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TEXTBOOK
OF PSYCHIATRY
BY
Prof. Dr.
EUGEN BLEULER
DIRECTOR OF THE PSYCHIATRIC CLIKIC, ZURICH
AUTHORIZED ENGLISH EDITION

BY
A. A.
BRILL,
Ph.B., M.D.
FORMER ASSISTANT PHYSICtAN OF THE CENTRAL ISLIP STATE HOSPITAL AND ASSISTENZARZT OF THE CLINIC OF PSYCHIATRY, ZURICH. LECTURER ON PSY'CHOANALY'SIS
AND ABNORMAL PSYCHOLOGY, NEW YORK UNIVERSITY
THE MACMILLAN COMPANY

1934
/"S 2.
COPYBIGHT, 1924,
By the MACMILLAN COMPANY.
All rights reserved no part of this book may be

reproduced in any form without permission in writing
from the publisher, except by a reviewer who wishes
to quote brief passages in connection with a review
written for inclusion in magazine or newspaper.
up and printed. Published January, 1924.

Reprinted July, 1924; June, 1930. Reissued
January, 1934.
Set
PRINTED IN THE UNITED STATES OF AMERICA BY

THE FERRIS PRINTING COMPANY, NEW YORK
TRANSLATOR'S PREFACE
When
after about five years in the
New York
State Hospital I
entered Burgholzli, the clinic of psychiatry at Ziirich, I found a

spirit in
tients
Having been accustomed
psychiatry there.
new
to look at pa-
through the eyes of the German psychiatry, as notably repreme not only as
sented by Kraepelin, Professor Bleuler's ways impressed
more
more
interesting but also as
instructive
scope and result. Professor Bleuler was the
and farther reaching
first
noted psychiatrist
in
who
recognized the great value of Professor Freud's discoveries and impressed his feelings on his co-workers.^ In Burgholzli the psychoanalytic
methods were applied to all accessible patients, and the Freudian

mechanisms were investigated even in the organic psychoses. This
resulted in many works of great importance which have exerted much
influence on psychiatry and psychopathology in general.
It was while I was Professor Bleuler's assistant, in 1907, that he
spoke to me about writing a textbook on psychiatry, and I volunteered
to put it into English. Since then I have translated a number of Professor Freud's works and became closely identified with the psychoanalytic movement, but my interest in psychiatry, through which I
first became acquainted with psychoanalysis, has remained just as
deep.
this
It is therefore
work
with a strong feeling of satisfaction that
present
to English readers.
This translation was made of, the author's fourth German edition,
and as far as was possible "the .German text was -strictly followed. The
only part omitted, was the addendum dealing witli forensic psychiatry. The autho-i:'s iêas are based on the Swiss, German/ and Austrian laws which "are quite different' from: ours, and as"' ours are so
numerous, so- -indefinite and 'so contradictory it was thought' best to
|
omit this subject for the present.

This book was primarily written to furnish the student and the
general practitioner with a general knowledge of psychiatry-.
The
author endeavors to present clear concepts, and whenever that is not
^The works
of the Zurich school are too well known to be mentioned here.

For a complete bibliography of Bleuler's works the reader is referred to
Hans W. Maier's paper on Eugen Bleuler, Zeitschr. f. d. gesammte Neurologie
^
und
Ps3'chiatrie,
LXXXII.
7^77^
TRANSLATOR'S PREFACE
vi
He lays stress on the

understanding of psychology, because, to put it in his own words,
"psychiatry without psychology is like pathology without physiology,
and also because a good physician can be only he who understands the
possible he lucidly exposes the existing gaps.
whole human being."

Dr. George H. Kirby, Director of the N. Y. Psychiatric Institute,
and Professor of Psychiatry at the Cornell University Medical College,
who is most qualified to judge the development of psychiatric instruction in the United States, has rendered a great service by writing the
introduction.
tions in the
I
am
work
further indebted to
him
for
many
helpful sugges-
of translation.
owe gratitude
also to Dr.
M.
S.
Gregory, Director of the Psycho-
pathic Pavillions of Bellevue Hospital and Professor of Psychiatry at
N. Y. University Bellevue Medical
College,
and Dr. M. B. Heyman,
the Superintendent of the Manhattan State Hospital,
New York
City,
the former for his encouragement and valuable suggestions, and the
latter for a
number
of handwriting specimens of patients in his hospital.
A. A. Bhill.
November, 1923.
INTRODUCTION
The
will
appearance of a translation of Professor Bleuler's textbook

felt by psychiatrists in English-speaking
supply a need long
countries.
During
his twenty-five years' service as a teacher at the
University of Zurich and Director of the Cantonial Hospital at Burgholzli Bleuler has
been a most indefatigable worker and painstaking
investigator in the field of psychopathology and his

tific
numerous
him
contributions and original observations have brought
national recognition
modern psychiatry.
At least two of
as
scieninter-
an outstanding leader in the progress of
Bleuler's monographic studies
have already been

