of simple overwork the sleep
is
light, attains its greatest
an incomplete abatement
ing.
depth very slowly, and of its profoundness in the
shows morn-
work is markedly decreased by It can arise from insufficient intensity of distractibility. the goal ideas, from unusual vividness of individual presentations, or finally from an increased susceptibility to
Finally the capacity for
influences. Inadequacy of the goal ideas is the cause of distractibility in paresis and dementia probably
distracting
58
The vividness of individual presentations is seen praecox. in the distractibility of acute exhaustion psychoses, and
and probably also dementia prsecox and paresis. The increased susceptibility to distracting influences is a reguespecially in manic-depressive insanity,
in excited periods of
lar
symptom
of
neurasthenia, where quite insignificant
forms of irritation
all
may become
altogether intolerable.
Disturbances of Self-consciousness.
The sum
total of
those presentations which form the complex idea of

personality constitutes selfthe permanent background of our and exercises a characteristic influence on the
our physical consciousness.
and
mental
is
This
mental
life,
our mental processes. In content as well as scope, self -consciousness is determined by the experiences of each individual. It is a familiar phenomenon in dreams
course of
all
may carry on a complete dialogue indeed, one be completely taken back by some particularly strikmay Apparently in such ing expression of his interlocutor. cases the unity of self -consciousness is lost, which in the waking state permits us to oversee all our thoughts and
that one
;
inner impulses at once. Such a dual personality or splitting of self-consciousness often occurs in mental disease. Possi-
bly the
first
indications of this are found in those cases in
which sense deceptions appear to the patients as strange
Whenever a patient suffering from delirium tremens overhears some derisive dialogue
phenomena
of external origin.
about himself, or plans of a threatening nature being devised against him, there is no doubt in his mind that these are of external origin and not the hallucinatory
Unbeknown to expressions of his own thoughts and fears. himself he plays the role of two different persons. Splitting
often observed in dementia prsecox, where the patients refer to foreign influences and enemies
of self-consciousness
is
59
residing within their bodies, the thoughts and actions of which they differentiate very clearly from their own. Some
hysterical
symptoms may be
The temporal connections

past
similarly explained. of one's personality with the
may be
disordered in such a
way
that the
memory
of
certain periods of
pletely lost.
life of longer or shorter duration are comIf during any such period of life there has
been no development, self-consciousness remains on the
same plane that

tions of
this case the interval is bridged over
was at the beginning of the period in by means of falsificamemory or inferences. The patient depends upon
it
;
inferences in the interruptions in self-consciousness occurring in clouding of consciousness, sleep, fainting, befogged
states,
and
delirious
conditions,
and on fabrications
in
Korssakow's psychosis where
loss of
memory
is
produced
by
"
disorder of the attention.
The
so-called condition of
represents another form of disis a more or less regular alternation of different states in each of which there is
double
consciousness
"
turbed self-consciousness where there
only for the experiences of similar previous states. Thus two different personalities are dovetailed, each of
memory
disposal only a part of the total experience of the individual. As a rule, one of these personalities
its
which has at
belongs to an earlier stage of development than the other, and consequently does not possess all the skill and knowlSometimes there takes edge that the other commands.
place a reversion to a particular period of the individual's past life, which has been conspicuous because of certain experiences.
may
This condition, called ekmnesia by the French, be induced experimentally by hypnosis, and is charac-
teristic
especially of hysterical insanity. Self -consciousness is no fixed mental construct,
more
but
it
changes continuously with experience.
So disease processes
60
The are able to falsify it, though not in like manner. The alteration of self-consciouscause of this is not clear.
ness in the depressive stages of manic-depressive insanity is often very striking, while in melancholia it may be
insignificant in spite of the extensive delusional conception
of the environment.
Also in delirium tremens the patients

Since the most extensive
have the most fantastic experiences without suffering any

-alteration of self-consciousness.
alterations of self-consciousness occur in paresis, dementia prsecox, and in manic-depressive insanity, the hypothesis
sis
plausible that this disease

will.
symptom
is
related to dis-
the other hand, we are accustomed to ascribe disturbances of the will in large measure to the
turbances of
On
character of the psychic personality. The particular form of the falsification of self -consciousness
is
determined by the morbid disposition.
Thus
in
manic patients the peculiar condition of self-consciousness leads to the development of expansive ideas, which in reality are nothing more than a playful expression of the emotional elation. In the depressive and stuporous phases of manicdepressive insanity the patients become not only depressed and abject, but they even feel physically altered turned
to stone, dead, and transformed into other individuals, such as the devil and animals. Similarly the paretic in
accord with his expansive and pessimistic ideas comes to believe that his body is variously altered. In dementia
pnccox this condition, although present, is less pronounced, and in contrast to paresis and manic depressive insanity is
not infrequently associated with ideas of some sort of external influence which produces the alteration. In paranoia, the disturbance of self-consciousness is very slight and confined to the
abilities.
delusional overestimation
of
the
patient's
61
In advanced deterioration, self-consciousness ultimately In dementia prsecox and paresis this is the disappears.
usual terminus of the mental
life.
It is to
be especially
emphasized, however, that this

ration,
cases,
is
not the result of deterio-
but a special symptom of these diseases. In some on the other hand, even when the store of ideas is
still
much
This
impoverished, the patient
retains his self-con-
sciousness
is
and can give an account
of his
particularly
common
in epileptics.
own condition. Even in pres-
byophrenia, where, on account of the marked disturbance of attention, experiences disappear entirely from memory and are replaced by the freest invention, self -consciousness
is
retained.
6.
DISTURBANCES OF THE EMOTIONS
lation to
Every sensory impression which sustains any intimate reman's welfare is accentuated in consciousness by a concurrent feeling of pleasure or pain, depending on its apparent tendency to advance or retard the general aims of
life.
Therefore, the feelings are a direct indication of the attitude of the ego to the perceptions of the external world.
According to Wundt, one can distinguish three opposite states of feeling, which rarely exist alone, but almost always accompany mental processes in various combinations;
namely, pleasure and displeasure, excitement and calmness,
perhaps preferably retardation, and finally tension and Disturbances of the emotional life often form relaxation.
the
first
striking
symptom
of disease.
But the recognition
and estimation of these disturbances is difficult, because we lack an adequate normal standard. Even in health the emotions show marked personal peculiarities, closely allied
to the abnormal.
Diminution and Increase of Emotional
Irritability.
is
The
diminution of the intensity of the emotions and most frequent disturbance. In normal
in the environment
is
their simplest
life
one's interest
reflected in
more or
less intense fluc-
tuations of his emotions.
Diminution of these emotional
accentuations indicate indifference toward the impressions This is characteristic of most forms of the external world.
mental deterioration, of which it is one of the first and most striking symptoms. Emotional indifference may be
of
marked even when external impressions are well apprehended

and elaborated.
63
This striking disproportion between disturbances of the intellect and the emotions is most pronounced in dementia praecox. In paresis, on the other hand,
mental elaboration
is
disturbed to a
much
greater degree
than the emotions.

All phases of the emotional life seldom suffer equally. Naturally the patient loses most easily those feelings which are not directly connected with the changes of his own ego,
but are related to the more remote, external world, and further those feelings which have lost their sensory proper-
and are aroused only through the higher mental processes as concomitants of general ideas and moral principles. The active interest of the patient becomes exclusively selfish.
ties
He
loses all pleasure in
mental work, and
all feeling for
the
higher claims of propriety, morality, and religion.
Considera-
tion for his environment, his family, relatives, and finally for mankind in general, has no influence on his conduct. He
loses the sense of
shame and lacks

is
all
comprehension of the
conventions of social intercourse.
Emotional deterioration
symptom
of
very often the first striking dementia praecox, and advances with the
It regularly occurs in senile deis
progress of the disease.
mentia, and sometimes

its
an early symptom
of paresis.
In
appears, also, in simple senility. Emotional deterioration is also prominent in many forms of simplest form
it
" moral imcongenital imbecility, especially the so-called in which the patients show a certain shrewdness becility/
7
in the
attainment of
selfish
advantages which often conceals
the real severity of the disease. Lower or sensuous feelings possess a greater momentary intensity, but are at the same time more transitory than
the higher moral aesthetic sentiments, which accompany and determine our thoughts and actions throughout our entire
64
life,
and act as checks on sudden emotional impulses
of the
lower order.
The absence
of these checks in imbecility gives rise to
sudden, but transitory, outbursts of passion. Without a firm foundation for the emotional life a mere trifle, a word, the tone of the voice, suffices to plunge the patient from the
most
spair.
blissful self-complacency into
the most profound de-
This
is
an
The emotional
of
especially prominent symptom in paresis. indifference characteristic of the end stages

is
dementia prsecox
is
tional ebullitions. indifference
A permanent
regularly accompanied by such emocharacteristic of emotional
lack of insight.
The retardation
of depressed
superficial
manic-depressive patients sometimes presents a
similarity to the emotional indifference of the deteriorated, but the former realize their condition, and often complain
that they are forsaken and desolate.

of the emotions is characteristic of
An
especial vivacity
children.
women and
The emotional
influenced
states are highly unstable and are readily by momentary conditions. The great ease with which vivid feelings appear and disappear is characteristic
of
some
of the psychopathic states.
This condition under-
lies
the syndrome of hysteria.
In this disease ideas have
such an intense emotional tone that a powerful influence is exerted not only over the will but also over such physical
processes as are, in general, not under voluntary control; as, breathing, circulation, pulse, muscles of the bladder, rectum, and hair, secretions of the glands, as well as the
accuracy of movements and the clearness and intensity of

sensations.
temporary increase of the emotional irritability is seen in some of the excited stages of paresis, catatonia, and in
Since the manic-depressive insanity. vividness of the temporary emotional state forces the
of
manic phases
65
restraining influence of the higher feeling completely into
the background, this condition
is
accompanied by the im-
change of mood. A similar condiportant phenomenon tion is observed in the intoxicated individual, in whom
the exuberance of
feeling
abrupt change of
for
mood.
is so often accompanied by In this condition it is possible
one to influence markedly the tone of feeling of the patient except in catatonic excitement, where negativism
prevails.
Morbid Temperaments. The same experience may arouse wholly different mental attitudes in different individuals,
according to the constitutional tendency to certain tones of Because of the feeling, the temperament of the individual.
infinite variety of
impossible to describe
the combinations of feelings it is almost all the different types of temperafield this difficulty is
ment.
In the morbid
of the forms.
even greater;
hence we must content ourselves with a brief sketch of only
some
Since displeasure exerts in general a stronger influence over our mental life than pleasure, we would expect to find This it playing the more prominent role in morbid states.
to discover in
increased susceptibility to the unpleasant leads to a tendency all of life's experiences only that which is
unpleasant. The past is crowded with sad experiences and the future a source of anxiety. The individual's own wellbeing is the centre of his thought, and every insignificant
ailment
regarded as a sign of threatening disease. The dejection which in normal life accompanies sad experiences gradually wanes, but in disease even a cheerful environis
ment
fails
it.
to mitigate
sadness, indeed,
it
may even
in-
tensify
Whenever morbid sadness is accompanied by an inner tension, the emotional state becomes one of apprehensiveness.
66
feels
The patient
a lack of security and freedom, together with a lack of confidence in his own ability. He awaits
with apprehension the outcome of every act, and doubts its In this state his own physical justification and fitness.
a very fruitful source for the development of There develops a self-torture and an all sorts of doubts. of liability. This type of feeling furnishes exaggerated feeling
condition
is
is
the basis for the morbid fears to be described later, and also often seen in the incipient stages of melancholia.
When
this increased susceptibility to the unpleasant is
associated with excitement, there exists what is known as an irritable disposition. This is characterized not only by a
general tone of displeasure toward everything, but
by an
emotional excitement which demands expression and is held in check only by a constant struggle. This lack of
means a persistent variation of the emotional equilibrium and a condition of instability with occasional violent
control
outbursts of feeling, which sometimes take the form of

despair
and sometimes
in
of anger.
Despair
is
encountered
is
chiefly in congenital
neurasthenia, while
anger
found
especially
the
epileptic
and
hysterical
constitutions
(Irabundia Morbosa).
Morbid sensitiveness to the outer world does not always

lead to passionate outbreaks, but sometimes produces that type of temperament termed seclusiveness. Seclusiveness is
not accompanied by that passionate feeling of anger that goes with the defiance of a normal individual, but it indi-
more or
cates a sort of shrinking from the impressions of life with a less clear consciousness of one's own insufficiency.
Conversation with strangers, entering a new environment, unusual demands, and difficulties appear to a patient as unsurmountable obstacles. This condition underlies the
conduct of
many
of the merely
"
peculiar
"
individuals.
67
history of such peculiarities often antedates the outset of
dementia prsecox.
The pronounced feelings of pleasure are found in those happy sunny dispositions that are always in good humor, see things on the best side, and are most enthusiastic.
often a pressure of activity, which incites the individual to various changing unsuccessful pursuits; a combination, which also exists in
is
Associated with this state there
manic-depressive insanity. Another modification of the emotional
life is
fanaticism.
Here
develops prominently types of feeling, of a religious and sexual nature, which control especially thought and action. These individuals may exhibit the
also
there
most extraordinary feeling of happiness that rises above all external sadness and adversity. The hysterical constitution arises from this sort of a basis. Closely related to these
fanatics are the morbid swindlers with their great love for
adventure, and for the exciting and the unusual. The exaggerated joy in their own inventiveness forces all deliberation into the background. exist here.
Hysterical
symptoms
also
closely allied disposition is morbid frivolity,
charac-
by superficiality of the emotions. Here there is an increased susceptibility to superficial distractions while serious things are not taken seriously. Life in general is regarded as a joke. Associated with this morbid frivolity, which is an essential element in some forms of imbecility and weakmindedness, there is regularly a defective development of the higher feelings, a selfishness and instability of
terized
the
will.
A common characteristic of this condition of frivolity is an

exaggerated
self -consciousness.
The
patients'
own
abilities
and work appear to them
in
an
especially favorable light.
68
These patients not only grossly overestimate themselves, but have a corresponding lack of sympathy for others. This
selfish
onesidedness of the tone of feeling exists in
many
born criminals, also in the pseudo-querulants, where it is It is probably also a combined with great irritability.
favorable soil for the development of genuine querulants and perhaps the allied forms of paranoia.
Morbid emotions are distinguished Morbid Emotions. from healtliy emotions chiefly through the lack of a sufficient cause, as well as
by
their intensity
and
persistence
furthermore the tone of feeling usually corresponds to some of the well-known mixed feelings. Even in normal life
moods come and go
in
an unaccountable way, but we are
always able to control and dispel them, while morbid moods defy all attempts at control. Again, morbid emotions sometimes attach themselves to some certain external occasions, but they do not vanish with the cause like normal feelings,
and they acquire a certain independence. By far the commonest form of the unpleasant morbid emotions is /ear, which may perhaps be regarded as a combination of a feeling of displeasure with an inner tension. It influences the whole physical and mental condition more profoundly than any of the other emotions. The inner
exhibited physically by the facial expression, bodily attitude, convulsive action of the muscles, in a moan or an outcry, in an act of defence or escape, in attacks on
tension
is
the surroundings or the patient's own life. Besides this there is apt to be precordial oppression, palpitation, pallor, increased respiration, tremor, and sometimes perspiration
and an increased
conditions fear
desire to urinate
and
defecate.
In morbid
patients feel often well aware that their fears are groundless.
usually without an object at first. The afraid without knowing why, and indeed are
is
In the
69
constitutional psychopathic states the indefinite fear often
assumes peculiar forms, as the feeling of homesickness and the like. In acute mental disturbances the indefinite anxious forebodings
fears.
become
fixed into
more or
less
definite
fear, like all extreme emotions, is always a clouding of consciousness. accompanied by Fear is not maintained at the same intensity for any
Extreme
considerable length of time, but shows remissions, and aggravations, the latter especially at night. Fear is most
pathognomonic of melancholia of involution, where it is seldom absent. It occurs frequently in depressive forms of manic-depressive insanity, but may be absent. It occurs
also in the befogged states of epilepsy, in delirium tremens, and in the beginning of catatonic excitement. Paresis
sometimes presents fear in
its
most extreme form.
A large group of disturbances characterized by fear is found in the so-called compulsive fears, phobias. These fears
are sometimes associated with some personal experience or idea which has given rise at some time to fear. In the lightest forms such fears are encountered in normal individuals, but here they lack the persistency
and obtrusive-
ness which characterize the phobias. The compulsive fears are characteristic of
some forms
of
may appear transitorily in These compulsive fears include manic-depressive insanity. the fear at the sight of or contact with certain objects, as
spiders, knives, needles, etc.;
the psychopathic states, but
on deserted
also the fear of being alone the fear of crowded rooms, of open or streets, closed doors, etc. (see pp. 499-503). These patients are
tormented by the idea that their clothes do not fit properly, that they themselves are soiled or poisoned by contact with
others, that they might have swallowed needles or fragments of glass, that in tearing up any scrap of paper they might
70
etc.
Other closely allied disturbances are the feelings of discomfort which arise whenever individuals are compelled to come into any sort of relations with others, as in erythrophobia, morbid blushing.
have destroyed valuable papers,
While fear has been designated as sadness with inner tension, simple dejection is defined as sadness with inhibition ; in other words, anguish with a feeling of insufficiency. The basis for this emotional state is found in the sorrow
arising in the person himself,
all of
which impresses
itself
upon
the experiences of life. As the result of this, the entire past seems but a series of misfortunes and failures;
the present
all sorts of
is
troubled and dark, and the future dubious;

arise,
sad thoughts and forebodings

is
which
may
lead to delusional ideas of
but the most painful

feel neither
self-reproach and persecution, the feeling of desolation. Patients
pleasure nor sorrow; indeed, they do not respond emotionally to any of the impressions of the outer One patient expressed himself by saying that he world. " To be sure I see things well like a cinematograph. felt I don't feel them." The normal pleasure in enough, but
mere existence gives place to a feeling of weariness of life. The alteration of the tone of feeling which is characteristic of some of the circular depressive phases of manic-depressive
insanity as a rule
accompanied by a retardation of thought and action. The patients regard their condition as the most agonizing; they feel as if they were inwardly dead, had
is
become
heartless
and morally
physical
desolate.
They frequently
entertain ideas
of
alteration.
patients are not without feeling, their occasional attempts at suicide.
In reality these as may be judged from
The retardation may
suddenly give place to excitement. Sadness with excitement is occasionally observed in manicdepressive
insanity,
occurring either as an independent
71
of the disease.
phase or as a transitional stage between different phases In this case the mood is sometimes sad,
sometimes anxious or passionate, the patients expressing themselves in wailing and moaning, in states of anxiety, or in outbreaks of irritability. The latter form is particularly
common.
The
patients are fretful, discontented, at variance
with themselves and their environment, and annoyed by trifles. They grumble and growl in the most intolerable
manner and show outbursts

provocation.
conceit
of passion of this
An emotional state
on the slightest sort combined with
sarcastic is exaggerated sometimes encountered in syphilitic insanity. Many of the emotional states of the hysterical patient exhibit a mixture
and an attempt to be
of sadness
and excitement with passionate
irritability.
epileptic presents a special type of emotional disturbance namely, a simple dejection with a feeling of weariness of life. Occasionally it is associated with a feeling of
;
The
is a sort of homesick feeling with an indefinite yearning and inner restlessness, which
inhibition,
but usually there
leads to suicidal attempts, indulgence in alcohol, or aimless wandering. Yet irritability with sudden violent outbursts
In the epileptic bequite common. fogged states a tense anxious feeling predominates, someof great intensity
is
times combined with great irritability. Furthermore in all of these emotional states there may be a mixture of a sexual
or ecstatic feeling of pleasure.
The morbid feelings of pleasure are less frequent than those of displeasure. They occur especially in alcoholic intoxications and alcoholic psychoses, manic-depressive insanity, paresis, dementia praecox, morphin and cocain intoxication.
The
feeling of increased strength, enthusiasm,
enterprise
which
the facilitation
and from alcohol probably originates in of the release of motor impulses in the brain,
results
72
while further action of the drug causes irritability, restlessIn the manic forms of manicness, and aimless activity.
depressive insanity in which there of pleasurable feelings, irritability,
is
a similar combination
the emotional disturbance

origin.
is
and pressure of activity, believed to have a similar
This belief
perimentation. the disorder.
substantiated by physiological exIn both conditions there is no insight into

is
The emotional
attitude in both bears the

is
stamp
of a
wanton happiness, and self-confidence
greatly
increased.
The high
spirits so characteristic of the chronic alcoholic
represent another type of morbid feeling of pleasure, and are designated drunkard's humor. The same state may
exist in delirium
tremens where, however,

fear.
a sort of concealed
arise
Its origin
is
mingled with unknown, but may

it is
from the drunkard's insusceptibility to however, humiliation and his moral apathy to vice. In paresis the pleasurable feelings are apt to be marked, especially the In this disease, however, these feelfeeling of well-being.
ings often exist unaccompanied by motor excitement, and in spite of the expansive ideas, there is absent the lack of
restraint
and fresh energy that is so characteristic of the manic exhilaration. In the later stages of paresis the feelwithout a trace of the
ing of well-being subsides to a silly thoughtless happiness irritability which is found in the
In dementia prsecox, during the excited stages, pleasurable feelings take on the form of a silly, purposeless hilarity and exuberance with outbursts
later stages of the alcoholic.
of silly laughter, which, in contrast to the hilarity of the manic forms of manic-depressive insanity, seem to bear no
relation to the patient's ideas
and environment. Cocain, morphin, tobacco, and the bromides also produce In tobacco smoking characteristic feelings of well-being.
73
the feeling of agreeable contemplation is due purely to a soporific effect; the bromides produce a feeling of well-
being by relieving a state of inner tension. The feeling of ecstasy, which occurs especially in epilepsy, and sometimes
in hysteria, seems to be very similar to the dreamy state which follows opium smoking. The origin of morbid feelings of pleasure is very difficult to determine, both because they may arise from a great many different disturbances,
sometimes somatic and vaso-motor, sometimes primarily emotional, and sometimes intellectual. Different types of
feeling
may
exist at the
same time or may succeed each
other rapidly, as seen in the mixture of fear and humor in the alcoholic and of ecstasy and anger in the dreamy states
of the epileptic.
Disturbances of General Feelings.
General feelings are
those emotional states which stand in close and inviolable

relation to self-preservation, such as feelings of fatigue and hunger. They are to be regarded as admonitions, which
gradually develop out of the experience of countless generations into involuntary and instinctive impulses. In ordinary life these feelings inform us of our bodily needs, and they
imperiously exact actions adapted to the circumstances. The performances of these actions can usually be inhibited
by conscious
self-denial;
although often only by means of great the feelings themselves are, on the contrary,
volition,
only thoroughly silenced in some way or other.
when
the indicated need

life
is
relieved
In normal
a general feeling
may disappear when we pay no heed to it. We are able to overcome weariness when work demands our strength; hunger abates when we are unable for a long time to satisfy it. When at last we have the opportunity to attend to our needs for rest and food, we miss at first the painful weariness and hunger which makes the restoration of our strength
74
so easy.
Only when we have rested
for
some time do we
again experience a feeling of weariness, while hunger gradually returns as soon as we begin to eat. In normal life the performance of mental and physical
The basis is accompanied by a feeling of pleasure. for this experience lies in the fact that the formation and
work
maintenance of personality depends upon activity. If this feeling of pleasure is absent, one regularly develops a form
This is the form of ennui that develops from and soon forces one to some sort of endeavor. To a normal man enforced idleness is most irritating. Among the insane this form of ennui is usually absent because
of ennui.
idleness
the patients, even although unemployed, are completely absorbed in their own morbid mental processes. The appear-
ance of this ennui in a patient may, therefore, be regarded as a favorable sign; yet one must be cautious not to confuse it either with the feeling of discontent that is often referred
to
of
by the dejected patients as ennui, or with the pressure The complete absence of activity of the manic patients.
ennui in dementia prsecox is a very important symptom. Here there is a complete loss of volitional impulse from
which the desire for activity takes its origin. The patients can in spite of clear consciousness lie abed weeks and months without in any way becoming uneasy at the lack
Their lack of ennui always indicates a profound disorder of the mental life, and especially accomof activity.
panies progressive deterioration.
A wholly different significance attaches to that unpleasant

which accompanies excessive exercise as a sign of warning. This form of weariness generally indicates in a normal individual an actual need for rest; in other words, fatigue. Patients sometimes fail to show their fatigue, although there is real
feeling often designated as weariness
75
need for rest. In many excited states, especially in manic forms of manic-depressive insanity, there is often a complete absence of fatigue in spite of the fact that the patients
are exhausted
by continual
restlessness.
The
feeling of hunger is similarly disturbed in these
same
often
psychoses.
In paretic and catatonic patients there
is
a senseless voracity, although the well-nourished patients have no need of such an amount of nourishment. In the
constitutional psychopathic states and in hysteria, without any perceptible relation to the state of bodily nutrition, there may be a prolonged absence of the feeling of hunger,
which
is suddenly replaced by gluttony. Severe disturbances of the feeling of nausea are almost
always signs of a far-advanced deterioration. Such patients consume the most disgusting things,, even their own dejections.
Not infrequently they swallow
nails, stones, pieces
of glass, or animals, not only with suicidal intent, but con-
stantly overpowering their nausea from pure greediness. These patients also lose those feelings which cause us aversion at the mere contact with filth or dirt and impel one to keep clean, not only the body, but the whole environment. They recklessly soil themselves, even intentionally, with their own food, their own saliva, urine, and even feces.
The feelings of physical pain are often abolished. In conditions of excitement, especially with intense fear, even severe injuries produce no sensation at all, although conSuch patients pluck out their tongues or eyes, cut open the abdomen, etc., deeds which would be utterly impossible for a man with a normal
sciousness
may
be perfectly
clear.
sense of pain.
This insensibility to physical pain is often found in demented patients, especially in paretics, in whom, to be sure, the destruction of the nervous conducting paths
76
is
an
essential antecedent.
to pain encountered in
is
epileptic patients in these conditions the threshold essentially different; of pain only appears to be raised.
The absence the hysterical and
of the sensibility
There
is finally
a group of feelings which pertain to the
maintenance
of the race rather
than to self-preservation;
namely, the sexual feelings. patients the feeling of shame
Among bewildered and excited may pass wholly into the back-
ground; yet one sometimes observes distinct evidences of the feeling of shame in the great excitement of manicdepressive cases sexual feelings.
when it is not overpowered by The rapid disappearance of the
increased
feeling of
shame even without sexual excitement is a striking symptom of dementia prsecox. Such patients denude themselves recklessly,
and masturbate
also tend
gestures.
speak shamelessly about sexual matters, persistently and openly. These patients
(copralalia)
to
employ obscene language
and
Sexual feelings in mental disease are either increased, Sexual indifference occurs in many abolished, or perverted.
forms of the constitutional psychopathic

ticularly in hysteria, also in morphinism.
states,
and par-
An
is
sexual excitability which

,
is
more frequent,
increase of found in some
idiots, but in a more pronounced degree in dementia praecox, and also in the excited stages of paresis, the manic forms
of manic-depressive insanity,
verted sexual feelings are
and
in senile dementia.
Per-
those in which sexual feelings occur exclusively in connection with persons of the same sex, associations with certain objects, or accompanied by
brutality (see p. 92).
D.
DISTURBANCE OF VOLITION AND ACTION

disturbances of the psychic
life
ALL
find their final ex-
pression in volition and action. The idea of a definite aim (some change either in ourselves or our environment) forms
the starting-point of a volitional act. This idea is accompanied by feelings which are converted into impulses for
the attainment of that aim.

is is
The
direction of
any action
determined, therefore, by an idea, while its performance determined by the intensity and the duration of the
accompanying feelings. Morbid disturbances of volition manifest themselves in the most varied ways: the energy of the volitional impulse can be diminished or increased; its release facilitated or impeded; or the direction can be modified by external or internal influences; morbid impulses can forcibly suppress the normal will; or natural impulses can assume morbid forms; finally, the conduct of the insane is naturally influenced by all those disturbances which occur in other spheres of their mental life, although the volitional process itself presents no disturbance.
Diminution of Volitional Impulses.
pension of volitional activity is
It is
The complete
sus-
termed paralysis
of the will.
produced by extreme fatigue, profound alcoholic
in-
toxication,
and
It
in the narcoses of chloroform, chloral,
and
morphin.
characterized by an absence of energy. Ordinary impulses find no issue in action, while even the most powerful incentives of personal well-being and moral
is
claims
fail
to
influence
the patient.
77
more or
less
78
complete paralysis of the will occurs in the end stages of progressive mental deterioration senile dementia, dementia
:
prsecox,
and
paresis.
This
is
characterized by a
marked
diminution of personal
the lower,
initiative,
except in gratification of
selfish, greed, If left to themselves, the gluttony, and sexual desire. patients are content to sit around, inactive, displaying very
and vegetative impulses, such as
animation and staring vacantly into space. In dementia prsecox it can often be shown that the patients have
little
not lost the voluntary control of their actions, but normal In the end stages of incentives fail to influence them.
deterioration
reflex.
the
only movements are
involuntary
and
Similarly, defective volition appears in congenital
imbecility as the result of defective development. Increase of Volitional Impulse. The universal indication
of the increase of volitional impulse is motor excitement. But we are really justified in speaking of an increase of volitional
impulse only when there is a marked disproportion between the intensity of the excitation and the importance of the
In alcoholic delirium, for example, we find marked unrest which cannot be explained by the patient's delumotives.
sions, hallucinations, or emotions,
but must be referred to a
morbid motor excitation. Patients will not remain in bed, show a pronounced restlessness, and constantly busy themselves as if employed in some occupation. In alcoholic intoxication, increase of volitional impulses begins with simple loquacity, and increases to brawling, screaming, and aimless
activity.
In chronic cocain intoxication (see
p. 210) there
develops a peculiar motor excitability which seems to form a transition to the morbid pressure of activity which is a
characteristic
p. 387),
symptom
of manic-depressive insanity (see
and
is
sometimes found in exhaustion psychoses and
paresis.
79
of activity takes the
In the lighter hypomaniacal disturbances this pressure form of general instability and busy-
ness, great talkativeness,
ticulation.
Such
to animated gespatients collect all sorts of useless things,
and a tendency
begin countless undertakings which they never finish, and, when unrestrained, travel aimlessly about. In more marked
excitement the goal ideas become more and more inconstant, and one can hardly detect any purpose at all in their
ever changing, incoherent activity. Patients scream, laugh, sing, dance, disrobe, tear their clothing, smear themselves,
wash in their own urine, destroy everything they can and pound incessantly with their hands and feet.
reach,
Catatonic excitement furnishes a picture essentially different from that of the manic pressure of activity. In
the manic excitement,
all
impulses lead to more or

first
less
purposeful actions, though they might at
appear pur-
In catatonia, on the contrary, we poseless and senseless. have to do with movements which at most have no definite
aim.
is
Although the characteristic excitement in catatonics
more moderate, the movements are entirely purSuch patients make grimaces, contort the body, poseless. run about, clap their hands, and utter a succession of senseless noises. These movements are not pure volitional acts, as there is no antecedent idea of their purpose. Patients themselves often assure us that they do not know why
often
they perform such absurd antics. The strength Impeded Release of the Volitional Impulse. and rapidity with which a volitional impulse is converted
into action
also
is dependent, not only on its own on the resistance which it has to overcome.
intensity,
but
Thus, fright
and
present obstacles to the realization of our which can be overcome only by the most strenuous intention, exertion of the will.
fear
may
80
The psychomotor
retardation,
which
is
the most important
disturbance in the depressed states of manic-depressive insanity, is probably due to a similar increase of resistance.
Such patients require special exertion of the will for almost every movement. All the actions are characteristically slow and weak, except when a powerful emotional shock
breaks through the resistance. The retardation may become less pronounced under the influence of continued effort.
In severe cases independent volitional action is almost imIn spite of every apparent exertion, the patients possible.
cannot utter a word or at best answer only in monosyllables, and are unable to eat, stand up, or dress. As a rule they clearly recognize the enormous pressure lying upon them,
" stupor is usually applied to these disturbances, but they are only superficially related to the stupor of catatonia.
which they are unable to overcome.
The name
"
not rendered
In catatonic stupor the release of movements in itself is difficult, as action is occasionally both rapid
and powerful. But every impulse is almost immediately followed by the release of an opposing impulse which prevents the consummation of the act. Thus, we often see the
desired
movement begin
all right,
but
it is
immediately
in-
terrupted and extinguished by the opposing impulse. Here the impulse is not hindered by internal resistance, but is simply quenched by a counter impulse. In contrast to the retardation, in which there is a continuous hindrance, one As soon as the blockmight refer to this as a blocking. ade is raised, the counter order disappears, and the action
proceeds without the slightest difficulty. As a result of this blocking of the will
many
reactions
which normally occur without special act of volition are

suppressed at their inception. The patients will not look up when accosted, or shake hands when the hand is proffered.

If
81
one threatens them with a knife, or pricks the eyelid, they may perchance shrink away, but they never make any welldirected effort to protect themselves;
in the
most uncomfortable
positions,
and
they continue to lie will sit for hours
of steps they could the persistent holding open of Possibly the eyelids, the regular swallowing of saliva, and the retention of urine and feces may be explained in this way. The
in the sun,
when by taking a couple
reach the shade.
whole attitude of the patient becomes strained and unnatural.
In blocking of the will there is no lack of impulses, but rather a balance of counter impulses. Hence we do not find the lassitude characteristic of retardation but a rigid
which discloses the play of opposing influences. Movements take place with an excess of tension which extension,
tends almost equally over all associated groups of muscles: the resulting action depends on relatively slight preponder-
ance of one group of muscles over the opposite group. Hence both station and movement appear tense and stiff.
Occasionally the relative strength of impulse and counterimpulse varies, sometimes one and sometimes the other
gaining the upper hand. A movement suddenly stops and then just as suddenly begins again. It proceeds by jerks
and
is
awkward and clumsy.

all this
ness of
Possibly it is the consciousthat leads to the innervation of opposition
more remote muscle groups. The entire limb is apt to come into play for the simplest movements, which thereby become ponderous and indefinite. Facilitated Release of Volitional Impulses. Both the impressions of the outer world and our inner experience develop in us continually more or less tension of the will, which tends to relieve itself in the most varied expressions.
Part of these operations are independent of voluntary con-
82
trol.
The
is
greater part of them, however, are subject to inhibition through voluntary effort. The ease with which
impulse
converted into action depends upon the development of the inhibitions which we control. Our mental
development means in general an increase of inhibitions.
The
child reacts immediately, while
growing self-control
enables the
to suppress numberless impulses, before they develop into action. The female sex with its heightened emotional irritability tends to remain on the plain of
man
the child.
The
on
restraining power of the inhibitions naturally depends the strength of the impulses and the intensity of the
emotional state, from which they originate.
On
the other
hand, there are well-recognized influences that facilitate the release of impulses and thereby lessen the resistance to
the conversion of an impulse into action. This operates to a greater or less degree in all forms of psychomotor activity.
Whenever movements are continued there arises a degree of excitement which means a diminution of
tion.
it
certain
inhibi-
has already been pointed out that morbid Indeed, inhibition is gradually reduced by activity. Still more evi-
dent
is
the increase of excitement in manic
and catatonic
patients when their restlessness is not restrained. An unrestrained discharge of impulses always makes it more difficult for the patients to control themselves.
A
by
most
significant diminution of inhibition is
alcohol.
Ether and cocain have a similar
effect
produced both
in the acute
and chronic
intoxications.
The
facilitated release of volitional impulse is a constant
symptom
leaves
in
some forms
of
morbid constitution, especially
in hysteria.
little
In this disease the intensity of the emotions room for the reasoned action, hence these patients
sometimes suddenly find themselves performing strange and
83
incomprehensible acts, as thieving, cheating, and self -mutilation, apparently at variance with their intention.
The motives of Heightened Susceptibility of the Will. action have two sources: external stimuli; and those
relatively constant principles of action
which
arise
from
within rather than from without, and render the individual's conduct more or less independent of his surroundings. The
control of actions
in children
by these general principles is lacking only and unstable individuals. In diseases this conweakness of the
in
conflict
will,
trol is lost in
increased psychomotor
excitability,
and
with
overwhelming morbid
impulses.
Weakness
of will is
found in
all
forms of imbecility, where
the fixed principles of action are lacking. There is no inThe chief characternal unity or consistency in conduct.
teristic is
a hypersuggestibility, through which the patients become the prey to every accidental influence. This condition
purest form in paresis. Similar phenomena are induced through suspension of these fixed principles of action by means of hypnotism.
is
found in
its
Transient hypersuggestibility is found in catalepsy, where often the limbs of the patient will remain in any position in which they are placed until, as the result of extreme
muscular exhaustion, they tremblingly obey the laws of In this condition there is often found a moderate, gravity. but constant, muscular resistance called cerea flexibilitaSj
in
which
it is
possible to
mould the limbs
into
any desired
Less often patients are found who will repeat for position. some time any simple movement, once started, or who will
laboriously imitate everything done in their presence
echo-
praxia.
patient involuntarily repeats every word he hears, although at the same time giving evidence of considerable elaboration of impressions by his
In
echolalia
the
84
Indications of these symptoms, especially cerea flexibilitas, are occasionally observed in the most varied diseases, such as hysteria, epilepsy,
ability to solve simple problems.
manic forms
of
manic-depressive insanity,
paresis,
and
alcoholism; but the whole group of symptoms is most pronounced in dementia prsecox, especially the catatonic
form.
Distractibility of the will is
a morbidly easy translation of
ideas into action.
It usually
ceptibility of the will,
accompanies heightened susbut is differentiated from it by a

It is
is
reaction to internal as well as to external stimuli. to conduct what the distractibility of the attention
intellection,
to
and
effectually prevents
all
permanent
volitional
control of action.
Sudden
resolutions are half carried out
only to yield to new ones. The patients are wholly under the influence of the environment, whether good or bad. Distractibility of the will is found in certain conditions of
It accompanies hystemanic and delirious excitement. ria and some forms of imbecility as a permanent personal
characteristic.
Interference and Stereotypy. The carrying out of any act is in general determined by the goal idea. Since simple our movements are usually governed by the principle of
economy, we seek to reach the goal with minimum expenditure of strength and time. In case this principle is clearly
transgressed, or if the act is clearly inappropriate, we have a disturbance of conduct which is provisionally called interference, in
which the correspondence between intention and accomplishment is interfered with by the interpolation of
incongruous impulses. Here, apparently, incidental impulses break into the natural flow of conduct. A similar
condition obtains in the blocking of the will. One may regard the blocking of the will as a special case in which the
85
incidental impulses are directly opposed to the original impulses; then interference would be regarded as a crossing
of the original impulses
by the incidental impulses in various The blocking of the will would then be only directions. a special form of the general disturbance which may be Both described as a crossing of the voluntary impulses.
symptoms belong to catatonia. The incidental impulses may influence action in many The simplest form is probably seen in the different ways.
reiterated repetition of chance impulses. Normally every as soon as the aim is realized, is forced into the impulse,
background by other impulses. But where the pursuit of any definite aim is disturbed and there still remains a general pressure of activity, any impulse once released has a good chance to be repeated as long as the active residua Such an of the impulse are not obliterated by new aims.
impulse becomes, so to speak, an incidental impulse which breaks through the more or less aimless operations of the
will
and becomes more

is
insistent with each repetition.
This
disturbance
called stereotypy
(Kahlbaum).
Whenever stereotypy is marked (a) by a blocking of the will we find a continuous tension of definite muscle groups; whenever it is marked (6) by crossing of voluntary impulses we find a reiterated repetition of the same movement, (a) In muscular tension the patients remain in the same place and attitude for an almost incredible length of time in spite of the greatest discomfort. They stand in the same
corner, kneel in a definite place,
lie
in
bed with
legs curled
up and head extended, so

a
rigid that they can be lifted like
Others grip a piece of bedspread with their teeth, log. or convulsively grasp a piece of bread or torn-off button. The expression of the countenance is also rigid, mask-like,
the forehead
drawn up as
if
in surprise, the eyebrows ele-
86
The eyeballs are often are protruded like a snout. lips
vated and the eyes often wide open.

turned side wise and the
(b) Stereotyped
movements have an unlimited variety. The
patients turn somersaults, rap rhythmically, walk about in peculiar places, hop, jump up and down, roll and creep on
the ground, pick at the clothing or hair, and grit the teeth.
These movements can be repeated innumerable times, for weeks or even months. In all these movements the patients
are absolutely reckless of themselves and their environment. Mannerisms are a kind of stereotyped movement, consisting of ordinary
movements
peculiarly modified.
gait,
The
go in
patients walk with a peculiar
drag one
foot,
straight lines or in circles, hold their spoons at the very end, eat in a definite rhythm, and shake hands with stiffly
Mannerisms are especially common in speech. Grunts, lisping, peculiar words, phrases, and inflection, and numerous repetitions of the same words are among the most frequent forms. Stereotypy is a characteristic of the catatonic forms of dementia prsecox, but also occurs in exhaustion psychoses and in paresis, where it is
extended fingers.
is occasionally observed a form of stereotypy which is scarcely the same as that just described. It consists of peculiar rhythmical movements, especially rocking the body while sitting and
only a transient symptom. In the end stages of catatonia there
standing, nodding or shaking the head, clapping of the hands, etc. This symptom always indicates a complete
deterioration of the will.
It
is
likewise observed in the
most profound idiocy. It is a fair hypothesis that these movements are the expression of certain primitive arrangements of our nervous system, which in the absence of the
higher processes determine the activities. In stereotypy voluntary activity never proceeds to a goal.

Even when the
87
patients are active their activities move in a circle. On the other hand, there is a type of crossing of impulses in which the incidental impulses produce only a superfluous embellishment of the intended act. The act is
finally
accomplished, but only after
all sorts
deviations.
The
patients skitter along,
and go backward, walk

of additions
on their knees, bend away backward, or drag one foot: they extend their hands in wide circles, or with sudden swoops or stiff jerks. In shaking hands they touch one's hand only with the little finger, or with the back of the hand. In eating they grasp the spoon by the tip, arrange
the food in
ful;
little piles,
is
or count seven between each
mouth-
the water
The bed
drunk in little sips or after long pauses. clothing and their garments are arranged in a
peculiar way. The catatonic grimacing garded as belonging here.
may
also be re-
From
by
this
transitions to those disturbances

Schtiles derailment of the will,
embellishment of conduct there are regular which have been termed
where acts are completed from the way in which they are begun. very differently For instance, in grasping the spoon to eat the patients may twirl it about in a circle, then lay it down again, or in carrying a glass of water to the mouth upset it on the table,
suddenly turn it upside down, and return it to the table. Also in their speech it is often observed that the patients
will
suddenly stop and begin anew with another thought, which in turn is just as abruptly left for another, so that
the goal idea
is finally lost sight of. It is in this way that desultoriness arises (see p. 40). In this crossing of impulses many of the acts stand in no definite relation to any
goal idea. The patient suddenly beats his companion, perches himself like a bird on the foot of the bed, grips
his finger in the anus, stands
on
his head, or filths
on
his
88
Occasionally, aggressive
dinner plate.
and
violent attacks
originate in this way.
In this derailment of impulses one gets the impression that the original purpose in the act is forced into the background;
for instance, the patient will exert the greatest
effort of the will
when
started in a certain direction
when
he could easily succeed by making a little detour. He will push persistently against a locked door toward which he
has started when he could easily leave the room by an open door close at hand.
Diminished Susceptibility of the Will.

of the blocking of the will
it
In the description
cer-
was shown how, under
tain circumstances, every impulse of the will can be rendered The blocking of the will is ineffective by counter impulses.
but a partial symptom of a very general disturbance
namely,
will,
the impulsive resistance to every outer influence of the
which by Kahlbaum has been designated negativism.

negativism there
is
In
external impressions, an inaccessibility to social intercourse, and an opposition to every request; and it may even extend to the regular perall
a blocking of
formance of contrary actions (the negativism of command), and finally to the suppression of nature's demands, as in
micturition.
In this way conduct in every respect becomes just the opposite of that which is striven for and that which would
be expected normally. Patients do just the opposite of that which they are requested to do press their teeth
:
together
eyes
when asked when an attempt

refuse
to
is
show
made
their tongue, close the to examine their pupils,
and
they
to
answer
speak
questions
mutism,
sometimes
spontaneously.
will
They
offer
although the
to
most powerful, but almost always

every external encroachment:
passive, resistance
not allow any one to
89
dress or undress them, will not bathe or take care of themselves, and offer strenuous resistance to compulsory
feeding,
but when unmolested eat greedily.
The
feces
are often retained with the greatest exertion, especially if As soon as they are the patients are taken to the closet.
returned to bed, the evacuation immediately takes place.
They
persist in leaving their
others, likewise they will
although
it
own bed and crawling into smear and spoil their own food, may be even better, and steal or fight for that of
The impulsive character
of its origin is
their companions.
most
clearly
demonstrated in the occasional cases of nega-
Such patients continue lying on their back if requested to arise, or they turn around if asked to go forward, and remain silent if told to speak. Negativism is not due to voluntary opposition. Patients sometimes admit after the attack that they do not know why they acted as they did. Negativism, stereotypy, and loss of will probably all have the same basis. They often occur in the same patient, and may be easily made to pass into one another. These various disturbances of the will are most frequent in catatonia, and are sometimes found in a less pronounced form in paresis, senile dementia, and
tivism to requests.
idiocy.
scious resistance of terrified patients.
Catatonic negativism must not be confused with the conIn catatonia there is
no conscious reason for resistance, and no persuasion can overcome it. It is not influenced by pain, and the manner
of resistance is
always constrained and often absurdly

stubbornness
of
imbecility,
is
in-
appropriate.
The
epilepsy,
hysteria, paresis,
and
senile
dementia
closely allied to
negativism, but in contrast to negativism it always starts with an idea, and is more or less influenced by persuasion,
new
ideas,
and emotional changes.
Moreover, in stubborn-
90
is fretful, irritable,
ness the general emotional attitude

unruly.
and
The
patient shows
fight,
and
is
often dominated
by confused, malevolent delusions, whereas the negativistic patient shows great equanimity, seldom defends himself, and almost never attacks, but merely resists.
arise
Compulsive acts are those which do not Compulsive Acts. normal antecedent consciousness of motive and from
desire, but
seem
to the
patient to be forced
which
is not his
own.
As a
the morbid impulses;

their approach,
upon him by a will the patients struggle against rule, often caution those about them at
to prevent harm to others. The accomplishment of the act is accompanied by a feeling of relief, and is usually followed by clear insight
and adopt measures
into the nature of the act, accompanied
by chagrin and
remorse.
Compulsory acts are generally accompanied by great emoand stand in close relation to compulsory ideas and fears already described (see p. 69). These disturbances all originate on a basis of congenital morbid endowment, and are all a part of the symptoms of the contional excitement,
stitutional psychopathic states.
Impulsive Acts. Impulsive acts are distinguished from in that they do not seem to the patient to be compulsive acts,
influenced from without, but are the direct expression of a
sudden overwhelming impulse, which gives no chance for

tion or resistance.
reflec-
They
are found in the
most varied morbid conditions.
Probably the pressure of activity in manic forms of manicdepressive insanity is of this type. Here belong also the
wanderings
and
assaults
of
the epileptic
(see p. 446),
the excesses of the dipsomaniac, as well as the morbid
impulses of hysteria, self-inflicted injury, theft, and fraud, Their origin does not lie in definite feelings of pleasure or

dislike,
91
but in marked motor excitement.
The outbursts
of the catatonic are. thoroughly representative of impulsive acts, although the basis lies not in a pleasurable or un-
pleasurable feeling but in a powerful pressure of movement. The patient is controlled by the consciousness that he must
do
this or that,
without a definite reason and without fore-
thought, although he sometimes appreciates the foolishness of his act. Occasionally there is an idea that his limbs are
controlled
by an
invisible power, as
God, the
devil, or
is
some
domi-
electrical influence.
The
patient 's
consciousness
nated by one blind impulse without clear motive or realization of the outcome. There is no opportunity to resist the
impulse.
The execution
is
tients are correspondingly dangerous.
rapid and reckless, and the paThis is clearly seen
in the impulsive acts of the catatonic, such as the shouting,
sudden attacks, denuding, the senseless attempts to strangle themselves, to cut out the tongue, and to gouge out the
eyes.
A disturbance of the natural impulses Morbid Impulses. is a symptom of all general morbid changes of volitional In paralysis and inhibition of psychic processes all action.
the appetites are diminished; in excitement, on the other hand, appetites are increased, especially sexual desires. The latter seldom lead to actual assault, but manifest themselves
in
ambiguous phrases, abusive language, and by more or
less reckless
masturbation: in women, by shameless exextreme uncleanliness, or incessant washing with posures,

water, saliva, or urine,
combing and unloosing the hair; in adornment and flirtation, by an alternalighter forms, by tion between seductive, shamefaced, and sentimental manners, by hand pressing, letter writing, significant glances, and the like. Less frequently in manic excitement there is found an increased desire for food, although restlessness
92
usually hinders the patients from taking sufficient nourishment. On the other hand, excessive greediness is not infrequently found in idiots, paretics, and especially in catatonics.
Incredible quantities of the

things, sand,
most unpalatable and

etc.,
disgusting
stones,
seaweed, feces,
are
sometimes devoured by such patients. In these last cases there is not a simple increase of healthy impulses, but probably a simultaneous perversion of the appetite both in nature
and
direction.
The same
is
true of the well-known excessive
by pregnant women. Much more numerous, however, are the morbid sexual impulses, which in recent years have been most thoroughly The most pronounced of these are the coninvestigated. sexual instincts, in which the sexual feelings and desires trary are exclusively directed toward members of the patients' own
desire for eating suddenly manifested
sex.
Sadism consists
in the
attempt to increase or induce
sexual excitement by brutality. In the final stage of its development actual sexual congress is a matter of indiffer-
In masochism, on the other hand, the endurance of pain increases sexual excitation or may be substituted for it. The satisfaction of sadism appears to arise from the
ence.
feeling of absolute
masochism
arises
will of another.
power over the victim, while that of from the most complete subjection to the In fetichism particular articles of clothing
either the necessary adjuncts
or parts of the
body become
for satisfactory coitus, or the simple observation or contact
with the fetich
may
satisfy the sexual impulse.
The most
common
clothing,
fetiches are boots,
shoes, handkerchiefs, underfurs.
and
finally velvet
and
Besides the perversion of normal impulses as seen in the above, there is a group of morbid impulses which seem to
bear no relation to normal
life.
Such are kleptomania, the

irresistible
93
impulse to steal
all
manner
of worthless
and
things; pyromania, the impulse to burn. Both these usually arise on the basis of an epileptic or hysterical
useless
endowment. The whole series of abnormal impulses are partial symptoms of a general morbid endowment, and indicate conIt is possible that kleptomania and genital degeneracy.
pyromania should be regarded as compulsive acts. impulse appears as an obtrusive compulsion which
sisted as long as possible, while the
is
The
is
re-
performance of the act
accompanied by a feeling of Disturbances of Expression.

their
relief.
ideas, patients express among the most important clews to morbid psychic impulses. full delineation of the symptoms of the various disease
The movements by which feelings, and impulses are
types occurs in the clinical portion of this work. In this place we confine ourselves to a few characteristic indications.
by lack of interest, notwithstanding accurate apprehension, by listlessness, strained

is
Dementia prsecox
indicated
attitudes, senseless grinning or laughter, with
sudden im-
petuous movements.
In dementia prsecox the change that
movements is very striking, particularly the loss of grace. The catatonic movements are either stiff and wooden on account of the superfluous tension; or careless and listless as a result of an insufficient expenditure of energy; and again they are gross and awkward because associated groups of muscles are involved in the movements. The naturalness of the movements is
occurs in the character of
destroyed by the tendency to ornamentation, which gives them the appearance of being affected, and finally there is
a lack of uniformity in the movements of expression. Paretics may often be recognized by their awkward
friendliness
and production
of silly expansive ideas.
De-
94
pressed patients sit around collapsed and flaccid, with troubled expression. Their movements are slow and laborious.
The apprehensive
patients are restless, bite their
In extreme retardation, they nails, and wring their hands. lie motionless in bed with fixed expression and whisper their
answers with great exertion.
The
manic-depressive, on
the contrary, moves rapidly about, talks, cries, sings, plays tricks on his fellows, and busies himself with all sorts of
things.
hair to
The hysterical patients arrange their clothing and make an impression. The paranoiac endures his
him the
all his
hospital confinement with dignity, carrying with
pretensions. Alterations of speech and writing are of the greatest diagnostic value. Delusions are usually betrayed by the content of the communications. In manic patients there
documents which prove
incessant babbling, with a tendency to puns and rhymes. This is also found in excited paretics with more or less disIn both diseases speech may turbance of articulation.
is
be reduced to an incomprehensible gibberish, though from

different causes.
In retarded patients speech
is
low and
difficult.
Melan-
choliacs express their thoughts laconically,
up a monotonous lamentation. for weeks at a time, and then suddenly begin fluently or sing, although more or less confusion
is
and often keep Catatonics are often mute

to speak of speech
always present. Their stereo typy is manifested by constant repetition of the same words, phrases, or even senseless syllables, while they frequently make up entirely new
words.
Disturbances of writing correspond both in content and form with those of speech. The manic-depressive patient fills sheet after sheet of paper with large, showy, and hastily written characters, which are often illegible even to the

writer.
95
The
paretic's writing
ment
of
words and
uncertainty.
for emphasis.
shows omission, misplacesyllables, blots, untidy corrections, and Hysterical patients use innumerable marks
In melancholiacs the individual characters are incomplete, small, and crowded. The same is true in retardation. Catatonic patients cover the paper with uninwritten verbigeration. repeated In psychoses associated with brain lesions there are apt to be present disturbances of speech and writing such as
telligible scrawls, endlessly
inability to read
syllables,
aphasia, paraphasia, agraphia, paragraphia, perseveration, and to combine letters into words and
indistinct enunciation, scanning or
monotonous
is
speech, also ataxia in writing.
Conduct arising from a Morbid Basis.
Since conduct
the expression of the entire psychic life, we readily understand why it is more or less seriously disturbed by morbid
changes in any part of the psychic individual, while, on the other hand, no isolated act can be taken as an infallible index of the exact morbid condition. Delusions of sinfulness impel patients to penance, self-mutilation, or suicide. Delusions of persecution lead to mysterious precautions, to misanthropic isolation, to restless wandering, or even to
outbursts of rage and murderous attacks against supposed enemies. Hypochrondriacal delusions may lead to revolting smearing, self-mutilation, or injurious and absurd curative attempts, often with the evident purpose of attracting
attention and sympathy.
Mental excitement very soon leads to conflicts with the environment, to breaches of the public order, and quite often to resistance to civic authority. Patients behave in a reck-
and striking manner. They are ungovernable, irritable, and violent under contradiction and restraint. At first they act as if intoxicated, and later become still more restless
96
less
and even dangerous. There is usually also a tendency to sexual excesses, in which they indulge without regard to decency or morality. Such excited states are regularly ac-
companied by all sorts of mad pranks, destruction of property, adventurous journeys, brawls, and public scandals. When
associated with expansive ideas, the patients purchase large
amounts of useless stuff, prepare and spend large sums of money.

in their neighborhood belongs to
for mythical undertakings,
The idea that everything them induces the patients

happen
on,
to innocently appropriate whatever they embezzlement, or to fraud.

letters to
to
Paranoiacs systematically prepare their claims, address
and publish pamphlets. In notice they appear on the street compel in unusual costumes, attack prominent persons, and create
prominent
officials,
their attempts to
public scandals. Love-letters, proposals, etc., are directed at the supposed secret lover. The religious paranoiac founds
a church and seeks a martyr's crown.
METHODS OF EXAMINATION
IN mental disease
it is
of the
student employ a definite the patient. Any method to be satisfactory must include the (a) anamnesis of the family, and (6) personal history
previous to the disease, (c) the anamnesis of the disease, (d) and finally the status praesens. (a) The importance of heredity as an etiological factor
necessitates a careful consideration of the family history, not only as regards the presence of mental and neurological
diseases,
tion.
utmost importance that the routine method of examination of
This can
but also evidences of defective physical constitunever be elicited by simply asking the
general question if there is a history of insanity or nervous diseases in the family, but it requires a detailed inquiry into the habits, traits, and physical illnesses of all the memstress
tions,
(6)
bers of the direct branches of the family, laying particular upon mental peculiarities, alcoholic and other addic-
personal history should begin with an inquiry into the conditions attending gestation and birth, such as,
and The
criminal tendencies.
exhausting diseases, deprivation, severe emotional shocks, mental anguish, and birth trauma. In infancy there is the
and their sequelae, convulsions, head injury, paralyses and the tardy appearance of walking and talking, and in childhood, the progress in school and conditions accompanying puberty and menstruapresence
of
infectious
diseases
masturbation, sexual impulses, emotional manifestations, timidity, morbid tempeculiar

H
97
tion, also the existence of
98
peraments, religious experiences, etc. If married, the conditions attending child-bearing should be known, as well as severe illnesses, such as, typhoid fever, injuries, mental
shocks,
and deprivation; and
if
employed, the character of
the work, the materials handled, the sanitation and undue

physical
and mental strain, excessive indulgence in eating, Perdrinking, and amusement, and also drug habituation.
idiosyncrasies,
exaggerated egotism, one-sided intellectual development, with attainments in one field and
sonal
lack of development in another, should be included in your
list
of inquiries.
In
eliciting
such facts
it
should be borne in
It general questions are wholly inadequate. requires close and detailed questioning, and even then important facts are very apt to be overlooked.
mind that
In determining the cause of the disease one should guard

against mistaking for causes the actual early symptoms of disease; such as the excesses of the paretic, the self-con-
demnation of the melancholiac, and the masturbation

hebephrenic.
(c)
of the
the anamnesis of the disease particular attention should be paid to the character of the onset and the
eliciting
In
In securing this information it is usually most satisfactory to follow out the outline prescribed for making a mental status; i.e. elicit information concerning the
symptoms
to date.
presence of hallucinations or illusions at various periods, of disorder of orientation, attention, memory, train of thought,
judgment, and in the emotional and volitional fields. It is often difficult to determine the actual date of onset
of the disease because the initial
change in disposition
is
sometimes so insidious that the true significance of certain peculiarities is not appreciated until emphasized later by the
occurrence of the more striking symptoms. In case there have been one or more previous attacks of mental disease
there should be the
99
same
careful inquiry not only into the
character of the
their duration,
symptoms presented at these periods and

some
field of
but also particularly as to whether the patient
fully recovered or suffered residual defects in
the mental
life.
(d) Status prcesens.
This êxamination should include ob-
servations of both the physical and mental conditions of the patient. In view of the fact that many persons are
particularly sensitive about undergoing a mental examination it is desirable to begin with the physical examination. Dur-
ing it there is always opportunity to frame questions in such a way that the answers will give valuable information as to the mental state; as, for instance, the memory can be
determined by questions as to the date of appearance of certain physical signs, or the orientation may be ascertained
by questions as to those who are caring

their food
is
for them,
by
whom
prepared, etc. Indeed, the great variety of physical symptoms to be inquired into offers sufficient chance to cover all fields of the mental status; even hallucinations
and
illusions of hearing
and
sight
may
be disclosed by the
examination of the senses of hearing and sight. The general survey of the body should include the state
of nutrition, the present
body weight compared with
earlier
weights, the presence of anaemia or cachexia, signs of premature senility, or delayed pubescence, also evidences of socalled physical stigmata, as harelip, malformation of the palate, of the ears, or sexual organs, albinism, congenital
strabismus, malposition of the teeth and eyes, etc. Trauma, scars, and residuals of previous diseases should not be overparticularly those of syphilis. The physical examination should be careful enough to eliminate such
looked,
and
chronic nephritis, uraemia, diabetes, pernicious anaemia, Graves' disease, tuberculosis, syphilis,
chronic diseases
as
100
lead poisoning, and chronic gastritis. The condition of sleep and of the gastro-intestinal tract needs special attention because of the frequency with which disturbances exist
in these fields.
In the examination of the nervous system, the measurements of the cranium will give some indication as to the
development of the cortex, but it is of more importance to observe the disproportion between the cranium and the rest
of the body.
The circumference
of the skull taken along
the line just above the external occipital protuberance and the glabella should measure in an adult between 48 and 56
centimeters, while the distance between the extreme lateral points as taken by craniometer should be between 14 and 15
centimeters. The examination of the eye grounds should not be omitted, as it often reveals vascular sclerosis, which might otherwise escape notice. Likewise, a careful ex-
amination of the ears sometimes discloses a

for peripheral hallucinations.
sufficient cause
Then the muscular system should be examined. First determine the condition of muscular tonicity by employing passive movements and examining the tendon reflexes.
Both of these may be difficult on account of lack of cooperation and inability to secure complete relaxation of the limbs;
hence
important to have the patients in a comfortable and restful attitude, such as in a recumbent position, with
it is
by engaging them in conversation, giving them figures to add or something to read aloud. In eliciting the knee jerks, if the patient is lying on his back, place left hand beneath the knee and gently lift it, allowing the foot to rest on the bed. If you find the leg relaxed, strike
their attention distracted
the tendon at any time.

relax until
will
Frequently the patient will not have raised the knee high enough so that it you
itself in
support
that position.
If the patient is sitting,
101
he should recline backward in an easy posture, with both feet

squarely on the floor and brought as far forward as possible without causing the toes to leave the floor.
The ankle clonus is best elicited now by slipping the right hand under the toes and sole of the foot and quickly jerking
the foot
upward
for a
few inches, so that the weight of the
elevated leg and thigh rests on your hand. The Achilles is determined by asking the patient to stand leaning jerk
forward and supporting his weight by placing his hands on the top of a table or back of a chair. The ankle is then
lifted in the rear
tendon
is
and allowed to rest on your knee, when the struck. The wrist and jaw reflexes should also be
determined.
The muscles should be examined further by palpation and by the exercise of active movements which will determine the
presence of paralysis (flaccid, spastic, or accompanied by Such contractures), as well as disturbances of coordination.
movements are the voluntary

is
raising of the legs while the
patient recumbent, attempts to touch the knee, to touch the end of the nose with the forefinger with or without closed eyes, standing erect with eyes closed and feet close
together, closing the eyes, opening the mouth, and protruding
the tongue upon command, and then reversing the order. These tests should also include voluntary writing, and speech,
as well as the enunciation of different words, such as "electricity," "Massachusetts artillery brigade," "around the rugged rock the ragged rascal ran." The movements employed above will also demonstrate tremors (fine, coarse, fibrillary,
and retractile of the tongue), which should be noted. The mechanical irritability of the muscles and the nerves is then determined by percussion of the muscles, and the mechanical stimulation of the peripheral nerves. The nature
of
spasms should also be investigated
(epileptic, hysterical,
102
choreic,
Finally, the irritability of the muscles nerves to electricity, wherever there are indications for
and athetoid).
and
its use,
should be determined, since disturbances in it as well as in all of these other fields may have distinct bearing
condition.
upon the general brain
Following this the sensibility should

hypersesthesia, analgesia,
be tested, including
the sensations of pain, touch, and temperature, for areas of
and
paraesthesia.
For
this pur-
pose the simplest implements are the best; namely, a camel' shair brush, a needle, and small bottles of hot and cold water.
It
may also be necessary to examine the stereognostic sense.

Vasomotor, secretory, and trophic disorders should be
recognized and recorded, particularly cyanosis of the extremities,
dermography, glossy
skin,
canities,
alopecia,
ony-
chogryphosis, naevi, herpes, scleroderma, the various trophic disorders of the bones
and hyperidrosis; and joints, includ-
ing spontaneous fractures and hsemotama auris. In the examination of the pulse there is nothing to be
found peculiarly characteristic of any special form of mental
and depressive states is usually elevated, and depressed in manic states, corresponding with the vasomotor symptoms ordinarily accompanying these states. The fall in blood pressure observed in the end stages of paresis is in accord with the progressive terminal cardiac weakness. The examination
disease.
The blood
pressure
in
fearful
been thus far unproductive of characteristic In any given psychosis the blood states may disorders. vary considerably in the different stages. In the psychoses
of the blood has
studied by us
1
dementia prsecox, manic-depressive insanity,

in
"Blood Changes
Dementia Paralytica," American Journal
of
Med.
Soc., Vol. 126, p. 1074.
"A
Contribution to the Study of Blood in Manic Depressive Insanity,"

of Insanity,
American Journal
LIX, No.
4,
1903.
and dementia paralytica
istic
103
the only apparently characterblood states were those found in dementia paralytica,
where there was a progressive anaemia and a progressive increase of polymorphonuclear leucocytes accompanying
the advancing course of the disease and the presence of a The chemical leucocytosis accompanying paralytic attacks.
investigations of the urine, gastric contents,
and
of
body
metabolism, while still fruitful fields for study, do not warrant routine examinations except in the matter of urine and gastric
contents to obtain indications for treatment.
careful physical examination should include in doubtful cases the examination of the cerebrospinal fluid for the pur-
pose of differentiating between functional or organic disAs much depends upon the technique, the method eases.
is briefly
stated.
With the
strictest aseptic precautions the
needle
is
vertebrae,
inserted between the fourth and fifth lumbar and three or four centimeters of fluid withdrawn.
This
is
is
speed
if the immediately centrifugalized 10 minutes if only 2500 revo3000 revolutions, or 30 minutes
lutions can be obtained.
The supernatant fluid is poured out of the glass and then a pipette is carefully introduced into the bottom of the tube and the sediment all withdrawn.
is
This
thoroughly mixed by blowing

it
it
out into the tube and
sucking
up
again,
when
three drops of equal size are
slides, which are allowed to dry in the air. The slides are fixed by a half-hour immersion in equal parts of absolute alcohol and ether, stained with a few drops of
dropped on three
Unna's polychrome methylene blue, washed in water, then in alcohol, cleared in xylol, and mounted in balsam.
With a magnification of 300 to 400 times the presence of three

or four lymphocytes in a single field may be regarded as normal. At least three lumbar punctures are necessary
for
final decision.
The
bacteriological examination of the
104
cerebrospinal fluid as well as of the blood has thus far yielded such varying results in the hands of different observers that
a routine examination cannot be recommended for diagnostic purposes.
The most
difficult
part of the examination
mental status.
In this matter much
securing the depends upon the

is
acuteness of the observer, as the patient often enough cannot
be depended upon for cooperation. Unfortunately, we have no scientific standards for determining the mental symptoms,
but must depend upon the simplest psychological
tests;
namely, the asking of questions. For convenience and thoroughness of examination
it is
most important to always have before one an outline
of the
method of examination. If for purposes of record or otherwise, and particularly in medico-legal cases, it is necessary to write down the observations, it is always best to write in full the question and the answer verbatim as given by the patient. Upon subsequent examinations the same questions should be asked, and the answers compared. The general
arrangement
of
this
outline
should
follow
closely
the
presentation of the general symptomatology; i.e. disturbances of perception, clouding of consciousness, disturbances
of apprehension, of attention, of
memory,
of orientation, of the
train of thought, of judgment, of the emotions,

tions.
1.
and
of the voli-
Disturbances of
sions).
elicited
Perception (hallucinations and illuHallucinations can oftentimes be most readily

directly
if
by asking the patient

if
he hears voices or about him.

Fre-
sees pictures or visions, or,

if
this question is not understood,

is
he hears noises or voices when no one
quently the patient does not consider the hallucinations as a

peculiar sensory experience
negatively.
and
will
answer your questions

closely as to
Then he should be questioned
how he
sleeps nights,
105
is
and whether or not he
disturbed.
Again, he
associates,
may
be questioned as to whether or not intimate
shopmates, employers, or business associates, whom you know to be absent, converse with him. Such questions often elicit the desired evidence of hallucinations.
Sometimes sense deceptions are

for instance,
elicited only
when one
seeks
for the basis of certain delusions held
by the patient, when,
will admit that he believes he is persecuted remarks that he hears. Patients observed assuming listening attitudes and addressing remarks to unseen persons, or gesticulating earnestly in a definite
he
because
of
good be regarded as suffering may from sense deceptions, although these are denied by them when questioned directly. In the matter of religious
food without adequate reason,
hallucinations, such as the voice of God, one should be " " voice of conscience particularly careful not to mistake the
direction, or persistently spitting out or casting aside
or the
"
voice of the heart
distinction
which some
as genuine hallucinations, a patients are loath to admit. Again,

to be true hallucinations
"
sometimes what in
many appear
are not such, but are really genuine perceptions. In this matter one cannot exercise too great care. What has been
indicated in reference to hallucinations
and
illusions of sight
and hearing
2.
refers equally well to the hallucinations
and
illusions of the other senses.
Clouding of Consciousness and Disturbances of ApThe determination of unconsciousness, of prehension.

befogged states, and of diminished sensibility depends mostly in clinical practice upon the patient's reaction to definite
stimuli, such as
one uses in any neurological examination ; namely, the test of pain and touch sense by the use of the
needle, of hearing by the use of speech, of sight by writing tests or the perception of colors. Further, the compre-
106
hension of simple or confused pictures (medleys) placed before the patients gives an insight into these defects.
such as Hipp's chronoscope and the apparatus of Ranschburg, have been devised for the accurate determination of the process of perception, which are not
Many elaborate
tests,
wholly suitable for general application or for bedside use. Attention (blunting, blocking, 3. The Disturbances of and distractibility) can usually be retardation, passivity,
determined in a satisfactory manner by the use of the progressive adding and subtracting test, such as, subtracting 7 successively from 100 down to 0. The variations in the
rapidity and the occasional blocking afford good demonstrations of the stability of the attention. The introduction of distracting influences during the test, such as dropping a
cent upon the floor, will bring out distractibility of attention. In the application of such a test one must always take into account the social grade of the individual as well as the degree
of his education.
4.
Memory
is
(defects
in
the
impressibility,
retentiveness,
accuracy, and
of
fabrications of memory).
The
retentiveness
usually determined by a series of questions directed toward the retention of certain school knowledge,
memory
such as the multiplication table ; or the uninterrupted adding or subtracting of 3, 7, or 12, the time required being measured
by a stop-watch.
The
retentiveness in patients sensitive
to being subjected to such tests can be estimated only

facts in history.
by
asking questions concerning the past personal experiences or

readily determined by asking the patient to repeat numbers of more than one figure which are dictated to him ; also unfamiliar
impressibility of
The
memory can be most
combinations of syllables. This may be done both orally and by writing. Again, he may be asked to recognize in a
107
group of pictures a certain picture which has previously been shown to him. Questions directed to ascertaining recent occurrences in their daily lives, such as what he had
for dinner yesterday,
what the nurse or doctor
him,
may
be asked.
is doing for In the determination of both the
retentiveness
and
impressibility one
must never demand
from an uneducated person more than he ever acquired. The accuracy of memory and the fabrications will already have been elicited by the questions asked in reference to
remote and recent personal experiences.
5.
Orientation
(apathetic,
orientation
place,
and
perplexity).
amnesic, and delusional disThe orientation as to time,
is determined by such questions as: the date of the month, the day of the week, and " " the season and year? Where are you now? " " What
and persons
is
"
What
the
is
name of the place,

"
of the building
of the city?
"
and its character, and
Who
is
duty here,
and what
are these persons about you, their " In case the your mission here?
patient is not disposed to or is unable to respond, his orientation as well as his power of apprehension can be determined
by watching
carefully his conduct in his environment; for instance, noting the names with which he addresses his
associates, his religious observances, his ability to find his way about in familiar environment, etc.
6.
Train of
Thought (paralysis
of
thought, retardation
of
thought,
compulsive ideas, simple persistent ideas, per-
severation, circumstantiality, flight of ideas, desultoriness). If the patient is at all communicative and has answered the
foregoing questions, you already have to judge of the wealth of his store of
its
had some opportunity

ideas, or the degree of
impoverishment,
if
present; also to
other disturbances of the train of
some extent of all of the thought, and particularly
the retardation of thought.
If the patient is productive
108
and volunteers much speech, there
is usually little difficulty of simple persistent ideas, cirin determining the presence cumstantiality, flight of ideas, and desultoriness. In case
the patient
not productive, the disturbances in the content of thought can be elicited by requesting him to recite connectedly the incidents of some recent personal experience;
is
such as the detailed account of the nurse's method of caring for him or the account of the journey to the hospital. It
" " Is that Yes, yes," or, tinually urge him by interjecting " In this way circumstantiality, flight of ideas, and so? desultoriness is usually detected. Another method is to
may be necessary in
order to keep the patient talking to con-
peruse the voluntary writings of the patient, particularly
home
letters.
There are
many more
associations of ideas.
Of
accurate tests for determining the these, the one most easily carried
out at the bedside is to give the patient any sort of a word, such as "horse," and then ask him to speak aloud the ideas
arising in his mind, which you may write down, or you ask the patient himself to write down all ideas occurring may to him in a definite period of time after being given the initial
first
way one can obtain some conception of the between the inner and external associations, of relationship
word.
In this
the prominence and frequency of fixed associations, senseless and sound associations, of Uniformity and the desultoriness
of the train of thought, as well as the wealth of the store of
ideas, the tendencies to
sudden
cessations, or the tenacious
holding of a single idea.
Usually by the time one (delusions). has reached this stage of the examination real delusions
7.
Judgment
have been actually expressed or some hints have been accidentally dropped which will serve as a basis for further
questioning.
In determining delusions, direct questions
are less pernicious than in eliciting
109
some
of the other
mental
symptoms. One may ask the patient if he is troubled in any way, if the affairs at home are moving smoothly, if his business is successful, and if he is at all apprehensive
of his welfare, etc.
Should your patient show considerable
reserve
refuse to speak of personal matters, as often happens immediately after his liberty is restrained or he is placed in a new environment, one must be tactful in approach-
and
ing the matter of delusions. Sometimes the simple direct question as to why he has been deprived of his liberty or
submitted to the care of the physician may be sufficient. Again, it may be necessary to introduce a subject of much interest to him, such as his employment, literature, or travelasked to express his judgment as to cost of manufacture of the material with which he works, the
ling,
or he
may be
contentions of trade unions, the utility of trusts, or his opinion of the countries in which he may have travelled. A
free discussion of a
matter of general
interest,
but at the same
time bearing upon the individual's livelihood, usually uncovers some of his delusions, if any be present. In the case
of women, domestic difficulties, church or social relations, and especially neighborhood differences, are usually fruitful The various somatic sources for discussion and inquiry. delusions are most often brought out by questions as to the health of all the various organs of the body. The evidence of systematization of delusions can often be best determined " What is the object of all this? " or, by asking directly,
"
Do
" these various ideas bear any relation to each other ? Defective judgment in other matters than delusions will
usually be established by such general discussions as those " What do you think advised above or by such questions as, " " of the restriction of your liberty? How much does it " cost you to live ? "Are you receiving sufficient wages, and
110
live
" " within your income? Figure up your cost " of living." Who aids in the support of your family, and do they do as much as they should? " etc.
do you
Emotional Field (emotional deterioration, increase emotional irritability, sad disposition, irritable disposition, of
8.
seclusiveness,
sunny
disposition, fanaticism, morbid frivolity,
fear, phobias, dejection, sadness, feelings of pleasure, feeling
of well-being, disturbances of hunger, nausea, pain,
and
of
of
the sexual feelings.)
In this
field
one has to depend rather

the
more upon observation than upon interrogation
patient, as there is large opportunity for simulation and Most patients if asked if they loved their parfalsehood. " Yes " even though they might be totally ents would say
and exhibiting profound emotional deterioration. One rather has to rely upon the observations of others as to relations which the patient maintains with his family, in his work, and in his social environment, which would exhibit increased and diminished emotional Likewise one irritability and persistent sadness or elation.
barren of
all
affection
cannot depend upon the patient for accurate observations as to whether or not he is of a sad, sunny, seclusive, or irritable disposition, or given to fanaticism or morbid frivolity.
The
persistent feelings of fear, of sadness, and of well-being usually become apparent to one during a prolonged examina-
tion
and do not need
special inquiry.
Yet
in this matter
one sometimes must ask the patient directly how he feels, or whether or not he is fearful or dejected. The disturbances
of the general feelings of pain, of hunger, nausea,
and
of
the sexual
of the conduct than
more readily determined by observation by questioning. In questioning those most intimately associated with the
life
are
patient one may ask such questions as these whether or not there has been a change of disposition; previous to illness
:
was the individual of a sition; was he fond of
sociable, cheery, or
111
melancholy dispo-
solitude,
now fond
geous, irascible, suspicious, of his family or apathetic,

obligations, or
is
was he silent, timid, couraor proud and egotistical; is he

is
he
fulfilling his
family
he negligent, disrespectful, or insensible to the feelings and interests of others; is he fulfilling his religious obligations, or does his general conduct
and business
show unnatural
fear, sadness, or exaltation.
We have at best no very accurate means of measuring the

Feelings of displeasure, of pain, fear, and anger can be created experimentally in various ways and by hypnosis, and the latter method has been employed by Lehmann to determine the
life
emotional side of the
of the patient.
upon respiration, pulse rate, and blood pressure. Furthermore, the writing scale and the ergograph, which are used to measure the finer expressions of the will, are serviceable in measuring the outward expressions of emotional excitement.
9.
influence of emotional states
Volitional
Field
(paralysis of
the
will,
pressure of
activity,
will,
psychomotor retardation, stupor, blocking 0} the muscular tension, hypersuggestibility of the will, catalepsy,
cerea flexibilitas, exhopraxia, distractibility of the will, interHere also ference, stereotypy, mannerisms, negativism).
one must depend to a large degree upon observation of the conduct, both spontaneous and in obedience to command or
suggestion.
paralysis of the will can be determined by watching the patient's voluntary movements, also the reaction in response to the call to dinner or when requested
Thus
to attend
tion,
some simple duty. Pressure of activity, retardastupor, and blocking of the will, as well as muscular
tension, are usually evinced before one has reached this stage of the examination. The methods of physical examination
are sure to bring out these defects as well as cerea flexibilitas
112
and catalepsy. If not, one has simply to grasp the arm and place it in an awkward and uncomfortable position or to
patient to perform certain movements, as walking, shaking hands, or writing. If negativism is presDistracent, it also will be elicited by these methods.
tibility of
command
the
the will, interference, stereotypy, and mannerisms
are elicited
by similar commands. The observation of the conduct by nurses and others should be inquired into, as in this way the varying periods of mutism, negativism, muscular tension, and tendency to eat the food of others and to get into others' beds, to stand in awkward and statuesque positions, can be elicited, which
may
In the
not be present at the time of your examination. finer analysis of disturbances of volition, partic-
ularly psychomotor excitement, retardation,
and
tension,
Kraepelin suggests the writing scale, by which one can determine the path of the writing, the rapidity, and the pressAlso the ergograph, invented by Mosso, can be employed to measure the strength of the movement, the effect
ure.
of retardation, fatigue,
and muscular
tension, as well as
the rapidity with which the contraction and relaxation of the muscles follow under the influence of the impulses of the Both of these instruments, however, have their will.
drawbacks which render their routine application unsatisfactory.
The more
severe disturbances in the release of the
volitional impulses can be measured by the use of the watch, such as in counting as rapidly as possible from 1 to 30, rapidly repeating the alphabet, or in simply raising the arm.
CLASSIFICATION OF MENTAL DISEASES

CONSIDERATION OF THE FACTORS ENTERING INTO A PROVISIONAL CLASSIFICATION
*
THE principle requisite in the knowledge of mental

is
diseases
definition of the separate disease processes. In the solution of this problem one must have, on the one
an accurate
hand, knowledge of the physical changes in the cerebral cortex, and on the other of the mental symptoms associated
with them.
Until this
is
known we cannot hope
to under-
stand the relationship between mental symptoms of disease and the morbid physical processes underlying them, or in-
deed the causes of the entire disease process. There are still other difficulties to be encountered in obtaining that
fundamental knowledge necessary for a scientific classification of mental diseases. In the first place, it is almost to establish a fundamental distinction between impossible
the normal and the morbid mental state, as was frequently indicated in our discussion of the general symptomatology. It is equally difficult sometimes to distinguish between the
transition states existing between different forms of recognized types of mental disease. Again, the symptoms of the
disease are apt to be greatly influenced and exaggerated by the morbid hereditary basis which underlies so many forms
of
mental disease.
Finally, as the functions of different
parts of the brain differ, hence the character, intensity, and location of the morbid process influence greatly the gradations in the
form of the mental disease.

115
116

no sure foundation upon
Never-
Clearly, then, there is at present
which to construct a
theless, there is
final
standard classification.
always a demand for some grouping of our
knowledge as a basis for practical work, particularly in teaching. Judging from experience in internal medicine,
the safest foundation for a classification of this kind
is
that
offered by pathological anatomy. Unfortunately, however, mental diseases thus far present but very few lesions that have positively distinctive characteristics, and furthermore
there
is
the extreme difficulty of correlating physical and
mental morbid processes. Likewise it has been impossible thus far to establish a classification upon an etiological basis. Although there are
some agents that produce very definite symptoms, such as alcoholic intoxication, certain acute infectious diseases,
head
injury,
and
particularly the
more profound types
of
hereditary degeneracy, yet very many sanity are wholly without any distinctive etiological factors. And furthermore, one often has to admit that any single
individual cases of in-
pathogenic factor
of
symptoms. work in conjunction with each

difficult to ascertain
itself known by a great variety the causes of mental disease often Again,
may make
other, rendering it extremely the relationship between the causes and
the symptoms.
The most popular method

has been the so-called
of classifying
mental diseases
clinical
classification.
is
The grave
apt to be an overvaluation of some symptoms resulting in the accumulation in one group of all cases having in common some one
defect here arises from the fact that there
symptom. In this way all sad and anxious emocame to be regarded as melancholia, all excited states as mania, and delusional states accompanied by hallucinations as paranoia. The difficulty becomes apparent
striking
tional states
117
when a
tial,
single case thus classified presents during its course the characteristics of several groups. It is, therefore, essen-
as
was pointed out by Kahlbaum,
to distinguish beitself.
tween transitory mental states and the disease form
The
conception of the disease demands knowledge not only of the present state, but also of the entire course of the disease.
scientific
Judging from our experience in internal medicine

fair
it is
assumption that similar disease processes
will
produce
identical
symptom
pictures, identical pathological
anatomy,
identical etiology. If, therefore, we possessed a of any one of these three fields, comprehensive knowledge
and an
we pathological anatomy, symptomatology, or etiology, would at once have a uniform and standard classification A similar comprehensive knowledge of of mental diseases. either of the other two fields would give not only just as uniform and standard classifications, but all of these classifications would exactly coincide. Cases of mental disease in the same causes must also present the same originating symptoms, and the same pathological findings. In accordance with this principle, it follows that a clinical grouping of psychoses must be founded equally upon all three
which should be added the experience derived from the observation of the course, outcome, and
of these factors, to
treatment of the disease.
In the classification presented here there are treated

of all those forms of insanity that are
first
produced by
external
namely, those psychoses that arise in connection with infectious diseases, those that follow upon severe excauses;
haustion, and finally those produced Next are considered the psychoses
relation to the products of intoxication. Our knowledge of these
by intoxicating agencies. presumed to bear some faulty metabolism and autois
definite only in
118
reference to thyrogenous insanity; but there are certain points of similarity which would indicate that dementia prse-
cox and dementia paralytica should also be classed here. The forms of insanity arising from diseases of the brain,
the organic dementias, comprise the next group. Here external causes also play some role, as, for instance, the
syphilitic lesions,
head
injury,
and cerebral embolism.
Next
:
come the
insanities associated
with the involutional period
melancholia of involution, senile dementia, and the presenile state with delusions of prejudice.
The next group comprises manic-depressive insanity in which a morbid constitutional basis occupies a prominent The same condition obtains to a still more marked position.
degree in that gradual morbid transformation of the entire psychical personality designated paranoia, which is described
next.
In epileptic insanity, which comes next, besides the
prominent morbid constitutional basis, there often exist other morbid conditions as head injury, arteriosclerosis, and
infectious diseases.
The
epileptic attacks
sometimes date
from some particular revolution in the physical organization.

These facts give to epilepsy an intermediate position between auto-intoxication, organic brain disease, and heredi-
We do not, however, believe that tary mental diseases. the disease group recognized to-day as epilepsy presents a
clinical unity.
it
Further knowledge probably will disclose in In hysteria, while the several different disease processes.
faulty constitutional basis is prevalent, the various forms of mental disorder seem to be released wholly through the
action of the emotions.

Closely associated with hysteria are the insanities of degeneracy. The morbid constitutional basis encountered here
varies greatly
and
it is
often impossible to differentiate the

several different forms of psychosis.
119
Yet one may formulate
two
large groups
namely, the constitutional psychopathic
and the psychopathic personalities. The former comthose morbid constitutional states which are recognized prise by being more circumscribed, as developing gradually at first,
states
or as appearing only at times; the latter include the characteristic morbid developmental forms of the entire psychic personality, which are justly regarded as an expression of
degeneracy. In some instances this division is inadequate. Finally there are described those forms which indicate a
ment
an incomplete developSometimes the basis for this lies in a faulty development of the body, but more often there exist in the undeveloped brain disease processes, which
restriction of
mental development
of the psychical personality.
produce a partial destruction of the tissue, thereby rendering mental development impossible. Strictly speaking, these latter cases should be regarded as organic brain diseases.
We
are not yet in a position to distinguish accurately between restricted development and diseases of the brain,
and furthermore, the mark of congenital weakness predominates to such a marked degree in the clinical pictures that any distinction between both of these groups which are so intimately related from an etiological standpoint
itself. Indeed, we might go even a step and consider these forms of defective development as states of mental weakness which were produced by
hardly
commends
farther
profound mental disease in the earliest stages of development. Also in these cases the development of psychical
personality
was destroyed
at the outset.
it
In concluding the subject
should be emphasized that
many
of the disease pictures differentiated in the following
pages are but attempts to present a part of our observations in a form suitable for teaching purposes. It must be
120
admitted that even to-day it is impossible, in spite of honest efforts, to create a "system" of psychiatry that will include all cases. Attempts of this sort that have been made only
bring confusion. While this assertion may prove somewhat disquieting to the student, to the investigator it means a frank acknowledgment of real conditions and an honest
effort
to establish accurate
clinical experience.
and fundamental knowledge
from our
I.
INFECTION PSYCHOSES
disturbances here described are supposed from toxins of infectious diseases.
THE mental
They
to develop primarily
are fever delirium, infection deliria y
and
post-febrile
psychoses.
of the fever,
Fever delirium follows rather closely the clinical course and in a measure depends upon it. The
infection delirium corresponds to the initial deliria of other authors, appearing at, or near, the onset of infectious dis-
The remaining group includes eases, independently of fever. the various forms of mental disturbance which follow the
infectious disease, developing during or following the fever,
permanent mental enfeeblement. Other writers describe these under the various diseases which they accompany; as, typhoid delirium, pneumonic delirium, influenza insanity, and insanities following exanthemata. The mental symptoms arising from the toxins of the different infectious diseases cannot as yet be suffito
ciently differentiated to permit of their being considered as characteristic of the corresponding disease. The only
and which are apt to lead
istic of
distinguishing features are the physical symptoms characterthe different diseases. It is still a question whether
the changes in the cortical neurones are due directly to the toxins produced by the micro-organism, or to an autotoxin
developing within the body as a result of the infectious

disease.
A.
FEVER DELIRIUM
The
clinical picture of fever delirium presents four differ-
ent grades
corresponding to the intensity of the toxic

121
122

upon the
cortical neurones, varying
action
from moderate
irritation to paralysis
Etiology. fluence on the type of delirium, which apparently is modified only by the rapidity of the development of the fever, its
intensity,
and finally to complete destruction. The form of febrile disease has very little in-
and duration.
There seems to be
little
ground
for
the claim that the mental disturbance occurring during typhoid is more or less characteristic. Besides the toxin
produced in the febrile disease, the rise in temperature, acceleration of metabolism, and disturbance of circulation should be regarded as causative factors. In addition there should be included alcohol, which plays such an important
role in
pneumonia, giving rise to symptoms characteristic of delirium tremens, such as illusions and hallucinations of
objects of great sensory vividness, the occupation delirium, tremor, and a mixed emotional state showing both elation and anxiety. Furthermore, the individual's
many moving
power
of resistance
is
of importance.
It is well
known
that children, women, and nervous men show a tendency to develop delirium with any severe form of fever.
The
pathological
ance of the cortical cells very similar to that
anatomy exhibits mostly a disappearwhich can
be produced experimentally by the application of superheated air to test animals as well as many other deleterious
agents.
Symptomatology.
In the lightest grade of fever
delir-
ium
is irritability, some restlessness, general hyperinsomnia with anxious dreams, a feeling of numbsesthesia, ness in the head, and a desire to be left alone.
there
In the next grade there

sciousness;
illusions
is
a marked clouding of conlargely
and hallucinations
dominate
The ideation, producing a dreamy confusion of thought. designs on the carpet and ceiling appear as moving forms
INFECTION PSYCHOSES
123
or grinning faces, the bedpost assumes the form of an Frightful outcries or beautiful music are heard, angel. patients have airy floating sensations, and are led about
These dreamy experiences are interrupted momentarily by a return to The emotional attitude becomes normal consciousness. either much exalted or depressed, and motor activity inthrough gorgeously decorated rooms.
creases greatly.
In the third grade the disturbance of
consciousness
becomes very pronounced. The patients prattle constantly, the content of thought showing even greater dreamy confusion. There are many varied emotional outbreaks and frequent wild impulsive movements, which soon become irregular and uncertain, indicating the onset of paralysis.
The
intense restlessness
is
interrupted by short periods of
sleep.
In the fourth grade the movements become absolutely At this time carphologia appears with subpurposeless. sultus tendinum. The utterances become indistinct, and
consist in
mumbling over incoherent words and
sentences.
From
this the patient
may
enter into a state of
coma
vigil,
open eyes, he is oblivious to and unable to indicate his desires. roundings

when, in spite of
all his sur-
The urine
and fseces are passed involuntarily. The intensity of the motor activity varies in different individuals, sometimes reaching an extreme degree and at
other being confined to spasmodic twitching or choreiform movements of the extremities, or merely of the
face
tion.
and tongue, the
latter
producing peculiar enuncia-
Course.
The duration
of the psychosis in three-fourths
of the cases does not
extend beyond one week, and usually
the delirium subsides with the temperature.
Some
of the
124
delusional ideas held during the disease for a long time.
may be
retained
The
of the
prognosis
initial
is
disease.
naturally poor because of the severity If the delirium advances to the
third or fourth grade, at least one-third of the cases die. Where there is hyperpyrexia the prognosis is extremely
doubtful.
into
A few cases emerge from the fever delirium an exhaustion psychosis, or may end in dementia.
the delirium
may be the starting-point of other as manic-depressive insanity, dementia prsecox, psychoses, or dementia paralytica.
Finally,
Besides the treatment of the initial disease, the ice cap should be applied to relieve cerebral hypersemia. Cold
baths or cold packs with friction are most serviceable. In case of cardiac weakness one must be cautious in the
use of the bath, and
lant.
necessary administer a cardiac stimuFor this purpose strong coffee is valuable. Antiif
pyretics are not only useless, but often aid in producing and One of the most important intensifying the delirium.
indications
constant attendance, both to prevent harm to others and injury of the patient by escaping out of doors
is
or jumping out of windows.
If
the excitement becomes
excessive, one should resort to the prolonged
warm bath
This measure rarely fails to bring quiet. In (see p. 140). addition, however, a clever, reassuring nurse is most essential.
The method
sheets so
of
applying
much
in
vogue in
it
pitals should be decried.
and restraint private homes and general hosIf impulsive movements are
strait
jackets
sides, or to resort to padded rooms. The use of hypnotics and narcotics is harmful and distinctly contraindicated. Furthermore, the proper use of hydro-
a prominent feature, padded beds with high
may
be necessary to improvise
therapy usually renders their administration unnecessary.
INFECTION PSYCHOSES
B.
125
INFECTION DELIEIA
This group comprises psychoses which appear to stand

in intimate relationship to the specific toxaemia of certain infectious diseases, including the initial deliria of typhoid
and smallpox and the deliria accompanying malaria, acute chorea, and influenza. There are also grouped here deliria that develop in some septic states, as well as those occurring in toxic states of a less specific nature and presenting the " course of the so-called Acute Delirium." Initial Deliria. the infection deliria, the initial deOf lirium of typhoid is best known. Nissl has reported on the pathological anatomy in one case in which there was
distention of the vessels of the cortex, with increase of white
blood corpuscles and pronounced degenerative changes in the nerve cells. The cell bodies were swollen, the chro-
mophiles were dissolved, and the processes diffusely stained for some distance. Karyokinesis was observed in nuclei of
These changes, which are similar to those produced by experimental intoxication, tend to prove that we have to do with a psychosis depending upon inthe glia
cells.
toxication.
l Aschaffenburg distinguishes two forms of initial delirium of typhoid. In the first the delirium is not accompanied by
psychomotor activity, but there are numerous and pronounced

delusions, mostly of a threatening and persecutory nature; such as, cursing voices, visions of fright-
hallucinations
and
ful and threatening forms, and ideas of poisoning and personal injury. The emotional attitude is usually one of intense anxiety and sadness. The patients are often productive and relate adventurous experiences.
The
other form, which, indeed,

1
may
f.
develop directly from
Aschaffenburg, Allgem. Zeitschr.
Psychiatrie LII, 75.
126
FORMS OF MENTAL DISEASE

first,
The
is characterized by great psychomotor activity. delirium usually develops rapidly with marked hallucinations, incoherent delusions, delirious confusion of
the
thought, sometimes flight of ideas, also an intensely anxious emotional state, together with senseless impulsive movements.
delirium the sleep is greatly disturbed, and there is little appetite; on the other hand, there is usually but slight rise in temperature, and the pulse is not
initial
During the
accelerated.
The
onset
may
be rendered
recognition of the type of delirium at the difficult by the absence of the char-
typhoid symptoms, which may not appear until the delirium is well established. Farrar 1 lays stress upon
acteristic
impaired associative activity, fallacious sense deception, with

developing delusions, disorientation, psychomotor excitement, and anxious affective states. He also calls attention
to certain prodromal symptoms, which may exist from a few hours to many days, as, nervousness, insomnia, and nocturnal restlessness, and believes that cases with a sudden
onset are more uniformly fatal and occur particularly in individuals with a faulty heredity. The initial delirium of smallpox usually develops between the third and fifth days, and is characterized by a short
violent course.
The symptoms
are similar to those observed
in the initial delirium of typhoid, but are characterized
by and violent conduct with a tendency to commit suicide, in which respect one is reminded of the epileptic befogged states. Tremor and convulsions sometimes develop. The symptoms suban even greater clouding
of consciousness, side with the appearance of the eruption, but occasionally extend over into the pustular stage. It rarely happens
that the psychosis passes over into a condition of dementia.

'Farrar, "On Typhoid Psychoses," Medical Reports of the Shepard and Enoch Pratt Hospital, 1903. Vol. 1, No. 1, p. 42.
INFECTION PSYCHOSES
127
The
recognition of the smallpox delirium depends wholly upon the fever, the physical symptoms, and circumstances pointing to this infectious disease.
Another type
smallpox may in which the patients present only vivid hallucinations of sight and hearing, while in other respects they remain well
mental disturbance characteristic of develop between the eruption and pus fever,
of
The oriented, clear in thought, and orderly in conduct. varied visions and voices simply annoy them without causing
much
by
effect.
The course in these initial deliria is frequently characterized

partial remissions during the daytime,
in
which the
patients continue somewhat clouded and do not wholly regain insight into their condition. The duration of the
symptoms
much
rarely extends beyond one week, and usually is shorter. The delirium usually clears with the onset
it
of the fever, but
may
pass over into the characteristic
fever delirium.
The outcome The
is
distinctly unfavorable, as forty to fifty per
cent, of the patients die.
accompanying malaria is distinctly intermittent, either accompanying or replacing the fever. It occurs most frequently in the tertian and quotidian forms,
infection delirium
and
rarely in the quartan. The delirium may appear only in the early stages of the disease, during this time replacing
the fever for a few days.
and
consist of states of
found clouding of
violence.
The symptoms develop suddenly, marked anxious excitement with proconsciousness and a tendency to reckless
All of these symptoms suddenly disappear after a few hours' duration, and are followed by profound sleep, from which the patient awakes with little or no memory of
the attack.
The delirium always responds
readily to the
use of quinine.
128

*
The delirium that accompanies acute chorea, when associated with acute polyarthritis and
particularly
endocarditis,
seems to belong to the group of infection psychoses. It is characterized by a clouding of consciousness with a peculiar
dreamy confusion of thought, some hallucinations and deluThese patients apprehend sions and emotional irritability. but continue disoriented and single impressions fairly well, are inattentive and distractible. Their speech is characterized by monotonous disjointed sentences, in which they occasionally weave incidental observations. While they may hear voices calling, see strange visions, and express persecutory or fearful delusions, these ideas are not clear and are never elaborated further. The emotional attitude varies, as at times they are anxious, at others elated, and occasionally show outbursts of passion.
This mental picture is accompanied by a condition of almost constant choreic excitation, in which the characteristic choreic
movements continue
in
both day and night, preventing sleep greatly with nutrition. The duration of the psychosis is from a few days to a few weeks, and not infrequently terminates
fatally.
an exaggerated form and also interfering
Other infectious diseases that may give rise to a delirious state which apparently depends upon a toxaemia, are in2 In the first fluenza, hydrophobia, and certain septic states.
there
apt to be clouding of consciousness, delirious hallucinations, confusion of speech, and anxious excitement.
is
Sometimes there
is
also present paralysis of speech
and
psy-
deglutition, as well as polyneuritic

1
symptoms.
.
The
Mobius, Neural. Beitrage, II, 123, 1894 Zinn, Archiv f Psy. 411, 1896; Krafft-Ebing, Wiener Klin. Rundschau, 1900, 30.
;
XXVIII,
Hogyes, Lyssa, Nothnagel's Handbuch der Pathologic u. Therapie,

1897.
V,
5, 88,
INFECTION PSYCHOSES
chosis
129
accompanying hydrophobia
In
is
a delirium in which
hallucinations
patients
may
predominate. septic states the develop a delirium in which there are many
the
hallucinations, clouding of consciousness with disorientation, low and indistinct mumbling, and attempts to grasp at invisible objects.
At times the condition

is
is
one of pronounced
delirious excitement.
a group of cases which seem more properly classified here than elsewhere. It includes those delirious
Finally, there
states that
sometimes accompany furunculosis or follow a slight

illness,
angina, intestinal catarrh, obstinate constipation, etc., may occur in the course of any other type of Some psychosis, which suddenly takes a turn for the worse.
physical
or
would include
other states of
this particular type of delirium
with certain
marked excitement, and denominate them all The delirium seems to arise from a recent active infectious involvement of the cortex, as shown in the pathological anatomy, by an acute destruction of
"
Acute Delirium."
the nerve
cells,
sometimes including
the
fibres,
in ad-
dition to an increase of the glia, and vascular changes with diapedesis of leucocytes and occasionally an escape of the blood corpuscles.
The patients become sleepless, bewildered, and distractible. Numerous hallucinations of sight and hearing appear, and incoherent expansive and persecutory delusions are expressed. They prattle away, sometimes pray, and finally
be resolved into a repetition of a few senseless words and syllables. Emotionally, they may be anxious,
speech
may
elated, or irritable.
The
is
activity
is
greatly increased
and
accompanied by impulsiveness, with pounding, dancing,

yelling, etc.
rapidly.
usually refused and the patients fail Temperature develops; and there appear ecchy-
Food
moses or
fat
embolism, furunculosis, gangrene of the lung,
130
severe catarrh of the nose, gangrene of the mouth, sometimes parotitis and retention of urine and feces. In the
vast majority of cases the delirium runs a fatal course in from one to two weeks.
An accurate
The
differentiation of this
form
of psychosis based
alone upon the
symptoms
is
at present almost impossible.
delirious states
which sometimes develop in paresis and
catatonia are recognized only by the previous history of symptoms characteristic of these diseases antedating the
delirium.
Collapse delirium, which
may arise from an
iden-
tical toxic state,
can be distinguished only by the relative

it
the clouding is less profound, the activity less turbulent, while the hallucinations and delusions are more vivid, and in the speech both distractibility
observations that in
and flight of ideas prevail. The treatment of these different infection deliria depends in some measure upon the treatment of the underlying
In view of the toxic origin of the disease a thorough flushing of the body combined with infusion of normal salt solution is excellent practice. One may employ
physical disease.
the prolonged warm bath (see p. 140) for relieving the motor excitement. Sufficient liquid nourishment is always indicated, which nasal tube.
may have
to be administered by stomach or The bowels must be kept open, for which
purpose high rectal injection of normal saline solution may be used twice daily. Furthermore, the mouth should be
cleaned by frequent swabbing.
In case medicinal sedatives
seem
advisable, alcohol and paraldehyde are well recommended, but powerful narcotics and sedatives should be
sedulously avoided. Failing heart action should be supported by the use of caffein, camphor, or ether.
INFECTION PSYCHOSES
POST INFECTION PSYCHOSES
131
0.
These psychoses are in general characterized by a more or less pronounced degree of intellectual and emotional weakness, together with, in
most instances, pronounced delusion
The
formation and a prevailing sad or anxious emotional attitude. postfebrile psychoses described here by no means include
all of
in infectious diseases.
the psychoses appearing after the febrile period The exhaustion psychoses as well as
of
most any other form

this period.
mental disease
may
develop during
The
first
symptoms often, but not always,
appear before the fever wholly subsides. The mildest form of postfebrile infection psychosis is represented by those cases in which after the subsidence of the
fever in a severe attack of infectious disease, the patients
show their former physical and mental energy. They and sluggish, and are very susceptible to fatigue. They cannot collect their thoughts, and find it difficult to read and write, are indifferent, idly lie abed, and let things go as they will. Orientation is undisturbed and there usually are no hallucinations, although transient hallucinations may appear after closing the eyes, when for a few moments they
fail
to
are dull
hear unintelligible sounds, see faint visions, or experience

peculiar bodily sensations which are interpreted by them as grave symptoms. In emotional attitude they are sad and
troubled, sometimes irritable, and occasionally at night they suddenly develop a state of great anxiety. They may at times exhibit a distrust of their surroundings, transitory fear
of poisoning, hypochondriacal ideas,
and even delusions
of
persecution, which
may give rise to aggressive attacks and attempts at suicide. In actions they are inclined to be reserved, sort of stupid, and reticent about their delusions.
Physically, sleep
and appetite are poor and body weight
much
reduced.
132
This mild form follows particularly influenza and polyarthritis,
and whooping cough
in children.
seen in tuberculous and choreic cases.
It is occasionally After a duration of
a few weeks to a few months, improvement gradually sets in, provided the underlying physical disease has cleared up.
This syndrome, although suggestive of chronic nervous exhaustion, may be differentiated from it by the fact that
the
symptoms
are
more severe and stubborn, and do not
improve under rest and relaxation.

exhaustion.
Furthermore, there is not the same clear insight that exists in chronic nervous
second group of postfebrile infection psychoses
is
char-
by more pronounced symptoms; namely, prominent hallucinations, fantastic delusions, and active excitement with anxiety. When the symptoms first appear, which is always during the febrile period, there is complete disorientation with marked confusion of thought, and very many hallucinations which may involve all of the senses. After the temperature subsides and the symptoms of the initial disease disappear, the patients gradually become somewhat oriented and more composed, but the hallucinations and delusions persist. They still hear threatening voices, see grinning faces looking in at the window, and must get out of the bed and at them. Some one pulls the bedding, the food is not genuine, they are poisoned, no one
acterized
do the right thing for them, etc. Emotionally, are dejected, anxious, and ill-humored. Sometimes, in they outbursts of passion, they attempt suicide and become
is
willing to
violent.
They are apt to be obstinate, quarrelsome, conand resistive. Physically, there is faulty nutrition strained, and insomnia. As the appetite and sleep improve, the hallucinations and delusions disappear. The patients gain insight into their condition, begin to busy themselves, and

resume
their
133
accustomed conduct, but for some time they show an unusual susceptibility to fatigue, and an absence of the wonted mental and physical energy, together with weakness of memory. A few cases never comcontinue to
and always due some complication. The duration varies from several months to a year. This form follows especially typhoid, smallpox, articular rheumatism, and sometimes
pletely recover. to exhaustion or
A fatal termination is rare,
develops during tuberculosis. In adults, there may be some difficulty in differentiating this condition from melancholia of involution developing
during an attack of some infectious disease. It, however, may be distinguished by the greater prominence of hallucinations, the predominance of delusions of persecution over self-accusations, and the great irritability in contrast to the
anxiety of the melancholiac. It may be differentiated from dementia prcecox by the greater affect and disturbance of
apprehension and orientation at the onset of the disease, and by the absence of negativism and stereotypy; from the depressive phase of manic-depressive insanity by the absence
psychomotor retardation. third and severest form of postfebrile infection psychosis is characterized by a severe delirium which soon passes over into a condition of stupor. In spite of improvement in
of
The
the physical condition the patients continue dull, and incapable of perceiving and elaborating external impressions, and
have poor memory and judgment. Emotionally, they are indifferent, sometimes peevish. They may be quiet or childishly restless.
care for
They lie abed unable to take their food or themselves, and have to be petted and handled like
small children.
and
Physically, they fail markedly in nutrition, occasionally give evidence of severe cerebral disorder,
ashemiplegia, disturbance of speech, and epileptiform attacks.
134
The prognosis is dubious, as after an extended course of many months only one-half of the cases recover. The other cases
improve gradually but present as residuals, weakness of will-power, poor judgment, forgetfulness, poverty of thought, and apathy. This form follows chiefly typhoid fever, and sometimes malaria. It may be distinguished from the stupor
of the catatonic state by the absence of negativism, and from the stupor of the manic-depressive by the absence of retardation and the presence of faulty memory.
treatment of all these three types of postfebrile infection psychosis is mostly symptomatic, with very careful
The
nursing, rest in bed, nutritious diet,

Still
and cautious watching.

is
another group of postfebrile infection psychoses
Cerebropathia psychica toxamica," which was first " 1 described by Korssakow Psychosis," (Korssakow's " " Neurocerebrite Toxique"). Polyneuritis Psychosis," It is characterized by a pronounced disturbance of that element of memory which we call impressibility also by disorientation and the physical signs of polyneuritis, associated somethe
,
"
times with a delirious excitement or stupidity.
The symp-
toms
of this form of polyneuritic psychosis are very similar to the alcoholic polyneuritic psychosis (see p. 184), and can be distinguished only by their more prolonged course and the
The duration of the history of the underlying physical state. psychosis extends over many months, in case death does not
and the outcome is rather more favorable than in the alcoholic cases. The treatment is practically the same as
occur,
that outlined in the other forms, with the exception that some attention must be paid to the muscular atrophies,
Korssakow, Gazette russe hebdomadaire clinique, 1889, No. 57 Meyer in Raecke, Archiv f. Psych., 1903, Bd. 37, H. I; Turner, Jour, of Ment. Sci., October, 1903; Miller, Am. Jour. f. Ins., LX, No. 4, 1904;
;
Frie
ftnder,
Monatschr.
f.
Psych., VI, 4491
Raimann,
idem., XII, 329.

which demand the use
of electricity
135
after the
and massage
subsidence of the acute neuritic symptoms. There is still another form of postfebrile infection psychosis, different from any of the preceding forms, which is
characterized
by the sudden appearance
of active excite-
ment with clouding
of consciousness, flight of ideas,
and
fantastic expansive delusions, simulating the symptoms of the expansive paretic. Following a few indefinite prodromal
symptoms there appears
first,
usually during the febrile
period, considerable restlessness, then disorientation, distractibility, and hallucinations of sight and hearing, and
finally the
most elaborate grandiose

extensively.
delusions.
The patients
also
fabricate
Emotionally, they are some-
times irritable,
sometimes elated, but always changing from one state to another. There is absolutely no rapidly In addition, the patients are productive and show insight.
a flight of ideas with a tendency to rhyming. The restlessness is so great that they cannot remain in bed. Little food
is
taken, sleep is scanty, and nutrition suffers greatly. This form follows typhoid. In part of the cases the course is rapid and the outcome favorable. After some months the excitedelusions gradually disappear. The patients, continue to be irritable, susceptible to fatigue, and however,
ment and the

upon
ideas
slight
mental application easily develop again

fabrications,
flight of
and delusional
silly
and may show a charis
acteristic
elation
even when convalescence
well
established.
In a considerable number of cases dementia
ensues.
This form
may be
distinguished from paresis
by the
absence of physical signs. The treatment consists mostly of continued rest in bed, prolonged warm baths to alleviate
the excitement, a nutritious diet, and very careful nursing.
II.
EXHAUSTION PSYCHOSES
THE exhaustion psychoses, collapse delirium, amentia, and chronic nervous exhaustion, include those forms of mental disease that seem to arise from excessive exhaustion or insufficient restoration of the
nervous elements in the cerebral

"
is most applicable to those that immediately follow a severe and radical psychoses change of the physical organism, such as that produced by
cortex.
The term
"
exhaustion
acute diseases, excessive loss of blood, and childbirth. But even here one cannot always exclude the possibility of a toxaemia arising from an infectious organism or from the
destruction of tissue.
result in
more accurate knowledge may these forms being grouped elsewhere and asother etiological factors. This occurred in " of acute dementia," which is now classed
of
cribed
to
the
case
in the
it
group
post
infection
represents a
phase in
psychoses, except when catatonia or manic-depressive
insanity.
and amentia, though they run a slightly many symptoms in common; namely, a profound disturbance of apprehension and of the coherence of thought, as well as hallucinations, flight of ideas, and psychomotor excitement. Exhaustion arising from more prolonged mental and emotional stress, or extended physical illness, produces the less acute but more chronic
Collapse delirium
different course,
have
psychosis,
thenia).
chronic
nervous
exhaustion
(acquired neuras-
136
A.
137
COLLAPSE DELIRIUM
This psychosis
profound
is
characterized
of
by an acute onset with

great
clouding
consciousness,
incoherence
of
thought, dreamy hallucinations, a changeable emotional attitude, and great psychomotor activity, a rapid course, and a
fairly favorable prognosis.
Etiology.
Among
birth
sive
is
Collapse delirium is a rare form of insanity. the exhausting conditions giving rise to it, childthe most prominent; others are loss of blood, exces-
mental
anxiety. tion are
emotional shock, and deprivation with The acute diseases which may lead to this condistrain,
pneumonia and
erysipelas.
is
Oftentimes a fright
acts as
occurring while the patient the exciting cause.
in a
weak condition
Pathological Anatomy. Unfortunately but few cases have been examined pathologically. Alzheimer, 1 in a case which seems to belong to this group, found throughout the
cerebral cortex a fine granular disintegration of the chromatic substance, and without much involvement of the
nucleus or increase of
glia.
Following a few days of insomnia and the patients rapidly become disoriented and restlessness, everything about them seems changed and unnatural.
Symptomatology.
Numerous dreamy
illusions
and
designs on the carpet assume gas light appears like the sun, neighbors pass to and fro, beautiful music is heard, and patients pass through all sorts
of
hallucinations appear; the the form of threatening figures,
dreamy experiences. They become very talkative, the content

1
of speech show-
ing great incoherence with a
flight of ideas,
many
allitera-
Wanderversammlung
d.
suedwest
Neurolog.
u.
Irrenraetze
an
Baden-Baden, 1897.
138

rhymes, and repetitions, which
tions,
may
be sung as well
depressive.
as spoken.
Numerous
delusions are expressed which are
incoherent, changeable,
and both exalted and
In
emotional attitude patients are
much
exalted and some-
times erotic
; depression with anxiety, however, may prethe emotional tone. Occasionally there is irritadominate
bility
with exhibitions of passion.
The motor excitement is very pronounced; patients remove their clothing, race about the room, overturn furniThey are both destructive and ture, and pound the door. untidy, and often exhibit the most reckless and impulsive
movements.
a whisper,
They
prattle
away
incessantly, sometimes in
now at the top of their voice, and again gesticuand clapping their hands. The attention cannot be lating attracted and questions are rarely answered. They will not
obey requests, but almost always exhibit a purposeless resistance to everything, even to bathing and dressing.
great insomnia. If the patients Likewise they take sleep at all, it is only for short intervals. but little nourishment, and in many cases require mechaniPhysically.
is
There
The condition of nutrition is wretched, and a marked loss of flesh and physical weakness. The skin is pale and clammy, the temperature usually subnormal, and the pulse weak and irregular. The reflexes are usually
cal feeding.
is
there
exaggerated.
Tremor
is
sometimes present and there
is
tendency to acute decubitus. The duration of the disease Course.

of only a
is brief, sometimes few hours or days, and rarely lasting over one to
The return to consciousness is usually sudden, often following a sound sleep. When the patients awaken, the hallucinations and illusions have disappeared; they are
two weeks.
conscious of their surroundings and ask for nourishment. They may continue talkative, perhaps showing a flight of
ideas,
139
some
several hours
exaltation, grumbling, and fretful manners for and even days. Brief relapses sometimes occur.
is
As soon
rapidly.
as nourishment
freely taken, the weight increases
Diagnosis.
The
differentiation
from infection delirium
has already been considered (see p. 130). The epileptic befogged states are distinguished by the greater clouding of consciousness, a more uniform emotional tone which is
mostly anxious or ecstatic, and the fact that the activity does not conform to the thought or the emotional expressions.
The
catatonic excitement is recognized
orientation,
and the
characteristic
by the clearer catatonic movements.

can be
dif-
The
tion
delirious excitement of dementia paralytica
by the history of preceding mental deterioraand the presence of characteristic physical signs. The delirious mania of manic-depressive insanity, in the absence
ferentiated only
of a history of previous attacks, can be recognized only by a greater disturbance of apprehension and the very vivid
hallucinosis.
Amentia
is
differentiated
by the longer course

is
and
if
distractibility of the attention.
Prognosis. Recovery from the mental disorder the patients do not die from collapse.
usual
Treatment.
tain nutrition
The important indications are first to mainand next to alleviate the excitement. The
accomplishment of which
it
patients must, therefore, receive a sufficient quantity of

liquid nourishment, in the
is
often necessary to resort to forced feeding by stomach or nasal tube. little alcohol (one to two ounces) added to
the milk and egg is extremely valuable. Broths and peptonized meats may be given in small quantities. Where mechanical feeding is contraindicated, because of vomiting or
abrasion and hemorrhage of the mucous membrane, nutrient
enemata can be substituted.
Failing in this one can always
140

normal
saline solution,
resort to the hypodermoclysis of
one
to
two pints, with the expectation of securing excellent reimpending

collapse.
sults, especially if there is
The
infu-
sion should be given under low pressure in the back, rump,
or breast.
In the alleviation of the excitement, by far the most efficient remedy is the prolonged warm bath, into which the
patient should be placed at once
and kept there
until the
The bath should be maintained at The all the time. patients may remain in the bath without fear of harm for hours and even days at a time, but usually they become quiet in less than an hour, when they should be returned to bed. As soon as the excitement reappears, they should
excitement subsides.
ninety-five to ninety-eight degrees F.
again be placed in the bath. If the patients exhibit fear in entering the bath and require holding, the bath can do
but
little
good.
In such
cases,
one
may
injection
of hyoscine
hydrobromate,
-^
give a hypodermic to -$ grain, or

first
trional, 15 grains, shortly before the
bath for the
few
become accustomed to the bath they usually like it, and some even fall asleep in it. If the bath is not available and one must resort to hypnotic and sedative drugs, hyoscine hydrobromate -^ to grain and paraldehyde forty-five minims to one drachm may be relied upon for the best results. / One should not be persuaded to overload the system with sedatives in an effort wholly to subdue the excitement in the hope of securing quiet for others. \ Excitement, of itself, is by no means the most serious symptom. It is sufficient if you succeed in procuring even a few hours' sleep and prevent the patients from wholly exhausting themselves. Prolonged warm baths
times.
As soon
as the patients
properly applied usually render unnecessary the use of If the patients collapse, hot coffee by mouth or sedatives.
141
rectum, strychnia, dignitalis, or hypodermic injections of
camphorated
sufficient
oil
are indicated.
It is best that the patients
be isolated in a quiet place, with attendance to control them at all times. Constant
attendance must be enforced in order to prevent injuries, and this must be observed until convalescence is well established.
Mechanical restraint should not be employed; a
padded bed or room is preferable. During convalescence the same indications obtain here as in convalescence from any acute disease careful feeding, graduated exercise, and freedom from all forms of excitement. Finally, one must
:
be assured of complete recovery before the patients are permitted to resume their usual occupation or responsibilities. A good index of this is found in the weight, which should
always return to normal.
B.
ACUTE CONFUSIONAL INSANITY (AMENTIA)
is characterized by the numerous illusions and hallucinations, rapid appearance of clouding of consciousness, and motor excitement, with a
This form of exhaustion psychosis
duration of two
Etiology.
to three
months.
of exhaustion giving rise to
The conditions
amentia #re chiefly childbirth, also acute illnesses, excessive loss of blood, excessive mental strain, and night watching.
An emotional shock may be the final exciting factor. Women

are
more frequently
affected than
men.
Cases of amentia
represent about one-half to one per cent, of the admissions to

hospitals.
Symptomatology.
less,
At
first
the patients are anxious, rest-
and
forgetful,
sometimes complaining of numbness and
confusion in the head, and inability to gather their thoughts or concentrate their attention. In the course of a few days
disorientation appears; the surroundings
seem changed, and
142

Hallucinations of the dif-
they do not recognize relatives.

ferent senses appear.
They see strange faces and hear birds are flying about, lions are roaring, strange voices, poisonous powder is thrown at them, and they are threatened
and cursed by form the basis
strangers.
for
The numerous
hallucinations
depressive delusions, which are dreamy, incoherent, contradictory, and often repeated. Their children are dead, the home is lost, they are to be
many
hung, are under the influence of some magnetic power which draws them about, and in the end will consume them. In
a few cases the delusions are expansive; they then believe themselves exalted to some high position, possessed of great
wealth, or they have journeyed around the world. will convene Congress, and send an army to Cuba.
They They
sometimes fabricate extensively.
by the surroundings and the endeavor to grasp what transpires. It is usually patients
attention is attracted
possible, also, to direct the train of
The
before them,
by movements and
thought by objects held gestures; but they under-
stand readily only the simplest occurrences. Some patients claim that everything is changed, things are not genuine,
the chairs and windows are not the same to-day as yesterday, the thermometer is not correct, the clock is not right,
and the papers are
Often the patients incorrectly dated. appreciate this inability to understand things, and complain " that they cannot "think right or that some one "has made
them
crazy."
is
disturbance of the train of thought. The patients are unable to complete one idea before others interrupt, producing a flight of ideas.
There
marked
Words and sounds
caught up from the surroundings find a place in their expression, though not necessarily influencing or directing the
train of thought.
The speech
is
sometimes made up of
single, incoherent,
143
and disjointed words and phrases. Occasound associations and rhymes are heard. In spite sionally of distractibility and flight of ideas, one occasionally finds
the patients holding to single indefinite ideas, usually of persecution. The consciousness is much clouded. The persistence of clouded consciousness, with difficulty in arrang-
ing the impressions and ideas, is a characteristic and striking feature during the intervals when the patients are quiet and
present a normal emotional attitude. The emotional attitude varies considerably, sometimes with
prevailing happiness, but more often with depression. Alternations of the attitude are characteristic; for short periods
the patients may be elated, and hilarious, with perhaps some sexual excitement, when they suddenly become excited and irritable, or they may even be dull and stupid.
In the psychomotor
field there is
a marked pressure of
They move about restlessly, crawl in and out of activity. bed, destroy clothing, pound and beat, but the movements are not very quick, are performed without display of much energy, and are planless. The motor excitement is distinctly intermittent, there being intervals of complete quiet.
The sleep is much disturbed, the appetite is and sometimes there is complete refusal of food. The poor, body weight falls, but the condition of nutrition is better than in collapse delirium. The deep reflexes are increased, the pulse slow, and the temperature subnormal. Course. The height of the disease is usually reached within two weeks, during which time there may have been
Physically.
remissions of a few hours or even a day with clear consciousFrom ness, insight, and disappearance of hallucinations.
this time the symptoms present characteristic fluctuations. The more active symptoms may disappear, and the patients become more coherent in speech, when again they develop
144
excitement.
Genuine improvement develops gradually. have become clear, long conversations or Even letter-writing tend to create confusion. In the lighter cases, which are the more numerous, even after the patients have
after they
become quite
clear,
the emotional attitude
may show
slightly elated or depressed condition, as seen in hyperactivity and garrulity, or distrust, anxiety, and irritability.
The
from three to four months. In the severer cases, lasting some months, even when the patients have become clear, a few hallucinations may persist for a short time, and occasionally indefinite and transitory exentire course
is
pansive or depressive delusions are expressed. The patients may appear unnatural and irritable and show outbursts of
passion.
Even
after all the
symptoms
of the disease
have
disappeared, the patients are very apt to show increased susceptibility to fatigue, while for many months emotional
shocks or injuries are prone to create relapses.

rises rapidly
The weight
during convalescence.
Diagnosis.
is
The manic form
of manic-depressive insan-
ity distinguished from amentia by the fact that there is less disturbance of apprehension than of the psychomotor sphere; in the manic state, in spite of great motor excite-
ment, the patients usually give evidence of at least a partial comprehension of the environment. Again in amentia the
movements are
are
still
slower, more planless, and less precipitous, in quiet intervals, when there is no activity, the patients and,
hazy and confused.

is
The condition
of catatonic
excitement
distinguished by the fact that the catatonic in the midst of the greatest excitement are usually patients able to comprehend their surroundings, to reckon time
correctly, to recognize persons,
and to record some passing
events. The amentia patients even during quiet are somewhat disoriented and fail to recall passing events. Further-
145
more, the characteristic catatonic features are absent. To be sure, catalepsy and automatism may be present, but
genuine negativism, verbigeration, stereotypy, mutism, and
mannerism are absent. Death rarely occurs except as the Prognosis.

suicide, of
result of
collapse during the intense excitement at the or precarious physical conditions; as, heart failure, onset,
sepsis,
and
phthisis.
The
patients almost
always fully
recover their mental health.
Treatment.
The
indications for treatment are identical
with those in collapse delirium; namely, maintenance of nutrition and the alleviation of the excitement (see p. 140).
On
account of the great tendency to relapse, one should be extremely careful about allowing the patients to enter an
environment in which they might be subjected to an emotional shock. For this same reason, one cannot resist too
long the entreaties of the patients and their relatives that they be allowed to enter their accustomed life, before they
have regained their normal weight, the menses have reappeared, and the emotional attitude has become wholly
stable.
a.
ACQUIRED NEURASTHENIA
CHRONIC NERVOUS EXHAUSTION
ACQUIRED neurasthenia
power
is
characterized
by a diminished
to fatigue,
of attention, distractibility, defective
mental application,
difficulty of thinking, an increased susceptibility increased emotional irritability, and a great variety
of physical
symptoms, mostly subjective, including hypochondriasis. Acquired neurasthenia must be clearly distinguished from
the psychopathic states or congenital neurasthenia (see No doubt there are many transitional states between p. 155)
.
the two diseases, and especially where both defective heredThe difference ity and exhaustion are prominent factors.
symptoms, their course and outcome, in individuals free from hereditary taints, it seems, is sufficiently distinctive to justify the restricted use of the term acquired neurasthenia. The real nature of the disease has been most Etiology.
in the
logically pointed out
kind of chronic intoxication resulting
by Mobius, who claims that there is a from the effects of
exhaustion upon nervous tissue, corresponding in a measure to the intoxication resulting from the prolonged excessive
use of alcohol.
offers
This view, certainly,

conception
of
is
clearer
the
disease
helpful because it and aids in
distinguishing between those cases which simply involve an accumulation of the effects of fatigue and those in which the morbid hereditary and inherently impaired powers of resistance
play the essential role (congenital neurasthenia).

relaxation
The
with
rapid, irregular,
little
and extravagant manner of living, and lack of sufficient and wholesome

146
147
sleep in individuals actively engaged in business or taxed with the responsibilities of the household, is distinctively
characteristic
regions,
of the
American people in the temperate
and accounts
in our nation.
for the great prevalence of this disease Besides excessive mental application, the
is
worry attendant upon responsibility
an important
factor.
the other hand, prolonged and excessive physical exertion is at times undoubtedly an important factor in producing neurasthenia, particularly excessive bodily exercise, as is occasionally seen in sports, such as golf, rowing, basket But of especial importance are our faulty methball, etc.
On
nourishment.
ods of living, with insufficient relaxation and improper Moreover, considerable depends upon the
individual powers of resistance. This is particularly applicable to that considerable group of individuals, who always feel unequal to the demands made upon them and find
themselves quickly and completely exhausted upon any strenuous effort.
Of the men, naturally those who are more talented, better educated, and more active, are the individuals who most often suffer from this disease. Indeed, it is a fact
worthy of note that great capacity for work is frequently accompanied by greater susceptibility to fatigue. Women, because of their weaker powers of resistance and their greater emotional irritability, are more susceptible than men, particularly the
The
disease
overburdened mothers, teachers, and nurses. may appear at all ages, but is most often met
between the ages of twenty-five and forty-five, the period of life during which the greatest mental strain occurs. At an
earlier
age it is seen in ambitious students who apply themselves too closely to studies without relaxation. Occasionally
symptoms, which
differ in
no respect from those described
here, develop after emotional shocks
and acute
illnesses,
148

and operations.
especially influenza, childbirth, loss of blood,
The
"
nervous weakness"
It is doubtful
cence from severe illness

haustion.
fright.
is
if
which appears during convalesonly in part due to simple exthe disease ever develops after a
Symptomatology.
Prolonged
work
produces
and with
it difficulty
of further application.
Up
fatigue to a certain
which may be considered as a safeguard against overwork, may be overcome by an increased exertion of will power, which in long and fatiguing work gives rise to
degree, this fatigue,
" a feeling of increased effort." Associated with this there soon develops a characteristic feeling of disinclination and
then a fagging of the

of overexertion
is
will,
and when
relieved.
danger While the increased exertion of
this appears the
the will can for a time balance the effects of fatigue through an increased expenditure of power, the effects of fatigue
ultimately gain the upper hand and force one to cease work. The first indications of exhaustion are when, under certain conditions, the increased exertion of will continues for some time in spite of the uncomfortable feeling of fatigue.
This
what happens when work is performed under intense emotional excitement. The signs of fatigue, which call for relaxation, either do not appear or are overwhelmed, and work is prolonged beyond a permissible degree. This in time leads, on the one hand, to an exhaustion of the available supply of strength, which recuperates only very slowly, and is manifested by a sort of prolonged weariness, which persists after relaxation and is still present to some extent when work is again undertaken. It also involves an increased susceptibility to fatigue and a more rapid diminution of the
is
capacity for work. On the other hand, under such circumstances, the increased exertion of the will also persists and
brings with
it
an increased emotional
irritability.
149
Unfortunately, there are as yet no experiments on the But we know effect of prolonged overexertion on the mind.
from long experience,
that,, first of all,
the ability
to
con-
tinuously exert the attention fails. The patient is easily distracted by little things and is inattentive. He is no longer able to think clearly and sharply, and requires much
more time
forgetful of
for his
accustomed work.
He
is
is
also apt to be
names and
figures, so that the
same work has to
be done over several times before he
sure of his results.
His susceptibility to fatigue is greatly increased, and his work is carried out only with constantly increasing difficulty,
requiring greater exertion
and more frequent
rests.
As the
he
is
result of this difficulty of work, the patient also loses the
wonted pleasure
in his occupation.
He
finds that
compelled to force himself to the work which he previously performed with ease and pleasure. He, furthermore, shrinks from new undertakings because of obstacles which
appear unsurmountable.
Under the
attitude also
influence of these conditions, the emotional
becomes changed.
The
patients
become
easily
flustered, are ill-humored, unreasonable, peevish, faultfinding,
and impetuous. Customary amusements fail to please,^ and they become discontented with their occupation.
irritable,
Trifling affairs, like the
misconduct of a
child,
inconven-
iences at work, which normally would pass unnoticed, disturb them for hours and even days, and may lead to impulsive
outbursts, which they later regret.
patients have not only a keen insight into these defects, but also a tendency to exaggerate their symptoms.
The
They
assert that the
memory
is
becoming profoundly
is
af-
fected, and that the judgment
failing.
The
physical
symptoms
are even
increasing their
more strongly exaggerated, which aids in misery. The excessive anxiety about their
150

of
condition
health leads to
hypochondriasis, in
which there
is
a characteristic symptom, a tendency to pay undue
attention to any trifling symptoms that may be present. They believe that they are suffering from some incurable
disease,
and
especially the one
most dreaded.
There
may
be some genuine disorder, but the real symptoms are greatly enhanced by the attention habitually paid to them. Canker
considered infallible evidence of syphilis, a cloudy urine indicates Bright's disease, and a cough means consumption. In the beginning these fears may not be conis
in the
mouth
sidered in a very serious light, but when they interfere with the livelihood of the patients they may lead to such feelings of despair that the patients no longer hope for recovery,
make their wills, and not infrequently attempt suicide. The appreciation of their incapacity creates a feeling
of reserve, timidity,
and a lack
of self-confidence.
They
cannot trust themselves in public and fear fainting upon the slightest exertion. Associated with the loss of willpower, there should also be mentioned the tendency to
compulsive thoughts and impulsive acts, which sometimes explain the suicidal attempts. Here are included the various phobias, which are fully described in the constitutional psychopathic states. In the strife to overcome impulsive
ideas, the patients often reach
an emotional
crisis of
short
and moaning, and even attempts are more apt to follow continued
longed
visits or
duration, with restlessness, wringing of the hands, crying at suicide. These states
excitations, such as pro-
unusual noisiness.
Physical symptoms. feature of the psychosis.
These form a very characteristic Among the most important symp-
toms are headache, insomnia, general muscular weakness, parsesthesias, cardiac and gastro-intestinal disturbances. Cephalalgia, which appears early, may be expressed as a
151
headache, a feeling of numbness or a pressure in the head, which interferes with work. This is usually situated over
the eyes or in the occiput, and increases with exertion until it becomes unendurable. It is more prominent in the morning
and passes
oft
feeling of pressure, as
Sometimes there is a during the day. if the head were held in a vice or by
a constricting band. It may be associated with vertigo, dimness of vision, roaring in the ears, or painful pressure
points in the scalp.
Insomnia
onset.
is
usually an aggravating
symptom from
the
upon
of sleep, obtained either immediately or in the early morning, after hours of restless retiring,
The few hours
tossing, are unrefreshing
and disturbed by dreams.
In some
cases, there is an unnatural drowsiness which causes the patients to fall to sleep at all times and particularly after
some
exertion.
General muscular weakness
is
always in
evidence; patients are always languid, and tire easily walking or from slight muscular effort.
upon
Both the
superficial
and deep
reflexes
may
be increased.
Rhythmic twitchings are occasionally noticed, particularly twitching of individual muscles and especially those of the
Moderate stuttering is sometimes complained of. There is slight tremor of the eyelids and hands, but usually
eye.
a marked
tremor of the tongue. Subjective sensations, variously located, are prominent, such as parsesthesias or feelings of formication in the trunk and limbs, also darting
fibrillary
pains and burning sensations. The patients are usually alarmed by various cardiac sensations; such as a gnawing or burning sensation, palpitation
and precordial pain and pulsations in different parts of the body. The pulse rate varies considerably and is easily influenced by work or emotional excitement. Associated
with the cardiac disturbances or occurring independently,
152
there
may be vasomotor
ized sweating,
and anorexia is frequent, but the nervous dyspepsia, gastric and intestinal, is by far the most prominent digestive disorder. When the stomach is
variable
and The appetite is
disorders; as cold extremities, localblushing or abnormal dryness of the skin.
empty, there
is
usually present a gnawing sensation which
is
quickly relieved by eating. Gastric fermentation, probably due in part to deficiency of the digestive fluids, especially
hydrochloric acid, causes distention of the stomach, accompanied with discomfort and pain. Extending into the
intestines, the fermentation gives rise to
colicky pains, the latter
borborygmus and of which may be severe enough to
simulate genuine
digestion is usually not impaired sufficiently to create disturbances of nutrition, but in severe cases it may even cause cachexia and anaemia. The
colic.
The
usually constipated and the tongue coated. Diarrhoeas are apt to appear for short periods, and may be persistent for a considerable time.
bowels are
In the sexual
life
there
is
more often a
is
loss of sexual desire,
but in a few cases there

gence, although at the
a tendency to excessive indulof
same time patients may complain

is
impotence. In those cases in which there
frequent recurrence, the patients tend to become chronic invalids of a most distressing type. They go the round of physicians, pass from one sani-
tarium to another, taking
all kinds of drugs. Mentally, into a state of lethargy in which all thought centers they pass about their own misery. All attempts at business are aban-
doned, and the cares of the household are renounced. They betake themselves to the seclusion of a charitable institution
with
its
demand
freedom from annoyances, or if they remain at home, the utmost consideration for every whim. They
have no thought for the maintenance of the family or ap-
preciation of the burden which they create. demand for sympathy leads to prevarications
153
The and
increasing to various
assumed contortions,
in order to assure the physicians or
friends that they are in a critical condition.
The
daily
!
My God, doctor, I am dying greeting from one patient was, Just feel of my abdomen. Have you no compassion for a " A female patient remained in bed for years, dying man?
and when received at the hospital from the hands of a tender-hearted mother, had not had her hair combed in two years, and one of her toe nails had grown to the
length of five
inches.
It is this
class of patients
"
who
eventually become habitues of morphin, cocain, chloral, antipyrin, and other drugs.
It may, is gradual. an acute illness, especially however, develop rapidly, following influenza and also childbirth. There is a great variation in
Course.
The onset
of the disease
the prominence of the symptoms.
daily
improvement
toward evening
is
characteristic.
Under
stress of circum-
stances, the patients are usually able to pull themselves to-
gether for a special occasion, but the following day witnesses an exacerbation of the symptoms. The course is often
protracted and the convalescence gradual. The differentiation of neurasthenia Diagnosis.
other forms of mental disease
is
from
of the greatest importance
because of
In the
bearing upon the prognosis and treatment. place it is necessary to exclude organic disease of the internal organs. The diagnosis of neurasthenia should
its
first
rather be reached
by a process
of exclusion, after a
most
thorough physical examination. The psychoses most apt to be confounded with neurasthenia are dementia paralytica, dementia prsecox, and melancholia of involution. The difficulties in dementia paralytica arise
only in the
first
stages of the disease.
Signs of
154
nervousness without definite cause in a
man
of healthy con-
stitution, appearing for the first time in middle life, should at In neurasleast arouse suspicion of dementia paralytica.
thenia the alleged memory defect varies from day to day, is easily corrected upon effort, and does not show the defective
time element which

ory in the paretic.
is
so characteristic of the defective
mem-
Neurastheniacs complain of mental im-
pairment, but are able to amend errors in writing and speech, while the real mental defect in the paretic is unrecogrecognized, its extent is not appreciated. The defect, therefore, in the work of a neurastheniac is quantiThe symptative, while that in the paretic is qualitative.
nized, or,
if
toms
of the neurastheniac ameliorate as the
day advances, so
that the evening finds

paretic usually
him
at his best ; on the other hand, the
awakens refreshed, and more capable, but more during the day. Again, the neurastheniac has fatigues a keen insight into his condition, and tends to exaggerate his symptoms, but the paretic has little or no insight, or, if present,
he rather minimizes than exaggerates his symptoms.

of the neurastheniac are mostly
The sensory disturbances
The subjective, while those of the paretic are objective. of the characteristic physical signs of paresis should presence
leave no doubt; such as, Argyl Robertson pupil, increased myotatic irritability, ataxia in speech and gait, tremor of
the facial muscles and of the tongue, epileptiform or apoplectiform attacks, etc.
The depressive phases of the other psychoses, especially dementia prcecox and melancholia, are distinguished with
difficulty, particularly where these psychoses follow some acute disease, or appear in neuropathic individuals who have succumbed in the struggle with more favorably endowed associates. While the neurastheniac is ill-humored and
irritable
because he appreciates that his mental ability
is
155
impaired, his emotional attitude becomes happier just as soon as some external excitement or a jolly company allows him
to forget his troubles, or as soon as he is relieved of the responsibilities of his occupation, and can secure the benefit of
rest
and relaxation.
In the despondency of other psychoses
there develops a feeling of anxiety and sadness without any good reason, which, under the influence of distraction, is
not only not alleviated but may even be intensified. The diminution in the power of comprehension and the ill-humor
at the onset of dementia prsecox is recognized especially by the dulness of the patient, his indifference to the future,
and sometimes
also
by the
senselessness of his hypochon-
driacal complaints.
external causes of exhaustion are comparatively insignificant one naturally suspects that there is at the bottom a constitutional nervous weakness, which demands not
rest
Where the
and relaxation but
exercise
very sharp distinctions cannot be
and occupation. While drawn between these states,
yet there are some symptoms in congenital neurasthenia which are rarely, or to only an insignificant degree, found in simple neurasthenia; namely, the great susceptibility of the individual symptoms to mental suggestion, especially
the abrupt fluctuations of the emotional attitude, the anxious states, and the lack of strength.
The prognosis in simple nervous exhaustion as favorable, but it depends upon the extent to regarded which the exciting causes can be removed, as well as upon the
Prognosis.
is
individual's powers of resistance.
Under proper treatment
most patients greatly improve, but the probability of a return of the disease sooner or later becomes much greater, if the patient must enter his old environment and undertake the same responsibilities that lead to the first breakdown. The more frequent the recurrence of the
156

is
disease, the less liable
the patient ever to regain his
former health.
Where possible, it is the duty of the family physician to bear in mind prophylaxis. Individuals who are handicapped by a defective heritage must be well guarded during their development, with due attention to moral and physical hygiene. Later, when it becomes necessary to enter actively into the severer duties of life, the limitation of mental application and physical exertion, together with the avoidance of worriment and anxiety, must be constantly
Treatment.
kept in mind. In the treatment of the disease after

the individuality of the physician
is
its
development,
of
prime importance;
It
lift
he must recognize and
utilize his
power
of influence over the
patient in addition to various therapeutical agencies. requires confidence in order to inspire the patient and to
him from
morbid anxiety and depression. Isolation with a changed routine of life demands immediate attention. In the lighter cases a trip to the mountains or a sea voyage to relieve the asthenic condition, or where this is impracticable, removal from the customary surroundings into a quiet, restful, but attractive place, will accomplish the same
his
result.
Next, insomnia must be combated. Enforced rest in bed with change of environment, removal of cares and relaxation, and the establishment of a fixed routine usually relieve the
one should not have to employ sedatives until the patient has had a chance to react to the new method of life. Before resorting to the use of drugs,
sleeplessness.
rate,
At any
the simple hypnotic measures should be exhausted; such as, warm liquid nourishment upon retiring, a hot bath, gentle
massage, etc. If it seems necessary to resort to drugs, then employ the triple bromides in five-grain doses repeated every
half hour for five doses
if
157
necessary, administered
on
alter-
nate nights with trional, veronal, or somnos.

serviceable
Hydriatics are of great service in this disease, the most methods being the cold ablutions, the spray, the
simple douche, and the dripping sheet. In the last method, which may be carried out at home, after a cold ablution,
eighty-five to seventy-five degrees, the patient standing in
or on a dry surface, with a cold towel about the head, a linen sheet dipped into water seventy-five to fiftyfive degrees, is wound dripping about the patient, the nurse
warm water,
same time applying friction until a thorough reaction takes place. The douche, as carried out at bath institutions, is of great value.
at the
In the more severe cases, the secret of successful treatment lies in a well-regulated routine suited somewhat to the tastes
of the individuals, of sleep,
but requiring of all a definite amount nourishment, mental and physical exercise, alter-
nated with rest and relaxation, together with baths and outof-door life. All of this may be carried out under the supervision of a physician who is willing to spend time and thought in attending to the details. The relative amount of exercise
and forced rest must vary in individual cases. The anaemic and debilitated who have been exhausted by long suffering or the prolonged care of invalids, together with anxiety and worriment, require forced rest for a few weeks with a full nutritious diet, massage, and passive movements. Others, from the beginning, need graduated daily exercise, which must be purposeful and suited somewhat to the tastes. The diet, also, must depend upon the condition of the nutri-
Where indigestion or constipation exists, the usual means should be used to counteract these conditions, always giving preference to physical agencies. Electricity and
tion.
massage are of value, but only secondary to the above
158

Sometimes
local treatment is called for in cor-
methods.
recting uterine troubles, errors of optical refraction, or in removing nasal obstructions.

Finally, the patient should not
be considered suitable for
discharge until
relapse.
you have placed her beyond the danger of This involves on her part a thorough understand-
ing of the conditions leading to her breakdown, an inculcation of the correct principles of living
and an appreciation
of her
own
limitations.
and requires and working Such training
should be established early, and throughout the period of treatment no opportunity should be lost in impressing these ideas upon her mind.
III.
INTOXICATION PSYCHOSES
intoxication psychoses is here used in a narrow sense to include all psychoses arising from toxic substances
THE term
taken into the body.
They
are divided into acute
and
chronic
intoxications,
according to the length of the time during which the toxic

substances have been ingested.
1.
ACUTE INTOXICATIONS.
common by
The acute
intoxications are characterized in
a delirious state of short duration, with pronounced psychosensory disturbance, dreamy fantastic delusions, pleasurable emotional attitude, often with conditions of ecstasy,
and without much motor excitement. The number of toxic substances, including ptomaines, which might be mentioned here is large. The transitory character and the infrequency of the toxic deliria make them of little importance to the clinician. They are, howof great scientific value to investigators, who are able to study pathologically and psychologically the effects
ever,
of the different toxic substances.
Some
of
them which
are characterized
mentioned here.
form
is
by peculiar mental symptoms will be The mental state produced by chlorohallucinations of sight only. In are hallucinations of sight in appears yellow; hasheesh delirium is
characterized
by
santonin poisoning there
which everything
characterized
by disturbance of the taste and muscle senses. Hasheesh and opium smoking produce a complacent feeling of well-being, and of a dreamy, pleasurable existence.
159
160

carbonic acid
The
narcosis
is
characterized
by
its
short
duration and the presence of pronounced sexual hallucinaIn the toxic condition produced by atropin there is a severe disturbance of apprehension, with isolated hallutions.
marked confusion of thought, elated emotional The course is attitude, and active motor excitement. either fatal or the psychosis clears very quickly with no
cinations,
recollection of the events.
The duration
of all these conditions is short,
from a
The prognosis dethe severity of the intoxication. In pends entirely upon diagnosis one must rely in great measure upon the knowlfew hours to a few days at the most.
edge of the circumstances and upon the physical signs. The treatment is limited to the employment of means to
rid the
body
of the toxic substance,
and the application of
special antidotes.
The psychosis produced by lead poisoning, encephalopathia saturninia, is more frequent and differs from the
above delirious states by its longer duration, characteristic nervous symptoms, and poorer prognosis. The physical symptoms usually precede the mental disturbance; that is,
wrist drop, peroneal paralysis, tremor, pains in the limbs, and sometimes colic. The immediate prodromes are restlessness
and headache.
The onset
of the delirium
may be
acute or subacute.
and
There are many hallucinations of sight hearing, great psychomotor disturbance, many delusions with great fear, and complete clouding of consciousness.
incoherent, and in the height of the delirium there are frequent reckless impulsive movements.
is
The speech
is
There
is
complete insomnia, and very little nourishment taken. The active excitement is followed by a condi-
tion of stupor or coma, sometimes antedated
by stupor with
excitement.
INTOXICATION PSYCHOSES
161
Epileptiform convulsions may also appear, and amblyopia is frequent. The convalescence is gradual, extending over several weeks. Some cases terminate fatally in coma. While most of the patients recover, there are many
who, upon regaining clear consciousness, present a degree of mental enfeeblement in which simple apathy is a prominent feature. A few present progressive muscular atrophy, simulating dementia paralytica. The whole duration of the psychosis in favorable cases is from a few weeks to three
months.
2.
CHRONIC INTOXICATION
toxic substances
to disturbances of the mind, those best
whose continued use leads known and of most Almost clinical value are alcohol, morphin, and cocain. all nations, according to anthropological data, have had a
the
OF
many
drug whose habitual use has been a source of danger to its It is a striking fact that these substances have people.
always been used first for medical purposes, and later continued for their exhilarating and alleged supportive effect.
A. ALCOHOLISM
The acute
intoxication of alcohol
is
described here rather

its
than under the acute intoxications, because of association with chronic alcoholism.
Acute alcoholic intoxication produces at
tion of the
ternal
first
close
a diminu-
and elaboration of exand an acceleration in the release impressions, of voluntary impulses. The perception of simple sensory An attempt is difficult, sluggish, and uncertain. impressions to solve a simple problem shows a distinct diminution in
power
of apprehension
intellectual power.
In speech one can discern that the association of ideas
most
closely related to the
prominent, such as the use of
motor elements of speech is compound words and rhymes.

is
The
release of
motor impulses
much
accelerated so that
those expressions find utterance most readily that are most familiar. The choice between two movements is precipitous,
frequently incorrect, and sometimes already executed before the proper direction is determined upon. Later, or fol162
ACUTE ALCOHOLISM
163
lowing larger doses, the psychomotor activity is displaced by paralysis, the rapidity and extent of the paralysis depending
both upon the amount taken and the susceptibility of the individual. The muscular strength, at first slightly increased,
is
soon
much
diminished.
work.
influence the capacity for good mental are not easily gathered, rendering the Thoughts solution of complicated problems very difficult. This increases
Even small doses
with the amount taken.
thoroughly intoxi-
cated
or
man is unable to comprehend what is said to him what goes on about him, cannot maintain his attention He has no conception of or direct the train of thought. the significance or the bearing of his actions. The internal association of the train of thought is very much disturbed, as indicated by the tendency to the repetition of
phrases and the use of commonplace remarks, also in the fondness for quoting obscene rhymes and in the use of jargon. Finally apprehension may be so far lost that he
becomes insensible and unconscious.

the intoxicated state
is
Memory
of events of
very meagre. In the psychomotor field, at first, there is a light grade of overactivity, with the disappearance of the usual restraints which regulate the actions of our daily lives. He
is
and jolly, speaks and acts without reThe ready release straint, and even becomes reckless. of motor impulses promotes the feeling of increased muscular strength. Later the motor excitation increases;
active, gay, free
the facial expression loses its character, each action is exaggerated; the voice is louder, and the smile broadens
He becomes profane, grumbles, and growls. and passionate, and a single word or a trifling hasty accident suffices to start a quarrel or to lead to an assault.
into laughter.
He
is
Finally the excitation, as the disturbance of apprehension
164

by
increases, is replaced
profound disturbance of
and there is a speech, a staggering gait, and even

signs of paralysis,
complete motor paralysis. The emotions at first give
way
to a feeling of well-being.
There
a certain degree of exhilaration, and freedom from care. He becomes light-hearted and happy. Later
is
irritability appears.
is
Higher moral feelings are lost. He shameless, and because of the increased sexual excitaof the intoxication
It
bility is often led to filthy excesses.
The duration
the individual.
depends much upon
though
ill
usually disappears quite rapidly, aleffects may be observed for twenty-four to thirty-
six hours later: headache, lassitude, nausea,
and anorexia.
Fatigue predisposes to rapid appearance of paralytic signs, even without the intervention of the period of excitation.
Individuals
who
are rendered sluggish
also to be quarrelsome, aggressive,

cruel.
and sleepy are apt mischievous, and even
As the result of experimental investigations of acute intoxication in test animals, Nissl has demonstrated a profound change in the cortical neurones, seen in the destruction of
many
irregular amalgamation of the Nissl granules, the diminution in size and irregularity
cells,
in the fading
and the
of the nucleus,
disappear.
cells.
whose membrane and nucleolus may finally Dehio has observed similar changes in Purkinje
CHRONIC ALCOHOLISM
CHRONIC alcoholic intoxication depends upon a chronic degenerative process in the central nervous system, and is characterized by a gradually progressive dementia, with diminished capacity for work, faulty judgment, defective memory,
moral deterioration, occasional delusions, infrequent halluci-
and various nervous symptoms. Defective heredity is an important etioEtiology. logical factor, and is manifested by a diminished power of resistance in the individual. Some observers have renations,
ported as high as eighty per cent, of cases with defective heredity, in at least one-half of whom the father had been a
chronic drinker.
two per
Head injury, according to Moli, in twentycent, of the cases, has been regarded as a factor
Male alcoholics
in producing lessened resistance to alcohol.
greatly predominate. At Heidelberg only six per cent, were women. Hirschl, in Vienna, found among the male insane thirty per cent, alcoholics and among the women only four per cent, alcoholics. Alcoholism is more prevalent among those who come in contact with it, especially the bartenders, liquor dealers, brewers, and waiters. The extensive use of alcoholic drinks by many classes of society and the laxness
of public sentiment in regard to it should also be regarded as etiological factors. Furthermore, the ignorance of most
people as to its proven deleterious effects is in a measure an important element. There are thousands upon thousands
who
daily take a little beer, wine, or liquor because they are
does them good," and strengthens them. In the brain, in advanced cases, Pathological Anatomy. there is regularly more or less chronic leptomeningitis and
convinced that
"
it
pachymeningitis with or without hsematoma. The cerebrum is below normal in weight, its convolutions more or less
165
166

its
shrunken, and
ventricles dilated, the
ependyma
of
which
in rare instances is granular.
The
larger vessels at the base
and
in the fissures present arteriosclerotic patches or atheis
roma, but the most characteristic lesion
mostly localized, of the small terminal cortex and other parts of the brain. The cortical neurones
present a gradual
of Nissl."
sclerosis,
the endarteritis, arteries of the
called the
"
chronic
change
Nissl, in his experimental research with chronic alcoholism, in test animals, found a moderate thickening of
the pia, especially at the base, destruction of many of the cortical neurones, with an increase of neuroglia, and besides
these other extensive characteristic cortical changes, the meaning of which is still unknown. Alterations in the internal
organs
are
equally
prominent;
namely,
chronic
gastritis, cirrhosis of the liver, chronic nephritis, fatty infiltration of the myocardium, and chronic endocarditis with
greater or less degree of general arteriosclerosis.
There is a gradual and progressive Symptomatology. enfeeblement of the intellectual faculties. The capacity for
work
is first
to suffer.
The power
becomes difficult gradually and the susceptibility to fatigue increases.

fails, it
.
mental application to maintain the attention,

of
New and
is
unac-
customed work requires unusual application and
accom-
plished only with difficulty Patients prefer to continue in the same old ruts, and are indifferent in applying themselves to
any mental work. Consequently intellectual development not only ceases, but retrogrades, showing an increasing lack in judgment and a poverty of ideas, enhanced by a gradual failure of memory. Finally there is inability to acquire anything new, important facts are forgotten, and the past is recalled only as a somewhat confused and distorted picture. The defects of judgment and memory offer a fertile soil for the development of numerous more or less pronounced delusions.
CHRONIC ALCOHOLISM
167
These delusions tend to show a striking lack of judgment, are peculiarly ideas of injury, which sometimes take their origin
from isolated hallucinations, but more frequently from genuine perceptions which are falsely interpreted. In the more severe cases, a condition of advanced deterioration is
reached.
Moral
deterioration
symptom. There is and the patients soon lose sight and the sense of honor. This
their
a prominent and characteristic a profound change in moral character,

is
of the higher ideals of

is
life
especially noticeable in
own
estimation of their alcoholic habits.
They
dis-
regard their depravity with nonchalance, and claim that the liquor, taken for their physical benefit, does them no harm. When reprimanded for continued inebriety, they accuse a
friend of having given
them the
are driven to drink
by
liquor, or claim that they their wives. faithful promise to
abstain from further use of alcohol
may
be volunteered
but when encountered coming from a saloon an hour later, he fails to show any feeling of
by an
habitue*
shame.
Some claim that their work necessitates stimulation; others take only as much as can be regarded as a food. It is of interest to note the variety of conflicting excuses offered
by mechanics for the necessity of taking liquor: the cook, the fireman, and the iron moulder require it because of the great heat; while the night watchman, the truckman, and the iceman need it to keep off the cold. Many are driven
to drink
of a relative, a sick child,
incentives.
by unfortunate circumstances at home; the death and an ugly wife are frequent
patients lose all affection for their families, become indifferent to the tears of their children, have little interest in their welfare, disregard the real infidelity of their wives,
The
168
at the

same time developing a
certain exaggerated feeling of
self-importance, noticeable especially in conversation. They are unable to take matters seriously, and display an un-
natural sense of humor,
drunkard's humor.
There is a corresponding increase of emotional irritability, which is more evident during intoxication. Patients are
quarrelsome, engage in strife and abuse on small provocation, misuse their children, and are destructive of clothing
and
furniture.
Their complete and abject submission
when
opposed by a superior force or when incarcerated is in marked contrast to their behavior at home. Their inoffensive behavior and attitude of humiliation before others
sympathy from the inexperienced. They become entirely unstable, cannot remain at home, visit from saloon to saloon, tramp from one city to another, and engage in their usual occupation only for a few days or
often excites
hours at a time, offering the excuse that they are physically unfit for continued labor. They leave the support of the
family to the wife and children,
they browbeat for enough money to keep them in liquor. Others degrade themselves by pawning clothing and furniture, and even steal
in order to satisfy their appetite.
whom
Physically.
The most prominent

first in
are: fine tremor, noticed
physical symptoms the more delicate move-
becoming general; muscular weakness with atrophy; uncertainty in gait; defective speech, sometimes thick, sometimes slurring, with occasional aphasic symptoms; peripheral neuritis; frequent headaches and sometimes verlater
tigo.
ments and
The tendon
reflexes are often increased, rarely lost.
there are frequently found areas of hypersesthesia, anaesthesia, parsesthesia, as well as painful pressure points. Epileptoid attacks occur in about ten to
In the sensory
field
thirty-five per cent, of the cases, usually during
an attack
of
CHRONIC ALCOHOLISM
169
delirium tremens or at the conclusion of a spree, but also during the course of chronic alcoholism and even after more
or less prolonged abstinence. They occur mostly in persons addicted to distilled liquors, and differ from genuine epileptic
attacks in that they are infrequent, but unusually severe, while the absences, ill-temper, and befogged states peculiar
to epilepsy are absent.
Furthermore, the epileptic attacks but not always, disappear with enforced abstinence. usually, In the sexual life there gradually develops, in spite of increased sexual irritability, impotency which often leads to jealousy and fornication. Furthermore, the progeny is
rendered not only susceptible to alcoholism, but is particularly apt to exhibit evidences of defective physical and men-
development, and also epilepsy. of the children of alcoholic mothers

tal
The
is
rate of mortality twice as great during
the
first
two years
of
life
as of non-alcoholic mothers.
This
rate also increases with successive childbearing, reaching as high as seventy-two per cent.
The chances of recovery depend upon the Prognosis. extent of mental deterioration and the character of the
treatment.
If the patients already
show moral
deteriora-
tion, prolonged treatment is apt to be of little avail; each time they relapse into their former habits, becoming at last
mental and physical wrecks. Cases when taken early and submitted to an extended treatment have a fair prospect
of complete recovery. In many reputable inebriate institutions from one-fourth to one-third of their cases recover
permanently.
The recognition of chronic alcoholism preDiagnosis. sents few difficulties in view of the history, the typical
and the physical symptoms, the latter being at times made more evident by the presence of neuritic symptoms. Treatment. The successful treatment of chronic alcofacies,
170
FORMS. OF MENTAL DISEASE
holism demands complete abstinence from alcohol in every form. A few patients are capable of carrying out this injunction successfully by themselves, but the vast majority, and especially those whose occupation brings them into bad associations, require the treatment afforded by a special
institution for alcoholics.
The
success of this or
is
any other
materially
plan of treatment in the
chronic alcoholic
impeded by the general
indifference of the environment
and
the attitude of physicians. Very many physicians, wholly ignorant of the favorable results of treatment in reputable
institutions, injudiciously advise the friends that it is of
no use to waste money hi a long sojourn at an
institution.
Even
institution physicians are not
beyond
criticism in this
respect,
and
is
will force the patient's discharge
"
as soon as
the patient himself does not appreciate the necessity of treatment or because of delusions resists any restriction of his liberty, then one must resort
the drink
If
out of him."
to a legal commitment to an institution, which is in many states even for a period of two years.
now possible
committed to your care the alcohol can be suddenly withdrawn, except in a few cases where
As soon
is
as the patient
is
there
a disturbance of the heart.
The abstinence symphallucinations,
toms, insomnia, anorexia, and
occasional
which
arise in consequence of withdrawal, tend to quickly
disappear, and should cause no alarm. Improvement begins If the patient in a few days, and progresses gradually. is received in a condition of drunkenness, ergot administered
in fifteen-minim doses
and repeated every two hours, or apomorphin given hypodermically, beginning with -^ grain and repeated until vomiting sets in and the patient falls to sleep, are remedies well recommended to ward off delirium tremens and to restore the equilibrium of the patient. But
for the benefit of the psychical effect,
it is
sometimes ad-
CHRONIC ALCOHOLISM
171
vantageous for the patients not to be relieved of all sufferSevere cases require a hospital residence of nine to ing.
twelve months, or even longer. An index of the power of resistance may be found in the patients' insight into their
own
condition,
and
willingness to prolong hospital treat-
ment.
In light cases it sometimes suffices to place the patient to live in a family and community where total abstinence pre-
Even here it is necessary that the patient be kept under close surveillance, especially during the first few months. A similar arrangement is sometimes an excellent plan to adopt for a time after discharge from an institution, particularly where the patient has to return to an unfavorvails.
able environment.
cessful in the
Hypnotic suggestion has been very suchands of some physicians, both in establishing
a disgust for liquor and in creating will power to combat the habit and withstand the enticements. Its employment,
if
successful, permits the patient to
remain at work and with
sive sanitarium residence.
the family, rendering unnecessary a prolonged and expenMuch depends upon the per-
sonality of the physician in charge of the patient or the individual at the head of the family, who must inculcate
the principles of temperance and rehabilitate the powers of A very important means for the assistance of resistance. the patient in his struggle against the alcoholic habit are the various temperance abstinence societies, the most powerful of
which in
this country are the
Society of the Catholic
Temperance Abstinence Church and the Good Templars.

:
Upon
series of characteristic
the basis of chronic alcoholism, there develops a psychoses namely, delirium tremens,
Korssakow's psychosis, acute alcoholic hallucinosis, alcoholic

hallucinatory dementia, alcoholic paranoia, alcoholic paresis,
and
alcoholic pseudopareses.
DELIEIUM TREMENS
DELIRIUM TREMENS is characterized by the rather sudden development of numerous fantastic hallucinations, mostly of sight and hearing, indefinite and changing delusions, principally of fear and often of a religious nature, with clouding of consciousness, restlessness, tremor, ataxic disturbances, with rapid
course
and good prognosis.
Etiology.
The
etiology of delirium tremens
means thoroughly understood.
by no In the greater number of

is
cases excessive alcoholism appears to be the important factor, though it is generally recognized that the disease may de-
velop in connection with an acute febrile disease or some pronounced emotional excitement, as imprisonment and
injury.
Careful analyses of cases tend to
show that bodily
injury is really significant in not more than five to ten per cent, of cases, while the disease, pneumonia, occurs far more
frequently (Bonhoeffer forty per cent.). It seems probable, therefore, that in chronic alcoholics, any disturbance which
overtaxes the functional activity of the body or disturbs its equilibrium tends to produce delirium tremens; thus, severe
chronic disturbances of the general nutrition are of great importance among the predisposing factors, such as that arising
which occurs in most cases, and prevents the many weeks and even months. Furthermore, the symptoms of delirium tremens in no way resemble those of acute alcoholic intoxication, hence the
from
gastritis,
taking of sufficient food for
delirium cannot be due to alcoholic intoxication alone.
Again, the amount of alcohol ingested immediately before the attack seems to bear no definite relation to it, as, in
some
cases, the patients
have had no alcohol for weeks;
withdrawal, and In the in some it appears in spite of continued drinking. of delirium tremens, other particular factors development
others develop the condition only
upon
its
172
DELIRIUM TREMENS
173
must be at work besides the excessive use of alcohol. Just what they are is not definitely known. It is believed that the numerous and severe organic changes accompanying chronic alcoholism play an important role and undoubtedly produce, as shown by the poverty of the blood and abundance of adipose tissue, profound disturbances of metabolism. Jacobson points to the presence of a decomposition material
in the intestine; Hertz places delirium tremens
on the same
basis as uraemia;
Elsholz finds blood changes indicative
of a particular auto-intoxication; and Bonhoeffer suggests an intoxication arising out of the process of digestion, the product of which is normally secreted by the lungs, which
intoxication
become
tremens.
particularly apt to develop when the lungs diseased, as so frequently happens in delirium
is
findings in the blood and urine, which result directly from the action of the alcohol or indirectly through the fever, also the frequent occurrence of fever and
But the
mental picture, point conclusively to the fact that in delirium tremens we have to do not only
finally the characteristic
with the simple increase of the chronic alcoholic intoxication, but with an essentially different sort of an intoxication to which
the excessive alcoholism is only
common
a predisposing factor. The occurrence of abortive attacks of delirium tremens,
preceding for some time the genuine attack of delirium tremens, seems to distinctly favor this view, and to point to the additional fact that in delirium tremens there is only a
sudden increase of disturbances which have been present some time, but in a milder degree.
Male patients greatly predominate in delirium tremens. According to Bonhoeffer seventy-four per cent, of cases occur between thirty to fifty years of age. The disease occurs more
frequently in
summer than
in winter.
Besides a pronounced degree of
174

stasis
venous
and edema
*
of the brain,
which
is
usually pres-
ent, Bonhoeffer
finds a
marked degree
of fibre atrophy in
the radial fibres of the central convolution, in the fibretracts of the worm of the cerebellum, and especially in the
columns of Goll in the cord, while there is little or no alteration in the parietal or Broca convolutions; these lesions are not found in simple alcoholism. In the large pyramidal
cells
and
in the
motor
cells of
the anterior central convolu-
tions, the outline of the unstainable
completely lost, a considerable distance.

observed.
substance is more or less and the processes are markedly stained for
of cells
number
Occasionally nuclear changes are appear to be destroyed. A
similar condition prevails

calls attention to
among
the Pur kinji
cells.
Nissl
and
to a cell
a partial destruction of the cortical cells, change, which is suggestive of other acute cell
changes, in which there is staining of the achromatic substance, especially the axis cylinder processes, vacuolization in
the
cell
substance and moderate swelling, besides chronic
cell changes and an increase of glia. part of these changes are due to chronic alcoholism, among which should be added miliary hemorrhages, which in places occur in great numbers,
particularly about the nuclei of the eye muscles, as well as In the internal organs there are certain vascular changes.
found fatty degeneration and fibroid myocarditis of the heart,

cirrhosis of the liver,
and acute and chronic
alterations in
the kidneys.
five of
Furthermore, Jacobson discovered in forty-
seventy-two autopsies an acute hyperplasia of the in nine cases a hypersemia. spleen, Among the first symptoms to appear Symptomatology. are the sense deceptions; illusions and hallucinations of all
and
the senses, but more especially of sight and hearing.

Bonhoeffer, Monatsschr. f. Psychiatric u. Neurologic, Archiv f. Psychiatrie, XXXI, 3.
I,
These
229; Troem-
ner,
DELIRIUM TREMENS
appear at
first
175
during the day and annoy the patients conThey are perceived with great clearness, and with stantly. the terrifying content produce a marked alteration in the
emotions.
The
patients see
all sorts
of animals, large
and
small, moving about them; rats scamper about the
floor,
serpents crawl over the bedding, insects cover their food, and birds of prey hover about in the air. These forms almost
always show more or
less active
movement, depending upon
the restlessness of the body and the eye movements. Double sight is sometimes observed. This unsteadiness may in a
measure account for the frequency with which the flitting and scurrying animals appear. Fantastic forms are seen, mermaids, satyrs, and huge quadrupeds. Crowds press
upon them, troops

under the bed.
file
by.
omnipresent, peering in at the
The devil and his imps are windows or crawling from

the roaring of beasts,
The patients hear all sorts of noises,
ringing of bells, firing of cannons, crying of distressed children. They are taunted by passing crowds, are threatened with death, are cursed, called traitors, thieves, and murderers.
Parsesthesias of
the skin lead to the ideas that
ants are crawling over them, that bullets have entered the body, and even the absence of wounds does not deter them
from exposing limbs which have been shot
full of missiles.
irons are being applied to their backs, and dust is thrown in their faces. They can detect the odor of gas, sulphur fumes are being forced through the keyhole. Real
Hot
room assume life; the tufts on the bedding become creeping things, and the bedposts, demon guards. The content of the hallucinations is not always of a terrifying nature. Sometimes angels are seen; beautiful music is
objects about the
heard.
Christs,
God appears
and
to them, announcing that they are empowered to cast out devils; they are com-
176
manded
to go to confession and to proclaim the gospel message; they are in beautiful surroundings, are richly dressed, in palatial quarters, attended by lovely maidens.
Sometimes the scenes are of a lascivious character. Occasionally there is a mixture of the fearful and the beautiful, but more often, when there is a change of the emotions, the
former
is gradually replaced by the latter, as the course of the disease progresses. The hallucinations in a few cases, and especially after the height of the disease has been passed,
are nothing more than a passing show for the patients; they then gaze at the hideous forms and listen to the various
noises quite unconcerned. The results of various experiments
seem to indicate that
the hallucinations and illusions originate in disturbances of the central processes. Hallucinations seen through a
colored glass are not similarly colored. Also the hallucinations can be made to appear by directing the patient's
attention to their sensory
fields,
and by asking them what

enter into the picture of
they see and hear.
The various
hallucinations
may
an occupation delirium, when the patient is busy gathering up the gold lying about him, driving a flock of sheep, leading an orchestra, or addressing an audience. On the basis
of these delirious experiences, the patients
may
develop a
whole fabric of delusions concerning their environment and their experiences, but these delusions are never elaborated, do not influence the thought or action to any extent, and are
quickly forgotten. There never develop delusional ideas in reference to the personality of the individual. The patients
always
know who and what they are. The process of perception in itself, according to Bonhoeffer, 1
1
does not present any very striking disturbances, the pain,

Bonhoeffer, Der Geisteszustand der Alcoholdeliranten, 1897.
DELIRIUM TREMENS
177
muscular and temperature sense of the skin, as well as the

acuity of sight and hearing and the measuring of distances by the eye, being normal. The field of vision is sometimes
restricted, the recognition of color is uncertain,
tactile sensibility
and the
is in-
on the
finger tips
is
and the forehead
sometimes very greatly disturbed, many patients being unable to sit up, to stand or walk, and very anxious to remain in bed. This, he becreased.
The
sense of equilibrium
lieves,
accounts for the disorientation of the body in space.
Patients frequently complain that the floor is shrinking and that the walls are coming together, which may be due to disturbances of the eye muscles or of the labyrinthine
sense.
Disturbances of apprehension are prominent. There is defective interpretation of the impressions excited in the
various sensory
to obtain
with the result that the patients misinterpret noises, do not recognize pictures, and are unable
fields,
any sharp and clear impressions. The disturbance becomes more apparent when the patients attempt to read.
Instead of correct sentences, they read a senseless series of
words and sound associations, noticeable especially when the type is small and indistinct. Sometimes there is no relation at all between the reading and the subject-matter. This same defect is sometimes due to aphasic disturbances. shows marked disturbance. While it is for instance, possible to hold the attention for a moment, to get a response to your reading test, at the long enough
attention also
The
next the attention
your efforts. The promakes the disturbance of apprehension appear even greater than what it is. Forcible
fails in spite of
nounced disturbance
of attention
hold the patients for a short time, but they usually relapse, and they note only those objects that especially attract them.
language
may
178

is
always a moderate clouding of consciousness. The surroundings are not correctly comprehended, and the ideas
There
which are excited by occurrences in their immediate surroundings are confused and contradictory.
degrees of insensibility are
there
is
The
greater
found only in severe cases and
especially following epileptoid attacks.
On
the other hand,
profound disturbance of orientation, except in the The surroundings are mistaken for the barlightest cases. the church, or the prison, and strangers are greeted room,
as old friends.
Time
orientation
illness-
is
also incorrect.
Usually
the duration of the
seems to the patients much

is
prolonged, even to months.
The memory
for
remote events
well retained.
The
patients recall correctly where they live and facts concerning their families and occupation, and the length of time they may have resided in different places. But the impressibility of the
memory
is
greatly impaired, as
may be
determined by giving the patients a series of words or numbers to recall later. Memory for recent events is very defective, especially as regards the temporal arrangement.
Fabrications of
memory
frequently appear.
The train of thought is mostly coherent, yet the patients show considerable distractibility. The goal ideas are flighty and not very well fixed. During a conversation trifling incidents or hallucinations
off into
may
hinder the thought or lead

patients experience
it
various directions.
The
diffi-
culty in collecting their thoughts, are unable to recognize

contradictions,
and
fail
in trying to solve problems
which
require thought. In emotional attitude the patients are anxious and fearful or happy and cheerful, depending upon the character of the
hallucinations or illusions. intense fear to jolly
They may change rapidly from laughter, and even indulge in witty re-
DELIRIUM TREMENS
marks.
179
and the fear of death may rapidly and in this way there may develop a mixture of concealed anxiety and humor, when it seems as though the patients, in spite of the dreadful pictures and fears, still recognize more or less clearly the humorous impossibilities and contradictions in their delirious experi-
Thus
elation
follow each other,
ences.
In actions the patients are more or less restless and talkative. They are seldom able to engage in work, though
occasionally a patient continues at his occupation until the disease is well established. Usually they take an active part
numerous hallucinations. They plug the ears to out disagreeable noises, crawl under the bed to elude keep persecutors, escape from the window to get away from the
in their
sulphur vapors and the enemies waiting outside the door; they answer the imaginary voices, run to the station for
protection, or
amuse themselves with
their beautiful sur-
roundings and join in the happy company of imaginary
Sometimes they are assertive and aggressive, demanding attention or carrying out divine commands. When in fear they sometimes commit assaults, but they rarely
revellers.
attempt
suicide.
Many chronic alcoholics develop what in their own parlance " is called a touch of the horrors," which in reality is an abor1 tive form of delirium tremens. Some of these cases come under
the care of the family physician, but the majority of them go without medical attendance. The symptoms are those of the prodromal stage of delirium tremens. During a debauch or following abstinence or mental shock, there develops some parsesthesia, a vague feeling of fear, as if some one were
constantly behind the patients, the slightest noise causing them to be startled. While in this state they have isolated
1
Berkley, Mental Diseases.
180
One patient saw for a hallucinations of sight and hearing. moment a number of rats scampering across the floor, others
were attracted by unnatural voices.
It very
frequently
happens at night that some object appears at the window The patients are perfectly confor a second and is gone.
scious,
and appreciate
their condition.
Some
of the physical
signs of delirium
tion
is
tremens are usually present. The condiof short duration, rarely lasting over a few hours or
Besides the various sensory disturbances,
days.
Physically.
such as neuritic disturbances, parsesthesias, hypersesthesias, and circumscribed areas of anaesthesias which may form the
basis for illusions
lack of
and hallucinations, there is sometimes a insensibility which will permit the patients to sustain
There
is
severe injuries without complaint.
often present
great muscular weakness. The muscular movements tend to be coarse and unsteady, and the gait uncertain and staggerThere is some ataxia and pronounced tremor of the ing. tongue and fingers, and sometimes of the extremities and Speech is often ataxic and paraphasic, with maleyelids. position of words and syllables, and in the severest cases may be slurring and unintelligible. Occasionally in the
severe cases muscular spasms are noticed. Epileptiform seizures are frequent, occurring mostly before the attack,
in ten per cent, of the cases one to
break, less often during the attack,
two days before the outand sometimes accom-
panied by transitory paralytic symptoms, such as hemiThe tendon reflexes are exaggerated. Insomnia is paresis.
marked from the first, and persists unless the patients become stuporous. The condition of nutrition suffers, because of the small amount of nourishment ingested, which is due in part to the delusions of poisoning and in part to the
gastritis.
There
is
apt to be a slight
rise of
temperature
DELIRIUM TREMENS
during the
grees.
first
181
The pulse
few days, rarely reaching one hundred derate is low as well as the respiration,
is
and
occasionally there
profuse perspiration.
In a large percentage of cases the urine contains albumen and casts, which clears up with the psychosis. Elsholz finds
in the blood a relative leucocytosis, with a diminution of the
eosinophiles at the height of the psychosis. The duration of the delirium varies from a few Course.
days to two weeks, rarely extending beyond three weeks. The improvement comes with sleep. The hallucinations
usually fade away slowly, though sometimes they disappear within a night. With the improvement of sleep the physical
symptoms disappear
gradually. The memory of the events of the psychosis, in spite of great clouding of consciousness, is sometimes surprisingly clear, though it later tends to
fade.
A few suffer a second attack few days or even a week of clear consciousness have intervened, and in spite of the fact that they have
after a
show rapid the improvement of sleep.

Not
all
cases
clearing
up
of
symptoms with
Others show a complete alteration in the character of the psychosis after the hallucinations and
continued abstinent.
illusions
istic
have disappeared, some developing the character-
dementia.
polyneuritis psychosis or the alcoholic hallucinatory certain number of cases pass into alcoholic
paranoia, to be described later. In the more severe cases the physical signs become more prominent and there develop convulsions, muscular twitch-
and disturbances of the eye muscles. At the same time the insensibility and the incoherence increases, the movements become weaker and the pulse smaller, and finally death ensues, with sudden loss of consciousness or
ing, ataxia,
collapse.
182
Diagnosis.
if

The
diagnosis of the disease
is is
not
difficult
known. Fever delirium and the epileptic befogged states may be confused with delirium tremens. In the former there is a more marked
previous history of alcoholism
clouding of consciousness, and, especially in the epileptic condition, confused delusions of a religious character stand
moderate restlessness without impulsivethe active hallucinations, and the muscular tremor of ness, the alcoholic.
in contrast to the
The delirium
of dementia paralytica is differentiated
from
the alcoholic delirium by the previous history of change of character, evidences of failure of memory and judgment,
paretic physical signs,
and the more profound clouding of with a change of personality. consciousness, The outcome is usually favorable. In the Prognosis.
unfavorable cases (three to nineteen per cent.) pneumonia is the chief cause of death and greatly increases the fatality.
Other causes of death are cardiac

ing injury,
failure, infection follow-
and
suicide.
the development of delirium tremens in chronic alcoholics who have suffered injury or
Treatment.
In warding
off
have developed pneumonia, one should withdraw the alcohol at once and attend particularly to nutrition and sleeplessness.
Frequently repeated doses of ergot or the administra-
tion of
respect.
apomorphin hypodermically
(see p. 170) aids in this

is
The
first
indication for treatment
the establish-
ment
of proper nutrition, which requires frequently repeated administration of small quantities of liquid. If necessary, Gastritis with nausea artificial feeding should be resorted to.
and vomiting may necessitate lavage. The second indication is to combat insomnia, for which purpose a combination of 3J grains each of chloral, potassium, and sodium bromide is most efficient, repeated every hour until sleep is secured.
DELIRIUM TREMENS
In case the cardiac condition
will
183
not permit the use of chloral, paraldehyde or chloralmide may be substituted. The patient should be confined in bed and watched constantly.
If
excitement increases to such an extent that the
patient cannot be kept in bed, then the prolonged warm bath must be employed (see p. 140). Great excitement may
necessitate its continuous use, combined sometimes with the use of chloral and the bromides or paraldehyde, or in its
extreme
cases, the use of hyoscine.
As already indicated, alcohol should always be withdrawn.

In case the slightest evidence of cardiac weakness develops, one should not hesitate to make use of caffein, camphor, or camphorated oil, or in urgent states normal saline
infusion.
KORSSAKOW'S PSYCHOSIS
described a number of cases of apand associated with polyneuritic symptoms, which were characterized particularly by a profound disturbance of the impressibility of memory, disorientation, and a tendency to fabrications of memory. Later experience
In 1887 Korssakow
parent toxic origin
demonstrated that while this psychosis occasionally appeared in connection with other toxic states (see p. 134), it developed
most often on the
basis of chronic alcoholism.
It also be-
came apparent that the polyneuritic symptoms are not a constant accompaniment of the psychosis. The intimate relationship of this psychosis to Etiology.
Korssakow, Archiv f. Psychiatric, XXI, 669; Allgem. Zeitsch. f. XLVI, 475; Tiling, ebenda, XLVIII, 549; Uber alkoholische Paralyse und infektioese Neuritis multiplex, 1897 Jolly, Charite'annalen,
Psychiatric,
;
XXII; Moenkemoeller, Allgem.

Raimaim, Wiener
15 ;
klin.
Psychiatric, LIV, 806; Wochenschrift, 1900, 2 Elsholz, ebenda, 1900, Heilbronner, Monatsschrift f Psychiatric, III, 459.
f.
;
.
Zeitschrift
184
alcoholism has already been pointed out. Jolly regards it as a severe form of delirium tremens, while Bonhoeffer deIt develops in scribes it as a chronic alcoholic delirium.
It is three per cent, of the cases of delirium tremens. much more apt (eleven per cent.) to occur during the second
or
subsequent
attacks
of
delirium
tremens.
Women
appear to suffer in a proportionately larger percentage than
men.
There is an extensive destructive Pathological Anatomy. process involving the nervous tissue from the cortex to the
peripheral nerves. The nerve cells present the usual signs of an acute process while the nerve fibres give evidence of varying degrees of destruction, especially in the region of the
central convolutions, when there is a prolonged course of the disease. In the spinal cord there is an extensive atrophy
of the fibres, particularly in the
ticular
columns of Goll. Of parare the numerous small hemorrhages, ocimportance curring especially in the central gray matter, where they are
regarded as the cause of the oculomotor paralyses. The acute hemorrhagic polyencephalitis superior, described by
Wernicke, according to Elsholz and Bonhoeffer, is frequently associated with Korssakow's psychosis. The above anatomical lesions, which are indicative of an extensive destruction of nerve tissue, in reality are only what one would expect to find in severe alcoholic intoxication.
Symptomatology.
to those of
The symptoms at the onset are similar delirium tremens. But after the usual course of
and insomnia disappear. The and in addition there
the delirium symptoms, disorientation continues, while the

hallucinations, restlessness,
delirious experiences are not corrected,
develops a very striking disturbance of impressibility of memory (Merkfahigkeit). The symptoms sometimes follow
a rapidly developing stupor with hallucinations, and they
still
185
more
rarely develop gradually
from the chronic alcois
holic state.
In severe cases this disturbance of memory
so pro-
nounced that the patients cannot remember for a few minutes or even seconds that which they have just experienced. They are conscious and understand what is said to them,
yet they are wholly unable to put together their recent experiences or to form any picture of the course of events in
They do not know what has happened in the past hour, although in the meantime they have washed and prepared for and eaten dinner and been visited by the
their lives.
physician, and, indeed, even if told all this, they cannot fit it into their memory and correct the defect. few very
striking impressions
may
be retained, but they are never
connected with the events immediately preceding or followThe first result of this disturbance of memory is a ing.
complete loss of orientation. The patients have no conception of the time. They cannot tell where they are or those
about them, and usually greet the physician as an old acquaintance, though they cannot recall the name.
While the memory
is
more
particularly affected for events
since the onset of the psychosis, yet it sometimes happens that there is a distinct loss of memory for events extending
back several months or even years. They cannot tell you how they have been employed, or where they have been, or have lived during all this time. Some forget that they are
married or have children.
called,
A few striking incidents may be re-
but the time of their occurrence cannot be established.
The
are not only not recognized by the patient, but are very apt to be filled in with falsifications of memory, which are related by the patient with a feeling of
lapses in
memory
absolute certainty. These falsifications may apply only to the lapses of recent date. The patients then relate visits
186
which they have just had, or journeys which they have made, and give a detailed account of the good times they have had, while in reality for months they have been leading a wholly uninteresting and monotonous existence. These fabrications can usually be drawn out by questioning and influenced by suggestions. The fabrications are not always limited to mere filling the lapses of memory with ordinary experiences,
but the patient
gether
may strive to amplify the incidents with altofictitious events.
new and
This latter tendency is
pronounced only during the earlier stages of the disease. Indeed, the fabrication may extend to an intricate and fantastic falsification of the last ten years of the patients'
lives,
concerning which they relate
all
kinds of wonderful
experiences.
The apparent accuracy
of these fabrications
forcibly impresses one, together with the wealth of detail
and
the absolute certainty which they possess for the patient at the time. Although the facts are frequently altered, each
time they are related as clearly and assuredly as if they had occurred only yesterday. Occasionally, expansive and depressive delusions are added, but these also tend to change rapidly and as suddenly appear and disappear. Some-
times hallucinations also occur at the beginning, which later

disappear. The function of the intellect outside of the disorders
already
patients
mentioned
is
not
particularly
impaired.
The
show good judgment on other matters, understand

answer questions to the point,
cleverly conceal the lapses in their
facts presented to them,
and know how to
memory.
the other hand, they do not possess a clear insight into their condition and are unable to employ themselves profitably.
On
They can write letters well and carry out orders, but they become shiftless and lead a thoughtless and inlife.
active
The emotional
187
attitude at the onset is mostly anxious, but becomes one of indifference and apathy, though sometimes there is distrust and irritability, while in other
later it
cases a certain degree of good Usually the emotional attitude
humor
is
or elation exists.
also easily
changed by
suggestion into one state or another. The conduct and actions of the patients after the subsidence
of the delirium
become
orderly.
The
patients
may com-
plain a little about their surroundings, but they are mostly As a result of faulty memory they are always quiet. neglecting to attend to personal duties, or repeating what
they have already done; hence the same questions are frequently asked, and numerous letters are rewritten. Delusions,
if
The
present, do not greatly influence the conduct. physical symptoms are usually those of alcoholic
These, however, may be absent. The extent of the symptoms also may vary considerably, but usually they are confined to minor paralytic signs, atony and reduced
neuritis.
volume
of
Romberg
pressure;
certain muscle groups, especially in the legs; signs; sensitiveness of the nerves and muscles to
less extensive anaesthesia, parsesthesia, or
more or
hypersesthesia; loss, seldom increase, of the tendon reflexes; cystic disorders, some degree of ataxia; difficulties of
deglutition
and speech; and
paresis of the
facial
nerve
and
especially paralysis of the eye muscles (abducens).
The
pupils are often unequal, and notched, and sometimes do not react to light. There is also tremor of the fingers, and fre-
quently a history of epileptiform attacks. Furthermore, symptoms indicative of chronic alcoholism may be present,
as nephritis, hypertrophy, or atrophy of the
ascites,
liver, icterus,
and edema;
also faulty nutrition, anorexia,
and some-
times nausea.
Course.
Following the rapid development of the disease,
188

is
usually a long one. In some cases death ensues from paralysis of the heart or respiration. Not infre-
the course
quently a rapidly developing tuberculosis leads to death. After a period of several months, there may be gradual improvement, with disappearance of the neuritic symptoms,
a return of orientation and improvement of memory.

small
In a
number
of cases the
improvement may,
in the course
of five to nine months, be sufficient to permit the patient's
returning home, yet there regularly remains a considerable increased susceptibility to fatigue, uncertainty of memory, emotional apathy or irritability, weakness of will, and limited
Further indulgence in alcohol tends to quickly inUsually the disease tertensify these residual symptoms. minates in a permanent dementia, which is particularly
activity.
characterized by the persistence of falsifications of memory. The conditions of excitement at the onset of Diagnosis.
the post infection psychoses may be differentiated by the fact that clouding of consciousness is much more pronounced, and hallucinations and illusions are more in the background;
further, the alcoholic
absent, the emotional attitude does not present the alcoholic characteristics, and finally the Paresis is distinprognosis is distinctly more favorable.
tremor
is
guished by the usual history of a gradual onset. Pronounced neuritic symptoms with paralysis of the eye muscles and the alcoholic tremors speak for Korssakow's psychosis, while
indications
of
graphia, and stupid or humorous emotional attitude of the alcoholic con-
aphasia, hesitating speech, marked paracerebral paralysis point to paresis. Again, the
trasts with the silly happiness of the paretic, while the only intellectual disturbance of Korssakow's psychosis is seen in
the memory, which may not involve the more remote events of life, as in paresis. Presbyophrenia also is characterized
by impaired
impressibility of
memory,
loss of orientation
ACUTE ALCOHOLIC HALLUCINOSIS

and fabrication but
;
189
this disease occurs
mostly in the senile
may not be preceded by an alcoholic history, and is not accompanied by neuritic disturbances. Again, the activity of the patients is greater; they are communicative,
period,
often garrulous, trouble themselves about the environment, display a childish emotional state and a certain busyness, The diagnosis may be difficult if the especially at night.
presbyophrenic
alcoholism.
patient has
been addicted to excessive
During the early stages of the disease the treatment is identical with that in delirium tremens The alcohol must be absolutely withdrawn, (see p. 182).
Treatment.
and the patient placed
either in
an
institution or in a
particularly satisfactory family environment, because of the great weakness of will displayed by the patients. Later in
the course of the disease,

electricity,
it
may
be necessary to employ
massage, and gymnastic movements in order to combat the muscular atrophy accompanying the neuritis. Some improvement of the memory disturbance may result from systematic mental exercises.