His description and illuminating analysis of
negativistic phenomena was translated by Doctor William A. Whit^ in
1912 under the title of "The Theory of Schizophrenic Negativism." In
the same year another of his important studies, entitled "Affectivity,
Suggestibility, Paranoia," was translated by Doctor Ricksher. American psychiatrists also have had an opportunity to become acquainted
with another of Bleuler's important contributions, a summary' of which
he gave in an address on "Autistic Thinking" delivered at the opening
exercises of the Phipps Psychiatric Clinic, Johns Hopkins Hospital, in
1913. Those who had the pleasure of hearing and meeting Professor
Bleuler on that occasion were immediately charmed by his pleasing
personality and scholarly attainments, as well as impressed by his
ability to present a complex subject in clear and simple language and
to show by a penetrating analysis of symptoms how the ordinarily incomprehensible or illogical ideas and bizarre reactions of dementia
praecox had very plainly their counterparts in normal day-dreaming
and in childhood phantasy and play.
Of Bleuler's special studies, that on dementia praecox is generally
conceded to be the most important. This monographic work of over
400 pages was published in 1911 as one of the volumes of Aschaffenburg's Handbook under the title of "Dementia Praecox oder Gruppe
der Schizophrenien."
Unfortunately this work has not been translated although the textbook which now becomes available in English
contains a comprehensive chapter on Schizophrenia (dementia praecox)
translated into English.
INTRODUCTION
viii
with an admirable symptom-analysis, and psychological interpretation

of the development
The
first
and course
of the disorder.
edition of the textbook which appeared in 1916
crystallization of Bleuler's long experience as a teacher
gator
and contained
psychopathological
analysis.
systematic
formulations
The warm
and
presentation
their
of
his
application
reception accorded the book
is
and
was a
investi-
important
in
attested
clinical
by the
fact that four editions have already appeared.
The book marks
a notable advance in psychiatry in that
it
em-
phasizes sharply the contrast between the older descriptive psychiatry

of Kraepelin and the newer interpretative psychiatry of the present
time which utilizes the psychoanalytical principles and general biological viewpoints developed by Freud and his pupils in Europe and
by Meyer, Hoch, White and others in this country. Bleuler was apparently one of the first psychiatrists to grasp the great importance of
a psychodynamic viewpoint in the study of mental disorders and
as early as 1906 he published a paper on Freudian mechanisms in the
symptomatology of the psychoses. Although he became convinced
of the value and importance for psychiatry of many of Freud's formulations, he has always preserved a well balanced and distinctly
independent attitude toward psychoanalytic theories and in the course
of his work he has not hesitated to criticize certain aspects of the
Freudian psychology.
As an introduction to the study of clinical psychiatry the physician
and the student will find the chapters dealing with the principles of
psychology and psychopathology particularly helpful and stimulating.
While Bleuler adheres to Kraepelin's general scheme of classification
of clinical types, it will be found that unlike Kraepelin he does not
stop with the mere enumeration of symptoms but seeks through the
application of psychological principles to give an interpretation and
explanation for the particular reaction type under consideration. This
applies not only to the so-called functional mental disorders and
psychopathic states but he also discusses most interestingly the psychology and affective reactions of the toxic and organic syndromes.
Bleuler's book will be of interest and help to all those who wish
to advance beyond the formal descriptive psychiatry of a period now
Teachers, practicing neuropsychiatrists
rapidly drawing to a close.
and state hospital physicians will find the book to be of great value and
assistance in their clinical work, as it will furnish them a comprehensive presentation of the principles of modem psychiatry and their
practical application in a form not hitherto available in a psychiatric
textbook.
It is a
work which, as already intimated, marks a
distinct
INTRODUCTION
ix
advance beyond the boundaries of the Kraepelinian psychiatry. To

Doctor Brill, a former pupil of Blculcr's, the profession is indebted for
the successful completion of the difficult task involved in the translation.
George H. Kirby.
Psychiatric Institute,
Sept.
1,
1923.
CONTENTS
PAOK
Translator's Preface
Introduction
vii
CHAPTER
Psychological Introduction
The Psychological
The Psyche
Principles
1
1
Consciousness
Concerning the Theory of Cognition
The Unconscious
The
Individual Psychic Functions

a)
b)
The
10
Centripetal Functions
12
Sensations
12
Perceptions
12
Concepts and Ideas

Concepts
13
13
Ideas
d)
e)
Memory
28
/)
Orientation
32
g)
Affectivity
32
h)
Attention
i)
Suggestion
40
42
Associations,
Thought
17
23
Intelligence
k)
Dereistic Thinking
I)
Belief,
m) The
n)
The
II
16
The
The
c)
45
Mythology, Poetry, Philosophy
47
Ego
49
Personality, the
Centrifugal Functions
50
General Psychopathology
1.
54
Disturbances of the Centripetal Functions
55
Disturbances of the Sensory Organs
55
Central Disturbances of the Sensations
and
Perceptions (Hyperesthesia, Anesthesia, Analgesia.
Perception,
sions, Hallucinations)
xi
Comprehension,
Illu-
56
CONTENTS
xii
PAGE
2.
Disturbances of Concepts and Ideas
68
3.
Disturbances of Associations and of Thought. ...

General Facilitation of the Psychic Processes.
71
Flight of ideas
71
Melancholic Retardation of Associations (In74
hibition)
Associations in Organic Psychoses
Schizophrenic
(Dreamlike)
74
Disturbances
of
Association
77
Associations of Oligophrenics
82
Associations of Epileptics
82
84
84
The Associations
of Hysteria
Associations of Neurasthenics
Associations of Paranoiacs
Other Disturbances of Association
Confusion
85
85
Diffuseness and Circumstantiality
86
86
Overvalued Ideas, Obsessions (Obsessive Acts)
87
Delusions
90
4.
Disturbances of Memorj^
5.
Disturbances of Orientation
6.
Disturbances of Consciousness
97
110
Ill
Clear Mindedness (Besonnenheit)

7.
116
Disturbances of Affectivity
117
Morbid Depression
119
The Pathological Elated Mood
(Exaltation,
Euphoria)
Morbid
Apathy
122
Irritability
123
124
Variable Duration of the Affects
124
Emotional Incontinence
125
Affective Ambivalence
125
Congenital Deficiency and Perversions of Particular Affective
Groups
126
Exaggerations and Onesidedness of the Affective Causes,
Morbid Reactions
Pathology of Affective Disturbances

8.
Disturbances of Attention
9.
Morbid
10.
Suggestibility
Disturbances of Personality
126
131
133
135
137
CONTENTS
11.
xiii
Disturbances of Centrifugal Functions (Actions,
Weakness
of Will, Stupor, Inhibited Actions,
Hyperkineses,
Akinesis,
Stereotypes,
Morbid
Compulsive Actions, Katalepsie,

Negativisms, Inadequate Manifestations of
Affects, Speech Anomalies, Writing Anomalies)
Impulses,
III
Physical Symptoms
IV
The Manifestations
157
of
Mental Diseases
161
Morbid States
Syndromes
V The
142
161
164
Course of Mental Diseases
167
VI
The Borderlines
of Insanity
170
VII
Classification of
Mental Diseases
173
VIII
IX
The
Recognition of Insanity
184
Differential Diagnosis
193
Compilation of the Differential Diagnostic

cance of Individual
Signifi-
Symptoms
194
194
Disturbances of Perception
Disturbances of Association
195
196
Disturbances of
Memory
197
Some
198
Special
Syndromes
Causes of Mental Diseases
The Treatment of Mental Diseases

XII The Significance of Psychiatry
XI
XIII
196
Affective Disturbances
The
Individual
L-V.
I.
200
in General
214
226
Mental Diseases
230
The Acquired Psychoses with Coarse Brain

Disturbances. The Organic Syndrome ....
230
Insanity in Injuries to the Brain
240
Insanity in Brain Diseases
242
III.
Syphilitic Psychoses
244
IV.
Dementia Paralytica
Senile and Presenile Insanity
II.
V.
choses)
Presenile Insanity
250
(Senile
Psy276
279
CONTENTS
xiv
PAGE
279
Arteriosclerotic Insanity
Senile
Dementia (Simple Dementia
Senilis)
VI.
The Toxic Psychoses