This psychosis is characterized by the sudden development of coherent delusions of persecution, based mostly upon
hallucinations of hearing, with barely sciousness.
Etiology.
l
any clouding
of con-
The
etiology of acute alcoholic hallucinosis
is
one identical to that in delirium tremens (see p. 172). case should develop into delirium tremens and another into
acute alcoholic hallucinosis
yet unknown. The various explanations offered for this by Bonhoeffer and others are
is
1
Why
Mitchell,
p. 251.
Types
of Alcoholic Insanity.
Amer. Jour,
of Ins. Oct. 1904,
190

Acute alcoholic hallucinosis represents, in
not satisfactory.
America, forty-five per cent, of the cases of alcoholic insanity committed to institutions, and occurs mostly in men of middle
life,
many
of
whom
have been habitual daily drinkers for
years.
Symptomatology. Occasionally, there are a few prodromal systems, such as indisposition, headache, dizziness,
insomnia, and irritability. The onset is usually sudden. The patients at first are disturbed during the evening or at
night by indefinite noises, like shouting voices, cryings, and
ringing
definite
bells.
These
hallucinations
soon
become more
when they hear their own names called and numerous epithets. The patients then hear remarks about themselves, which appear to come from the next room or from
fellow-workmen.
These remarks are usually quite
clear,
and occasionally are heard in only one ear. The voices are recognized as those of an acquaintance, a chum, or a fellowworkman, but rarely as those of the immediate family, and consist of imprecations and references to misdeeds of their
past
They hear themselves called murderers, liars, and thieves. They learn that they are to be electrocuted,
lives.
that the wife
is
unfaithful, or that the children have been
drowned. They are laughed At times they overhear long

welfare, in
at because of their anxiety. discussions concerning their

of their past lives are reis
which various events
hearsed or an indictment for murder

Again, a group of
read against them.
men under their window discuss means of them and bringing them to a public place for the capturing purpose of having them lynched. All this is so very real to the patients that it is impossible to convince them to the
contrary. Furthermore, it almost always happens that the voices are not spoken directly at them, but they only overhear what is being said among others about them. The

content of these hallucinations
nature.
191
is always of a depreciatory Besides these numerous hallucinations of hearing,
there are a few hallucinations of sight, especially at night. Strange and threatening forms appear before them, some
crawling from under the bed, others creeping on the wall; brilliant specks come across the field of vision, and they may even see double. At times the food has a peculiar taste,
and
excites suspicion.
In connection with these various hallucinations there

regularly develop pronounced delusions, mostly of a depresThe patients believe that they are the center sive nature.
of attraction; every one about
them watches and threatens
them.
Their every thought and action is known and commented upon. Passers on the street jeer at them, fellow-
passengers on the trolley watch them closely, visitors in the factory are told all about them and stand and gaze at them,
enemies shoot through the fence at them, and detectives in citizen's clothes follow them wherever they go. They are
on the alert for impending arrest, or they go into hiding, and refuse to leave their homes. These patients argue that they are condemned to die, and show considerable emotion. Fellowdistrustful of their surroundings, are constantly
patients refuse to speak to them because they are implicated in the seduction of their wives. Sometimes they refuse to
answer questions or associate with any one until brought to

the court
room
for the
supposed
trial.
At times they
find
consolation in prayer and in reading the Bible. These various delusions usually remain within the realm of possibility, and appear more like attempts on the part of the
patient to explain the hallucinations. Occasionally, however, the delusions are of a fantastic nature and simulate
those occurring in delirium tremens, sometimes also being associated with expansive delusions.
192
consciousness is barely disturbed, there being only a dazedness. Yet at night, and at the onset, there slight may be a slight transitory delirium. The patients are mostly
oriented, their speech coherent,
The
and they are able
to
make
an accurate statement
of their
symptoms, except occasionally
They rarely possess clear insight, but they often realize that they are different, and frequently accuse their persecutors of drugging
in giving the correct time of their occurrence.
them
"
or
making them
crazy.
Others claim that they are

onset
is
only
nervous."
attitude at the
The emotional
usually that of
anxiety, but later in the course of the disease there is that characteristic mixture of anxiety and cheerfulness seen in
delirium tremens,
when
the patients relate their frightful
experiences with indifference, or perhaps laugh at the absurdity of their attracting so much attention. When not
in fear, they are quiet, reserved,
and
in replying to questions
are monosyllabic. In conduct the patients
may remain
work
quite orderly,
and not
infrequently continue at
for days
But even during

silent,
this period peculiarities of
as the result of their delusions.
and even weeks. manner develop They become reserved,
and avoid acquaintances;
later they often apply to the
police for protection or hide under the bed, and some even attempt suicide. In our experience these patients are some-
into their
times the most dangerous of the insane. They take the law own hands, purchase firearms, and assault those
maligning their character or planning their destruction.
The sleep is regularly disturbed. The appetite fails and there is a loss of weight. The reflexes are occasionally exaggerated, and tremor of the tongue and hands
Physically.
is
often present, though not always.
Occasionally, there are
neuritic
symptoms.

Course.
or subacute.
193
The course
of the psychosis
may
be either acute
When acute, the duration varies from two to three weeks, with rapid disappearance of the symptoms, sometimes during a night. The prospect for a short course
seems better the nearer the symptoms approach those of
Occasionally, abortive forms of acute alcoholic hallucinosis are observed, in which the patients for
delirium tremens.
a few hours or a couple of days suddenly develop isolated transitory hallucinations, with anxiety, and a few persecutory
delusions, such as, that they are to be poisoned, assaulted
by fellow-workmen, or are watched by the police. In the subacute form the symptoms may persist from one to eight months, with numerous fluctuations, and then disappear
gradually.
The memory
The
for
events of the psychosis
is
usually excellent.
Diagnosis.
differentiation
is
and acute
fined.
is
alcoholic hallucinosis
between delirium tremens by no means sharply de-
There are cases of the latter in which the orientation

for only a short time, hallucinations
markedly disturbed
of hearing are very pronounced,
and there seems
to be a
definite delusional connection between the various individual morbid experiences, while, on the other hand, the difficulty
of apprehension, the disturbance of the impressibility of
memory, the presence

delirium tremens.
of visual
suggestibility, restlessness,
and tactile hallucinations, and tremor give the stamp of
Provided they are not simply cases of
undeveloped delirium tremens, may they not possibly represent a combination of delirium tremens and acute alcoholic
hallucinosis, similar to those cases of delirium
tremens occa-
sionally seen in epileptics, paretics, hebephrenics, and
manics ?
But usually the retention of a good of restlessness and striking physical

of hallucinations of hearing
orientation, the absence signs, the predominance
with coherent delusions based
194

sufficiently
upon them, and a more prolonged course are
distinctive evidences of acute alcoholic hallucinosis.
The
differentiation
from dementia
prcecox,
particularly
the paranoid form, may be difficult, but in dementia prsecox the onset is far more gradual: there is stupidity; looseness
of thought; a lack of energy for work; peculiar conduct, such as, staring, impulsive acts, and catatonic signs. The in dementia prsecox are directed to the while in the alcoholic psychosis the patient simply patient, overhears what is said. The delusions involve mostly the
hallucinations
physical
and mental
personality,
which in the alcoholic
psychosis are not involved. Finally, the emotional attitude is superficial, while in the acute alcoholic hallucinosis the
is genuine and often desperate, except for the occasional appearance of the alcoholic humor. Paresis may be
anxiety
differentiated
of paretic physical signs
by the same signs in addition to the presence and weakness of memory and judg-
ment.
Some
cases of manic-depressive insanity
may
present
some
similarities to acute alcoholic hallucinosis,
but they
can be successfully differentiated by the previous history

to delusions of self-accusations, which are absent in the alcoholic condition.
of the case,
and by tendency
usually favorable, as a large proportion of the acute cases recover. There is great danger of relapse with continued drinking, and subsequent attacks
Prognosis.
is
The outcome
are
more prolonged. Some patients have four or five attacks. The outlook in the subacute cases is not as favorable, as less than twenty-five per cent, wholly recover. In some cases
there finally develops a condition of permanent dementia, with hallucinations and delusions.
Treatment.
The
chief indications are the absolute withdiet,
drawal of alcohol, the administration of a nutritious
and incessant watching to prevent injury
to self
and
others.
ALCOHOLIC HALLUCINATORY DEMENTIA
195
The course
of the disease
may sometimes
be cut short at the
onset by the use of hypnotics to overcome the insomnia and of the prolonged warm bath to ameliorate the anxiety.
ALCOHOLIC HALLUCINATORY DEMENTIA

This type of alcoholic psychosis, provisionally called alco1 hallucinatory dementia (or alcoholic paranoia ), is
holic
characterized
lucinations,
by the sudden development
of
numerous
hal-
fluence
and
many depreciatory delusions of reference, persecution, associated somatic delusions,
in-
and
occasional change of personality, with some emotional anxiety and irritability, usually leading after a long course to moderate
dementia.
It frequently represents the
end stage
of the
acute alcoholic hallucinosis and as often follows delirium

tremens.
Symptomatology.
The onset
is
sudden.
If
acute
al-
preceded, the patients having become oriented and quiet, and having corrected at least a part of their delirious experiences, continue somewhat constrained and suspicious. Then hallucinations, particularly of hearing, develop again,
coholic hallucinosis or delirium
tremens have
and the
patients complain are reading their thoughts, and that they are being influenced in various ways. They feel that they are being hypnotized,
electrified, or
of hearing threatening voices, that others
chloroformed, are experimented upon when think that men are breathing on them, smearing asleep; mucus over them, changing their clothing, and creating disgusting odors about them.
Comments
daily papers about themselves, and to them from the stage. Very often their delusions have a
are printed in the actors make allusions
sexual content,
when they claim that they have been ashave their semen drawn off nightly, and that their saulted,
1
Luther, Allgem. Zeitschi fur Psychiatric, LIX, 20, 1902.
196
organs are being shrunken up. These delusions are usually not elaborated, but remain unchanged from week to week, and are almost always expressed in the same phraseology.
Witches and
spirits are
everywhere, assuming various forms,
offering threats; everything is poisoned, and cannot escape the hypnotic influence. Occasionally, they the delusions are still more fantastic and quite changeable. Expansive delusions may appear, but they also are limited
and constantly
in content, although they are fantastic.
The patients' judgment concerning the surroundings, except in the severer

cases, is quite
their associates, follow a daily routine,
good; they exhibit activity, converse with show a tendency to

in as far as their
employ themselves, and are quite natural,

delusions are not involved.
disturbances.
striking Nevertheless, one can detect a considerable
The memory shows no
is one of anxiety or the patients at times to attempt irritability, impelling suicide or attack their persecutors. Later, there regularly
degree of mental weakness. The emotional attitude at the onset
develops a more or less humorous attitude, manifested in witty and facetious remarks and rendering the suspicious
and
patients more pliable and approachable. Physically, besides the alcoholic tremor, there are often present more or less severe neuritic disturbances.
excitable
Course.
enforced,
is
The course
of this disease, unless abstinence
is
hallucinations
progressive. and delusions slowly subside.
With
persistent abstinence, the
In some cases
they
entirely vanish, leaving the patient in a condition But usually they persist for of simple alcoholic dementia.
may
many
years,
though steadily becoming weaker.
Numer-
ous fluctuations of the
symptoms
are characteristic; at times
the patients express some insight into their condition; they think that they are sick, but they have no idea of how they
ALCOHOLIC PARANOIA
came
into such a state,
197
also to associate
and they are able
manner with their supposed persecutors; at other times they become excitable without apparent cause,
in a friendly
complain of threatening hallucinations, and also become aggressive, but they are usually quieted without difficulty.
Diagnosis.
Alcoholic hallucinatory dementia
may
be
distinguished from some of the end stages of dementia prcecox by the history of the development of the disease, by the fact that the patients possess a greater emotional and intellectual
activity, are
more natural and approachable

humor.
if
in conduct,
and
show the
characteristic alcoholic
Furthermore, the
symptoms do not progress
total abstinence is maintained,
but rather tend to subside. There is, occasionally, a case of severe alcoholism, with pronounced catatonic symptoms. In such cases it would seem justifiable to assume that there
is
a combination of both diseases.
ALCOHOLIC PARANOIA
This form of alcoholic insanity comprises a small group of who gradually develop a delusional state
chronic alcoholics
characterized particularly by delusions of jealousy.
naturally follows excessive drinking, together with the wife's aversion to sexual intercourse, and the increasing impotency of the alcoholic, is the nucleus about which the delusions of
Symptomatology.
The family
discord
that
The tendency displayed by the alcoholic to jealousy form. lay the blame for everything upon some one else, naturally
engenders the idea that the wife is unfaithful, and that the real cause of these difficulties lies in the fondness of the
wife for other
Insignificant occurrences are regarded as important evidence of this infidelity: the assistance of some one in carrying a
men
or of the
men
for other
women.
bundle, the fondness of a friend for their children, the
198
voluntary implication of a neighbor in a family quarrel. The frequent clanging of a car bell means that the motorman is a correspondent. A side glance from a passer on the
street, the arrival of
an unusual
letter,
and even association
with another man's wife are held as
sufficient proof of the
suspected misbehavior. Furthermore, the home and children are neglected. Patients have seen the wife enter the
apartments of a neighbor, and from noises which they have heard are sure that she was guilty of adultery. Frequently,
the children are disclaimed as those of other men, and hence must share in the abuse. Sufficient evidence of this is found
in the fact that they have different colored hair or different
The saloon keeper is implicated, if he refuses dispositions. to give them credit for liquor, or the coachman, if he hapAssociated with pens to be amiss in any of his duties.
these delusions of infidelity there
soning.
may be
delusions of poi-
These delusions of jealousy are by no means confined to married persons, but also exist in the unmarried when those
persons with
whom
mother,
sister,
they are most intimately associated, the the paramour, and sometimes the clergy
of their jealousy
become the objects
and
assaults.
These
and usually remain within the realm of possibility. The patients, however, state them coherently, oftentimes displaying considerable emotion, and, indeed, in this way they frequently convince chance acdelusions are not elaborated
quaintances of the great injustice done.

sional
There are occa-
hallucinations of hearing, when the patients hear peculiar noises about the house, such as a creaking of the
door,
whispering, rattling of the shutters,
or suspicious
sounds in another room. There may be a peculiar odor in the house, or an odd taste in the food, which is offered as proof that an effort is being made to poison them. This
ALCOHOLIC PARANOIA
incites
199
them
to nail
down
the windows and to fasten the
door in order to keep out the lovers. There is no clouding of consciousness.
In actions, the
patients usually exhibit marked weakness; they bemoan their misfortunes while submitting to the injustice. At times the actions are entirely out of accord with their delusions,
and
this is especially true in cases of long duration.
A man may live peaceably with his wife, whom he accuses of

committing adultery night after night.
very
irritable,
and
in fits of anger
Sometimes they are may be both aggressive
and
destructive.
When under
is
the influence of alcohol, the
conduct of the patients
apt to be wholly changed; then
they become aggressive and threatening and, not infrequently, make murderous assaults upon their wives or the objects of
their jealousy.
The
usually progressive. delusions seldom disappear permanently, though abstinence from alcohol often brings improvement, especially in
Course.
The
course of the disease
is
conjunction with confinement in an institution. When removed from home environment, the delusions subside and
In some patients patients are able to live very comfortably. the delusions subside and are denied; they desire to " let " bygones be bygones "; everything is past," and allow the
inference that they have been mistaken. improvement, oftentimes accompanied by
sight, influences
This apparent
an alleged
inre-
one to yield to their importunities for
lease; but regularly the return to home surroundings, with an opportunity to secure alcohol, soon leads to recurrence
of delusions.
Diagnosis.
It is often difficult to distinguish the delu-
sions of infidelity expressed
by the patient from actual

of the alcoholic freof
occurrences and facts.
The conduct
quently results in
an actual and permanent estrangement
200
the
man and
wife,
adultery.
One must
which naturally smooths the way for rely in his judgment upon the grounds
patient.
for jealousy offered
by the
The
positiveness with
which the patient draws

data,
his conclusions
from
insignificant
and the conviction with which he applies these to others, and finally the occasional relation of strange condoubt as to the delusional origin Indeed, under some circumstances we can come to the conclusion that a jealousy which appears to be justified by real circumstances, nevertheless, on account
clusions should leave little of the ideas of jealousy. of its peculiar basis, must be regarded as morbid. This is especially clear when we observe how the patient disregards,
real, open adultery of the wife, while the delusion leads to passionate outbreaks. Delusions of infidelity may occur in the psychoses of the period of involution and occasionally also in dementia prsecox. In
with unconcern, the
general, the delusions are less apt to be fantastic in the alco-
and there are lacking the physical sensations, the hallucinations, and the nocturnal experiences which are
holic psychosis,
encountered in the other psychoses. In addition to this, there is a striking contrast between the subsidence of the
symptoms, the weakness of will shown by the alcoholic upon enforced abstinence, and his brutality and animosity when unrestrained. This psychosis is differentiated from paranoia
by the lack of a stable systemization of the delusions and by the symptoms of chronic alcoholism.
Treatment.
In these cases the treatment
is
confined to
enforced abstinence and careful watching or confinement in
an
institution to prevent assaults.
ALCOHOLIC PARESIS
This psychosis represents in the majority of cases a simple combination of the symptoms of chronic alcoholism with
ALCOHOLIC PSEUDOPARESIS
those of paresis.
There*
is
201
added to the defective memory
the expansive delusions and the emotional deterioration of paresis, the hallucinations and delusions of infidelity of the
alcoholic; while the speech disorder of the paretic
is
accom-
panied by the tremor and neuritic disturbances of the alcoholic. Epileptiform attacks also are particularly numerous.
Usually the signs of alcoholism have existed for some time before the paretic symptoms develop. On the other hand,
the
initial
that the alcoholic
symptoms may lead to such symptoms develop.
excessive drinking
ALCOHOL PSEUDOPARESIS
There are included here severe cases of alcoholic hallucinatory dementia with more or less pronounced signs of Korssakow's psychosis, in which physical symptoms predominate,
as,
tremor, speech disorder, ataxia, paralyses,
These cases are disrigid pupils, and paralytic attacks. tinguished from true paresis by the history of their development, the predominance of the polyneuritic symptoms, the active hallucinations, and the more prolonged course, which leads to a simple alcoholic dementia and not to the absolute dementia and death that characterizes paresis.
B.
MORPHINISM
of
THE
extensive use
and abuse
morphin
for its alluring
effects place it
second only to alcohol in the production of
mental and physical wrecks.

intolerance of pain among people of this age, together with the laxity of the physicians in disEtiology.
The
pensing analgesics, accounts in part for the extensive use of this drug. Being an expensive drug, its victims are
limited to the better classes.
the patients are those

effects
who
Considerably over one-half of are best acquainted with its ill
At physicians, dentists, and professional nurses. least one-half of these patients are men. On the Continent
it is
claimed that seventy-five per cent, are men. An important etiological factor is the defective constitu-
tional basis, evidences of
which in very many cases are
earlier
manifested by various neuroses, as hysteria.

free
Individuals
from
this hereditary taint usually
succumb to the drug
employment in persistent painful affecas neuralgia, sciatica, rheumatism, headache, dystions,

menorrhcea, and different forms of colic. The pleasurable feeling and the mental stimulus which supplement the analgesic effects are here the cause of its continuance. The
after its continued
majority of cases develop between the ages of twenty-five

to forty years.
In animals to which morphin had been administered for a prolonged period, Nissl has
demonstrated a shrinkage of cortical neurones with an

increase of the neuroglia.
202
MORPHINISM
Symptomatology.
Acute Morphin Intoxication.
203
The
physiological action of morphin is to first produce an acceleration and excitation of the process of comprehen-
sion
and a psychomotor retardation, which

in the
later passes into
a befogged state, with changing fantastic hallucinations and
an intense weariness
psychomotor functions.
Then
ensues a quiet, pleasurable feeling, which acts as one of the strongest enticements for the habitue. For him it also pro-
duces a necessary stimulus for mental work, which cannot be accomplished by the exercise of the will power alone.
There develops a metallic taste in the mouth, and sometimes

rumbling in the bowels. Fortunately the drug fails to produce these pleasurable effects for all, owing to idiosyncrasies.
Many
after its exhibition suffer
in the head,
general feeling of discomfort,
from a disagreeable fulness nausea, and
Following the intoxication there is apt to be headache, profuse perspiration, and diminution in all of
colicky pains.
In the prolonged use of acute intoxication disappear, and the morphin individual obtains only the exhilarating and the quieting
the effects of
effects,,
the secretions of the body. Chronic Morphin Intoxication.
which aid in endurance of annoyance incident to

his
his
work or
home
life.
The
beneficial effects of this
drug diminish with usage, and soon necessitate increased dosage, which may, in time, reach from thirty to fifty grains
must also be increased. The character of the symptoms and the time of their appearance depend mostly upon the individual constitution and its powers of resistance. Some continue addicted to
daily.
The frequency
of the doses
morphin throughout life without pronounced ill effect; others succumb in the course of a few months. In these the memory weakens, and the capacity for mental application diminishes. Difficult and exhausting work becomes impossible without
204
its

administration.
Consequently the patients are either in a condition of exhilaration, stupidity, or nervous irritability,
none
of
which are compatible with mental work.

:
Emotionally, these patients exhibit many variations they are sometimes dejected, irritable, cross, hypochondriacal;
sometimes confidential, over-nice, with pronounced affectation;
and occasionally anxious, there is a pronounced change

in
especially at night. Morally, of character, noticeable esirresistible
pecially
willingly
reference
to
their
habit.
They
submit to
all sorts of
depraved means in order to
secure the drug. Finally all idea of personal responsibility vanishes. The home and the business suffer alike, and they
fall
into a state of apathy
and
indolence, with
will
power and energy. They are careless and the personal appearance. In actions they are apt to be sleepy during the day, and active and restless at night, reading, busying themselves about foolish trifles, and talk-
an absence of about the dress
and obstinate
ing incessantly. They are also disagreeable, faultfinding, to the extreme. Very many of them become
addicted to alcohol, and other drug habits. The patients lie Physically, the sleep is much disturbed. awake for hours, their minds busied with all sorts of fantastic ideas,
sometimes accompanied by genuine hallucina-
tions of sight. Disturbances of sensibility are usually present, such as parsesthesias and hypersesthesias, especially
about the heart, the intestines, and the bladder. There is usually an increase of the tendon reflexes. The movements
are uncertain, sionally there
tremulous,
is
and sometimes
ataxic.
Occa-
difficulty in speech,
also paresis of eye
muscles (double vision and defective accommodation). The

general nutrition suffers, and there is loss of weight. The skin is flabby and dry, due in part to the absence of normal
secretions.
The
appetite, especially for meat,
fails,
though
MORPHINISM
sometimes there
is
205
mouth
there
is
creates unusual thirst.
a ravenous appetite. Dryness of the In the circulatory system
ringing in the ears,
noticed palpitation, and slow, irregular pulse. The numbness, vertigo, and syncope, as well
as the profuse perspiration to vasomotor disturbances.
and shivering, are attributable The lack of sexual desires and
impotence are prominent symptoms; in women there is amenorrhcea and sterility. The ensemble of these symptoms
creates the picture of premature senility.
Abstinence Symptoms. The abrupt withdrawal of morin individuals who are addicted to large doses produces phin
in the course of a
few hours a characteristic train of symp-
abstinence symptoms. These, according to Marme, are due to the action of oxydimorphin. The withdrawal even in milder cases is always attended with more
called
less disturbance. The patients become tremulous and uneasy, experience a tickling sensation in the nose and
toms
or
begin to sneeze;
feel oppressed,
complain of paraesthesias of
sleepless.
different parts of the body,
and are
The adminis-
tration of hypnotics, especially chloral, at this time, only increases the excitement and aids in bringing about a
delirious condition with hallucinations
sion.
and dreamy confu-
In spite of precaution, however, a condition very similar to delirium tremens may appear. This condition
but a few hours, or at most a few days. Occasionally there appears a condition of dazedness, with hallucinations
lasts
and convulsive movements.
involuntary movements, the diaphragm, paresis of the muscles of accommodation, tenesmus, paleness and flushing, vomiting, palpitation of the
Physically, the patients display twitchings of the limbs, spasm of
heart, fainting and collapse with heart failure, which is sometimes fatal. The secretion of saliva and perspiration, which during the ingestion of morphin has been diminished,
206
now becomes excessive, and there is colliquative diarrhoea. Albumen is usually present in the urine. The duration and
symptoms depend upon the constitution of the patient, the duration of the habit, and the size of the habitual dose. The symptoms disappear gradually, except
intensity of the
where they may vanish rapidly after a In the course of a few days, perhaps weeks, prolonged sleep. the patients begin to sleep and develop an appetite, but
in the lighter cases,
from
this point convalescence progresses very slowly.
The rapidity with which the symptoms of Course. chronic morphinism develop varies with the power of resistance of the individual and the quantity of morphin
ingested; in some cases it requires a few months, in others The duration also varies; some die within several years.
a year of inanition, heart

live for
failure, or in collapse,
while others
doses.
many years
The
in spite of large
and increasing
Diagnosis. may be recognized by the varying emotional attitude; periods of mental -freshness and unusual energy with a feeling of well-being, alternating with
disease
great weariness, stupidity, dejection, and irritability, and furthermore by the physical signs the loss of sexual power,
:
anorexia, myosis, and general muscular weakness, amounting in some cases almost to paresis. Scars from the hypo-
dermic injections should always be looked
for.
The
surest
means
of diagnosis
is
seclusion or close surveillance for a
week, during which time the demand for the drug or some abstinence symptoms will appear.
Prognosis.
The prognosis
is
always very serious.
Less
than ten per cent, recover permanently; relapses are the A few cases die from overdoses of the drug. The greater danger lies in cardiac weakness, which may lead to sudden collapse and fatal termination. The drug may be withdrawn with the proper precautions and the patients
rule.
MORPHINISM
suffer
207
no ill-effects. Often, when the patients do not reinto morphinism, they revert to substitutes, of which lapse the most important are cocain, alcohol, chloroform, ether,
and
chloral.
The treatment
is
preeminently unsuccessful in
is
those with strong neuropathic tendencies. The only successful method of treatment Treatment.
complete abstinence.
For
this
isolation in a reputable institution.
purpose the first requisite is This method of treat-
ment, however, cannot be safely undertaken in all cases, and especially where conditions of physical weakness are
present, also during pregnancy, acute and severe chronic There are two methods of withdrawal, the diseases.
gradual and the rapid, the latter of which requires the greatest skill and is by far the most efficacious. The former
involves
much time and patience, and is apt

traits
to create chronic
and disagreeable
which
itself.
in the
eradicate as the habit
end are as difficult to For these reasons only the
rapid method is outlined here. It is necessary that the patients be placed in bed. In mild cases the drug may be
withdrawn abruptly. Even in these the abstinence symptoms may appear. In cases where the dose has been large, the quantity is immediately reduced one-half, and after twenty-four hours to a nominal dose of one grain daily for several days, and in the course of two weeks entirely withdrawn.
During the period of withdrawal the drug
is
best
given in single daily doses in the early evening. If previously taken hypodermically, the drug should at once be
changed to administration by mouth. Abstinence symptoms occur within the first thirty-six to forty-eight hours
after the withdrawal of the drug
and demand
careful watch-
ing on the part of the physician. To guard against these and to add to the comfort of the patient, alcohol in small doses with light nutritious diet may be given. Where there
208
is
impending collapse, faradization of the skin, injections of ether or camphor, the administration of hot coffee or hypodermic injections of strophanthus and strychnia are indiIf these fail, cated, the last of which is often essential. finds immediate relief in return to the usual dose one always
The greatest restlessness and insomnia often If unto the influence of ice packs on the head. yield The local successful, the various hypnotics may be tried.
of morphin.
pains
tion
may
also be relieved
by the application
early;
this,
of ice.
is
Purgacontra-
should be
applied
however,
by pregnancy or an acute, serious, or chronic Diarrhoea demands no special attention. Finally, disease. it requires many months, and in some cases a year, to reestablish the former mental and physical health so that
indicated
they are able to return to their old associations without

fear of relapse.
it is
Even
after being fully reestablished in
health, necessary from time to time that the patients be subjected to close surveillance to ascertain if there is a
return to the old habit.
C.
COCAINISM
COCAIN, in distinction from alcohol and morphin in its effects, is characterized by the great rapidity with which it
produces profound mental enfeeblement and physical inaniIt is of rare occurrence to encounter symptoms of tion.
cocainism alone, because of the frequency of its complicaFor this reason it is tion with alcoholism and morphinism.
draw a pure clinical picture of the disease. The conditions giving rise to cocainism are Etiology. similar to those encountered in morphinism. Most of the have a strong neuropathic basis, and many of them patients
difficult to
have previously been addicted to morphin. Early in the history of cocainism the habit arose from the substitution
in the treatment of the latter habit, but at the present time most of the patients are physicians of cocain for
morphin
or druggists.
The usual method

it
of administration is
by the
syringe, although may be taken by insufflation. Acute Cocain Intoxication. Cocain in Symptomatology. small doses produces moderate mental excitement, with a
feeling of
and
well-being, increase of pulse rate, a fall of blood pressure. Its effects in the psychomotor
warmth and
field are similar to
those of acute alcoholic intoxication: an
excitement followed by paralysis.

energetic,
feels
is
condition
The patient is active, to write, and is talkative. This impelled sooner or later followed by drowsiness. Large
doses lead to delirious states with a tendency to collapse. Nissl has found in experiments upon rabbits that in the
210

is
but a very slight alteration in a moderate disintegration of the chromophilic granules, some staining of the achromatic substance, and a moderate increase of the glia cells.
acute intoxication there
the cortical neurones;
i.e.
Chronic Cocain Intoxication.
In one accustomed to the
prolonged use of the drug, there is a continuous mental state of nervous excitement with a flight of ideas, complete incapacity for mental work, lack of will-power, and defective memory. The patients are overenergetic, but their activity
and very productive, writing lengthy, meaningless letters, and evolving on paper impracticable schemes. They neglect their professional and home
is
planless; they are talkative
duties, also their personal appearance.
In emotional
atti-
tude there
is
a variation between exhilaration with a proof well-being and great irritability and are very apt at times to mistrust their surthe same time they exhibit more or less in-
nounced
anxiety.
feeling
roundings.
They At
difference as to the legal consequence of their acts.
The
memory becomes
paired.
Physically, the
defective
and the judgment much imis
most prominent symptom
the profound
disturbance of nutrition; the patients lose weight very rapidly, the normal expression changes, they look sleepy and tired, the skin becomes flaccid and pale. This is due
in part to the fact that the drug supplies the place of nutritious food, for which they have lost all desire, and in part
to
excessive glandular action which drain upon the body tissues. There
irritability,
makes a continuous
is
muscular weakness
and increased myotatic

muscular twitchings.
normally, and there
is
noted sometimes in the
The
pupils are dilated,
but react
In the
cir-
tremor of the tongue.
and a tendency
culatory system there is slowness of the pulse, palpitation, to faintness. In spite of increased sexual
COCAINISM
excitement, the sexual power diminishes.
turbed,
211
The
sleep
is dis-
and occasionally interrupted by
hallucinations.
may develop Upon a definite psychosis which bears close resemblance to the acute alcoholic hallucinosis.
Acute Cocain Hallucinosis.
irritability
the basis of chronic cocainism there
Following a few days of with anxiety and some restlessness, there appear
suddenly hallucinations of different senses; the patients hear threatening voices compelling them to act strangely, and see moving pictures on the wall, which are filled with
large
and small
objects.
Characteristic of the hallucina-
minute black specks moving about on a light which are mistaken for flies, mosquitoes, and other surface, tiny objects. This, according to Erlenmeyer, is an evidence
tions are the
of multiple disseminated scotoma.
Peculiar sensations in
the skin create the belief that
they are being worked upon by electricity, being thrust with needles, or that poisonous material is being thrown upon them; but most characteristic
the sensation that foreign objects are under the skin, especially at the ends of the fingers and in the palms of the
is
hands.
The muscular
the action of some poison.

are being read by
twitchings, they believe, are due to The hallucinations of hearing
make them suspicious of their surroundings.

means of some
Their thoughts
secret contrivance; they are
being spied through holes in the ceiling. Some patients become so thoroughly frightened that they attempt to kill
their
supposed persecutors,
or
in
despair
may commit
suicide.
A characteristic symptom is the silly delusions of infidelity.

Wives or These are frequently obscene in character. of receiving many husbands are accused of illicit relations, love letters, of stealthily leaving the house and neglecting
the family for immoral purposes, or of becoming
known
as
212

In reaction to these ideas patients are
public characters. usually vindictive
and may even become

clear.
aggressive.
The consciousness remains

tion, except in rare instances
is good orientawhere the excitement is very
There
great, or immediately following fresh injections of the drug.
In emotional attitude patients are always dejected, excitable, irritable, and sometimes passionate. Occasionally they are
reserved
and
reticent concerning their delusions.
In actions
they are usually very restless and unstable, though some may appear quite orderly. In the markedly delirious conditions
which sometimes appear there is always great restlessness. Acute cocain hallucinosis develops rapidly and may run its full course within a few weeks. The symptoms increase under the influence of single doses of cocain. The rapidly
delirious state soon disappears after the complete with-
drawal of the drug, sometimes within a few days, while the delusions may remain for weeks or even months. The co-
morphinism and cocainism in the same individual, which is of common occurrence, frequently leads to a combination of the symptoms. Morphinism alone seldom produces a rapid development of pronounced mental disexistence of
turbance, unless in connection with cocainism. Acute cocain hallucinosis is differentiated from acute
alcoholic hallucinosis
greater severity of the

delusions of
by its more rapid development, the symptoms, and by the fact that the jealousy appear earlier and as an acute symp-
tom.
a single dose of cocain during the psychosis produces an exacerbation of the symptoms, while in alcoholism it has little or no effect. Finally, the sensation
effect of
The
of objects
under the skin
is
characteristic only of cocainism.
The prognosis in cocainism is unfavorable for complete recovery. The symptoms of intoxication clear up after the
withdrawal of the drug, but the power of resistance
is
pro-
COCAINISM
213
foundly affected, and few resist temptation for any great

length of time. Treatment.
is
The only
The withdrawal
in morphinism, is best. attended only by unimportant usually symptoms, such as uneasiness, a feeling of pressure in the chest, with difficulty in breathing, also palpitation of the
complete abstinence. drawal, similar to that

is
successful method The rapid method
of treatment of the with-
employed
heart,
and insomnia, and occasionally by a tendency to
faintness which it is
simulates collapse. If such emergency arises, necessary to employ stimulants, as alcohol, camphor,
The insomnia may be combated with prolonged warm baths, paraldehyde trional, and also by a
coffee, strychnia, etc.
nutritious diet.
An
essential element in successful treat-
ment is confinement in an institution, where it can be mined with certainty that the patient does not have
to the drug.
deter-
access
Prolonged treatment with the employment of
every possible means to fortify
him against relapses is an which requires patience on the part of the important factor, patient and perseverance and tact on the part of the physician.
morphinism and cocainism be withdrawn first.

If
coexist, cocain should
IV.
THYROIGENOUS PSYCHOSES
THE two
forms of psychosis arising from disturbance of
the thyroid gland are myxcedematous insanity and cretinism. They develop directly as the result of an absence of glanducretinism appearing in early childhood, and myxcedematous insanity in adolescence and later. Rightlar activity,
fully the
symptoms accompanying Graves's
disease belong in
this group,
but are not described because of their com-
paratively infrequent occurrence.
A. MYXCEDEMATOUS INSANITY
The mental disturbance
characteristic of
myxcedema
is
that of a simple progressive mental deterioration accompanied by the characteristic physical symptoms of the
disease.
is
The lack of glandular activity in the thyroid to be the exciting cause by failing to neutralize supposed or care for some toxic product of metabolism. The gland
Etiology.
in all cases
is
found atrophied or diseased.
This
is
fre-
quently the result of connective tissue increase, sometimes

of colloid degeneration, of the gland.
and
rarely of tuberculosis or syphilis
is
The onset of the mental disturbance Symptomatology. with increasing difficulty of apprehension. The gradual,
patients do not comprehend written or spoken language as well as formerly, and are unable to collect their thoughts.
It takes
them
longer to perform ordinary duties, such as

214
215
Memory for recent events dressing, and they also tire easily. becomes defective. The increasing difficulty in applying the mind and in performing even simple acts finally renders
them completely helpless. sciousness. At first they
no clouding of conexhibit some insight into their but later this gives way to indifference and stupidity, defects, not only in reference to themselves and their condition, but
There
is
also to their environment.
pain,
They rarely express pleasure or and very seldom give evidence of thought for themIn emotional attitude
restlessness
it is
selves or their future.

tic for
characterisfearful-
them
to be anxious, dejected,
Sometimes they develop
and at times and moderate
excite-
ment with stubbornness.

Physically,
In rare cases there
may
appear
conditions of confusion with hallucinations
and
delusions.
they present characteristic cutaneous and
nervous symptoms.
The skin becomes
thick
and
dry,
rough, inelastic, obliterating the characteristic lines of expression in the face, producing thick lips, broad nose, and
The mucous membrane is similarly involved, and the tongue is thick and unwieldy. The cutaneous change is most marked in the supraclavicular region, in the upper arms, and in the abdominal wall. The voice is changed, becoming rough and monotonous, and the speech is slow and difficult. The nervous symptoms condeforming the hand and
fingers.
headache, vertigo, fainting, convulsive spells, and a fine tremor. Finally the skin and mucous membrane
sist chiefly of
become anaemic and very sensitive to cold, menses cease, and temperature becomes subnormal. The blood changes vary; sometimes there is an increase of the red corpuscles, and at other times a diminution. Course. The psychosis is of gradual onset, and unless treatment is applied, progresses to advanced appropriate deterioration, extreme physical weakness, and profound dis-
216
turbance of nutrition, the disease terminating fatally through the intervention of some intercurrent disease. Occasionally
there are intermissions, and in a few cases marked improvement occurs in spite of the absence of treatment.
Treatment.
sheep,
The administration of beginning at one and one-half
dried thyroids of the grains, one to three
times daily,
disease.
be regarded as a specific remedy in this The dose is gradually increased, guarding carefully
may
against intoxication symptoms, indicated by headache, dizziThe improvement beness, and irregular cardiac action.
comes evident within a week and increases very rapidly. The patients become active and show an interest in themselves and surroundings; they improve in memory and in
judgment.
rapidity.
The physical symptoms improve with equal In the most successful cases the patients appear
persists for
quite well at the end of

tude, which
two months, except for some lassia long time. Not all cases recover
through medication;
difficult to ascertain
the
number
of unsuccessful cases is
at present.
Relapses
may
occur.
B. CRETINISM
Cretinism
is
characterized
by a more or
less
high-grade
defective mental development, associated with loss of function of the thyroid,
and accompanied by
is
definite physical
symptoms.
Etiology.
The
disease
mostly endemic in mountain-
ous regions.
In Europe the cases are most numerous in
the Alps and Pyrenees; in America, in Vermont. Sporadic cases occur as the result of congenital absence of the gland
or its atrophy during or following a fever, or in connection with goitre. The disease arises from an organic infectious material, and is in some way associated with disease of the
parathyroid gland.
It is
unknown whether
this infectious
organism
is
217
the cause of an atrophy, a non-development, or disease of these glands, in this way producing a failure of
mental development;
or whether
action of the organism or its Other important factors are defective neuropathic basis
due to the direct toxin upon the nervous system.

it
is
and
unhygienic surroundings.
The morbid anatomy is still Pathological Anatomy. doubtful. Asymmetries and dilatation of the ventricles of
the brain and atrophy have been found, also hyperostosis of the cranium. The cortical neurones are deficient in num-
ber and processes, and are of the stunted globose form peculiar to idiocy and other forms of defective development. The symptoms of the disease are first Symptomatology.
noticed during the first and second years, except in a few cases where the children are born goitrous. At that time
they appear
are slow
creases
dull, stupid, indifferent, sleepy, and unable to care for themselves; have not learned to walk or talk, and
and awkward in their movements. The gland inin size from the sixth to twelfth year in three-fourths
it
Mentally, the to develop, presenting the symptoms of impatients becility;^ they are dull, stupid, incapable of apprehending or
diminishes.
fail
of the cases; in the remaining
of elaborating impressions, presenting
about the capacity of
a five-year-old child.
matic,
They
are rather indifferent
and phlegany
and quite incapable
of applying themselves to
work.
A few cases present a condition of extreme stupidity.

life,
Their condition remains unchanged throughout
except
as interrupted by short periods of excitement, similar to those occurring in idiocy. This condition may form a basis
for the
development of other psychoses, especially manic-
depressive insanity.
Physically, the long bones fail to develop in length, instead,
becoming thicker.
The head
is large,
and the neck
218
short

and
thick.
The nose
nent, the skin is The especially in the neck, hanging dependent in folds. broad face, with heavy cheeks and eyelids, with thick lips and broad short nose, presents a very characteristic picture.
broad, and the ears are promithickened as if padded, and in places,

is
and pudgy. The tongue is thick and clumsy in its movements. The hair is scanty, and dentition The speech consists of inarticuis late and the teeth poor. late sounds, which are loud, coarse, slurring, and stammerThe movements are unwieldy, the gait slow and cuming. bersome. Convulsions are rare. The sexual organs develop slowly, and in severe cases remain entirely undeveloped.
The limbs
are large
Patients have
little
power
of resistance, readily
succumbing
to intercurrent diseases.
The hygienic surroundings must be imwith special attention to drinking water. Many proved observers agree that it is advisable as a prophylactic measure
Treatment.
to send children
and
families with cretinoid tendencies to
the high mountains, which may bring about a complete recovery in children who already show some signs of disease.
Potassium iodide in small doses seems to be
beneficial.
According to recent observation the administration of desiccated thyroid, if given early, may aid in preventing the
development of the disease.
After an extended duration the
same drug may improve some of the physical symptoms, thickness of the skin and amenorrhoea, but the mental
symptoms cannot be
altered.
V.
DEMENTIA PR^COX
l
DEMENTIA PR^COX
is
the
name
provisionally applied to
a large group of cases which are characterized in common by a pronounced tendency to mental deterioration of varying
grades. The disease apparently develops on the basis of a severe disease process in the cerebral cortex, but whether
always the same is by no means certain. Dementia fortunately does not occur in all cases, but it is so prominent a feature that the name dementia prsecox is
the process
is
best retained until the

Etiology.
symptom group is better understood.

is
one of the most prominent, comprising from fourteen to thirty per cent, of all admisdisease
sions to insane institutions.
The
As the name
indicates,
2
it is
More than sixty per cent. of the life. cases appear before the twenty-fifth year. This, however, varies in the different forms; in hebephrenia almost threea disease of early
1
Finzie Vedrani, Rivista sperim.de freniatria,

;
XXV,
1899; Chris-
Ann. me"dico-psychol. 8, 9, 43, 1899 Trcemmer, Das Jugendirresein (Dementia praecox), 1900; Serieux, Gaz. hebdomad. Mars 1901; Revue de psychiatric, Juin 1902; Jahrmaerker, Zur Frage der Dementia praecox, 1902; Meeus, Bull, de la soc. de me*d. ment. de Belgique, mars-sept. 1902; Masselon, Psychologic des dements precoces, 1902; Stransky,
tian,
Psych. XXIII, 1903 Bernstein, Allg. Zeitschr. f. Psych. LX, Meyer, British Medical Journal, Sept. 29, 1906. 2 In our experience in Connecticut the age of onset has been under 25 of the cases in the hebephrenic form 45 years of age in only 34
f.
;
Jahrb.
554, 1903
develop the disease under 25 years of age, in the catatonic form 38 %, and in the paranoid only 11 %. The average age of onset in all forms is from one to four years earlier in the male than in the female patients.
219
220
fourths of the cases appear before the twenty-fifth year, in catatonia sixty-eight per cent., and in the paranoid only
forty per cent.
any way
the other hand, cases that cannot in be distinguished from hebephrenia have been ob-
On
served in patients between fifty and sixty years. The disease in the younger cases seems to take the form of a simple gradually progressive deterioration; in the somewhat later periods, it assumes the acute and subacute forms with
catatonic
symptoms while
;
still
later the
more pronounced
delusion formation appears.
Kraepelin reports that in the
hebephrenic form sixty-four per cent, of the cases are men, in catatonic and paranoid forms women slightly predominate but in our experience men slightly predominate in the hebephrenic and catatonic forms, while in the paranoid form
;
Defective heredity is a sixty-nine per cent, are women. very prominent factor, as it appears in about seventy per
cent, of cases reported
by Kraepelin, but
It varies
in not
fifty-two per cent, of our cases. different forms, being far more
more than somewhat in the
prominent in the paranoid
and equally
forms.
less prominent in the catatonic and hebephrenic Various physical stigmata are occasionally encountered, such as asymmetries and malformations of the skull,
ears,
and
palate,
nipples,
puerile
expression,
strabismus,
superis
numerary
general physical
weakness.
There
frequently an
earlier history of deliria
erate forms of fever, of convulsions in

ceptibility
accompanying modyouth, and great sus-
to alcohol, as well as the absence of sexual impulses and their early or unnatural development. Besides the above evidences of a faulty endowment thirty-three
per cent, of the patients previous to the onset of the disease
have been only moderately bright.

seclusiveness,
affectation,
twenty per cent, exhibit mental peculiarities from early youth up, such as
least
[
At
eccentricity,
precocious
piety,
DEMENTIA PILECOX
impulsiveness,
221
and moral
instability, while
seven per cent,
have always been weak-minded. In women, child-bearing seems an important factor, as twenty-four per cent, of the
female catatonics become afflicted during pregnancy, or at childbirth, but particularly the latter. This occurs in
only nine per cent, of the female hebephrenics. In ten per cent, of the cases there is a previous history of some severe acute illness, particularly typhoid and scarlet fevers/from
which time the patients have exhibited some change, as

increased
irritability,
susceptibility to
fatigue,
and im-
pairment of the full mental capacity. Head injuries precede a very small number of cases. Alcoholism, likewise,
an unimportant factor, but more than five per cent, of the male patients develop their disease while incarcerated These and the puerperal cases are particularly in prison. Pregnancy apt to develop into acute and subacute forms. favors the paranoid forms; and child-bed, the catatonic forms.
is
Pathology.
The nature
of the disease process in de-
mentia prsecox is not known, but it seems probable, judging from the clinical course, and especially in those cases where there has been rapid deterioration, that there is a definite
disease process in the brain, involving the cortical neurones. This view is further upheld by the fact that in those cases
which have been subjected to the most modern methods of research, anatomical lesions have been found which can be explained only upon such a basis. In a few cases this
is a reparable lesion, but in most cases the impairment of function is permanent and progressive. This pathological
basis finds clinical expression in the
few cases that recover and the larger number that show a permanent mental defect. The means by which these assumed changes are brought about in the nervous system are no better known than those that exist in epilepsy and idiocy. The relationship of the dis-
222
ease to puberty, disturbances of menstruation, child-bearing, and climacterium, and the absence of every recognizable external cause, suggests first of all an autointoxication, which may be in some way related to processes in the sexual organs.
Defective heredity, which exists in such a large percentage of cases, may be presumed to create a lessened power of
resistance to the essential causes of the disease.
Symptomatology.
In the
field of
apprehension there
is
usually very little disturbance. Ordinary external impressions are correctly apprehended, the patients being able to recognize their environment and to comprehend most of what takes
Yet accurate tests show that very brief place about them. stimuli are not well apprehended. During the acute or
subacute onset of the disease, apprehension is affected, and there is some disorientation. This may also appear during
transitory stupor or excitement; but even in these conditions, and especially in the apparent stupidity and indiffer-
ence which characterize the later stages of the disease, it is surprising to see how many things in the environment are
apprehended. Indeed, it is not unusual to find that patients even notice changes in the physician's apparel, in the furNevertheless, as the disease advances and niture, etc.
deterioration appears, apprehension, as well as other mental
phenomena, becomes perceptibly impaired.
The
orientation
know where they
mostly undisturbed. Patients usually are, recognize those about them, and are
is
aware of the time. In stupor and in states of anxiety, the orientation may be considerably clouded, yet it is characteristic of dementia prsecox that, even in spite of considerable
excitement, the patients continue to apprehend well. the other hand, the delusional form of disorientation
exist (see p. 28).
is
On may
Apprehension
always more or
less distorted
by
halluci-
DEMENTIA PRÊCOX
nations^ especially in acute
223
of
and subacute development
the
Occasionally, they persist throughout entire course of the disease. They, however, tend to dis-
disease.
the
appear in the end stages, though they occasionally reappear

during exacerbations. Hallucinations of hearing are most prominent, next come hallucinations of sight and touch, the feelings of currents, of movements, and of influence.
are distressing, and result in fear; but later they do not excite much reaction, except during exacerbations.
Hallucinations at
first
Consciousness is usually clear, but in conditions of excitemeirtrand stupor there is always some clouding of consciousness.
It
is,
however,
much
less
marked than one would

happened
in the
judge from superficial observation, as the patients later are

able to give
interval.
some
details of things that
On
the other hand, there

is
is
voluntary attention, which
pronounced impairment of one of the most fundamental

is
symptoms.
The
controlling force of interest
altogether
lacking, so that the presentation which happens to be the clearest and most distinct at any given moment is an accident of passing attention, never persistent enough to occa-
In spite of the fact that the patients perceive objects about them correctly, they do not observe them closely or attempt to understand them. In
sion connected activity.
it is absolutely In the to attract the attention in any way. impossible catatonic form of dementia prsecox the presence of nega-
deep stupor and in the stage of deterioration
tivism inhibits
as
all
active attention.
This becomes evident
gradually disappears. The patients emerging from this condition are caught stealthily peeping about when unobserved, looking out of open doors or winthe
negativism
dows, and following the movements of the physician, but
224

object
is
when an
There
is
held before
them
for observation they
stare vacantly about or close their eyes tightly.
a characteristic and progressive, but not profound, impairment of memory from the onset of the disease. Memory images formed before the onset of the disease are retained retention is good. Though with remarkable persistence,
their reproduction is increasingly more difficult, unusual stimulation or excitement may occasion the recollection
of events long since supposed to be effaced of deterioration recollection

is
not
free.
by the advance The formation of
new memory images is increasingly difficult with the advance of the disease. Memory for recent events is poor.
Events previous to the onset, especially school knowledge, may be recalled after the patients show advanced deterioration.
Some few patients keep
a careful account of the length
and elsewhere. Events and excitement are not remembered at all, during stupor or at most indistinctly. The train of thought sooner or later in the course of the
of their residence in the hospital
disease
is
acteristic looseness
profoundly disturbed by the appearance of a charand desultoriness, which has already been
described (see p. 40). One finds even in the mild cases some distractibility, a rapid transition from one thought to another
without an evident association, and interpolation of highsounding phrases. In severe cases there is genuine confusion
of thought with great incoherence and the production of new words. In cases of the catatonic form especially, we meet with
evidences of stereotypy; the patients cling to one idea, which they repeat over and over again. Besides, there is occasionally
noticed a tendency to rhyme or repeat senseless sounds. In judgment there appears from the onset a progressive
defect.
culty under familiar circumstances, they
While patients are able to get along without diffifail to adapt them-
DEMENTIA PILECOX
selves to
225
new
the meaning tional. This condition of defective judgment becomes the The patients bebasis for the development of delusions. lieve that they are the objects of persecution, and they may
to their inability to grasp of their surroundings, their actions are irraconditions.
Owing
have delusions of reference and

of
self-accusation.
The lack
judgment becomes still more apparent in the silliness At first the delusions may be rather of their delusions. but later they tend to change their content frestable,
quently, adding new elements suggested by the environment. Even relatively persistent delusions are constantly taking on new meanings. Furthermore, the delusions, which at first are of a depressive nature, later may become exIn most cases the wealth of delupansive and grandiose.
sions so apparent at first gradually disappears. delusions may be retained with further elaboration
few from time to time, but they are usually expressed only at random. During exacerbations the former delusions, whether depres-
sive or expansive,
may
again come to the foreground.

there
In
the
paranoid forms, however, persists beginning a great wealth of delusions, but these become
the
from
more and more incoherent.

disturbance of tb^jemoiLonaLêld
is
another of the
/The
characteristic
and fundamental symptoms.
There
is
a pro-
gressive,
tionaJLlife.
more or less high-grade, deterioration of the emoThe lack of interest in the surroundings already
spoken of in connection with the attention may be regarded as one phase of the general emotional deterioration. Very
often
it is
this
symptom which
first calls
attention to
the^
*
approaching disease. Parents and friends notice that there is a change in the disposition, a laxity in morals, a disregard
for formerly cherished ideas, a lack of affection
toward
rela-
tives
and
friends,
an absence
of their
accustomed sympathy,
226
and above all an unnatural satisfaction with their own ideas and behavior. They fail to exhibit the usual pleasure
in their
employment.
As the disease progresses the absence of emotion becomes more marked. The patients express neither joy nor sorrow,
have neither desire nor fears, but
from one day to another quite unconcerned and apathetic, sometimes silently gazing
live
into the distance, at others regarding their surroundings with a vacant stare. They are indifferent as to their personal appearance, submit stupidly to uncomfortable posi-
and even prodding with a needle may not excite a reaction. Food, however, continues to attract them until
tions,
Indeed, it is not unusual to see these patients go through the pockets and bundles of their friends for delicacies, without expressing a sign of recdeterioration
is
far advanced.
ognition.
This condition of stupid indifference

short periods of irritability.
may be
interrupted by Early in the disease, and especially during an acute and subacute development, the emotional attitude may be one
of depression
and anxiety.
This
may
later give
way
to
moderate elation and happiness. The latter, however, in a few instances prevails from the onset. Yet emotional
deterioration remains a fundamental
symptom.
found
dis-
Parallel with the emotional disturbances are
turbances of conduct, of which the most fundamental is the progressive disappearance of voluntary activity. One
of the first
symptomToTthe
is
disease
may
be the loss of that
activity
which
his duties
and
sit
He may neglect peculiar to the patient. for the greater part of the day, unoccupied
though capable of doing good work if persistently encouraged. Besides this characteristic inactivity, there may appear a
tendency to impulsive
dow lights,
acts. The patients break out wintear their clothing into strips, leap into the water,
DEMENTIA PILECOX
227
break furniture, throw dishes on the floor, or injure fellowpatients, all of which seems done without a definite motive.
These states usually pass off very quickly, though in some this tendency may be more marked for a period of a few
days.
inability to control the impulses is also present in the stuporous conditions, and especially in the catatonic form of
The
dementia prsecox. Here each natural impulse is seemingly met and overcome by an opposing impulse, giving rise to
actions directly opposite to the ones desired. In this condition, which is called negativism, the patients resist everyis done for them, such as dressing and undressing, refuse to eat when food is placed before them, to open they their mouth or eyes when requested, or to move in any direc-
thing that
tion.
In extreme conditions there
may even
be retention
of urine
and
feces.
intensity at different times. patients suddenly relieved of
This condition varies considerably in It is not unusual to see the

it,
assume
their former activity,
after
talking freely and attending to their own needs, and again an interval of a few hours or days relapse gradually into the negativistic state.
ânother condition is produced by the repeated recurrence of the same impulse, giving rise to a great variety
Still
movements and expressions. The verbigerations and mannerisms of the catatonic are explained in this way. The patients repeat for hours similar expressions,
of stereotyped
utter
monotonous grunts, tread the floor in the same spot, dress, undress, and eat in a peculiar and constrained manner.
it is
While these symptoms vary considerably in individual cases, unusual not to find at least some of them present in
every case.
Frequently also hypersuggestibility of the will and automatism are present, particularly in the stage of deterioration.
228

show
The
patients are not only very pliable, but they may echolalia or echopraxia for longer or shorter periods.
Some
patients, however, never show these symptoms at any time during the disease.
fundamental symptoms of the disease is the discrepancy or lack of uniformity between the emotional attitude and the content of thought. Thus, patients laugh and cry without apparent reason; they cheerfully refer to
of the
One
their attempts at suicide, and exhibit great anxiety or outIndeed bursts of passion upon the slightest provocation.
between the ideation and the emotional attitude gives one the impression of childishness. The whole conduct shows many similar incongruities; the discrepancy
this discrepancy
seen between the feelings and the facial expression is called paramimia; such as, weeping on cheerful occasions, and
laughing
when sorrow should

and crying,
etc.
prevail; also the combination
There are many other symptoms, as mannerisms, eccentricities, and perhaps also the confusion of speech and the use of neologisms, which may be explained on the basis of a disruption of the natural connecof laughing
loss of
tion between the processes of thought, feeling, and will. This spontaneity frequently leads to the idea that the pa-
tients are being controlled by the will of another. They feel that their acts are not their own, but that they are compelled to do unnatural things. Hence some patients come to
believe that they are being hypnotized.
capacity for employment's seriously impaired. The patients may be trained to do a certain amount of routine
The
A fail when given something new. few patients display artistic abilities, as, for instance, in drawing or in music, but their efforts are characterized by eccentricities. They may show some technical skill, but their
work, but they utterly
productions exhibit the absence of the finer aesthetic feelings.
DEMENTIA PILECOX
Physical Symptoms. epileptiform nature, are
,
229
Attacks either of a syncppal or an among the most important physical
symptoms.
These
may
of the disease or but once.
occur frequently during the course They rarely involve alone single
groups of muscles, or are apoplectiform in nature followed
by more or less prolonged paralyses. Occasionally these attacks represent the first symptom of the disease. They occur in about eighteen per cent, of the cases and are twice
as frequent among women as among men. In addition, There is still another hysterical attacks are also observed.
type of convulsive movement, involving the muscles of the

eye and speech, which is both characteristic and of frequent occurrence in dementia prsecox. Some of these movements
correspond exactly to the movements of expression; wrinkling of the eyebrow, distortion of the mouth, rolling the eyes, and those other facial movements which are characterized
as grimacing.
These movements remind one of choreic
There
movements and are quite independent of ideas and feelings. may be associated with them smacking of the lips, clucking the tongue, sudden grunting, sniffing, and coughing. Furthermore, in the lips we observe very rapid rhythmical movernents. More often there exists a peculiar choreiform movement of the mouth which may be described as an athetoid ataxia.
There is usually an increase of the deep reflexes as well as of the mechanical irritability of the muscles and nerves.
The
pupils are often dilated, particularly in conditions of excitement, and are occasionally unequal. Not infrequently
to
sensibility
as cyanosis,
occur in
all
Vasomotor changes, pain is diminished. circumscribed edema, and dermograph, may stages of the disease, but are most often met in
Excessive perspiration
is
the stuporous states.

present.
is
sometimes
The
secretion of saliva
frequently increased.
230
The
heart's activity varies, sometimes being slowed, more often accelerated, but also sometimes irregular and weak. The menses usually cease or are irregular. The body tem-
perature is often subnormal. In many cases there has been detected a diffuse enlargement of the glands, which
sometimes undergo atrophy just before the onset of the disease. Exophthalmic goitre and tremor are sometimes
present.
is
Anemia and
apt to be
little
chlorosis are frequently observed.
The
disturbed during the developmental sleep stage, at which time there is also anorexia and the patients tend
to take
much
nourishment; but later in the course of the disease the taking of nourishment may vary from absolute
of food
refusal
to
extreme gluttony.
usually falls at the onset of the disease, degree, even in spite of the fact that the patients are taking a sufficient quantity of nourishment. On the other
The body weight and often to a marked
hand, the weight usually rises later and not infrequently rapidly and to a marked degree.
group of cases comprising dementia divided into three smaller groups the hebephrenic, prsecox is the catatonic, and the paranoid, each of which differs someClinically, the large
:
what
in the grouping, prominence,
and course
of the funda-
mental symptoms.
HEBEPHRENIC FORM
The hebephrenic form
dementia prsecox is charactergradual or subacute development of a simple more
of
ized by the or less profound mental deterioration.

of the cases of
An
acute onset
is
rare.
This form represents in our experience fifty-eight per cent,
dementia prsecox. The larger number of cases
develop under twenty-five years of age. The first symptoms may appear at the beginning of puberty. The onset may
be so insidious that the actual date cannot be placed.
Some
DEMENTIA PILECOX
of these patients
231
do not even come under the care of the
physician until years after the onset of the disease. The hebephrenic form should include a small group of
cases which gradually develop a simple hypochondriacal dementia. The prominent symptom is a constantly increas-
and mental incapacity, accompanied by all kinds of morbid sensations, which finally compel the patients to desist from any sort of activity. At the same time there develops an emotional indifference and
ing feeling of physical
general
languor
without
hallucinations
or
pronounced
delusions.
Symptomatology. Usually the patients first complain of headache and insomnia, which are soon followed by a
gradual change of disposition.
activity
They
lose their
accustomed
self-absorbed, shy, sullen, and or perhaps irritable and obstinate. They may seclusive, be rude and assertive, or perfectly indifferent. They become
and energy, becoming
careless of their obligations, thoughtless,
and unbalanced.
They accomplish nothing, but rather
sit
about unemployed,
apparently brooding, or they leave their work to go to bed, Others, lying there for weeks without evident reason.
instead
x>f
this inaction, exhibit

effort is impossible.
a marked
restlessness,
and
continuous They leave their work, stroll about or travel from place to place, especially at night. Others, with increased sexual passion, indulge in illicit and
promiscuous intercourse. During this period, which
may extend through
several
months, remissions are common, when for a short time the patients improve greatly and may even appear natural. This period, on the other hand, may rather be characterized
by alternating periods
of depression
ing severity. Women disease during the menses.
and elation of increasusually show premonitions of the
232

is
Sometimes the onset

depression.
characterized by a period of
marked
The patients become apprehensive, dejected, and reserved. They are troubled with thoughts of sad, death, and sometimes suddenly attempt suicide, often
in a peculiar
are usually hypochondriacs, and complain of nervousness and weakness; they search quack medical literature and frequently ascribe their troubles
manner.
They
There is also a mistrust of the environment and a feeling that they are being watched, imposed upon, or badly treated. But most striking is the emotional indifference with which the patients express and defend their morbid ideas.
to former masturbation.
Many
cases develop
no
further.
The more
severe cases
at this time begin to show hallucinations, especially of hearThe patients are annoyed by ing, and less often of sight.
strange noises, unintelligible voices, unfavorable comments upon their personal appearance; they hear threats and
imprecations, music
and
singing, telephone messages,
and
commands from God.

crosses
They may
also see heavenly visions,
on the wall, dead relatives, frightful accidents, and deathbed scenes. Occasionally they smell various odors,
especially illuminating gas
and sulphur.
beperience various hypersesthesias lieve that the head is double, that the throat or nose is
They may which lead them to
ex-
occluded, that the genitals are being consumed, or that the bowels are all bound together.
At the same time delusions become a prominent part of the picture and are mostly of a depressive character. The patients believe themselves guilty of some crime, accuse themselves of being murderers, claim that
unfit to live,
its
they are
lost,
are
damned,
have practised self-abuse, and can

ill
never recover from
effects. They suspect their surdetect poison in the food, are being worked upon roundings,
DEMENTIA PILECOX
others, their thoughts are not their own, friends turned against them and are trying to do them harm,
233
by
have
some them constantly, and they are being harwatching assed by various agencies. Women are followed by men who would ravish them. Later in the course of the disease, and occasionally from the onset^ the delusions are expansive;
one
is
the patients then regard themselves as prominent individuals the President, the Son of God, the Creator, the possessor of
:
They converse with God, are the Saviours of and possess all knowledge. Some patients are conmen, trolled by sexual ideas, fancying perhaps that they are bethe universe.
trothed to prominent individuals. Men believe themselves possessed of many wives, or regard themselves as the center
of attraction for all
women.
fabri-
These delusions
may be augmented by numerous
cations; the patients claiming that they have been President for a century, chief commandant in various engage-
ments, have been knighted, that they have been in heaven, have gained possession of the key of hell, have just returned
from a
visit to
Mars.
These fabrications, together with the
delusions, gradually recede to the background.
At
first
they become
less
numerous,
less fantastic,
then incoherent,
and
still
more
scanty, until finally, in the
advanced stages
of the disease, there remain only incoherent residuals of
former delusions which

elicited,
never be expressed except when or during excitement.
may
Some
first
insight into their condition is often expressed at
by the patients. They are conscious that a change has come over them, and often complain that the head feels strange, benumbed, or empty. These ideas may be expressed in connection with somatic delusions, when they will claim
that the brain
is
rotting, the
different in every
way, or are very
memory failing, that they are much confused. But
234
even this scanty insight gradually disappears as the disease

progresses.
is
In those forms of the disease which develop slowly there at first neither clouding of consciousness nor disturbance In the acute or subacute onset, cloudiness
unite in the clinical picture hallucinations and delusions, anxiety
disorientation
of orientation.
and general
with
may
pronounced
restlessness,
of thought. The patients mistake persons, do not appreciate where they are, and are unable to record passing events. Physicians are regarded as enemies trying to kill them, working upon them with
electricity, etc.
and
and incoherence
are confined in a prison for some grave offence, or are among the heavenly hosts, surrounded by
They
saints.
The
at
first
train of thought in the gradually developing cases is very little disturbed, the content of speech being both
coherent and relevant; but later in the disease and with progressive deterioration there develops the characteristic
of thought and desultoriness, often combined with the use of neologisms and embellishments.
looseness
The memory at first suffers only moderately. Memory of and the chronological order of events is well re* tained for a long time. Some of the patients are able to
earlier life
with surprising accuracy the exact definitions in geography and many historical events almost word for word, as committed to memory years before. But with the progtell
ress of the disease there is
an increasing impoverishment
impressibility of memory is retained, but the patients fail to make use of it, because there is a total lack of interest. Without this there is no incentive for observation
of the store of ideas.
The
what
there
is
is
and thought, and they fail to observe on about them. As the disease progresses, going increasing limitation of thought. For this same
DEMENTIA PRJECOX
235
reason past experiences are seldom recalled, and so finally fade from memory; though it is not unusual for patients,
in reaction to unusual stimulation, to recall events that
seemed to have
entirely passed
from them.
The defect in judgment appears early, develops rapidly, and becomes profound. This may not be evident while
the patient is confined at home, or during the early part of the residence in an institution, as long as his thought is employed with familiar facts, and his range for action limited.
It
becomes apparent, however, when he leaves the trodden path and attempts to adapt himself to new circumstances. He is unable to reason, to perform mental work, to recog-
nize contradiction, or to overcome obstacles. can also be seen in his tendency to formulate
senseless, incoherent delusions.
The defect and hold to
In emotional attitude the most prominent and permanent Whenfeature is that of emotional dulness and indifference.
ever we find emotional activity it is increasingly self-centered. At first there is usually more or less depression, with anxiety,
peevishness, and often irritability. Exaggerated expressions of religious feelings are apt to be prominent, the patients
being devout, praying frequently, reading their testaments, at first apparently in the spirit of penitence, but later because they are led by God or ordained to do some special work. The sexual feelings very often play a prominent role, particularly in those who have been addicted to the
habit of masturbation.
matters,
Thought may center about sexual

literature,
when they enjoy obscene
write long
letters to acquaintances, and give expression to their lascivious feelings, masturbate, and solicit intercourse. Female patients are more apt to associate with their own
sex.
in the course of the disease.
In both sexes these feelings are apt to disappear later Later in the disease the de-
236
lusions, both expansive and hypochondriacal, are expressed without display of emotion. Patients fail to express emotion at the loss of friends, at the visits of relatives, or at an un-
usual supply of food, fruit, or candies. They live a very empty life, devoid of any cares or anxieties, and without thought for the future.
In conduct and behavior, the most characteristic sympthat of childish silliness and senseless laughter. The voluntary activity is inconsistent and lacks independence.
tom
is
At one moment patients

pearance, perform such as prowling about
are increasingly headstrong, at the

of outlandish
next as supremely tractable.

all sorts
all
They neglect their personal apand foolish deeds,
night, setting fire to buildings,
throwing stones to break windows, and travelling about without evident purpose. They may even run away and secrete
themselves, or as unexpectedly
forget
their obligations,
demand some one in marriage,

finally
and
are completely inca-
pable of
continued and
young man was

voices of evil
comprehensive employment. A found throwing stones into trees because the A student ran from his spirits annoyed him.
mates to a graveyard and covered himself with leaves in

order to obtain aid in committing his ivy oration. A girl of fourteen attempted to stab her lover, believing him to be
unfaithful.
young married woman
solicited intercourse
among gentlemen friends, even bringing them to her

for that purpose in the presence of her
home
husband and
children.
The
patients are very often seen to converse with themselves, sometimes aloud, while associated with this there is
almost always
silly
prominent and symptom. It is unrestrained, on all occasions without the least provocation, and appears
altogether without emotional significance. Besides these actions, mannerisms, such as peculiarities of speech and
is
laughter. characteristic
This
silly
laughter
is
a very
DEMENTIA PILECOX
237
movements, eating and walking, are often present. A few of the mannerisms characteristic of the catatonic may prevail: echolalia, echopraxia, stereotyped expressions and
movements.
The speech presents peculiarities indicative of looseness Their remarks may of thought and confusion of ideas.
be
artificial,
containing
many
stilted phrases, stale witti-
The incisms, foreign expressions, and obsolete words. coherence of thought becomes most evident in their long drawn out sentences, in which there is total disregard for grammatical structure. The structure changes frequently, and there are many senseless interpolations. All this becomes even more apparent in their letters, which are verbose with frequent repetitions, while the handwriting is characterized by a marked lack or a superfluity of punctuation marks, shading of letters,
and copious underlining.
During the onset of the disease Physical Symptoms. the condition of general nutrition suffers. There is a loss
of weight,
is
and some patients even become emaciated.
The
appetite strained by
Patients eat sparingly or not at all, repoor. suspicion and fear, or because they are so directed
by God.' The sleep also is much disturbed, both by anxiety and distressing dreams. The pupils are occasionally dilated. The tendon reflexes may be exaggerated, and vasomotor disturbances may be present. The skin loses its normal healthy appearance, becoming dry and flaccid. The menses Later in the course of the disease cease or become irregular. the appetite returns and often becomes excessive. At this time the weight often rises rapidly, and the emaciated condition is frequently replaced by great corpulence. The menses also reappear and remain normal, and the evidences of muscular and nervous irritability disappear. Course. The course of the disease in the hebephrenic
238

is
form
characterized by
all sorts
of variations.
Suitable
treatment during the active stages at the onset usually
But there develops later produces some improvement. a condition of uniform dementia, which may be permanent,
or interrupted by repeated exacerbations. Occasionally there develop conditions of pronounced excitement with
mischievousness, talkativeness, clownish behavior, laughing, giggling, a tendency to sexual acts, and senseless wandering
about.
In other cases there develop profound clouding,
with impulsiveness, greater incoherence of thought, dancing, smearing, destructiveness, and assaults. These conditions
are usually of short duration. They may recur suddenly and without warning. The degree of mental defect increases from year to year, more especially following the transitory
periods of excitement. Of the cases that are admitted to insane institutions, about seventy-five per cent, reach a profound degree of deteriare dull, indolent, apathetic, to apprehend the surroundings. anergic, sluggish, They remain seated for hours wherever placed, are incapable
oration.
These
patients
and
fail
of caring for themselves, are untidy, have to be dressed
and
undressed, and led to meals. At table they are slovenly, spattering and smearing themselves with food. They give
little evidence of voluntary activity. They seldom speak, are unproductive and mute; occasionally they may be seen to laugh sillily or repeat to themselves some unintelligible
but
word or
syllable.
is
Their attention
for a short time.
attracted with difficulty and held only External objects usually fail to make an
impression upon them.
prehended,
seldom
Questions are apparently uncomexciting intelligible answers. These
are usually monosyllabic
and
irrelevant.
Simple directions,
Relatives
however,
may
be correctly carried out.
and
ac-
DEMENTIA PILECOX
quaintances
historical
239
may
not be recognized.
Bits of former knowl-
edge are retained in lems in arithmetic.
many
cases for a long time, such as
and geographical facts and the ability to solve prob-
In this respect the patients often surone. One of patients was able to name the islands prise of the Pacific and give the names of their sovereigns. Another, who for two years had been mute, unable to care
my
through the day with bowed unmindful of his surroundings, recognized head, entirely a college mate, straightened up with an air of dignity, and laughed at some college jokes. In the course of time even
for himself, untidy, sitting
such
relics of
left
nothing
former mental activity disappear, and we have but the unproductive vegetative organism.
A few patients retain some remnants of mental activity,

they are quite unbalanced,
of hallucinations
silly,
but
and present the
residuals
and
delusions.
Instead of the extreme
stupidity and indolence

talkative,
some patients continue restless and an incoherent babble with silly laughter. producing
During the periods of transitory excitement these patients are very apt to be aggressive, breaking windows and attacking fellow-patients, to masturbate shamelessly, pull out their
hair,
it
and frequently show homicidal tendencies.
Usually
requires several years before the patients reach this stage In cases with an acute onset it may appear of dementia.
within a year. In about seventeen per cent, of the cases the degree of deterioration is not as far advanced. These patients, after the
subsidence of the more acute symptoms, show a certain amount of mental activity and are capable of some employ-
ment under supervision. They are oriented and have a certain amount of insight into their mental incapacity, but lack mental energy and the power of application. They
have
little interest
in the surroundings,
no care for their
240

livelihood,
own
tented to live
to present
and no thought for the future, but are conand be cared for. In conduct they are apt
is weak and memory defective. Imporbe retained, together with school knowl-
many mannerisms.
The judgment
tant events
edge, but
may memory
is
for events subsequent to the onset of the
psychosis
very poor, while they are quite incapable of
The hallucinations and acquiring additional knowledge. delusions of the various stages of the disease for the most
part entirely disappear. While retained in a few cases, they are of little importance to the patients, rarely influencing
As in the other grades of dementia, so here, a tendency for the deterioration to increase as the patients advance in age. This is especially noticeable foltheir behavior.
there
is
lowing short periods of excitement, which are apt to be coincident with menstruation. At these times the patients
and sometimes violence, with a reappearance of former delusions and hallucinations, talkativeness, silly behavior, and incapacity for employment. The delusions are more apt to be expansive, changeable, and incoherent, but at times there may be verbigeration and repetition of single phrases. The
restlessness,
show motor
with great
irritability
actions are usually purposeless.
few of these cases leave the institution apparently recovered, but upon reaching home the patients fail to employ themselves profitably. They spend much time in reading,
evolving impractical schemes, and pondering over abstract and useless questions. Or, if employed, they show a lack
of interest, are unbalanced, and unable to advance in their Later their field of thought beprofession or occupation.
comes more circumscribed and their relations with the

outside world correspondingly meagre. They become seclusive and so much disinterested in intellectual work that
DEMENTIA PILECOX
241
they pass their time in purely machine-like action, engaged

in gardening or transcribing. Finally in about eight per cent, of the cases the
symptoms
of the disease entirely disappear, leaving the patients apparently
in their normal condition.
Not
all of
these cases should be
regarded as perfect recoveries, because in some instances there have been recurrences in later life, followed by deterioration.
In
still
other cases there has been a stunting of mental depatients have been unable to realize their Young men and women whose academic or
velopment. ambition.
The
collegiate courses
have been interrupted by the psychosis
find themselves unable to enter into active business or professional

life. These patients are able to care for a farm or a small business where there is little demand for in-
In this way we lose sight of the mental shipwreck following dementia prsecox, because enough mental capacity is retained to permit them to maintain the
tellectual
work.
battle of life in their chosen
narrow
field.
CATATONIC FORM (Catalonia)
The catatonic form of dementia prsecox is especially characterized by stuporous states with negativism, hypersuggestibility,
and uniform muscular
tension;
excited states
with stereotypy and impulsiveness; leading in most cases, with or without remissions, to mental deterioration. This form
comprises in our experience about eighteen per cent, of the entire group of dementia prsecox.
Pathological Anatomy. Alzheimer, in fatal cases of acute delirium which he believed belonged to catatonia,
has described profound changes in the cortical neurones of the deeper layers. The nucleus was much swollen, its
membrane
wrinkled, and the cell body shrunken, with a tendency to disappear. In the glia there was an increase of
242
fibres

which fastened about the
cell in
a peculiar manner.
Nissl, in all prolonged cases of catatonia, has demonstrated
extensive changes in the cells, which vary considerably in degree as well as kind. Even in cases where there appeared to be no atrophy in the cortex, he found a number of cells
which had undergone degeneration. In the deeper layers of the cortex very large glia cells were found which normally Elsewhere the cortex appear only in the outer layers.
contained glia
cells
with slightly stained
cell
bodies
and
large pale nuclei with small vesicles, which were in close approximation to the degenerated nerve cells, not only at
body, like the satellite cells, but also surrounding it. This pathological lesion and the type of glia cells are not peculiar to catatonia, but they are found to
the base of the
cell
a striking degree in the deeper cortical layers in this disease. The onset of the psychosis is usually Symptomatology.
subacute, with a condition of mental depression quite The similar to that observed in the hebephrenic form. patients for several weeks before the onset may have ap-
peared unusually quiet, serious, or even anxious, complaining of difficulty of thought, of headache, or of peculiar sensations in the head. Besides this, they may have suffered
from insomnia and
loss of appetite,
and have
left their
work
because of nervousness and general ill health. Gradually the patients show great anxiety, and express fear of impendTheir religious emotions become more promiand hallucinations and delusions appear. A voice nent, from heaven directs them to do all sorts of things. One patient is commanded to spit to the right, and another to convert sinners. There is a vision of Christ on the cross, the Virgin Mary appears, faces are seen at the window and pictures on the wall, spirits hover about, some one speaks from the radiator, and there is music in the next room. They
ing danger.
DEMENTIA PILECOX
243
hear their children cry for help. Some one calls their name, and they hear their own thoughts. Little birds speak to
Specks of poison are detected in the food; sulphur fumes are set free about them; some one pulls at their hair,
them.
injects
The
water into their limbs, or applies electricity to them. delusions are usually of a religious nature, are inco-
herent and changeable from day to day. The patient is persecuted for his sins, a priest has come to anoint him before he dies.
is
God has
transferred
him
to heaven, where he
surrounded by angels. He no longer needs food, as Christ has forbidden him to eat. He is. eternally lost,
is
possessed of the devil, has caused destruction of the whole world; all are dead; he is surrounded by spirits, his children
are lost, the wife false, his body has been transformed into mules' hoofs, his hands into claws, his brain has been drawn
and while hung to a cross, his limbs and body have run away like molten metal. The delusions may later become expansive, though they are occasionally expansive from the The patient then believes himself transformed into onset.
off,
Christ, has all power,
can create worlds, has lived for thousands of years, possesses all knowledge, can cast out evil spirits, is a millionaire, owns railroads, etc.
During the
of
earlier stages of the disease
some
peculiarities
movement and
which may patients assume constrained attitudes, holding the arms in awkward positions, as in the form of a cross, etc., standing or walking in an awkward manner, all of which may
be symbolical of their ideas. One patient stood for hours with hands behind him and head thrown back, staring
fixedly at the ceiling,
action appear, particularly constraint, increase to a state of muscular tension. The
and another lay in the form of a cross upon the floor. In some there is a tendency to execute rhythmical movements, such as rolling the head from side
244
to side, or expectorating at stated intervals in a fixed direction.
In this period of depression the consciousness

clouded, orientation
is
is
somewhat
slightly disturbed,
do not apprehend
fail
clearly
may know that they are at
and the patients what goes on about them. They home or in an institution, but they
to appreciate the mental condition of their fellowpatients, mistake those about them for friends and acquaintances, or they claim that everything is changed and that they cannot understand the mystery of it all. Some believe
themselves translated to heaven, that they are in a or in a foreign city.
cloister,
Thought
is difficult.
is
loose and somewhat desultory and reasoning The memory for remote events is well retained
is Although the surprisingly good. be mistaken for Christ or some one else, he
and
is
impressibility
physician
may
always remembered.
are seen.
Occasionally genuine falsifications of
memory The emotional

delusions
jected,
attitude is at first quite in
accord with the
and
hallucinations.
The
patients are sad, dedistrustful,
anxious,
complaining,
irritable,
and
sometimes threatening; when interfered with, they are very apt to become violent. Occasionally sexual excitement leads to masturbation and obscenity. Later they lose their
early anxiety,
become indifferent or contented with their and the delusions are expressed without environment, emotion. Some patients are even cheerful and happy, or
ecstatic.
The disturbances in conduct and actions are very striking. The patients cease work and lie listlessly about; they laugh
without apparent reason, indulge in excesses, neglect themselves, and sometimes utter threats. Many patients pray
constantly
and devote much time
to attending church ser-
DEMENTIA PR.ECOX
vices; not
245
a few attempt suicide or assault friends or relawithout reason. tives

Following this preliminary period of the disease, which most respects is quite similar to that in the hebephrenic
in
form, the more characteristic catatonic symptoms appear; namely, the catatonic stupor and the catatonic excitement.
In at least one-third of the cases these symptoms appear at

the very onset of the disease.
The catatonic stupor is chiefly controlled by the symptoms negativism and automatism. Negativism often occurs first in the form of mutism, when the patients refuse
to speak. They begin by speaking low, breaking off in the midst of a sentence or answering in monosyllables, then
whisper unintelligibly, and finally refuse to speak Some patients in this condition may be peraltogether.
they
may
suaded to write or sing answers to questions. When addressed they remain with closed eyes or staring fixedly at some distant object, apparently paying absolutely no attention to the physician. Even shaking patients, pinching them, or prodding them with a needle fails to elicit a re-
sponse, except
when
in pain;
then the
more
closely pressed together or the

indifferently.
is
may become patients may move

lips
away
and
Further evidence of negativism

persistent resistance
seen in the obstinate
which the patients make to every attempt at handling them. They resist being put to bed and being taken out, dressing or undressing, moving forward or backward, opening the eyes or closing them. The active resistance is well demonstrated by suddenly withdrawing the hand which has been placed against the patient's forehead, when it springs forward with a jerk. The physical origin of this resistance becomes more apparent in those cases in which the desired action is only elicited by com-
246
manding the patient contrariwise. One may get a patient to open his eyes by urging him to close them tightly, to lower the hand by telling him to lift it, etc. Even the most natural impulses are resisted, as seen in their stubborn refusal to wear shoes or stockings, in the tendency to sit on the floor rather than in a chair, or to sleep under the bed and not in it, and go to the closet by the longest route. They prefer to eat another's food, and some
persist in crawling into the beds of others.
Finally the re-
fusal of food
and the retention of urine and feces are evidences

for a
of
months.
more extreme negativism. The absence of food
The former may last for week will not overcome

It is not
this disinclination to take food voluntarily.
un-
usual for this form of negativism, as well as the others, to appear and disappear suddenly. Sometimes the patients
will begin to eat
main
in
bed
if
transferred to another ward, or will regiven a different bed. The urine and feces
if
may
be retained until there

it is
is
marked
distention.
In a
few cases
There
necessary to overcome this by catheterization
and enemata.
usually associated with negativism an unusual uniformity of the muscular tension which is exhibited in several ways, especially in the extraordinary uniformity
is
by the body or its various parts. In this condition patients maintain the same position for weeks and even months. The usual position is on the back, with
rolled
of position maintained
limbs stretched out, the eyelids closed with the eyeballs upward and inward, or with the eyes open staring fixedly in the distance, the face mask-like with lips slightly
closed
same time protruded. The hands are very often clenched, as if there were permanent contractures, the fingers producing pressure marks on the palms. Plates 1 and 2 represent two stuporous catatonic patients. The
at the
and
PLATE
1.
Muscular tension
iu catatonic stupor.
DEMENTIA PILECOX
boy
rigidly
247
maintained this uncomfortable position for with his head thrown far backward, eyes tightly weeks, While in closed, and face mask-like with protruded lips. this condition he required daily feeding by nasal tube. The
maintained this same position for over four years without a known voluntary attempt to change it. The body and head are slightly bent forward with the eyes staring
directly in front of her, the lips protruded, the arms flexed, and hands so tightly clenched that cotton must be placed in the fists to prevent pressure sores.
woman
While in bed she
lies
straight upon the back with knees strongly adducted and arms drawn closely to the chest, but with the fists in the same constrained position. During this long period it has
been necessary to feed her by spoon. Others lie rolled up like a ball, with head thrown forward and knees drawn to the chin. In the extreme condition these patients may
be rolled about or
lifted
and
laid across
some
object without
is
movement, as
rigid as a piece of wood.
Muscular tension
not evenly distributed, but is most frequently seen in the hands, arms, face, and lower limbs. The gait is often influenced
by
all,
this condition,
some patients being unable to
move
at
falling rigidly to the floor
when
raised to their
feet; others walk
stiffly, with unbent knees, on tiptoes, or on the outer side of the feet with the body bent forward or
backward. The movements are usually slow and constrained.
Sometimes the counter impulses seem to be suddenly overcome and the movements become rapid.
The
less
hypersuggestibility
is
frequently in echopraxia
seen especially in catalepsy, and and echolalia, the latter of
which are usually

ical
of short duration.
In the echolalia and
echopraxia the patients simply repeat in a wholly mechan-
hear or see done in their presence.
and monotonous manner what they may happen to They imitate or mimic
248
every act of some person in their environment. Questions asked are only repeated. The condition of catalepsy is She had well seen in the patient depicted on Plate 3.
been placed in this awkward and very uncomfortable posiThe feet are tion, which she maintained until relieved.
separated,
drawn backward, and elevated so that the toes barely touch the floor; the arms are elevated and drawn backward and the head is extended as far as possible. These disturbances of the will become evident when one
;
requests the patient to protrude his tongue, in order that it may be punctured with a needle. Although he sees the
needle and comprehends that you are threatening him with it, yet upon request he shoots out his tongue without hesitation,
and
will
command
These
him.
He
repeat the experiment as often as you frowns when pricked, but is unable to
suppress the impulse released by the
apparently opposite states of negativism
command. and hyper-
suggestibility
may
stage to loud and unrestrained shouting or to incessant gives way prattle; the patients awake from the stupor and talk as if
during
the
of
pass directly from one into another stupor. Absolute silence suddenly
nothing had happened, and again in a few hours relapse into their former stuporous state. Sometimes these changes
can be brought about by mere suggestion. are quite characteristic of catatonia. Interrupting the stupor or following it,
even preceding
is
it,
Such changes
and sometimes
we have
the catatonic excitement, which
characterized
ments.
often follows the initial condition of depresrapidly sion already described. The patients suddenly leap from bed, tear their clothing, break the furniture, race about the
The and
by impulsive actions and stereotyped movecondition of excitement usually develops
room, shouting or singing, throw themselves upon the
floor,
PLATE
2.
Muscular tension
in catatonic stupor.
DEMENTIA PR.-ECOX
249
rotating the head from side to side, breathing rapidly, churning saliva in the mouth, or making a peculiar blowing
sound.
They may run about the house
for hours at
a time,
While lying striking the bed or the wall in a certain place. in bed the body may be swayed regularly back and forth,
or the bed tapped at a certain place at regular intervals In walking they are apt to assume peculiar attitudes.
One
a
patient stood for hours against the wall in the form of " the Father, the Son, and the Holy cross, repeating,
77
; another, holding his nose tightly with his hands, uttered a monotonous grunt for hours at a time. Mingled with these movements are seen numerous impulsive move-
Ghost
ments when the patients jump about from one object to another, pounding themselves, knocking their heads against the wall, wringing their hands, jumping up and down on the bed, and stamping on the floor. All of these most varied movements are carried out with great strength and recklessness,
and are
without regard for the surroundings or themselves, for the most part purposeless and impulsive. In the
midst of their ceaseless tramping about the room they may suddenly grab at the clothing of the physician or assault a fellow-patient. During this excitement the patients are
very untidy and filthy, expectorating in the food, smearing with feces and food, urinating in the bed and clothing, and evein washing themselves with urine. Sexual excite-
ment veiy often accompanies this condition. Mannerisms in facial expression and speech are especially characteristic of these catatonic states. Accompanying
speech there
is
senseless shaking
a peculiar gesticulation, winking of the eyes, and nodding of the head, and drawing of
the muscles of expression. intonation or may quiver.

scanning, rhythmical, or
The voice assumes a peculiar The manner of speech may be The content of speech explosive.
250
is
less syllables
often quite characteristic, consisting of a series of senserepeated in a fixed measure or rhyme. Words
or short sentences are likewise repeated; the words may be clipped or the last syllable drawn out. Usually these
expressions bear no relation to the trend of conversation.
One
patient,
when asked how he

I see
felt,
repeated for three

the
minutes,
"I see you, Another common
you."
is
disturbance
inconsequential
The patients react to every answering of questions. but not according to its sense. The answers question
are
generally
less
more or
irrelevant, though occasionally they have remote reference to the question as though
the desired information was avoided.
The
following
is
an
example: How do you
feel this
Did you
lady
sleep well?
"
It is a fine morning." morning? It was a cold night." Who is this
"
(indicating a nurse) ? " clothes (dressed in white).

(the
"
What
The lady with the black " is her name? Clara
Swanson"
name
of
fellow-patient).
How many
windows are there
in the
many of us are
day
of the
there in
is
room? "Three" (four). How " " the room ? Three (four). What
"September 35" (October
5).
month
it?
How much money have I here? " Two dimes " (a quarter). How much now? "Two dollar bills" (one dollar bill),
etc.
Such responses
in a medico-legal case
would be very sug-
gestive of simulation, but their apparently close relationship to negativistic states should in such cases lead one to
search for other negativistic signs.
In their voluntary speech genuine desultoriness is often seen (see example, p. 40). Neologisms, the repetition of senseless expressions, and the use of sentences that are wholly
devoid of connection are frequent, while at the same time
PLATE
3.
Cerea
flexibilitas in catatonic stupor.
1.
Catatonic writing showing verbigeration.
DEMENTIA PR^COX
251
voice.
the patient affects lisping and grunting, or speaks in a falsetto Agrammatism is sometimes present, in that the
patients
seem unable to construct sentences and use only
infinitives in speaking.
Verbigeration is also a frequent symptom in the catatonic excitement as well as in the stupor. It consists in the use of many motor expressions, the tendency to stereotypy,
and the
repetition of similar impulses.
The
patients will
repeat for hours

sions, or single
and even days at a time senseless expressyllables, usually in the same monotonous
manner, though sometimes modified by shrieking or singing them. Verbigeration is especially noticeable in the
voluntary writings of the patient, which are
striking
made
still
more
of
by
excessive underlining, shading,
and addition
symbols. Catatonic stupor often passes abruptly into catatonic excitement and vice versa. The excitement is more apt to
precede.
Sometimes one state replaces the other
for only
a few minutes or hours.
The degree
of stupor or excitement
varies considerably in individual cases.
During the stage of catatonic stupor and excitement, the is somewhat clouded, but the patients seldom lose their orientation completely. In spite of the fact that seem quite unconscious of and unable to comprehend they
consciousness
awake from a condition and give the names of those about them, telling the day and the month, and showing surprising knowledge of what has happened within their limited range of obsertheir surroundings, the patients will
of stupor
vation.
Partial insight into the conditions of stupor
and
excite-
ment
is
frequently expressed
by the
patients,
when they
refer to their peculiar acts as foolish,
but say they could not

felt
help doing them.
Others say that they
compelled to
252
until
do what was requested, that they could not remain quiet it was done, or that they are commanded by God but whatever the explanation, it is apparent that their peculiar
;
acts are distinctly impulsive

ing.
and not the outcome
of reason-
The
states exhibits
emotional attitude during these distinctly catatonic no striking disorder. They are mostly in-
different as to their delusions and conduct. Threats make no impression upon them. Provided negativistic symptoms are not present, they will not wince when threatened with a burning match or an open knife, and will not even
wink when the eye
is
approached with a needle.
Occasion-
ally there are observed changeable states of childish petulancy, irritability, or silly elation and ecstasy.
In some cases elevated temperature, varying between one hundred and one hundred and two degrees during the acute onset of the symptoms, may persist
Physical Symptoms.
for
ized
Cyanosis, dermography, and localoften occur. Convulsive attacks are also sweating encountered in a few cases, mostly at the onset. There
two or more weeks.
is
during the stage of depression. This becomes more prominent during the stupor and may reach
loss
of weight
extreme emaciation in
spite
of
forced
feeding.
Later,
sometimes
stupor, the weight rises. the stage of deterioration the patients usually beDuring come quite fleshy. During stupor the skin is cold and clammy, the heart's action slow and feeble, and the bowels
beginning
during
constipated. Course.
The usual course
in the catatonic
form
is
de-
pression and stupor, followed by excitement, passing into dementia. In a few cases the stupor is immediately fol-
lowed by dementia without the intervention of the characteristic
excitement.
Occasionally the excitement precedes
DEMENTIA PILECOX
the stupor and
disease.
253
may even appear
at the very onset of the
prominent feature in the course of the disease, which rarely appears in other forms of dementia prsecox, is the Remissions for a few days or a few hours occur remissions.
in almost all of the cases.
The consciousness
of the patients
becomes perfectly clear. They apprehend and remember events, are quiet and rational, and often express a feeling
of illness.
At
these times close observation discloses a
manner and actions, an inconsistent and a lack of full appreciation of their emotional attitude, previous condition. These brief remissions occur most frequently in the states of excitement and are both less frequent and less complete in stupor. In at least twenty
certain constraint in
per cent, of all the cases, the remissions are long enough for the patients to seem to have completely recovered. Yet, in these cases, one often detects peculiarities which indicate
that recovery
ness,
and
not complete, such as irritability, seclusiveA reforced, affected, or constrained manners.

is
lapse usually occurs within the
first five
years,
though
it
may
not come within fifteen years.

in fifty-nine per cent, of the cases is ulti-
The outcome
In these cases, mately pronounced mental deterioration. the stupor and excitement disappear and the hallucinations
and delusions become less prominent, but the patients give numerous evidences of dementia. They are stupid and indifferent, and have lost their mental activity. They are
able to comprehend simple questions, but they lack mental The memory is defective, the judgment poor, and initiative. they are unable to acquire new knowledge. They have no
regard for themselves, their personal appearance, or their future. They remain contented wherever they happen to
be,
and never express any
desires.
They
are wholly unfit
254
for intellectual
employment, as they have no idea of how to work. Upon questioning, and in a few cases voluntarily, delusions and hallucinations are expressed; the former are usually expansive but quite incoherent, and without effect
upon the conduct
of the patient.
Some
selves,
in one place
of the patients are very inactive, remaining stupidly most of the time, sometimes muttering to them-
but taking no interest in their surroundings. Other patients are active, restless, and unbalanced. In both of
these groups, and especially in the latter, we find mannerisms. The movements lack freedom, are constrained and peculiar;
the patients walk on tiptoe, along cracks, or with bent limbs, with head thrown forward and with cramped hands. The
head
is
usually held in peculiar positions.
When
sitting,
they always assume fixed positions, shaking or nodding the head at regular intervals, making a blowing noise with the
to meals only through certain doors, or perhaps backwards. The mannerisms are especially marked in dressing and at table. They may eat
lips or grunting.
They pass
with great rapidity,
filling
the
mouth
to
its fullest
extent
before swallowing. Others eat very deliberately, waiting a certain interval between mouthfuls, perhaps counting three, each bit of food being prepared and carried to the
mouth
in a certain definite
manner.
Many
patients eat
with their hands, others hold the knife and fork in some
peculiar fashion.
One
of
my
patients refused to eat unless
he had been allowed to stand on his head and crawl under

the table.
writing.
Similar mannerisms are evident in speech
and
In speech, neologisms may prevail, especially the transitory periods of excitement, when in addiduring tion there may be a genuine word- jumble.
deterioration gradually deepens, particularly following the short periods of excitement, which appear in most
The
DEMENTIA PRÊCOX
255
At these times the patients are restless, irritable, cases. and threatening, and express delusions of persecution. The speech, in addition to shouting and laughing, shows marked
confusion.
Impulsiveness also
the
destructiveness,
prominent, as seen in aggressiveness, and even homicidal

is
attempts.
In twenty-seven per cent, of the cases the dementia is of a Here the patients return to clear consciouslighter grade.
ness, are quiet
home, and in a few cases resume their former occupations. But a profound change in character has occurred; their former mental
and
orderly, able to return
vigor does not return, they are
listless, dull, and lack energy and endurance. Their judgment is defective. They are cleanly and orderly in conduct except for a few catatonic
mannerisms.
distrustful,
Some
or
silly.
of the patients are very quiet, seclusive,
self-conscious;
while others are somewhat
childish
and
These cases not infrequently present periodical attacks
of
excitement very similar to those exhibited in manic-depressive These attacks are of short duration, not more insanity.
than a few days or weeks, but the intervals vary greatly.
The
patients become loquacious, distractible, less accessible, are elated, and have a pressure of activity in which the movements are mostly purposeless, stereotyped, and characterized
These periodical attacks may not develop until after several years have elapsed. There should also be included here a series of cases in which there is a
by impulsiveness.
regular alternation between brief periods of excitement and brief intervals. In women these attacks seem to bear some
relation to the
menses (menstrual insanity). The patients begin to laugh much, to wink their eyes, and to wander about; then there suddenly develops an extremely active
excitement.
The weight
falls
rapidly,
sometimes
five
to
256
eight pounds in twenty-four hours. The improvement comes almost as rapidly, although toward the end of the attack
a slight diminution of the dazedness and activity. The patients become clear and orderly, but for a time conthere
is
tinue very quiet, apathetic, and rather stupid, and usually fail to gam an insight into their condition, although they may be able to recall several incidents of their psychosis.
is regained rapidly. These attacks may recur at intervals of one to three weeks for a long time. In the greater number of these cases the intervals become shorter,
The weight
but in either event there ultimately develops a condition of

profound dementia. About thirteen per
cent, of the cases
seem
to recover.
Some
of these patients manifest slight peculiarities in conduct
and a change
which is apparent only to those A number of these cases closely associated with them. later in life suffer from another attack, terminating in
in character
dementia.
Unfortunately,
will recover,
it
what
impossible to determine what cases cases will have long remissions or will
is
become
deteriorated.
This
much can be
said,
however,
that those with an acute development, also those in which the stupor or excitement is very pronounced, are more apt
to have a remission.
Marked improvement is not a favorable
indication, provided that with the clearing of consciousness, there is not a corresponding improvement in the emotional
attitude;
if
senseless delusions are expressed without corif
responding effect or excitement;
mannerisms and stereo-
typy persist; and
a recurrence of periods of excitement. Prolonged stupor of itself does not necesindicate deterioration, as patients have remained in sarily
finally, if
there
is
stupor from three to five years. The fatal termination of the catatonic cases usually occurs
DEMENTIA PILECOX
as the result of
culosis is
257
some intercurrent
disease, of
which tuber-
the most prominent.
PARANOID FORMS
In both the hebephrenic and catatonic forms of dementia prsecox delusions are characteristic, but they tend In the paranoid forms of the to fade within a short time.
disease,
on the other hand, delusions and usually
also hal-
lucinations persist for

of
many
years, although there are evidences
a more or
clear.
less
rapid deterioration while consciousness re-
mains
The paranoid forms, comprising twenty-two

group of dementia prsecox, consist of
per cent, of the entire
two groups of cases. First Group (dementia This group is paranoides). characterized by the persistence of numerous incoherent and changeable delusions of both a persecutory and an expansive nature associated with a moderate degree of excitement, and a rather rapidly developing dementia. The onset of the disease, as in the Symptomatology. other forms, follows a period of headache, malaise, and insomnia with a rapid loss of energy and often irritability. The patients act peculiarly, are unusually devout, seem depressed and anxious, and remain alone. Very soon they
divulge a host of delusions, almost entirely of persecution; people are watching them, intriguing against them, they are not wanted at home, former friends are talking about
them and trying to injure their reputation. These delusions are changeable and soon become fantastic. The patients claim that some extreme punishment has been inflicted upon
them, they have been shot down into the earth, have been transformed into spirits, and must undergo all sorts of torture.
are being replaced a
Their intestines have been removed by enemies and little at a time; their own heads have
258
been removed, their throats occluded, and the blood no longer circulates. They are transformed into stones, their countenances are completely altered, they cannot talk, eat, or walk like other men, etc.
Hallucinations, especially of hearing, are very prominent during this stage; fellow-men jeer at them, call them bastards, threaten
them, accuse them of horrible crimes, and
numerous slanderous telephone messages are overheard. Occasionally faces and forms are seen at night, or a crowd of men throwing stones at the window. Foul vapors may be thrown into their bedding. The patients show agitation; they are anxious, restless, quarrelsome, and emotional. They laugh, cry, and sing.
The
orientation
all
perform
In conduct, they may is not disturbed. kinds of serious and outlandish acts, attempting
and committing arson. The emotional attitude soon changes and becomes more and more exalted. At the same time the delusions become The less depressive and more expansive and fantastic. patient in spite of persecution is happy and contented, extravagant and talkative, and boasts that he has been transsuicide, assaulting persons,
formed into the Christ; others

lived
will
ascend to heaven, have
many lives, and traversed the universe. They have the talent of poets, have been nominated for President, and have represented the government at foreign courts. These delusions may become most florid, foolish, and ridicuA patient may say that he is a star, that all light and lous. darkness emanate from him; that he is the greatest inventor ever born, can create mountains, is endowed with
all
the attributes of God, can prophesy for coming ages, can talk to the people in Mars; indeed, is unlike anything that
has ever existed.