The Acute Toxemias
1.
299
299
300
Pathological Drunkenness
2.
The Chronic
303
Intoxications
303
A. Chronic Alcoholic Poisoning
The Simple Drinking Mania
...
Delirium Tremens
ganic
Psychoses
with
Or-
Symptoms
Alcoholic
303
326
341
Alcoholic Hallucinosis
Alcoholic
The
286
294
Presbyophrenia
Korsakoff
345
Psy346
chosis
Alcoholic Pseudoparesis
350
Polioencephalitis Superior
350
Alcoholic Leukencephalitis of the
Corpus Callosum
351
Chronic Delusions of Jealousy in

Alcoholics and Alcoholic Para-
351
noia
VII.
351
Alcoholic Epilepsy
353
Alcoholic Melancholia
354
B. Morphinism
354
C. Cocainism
359
Infectious Psychoses
361
362
B.
Fever Deliria
Infectious Dehria
C.
Acute Confusion, Amentia
364
A.
VIII.
Dipsomania
363
D. Infectious States of Weakness

Thyreogenic Psychoses
Psychoses in Basedow's Disease
Myxoedema (Cachexia
Strumipriva)
Endemic and Sporadic Cretinism

IX.
Schizophrenias (Dementia Praecox)

A.
B.
C.
The Simple Functions

The Complex Functions
The Accessory Symptoms
365
365
365
366
367
372
373
384
387
CX)NTENTS
XV
TAtm
The Subdivisions (Paranoid, Catatonia,
D.
Hebephrenia, Schizophrenia Simplex)

E.
The Course
F.
What
G.
Combination
434
Is Included
of
under the Term

Schizophrenia
436
with
437
other Diseases
H.
Diagnosis
I.
Prognosis
438
440
441
Causes
Frequency and Prevalence
M. Anatomy and Pathology
N. Treatment
K.
442
442
443
L.
X.
XI.
XII.
445
465
Epilepsy
Manic-Depressive Insanity
Psychopathic Forms of Reaction
(Situation
493
Psychoses)
510
2.
Paranoia
The Delusion of Persecution of the Hard
of Hearing
3.
Litigious Insanity
533
Induced Insanity (Folie a Deux)

The Reactive Mental Disturbance
534
1.
4.
5.
533
of
Prisoners
535
6.
The Primitive Reactions
537
7.
Reactive Depressions and Exaltations.

The Reactive Impulses (Impulsive In-
537
8.
sanity of Kraepelin)
538
9.
The Reactive Changes of Character ....
540
10.
The Neurotic Syndromes

A. Hysterical Syndrome "Hysteria"..
540
B.
vous Exhaustion
(Pseudo-) Neurasthenias ....
Expectation Neurosis
Compulsion Neurosis
Accident Neuroses
The
C. The
D. The
E. The
The Psychopathies
A.
540
The So-Called Neurasthenic Syndrome. Neurasthenia and Pseudoneurasthenia

Actual Neurasthenia, Chronic Ner-
XIII.
413
Nervosity
556
557
558
560
560
564
569
571
CONTENTS
xvi
CHAPTER
PAGE
C.
The Aberrations of the Sexual Impulse.

Abnormal Irritability
D.
Instability
582
582
E.
Special Impulses
586
F.
The Eccentric (Verschrobene)
G.
Pseudologia
H.
Constitutional
B.
Phantastica
(Liars
572
587
and
587
Swindlers)
Ethical
Aberrations
(Enemies of Society, antisocial bemoral