Associated with these variegated and ever changing ex-
DEMENTIA PILECOX
259
pansive delusions there are delusions of persecution almost as absurd and extreme, but expressed without corresponding emotion. Patients smilingly complain that they have
been deprived of their limbs, have been pierced with thousands of bullets, and been thrown into hell, where they were
exposed to furnace flames. Suggestions for many of these delusions may be obtained from pictures on the wall or from
reading.
The
hallucinations also
become more extreme.

daily,
Angels descend from heaven and
commune with them
God
them, the President directs their conduct, beautiful visions are displayed at night which are full of
also talks to
meaning. These patients are usually talkative and express freely Some of them fill hundreds of sheets their many delusions.
of paper trying to describe them.
At
first
they are quite
coherent, but later there is such a wealth of ideas loosely expressed that it is difficult to follow them. They wander aimlessly about from one delusion to another,
and show same ideas. Questions, however, are answered in a coherent and relevant manner. Later in the course of the disease the speech becomes more and more difficult of comprehension, because of the number of peculiar phrases and neologisms to which they attach The writings likespecial significance and freely repeat. wise become more and more unintelligible. The patients rarely possess insight into their condition. The consciousness usually becomes somewhat clouded, esfrequent repetitions of the
pecially later in the disease.
Orientation as to place is least disturbed, but people are soon mistaken and often designated as celebrated personages, and all conception of
time is lost.
Patients recognize relatives and can give a fairly
where they are. They may recall some past knowledge, but they soon become unable to use
clear statement as to
260
it

to follow long conversations. cannot apply themselves to any mental work. The
fail
in reasoning
and utterly
They
patients
feelings,
show an
exaltation of the ego with heightened
and demand
patients
they are self-conscious, with an important manner, In emotional attitude they special attention.
are almost always exalted, rarely depressed, although a few

irritability, and occasionally often in connection with the menses. Insome passion, creased sexual excitement is also common. Some patients are able to do some mechanical work, but need supervision
show restlessness, some
because of their capriciousness and fickleness.
There is very little physical disPhysical Symptoms. turbance except the loss of weight and insomnia at the onset, faulty nutrition,
and
occasionally increased vasomotor
irritability
Course.
with easy blushing and blanching. The course is progressive without remissions.
The
signs of mental deterioration
may appear
within a few
months, and are usually well marked by the end of two years. The patients may for a long time retain clear consciousness and partial orientation, but the content of thought becomes thoroughly incoherent and there is a lack of energy and plan in their activity, which incapacitates them for all mental application. While active and somewhat interested
display a self-conscious From this stage of dementia there may be no serenity. further progress for a number of years. Occasionally transitory exacerbations of excitement or depression occur.
in
their
environment, they
still
Finally there may be periods when the patients disclaim their delusions and refer to them as foolishness, but at the
same time they do not regain

Second Group.
clear insight.
is provisionally grouped here a which are characterized by fantastic delusions usually accompanied by numerous hallucinations
There
larger series of cases
DEMENTIA PRÊCOX
261
which are more coherently developed and expressed for a number of years, when they either become incomprehensible or dis-
appear
altogether, leaving the patients in
a condition
of
mod-
erate dementia.
Symptomatology.
The
first
symptoms
those of despondency with some
to appear are self-accusation. The pa-
tients are troubled with thoughts of
death and religious
vice.
doubts; they are unusually devout, and seek religious adThey fear that they have done wrong, have committed
some
crime, or are suffering the penalty of self-abuse. Coherent delusions of persecution develop gradually; people watch them, peculiar actions are noticed, acquaintances
are less friendly, and children on the street jeer and laugh at them, perhaps mimicking their manners. Strangers on the street turn and stare. In public places, in the cars, and
at the church, they observe peculiar acts which refer to them. They believe themselves libelled by the newspapers. They
understand these mysterious occurrences and
will shortly
Affairs at expose the offenders and bring them to justice. home are unsatisfactory; the children are different, and the
husband or wife
is
unfaithful.
Hallucinations) especially of hearing, rarely of sight, are prominent at this time, aiding in the elaboration of the
Enemies take advantage of their confinement by standing below the window, calling them all sorts of names,
delusions.
announcing that they are to be imprisoned, that they have committed murder, and are to be put to the rack. Voices
are heard from the walls
and from under the floor, stating that they are wretches and outcasts of society. Very often the noises really heard, such as the blowing of whistles and
the ringing of
delusions.
bells,
They
are misinterpreted in accord with their complain that the food contains poison
which they can
taste,
they suspect phosphorus in the tea
262

clothing.
and detect kerosene on the
They
notice that
their clothing is changed, buttons are missing, there is a rip in the coat and a pocket torn. Objects in their surround-
ings are changed in order to confuse them.
Delusions of physical influence become particularly prominent. Many common somatic sensations, such as twitching of individual muscles, headache, specks before the eyes,
pain about the heart, and cramp in the bowels are all evidences of such influences wielded by their enemies. The
explanations of these somatic sensations are often most An itching of the foot is sufficient evidence fantastic.
that a poisonous powder has been blown into their shoes, pain in the back indicates that they have been shot there
while asleep, a frontal headache is the result of poisonous vapors, which are set free in the room at night in order to A tremor of the fingers is prodestroy their intellect.
duced by means of electric currents sent through the air. Something is placed in their food to create sexual
excitement.
Their persecutors employ the most varied means in pro-
ducing physical discomfort.
All
known
agencies are men-
tioned, as, magnetism, hypnotism, X-rays, telepathy, and electricity. Organs of the body are removed and then re-
placed out of order, and the intestines are shrunken. It is quite characteristic for the patients to refer to these physical changes by some invented names, such as, ugly duberty,
Others complain that their minds are influenced, their thoughts are gone, they have no control over their thoughts, which, in spite of themselves,
snicking, lobster cracking, etc.
are always to others.
evil.
attribute the origin of such thoughts " Frequently they complain of drawing of the
They
thoughts," and they may say that they don't know whether their thoughts are their own or suggested by some one else.
DEMENTIA PILECOX
Sometimes
especially their thoughts
263
become audible (double thought),

Their thoughts are
when
reading.
known
to the
whole world.
Ideas of spirit-possession are often a prominent feature. Here the enemy enters and takes possession of the body,
causing the bones to crack and the head to rattle; obscene remarks proceed from the stomach; their ears are filled by
all
sorts of noises
made by
fall
cause the testicles to
and
these spirit-possessors. the throat to dry up.
They
In connection with the delusions of influence there develops in almost

sive delusions.
all cases more and more pronounced expanThese are as variegated and fantastic as persecution. The patients have been awarded a
those of
prize for bravery

dresses,
and now
rule the country, possess beautiful
and are betrothed to the king, etc. God daily appears to them and gives them a blessing. They have
recently been intrusted with millions which they are to invest in mining. They have consummated an immense
which they are president. All of the many delusions expressed by the patients are at first coherent, and may be partially systematized; but in the course of a few years, they tend to become somewhat incoherent, and at the same time
trust, of
the hallucinations become more agreeable. The consciousness during the development of these delusions,
and
clear,
for a long time afterward, perhaps years, re-
mains
able at
and the patients are

to offer to
oriented.
Thought
is
coherent, but centers about the delusions.

first
The patients
are
objections,
ideas; as deterioration appears gradually in the course of several years, thought becomes confused, and the delusions
and
some basis for the delusions, to show some " method " in their
refute
but
later,
incoherent, contradictory, and changeable. There is rarely insight into the disease. Many patients appreciate that they
264

and ailments are rather
are not normal, but their defects
regarded as the work of their persecutors. The emotional attitude is at first one of depression, with anxiety and combativeness, but later this gives way to a
certain
amount
of happiness
and
cheerfulness, with con-
There may be transitory outbreaks of siderable egoism. In some cases stuporous anxiety as well as of irritability.
states
have been observed.

conduct
is
The
mostly in accord with the delusions; the
patients are suspicious, journeying about to get rid of their enemies, applying to police for protection; or, taking the
matter in their
or attempt to
own hands, they attack supposed persecutors Others for expose them through the papers.
armor
for themselves, place
self-protection contrive a sort of
metals in their shoes or wires in their clothing to divert the In accord with expansive delusions electrical currents, etc.
they may decorate themselves in fantastic costumes, adorn themselves with badges, assume a superior air, and use highflown language.
Furthermore, during the course of the disease peculiarities of conduct develop, such as, grimacing, striking gesticulations,
mannerisms in
eating, walking,
and speaking, as
well as signs of negativism or of stereotypy. Course. The duration of the disease extends through many years. It is sometimes possible to discern certain
stages in its development: at first a change of disposition, then a prominence of delusions of persecution, later the appearance of delusions of grandeur, indicating the onset
of deterioration, of
collapse
may
occur.
away and entire the delusions. Remissions in the symptoms The outcome is always deterioration. The
and
finally the
fading
rapidity with which the dementia develops varies greatly. Usually some signs of dementia appear within two or three
DEMENTIA PILECOX
years.
265
other hand, there are cases which deteriorate within a few months, and there are others which do not
On the
fade, are never exare forgotten or wholly denied, and at the same pressed, time there appears some insight. But in all these cases
dement for a number of years. In some cases the delusions gradually
there
still
remains some impairment of
memory and
judg-
ment, apathy, and a

activity.
energy and Or the delusions and hallucinations may be reloss of the characteristic
tained, while the patients become quite indifferent to them, rarely complain of persecutions or show agitation. They are usually capable of employment, and sometimes
and
" " are even industrious, the former Pope becoming a trusted " " farm-hand, and the queen a good seamstress.
More frequently the outcome
is
characterized
by an
in-
creasing confusion of thought, when the delusions become more and more incoherent and unintelligible, while the
peculiarities of
conduct increase with a tendency to occaIf the detesional states of excitement and impulsiveness.
rioration advances further, the patients of silly, quiet dementia.
may
reach a stage
There are not only no pathognomic signs of dementia prsecox, but even some of the more characteristic signs of the disease, such as, negativism,
automatism, stereotypy, and mannerism, occur in other
eases; for instance, paresis, senile
dis-
Diagnosis of dementia praecox.
and other organic psychoses, as well as in some of the infection psychoses, and even hi manic-depressive and epileptic insanity. Hence the diagnosis must rest on the entire picture and not upon any single
symptom.
cesses
is
may
While it is possible that different disease proexhibit at times similar groups of symptoms, it
altogether improbable that these
same
diseases will at
all
times resemble each other, both as regards the manner
266
in
which the symptoms develop, their course, and their outcome. The slowly developing cases of hebephrenia must be distinguished from acquired neurasthenia. This differentia-
tion depends especially

tia,
upon the presence
of signs of
demen-
the
silliness
of the hypochondriacal ideas,
especially
sexual hypochondria, faulty judgment, emotional apathy, and the fact that the patients do not improve with quiet and
relaxation.
The emotional apathy of the hebephrenic stands out in contrast to the increased emotional irritability of the neurastheniac. Finally, any evidences of hallucinaof
tions,
automatism,
or
stereotypy
distinctly
indicate
dementia praecox
(see also p. 155).
dementia praecox, occurring in middle life, from paresis in which the physical symptoms have not yet appeared, may be quite difficult. The catatonic
differentiation of
The
symptoms that
occasionally occur in paresis catalepsy, and stereotypy are by no means mutism, verbigeration, as varied and characteristic as in catatonia; while the general
incapacity and genuine weakness of will is more prominent in contrast to the eccentricities and the unruliness of the
catatonic.
is
Furthermore, the mental deterioration in paresis
apt to be more rapid and more profound and character-
by greater disorder of the apprehension, orientation, and impressibility of memory, while these faculties in comparison with the emotional stupidity and the weakness of judgment in dementia praecox are retained for a relatively long
ized
time, although they may be temporarily overpowered by negativism. The appearance of definite hallucinations and of
persistent
dementia praecox. The speech disturbances of the paretic may be closely simulated by the mannerisms of dementia prsecox; even epileptiform
mannerisms speaks
for
and apoplectiform attacks may occur
in dementia praecox.
DEMENTIA PR^COX
267
In such doubtful cases one must depend upon the lymphocytosis in the cerebrospinal fluid as determined by lumbar puncture
and the microscopic examination
of the
fluid
(see p. 103).
In the acutely developing cases of dementia praecox, the

clouding of consciousness and the confusion of speech often render it difficult to distinguish amentia. Here one must
depend upon the presence of negativism, stereotypy, and

present in amentia, they are not marked. In amentia, the patients are more natural in their The acts, less constrained, and not silly and eccentric. of memory is far more disorientation and impressibility
automatism.
If the latter are
turbed in amentia than in dementia praecox. The amentia patient, in spite of his best efforts, is unable to solve long
mental problems, loses the thread in long conversations, and indulges in incoherent reminiscences, yet he is able to answer
some questions rapidly and to the point.
On the other hand,
the dementia prsecox patient answers in a silly manner or perhaps not at all. Again at times he surprises one by
his correct conversation,
or he even solves
historical
and his thoughtful, bright remarks, a difficult problem and recalls correctly
facts.
and geographical
is
In amentia the emotional
attitude
altation
and
exceedingly changeable from depression to exvice versa, while in dementia praecox, even
during excitement, a certain emotional stolidity and apathy The amentia patient may not have a very accuprevails.
rate knowledge of the surroundings, yet he attends to and watches what takes place ; but in dementia praecox the patient exhibits remarkably little interest in those things
that he comprehends well.
Finally, in
amentia there
is
always a history of some exhausting etiological factor, which only occasionally antedates dementia prsecox.
Beginning cases of catatonia
may be mistaken
for epileptic
268
befogged states, particularly when an epileptiform attack has occurred. The negativism of the catatonic contrasts with
the anxious resistance of the epileptic, while orientation is much more disturbed in the epileptic. Silly answers to
simple questions and rapid and correct obedience to commands speaks for catatonic. In epileptics an anxious or
ecstatic emotional attitude prevails.
more apt to make frequent assaults while the impulsive acts of the catatonic are purposeless and manneristic.
The epileptic is much and attempts at escape,
The
greatest difficulty arises in distinguishing the depresinsanity from the periods which one encounters at the onset of the hebe-
sive phases of manic-depressive
of depression
phrenic and the catatonic forms.

hallucinations
The
early appearance of
many delusions, especially ideas of physical influence, and the retention of a clear consciousness speak for dementia prsecox, as well as an emotional attitude which does not correspond to the depressive
senseless
and
character of the delusions.
The
catatonic patient remains
quite indifferent during the visit of a relative, while in manicdepressive depression the feelings are apt to be intensified. Hypersuggestibility of the will may exist in both conditions,
but a manic-depressive patient will not upon request protrude his tongue for the purpose of having it perforated with a needle. The uniform lamentations that sometimes occur
in manic-depressive
depression are the expressions of a

feeling of sadness,
persistent
and overwhelming
and not
the result of a senseless persevering impulse. The conditions of negativism of the catatonic and of anxious resist-
ance and retardation of the manic-depressive are at times distinguished only with difficulty. In the former there is
uniform, rigid, and stubborn resistance to every passive movement, and if pain is produced by pricking the eyelid,
DEMENTIA PR^COX
there
is
269
a simple withdrawal without effort at defence; while in retardation the passive movements are mostly permitted. In case the retarded patient shows some resistance
he does not persist in returning his hand to the same position, and if one threatens to approach him he utters an outcry,
shrinks back, or defends himself. Voluntary movements in catatonic stupor are rare, but when executed are carried
out without delay, and at times even rapidly, except when these movements are made by request, then there is always
In retardation, all voluntary movements are carried out very slowly. There is sometimes a certain resistance
delay.
due to apprehension and fear, but this is active. The differentiation between manic-stupor and catatonic
stupor
istic
is
quite difficult
and depends upon the characterdistractibility of the attention
happy temperament,
by the environment, the susceptibility to command, the accessibility to conversation, and finally the occasional
purposeful and frolicsome character of the movements of manic-stupor in contrast to the silliness, indifference, insusceptibility,
and the
senseless impulses of the catatonic
stupor.
The excitement
from
of the catatonic
is
to be distinguished
of manic-depressive
the excitement of the
manic phases
In the catatonic excitement the clouding of coninsanity. sciousness is less marked than in the manic excitement,
the patients being partially oriented, even in the greatest excitement, while in the extreme manic states there is the catatonic
complete disorientation. On the other hand, the speech of who has less motor excitement is more senseless
difficult to follow
and
than that of the manic who has ex-
treme motor excitement.
The
catatonic speech abounds in
verbigerations and stereotyped expressions and is free of comments upon the surroundings, while the speech of the manic
270
presents the characteristic flight of ideas, and is centered upon, or drawn largely from, the immediate surroundings.
Also attention
readily distracted by the surroundings, while the attention of the catatonic cannot be. The emois
tional attitude of
the manic
is
exalted, frolicsome,
is
and
irritable, while that of the catatonic
silly,
childishly
happy, and
indifferent.
The movements
of the catatonic
are purposeless, frequently repeated, in contrast to the pressure of activity of the manic, in whom the movements are
always purposeful, related to the surroundings, dependent upon ideas, impressions, and emotions, and always appearing In catatonia there is no parallel between the in new forms.
excitement in speech and that in movement; for instance, the patient may be extremely productive, lying quietly in
bed, or he
may be
The increased
of the
extremely active and not utter a word. activity of the catatonic is more apt to be
room or of the bed, while that limited only by his confines, and in addition to this the individual movements of the catatonic tend to be
limited to one corner of the
manic
is
manneristic, stilted, unnatural, and associated with silly impulses; those of the manic, natural and more comprehensible.
The extreme
excitement of the paretic
may
resemble closely
the catatonic excitement.
In addition to the history of the
development of the disease, the age, and the physical signs, paresis may be recognized by the more profound clouding
of consciousness, the greater disorientation, of the impressibility of
and disorder
memory.
where there have been hysfrequently be differentiated from
latter fails to
Dementia
terical
prsecox, especially
attacks,
hysterical ness, the
must The insanity.
show the
desultori-
weakness of judgment, the indifferent emotional
attitude,
and the
similarity
and purposelessness
in the con-
DEMENTIA PILECOX
271
duct of the dementia prsecox patient. All of these symptoms stand in contrast to the shrewdness, capriciousness,
slyness,
and the purposeful obstinacy of the hysteric. Finally, pronounced hallucinations and delusions favor dementia prsecox. But there is still a large number of cases, which present at the outset clear symptoms of hysteria, but which later show unmistakable evidence of the deterioration of dementia prsecox. The very same condition may exist in manic-depressive insanity, in epilepsy, in paresis, and in brain tumor, which would favor
keenness, tyranny,
the view that in constitutionally defective individuals the early stages of these diseases may resemble very closely
the picture of hysteria. The distinction of the paranoid forms of dementia prsecox from pure paranoia depends upon the lack of system, the
rapid development of fantastic delusions commencing with prominent hallucinations; while in paranoia the onset is
very gradual, sometimes extending over one year with only a few hallucinations. The delusions in dementia prsecox
are extremely fantastic, changing beyond all reason, with an absence of system and a failure to harmonize them with
furthermore, the delusions of physvery prominent. In paranoia the delusions are largely confined to morbid interpretations of real events, are woven together into a coherent whole, gradually
life;
events of their past
ical influence are
becoming extended to include even events of recent date, while contradictions and objections are apprehended and In emotional attitude the dementia prsecox explained.
patients soon show clear and marked changes, depression or silly elation, sexual excitement, and remissions; while in paranoia the emotional attitude is uniformly natural,
the
demeanor
of
is
almost
capable
occupation
for
normal, and the patients are In paranoia a long time.
272
there
less

be partial remissions when the patients react actively to the delusions, but the delusions never
may
disappear. In the absence of history of the early
life
and
of the psy-
chosis, imbecility may be confused with the end stages of dementia prsecox. The recognition of dementia praecox
then depends upon the presence of exacerbations in which dementia praecox signs appear and occasional utterances
which evince extensive

Treatment.
earlier
knowledge.
of the causes of
Our meagre knowledge
the disease restricts the indications for treatment to the

individual symptoms. The cases which develop acutely or subacutely demand careful watching in order to prevent
suicidal attempts. Unless this can be with the aid of a sufficient nursing force at accomplished home, it is best that the patient be sent to a hospital. Cases
self-injuries
and
form with gradual onset can be much more safely cared for at home. At the onset in all forms of the disease the patient must be placed in a quiet and restful environment, free from all irritating circumstances,
of the hebephrenic
and
in the charge,
if
possible, of a judicious nurse.
It is
usually advisable that the patient should not be in charge of a member of the family. In the acute and subacute
cases,
bed treatment should be regularly prescribed.
The insomnia is best combated by the simplest measures, as

hot baths upon retiring, warm liquid nourishment, or the hot or cold pack. If the patient does not secure six or seven hours sleep by the simple remedies, one may resort on alternate nights to sparing doses of some hypnotic, as, trional, veronal, somnos, chloral, or paraldehyde. These drugs
should not be given for long periods without being alternated. Conditions of excitement are always best controlled by the
prolonged warm bath (see p. 140), at
first
preceded by a pre-
DEMENTIA PILECOX
273
to -$ grain, or liminary dose of hyoscine hydrobromate in the same dosage. The extreme scopalamine hydrobromid
-^
excitement sometimes encountered, especially in the catatonic

form, may not yield to the prolonged warm bath, in which event one can often successfully employ hot or cold packs
(see
p. 321).
These
packs,
however,
are
not
applied
risk, and usually require the supervision of a physician. But in the employment of any sedative it must be borne in mind that the remedy is not curative, and, therefore, it is not advisable to employ high doses in order
without some
to wholly curb the excitement.
If it
seems essential to
secure quiet where these other measures have failed, one may occasionally resort to a hypodermic of hyoscine hydro-
bromate
-L^J-Q
ment
in a
is
still
with morphine sulphate J grain. If the exciteunabated, nothing remains but confinement
padded room with careful watching. Simple persuasion on the part of a well-trained, tactful nurse or physician often
succeeds in bringing about quiet, at least temporarily; but this requires great patience, a kindly disposition, and selfcontrol.
While the condition of nutrition demands careful attenit becomes parthe stuporous states. The patient ticularly urgent during should eat a liberal quantity of easily digested food. In
tion during the early stages of the disease,
order to estimate the state of nutrition such cases should
be regularly weighed at least once a week. During stupor with refusal of food, the patient should not be permitted
to go without food and water for more than three days. If the patient is illy nourished, one should resort to feeding by stomach or nasal tube at the end of thirty-six hours.
The patient may be fed artificially two or three times daily, the total amount aggregating two quarts of milk with six raw eggs, and, if need be, an ounce of olive oil, varying
T
274
quantities
of

meat
juice,
and stimulants,
particularly
whiskey.
The excretory
functions
must be
daily watched, particu-
larly during the stuporous states, when patients retain the feces and urine. During the acute manifestations of the
frequent high flushings of the lower bowel with normal saline solution are well recommended.
disease,
During the periods of despondency at the onset of the disease, in addition to the bed treatment already referred
to,
the patient should be given an opportunity at times during each day to leave the bed for short periods and exercise.
Furthermore, simple methods of occupying the mind, at the same time affording some diversion, as, reading, playshould be a part of the daily routine. Friendly encouragement, with a frank discussion of the various delusions and hallucinations, persistently
ing games, needlework,
etc.,
carried out by a kindly and tactful nurse and physician, is not the least important feature of the treatment, and must not be overlooked.
As the more acute symptoms improve and the

increased activity subsides, the patient may to leave the bed for longer periods, but at the
fear
and
then be allowed
same time the
graduated exercise and mental application should be increased. The whole effort of the physician should then
be directed to developing remaining mental capacity and preventing further mental defect. This requires a considerable
in
amount
of specialized attention in the individual cases
order to prescribe means that at the same time are adapted to the patients' needs and traits and also are
suited to their environment.
sufficiently
Very many patients improve

able
to
so
that
they are
liberty.
return
to
their
homes or to their full must not overlook the
But
possibility of exacerbations,
in advising this, one and in
DEMENTIA PILECOX
275
women
the possibility of pregnancy, and the resumption of
excessively
burdensome home
of
cares.
advanced grades
surveillance.
deterioration
The cases exhibiting must be kept under

care of these
An
essential feature of the

is
mental shipwrecks
of doors.
healthful employment, preferably out
VI.
DEMENTIA PARALYTICA
(Paresis)
DEMENTIA PARALYTICA/
a chronic psychosis
or general paresis of the insane, is
of middle age, characterized by progressive mental deterioration with symptoms of excitation of the central nervous system, leading to absolute dementia and paralysis,
and
pathologically, by
a fairly
definite series of organic changes
in the brain and spinal cord, probably the result of some toxin, in the origin of which syphilis is most often an important
factor.
Etiology.
ilized
is most Europe and North America, hence, it seems to be a disease of modern civilization. In America, the disease comprises
The nations and
disease
is
unknown among the
unciv-
prevalent in western
from
per cent, of the admissions to insane institutions, but in some European cities, notably Berlin and Munich, the paretics average thirty-six to forty-five per
five to eight
The disease is somewhat more prevalent in large cities and manufacturing centers, while it is relatively rare in farming communities. The procent, of the
male admissions.
Voisin, TraitS de la paralysie gSneYale des alie'ne's, 1879 ; Mendel, Die Mickle, General Paralysis of the progressive Paralyse der Irren, 1880. Insane, 2. ed. 1886. v. Krafft-Ebing, Nothnagels spezielle Pathologic u. Therapie, Bd. IX, 2, 1894. Ilberg, Volkmanns klinische Vortrage, 161 ;
Binswanger, Deutsche Klinik, VI,

2
2, 59,
1901.
Diefendorf, Brit. Med. Jour., No. 2387, p. 744.
f.
Psy.,
XXVI,
3.
2.
Gudden, ebenda.
v.
Wollenberg, Archiv. Krafft-Ebing, Jahrb. f. Psy.,

.
XIII, 2 u.
Psy., 1900.
XIV,
321.
Oebecke, Allgem. Zeitschr. f Psy., XL. Hirschl, Jahrb. f. Bar, Die Paralyse in Stephansfeld, Diss., Strassburg,
276
DEMENTIA PARALYTICA
277
portion of male to female paretics is 1 to 3.9 to 7. This disproportion has recently gradually decreased. Negresses show
a striking tendency to the disease; in Connecticut, the negress paretics are ten times more prevalent than the female white paretics. Women suffer more often from the
depressive form and least often from the agitated form, and in them the disease lasts longer. Our average age of onset
hundred and seventy-two cases is forty-two years. Kraepelin in two hundred and forty-nine cases finds that it occurs preeminently in middle life, as eighty-one per cent, of the cases occur between thirty and fifty years, the disease
in one
rarely appearing
of age.
The
before twenty-five or after fifty-five years average age of onset in our women was two years
younger than in men, and one-third of the women became afflicted between thirty and thirty-five, while one-fourth of
the cases occurred after
finds that the onset in
fifty years.
women
Kraepelin, however, averages later. In our ex-
perience,
the onset
is
earlier in syphilitic
and
alcoholic
Our natives are slightly more prone to paresis than our foreign-born. l * Recently a number of cases of juvenile paresis have been reported occurring between the ages of ten to twenty years in which hereditary paresis, syphilis, and alcoholism are
prominent
acterized
Clinically, the juvenile form is chardeterioration of three to four years' duraby simple tion with numerous paralytic attacks, choreic disturbances,
women.
factors.
and paralyses. The disease afflicts

1
chiefly the unmarried,
and among the

De
la paralysie
Alzheimer, Allgem. Zeitschr.

v.
f.
Psy., LII, 3.
Thiry,
progressive dans le jeune age, 1898.
1901, 21.
Rad, Archiv
Frolich,
f.
Psy.,
XXX,
Hirschl, 82.
Wiener Klin. Wochenschr.,

Mingazzini, Monatsschr.
f.
Psy., Ill, 53.
Uber allgemeine progressive Paralyse der Irren
vor Abschluss der koerperlichen Entwicklung, Diss., 1901.
278
women especially prostitutes; in our experience prostitutes are forty-five per cent, more prone to the disease than other women. Married women are usually childless. Not infrequently the disease occurs in man and wife; sometimes tabes is present in one and dementia paralytica in the other and paresis occasionally exists in the parents. The male
paretics come from all classes and from most professions and trades, though the disease is more prevalent among hotel and saloon keepers, quarrymen, carriage and hack drivers, bakers, sailors, hostlers, mechanics, masons, salesmen, and clerks, and least prevalent among farmers, servants, and
comparatively insignificant, except in juvenile paresis, as it occurs in only

factory employees.
is
Defective heredity
per cent, of cases. Among the causes of the disease, syphilis is statistically the most prominent. Its prevalence varies, according to
fifty
various authors, from one and six- tenths per cent, to ninetythree per cent., but most observers place it between thirty-
In our experience it existed in fifty-two per cent. Gudden in the Charite, and Kraepelin at Heidelberg cannot establish a clear history of syphilis in
four
sixty-five per cent.
and
more than thirty-four per
cent, of
male
paretics.
In other
but five and five-tenths per psychoses, we cent, of the cases. Therefore, there seems to be some relabetween syphilis and paresis, a view which receives tionship
find syphilis in
further support not only by the experiments cited by KrafftEbing, in which nine paretics inoculated with syphilis failed
to develop secondary syphilic lesions, but also
by the
clinical
observation that paretics infected with syphilis during the This latter is disease do not show secondary manifestations.
now doubted by Marchand, Gabiana, and Garbini, who have

reported seven cases in which paretics developed syphilis. Other apparently significant facts are the infrequency of
DEMENTIA PARALYTICA
paresis in
its
279
women
of the better classes
frequency
among
wife.
prostitutes,
and Catholic priests, and the occurrence of pare-
Other important causes are excessive which existed in sixty per cent, of our cases, head alcoholism, injury twenty-three per cent., and mental shock. Finally, a
sis in
man and
factor which cannot be overlooked

life
is
the ensemble of modern

insufficient relaxation,
with
its restless
overactivity and
coincident with the struggle for existence in large cities, and the common excesses in eating and drinking. In view of the uniform course of the disease Pathology.
leading to dementia and nervous paralysis, accompanied by a general and extensive destructive process, involving not
only the central nervous system, but also the general vascular system, and to a limited extent the internal organs of the
seems probable that we have to do with a toxic process. There exist symptoms of excitation of the neurones,
body,
it
their rapid destruction, gradual sclerosis, occasional exacer-
bations of the symptoms, and the possibility of a regeneration of the neurones, all of which can be reproduced by experimentation upon test animals with any toxic material
which causes a destruction

cal facts are
of the neurones.
These anatomi-
wholly in accord with the clinical observations ; the gradual onset, great clouding of consciousness, namely, rapid or gradual deterioration, and marked remissions, some
which almost approach complete recovery. The vascular and the broad extent of the process indicates that the toxin reaches the neurone by means of the blood vessels. The involvement of the kidneys, heart, and the entire vascular
of
lesions
system, the fragility of the bones, the alternate loss and increase of the body weight, ending at last in great emaciation, all speak for the profound general disturbance of
nutrition of which the mental are obviously the
most
severe,
but not the only symptoms.
280

elevation of temperature, as well
The sudden and high
as the prolonged subnormal temperature,
and
finally the
paralytic attacks, judging from our experience in eclampsia, myxedema, and uremia, can best be explained by intoxicaViewed in tion arising from disturbance of metabolism.
this light, the
pathology of paresis resembles that of myxe-
dema, diabetes, osteomalacia, and acromegaly, except that in

these diseases the toxin does not involve the nervous tissue.
The character
of the toxin
and the sources from which
it
arises are questions still in doubt. sole cause of paresis, as long as it
Syphilis cannot be the does not exist in more than
thirty-four to sixty-five per cent, of the cases.

paresis,
Furthermore,
anatomically, is not a simple syphilitic process. the late manifestations of syphilis arise within a comAgain paratively short time after primary symptoms, while paresis
does not develop until ten or more years have elapsed after the initial lesion. Taking into consideration all of these
facts,
the only acceptable view
is
that in a considerable
number
of cases syphilis somehow produces a profound change metabolism which in turn gives rise to a toxin, which secondof ary product is the direct cause of the pathological changes char-
Other apparent etiological factors, as, alcohol, head injury, lead, and excesses, may bear a similar causal relation to this disturbance of metabolism.
acteristic of
dementia paralytica.
The pathological changes here Pathological Anatomy. enumerated can, as a whole, be regarded as pathognomic of this disease. Hyperostoses and exostoses of the cranium
with, but more especially without, thickening of the tables, are occasionally present. The dura is usually adherent to
the
1
calvarium
in
places.
Pachymeningitis
;
interna
.
and
215.
f. Psy., IV, 413 Allgem. Zeitschr. f Psy., LX, Nacke, ebenda, LVII, 619. Cramer, Handbuch der pathol. Anatomie des Nervensystems von Flatau-Jacobsohn-Minor, 1470, 1903.
Nissl, Monatsschr.
DEMENTIA PARALYTICA
hematoma
are
281
is
common.
The
false
membrane
almost
always situated on the vertex over the frontal, parietal, or
temporal lobes, and is of varying thickness, from a thin, almost imperceptible rust-colored membrane, to a thick,
firm, white
membrane, with small or
large, fresh or partially
absorbed
clots.
The pia is thickened, whitish, and translucent along the vessels, and especially over the vertex of the frontal and parietal lobes and the first three temporal convolutions, and rarely over the occipital lobes. The internal surfaces of the frontal poles are often adherent. The leptomeningitis is always more intense over the poles of the frontal lobes. The Pacchionian granulations are usually increased in size. The pia over the atrophied convolutions and broadened The confissures often contains blebs filled with serum.
volutions are atrophied, especially in the frontal lobes.
In
these portions the cortex is narrow and often strongly adherent to the pia, tearing upon its removal. In the other portions of the cortex, and in the basal ganglia, the atrophy
is
much
less
marked.
The
ventricles are dilated,
and the
t
choroid plexuses may contain many cysts. The ependyma especially of the fourth ventricle, and the inner walls of the
which give the usual surfaces a frosted appearance. These granulaglistening tions are composed of an increase of neuroglia, which in
lateral ventricles, present granulations,
many
cases
^has
undergone
hyaline
degeneration.
weight of the brain is regularly below normal, and in cases of long duration may be reduced to nine hundred
The some
grammes.
to thirteen
The average weight

hundred grammes.
1
is
eleven hundred
and
sixty
Microscopically,
1
nerve
cell
changes of varying intensity
Binswanger, Die Pathologische Histologie der GrosshirnrindenErkrankungen bei der allgemeinen progressive!! Paralyse, 1893. Nissl,
282

None
of these cell changes are
are found in the cortex.
pathognomonic
for paresis.
Many,
especially the acute alter-
ation (see Plate 4, Figure 2), apparently represent a destructive process, while in others, as, for instance, the chronic
change
cell
sclerosis
(see
Plate
4,
Figure
5),
the
cell
may persist for some time. Furthermore, in cells giving evidence of sclerosis, there may also appear evidences of a
grave alteration (see Plate 4, Figure 3) apparently leads to absolute destruction of the cell. Undoubtedly also the acute and the chronic changes
superimposed acute change.
The
can terminate in a destruction of the
cell.
Of
all
the
cell
changes only the acute alteration involves uniformly the entire cortex. Both the extent and the intensity of the
destructive processes are apt to vary. There is least involvement of the occipital lobe, especially in the calcarine
area,
and
central.
of the central convolutions, particularly the preFurthermore, in a disease area, normal cells may
be found lying side by side with altered cells. In all cases there is involvement of the greater portion of the cortex, but
only in the severe or prolonged cases are all of the cortical cells diseased. The nerve fibres in the cortex and corona
suffer
atrophy in proportion to the extent of the degenera-
tion in the cortical neurones.
Where the
clinical course
has been prolonged and the neurones are much degenerated there remain but a very few normal fibres. Similar destruction of the nerve fibres
may be found in senile dementia

it is
and
epileptic insanity,
but
not as far advanced as in
As the
result of the degeneration of the nerve cells

is
and
their processes, there
an atrophy
of the cortex,
its
extreme cases
may
shrink to one-half
which in normal width.

f.
Archiv f. Psy., Bd. 28, S. 989. Bd. 53, S. 172.
Heilbronner, Allgem. Zeitschr.
Psy.,
FIG. 3
FIG. 1
FIG. 2
FIG. 6
Fig. 1
Acute alteration in dementia paralarge pyramidal cell. Fig. 2 Plasma cells Grave alteration in dementia paralytica. Fig. 4 Fig. 3 crowded about a vessel in dementia paralytica. Fig. 5 Chronic cell change in
Normal
lytica.
Fig. G
Rod-shaped
cell in
DEMENTIA PARALYTICA
This degeneration
283
may be more marked about
the vessels.
are no longer arranged uniformly, but are turned in all directions, either closely pressed together, as seen in Figure 3, Plate 5, or surrounded by areas comcells
The remaining
walls.
posed only of sclerotic tissue and vessels with thickened Figure 3 should be compared with the normal cortex
2.
as represented in Figure
characteristic of paresis.
The
This anatomical picture is most cell changes already described

all
may
be found in other conditions, but in none do
the
elements of the cortex suffer to such a profound degree as here. In senile dementia, idiocy, and even in dementia
prsecox,
many
cells
and
fibres are destroyed,
but the general
conformation of the remaining elements is undisturbed. This distortion with the presence of scar tissue is present to a recognizable extent in dementia paralytica, even when the
process is not far advanced. In the areas of degeneration there may be a considerable increase in the neuroglia tissue, in which spider cells take a
prominent part, appearing especially in the deeper cell This great layers of the cortex and about blood vessels.
increase of spider cells may be seen in Figures 5 and 6, Plate 5, in comparison with Figure 4, which represents the neuroglia present in the normal cortex. The increase in
neuroglia does not necessarily correspond to the destruction of nerve cells, as normal nerve cells are often surrounded
by considerable
areas
all
neuroglia, and,
cells
the nerve
may
on the other hand, in some have disappeared without an
appreciable increase of the neuroglia. Vascular lesions in the cortex form a prominent part in the microscopical picture. The vessels are increased in
number and their walls thickened, as may be seen in Plate 5, Figure 3. Some of the vessels are dilated, a few totally obliterated, and others show small aneurisms; but the
284

is
characteristic feature of this vascular change
the
infiltra-
tion of the perilymph spaces with ordinary
lymph
cells
and
particularly plasma cells (see Plate 4, Figure 4), the latter of which may be regarded as distinctive of paresis, since they are
Furthermore, the rarely found in other disease processes. of these cells stands in rather definite relationship prevalence
to the extent of the disease process. in the acute stages of the disease
They are most prevalent and later may disappear.

is
Another form of
cell first
cell,
distinctive of paresis,
4,
the rod-shaped
Figure 6). The cell is long and narrow, sometimes curved, with a clear nucleus and one or more nucleoli. These cells are found in large
described by Nissl (see Plate
in proximity to blood vessels and lying to the long axis of the large nerve cells. parallel In addition to the finer microscopic changes in the cortex, one occasionally finds small areas of softening, which are
numbers mostly
discernible
by the readiness with which
either the superficial
layers of the cortex or the entire cortex are detached
from
the white matter.
expect countered.
others
*
to
Gross focal lesions, such as one might accompany paralytic attacks, are rarely en-
On the other hand, Lissauer, Starlinger, and have pointed out that in the cases with circum-
scribed paralyses, hemianopsia, word blindness, and aphasia there really are present corresponding definite circumscribed disease areas in the cortex with recognizable
secondary degeneration in the corona, basal ganglia, pons,
and cord. The basal
and cerebellum also present degeneration of the nerve cells and fibre tracts. Weigert has demonstrated an increase of neuroglia in the
ganglia, central gray matter,
granular layer of the cerebellum, with a destruction of the Purkinje cells and their processes. The cranial nerve nuclei
1
Starlinger, Monatsschr.
f.
Psy., VII, 1; Storch, ebenda, IX, 401.
MU
^-lSlill
.'V -;;'
V-.V
:--'". .V ..'";*.*-o,
;.>:-. -V.a?--"
,v r
FIG. 1
FIG. G
FIG. 4
Normal cerebral cortex. Fig. 3 CereCerebral cortex in idiocy. Fig. 2 Fig. 1 Glia in normal cerebral cortex. bral cortex in dementia paralytica. Fig. 4 Glosis with presence of spider cells in cortex in dementia paralytica. Fig. 5 Showing the relation of spider cells with vessel walls in deep layers of Fig. (5
cerebral cortex in dementia paralytica.
DEMENTIA PARALYTICA
of the medulla
cortical cells.
285
show
l
similar changes to those seen in the
is involved to a greater or less extent in the most important lesion being degeneraalmost tion of the fibre tracts in the posterior and lateral columns.
The
spinal cord
all cases,
Degenerative changes are occasionally found in the peIn the internal organs vascular changes ripheral nerves. are so frequently found that they seem to bear a definite
Of these, atheroma of relationship to the disease process. the aorta and arteritis of the vessels of the liver and kidneys
are the most prominent.
Symptomatology.
From
the onset of the disease there
is
increasing difficulty of apprehension of external impressions. Patients are unable to grasp clearly and sharply the char-
acter of the environment.
to recognize former well-known objects,
Later they mistake persons, fail and overlook im-
portant details. Attention is maintained with effort. Long and complicated sentences are not comprehended, and they often miss the connection of things. Customary duties are performed with difficulty and often incorrectly. Thus, there
develops a clouding of consciousness; the patients live a dreamy existence, as if constantly under the influence of liquor.
an important diagnostic sign. Later the disorientation increases. The patients may answer questions quite correctly and upon superficial examination seem to conduct themselves in accord with their environment ; but at the same time they neither know where they are, with whom they are speaking, nor the significance of what is
This condition of torpor
is
taking place about them. They fail to recognize the season or the time of day. A patient may say that it is summer
Westphal, Allgem. Zeitschr. f. Psy., Bd. 20-21. Westphal, Archiv H. I., Bd. 12. Westphal, Virchow's Archiv, Bd. 39. Fuestner, Archiv f. Psy., Bd. 24. 1.
Psy.,
1
f.
286
while leaning

upon a hot radiator and looking out upon a
This condition
finally reaches
snow-covered landscape.
of absolute disorientation,
one
when
the patients cannot perceive
any external impressions. At the onset of the disease there is usually an increase of The patients tire easily at their acthe sense of fatigue. customed duties and require more frequent and longer Hallucinations play an unimportant part. periods of rest. In the greater number of cases none appear, but in some cases there exist for some time very many hallucinations of
or elaborate
all senses.
Again the
clinical picture
of the acute alcoholic hallucinosis.
be very like that Hallucinations of sight
may
Hallucinaare often present in patients with optic atrophy. tions of touch in connection with delusions of influence are
not infrequent.
memory are very characteristic and are the most prominent of the mental symptoms. The among memory at first becomes defective for recent and passing
defects of
The
events.
This defect
is
the patients,
for
who complain
it.
sometimes keenly appreciated by of and sometimes devise means
correcting
defective.
Later,
memory becomes
is
more
The memory
progressively especially defective in the
temporal arrangement of experience, and the patients fail to recall the time of the occurrence of events. They cannot
inform you when the mail arrived, when they had breakfast, or when they last saw you. These patients may live so
completely in the present moment that they may ask several times a day where they are, how long they have been there, or if they have ever seen you before. The early events of
life
are comparatively well retained for some time, the patients being able to tell of their occupation, former places
of residence,
and events
of their childhood.
This remote
also the
memory
also suffers late in the disease,
and here
DEMENTIA PARALYTICA
time element
is
287
the
first
to be affected.
Dates of marriage,
for-
births of children,
and important events are completely
gotten.
of
and even the names

memory, when
forgotten,
Finally they are unable to recall the place of birth of their parents and children. Lapses
may
definite periods of time are completely occur following epileptiform or apoplecti-
form
seizures.
store of ideas
The
terminating in a complete destruction of all the
undergoes a progressive impoverishment, mental
The rapidity of this process varies with the possessions. of the disease and the power of resistance as well intensity
as the intelligence of the individual. The more intelligent resist longer, and the most frequented paths of thought are retained longest. As memory fails, its place in the intellectual
life is
often
made good by
reminiscences
enters the
disappear,
the imagination. As real invention runs riot. Whatever
mind is related as genuine; stories, or what may have been told them by another, become a part of their own experience. The patient relates that he was in a terrible
railroad accident last night, in which a dozen were killed;
he led the troops at San Juan; yesterday he had a conference with the British ambassador. He has captured a hundred beautiful women from a Turkish harem, and discovered a
new and
inexpensive motive power for automobiles. These dreamlike fabrications are most pronounced in cases of optic atrophy. Very often such fabrications are used in
the gaps in recent memory. They can be brought out and influenced by suggestion on the part of the listener.
filling in
The
all
patient may be somewhat dubious at first when expressthese absurd reminiscences, but at the next interview ing
doubt
will
memory
to
have disappeared. external influences

of
is
This susceptibility of the a part of the general

Their ideas
susceptibility
thought of the patients.
288

and
fail
are never firmly grounded,
to exert a lasting influ-
ence upon their thoughts and actions. Any accidental impulse suffices to distract and lead them into another
channel.
Impairment of judgment is another very prominent symptom. It may be the first to call attention to the disease.
Objects of former criticism
The former conservative

business
life
to arouse comment. which have made their principles

fail
now
a success are
lost sight of,
unity and system.

senseless
Weighty
obstacles are overlooked
and new plans lack and

Business
schemes produced with perfect serenity.
and
standards are completely disregarded. Their conceptions have no bearing upon the environment, but center almost entirely about themselves, so that they come
social
to live in a sort of
upon
sions,
their
own
ideas
dream world, in which everything depends and wishes. The formation of deluresults
which partially
from
varies
much
in different cases.
this defect of judgment, In some there are but few
delusions, but in most cases the delusions form a prominent feature in the early stages of the disease. These delusions are transitory, unstable, without system, and show confusion
and incoherence. They are characterized by vagaries, senseIt only lessness, numerous variations, and contradictions.
rarely stable
It is
happens that for short periods the delusions are and uniform like those of paranoia.
not unusual at the onset for the patients to express some insight into their mental disease, complaining of their
failing
memory,
irritability,
and increasing
difficulty of
thought.
Later, with increasing deterioration, all genuine The patients then usually exhibit a feelinsight disappears.
ing of well-being; they claim that they never felt stronger or more vigorous mentally. At times during the course of
the disease the patients
may make various hypochondriacal
DEMENTIA PARALYTICA
289
complaints, but even then they fail to recognize the real physical symptoms of the disease.
The emotional
first
life
shows a profound disturbance.
At
The patients are is usually increased irritability. disturbed at home and work, are sullen, peevish, and easily apt to show considerable passion at trifling annoyances, and
there
completely lose control of themselves.
they
may
the other hand, show an unusual insensibility to the claims

to
On
of others, indicative of the deterioration of the finer feelings.
They then
fail
show sympathy at the
suffering of their
children, are indifferent to immoral surroundings, and do not take their wonted pleasure in reading or professional
pursuits.
The emotional
attitude
it is
is
much
in accord with the char-
acter of the delusions;
elated with expansive, or dejected with depressing delusions. Later the emotional tone becomes very unstable, and there are frequent and abrupt
changes.
In the midst of laughter they

tears, or misery
may break
out in
a storm of
These changes of emotion
be brought by simple sugor by raising or lowering the tone of voice, or even gestions
may may
give
way
to silly happiness.
by the expression
of the face.
complaining that he had lost all blood and could not breathe, when tickled in the ribs and
patient lying on the floor, his organs, that he had no
asked
how he
felt,
feeling fine;
come
" I am exclaimed, beginning to laugh, and see me again/' In the demented
forms of the disease, where there may be only a few delusions, no especial emotions are shown, the patients being in a condition of simple joy or irritable dissatisfaction most of
the time.
There
stability
is
a profound change
will
of disposition;
the former
to progres-
and independence
of action give
way
sive
weakness of the
power.
The
patients
become very
290
tractable,

but occasionally
may
be extremely stubborn.
Early in the disease they are led to indulge in all sorts of excesses and sometimes persuaded to deed away property.
angered and determined to commit an assault upon some one, they may be easily influenced to desist by a simple
suggestion.
When
window
patient about to leap from a third-story because of fear, was readily prevented by the sugit
gestion that
would be better to go down and jump up. Any impulse that arises may be acted upon without referaccomplishment. One patient is said to have stepped out from a second-story window for the purpose of picking up a cigar stump.
ence to the extreme difficulty of
its
of
In conduct, the patients show a disregard for the demands custom and law, are unconstrained, and often commit
grave offences into which they have no insight. As a reason for such conduct, they often say that they acted so because
it
happened to come into their minds. The social restraints normally imposed upon one by the environment
never interfere with the carrying out of their wishes.

are quite reckless of personal safety,
They
injure
and occasionally
themselves severely in their foolhardy actions. In conditions of great clouding of consciousness or in advanced
deterioration there are sometimes present some symptoms characteristic of the catatonic form of dementia prsecox,
such as catalepsy, verbigeration, negativism, and stereotyped movements; but these are transitory and change more readily and frequently than in catatonia.
Physical Symptoms.
in both the
The
physical signs of the disease,
motor and the sensory fields, are as extensive and profound as the psychical. These may appear either before the mental symptoms or not until dementia has become well advanced; usually they are coincident. Of the sensory symptoms, headache is often the first to
DEMENTIA PARALYTICA
291
appear, accompanied by a feeling of pressure as if the head were being held in a vice, together with ringing in the ears and dizziness. The special senses at first give evidence of
excitation,
which
later subsides into a state of insensibility
corresponding closely in degree to the stage of deterioration. Some patients have difficulty in the recognition and localization of objects held before them, which by Fuerstner is ascribed to involvement of the occipital cortex. Word blindness and asymbolism are often observed. Hemiaattacks.
nopsia occasionally follows apoplectiform or epileptiform Optic atrophy is found in five to twelve per cent,
of the cases.
Disturbances of the senses of taste and smell

loss of the
have also been observed by some, especially the

sense of taste for saline solutions.
The disturbance
of the
cutaneous sensations
is
quite often prominent; at
first
there
uncomfortable sensations, burning or drawing sensations, rheumatic pains, etc. Hence, many patients are for a long time regarded as neurastheniacs. In
may be
all sorts of
an increased sensitiveness to cold. Later analgesia appears, which may be so pronounced that needles
some
cases there
is
through a limb without pain. Finally, the patients may pull out their hair, disturb an open wound, draw out their toe-nails, and persist in mangling
can be thrust
entirely
their
own
flesh.
Of the motor symptoms paralytic attacks, mostly epileptiform or apoplectiform, are very important, occurring in from forty-six to sixty per cent, of cases. The attacks may
only of a transitory dizziness with perhaps an inability to speak. Attacks of this sort are often the first symptoms to call attention to the disease.
be very
light, consisting
Occasionally the attack consists of a suddenly developing
aphasia lasting several days, unaccompanied by paralysis. In the epileptiform attacks, which may be either of the
292
Jacksonian or of the ordinary type, confusion or stupidity may usher in the attacks, which begin with a fall to the
floor,
loss
of
usually Clonic movements predominate and are often synchronous with the pulse. Convulsive movements may be confined to
in
consciousness, and convulsive movements, one limb, extending gradually to the others.
a single group of muscles or to one limb. The duration of the attack is from one to several hours, but sometimes
clonic
movements
of varying intensity continue in
one or
more limbs
cus,
daily,
for days.
condition similar to status epilepti-
where there are from twenty to one hundred attacks
persist for days, often terminating in death. the attacks the temperature is often febrile, the During urine frequently contains albumen, and there may be reten-
may
and feces, as well as paralysis of the muscles of The fatal termination is usually due to aspiradeglutition. tion pneumonia. The attacks pass off slowly, sometimes
tion of urine
leaving the patients in a condition of confusion. In the earlier stages of the psychosis, these attacks leave the
more profound deterioration, and sometimes also with signs of transient aphasia, hemiplegia,
patients in a condition of
hemianopsia, convulsive movements, or areas of anaesthesia. Apopkctiform attacks often occur, and may be the first
important sign of the disease.
In these attacks there
is
the usual loss of consciousness and stertorous breathing, with occasional high elevation of temperature, accompanied
by hemiplegia and aphasia.

loss
In some attacks there
is
no
of
consciousness,
transitory paralysis.
similarly appear;
simply the sudden appearance of Transitory sensory disturbances can

paraesthesias, anaesthesias, or
as, severe
defects of vision.
It is a distinguishing feature of these
apoplectiform attacks that the paralysis disappears quickly and without evident residuals. Other somewhat similar
DEMENTIA PARALYTICA
293
attacks, occurring in the course of the disease, are those in which there is a sudden development of extreme confusion,
with motor restlessness,
difficult speech, flushing of
the face
and body, vomiting, and high temperature. These last from a few hours to a few days and pass away quickly, leaving the
patient in his former state. The frequency of the apoplectiform and epileptifonn attacks depends somewhat upon the character of the treat-
ment.
cesses
They may result from emotional disturbances, exin eating, and especially from an accumulation of feces
appear without evident
hi the rectum, but they frequently
Bed treatment, regularly, reduces then- frequency. occur most often hi the demented form of the disease. They Motor disturbances of the eye include transitory paralysis
cause.
of single muscles (eighteen per cent, of the cases) and rarely complete ophthalmoplegia. Differences of the pupil occur
in
about fifty-seven to eighty-three per cent, of the immobile pupils in from thirty-four to sixty-eight per
sluggish reaction to light hi thirty-five
cases,
cent.,
and
and
five-tenths
per cent. (Argyll-Robertson pupil).
The musdes of the face lose their tone, the nasolabial fold and other lines of expression disappear, and the countenance becomes expressionless. This washed-out, expressionless
well represented by the group of three paretics seen hi Plate 6. Lack of tone in the muscular system is also seen in their slouching and inelastic
is
character of the countenance
attitude.
There
is
also a loss of control of the muscles,
giving rise to
incoodination, noticeable mostly
when the
mouth or
muscles
is
eyes are forcibly opened.
fine
tremor of these
almost always present. The voice loses its characteristic tone and becomes monotonous. Tremor of the
tongue, which
retractive, is
either finely fibrillary or coarse and a constant sign. In advanced cases there is
may be
294
often a rolling of the tongue about the mouth as if it were a quid. This in some cases has been explained by the presence
of areas of anaesthesia in the of the teeth
is
occasionally
mucous membrane. Gritting associated with these movements
of the tongue, or
may be present alone. Disturbances of speech are among the most characteristic
They are
either aphasic or articulatory. often appears after paralytic attacks. Transitory aphasia Paraphasia, which may appear at the same time, is more per-
symptoms.
and sometimes lasts several months. Word blindness and word deafness are rarely encountered. There is occasistent
sionally
agrammatism, as seen
in the misuse of infinitives
of conjunctions. There may be an elision of as in the use of elexity for electricity, or a redusyllables, plication of syllables, as electricicity, and finally there may
and omission
be tendency to repeat
syllables,
forming a genuine word
clonus, as Massachusetts-etts-etts-etts.
Disturbances of articulation are more frequent. They may follow paralytic attacks, but more often occur in-
dependently of them.
As the
result of difficulty in
move-
ment of the lips and tongue frequent pauses are made between syllables or words and when hesitating speech accompanied by a fall in the tone of voice produce a scanning speech. Gliding over the poorly articulated sounds gives rise to an indistinct and slurring speech. These difficulties
lead to the substitution of words or syllables similar in sound but more easily pronounced, or to the elision of difficult syllables.
Many
patients, in their efforts to
overcome
The
these difficulties, stutter and produce an explosive speech. patients often appreciate the difficulties of speech, but
are ready to explain them by dryness of the mouth or loss of teeth. Speech disturbances are readily observed in ordinary conversation. The test words and phrases, if used,
DEMENTIA PARALYTICA
295
attention
should be introduced into long sentences, because, if the is concentrated upon single words, they may be pronounced correctly. Words and phrases used for this
purpose are: electricity, national intelligency, methodist episcopal, ninth riding Massachusetts artillery brigade, etc.
The
elicited
central
and ataxic speech disturbances are best
by asking the patients to read aloud. Writing usually shows defects similar to those noticed in speech, but they are proportionately more prominent (Plates 7 and 8). Patients, on the other hand, who speak clearly may produce on paper an unintelligible muddle of words and syllables. In advanced cases there is complete agraphia (Plate 7, Figures 2 and 3). The patients are then able to make but a few unintelligible marks, and may even give up without making
a
sign.
The handwriting
is
characterized
by
irregularities
caused by the tremor, excessive pressure on the pen, and carelessness. The irregularities are more extensive than in
the case of the senile, whose lines regular tremor.
show the
effect of
fine
Ataxia appears
delicate
first
of all in those finer
movements such
Later the more
as are employed by skilled workmen.
movements in locomotion, such as turning about quickly, become ataxic. The clothing cannot be readily buttoned, the gait becomes unsteady, swaying and shuffling.
In from sixteen to twenty-four per cent, of the cases of paresis there are tabetic signs; such as, loss of reflexes,
ataxia,
Romberg
sign, paralysis of the
rectum and bladder,
and occasionally
girdle symptoms, lancinating pains, and crises. In from six to eight per cent, of cases, genuine tabes antedates for several years the appearance of the paretic
symptoms (ascending
1
1 paresis or tabo-paresis).
In about
die spinalen
Cotton, Amer. Jour, of Insanity, Vol. 61, p. 581. Gaupp, Uber Symptome der progressiven Paralyse, 1898. Torkel, Besteht
296
fourteen per cent, of the cases of paresis there are evidences of involvement of the lateral column of the cord, as shown
by the spastic paralyses. In many cases spastic and tabetic symptoms are variously combined. Intention tremor may be present, and in a few cases choreiform movements are marked enough to simulate Huntingdon's chorea. Later in the course of the disease the patients become bedridden and often develop contractures and muscular atrophy. The body also tends to assume a curved position with a fixed tension of the muscles of the neck so that the head is thrown forward and the body does not rest upon the bed throughout
its
entire length.
During
this stage of
the disease
is occasionally noticed convulsive movements of the individual muscle groups, especially during active and pas-
there
sive
movements, but also when the muscles are at
rest.
1
pressure of the spinal fluid, according to Schaefer, is increased in two-thirds of the cases from normal (40 to
The
70 millimetres) to 150-380 millimetres.

finds that the
Furthermore, he
albumen is increased and contains serum albumin, while the normal fluid contains only globulin. The microscopical examination of fluid shows a lymphocytosis
(see p. 103).
The tendon
reflexes are usually exaggerated,
sometimes so markedly that the entire body shakes when the tendon is struck. Frequently the exaggeration diminishes,
twenty to thirty per cent, of the advanced cases the reflexes are lost. In eighteen per cent, of the cases there is
in
and
a difference in the two sides.

is
The
loss of the patellar reflexes
Babinski reflex
usually associated with immobile pupils and myosis. The is often elicited in connection with spastic
eine gesetzmassige Verschiedenheit in Verlaufsart und Dauer d. progressiven Paralyse nach d. Charakter d. begleitenden Rmaffektion ? Diss., Marburg, 1903.
1
Schaefer, Allgem. Zeitschr.
f.
Psy.,
LIX,
84.
ft
FIG.
Fia. 2
PLATE
Fig. 1 shows, besides the excessive pressure elision, substitution of letters and syllables. The patient has attempted to write from dictation, " Around the rugged rock the ragged rascal ran."
Figs. 2
patients, after an attempt to write, simply laid the pen
and 3 represent conditions which approach complete agraphia, down.
in
which the
DEMENTIA PARALYTICA
symptoms.
creased at
297
The
electrical irritability of the
muscles
is in-
Disturbances of the first, but later diminished. bladder are often present, both retention and incontinence,
the latter usually being the result of the former. Sluggishness of the bowels may extend to obstinate constipation.
Finally in the end stages there is paralysis of both sphincters. The sexual power may be increased at the onset, but later The vasomotor disturbances consist of it is diminished.
erythema, persistent blushing of the skin, rush of blood to the head, dermographia, and cyanosis. The so-called trophic changes, acute decubitus, increased fragility of the ribs,
and othematoma, stand in close relation to the vasomotor changes, and are of frequent occurrence. Furthermore, there is a loss of vitality and of the power of repair in all tissues, so that a very trifling injury may lead to an extensive
lesion.
Acute decubitus once started
is difficult
to heal.
temperature during the course of the disease is mostly normal, except toward the end, when it is apt to be sub-
The
normal.
striking peculiarity
is
the excessive elevation of
trifling disturbances, such as mild bronoverdistention of the bladder, or obstinate constipachitis, There is often a rise of temperature during paralytic tion.
temperature with
attacks,
as already mentioned, there may be short periods of a few hours or more of an excessively high temperature apparently without adequate cause.
and
finally,
The sleep is usually somewhat disturbed during the first stage and more so during the second, where there is motor
excitement, but in the last stage the patients are sluggish and may sleep much of the time. This varies, however, as
in
some
cases the patients
may, from the onset, show a
tendency to sleep continually, while in other cases insomnia The appetite suffers persists throughout the whole course. at first and during excitement, but later the patients eat
298
well.
The condition of nutrition is poor until excitement subsides and deterioration is well advanced, when there is
usually an increase in weight, which
may
last until death.
loss of appetite and impaired nutrition coexist, to extreme emaciation. leading Occasionally albumen and l sugar are present in the urine. The blood changes consist
Sometimes
moderate and progressive anaemia, in which the fall in haemoglobin is most marked, a progressive increase of the
of a
polymorphoneuclear leucocytes reaching its highest point during the terminal state, and a transitory leucocytosis
accompanying paralytic attacks. D'Abundo has called 2 attention to an increased toxicity of the blood, and Idelsohn
finds that the blood of paretics in a considerable proportion
of cases inhibits or prevents the
growth of cultures of
bacteria.
The mental and physical symptoms enumerated above represent in general the clinical picture. The grouping of
the individual symptoms, however, varies widely in different This has led to the recognition of four types of cases cases.
:
the demented, expansive, agitated, and depressive, each of
which presents a somewhat different course from the onset. The deviations from these types deter many from the
acceptance of this differentiation, but its value becomes apparent in a considerable number of cases where one is
able to forecast the future duration of the disease
and the
character of
many
of the
symptoms.
The demented form, because of the simple deterioration, unaccompanied by many delusions and hallucinations, its rapid course without remissions, and the relative frequency
of its occurrence should be regarded as the type of the
Diefendorf, Amer. Jour. Med. Amer. Jour. Med. Sc., 1897.
2 1
Sciences, Vol. 126, p. 1047.

640,
Capps,
Tdelsohn, Archiv f . Psy.,
XXXI,
^
TS -3
9 a
ii
DEMENTIA PARALYTICA
disease.
299
The
clinical picture of
megalomania, which has
been and
until
it is
still is,
disease, has in
by some, regarded as the prototype of the recent years become less and less prominent,
in less
now encountered
than twenty-five per cent,
of cases.
DEMENTED FORM
The demented farm
is characterized
by gradually progres-
sive mental deterioration without

tions, delusions, or great
prominence of either hallucina-
psychomotor disturbance. Transitory periods of delirious excitement, of anxious unrest with hypochondriacal ideas of depression, delusional states, or periods
megalomania may occur in this picture, but they are insignificant when compared with the rapid advance of profound deterioration. The onset of this form is very gradual. The symptoms at
of
first
may
resemble those of neurasthenia; patients complain
of inability to apply themselves to work, loss of energy,

indefinite pains, feeling of pressure in the head,
and
irri-
tability. They are forgetful and flighty, at times drowsy, and at others somewhat confused. Soon mental deteriora-
becomes apparent in the inability to explain their actions, in errors of judgment, failure of memory, and absence of the usual moral feelings. Their work is irksome, and they occasionally fall asleep over it. They forget to
tion
go to meals, make mistakes in
figures,
and overlook im-
portant matters. They are usually good-natured, tractable, are easily led astray, and often drink to intoxication. In
some cases, however, they become obstinate and self-willed. The household suffers, dinner is uncooked or improperly Patients are seasoned, and the children are neglected. reckless and may even act in opposition to established preThe consciousness soon becomes clouded and the cepts.
300
patients
lose
fail

to thoroughly
comprehend their environment, account of time, get confused as to place, and mistake persons. They may even get confused in their own home
and not recognize
friends
and
relatives.
Transitory hallucinations and delusions may appear, but the latter are very weak, childish, arid easily influenced by
Occasionally there are weak attempts at fabrication. During the early stages there may be some anxiety with weeping and praying, and frequently also an increased
suggestion.
irritability,
some sexual excitement,
aggressiveness,
is
and
assaults; but the characteristic emotional change
a pro-
gressive deterioration of the feelings. The patients become increasingly dull and apathetic. They are perfectly con-
tented wherever placed as long as the simplest needs are satisfied; such as, food, drink, and tobacco. They have a
complacent smile when addressed, greet strangers very Often at first cordially, and are friendly with every one.
is some insight when the patients complain of slowness of thought and failure of memory, but the increasing deterioration obscures this feeble capacity. On the other
there
hand, they
may
express a feeling of well-being
and
perfect
confidence in their business capacity.

capacity for work suffers soon. The patients become careless in their duties, forget engagements, allow letters to
The
go unanswered, go to work at all hours, and finally stay away altogether. A few patients may struggle along with
their work, realizing
and worrying over
difficulties
and
fre-
quent errors, while others neglect their occupation to look after all sorts of unnecessary and unprofitable affairs. They
may become
restless,
wandering aimlessly about, indulging
in excesses or
committing petty crimes.
They lack
will
power, are easily led astray, are unable to care for themselves, forget when to go to meals, and neglect their per-
DEMENTIA PARALYTICA
sonal appearance.
301
On
inaccessible, repulsive,
and
the contrary, some patients are surly, answering questions as
if angry, rebuffing friendly advances, and opposing without reason anything desired of them.
A few patients,
in spite of
tion, present a good demeanor.
an advanced stage of They greet one
deterioracorrectly,
and appear perfectly at ease in talking about themselves, but at the same time are disoriented, and are unable to give any coherent account of their lives. The patients usually enjoy a good appetite, sleep well, and are the picture of The mental deterioration may have been so gradual health. and so unobtrusive that the friends and relatives fail to
appreciate the profound degree of deterioration exhibited.
This form of dementia paralytica embraces forty per cent, of the cases admitted to institutions. Paralytic attacks
occur in almost one-half of the cases.
frequent than
in the other forms.
Remissions are
less
half of the cases
The duration in almost does not extend beyond two years. In

first
eighteen per cent, of the cases death ensues within the year, and it is very rare that the disease lasts five years.
EXPANSIVE FORM
The expansive form

of
is characterized
by great prominence
course,
expansive delusions, a
prolonged
and
greater
prevalence of remissions. The onset is usually gradual, with change of character, difficulty of mental application, signs of failing memory and
judgment,
physical
increased
irritability,
spells,
and, in
addition,
such
dis-
signs
as fainting
transitory speech
turbances, syncopal attacks, the onset is quite sudden.
and headaches.
Occasionally
Following these prodromal symptoms, there
may
first
302
develop the picture of the depressed type with delusions of

persecution, self-accusation, and anxiety, but usually from the onset there is a condition of excitement with elation,
which transitory states of depression with weeping may occur. In case there have been signs of despondency and illness, these then disappear
and grandiose
delusions, during
deand the patients gradually occasionally suddenly a marked feeling of well-being; they are bright, velop They busy themselves affable, talkative, and energetic. with new and elaborate schemes for getting wealthy, stake out property, and draw designs for wonderful machines.
They
and
at
are busy from early morning to late at night, soliciting patronage, ordering large quantities of material for building
for other purposes.
first
are
The numerous expansive delusions within the range of possibility and may appear
attractive to the unsuspecting, but soon pass into the realm of absurd imagination, reminding one very much of the
prattle of children.
These, with the restlessness, present
the characteristic picture of megalomania. The patients claim never to have felt better in their lives, can lift tons,
can whip the best man on earth, have the strength of a thousand horses, and can move a train.
They believe their English the best; they speak as fluently several other languages; their voice is clear and distinct and can be heard for many blocks, because of its excellent
qualities.
compose
subject.
inspiration to write a book; can beautiful poems; can deliver an oration on any
They have the
associate only with the most cultured people; only the genuine blue blood courses through their veins; they are going to build a marble mansion at Newport, and
They
have a floating palace. Business is flourishing; they are " mint of money/' have several gangs of men making a for them, and still there is more work than they working
DEMENTIA PARALYTICA
303
can attend to; besides their regular business, chickens are being raised by a special method at an enormous profit;
they have secured rich gold claims in Nevada, which are doubling in wealth daily.
and
Formerly they were brakemen, but now run the fastest finest train in the world from New York to Chicago without a single stop, allowing none but millionnaires to ride;
besides a profitable law business, they are now engaged in writing a novel which will startle the world, and for which they have received priceless offers from publishers in this
country and in Europe.

ful
A ship carpenter developed wonder-
power
in a vessel
in his eyes, so that he could detect defective wood by simply standing in the hold and looking out-
ward, and for this reason he was appointed detective of a marine insurance company, and had travelled all over the
world inspecting vessels. He had become so wealthy that all the banks in the state were in his possession. A seamstress had devised a new method for cutting
dresses,
which had won her world-wide fame, having been
Europe because of her wonderful She herself could cut and sew a hundred dresses a day, and had under her five hundred girls, all of whom used gold thread. She could sew on a thousand buttons a
called to all of the courts of
success.
minute. A jockey had discovered a new way of breeding and training runners, and now from his Kentucky ranch was supplying every circuit and handicap with winners. The utter absurdities which increase from day to day are proof of the increasing mental weakness. The delusions abound in contradictions and become more incoherent, the product of a more dreamy ingenuity. The patient now
drives the largest engine in the world, drawing a thousand palace cars, all lined with gold and trimmed with pearls,
which encircles the globe every twenty-four hours, stopping
304
only at New York, San Francisco, Calcutta, Paris, and London. He now has formed a chicken trust to extend over the
system of the be employed in hatchworld, so that only the Chinese ing the eggs. Another has a most wonderful herd of cattle,
will
whole earth, and
will reconstruct the social
whose horns are forty feet high, whose eyes are diamonds, whose feet are gold, and each cow produces five hundred
milk in twenty-four hours, the patient himself milking a thousand a day.
pails of
The
patients are the most beautiful beings that ever lived.

all of
They have married seven hundred

thousand children,
dresses;
whom
millionnaires, have twenty have gold slippers and gold
they can
castle ten
they themselves wear only diamond trimmings; fly away in the air to a world where there is a
thousand miles long filled with lovely people who do nothing but amuse themselves. They are not human, but divine; can create a universe, visit all the stars, have sent Christ to Mars; whatever they touch turns to gold.
They know
all
sciences,
are the greatest physicians in
a hospital of marble twenty stories existence; high, provided with a bar for the doctors, where the choicest wines and the best Havana cigars will be supplied; and there
will build will be a dissecting room, with a huge ice box, where ten thousand bodies can be kept all the time.
They
will build
the Chinamen here to work.
a tunnel through the earth and bring all One patient said that he was
going to build towns; that he had been to Washington to see the President, that he wanted six thousand billion gunboats, one million bomb-shell boats, one million marines, and that he would cross the ocean and blow up all of the countries and bring the people out west and put them on farms; that he would blow up the Queen's buildings, and that he
would give each one
of the marines
two bags, and each
DEMENTIA PARALYTICA
would have to go two times and diamonds.
in order to bring
305
away the
silks
These delusions are almost entirely self-centered. They may change rapidly, each day new and extravagant ideas
filled with the most glaring contrathe tendency to expansiveness is less marked. Transitory hallucinations of sight and hearing are occasionally expressed, but they never take a prominent
appearing, which are

dictions.
In
women
part in the disease picture. Consciousness is somewhat clouded during the development of the megalomania. There is usually disorientation
for time, places,
and persons,
the patients are too
much
absorbed in their numerous ideas to note the surroundings or to take account of time. Later they become acquainted
with the place and a few of the persons, but they rarely know the month, day, or the year. The content of thought is
centered entirely about
self
and the many varied delusions.
At
first it is usually coherent, although at times, in connection with great psychomotor restlessness, there may be incoherence, distractibility, and sometimes flight of ideas.
The
patients are usually talkative, and may produce a continuous stream of delusions. Incoherence of thought is
their letters.
attitude corresponds closely to the content
more evident in The emotional

contented,
of the delusions; the patients are cheerful, happy, hopeful,
and
exalted.
Everything in the environment
is
pleasing; they are in luxurious quarters, have the best of food, plenty of servants, fine clothing, fast horses, and are
associated with the finest
happens that for a short time, a few moments or hours, rarely

days, they lose spirits and become depressed, complaining of confinement, and expressing hypochondriacal delusions,
men
in the world.
It often
or
weep
bitterly because of harassing persecutions.
Even
306
when most miserable it is often possible by suggestions to reestablish the feeling of well-being, showing the great instability of the
is
emotional condition.
itself
always present, manifesting
Increased irritability upon the slightest
provocation. Disagreements or doubts relative to their superiority or immense wealth may arouse anger or even an
Later in the course of the disease the aggressive attack. are usually in a uniform state of quiet cheerfulness patients
in spite of their bedridden condition with filthiness, paralysis,
and even
asked
"
contractures.
feels,
The
paretic
on
his deathbed,
when
how he
often drawls out with
some animation,
Fine, fine."
In the psychomotor field excitement predominates from the onset and may reach an extreme degree. At first the
patients are restless, bustling about on new and important business, remaining up until late at night, devising plans, writing many letters, and travelling about from place to
place.
They are very
talkative
and make confidants
of
every one they meet.

disease they
For short periods in the course of the may develop extreme restlessness, with insomnia,
complete clouding of consciousness, recklessness, aggressiveness, and impulsiveness. They shout from fear, mutilate
their
own
bodies,
and rush about
blindly diving into
any
obstacle.
It is impossible to attract their attention or to
get coherent answers. They fight off imaginary enemies and shout threats and curses. These conditions of excitement
rarely last longer
than a few hours or days, and disappear
gradually, usually leaving the patient in a state of profound deterioration.
more
In actions the patients soon become foolish and show a lack of judgment and moral obtuseness. They develop bad habits, smoke or swear, enjoy telling obscene stories, seek
the
company
of lascivious
women, and become
disorderly in
DEMENTIA PARALYTICA
dress
307
and careless in appearance. They may assault or commit thefts, but every action shows an absence of plan, When conrecklessness, and utter disregard for others.
fronted with their observed behavior,
it is all
denied with
perfect serenity. As the disease advances, the activity production of unintelligible letters and
is
limited to the
plans, scribbling
on paper, and collecting useless rubbish. The patients are happy and contented throughout it all, invariably asserting
with brightening countenance that they are feeling fine. " They may be heard mumbling to themselves, millions," " " fine horses," "beautiful women," mansions," grand mere relics of former ideas which now represent the last
traces of their intellectual
life.
The expansive form comprises from fifteen to sixteen per cent, of the paretics. The duration is more prolonged, less than one-third of the cases dying within two years. Some
cases even live fourteen years. Remissions occur in onethird of the cases, which in part accounts for the prolonged course. It sometimes happens that the expansive form
passes over into the depressive, and vice versa, and this may take place several times, simulating the picture of manicdepressive insanity.
AGITATED FORM
The
agitated
form
is characterized
by a relatively sudden
onset with a condition of great psychomotor excitement
and
delirium,
most extremely expansive delusions, great clouding of consciousness, and a short course. The
the presence of the
and
usual prodromal symptoms are lacking and there rapidly develops extreme megalomania. change of disposition is often noticed for a time previous to the sudden outbreak.
The
patients rapidly
become very
energetic,
and express a
pronounced feeling of well-being.
They
are born again,
308
and the strength of ten thousand men ; could carry an ocean vessel or fly to the moon in a second. They have acquired all knowledge, can educate a thousand
possess the ambition
teaching them to speak every known language. They themselves are Gods, Gods over God, have created God and the universe; have been everywhere from the heights
of heaven to the depths of hell. They are now establishing a new method of reckoning time; by their decree the days are to be one thousand hours long, the weeks are to
men an hour,
contain one thousand days, and the years ten thousand
and by a new size and The world moves and stands at shall have a third eye. are interested in all wars and have their command. They marshalled huge armies. Their wealth is fabulous, more
months.
formula
to create animals,
They know how

shall
man
be increased a hundred-fold in
than any one man ever possessed before. All quantities are reckoned in the ten thousand billions; they own ten thousand
billion houses;
ten thousand billion cows; ten thou-
sand
billion acres of land, etc.
Their houses are built of

set
Italian marble, with gilded
domes
with diamonds, the
floors are of onyx, the furniture,
pure gold, and the hang-
ings, the finest fabric, trimmed with pearls and sapphires. Their ideas become more and more expansive, and finally
seem even to surpass the bounds of imagination. In the midst of these megalomanic delusions, one occasionally encounters the most extremely pessimistic ideas which
are sometimes hypochondriacal. The patients claim that they are suffering untold misery from sharp pains in the back; some one entered the room at night and disem-
bowelled them, so that the following morning they could not go to stool; miles of fine electric wires have been placed
in the flesh, about the limbs
and completely
filling
the skull,
through which
electrical currents are nightly applied, causing
DEMENTIA PARALYTICA
the flesh to burn.
ing
309
memory
be some insight into the failand the defective nutrition, which leads them
There
may
momentarily to fear that they are suffering from cancer of the most malignant type, but at the same time one is assured that they are undergoing a process of purification which will leave them healthier and mightier. Sometimes they are perplexed at their own stupidity for allowing themselves to be confined in a hospital instead of going to
to
Europe consummate a deal by which millions would have been made. Hallucinations of sight and hearing may be present, but are not prominent, and fail to influence greatly the
clinical picture.
The psychomotor
showing
are
talkative,
condition is one of great restlessness, The patients occasional impulsive movements.
sing, laugh, shout, and prattle away like over their innumerable plans and many pleaschildren ures. They are constantly in motion, going from one thing
to another, working in a planless way on various schemes, scribbling unintelligible letters to millionnaire friends, issuing to military staffs, and sending cablegrams to the different crowned heads. They have no care for themselves,
commands
neglect personal appearance, forget about eating, smear their dresses or the walls with the food placed before them,
masturbate, and expose themselves indecently.
Thought is usually incoherent, and there is often observed a flight of ideas. Emotionally, there is a marked irritability,
and
interference quickly leads to outbursts of passion, with cursing, threats, and aggressiveness; but elation predomiPhysically, the condition of nutrition suffers profoundly, and there is a great loss of weight, because of the
nates.
small
amount
of food ingested
and great
restlessness.
The
temperature may be subnormal. A few cases of the agitated form
may
be characterized as
310
These cases present an extreme grade of galloping paresis. excitement and profound clouding of consciousness, leading within a few weeks or months to fatal collapse. It sometimes
represents the end stage of the agitated form and occaThe patients are comsionally also of the depressed form. unable to comprehend the surroundings pletely confused, or to respond to questions.
singing,
They
are noisy, shouting
and
producing an
is
unintelligible babble, with
many
The
repetitions of syllables or purely inarticulate sounds.

restlessness
extreme, the patients being in constant motion, the bed or wall, forcing the legs up and down, pounding running about the room, slapping their hands, waltzing to
and bruising themselves extensively by their reckless movements. Insomnia is extreme and food is refused, or if taken, cannot be retained, and the patients are wholly unable to care for their personal needs. The weight falls rapidly, the temperature becomes slightly elevated, and the heart's action feeble and irregular. Epileptiform and attacks are frequent. Within a few days or apoplectiform
fro,
and
in
weeks the restlessness subsides into a condition of stupor, which the movements are uncertain and tremulous. The
temperature becomes elevated as the result of infection from the various wounds or acute decubitus, the mouth is filled
with sordes;
profuse perspiration
and diarrhoea appear,
which with heart failure lead to death. The agitated form represents about eleven per cent, of the Remissions occur in one-fourth of the cases. paretics.
Paralytic
attacks are
frequent.
The duration
in
more
than two-thirds of the cases
is less
than two years.
DEPRESSED FORM
This form is characterized by despondency and depressive delusions which prevail throughout the whole course of the disease.
DEMENTIA PARALYTICA
The
their
onset in this
failing
311
patients notice
form
is
insidious.
The
memory, decreasing power of application, weariness upon exertion, and change of disposition. greater The persistent headaches, the numerous pains, and failing
memory
lead
them
to consult one physician after another.
They worry about themselves and soon become hypochondriacal. They claim that they are suffering from a complication of diseases and that they can never recover. During
this stage they are not infrequently regarded as neuras-
theniacs, hypochondriacs, or hysterical patients. But their hypochondriacal complaints sooner or later be-
come
is
entirely senseless.
They then complain that the

is filled
scalp
rotting away, the skull is brain to shrink, the mouth

is lost,
filling in with bone, causing the
with
sores, the sense of
taste
the throat
is
clogged up, so that the food passes

is melted away, and the excrement has been accu-
up
into the brain, the
stomach
intestines are so paralyzed that
mulating within them for many months, the kidneys have been moved, so that water passes directly through their bodies. They claim that they are dead, the blood has
ceased to circulate, and they have turned to stone. The have dried up and their manhood has disappeared ; " " a false passage has formed so that the vital fluid passes
testicles
out of the rectum.
In connection with these ideas they are
constantly fingering different parts of the body, especially the face and sexual organs. They may sit for hours with hands on their throat for fear feces will pass into the mouth,
or
may
apart if Delusions of self-accusation are usually associated with

these hypochondriacal ideas
in the
clinical
abed as moved.
lie
if
dead, claiming that they would
fall
picture.
and occasionally predominate The patients believe themselves
great sinners, that they have committed the unpardonable
312
sin,

must
die
have stolen property, and injured their children. They have caused the death of a friend by and every one knows that they are murderers. negligence, They persist that they have always been impure and have
on the
cross,
months because he had not provided his family with sufficient food and was being held up to the whole world as an example and must
led
many
astray.
A patient
moaned
for
Very often fear develops in connection with these ideas of self-accusation, when the patients are in terror because they are being constantly
watched, expecting at any moment to be imprisoned or carried away to the scaffold; or they dread personal injury
suffer the penalty of death.
and abuse.
Delusions of persecution are usually accompanied by halsuspect plots against their lives and complain that their families, are being outraged. They are being regarded as desperadoes on whose head there
is
lucinations of hearing,
when they
a high price.
into exile.
of
them
crowd
The troops have been summoned to escort They hear themselves slandered by a
Hallucinations of the other senses
men
outside, or overhear intrigues against them.
Others threaten them.
are infrequent. The consciousness soon becomes
much
clouded.
There
is
is
considerable disorientation; friends are mistaken, and time confused. Occurrences in the surroundings have reference
only to themselves. The bathing of others suggests to their minds that they have polluted their fellow-patients, and the
preparation for the morning walk signifies that the whole company are getting ready to attend their public prosecution. At the table others are deprived of food on their
In this condition they develop great anxiety with restlessness; pace back and forth in their rooms, moaning
account.
and groaning, sometimes uttering
single
expressions,
as
DEMENTIA PARALYTICA
"
death,"
their hair,
313
"
destruction," pick at their finger-nails, pull out
Finally they cannot be persuaded huddled up at one side, with the head buried in the clothing. In this condition they may
to leave the bed, but
lie
frightens farther into their rooms.
and are unable to eat. Every unusual sound them and causes them to shudder and shrink back
attempt suicide or mutilate their own bodies; one patient tore through the anal sphincter into the vagina with her hand.
Extreme anxiety with
restlessness does not exist very
long at a time, usually only for a few hours or at most a few weeks. It may appear and disappear suddenly. In
the interval the patients are not as agitated but yet are despondent and seclusive. The depressive delusions are retained but they show far less emotion. The mental depression is not always uniform, as one occasionally notices emotional indifference, and even transitory periods with a
feeling of well-being
is
and
of elation.
When
deterioration
well advanced, expansive delusions occasionally appear. More or less prolonged stuporous states appear at times
when the patients become abed in one position oblivious to the surroundmute, lying ings, refusing nourishment, and allowing the feces and urine
during the course of the disease,
to pass unheeded.
ignored.
Requests are carried out slowly or wholly The patients appear indifferent, but at times they
display some emotion, or they may show some anxiety. Hallucinations and illusions may be more or less prominent or entirely wanting. Consciousness is usually clouded.
These states
months. form of dementia paralytica comprises depressive one-fourth of the cases, and appears rather late in life,
may
last several
The
mostly after forty years of age. Remissions occur in less than twelve per cent, of the cases, while paralytic attacks
314
occur in twenty-five percent. This type is one of the severer forms, as over seventy per cent, die within two
years.
Course of dementia paralytica. Dementia paralytica may be divided into three stages: the stage of onset, the stage of acute symptoms, and the terminal stage of dementia The lines
.
of division are very indefinite, as the first stage may very quickly
pass into the acute stage, when the symptoms remain in abeyance for a few years ; or the case may be one of apathetic deterioration from the onset, devoid of
indicative of definite stages.
any prominent symptoms The terminal stage is apt to
be prolonged.
the patients are dull, stupid, apathetic, entirely indifferent to their surroundings, unable to care for themselves, or occasionally expressing incoherent fragments
it
In
They sit unoccupied save for the taking which they often have to be helped. The physical symptoms in this stage advance to general paresis
of nourishment, to
of former delusions.
of all of the muscles, necessitating confinement in bed.
Sensation is greatly impaired, muscular atrophy and weakness become marked, and finally contractures appear. In the end patients become nothing more than vegetating
organisms.
The course
of the physical
symptoms by no
mental symptoms. On means the one hand, there are cases in which speech disturbances and incoordination may antedate for a long time the apcorrespond to those of the
pearance of faulty memory or judgment, and on the other hand, the mental symptoms may appear first.
The two important paralytic attacks and
factors in the course of the disease are
remissions.
The attacks may appear
at any time during the course, producing an unexpected progress in the deterioration or even a fatal termination.
They may usher

of
in the disease, being followed by a condition advanced deterioration, but more frequently occur during
DEMENTIA PARALYTICA
315
the terminal stage. These attacks accompany chiefly the demented and the expansive forms.
Remissions are most often encountered in the agitated and expansive forms and very rarely in the demented forms. The
improvement, which
is
earlier stages of the disease.
usually rapid, appears only during the Both the physical and mental
symptoms show marked improvement; the consciousness becomes clear, the content of thought coherent, and the delusions and hallucinations disappear. The patients often
look back upon their psychosis as a sort of dream, without In the course of a month or two they may clear insight. have improved so much that, as far as the limited associations
When of the institution permit, they appear perfectly well. at liberty, however, it is apparent to their friends that they
have
lost their
former mental energy; they
tire easily,
and
for
are changed in disposition.

exercise care.
Yet they are usually eager
employment and disregard the advice
of the physicians to
Some
of the patients are able to engage
successfully in their former occupation and support their In other cases the remission is only partial; the families.
become clear and coherent, while the expansive and depressive delusions disappear; but there still remains
patients
a tendency to excessive activity, with a desire to enter into uncertain business ventures, to be lavish with money, carepersonal appearance, and irritable and fretful in disThe duration of the remission seldom lasts over position.
less in
three or four months, but in
some
cases
it
extends over three

paresis, there
or
more
years.
Diagnosis.
During the early stages of
may
be considerable
difficulty in distinguishing acquired neuras-
thenia (see p. 153).
The
cholia of involution
depressive form of paresis is distinguished from melanby the evidences of mental deterioration:
316
weakness of judgment, moral instability, failure of memory, defective time orientation, silliness and incoherence of the
and presence of physical signs. The melancholiac a greater prominence of self-accusations and good shows orientation, except in cases with many hallucinations and
delusions,
delusions.
The
intense apprehensiveness of the paretic
is
than that encountered in melancholia, and is relieved by short periods of moderate but occasionally distinct feeling of well-being. The melancholiacs have their good days, but they never show elation.
less persistent
depressive phases of manic-depressive insanity are distinguished by the absence of any signs of mental deteriora-
The
and by the presence of retardation among the motor phenomena. In the stuporous states the manic-depressive patient takes some notice of and partially apprehends his surroundings, although he takes no part in them; he shows some anxiety and discomfort when threatened with a needle and seldom moves voluntarily and then slowly, while the
tion
is partially disoriented, does not react when threatened with a needle, and occasionally moves freely and even
paretic
and usually presents characteristic physical signs. The manic phases of manic-depressive insanity are differentiated from the expansive and agitated forms of paresis by the absence of mental deterioration. The paretic is unable to recall correctly recent events, and especially the date of their occurrence. His delusions are more extreme, his emotional attitude is fantastic, and contradictory; and dependent upon the surroundings and sugvariable, The manic, on the other gestions, and he is more pliable. is more alert and quick in apprehending when his hand, attention can be attracted; he shows an accurate memory;
restlessly,
his delusions are less often contradictory, are expressed with

less
assurance and more facetiousness;
and he
is
seldom
DEMENTIA PARALYTICA
contented and
is less
317
pliable.
In conditions of extreme exciteis
ment, the orientation and the coherence of thought disturbed in paresis.