oligophrenics,
moral
ings,
idiots,
and imbeciles.
Moral Insan.
587
591
593
ity)
I.
XIV
The Contentious
(Pseudo-Litigious)
Oligophrenias (Psychic Inhibitions
of
Development)
ILLUSTRATIONS
P/l'.K
1.
Paretic expression
251
252
2-
Paretic expression
3.
Paretic writing
253
4.
Cortex in paresis
262
5.
Normal
6.
Gliosis in paresis
7.
Round
8.
Plasma
9.
Senile writing
291
Pyramidal
293
10.
cortex
264
265
266
infiltration
cell
269
cells
cell in senility
11.
Presbyophrenic
295
12.
Cortex in presbyophrenia
297
13.
Plaques
14.
Plaques magnified
in
presbyophrenia
298
298
15.
Normal
16.
Writing of a chronic alcoholic
cortical cell
299
305
17.
Writing of a delirious patient
18.
Cretin
19.
Two
20.
Myxoedematous
21.
Cretin excitation
22.
Hebephrenic
381
23.
Catatonic
382
24.
Hebephrenic writing
395
25.
Schizophrenic writing
396
26.
Paranoid praecox writing
397
27.
Drawing by paranoid praecox
399
28.
Letter of schizophrenic patient
401
29.
From
402
30.
Catatonic attitude
334
!^
cretins in profile
368
369
cretin
370
371
a note book of a chronic catatonic
403
xvii
ILLUSTRATIONS
xviii
page
Pig.
31.
Permanent catatonic attitude
404
32.
Stereotyped attitude
405
33a and 33b.
406
Snout cramp
34.
Grimacing catatonic
35.
Manic schizophrenic woman
36.
Chronic catatonic
408
409
women
421
37a.
Manic writing
470
37b.
Manic writing
471
38.
MelanchoHc expression
472
39.
Veragutii's fold of upper lid in depression
473
40.
Normal
473
41.
Writing of depressed patient
42.
Mixed condition
43.
Imbecile somewhat microcephalic
fold
in constant
477
euphoria
480
605
44.
Imbecile laughter
606
45.
Pygrocephalus
607
46.
Microcephalus
608
47.
High grade microcephalic
609
48.
Cerebral infantile paralysis
610
49.
Idiot
612
50.
Idiot
613
51.
Microgeria in imbecile
614
TEXTBOOK OF PSYCHIATRY
CHAPTER
PSYCHOLOGICAL INTRODUCTION
THE PSYCHOLOGICAL PRINCIPLES
The Psyche
The human psyche
is
so largely dependent in all
the cerebral cortex and on this alone that

there.^
But not
all
it
is
its
functions on
said to be located
functions of the cerebral cortex belong to the
complex which we ordinarily
call psychic.^
Thus what has been
called
psychic fluctuations of the vascular tone or of the secretions are
which though depending on the psyche

some manner are not psychic.
Like the reflex mechanism, the purpose of the psyche is to receive
external stimuli and to react to them in a manner beneficial to the
individual or the genus. There are, however, great differences between
the two modes of reaction. The influence exerted upon a reflex through
a stimulus other than the one initiating it (or the initiating and directing group of stimuli), is so limited qualitatively and quantitatively,
that we ordinarily take no account of it. On the other hand, in the
psyche this influence is qualitatively and quantitatively almost unlimcortically directed functions,
in
noteworthy that not only actual stimuli play

but also former stimuli,
especially ''experiences" and "memories"; on the other hand, such
memory effects play a very slight part in the reflexes. In other words,
the reflex always reacts in the same manner to the same stimulus, while
the psyche has infinite possibilities of reaction, which are highly complex and plastic, that is, they differ with the same stimulus according
ited.
It is particularly
an essential part
^Comp.
in determining the reactions,
Naturgeschichte der Seele, Springer, Berlin, 1921.

vertebrates evidently not all psychic functions have gone into
Even in man
the cerebral cortex; that is particularly true of the lower ones.
there is still some connection between basal ganglia and affectivity.
* Contrary
to general assumptions, the line of demarcation between psychic
and non-ps.vchic cortical functions is quite indefinite.
It is certain that
only small parts of the cortical functions are conscious.
(Cf. Section on
"Unconscioua.")
"
In
Bleiiler
many
to the particular circumstances, while those of the reflexes are simple
and very
Thus
stable.
as far as objective conditions are concerned
the difference between reflex and psychic reaction
is
enormous
in de-
An absolute difference is ordinarily

but none in principle.
assumed on the subjective side, whether correctly or incorrectly no one
gree,
can
tell
The assumption
(Pflueger's spinal cord soul!)
psychic functions can become conscious but not
is
that only
reflex:es.
Consciousness
Some authors
consider consciousness as the very essential quality
of psychic processes.
It is
an indefinable something, a quality of the
same, in fact that quality which most clearly differentiates us from
We
can imagine a machine which will perform comwe will never ascribe consciousness to an apparatus constructed by us, that is, we cannot assume that it ''knows"
what it is doing, that it "feels" the influences of its environment,
that it knows the "motives" of the reaction. The same idea is ex-
an automaton.
plicated reactions but
when we inquire whether someone

has consciously or unconsciously arranged his hair.
To compare consciousness with a form which has for its content
pressed by the word "conscious,"
conscious processes is misleading. Nor can one do anything in psychopathology with such a definition as "the sum of all real or simultaneously present ideas" (Herbart), which is about what one would call
We
cannot get along, however, without differand unconscious psychic processes on

the one hand, and between psychic and physical on the other.*
the actual psyche.
entiating between
Wundt
conscious
defines consciousness as the "association of the psychic
structures."
This definition
is
also used elsewhere in the concepts
referring to the "disturbances of consciousness," where
it is
merely a
question of a disturbance in the association of the psychisms.

sciousness in our sense cannot very well be disturbed;
present or absent
On
it
is
Coneither
the other hand, extent and clearness of con-
sciousness are relative terms.
The
extent of consciousness
corre-
sponds to the number of the (actually or possibly) simultaneously
and clearness
of consciousness depends on
concept or on one idea of a
partially forming concept, as well as on the degree of exclusion of
existing conscious ideas,
the
completeness of one
conscious
irrelevant ideas.
The psychism
itself
and not a mere quality or form of
it
is
involved in expressions like "consciousness of time and place" for
which we had better substitute "orientation as to time and place."

*
See pp.
7-8.
The
expression "dual consciousness" for "dual personality"
jut
is
as inappropriate.'^
Furthermore, one
is
may
reflexes
assume consciousness
inclined to
when one observes purposive
This
actions.
is
be purposive; even an automaton
in our sense,
not correct, for even
may
react differently
to different situations, as in the case of automatic scales in the mint.
The
ability
to
remember a
certain experience has often been con-
had been present, and it has

an action performed in a twilight state has been
sidered as a sign that consciousness

also been said that
"without consciousness."
This
is
also wrong.
Likewise one should not identify "conscious" and "voluntary."
The
act of dressing oneself
is usually voluntary, but not conscious,

whereas compulsive actions are conscious, but not voluntary, that is,
they are contrary to our will. And neither of these holds good in
automatic actions like scratching oneself, mimicking motions, etc. and
;
in pathological automatisms.^
Concerning the Theory of Cognition

Consciousness
Two
rences.
is
said to differentiate psychic from physical occur-
fundamentally different
assumed, those that refer to the "inner
series of experiences
life,"
have been
to that which "takes place
merely in time," the conscious or the psychic, and those experiences

which refer to the outer world or to that which has extent, namely, the
physical.
The
relationship between these
Most
ferently conceived.
two forms
suitable for the naive
of experiences
mind
is
is
dif-
the conception
Dualism, which assumes a carrier of consciousness independent of

the body. One sees the body remaining after death, while all psychic
manifestations disappear with the cessation of life. The "soul," used
here according to the earlier views, representing not only the psychic,
but a fusion with the term life, has separated itself from the body.
That it has not simply been resolved into nothingness is sho^Mi by
its reappearance in dreams, in waking hallucinations, and in the
of
illusions of those
can free
itself
who
from
which, regardless of
far
removed from
survived.
And
that the observer's
own
soul
body is shown by his dream experiences, during

time and space, he perceives things which are
his
his motionless body.
^Disturbances of Personality, p. 137.
"The subject of "self-consciousness" uill be discussed at the end of the

chapter on personality, p. 50.
' Ziehen,
Zum gegenwartigen Stand der Erkenntnistheorie Wiesbaden, Bergmann,
1914,
Dualism
is
an
essential constituent of religions
for thousands of years
and
it
has been attacked
by most scimost important fundamental elements, the dream experiences, and the apparitions of spirits, have proven illusory, and what
is more, it has been shown that the psychic functions of man are in
all respects dependent upon the brain.
On the other hand, it is selfevident, even if one does not always bear it in mind, that in reality
the physical world cannot at all be as we perceive and imagine it,
and finally, every certain proof is lacking that iV even exists.
Thus monistic views have been formed regarding the relationship
They can be divided approximately into three
of the two series.
entists.
is
at present
still
rejected
Its
categories:
The
first
which Spinoza is the foremost repwhose two attributes are extenand thought (psychic series). However, from
of these categories, of
resentative, assumes a "substance,"
sion (physical series)
the viewpoint of the cognitive theory,
ness)
ception
From
Substance, physical
faulty.
is
attributes (in
possible only in regard to conscious
a part of these
we form
conclusions
concerning external influences, which