It often
more
happens that periods of excitement at the onset of the disease are mistaken for delirium tremens, especially where early paretic symptoms have escaped notice in an
alcoholic (see p. 183).
by the absence of the characteristic physical signs, good orientation, and the presence of catatonic features (see p. 270). The sois
Dementia prcecox
usually differentiated
symptoms, if they occur in paresis, are aca greater disturbance of memory and greater companied by insensibility and cloudiness than what one encounters in
called catatonic
dementia praecox. In case these distinguishing features cannot be determined, on account of negativistic signs, then
one has to depend upon the presence or absence of physical
signs.
The presence
of simple difference of pupils, increased
reflexes,
moderate tremor, and, indeed, even attacks of dizziness and of an epileptiform nature, are not conclusive for
paresis.
If
helpless in simple figuring tests,
a patient with such symptoms is uncertain and is unable to orient himself
as regards time and to readily recall early experiences, and is easily influenced in action and feeling, provided it is not the
mechanical response to stimuli, then the condition is more indicative of paresis. The states of dementia in paresis lack the tendency to adornment, the mannerisms, the occasional
exacerbations, refusal of food.
and the
persistent stupor, negativism,
and
In the paretic excitement, there
may
occur
impulsive and stereotyped movements; but they are not accompanied by the irrelevant and incoherent speech of the catatonic, and furthermore, the excited paretic is not
oriented to the extent that the catatonic usually is. In the paranoid forms there is neither the paretic inability to com-
318
prehend the surroundings nor the permanent feeling of wellbeing, hallucinations are much more frequent and expansive delusions develop more slowly, while the paretic does not show
the delusions of influence so
common in
paranoid dementia.
The late
cases of dementia prsecox, in which despondency may predominate, are distinguished by the susceptibility to ex-
ternal influences, such as
commands, and by the impulsive
restlessness or stupor with resistiveness.
diagnosis may spinal fluid.
rest
Ultimately the the examination of the cerebroupon

is
The
differentiation of paresis
apt to be most
difficult
in those diseases in
which there are extensive

(see p. 331),
cortical lesions,
particularly cerebral syphilis
arteriosclerotic
insanity (see p. 338),
and
senile dementia.
Senile dementia
may be recognized by the age at onset, the more prolonged course, comparative poverty of delusions, and absence of
characteristic
motor symptoms.
toms similar to those

paralytica.
focal
disk.
Cases of cerebral tumor occasionally present mental sympin the demented form of dementia
The
chief point of differentiation, in case

exist,
is
no
symptoms
the presence of the cupped optic
The prognosis of the disease is decidedly unPrognosis. favorable. Death occurs in the vast majority of cases within
two years; the length of life, however, varies in the different forms. A few cases survive five or six years. One case of eighteen years' duration has been reported. There are, however, some cases of so-called arrested paresis Undoubtedly not a few of these cases were never paresis at all, but rather
.
belonged to the group of organic psychoses characterized by

degenerative changes in the cortex, especially syphilitic, which during life are differentiated only with great difficulty. Again, there is a possibility that some of
extensive
DEMENTIA PARALYTICA
319
these cases represent a group of cases still undifferentiated, which at the onset present the characteristic mental and
physical symptoms of paresis, but later subside into a condition of dementia with possibly a few delusions and the
It cannot be positively residuals of the former physical signs stated that some of these are not paretic cases which fail to
.
run the usual
fatal course.
It is still
a mooted question
whether patients may not even recover from paresis. In the first place, Tuczek reports a genuine case of paresis, confirmed by autopsy, with a remission of twenty years. Again, Alzheimer has found in paretics, dying during a complete
When one remission, the characteristic paretic lesions. considers that these remissions often cannot be distinguished
from genuine
recoveries, except for the later recurrence of
the disease, it at once becomes apparent that a complete subsidence of all mental symptoms may occur, which, extending through a series of years, encourages the belief that
recoveries are possible. The immediate causes of death are paralytic attacks, pneumonia, and intercurrent diseases,
sometimes septicaemia following infection from wounds, sometimes suffocation caused by food entering the air passages; but the usual manner of death is from marasmus
and heart
failure. The patients become emaciated, the muscles atrophy, the heart weakens, the pulse becomes im-
perceptible,
and
life
gradually flickers out.

is
Treatment.
tomatic.
The treatment of the disease is mostly sympa history of probable
In cases where there
syphilitic infection the intensified mercurial treatment is 1 It consists justified by the small number of reported cures.
in the
intramuscular injection of mercuric salicylate in albolene, beginning with J grain twice weekly and increasing
1
Collins,
Med. Record, Vol.
9, p.
125.
Dana, Jour. Amer. Med. Ass'n,
May
6,
1905.
320
to 1 J grains, administered for six weeks, and then an interval of six months during which general tonics are pushed.
Following this, another period of similar mercurial treatment. Some prefer the injection of bichloride of mercury,
J to J grain daily, given for six to eight weeks, repeated after an interval of six months. All other specific methods of
treatment have fallen into disuse.
utmost importance that the patient be submitted forced rest, with removal from business and uncomto fortable surroundings, and the establishment of a suitable
It is of
Quiet and daily routine in the physical and mental life. tractable patients in good circumstances may be treated at
home, but others usually require sanitarium or hospital treatment. Suitable rest and relaxation cannot be procured " " at the fashionable health resorts with the numerous cures
and attractions. Next to rest, there should be outlined a simple
nutritious
diet, including abstinence as regards alcohol, coffee, tea, and A carefully planned daily routine, including extobacco.
ercise in the
open
air,
and
carefully executed hydrotherapy
with gentle massage,
is
of importance.
The
conditions of paretic excitement are best relieved
by
the bed treatment and the use of the prolonged warm baths 1 At the first application of the bath, it may be (see p. 140).
is inaccessible, the cold packs may be substihands of several American physicians seem to give excellent results. The packs to be effective must be properly applied. The partial pack usually suffices to bring about the desired result, applying it to the lower extremities, or to the arms. In the whole pack a large and heavy woollen blanket is spread upon the mattress, and over it is laid a coarse linen sheet, well wrung out in water of a temperature from sixty to seventy degrees, so placed that the patient can lie at the junction of the middle, and right third of the sheet. When the patient is in position, with the arms elevated, and provided with a wet turban, the right portion of the sheet is drawn across the body and tucked. The arms are lowered
1
Where the warm bath

which
in the
tuted,
DEMENTIA PARALYTICA
321
necessary to give preliminary doses of hyoscine. If the excitement is extreme, forced feeding or hypodermoclysis with normal saline solution (see p. 139) given twice daily should be employed. The conditions of extreme anxious
restlessness
and agitation should

if
also be treated with the
prolonged
necessary the use of the hypodermoclysis, but not infrequently these patients fail to yield to any form of treatment, when all that remains to be done
is
warm bath and
to
watch the patient carefully to prevent

last stages of the disease,
injuries
and to
is
maintain nutrition.
In the
extreme cleanliness
most
in order to prevent bedsores. The bedmust be kept dry, clean, smooth, and free from clothing crumbs, and the body frequently cleansed with cold water. Alcohol or hardening applications are better withheld, and instead the skin should be carefully rubbed with cocoa
essential
butter.
Frequent changes of the position of the body every
hour, day of acute
and
night, aid greatly in preventing the occurrence
and hypostatic pneumonia. Acute decubitus, once formed, is very obstinate and should be treated surgically like an ulcer. Where there is a marked tendency to the formation of acute decubitus and also where it does not heal readily, the best method is to keep the
decubitus
and covered with the left portion of the sheet, which is drawn body and securely tucked, especially about the neck and feet. The patient is then covered with several woollen blankets. The duration of the pack should be from one-half to one hour, and may be followed by brisk rubbing with alcohol. The duration of the partial pack may be more extended than that of the whole pack. When the patient falls asleep in it, it is not necessary that it be removed until he awakes. There is no harm in an immediate renewal of the partial pack. It should be remembered in the application of these partial packs, as well as in the whole packs, that all air must be excluded from in under the cover of
to the side
across the
woollen blankets, for which purpose

cloth or oil silk.
many
use a final covering of rubber
322
patient

continually
in
the prolonged warm bath. The nourishment during this stage must be liquid, in order to prevent choking. Daily percussion of the lower abdomen
to detect distention of the bladder
and observation
of the
is
condition of the bowels is also necessary.
In case there
paralysis of the bladder, the patient should be regularly catheterized, followed by a washing of the bladder with a
saturated solution of boracic acid.
Finally,
the
mouth
should be kept thoroughly clean. The paralytic attacks may yield to ice packs on the head or to amylene hydrate (thirty to sixty minims) or chloral hydrate, the former of
which may be given by subcutaneous injections in a five to ten per cent, solution. If immediate action is demanded,
chloroform
may
be employed.
VII.
ORGANIC DEMENTIAS
here used in a limited sense, applying only to those psychoses that are associated with organic disis
THE term
ease of the central nervous system,

gliosis,
and includes cerebral

sclerosis,
Huntingdon's chorea, multiple
cerebral
syphilis, tabetic psychoses, arteriosclerotic insanity, brain tumor, cerebral trauma, and cerebral apoplexy.
This disease, described by Fuerstner, presents numerous tumorlike accumulations of glia in the superficial layers of the cortex with the formation of small
Gliosis of Cortex.
cavities
and atrophy
of
of the nervous tissue.

is
The
toms may be
tability,
chronic, the mental sympsudden onset with convulsions and irri-
but later there develops a progressive deterioration
with failing memory, accompanied by disorder of speech, optic atrophy, and often tabetic symptoms. Diffuse cerebral sclerosis,
in
which there
tissue,
is
is
an extensive increase of
the
supportive dementia.
accompanied
by progressive
The mental symptons of HunHuntingdon's Chorea. tingdon's chorea are distinctive, consisting usually of a progressive dementia with faulty
paralysis
1
of
memory, weak judgment, Patients thought, apathy, and irritabihty.
Facklam, Archiv f. Psy., XXX, S. 138. Zinn, Archiv f. Psy., XXVIII, S. 411. Diller, Am. Jour. Med. Sciences, Dec., 1889, April, 1890. Hallock, Jour. Nerv. & Ment. Dis., 1898.
Sinkler,
Med. Rec., XLI,
p. 281.
324
are unstable in employment. Suicidal attempts are not infrequent, and occasional homicidal tendencies are encountered.
if
Hallucinations
present are unaccompanied by emotion.
and delusions are infrequent, but Anxious states,
outbreaks of anger, restlessness, sometimes develop. The choreic movements are intensified by any mental excitement.
Physically
the
choreic
movements
of
Huntingdon's
chorea differ from those of acute chorea in that they are less extensive and less frequent. They involve the entire
trunk, limb, head and face, and are jerky, at times quick, but often sluggish. The speech becomes hesitating, indistinct,
and
indecisive, while the writing
The voluntary movements
is rapid and hasty. are rendered uncertain, yet it
is surprising to observe how advanced cases maintain their equilibrium in walking. The arms, head, and trunk may be drawn into various awkward positions, the
patient
still
keeping
on
his
feet.
The
accompanying
photographic group (Plate 9), of three cases of Huntingdon's chorea, shows the rapidly changing attitudes of these
As patients who were trying to look at the photographer. muscular strength wanes, the disease advances, general until in the end stages the patients become bedridden. The deep tendon
muscle
reflexes are usually exaggerated,
and the
irritability
increased.
Sensation does not suffer.
Epileptiform and apoplectic attacks rarely occur.

course of Huntingdon's chorea is slowly progressive, leading in the greater number of cases to considerable
The
dementia in the course of ten to thirty years. The mental symptoms usually appear coincidently with the first of the
choreiform movements, but they may not appear for years ; indeed, the writer knows of one case of Huntingdon's chorea
of fifteen years' standing in which the individual still conducts While the successfully a large and lucrative law practice.
ORGANIC DEMENTIAS
325
underlying mental process is one of progressive dementia, as described above, the onset of the mental symptoms may be sudden and of a manic character; occasionally
the
symptoms simulate the megalomanic phase
of paresis
again the clinical picture

character,
may
be distinctly depressive in
accompanied by active hallucinosis and delusion These various clinical states, however, are formation.
usually
only
episodic,
while
deterioration
progresses.
Marked dementia may have already become evident before

these various episodes appear. Furthermore, there is no relationship between the degree of choreic movements and
mental symptoms either group may be much more Sometimes the or much less advanced than the other.
the
:
choreic
movements improve considerably during the course
of the disease.
Where the mental symptoms antedate or predominate in the clinical picture, there may be some In such cases one must difficulty in differentiating paresis.
Diagnosis.
depend upon the absence
of pupillary disturbances or musthe presence of only a hesitancy in speech cular paresis, with hastiness and tremor in writing, without defect in the
content of speech and writing. In the mental field the emotional irritability is more disturbed, and there is proportionately less defect of memory and orientation. The history of Huntingdon's chorea in the antecedents should
leave
little
doubt as to the true character of the
disease.
The pathological anatomy of Huntingdon's chorea presents chronic leptomeningitis, with thickening of the pia and small cell infiltration, general cerebral atrophy with
shrinking of the cortex, white matter, and basal ganglia. The vessels exhibit extensive thickening of the adventitia
with increase in the perivascular spaces, and in places residIn four of the writer's cases, cell uals of old hemorrhages.
326
shrinkage was observed, and in one case also grave alter-
Trabantan cells were present in most sections, while glia nuclei were uniformly increased in the deeper In all, vascular alteration was preslayers of the cortex. ent, with round cell infiltration, as well as the presence In one case there was of free pigment about the vessels. a slight degree of ependymitis, and in another, numerous areas of thrombotic softening were found scattered over the
ation.
cortex.
Multiple Sclerosis. ple sclerosis involves

less
the disease process in multithe brain, there develops more or
When
In 215 cases reported by Berger in 1904, dementia occurred in only 24 cases (more than 10 per The type of mental disturbance is usually that of cent).
mental deterioration.
simple deterioration with failure of memory and judgment, together with apathy, as seen in an unnatural complacency and anergy. Besides the emotional apathy, there is some-
times present a tendency to uncontrollable laughter, and other emotional outbursts of an episodic character. The
mental symptoms, however, are rarely of such pronounced

character as to
An
bring the patient to insane hospitals. case of multiple sclerosis may be confounded atypical
with
dementia
paralytica,
particularly
if
nystagmus,
scanning speech, and intention tremor are tardy in appearance or absent. The burden of proof against dementia
paralytica then rests
upon the absence
of pupillary dis-
turbance, and of the characteristic paretic speech; while in the mental field there is absence of faulty time orientation and prominent defect of memory.
Cerebral Syphilis.
In cerebral syphilis there are two
groups of cases: simple syphilitic dementia,
and
syphilitic
term are not included the pseudoparesis. mental disturbances occurring during the early mani-
Under
this
ORGANIC DEMENTIAS
festations,
327
such as the occasional deliria similar in nature
to infectious deliria, or the hysterical and neurasthenic syndromes, in all of which syphilis seems to play the role only of an exciting factor. The distinctively characteristic
syphilitic psychoses develop
when
The
there
is
only during the late period, involvement of the cerebral vessels and the
development of gummata, vascular occlusion, and malacia.

vessel alteration is typically syphilitic and gives rise to a profound nutritional disturbance in the cortex. It is
from that occurring in paresis by the is only very slight infiltration into the adventitia of the vessels, and mast cells are rare but there is a marked proliferation of the intimal cells,
to be differentiated
pathological fact that there
with a tendency to
vessel
typical.
itself.
form vascular foramina

vessel formation
is
within the
The new
extensive and
The
elastic fibres of
the vessels tend to split into
layers, while the vascular cells do not show pigmentation. In simple syphilitic dementia there usually appears first, defective memory and judgment, and some absent-minded-
ness, as well as lack of insight into these defects.
Coin-
cident with the onset there usually occurs
some
sort of
an
apoplectiform seizure, which
may
be either of a mild or
a severe grade.
tion.
The
Emotionally there is a slight degree of elapatients are fond of boasting of their strength
and plan extensively for the future. If there to be present some feeling of illness, they are happens confident of recovery. But more prominent still is the
and
ability,
greatly increased emotional irritability, which often leads to strife and outbursts of passion. Delusions of influence
and reference are sometimes present, also ideas of oppression and mistreatment, to which are ascribed sordid motives;
but such delusional ideas are transient and rarely elaborated. Volitionally there is evident weakness of will,
328
as

in their tractability
shown
and
fickleness.
They tend
to
be thoughtless, disorderly in their work, neglect important for unimportant matters, and do all sorts of extravagant
things.
Finally, there
is
a striking susceptibility to alcohol.
The course of the disease is usually slow, although it may soon reach a stage of quiescence, with subsidence of the
prominent symptoms. Recovery is rare, in spite of antisyphilitic treatment, because the cortex has become extensively
involved.
There are occasional exacerbations.
Physically, the onset is usually with an apoplectiform attack J and as the result of this there may be residual hemiplegia
or monoplegia, sometimes paresis of the eye muscles, some slight fault of articulation, and also complete or reflex
iridoplegia.
This group of cases should also include that form of

progressive deterioration appearing in youth which arises
from congenital syphilis and

of paralysis.
accompanied by forms The pathological distinction between these

is
cases
and juvenile
paresis
is
that in the former there exists
only the vascular lesions characteristic of syphilis. However, Meyer and Kaplan have described some cases in which
there was a mixture of paretic and syphilitic lesions. To this group also should be added the cases described
Barrett, Bechterew, and Jurgens, in which the lesion one of disseminated syphilitic encephalitis.
by
is
In Barrett's case the deterioration was very rapid, leading

to complete dementia and death within two months, while in the case of Bechterew the course of the disease extended
through two years.

1
Amer. Jour, of Med.
Sc., Vol. 129, p. 390.
Handbuch der
Minor.
path. Anat. des Nervensystems.
Flatan-Jacobsohn-
Ref. Oppenheim, Syphilitische Erkrank des Gehirns.
ORGANIC DEMENTIAS
329
Syphilitic pseudoparesis includes those cases of cerebral
syphilis
which present pronounced mental symptoms, in addition to the evidences of focal brain lesions. The gradations
sis
between simple
syphilitic
dementia and pseudoparecases that
are so imperceptible in
many
some authors
do not attempt a differentiation, but describe both groups under cerebral syphilis. The onset of pseudoparesis, as in
The
simple syphilitic dementia, may be with paralytic attacks. attacks may be only syncopal, or aphasiform and of short duration, or there may be loss of consciousness with
more or less severe paralysis. Such attacks may antedate many months the mental symptoms, or they may be tardy in appearing and sometimes they never develop. Of the
mental symptoms, despondency is the first to appear, in which either hypochondriasis or apprehensiveness predominate. The patients feel stupid, the food does not agree
with them,
of infidelity. There
they are self-accusatory, fearful, and speak is a change of character, and they become
thought; at other times
indifferent, forgetful, confused in
they are irritable, excitable, and aggressive. Even delirious Hallucinations are usually excitement may develop. and often very prominent, mostly of hearing, present
though sometimes of sight and smell. The megalomanic delusions so characteristic of paresis predominate and with this there is emotional elation and a tendency to facetiousness, although
some patients are
irritable, suspicious,
and and
hostile.
Many
patients are productive both in speech
writing, exhibiting incoherence
others are inactive, sleepy, vary from one state to another.

residuals of syphilitic infection,
and even neologisms ; and reticent, and again others

Physically
,
besides the
and form attacks, such as hemiparesis, hemianopsia, and paraphasia, etc., there may be present optic atrophy, an increase,
of the earlier apoplecti-
330
absence or weakening, and particularly inequality of the tendon reflexes, and complete or almost complete loss of the light reaction of one or both pupils. Speech and writing,
however, show insignificant changes. The course of the disease is slow, leading regularly to a considerable degree of dementia. Some patients continue
orderly and are able to live at
ability to read
home; they possess the and amuse themselves, and follow up a simple
daily routine, but are wholly incapable of profitable employment, lack insight into their condition, and are thoughtless of the future. They continue oriented, but memory for
events of the psychosis and sometimes even for earlier life is faulty. The hallucinations and delusions tend to reap-
pear; these are never modified but only forgotten. In the severer cases the dementia is more profound;
the patients are continuously confused, maintaining their various expansive and persecutory delusions, exhibiting
and aggressiveness, or they may be childishly good-natured and thoroughly tractable. Transitory conditions of profound stupidity and confusion arise.
restlessness, excitement,
Paralytic attacks, either epileptiform or syncopal, with or without residuals, reappear with more or less regularity
throughout the course and
The
course of the
may symptoms may
terminate the disease.
not be as progressive,
but after reaching a certain stage remain unchanged a long time, until an exacerbation or some intercurrent disease causes death.
pathology of pseudoparesis exhibits the following syphilitic lesions: meningitis, foci of malacia, gummata,
The
and particularly the
syphilitic vascular lesions.

is
Through-
out the entire cortex there
a hyperplasia of glia cells, so much so that in places the "gliarasen" of Nissl is found, indicating a profound degeneration of nerve cells.
ORGANIC DEMENTIAS
331
much involved, and there of glia fibres, and hence development very Regressive changes practically no reduction of the cortex.
The nerve
is
fibres,
however, are not
also
little
neuroglia cells. In the deeper layers of the cortex there is a large increase of small round glia
may
be seen in
many
nuclei.
The
large vessels are deeply stained (Nissl's stain)
and the perivascular spaces are enlarged, although there is no infiltration of the adventitia similar to what one finds
in dementia paralytica. The small vessels are greatly increased in number, dilated, and present many anastamoses,
appearing
everywhere
to
be
overlaid
with
glia
cells.
According to
Nissl, this proliferation does not take place by as in paresis, but by the formation of new vessel budding
openings through the thickened endothelium among the numerous layers of the elastic coat. The muscular coat
Finally, rod cells are very rarely found. These extend throughout the cortex, but to a varying degree, in places being almost imperceptible. They are always more marked in the superficial layers of the cortex. Occa-
disappears.
lesions
sionally small old or fresh hemorrhagic foci are found. The similarity of pseudoparesis to general paresis
striking that the differential diagnosis
is
is
so
very
difficult
and
depends mostly upon the presence and persistence of the residuals of the paralytic attacks. These often exist from
the onset, which
is
paretic faults of speech
not true in paresis. The characteristic and writing, with the aphasia and
stumbling over syllables, the transposition and the repetition of syllables and letters, are absent, as well as the disturbances of the sensibility to pain. Memory is better than in paresis, and except in the very bad cases, orientation is preserved, i.e. names of persons are recalled and the patients
remember striking and also take some pride
incidents in their environment,

in neatness
and
order.
At the
332
onset,

when
differentiation
is
most
difficult,
one observes
that in paresis the memory defect is out of proportion to the disorder in the rest of the mental life, and hallucinations
are less prominent than in pseudoparesis.
The
treatment of
pseudoparesis presents but little hope, although the few favorable cases following antisyphilitic treatment warrant a
trial in all (see p. 319).
In most cases where mental symptoms develop during the course of tabes, the disease terminates as paresis, but there are a few cases which never
Tabetic Psychoses.
become
paretic.
Very mild mental symptoms often appear
during the early stages of tabes, i.e. some fault of memory, and an increased sense of fatigue, but more especially a
change in disposition.
hopeless,
cheerful,
Many
patients
become gloomy and
and have forebodings and fears, but others are happy, and confident, sometimes reminding one
is
of the feeling of well-being of the paretic.
The
characteristic tabetic psychosis, however,
an acute
hallucinosis with
some excitement resembling the acute The onset of the hallucinosis is sudden, with hallucinations of hearing, accompanied by some anxiety and restlessness. Later hallucinations of the other senses appear. The hallucinations are of a threatenalcoholic hallucinosis.
such as the voices of relatives calling for help, threats against their lives, the odor of sulphur, or the sensation of electricity, to all of which the patients
ing, disturbing
type
react.
Orientation remains clear.
attack
may be
for a
few weeks or
The duration of the several months, when the

There
symptoms
sions.
often disappear suddenly.
may be
remis-
psychosis may resemble a short hallucinatory delirium, or it may simulate a chronic psychosis with hallucinations and paranoid delusions, both of persecution
The
ORGANIC DEMENTIAS
and grandeur.
cess, similar to
333
Again
all
of these different
forms
may
represent different clinical stages of
the same disease pro-
the acute and chronic disease pictures which
one sees in
paresis, alcoholism,
and dementia
is
prsecox.
In
some
of the chronic cases there
a similarity to syphilitic
pseudoparesis. Besides these forms of tabetic psychoses there may develop in tabes the manic-depressive syndrome,
the catatonic orthe senile psychoses. The tabetic psychoses are differentiated from the forms of paresis by the fact that
the disease process
is
not progressive.
The grade
of dete-
rioration remains at a standstill,
and memory
paresis.
is
and furthermore, attention not disturbed to the degree that it is in

1
Arteriosclerotic
Insanity.
Arteriosclerotic
changes
in
the brain are very common life, yet it is doubtful if one is justified in considering them only as evidence of early senility, particularly in view of the fact
in the senile period of
that extensive
arteriosclerosis
may
exist
without accomeither
is
panying mental impairment.

that
One must conclude
the vascular
disease, in arteriosclerotic
insanity
not, in spite its great similarity, identical with that occurring in normal senility, or that in the former case the vas-
cular change is an accompaniment of only secondary importance in a disease process which is highly destructive of
nerve tissue.
especially
The varying extent

it
of the vessel change,
whether
involves the smaller or greater vessels,
may
account for the absence or presence of mental mani-
festations.
Alzheimer, Allgem. Zeitschr. LIX, 695.
f.
Psy., LI, 809;
idem, LIII, 863; idem,
Alzheimer,
Binswanger, Berl. Klin. Wochenschr, 1894, 49. Histologische und Histopathologische

Grosshirurinde-Nissl, Jena, 1904.
Arbeiten liber die
334
cases
This psychosis appears about the sixtieth year; yet some develop before fifty, but in the latter instance
there
is usually present a strong hereditary tendency to vascular disease. Alcoholism and syphilis may be regarded
as etiological factors.
life,
the arteriosclerosis
When the disease occurs later in may be associated with the charac-
changes of the nervous tissue which are dependent upon the vascular changes. Alzheimer speaks " This form of disease Senile Decay." of these cases as
teristic senile
attacks especially the cortical vessels that pass in from the pia, leading to the formation of deep wedge-shaped foci with destruction of the nerve tissue and an increase
of glia.
There is regularly found, besides Pathological Anatomy. the evidences of general arteriosclerosis, cardiac involvement, either cardiac hypertrophy or dilation, and interstitial nephritis.
The
cerebral vessels are thickened
and
rigid,
and the
the dura and pia thickened, the latter being cloudy, Several entire brain is more or less atrophied.
areas of hemorrhagic softening, either fresh or old, are usually found in the cortex, and the ventricles are much dilated.
the numerous disease foci are found, the path of the altered vessels. In these especially along areas the nervous tissue has disappeared, being replaced by a luxuriant growth of neuroglia, which shows little or no
Microscopically,
tendency to regressive changes.

addition to
The blood
vessels,
in
namely, a splitting and swelling of the elastica, thickening of the walls, and regressive changes in the muscularis and adventitia, also
the
usual
arteriosclerotic changes,
show a tendency
is
lymph
spaces there
In the to hyaline infiltration. increase of connective tissue, pig-
mentation, and granular cells. Comparing the normal with the arteriosclerotic cortex, as seen inFigures 1 and 2, Plate 10
5
.X'.V^
* *
.''
v '.":"
*
..*'*"**
*VV'*'
V*r^W
>:
^-
">
PLATE
Fig. 1
10
Fig. 2
Arteriosclerotic cortex.
Normal
cortex.
ORGANIC DEMENTIAS
it is
335
apparent how extensive the degeneration of cells has been. The few remaining nerve cells present a high-grade
Deeply stained glia nuclei are scattered everywhere, mostly surrounded by a clear space, and gathered in groups, particularly about The vessels themselves, both large and small, vessels. few nuclei, are hyaline and greatly thickened. Some present vessels appear to have a double lumen, which is very frequently found in the arteriosclerotic cortex. The disease process is not evenly distributed throughout the entire
cortex, as there are foci
alteration in the intercellular tissue.
noted.
where only moderate changes are one cannot judge of the extent of the Further,
vascular change in the cortical vessels by the appearance of the larger vessels in the pia, as the latter may be much
altered, while the
former show
little
change.
The nerve
fibres, both in the cortex and in the white matter, show changes proportionate to the vascular disease. There
usually are numerous cavities in the white matter, particularly along the line of the vessels. This condition, called
crMe, presents a very characteristic picture. Where this state is very pronounced and where the subcortical region is more involved than the cortex, it has been called,
etat
by Binswanger, chronic
subcortical
encephalitis.
Clini-
cally these cases are characterized by very many limited The focal symptoms and a very pronounced dementia.
pyramidal tracts
may show atrophy in the pons and medulla.

The first symptoms
of arteriosclerotic
Symptomatology.
insanity consist of a diminution of energy, and forgetfulness. The patients tire easily, lack the characteristic fresh-
and energy for work. They not only hesitate to undertake anything new, but lack ability to do original work. Emotionally, they are easily depressed, disheartened,
ness
at times whining
;
again, they
may be
irritable,
and sub-
336
ject to
FORMS OP MENTAL DISEASE
emotional outbursts. Emotional instability is apt to be present, as seen in rapid changes from one emotional state to another and in frequent weeping and laughing. Patients are forgetful and flighty, and mix up their work.
There
that
always present a very definite feeling of illness may even border on hypochondriasis. This may lead
is
to suicidal attempts.
Under the
influence of alcohol or
some emotional
develop. reference
a moderate degree of dazedness may in the course of the disease delusions of Later
stress
and particularly
of infidelity are prone to appear.
physical symptoms are more or less pronounced attacks of dizziness, syncope, or even convulsive attacks, which may be accompanied by paraphasic disturb-
The prominent
ances, disturbances of sensation, paresis,
and even
persist.
paralysis.
Residuals
reaction
is
of
these
attacks
usually
is
Pupillary
retained, or at
most
is
only slightly sluggish.
The usual vascular and

sclerosis are present,
cardiac
and there
symptoms of arterioalbumen in the urine.

standstill for years,
is
These symptoms
particularly
if
may
remain at a
the patient's method of living
carefully
regulated, but sooner or later apoplexy appears with its With each recurring attack there is further deresiduals.
mentia, in which attention and memory suffer. Later there develops complete disorientation, and indifference,
but at times there
is
childish irritability
and at others
happiness. Finally deterioration becomes so pronounced that they have to be cared for and fed like little children.
Not
all
there
cases develop this degree of deterioration; indeed, may be all grades of dementia. Aphasia, agraphia,
apraxia, and asymbolism, also word and mind blindness, are frequent complications of these vascular lesions, which
tend to
make
than
it
the mental deterioration appear even greater really is. There are old apoplectics of ten years'
ORGANIC DEMENTIAS
or
337
more duration who present only an increased sense of mental fatigue, ill-humor, and some weakness of will,
rendering them particularly susceptible to outside influences. In such cases the vascular lesions are supposed to be more
circumscribed or to have come to a standstill.
a group of cases of arteriosclerotic insanity that deserve special attention; namely, those comprising the
There
is
severe
progressive
form.
These
cases
are
characterized
by a very rapid course leading to profound dementia and death. The disease usually begins with an apoplectiform attack, although there may have been prodromal headaches,
some
forgetfulness,
and lack
of
energy.
Following this
there develops a condition of

hensiveness,
marked anxiety and appre-
sometimes with pronounced delusions of a
persecutory nature, occasionally hallucinations and delusions of self -accusation. The patients are usually clouded and that they do not even understand what goes on about them or what is said to them. They are
confused, so
irritable,
restless,
much so
aggressive,
wandering about, attempt
escape, trying to jump from the window, or commit suicide. Nocturnal restlessness is particularly marked. Nutrition
and
There regularly develop for longer or shorter periods conditions of even greater bewilderment and more active restlessness. The patients become even more clouded, so that they perceive practically nothing and their attention cannot be fixed. Obstacles placed before them are not perceived or are handled in a
sleep suffer profoundly.
wholly automatic manner. They will not avoid a test needle, although they wince from pain. Emotionally, they manifest lack of feeling, although occasionally there may be
some anxiety or again some elation. Insight is absent. The patients present an almost incessant, motiveless The speech activity, and they have no care of themselves.
338
is

and often
usually wholly incoherent, sort of babbling,
Such mental states usually end in death. Yet the excitement may disappear, leaving the patient in a condition of dementia which then becomes gradually
unintelligible.
progressive.
The
patients are wholly
listless,
disoriented,
and comprehend only the simplest questions. They have neither the energy to busy themselves nor the interest to mingle much in their environment. There is great emotional weakness and the patients laugh and cry very easily; even spasmodic laughing and crying may exist. In spite of
their great deterioration, they
may
be able to solve simple
mathematical problems, and not only recognize the members of their family, but derive some enjoyment from their visits. Physically, in addition to the residuals of the apoplectic
which paraphasic disturbances are apt to be is also a peculiar impediment of speech which may sometimes lead to genuine scanning. The
attacks, in
prominent, there
writing also presents marked changes. Individual letters are barely legible, even though ataxia is not evident. The
patients lose their ability to write the single strokes into a complete word. In the words that can be read omissions
These faults of writing are present from the beginning and may be regarded as a sign of rapid fatigue. The pupillary reaction is always maintained, although someare found.
times
it is
sluggish.
The
entire duration of the disease is
about four years, though there are cases of six to seven years' duration ; and again, some cases run a course of only
a few months.
fluenced
The prognosis in any case is always inthe general physical condition, especially the by condition of the heart, lungs, and kidneys, as well as the The
age of the patient.

diagnosis of arteriosclerotic insanity may be difficult, particularly the differentiation from paresis occurring in
ORGANIC DEMENTIAS
late
life.
339
place, it must be remembered that lesion of the cortex, while in arterioparesis is a diffuse
In the
first
sclerotic insanity there are
many
scattered foci.
Therefore,
we
find in paresis that the general psychic alteration is
more prominent than the physical signs. Paretics are usually clouded and exhibit loss of judgment before the
in arteriosclerotic insanphysical symptoms appear, while the apoplectiform attacks are very often the startingity
the psychical disturbances. In arteriosclerotic insanity disturbances of perception are more striking than disturbances of memory, while in paresis both are equally impaired. Emotionally, the paretic shows greater elation
point of
or depression ; while the arteriosclerotic patient is usually indifferent and apathetic, or he presents either hypochongreat elation of some paretics and the profusion of delusions is wholly lacking in the arteriosclerotic condition. Fabrication, aldriacal
despondency or indefinite
fear.
The
though a prominent symptom in paresis,

in
is
seldom indulged
it is
by the arteriosclerotic patient, and then
of
an
altogether different character, being meagre and without the florid embellishments of the paretic fabrication. These
patients also present in a marked degree lack of mental power ; yet at times they suddenly surprise one with their knowledge, although at other times they appear much de-
There does not appear to be such a complete loss of mental power as in paresis, but an inability to control it, and corresponding to this there is a greatly increased sense
mented.
of fatigue
not present in paresis. Finally, in spite of the apparent great dementia, many of the arteriosclerotic patients remain oriented to the end, recognize their relatives
is
which
and enjoy their visits, having good insight into their physical and mental helplessness. Further, physically there is a marked contrast between
340
the paretic and arteriosclerotic symptoms. In the arteriosclerotic state the physical symptoms are prominent ;
such as persistent, well-defined paralyses

contractures, aphasia, asymbolism,
with spasms,
word blindness, mind and astereognosis. The speech blindness, hemianopsia, disturbance is more of the type that arises from paralysis, while in writing, simple omissions are more prominent than the ataxia and the transposition of syllables seen in paresis. The pupils remain Very often perseveration is present.
normal.
in the
The presence
of arteriosclerotic changes elsewhere
body point to a similar condition in the brain, but the former is no sure criterion of the extent of the brain
involvement.
In the
earliest stages of the disease,
when the
diagnosis may difficult, the predominance of the general physical symptoms over the mental symptoms, the latter of which are more apparent to the patient himself
be most
than to the
friends,
always favors a diagnosis of arteriodementia
sclerotic insanity.
Simple
syphilitic
may
with
be differentiated from
arteriosclerotic insanity only
difficulty, particularly in the early stages. In the syphilitic psychosis, we perceive a slower development of the 'symptoms, and the dis-
turbances of
memory and
while the focal
symptoms and variable than in the arteriosclerotic condition; again,
perception are less pronounced, are more uniform, less manifold
the tendency to oculomotor disturbance, of optic disorder, and paralysis of the pupils is of importance as well as the
knowledge of syphilitic disease elsewhere in the body. In differentiating pseudoparesis we find that the course is
not as progressive as in arteriosclerotic insanity, while the hallucinations and delusions are not nearly as promi-
nent
and are often absent
in
arteriosclerotic
insanity.
The degree
of deterioration does not
become as great;
ORGANIC DEMENTIAS
341
memory
The
of
all,
is
better, orientation is retained,
and the patients
continue conscious.
treatment of arteriosclerotic insanity demands, first rest, freedom from occupation, avoidance of exciteall articles of diet
ment and
that interfere with the vascular

coffee, tea,
system; namely, alcohol,
and much tobacco.

be avoided, as
Forms
of excessive exercise should also
It is doubtful if swimming, rowing, bicycle riding, etc. the administration of potassium iodide or the employment of foods containing calcium have any beneficial effect.
In the later stages of the disease the patients are apt to
become bedridden, and require very careful nursing. Cerebral Tumor. In cerebral tumor all cases do not develop mental symptoms. Of 318 cases Gianelli discovered
but 299 that developed a psychosis.
If
the cortex
is
not
much
involved or
if
the tumor
is
of slow growth, mental
symptoms may not appear.

develop where there
in such cases there
is is
On the other hand, they may a small circumscribed growth, but always the possibility of chemical
or other destructive agencies extending over a broader If the growth is of considerable size, mental symparea.
toms are sure to appear.
According to Schusters, tumors of the hypophysis in about two-thirds of the cases develop a psychosis, of the cerebellum in one-third of the cases, and
stem in one-fourth of the cases. In these cases the influence upon the cortex may arise from increase of the general pressure and interference with the blood supply, both venous and arterial. In tumors
of the of the corpus callosum the destruction of the association
beween the two hemispheres has some effect upon the mentality. In general, then, the effect of tumors outside the cortex upon the mental processes depends upon their size. This theory receives some support from the fact that extenfibres
342
sive tumors, involving even the cortex,
may run their
course
without mental symptoms, if the tissue is gradually destroyed,
and not put under pressure ; while, on the other hand, even small tumors of the brain are often observed to produce
pronounced mental symptoms because they exert either
local or general pressure.
Schuster observes in his ex-
perience that those tumors lying nearest the cortex produce far more mental symptoms than those lying at a distance.
The
of
latter cause only a simple progressive disappearance the mental activity, indicating a cortical paralysis, while the former indicate signs of irritation.
The mental symptoms

varied.
of brain
tumor are naturally quite
Schuster in about fifty-six per cent of 775 cases of brain tumor accompanied by mental symptoms finds that these symptoms consist of a gradually progressive mental weakness. The patients become sleepy, inattentive,
forgetful,
easily,
unproductive
and are without
in thought, indifferent, fatigue either their characteristic energy or
prolonged work. Mental application calls for an unusual effort. They exhibit a degree of drowsiness and stupidity which may even extend to coma. In addition
facility for
to this, there develop the various symptoms indicative of tissue irritation and destruction, the character of which depends somewhat upon the situation and growth of the
tumor, such as apoplectiform attacks, convulsions, aphasia,

hemianopsia, etc.
Where
these
symptoms
are slight or
altogether absent, the picture may appear very much like a case of paresis of the demented form. In such cases the
differentiation
depends upon the absence of reflex pupillary disturbance and the absence of speech disorder. Other symptoms emphasized by Schuster are greatly
increased irritability with transitory periods of excitement, less often periods of despondency with delusions of per-
ORGANIC DEMENTIAS
secution
343
of the dorsal regions of the brain are apt to be accompanied by delirious states
self-accusation.
and
Tumors
with pronounced hallucinosis, although mental symptoms accompanying tumors of this region are less frequent than
in
tumors of the frontal
lobes.
Occasionally in brain tumors there exists a condition

of elation, even with distractibility of attention, productiveness, flight of ideas, and some increased activity; but more
frequently there exists a condition of childish happiness,
with a tendency to joking and punning. This mental state Schuster finds more characteristic of tumors of the
frontal lobes.
in brain tumor.
Finally the hysterical syndrome
may
exist
The
differential diagnosis in this state as well as in all of
those already mentioned depends almost wholly upon the presence and character of the physical symptoms,
indicative of focal lesions.
As regards
treatment,
one should
resort to anti-syphilitic treatment in cases of suspected

syphilitic
gumma, and
tumor
location of the
is
to surgical interference where the In suitable for such procedure.
recent years there is a gowing tendency to operate in all cases of cerebral tumor, if only for the temporary relief
of distressing symptoms. Brain Abscess. Brain abscess
be unaccompanied be of slow developby mental symptoms, particularly ment. In recent traumatic abscesses stupor is a prominent
may
if it
symptom. The patients are completely disoriented, and do not comprehend what is said to them. They are restless, Beresistive, and sometimes in a dreamy, delirious state.
sides this, there may develop catalepsy, aphasia, epilepsy, slow pulse, Cheyne-Stokes breathing, and other signs of
irritation.
Cerebral Apoplexy.
The mental symptoms
of cerebral
344
hemorrhage, embolism, and thrombosis usually depend in small measure only upon the focal disorder. Immediately
following the apoplexy the patients are usually unconscious, completely disoriented, and perform all sorts of strange
acts.
Sometimes there develop transitory states of active excitement, with noisiness and display of resistance. These acute disturbances usually disappear in the course of a few
days or weeks, leaving as residuals the symptoms of the original disease process, which almost always is an arteriosclerosis
or
syphilitic
endarteritis.
The
patients
may
become wholly clear mentally, or may exhibit the various symptoms of arteriosclerotic or syphilitic insanity, already In embolism, the mental symptoms sufficiently described. and entirely disappear. However, the permay suddenly
sistence of aphasic or paraphasic disturbances
it
may make
appear that the patient exhibits

exists.
more marked mental
weakness than really 1 Cerebral Trauma.

head
injury,
widely a considerable group of cases. It has been decomprise monstrated that in cases of severe trauma there exist
Mental disturbances accompanying designated as traumatic insanity,
profound cellular changes in the cortex, and besides this, areas of contusion and punctate hemorrhages at a distance
from the point of injury, particularly on the

of the brain,
inferior surface
and
at the tips of the frontal lobes, in the
temporal and
occipital lobes.
insanity in the narrow sense comprises traumatic delirium and traumatic dementia (post traumatic
Traumatic
constitution,
Meyer).
Cerebral
trauma should
also
be
regarded as a prominent etiological factor in epilepsy and in the traumatic neuroses. Insolation is regarded as a
form of cerebral trauma.

Meyer, Am. Jour, of Ins., LX, 373 Guder, Die Geistesstorungen nach Kopfverletzungen, 1886; Koppen, Archiv f. Psy., XXXIII, 568.
1
;
ORGANIC DEMENTIAS
Traumatic
delirium
345
(primary traumatic insanity) dethe loss of consciousness incident to the velops following head injury. The patients, instead of becoming clear,
present befogged states with complete disorientation, difficulty of thought, and very little or no memory of the accident.
Sometimes the amnesia includes a period just preceding the accident, and not infrequently there is amnesia for other
isolated periods of the
poorly,
There
ally,
is
and have often a marked tendency
of the patients. They perceive difficulty in seeing the connection of things.

life
to fabrication.
Emotion-
they are
irritable or indifferent.
They
are apt to be
restless, at times aggressive, often whining and talking considerably, the content of the speech being rambling and
incoherent.
ent.
There
is
Delusions and hallucinations are rarely presno_jJej|r_infught Jnto^jthe.- disease, and the
patients speak of themselves as being perfectly well. This state is sometimes accompanied by transitory aphasic
The symptoms of traumatic delirium may last for many weeks, some cases persisting for several months,
states.
after which the patients usually recover, although sometimes the condition of traumatic dementia supervenes. In traumatic dementia there develops sooner or later after
the immediate effects of the injury, and in some cases even where there never has been a loss of consciousness,
a change of disposition.
This alteration
is
indefinite that all the friends can say
even be so that he is a changed
may
man.
This change usually consists of an increased susceptito fatigue; i.e. unusual fatigue upon slight exertion; bility some forgetfulness, confusion of thought, inattention, un-
wonted
dency
timidity, occasional slight despondency, with a tento complain of many disagreeable sensations, as dizzi-
ness, ringing in the ears,
head pressure, and a certain sense of heaviness and stupidity. Accompanying these complaints
346
there
is
usually a keen sense of illness. The patient is irritable, irascible, and at times even exhibits some passion. Isolated convulsions sometimes develop, or even attacks
Not only a tentemporary dazed spells. dency to alcoholism, but also a striking intolerance to
of petite mal, or
the influence of alcohol and other drugs, often appears, as well as great intolerance to the sun's rays. The capacity for employment is impaired, in explanation of which the patient refers to various subjective sensations. Even games and conversations are avoided for the same
reason.
The
but
is
is
not distinctly progressive,
Many
sometimes characterized by distinct exacerbations. of these exacerbations can be traced to alcoholic
indulgence or trivial emotional causes. Deterioration is most pronounced where the trauma is associated with
alcoholism
or
arteriosclerosis, or
where
the
injury has
occurred during youth. Usually there are some nervous manifestations indicative of focal lesions of the brain, such
as changing pupillary disorders, tremors, paresis of facial muscles, and exaggeration of the tendon reflexes. There
are a few cases of traumatic dementia which for a time

like paresis,
may
appear by the changing character of the pupillary disturbance
but are differentiated from this disease
and the relatively slow progress of the disease. Undoubtedly some cases of paresis do develop from brain trauma as a starting-point. This, however, is a mooted point, yet there are many observations, including those of Meyer and Koppen, which indicate its validity. Some of the doubtful cases of traumatic dementia, simulating paresis, have presented on post-mortem examination an extensive arteriosclerosis
characteristic speech disorder,
of the brain.
and the
ORGANIC DEMENTIAS
347
treatment of traumatic insanity rests in early cases with operative procedure, particularly where there is an
indication
of focal
The
disorder.
In
traumatic
dementia,
indications
surgical interference,
even though there

far less successful.
may be
of focal irritation,
is
VIII.
INVOLUTION PSYCHOSES
forms of mental disease, described as involution psychoses seem to bear some relationship to the general
physical changes accompanying involution. Undoubtedly, the forms of mental disease included here can occur in other
THE
periods of life, also there are many other psychoses unrelated to involution that may occur during the involution period; as for instance, the alcoholic and infection psychoses, manicdepressive insanity, etc. The mental disturbances of the early involutional period are of a somewhat different stamp
than those characteristic of
senility,
symptoms common
to both.
though there are many Those occurring in the former
period are called melancholia and presenile delusional insanity, and in the latter, senile dementia.
A.
MELANCHOLIA
Melancholia
is
restricted to certain conditions of mental
depression occurring during the period of involution. It includes all of the morbidly anxious states not represented in other forms of insanity, and is characterized by uniform despondency with fear, various delusions of self-accusation, of
persecution,
1
and
of
a hypochondriacal nature, with moderate

;
v. Krafft-Ebing,
Die Melancholic
Christian,
6tude sur
la Me*lancolie,
1876; Voisin, M&ancolie, 1881; Dumas, Les Etats Intellectuels dans la Melancolie, 1895; Roubinowitsch et Toulouse, La Melancolie, 1897. Hoch, Rev. Ed. of Reference Handbook of Medicine, p. 117.
la
De
348
MELANCHOLIA
349
clouding of consciousness, leading in the greater number of

cases, after
tion.
a prolonged course,
to
moderate mental deteriora-
Etiology.
The
sixty.
disease
is
essentially
senile period, as the majority of cases occur
one of the early between the ages

in
of fifty
sixty.
and
It
seldom develops under forty or over
Sixty per cent, of the cases are
women,
whom the
disease tends to occur
somewhat
earlier,
some
relation
to
the
climacterium.
apparently bearing Defective heredity
occurs in only a little over one-half of the cases, but it is a striking fact that the parents and brothers and sisters of melancholiacs frequently suffer from apoplexy, senile de-
External influences, such as mental shock, especially illness and loss of friends, acute and chronic diseases, and surgical operations, seem to play a
mentia, or alcoholism.
rather important role as exciting causes of the disease. In many cases there is found Pathological Anatomy.
extensive arteriosclerosis
and kidneys.
atrophy.
cortex, in
and its attendant results in the heart Sometimes there is evidence of beginning brain Alzheimer found, in the deeper layers of the addition to the changes in the nerve cells, an exis
tensive
production of the neuroglia. The onset of the disease Symptomatology.

fibril
is
gradual,
and
months and even years by many indefinite prodromal symptoms; such as, persistent headache,
often preceded for
appetite, constipation, palpitation of the heart, ringing in the
ears,
vertigo, indefinite pains, general debility, insomnia, loss of
and increasing difficulty with work. The patients at first become sad, dejected, and apprehensive, and find no enjoyment in their work or home environment. They are overshadowed by doubts, fears, and self-accusations, and cannot be consoled.
confused,
They feel ill, complain of being dull, and forgetful, and find it difficult to do anything.
350
During this period there are occasional days when they are free from fear and sorrow.
Delusions of self-accusation become prominent. Sometimes the patients accuse themselves only in a general way:
they are wicked, are not worth anything, have made fools of themselves, have been impure, and are not worthy to live.
But usually the self-accusations refer to definite experiences. Patients become retrospective, and refer to many misdeeds in going over the past life which are held as an adequate Remote and often insignificant facts basis for their sorrow.
are recalled, such as the stealing of fruit in childhood, disobedience to parents and neglect of friends, which now cause them the greatest sorrow and anxiety. Their whole life has been made up of similar misdeeds. patient was miserable
because she had requested her sick sister to remain out of the kitchen another, because at the death of her mother she had
;
allowed
property.
herself
to think of
and mention the
division of
Many
refer to former sexual indiscretions.
Some
patients reproach themselves for everything; they cannot do anything right. Everything in the environment is a
source of special anxiety to themselves; the lamentations of a fellow-patient are directly the result of their own misdeeds.
Others want for food
if
they
eat.
These references vary from
day to day, or may be maintained with great firmness for a long time. Quite often the self-accusations refer to religious
patients are not as fervent in prayer as formerly; they no longer possess real religious feeling, or have sinned against the Holy Ghost, are possessed by the
experiences.
devil, etc. Occasionally their self-accusations center about actual misdeeds, which during health long since ceased to cause anxiety.
The
In addition to these self-accusations the patients sometimes harbor the conviction that they themselves must be
MELANCHOLIA
killed or that
351
one of their children
is
to be sacrificed.
" furthermore, are constantly rinding "signs" and meanings" which God has intended for them. There are often associated with these delusions of self -accusations
They,
many
other
depressive delusional ideas, chief among which are the fears The patients believe themselves so wicked of punishment.
that
God has
forsaken
them and they
are
doomed
to hell,
they will be turned out of their home, brought to court, thrown into prison, or killed outright. People are waiting
outside to carry
them
off,
a death warrant
is
already signed.
no need of taking food; they would rather starve and suffer for their misconduct, and even ask to be executed. Not infrequently they exaggerate their misdeeds and confess crimes which they have never committed, in order to
There
is
secure severer punishment

sciences.
and
to relieve their guilty con-
In other cases the delusions are of

driacal nature.
a more hypochon-
Patients insist that they are the most unfortunate individuals in the world; the stomach is gone, the lungs are filled up, the limbs shrunken, and all sensation
lost.
The brain and nerves

They
former sexual abuse.
are rotting away as the result of fear that they are dying of con-
sumption or cancer, and that they are going out of their minds and must end their days in an asylum. They maintain that the body has been poisoned, destroying all appetite, and now
they must starve. They also express considerable fear for themselves and families; they will be deprived of their home, some great calamity will visit them, the children will
they themselves will be robbed and driven from the church and damned by God.
die, or
killed, will
be
These depresrefuse to spend
sive delusions so thoroughly influence their actions that they
become
seclusive, eat sparingly or not at
all,
money, and
clothe themselves
and
their children scantily.
352

give
They
to
up everything because they have only a
short time
live.
Hallucinations of hearing and sight often accompany this condition, but they are usually indefinite and of short dura-
The patients also refer to an inner voice which commands them to commit suicide, or constantly repeats to them that they are wicked and guilty. The consciousness is usually clear. The patients are well oriented, with the
tion.
possible exception of
some delusional
ideas, in accordance
with which they may claim that they are in a prison, or they may mistake strangers for acquaintances and insist that the
letters
ideas,
which they receive are not real; but in spite of these it may be readily seen that apprehension itself is not
disordered.
much
is coherent and relevant, but the content is usumonotonous and centered about the depressive ideas, to ally which they constantly recur, recounting their various misdeeds and fears. Very often they show a tendency to repeat
Thought
certain phrases, as
"
Let
me
go home,"
"
I
"
Let
me
go home;
"
"
want to
is
see
my
children,"
want to
see
my
children."
There
usually some insight into the change which they have undergone and they will complain that their head is not right,
but they
such.
fail
to recognize
many symptoms
of the disease as
a smaller group of cases of melancholia of involution occurring somewhat later in life, in which the various
is
There
delusions of self-accusation, of fear, misfortune, and persecuIn these cases tion are much more fantastic and senseless.
the entire environment appears to the patients to be changed. Their home is transformed into a dungeon, into a house of ill
repute, or a deserted prison
escape.
from which there are no means of Things about them seem unnatural and have a
gloomy aspect; passing carriages are regarded as a funeral
MELANCHOLIA
353
procession; the tolling of the church bell indicates that some one has died. A spoon lying on the table means that medicine has been taken
by some one who

nails
is
now
at the point of
death.
Hammer and
found on the
floor signify that
scaffold is being secretly built for their execution. Chance remarks have a hidden meaning. Their food is the flesh and blood of their relatives. Everything is awfully changed for
them; friends and

are
relatives are not real;
the sun and the
moon look different; the end of the world has come; and they now to be passed into a lion's den. The patients accuse
themselves of horrible crimes, for which they are exiled or must die on the gallows; have murdered their husbands,
devoured their children, or have brought sin upon the whole world. All wickedness is due to them ; they have desecrated the communion bread, or have spat upon the image of Christ.
They
are totally unworthy, should be buried alive, no one should speak to them, hanging is too good, and they should
be thrown into molten metal. In some cases the so-called "

nihilistic delusions" (delire
de negation) predominate, when the patients claim that nothing exists, there is no more food, no more houses, no more trees, no cities, no day or night, no sun or moon, no
living being.
They
are alone in the universe, as there
is
no
They themselves have no name, no wife, no children. cannot eat, cannot speak, cannot die. Their body is all They shrunken up, their bowels never move, and food has been
world.
accumulating in them for months. They no longer possess a heart or lungs; they cannot breathe or even walk.
Extremely absurd hypochondriacal ideas are apt to be expressed. The patients claim that they have no breath, the
blood has stopped circulating, the veins have dried up, the eyes are rotting away, maggots are crawling under the skin,
their brain
is
solid rock, their limbs are
transformed to hoofs
2A
354

face to that of a wild animal.
and the
Occasionally sexual
delusions of a silly character are present, the patients
main-
taining that they have been outraged at night, are now in a house of ill repute, or surrounded by men disguised as women. These depressive delusions are definite, coherent,
and usually
well-retained.
There are a few
cases, especially
those with progressive mental deterioration, in which a few expansive delusions appear.
Hallucinations, especially of hearing, and also of sight are prominent. Voices and bells are heard, the devil commands
them, strangers insult them, and they hear the evil thoughts of others. They see strange forms beside them at night,
moving bodies and spirits. Occasionally they detect strange odors and tastes in food, and smell vapors at night. Consciousness in these cases is usually clouded and there is some disorientation for time, place, and persons. The train of thought is somewhat confused and monotonous, with a
tendency to repeat compulsively such phrases
I
it
do?"
is
"What
did I
do?"
"My God
how
What did my God !" Yet

as,
"
sometimes surprising to find
well patients answer
questions and describe their symptoms. Sometimes the patients are partially conscious of the nature of their illness
and complain that they have been made
foolish
and crazy by
In other
poison placed in their food or hypnotic influence.
cases the patients are wholly unable to recognize the contradictions in their absurd statements: at one minute they will
claim that they have been destroyed by poison, and at the next that they cannot die. The emotional attitude is uniformly one of depression. The
basis for this emotional depression seems to be fear, a feeling
of oppression,
it is
an inner
anxiety.
Some
patients claim that
a heavy weight were upon the chest. They are timid, uneasy, and feel as though homesick. The fear is
as
if
MELANCHOLIA
increased
355
by
association with those
who
are accustomed
to arouse in
them the deepest

create
little
feelings, while strangers
and
new environment
tional outbreaks
emotional reaction.
Emo-
may be present at times, when the patients are greatly agitated, and may even present a dreamy disturbance of consciousness. These frequently follow visits of
relatives or
some unusual occurrence.
In conduct, the patients no longer feel the impulse to work; work is hard to finish. Yet they cannot remain quiet, they cannot remain in bed, and wander about the house in an
They complain, lament, and pray; visit and the clergy in order to receive sympathy, physicians although they know that no one can help them. Many
aimless manner.
patients develop a feverish activity, they beg piteously for work, they work at night and struggle along until
completely exhausted their sorrow and fear.
in
order to take their minds off
The countenances
their anxiety.
of the patients give clear evidence of
Occasionally in very severe cases there
may
appear transiently no means represents an elated emotional
peculiar indefinite laughter,

state,
feel
which by but is rather
an expression
of desperate irony.
They
compelled to
talk about their condition.
They always have something to communicate to the doctor, but one finds that it is always the same old story. It is a striking peculiarity that these patients become quiet when transferred to a new environment. They become natural in their manner, are approachable, and
are able to conceal their anxiety. They claim that everything will be all right again if they could only return home and to
work, but careful observation shows the real depth of their emotional excitement. After the disease has been in existence some time, the patients may be able to remain quiet and more or less indifferent for a much longer time. But as soon
356
as one comes into close companionship with them, he will observe occasional evidences of emotional outbursts.
Commands
create
free
are carried out without delay, unless they
some anxiety. The individual movements are usually and unrestrained, although they are usually performed
without any special strength or rapidity, especially in patients much reduced physically. There is no striking disorder in
writing.
and many even refuse food sometimes because they wish to die, at others altogether, because they are not worthy of food. Others suspect poison or excrement in their food. Similarly, patients refuse to
patients eat irregularly
The
take medicines and to bathe themselves.
Some
patients are
untidy and even soil themselves. The tendency to commit suicide is more pronounced and more to be guarded against in melancholia than in any other form of mental disease. The desire to end life may be the
outcome of deliberation, or because they are repudiated by God. But usually the thoughts of death arise suddenly and
are
impulsive. Not infrequently they suddenly develop during convalescence. Often their attempts at suicide are
not remembered. Sometimes the suicidal attempts are among the first symptoms of the disease. Every melancholiac should,
therefore, be regarded as a dangerous patient,
so,
and the more
the more conscious he

his
is
ing
anxiety. patients resort to all sorts of devices to accomplish their purpose. Some attempt to drown themselves in the bathtub, others
Determined to
and the more capable of concealcommit suicide, these
ram
their heads against the wall;
many hang
or
their necks.
attempt to strangle themselves by tying something about In their agitation they seem to be quite insensible to pain. One of my patients reduced her scalp to
pulp with a hammer, fracturing her skull in several places.
MELANCHOLIA
Other patients swallow that they can secure.
glass, nails, ink, or in fact
357
anything
In case the anxiety is accompanied by greater excitement, the patients cannot remain quiet, but pace back and forth,
wringing their hands, pulling at their hair, moaning and lamenting until so hoarse that they can barely speak aloud. In their great anguish they persistently pick at their nose,
face, or fingers until
smeared with blood, pull out their
and pound themselves. Kraepelin whether this extreme picture really belongs to questions melancholia or should be classified in a group as yet unThese cases, anatomically, usually present differentiated. severe and extensive lesions in the cortex in which there
hair, tear their clothing,
is
destruction of very
many
sleep
nerve
cells.
is
Physical Symptoms.
Insomnia
is
nent symptom.
The
an early and promiscanty, much disturbed by
dreams, and unrefreshing. Occasionally there are observed the early signs of the senile changes; such as attacks of dizziness, sluggish pupillary reaction, paresis of the facial
muscles, and tremor of the tongue
and hands.
The
patients
also complain of uncomfortable sensations about the heart;
" a sort of tension, a pressure, or an anxious feeling," which The muscular power is diminis regularly worse at night.
ished and there

nutrition suffers
The is some general physical weakness. and the weight falls. Appetite is poor or
completely lacking, the bowels are very sluggish, the tongue The mucous surfaces are coated, and the breath foul.
anaemic.
The temperature frequently remains below normal.
Circulatory disturbances are often present; as, cyanosis, The pulse may be coldness and edema of the limbs. small and irregular or slow, and the arteries may give
evidence of
beginning
sclerosis.
Other changes, indica-
tive of senility, are sluggish reaction of pupils, grayness of
358
the hair, cessation of the menses, dryness and harshness of the skin.
Course.
There
is
duration, and a
of recovery the
still
more gradual convalescence.

lasts at least
a gradual development, a prolonged In cases

twelve months to
whole course
two
Short remissions, during which there is only a years. partial disappearance of the symptoms, are characteristic of
the entire course.
There
is
ment toward evening, and

during the morning.
of annoyance, fatigue,
visits.
often present a daily improvean exacerbation of the symptoms
Exacerbations often arise as the result
and
excitation, such as that
induced by
nutrition, gradual improvement an increase in weight, may be regarded as a favorable sign. The remissions become longer and more marked, and the anxiety gives way to irritability and fretfulness; the patients then begin to display interest in work and reading.
of the sleep
and
especially
Even when convalescence is well established, it is not unthem to have " bad days," during which they are troubled and fearful. The distinguishing characteristics of melanDiagnosis.
usual for
slow development, uniform course, long duration, gradual improvement, and doubtful
cholia
of
involution
are
the
These characteristics only partially suffice for of melancholia from the depressive of manic-depressive insanity. In addition, the disphase
prognosis.
differentiation
quietude of the melancholiac

dejected and hopeless
patient.
is
contrasted with the
more
attitude of
is
This difference
the manic-depressive especially well marked in the
early stages of the disease,
when the melancholiac shows
more
cholia
clearly anxiety
sive patient
the
and restlessness and the manic-depresa dismal despondency and sadness. In melanemotional attitude is much more uniform.
Although the melancholiac
may show some
variation in the
MELANCHOLIA
intensity of his feelings, the anxiety
is is
359
not possible, as
it
sometimes
is
always present, and it in manic-depressive in-
by consoling or joking with them, to make them cheerful and smiling. Furthermore, in the psychomotor field we do
sanity,
not observe the retardation, which

in manic-depressive insanity.
is
usually so pronounced
diffi-
The
patients have no
culty in expressing themselves orally or
by writing
If
they are
unhampered
in their
movements and
actions.
they hap-
pen to be silent and refuse to speak, it is evident that this arises from their desperation or their delusions. They are
usually communicative can secure consolation.
and
talkative
enough whenever they

in
some of the mixed phrases of manic-depressive insanity, in which the despondency is associated with some excitement and not with
differentiation is
The
by no means as easy
retardation.
In such cases the distinction depends upon the

irritable, is
fact that the emotional state in the

less
anxious than
mixed phases is usually accompanied by grumbling and
at times
faint-heartedness, that restless patients can be influenced by conversation to become quiet and even easily cheerful, and finally, that the excitement is not an expression
of the feelings, but
in
an independent disturbance which stands
no
The
is
relation to the intensity of the feelings. depression of catatonia developing during involution
distinguished from melancholy by the presence and persistence of hallucinations and the inaccessibility of the patients. The melancholiac is resistive and inaccessible only in con-
nection with his anxiety or his delusions. He is usually influenced by conversation, and participates in the conversation
when
visited
by
friends,
while the catatonic shows
emotional indifference, negativism, and constrained and manneristic conduct. The uniform lamentation and wringing of the hands in melancholia contrasts with the senseless
stereotypy of the catatonic.
360

characteristic
of
senile
Symptoms
dementia sometimes
develop in melancholia, rendering the prognosis less favorable. Such symptoms are, chiefly, the interference with the
impressibility of
memory, the tendency
to fabrications, loss
of orientation, emotional indifference, silly obstinacy,
and
nocturnal restlessness.
of delusions
is
The
fantastic
and
nihilistic
character
not an unfavorable sign, but senile physical changes are; namely, decrepitude, atrophic changes in the skin, bones, and muscles, and the evidences of arteriosclerosis
in the heart
and
vessels.
Melancholia has no connection with the arteriosclerotic

brain lesions.
The depressed
states occurring in arteriosck-
rotic insanity are distinctly
hypochondriacal and accompanied by evidences of dementia and of severe brain lesions. Considerable trouble may be experienced in differentiating
the depressed form of dementia paralytica. In melancholia one finds a subacute onset following definite prodromal
symptoms, greater or
less clouding of consciousness, a more consistent emotional attitude, and absence of evidences of mental deterioration early in the disease, while in dementia
paralytica there
a gradual onset with early evidence of mental deterioration, defective time orientation, poor judgis
ment
and contradictory delusions. silly the emotional attitude does not always corFurthermore, respond with the ideas expressed, and consciousness is more
and
memory,
deeply clouded.
The prognosis is not favorable, considering Prognosis. that only one-third of the cases fully recover. Twentythree per cent, of the cases improve so as to be able to return
home and
tenance of
live comfortably,
sometimes aiding in the main-
the family, twenty-six per cent, become deand nineteen per cent, die within two or three years. mented, The patients, being apathetic and anergetic, and taking little
MELANCHOLIA
exercise
361
ated, tious or chronic disease.
and insufficient food, become more and more emaciand finally succumb to cardiac weakness or some infec-
The prognosis is less favorable in cases occurring after fifty-five years of age. In those cases that improve, but do not recover, the depression
and the delusions gradually disappear, and the consciousness becomes perfectly clear, but the patients fail to develop full interest in the surroundings and to adapt themselves to any kind of work. They are dull, sluggish, and In those indifferent, and tend to be low spirited and tearful. delusions fade very graduthat become more demented the ally, but the patients fail to gain insight and show poverty of thought. They are forgetful, apathetic, and entirely unable
to apply themselves. They stand around stupidly or lament Others develop the typical in a monotonous fashion. picture of senile dementia. Residuals of former delusions,
as well as a few hallucinations
and some expansive
ideas,
remain.
Treatment.
"
The
all
chief essential is the establishment of a
rest cure," which, first of all,
demands the removal

influences,
of the
patients nearest relatives, the
from
deleterious
home
it is occupation. patient to a sanitarium or hospital. urgent if suicidal tendencies develop.
Hence
including the environment, and the customary usually necessary to send the
This
is
particularly
It is necessary in most cases that the patients be confined in bed with short intermissions, with sufficient and constant
attendance.
the patient can be confined in bed out of doors in a secluded, partially sheltered, and sunny place,
If
be found decidedly beneficial. It aids in alleviating insomnia and affords a more interesting and attractive
it
will
In very light cases a suitable change may be found in removal to a different boarding-place or into the
environment.
362
associations of a happy family. It is decidedly not advisable to attempt such distractions as might be afforded by long journeys, sight-seeing, and constant company. The rest in
bed should not be too prolonged; later it is best that it be gradually replaced by short drives or walks, combined with
daily change of scenery.
Of next importance
is
nutrition.
nutritious, given in small quantities
The food should be and at frequent intervals.
Monotony
combined,
in diet should always be avoided
tastes of the patient.

if
by consulting the Careful regulation of the intestines,
proves the appetite.
necessary, with rectal injections, usually imExtreme anxiety and restlessness often
necessitate artificial feeding
by stomach or nasal tube
in
order to maintain nutrition.

cardiac weakness,
to overcome,
it is
When this is contraindicated by
Insomnia, which
is
is
necessary to resort to saline infusions. both troublesome and often difficult

first
best combated at
by prolonged warm
baths in the early evening, warm packs, or gentle massage provided it does not increase the agitation. Hot malted
milk before retiring
may
aid in inducing sleep.
These
measures, well carried out, often render hypnotics unnecessary, the use of which is always inadvisable because of the
prolonged course of the disease.

is
Of the hypnotics, alcohol

fluid
the most
useful.
Paraldehyde, one-half to one
$ram, and one-half
trional in ten to fifteen grain doses, veronal seven

grains,
and somnos are the most
useful.
distressing condition of anxious restlessness may be combated with opium. It is best given in rapidly increasing
The
doses beginning with five drops and reaching thirty to fifty drops of the tincture of opium three times daily, which is
gradually reduced as soon as the restlessness begins to subside. This drug sometimes not only fails, but serves to aggravate the symptoms,
when
it
must be withdrawn gradually.
MELANCHOLIA
Improvement from this source,
a few days.
careful,
difficult to
if it is
363
to occur, appears within
Suicidal tendencies
necessitate
painstaking,
and constant watching, as melancholiacs are the most
thwart in their attempts at suicide. This care must be as strenuously observed until recovery is well established.
The psychical influence which may be constantly exerted over the patients by those in attendance is of the greatest value in alleviating distress, modifying the delusions, and
relieving the anxiety.
gentle,
For
this reason the
manner should be
friendly, and assuring, and some attempts should be made to lead the thoughts of the patients away from always As the patients improve there should their depressive ideas.
be a systematic effort to gradually engage them in some

light
employment, as sewing, reading, writing,

relatives are always deleterious
etc.
Visits
from
and
it is
in the height of the of the
disease
must be forbidden
Finally,
utmost im-
portance that the patients be kept under observation and safe index of this treatment until thoroughly recovered.
may
be found in their insight into the disease and the
return of normal sleep and nutrition.
B.
PRESENILE DELUSIONAL INSANITY

a small group of cases appearing during involu-
THERE
is
tion which are unlike either melancholia or senile dementia,
showing many of the characteristics of dementia praecox. It has been tentatively differentiated and characterized by the
of marked impairment of judgment, numerous unsystematized delusions of susaccompanied by picion and greatly increased emotional irritability.
gradual
development
Etiology.
The psychosis
is rare,
times in ten years' experience. The are women, in whom the disease appears between
to sixty-five years of age; while in There seems to be fiftieth year.
disposition to the disease.
occurring only twelve majority of the cases

fifty-five
men
it
occurs about the

pre-
marked hereditary
The onset of the disease is gradual, Symptomatology. with a change of disposition. The patients at first become
quiet,
ritable.
seclusive,
Then and transitory, but vague

definite.
discontented, moody, suspicious, delusions gradually develop which at

later
and
first
ir-
are
become more permanent and
driacal delusions.
appear are the hypochonpatients complain of the most varied and changeable nervous sensations and pains, spasmodic
Among
the
first
to
The
twitchings, vertigo, troubled dreams, debility, malaise, roaring in the ear, etc., which remind one of hysterical
complaints.
senseless,
These ideas
all
later usually
become somewhat
is
and the
patients complain that the spine
dried
up, the brain shrunken,
strength has departed,

364
etc.
365
Meanwhile, fantastic delusions of suspicion appear. The patients claim that their clothing has been exchanged or stolen; that articles of furniture have been removed and
others of less value substituted;
thieves are about.
They
suspect poison in the food; accuse the physician of trying to get rid of them, of being obscene, of removing the womb,
or making them ill for the purpose of studying their case. The husband believes that the wife is secretly dosing him. Delusions of infidelity are usually very numerous and prominent. The husband is accused of eying women on the
street, of flirting
servant,
and receiving
with every one he meets, of caressing the letters from the schoolmates of his
He arranges to meet women whenever he leaves and has intercourse with every one possible. The home, husband is suspicious of his wife because she leaves him at
daughter.
night, or is surprised
when he
returns
home
It is characteristic of all these delusions that
unexpectedly. they are
exceedingly unstable. They appear at one moment, are abandoned in the next, and again recur in another form. As regards insight, many patients admit that they might have
but they fail to really appreciate the senselessness of their ideas. Half an hour later you may find them in the greatest distress, because they
sick,
been mistaken and that they are
have been poisoned, or because some one has hidden under the bed ; they are going to die, etc. soothing word usually suffices to quiet them and dispel their fear.
Hallucinations
cases.
accompany the delusions
in only a
few
patients are sometimes threatened, or hear boast of intercourse with their wives. The cries strangers of their ill-treated children reach them. At night they may see dark forms stealing out of the room, or feel some one lying
The
beside their wives.
It is a noteworthy fact that the patients do not make a genuine attempt to intercept these guilty
366
parties.
If

a search
is
instituted
and they
fail
to find
one, they express anger only because connubial fidelity violated with such shamelessness and slyness in their
any was
own
presence. Consciousness
Thought is noted in the retention of the most fantastic delusions, while the consciousness of the patient is perfectly clear. The
patients cannot see the senselessness of the delusions, and while they may claim that they are open to conviction, they can never be convinced. Their memory for remote events is
unclouded and orientation unimpaired. coherent, but judgment shows a marked weakness,
is
unimpaired.
However, in the narration
of their delusions,
they add
all sorts of
The
emotional attitude at first is

it
embellishments and misrepresentations. one of depression and fear;

to
suicidal
occasionally
leads
attempts.
Later there
usually appear some excitement and irritability. The patients then talk a good deal, make verbose complaints, stir up boisterous scenes, fly into violent passion, and are abusive, but they are usually quieted without difficulty. They sometimes laugh and cry without cause. The conduct is characterized by all sorts of senseless
actions.
In accord with their delusions
many
patients run
about from one physician to another, and solicit much advice without attempting to follow any of it. Some stop
eating, seclude themselves, destroy everything within reach, and become violent. Jealousy leads to strict surveillance of
the husband or wife.
The servant
is
sent out in search of
them; torn letters in the waste basket are placed together in order to obtain proof of guilt, and the supposed seducers may
be publicly accused. With the advance of the disease the delusions become more
senseless; the patients claim that the wife
being tortured, the son nailed to the
floor,
and children are or suspended on a

fence;
367
the wife wanders nightly from place to place, and every one is talking about it. Female patients believe that their husbands have intercourse with their own children, and
even with other men, disguised as women.
They
are aware
of this only through sensations in their own bodies, whenever they are deceived. The precious Lord proclaims
everything, talks to them, and lies beside them at night like a shadow. Persons and the environment are changed; their bodies are disfigured and influenced. For this reason, many
patients remain in seclusion, veil themselves, and at times refuse to speak and then suddenly become very friendly and
These delusions frequently change, and may temporarily fade away, although some general signs of them are constantly recurring. In spite of progressing
communicative.
mental deterioration, the patients do not become incoherent. Some regard these cases as paranoia, but they Diagnosis.
certainly differ
from paranoia,
in that the delusions are not
systematized. frequently, the
The
persecutors remain indefinite or change suspected consorts are not regarded as
enemies, but are often thought to have been seduced. Moreover, the patients do not find in their delusions any broad
basis for action,
and except
for their occasional violent out-
breaks, do not treat the supposed persecutor as especially they associate with their faithless wives, in fact even force themselves into their company, and surprise one
hostile;
by becoming
just
friendly toward those persons
whom they
have
previously suspected and accused.
They
often prefer to
be confined in the hospital in spite of complaining of all sorts of persecution, because they enjoy the protection afforded
them
there.
Finally, the delusions
do not continue
stable,
but change frequently, and sometimes even in a short time. The conditions of excitement seem to depend less upon
deliberation than emotional vacillations.
368

consider these cases of dementia prcecox, which
Some
may
occur at this age, although not frequently. These patients do not present catatonic symptoms. The peculiar resistiveness and excitement occasionally manifested are not compulsive or spontaneous, but depend upon delusions or
moods.
The
patients do not
on the contrary,
become apathetic rapidly, but, continue irritable and interested, while
disturbances of judgment greatly predominate over those of the emotions and actions.
Prognosis.
The outcome
is
never
characterized
by
profound dementia or confusion of speech, but by a moderate deterioration, with isolated, changeable, and incoherent
delusions.
Recoveries or marked improvements are not
likely to occur.
Treatment.
The
treatment
is
wholly
symptomatic.
Most patients are troublesome and need hospital treatment, but some, under favorable conditions, are able to remain at
home.
0.
SENILE DEMENTIA 1
is
SENILE DEMENTIA
volution
characterized by
a gradually progres-
sive mental deterioration, occurring during the period of in-
and accompanied by a
It
series of lesions in the central
nervous system.
comprises several groups of cases, in-
cluding simple senile deterioration of lighter

grades, presbyophrenia, sional insanity.
Etiology.
involution,
senile
and severer
senile
delirium,
and
delu-
The
but
is
disease
may appear
at
any time during
sixty
and
encountered most frequently between Individuals with a seventy-five years of age.
endowment, worn with hardships, and may succumb before Men who have been more exposed to overwork and sixty. excesses develop the disease earlier than women. Defecfaulty constitutional
especially those addicted to excesses,
tive heredity occurs in
about
fifty
per cent, of cases, but
is
confined
mostly to senile deterioration in parents and in

sisters.
brothers and
Very frequently the disease develops immediately following an injury, particularly head injury,
shocks, also acute influenza and bronchitis.
emotional
febrile
diseases,
especially
Fuerstner, Archiv
f.
Psychiatric,
XX,
Noetzli,
Uber Dementia
f.
Senilis, Diss. Zuerich,
1895; Alzheimer, Monatsschrift

Scholoess,
Psychiatric u.
Colella,
u. 10, 1899; Annali di Neurologia, 1899, 6; Zingerle, Jahrb. f. Psychiatric, XVIII, 256. Pickett, The Jour, of Nervous and Mental Disease, 1904,
Neurologie, 1898, 101;
Wiener Klinik,
XXV,
p. 81.
2B
369
370

All
advanced cases of
senile
dementia present, both macroscopically and microscopically, atrophy of the nerve substance. The brain weight is from
two hundred to
five
hundred grams below normal.
There
may
be compensatory thickening of the cranium, and in-
The dura
crease of the cerebrospinal fluid (hydrocephalus ex-vacuo). The Pacis usually adherent to the calvarium.
chionian granulations are increased in size. Pachymeningitis interna hsemorrhagica is often present, and sometimes
to
an extreme degree.
over
the
The pia
is
somewhat thickened
uniformly
entire
cortex,
may
contain
many
corpora amylacea, and is almost always edematous. The convolutions are narrow and shrunken, and the gaping Minute fissures contain blebs filled with serous fluid.
hemorrhages are sometimes found in the cortex, corona
and basal ganglia. The ventricles are much dilated and ependymal walls thickened, and occasionally granular. The choroid plexuses usually present various stages of cystic The cerebral vessels exhibit arteriosclerosis, degeneration. in which there are often evidences of hyaline changes, but it is more characteristic of the vessels in senile dementia to show a rich pigmentation of the endothelial and adventitial cells. The fact that the blood vessels, in simple senile deterioration,
radialis,
are only moderately involved, favors the view that the vascular changes in senile dementia cannot be regarded as the particular cause of the disease. Further proof of this is
found in the fact that there are

sive vascular lesions of the
many individuals with extenbrain who do not exhibit signs

more or
less extensive,
of senile dementia.
Nevertheless,
vascular
lesions
commonly accompany
senile
dementia.
There occasionally occur combined forms of senile and " senile dearteriosclerotic insanity, called by Alzheimer
cay"
(see p. 334).
SENILE DEMENTIA
371
Microscopically, the nerve cells present different grades of the chronic cell change in addition to much pigmentation.
Complicating the chronic

those acute
cell
cell
change there
may
occur any of
changes described in paresis (see p. 282). Both the tangential and radical fibre tracts in the corona
present more or less atrophy. The neuroglia cells are more numerous and show an increase in the number of nuclei,
the
cell
bodies often forming distinct clumps (raseri) with a
thick network of fine glia fibrils. Many of the neuroglia cells show evidences of extensive degenerative processes; such as,
vacuolization,
nucleus.
cells
marked pigmentation, and atrophy of the The spinal cord presents an atrophy in its ganglion
fibre tracts.
and
Calcareous placques are sometimes
The entire pathological picture, however, pia. as well as the clinical picture, but as yet it is impossible varies, to establish any definite relationship between the different
found in the
pathological and clinical pictures. The other organs of the body present senile atrophy and arteriosclerotic changes. The condition of the heart, with
chronic endocarditis and fibroid changes in the myocardium, is of importance, as it interferes with cerebral circulation.
Symptomatology.: The apprehension of external impressions is slow and difficult. The patients fail to note
details
and to understand the connection of things that are complicated. They, therefore, become easily disoriented, cannot see the point in a discussion, and overlook important matters. They are drowsy, disinclined to think, somewhat dazed, and easily lose the thread of a conversation. Thought becomes stagnant and the patients are unable to change their viewpoints or to gain new ones. The old trains of thought,
being inaccessible to new ideas, do not get beyond the beaten paths. Ideas, once aroused, are constantly recurring, without any regard for the circumstances.
The mental
elabora-
372
tion of external impressions, the consideration of cause and effect, and the critical examination of ideas is always in-
adequate and uncertain.

total inability to
This
explains
the
comprehend the views and
patients conditions of
others, as well as the inflexibility of their opinions
and
their
Their delusional ideas susceptibility to delusional ideas. consist mostly of excessive fear of illness, senseless distrust, or childish egoism. Other prominent delusions are those of
and robbery. They commonly believe that many are done to annoy them and that their property has things lack of genuine insight into been taken from them.
reference
their infirmity, necessitating the
appointment of a trustee
or
conservator, creates still other ideas of persecution. Hallucinations and especially illusions are common.
The
failure of
memory
is
especially
memory
for recent events.
always a prominent symptom, Present and passing
time seem to be completely effaced from memory. Patients forget where they were yesterday, or where they have placed things, do not realize that they are relating the same story that they told yesterday or perhaps a few hours ago, cannot recall the names of recent acquaintOn the ances, and even forget the names of old friends.
events, within a short
other hand,
of recent
memory
for events of early life
is
well retained
and furnishes the
chief topics for conversation.
The gaps
are very often made good by extensive fabrications. Finally, as the result of the progressive impairment of memory, to which nothing new is ever added, there
memory
develops an increasing impoverishment of the store of ideas, with an extraordinary dearth and uniformity of the content
of thought.
and lack of sympathy are the prominent characteristics. The patients become apathetic; they fail to enter into the sorrows and joys of
In emotional
attitude, indifference
SENILE DEMENTIA
373
those about them, and do not grieve at the loss of friends. Self-interest, with the gratification of personal whims, precedes everything. They are no longer interested in their family or home. This may advance to genuine avarice, the
overwhelming even filial affection. The fundamental emotional tone is sometimes that of surly disfeeling of greed
satisfaction,
and
at others a
childish
happiness and an
irritability for short
exalted self-confidence.
There
may
be
are inconsiderate, arbitrary, dogmatic, periods. and offended at any opposition. The emotional states are
The patients
both superficial and transitory; extreme and tearful sympathy or silly happiness may be aroused on the slightest pretext
sexual feelings are frequently increased, impelling the patients to enter into improper sexual relations, especially with children ; to use
just as rapidly disappear.
and
The
obscene language, to dress in an attractive manner, plan marriages, and in extreme conditions to expose themselves.
The
conduct of the patients varies greatly.
Many remain
and contented, and, in spite of increasing decause no trouble and can be kept at home. Other mentia,
quiet, orderly,
an increasing restlessness: they abuse those about them at every opgrumble, quarrel, curse,
patients gradually develop
aggressive. Many to idulge in excesses, to masturbate, to wander patients begin away from home, to make foolish purchases and plans, to hoard all sorts of plunder, and ultimately get themselves into
portunity,
and often threaten and become
many
difficulties.
But nocturnal
restlessness is
most charac-
teristic.
It consists in getting out of
and
dishevelling the
bed, wandering about the house with a light, and rummaging chests and closets without evident purpose. During the day these patients are weary and drowsy and frequently fall to Patients are unable to sleep during conversation and meals.
care for themselves properly and are dirty about their clothing.
374

In addition to the insomnia, there
Physical Symptoms.
is
and some anorexia.
usually a pronounced deterioration in the general physique The patients usually look older than
they really are, the musculature is reduced, and the strength below par. A fine tremor is characteristic of the senile, and
can be distinguished from the tremor of the paretic and the

irregularities in the separate there are a series of physical sympstrokes. Furthermore, toms corresponding to the cortical lesions; namely, headache,
alcoholic
by the numerous
vertigo,
convulsive seizures with transitory or permanent
aphasic symptoms, hemiansesthesias, hemianopsia, ptosis, hemiparesis of the muscles of the eye, tongue, or extremities.
The
pupils are sometimes small, or unequal, and react slugThe reflexes are usually increased, gishly or not at all.
seldom
diminished.
The
speech
is
often
indistinct.
Neuritic disturbances are frequent. Finally, evidences of arteriosclerosis are frequently observed.
In the severer grade of senile dementia there develops great clouding of consciousness and complete disorientation. These
patients apprehend what is said to them and respond briefly in a sensible manner, but they are wholly unable to grasp
what is taking place about them. They have no idea of where they are, address their associates by the names of friends long since dead, and even fail to recognize their relatives. They have very little memory for what occurs in their daily lives, and gradually lose even their remote knowledge. They cannot tell how old they are, or how many children they have. They say they are twenty-five years of
age, have
had twenty-five
children, the oldest of

still
which
is
twenty-five years, that they
pregnant. They undress at call the physician by their husbands' names.

easily distracted
menstruate, and are now midday, thinking it night, and
They are and cannot hold long to one thought.
SENILE DEMENTIA
375
The store of ideas is greatly impoverished and the same remarks are repeated over and over again. They occasionally indulge in a peculiar senseless rhyming and a half-singing repetition of words and syllables. Numerous changing fantastic delusions are present, both depressive and expansive, and often also hypochondriacal and nihilistic. They cannot speak, eat, or sleep; nothing has passed their bowels in weeks, and the liver has rotted away. They have leaned against a radiator and burned a hole in the
lungs which has caused the heart to cease beating. Their abdomens have been cut open and organs removed, or they will be buried alive. On the other hand, they may claim
that they possess much property, hold an important position, or are in communication with God. The delusions are apt to
be
embellished
with
numerous
fabrications.
Hallucina-
and hearing are frequently present. The emotional attitude varies. The patients are sometimes apprehensive and dejected, sometimes irritable, and at others, elated and happy, while rapid changes from one mood to another are common. In actions they display more or less restless activity, which is especially marked at night. They regularly tear and throw about their bedding, creep about the room, picking into the corners, destroying and smearing their clothing, or they laugh, sing, and run about in a silly manner. They are very untidy, and wholly incapable of caring for themselves. Insomnia is pronounced, and very
tions of sight
little
nourishment
is
taken.
In the group of cases of senile dementia called presbyophrenia, the patients, in spite of a marked disturbance of
the impressibility of
alertness, the coherence of thought,
memory, retain fairly well their mental and to a certain extent, also,
good judgment. Women predominate in this group, and chiefly robust individuals are affected. Usually the disease
376
develops gradually, sometimes following more or less definite
prodromal symptoms which have been in existence for some weeks. It may appear as an episode during the course of
simple senile deterioration.
The patients are capable tion, and of comprehending
of entering into a long conversa-
in great
measure the occurrences
in their environment, but they utterly fail in obtaining
any
conception of their own condition or of their relation to the environment. They forget almost immediately what they
have been doing or what they have heard.

casional impression
is
Only an oc-
retained,
and
especially those ac-
companied by some
orientation
is
Place and, particularly, time feeling. disturbed. Patients cannot tell where they are
strangers as acquaintances ; regretting that they cannot just recall the name, but they are confident that they have seen them before. They know
or those about them.
They greet
neither the day nor the week. They make all sorts of contradictory statements as to their age, speak as if their parents were still living, and refer to their own infant children. The
store of
Their ability to reckon may be fairly well retained, as well as knowledge of the small affairs of daily life, like the price of articles of food, cooking
knowledge also
is
faulty.
receipts, etc., but all
beyond that is lost. They cannot recall and geographical facts, the name of the President, and, indeed, sometimes even the names and ages of their own
historical
children, but yet they

facts, as their
may
be able to recall a few remote

the playmates of their
own maiden name and
childhood.
The
patients do not appreciate these
marked
defects.
When quizzed, they will explain their inability to answer such

questions by the fact that they were never interested in such things, that women are not supposed to bother about such
matters, etc.
They usually make good the
lapses in their
SENILE DEMENTIA
recent memories
377
they were busy in the morning, had been out to call on their parents, other relatives were there, and they all drank some
by simple
fabrications;
such
as, that
Now they have come here to help with some work, but are soon going to return to their place of employment,
coffee.
where they are earning good wages. These patients rarely express delusions or have hallucinations.
Their judgment
their early
is fairly
well retained as far as

facts
it
involves
knowledge and
"
that ball
is
which are at their disposal.

is
" For instance, such senseless expressions as that the snow

black," or
square" cause them to smile, and
they become indignant if told that they steal or perjure themselves. On the other hand, the patients fail to recognize the
most absurd contradictions as regards the temporal relation of events, even when their attention is called to them. They will say that their parents are no older than they, that their daughter is only three years younger, though she was born more than ten years ago. In their conversation the patients are often energetic and loquacious, although they frequently
digress.
emotional attitude of the patients is usually that of happiness with an occasional brief show of peevishness or They exhibit an interest and readily familiarize irritability.
The
themselves with their environment and can appreciate a joke. In conduct they are, in general, orderly, and busy themselves
in one
way
or another.
restlessness.
Occasionally there is some nocturnal Symptoms of severe brain lesions, particularly

attacks, are rarely encountered.
paralysis
and apoplectic
This picture of presbyophrenia
a number of years. Again simple stupid dementia.