ing of forces
sarily
it is
modern tdrms matter, force and consciouscannot be placed side by side in this manner. For direct per-
and psychic
we
we
(psychic)
processes.
(with some probability)
call forces.
From
the group-
construct the idea of matter, which needs not neces-
have a corresponding
culty in this theory:
It
reality.
But
there
is
still
another
diffi-
has to conceive everything as conscious
whereas we observe consciousness only in beings similar to us and

cannot conceive of an elementary consciousness without content, which
To be sure, nowhere in
is really connected with a nervous center.
evolution do we see a point where consciousness may be said to have
appeared in man? in the amoeba? or in the atom? ^ And the ubiquity
of consciousness is so readily accepted just because one cannot conceive of something principally new suddenly appearing in evolution.
There is really no basis whatsoever for the assumption that the psychic
and the physical are so very different. We neither know v>'hat the
psychic nor what the physical processes are, and consequently nothing
about their relationship or difference. To be sure, for the being endowed with feeling, consciousness is something very special and the
only thing of importance. It is a matter of entire indifference to
us whether the world exists, the only thing of importance being whether
that which is conscious, our ego, is happy or unhappy.
The second form of monism starts from the idea that all proofs
for the existence of an external world are false conclusions, and
Cf. also Loeb's tropisms.
that consequently the physical world exists only in our ideas

or, in so far as
we
conceive
it
("esse
= percipi").
Even
could be carried through with logical consistency,
it
if
Idealism;
this
view
would not be
more general acceptance. For in the first place,

deny the outer world simply because it is imposto prove its existence.
Anyhow one is always forced to act
able to acquire a
is
it
sible
as
incorrect to
it
if
The philosopher who claims
exists.
to believe in the ex-
would have no reason for disseminating his

views if his pupils were only creations of his own imagination. No
matter how certain it were that a rock in the road had existence
only in my imagination, I would still have to go out of its way if
istence only
of
ideas
wished to avoid something unpleasant. If I wish to get rid of

is nothing for me to do except to eat,
whether food has reality or not.
Practically therefore, idealism
will lead to an impossibility.
Theoretically, however, it leads to
a conclusion which no one likes to accept, to Solipsism. For our fellow
I
the feeling of hunger, there
beings are part only

exists only in
am
my
of
the outer world, and
ideas, then there are
not only the whole world but also the only
conclusion
is
unavoidable.
if
the
outer world
no other beings beside myself.
The attempt
human
being.
This
to escape solipsism through
is a sophism.
Even if an absowere to imagine the world, it would not be my world, the
world which I imagine, not to mention the fact that such an absolute
ego cannot be imagined and that the whole assumption is entirely
without foundation.
Much more common than the idealistic monism is the materialistic
monism, the materialistic theory of cognition. It starts from the
fact that we always see psychic functions bound to matter, in particular to nervous centres, that they change with this matter, and
that the laws of the central nervous processes, so far as they come
the assumption of an absolute ego

lute ego
into
consideration,
are also the psychic
cludes that the psyche

is
laws.
From
is a function of the brain.
this
it
At present
conthis
the only view which can be carried out theoretically and prac-
tically
without contradictions, in the form of the so-called hypothesis

which assumes that central nervous functions are ''seen
of identity,
from within" and become "conscious" if

This view is almost the only
and in particular psychiatry, takes into
even accepted by those who theoretically
tionships.
course, this theory, too,
is
they occur in definite rela-
one which modern science,

consideration, in fact
it
is
advance another view. Of

impossible to prove, but the hypothesis that
the psychic functions are brain functions has a better foundation
than most assumptions which are accepted as self-evident in the
sci-
6
ences.
But
it is
by no means necessary as a basis for any mental
we are not concerned with

studying the psychic functions in connection with the brain. This
theory, too, is being zealously attacked, primarily on religious grounds.
science, including psychiatry, in so far as
Perhaps with the exception of

has been altogether duahstic.
its
But
earlier periods Christian
thought
the essential content of the Chris-
tian doctrine could be just as easily reconciled with materialism as
with dualism; as a matter of fact the more favored idealism would

encounter more
diflBculties.
Our confession
trine of the resurrection of the body.