Senile Delirium.
it
may persist unchanged for may pass over into a state of

is
This form
characterized by
a more
acute onset
and a
short course with great clouding of conscious-
378

j
active hallucinations,
and
delirious conduct.
It often
appears as an episode in the course of senile deterioration;

indeed, signs of beginning senile dementia usually precede the outbreak. Exciting causes are prominent; such as acute illnesses, mental shock, or injuries.
The patients rapidly develop many hallucinations of sight and hearing. They hear voices, threats, singing, see the devil, or crowds of men pressing upon them with knives. They are anxious and restless, claiming that they are in the
world below, surrounded by mighty powers, are bewitched and poisoned, the house is being flooded and huge boulders Disorientation is complete. The rolled about the room.
speech
is
irrelevant, incoherent,
and
flighty,
and
is
often
limited to unintelligible, disjointed words, or to a repetition There is usually great pressure of of senseless syllables.
speech.
The activity is greatly increased; they rattle doors and windows, shout for help, refuse food, resist, tear up the bedding, and crawl about the floor, etc. Insomnia is
extreme.
The
course of the delirium presents

less
many
fluctuations
and
sudden remissions, with more or

consciousness.
interval, or
it
The delirium may
complete return to clear reappear after a short
peevishness,
may pass over into a state of anxiety with which may persist, or in time entirely disappear.
In unfavorable cases the delirium becomes extreme, leading to collapse and death from exhaustion, injuries, or acute
febrile diseases.
Finally, there is a characteristic group of cases in senile dementia which has been called senile delusional insanity.
These cases develop gradually.

cent, irritable,
The
and suspicious. It are dominated by delusions ; that they believe that that they they are being robbed, are being ridiculed and insulted by
become retisoon becomes apparent

patients
SENILE DEMENTIA
their neighbors,
is
379
and are hindered in
being placed in their food.
that poison These delusions are ap;
their
work
parently scanty, somewhat incoherent, and are rarely elaborated, though they may remain unchanged a long time.
Hallucinations are often present, especially in deaf patients.
The
patients remain completely oriented. However, persons in the environment, who are involved in their delusions, may be mistaken for others. The emotional attitude usually
table
becomes indifferent, though occasionally the patients are irriand egotistical. In conduct they are orderly and tract-
able; they busy themselves
and only occasionally are
excited.
Diagnosis.
The
normal
senility,
to physiological changes such as the defect in the impressibility of

of the store of ideas,
common
memory, an impoverishment
an emo-
tional indifference, a paralysis of activity, and the development of stubborn unruliness, renders very difficult the
differentiation of the milder
forms of senile dementia.

is
wholly arbitrary. appearance of delusions and of excitement should leave no doubt as to the presence of a psychosis. The depressive states in senile dementia may be differentiated from melancholia by the dearth and the incoherence of the delusions and
the defective
certain
extent this
distinction
To a The
memory and emotional

It
dulness.
arteriosclerotic
The
differentiation of senile
is difficult.
dementia from
has already been indicated that focal insanity symptoms of themselves are not particularly characteristic of senile dementia, and point only to the fact that there is
an accompanying vascular prominent such symptoms
Therefore, the more the greater the role of are, arteriosclerotic changes. Inversely, a rapid and general decay of the mental activity, particularly a severe disorder
disease.
of
memory,
indicates senile dementia.
The same observawhich the dementia
tion holds true in syphilitic insanity, in
380
never becomes very pronounced until after a long duration, while hallucinations and delusions are more prominent. The senile delirium, except for the underlying basis of
deterioration, does not differ
from the delirium encountered

is
in other psychoses.
wholly symptomatic. The condition of faulty nutrition needs careful watching in order to secure the ingestion of a sufficient amount of easily diTreatment.
The treatment
gested food.
The insomnia
of the senile is
first
most
intractable.
employ the simplest remeit, the time the patient awakes dies; as, warm nourishment at after the sleep of the early night, prolonged warm baths, and
In combating
one should
sufficiently
warm bed
clothing, together with,
if
necessary,
hot-water bottles.
cautiously.
Warm
packs should be employed most
Of the hypnotic remedies, alcohol is most useful. Paraldehyde, chloralamide, and somnos are at times also efficient. Occasionally small and repeated doses of nitroglycerin give excellent results. These patients, if kept at home, must be watched closely at night, and placed in rooms without lights and with guarded windows in order to prevent injuries to self and danger from fire to others. If the insomnia and restlessness become extreme, the prolonged warm
bath (see
p. 140)
may
be used.
Failing in this, one should
improvise a padded room or a bed with high padded sides. In the cases accompanied by great anxiety, opium (see p. 362)
is
indicated
and often brings the desired
relief.
IX.
MANIC-DEPRESSIVE INSANITY 1
the recurrence
MANIC-DEPRESSIVE insanity is characterized by

groups of mental symptoms throughout the dividual, not leading to mental deterioration.
of
life of the
in-
of
symptoms are
sufficiently
well defined
to
These groups be termed the

of the disease.
manic,
the depressive,
and
the
mixed phases
The chief symptoms usually appearing in the manic phase are: psychomotor excitement with pressure of activity, flight
of ideas,
distractibUity,
tional attitude.
In
the
and happy though unstable emodepressive phase we expect to find

absence
of
psychomotor
retardation,
spontaneous
activity,
dearth of ideas,
and depressed emotional attitude; white the the mixed phase consist of various combinations symptoms of of the symptoms characteristic of both the manic and depresEtiology.
sive phases.
Manic-depressive insanity
is
one of the most
prominent forms of mental disease, and comprises from, twelve to twenty per cent, of admissions to insane hospitals.
Of the
etiological factors, defective heredity is the
most im-
portant, occurring in from seventy to eighty per cent, of

Kirn, Die periodischen Psychosen, 1878 Mendel, Die Manie, eine Pick, Emmerich, Schmidt's Jahrbucher, CXC, 2 Monographic, 1881 Circulates Irresein, Eulenburgs Realencyclopsedie, 2. Auflage; Hoche, Ueber die leichteren Formen des periodischen Irreseins, 1897; Hecke, Zeitschrift fur praktische Aertze, 1898, 1 Pilcz, Die periodischen Geistesstorungen, 1901; Thalbitzer, Den manio-depressive Psykose, Stem;
mingssindsygdom, 1902;
Hoch, Ref. Hand. Med.

381
Soc., Vol. V, 120.
382
cases.

The
relatives
have often suffered from the same form

is
of disease.
The
defective constitutional basis
often ap-
parent in individuals previous to the onset of the psychosis;
some are peculiar, some are abnormally bright, others are of an excitable disposition and subject to frequent and apparently causeless changes of mood, and still others are excessively shy and reserved; while a few are imbecile from birth.
Physical stigmata
in the disease
may also be present.
Women predominate
of the patients.
and represent about two-thirds
The
nal causes.
disease almost always appears independently of exterIn a few cases the appearance of the first
is
attack
coincident with the
first
menstruation.
The
first
and
subsequent may during succeeding periods of childbearing, but it is also a conspicuous fact that the attacks do not cease at the climacterium. In twothirds of the cases the first attack appears before twenty-five years of age, and in less than ten per cent, after the fortieth year, in
attacks
occur
both of which periods
women
The first attack may occur as early age, and as late as seventy years. The nature of manic-depressive insanity
nate.
greatly predomias ten years of
is still
obscure.
Several hypotheses have been formulated, but none are adequate. There are no demonstrable anatomical, pathological
lesions characteristic of this disease.
Apprehension of external impressions Symptomatology. in the manic states, with the exception of hypomania, is
more or less disturbed.
This disturbance
is
due largely to the
great distractibility of attention. The patients lose the ability to select and elaborate their impressions, because each striking sensory stimulus forces itself upon them so strongly
that
it
absorbs their entire attention.
Their attention
may
be held for a
it
is
holding objects before them, but distracted by something else. quickly Hence, the
moment by
MANIC-DEPRESSIVE INSANITY
383
environment is never fully apprehended, and the picture remains disconnected and incomplete, although there is no In the depressive serious disorder of the perceptive process.
forms
apprehension
especially
is is
more manifestly and extensively

this true in stupor.
disturbed;
Even
in the
lighter depressive states the patients are unable to elaborate
and comprehend
of the disease.
well their impressions. Consciousness is regularly disturbed in the severer forms
At the height
of
the manic excitement
the
Patients hazy impressions lead to disorientation. do not correctly understand where they are, mistake persons,
of relatives
and greet the physicians and nurses by the names

or neighbors.
This mistaking of persons sometimes arises from slight similarities of dress or facial expression, but at other times it seems to be due altogether to the capriciousness of the patients. In the less severe manic forms consciousness is very slightly disturbed. On the other hand, in
the depressive states of the disease consciousness clouded, particularly in the stuporous conditions.
is
more
Hallucinations are rare, except in the delirious form of the manic phase, and in the more marked stuporous depressive conditions, but even here they are neither a prominent
nor persistent feature. Furthermore, the hallucinations do not have the same sensory distinctness common to the sense deceptions of dementia prsecox. On the other hand,
numerous and varied
false sensations often
accompany the
pronounced hypochondriacal fears of the depressive patients. These are experienced all over the body. Patients claim
that they feel the food as
they
skin,
feel their
solving,
and
courses through the veins, that organs being consumed, that nerves are disthat little white worms are crawling under the
it
etc.
This
increased
sensitiveness
to
the
internal
processes of the
body stands out
in contrast to the loss of
384

manic manic to hunger, and to
central sensitiveness to external impressions in the states, as seen in the remarkable insensibility of the
patients to extremes of heat

pain.
and
cold,
Memory
itself,
does not suffer
Especially in the depressive states the patients are often unable to recall even simple It takes them a very long time to solve a simple facts.
although patients over their store of ideas.
injury from the disease often temporarily lose control
much
problem or to
relate some experience. During the disease It has the impressibility of memory is impaired. process been shown by special tests that manic patients make more
than normal individuals in recalling to memory their perceptions. There is sometimes a tendency to fabricaerrors
and to depict grotesque experiences. Memory for events of the attack is usually somewhat indistinct, partions
ticularly
where there has been pronounced excitement or
profound stupor.
Delusions are often present in manic-depressive insanity. In the manic phases they are changeable and frequently
appear in the form of playful boasts and exaggerations. Where the consciousness is -somewhat clouded, the patients
tend to elaborate more permanent expansive and persecutory delusions, the latter being directed particularly against the family; also delusions of jealousy and poisoning. In the depressive states hypochondriacal ideas are most
prominent, and are often associated with delusions of persecution and of self-accusation. The depressive delusions
sometimes beome markedly

expressed
insight;
fantastic,
similar
to
those
by
pare tics.
Patients
usually
express
some
they appreciate having undergone a change, but are quite apt to attribute it to misfortune or abuse of they some sort, rather than to mental illness.
385
Disturbances of thought are prominent symptoms. In the manic states a definite line of thought cannot be followed
out; ideas pass abruptly from one subject to another, and the line of discourse is lost in a mass of detail. A short
question
may
of a host of details
be answered correctly, but with the addition and side remarks that have only a distant
It is impossible relation to the subject circumstantiality. for the patients to relate any event coherently without
frequent inquiries and suggestions on the part of the listener to recall him from his digressions. There is a lack of voluntary
guidance of the train of thought
hence there are abrupt
changes in the succession of ideas influenced
happen to come into the field of vision, up from the surroundings. On the whole, there is a multitude of ideas which are not well connected. There is no controlling goal idea. The association of ideas follows along accustomed tracks, especially those that play an
important part in daily expressions; such as bits of slang and common phrases. The resulting incoherence of thought Observation of gives rise to the so-called flight of ideas.
external objects
plete,
by objects that or by sounds caught
may seem
it is
to be very accurate
and com-
but in reality
superficial.
tracts the attention,
is
apprehended, and
striking object atstarts a train of
thought, but before this has proceeded far something else obtrudes upon the sensorium, and another is started. In
thought is delayed. Instead an acceleration of the train of ideas, there is only flightiness and an instability. There is an abundance of words, not
spite of appearances, genuine
of
of ideas.
Sometimes
in the depressive forms there
is
slight degree of flight of ideas.
As a counterpart
of
to flight of ideas,
we have
retardation
thought,
which regularly accompanies the depressive
phases of the disease, and also some of the manic-stuporous

2c
386
states

and the forms
of
manic excitement
allied to
them.
Patients seem unable to marshal their ideas, and are often painfully aware of this. The individual ideas seem to develop
slowly and only after very strong stimuli. Hence, external impressions do not quickly and easily arouse a group of
associations, but the train of thought has to progress slowly
and requires an especial effort of the will. On the other hand, an idea once developed is not pushed aside by the appearance of new ideas, but it fades slowly and often sticks
with great persistency, especially if it arises in connection with some feeling. Thus there result great difficulty and
slowness of thought, monosyllabic answers to simple quesThis is apt to be regarded as tions, and a dearth of ideas. evidence of dementia, until close observation demonstrates
that there
is
no
real deterioration.
The emotional attitude in the manic forms shows more or There is a feeling of wellless elation and happiness. being with a tendency to joke and to make facetious remarks.
Irritability is Expressions of emotion are unrestrained. prominent, giving rise at times to outbursts of anger from trivial causes, but rapid changes in the emotional attitude
are
still
more
characteristic:
in the midst of joy patients of abuse
become
tearful,
and complain
and misfortune;
again, in spite of profound misery, they may burst out into boisterous laughter. These varying states appear and
disappear with the greatest rapidity.
Depression of spirits
sometimes appears for a few hours at a time during manic states. In the depressive states of the disease the emotional
regularly that of gloominess, despair, doubt, and anxiety. Patients complain particularly of the loss of in" " terest in things; they everything is the same to them," " are desolate and empty," they are dead, because they
attitude
is
have no feeling," " music does not sound natural," and
"
387
the crying of the children no longer creates sympathy." They feel as if they no longer belong to this world. One sometimes encounters moments when patients exhibit feeble
There are some cases of simple retardation in which there is no especial emotional tone. In the transition states and mixed
phases there is stupor with silent mirth, or restless mischievousness with anxiety. The disturbances found in the psychomotor sphere are prominent symptoms. In the manic states the increased
facility for
attempts at laughter and even brief gayety.
to pressure of activity.
the conveyance of stimuli into action gives rise Every sort of impulse leads to an
action, completely inhibiting all
or even
before
if
a volitional action
is
normal volitional impulses, begun, it is overwhelmed
accomplished. Furthermore, almost imperceptible impulses excite the greatest variety of movements, which are executed with unusual energy. In the mildest
half
manic states there appears a characteristic busyness and an excessive display of energy over trifles. If the disease is more severe, the actions become disconnected, and new
impulses intrude before any one object can be accomplished. In the severest excitement, the actions change as rapidly
as the ideas.
The
actions, however,
depend upon and bear
a definite relation to the ideas and emotions.

of the
The
intensity
motor excitement
largely
is
due to an increased
stimuli,
irritability
and depends
of
upon external
the removal
Unrestrained activity tends activity. to increase the excitement. The ready release of the motor
impulses perhaps accounts for the unusual absence of fatigue. In these conditions excitement may persist for weeks or
which reduces the
even months without any signs of exhaustion.

in the field of speech,
The psychomotor pressure of activity is prominent also and aids in the production of, flight of
388
ideas. The easily aroused motor-speech dispositions have a stronger influence in directing the train of thought than
the ideas arising from purely intellective processes. Instead of a logical sequence of ideas, we find that motor coordinations determine their succession; thus, we encounter those associations common in the everyday life; such as,
set phrases, slang,
of pure
as,
is
and rhymes, and finally a predominance sound associations, when are heard such productions " Sam, jam, bang, slam, hell, shell, bells," etc. Silence
impossible. The patients prattle away and shout at the top of their voices, scream, declaim with many gestures and in a pompous manner, perhaps ending in unrestrained
laughter, or they sing, now softly, now slowly. lowing is a sample of the manic production:
The
fol-
" I was looking at you, the sweet voice, that does not want sweet soap. You always work Harvard, for the hardware store.
Here is the right hand, the hand that they shot off yesterday. The love of God don't win gray hairs. I don't care if I am nine-
my father taught me to love. Neatness of feet don't win but feet win the neatness of men. Run don't run west, but west runs east. I like west strawberries best. Rebels don't shoot For three years I got over seven dollars a month devils at night. and some old rags. Take your time and be not disobedient, be God's laws are all right, but grateful when judgment day comes. Royal Baking Powder is compressed yeast. Women should never chew gum. Women should never smoke. Women should mind their own business. Fish-hooks are between the American flag, You must pay for your own red, white, and blue, Fourth of July. Prudence. I am no tobacco chewer, I am no street walker, fiddler, I am vaccinated, but McKinley does not win. My father is a Democrat. He had no work for three years."
teen,
feet,
Such incoherence
is
not the outcome of an excessive
repletion of ideas, but results from an inability to give normal individual, at direction to the train of ideas.
times,
389
if
might give expression to a similar production
he
could utter a sequence of ideas as they came into his mind. In the disease picture this ideomotor excitability regularly
leads to the expression of every idea that presents itself. The letter- writing of manic patients shows with equal
Single phrases and sentences may be well started, but are soon resolved into a senseless enumeration of catch phrases, bits of slang, and
clearness the
same disturbance.
rhyme.
and bold, while underlining, overwriting, and punctuation marks predominate. The psychomotor field in the depressive form presents a retardation of activity, due to the slowness of conversion In the of sensory and ideational stimuli into impulses.
The
script is coarse
mildest degree this retardation appears as a deficiency in the power of resolution. Actions may not only be performed
slowly, but even after being started
may fail
of completion.
The
and talking, are and without energy. Unless extreme, performed very slowly the retardation may be overcome by an emotional excitement, such as impending danger or some unusual stimulus.
simplest movements, such as walking
In the severest forms the retardation leads to a complete

abolition of all voluntary movements, producing a condition of stupor, when the patients are unable to leave the bed or
attend to their physical needs. Retardation may vary considerably in the extent to
which
tivity.
it
influences the different spheres of voluntary acThe patients may perhaps be able to dress them-
selves
employ themselves without difficulty, but from any act that demands resolution. Some they shrink patients are so taciturn and monosyllabic that it is impossible to engage them in conversation, and although they
to
and
are able to count or read aloud as rapidly as ever, they will sit for hours with a letter in front of them, unable to finish
390
writing
it.
Again there are patients who read rapidly, but line; and there are others who write long letters, but become speechless as soon as you address them. The symptoms enumerated above portray the disease
cannot write a
picture as a whole. As already indicated, these symptoms tend to arrange themselves into two large groups, representing the manic and the depressive phases of the disease,
and a third smaller group, the mixed phase.

individual cases
fail
Occasionally, to present sufficiently clear pictures to permit their definite assignment to any one of these phases, which condition, together with the occurrence of numerous
transition stages from one phase to another, emphasizes the fact that it is impossible to draw a distinct border
line
between the prominent phases of the
disease.
MANIC STATES
The manic
delirious mania.
states
comprise
hypomania, mania, and
Hypomania represents the mildest form of the manic " mania mitis," states, and has been variously designated " " folie raisonnante." or mitissima," and Consciousness, apprehension, and memory are undisturbed. The activity of the mind and of the attention is often increased; indeed, the patients may appear brighter and clearer minded than usual, because of their ability to grasp
but in reality they cannot make use of any valid comparisons. In the realm of ideation they show a moderate flight of ideas, which is more especially noticed in letters. They shift abruptly from one subject to another,
faint resemblances,
and are quite unable sion. They are very

being centered about
to bring a thought to a logical conclutalkative, the content of conversation commonplace affairs, their experiences
and
difficulties.
They
revel in
minute
details,
and often
distort the facts with exaggerations
391
and frequent misrepreis
sentations.
In the severer grades there
a striking lack
of coherence in the train of thought.
The patients are unable
to arrange logically a series of ideas without abrupt transiIn their writings and tions from one subject to another. rhymes they often develop a flight of ideas. Upon effort
they may be able, for short periods, to gain the mastery over their incoherent thoughts, as well as over their excessive
activity.
There
may
occur, for short periods,
more marked
Patients
excitement and dazedness.
Memory
tions
for recent events is not always correct.
in their conversation are easily carried
away with exaggera-
distortions, which arise in part from their keener perception and in part from accessory interpretations,
and
which never really come clearly into consciousness. Although there are no genuine delusions, yet there is a greatly exaggerated self-esteem. Patients boast of their own deeds and show a proportionate lack of appreciation for those of
others.
they lack insight into their condition. While they may admit a previous attack, they cannot regard their present state as anything but normal. They justify
Hence,
their actions in a
ible excuses.
most persistent way, and never lack plaus-
Moreover, they believe themselves misjudged
or falsely confined, as they never were
more healthy or
and
capable of work. Usually, in their estimation, the relatives friends, or those who have been instrumental in their
confinement, are the ones in need of treatment. As to the emotional attitude the patients are usually elated, happy, cheerful, and often exuberant. They derive great
and undertakings. Some patients develop a pronounced humorous vein and a tenpleasure from their associations
dency to see the funny side of things, to make facetious remarks, to invent nicknames, and to make sport of them-
392
selves

and
others.
They
are jovial
tinctly selfish,
while their
own
desires
and friendly, but disand wishes prevail.
On
the other hand,
increased irritability
may
develop,
when the
patients become discontented, intolerant, and quarrelsome with their environment. They are apt to become inconsiderate, saucy, and rude, whenever any one
opposes them.
fits
Insignificant occasions
may
They
lead to violent
are completely
of anger
and even
aggressiveness.
under the control of sudden impressions and emotions, which quickly acquire an irresistible power over them.
Their general conduct bears the stamp of impulsiveness and rashness; hence, on account of the slight disturbance of intellect, their conduct is often regarded as unscrupulous.
The most
motor
striking
symptom
of all
feel
is
the increased psycho-
patients compelled to be doing something all the time. They must take part in whatever goes on about them. Since the sense of fatigue is diminactivity.
The
ished, they
do not
feel
selves until late at night

ing, bustling
the need for rest, so they busy themand are up again early in the morn-
about on all sorts of business. They take long devote much time to pleasure, begin a diary, write walks, many letters, undertake long journeys to renew old acquaint-
and do many other things which they never would have thought of before. They suddenly change their occuances,
pation, attempt journalism, write verse, purchase property, give away many presents, build castles in the air, and start
numerous undertakings that are beyond both their capital and physical strength. Their actual capacity for work, however, is much diminished. They lack perseverance, become negligent, and apply themselves only to that which is agreeable. In general demeanor it is obvious that the patients are self-conscious and attempt to attract attention. They
in
393
dress in a conspicuous manner, and adorn themselves with and cosmetics. Their handwriting is characteristically large and coarse, with a display of many exclamation
flowers
and interrogation marks and much underlining.
In the
presence of others they always press forward, seek to assert

themselves, talk a great deal, gesticulate, and boast. They are apt to be discourteous and offensive in manner. In
spite of deep
mourning they indulge
in boisterous pleasures.
In the presence of women they relate questionable tales. They make free with strangers and persons of high rank, as if they were old friends. Their tendency to indulge in
all sorts of
often begin to drink
is particularly prominent. They and smoke, remain out late at night, keep questionable company, frequent saloons, and eat ex-
extravagances
are particularly apt to show increased sexual desires, and to dress in a striking manner, to attend dances, to read trashy novels, and to
fall
cessively of rich foods.
Women
in love.
Not
this
result during such attacks.
infrequently, betrothals and pregnancies Patients show extraordinary
craftiness
in
peculiar
and
senseless
behavior.
All
attempts on the part of

bursts
relatives to control
often irritate the patient,
and
are vain, give rise to passionate out-
them
and even
The
aggressiveness. disease picture as seen in the individual cases varies
considerably. The milder the disease process, the greater the opportunity for the individual's characteristics to enter
into the
Personal peculiarities are particularly apt to show themselves in the emotional field.
symptom
picture.
While many patients remain amiable, tractable, and approachable, and are troublesome only because of their restlessness,
others are extremely disagreeable on account of

irritability,
their imperiousness,
activity.
and
reckless pressure of
394
The number of hours of sleep is cut Physical Symptoms. short by late retiring and early rising, but the actual sleep
The appetite is regularly improved, and the The skin appears healthy, and the weight may movements are strong and elastic. The course in this form is usually uniform. Improvement is very gradual, and often accompanied by remissions. The duration is seldom less than several months, and sometimes lasts over a year. The disease may, however, last
is
profound.
increase.
for only a
few days.
This condition often follows mania.
Mania (Tobsucht). The border line between hypomania and the less severe forms of manic excitement is not always sharply defined. The onset of mania is almost
always sudden, following a short period of headache or malaise, although a few days of simple depression may precede the onset. The patients rapidly develop great psychomotor
a pronounced flight of ideas, clouding of consciousness, disorientation, and great impulsiveness. Consciousness is more or less clouded. This is seen in
restlessness, with
partial or complete disorientation.
Patients
know
the time
are, but they perceive only in a superficial way the events of the environment. They mistake those about them for old acquaintances. Sometimes they desig-
and where they
nate them as historical personages, as congressmen, public

officials,
or
well-known
millionnaires.
Apprehension
is
:
greatly interfered with
by the extraordinary
distractibility
sounds from the surroundings are caught up and woven

into their speech; an object held by the physician, or parts of his clothing, attract the attention and quickly lead the
thought in another direction, which
is
just as abruptly left
before the thought is half expressed, aiding in the production of a flight of ideas. Patients understand what is said
to them,
and are able
to give short, correct,
and pertinent
answers to questions.
lives
395
In this way facts concerning their
and occupation can be obtained by piecemeal. past Very often a patient shows some insight into his disordered condition, admitting that he is crazy and cannot control
himself.
In emotional attitude the patients are mostly happy and exuberant. Irritability, on the other hand, is very marked.
Trifling affairs, such as interference or contradictions,
may
lead to outbursts of passion with profane abuse, assaults, or destruction of the clothing or other objects. The rapid
changes of the emotions are still more characteristic. In the midst of joy they begin to lament and weep at the thought
of home, or because of abuse by their nurse. Abrupt changes to a condition of passion and rage are not infrequent.
In the psychomotor field there is great activity and excitement. Patients cannot sit or lie still; they run back and forth, dance about, turn handsprings, sing, shout, and prattle incessantly,
make all sorts of gestures, tear off clothing, down the hair, clap the hands, smear the person and pull room with grotesque designs, and ornament themselves in the most fantastic manner with clothing which has been
torn into
strips, as shown in Plate 11. Everything that they can lay their hands upon, from watch to shoes, is taken to
Bits of straw and pieces of stone, glass, and food are hoarded to plaster up a crevice in the wall or to pack a keyhole. In the absence of tobacco all sorts of material
pieces.
are used, leaves and bits of bread and even dried feces. They are especially apt to cram the nostrils and ears with foreign material, and to carry bits of glass, nails, stones, and
nutshells in
the mouth.
One
of
my
patients secreted a
an extracted tooth in his mouth for months. are quarrelsome and domineering, or mischievous They and playful. Because of great irritability, the most trivial
four-inch nail and
396
affairs
may
lead to extreme violence
patients are
more apt
is
to
show
this
Female tendency than male.
and abuse.
manifest in shameless masturbations, exposure, and demands for intercourse, by indecent attitudes and insinuating remarks.
Sexual excitement
Some
of these cases of
mania may show
shorter period complete dazedness.
a longer or The patients then apfor
prehend their environment only in a fragmentary manner and are wholly disorientated. There is also great incoherence of speech, often combined with pronounced hallucinations
and delusions. The hallucinations are usually transitory. Sometimes faces are seen on the wall, shining objects appear on the ceiling, and flash-lights are seen as signals in the sky.
Noises are heard, floors creak, locomotives whistle, bells ring, and poisonous vapors are set free in their rooms at
Sometimes they complain of feeling electric shocks. Delusions are mostly expansive, seldom depressive. They are changeable and embellished by numerous fabrications.
night.
Patients claim that they are royal personages or generals, that they have supernatural strength, can produce planets,
and are related to God, etc. Many of these ideas are recognized by the patients as pure fabrications, are expressed with a laugh, and forgotten the next moment. The sleep is usually much disturbed, Physical Symptoms. and the patients may go weeks with almost no sleep. Nutrition suffers in spite of increased appetite,
but food
is
taken hurriedly and irregularly. There often occur attacks of syncope, and sometimes even convulsive attacks of a
hysteroid character. The heart's activity is usually increased and the pulse slowed, while the blood pressure is diminished. The urine is found to show a striking diminution of
The quantity
the phosphates, while calcium and magnesium are increased. of urine also is often increased. Pilcz has
PLATE
11.
Self-decorated manic patient.
397
shown that both in the manic and depressive phases there is excreted an abnormal amount of acetone, diacetic acid, indocan, and albumoses, which, however, bear no definite
relation to the intensity of the
symptoms.
The height of the disease is usually reached in the course of a week or two, and in some cases within a few days. The intensity of the symptoms is fairly uniform,
Course.
with
only
slight
fluctuations.
Occasionally
there
may
appear a sorrowful and depressed emotional condition, with disappearance of the motor activity, or even a transient stupor, indicating a transitory depressive state.
ine
improvement
is
very gradual; furthermore, for
Genusome time
after the return of comparative clearness, the patients are apt, under strain, to show a flight of ideas and some in-
creased activity.
Even after apparent complete recovery, reverses and misfortunes, and more often trying conditions, intoxication can cause a recurrence of the symptoms. The
duration varies considerably, from a few weeks and even days to many months, and sometimes two or three years. The
usual duration
several years.
many months. Some cases extend over The cases with many delusions and those
is
with exacerbations of excitement

Delirious Mania.
is
last longer.
This, the extreme of the
manic
states,
characterized
by pronounced dreamy
clouding of conscious-
ness , intense psychomotor activity, great incoherence of speech,
a marked
flight of ideas,
numerous hallucinations, and dream-
like delusions.
is a question if they to manic-depressive insanity. The onset is really belong sudden, following a few days of indisposition, uneasiness, and insomnia. The patients suddenly develop the greatest
These cases are very rare, and there
possible restlessness with
many
:
hallucinations,
which are
present in all of the sensory fields
they see beautiful sights,
398
strange faces, and scenes of torture; hear distant music, ringing bells, cannonading, and the roar of wild animals.
Their food has a peculiar odor and taste, and small objects crawl on the skin. They see fire and hear the crackling
timbers.
fold,
Everything is changed. At the same time maniconfused, and dreamlike delusions appear, both of an
:
" chosen they are the have been elected Presidents, have wonderful power, ones," can create and destroy nations, possess millions ; they have
expansive and of a depressive nature
lost all friends, are to
be murdered, must enter
hell,
have
been taken to an immense height, and are

into the sea, etc.
now
to be cast
From
the
first
is
the consciousness
disorientation
almost complete.
oughly confused as to time, place, take their environment, and even their friends. Their speech is incoherent, abounding in sound associations,
greatly clouded, and The patients are thorand persons; they misis
rhymes, and numerous repetitions of single syllables and phrases, in which one can always detect many frag-
mentary references to objects in

tention usually
their environment.
At-
when a fragment
cannot be attracted except momentarily, of the desired response can be detected
in the incoherent speech.
Striking objects, such as a penny on the floor, will divert the attention and the train dropped of thought for a moment.
As
to the emotional attitude, the patients
show various
ecstatic joy
changes between extreme happiness and profound distress, and timidity, exuberance and apathy. Irri-
marked. In the psychomotor field the patients exhibit, from the beginning, signs of the most extreme excitement. They run about shouting and singing, disrobing, destroying everytability is very
thing within reach, and
they become
recklessly violent
MANIC-DEPRESSIVE INSANITY and

smear
themselves.
399
Occasionally they impulsively attempt suicide. At one moment they are praying, at the next cursing with the vilest language, or singing an obscene
and a minute
their
feet,
song; at one time they are insulting in speech and action, later are profuse in apologies and distasteThey chatter away, scream and stamp fully affectionate.
pound the window or door, race about at the greatest speed, mount the furniture and declaim in a loud voice with profuse and exaggerated gestures. The state of nutrition suffers Physical Symptoms. profoundly because of the small amount of food taken and
the excessive expenditure of energy. Occasionally there is a general muscular tremor. Sleep is greatly disturbed, and at the height of the disease is entirely lacking; the pulse
accelerated and the reflexes are exaggerated. Sometimes the conjunctivae are injected, and the vessels of the head and face distended. Occasionally there is profuse peris
spiration.
The height of the attack is quickly reached, within a few days or weeks, and the symptoms usually begin to abate at the third or fourth week. Brief intervals
Course.
of
composure often occur for a few minutes or a few hours, during which the consciousness remains clouded. The
improvement may be rapid, i.e. over night, but usually is gradual. For some time the patients, although clear, usually
retain residuals of their hallucinations, delusions, and peculiarities of conduct, and are especially inclined to be
irritable
and
distrustful.
But even these

few weeks.
signs
entirely
is
disappear in the course of a
There
rarely
any memory for the events of the acute stage of the psychosis. The disease may terminate fatally as the result of exhaustion, injuries, fat embolism of the lungs, or intercurrent infections.
400
It very often
happens that following a manic attack the exhibit a low-spirited condition with more or less patients general weakness, which sometimes is regarded as a sort of
reaction, but
which
really represents a
transition into a
characteristic depressed phase.

easily,
and are unable
These patients tire very to apply themselves to either physical
or mental work, are despondent, worry about the future, are reticent, sluggish, and indecisive. These symptoms
gradually disappear with the increase of weight. In some instances, where the condition is more severe, there may
remain a permanent lack of judgment and emotional irritability, and also restlessness.
insight,
some
DEPRESSIVE STATES
The depressive states comprise simple retardation and the delusional form. The mildest form of the depressive states is characterized by the presence of simple retardation unaccompanied by
any hallucinations or
simple retardation.
delusions,
and
is,
therefore,
termed
The onset
is
which follow acute
generally gradual, except in a few cases illness or mental shock. There appears
gradually a sort of mental sluggishness: mental processes
become retarded, thought is difficult, and patients find difficulty in coming to a decision, in forming sentences, and in It is hard finding words with which to express themselves. in reading or ordinary confor them to follow the thought versation. The process of association of ideas is remarkably
retarded; the patients do not talk, because they have nothing to say; there is a dearth of ideas and a poverty of thought.
Familiar facts are no longer at their command, and to remember the most commonplace things.
it is
hard
In spite of this great slowness of apprehension and thought,
consciousness and orientation are well retained.
dull
401
Patients
appear sluggish, and explain that they really feel tired and exhausted. They sit about as if benumbed, with folded hands and bowed head, exhibiting no initiative and What is said is uttered rarely uttering a word voluntarily.
and
in
low,
inexpressive tones.
Customary
actions,
such as
walking, dressing, and eating, are performed very slowly, When started for a walk, they as if under constraint.
halt at the
doorway or at the
first
turning-point, undecided
which way to go.
Their usual duties loom before them as
huge tasks, because they lack strength to overcome the retardation, and anything new appears unsurmountable. Sometimes they become bedridden. Because of this extreme retardation, the patients rarely commit suicide, although they often express the desire to
suicide are
die.
Attempts at
dis-
more to be feared when the retardation has and while the despondency still persists. appeared,
In the emotional attitude there
is
a uniform depression.
life.
The
patient sees only the
dark side of
the future are alike, full of Life has lost its charm; they are unsuited to their environ-
The past and unhappiness and misfortune.
ment, are a failure in their profession, have lost religious faith, and live from day to day in gloomy submission to
their fate.
Everything
life
is
spoiled for them;
they take no
pleasure in
and do not care to
live longer.
They are
anxious,
ill-humored, gloomy, shy, sometimes
pettish or
and sometimes irritable and sullen. They fear business reverses and begin to economize, even denying themselves and their families the necessaries of life. Sometimes numerous compulsive ideas appear. Patients
compelled, against their will, to ponder over certain things, and to busy themselves with depicting unpleasant scenes. Others worry themselves over the thoughts of how
feel
SB
402
they might be martyred or torn limb from limb. Even compulsions to act arise, such as to commit injury or to
set fire.
frequently present, the patients appreciating that a change has come over them. This very often is
Insight
is
characteristically expressed as a feeling of inadequacy.
The
"
patients say:
am
not
sick, I
am
only lacking a will of

"
I
my
own."
"
I can't pull myself together."
have no
energy, I can't get hold of myself."
"
I feel all
I can't make up my mind to do anything." recurring sadness is ascribed to external influences, such
gone and Sometimes the

as,
unpleasant experiences, changes in the environment, etc. The condition of retardation may, at some time during
the course of the psychosis, become so pronounced as to produce a condition of stupor. Patients then lie abed perfectly dumb, unable to comprehend their surroundings, or
to understand even simple questions.
There
is
no particular
emotional change to be noted, except occasionally when a look of anxiety or perplexity flits across the countenance. Voluntarily, the patients almost never speak. If able to answer questions, their responses are exceedingly slow-
They
sit
helplessly before their meals, allowing themselves
to be fed
by spoon, and holding
pressed into their hands. care for themselves, but are not filthy. This condition of stupor tends to disappear rapidly, and leaves no memory
of the events of the period.
firmly whatever may be These patients are unable to
variations.
Simple retardation runs a rather uniform course, with few The improvement is gradual, and the dura-
tion varies from a few
months
to over a year.
second group of depressive cases has been termed the
delusional form, which is characterized varied depreciatory delusions, especially
by
of
the presence of
self-accusation
and
of
403
evidences
a hypochondriacal nature, in addition

onset of this
to the
of retardation.
The
form
is
usually subacute, following a
and occasionally even a short period of exhilaration and buoyancy of spirits; a few cases appear after an acute illness or mental shock. The patients become profoundly despondent, and indulge
period of indisposition,
They feel that they have been great sinners, have neglected their duties and made many enemies, have never done anything right, and their whole life has been one long series of mistakes. They accuse
in all sorts of self-accusations.
themselves of bringing misfortune on others or of causing some great calamity. They claim that they are devoid of They feel that they are feeling and sympathy for others. fear arrest and imprisonment, they must being watched, die, are to be poisoned or shot. Others hold them in derision, laugh, and jeer at them. Their families are incriminated by their misdeeds, and are suffering imprisonment. They have lost everything, and will be driven into the street with their families, to wander about in utter misery. Hypochondriacal delusions are prominent and are usually associated with numerous false bodily sensations: their
health
is
ruined as the result of masturbation;
they are
succumbing to some malignant disease, and their organs are wasting away; cloudy urine signifies profound disease of the kidneys; they can never recover, and their body and face are altered. Female patients complain of being pregand often accuse themselves of immorality and masnant,
turbation.
These various delusions often become absurd and fanis that everything about them not their own; their friends and relatives have disappeared forever; they do not belong to
tastic.
A common
their
delusion
is
is
altered:
home
404

but a skeleton
this world; they themselves are changed, are
and cannot die. Though life, they cannot live struck on the head or pierced in the heart, they would still live on. Their heart has ceased to beat ; their stomach and
without
intestines are entirely gone; there are
no
feces
they are
is
full
all
to the
throat with
;
decomposing food; their skin

occasionally
dried
up
their bones are softening, etc.
Hallucinations
are
associated
with
this
are heard, disagreeable condition, odors permeate the room, terrible apparitions appear at night, and fearful scenes are depicted.
when groans and moans
The
what
consciousness
is
for the
patients are usually oriented,
most part unclouded, and the and comprehend correctly
transpires in their environment, although occasionally they develop some delusional ideas in reference to the home or institution and the persons around them. They under-
stand questions and answer coherently, but the content of thought and speech shows a constant tendency to revert
to their depressive delusions. Thought is retarded, as shown in their attempts to write letters or to solve a problem.
Insight into the condition
is
very often present, yet while
admitting recovery from previous similar attacks, they declare that their present condition is so much worse that they can never recover. Some of these patients go to an institution of their
own
accord.
The
emotional attitude
is
uni-
formly one of depression. The patients are dej ected, gloomy, and perplexed, and lament for hours in monotonous tones.
They say little to those about them, but sit staring into space and paying very little attention to their environment. It, however, becomes evident during the visits of friends and
relatives that they are not only not apathetic,
but capable of
is
showing considerable feeling.

Psychomotor retardation of thought and action
evident
in their dearth of ideas, their silence,
405
and slow and hesitating replies to questions, their sluggish and languid movements, their lack of independent activity and inability to
apply themselves to mental work. Some patients at times exhibit anxious restlessness, pacing up and down the room, swaying the body or rocking uneasily in a chair, picking at
the clothing or rubbing some part of the body. attempts are not infrequent.
Suicidal
Stuporous
states
may
also develop in this delusional type
patients then develop a condition of befogged consciousness, in which almost no external impressions are apprehended and consciousness is domiof depressive cases.
The
nated by numerous variegated and incoherent delusions and hallucinations. Everything appears changed in the most fantastic manner; the whole world is being consumed by fire or congealed into ice. They themselves are removed from everybody, have been taken up into a cloud and carried off to the farthest point of the universe, and left
to be shoved off into space, where they will keep falling forever, or they are crowded into a narrow
there alone.
They are
grave from which they can never escape. The walls of the room are closing in upon them, and passing troops have arrived to attend their execution. Crowds jeer at them;
they are made to wear a crown of thorns, or are turned loose to run naked in the street. Everything about them has a
most mysterious aspect; they are in the midst of historical personages, and are made to do penance for the whole world. They have been transformed in a most horrible manner,
are of a different sex, are swollen to the size of a cask, have two heads, the body of a serpent, and the feet of an elephant. While in this dreamy state their retardation is shown by
their inability to speak, to feed themselves, or to care for themselves in any way. They do not show active feelings,
406

stupidly in bed, are inaccessible and indifferent. occasional anxious expression, the resistance to passive
lie
but
An
movements, peculiar postures, and unexpected, impulsive attempts at suicide betray their anxiety and fear. Sometimes a few words or sentences are uttered very slowly and in low tones. These stuporous states disappear gradually, but even after consciousness has become clear, a few
hallucinations time.
and
delusions
usually
persist
for
some
of persecution
There are a few cases which present coherent delusions accompanied by many hallucinations with The hallucinations play a rather imclear consciousness.
portant part and persist for a long time, reminding one very much of acute alcoholic hallucinosis, save for the
psychomotor retardation. The patients complain of numbPhysical Symptoms.

ness in the head, ringing in the ears, dizziness, palpitation, chilliness in the neck, heaviness in the limbs, and of a feeling as if there was a weight upon the chest. The appetite is
poor, the tongue coated, and the bowels constipated. There usually a strong aversion to food, and it often requires considerable urging to administer sufficient nourishment.
sleep
is
The The and
disturbed by anxious dreams. facial expression and the general attitude are sleepy languid, the speech low, the eyes lustreless, the skin
is
much broken and
The body and cardiac activity Respiration weight always are weakened and slower, and blood pressure is increased, while the pulse is slow. The quantity of urine is diminished as well as the excretion of urea, phosphoric acid, and magnesia. The height of the disturbance is reached in a few weeks and runs a shorter course than the manic
sallow and without its accustomed firmness.
sinks.
states.
407
MIXED STATES 1
simultaneously varying combinations of some of the fundamental symptoms character-
In
these
states
there
occur
manic and depressive phases of the disease. The mixed states are most clearly seen during the transition periods when patients pass from a manic to a depressive phase or vice versa. At these times all the symptoms of one phase do not disappear simultaneously, so that symptoms
istic of both the
of the depressive phase develop before all of the
symptoms
of the
manic disappear.
flight of
manic
For instance, the characteristic ideas may have given way to typical retardastill
tion of thought, while there
remains emotional elation

this
and pressure
of activity.
few days farther along in
transition period, we find that there still is some elation, but retardation of activity has also developed. Later still,
and the
elation has given way to depression, and we have the In another case typical picture of the depressive phase.
during this transition period, the emotional elation may be the first symptom to subside and pass into despondency, while there still remain pressure of activity and flight of
ideas.
In a few days the
flight of ideas also

is still
has gone over
into retardation of thought, while there

of activity.
some pressure
Farther along, we find the pressure of activity replaced by retardation and the typical depressive picture. All together there have thus far been recognized six chief
types of mixed states.
mania, in which a depressed emotional state the usual elation. These are the cases of pronounced replaces manic excitement in which the patients exhibit a more or
(1)
Irascible
less
1
constant irritability; they heap abuse upon the environWeygandt, Ueber die Mischzustaende des manisch-depressiven
Habilitationsschrift, 1899.
Irre-
seins.
408
ment, and become passionately angry and even aggressive upon the slightest provocation. If the excitement is not
quite so pronounced, there is produced the picture of the grumbling mania, in which the patients show a feeling of
somewhat increased
self-confidence,
but without
elation.
They
are dissatisfied, intolerant, perhaps a little anxious, have some fault to find with everything, always feel that they are mistreated, are served poor food, and have to sleep on
a wretched bed.
They have a
facility for offending
and
vexing others, and for instigating trouble for every one about them. Each day they have a new complaint, and become The fundamental manic irritable if they are not heeded.
symptoms
instability,
(2)
are seen in the moderate flight of ideas, the great
and
restlessness.
Depressive excitement comprises those depressive cases in which the restlessness is out of all proportion to the intensity of their emotional despondency. These pa-
but always about the same thing they torment themselves and their environment by the same old
tients talk incessantly,
;
complaints ; they are forever expressing the same delusional ideas, mostly of a hypochondriacal nature and usually in
They complain that they have been have been poisoned, can never recover, and are mistreated, going to die, but at the same time they are not especially
anxious or sad, and they are able to apply themselves without fatigue. They may even, for short periods, make humor-
the same phraseology.
ous or sarcastic remarks, and show some

aggressiveness.
irritability
and
Unproductive mania is the manic state with dearth This form is often encountered. The patients are very slow and inaccurate in perceiving. One often has to repeat a question several times before they understand it. They
(3)
of ideas.
don't pay attention, give
many
false
and evasive answers.
409
give one the impression that they are weak-minded, but later they prove themselves to be quite intellectual. This condition of unproductive mania fluctuates considera-
They
bly; at one time the patients
may
temporarily give ready
answers, while at another
it is
impossible to get anything
out of them.
one of elation, happiness, and exuberance; they laugh readily and without sufficient cause and make fun over every little thing. Their speech is inattitude
is
The emotional
coherent and the content limited.
They speak slowly and
do not have much to say; indeed, if left to themselves, they remain speechless for long periods. It is characteristic of the thinking difficulty to be more intense at the beginning
of an interview, but as the conversation is prolonged, the patients gradually develop considerable pressue of speech.
There
is
always present an increased emotional
irritability.
The
pressure of activity is usually confined to grimacing, occasional dancing around, changing the clothing, and fussing with the hair, but the patients never show the restless busy-
ness so characteristic of mania.
Many
of these patients
ordinarily conduct themselves so well and quietly that a superficial examination fails to reveal any excitement.
Nevertheless, they are in an elated frame of mind, at times showing irritability; they are tractable or rude, and often
break out in boisterous laughter. Other patients are inactive and sit around, but upon the slightest provocation
they laugh uproariously,
or, for no apparent reason, become are incapable of any orderly employment, but saucy. They are rather given to all sorts of mischievous tricks, stealing
and hoarding a lot of things, tearing up papers and clothing and tying knots in them, plugging up keyholes, and pasting paper designs all over the walls. Sometimes they suddenly burst out in great anger. Also, they may show
410

and
transient periods of genuine mania with flight of ideas pronounced pressure of activity.
(4)
Manic stupor
is
the depressive state in which emo-
tional elation takes the place of the usual despondency.
The
patients are quite unapproachable; they do not bother themselves about their environment, will not answer questions, laugh without apparent cause, lie quietly in bed,
sometimes
all rolled
up
in the clothing, or dress
them up
in
a fantastic manner, but all of this is done without evidence of restlessness or emotional agitation. Sometimes a few
changeable
delusions
are expressed.
They
is
are
usually
well oriented.
Occasionally catalepsy
present.
In the
midst of this stupor the patients suddenly develop great activity, rush about, disrobe, tear their clothing, destroy
smear their food, sing and talk loudly and freely, often making bright and striking remarks, and then after a few hours as quickly return to the previous state. At other times one finds them quiet, perfectly clear and intellifurniture,
gent in conversation, but this
only for short periods. Many patients pace about in measured steps, never speak except to make an occasional witty remark, or rub up against the doctor in an erotic manner, and laugh. These patients
is
often have a good memory for what occurs, but they are wholly unable to explain their peculiar conduct. In some
cases the facial expression
is is
fixed
and
staring, in others it
more cheerful, happy, and amorous. Manic stupor often develops for a short time in a pronounced manic state, but it more frequently represents a transition state between a depressive stupor and a manic
state.
Depression with a Flight of Ideas. are easily aroused when they can cases
(5)
These depressive
show a
facility of
thought.
They read a good
deal,
show
interest in
and com-
411
prehend their environment, and, indeed, even evince some curiosity, in spite of the fact that they are retarded in their general attitude, are almost mute, and are despondent. These patients tell us as soon as they begin to talk again that they could not control their thoughts, that a whole
host of things would come into their minds which they had never thought of before. It seems, therefore, that there really exists a flight of ideas which, however, is not apparent
to others because of the retardation of the
articulation.
movements
of
Some
of these patients cannot express
them-
but can write, and often astonish one with numerous productions, containing delusional ideas of persecution and fear.
selves orally,
their
the depressive state with flight of ideas and emotional elation. These patients are happy,
(6)
Finally there
is
sometimes somewhat
are distractible, prone to witty remarks, and are easily aroused during conversation to a flight of ideas and at times even sound associations,
irritable,
but in general their demeanor is quiet. They lie quietly in bed, and now and then interpolate a remark or laugh
loudly.
Nevertheless there seems to exist an inner tension,
because the patients can suddenly become very violent. The mixed states occur most frequently in the transition
periods from manic to depressive states and vice versa. Indeed, it is only by the history of their development and their
transition into the well-known phases of the disease that we are able to recognize them as mixed phases and as a
type of manic-depressive insanity.
This observation
is
of
which mixed states almost wholly replace the typical manic and depressive phases. In such cases the recognition of the disease,
especial importance in those cases in
particularly in
the
first
attack,
is
extremely
difficult, if
not impossible.
412
Course.

The course
of
manic-depressive insanity is marked by a recurrence of attacks separated by lucid intervals. With but very few exceptions, attacks recur throughout
the
life
of the individual, appearing with greater frequency
between the ages of eighteen to thirty and forty to fifty. In five per cent, of cases the attacks from the first pass directly from one phase into another, sometimes with such " " has been
alternating insanity apregularity that the name to them, or if short intervals of lucidity have intervened, plied " If only one or two attacks occur during circular insanity."
the
life
of
an
individual, the separate attacks are in
no
way
It
essentially different
from those recurring frequently.
seldom happens that all are of the same type; at some time or other a depressive attack is sure to appear. On the other hand, one patient during life may suffer from all possible
forms, from hypomania to profound stupor. The first attack in sixty per cent, of the cases
is
depressive.
This is especially true in women, and when the disease develops early in life. The first depressive attack usually runs a mild course, and in about fifty per cent, of the cases
followed immediately by a lucid interval. In the other fifty per cent, of the cases it is immediately followed by a manic attack, which in turn is followed by a lucid interval.
is
almost always followed by a lucid If the first attack is interval, seldom by a depressive attack. of the succeeding attacks are manic. manic, the majority
first
manic attack
is
several depressive attacks may recur before a attack appears; in other words, the occurrence of manic several attacks of one type to the exclusion of other types
Similarly,
indicates that the greater number of attacks throughout Later in the course of life will be of the same character.
be a regular alternation between manic and depressive attacks. After a long duration of
the disease there
may
the disease there
is
413
more apt
to be a regular alternation
from one type to the other, if the early attacks have been mostly of one type. The mixed forms usually do not appear until after two or more manic or depressive
attacks.
The duration of the individual attack may vary from a few days to five years, but the usual duration is from six to twelve months. The depressive attacks average longer. The first attacks rarely last longer than a few months. In
the circular type of the disease
alternates
it
has been observed that
simple retardation, hypomania usually while severe manic states are followed by deep stupor, and again, when delusions and hallucinations occur in the manic
states,
with
they are usually also present in the depressive

lucid intervals
states.
vary considerably in length, from a few days or weeks to many years, and stand in no definite
relation to the duration of the attacks.
The
They
however, to be longer at the beginning and attacks recur, until finally they may disappear altogether, the attacks then passing directly from one into another.
are apt, shorter as the
At the beginning
of the disease the intervals are usually
of at least one or
more
years' duration.
Sometimes the
intervals are of such a definite duration that the patients
know
to
The intervals tend just when to expect the attacks. become shorter during the climacterium and to lengthen out again later. Sometimes, especially in young females,
the disease begins with a series of several short attacks with brief intervals, which are then followed by a prolonged interval of several years.
In the small group of cases in which from the beginning the attacks succeed each other without
lucid intervals, the type of the attack
is
hypomania and simple retardation.
usually light, mostly Sometimes, even after
414
a long series of such recurring attacks, there
may appear a
long lucid interval. During the intervals the patients are perfectly lucid, except in a few cases where the attacks are long, frequent,
and
are able to reenter the family, to employ themselves profitably, and to return to their profession.
severe.
They
The few who do not thoroughly recover are also usually able to return home, but are apt to show some restraint,
lack of independence, a tendency to be morose, an unusual susceptibility to fatigue, some sleepiness, and a diminished
capacity for work, or they may be irritable, quarrelsome, markedly egotistical, or unstable and easily excitable.
During the interval some of the patients

thorough appreciation of their disease.
"
fail
to
show a
admit
They
will
excited and nervous/' but attribute that they have been it to some family trouble or confinement.
It
tients
very often happens that during the intervals the pamay suddenly develop short periods of moderate
exhilaration, flightiness, irritability,
and unusual
activity,
or on the other hand, they may be unnaturally apprehensive,
and indifferent. These and without the history of symptoms disappear abruptly, other attacks might not be recognized as disease sympsuspicious,
despondent,
inactive,
toms.
The
transition
vice versa, is
from a manic to a depressive phase, and usually gradual, though it may be sudden,
often occurring during the night. In this transition the stages of alteration are usually quite perceptible. At first the countenance of the depressed patient becomes more
illuminated and the eyes appear brighter and the skin firmer
and more
dom.
elastic.
The
patient
first
interest in the surroundings,
His activity, at
is more affable, shows more and expresses a desire for freeincreasing slowly, now becomes
prominent;
better in his
415
felt
he
is
busy
all
the time,
is
happy, never
From this time life, and everything pleases. the manic state becomes quite evident. The manic patient
at
first
is
he
gradually loses weight, the pressure of activity abates, calmer and more in earnest, his many schemes recede
to the background
and then
entirely disappear.
is
Soon
his
movements become
less,
languid, he himself
seclusive, talks
and misonly occasionally mentioning His countenance loses its freshness, and at last fortunes. we have a typical depressive state.
his ill-feelings
usually little difficulty in recognizing the psychosis, where there has been a previous attack; yet the occurrence of more than one attack is by no means pathognomic of manic-depressive insanity, as it
Diagnosis.
is
There
may happen
in
dementia prsecox, especially in the catatonic
form, in paresis, melancholia, and in amentia. It is difficult to distinguish between the mildest forms
of manic-depressive
peculiarities
insanity
and
certain morbid personal

chiefly as a
which manifest themselves
more
or less regular vacillation of the emotional state.

depressive periods of ill-humor
The manicon the one hand, and of impetuous exhilaration on the other, are sometimes mistaken as simple whims and ascribed to all sorts of deleterious
influences, or
neurasthenia, and hypochondriasis,
they are apt to be designated as hysteria , since it is only in the

ill.
depressive states that the patients are considered
These
same patients themselves, however, often have insight into their periods of excitement and dread their approach. Usually the true nature of the disease is disclosed
by the
transi-
tion from one phase to another, and by the periodic recurrence of different phases. The simple lack of decision the inability of the depressive patients to
come
to a conclusion
is
so
characteristic that
it
alone often suffices in making the diag-
416
nosis.
These border-line cases are numerous, and are often encountered in sanitaria. In the mild forms of the manic states, when one sees the
patient in the
patient's
first
life, it is
is without a history of the often difficult to distinguish the patients
attack and
from some normal individuals.

chiefly
is
The
distinction depends
ity
upon the fact that the increased busyness and activnot uniform, but shows variations. In the forms of
mania there are also noticeable aggravations and regular transitions into opposite moods.
constitutional
of the condition
Such
patients, because of their frequent conflicts with their
environment and the law, are usually considered swindlers and vagabonds, or are regarded as morally insane. In addition to the vacillations, the clinical picture also shows an attitude of overconfidence, an irritability, a lack of plan
in their excessive busyness, an excessive emotional irritability,
and a lack of criminal tendencies. The differentiation of the disease from the exhaustion psychoses and from the excited stages of the catatonic and
hebephrenic forms of dementia prsecox will be found fully detailed in the differential diagnosis of those diseases.
The manic forms
ment by the exuberant emotional

bility.
are differentiated from hysterical excitethe presence of the flight of ideas, pressure of activity,
The
hysterical
and the great distractiexcitement comes in the form of

state,
brief separate attacks
with definite outbursts of temper.
Hysterical excitement usually subsides quickly pletely after a very short duration.
It is
and com-
simple retardation from the initial period of depression in dementia pmcox. In the manic-depressive patients the psychomotor retardation, with slowness of movement, low tone of voice, difficulty
difficult to distinguish
more
of thought with sparsity of ideas, slowness of application
of attention,
417
and
slight clouding of consciousness, stands out
freedom of moveand to the clearness of consciousness ments and thought, in dementia prsecox. Rapid appearance of senseless delusions and numerous hallucinations without clouding of
in contrast to the absence of retardation,
consciousness speak for dementia praecox. The differentiation of the depressive states from dementia
paralytica
and melancholia have been discussed under these
psychoses.
Acquired neurasthenia is sufficiently differentiated from the depressed forms under that disease. The unproductive mania is often mistaken for imbecility
with excitement, but can be distinguished by the evidences of flight of ideas and the manic demeanor of the
patients with only moderate restlessness. Manic stupor sometimes must be differentiated from
catatonia.
If,
it
in
manic stupor, the patients

in
struggle, the
cause for
lies
almost always leads to abuse and violence.
the irritable, fretful disposition which Again, the
patients pay more attention to their environment, and are influenced in their actions by circumstances, in contradistinction to the stupid or wilful indifference of the catatonic.
Furthermore, the manic-stuporous patient displays a poverty of thought and not a stereotyped and senseless speech
production.
The movements of the catatonic are apt to be planless, impulsive, and with a uniform pressure of movement, while in stuporous mania they are purposeful, playful, and adapted to the environment.
in
The prognosis of the disease is unfavorable Prognosis. view of the certainty of recurrence of the attacks throughout the life of the individual. It is favorable for recovery
from the individual attacks, except in five per cent, of cases, which from the onset pass directly from one attack into anSa
418
other.
While, with this exception, there are almost certain be other attacks and recoveries, the frequency of their to
recurrence and the duration of the lucid intervals
uncertain.
is
wholly
At present we have no means
of judging just
will be. In general it may be said, that it is safe to predict frequent recurrence of however, attacks with short intervals where the psychosis manifests itself early and without external cause. On the other hand,
if
what the future course
the
first
attack occurs late and following some external
cause, such as childbirth, there probably will be but few If pronounced mixed states predominate, the attacks.
If the onset is predisease will probably be more severe. vious to the period of involution, one should expect a recur-
rence during the climacterium. Mental deterioration occurs in only a few cases, where the attacks appear during the period of development and are
long,
frequent,
and
severe.
Even
these
patients in the
and retain a very good memory. They simply show some indifference, irritability, an increased susceptibility to alcohol, and slight
intervals are
conscious, well oriented,
There are a few cases that have manic attacks, lasting even ten years and more, very long which have been designated chronic mania. This condition is not one of dementia, but one in which there are
deficiency in judgment.
incomplete remissions. If observed carefully, these cases usually present not only manic states of varying intensity, but also evidences of depressive and mixed states. Furthermore,
it is
usually found that even in the lucid intervals the
patients have always been somewhat unstable, freakish, irritable, or have been schemers and incapable of any consistent
and productive employment.

constitutional
These cases are better termed
mania.
There
is
a corresponding series of transitions from the
419
depressive states. There are manic cases which in the intervals are shy, low spirited, and slow to make up their minds.
This defective constitution

individuals
is
more
characteristic in those
who suffer from periodic depressive states. there are cases in which the separate attacks of Finally periodical ill-humor present themselves without sharp
differentiation,
and are simple aggravations of a constitutional depression. Arteriosclerosis, or marked senile changes,
developing during the course of manic-depressive insanity, usually lead to states of dementia which obliterate the original mental picture.
Treatment.
The
disease, being deeply rooted in the per-
sonality of the individual, offers little chance to eradicate
the underlying causes. Individuals who seem to be predisposed to the disease certainly derive benefit from leading a careful life under favorable conditions and abstaining
absolutely from the use of alcohol.
Such persons should
not marry.
Individuals suffering from frequently and regularly recurring attacks can sometimes ward off an approaching
attack by the use of large doses of the bromides, even up to three hundred and sixty grains a day for a few days before the anticipated attack. Atropia, hypodermically, or bella-
donna
in the
form
of the extract in full doses, is highly recom-
mended for the same purpose. In those cases in which the attacks tend to develop during pregnancy or puerperium, artificial abortion has occasionally been performed for the
purpose of either warding off the attack or cutting it short. Kraepelin himself has not derived much benefit from this
procedure, but finds that, in spite of abortion, the disease recurs and runs its regular course. In all such cases measures should be adopted for the prevention of pregnancy. Individuals who have already suffered from an attack of
420

life,
the disease should be compelled to lead a quiet
free
is
from
irritating influences.
The
susceptibility to alcohol
increased, hence its use should be most scrupulously avoided. In the treatment of the patient during the manic attacks,
the
first essential is
the removal of
all
forms of external
excitation.
Except in the mild cases, it is unsatisfactory to attempt to care for the patient at home, and even the milder forms run a more moderate course under the influence of a quiet and well-regulated hospital or sanitarium environment than at home. Unrestrained activity tends to
increase the excitement
therefore the pressure of activity should be limited as much as possible. One of the best
;
means
cases.
of accomplishing this
is
is
confinement in bed.
Bed
treatment
especially indicated in
anemic and debilitated
In severe excitement prolonged warm baths (see p. 140), used in connection with the bed treatment, give the most satisfactory results. The patients should alternate from
the bath to the bed
;
i.e.
when the excitement subsides
in the
bath, he can be returned to the bed until it reappears. It may be necessary in order to first introduce the patient to the bath to give a preliminary dose of hyoscin hydrobro-
mate (-^Q
to
-^ grain).
applied will often relieve renders medicinal treatment unnecessary. If the bath is not available, the use of hyoscin hydrobromate hypodermically, or
The prolonged warm bath properly the greatest excitement, and usually
by mouth,
is
the best remedy for subduing the
intense psychomotor activity. Scopolamin hydrobromate ("2To to -&fi grain) or paraldehyde may be substituted for the
hyoscin.
As the excitement permanently
subsides,
con-
finement in bed can be gradually relaxed and the patient given an opportunity to exercise in the open, fin very extreme excitement with impending collapse the adminis-
tration of whiskey of
in the case of
421
is necessary, and cardiac weakness, digitalis or coexisting caffein should be added.) The general management of the
brandy or camphor
patient is usually a very important adjuvant in controlling the excitement. This requires the greatest amount of tact
and patience on the part of the nurse; gentle friendliness at suitable moments sometimes renders what appears to be a most dangerous patient quite tractable. The nurse must exercise self-control, be free from all prejudice, avoid the use of discipline, and above all be frank and truthful. The nutrition of the patients demands special attention. An abundance of nutritious and easily digested food should
be given the patients at regular intervals. They should not be allowed to gulp their food, and hence it usually requires the constant attendance of the nurse at meal-time. Because of the great restlessness, it often requires consider-
able patience to get an excited patient to take sufficient nourishment. In severe cases the patients should be weighed frequently in order to ascertain if the body weight is falling
off, and, where necessary, artificial feeding by stomach or nasal tube can be employed.
It is very often a difficult matter to determine just when manic patients have recovered sufficiently to be discharged from treatment. Because of their great importunity and
impatience to be set free, there is a tendency to discharge them while some symptoms still remain. One of the dangers
premature release is the tendency to alcoholic indulgence, which regularly leads to a recurrence of the symptoms. The safest guide in deciding this question may be found in the body weight, which should have returned to normal. In the depressed states the patients should at once be
in
given the benefit of the rest treatment with confinement in
bed and ample feeding.
Except
in debilitated
and anemic
422
cases, the patient should be permitted to leave the bed for a short period during the day to take exercise in the open. If this is not feasible, massage should be administered.
The
treatment taken in the open on a shielded but sunny porch should always be tried in preference to indoor confinement. If there is great agitation, opium in increasrest
ing doses (see p. 362)
is
often given with benefit.

controlled,
if
The insomnia should be
possible,
by the
aid of the variou^ physical measures, such as, hot baths at

night, hot liquid nourishment
etc.
and
upon retiring, gentle massage, Failing with these, one may employ on alternate days for short periods trional 15 grains, veronal 7J grains,
or paraldehyde 1 to 2 drachms. During prolonged periods of administration, these hypnotics should be varied.
The
nutrition also
demands
careful attention, for
which
purpose the patient should be frequently weighed. The food should be carefully selected and easily digestible. Abstinence from food often requires artificial feeding by nasal
or stomach tube.
exists, usually
The
relief of constipation,
which often
improves the appetite.
The patient must be relieved from all forms of excitation, and visits from relatives, long conversations, letter-writing, Rational conversation and encouretc., should be avoided. agement is helpful, except at the height of the disease, when
sometimes seems to be aggravating. In the lighter cases hypnotic suggestion has been used to great advantage in
it
relieving the insomnia, despondency,
and disagreeable somatic sensations. The greatest care must be exercised to prevent suicidal attempts, which are often to be most guarded
against at times when the patients, though still convalescing, believe themselves recovered, and also in the transition
periods between attacks.
X.
PARANOIA
PARANOIA
ment
of
is
a chronic progressive psychosis

life,
occurring
mostly in early adult
characterized by the gradual develop-
stable
progressive system of delusions,
without
marked mental
deterioration,
clouding of consciousness, or
disorder of thought, will, or conduct.
The disease is uncommon, constituting only Etiology. one to four per cent, of the cases admitted to insane hosMen are more often afflicted than women. The pitals.
disease begins
between the ages of twenty-five and forty. It on a defective constitutional basis, either condevelops
large percentage of the cases.
tricities
genital or acquired, defective heredity existing in a very
Peculiar traits
and eccen-
life, the patients being or seclusive. Some show perverted sexual moody, dreamy, instincts, or a marked aptitude for study or mental activity
may
be recognized early in
in special, limited fields.
Some have been abnormally bright
others have always been flighty, entering into many projects which they were unable to pursue successfully; many show
stigmata of degeneration. Exciting causes occasionally form the starting-point of the psychosis, such as an acute
illness,
excessive
mental
stress,
shock, business reverses,
deprivation, and disappointment.

Allgem. Zeitschr. f Psy., XXII, 368 Griesinger, Archiv. f Psy., I, 148; Sander, ibid., 387; Westphal, Allgem. Zeitschr. f. Psy., XXXIV, 252; Mercklin, Studien ttber primure Verriickheit, 1879; Amadie e
Snell,
.
Tonnini, Archivio italiano per
le
malattie nervose, 1884,

f.
1,
2; Werner,
Die Paranoia, 1891; Schule, Allgem. Zeitschr. Cramer, ibid., LI, 2 Sandberg, ibid., LII, 619.
;
Psy.,
L,
u.
2;
423
424

is
There
as yet no demonstrable, pathological, anatomical
basis peculiar to paranoia.
Symptomatology.
is
The development
of
the psychosis
is
very gradual, extending sometimes over years, and
usually so insidious that the disease is in existence long before it is recognized. During this period it may have been noticed that the patient had changed in disposition,
having become somewhat
irritable,
grumbling, suspicious,
and that he had made indefinite physical complaints, especially of malaise and insomnia. The first symptom to be noticed is that the daily mental or manual labor becomes distasteful, and little affairs at home or in the shop cause displeasure and arouse suspicion. The wife seems less attentive, the children less loving, shopmates less friendly, and the overseer more stern. The and
easily discontented,
accidental absence of the morning greeting, or imaginary slight on the part of a close friend, sets the patient to think-
ing that
ful, is
it
cannot
all
be accidental.
He becomes
distrust-
constantly seeking other evidences of unfriendliness, and careful watching soon satisfies him that he is neglected,
both at home and at work.

accuses his friends of slights,
of plots.
He
make complaints, and members of his fraternity

begins to
leaves his employment, holds aloof from his companions and friends, and often becomes rude and discourteous. Some patients are able to ignore for a time the
He
apparent indifference of friends, but others become much disturbed and suspect a malicious purpose. They are morbidly sensitive, considering that such trifles as harmless jokes, smiles, or accidental nods of the head have special
reference to themselves.
intrigue, bill
Items in the paper indicate some
posters contain hints, some daily passer always lights his cigar or coughs when near them; men similarly dressed always meet them near the same corner, or are shad-
PARANOIA
owing their footsteps.
accidentally overheard.
425
as to an evident purdispelled
Any doubts
pose in all this are sooner or later
by remarks
In this way false interpretations
gradually assume greater prominence, and the resultant persecutory delusions are constantly increased and aggravated. Those who conscientiously approach and question friends or supposed intriguers are further alarmed and justified by the indifference displayed and the little satisfaction obtained; some ignore them, others answer evasively. Trivial matters which formerly passed unheeded are now falsely and absurdly interpreted and enter into the struc-
A spot on the coat, a calloused a decayed tooth, or a headache are all regarded as finger, positive proof of treachery and an effort to get them out
ture of their delusions.
of the
a slow process of poisoning. The appearance of natural baldness is readily explained by the application
way by
of electricity during sleep.

later, in connection with these delusions of which are firmly held and well moulded by a persecution, coherent train of reasoning, there may also appear expansive delusions. These may be coincident with the persecu-
Sooner or
tory ideas at the onset of the disease, but more frequently are the outcome of the delusions of persecution. The insistent persecution lead
creasing attention which the patients attract and the perthem to cast about for the reason.
While some find

still
this in property
it
which they
really possess,
others believe that
lies
in their personal charms, while
others conclude that they have been born for a special mission, or are of noble descent. thrifty Irish woman, who
had accumulated considerable property by dint

of her enemies to secure
of hardest
labor, finds a sufficient cause for her persecution in
attempts
her hard-earned accumulations.
factory employee already approaching the limits of the
426
climacteric finds the reasons for her persecution in her
attractive appearance, and the desire of eminent men to seduce her. Where the expansive delusions are more directly evolved from the delusions of persecution, the patient asks himself why he is so molested and tormented, why so many,
not only individuals, but nations, seem directly interested in him, and why he is constantly accompanied by a secret Gradually it dawns upon him that he is a kidpatrol.
napped son
is
of a millionnaire or of a
of Napoleonic descent
crowned head, that he and lawful heir to the throne,
while his extensive landed properties are unlawfully used by the government. This explanation first appears in the
tendency to find evidences of persecution in
many
or
all
the events of their environment, and becomes prominent when the patients discover its purpose. Then all these
supposed facts assume a place in the chain of evidence which confirms their conclusions.
These delusions
may
only assume the form of an exag-
gerated feeling of self-importance. The patient considers himself especially renowned in his profession, a fine
lawyer, an excellent teacher,
an
interesting talker,
an
ideal
gentleman, a social favorite, or an individual worthy of great political distinction. Finally, a change of personality
may
result,
a direct descendant of Christ.

the
and the patient announces himself as titled, or The patients become aware
from
of this in various ways, one once receiving a salutation
President, another recognizing a striking similarity between himself and the equestrian statue of a famous
general.
Others are assured of their high station by the deference paid them by every one people bow to them, their
:
names are
in the paper, the orchestra begins to play as they enter the theatre, the prima donna directs her song at
them, and the birds chirp when they are near.
The appear-
PARANOIA
427
ance of the sun from under a cloud, casting its rays upon them, indicates that they are under the special guidance of
God.
All delusions, both persecutory and expansive, are held with great persistency, and built out into a coherent system, which
is
an
essential characteristic of the disease.
In the systematization of the delusions another prominent feature is the frequent appearance of retrospective
falsification
of
memory.
While
it
this
symptom
is
mostly
characteristic of paranoia,
may
also be present in the
paranoid forms of dementia prsecox and in melancholia. Here the patients, in reviewing their past life, find evidences
of persecution, or detect occurrences which at the time should
have indicated their superiority. The loss of a situation many years ago, derisive remarks by fellow-workmen, or
an by
injury,
now become
One
clear evidences of their persecution
patient recalled that when thirteen years of age a priest took from her a book, claiming that it was unfit for her to read. This incident she now regards as the be-
enemies.
ginning of years of persecution by the priesthood, who would seduce her and then hold her up as an example before the world. Another patient led his class in marching, and later
was chosen captain was

to have been a
of the boys' brigade:
these incidents
at that time should have
overhearing his
of the fact that he Another remembered parents whisper in an adjacent room, be-
made him aware
famous general.
coming mute at
his entrance,
and
later a disguised
woman,
which
who was
brother.
really his mother, visiting at the house,
all of
pointed to a noble birth and his displacement by a younger

similar incidents scattered throughout life are pointed out as striking evidences which aid in fortify-
Many
ing their system of delusions. An erotic element often appears in the delusions, which
428
in
cases has been pronounced enough to lead to the recognition of an erotic paranoia. Likewise, the religious
some
coloring
is
sometimes strong enough to establish a religious
paranoia. In the erotic cases the patient usually believes himself the object of admiration by some lady who is attracted to him
and
solicits his attention.
She makes him aware of
this
by daily appearing at her window as he passes, or by casting Other evidence is gathered sly glances as she drives by. by anonymous love poems in daily papers. fantastic methods of communicating his love
Numerous
to her are
devised, to which she responds by wearing certain articles Their of clothing, or arranging her hair differently.
mutual admiration
He
hears
it
publicly regarded as an open secret. indirectly referred to everywhere, and friends

is
would have him infer, from casual remarks, that they are well pleased. Sometimes this fanciful, romantic, and even
platonic love is maintained for years without action; at others the patient makes an effort to approach his supposed
fiance* e.
Her
rebuffs
may
at
for the
accomplishment
of
be regarded as necessary Later she may her desires.

first
appear to him in the guise of one of his companions. Hallucinations are always present at some time, but do
not play a very important part in the psychosis, and rarely Hallucinapersist through the whole course of the disease.
tions of hearing are apt to be the
most prominent.
At
first
very indefinite noises
Later they hear their names mentioned, or derisive laughter from a crowd; nicknames are called out, some one curses below the window,
annoy them.
and bits of conversation from adjoining rooms excite them. The remarks are more often of a depreciatory nature. Hallucinations of sight are rare, but those of general sensibilthe hair is plucked at night, the ity are quite frequent,
PARANOIA
skin irritated
bullets,
429
flesh pierced
by poisonous powder, the
or the countenance transformed
by by the nightly
application of an iron mask.
There
is
never genuine insight into the disease.
The
patient, on the other hand, may complain
of all sorts of
physical ailments, such as nervousness, indigestion, pains in the head and back, for which he seeks medical attendance, but he cannot be made to realize the fallacy of his delusional ideas. The memory is well retained, and judg-
ment, except as biassed by the delusions, is unimpaired. The emotional attitude of the patients stands in direct
relation to the character of the delusions.
They
are
irri-
tated by their persecutors, are shy and excitable, and at first usually despondent; some, however, tolerate the persecution
fare.
and regard
it
as essential to their spiritual wel-
All
sooner or later become arrogant, proud, and
dogmatic.
In conduct the patients appear quite normal for a considerable time.

of their disease
Some
of them, long before the real nature
becomes evident, attract attention by their eccentricities, peculiarities in dress, oddities in manner, excessive religious zeal, or an attitude of self-importance. Later they become seclusive, move about in their employment from city to city, leave one shop to enter another,
where they soon detect the presence of their former perseIn this way an cutors, and are again compelled to leave.
iron
moulder travelled from San Francisco to Boston in
order to avoid the persecutions of his trade-union. change affords only temporary relief to the anxiety, as suspicious circumstances are soon noticed which leave no doubt that
news about them has been passed on from their last situation until finally their existence becomes known the world over. They become unstable in their behavior and mode of
430
living, are
unable to conduct a successful business, and fail to support their families. In reaction to the delusions
they attempt to
call
public attention to their persecution
by writing newspaper articles and issuing pamphlets. Very often they apply to the police for protection. Frequently
into their
they assume the offensive, and take the matter of vengeance own hands. Not infrequently the first striking
one.
is a murderous assault upon some The paranoiac is for this reason the most dangerous of all insane. One patient assaulted the mayor of the city for keeping him from his fiancee; another drew a pistol upon a man with whom he was having an altercation over business matters, in the belief that he was the secret agent of the
evidence of the disease
French government sent to kill him. In accordance with expansive ideas the patient
may
address the President as his father, or demand access to a If millionnairess whose parents are keeping them apart.
confined in an institution, they may for a time ingeniously conceal their delusions until they find evidences of continued
persecution in their new surroundings, when the fellowpatients appear to them only as accomplices placed there
to aid in their discomfort.
is
Sometimes
their
confinement
regarded as an effort of their persecutors to
make them
insane.
tion,
patients submit gracefully to their detenconsidering it but another cross to bear before their
Some
final rescue
and the proclamation that they are
rightful
few patients even consider that they are being treated with the utmost consideration and the greatest
rulers.
attention, provided with the best quarters,
and granted
every possible privilege by those

injustice
who
recognize the great
done them.
of the disease
The course
always gradual, and
protracted. The onset is usually the disease has been in progis
PARANOIA
ress for
431
some time, even a few
years, before recognition.
When once established, the course is slowly progressive, with a gradual evolution of delusions which are constantly
being further systematized and made to encompass new environment. Several psychiatrists claim that the course
of the disease presents definite periods according to the stages of evolution of the delusions. At first there is the
prolonged period of insidious onset, by Regis called the

period of subjective analysis, followed by the persecutory period with the development of delusions of persecution with hallucinations, and finally the ambitious period acpatients usually are quite orderly, present an unclouded consciousness, and for many years are capable of considerable labor,
personality.
companied by a
change
of
The
both mental and manual.
After a duration of many years there appears a moderate degree of mental weakness. Patients become unable to apply themselves, take less notice of
their
environment and
less care of themselves.
In some
cases the disease may seem to be at a standstill for years, while in others partial remissions occur when the patients
for a time are able to rejoin their families,
but are rarely in
a condition to resume their accustomed occupations. The diagnosis depends upon the slow onset, the characteristic,
coherent, and systematized delusions of persecution with retrospective falsifications of memory, often associated with a change of personality, unclouded consciousness,
coherent
for
thought,
and absence
of
of
mental deterioration
many years.
dementia prcecox have already been differentiated from paranoia under the former disease.
The paranoid forms
few cases of dementia paralytica and melancholia may Dementia paralytica is to be distinsimulate paranoia.
guished by
its
rapid development, the early appearance of
432

The conduct
of a
emotional weakness, and physical signs.

paranoiac
is
entirely dependent upon the content of the he cannot be reasoned with, is persistent in the delusions;
prosecution of his ideas, and is rarely submissive to confinement; while the paretic opposes his retention weakly
and with some stubbornness. The melancholiac presents a more rapid onset (three to nine months), a marked disturbance of the emotional attitude,
or intermittently
fear, self-accusations, occasional
clouding of consciousness,
an absence
of system in the formation of delusions, of the disease
dences of mental deterioration within the course of
and evitwo years.
The prognosis
is
very poor, as no case of
naturally limited to the removal of irritating influences and to confinement in an institution where systematic routine, with out-of-door life
is
genuine paranoia ever recovers. The treatment of the disease
and ample
exercise,
may
ameliorate or ward
off
the condi-
tion of mental weakness.
There are a few cases of paranoia which have been desig1 nated by Hitzig as querulent insanity (Querulantenwahn) which deserve a brief description here. The psychosis is
of gradual onset,
legal injustice,
and usually
arises as the result of
a defeat in court,
some an unjust award of
an unfair adjustment of claims, damages, in which the patient has been the sufferer. He refuses to carries the case from one court to another, and finally settle,
loss of property, or
develops an insatiable desire to fight to the bitter end. He reaches a point where he is unable to view the standpoint
any one else with any sense of justice, and his personal and desire completely obscure his better judgment. The statutes appear inadequate, and even the fundamental He sets aside principles of the law fail of comprehension.
of
belief
1
Hitzig,
XXVIII, 221
Ueber den Querulantenwahn, 1895 Koppen, Archiv Pfister, Allgem. Zeitschr. f. Psy., LIX, 589.
;
f.
Psy.,
PARANOIA
all
433
cany on the struggle, solicits symdenounces those who do not side with him. pathizers, and Hearsay and bits of knowledge gathered at random are cited
business in order to
as evidence in his behalf, and money is squandered in the pursuit of justice to the most extreme limits. He cannot
abide by the ultimate decision after all the usual means of justice have been exhausted. Failing to appreciate the needlessness of further struggle, he writes to magistrates,
legislators, consuls, ambassadors, and finally to the President or foreign rulers. Answers to these letters only create greater embitterment. His letters are long and carefully
particular kind of paper, times written with colored ink.

written, usually
upon a
and some-
and often becomes greatly excited in conversation, although at the same time priding himself upon his ability to exercise self-control.
is
The patient
irritable
Consciousness remains unclouded.

served;
in fact,
is
it
accuracy he
Memory is well preoften surprising to see with what able to quote from law books, to repeat
is
parts of speeches, and to enumerate various dates. Thought continues coherent, but there is a great tendency to monoto-
nous repetitions of the delusions. in even a short conversation.
One seldom misses them
There
is
no insight into the condition.
On
the other
hand, the patient is often encouraged in his belief by the fact that there are always many men, and not a few physicians,
who
will testify to his sanity.
cases of querulency are apt, after a prolonged to present greater deterioration than other varieties course,
of
The few
paranoia; the content of speech becomes more and more limited and somewhat incoherent, the irritability increases, the patient becoms peevish, indifferent, and some-
times even stupid.
XI.
EPILEPTIC INSANITY
is
EPILEPTIC insanity
a psychosis based upon epilepsy
which is characterized by a variable degree of mental impairment and by the recurrence of certain transitory mental states, designated epileptic ill-humor and epileptic befogged states.
The befogged
and
dipsomania.
Etiology.
states include pre-
stupor, anxious and conscious
and post-epileptic excitement deliria, and possibly also

most frequent
pre-
Defective heredity is the
disposing cause of epilepsy, appearing in eighty-seven per cent, of cases, while in over twenty-five per cent, epilepsy 1 found in 1070 cases exists in the parents. Spratling
hereditary
sixteen per cent, of which displayed parental epilepsy. He also found similar ratios in parental alcoholism and tubernearly
cent.,
taint in fifty-six per
notes among progenitors and relatives of the extreme frequency of migraine, headaches, epileptics
culosis.
Fere
infantile convulsions,
tion.
mental disturbances, and deteriora-
All authorities agree that parental alcoholism is a Wildermuth prolific source of epilepsy in the offspring.
considers
disorders,
its
influence almost as powerful as that of mental including epilepsy. Other factors in the pro-
genitors which predispose to epilepsy are insanity, syphilis, rheumatism, diabetes, and possibly chorea. Evidences of
congenital defect are frequently found in malformation or asymmetry of skull, microcephaly, hydrocephalus, the so" " called epileptic p'hysiognomy (broad forehead, broad and
1
Spratling, Epilepsy
Fe*re*,
and
434
its
Treatment, 1904.
Les Epilepsies, 1890.
EPILEPTIC INSANITY
flattened nose, prognathism, thick lips,
435
and
staring eyes
with wide pupils), feeble-mindedness, precocity, moral delinquency, and sexual perversion. Among the exciting or immediate causes of epilepsy we find cerebral palsies, dentition, emotional shocks (fright,
excitement, anxiety, grief),
tis,
many
acute infections, meningi-
thermic fever, overwork, gastro-intestinal disorders, disease of heart and kidneys, tobacco, lead, and other poisons,
carious teeth, foreign bodies in the intercourse.
ear,
and even sexual
brain lesions (especially hemorrhages), are frequently assigned as the cause of epiinjuries,
falls,
Head
such as blows,
and in a certain number of cases a direct relation between them can be traced. Wildermuth gives their as three and eight-tenths per cent., and Heeres frequency as four and two-tenths per cent. Spratling says that " trauma is more frequently the cause of epilepsy in men than in women (eight and five-tenths per cent, men three and five- tenths per cent, women)/' The numerous scars often found on the head are more frequently the results
lepsy,
:
than the causes of the malady. Akoholic excesses are by far the most important causes of
About ten epilepsy beginning after the twentieth year. per cent, of chronic alcoholics are thus afflicted. All epileptics present a marked intolerance to alcohol, and its use by them, even in small quantities, hastens the onset and intensifies the symptoms of mental disorder. Many imbeciles
and
idiots
and a few
seniles (thirty-four
hundredths
per cent.) develop epilepsy. Epilepsy is essentially a disease of youth, convulsions
appearing in thirty-four per cent, of cases in infancy. Spratling found in ten hundred and seventy cases twentysix and five- tenths per cent, develop under the age of five
436
years; nineteen per cent, from five to nine years; twentyfour and four-tenths per cent, from ten to fourteen years;
and thirteen and

teen years,
six- tenths
per cent, from fifteen to ninefive-tenths per cent, found in fourteen hundred
a total of
fifty-six
and
under twenty years.
Gowers
fifty cases that in seventy-four and eight-tenths per cent, the onset occurred before the twentieth year.
and
As not all epileptics are insane, it is evident Pathology. that the pathology of epileptic insanity must be based upon
that of the seizures plus hereditary taint, constitutional defect, and other factors whose nature and influence are
not yet thoroughly known. There is a wide variation in views as to the nature of epilepsy, but it is now generally
regarded as a cortical disease which is general and profound. Gross lesions are of secondary importance and mostly act as contributing factors. Among the most important gross
changes revealed by autopsy are alterations in the texture and shape of the skull, old lesions of infantile cerebral
hemiplegia (four to ten per cent.), sclerosis of the cornu
ammonis, porencephaly, encephalic scars, neoplasms, etc. Wildermuth asserts that thirteen and three-tenths per cent, of his cases were due to polioencephalitis, and five and
eight-tenths per
called
cent, to other
maining eighty-three and

" "
In the regross lesions. nine-tenths per cent, of his cases
various anaidiopathic epilepsy tomical changes were found in the brain, which probably bore some relation to the clinical symptoms. The micro-
genuine
or
scopic changes thus far found are cortical gliosis merous cortical cell changes, such as chromatolysis;
late epilepsy
litic
and nuwhile in
we
find arteriosclerosis
lesions.
It is possible
and occasionally syphiand very probable that many
of the lesions
found in the brain are the results of epilepsy
and not the
causes.
EPILEPTIC INSANITY
437
periodicity of the seizures may possibly be explained the apparent tendency in the nervous system to a periodiby If the researches of cal reaction to any continued irritation.
The
it
Krainsky, Cabitto, Agostini, and others can be corroborated, would seem probable that idiopathic epilepsy is due to a
toxic condition arising from faulty metabolism, and that the immediate cause of the convulsions is the accumulation of
deleterious substances in the blood or a faulty chemotaxis This theory receives further weight
fact that the convulsions are frequently
of the cortical cells.
accomwhich point to intoxication, as drowsipanied by symptoms ness, headache, nausea, etc.; and also from the fact that
from the
epileptiform attacks occur in

intoxication,
many
conditions of chronic
especially
from
alcohol,
cell
"
From
the nature of the cortical
and uremia. changes we have a

lead,
right to expect that the inciting agents will be very active * nuclear poisons." It is now believed that the blood, sweat, urine, and gastric contents are hypertoxic for some time before, during,
and
after the seizures,
and hypotoxic
in the intervallary
periods, but no definite conclusion as to the sources of this alteration in toxicity has been reached. Epilepsy due to
circumscribed lesions, traumatic or otherwise, of the brain,
can hardly be ascribed to toxicity alone. Even if we should base the known cerebral changes upon a chronic intoxication, we would still need to explain the periodicity of the
accumulation of toxins, and also the hereditary relationship of epilepsy to other mental and nervous diseases. On the whole, it seems probable that the ultimate
attacks, the
and
characteristic cause of the symptom-complex epilepsy is to be found in morbid conditions of the nervous tissues , especially the cortical cells,
1
most
likely
due
its
to
chemical changes.
Spratling,
Epilepsy and
Treatment.
438

Epilepsy
Symptomatology.
per cent, this
unquestionably
produces
some mental deterioration

is slight,
in every case, but in about fifty
chiefly affecting the
most
striking feature of the epileptic
memory. The weakmindedness is
the slow evolution of psychic processes, external stimuli arousing only a meagre response in consciousness. In the
majority of cases of epileptic insanity the degree of deterioration once established may remain without marked progress
In a few cases, however, a condition of profound deterioration may be reached. Hallucinations are exceedingly infrequent except in the
for years or even
life.
befogged states and anxious and conscious deliria. When present in the interparoxysmal periods, they generally have
a religious character.
Illusions are quite frequent for a short period before and after attacks of grand mal. Consciousness is usually clear and orientation normal in the intervallary periods, except during the befogged states.
Apprehension of the daily routine

tion
is
is fairly
keen, but atten-
always somewhat impaired or

is
easily fatigued.
Memory
always impaired, sometimes to a great extent.
While prominent events and the ordinary daily routine may be recalled, the recollection of the general course of life, whether remote or recent, is more or less hazy. In contrast
to the
memory
defects found in other deterioration psy-
choses, patients are able to express clearly

their remaining
and coherently
narrow
circles of
thought.
shows a marked atrophy of the store In of ideas with scanty assimilation of new impressions. conversation and writing there is a strong tendency to detail
train of thought
The
and
circumstantiality. Their narratives are obscured by a multitude of data and irrelevant or unessential accessories
which greatly impede the progress toward and development

of the goal ideas.
The connection
is
not
lost,
however, and
EPILEPTIC INSANITY
the goal
is
439
thought is ing a large part of their time in reading the Bible or in praying aloud. Patients adhere to familiar paths, and their
vocabulary consists largely of set phrases, platitudes, Bible The narrowness of thought naturally texts, proverbs, etc.
leads to a greater prominence of the ego. This is especially noticeable in the conversation of epileptics, in which they
ultimately reached. The religious content of another striking symptom, many patients spend-
indulge in praise of self and family, and pay to personal matters.
much
if
attention
The imagination is practically abolished, and epileptics show no
inactive,
not entirely
ability to reconstruct or
recombine the materials furnished by old experiences or new perceptions. They occasionally, however, write verse which
shows an unruly and riotous fancy, as in the following:
"E
F
is is
the eel
the finch
who soars to the sky; who is fond of pie."
Judgment invariably becomes impaired as mental deterioration progresses, but delusions are not common except in some of the transitory epileptic mental states, when they are
accompanied by hallucinations.
hypochondriacal. "
Many
epileptics
is
become
The
true relation of ideas

sense," tact,
obscured or
even
lost,
and
common
and
discretion are
seldom displayed. Patients never adequately recognize the incongruity between their plans and their limited ability.
One man with marked mental and physical defects, whose schooling had been meagre, gravely proposed to study theology; and another who could hardly name the simplest flowers desired to become a florist. As a rule, however, epileptics Imve some insight into their condition, realizing that they have convulsions, poor memory, and difficulty of
thought.
Among
the most marked
symptoms
are those occurring in
440
the emotional

even when mental deterioration is not There is almost always an increased irritability
field,
advanced.
manifested by their peevishness, obstinacy, unruliness, also by frequent outbreaks of emotional excitement as well as
sudden alternations from elation to depression, and the

reverse.
particularly apt to occur in the proximity of the convulsions and is easily aroused by alcohol. Some " of an internal anguish," or fear. They patients complain are easily angered, are threatening, quarrelsome, violent, and
This
is
dangerous. Usually the finer feelings become blunted, and there often exists a uniform state of apathy. On the other
hand there are a few patients who

bility.
for years always display

irrita-
a placid, amiable disposition, free from evidences of
tic
Morbid and sudden impulses are frequent and characterissymptoms of epileptic insanity. These are largely due
to increased irritability or lack of self-control. Patients will attack any one who disturbs them, and often in a blind rage
suddenly
cent
inflict
severe
and dangerous
injuries,
even on inno-
any provocation. These impulses are by no means confined to the pre- or post-paroxysmal stages, as many suppose, but may arise at long intervals between the seizures. The wild state of blind
where patients run amuck, striking and assaulting the characteristic indiscriminately every one in their range, is a nerve storm which may justly be conepileptic furor, " sidered as an equivalent." These sudden impulses to violence and even homicide render epileptics especially danrage,
and
inoffensive bystanders, without
gerous.
are very infrequent, and their more so. accomplishment The conduct, apart from the stubbornness and morbid imSuicidal impulses
still
pulses above described, is usually good. Epileptics as a rule are neat, orderly, and observe the usual convention-
EPILEPTIC INSANITY
alities unless deterioration is
441
quite marked.
Some
patients
display marked sexual excitement, and some are inveterate masturbators. All epileptics show a diminished capacity
for work, especially
where the higher grades of mental and
physical training are requisite. They may engage with fair success in simple routine occupations where little or no
initiative is required,
but unless carefully directed and super-
vised, are apt to slight their
Physical Symptoms. toms in epileptic insanity are the convulsions, which may assume the type of grand or petit mal. In the former there may be an aura, followed by a cry, a fall, and tonic followed
first, but rapidly over the entire body. During the convulsions, extending which may last from two to ten minutes, consciousness is totally abolished, but returns gradually within a period of a
work or leave it unfinished. The most important physical symp-
by
clonic convulsions, usually localized at
few minutes up to several hours. In status epilepticus there may be from twenty to even several hundred attacks of grand mal, without a return to consciousness in the intervals.
In petit mal there is a very brief loss of consciousness (usually only one or two seconds), either without any con-
vulsive
movements
or with very slight ones which often
elude observation.
The reflexes are abolished during the convulsions, and in some cases are not restored for one or more hours. In 1088
observations on male epileptics, Keniston
1
found that the
normal plantar reflex (flexion of toes, etc.) was present in both feet immediately after clonus had ceased in forty-five, and one hour later in two hundred twenty-six, cases; the
Babinski phenomenon (extension of toes with dorsiflexion of ankle) occurred in one hundred three cases directly after
the seizure, and in one hundred twelve cases one hour later. Keniston, Journ. of Amer. Med. Assoc., March 21, 1903.
1
442
An extensor response was found in right or left foot in ninetynine and fifty-three cases, respectively, and a flexor response in right or left foot in ninety-nine and two hundred eleven
cases, respectively, while
a mixed response, that
is,
extension
in foot
and
flexion in the other, occurred in eighty-two cases
directly after a seizure
one hour
later.
and in one hundred forty-seven cases The plantar reflex was abolished in six hun-
dred sixty cases immediately after the convulsions, and in three hundred thirty-nine cases one hour later. The kneejerks were active in three hundred ninety-six cases,
moderate in one hundred thirty-seven, and absent in hundred thirty-nine cases.
five
The
speech of epileptics
is
often altered
and very char-
acteristic.
It is abrupt, with intervals after each phrase, often drawling, jerky, or strongly accented. During excitement it may be so rapid as to be indistinguishable, were
it
not for the fact that a few phrases are repeated over and over again. Tuberculosis and organic and functional diseases of the heart are quite frequent, and the pulse rate is often increased. Epileptics rarely complain of headache,
and often show an

gesia,
insensibility to pain
amounting to anal-
while their frequent wounds usually heal rapidly. Richter found anaesthetic areas in forty per cent, of his
cases, general analgesia in
and hemihypaesthesia
Paraesthesias
in
twelve and two-tenths per cent., ten and two-tenths per cent.
are very common. Sleep is often irregular and muscular strength diminished. Appetite is usually good, and most epileptics are greedy and gluttonous. As
residuals of seizures
we
find scars of all kinds, especially
on the head, broken noses, extensive burns, and absence of front teeth; and as causal residuals we see evidences of
alcoholic abuses, sequellse of early brain diseases, or arteriosclerotic alterations, and cranial scars.
syphilitic
We
occa-
EPILEPTIC INSANITY
443
sionally find after seizures small cutaneous hemorrhages, particularly in the conjunctiva.
In addition to the above general mental and physical symptoms which constitute the epileptic dementia, there
occur with more or less regularity certain transitory epileptic mental states, which occur periodically and independently of
external causes.
The most important
of these states
is
the periodical
ill-
humor, which according to Aschaffenburg occurs in 78 per cent, of epileptics and is characterized by a marked emotional
much involvement of consciousness. The separate attacks bear an extraordinary resemblance to each other. The same complaints, the same delusions, and the same impulses recur. The phraseology of the patients is definite, the behavior characteristic, and the expression similar. These attacks vary in intensity, and often come on in the morning. Sometimes the intervals are so
tension without
regular that the time of recurrence can be foretold with Patients usually awake peevish, irritolerable accuracy. often table, fault-finding, threatening, and quarrelsome;
commit sudden and unprovoked
assaults
on the nearest per-
son; break glass or destroy bedding and furniture, and use profane or obscene language. Very often the emotional
one of anxiety, when the patients complain of feeling homesick, and low spirited, and of being troubled with sad thoughts, have presentiments, and express delusions
condition
is
of self-accusation.
Occasionally hallucinations also appear.

of feelings of
At the same time the patients may complain
numbness, pressure in the head, ringing in the ears, and difficulty of thought. They are unable to work, wander about, sometimes remain in bed, and frequently attempt
suicide.
Less often the patients develop a state of expan-
siveness or ecstasy.
They then run about with
glaring eyes
444
and happy countenances. They shout, throw things about, and get into all kinds of trouble, tease their mates, pray loudly, and express expansive religious ideas. Occasionally
there is a flight of ideas. Furthermore there is great emotional Some patients irritability with a tendency to aggressiveness.
rapidly develop a condition of marked excitement. Sometimes the patients develop a delusional state with emotional
irritability
and anxiety and also occasionally accompanied by hallucinations, which condition might be termed a
paranoid condition. While the ill-humor usually occurs after a seizure, it may precede it, in which case the convulsion generally clears the
mental atmosphere. The attacks rarely last more than a few hours, but may persist for a week or more. Abatement is gradual, and is often followed by a feeling of complacency
or well-being. In some cases the hallucinations and delusions may persist with little change for weeks or months,
simulating closely
praecox,
certain conditions
found in dementia
but
finally the
hallucinations
and delusions en-
tirely disappear.
Befogged states represent the second large group of transitory epileptic states, and are characterized by a more or less
profound clouding of consciousness.
pre- and
post-epileptic insanity,
These states include

,
psychic epilepsy
epileptic
of
stupor, anxious delirium, conscious delirium,
some cases
somnambulism, and possibly dipsomania. The befogged states are sometimes preceded by the transitory states of ill-humor Alcohol may predispose to them, even when just described. taken in very moderate quantities. Here all sorts of morbid sensory Pre-epileptic Insanity.
impressions
vision,
may
arise,
flashes of light,
impairment of
indefinite
parsesthesias,
or strange sounds, peculiar odors, and which are not to be confounded with the
EPILEPTIC INSANITY
individual aura,
ideas,
falsified
445
when such
exists.
identifications,
There may be fixed monotonous repetitions of
words or phrases, involuntary or grotesque movements, and imperative impulses, as to strike, destroy furniture, or sometimes a few minutes or even In a short time kill. consciousness becomes clouded, and the conseconds vulsion begins. In a few cases the latter passes over into
a pronounced dreaminess lasting for hours or days.
Post-epileptic Insanity.
It is
more common and
is
char-
by deep dazedness after the seizure, lasting for hours or even days. Patients do not understand questions,
acterized
speak confusedly (paraphasia), are completely disoriented,
wander aimlessly about,
collect all obtainable objects,
and
even drink their urine. While active sensory disturbances are undoubtedly present, no account can be obtained from the patients, who have complete amnesia of all that has
happened. As a rule, they recover their normal mental and emotional attitude very gradually. Mental and emotional disturbances Psychic Epilepsy.
very similar to the above
appear in the intervallary of the convulsions, and are periods, entirely independent
may
then called
ditions are
equivalents," or psychic epilepsy. These conby no means rare,, and are frequently observed
"
in hospitals.
They
are
more
liable to occur in patients
who
have seizures at long
intervals.
The
essential feature of
psychic epilepsy is the disturbance of consciousness. Patients are confused, move and act in a mechanical or automatic
manner, and often present evidences of

tions,
illusions, hallucina-
and
delusions.
They wander
aimlessly about,
and do
not appear to recognize any one, but will sometimes reply

incoherently to questions. Occasionally they assume fixed or peculiar positions, or gaze steadily at one point. In some
instances they display a heightened excitement,
and again
446
a gloomy stupor, during which they may masturbate, expose their person, or attempt sexual assaults. Patients
have been known to set

such
fire
to their bedding or furniture for
The numerous trivial purposes as boiling coffee, etc. criminal acts, such as theft, arson, assaults, and even homicide, committed during these periods demonstrate the exThe
history of previous attacks
treme importance of the recognition of psychic equivalents

in their medicolegal aspect.
of grand or petit mal, even if very infrequent, the senselessness of the actions, with utter absence of motive or attempt at concealment, and either complete amnesia or only a very
hazy recollection of what has happened, should make the diagnosis clear. These attacks usually last only a short
seconds or minutes, an hour or more.
time,
but occasionally continue for
Under the head

tice
of psychic epilepsy should be included
some
Patients nocases of somnambulism, occurring in epileptics. those objects which are directly in front of them. only
eyes
The
Movements closed, half-opened, or staring. evidences of automatism, but there may be usually display traces of deliberation and purpose, as in avoiding obstacles.
may be
Sometimes higher psychic fields are involved, and patients may carry on long conversations, compose poems, or transact business. Next morning they do not remember what they have done, but may complain of lassitude, stiffness, or soreness.
Here the clouding of consciousness is Epileptic Stupor. intense and prolonged. Patients may eat, speak, or perform certain mechanical movements, but always as if dreamSometimes the eyes ing and without clear understanding. are closed, or the face dazed or staring. The same attitude is maintained for hours or even days, and the expression
justifies
the inference that confused terrorizing delusions
EPILEPTIC INSANITY
447
dominate the emotional sphere, although occasionally the demeanor indicates happiness or religious ecstasy. Patients
show absolute
indifference
to
their
environment,
never
answer questions, remain in bed, and soil themselves. They sometimes show active resistance if disturbed, may make sudden impulsive attacks, and instinctive suicidal attempts
are not infrequent.
is
The
reflexes are abolished, sensibility
blunted,
and
in single cases
temporary catalepsy
is
seen.
Nourishment
is
often refused,
either wholly or partially.
in severe cases the course
Epileptic stupor usually lasts from one to two weeks, but is longer. Recollection of the
events
is mostly lost. Improvement is generally gradual, but in a few cases the confusion may disappear in one day.
Where attacks
remain
for
are repeated and prolonged, patients may a long time dull and inattentive. Anxious Delirium. This form is more frequent than
stupor and may occur independently of seizures. The mental disturbance is profound. The attack develops suddenly,
and may be preceded by very brief periods of characteristic sensations, and numbness, or by
ill-humor,
fixed
and
regularly recurring hallucinations, as red objects, flames, etc. Apprehension is dulled, surroundings are changed, and
orientation
is
lost.
:
usually terrifying
and delusions are must be punished, must die, are patients

hallucinations
The
surrounded by devils, animals, or throngs of people who come out of the walls or floor. They wade in blood, their parents are perishing, the house is blown into the air, or
everything
carries
is
them
is
Sometimes God or Christ appears and sinking. in splendid chariots to heaven, but these trans-
ports are only transitory,
emotions
brutal
one of fear
and the predominant tone of their and dread. Patients are impelled to
and
incredible outrages, as cutting
or children, shooting, stabbing, etc.
up their parents They run away to escape
448

With
flushed faces, either
the horrors which confront them.

silent or
howling and shrieking, they rage furiously, with prodigious strength, destroying everything within reach.
The duration to two weeks.
of anxious delirium varies
from a few hours
Sometimes consciousness clears up suddenly after a long sleep, but usually gradually, so that transitory hallucinations, delusions, and normal ideas are mixed together in a characteristic manner. There is no recollection
of events occurring during the height of the delirium.
a rare form, which either follows a seizure or appears as a psychic equivalent. Patients appear from their conduct to be conscious, but in reality consciousness is greatly clouded, while numerous illusions
Conscious Delirium.
This
is
and hallucinations may inspire false ideas of danger. Expansive ideas are not uncommon. Answers to simple questions are coherent and relevant, but the whole demeanor, if closely observed, discloses some confusion and disorientation. The disposition is irritable, usually anxious, but sometimes elated, and delusional ideas often lead to impulsive acts. Legrand du Saulle reports the case of a merchant who, on suddenly recovering from an attack, found himself on the
Others have committed, with seemingly unclouded consciousness, senseless and even criminal acts
way
to
Bombay.
indecent assaults) without any insight into their significance. Attacks of conscious delirium may last for days, weeks, or even months,
(thefts, arson, rebellion, desertion,
and there may be a

intervals.
series of attacks
separated by short
Dipsomania in many respects resembles epilepsy, as it presents an apparently paroxysmal and periodical impulse
to senseless alcoholic excesses.
Among the prodromal sympfear,
toms are noted uneasiness, anxiety,

weariness of
life,
despondency,
increased irritability, a feeling of heaviness
EPILEPTIC INSANITY
449
in the head, anorexia, insomnia, and occasionally sexual excitement. Very rapidly after these manifestations there
appears an impulsive and irresistible desire to obtain relief, " " which is found in a mad rush for liquor. Some patients
develop a typical epileptic befogged state, in which they become abusive, aggressive, noisy, and undertake foolish journeys.
One man had attacks once
in
two
years,
when in the
space of two days he would drink several pints of whiskey,

ultimately becoming completely unconscious, and often, on coming to his senses, finding himself in strange places. After several of these attacks, he arranged that friends should
take him to a hospital on the dromes.
first
appearance of the pro-
Some dipsomaniacs
present no typical epileptic disturb-
ances, but in their attacks fall suddenly into a condition resembling inebriety, in which they continue without in-
to drink large quantities of or spirits, until they have spent their last beer, wine, gin, cent, and even sold their clothing to obtain means for During these attacks gratification of their morbid appetite.
terruption
day and night
intoxication
is
seldom complete, but consciousness
is
clouded,
and patients
retain only a hazy recollection of a few events
of their debauch, but often manifest deep contrition
abhorrence of alcohol.
Convalescence
is
and an and somegradual,
times accompanied by nausea, anorexia, gastric catarrh, unsteadiness, and tremors, while a few cases present symptoms
of collapse,
accompanied by delirium and hallucinations. The attacks of dipsomania may recur without any external cause, and in the intervals, which may last for weeks, months,
or even years in a few instances, patients have no craving for alcohol, and either totally abstain or drink very moderately.
There are
many
transitions or variations
characteristic picture of dipsomania.
from the Some patients mani-
450
fest
a disposition similar to that of epileptics, and a few perhaps present during life only one instance of an epileptic befogged state accompanying an attack of inebriety.
The diagnosis of epileptic insanity is generas soon as we can establish the existence of the ally easy It should, however, be differencharacteristic convulsions.
Diagnosis.
tiated from hysteria, dementia paralytica, tonic form of dementia prsecox.
and the catadeeply disin-
In
hysterical
insanity consciousness
is
less
turbed in the seizures, and we almost never see sudden

voluntary
falls,
serious injuries, or biting of the tongue.
The
seizures are also specially induced
by external
influences,
as mental emotions, physicians' visits, etc., and may be curtailed or suddenly aborted by very lively excitement or strenuous treatment. The development is more diversified
than that of the epileptic seizure, which is always uniform. In hysteria tonic and clonic muscular contractions of the
convulsions of the diaphragm, opisthotonus, jactitation, rolling on the ground, somersaults, lively moveentire body,
ments of expression (dramatic and passionate attitudes), alternate even in the same attack, and consciousness is never
abolished.
Dilatation and immobility of the pupils, usually considered an important characteristic of epilepsy, have
recently been found in hysteria also.
We
of
find in hysteria
rapid changes disposition, and dependence on external influences, while in epilepsy there is a rough irascibility, a limited waywardness, an inde-
extravagant
caprices,
pendent periodicity, and a prominent ill-humor. Mental weakness is more frequent and pronounced in epilepsy. In epilepsy coming on in middle life, we must consider the
which sometimes begins with epileptiform seizures. Here the consideration of the other symptoms, such as impaired pupillary reflex and
possibility of dementia paralytica,
EPILEPTIC INSANITY
451
inequality, characteristic speech disturbances, ataxia, incoorWhen, howdination, etc., will soon clear up the diagnosis.
ever, the epileptiform attacks occur at long intervals,
and
are accompanied
by one or more of the above symptoms, we
should be prepared for the possibly gradually developing symptoms of dementia paralytica.
The
initial
been mistaken for the stage of the catatonic form of dementia prcecox. In
epileptic befogged state has
the latter
we
find negativism, passive resistance, senseless
and correct execution of commands, eccenand stereotypy, with absurd acts, and less districities, turbance of apprehension and orientation. In epilepsy there is anxious resistance with indifference to orders, and
answers, rapid
uniformity of conduct, while there are frequent assaults, atrocities, and attempts to escape. Special weight attaches
to the previous history and the proof of separate attacks of vertigo or syncope, periodical ill-humor, and probable night
by occasional enuresis, injuries to the and severe lassitude or headache in the morning. tongue, The diagnosis of the befogged states, when only one convulsion has been observed during
life,
attacks, as evidenced
or perhaps not even
one, but only a brief syncope, presents
some
it
difficulties;
is
but
we must remember that

portant
while the convulsion
symptom
of epileptic insanity,
may
a very imbe absent or
replaced by an equivalent." Hence the periodicity of the attacks, clouding of consciousness, morbid impulses, crimes committed without motive or attempt at conceal-
"
ment, amnesia, and rapid course will facilitate the diagnosis. This depends essentially on the cause of the Prognosis.
When dependent on gross epilepsy and the time of onset. brain lesions, recovery is out of the question, and the mental
weakness often progresses to complete deterioration. When following head injuries, some recoveries have occurred, and
452
in

cases decided
many
and long-continued improvement has

spontaneously, but recurprolonged, and in the interval there
ill-humor.
in
resulted.
Genuine epilepsy
rence
is
is
may disappear
common
if life is
usually
some mental dulness with transient

cases
where the befogged states, especially stupor, have occurred, if they have been at all frequent. In some cases of anxious delirium death
Improvement rarely occurs
Conscious delirium is not dangeranxious delirium, if recurring at short life, intervals, tends to hasten the progress of deterioration.
occurs from exhaustion.

but, like
ous to
In epilepsy arising late in

favorable.
life
the outlook
is
very un-
On the other hand, in alcoholic epilepsy treatoften successful in effecting a cure, or at least great improvement. On the whole, while in some cases patients may improve sufficiently to go home, especially where the
ment
is
disturbance
is
largely in the emotional sphere, the prognosis

is
unfavorable, and patients should be subjected to prolonged observation and treatment before one assumes the risk of discharging them. This is all the
of epileptic insanity
more
may occur without any and thus the patient becomes a danger to the comseizures, munity. As far as life is concerned, we must remember that serious and even fatal injuries may result from accidesirable as attacks of furor
dents occurring during the convulsions or from the development of status epilepticus. Worcester found that sixty per
cent, of epileptics die as the result of their seizures.
Treatment.
insanity
is
As
far as the medical treatment of epileptic

little
can be done except to attend to bodily needs and combat any unfavorable symptoms which may arise. On the other hand, moral treatment, by which
concerned,
is
meant
suitable occupation
and
diversion, out-door
life,
helpful suggestions, educational efforts to retard the progress
EPILEPTIC INSANITY
of deterioration
453
and conserve what mental equipment is left, is of the highest value and an absolute necessity. Every one who possesses a remnant of physical or mental power should be obliged to do something. Occupation should be light, safe, avoiding high or dangerous places, varied, and
with ample intervals of
and wholesome, and
all
Diversions should be simple reading should be carefully selected,

rest.
consisting largely of history, biography, light essays, stand-
ard novels, and religious subjects which would help toward right living and avoid all exciting or controversial points
which might intensify the

epileptics are prone.
religiosity to
which almost
all
The treatment of epilepsy itself should be based on wellknown principles. Nutrition should be fostered by careful attention to the alimentary system. The diet should be
regulated,
and may
consist of fruits; cereals in moderation
and thoroughly cooked ; eggs, breads, milk, cocoa, chocolate, and a minimum of tea and coffee; simple puddings, such as rice, farina, and custard; fish and a moderate amount of meat, at noon only. The supper should be very light and taken at least two hours before retiring. All meals should be regular, and patients should be carefully supervised to " " insure thorough mastication and prevent food. bolting The reduction of salt in food has been advocated, not only to
diminish the irritability arising therefrom, but to enable us to materially decrease the amounts of bromids prescribed.
method diminishes by one-half the chance of bromism. Toulouse and Richet have introduced the hypochlorization method, which consists in using sodium
It is said that this
bromid
in place of ordinary salt, ten grains
of the former
being equal to
twenty
grains of the latter.
The kidneys
require attention,
and the
secretion of urine
should be stimulated by a free use of water.
The
skin
454
should be kept in good condition, and occasional hot baths employed to induce perspiration. If eye strain or other ocular symptoms are present, they should be remedied.
The teeth and mouth must be kept
in a healthy state.
It is very important to insist on complete and permanent abstinence from alcohol in all cases, and not merely in alco-
holic epilepsy
and dipsomania.
Every
from
epileptic is
less intolerant of its effects,
very severe mental

its use,
tional disturbances often result

is
more or and emoand nothing
any While innumerable remedies have been used to control or
to be gained
from
it
in
case.
abort the seizures, their utility is somewhat doubtful, since the convulsions are practically safety valves, which allow the
Unless the cause can be removed, it is perhaps better to allow the insane epileptic to have his Neverthefits, as they often clear the mental atmosphere.
elimination of toxins.
and lay opinion, it is advisable in every case, at the beginning, to administer the bromids, either singly or in various combinations, with proper precautions, until after due trial we can decide from
less,
in the present state of medical
condition of each patient mentally, emoand physically whether or no it is best to contionally, tinue their use. They should be given at the start in very
the general
small doses (6 to 8 grains) three times daily, after meals, in plenty of water, gradually increasing the amount until the
point of saturation is reached, which is indicated by the disappearance of the throat reflex. Then the dose, which varies
until
with the individual, should be reduced more or less gradually we establish a norm which can be continued for a long
In time, even years, with occasional short interruptions. some cases the epileptic disturbances disappear, not even
returning
is suspended, and we may the case as cured. It must be borne in perhaps regard
when the medicine
EPILEPTIC INSANITY
455
mind, however, that in a certain number of cases the seizures cease spontaneously without any treatment, not to recur
for years,
if
ever.
Hence we must not attach too much im-
portance to the curative power of the bromids. Should bromism occur, as evidenced by acne, digestive disturbances, bronchial disorders, cardiac weakness, increase
of the reflexes, anaesthesias,
etc.,
impairment of memory, stupor,
the bromids should at once be discontinued and an
free and and supporting treatment instituted, evacuations of bowels and bladder, promotion of regular normal skin action, and the use of digitalis and strychnin
eliminative
in small
rest in
and decreasing bed and a simple,
doses,
supplemented by absolute
Among
easily digested diet. the other countless remedies employed to control
may be mentioned argenti nitras, brom-ethyl, oxid of zinc, borax, adonis vernalis, and the Flechsig atropia, treatment by a regular course of opium in increasing doses,
the seizures
followed by bromids, with rectal lavage, and strict confinement to bed. While all these have given satisfactory results
in
some
cases,
When
among
none are so generally useful as the bromids. status epilepticus, which is comparatively infrequent
the insane, occurs, compression of the carotids should be tried if the arterial tension is very strong. Full doses of
bromid, opium, and chloral in combination

intervals of
of ether or chloroform be tried.
collapse,
may
be given at
two hours, by mouth or rectum, and inhalation Combat exhaustion and and treat all complications promptly, especially
supporting the heart.
Treatment directed to the causes of epilepsy is not promising in insanity, as the disease has been of too long duration. Hence head operations are usually contra-indicated. The
time to operate for trauma,
or immediately thereafter.
etc., is
when the
lesion occurs,
The
prevention of epilepsy can
456
only be secured by preventing marriages of the epileptic,

insane, defective,
Finally, in
self
and
alcoholics.
liability to assaults
view of the
and
injuries to
or others, every epileptic should be under constant surveillance at all times, night and day.
XII.
THE PSYCHOGENIC NEUROSES

are
NEUROSES
characterized
commonly designated as a group of by changing and transitory nervous
diseases
disturb-
ances, to be distinguished from psychoses by the fact that the symptoms do not involve the mental field. But in prac-
psychoses without nervous symptoms or neuroses without mental symptoms are not encountered. Among the neuroses there is a distinctive group of cases, the individual
tice
symptoms
of
which are
of a purely psychogenic origin.
This
group, which comprises hysterical insanity, traumatic neurosis, and dread neurosis, is in general characterized by
a more or
less
marked
hysterical constitution, the
numerous
manifestations of which are seen on every side. While are traumatic neurosis and dread neurosis closely related to hysterical insanity, they are, however, characterized
clinical
by a
method of development, by and a different course. symptoms,

different
different
A.
HYSTERICAL INSANITY*
difficult
to give a perfectly satisfactory definition of hysterical insanity, it may be described as a
Although
it
is
Beitrage, I
Moebius, Schmidt's Jahrbiicher, 199, 2, 185 (Literatur) Neurologische Monatsschr. f Geburtshilfe und Gynkaologie, I, 12 Pitres,
;
Lemons cliniques sur Thysterie et Thypnotisme, 1891 Gilles de la Tourette, Traite clinique et therapeutique de Thysterie, 1891; Janet, Der Geisteszustand der Hysterischen (die psychischen Stigmata) deutsch von Kahane, 1894; Sollier, Genese et nature de Thysterie, 1897; L 'Hysteric et son traitement, 1901 Ziehen, Eulenburgs Realencyclopaedie, 3. Auflage; Krehl, Ueber die Entstehung hysterischer Erscheinungen Volk; ,
457
458
neurosis in which mental states produce manifold physical symptoms with extraordinary ease and facility.
Hysteria develops upon a morbid constitutional basis. Defective heredity occurs in seventy to eighty An equally important factor is the influcent, of cases. per
Etiology.
ence of defective education and training. Other factors are trauma, shock, acute and chronic diseases. Mental stigmata
are often recognized in early life ; as, irritability, waywardness,
indolence, talkativeness, undue piety, and sudden and rapid changes of emotional attitude. Sometimes such physical
disturbances as chorea, headache, and loss of speech have been noted. More than two-thirds of the patients are
women.
is more prevalent among more prominent, as mutism, males, special symptoms reflex convulsions, paralyses, and attacks of screaming, convulsive coughing, and silly befogged states (Chorea
In children, 1 in
whom the
disease
are
These symptoms are easily produced by physical but more especially by emotional disturbances, and injuries, not infrequently result from psychical infection (school
Magna).
epidemics).
Poverty, seclusion, and faulty physique favor
their development.
Hysteria does not often develop in adult
life,
although the
symptoms may become more prominent during the climacterium. The role played by the disturbance of the female
sexual organs in the production of the disease is not clear. On the one hand, it has been observed that disturbances of
these organs may produce severe physical and mental disorders without creating hysterical symptoms, that the
manns
klinische Vortrage,
;
Klinik, VI, 2, 155, 1901
Neue Folge, 330, 1902; Fuerstner, Deutsche Jolly in Ebstein u. Schwalbe, Handbuch der
Sanger, Monatsschr.
f.
praktischen Medizin. 1 Bruns, Die Hysteric im Kindesalter, 1897 ; Psy., IX, 321.
459
disease sometimes appears long before puberty, and finally that it develops in individuals with normal sexual organs.
On
the other hand,
it is
known
that uterine disturbances
relief of
frequently exist and are a source of complaint, and that the even minor uterine disorders leads to a marked im-
provement. It seems probable, therefore, that disorders of the female sexual organs act only as prominent exciting
causes.
The true nature of the disease is still unPathology. known. A short and satisfactory explanation is that hysteria
a congenital morbid mental state whose chief characteristic lies in the fact that, as Moebius expresses it, physical symp" toms are produced by ideas." To this might be added that
is
these ideas are strongly emotional, and, indeed, also indefiThis would account for the fact that the physical nite.
symptoms do not always correspond
to the character of the
stimulus or to the content of the ideas, that they can appear in fields not accessible to the influences of the will, and somerelation
times are not even noticed by the patients. The internal between sadness and tears is no better understood
than that between fright and hemianaesthesia. cause a movement of the bowels and whitened
Terror can
hair, just as
hysteria can produce edema and disturbances of the heart's action. Even clouding of consciousness may be brought
about by states of feeling. While it must be confessed that this is not an entirely satisfactory explanation of the nature of hysteria, yet it seems probable that increased emotional
excitement and the morbid prominence and duration of the involuntary expressions that accompany it play an important role in the production of the disease.
There
disease.
is
no known anatomical pathological basis for the

Apprehension
presents
Symptomatology.
no
striking
460
disturbance.
On
the contrary,
uncommon
sensitiveness;
many patients exhibit an are very keen in the perthey
ception of details in the environment, and especially any A few patients are gifted along certain lines, while defects.
others are dwarfed mentally.
Although the patients appear
vivacious
bility
and
bright, close observation discloses distractiof
and lack
sound judgment.
They are easily attracted
by anything new
sician,
or striking, are deeply impressed by show, become the clients and champions of the most recent phy-
and adopt
peculiarities in dress
and ornament.
in gossip
This
weakness
all
is observed especially in the field of religion.
are eager for sensation,
and take pleasure

it
They and in
sensuous enjoyments.
is
Memory
balanced.
correctly
generally accurate, yet
is
often not well
Furthermore, what is perceived is not always In some cases there is a marked interpreted.
fabrications.
tendency not only to amplify events of the past, but even to

distort
them by pure
Patients will rehearse
startling personal experiences and, in order to

tales all the
make
their
more credible, will present marks of violence, which they themselves have made. In such cases there is no doubt that the patients consciously deceive in order to arouse sympathy or to cause a sensation. But in the minor
variations
from the truth shown by the average hyssay
terical patient it is difficult to
how much
is
intentional
is* due to the subjugation of a lively imagination. In some cases, no doubt, memory by the imagination dominates entirely all thought and action
deception
and how much
without creating the picture of a real delusion. Disturbances in the emotional attitude are very important symptoms. The fluctuation of the feelings determines to a
large extent the whole
mental
life
of the patient.
Their
influence
is
stronger than rational deliberation or moral
461
Patients are excitable, and take an active perprinciples. sonal interest in everything around them, are extraordinarily sensitive, and exhibit a tendency to outbursts of feeling on
slight provocation.
Occasionally there
is
heightened sexual
excitement, but, on the other hand, there may be an absence of all sexual feeling. Frequent and abrupt changes in the
emotional attitude are also
characteristic.
One never
find the patients ; they pass abruptly from a state of merriment into passionate anger at one moment they may be distastefully sentimental, at the next crotchety
knows where to
and
antagonistic.
This increase in the emotional irritability is perhaps a cause of the concentration of thought upon self. Some patients even seem to take pleasure in meditating upon and
busying themselves over their ill-health.
hypochondriacal
Thus numerous
ideas originate and dominate thought. emotional depression has a more powerful influMoreover, ence than in the normal person in producing all sorts of physical ailments. The ease with which this influence is
excited
and the variety
of the
symptoms
are especially charInsignificant feel-
acteristic of the hysterical constitution.
ings of discomfort receive
undue
attention,
and may even
Real complaints are greatly the lively imagination of the patient until exaggerated by hypochondriacal ideas are evolved. Genuine pain arising
create sensations of injury.
from a
definite lesion fails to disappear
with the removal of
the cause, but continues indefinitely, and
may even become

coincident
more widespread.
with menstruation
The headache and backache
may
be the
foci
grievous and agonizing
condition, the
from which there arises a symptoms of which the
patients rehearse in all detail
on every possible occasion. Patients develop a most remarkable attitude toward their disease. They believe that it is an object of distinction, and
462
even become proud of their invalidism. This is also evident in their failure to cooperate in treatment. Although
complaining bitterly, they lack all feeling of personal responsibility in carrying out treatment, and may even stubbornly refuse to
assist.
However, any new or striking
method
of treatment, although it may entail some suffering, often will be undertaken for the sake of notoriety. Many
deny themselves the pleasures of life, and continue to attend entertainments, to visit and receive company, in spite of the claim that their suffering is even
refuse to
enhanced by such endeavors.
Many
terrible
fears,
patients complain particularly of mental suffering : thoughts that constantly torture them, ungrounded
the
memory of
the failures of their
lives, etc.
These
are repeated over and over at every opportunity with great show of emotion, but not without emphasizing their own
heroic struggle or martyrlike submission. Occasionally they wish they were dead and utter threats of suicide ; sometimes
attempts, such as tying a ribbon about the neck or jumping into shallow water.
they
make melodramatic and even absurd
The numerous hypochondriacal complaints necessitate constant medical attendance. Some patients develop a On the state of absolute dependence upon one physician.
not unusual for patients to change physicians frequently, to visit celebrities and ask for many conother hand,
it is
sultations.
gratify
if
They often fall into the hands of quacks who them by offering some wonderful cure. These cures,
is
effected, are usually as transitory as
An
exaggerated self-consciousness
they are striking. a common symptom.
Hysterical patients are markedly self-conscious, and display a corresponding lack of regard for the interests of others.
They
perceive with morbid acuteness any encroachment
463
upon their own comfort, but accept the most extreme sacrifice on the part of others as a mere matter of course. They are always exacting beyond reason, dissatisfied with the best efforts of others, and deeply grieved over neglect or lack of sympathy. The insatiable cravings of many hysterical
patients develop out of this heightened self-consciousness. Dissatisfied with what they have, they are constantly asking
new new clothing, different food, etc. furniture, quarters, It is often surprising to see how undeserving patients successfor something new, usually objects difficult to obtain,
new
fully establish intimate relations
with churches,
societies,
and well-meaning philanthropists, who

unreasonable demands.
the family. In the volitional
most These patients regularly tyrannize

gratify the
an increased
the most pronounced symptom is Patients susceptibility to external influences.

field
yield readily to all sorts of influences, quickly become enthusiastic in any cause and just as quickly lose interest. In
contrast to this extraordinary pliancy of the will to the most varied and insignificant conditions there is frequently observed the apparent opposite state of wilfulness. When " get something into their head," they are most patients obstinate and headstrong in their purpose. Some subject
themselves to great discomfort and pain, even torture themselves, and refuse to eat or speak without any apparent In reality these apparently contradictory states of reason.
the will arise out of the pliancy of the will to accidental influences, whether they are external impressions or personal
The unreasonable and impulsive conduct hysterical patient arises from the same source.
fancies.
erratic,
of the
Consequently, in conduct the patients are unstable and and change rapidly from one act to another without
sufficient reason.
Because they lack uniformity and per-
464

more or
less restlessness, which
sistency, there develops
stands
out in strong contrast to their physical weakness and helplessness. They have a pressure to do something, to take
part in something, to distinguish themselves, to do some misIn manner they are at chief, and they long for adventure.
times vivacious and frank, at others reserved and bashful, or, again, silly and sentimental. They are demonstrative
and often express themselves in the most exaggerated terms. Their vehemence of expression by no means always corresponds to the intensity of their feelings, as the latter often
fluctuate
rapidly from one state to another. Patients characterize their own condition by such expressions as " " " Most horrible!" Excruciating "Inexpressible!" and in
!
depicting their suffering it is not unusual for them to add color to the description by copious weeping or even fainting. In spite of their intense misery, the thought of self-enjoy-
ment usually remains

several sheets of her
in evidence.
home
patient, after filling letter with the most horrible self-
One
execrations, closed with the request for macaroons. The capacity for employment is impaired; the patients
have no disposition for earnest and strenuous occupation,

feel
lack perseverance, are weak and easily exhausted, and always that they must spare themselves. On the other hand,
they pass
much time with
trifles,
arranging and rearranging
pretty ornaments in the rooms, and dillydallying with their toilet and personal adornment.
The physical symptoms of hysteriPhysical Symptoms. cal insanity are wholly functional and are often referred to " as stigmata." They consist chiefly of different degrees of paralyses of a single limb, astasia abasia, choreiform movements,
contractures,
localized
aphonia, impairment of
ances,
and general convulsions, speech, numerous sensory disturbanaesthesia,
including
parsesthesia,
hypersesthesia,

and
fits,
465
visual disturbance;
loss
of appetite,
respiration,
and
globus clavus, singultus, fainting obstinate vomiting, disturbance of Anaesthesia of anomalies of secretion.
of the
the
mucous membrane
mouth and
of the cornea is
regarded as a characteristic symptom of hysteria. Finally, It is characteristic of disorders of sleep are very frequent.
all
these
symptoms that they do not
follow anatomical
and
physiological rules, but are dependent in their appearance, Hemipersistence, and departure upon psychic influences.
crania or convulsive
movements can often be made
to dis-
appear by pressure upon the eyeballs. Contractures or paralyses may be made to vanish by firm pressure over the ovaries or in the hypogastric region, or by an unexpected
dash of cold water upon the face or body. Patients who for years have been bedridden, reduced to a skeleton by
fasting,
and
secretly inflicting
wounds upon themselves
to
incite sympathy,
may be immediately transformed into entirely different individuals by a sharp command, new environment,
or
some sudden freak. But such transformations are usually short-lived, and the patients relapse either into their former, or a still more distressing, condition. Furthermore, the
symptoms sometimes disappear when the
patients believe themselves unobserved or are left alone, only to reappear as soon as their illness is referred to, or when confronted by the
physician.
These various mental and physical symptoms just described are characteristic of the hysterical personality and constitute
the
groundwork upon which
there develop other characteristic
transitory hysterical states.
Of these transitory hysterical conditions, the befogged states are the most prominent. They are characterized by a marked clouding of consciousness, of varying duration, and
either follow, take the place of, terminate in, or are interrupted
2H
466
by,

a convulsion.
its
throughout
In the simple hysterical attack there is, entire course, only a clouding and not a com-
plete abolition of consciousness. The patients usually sink to the floor without injuring themselves, and during the
attack often show in one

fluenced
way
by
external stimuli.
or another that they are inThe attack may consist of
simple fainting, or may be accompanied by pronounced convulsive movements. The convulsive movements do not
seem more and at times even appear purposeful. The complicated patients twist themselves about, groaning and screaming, they roll over and straighten out, strike their feet on the floor, or roll themselves up like a ball; at the same time there is a spasm of the diaphragm, marked slowing of the pulse, flushing of the face, and rolling of the eyes. Very often the back is so strongly bent that the patient's body rests on the bed only at the back of the head and at the heels, forming the arc of a circle. At intervals the patients may turn somer-
show
fixed rigidity or uniform trembling, but
suddenly leap up, clutch at various articles, or cling to something; they may also make grimaces. Occasionally they exhibit delirious states, in which they imagine that they
saults, or
are passing through some exciting experiences and make all sorts of active movements. Often the patients repeat
some actual occurrence in all its details, but usually in a theatrical manner. Sometimes the content of the delirium
patients find themselves in some fearful predicament or a state of ecstasy with heavenly visions and feelings of joy.
is
wholly
fictitious,
when the
All of these different
symptoms
of the hysterical attack
may succeed each other in various ways. Frequently, they are repeated over and over in a regular order. The delirium
may be
interrupted by fainting spells or convulsions. Sometimes the physical and mental symptoms of the attack
467
occur separately, and at other times combined in various
ways.
Following the attack, the patients lie quietly with relaxed limbs, occasionally showing a slight tonic rigidity, breathing
and with a slow pulse rate, the eyes turned upward or rotated laterally. They are irresponsive, except to a powerful stimulus, such as an electric shock or sudden terror, which sometimes entirely arouses them. Such a condition, interrupted by occasional convulsions and short lucid intervals, during which food can be taken, may last from a few
quietly,
hours to three weeks.

terical lethargy.
This condition has been termed hys-
Sometimes the befogged state simulates ordinary sleep. The patients become drowsy, the eyes close, the limbs become relaxed, as in a profound sleep, and the respiration deep and regular. This state is usually of short duration, and the
patients
val,
awaken gradually with no

it is
recollection of the inter-
although
if
possible to arouse
strong stimulus,
when they rub
their sleepy eyes
them by means of a and look
about as
surprised.
This last form borders closely upon somnambulism, which occurs during the natural sleep of hysterical patients. The
wander about the room, open the and perform many peculiar acts, all of which are window, well coordinated. Sometimes they destroy clothing, hide
patients leave their beds,
objects, or set fire to furniture; later they return to their beds, and arise the next morning with only a confused recollection
of
may occur during the daytime, either independently or in connection with a convulsive attack, a fit of laughing or crying. The patients then walk about, muttering unintelligibly to themselves,
Similar attacks
are oblivious to the environment, and not the least distractiIt is very difficult to ble, although able to avoid obstacles.
what has happened.
468

them from
this state,
arouse
even by the application of pow-
erful electrical currents.
This last condition
is
states with inconsequential speech,
perhaps related to those befogged which have been described
It occurs mostly among prisoners awaiting trial, who suddenly become dazed, suffer from active hallucinations, and when questioned give inconsequential answers in spite
by Ganser.
of the fact that they apparently
although with some

exist extensive
difficulty.
comprehend the questions, At the same time there

of anaesthesia
and variable areas
to
pain.
After a duration of a few days, the symptoms disappear, and the patients have no memory of the psychosis. In a few
cases a series of these befogged states
several months.
may
extend through
Befogged states with
silly
excitement are encountered in
young patients in whom the clouding of consciousness is moderate, and does not prevent a recognition of their environment.
Patients usually exhibit a happy, unrestrained sometimes with marked silly behavior. They permood, form all sorts of foolish, wanton pranks, scream, imitate the The cries and behavior of animals, and scramble about.
real morbidity of this apparently conscious behavior
becomes
evident when, as occasionally happens, it is suddenly terminated by a light convulsive seizure, and then, without
memory
of the foregoing behavior, the patients pass into a
short period of depression. The memory of the events during the befogged states, as well as occasionally for events just prior to the onset, is
always
ished.
much
disordered,
and sometimes completely abol-
sort of dual personality, in
In some cases there are encountered examples of a which the recollection of previous
attacks occurs only during subsequent attacks, being comIt occasionally happens during pletely lost in the interval.

an attack that some
469
definite period of the patient 's life is
lived over again, similar to what occurs in hypnotic states. Such alterations in personality arise only under the influence
of autosuggestion.
Nissl finds that twelve per cent, of female insane patients
from various psychoses present some hysterical symptoms. These occur especially in manic-depressive inBut in sanity, and also in the early stages of dementia.
suffering
addition to this there occur during the course of hysterical insanity well-defined mental disturbances, which are a part
of the hysterical personality.
states of
These include sad and anxious
varying duration which appear independently of any sufficient cause and are accompanied by indefinite
delusions of self-accusation
may
is
also speak of
if
and persecution. seeing forms and hearing
The
patients
threats, but it
these are genuine hallucinations or are really connected with dreams. Conditions of excitement, arising
doubtful
as the result of jealousy, spite, and the like, more frequently appear in the form of passionate outbreaks with violent abuse, and sometimes a tendency to destroy objects, or even
to smear their bodies.
These usually pass off in a few hours or at the most a few weeks. Sometimes they recur in connection with the menses.
of the disease is usually protracted, over many years. In women espesometimes extending cially the onset of the disease is early, frequently appearing
Course.
The course
at the age of puberty, but it may occur even earlier. The individual symptoms may show the greatest variation in their
appearance and prominence; indeed, the rapidity and abruptness with which the symptoms change is distinctly characIn a way the disease may be teristic of hysterical insanity.
regarded as a series of attacks which recur on the basis of the hysterical personality. These attacks rarely last longer
470
than a few months, and usually do not exist more than a few days or even hours. But the different depressed, excited, and befogged states, together with the physical disturbances, may produce a variegated and incongruous picture extending over considerable time. The course of the
disease in children is characterized by less variety of symptoms and a shorter duration, while in males there is a far more uniform picture with little variation of the individual symptoms, which may persist unchanged for years. The diagnosis of hysterical insanity is most Diagnosis. The constitutional psychopathic states predifficult in men. sent a more uniform course, while hysterical befogged states In and various physical symptoms are not encountered. traumatic neurosis there is a far more uniform development. The differentiation from epilepsy has received sufficient consideration under that disease. Finally there may be some difficulty in differentiating the hysterical befogged states with inconsequential speech from catatonia, in which inconsequential speech is frequently encountered, and in which the areas of analgesia may be mistaken because
of the presence of negativism.
tically
In catatonia there
is
prac-
no clouding
of consciousness.
of
The
differentiation
hysterical
insanity
from those
psychoses in
which individual hysterical symptoms some-
times appear, such as manic-depressive insanity, dementia prsecox, paresis, etc., must depend wholly upon the presence
of the
symptoms which are
characteristic of those forms of
disease.
The prognosis of hysterical insanity, as rePrognosis. the befogged states, is, in general, good; sooner or gards
later, either
ment
with or without treatment, there is an improveor at least a considerable change. The disease in itself does not progress. The improvement or aggravation of the

symptoms depends very materially upon the
ditions in
471
peculiar con-
which
is
the patients find themselves.
At any
rate
dementia never develops.
where there varied forms
The prognosis is less favorable an increasing tendency to relapses into the

Hysteria in children
is
of the disease.
decidedly
more hopeful, as the symptoms usually disappear with the

development of the child. Occasionally, remarkable cures by the removal of prominent exciting causes as, diseases of the sexual organs, injurious environment, and improper hygiene. In male patients there is a severe form
are effected
;
of
hysterical
insanity
with pronounced hypochondriacal

to all
complaints which Treatment.
is resistive
modes
of treatment.
The disease, developing as it does upon a psychopathic basis, demands prophylaxis in the way of care of the pregnant mother, and careful supervision of the education and training of psychopathic children. The pregnant neurotic mother should avoid all forms of excitement and sources of fear and worry, and conform as closely as possible to a life of mental equanimity. The child, especially if it
shows a tendency to insomnia, with night terrors or restlessness and evidences of unnatural excitability and precocity, must be removed from the presence of a hysterical mother,
who
naturally least fitted for environment, where the child

is
its training.
Such pernicious
bursts
and
fits
of
must witness emotional outand other hysterical symptoms, temper

the formative period
years.
has an indelible
effect, particularly in
between the
fifth
and twelfth
Relieved of such surroundings, the main object in the education should be the development of physical strength
and
vigor,
nutrition.
cise,
and the maintenance of an effective state of For this purpose, plenty of out-of-door exerwith an abundance of sleep and wholesome diet, must
all
be prescribed in connection with a discouragement of
472
elements of precocity in the mental, moral, and sexual life, and inculcation of self-control and the nobler senti-
ments.
The same
care
must be continued during the
period of puberty and youth, but should include advice in relation to sexual matters, sentimental love affairs, and
later relative to the
assumption of the duties of early maritself
ried life, especially sexual relations. In the treatment of the disease
the element most
essential to success lies in the personality of the physician, who must inspire the patient with confidence and secure
the
cooperation
cases, it is
family. Except in the lighter of first importance to isolate the patients and
of
the
establish a suitable routine in the mental

life,
and physical
thereby removing from the environment the disturbwhich have always been a source of annoyance and have acted as exciting causes. This isolation, although
ing factors
best carried out in a small, well-selected sanitarium, under
the direct supervision of a physician, can be accomplished, with the aid of an efficient nurse, at the home. At all events
the patient must be given over entirely into the hands of the physician, who establishes confidence and control, not
by harsh and dogmatic opposition, but by gentle persistence, in which he must combine firmness and even boldness. This
accomplished, he
is
in
a position to bring about great im-
provement, and often recovery, by simple remedies. Attention should be directed to any possible organic disturbances in the stomach, intestines, kidneys, heart, lungs, and sexual Iron should be prescribed in anemia, and restoraorgans.
tives
employed
in conditions of emaciation, as well as bitter
tonics for anorexia.
On
upon
the other hand, mechanical
to produce measures the most important are hydrotherapy,
therapy can be relied excellent results. Of the mechanical

electricity,
473
massage, exercise, and employment. In the use of hydrotherapy Collins regards the tonic bath the best, in which
the water, at a temperature varying from
degrees,
is
fifty-five to sixty
applied under from fifteen to twenty pounds' from four to five seconds, followed by a Fleury spray of eighty degrees and similar pressure for one to two seconds. In the use of the bath hysterogenic zones
pressure for
must be protected. The reaction should be passive movements, walking, or gymnastics, hour following the bath. Where this bath
duce the desired
effect or is
facilitated
by
for
one halfto pro-
fails
not well borne, he suggests

It is
the use of the Scottish spray.
always desirable, when
possible, to avail oneself of a hydriatic institution for these
purposes.
in a house
The treatment can be accomplished, however,
supplied with water under sufficiently high pressure by the simple use of a detachable hose and a tube. This should always be under the direct supervision of the
physician,
who
will find it necessary to
vary the details of
the treatment according to individual cases. When the bath is not accessible, the drip sheet may be used, the description of which
may
be found under the treatment of acquired

is
neurasthenia.
In the application of electricity the faradic current
of
most
service in improving the nutrition
and
in relieving
anaesthesia
and
hypersesthesia.
The
daily routine of the hysterical patient should be one
of activity, alternating with rest
and relaxation, including and out-of-door exercise, combined massage, gymnastics, with some sport which tends to increase self-reliance. There are a few cases which require surgical treatment
for the alleviation
of organic disturbances in the sexual
organs, especially where the symptoms of the disease seem

to bear a definite relation to the menstruation.
Removal
474

normal ovaries has produced but it is the general verdict of
of slightly diseased or even
improvement
in a
few
cases,
to-day that this drastic procedure has more often been of 1 detriment than benefit, and should be discarded.
because those susceptible to hypnotic suggestion are apt to be influenced by any powerful suggestion that happens to be presented. Fur-
Hypnotism
is
of limited value,
thermore, hypnotic experience brings about an undesirable dependency of the patient upon the physician, which makes
impossible an effective subjugation of their own wills in the strife with the morbid influences. The greater the influence
the more easily autosuggestions arise, and the the efficacy of the hypnotic suggestion is nullified quicker by other and opposing ideas. In mild cases, and especially
exerted,
in children, suggestive therapy is of considerable
in
importance overcoming individual hysterical symptoms, such as
paralyses, sensory disturbances,
and tremor.
On
the other
hand, simple suggestion is a therapeutic measure of great value in every case, and often suffices for the complete dis-
appearance of paralyses, contractures, aphonia, etc. In the treatment of the hysterical attacks, the patient can often be restored to clear consciousness by a brisk
command, or, if this fails, by a dash of cold water upon the face, by the electric brush, or pressure over the ovaries or upon the hysterogenic zones. In very severe cases inhalations of chloroform
1
may be
necessary.
Angelucci, e Pieracini, Rivista sperimentale di freniatria,
XXIII,
290.

B. TRAUMATIC NEUROSIS
l
475
(Traumatic Hysteria)
Traumatic neurosis
is
arises as the result of
trauma and
gradual appearance of a prolonged period of mental depression accompanied by numerous motor and sensory nervous symptoms. The trauma may occur in
characterized
by the
the form of sudden fright, intense anxiety, great misfortune, or an injury in connection with a fire, railroad accident, explosion, earthquake, sunstroke, or electrical shock.
Cases of this sort were
first
by Erichsen in 1886, but it Oppenheim and Striimpell in 1889 that the disease was The clearly differentiated and received its present name. of such a disease has always met with more or recognition less opposition, especially by French writers, and more recently from Schultze, Hoffman, and Mendel, who maintain
that the disease
is
recognized and well described was not until the investigation of
either hysteria or neurasthenia of trau-
matic
origin.
no adequate explanation of the pathology of the disease. Westphal and his school consider that there is an organic basis to be found in changes
Etiology.
is
At present there
of the central nervous system.
Charcot regards the disease as closely related to the hypnotic condition, because the
1
Oppenheim, Die traumatischen Neurosen,
2.
Auflage, 1892
Schultze,
;
Sammlung
sche
klinischer Vortrage, N. F., 14 (Innere Medicin, No. 6) DeutZeitschr. f. Nervenheilkunde, I, 5. u. 6, 445; Striimpell, Miinch-
ner Medicinische Wochenschrift, 1895, 49 u. 50; Sanger, Die Beurteilung
der
f.
Nervenerkrankungen nach Unfall, 1896; Fiirstner, Monatsschr. Unfallheilkunde, 1896, 10; Schuster, Die Untersuchung und Begutachtung bei traumatischen Erkrankungen des Nervensystems, 1899;
Sachs und Freund, Die Erkrankungen des Nervensystems nach Unfallen mit besonderer Beruchsichtigung der Untersuchung und Begutachtung, 1899; Bruns, Die traumatischen Neurosen. Unfallsneurosen, Nothnagels
Handbuch, XII,
1, 4,
1901.
476
disease picture wholly resembles the picture of a firmly rooted autosuggestion. The psychical origin of the disease This theory is substantiated is the generally accepted view.
by the
facts that the neurosis
sometimes appears without
known
injury, as when it follows fright or slight injury to other parts of the body than upon the head; and that the manifestations of the disease are not necessarily limited to
the part where the injury occurs, but may be general. In cases following head injury it is held that delicate pathoExperilogical changes occur in the cortical neurones.
mentation upon test animals, in which definite pathological lesions in the neurones can be produced by concussion without severe injury, would seem to verify this supposition. It is doubtful whether the emotional disturbance at the
time of the accident should be regarded as the cause of the disease, as very frequently weeks and even months elapse
symptoms appear. An important factor, the psychical influence of membership in undoubtedly, accident insurance societies, of possible indemnities, and of
before the
first
is
suits for
exist,
damages.
At any
rate, in cases
where these factors
the neurosis seems to run a more unfavorable course.

until settlement is reached,
The symptoms regularly worsen when they are apt to improve
rapidly and often entirely Another element of importance is the defective disappear. constitutional basis, in which alcoholic intemperance plays a considerable role.
The symptoms develop gradually Symptomatology. in the course of a few weeks or months following the shock,
and
consist chiefly of despondency with anxious fears
of the
power
of physical
and mental
resistance,
and and an
loss
in-
capacity for any Patients seem quiet

is
earnest employment.
slow,
and they take
less
and low spirited. and less interest
Apprehension
in the environ-

ment.
477
becomes unusually uniform and centers mostly about the accident, to which sluggish, the patients refer over and over and often describe in " hard luck," present deplordetail, laying stress upon their able condition, and hopeless future. Sometimes comHypochondriacal ideas pulsive ideas and phobias appear. become very prominent. Patients cannot rid themselves of thoughts of the accident and fear that they have been
association of ideas
The
and
severely injured, because they are not the same, are always They observe caretired, exhausted, and unable to work.
fully everything
about their physical condition connected
with the injury. In emotional attitude patients are very irritable, sensitive, and easily thrown into a state of perplexity or confusion, are unable to express themselves with perfect coherence,
and are conscious that
their thoughts and actions are conhindered by feelings of inward oppression and stantly anxiety. This anxiety may lead to passionate outbursts
and even
Memory, in spite of complaints to the contrary, is good, if one makes allowance for the lack of interest in the environment and the faulty attention.
suicidal attempts.
When
agitated, the patients
may
not be able to solve even

is
simple problems.
Their capacity for work
greatly
ham-
pered by hypochondriacal notions and numerous nervous complaints. Whenever they attempt to do something, headache, palpitation of the heart, excessive perspiration,
etc.,
develop.
The mental symptoms usually do not

casionally befogged states or
an acute hallucinatory
it is
Ocprogress. exciteusually
ment appears.
If
mental impairment develops,

lesion.
due to a cerebral
Physical Symptoms. Sleep is disturbed by anxious dreams, the appetite is poor, and nutrition becomes impaired.
478
Patients complain of various sensations in the head and back, especially parsesthesias and pains in parts of the body
injured at the time of the accident. Pain, which is usually the most prominent symptom, is persistent and troublesome
and may lead
to immobility of the parts involved.
In addi-
tion, patients complain of ringing in the ears, loss of strength, palpitation of the heart, difficulty of urination, and occasion-
obstinate vomiting. Some cases present objective symptoms, such as areas of analgesia and of hypersesthesia, constriction of the field of vision, difficulty of hearing,
ally
increased tendon reflexes, paralyses, slowness tainty of movement, and disturbance of gait
and uncerand speech.
Tremor, especially of the
fibrillary type, is often present,
being either general in character or involving only muscles of the paralyzed part. Paralysis may occur in the form of
hemiplegia or paraplegia, but the facial and hypoglossal nerves are seldom included. The paralysis almost always
occurs on the
same
side as the accident }
and
is
frequently
accompanied by contractures. There is often an acceleration of pulse and sometimes of respiration following emotional disturbance, pressure on the painful points, or muscular
Occasionally, also, vertigo or even epileptiform Localized attacks may be produced in the same way.
exertion.
muscular spasms
and convulsions are common.
Vaso-
motor disturbances occur, as localized blushing, cyanosis, and dermography. Sensory disturbances, both subjective and objective, of which hypersesthesia is most prominent,
usually involve the injured side of the body. All of the motor and sensory nervous disturbances are to be
distinguished from those accompanying organic brain
and
cord lesions by their location, their broad extent, changing condition, and the fact that they worsen under the influence
of emotional
and physical disturbances.
Friedmann adds
479
that these patients have little power of resistance to alcohol, galvanization of the head, and compression of the carotids.
Diagnosis.
The
diagnosis
is
terical insanity is distinguished
often very difficult. Hysthe lack of uniformity of by
the
symptoms
in a given case;
the hysterical patients prealteration of
sent a variegated
and transitory
symptoms,
capriciousness, pronounced changes of disposition, desire for undertaking something new, and great pliancy. Furtherdoes not present befogged states. more, traumatic neurosis
constitutional psychopathic states are differentiated by the fact that the onset is not sudden, does not depend upon an injury, and has a less favorable course.
The
Simulation should always be taken into consideration. Unfortunately the various objective symptoms, constricted
field
of
vision,
acceleration
of
pulse,
increased
tendon
reflexes, and absence of galvanic excitability, are of little value in establishing a positive knowledge of the existence of a mental disorder. Deception cannot be unmasked by the
presence or absence of any one
symptom
or group of
symp-
toms, but must depend upon the conformity of the whole clinical picture to one of the known disease-symptom groups.
Recently psychological tests have been successfully employed to prove the mental symptoms; as, for example, psychological tests of the power of apperception, test of diminution of the
ability to figure, the susceptibility to training,
fatigue.
and
especially
Thus
it
has been shown that in traumatic neurosis
there should be a
marked loss in the capacity for work and a very great increase in the susceptibility to fatigue. The lighter cases of traumatic neurosis apPrognosis.
pearing soon after the accident may improve rapidly, but even some of these run a long course and have an unfavorable outcome.
Yet, after a duration of many months or even a few years, the disease may terminate in recovery or
480
great improvement. The prognosis is less favorable in the presence of pronounced focal symptoms or general
arteriosclerosis.
Treatment.
all
The
first
indication
is
to dispel as far as
ideas of litigation. Next to this, employment possible It often happens that the symptoms is of the greatest value. of the disease disappear rapidly as soon as litigation is
settled or patients are compelled to go to work again. residence in an institution with the opportunity for employ-
distraction frequently serves to bring about great improvement or recovery. In all cases hydrotherapy, massage, exercise, electricity,
ment and
and hypnotic suggestion, as well
as dietetic regimen, are of value.

C.
DREAD NEUROSIS
comprises a small group of neusuffer from a more or less
The dread
rotic cases in
neurosis
which the patients
constant feeling of
entire
life.
anxious suspense
which dominates
the
anxiety develop are that normally take place without conscious usually processes interference, such as walking, standing, drinking, writing, etc. The anxiety almost always appears for the first time
The
conditions about which the
immediately following some real but trifling condition, such as an experience during which the eyes have been subjected
to
fatigue or a dazzling light, moderate overexertion, fatigue after a long walk, etc. Anxiety about sleep may
periods of emotional stress. Frequently some physical disease initiates some of the symptoms: a feeling
follow
weakness follows a mild rheumatic attack, or pain in the In addition to feelings of anxiety there leg follows a fall.
of
regularly develop uncomfortable and even painful sensations, as well as a sort of paralytic weakness which interferes with

the movements.
481
The
painful sensations, especially, accom-
pany the process
of apprehension,
while
the
muscular
though both occur together. The anxiety and the accompanying sensations usually occur first in connection with some simple
will,
weakness appears during exertion of the
act,
such as eating certain kinds of food, reading in bright But they gradually sunlight, or sleeping in a certain place.
become more extensive and may

lar acts
wholly impossible.
render some particuIn one patient insomnia first

finally
developed whenever she anticipated doing something unusual the next day, such as going to the city, but later the most trifling affairs would cause it to appear.
The
clinical
picture
is
reading, letters will disappear,
variegated; while patients are then there is a feeling of heat,
a sensation of tension, photophobia, and pains that streak across the forehead, which ultimately compel them to cease
reading altogether. Similar disturbances develop in connection with hearing. In writing the fingers soon stiffen, or there is great weakness. Swallowing can be rendered
by the appearance of a cramp in the throat. Walking is hindered by weakness in the legs, pains, etc. Sleep may be impaired by an increasing restlessness, twitching of the limbs, and palpitation. Some cases of psychical impodifficult
tency belong here. Patients mistake the true origin of the disorder and begin to refer it to real diseases of the eyes, ears, muscles, and nerves.
This causes them
still
their self-confidence.
greater anxiety, and undermines Attention is directed more and more
to these supposed physical disorders,
and thus there de-
velops a vicious circle, each factor adding fuel to the other and making it impossible for the patients to free themselves.
Increasing sensitiveness of the eyes causes the patients to systematically avoid light, therefore they do not venture out
2i
482
Pain and weakness, which interfere with walking and standing, cause the patients to gradually limit their movements and ultimately to remain In this state both active and passive in bed altogether.
save at twilight or on cloudy days.
movements may produce excruciating movements of the head are singularly
pain.
free.
Speech and
Furthermore,
the disorder ordinarily does not extend into other fields, but confines itself to the particular process which was originally involved, as, for instance, to sight or to walking.
Consciousness remains clear patients are oriented, orderly,

;
and do not exhibit emotional
deterioration.
They com-
placently endure the severe suffering which they regard as purely physical. Hysterical symptoms are never a part of the disease picture.
Course.
The course
of the disease is usually protracted,
though there are frequent remissions. Efforts upon the part of the patients to overcome their symptoms only aggravate the
condition.
Strenuous
efforts
to
relieve
the
patients by usually effect only a transitory improvement. On the other hand, many of the patients get well of their own accord. There is some question as to the clinical Diagnosis.
position of the dread neurosis; indeed, the lighter forms have often been considered as cases of nervousness or
neurasthenia,
psychasthenia.
various
mechanical
and medicinal
devices
while Janet describes
many such
cases under
Against the former view may be cited the fact that the patients need not at any time exhibit any other nervous
symptoms, while there is at no time any evidence of nervous exhaustion. Although the symptoms may originate in some physical ailment, they do not disappear with the recovery from that condition and restoration of strength.
The
differentiation of hysterical insanity depends
upon the
483
presence of the unconscious influencing of the physical processes through emotional excitation, while in the dread
alone the condition of weakness and instability which deprives the patients of their ability to withstand
neurosis
it is
In hysteria the symptoms frequently alternate from one field to another, but in the dread neurosis the symptoms are uniform and progressive.
the supposed physical
affliction.
The phobias are distinguished from this disease by the that the fears are more general in character, while in this disease there is some definite personal experience
fact
which forms the starting-point. In the phobias the fears frequently change in several different directions, but in the dread neurosis fear is uniform, always hypochondriacal, and has to do only with the patients' own bodies. Furthermore, in the phobias there are real states of anxiety which embarrass the patients or force them to secure protective
of the origin of their difficulties,
measures, but in this disease the patients are not conscious which appear to them as
real pain, actual weakness, or genuine ataxia.
patients recover of themselves, without any treatment. In some way or other, frequently through the influence of some one whom they trust, they
Treatment.
Many
regain self-confidence and with it the strength to conquer the disease. On the other hand there are many cases in
which
failure at the first trial destroys all

first
Patients at
ment, but in to cherish a vague fear that they cannot recover. Simple hypnotic treatment often effects a rapid and permanent
hope of recovery. seem to react well to new methods of treatreality from the very beginning they are apt
recovery. Cases of even ten years' standing have been restored in this way. This form of treatment, however, is often difficult, and demands that one should thoroughly
understand the technique, in order to gain the confidence of
484
the patient, without which success is impossible. In severe cases it is often necessary to begin by giving only quieting
suggestions, because premature suggestions as to the cure might prove disastrous. This method rarely fails. In case
it
does, one
may employ waking
is
not as effective.
suggestion, but its influence in this, there is no hope for cure. Failing
XIII.
CONSTITUTIONAL PYSCHOPATHIC STATES

(Insanity of Degeneracy)
THE fundamental symptom
in
chopathic states is the continuous
the constitutional psymorbid elaboration of
normal stimuli as manifested in a morbid misdirection of thought, feeling, and will throughout life. These states develop on a morbid constitutional basis. The commonest
type of psychopathic degeneracy is characterized by those little imperfections of the individual constitution which
These symptoms ordinarily designate as nervousness. form the groundwork upon which the more marked forms of the insanity of degeneracy develop. These various forms of the insanity of degeneracy are hard to group, because there are so many combinations and border-line states. In
the present state of our knowledge the best arrangement
we
seems to be constitutional despondency, constitutional

ment, compulsive insanity, impulsive insanity, sexual instincts.
excite-
and
contrary
A. NERVOUSNESS 1
states
1
Nervousness comprises several congenital morbid mental which are characterized in general by an inability to
Saury, Etude clinique sur la
folie he*re"ditaire
(les de*ge*ne"res),
;
Koch, Die psychopathischen Minderwertigkeiten, 1893 Pathologic und Therapie der Neurasthenic, 1896;
Nervositat und neurasthenische Zustande, la Tourette, Les e*tats neurasthe*niques, 1898
psychasthe*nie, 2. Bande, 1903.
2.
;
1886; Binswanger, Die
Krafft-Ebing, Auflage, 1900; Gilles de Janet, Les obsessions et la
v.
485
486
withstand the misfortunes of life, together with a lack of symmetry in the development of the entire psychical personality.
Intellectual
endowment usually
is
not equal to the average,
although occasionally it may be excellent. Some particular faculty may be unusually well developed; as, for instance, the sense of form, of color, or memory for numbers. Some
patients may be able to perceive keenly, but yet lack insight into character, or may possess profound knowledge without any practical bent. Some patients are remarkably
a prominent symptom. Hence patients tire quickly and have little endurance. Occasionally they learn with difficulty and quickly forget what they have learned. Attention shows an increased distractiis
precocious. Increased susceptibility to fatigue
Patients are very sensitive to interruption, and are easily distracted from their customary ideas and plans by anything new. These symptoms give rise to flightiness and
bility.
An unusual activity of the imagination often present. Ideas possess a great sensory vividness and are easily united. Consequently there develops a strong
superficiality.
is
tendency to revery, which

bility of the attention.
is
also favored
by the
distracti-
While egotism usually prevails, on the other hand, selfdepreciation and a lack of self-confidence may be present.
Most patients lack the sense of reality. To them the daily occurrences of the immediate environment seem distant; " " indeed, things do not conthey have a far-away feeling cern them any more than if they lived in another world.
;
Deceitfulness
is
also a
common symptom,
from the tendency

products of their
are easily falsified
of patients to
arising in part themselves with the busy
own
imagination. Superficial recollections by the addition of fictitious facts, even
CONSTITUTIONAL PSYCHOPATHIC STATES
487
without the patients being conscious of it. Furthermore, the emotional states exert a great influence over the ideas;
hopes and fears guide the thoughts, while vivid impressions as well as accidental ideas dominate intuition and recollections.
In the emotional
field
there
is
a tendency to asymmetrical
development. Great sensitiveness, eagerness, and excessive enthusiasm may predominate, while the more natural feelIn connection with an artistic sense of ings are arrested.
appreciation obtuseness.
there
may
be
lack of
tact or
for
a moral
Unnatural affections arise;
instance,
fanatic affection for one of the animals, an idolatrous adoration of some person, also numerous idiosyncrasies, or a
senseless abhorrence or fear of certain persons, objects, or
There are many striking peculiarities morbid tender-heartedness, of the emotional attitude,
disease
symptoms.
extravagances, or persistent timidity and cowardice. Rapid and sudden changes of the emotional attitude are frequent exuberant happiness suddenly changes to seclusiveness or
:
outbursts of fury; patients become excessively angry and just as quickly placid.
In accord with the feeling of egoism, the patients attend chiefly to their own thoughts and busy themselves with
own welfare. Thus they observe in a most painstaking manner the minor physical changes, which then rapidly multiply and cause apprehension. Constant thought of self and superficiality of the feelings gradually leads to selfishtheir
ness.
Patients are cold, unapproachable, associate with no
one, and are most inconsiderate of nearest relatives. They degrade themselves in numerous ways in an effort to arouse special recognition and sympathy. The actions of the patients show constant constraint. Voluntary impulses do not arise from established principles,
488
but from momentary feelings and impulses, as well as through accidental impressions. Fears and passionate impulses
interfere with a
harmonious development and release of
voluntary action.
Hence patients are never able to follow to its conclusion, as is clearly indicated in their anything occasional foolish and weak attempts at suicide, showing
inability to transform their desperate feelings into reso-
an
lute acts.
The
do
patients themselves usually feel their inability to If at the outset satisfactory and uniform work.
they seek to become masters of their own imperfections by means of a strong exertion of the will, they gradually
lose ground.
constant struggle regularly leads to weari-
ness
and enervation.
acts,
from any
Impulsive
patients gradually withdraw serious activity and let things go as they will.
Many
foolish
journeys,
precipitate
betrothals,
changes of location and profession, and attempts at suicide

are constantly occurring.
Impulsiveness becomes more and more
prominent, and
certain habits of will often develop which are exceedingly difficult to break up. Patients must conduct their business
always in a certain way, and at once become embarrassed and ill at ease as soon as a change takes place. They are apt to fall an easy prey to the misuse of drugs, become drunkards,
drink strong tea and coffee, and are frequently given to excessive dosing with quack remedies.
The
sexual
life
is
usually an important factor.

to
Sexual
impulses develop early and
an abnormal degree, often to masturbation, which usually becomes deeply leading rooted and is often practised in addition to regular sexual intercourse. Occasionally the sexual impulse becomes the central point about which the entire life revolves, producing the picture of sexual neurasthenia. The sexual desire may
489
be accompanied by an intense feeling of discomfort, even incapacitating the individual, and disappears only with
gratification.
the other hand, intense feelings of anxiety the sexual act, frustrating its accomplishmay accompany ment and leading to mental impotence. Increased sexual
On
excitement induces reckless masturbation, resulting in a constant overexcitation, premature ejaculation, and spermatorrhoea, associated with hypochondriacal fears. Ultimately all kinds of morbid sensations and ideas may develop
around
this central point.
The weakened power

the most varied ways.
delirious, or faint
of resistance
may
manifest
itself in
Nervous individuals often develop

Furthermore, there
a high temperature upon slight provocation, easily become

during excitement.
is great susceptibility to alcohol, as well as to tea and coffee, rapid collapse under stress, inability to withstand hunger or
thirst,
and a great dependency upon weather and temperaThere

is
ture.
also a tendency to pressure in the head,
headache, bility of the heart.

general
false sensations of all kinds,
and increased
is
irrita-
The taking
of food
also involved in the
appetite alternates with loss of appetite, nervous dyspepsia often develops, as well as sensations of pressure or fulness in the stomach, etc.
disturbance;
voracious
Sleep
is
frequently disturbed.
In some cases there
is
an
extraordinary demand for sleep, so that even after eight or nine hours of sleep the patients can hardly be aroused.
Many
their sleep
patients feel a great weariness upon awakening, is disturbed by restless dreams.
and
Degeneracy is often apparent in various physical defects; such as, a lack of development of the body beyond a puerile
stage, either a very youthful or a senile countenance, localized or general cessation of development of the brain and
skull,
abnormal position of the
teeth,
malformation of the
490

and hands.
Occasionally there
ears, palate, sexual organs,
are residuals of an old cerebral disease.
is
Since nervousness according to our conception a congenital morbid state, one cannot speak of the disease
Course.
as having a characteristic course. Usually the morbid constitution first shows itself in childhood by great restlessness,
by
irritability, sensitiveness to injuries,
minor nervous
dis-
turbances, convulsions, enuresis, night horrors, stuttering, etc. Later, difficulties are encountered in teaching the
on the one hand, great irritability, passion, and rebelliousness, and on the other, susceptibility to seduction
children;
and sexual
sense
of
influences, fickleness, anxiety, irresolution, great
fatigue,
and
distractibility.
Occasionally there
develops a tendency to lying, thieving, and truancy. Many of these symptoms may improve under favorable circumstances.
There
is
often observed an increase of the morbid
symptoms during the period
of development, in spite of all corrective measures. This may be due in part to possible the unfavorable influence of the general physical and mental
evolution at this period,
and
in part to the gradually in-
creasing demands of life. Furthermore, persistent masturbation, alcoholic excesses, exhausting diseases, pregnancy in women, and, under some conditions, intense emotional
excitement are pernicious influences which regularly aid in bringing the disease to its full development. Nervousness is often mistaken for neuDiagnosis.
rasthenia.
In neurasthenia the symptoms of fatigue only
are present, except in marked conditions, while in nervousThe more marked ness there are signs of degeneracy. these signs are in a given disease picture, the more cautious
one should be in considering as a cause for the condition an alleged nervous exhaustion. The symptoms of simple
nervous exhaustion rapidly
mend under
the influence of rest,
491
but the symptoms of nervousness, when once aroused, run an independent and, under certain conditions, a progressive
course, even
if
the immediate exciting factors have

this,
been
develops at any time from youth up without any appreciable external cause and assumes varied forms, while nervous exhaustion
corrected.
In addition to
nervousness
never attacks healthy nervous systems without some powerful injury.
Prophylaxis is of greatest importance. Defective persons should be dissuaded from marrying each
Treatment.
Of the particular injurious influences to be combated, alcoholism is the most prominent. During childhood patients need special attention paid to their education and training, which should be proportionately divided between the body and the brain. The mental development
other.
should be retarded
if
there are
Particular stress should be laid

received,
any evidences of precocity. on the amount of sleep
and the patients should be permitted all the sleep they desire. At the time of the awakening of the sexual impulses, the children must be carefully watched and inVery often
it is
structed.
best that the childhood should be
passed in the country, in order to give the body as much opportunity as possible to develop, to eliminate confinement
to avoid the pernicious influences of bad If the disorder is very pronounced, associations in cities.
in school,
and
manual training under the supervision of a physician is desirable. Psychopathic children, on account of their faulty The constitution, do not tolerate routine training well.
In training should be adapted to personal peculiarities. the choice of an occupation one must take into consideration
Uncongenial and annoying employment makes the symptoms worse, while simple, regular, and uniform work often does much good. Patients should
their imperfections.
492

all
Alcohol in any form must be forbidden. Furthermore, morphin and hypnotics can be prescribed only with the greatest care.
avoid
excesses.
The individual symptoms themselves are best combated by means of an intelligent training under medical supervision, regulation of the entire
life,
with due regard to a pro-
portionate amount of work and recreation, sufficient sleep and nourishment. Long-drawn-out " cures " are usually
unsatisfactory, especially in institutions, as the complaints and hypochondriacal fears tend to increase under' such conditions,
and should be resorted
reasons.
On
to only for very definite the other hand, the necessity of meeting some
regular obligations serves as an important remedy. If relaxation is necessary, it is usually best accomplished by a short journey or a sojourn at the sea or in the mountains.
These patients, in general, demand frequent but short periods of relaxation.

is
best obtained
artistic efforts,
Where there is despondency, diversion means of social intercourse, distractions, by and amusements.
CONSTITUTIONAL DESPONDENCY
B.
Constitutional despondency -is characterized sistent feeling of sadness which pervades all of
riences.
Intellect
by a
life's
per-
expe-
shows no striking disturbances.

in
Some
patients
are well endowed, while others from youth are
somewhat
backward
tigue
is
mental development.
;
The
susceptibility to fa-
greatly increased
piece of
while patients are capable of takintelligence

rests,
ing
up a
work with
quickly,
demand frequent
and skill, they tire and are wholly unfit for
steady application to mental or physical work, because of

resulting headache, insomnia, or general malaise.
Under

stress of circumstances
493
they are often able to temporarily

Distractibility of the attention
overcome these hindrances.

is
greatly increased, so that even the most trifling affairs in the surroundings may greatly interfere with systemHence their work is uncertain, and sometimes atic work.
has to be done over several times.
There
to display hypochondriacal complaints.
a tendency Consciousness reis
thought is coherent. Patients often appreciate their unfortunate condition. In emotional attitude they are oppressed and sorrowful. They may have always been especially susceptible to the
unclouded,
cares, sorrows,
mains
and
and misfortunes
of
life.
Present pleasure
is
always clouded by past sorrow or troubled fears for the
Many patients to all external appearances seem normal and only disclose their sadness to their families or the physician. Under the influence of some excitement they may temporarily become happy and cheerful, but soon
future.
Any undertaking dismays relapse again into their misery. and they take little or no pleasure in any occupation. them, They lack self-confidence, are easily discouraged, feel that
they are of little use in the world, are nervous, sick, and fear the outbreak of some awful disease, especially insanity.
are always troubled with the feeling that they have done something wrong, or that some ill will befall them.
Some
They are especially apt to worry about The sexual impulses are usually awakened
their sexual
life.
early
and lead to
excesses, especially masturbation, the consequences of which the patients always paint in the darkest colors. Sometimes
the patients are sentimental.

greatly influenced. If anxiety predominates, patients shrink from every obligation, dread the most remote possibilities, and avoid everything to which they are unacis
Conduct
customed.
Many
patients are deliberate, find
it
difficult
494
to arrive at a decision, and tend to exhibit great precision and punctuality in little things. They use an endless amount
of time without accomplishing anything.
They
stick
so
tenaciously to every task that they are gradually reduced to a smaller and smaller sphere of activity. They excuse
themselves for not going out into society because they have not time, and they cannot travel because it is too diffi-
Ultimately their whole activity may be confined to keeping the house clean and preparing meals on time. Some patients are constantly thinking of death and are always making preparations to die. Though they may
cult to get ready.
not seem in earnest about

that they
it,
yet
it
not infrequently happens
make attempts
at suicide.
Very often
all sorts
of nervous complaints interfere with their ability to work, such as pressure and pain in the head and peculiar sensations in all parts of the body. Occasionally some peculiar
motor symptoms are observed, as grimacing, choreiform movements, clucking with the tongue, snuffling, and twitch" " These tics accompany all the different ing of muscles.
forms of degeneracy.
Course.
The
Sleep is usually much disturbed. course of the disease is prolonged, with
irregular remissions; but within certain limits
uniform course, lasting for years. becomes worse after emotional shocks and physical disease and even without any apparent cause. Gradually the
runs a very The condition regularly

it
patients may become better, but it rarely happens that they are entirely free from symptoms. At first remissions may
occur, but later there
persist, until finally
a tendency for the symptoms to there is a continuous morbid condition

is
with
little
variation.
Even during the
remissions, patients
always display some evidence of mental peculiarities: they

are quiet, dull, shy, or unfriendly.
Treatment.
The
patients can be
made very comfortable
495
by a well-regulated life in a favorable environment/ but family strife and increased responsibilities always diminish
chances of recovery. On the other hand, absolute freedom tends to make the patients worse. Suitable employment is
must be so adjusted as to gradually increase the responsibility and the exercise of strength. While the
necessary, which
therapeutic agencies, as massage, hydrotherapy, electricity, etc., are of importance, their chief value lies in the
special
psychical influence which can be exerted through

creating
fidence.
them
in
new energy
for
work and
is
Hypnotic suggestion insomnia and pain.

0.
in establishing self-conoften helpful in cases with
CONSTITUTIONAL EXCITEMENT
Constitutional excitement constitutes a small group of cases characterized by permanent moderate psychomotor
excitement.
The intellect of these patients is fairly good, but they are hindered in acquiring full and complete knowledge, because they are not persistent at their studies and are
extremely distractible. Perception is usually unimpaired, knowledge of life and the world is superficial, mental elaboration of experiences
is
hazy and scanty, and memory of early

one-sided,
experiences
falsified
less,
is
fleeting,
with
many
additions.
and often colored and Thought is flighty and aim-
and judgment
is
hasty and superficial.
In emotional
less.
happy and thoughta marked feeling of egotism and are boastThey possess
attitude the patients are
own capabilities and accomplishments. They do not appreciate their imperfections. Toward others they are apt to be lofty, irritable, dogmatic, and unsympathetic.
ful of their
They usually
deride, torment,
and abuse those who do not
496
agree with them, but on the other hand, they do not become mortified when reproached and insulted. They devote much
time to amusements and diversions of

to
all
kinds and are given
making fun of themselves and others and playing tricks. They readily adapt themselves to new conditions and are
always longing for a change. Occasionally transitory, anxious, or despondent emotional conditions develop.
In actions and manner the patients are
stable.
restless
and un-
They
are
easily
approachable,
often loquacious,
but wholly untrustworthy and vacillating in their judgment. Consequently their lives are one series of thoughtless,
venturesome, and often foolish acts. Even in school they are
rebellious
and
disorderly.
They
react badly under military
discipline, neglect the rules of cleanliness and order, misuse
furloughs, neglect their duties, and frequently need to be punished. Sexual impulses often develop early and lead to ex-
They frequently become addicted to the use of alcoThey are constantly moving and changing employment without sufficient reason, always beginning something new
cesses.
hol.
and devising great schemes which are soon forgotten. They often make propositions which they cannot live up to, assume lofty titles, and secure recognition by boasting. The lack of plan in their undertakings is most characteristic and clearly shows how little their pressure of activity is
held in check
their resources,
by careful reasoning. They soon exhaust and then they begin to borrow, to cheat, and
In trying to maintain their credit they always refer to some great "deal" which they are about to put through, a position which awaits them, their intimacy with
to swindle.
prominent individuals, betrothals to heiresses, etc. When thwarted they maintain that they are in the right, that they
had no idea of fraud, and that they will shortly be in a position to meet all of their obligations. Following punish-
497
ment, they again return to their old tricks, until finally the morbid character of their conduct is recognized. The similarity of constitutional excitement Diagnosis.
to hypomania is very striking. The differentiation depends upon the fact that in constitutional excitement the excite-
ment
but
of
is
is less
pronounced, does not recur in definite attacks,
constitutional
a fixed personal peculiarity. Nevertheless some cases excitement develop transitory exacer-
bations
and even
delirious states, while others
show
periodi-
cal vacillations together with irritability
and
rebelliousness,
and, finally, occasional anxious states with indefinite delusions of persecution. These cases are only another indication
have to do with a permanent disorder of the mental equilibrium which constitutes the first step toward
that
really
we
true manic excitement.
These cases also remind one of those
cases of manic-depressive insanity, hi the lucid intervals of which moderate excitement of the same character occurs.
Some
refer to
both conditions as a chronic or constitutional

of constitutional excitement
mania.
The mildest forms
approach
very closely to certain defective constitutions which are ordinarily regarded as belonging within the realm of normal
man. These are usually encountered in whose members have suffered from forms
sive insanity.
families
some
of
of manic-depres-
They
comprise certain brilliant but never-
theless one-sided personalities

versatility,
which charm one by

their artistic
abilities,
their
their
enthusiasm,
and
happy, sunny dispositions, but who at the same time astonish one by their restlessness, volubility, lack of steadiness and
persistency in employment,
and
their tendency to evolve
numerous schemes.
Occasionally they exhibit periods of unreasonable despondency, which sometimes follow over-
work and disappointments. tx
The frequent
history of de-
498
spondency ending in suicides occurring in the parents, brothers, sisters, and their children, or of genuine manicleads to a strong presumption that sanguine temperaments of this sort are nothing more than initial psychopathic stages of manic excitement.
depressive insanity,
Treatment.
The treatment
is
difficult
because
the
patients lack insight into their condition and, therefore, will not submit to medical advice. In many cases it is
necessary to occasionally restrict the freedom of the patients, because otherwise they get into serious difficulties. By
means
of firm
and
friendly guidance
and
especially
by
suffi-
cient protection against sexual
and
alcoholic excesses these
patients can sometimes be made to follow some useful employment, but in spite of all advice and regulation they
always remain
care
fickle
and
unreliable
and a source
of constant
and anxiety to
D.
their friends.
COMPULSIVE INSANITY
In this psychopathic state compulsive ideas and compulsive

fears are the
The
ing of
intellect is
predominant symptoms. not only undisturbed, but
may
be unusu-
ally good.
mental
Patients exhibit throughout a pronounced feelillness and frequently a clear insight into
the morbidity of the individual symptoms. Many present symptoms of constitutional despondency before the compulsive ideas
Moreover, the initial symptoms usually develop during conditions of despondency. The compulsive symptoms may be grouped under three
fears appear.
and
heads
the tormenting ideas (manies mentales), the phobias,
and the impulsions.

Tormenting Ideas. The feeling of anxious uneasiness which accompanies all of these symptoms produces a seIt is not improbable ries of psychogenic disturbances.
499
that the sensation of strangeness referred to in nervousness is nothing more than a peculiar expression of a concealed anx-
which impairs the patients' sensations and influences the perception of the outer world. Consequently the feeling frequently arises in the patients that they cannot comiety,
prehend anything more, cannot follow conversation, or cannot get the sense of that which is read. Thus there develops an endless repetition of the same tormenting thoughts which
disturb the patients all the more if they attempt to dispel them. Associated with these feelings there develop peculiar physical sensations all over the body; such as, weariness,
palpitation of the heart, blushing, blanching, nausea, and sometimes even vomiting. Furthermore, the anxiety leads
to a mixture of voluntary and involuntary impulses, which are thus altered in various ways. Finally the patients evolve
peculiar
methods of self-relief. The simplest form of compulsive insanity is represented by the simple compulsive ideas which force themselves upon the patients against their will, and in this way influence the
freedom of thought.
Sometimes the compulsive idea
is
very simple or at least not irritating. It is only the frequent Sometimes repetition of the idea that causes annoyance.
accompanied by an hallucinatory picture of great vividness. Odors and melodies may similarly haunt patients.
the idea
is
are disgusting or create horror. Many patients complain because they are compelled to contemplate the sexual organs of those about
Such ideas are
especially annoying
when they
them.
Others when at stool have to dwell upon

is
all sorts of
disgusting scenes.
In another group of cases there
a compulsion to ponder
over certain definite things; for example, the names of per1 sons (onomatomania), and particularly difficult names.
1
Magnan, Psychiatrische Vorlesungen, 1893.
500

recollect
Unable to
about
it all
name
lie
casually heard or seen, the

it,
patients immediately strain every nerve to recall
think
day long, and the tension cannot
awake nights
trying to recall it, be relieved until they succeed.
Some
patients feel compelled to inquire the names of people whom they meet on the street; others feel that they must
form a
definite picture of the face, form, or color of the hair
Other patients dwell on figures (arithmoand are compelled to busy themselves with the mania), number of the house, the street, the number of guests about the table, the number of forks, knives, and glasses, the numof strangers.
ber of designs in the carpet or wall paper. Compulsive ideas sometimes take the form of questions; "How was the universe created?" as, "Who is God?"
etc.
Sometimes these questions
refer
surroundings, when such questions arise as, Why does " " that chair stand thus and not so ? does it have Why " " four legs and no more or less ? Why is that house painted " This has been been called Grubelgreen and not brown ? a passion for pondering over things. sucht
to objects in the "
patients are in doubt as to the accuracy of their memory; still others have the feeling that they may not
Some
recognize their acquaintances when they meet them again, or will not remember what they last said to them. Someaccusation.
times these feelings of uncertainty seem like ideas of selfPatients feel that they have neglected something or have not done something right. When urinating or defecating, the patients may have the feeling that the dis-
charge is incomplete, and therefore they must make further efforts. After every conversation the idea arises that
they may not have made themselves clearly understood. After leaving a friend, they sit down and write a letter in order to be sure that they are understood, but the letter is

barely off before they are in doubt as to whether they themselves clear in it. These patients weigh every
501
made
word
before they express themselves, trying to avoid false interSome patients always have the idea that they pretations.
have taken some other person's hat, umbrella, or overcoat. In counting money they carefully scrutinize every coin
might have made a mistake, or that they had not paid out enough, and hence would be accused of
for fear that they
Many patients accuse themselves- of not having confessed everything at the confessional or of not being " contrite of heart."
fraud.
Very often the patients have the fear of destroying or misplacing something of value. In many cases their fears
that they are guilty of crime, of homicide, have committed a theft, or have poisoned a relaIn the lighter forms these doubts exist only in one tive.
are quite
silly;
they
feel
in t{ie severer forms they influence all the " actions of the patients. Perhaps it would have been bet" if I had not drunk that glass of water," or I have harmed ter " Had I not gone myself by taking that piece of cake."
field of activity;
out of doors, it would have been better; that accident would not have happened or that fire would not have broken out."
It is actually impossible for these patients to
remain at rest
because of the uncertainty as to whether they have closed a door or have sealed a letter that they have mailed. Consequently they manifest an ever increasing painstaking in all the little details of daily life. They are always turning back to see if they have locked the door, or tearing open
letters to see
they have enclosed the right one. It is often characteristic of these patients to make use of some parif
ticular phrase or
such as
is
"
movement which they have discovered, High Jinks," or to cough, upon which all doubt
This whole group of cases has been desigdispelled. nated by Legrand du Saulle as "folie du doute."
502

is
There
their
also a condition called erythrophobia, in
which
patients fear blushing.
When any
one enters the room or
is spoken, they immediately blush, which causes discomfort for fear that they may be thought guilty great It may even create so much annoyance of some misdeed.
name
that they are compelled to give up business. There is also the fear of wearing new clothing because of the newness and
accompanying physical discomforts.
The strongest feelings are connected with the welfare of the body. Many patients perceive all kinds of sensations When dropping in their bodies which cause them anxiety.
off to sleep,
Some
the body seems to increase to an enormous size. patients have the uncomfortable feeling that the urine
is trickling.
They fear that they are going to lose their minds or become paralyzed. Others have the idea they will Some fear a sunstroke, and in consesuffer from syphilis.
quence are taking all possible precautions still others have the foolish fear of snakes, of cats, or that a beetle will crawl Some avoid going into the street for fear into their ears.
;
that a stone or a
man may
"
fall
upon them from a
building.
The
sexual relations also offer a fruitful field for
compul-
sive fears.
Such
fears often frustrate the sexual act.
Phobias.
In the
"
phobias
fear arises
in
connection
with certain definite conditions. It is impossible to draw a sharp distinction between the states described above and
those of phobia, as they are often intimately associated. But the phobias are always characterized by the sudden
appearance of pronounced anxiety in connection with the

general
subjected to them, patients may suffer from palpitation of the heart, become pale, tremble, have a cold sweat, nausea, faintness, polyuria,
idea of fear.
When
weakness of the
legs,
themselves and collapse.
and finally may even lose control of The conditions in connection with
503
which such attacks of fear arise are varied, yet there are some forms which recur with notable regularity. Sometimes the same patient may suffer from a whole series of phobias. The best known of these is agoraphobia, in which there is
great fear of public places. Patients are unable to walk down a long, broad street or in a place where they are alone. When they attempt this, they are so overcome that they can-
not proceed.
When
the condition
is
extreme,
they are
afraid to go out on the street at all, some even remaining in bed. Closely related to this is the fear of height which pre-
vents patients from standing near a railing, on the brink of a precipice, going over bridges, or of being in a theatre. Among other morbid fears might be mentioned that of
being alone in the dark, riding on trains, and going through
These patients find no pleasure in travelling, do not enjoy going to church, and always sit near the door,
tunnels.
ready to
Various phobias may develop in connection with the occupation of the patients; for instance, barbers sometimes suffer these attacks
fly at
the
first
sign of danger.
they see a razor, or telegraphers when they catch sight of their instruments, etc., which finally necessitates giving up the occupation.
whenever
Among women,
especially, there occurs the fear of dirt
(mysophobia), contagion, or infection. The countless bacteria always present in the air are one of the chief sources
of annoyance. of the
bad
air
The patients are everywhere complaining and throwing up windows; they are afraid
of handling brass or copper, or are always taking things up by nails or pieces of glass. They notice in their food a
shining bit which may possibly be a pin. Books, especially, Occasionare avoided as a possible source of contagion. a patient has the fear of destroying something of value. ally
One lady was always
in fear of throwing
some important
504

it,
letter into the fire or destroying
and
for this reason care-
fully avoided touching any paper and finally even printed
books. Patients are constantly washing themselves, and are fearful of disease from touching money, books, or papers. In taking food they have to wipe the dishes frequently and
inspect carefully every morsel. As the result of fear of misplacing something or of soiling themselves there develops the fear of contact, delire du
Patients throw away all the needles in the house, toucher. and they give up sewing for fear that they may injure themselves. They no longer wash the windows, because the glass break and cut them. They refuse to shake hands, might but wear gloves and open windows with their elbows. They
begin the habit of washing not only their hands, but also all of their clothing. Some patients spend the entire day
in dressing, undressing,
and washing.
A common
crises.
characteristic of almost all phobias are the
As soon
as one threatens to do that feared
by the
patients or to hinder
them from
carrying out their usual
means
until
of protection, they develop
an anxious condition with
excitement.
It is quite astonishing to see

disease,
how
it.
patients,
now hoping for relief of the

real
suddenly turn about
and oppose any

Impulsions.
fears apparently
attempt at combating
In this last series of cases the compulsive take the form of impulses. In reality,
however, we
still
have to do only with
fears
which are
di-
rected against the dangers that the patients suppose are threatening them. Such questions as the following press " themselves upon the patients What would happen if you should undertake to do this or that, if you should kill some
:
one with that knife, or set that building on fire, or shout " aloud in church ? Whenever they see sores or ulcers they
feel
impelled to touch them, and at the sight of
filth
must

wallow in
it.
505
It
seems to them they must smear every-
Religious anxieties create the idea of thing with urine. fouling the communion bread, or of bringing it in contact
with the genitals. Other patients think that they must bore nails into the heads of their children, cut off their heads,
commit sexual
assaults
the table, or rip Usually these thoughts arise in connection with beloved
ones.
upon them, steal the silver from open their own abdomen or that of others.
illusions are associated
Sometimes
with these ideas,
when
the patients see a bloody knife suspended before their eyes, are followed by a picture, feel as if their arms
to grasp a pile of
filth, etc.
and hands are extending out

Thus, there arises a fear of
impulses of these kinds.
to
all objects, which can call up The patients no longer venture attend communion and show the greatest anxiety when
coming in contact with dangerous weapons.
Many patients
permit themselves to be locked up or to be bound, in order In reality, howthat they may withstand these impulses.
most
ever, these patients never perform the dreaded acts; at it only happens that they are unable to withstand
the temptation to flee from some religious ceremony or during prayer to substitute some blasphemous or obscene
expression. The consciousness of all these patients is entirely clear. They have an insight into their condition, and the desire,
but not the strength, to free themselves from it. They know well enough that no real harm threatens them, but that they " fear of the fear." Their are overwhelmed only by the
emotional attitude shows anxiety which often is in marked contrast to their courage in real danger. They are usually In their behavior and actions of a weak, dependent nature.
they frequently show nothing abnormal, and control themselves perfectly before strangers.
506
Course.

The course
of the disease varies
much.
Com-
plete disappearance of the symptoms seldom occurs, and then only for a short time, but rapid improvement is often
noticed, usually during the period of development. The prognosis in general is unfavorable. Prognosis.
Occasionally, especially in cases of simple compulsive ideas,
agoraphobia, and the allied symptoms,
the
disturbance
may disappear for longer or shorter periods, but there is great fear of relapses. There are many cases in which striksymptoms appear temporarily only under the influence of In the folie du doute and specially unfavorable conditions.
ing
the fear of contact there
is little
chance for improvement.
the other hand, compulsive insanity never develops into other psychoses, as the patients often fear.
On
Treatment.
The treatment
is
chiefly directed to
com-
In youth careful bating the condition of degeneracy. attention to the demands of physical development is necesoff by and all deleterious influences removed training, which tend to weaken the physical and mental powers of The symptoms of the disease can be combated resistance. by persistent and patient training with a view to strengthening and encouraging the patients to struggle step by step against the morbid compulsion. The significance of their condition should always be made clear to the patients, and they must be impressed with the fact that they will overcome it more by abstraction and diversion than by exercise
sary.
Threatening peculiarities should be warded
careful
of will power.
Occasional interviews with the physician
aid in quieting the patient and giving
him
additional cour-
age. Hypnotic suggestion may in supporting the patients, but its influence
be of value during crises

is
transitoiy.

E.
507
IMPULSIVE INSANITY
Impulsive insanity is characterized by the development of morbid tendencies and impulses which either dominate over
volition continually or in recurring
paroxysms.
which appear without motive, are performed because of an irresistible impulse. The impulses do not arise as the result of a conscious plan, but appear suddenly,
These
acts,
are quickly executed, and often quite indefinite, thereby causing the actions to appear unpremeditated, purposeless, and even absurd. In case the act is serious or dangerous,
accomplishment may be preceded by a conscious struggle. But yet the worst acts are often performed without delay, and as a matter of course. Neither the regret that follows
its
the act nor the fear for the results suffices to suppress the
who suffer from triwhich appear only under fling insignificant impulses, certain circumstances, disappear rapidly, and lead to very simple acts, represent a sort of transition stage between normal health and impulsive insanity. Maudsley tells of a man who for weeks was annoyed by an impulse to overturn two stones which lay upon a wall, finally forcing him to sneak
and
out at night in order to perform the absurd act. pulses become of more consequence to the patient
are constantly involving the environment
recurrence of similar impulses. Those so-called normal individuals
Such im-
when they
interfering
and
with comfort and occupation.

certain
definite
directions
to
The impulses that develop in are of far more importance.

to set fire, to steal,
These include the impulse

destroy or
kill.
tramp,
and
to
In the impulse to ramble the patients are suddenly seized with an intense desire to roam about, sometimes in connection with some sort of an adventurous purpose. So they
508

until their
wander about here and there
means are exhausted.
They have a clear memory of their experiences, and they do not see anything peculiar in their conduct. Occasionally
during these periods they commit
false
all sorts of
frauds,
assume
names, and are boastful. The impulse to set fire (pyromania) is exhibited espeSomecially by young females, most often during puberty. times the morbid pleasure of seeing things burn and at
hearing the crackle dates from early childhood. Another common form of impulse is the tendency to skilful but foolish stealing
(kleptomania), encountered almost exclusively
among women, and especially during menstruation and pregnancy. The stolen articles are frequently almost or
quite worthless for the patients.
desire for
In some cases there

is
is
definite thing which accumulated in Sexual impulses may accompany this great quantities. Further expressions of degeneracy of normal condition.
some one
impulses are seen in
silly
tendency to play,
marked
fondness for animals, irresistible increase of sexual impulses, and
many
similar digressions.
Morbid impulses to destroy and kill are other instances. There is a special group of young women who show a morbid impulse to beat little children intrusted to their care. Here
there exists a close relationship to those sexual impulses which have been called sadism, masochism, and fetichism.
The men who prod women, who snip hair, slash ladies' dresses, steal women's shoes or linen, and many exhibitionists
belong to this class. The mental endowment of these patients usually shows no marked defect, but in some severe cases there is a more or
less
high grade of mental weakness. In the emotional field the defect is more evident; the patients are apt to be childish,
unstable, shy, seclusive, or vulgar.

Course.
ing
certain
509
The symptoms
periods
of
of the disease appear only dur-
life,
and
period of development, at which of lessened resistance in both the physical and mental
particularly during the time there is a condition

fields.
In some cases there

tal
is
development and the formation

is
improvement, with physical and menof a stable personality.
Periodicity
Diagnosis. relapsing of criminals with the regular repetition of similar criminal acts in these patients. The criminal sets fire, kills,
noticed only occasionally. One should not confound the ineradicable
and
from selfish motives, and for some definite purpose, perhaps to do some one injury, while the patient suffering from impulsive insanity is forced by the dominating impulse to the deed against his will. Frequently
steals,
but he does
it
the patient has a feeling that the action

natural,
is
inconsistent, un-
and morbid. Compulsive insanity is distinguished the fact that the patients do not commit deeds that are by in their minds; they often have an abhorrence of them and
to something which really does not In impulsive insanity there is apt to be associated exist. with the idea of the morbid act a feeling of desire and
fear that they
may yield
eagerness for
its
main quiet
until
it is
performance, and the patients cannot redone. The performance of the act is
relief,
immediately followed by a feeling of

brings disappointment.
while failure
Treatment.
rally lies
The treatment
of impulsive insanity natu-
adapted
in the education of the patients, which must be to individual cases and carefully conducted, with
proper regard for the physical development. It is of greatest importance that the patients do not become addicted to
the use of alcohol.
tection of society, need to be confined in
There are some cases which, for the proan institution where
life.
they can be educated to lead a useful
510
F. CONTRARY SEXUAL INSTINCTS
This psychopathic state, which received its name from Westphal, refers to those sexual propensities, appearing
for each other,
mostly in youth, exhibited by individuals of the same sex with an indifference or even an abhorrence
of the opposite sex.
The condition has
also
been well
described by Krafft-Ebing, Moll, and Schrenk-Notzing. The contrary sexual instincts are far more Etiology.
an uncommon condition, the cases reported to date numbering but a few hundred, although homosexual patients maintain that it is by no means rare. Ulrichs, in his own morbid experience, claims to have encountered two hundred cases. It is more prevalent in certain employments, such as among
prevalent
among men.
It is
decorators, waiters, ladies
tailors;
also
among
theatrical
people.
Moll claims that
women comedians
are regularly
homosexual.
The condition develops from a

is
state of degeneracy. It a view of Krafft-Ebing, emphasized by the statements
of the patients themselves, that the peculiar perversion of
Schrenk-Notzing, on congenital. some stress upon accidental factors hand, lays which happen to exert an influence upon the sexual feelthe
sexual
impulse
is
the other
ings long before the age of sexual development, such as the intercourse of naked boys while bathing, wrestling, etc.
Sometimes passionate friendships

dren
1
exist
among young
chil-
who
are
still
ignorant of the sexual differences.

Psy., II,
1.
But
Westphal, Archiv
v. Krafft-Ebing,
f.
Psychopathia Sexualis, 1900.
Moll, Die contrare Sexualempfindung, 1891. Schrenk-Notzing, Die Suggestionstherapie bei krankhaften Erschei-
nungen des Geschlectssinnes, 1892.

it is
511
only with the abnormal child that such accidental influences upon the early sensual feelings can have any
power
in the later development of the sexual impulses. It seems most probable, then, that the morbidity of the condition depends not upon impulses which are perverted
from the onset, but upon a characteristic tendency
origi-
nating in a hereditary state of degeneracy. Sexual impulses develop early and Symptomatology. usually to a marked degree, sometimes leading to onanism.
The natural heterosexual impulses may have developed first, being displaced later by stronger morbid tendenThe patients, both in the waking and dream states, cies.
experience
tion
pleasurable
sexual
sex.
feelings
with their
own
Attempts
at
only in connecnatural sexual
intercourse are unsuccessful, or accomplished only with Close associations are usually formed with difficulty.
some individuals
into
sex, which usually develop with extravagant display of passionate friendship,
of the
same
affection, letter writing,
exhibitions of jealousy.
ing,
sending gifts and flowers, and This frequently extends to kiss-
embracing, and occasionally to masturbation and other forms of sexual perversion, but rarely to pederasty. In these friendships the physical and mental superiority
of one individual over another
may
aid in arousing the
sexual feelings.
Usually both individuals are homosexual, but sometimes the patient desires intercourse only with a normal individual. Frequent changes of the affection,
with disruption of these friendships, often occur, showing the fickleness of the patients, though in some cases such
relationships
social
uals.
are
maintained
for
years.
Differences
in
rank
is
of less importance
than in normal individ-
few patients of the better classes are attracted

especially
by mechanics, and
by
soldiers.
512
The patients usually remain unmarried. Those who do marry, either in the hope of overcoming their perverse tendencies or from the desire to have children, are usually
true to their marital duties, except in the matter of sexual
intercourse.
regularly, in
Some
indulge occasionally, but most of
them
homosexual intercourse.
Other symptoms indicative of a morbid constitutional

basis are usually present, especially the physical stigmata.
usually unimpaired, as well as the ability to comprehend, but there is an increased sense of fatigue, lack of perseverance with mental work, and a tendency to
Judgment
is
dream.
Imagination
is
prominent and interferes with the
capacity for purely rational activity.
Some
are especially
in an artistic way, being good musicians and but they also possess a keen sense of appreciation Mental weakness may exist. Many of their abilities. have an insight into the morbidness of their impatients
endowed
artists
;
and defend themselves on the ground that the impulses are the natural and involuntary product of their
pulses,
In the emotional life they present irritability, constitution. are sensitive, moody, and impressionable, often timid, and given to passionate outbursts of feeling. In actions they appear effeminate, vain, pliable, unstable, and are sometimes sluggish.
easily
They are often careless about their work, The sexual imdistractible, and untrustworthy.
pulses are apt to gain control over them, causing neglect Fetichism and other perversities may also be of business.
present.
The
condition
of
sionally present,
when
psychic hermaphroditism is occasexual feelings are exhibited toward

is
both sexes, though usually stronger toward one sex than

the other.
individual
Where homosexuality
may
very pronounced, the experience a change of personality, a man
513
becoming feminine in manner, gait, and countenance. He becomes affected in manner, vain, coquettish, takes great
pains with his personal appearance, desires to be in fashion, wears flowers, and uses cosmetics. Some develop a fond-
women's employment, do needlework, arrange rooms after the fashion of a woman's boudoir, and their they may even dress in women's clothes, padding the hips and breast, talk in a falsetto voice, and in every possible
ness
for
way
traits
simulate feminine traits.
may make
their appearance in childhood.
Early evidences of such A few
patients present physical characteristics indicative of the opposite sex; men are beardless, possess high-pitched,
soft white skin, with a more marked and well-developed mammae; while the pannicus adiposus homosexual females have a deep, coarse voice and show a tendency to grow beards. The former are called by KrafftEbing androgyny, and the latter gynandry. Hermaphroditism has never been encountered in homosexual individlight voices,
have
uals.
The course
age,
is
of the disease,
which usually reaches
its full
development between twenty-five to thirty-five years of

there
is
always prolonged. In the acquired homosexuality often a long struggle before the patient becomes
confirmed pervert. The homosexual tendencies may appear periodically, with or without accompanying states
of general excitement.
matter to identify homosexual patients where there has been a marked transDiagnosis.
It
is
not a
difficult
position
of
the traits
characteristic
of
the
sexes.
Yet
normal sexual instincts
may
exist in spite of such a trans-
position. Usually the condition becomes known to the physician only through the communication of the patient. It is necessary to distinguish between contrary sexual in2L
514
stincts

and mere
practice of homosexual acts, the latter being pure perversity, as practised among prisoners, etc., who return to normal sexual relations upon gaining free-
dom.
Prognosis.
ally thought.
The prognosis is more favorable than is usuVery many cases improve, and some even The
most
successful
recover under the influence of treatment.
Treatment.
method
of
treat-
ment
is
is
through the use of hypnotic suggestion.

first
is
This
directed
against the increased sexual excitability
and masturbation which
frequently present; next
it is
applied to the insensibility of the patient toward his own sex, and finally in creating an excitability toward the
opposite sex
and a tendency to heterosexual intercourse.
The hypnotic influence over the patient, dealing as it does with a deeply rooted habit, is acquired slowly and with
Schrenk-Notzing lays great stress upon regular natural intercourse, but excessive coitus must be avoided, because it may have an injurious effect upon the selfconfidence. Treatment directed at the general nervous
difficulty.
and should include the establishment of a routine in the physical and mental and relaxation. life, with attention to the diet, exercise, One should remember that even though marked improvement or recovery takes place, the original defective basis
condition
is
also of importance,
still
remains.
XIV. PSYCHOPATHIC PERSONALITIES
THOSE psychopathic
bid constitutional
conditions which develop on a morbasis include an extensive borderland
between pronounced morbid states and mere personal eccentricities which are wont to be regarded as normal. We consider personal deviations from the regular course
morbid only when they are of special consequence to the physical and mental life; but the distinction is one of degree and is to a certain extent
of mental development as
arbitrary.
a considerable group of such morbid conditions which may be properly regarded as mental deformities.
There
is
They are not characterized by any definite disease process, but rather by a general deviation from the normal mental life. Our discussion of this group will be limited to conspicuous types which are of special interest to the psychiatrist.
A.
BORN CRIMINALS
were the
first
The French
alienists
to call attention to the
fact that there
was a form
of insanity in
which the
dis-
the feelings and the conorder was limited to the duct. In 1835, Pritchard grouped together, under the name of "Moral Insanity/' those diseases in which there existed
fields of
a perverse state of the feelings, temperaments, dispositions, habits, and actions, while the intellectual functions pre-
sented no apparent abnormalities. The possibility of a circumscribed impairment of the morals was combated by
515
516
pointing out the correlation between the different phases of the mental life and the presence of concurrent intellectual " " abnormalities, hence Moral Insanity ceased to be regarded as a separate disease and came to be classed as one of the
sub-forms of imbecility. One of the causes of this change of attitude was the supposedly demoralizing effects of the
doctrine on criminal law.
Daily experience teaches us that the intellect and the emotions develop more or less independently of each other.
There
are,
undoubtedly,
men
with conspicuous mental
are morally bad and vice versa. must that the complete independence of the admit, however, separate fields does not obtain. Even in congenital emotional indifference there
is
endowment who
We
always present a certain im-
But unquestionably pairment of intellectual capacity. there is a large number of individuals in whom the inadequate development of the moral feelings is more conspicuous than that of the intellect. The doctrine of " Moral Insanity " has received new meaning through the activities of Lombroso and the Italian positivistic school in the attempt to describe and differen-
"Delinquente nato." According about twenty-five per cent, of criminals, and a to Lombroso
tiate the
still
born criminal
higher percentage among the murderers, carry the of the born delinquent. It is a reasonable hypothesis that in these conditions we have to do with various grades
marks
of psychopathic
degeneracy.
The
lighter forms
may
be
scarcely distinguishable from the inadequate moral development of normal life. But on the other hand, there are per-
sons whose
morbid degeneracy.
shocking moral incapacity clearly indicates At the present time there is a certain
justification for calling the severest
forms of criminal en-
dowment " Moral Insanity"
or "Moral Imbecility."
But
PSYCHOPATHIC PERSONALITIES
517
more exact characterization of the various conditions which have hitherto been collectively designated by this term would help to clarify the matter; for instance, it would be advisable to differentiate between those who suffer from constitutional excitement, the unstable and the morbid swindler, and the group which we are here describing and which is characterized in general by moral stupidity.
The general causes of this type of degeneracy Etiology. are practically the same as those which we have come to regard as the causes of degeneracy itself. Alcoholism in
the parents easily stands first. Among two hundred inmates of a reform school seventy-eight had drunken fathers; five, drunken mothers; and in two cases both parents were drunkards. There were also twenty-four cases in which
from mental disturbances, twenty-six and many more from other nervous diseases. epilepsy, The correlation between illegitimacy and born criminals
parents
suffered
from
is
partially accounted for
by the presence
of defective hered-
ity
and
of alcoholism in the parents.

facts,
together with the prevalence of stigmata and the unresponsiveness of the genuine criminal nature to all
These
educational influences, indicates the existence of a certain
group of cases with abnormal endowment gradually mergMoreover, some of these patients after ing into disease. a long criminal career develop severe psychoses which lead
to deterioration, especially the paranoid forms of dementia
prsecox.
Symptomatology.
The
intellect of
these patients
is toler-
ably developed within the limits of practical life. They comprehend well, acquire a certain amount of knowledge and experience, which they may exploit with some craftiness
;
in their thought.
they show no defect of memory and are fairly logical But their views are narrow. They cannot
518
perform exacting, intellectual work and are unable to develop any coherent conception of life. Experts on criminal natures have demonstrated a decided lack of comprehenBorn criminals do not feel the sive reflection and foresight.
need of reflecting beyond the present and the more immediate future.
youth there are conspicuous moral defects, such as a lack of sympathy, shown by barbarous cruelty to
in early
Even
animals, malicious teasing, illtreatment of their playmates, and general unresponsiveness to kindness. Later there
develops pronounced selfishness without sense of honor or
proper affection for parents, brothers, and sisters. Here belong those monstrous children who even at the tenderest
age try to murder the members of their family for trivial reasons, and then report in a stupid, matter-of-fact way the
details of their plans,
failure.
and show obvious

education are
love
Attempts most important incentives

ing.
at
regret at their fruitless, since the
and ambition
are lack-
Force alone
is
able to suppress the manifestations of
soon met by duplicity, cunning, deceit, callousness, stubbornness, and a disposition Patients manito lie. Development throughout is selfish.
their unbridled selfishness,
but
it is
and companions only when they anticipate some advantage from it. The
fest affection
toward parents,
itself in
relatives,
egotism expresses
vanity, braggadocio, peevishness, love of idleness, excesses, foolish prodigality, and often in weak sentimentality. Usually, there is little resistance
to temptation
and sudden impulses, and there

vindictiveness,
is
great
insta-
emotional
bility,
irritability,
unreliability,
and
susceptibility to alcohol.
It is evident that
such an endowment
will lead
almost with
necessarily to a criminal career.
It usually begins
truancy, loitering, begging,
and petty
larcenies, oftentimes
519
in connections with gangs, and, in females, with prostitution.
Often this leads to commitment to reform schools.

"children of the well-to-do classes
Such shock their parents at an
by vulgarity, lying, persistent laziness, petty larand peculations. They wander from one teacher cenies, to another, always with the same lack of success, until finally it becomes impossible to protect them from the reearly age
sults of their conduct.
The
is
further
life
of these morally incapable personalities
a constant conflict with society.
They soon
find
them-
selves thoroughly out of
harmony with any social environ-
ment in which they are located. But they are wholly unable to appreciate that it is their own actions which necessitate their being
condemned
and
tyrs
penitentiaries.
They
to pass their lives in prisons rather consider themselves mar-
are cruelly persecuted, while others, no better than they, live in honor and wealth. They regularly fail to comprehend the probable outcome of their lives. They are con-
who
vinced that
when they
it will be possible for them to succeed, even are determined to return immediately to their
old ways. Many submit with cringing docility to imprisonment, while others even in confinement continue their
struggle against the regulations of society by insubordinaBut as a rule they are cowardly tion, deceit, and treachery.
and less inclined to open violence than to passive opposition and to treachery. They are frequently hypochondriacal, and there is often an increased susceptibility to bodily pain.
Their inaccessibility to friendly advances
From
majority
this
of
morally "professional criminals"
class
of
quite noticeable. defective individuals the

is
originate.
conflicts
These
criminals derive increasing pleasure

laws, pride themselves
from
with the
on their performances, and conscious effort to develop themselves for their art.
show a Thus
520
there develop criminal

ingly their criminal acts
cunning and
who become exceedBut it is a notable fact that in they often show an astonishing degree of
'
"
specialists/
skilful.
heedlessness
and lack
of
foresight.
Evidences
of
pro-
nounced physical degeneracy often accompany the criminal natures. There are no definite and inevitable deviations, but there is a considerable group of signs of degeneracy, which show unmistakably that confirmed criminals often possess an inferior physical endowment. The number and variety of these signs are certainly more apparent in criminals than in the general population. This fact of itself naturally proves nothing in an individual case. A given person may, therefore, be mentally sound in spite of numerous signs of degeneracy. On the other hand, we would expect a larger percentage of mental deviations in men of that To be sure sort than in those who present no stigmata. do not need to be criminals on that account. Rather, they the born criminal is only one of the forms in which degeneracy expresses
Diagnosis.
line
itself.
It is exceedingly difficult to
draw a sharp
Hence, judges of the " moral imcourt especially combat the assumption of a But the existence of the moral incapacity exbecility." tending back into early youth, in spite of satisfactory
disease.
intellectual
between health and
development and the complete unresponsiveness of the patient to all moral influences, justify the assumption
of a
morbid personality. Moreover, the existence of numerous and definite signs of physical degeneracy, as well as the
history of injurious prenatal influences, such as alcoholism or mental disease in the parents, are significant, but in any
individual case they are of value only as indicating the necessity of a careful scientific examination of the mental
condition,
and are not proof
of disease.
It is a notable
521
fact that many of these patients fail to show any striking disturbances during imprisonment or while confined in institutions, but their great incapacity at once becomes evi-
dent as soon as they are released and exposed to the
numerous
vicissitudes of
life.
Treatment.
tunately offers
success.
If
The treatment
of
bora criminals unfor-
little opportunity and still less prospect of a quiet, rigid, but at the same time kindly education in a limited sphere, preferably under psychiatric
supervision,
does not succeed, the individual cannot be
prevented from entering a criminal career. Lombroso has advocated the view that many of these persons under favorable conditions need not come into conflict with the law, but may gratify their criminal tendencies in other and inconspicuous ways.
true only of the lighter forms, which closely approximate health. Baer reports that occasionally children who were originally emotionally deThis, however,
is
ficient
have later in
life
improved considerably.
It is also
a well-known fact that some of the criminal tendencies

that appear early in life, such as the propensity to lie, to steal, and to cruelty, can almost completely disappear as the patient matures mentally. In later life the best that
one can do
to compel the person to follow a regular occupation under proper control, to choose proper associates, and finally to abstain from alcohol and sexual excesses.
is
Unfortunately, this can be carried out successfully only in the light cases.
B.
THE UNSTABLE
The "unstable," as the French call them, constitute a second large group of psychopathic personalities which are characterized by a weakness of will in all their activities. The intellectual endowment may be Symptomatology.
522
very good, but is often only mediocre. Some patients astonish one by their rapidity of comprehension, their ease
of committing things to
memory, and
are
their ability to ex-
press
themselves.
Patients
often
keen observers,
quickly recognizing the defects and peculiarities of their environment, are vivacious and understand thoroughly how to
use their information to the best advantage. On the other hand, they lack altogether energy for continuous and satis-
out zealously, but soon grow weary and are, therefore, unable to complete any course of education. They never probe to the bottom of things and
factory work.
They
start
their
is
knowledge
is
superficial
and fragmentary.
is
Knowledge
often readily acquired but
fore, is quickly forgotten. times arouse great expectations, which are never because of their inconstancy and unreliability. It
not elaborated and, thereAt school their talents somefulfilled

is
often
They could do much better if they only would," but unfortunately they lack the power to will.
said of such children,
"
Higher
Conception
intellectual
is
development
is
always
defective.
confused and indistinct, judgment is immature and onesided, and the understanding of life un-
developed and short-sighted.
Their interests center on
sports and on frivolous pleasures, and they do not respond to more serious matters. They often show a propensity to dream, to poetical or dramatic efforts, etc., but they are never earnest or thorough.
In emotional attitude the patients show abrupt changes, at times being elated and confident, and at others spiritless,
They are very easily aroused to and as readily disheartened. There is usually enthusiasm, an increased irritability, sensitiveness, and peevishness. They are offended and dispirited upon slight provocation, are suspicious and prejudiced, but one can easily put them
sensitive, or pessimistic.
into
523
good humor again. Very often their relations with their become strained. The patients often become dissatisfied and embittered, the cause of which in their opinion never lies in their own behavior, but in the unkindrelatives
ness of their people.
Although they are generally harmless
and good natured, they are dominated by the most pronounced selfishness. Their own welfare is their chief concern, while they show little interest in their environment and even less sympathy. They are not inclined to submit to privation, but demand comfort and luxuries, and
gratuitous insult. They often show vanity in the effeminate care of their personal appearance, their affected utterance, and tendency to braggadocio. The patients' lack of perseverance, of power of resistance,
regard
all
restrictions
as
and energy usually becomes evident as soon as they are deprived of home influences. At school they are considered pliable, unstable, and easily led off into foolish pranks, but they are susceptible to education, which, howAs soon as they have to stand on their ever, does not last. own feet, they are helpless. Since work is not agreeable, they often change, hoping to find an easier occupation. They lack punctuality, neglect their business, do not work full hours, and allow little things to interfere with fulfilling their
obligations.
They excuse
their unproductive-
ness in various ways. In one place the work is stultifying, in another too strenuous, the shop is unsanitary, the foremen are too severe, etc. Conditions of emotional excite-
ment
are aroused
by
ridiculously trifling occurrences
and
prevent the patients from working; under no circumstances can they continue work, they must cool down, and must
seek diversion by going to the theatre. They are often hypochondriacal, are deeply concerned for their health, feel
exhausted, have headaches, or a feeling of faintness as soon
524
as they are set to work. Hence, they are frequently discharged as useless, or at most are tolerated as unpaid assistants,
and are wholly incapable
of obtaining
an indepen-
dent livelihood.
They are usually not ashamed of this state of affairs. They see no impropriety in being supported by others, and believe circumstances justify their conduct. Even though they
useless articles in large
future.
earn nothing, they are careless with their money, buying amounts without thought of the
They
readily
yield
to
temptation.
If
placed
under
guardianship, they become slack, indolent, and unproductive, but they lead their useless lives without gross disturbances, tend to fill them with loafing and useless fads,
take cures
weary.
when not
sick,
and seek recreation when not
In bad company, they give themselves up to sexual
extravagances, get diseased, and begin to drink and gamble. Under these influences they sometimes do very questionable things and even perform criminal acts. Such patients
sometimes develop the picture of "pseudo-dipsomania" They may abstain for months and then upon some occasion
when their weak
will is
overpowered, they begin to drink and
continue drinking until thoroughly intoxicated and their money is all gone. It is not their emotional condition
that impels the patients to drink, but mere incidents, such as an intimate friend or a farewell banquet. The de-
bauches are not periodical, but are determined by external circumstances. Moreover, the patients are not excited by
the alcohol, but are simply intoxicated.
A very
Lighter grades of this weakness of will are very common. large proportion of those whom Aschaffenburg calls
"habitual criminals/' and particularly a large number of tramps, mendicants, and even prostitutes belong to this
525
group. The instability first becomes evident as soon as these individuals encounter some difficulty in their lives.
Investigation shows that a large number of vagabonds are forced into their life by their congenital instability and not
by unusual circumstances. The same condition is clearly shown to exist in the offspring of well-to-do parents, who, notwithstanding an apparently good endowment and good education, continue wholly unstable. One rarely fails to
find in these families traces of degeneracy.
Diagnosis.
The gradual appearance
of the
symptoms
of instability, as the patients attempt to undertake the duties of life, resembles somewhat the picture of dementia
prcecox.
But without question they are two
totally different
conditions. Instability often leads to idleness and abandonment of certain lines of work, but never to dementia. The condition of the patients remains essentially the same as it was in youth; they are not dull and apathetic, but only afraid of work. They retain their hobbies and always feel the necessity of passing the time in some agreeable way. Notwithstanding their perverted and onesided ap-
prehension, they develop neither delusions nor hallucinations. Finally, the patients are natural in their manners;
their will is
tricities.
weak and
yielding,
but never shows eccen-
Other forms of the insanity of degeneracy sometimes

resemble the unstable; for instance, the increased suggesThe unstable do not show tibility reminds one of hysteria.
the extensive influence of the emotional states
upon the
physical processes, although there are occasional hysterical symptoms. Like the born criminals the unstable present
great
susceptibility
to
temptations,
distaste
for
work,
superficial intellectual work, lack of foresight, selfishness,
and are often enough impelled
to criminal careers.
Never-
526

two forms
of psycho-
theless, it is better to distinguish the
pathic personalities.
The unstable
lack the passion and
persistency characteristic of the born criminal ; there is no trace of the independent criminal will and of professional
warfare against social order. When the unstable commit crimes, they are the result of opportunity and temptation, and are limited to actions which demand neither resolution
nor energy. Treatment.
Since this disease represents a form of degeneracy, the treatment is limited. The value of educational measures in individual cases, such as afforded by
strict
ment
of physical capacity for work,
regimen in the performance of duties and developdepends on the severity

In later years sanitarium
all
life
of the disturbance.
may
helpful, where it is possible to remove inhibitions and to direct employment.
sorts of
be morbid
patients rarely possess sufficient
Unfortunately, the determination to submit
to compulsion for any length of time. In some cases total abstinence from alcohol causes great improvement. Under
favorable circumstances
it
is
sufficient
if
one
is
able to
protect the patients against relapses for

C.
some time.
THE MORBID LIAR AND SWINDLER
tastica
liar and swindler the "pseudologia phanhas been described by Delbrueck. This disorder consists of a morbid hyperactivity of the imagination, in-
The morbid
"
accuracy of memory, and a certain instability of the emotions
and
volitions.
Symptomatology.
At
first
glance these patients often
They apprehend quickly, easily situations, and readily acquire special information, such as geographical and historical data, citations from poets, and even foreign languages. They can
appear specially gifted.
comprehend new
527
converse fluently on the most varied subjects, have heard and are sure in their judgments. They thus give the impression of being cultured and well
of almost everything,
read, but in reality their knowledge is very superficial and made up of isolated, incoherent scraps, and a mixture of
details,
which are
insufficiently
comprehended and elaboTheir thought lacks
rated and at times even

system, order,
falsified.
and coherence;
life
and
their conception of
is
judgment is immature shallow and insincere.

their
There
sions
associated with the susceptibility to
new
impres-
an extraordinary mobility of the content of memory. But both of these symptoms are an expression of one and the same fundamental disturbance; namely, an increased
lability of
the psychic
life
processes.
alter
Recollections,
moods,
wishes,
and accidental impulses
and
color the experi-
ences of
in various ways, so that
before long there
appears an inextricable mixture of truth and fiction. In morbid liars these fabrications and falsifications of memory appear on a large scale. At first there may be an indistinct
feeling of uncertainty as to their statements, but very soon the actual and invented details become so mixed
that the patients themselves are no longer able to account

for their real origin.
The
of
specially characteristic feature of
morbid lying
is
the
satisfaction which the patients derive from wilful
falsifications
"joy of lying." They are very apt to embellish the most unimportant statements with alterations
memory
the
and additions indeed, they often cannot tell a story twice alike. The activity of their imagination enables them to
;
fancy unreal occurrences in a dreamlike fashion ; they think of themselves as participating in them, and finally they recount them as actual facts, clothed in varying forms.
In this way patients come to involve themselves in a maze
528
of statements
and narrations from which there is no other escape except by new falsehoods. The most extraordinary experiences are related in a most matter-of-fact way, with
a cautious secrecy or with outbursts of emotion;
their descent
such as
families, dangerous experiences, unheard-of incidents like those encounpowerful enemies, tered in dime novels, etc. Indeed, many details may be
from royal
borrowed directly from their reading. The content of these fabrications can change according to need or fancy. Yet some elements tend to recur. In spite of appearances
the patients do not present genuine delusions. They know well enough that they are fabricating, but allow themselves
to be carried
it
out.
their
away by their material, and keep on spinning They are soon forced by the contradictions with earlier utterances to new fabrications, but even with-
full
out this they are unable to withstand the impulse to give sway to their imagination on every occasion. For the
time being they completely forget the distinction between reality and fiction. When confronted with their lies, they are
either contrite
and promise to do better, only to justify their conduct by a new tissue of fantastic lies; or they disavow outright their early statements, assuming the attitude of
innocence
injured
and
declining
further
discussion.
If
they can gain a little time in this way, they very soon astonish one by further disclosures.
and
In emotional attitude the patients are usually high spirited self-conscious. They live from one day to another in
a wholly indifferent manner, have no care for anything,

trust their star, are thoughtless,
and are always devising

there
are
occasional
jokes
and pastimes.
At
intervals
dramatic outbreaks of despair or of angry irritability. Any criticism of their pretensions is apt to be met with
real excitement,
but such emotional fluctuations are usually
superficial
529
and soon give way to the usual self-complacency. Patients show absolutely no insight, but, on the other hand, consider themselves specially gifted, clever, and boast most
brilliant attainments,
impressively of their family connections, liberal education, and prospects. They lay the blame
for
upon adverse circumstances, inadequate support, or the hostility of relatives, etc. Even
any apparent lack
of success
in their simplest narratives, they are easily led into apparent
exaggerations. In conduct patients are clever, confident, and presumptuous. They are uncommonly curious, like to participate in
everything, and understand how to make an impression, and to inspire common people with confidence and respect.
They have a tendency
to gossip, to read
much, and to busy
themselves, but not persistently, and they are fond of pleasLeft ures, dissipations, entertainments, and gay society.
to themselves they are prone to live an irregular, extravagant, and prodigal life, are exceedingly polite, dress in the latest fashion, and lavish their money on trifles. With this sort of an endowment these morbid patients are naturally impelled to the career of swindlers and tramps. The tendency to swindling of all kinds appears even in early
youth. Thirst for adventures leads patients to undertake adventurous journeys, during which they employ their gift for lying to make credulous people believe their fabulous
tales concerning themselves, their past history,
and
their
future prospects, and to lure money from their pockets. They know how to conceal their real personality so that it
is
often impossible to expose them. They are especially apt to pose as scions of a famous family, who have been
compelled by various circumstances to flee and to conceal themselves, but they have the prospect of securing great riches. They know how to establish the probability of all
530
this
by all sorts of dodges, such as forged letters and papers. They swindle every one possible by relating to them pathetic stories. They present themselves as colleagues, turn up under different names, and use high-sounding titles to order
Their procedures resemble those of the ordinary swindler, but it is noteworthy that these patients swindle in reference to things of little consequence
merchandise of
all
kinds.
and often get no advantage out of their representations. Many patients simply wander about acquiring a livelihood by irregular but respectable occupations, boast and lie for no other purpose than the mere pleasure derived from their falsehoods and impressions which they make on their
surroundings.
Morbid swindling and lying are also forms of degeneracy. They are very often accompanied by definite hysterical symptoms. However, they should not be regarded simply
as a type of hysteria, because they often occur without Moreover, they are in some respects hysterical symptoms. related to the group of the unstable; indeed, there are even
transition forms into that group.
There
is
really
some
question as to whether these patients should not be included in constitutional excitement. While it is probably as
difficult
to
draw sharp
still
lines here as for other
forms of
degeneracy,
prominent psychomotor excitement
may
lying.
be the cue.
It is lacking in
morbid swindling and

irritability,
Great
fondness
distractibility,
marked
loquacity,
for
new
undertakings,
constitutional
great
instability,
and
which
restlessness
indicate
excitement,
in
fabrications often occur but are not necessarily concomitant symptoms. On the other hand, fondness for invention of
details, dignified
manners, a great
gift for fabrications
un-
accompanied by excitement, and the
clever ability to take
advantage of credulous persons, are rather the charac-
teristics of the
531
born swindler. It seems of special importance that in constitutional excitement the tendency to swindle appears at a certain time and may show definite
exacerbations, while in born swindlers it is a permanent personal peculiarity. Also, the occurrence of frequent and sudden changes of disposition, especially periods of causeless
dejection and despair, favors the diagnosis of constitutional excitement.
liar
The prognosis and treatment of the morbid swindler and are the same as that indicated in the related forms of
the insanity of degeneracy. Many of these patients cause so much trouble that they require permanent custody.
D.
THE PSEUDOQUEBULANTS
The pseudoquerulants comprise a group of morbid personalities whose conduct resembles somewhat that of genuine querulants (see p. 432), but who never develop genuine delusions. Whether these pseudoquerulants comprise a
uniform group
is
is
undecided.
The
ocre,
intellectual capacity of the patients is usually
medi-
but
certain craftiness,
sometimes very good. As a rule they possess a which enables them to utilize any ad-
vantage and to correctly comprehend the weaknesses of their opponents; some show a tendency to quibbling and
Memory is generally good, however; its often suffers because of personal coloring. The accuracy memory of earlier events is unconsciously modified in accord
hairsplitting.
with their emotional needs.
Judgment
is
also
biassed,
irrelevant, tends to exaggerations, is in
many ways
perverse
Hence persons and feelings. conditions are often incorrectly judged. Patients themselves are often uncommonly credulous ; that is, ideas and
and influenced by intense
532
communications which correspond to their tendencies and views are considered correct without further proof, but if they do not conform to their desires, the patients oppose
them with the most extreme and obstinate distrust. This marked personal influence over apprehension, memory, and judgment arises from an increased emotional The patients are very passionate and become irritability.
greatly excited over
trifles.
They regard every
real or ap-
parent infringement upon their rights as gross injustice, which they believe themselves justified in combating with the keenest weapons. They are, therefore, revengeful and
persistent in their hostility, regard every opposition as a personal matter, are always ready to impute to their adversaries dishonorable motives,
every possible way. a marked egotism. Patients regard themselves as especially

intelligent
to carry on their fight in Associated with their passion there is
and
and superior to their environment, and are also to consider their own affairs as matters of public disposed
that they themselves are champions of an Hence even trifling affairs lead to long-
importance
important cause.
drawn-out
litigations,
because they
feel
under obligation to
of sen-
fight to the finish for their rights.
The combination
sitiveness with recklessness
volves patients in
and arrogance inevitably inmany difficulties and conflicts with their

arise
innumerable misunderstandings and provocations which gradually involve them in a perfect

environment.
Patients follow up, as far as they possibly can, each affair with bitter determination. They do not rest with the judgments which are handed down,
of complications. reject favorable settlements, appeal to higher courts,
There
maze
and
seek to interest the public in their suits. They do not give up the fight until every possibility of success has disap-
peared; however, they sometimes renounce beforehand the
533
most extreme measures, if the disproportion between the prospect of triumph and the probable cost is very great.
Then they attempt to obtain satisfaction in other ways, by charges of forgery against the witnesses, who have not agreed with them, or by petty denunciations, false dealings,
slanderings, etc.
These give
rise to
new controversies, which

in
only increase the embitterment of discord. Meanwhile there
and develop other elements

develop,
one
way
or
another, petty misdemeanors which, in their minds, soon grow to be occurrences of the gravest import. Thus, then,
it fairly
rains complaints
and counter complaints
of insults,
damages, warrants, examination of witnesses, trials, legal expenses, attachments without number, so that patients are constantly busy in one court or another. Their
claims for
means
of natural livelihood
become more and more depleted.
In addition to their vexations and constant excitement the
demands of a livelihood come in to increase the irritability and embitterment of the patients. The development of this condition of affairs may require
ten years or more. There is progress in the disease only in so far as the relations of the patients to their environment gradually become more and more strained. They not only
feel
that
upon every occasion they are treated
and
manner, but they also think their acquaintances are angry and retaliating. Thus, there are continuous warfares which, because of their contrary dishostile
an unfair neighbors and

in
positions, are being constantly incited
but they never go as far as to
by every little incident, form true delusions. The
patients regard their opponents, without exception, as blockheads, trash, and scoundrels. They are not always at strife
with the same persons, sometimes this one and sometimes that one, although the hostility toward certain ones may be
held for
many
years.
The same occasion does not always
534
serve as the starting-point for all the controversies that arise later, but there are numerous individual occurrences, which
are not necessarily related, although they may have all In arisen from the same source of personal animosity.
other words they lack the subjective bonds which unite and draw together all the individual experiences into a continu-
ous chain.
Diagnosis.
The pseudoquerulants are distinguished from
the genuine querulants by the absence of genuine delusion formation. The controversies of querulants arise only from an endeavor to obtain expiation for an injustice originally
inflicted
on them, and which appears to them as the out-
come of hostile persecution. This is the reason why they are dissatisfied with the court's verdict, regard later failures
as a further continuance of that persecution, and resort to the most desperate measures in order to win. In pseudo-
querulants there
usually give
rarely
is
up when they
doubt the
nothing of this kind. The patients see they can obtain nothing more, impartiality of the courts, and come
to regard
them
them.
They
as accomplices of their enemies and slander forget the old quarrels, or at least do not revive
them, and are not always striving to renew investigations. The circle of their enemies also becomes enlarged as a result
of
some particular personal friction, which, however, has no delusional connection with the central point of their struggle. Not infrequently the rights of the pseudoquerulants are
maintained by the courts on
many
points.
This also
is
is
an
indication that their contact with the courts
not influ-
enced by uniform delusions. Patients are usually much the worse for their incessant conflicts; they by no means carry them out with the grim satisfaction which is afforded
the querulants in the fulfilment of their delusional tasks. On the other hand, they are sometimes rather unhappy
535
because of their everlasting troubles. Occasionally the removal of the chief source of trouble by some change in the
manner of living may produce a marked improvement, if some other occasion does not arise to create new difficulties. As the patients grow older they become dull and indifferent, but on the other hand they are often stubborn.
Pseudoquerulants never develop later into true querulants.
One seems
justified in spite of their external similarities in
maintaining that they represent totally different conditions. Pseudoquerulancy is a form of constitutional endowment
which
exists
from youth up and continues without
essential
change, while in true querulancy we have a disease process which begins at a definite time and runs its regular course. There is a sharp line between psychopathic pseudoquerulants
and the ordinary manifestations irritable, litigious, and obstinate.

Treatment.
of those persons
who
are
There
is
little
opportunity for
efficient
treatment of the pseudoquerulant. A temporary residence in an institution, or a change to an environment which is

free
from the former difficulties, may be an advantage. In way the removal of the chief source of trouble or the friendly intervention of trusted persons is helpful. Patients do not do well without some restraint of their liberty.
the same
XV. DEFECTIVE MENTAL DEVELOPMENT

UNDER
this
heading are described those mental states
which are the result of an incomplete or early interrupted development of mental life. As distinguished from the promental deterioration, these states may be regarded retarded mental development. It not infrequently happens that both conditions exist in the
cess of
as conditions of
same individuals, as when a deterioration psychosis develops in an individual with defective development. A defective hereditary endowment is almost always present. The pathological basis for defective mental develthe incomplete development of the cerebral cortex. This is often due to some disease occurring during fetal or infantile life which has an injurious influence upon the devel-
opment
is
oping nervous elements.

facts
is
Our knowledge
of the anatomical
as yet so incomplete that it is impossible, on a pathological basis, to differentiate between the different grades
of defective mental development.
In a general way the
lighter forms are designated imbecility, and the severer

idiocy.
A. IMBECILITY
This form of defective mental development is characterized by a moderate degree of mental incapacity which is usually
of equal prominence on all sides of the mental life. Clinically imbeciles may be divided into two groups, the stupid and the active y according to the degree of mental activity.
The fundamental symptoms

536
in the stupid
form are obtuse-
DEFECTIVE MENTAL DEVELOPMENT

ness
537
and
stupidity.
There
is
an
inability to receive
many
the experiences of life; consequently the knowledge of the outside world confines itself to the immediate surroundings, while events without
impressions, or to grasp
utilize
and
the patients' narrow mental horizon pass unnoticed. Probably the sensory presentations are retained, but there is an
absence of an elaboration of individual experiences into general ideas. The individual and insignificant elements make
up the fund relations and

is
of experience.
Essential
and fundamental
distinctions are not recognized. Thought limited mostly to daily experiences, usually travels scanty, the same path, and, according to the research of Buccola,
really retarded.
is
Judgment
is
defective
and uncertain, and often determined

Pa-
by chance ideas not the outcome of past experience.

actions, either in reference to themselves or others.
is
tients also fail to consider the possible consequences of their
Memory
accurate only for the most prominent events of life. Yet sometimes trifling incidents are firmly retained, while the more essential are forgotten. The narration of events, as
remembered by them, is noticeably faulty because of numerous omissions and changes. The same events narrated at different times show many contradictions, though sometimes they may be repeated parrot-like. Consciousness The patients recognize the surroundings and is unclouded.
comprehend questions.
fectly sound.
They have no
insight into their
mental condition, but usually regard themselves as perIn the patients' actions and conversations their own per-
always comes into prominence. The central point about which the whole life revolves is their own physical
sonality
eating and drinking and the possession of while all else is indifferent. Occasionally things desired,
well-being,
538

fail
and relaThe superficial sorrow at the loss of some relative tives. is quickly lost in the pomp of the funeral procession and the joy over a new suit of mourning. The absence of sympathy for those who are in want and unfortunate may explain
they
to
affection for parents
show the natural
the cruelty which they sometimes display toward animals
and
in their
combats with others.
attitude these patients are indifferent, apaat times shy and anxious, but more often displaying a thetic, Occasionally patients exhibit simple, childish happiness.
In emotional
sudden outbreaks of passion, especially if irritated or if they In conduct they are usually believe themselves misused.
harmless and tractable, but under evil influences they become ill-humored, sometimes stubborn and peevish. The sexual
impulses often remain wholly undeveloped, or they are perverted. Attempts to rape, especially children and even
Patients are incapable animals, are sometimes observed. of independent activity, yet they are able to do things under
supervision.
nical ability,
An
some knowledge
occasional patient shows a striking techof music or a certain knack
in drawing,
but even this knowledge does not aid them in
producing valuable work.

Lighter grades of this type of imbecility often fail of recognition because of the absence of sharp border lines between
them and the

viduals.
stupidity sometimes present in normal indiImbecilic defects, however, become more and
more apparent as the individual advances in age and is compelled to take up some responsibility in life. Yet these
may not be recognized, because of the patients' to utilize a certain amount of experience and to ability engage regularly in a simple occupation. But just as soon
defects
as anything extraordinary occurs, a mental shock or a temptation which demands discretion and decision of action,
539
-the mental and moral incapacity becomes evident. Unfortunately at this time their actions are judged from a legal and not from a medical standpoint. Rigid military discipline brings to the light many such cases, especially in those countries where military service is required. It becomes
most apparent in stubbornness, insubordination, desertion, and attacks upon officers. Lack of judgment in handling
these cases sometimes results in suicidal attempts. Imbecility is usually recognized at an early date.
In
infancy
it
may
be noticed that patients are tardy in learning
how
to laugh, to imitate, and to speak. Later, at school, are backward in studies, are sluggish, indolent, show they poverty of thought and inability to comprehend, and soon
become the sport
of their playmates.
They
find difficulty
and reckon, and the few facts in or grammar which are committed to memory geography are soon forgotten, since they are not essential to their
in learning to read, write,
limited experiences of
life.
fairly
good memory may con-
ceal their incapacity for a long time.
patients are very often refractory, hard to train, and have a tendency to develop bad traits, such as stealing,
The
annoying dumb animals, and indulging in sexual improprieties, which often necessitates their commitment to industrial schools.
During youth and puberty their mental incapacity becomes still more evident, because of the marked contrast to the rapid mental development of their playmates. At this time their own development comes to a
standstill or
may even retrograde, presenting resemblances to the progressive deterioration of dementia prsecox. In the active or energetic type of imbecility there is a morbid activity of the attention and imagination, in contrast to
the general sluggishness of the stupid form. Patients are attracted by every new impression, and unable to direct their
540
attention permanently to any one object; hence their observations are hasty and superficial. They are always ready
judgment without deliberation. This susceptibility and accidental impressions renders their view of the outside world very incomplete and fragmentary. Such vague pictures lead to faulty conceptions and form the basis
to pass to new
incorrect judgment. Circumstances existing only in their imagination are of far more importance in their defor
liberations
than absolute
facts.
Thought, therefore, becomes

patients vacillate
unsteady and shows

in their plans
many inconsistencies;
from day to day, draw inconsistent conclusions from the same premises, and thus their views of life and the
outer world lack reality. Their flighty conversation contains a frequent repetition
of certain high-sounding
remarks and commonplaces which
often have
little
bearing upon the sense.
They
are very
apt to lose the thread of conversation, refer to the most diverse subjects, but usually finish with some very striking remark. Such a bombastic style very often conceals from
the inexperienced the actual mental enfeeblement, and leads to their being regarded as unusually bright individuals.
It is quite in accord
with these mental peculiarities that
patients not only embellish
and
distort their recollections
with
many
fanciful ideas,
but also fabricate extensively.
In spite of evident contradictions in their statements they reassert them tenaciously and refuse further discussion. Accusations of the patients against relatives and fellow-patients should, therefore, be accepted with the greatest caution.
These energetic patients possess a better memory than the apathetic, are able to acquire some new knowledge, and to adapt themselves to new environment to a certain extent.
emotional attitude presents a mobility equal to that encountered in the attention and the imagination. Every
The
541
impression is accompanied by an accentuated but rapidly vanishing tone of feeling, and the moods vacillate from one
extreme to another, showing despondency and exuberance, despair and enthusiasm, which appear upon little provocation.
Violent likes and dislikes change from day to day;
the dearest blessed doctor of to-day becomes the vilest scounWhile extravagant in their emotional exdrel to-morrow.
pressions,
with a tendency to emotional outbursts, they
are readily diverted and pacified. Irritability and sensitiveness are always present to a greater or less degree, especially
patients believe themselves interfered with; often they are docile and good-natured. An exaggerated feeling of self-importance regularly accompanies this form, some
patients even believing themselves specially endowed and often boasting of their prospects, while at the same time showing a lack of insight into their diseased condition.
when
Any
shortcomings on their part are explained by the hosor lack of support.
tility of relatives
In conduct the patients are odd, freakish, sometimes loquacious, forward, pretentious, and silly; sometimes quiet,
docile,
and
reticent.
They
are apt to dress in a peculiar
or to be slovenly in appearance. They work with varying zeal. In youth they are frequently considered bright, especially by the parents, but later become fickle,
manner
unable to employ themselves at

aimlessly about, drink,
all,
leave home,
wander
of these
and indulge
in all sorts of excesses.
Many
prostitutes belong to this class.
In
many
cases, where there seems to be only a light grade of imbecility, there may be some question whether we are not really dealing
with conditions of degeneracy, but the presence of profound mental deficiency, in spite of a certain amount of superficial activity,
should leave no doubt. Gudden designated " such patients as high-grade imbeciles."
542
Imbecility
may form the basis for the development of other
psychoses; as, manic-depressive insanity, the psychoses of involution and dementia prsecox, the last of which in seven
per cent, of cases appears on an imbecile basis. Furthermore, it often happens that imbeciles present at times some of the symptoms characteristic of other psychoses; such as, periods
of excitement
and
depression,
not of the manic-depressive
single transitory expansive or persecutory delusions, type, occasional hallucinations, and especially the attacks characteristic
of
the
constitutional
of physical degeneration are often

skull,
psychopathic states. Signs found in anomalies of the

ears, puerile
malformation of the palate, misshapen
expression, chorea, etc. Course. The course
of imbecility is quite uniform; unsuccessful in their attempts to enter a patients, profession or to become employed in mechanical arts, engage
some
in simple labor,
and
failing in this,
they become a burden to
the family.
It is
psychosis later in
not infrequent for them to develop some forms of the insanity of degeneracy, life,
.
manic-depressive insanity, and senile dementia Others show irregular periods of excitement, with aggressiveness, great
irritability,
symptoms
and variable emotional moods. Also, the various of epilepsy not infrequently develop, which may
In some of these cases the
also lead to further dementia.
signs of epileptic
dementia predominate, and in others the epileptic attacks. Usually it becomes necessary at some time during their life to confine them in almshouses or hospitals for the insane.
Diagnosis.
which are
difficult to differentiate
There are some cases of dementia prcecox from the lighter active
forms of imbecility. The character of the onset, dating from childhood, the absence of hallucinations and pronounced delusions, and of any evidence of earlier acquired knowl-

edge, speak for imbecility.
543
prae-
Furthermore, in dementia
cox patients
may show some
improvement, while imbeciles
present no change. There are a few cases of hysteria with a moderate degree of deterioration which might be confounded with imbecility,
but in them the course of the disease is not as uniform and the mental weakness is not as evident on all sides of the
while in imbecility but few patients present There are all possible transition stages hysterical symptoms. between imbecility and the normal state, among which
psychical
life;
should be classed those weakminded individuals

of
who
are
overcredulous and superficial in knowledge, getting a smattering
everything,
who take hold
of everything
but knowing nothing thoroughly, new with enthusiasm, are easily
led astray and indulge in excesses, and who are always in doubt as to their real motives for action.
Treatment.
The treatment
of
congenital
imbecility
consists principally in providing
an appropriate education,
with a view to developing any capacity that may exist. This is best accomplished in the hands of some competent tutor or in a private or state institution established for that
The training should by no means be directed toward mental education, but should include manual simply The use of alcohol should be strenuously avoided. training. The removal of adenoids, if present, even though they may
purpose.
not appear to impair the health of the child,

essential.
all
is
highly
Furthermore, be corrected. If, in spite of training, the patients develop
diseases of eyes
and
ears should
dangerous tendencies, hospital care
is
necessary.
544

B. IDIOCY 1
Idiocy is characterized by a more profound degree of mental incapacity than imbecility.

2
Etiology.
Defective heredity
tant etiological factors.

tive heredity in
one of the most imporIdiocy may be regarded as the final

is
stage of hereditary degeneration.
Wildermuth
finds defec-
seventy per cent, of cases, mostly in the form
of alcoholism in the parents. Possibly, also, intoxication of one or both parents at the time of copulation predisposes
to idiocy.
Severe
illness or
and hereditary tendency to tuberculosis

noted as causes.
mental shock during pregnancy (Piper) have been
Injuries at the time of birth, prolonged but especially compression by narrow pelves or asphyxia, In idiocy developforceps are probably important factors.
ing after birth (one-fourth to one-third of cases) the most typhoid fever, important causes are infectious diseases,
measles, scarlet fever,
and diphtheria;
rachitis.
also
head
injuries,
congenital syphilis,
and
no longer regarded as a cause of idiocy, but rather as an accompaniment, recent investigation showing that the growth of the calvarium is determined by the proportional growth of the brain and not vice versa. Malformation of the cranium Premature
ossification of the cranial sutures is
occurs in at least one-half of the cases, in which anomaly
An
1
macrocephaly is far more prominent than microcephaly. extreme grade of the former of these conditions is repreEmminghaus, Die psychischen Storungen des Kindesalters, 243 f. J. Voisin, Sollier, Der Idiot und der Imbecille, deutsch von Brie, 1891
; ;
L'idiotie,
1893
Pellizzi, Studii clinici
ed anatomo-patologici sulF
idiozia,
1901
Bourne ville, Recherches cliniques et the"rapeutiques sur
1'epilepsie,
rhyste*rie et 1'idiotie (Regelmassige Jahresberichte iiber die Idiotenabtei-
lung des Bicetre).

2
Piper, Zur Aetiologie der Idiotic, 1893.
545
sented by Plate 10, Figure 1, while Figure 2 represents the condition of microcephaly. Furthermore, the early closure of the suture has nothing to do with the malformation of the
Narrowness of the base of the cranium accompanies more often the profoundly stupid forms of idiocy, and smallMore than one-half ness of the vertex the excited forms.
brain.
of idiots are first-born,
1
and four to
five
per cent, are twins.
The male sex predominates. Some cases present Pathology.
defective development of the central nervous system, either smallness or increased size of the entire encephalon or malformation of some of its parts;
absence of corpus callosum, of cerebellum, inequality of hemispheres, sparsity or anomalies of convolutions, and
microgyri, which conditions represent cessation of development, or a reversion to structures characteristic of lower
animals.
In
many
cases
evidences
of
genuine
disease
processes are found, particularly encephalitis, meningitis, hydrocephaly, and tumor formation, causing extensive
destruction of the cortex (porencephaly) or a general atrophy. Similar conditions may be due to vascular changes, of which the most important are endarteritis, thrombosis, and em-
bolism; also occlusion of vessels caused by traumatic hemorrhage at the time of birth or later. Syphilitic disease, either
meningo-encephalitis or endo-arteritis, may lead to idiocy. Pupillary disturbances in idiocy are usually associated with
syphilis.
1
Bourneville has described a series of cases of
Hammarberg, Studien und Klinik und Pathologic der Idiotie, Deutsch von W. Berger, 1895; Pfleger und Pilcz in Obersteiner's Arbeiten,
Heft V, 1897; Pilcz, Jahrb. f. Psy., XVIII, 526; Mingazzini, Monatsschr. f.Psy., VII, 429; Kotschetkowa, Archiv f. Psy., XXXIV, 39; Koppen, Archiv f. Psy., 896; Konig, Deutsche Zeitschr. f. Nervenheil-
XXX,
kunde,
1440.
Anton, Handbuch der patholog., Anatomic des Nervensystems von Flatau-Jacobsohn-Minor, 416, 1904; Weber, Ibid.,
1897,
XI;
546
tuberous hypertrophic sclerosis, which are characterized by an excessive tumorlike development of glia following an
extensive destruction of the cortical tissues.
The amaurotic family idiocy described by Sachs and Tay occurs almost exclusively among Jews. The disease develops during the first two or three years of life in healthy children,
accompanied by general paralysis and atrophy of the optic nerve, and always terminates fatally in a few months or While the real nature of the disease is still unknown, years. it is probably not due to arrested development, but to an
is
extensive disease process.

Microscopically we may find either an insufficient development of the neurones or evidences of former disease processes.
In underdevelopment the nerve

thinner, the
cells
do not develop beyond
an embryonic stage (Hammarberg).
number
of cells is reduced,
The cortex is much and they stand
tween them, so that the
closer together in regular rows with much less gray matter bedifferent layers cannot be clearly dis-
tinguished (a characteristic of lower animals). The cells themselves are embryonic in structure, being mostly of the
same
size
and globular
in form.
The degree
of underde-
velopment may
vary in different parts of the cortex.
(See
development, with the usual number and arrangement of cells, but in areas the cells have entirely disappeared, as the result of a disease
process,
Figure 1, Plate 5.) In other cases there
may be normal
and the
glia
has increased.
In the few cases of
hypertrophic sclerosis, the increase in the size of the brain is due to the great increase of glia, either as an accom-
paniment or as a result of a degenerative process in the The nature of the causes which produce such cortex. lesions in fetal and early life is still unknown. They may be due to intoxication or infection.
Fig.
1.
Macrocephaly.
Fig.
2.
Microcephaly.
Fig.
Figs. 3
3.
Fig. 4.
and
4.
Representing asymmetries of cranium and face.
PLATE
12

Symptomatology.
547
The symptoms of the
disease are best
considered in two groups, the severe and the light forms. The symptoms of the former correspond to the mental state presented by an infant during the first days following birth, while the symptoms of the latter correspond to the mental
states of later infancy. In the severe cases of idiocy patients are wholly unable
comprehend external impressions, to gather experience, or become acquainted with the environment, to form clear ideas or judgments, and indeed they do not possess self-consciousness. The emotional life is limited to mere fluctuato
Consequently the impulses arising from these feelings lead only to simple actions, such as the taking of food. The patients have no choice of food
tions of the general feelings.
and eat anything placed before them, even to pieces of clothing and rubbish. Idiots are not excitable; they show very little, if any, fear or pleasure, at the most manifesting some pleasure in kicking or swaying movements while hunger or physical pain may be expressed in monotonous or shrill If repeatedly pricked in the same place, causing them cries.
;
to cry out with pain, they do not try to protect themselves. Some even pound themselves and inflict severe wounds,
but immediately repeat the

vented.
act.
One
girl
would impul-
sively bite deeply into the flesh of her arm, unless preis delayed, and the whole physical development The countenance is usually stupid and vacuous. The movements are clumsy and awkward; patients do not walk until late, and some never even learn to stand, but are absolutely helpless. Some restlessness may develop, with a tendency to move aimlessly about, to sway the head or body back and forth rhythmically for a long time, to clap the
Teething
retarded.
hands, or to grunt.
Convulsive attacks are of frequent
548
occurrence.

These patients are so utterly helpless that
without constant attention they would quickly perish. In thelight cases it is possible to fix the attention momentarily
by the aid of some
striking object, but the patients
selves are quite unable to direct the attention.
themA few clear
may enter consciousness, and a limited number of ideas may be formed, which are extremely simple, always incomplete, and without connection. Memory is
sensory impressions
very poor ; there
is
no
ability to
make a
selection
from
dif-
ferent impressions in order to establish a basis for the formation of concepts; indeed, a psychic personality is never developed. Speech, and therefore intercourse with the
Unable to form sentences, idiots present a mixture of incomplete words or They syllables similar to the early efforts of an infant. do not imitate, play, or busy themselves, and are very susenvironment,
is
poorly developed.
ceptible to fatigue.
tional attitude,
The lower sensory or selfish feelings dominate the emoand liberate only those impulses for action
which gratify momentary pleasure. Idiots never feel attracted toward any special individual, never express gratitude, nor
show
grief.
When
irritated
by rough treatment
or opposed, they may show sudden outbursts of rage, attempting to destroy something or to injure some one. Sexual desires may either remain undeveloped or appear
early
and lead to
reckless masturbation
is
and sexual
assaults.
Often the appetite for food

tients eating ravenously
abnormally developed, pa-
and feeding themselves with their hands. A few show some one-sided capabilities, such as a good memory for numbers or words or some very simple
technical
skill.
Many idiots
are fond of music.

idiocy
In the
lighter grades of
tinguished, the stupid or anergic,
two types may be disand the excited or active,

depending upon the distractibility of the attention.
549
The
anergic patients are torpid, thought is sluggish and very limited, and there is pronounced emotional indifference.
In the active patients the attention wanders aimlessly, filling consciousness with a variegated, incoherent jumble. The emotions change rapidly. At one time patients are
show purposeless activity, running about, laughing, crying, and clapping the hands. Between these two groups there are numerous transition stages.
stubborn, at another
In idiocy transitory periods of excitement or depression may occur which present some similarity to epileptic excitement, attacks of manic-depressive insanity, and the excitement which occurs in the end stages of dementia prsecox.
Compulsive ideas, morbid impulses, periods of anxiety, sometimes with suicidal tendencies, may appear, and occasionally
there
ideas.
may
be simple, childish, expansive, or persecutor^
Physical Symptoms.
physical development; dwarfish. Countenance
There
is
is
the stature
a stunting of the whole is undersized or even
childish.
Hair
is
often absent
from the face and pubes.
genitals are undeveloped; menstruation absent, late, or irregular. Teeth are late in developing and often faulty in arrangement, and the palate
The
The special senses, especially usually asymmetrical. are blunted. In eighty per cent, of cases the sohearing, called stigmata of degeneration are present (Wildermuth),
is
viz.
malformation of the eyes, pecially the bones of the face.
ears,
mouth, nose, and esOther frequent symptoms
are increase or loss of the reflexes, incoordination of the lower extremities and of the eye muscles, and difficulty of
speech, with elision of the end syllables, stuttering, halting, and faulty articulation of some or most of the consonants.
All idiots are
awkward and
often
show associated move-
550

Mirror- writing
of
focal
is
ments.
Evidences
cerebral
found, especially lesions are
among
the
girls.
manifested by
hemiplegia, paresis, contractures, convulsions, choreic and athetoid movements, aphasia, and in thirty per cent, of the
cases, especially in boys, epilepsy
(Wildermuth).
of the
disease,
Diagnosis.
difficult
The
recognition
which
is
only in infancy and in very early childhood, depends the insensibility of the children to external influences. upon They do not manifest a feeling of hunger, even when lying
upon the breast or at the approach of the mother, are not attentive, do not smile or cry, and may be continually restless; many give evidence of some cerebral disturbance, as paralysis or hemiplegia. The limbs may remain in a fetal condition; they do not learn how to walk or talk, and
are unable to understand speech.
Prognosis.
The prognosis
is
unfavorable.
While
idiots
can never reach the rank of normal men, the question of how much they can develop is of great importance. In
general
for
it
can be said that
if
their attention can be held
some time, and they give evidence of memory, i.e. recognize articles and resist what they have once experienced as disagreeable and appear to understand speech, the prognosis is more favorable. The appearance of epilepsy
in early childhood is very unfavorable.
idiots often lose
what
little
During puberty knowledge they may have ac-
quired,
and some even present the hebephrenic or catatonic
picture of dementia prsecox. Their life is usually short, because of their lessened powers of resistance to intercurrent
diseases.
parents should be encouraged as an important prophylactic measure. The con-
Treatment.
of
Temperance
in
faulty nutrition, which is frequently present, improves with the relief of insomnia, the prevention of
dition
551
strict
masturbation, removal of sources of focal irritation, and cleanliness. Epileptic attacks should be combated
with bromids, atropin, or other suitable measures, with
profound deterioration. Craniectomy in some cases of microcephaly is an irrational procedure and is fast disappearing from practice.
the
hope
of
preventing
Besides treatment of the physical condition, the patients should receive training in institutions for the feeble-minded.
Idiots left to themselves or in a poor environment rapidly go to the bad. Harmless patients in the care of sisters or
brothers
may become threatening or aggressive and

This, however, requires
sexual assaults.
to training. of kindliness
attempt Such patients are somewhat susceptible
a greater amount and patience, and more experience than can be obtained in the ordinary home. An effort should first be
made
to teach
them
to walk
and use
their hands, also to
employ
their different senses, to direct their attention
and
to speak, followed by special instruction in the perception of objects, in distinguishing them, and in forming simple
many patients yearly leave institutions well enough trained to be of use in ,a limited field. They, however, continue to need some care
judgments.
As a
result of
such training,
and supervision throughout life, as their inability to get along in the world and to utilize knowledge stands in striking
disproportion to knowledge taught them.
INDEX
Acquired neurasthenia, 146.
course, 153.
Amaurotic family idiocy, 546. Amentia, 136, 141.

course, 143. diagnosis, 144 139.
etiology, 141.
;
diagnosis, 153; from congenital neurasthenia, 155. from dementia paralytica, 153, 315. from hebephrenia, 266. from manic-depressive insanity, 417. etiology, 146. physical symptoms, 150. prognosis, 155. symptomatology, 148. treatment, 156. Activity, 78. (See pressure of activity.)
from collapse delirium,
from dementia prsecox, 267.

physical condition, 143. prognosis, 145.
symptomatology, 141.
treatment, 145. Anxiety, hi melancholia, 354. Aphasia, in paresis, 294. Apprehension, disturbances of, 16, 104;
in manic depressive insanity, 382. Arrested paresis, 318. Arteriosclerotic insanity, 333. from melancholia, 360. diagnosis, 338 from paresis, 338. from senile dementia, 379. pathological anatomy, 334. severe progressive form of, 337.
;
Acts, compulsive, 90. impulsive, 90 ; in catatonia, 248. Acute alcoholic hallucinosis, 171, 189. course, 193. diagnosis, 193.
etiology, 189. physical condition, 192. prognosis, 194.
treatment, 194.
treatment, 341. Articulation, disturbances of, 294. Aschaffenburg, 125, 524. Associations, external, 31.
internal, 31.
Acute cell alteration, 282. Acute confusional insanity,

amentia.)
141.
(See
Agitation, in dementia praecox, 258. in depressed paretics, 312. in melancholia, 355, 357. Agoraphobia, 503. Agostini, 437. Alcoholic hallucinatory dementia, 171, 195. course, 196.
diagnosis, 197.
predicative, 31.
Ataxia, in delirium tremens, 180.

in paresis, 295.
Atropin delirium, 160.

Attacks, apoplectiform, 229; in paresis,
292. epileptiform, 201, 229; in paresis, 291. epileptoid, in chronic alcoholism, 168; in delirium tremens, 180. paralytic, 291.
Alcoholic paranoia, 171, 195, 197.
course, 199. diagnosis, 199.
Attention, 18.
active, 18. aimless, 18.
treatment, 200. Alcoholic paresis, 171, 200. Alcoholism, 162.
acute, 162. chronic, 165. (See chronic alcoholism.) in dementia paralytica, 279. Alcohol pseudoparesis, 171, 201. Alzheimer, 137, 241, 370.
blocking blunting
of, 20. of, 19.
distractibility of, 21. disturbances of, 18.
in amentia, 142. in collapse delirium, 138. in delirium tremens, 177.

passive, 18.
653
554
Attention (Continued)
passivity of, 20. retardation of, 20.
INDEX
Cerebral tumor (Continued) treatment, 343. Cerebropathia psychica toxamica, 134. Cerebrospinal fluid, 103, 296. Charcot, 475.
Childishness, 228. Chloroform intoxication, 159. Chorea, acute delirium of, 128. Huntingdon's, 324. Chorea Magna, 458. Chronic alcoholism, 165. diagnosis, 169. etiology, 165. pathological anatomy, 165. prognosis, 169. symptomatology, 166. treatment, 169. Chronic intoxication, 162.
suppression
of, 19.
Automatism, 227, 245.

Babinski
reflex, 296, 441.
Baillarger, 7. Barrett, 328. Bechterew, 328.
Befogged states, 15, 465. determination of, 105. hysterical with inconsequential speech,
468.
hysterical with silly excitement, 468. in epileptic insanity, 444. Blocking of the will, 80. Blood changes in dementia paralytica, 298. Bonhoeffer, 172, 173, 184, 189. Born criminals, 515. diagnosis, 520. etiology, 517. symptomatology, 517. treatment, 521. Brain abscess, 343. Bromism, 455. Busyness, 79, 392.
Chronic nervous exhaustion, 146. acquired neurasthenia.)

Circumstantiality, 36, 385, 438. Classification of mental diseases, 115. Cocain hallucinosis, acute, 211. Collapse delirium, 136, 137.
course, 138.
diagnosis, 139; 130.
(See
from acute delirium,
Cabitto, 437.
from epileptic befogged states, 139. etiology, 137. pathological anatomy, 137.
prognosis, 139.
Capacity for mental work, disturbances

of, 57.
treatment, 139.
Carbonic acid narcosis, 160.

Carphologia, 123. Catalepsy, 83, 247. Catatonia, 241. (See dementia praecox, catatonic form.) Catatonic excitement, 79, 248; differentiated from amentia, 144; from collapse delirium, 139 from acute
;
Compulsive insanity, 485, 498.

course, 506. prognosis, 506. treatment, 506.
Concepts, disturbance of the formation

of, 29.
Conduct
arising
from a morbid
basis, 95.
delirium, 130. Catatonic stupor, 80, 245; differentiated from post-infection psychoses, 134. Cells, plasma, 284. Cells, rod-shaped, 284. Cell sclerosis, 282. Cephalalgia, in acquired neurasthenia, 150. Cerea flexibilitas, 83, 248. Cerebral apoplexy, symptoms of, 343. Cerebral hemorrhage, symptoms of, 343. Cerebral syphilis, 326; differentiation from paresis, 318. Cerebral trauma, 344. course, 346. insolation in, 344. treatment, 347. Cerebral tumor, 341. diagnosis, 343 ; from paresis, 318.
Confusion, 42. characterized

desultory, 43. dreamy, 43.
by
flight of ideas, 43.
combined form
of, 43.
hallucinatory, 43. stu porous, 43. Congenital neurasthenia, 146. Consciousness, clouding of, 14, 50, 105. clearness of, 15.
double, 59. Constitutional despondency, 485, 492. course, 494. treatment, 494. Constitutional excitement, 485, 495. from hypomania, 497. diagnosis, 497 treatment, 498. Contrary sexual instincts, 92, 485, 510.
;
INDEX
Contrary sexual instincts (Continued)
course, 513. diagnosis, 513. etiology, 510. prognosis, 514.
555
Delusions (Continued)
of of of of of
symptomatology, 511. treatment, 514. Constitutional psychopathic states, 470, 485. Constraint, 243. Convulsions, 161, 547. Cortex, gliosis of, 323. Craniectomy, 551. Cravings, insatiable, 463. Criminals, 509. born, 515. professional, 519. Crises, in phobias, 504. Cretinism, 216. etiology, 216. pathological anatomy, 217. symptomatology, 217. treatment, 218.
15. Deceitfulness, 486. Dejection, 70. with a feeling of weariness of Delbrueck, 526. Delinquente nato, 516. Delire de negation, 353. Delire du toucher, 504. Delirium, acute, 129. diagnosis, 130. anxious, 447. conscious, 448. occupation, 176. Delirium tremens, 172. abortive form of, 179. course, 181.
persecution, 53, 262, 312, 425. physical influence, 262. self-accusation, 53, 311, 350. self-aggrandizement, 53. suspicion, 365. religious, 243.
sexual, 54.
somatic, 54. systematized, 52, 427.
unsystematized, 52. Dementia, acute, 136. simple hypochondriacal, 231.
Dementia paranoides, 257.

tia prspcox,
(See
demen-
paranoid forms.)
Dementia
paralytica, 276. agitated form, 298, 307. course, 314. demented form, 298, 299. depressed form, 298, 310.
diagnosis, 315; from acquired neurasthenia, 153. from acute alcoholic hallucinosis, 194.
Dammerzustand,
from
339.
life,
arteriosclerotic
insanity, 318,
71.
from from from from from
collapse delirium, 139. delirium tremens, 182.
dementia prsecox, 266, 270. Korssakow's psychosis, 188.

melancholia, 360.
etiology, 276.
expansive form, 298, 301.

pathological anatomy, 280. pathology, 279. physical symptoms, 290.
prognosis, 318.
treatment, 319.
Dementia prsecox, 219.

catatonic form, 241. catatonic form, course, 252. catatonic form, diagnosis, from amentia, 267. from epileptic befogged states, 268. from mania, 269. from manic stupor, 269. from melancholia, 359. from paresis, 266. catatonic form, physical symptoms, 252. catatonic form, symptomatology, 242. diagnosis, 265; from acquired neurasthenia, 266. from acute alcoholic hallucinosis, 194.
diagnosis, 182;
from acute alcoholic
hallucinosis, 193.
epileptic befogged states, 182. paresis, 182, 317. etiology, 172.
from from
pathological anatomy, 173. prognosis, 182. symptomatology, 174.
treatment, 182. Delusions, 48. expansive, 53, 233, 243, 263, 302, 307, 396, 398, 425. fantastic, 54, 257, 365. hypochondriacal, 54, 351, 364, 403. nihilistic, 53, 353. of infidelity, 198, 365.
of jealousy, 54, 197.
from alcoholic hallucinatory dementia,
197.
of mental soundness, 55.
(See insight.)
from manic-depressive insanity, 416. from paresis, 317.
556
Dementia praecox (Continued)
INDEX
from post infection psychoses, 133. from presenile delusional insanity,
368.
Echolalia, 83, 228, 247. Echopraxia, 83, 228, 247. Ekmnesia, 59. Elsholz, 173, 181, 184. Embolism, 344.
etiology, 219.
exacerbations
in,
255.
Emotional attitude, 138, 143, 149, 178,

196, 204, 225, 235, 244, 252, 260, 264, 289, 300, 305, 309, 366, 372, 375, 377, 379, 386, 398, 401, 429, 440. Emotional deterioration, 63. Emotional field, 110. Emotional irritability, diminution of, 62. increase of, 62, 110. Emotions, disturbances of, 62. morbid, 68. 192, 258, 354, 391,
hebephrenic form, 230. hebephrenic form, course, 237. hebephrenic form, diagnosis, acquired neurasthenia, 266. hebephrenic form, diagnosis, amentia, 267.
from from
from imbecility, 272.

hebephrenic form, physical symptoms,
237.
hebephrenic
231.
form, symptomatology,
paranoid forms, 257. paranoid forms, course, 260. paranoid forms, physical symptoms,
260.
Energy, specific, 3. Ennui, 74. Epidemics, school, 458.

Epilepsy, psychic, 445. Epileptic befogged states, 444; differentiated from catatonia, 267; from delirium tremens, 182. Epileptic furor, 440. Epileptic insanity, 434. diagnosis, 450 from paresis, 450. etiology, 434. pathology, 436. physical symptoms, 441. prognosis, 451. symptomatology, 438. treatment, 452. Epileptic stupor, 446. Erichsen, 475. Erythrophobia, 502. Etat crible, 335. Examination. (See methods of examina;
paranoid forms, symptomatology, 257. paranoid forms, second group, 260. paranoid forms, second group, course,
264.
paranoid forms, second group, symptomatology, 261.

pathology, 221. physical symptoms, 229. symptomatology, 222. treatment, 272.
Depression, constitutional, 419. with a flight of ideas, 410. Depressive state with flight of ideas emotional elation, 411. Derailment of the will, 87.
Desultoriness, 37, 40. Deterioration, mental, 253. Dipsomania, 448. Disorientation, 26, 107. amnesic, 28, 107. apathetic, 27, 107. delusional form of, 28, 107. Disposition, irritable, 66.
and
tion, 97.)
Excitement, catatonic, 79.

hysterical, 416, 469.
motor, 78.
periodic, 255.
Exhaustion psychoses, 136.

Expression, disturbances Eye, motor disturbances
paralytica, 293.
of, 93.
sunny, 67.
Distractibility, 57, 394. of attention, 21.
of, in
dementia
Double consciousness, 59. Dread neurosis, 480.

course, 482.
diagnosis, 482 ity, 482.
;
Fabrications, 25, 185, 233, 287, 339, 372, 375, 377.
Fanaticism, 67.
from hysterical insan- Farrar, 126.

Fatigue, 74. increased susceptibility to, 57, 148, 149, 286, 486.
from nervousness, 482. from neurasthenia, 482. from phobias, 483.

treatment, 483.
recovery from, 57.

Fear, 68.
Drunkard's humor, 168.
compulsive, 69.
in melancholia, 354.
Dual personality,
58.
INDEX
Feeling of shame, 76. Feeling of well-being, 72.
Feelings, 73. Fe>6, 434. Fetichism, 92. Fever delirium, 121. course, 123. diagnosis, from delirium tremens, 182. etiology, 122. pathological anatomy, 122. prognosis, 124. symptomatology, 122. treatment, 124. (See ideas, flight of.) Flight of ideas. Flightiness, 486. Folie du doute, 501. Frivolity, morbid, 67. Fuerstner, 323.
557
Hoffman, 475. Homosexuality, 512. Horrors, touch of, 179.
Humor, drunkard's,
168.
Hunger, 75. Huntingdon's chorea, 296, 323.

course, 324. diagnosis, 325. pathological anatomy, 325. physical symptoms, 324. Hydrophobia, 128.
Hyperprosexia, 22.
Hypersuggestibility, 247, 248. Hypnotism, '171, 474, 483, 514. Hypochlorization, 453. Hypochondriasis, 150, 311, 415. Hypomania, 390. Hysterical constitution, 457. Hysterical insanity, 457. course, 469.
diagnosis, 470;
Gabiana, 278.
Garbini, 278. Gianelli, 341.
Gliarasen, 330, 371.
Gliosis of cortex, 323.
from catatonia, 470. from dementia prsecox, 270. from epileptic insanity, 450. from manic-depressive insanity, 415.
Gowers, 436.
etiology, 458.
Grave alteration, 282. Graves 's disease, 214.

Grtibelsucht, 500. Gudden, 278, 541.
pathology, 459. physical symptoms, 464.

prognosis, 470.
treatment, 471. Hysterical lethargy, 467.
189, 286, 365, 428,
Ideas, compulsive, 33, 401. delusional, 364. disturbances of the formation of, 29.
fixed, 51.
flight of, 37, 43, 385, 387,
Habitual criminals, 524.
Hagen,
7.
Hallucinations, 3, 5, 10, 104, 137, 174, 198, 222, 232, 242, 258, 261, 300, 305, 309, 312, 352, 354, 372, 375, 378, 383, 396, 404, 438.
390.
dermal, 12. elementary, 4. microscopic, 13. muscular, 12. of general senses, 12.
of of of of of
hypochondriacal, 461.
pessimistic, 308. simple persistent, 34. store of, 287.
tormenting, 498.
Idiocy, 544. diagnosis, 550. etiology, 544. pathology, 545. prognosis, 550.
hearing, 11.
memory,
sight, 11. smell, 12.
taste, 12.
7.
25.
psychic,
reflex, 9.
treatment, 550. Ill-humor, periodical, 443.
Illusions, 3, 5, 10, 104, 137, 174, 372,
Kahlbaum, 4. Hammarburg, 546. Hasheesh delirium, 159.

Headache, 290.
stable, of
438
Head
injury, 344.
(See dementia praeHebephrenia, 230. cox, hebephrenic form.)
apperceptive, 8. dermal, 12. muscular, 12. of general senses, 12.

of sight, 11. of smell, 12. of taste, 12.
Hertz, 173.
Hirechl, 165.
558
Imagination, 44, 287, 439. disturbances of, 43.
INDEX
Kahlbaum,
6, 7, 9, 88.
Kaplan, 328.
Keniston, 441.
morbid excitability
of, 30.
simple sluggishness of, 44. Imbeciles, high grade, 541.

Imbecility, 536. course, 542.
Kleptomania, 92, 508.
Koppen, 346. Korssakow's psychosis,

543
;
16, 24, 25, 28, 134,
from hysteria, from dementia prsecox, 542. symptomatology, 536.

diagnosis, 542
;
171, 183. course, 187. diagnosis, 188. etiology, 183.
treatment, 543. Impulsions, 498, 504. Impulses, 440. morbid, 91, 508.
pathological anatomy, 184. physical symptoms, 187. symptomatology, 184.
Impulsive acts, 90. Impulsive insanity, 485, 507.

course, 509.
treatment, 189. Kraepelin, 220, 277, 278. Krafft-Ebing, 510. Kranisky, 437.
from diagnosis, 509 ; sanity, 509. treatment, 509. Impulsiveness, 488.

Inadequacy, feeling
Indifference, 45.
of,
compulsive in-
Legrand du
402.
Infection deliria, 121, 125. course, 127. outcome, 127. treatment, 130. Infection psychoses, 121.
Influenza, 128.
Saulle, 448, 501. Lesions, focal, in dementia paralytica, 284. vascular, in dementia paralytica, 283. Liar, morbid, 526. Lombroso, 516.
Macrocephaly, 544.
Malaria, delirium
of,
127.
Mania, 390, 394.

chronic, 418, 497. constitutional, 418, 497. course, 397. delirious, 390. course, 399. physical symptoms, 399. grumbling, 408. irascible, 407. physical symptoms, 396. unproductive, 408. Manic-depressive insanity, 381. course, 412. delusional form, 402. depressive states, 400. course, 406. physical symptoms, 406. diagnosis, 415. from acute alcoholic hallucinosis, 194. from amentia, 144. from collapse delirium, 139. from dementia pracox, 268, 269. from melancholia, 358. from paresis, 316. from post infection psychoses, 133, 134. duration, 413. etiology, 381. mania, 390. manic states, 390. mixed states, 407.
Influenza insanity, 121. Insanity, compulsive, 33. epileptic, 434. hysterical, 457. impulsive, 485, 507. manic-depressive, 381. myxcedematous, 214. of degeneracy, 485. post-epileptic, 445. pre-epileptic, 444. querulent, 432.
Insight, 233, 251, 259, 288, 300, 309, 352, 365, 372, 384, 402, 404, 439. absence of, 55.
Insomnia, 151, 156, 357, 362.

Interference, 84. Intervals, lucid, 413.
Intoxication psychoses, 159. Intoxications, 159. Involution psychoses, 348.
Irabundia Morbosa, 66.

Irritable disposition, 66.
Janet, 482. Jolly, 182.
Judgment, 47, 108, 224, 235, 288, 366

439. Jurgens, 328. Juvenile Paresis, 277.
INDEX
Manic-depressive insanity (Continued) nature of, 382.
prognosis, 417.
559
liar,
Morbid
67, 526.
simple retardation, 400.

course, 402.
treatment, 419.
diagnosis, 530. from constitutional excitement, 530. from the unstable, 530. prognosis, 531. symptomatology, 526. treatment, 531.
Manies mentales, 498. Mannerisms, 86, 240, 249, 254. Marchand, 278.
Morbid personal peculiarities, 415. Morbid swindlers, 67, 526. Morbid temperaments, 65.
Morphinism, 202.
abstinence
Marme,
205.
Masochism, 92. Megalomania, 302, 307.

Melancholia, 32, 348.
course, 358.
diagnosis, 358 from acute neurasthenia, 154. from arteriosclerotic insanity, 360. from paresis, 315. from post infection psychoses, 133. from senile dementia, 360.
;
symptoms
in,
205.
course, 206. diagnosis, 206. etiology, 202.
pathological anatomy, 202. prognosis, 206. symptomatology, 203. treatment, 207.
Morphin intoxication, acute, 203.

chronic, 203.
etiology, 349.
Motor excitement,
78.
pathological anatomy, 349. physical symptoms, 357. prognosis, 360. smaller group, 352. symptomatology, 349. treatment, 361.
Multiple sclerosis, 326. Muscular tension, 85, 246.
Mutism, 88. Mysophobia, 503.
Myxcedematous
course, 215. etiology, 214.
insanity, 214.
Memory,
23, 178, 224, 234, 244, 286, 366, 372, 384, 391, 429, 438. accuracy of, 25, 106. disturbances of, 23. fabrications of, 106. hallucinations of, 25. impressibility of, 23, 106, 384. retentiveness of, 23, 24, 106. retrospective falsifications of, 427. Mendel, 475. Menstrual insanity, 255. Mental elaboration, disturbances of, 23. Methods of examination, 97. anamnesis of the disease, 98. family history, 97. muscular system, 100. personal history, 97. status praesens, 99. Meyer, A., 328, 344, 346. Microcephaly, 544. Moebius, 459. Moli, 165. Moll, 510. Monomania, 51. Mood, change of, 65. Moral imbecility, 516, 520. Moral insanity, 515, 516. Morbid emotions, 68. Morbid feelings of pleasure, 71. Morbid frivolity, 67.
physical symptoms, 215. symptomatology, 214. treatment, 216.
Nausea, 75. Negativism, 88, 89, 227, 245, 246. Neologisms, 250.
Nervous dyspepsia, 152.

Nervousness, 485.
course, 490.
diagnosis, 490 treatment, 491.

;
from neurasthenia, 490.
Nervous weakness, 148.

Neurasthenia.
(See
acquired
neuras-
thenia, 146.) congenital, 146. sexual, 488.
Neurocerebrite toxique, 134.

Nissl, 125, 164, 166, 174, 202, 209, 242,
284, 331, 469.
Onomatomania, 499.
Opium smoking,
Oppenheim, 475.
159.
Oppression, feeling of, 354. Organic dementias, 323.

Pain, 75. Paralysis of the will, 77.
560
Paramimia, 228. Paramnesia, 25.
Paranoia, 53, 423.
course, 430. diagnosis, 431.
INDEX
Psychoses (Continued)
post-febrile, 121.
post infection, 131, 188.
Pyromania, 93, 508.

Reasoning, disturbances
of, 47. Reflexes, in dementia paralytica, 296. in epileptic insanity, 441. Relapses, in delirium tremens, 181. Remissions, 301, 307, 310, 314. in catatonia, 253. in paresis, 314.
from dementia prsecox, 271, 431.

erotic, 428.
from melancholia, 431.

etiology, 423.
prognosis; 432.
religious, 428.
Paresis, 276.
treatment, 432. (See dementia paralytica.) ascending, 295.
Reperception,
6, 7.
arrested, 318. tabo, 295. Peculiar individuals, 66. Perception, 176. disturbances of, 3, 104.
falsifications of, 17.
Resistance, in catatonia, 245. Rest cure, 361. Restlessness, 362. nocturnal, 373.
Retardation, 80, 389, 400, 404, 405.

of attention, 20. of thought, 385. Richet, 453. Rigid tension, 81.
phantasms,
4.
Perplexity, 27. Perseveration, 35, 107. Personality, dual, 58. Petite mal, 346. Phobias, 69, 498, 502. Piper, 544.
Pleasure, morbid feelings of, Pneumonia delirium, 121.
71.
Sachs, 546.
Sadism, 92.
Sadness, 70. Santonin, 159. Schaefer, 296.
Schrenk-Notzing, 510.
Schules, 87. Schultze, 475. Schuster, 342. Seclusiveness, 66. Self-accusations, 403.
Porencephaly, 545.
Practice, 57.
Presbyophrenia, 16, 375;
differentiated
from Korssakow's psychosis, 188.

delusional Presenile insanity, 364. 367. diagnosis, etiology, 364. prognosis, 368. symptomatology, 364. treatment, 368. Pressure of activity, 78, 387, 392. Pritchard, 515. Pseudodipsomania, 524.
348,
Self-aggrandizement, 53.
Self-consciousness, 58. falsification of, 60. splitting of, 58. Self-depreciation, 53. Self-importance, 426. Senile delirium, 377. Senile delusional insanity, 378. Senile dementia, 24, 348, 369.
diagnosis,
Pseudohallucinations, 7. Pseudoquerulants, 531.

diagnosis, 534.
379 from melancholia, 360 from paresis, 318.

;
treatment, 535. Psychic epilepsy, 445. Psychic hermaphroditism, 512. Psychic weakness, 50. Psychogenic neuroses, 457.
Psychomotor retardation,
80, 389.
Psychopathic personalities, 515. Psychopathic states. (See constitutional Sensibility, psychopathic states.)
Psychoses, polneuritis, 134.
etiology, 369. pathological anatomy, 370. physical symptoms, 374. severer grade of, 374. symptomatology, 371. treatment, 380. Senile decay, 370. Senility, 379. Sensations, false, 383. Sense of reality, 486.
17.
Septic states, 128.
INDEX
Sexual Sexual Sexual Sexual Sexual Sexual
delusions, 54. excitability, 76. feelings, 76, 373.
feelings, perverted, 76. indifference, 76.
561
Thought (Continued)
acceleration of, 56. circumstantiality of, 107.
confusion
of, 42. desultoriness of, 107.
(See desul toriof, 56.
neurasthenia, 488.
ness.)
Simple syphilitic dementia, 326, 327.

course, 328.
diagnosis, from arteriosclerotic insanity, 340.
disturbance of the rapidity

paralysis of, 31, 107.
rambling, 38. retardation of, 32, 56, 107.

train of, 107.
Simulation, 479.
Smallpox, initial delirium Somatic delusions, 54.
of,
126.
Thrombosis, 344.
Tics, 494.
Somnambulism, 446, 467.

Speech, 180, 294, 387, 398, 442.
explosive, 294. hesitating, 294. inconsequential, 250, 468. scanning, 294. slurring, 294. Spirit possession, 263. Splitting of consciousness, 58. Spratling, 434, 437. States, sad and anxious, 469. stuporous, 313, 405. Status epilepticus, 455. Stereotyped movements, 86. Stereotypy, 85, 227, 248. Striimpell, 475. Stubbornness, 89. Stupor, catatonic, 80. manic, 410; differentiated from catatonia, 417. Subsultus tendinum, 123. Suggestion, simple, 474. Suicide, 356, 363. Sully, 25. Superfluous embellishment, 87. (See morbid Swindlers, morbid, 67.
Tobacco, 72.
Tormenting
ideas, 498.
Toulouse, 453.
Tramps, 529.
Transitions, 414. Traumatic delirium, 344, 345. Traumatic dementia, 344, 345. Traumatic hysteria, 475. Traumatic insanity, primary, 345. Traumatic neuroses, 457, 475. diagnosis, 479. from constitutional psychopathic states, 479. from hysterical insanity, 479. etiology, 475. physical symptoms, 477. prognosis, 479. symptomatology, 476. treatment, 480. Typhoid delirium, 121. Typhoid initial delirium of, 125.
Ulrichs, 510.
swindlers
Swindlers, 529. Syphilis, 278.
and
liars.)
Unconsciousness, 15. determination of, 105. Unpleasant, increased susceptibility

the, 65.
to
Syphilitic pseudoparesis, 326, 329. course, 330.

diagnosis, 331
;
Unstable, the, 521. diagnosis, 525.
from
senile dementia,
379.
pathology, 330.
physically, 329. treatment, 332.
from born criminals, 525. from hysteria, 525. from dementia prsecox, 525. symptomatology, 521.
treatment, 526.
Vasomotor disturbances, 297.

Tabetic psychoses, 332. Tabo-paresis, 295.
Verbigeration, 95, 251.
Visions, 104. Voice of conscience, 105. Voices, internal, 12.
Tay, 546. Temperature, 252, 297. Tension, muscular, 85.

rigid, 81.
Thought, 178, 224, 234, 244, 263, 305, 309,

352, 354, 366, 371, 385, 438.
Volitions, 77. Volitional impulses, crossing of, 85. diminution of, 77. facilitated release of, 81.
2o
562
Volitional impulses (Continued)
release of, 79. increase of, 78.
INDEX
Westphal, 475. Wildermuth, 434, 435, 436, 544, 549, 550.
Wilfulness, 463. Will, blocking of, 80.
impeded
Wanton
bath, prolonged, 140. Weariness, prolonged, 148. Weigert, 284. Well-being, feeling of, 72.
Warm
happiness, 72.
diminished susceptibility
distractibility of, 84.
of, 88.
heightened susceptibility of the, 83.

hypersuggestibility of, 83, 227. paralysis of, 77.
Wernicke, 184.
weakness
of, 83.
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CLINICAL PSYCHIATRY

KRAEPELIN'S "LEHRBUCH DEE PS YCHIATRIE "

ROSS DIEFENDORF, M.D.

PSYCHIATRY IN YALE UNIVERSITY

THE MACMILLAN COMPANY

COPYRIGHT, 1902, 190T,

THE MACMILLAN COMPANY.

PREFACE TO THE FIRST EDITION

classes in psychiatry in the

the Kraepelin psychiatry to our peculiar American

traumatic neuroses, also the treatment in epileptic and

and acquired neurasthenia.

PREFACE TO THE FIRST EDITION

The only omissions

are the general etiology, diagnosis,

The work has been done

PREFACE TO THE SECOND EDITION

psychogenic neuroses and the psychopathic states which

The chapter on Psychopathic

given fuller consideraPersonalities did not

appear in Kraepelin's earlier edition.

tions without explicit references occur under the

PREFACE TO THE SECOND EDITION

Physician and Pathologist of the Connecticut

under special obligations to

for help in reading proof

double thought, apperceptive

illusions, reflex halluci-

illusions of hearing, sight, taste,

Disturbances of Mental Elaboration

External association of ideas, internal association of ideas,

cumstantiality, flight of ideas, rambling thought, desultoriness.

Disturbances of Judgment and Reasoning

systematized delusions, delu-

ment, delusions of mental soundness (absence of insight),

Disturbances of Self-consciousness Dual personality, double consciousness, falsifications of

..... .... ......

Disturbances of the Emotions Diminution and Increase of Emotional Irritability

Emotional deterioration, temporary increase of emotional irritability, change of mood.

Increased susceptibility to the unpleasant, apprehensiveness,

morbid Morbid Emotions

Fear, compulsive fears, phobias, dejection, sadness with ex-

........ ... ....... .65 .......... ......

D. Disturbance of Volition and Action Diminution of Volitional Impulses

...... ...... .......

Facilitated Release of Volitional Impulses Distractibility of the will.

Heightened Susceptibility of the Will

Interference and Stereotypy

Crossing of voluntary impulses, stereotypy, mannerisms, superfluous embellishment, derailment of will.

.......... .......... ........ .....

thought, judgment, emotional

FORMS OF MENTAL DISEASES

Consideration of the Factors entering into a Provisional Classification

Infection typhoid, of smallpox. delirium of malaria. Delirium of chorea. Deliria

pathia psychica toxamica.

Exhaustion Psychoses A. Collapse Delirium