is
of faith contains the doc-
If the theory of
correct, then with the resurrection of the
materialism
body the soul must
eo ipso be resurrected at the final judgment.
also
Difficulties arise only
in connection with secondary doctrines like those of purgatory, the
existence of bodiless souls, etc.
Moreover, partly as a result of un-
clear thinking
and partly from rancor, the materialism
tive theory
usually identified with ethical materialism, which, re-
is
of the cogni-
gardless of morality and consideration for other people, egoistically
merely for ''material" goods, by which is meant money, posigood food, drink, and women. But the materialism of the
cognitive theory has nothing in common with such ideas except its
name. One may accept any view of the cognitive theory and still
be either good or bad. But on the basis of the materialistic view,
one can deduct a utilitarian ethics by strict logical reasoning, which
is superior to all other, which professes to have originated from
revelation or the categorical imperative, or from other incomprehensible eternal laws, and which at the same time can be fashioned by
every one according to his own desire.
strives
tion,
Many modern
scientists hold to the theory of psycho-physical

This theory starts from the idea that both series are
so heterogeneous in principle that one cannot act upon the other.
To explain this relationship nevertheless, Ceulincex assumed that if
the psyche wished to perform a physical movement, it was accom-
parallelism.
by an interposition of divine power, and that every

time a stimulus strikes the sensory organs the corresponding sensation is produced in the psyche (Occasionalism)
Leibniz, as is well
plished in each case
known, held the view that these two series (which were complicated
by his theory of monads) were so arranged by preestablished harmony,
since the beginning of creation, that they run an entirely uniform
course like two ideal watches, so that every act of the will has a corresponding equivalent movement, and every stimulus on the senses a
corresponding equivalent sensation.
ical parallelism contains
But
one great error:
this theory of
For
if
psycho-phys-
the physical series
cannot react upon the psychic then it can reveal neither its existence
nor its nature to our psyche. It is then quite useless to assume that
the outer world exists, at any rate it surely does not exist as we
think we perceive it, and then there is no perception, but only
hallucination.
still have some meaning within
inasmuch as the conscious side of
the substance has knowledge of the physical part which is really sub-
The concept
of parallelism could
monistic conceptions
(Spinoza)
stantially identical with
it.
Many
view psycho-physical parallelism simply as a confirmation

of our ignorance regarding the relationship which undeniably exists
between the psychic and physical sometimes, and this is particularly
true of experimental psychology, with the secondary thought that
we must examine what processes correspond to each other in the two
This view is also possible, but the name, which is otherwise
series.
Some clinicians,
used quite differently, easily leads to confusion.
without realizing it, get still further away from the original idea,
when, for instance, they consider hysteria as a disturbance of the
psycho-physical parallelism, because the psychic reaction to the exHere, of course, the
periences becomes too strong or too weak.
physical "parallel processes" in the brain certainly correspond to the
psychic phenomena.
In this case therefore the expression
is
highly
misleading.
Wundt
has assumed a peculiar view concerning the psycho-physical

Like many others, he does not only limit the psychic
parallellism.
but also makes the psychic go beyond

by assuming that certain synthetic functions of our
mind take place in the brain without parallel processes. This is an
inconsistency which is not only impossible to prove, but which, among
other things, is opposed by the fact that we have an analogous
series to the brain functions,
the physical,
synthesis
in
the physical
sphere.
Many
reflex
processes
are
the
Likeresult of a whole group of stimuli, which act only as a unit.

the
to
not
equal
machine
is
complicated
wise the performance of a
simple
sum
of the effect of the individual constituents, at least
if
sum
and constituents have the same meaning as in Wundt's synthesis.

In the dispute between idealism and materialism one senses an
uncertainty regarding the value of reality of these two series. But
if one only follows up the thought, this question can be very' easily
Only its own psychic processes have absolute reality for
settled.
every psyche
(it
light or the rose,
the pain.
This
is
not in their "contents,"
but not the

is
light,
so certain that
the rose)
it
i.e.
we
perceive the
If I feel a pain. I feel
can only be expressed tauto-
8
logically.
Since there are also hallucinated pains, this pain need not
necessarily have a corresponding process in the aching part of the
But
a skeptic does not wish to believe that I feel pain, it

me to prove it. The psychic series therefore
has absolute, or better, indisputable reality, but only for the psyche
This reality is therefore subjective. But for the exin question.
body.
will
if
be impossible for
That the table

istence of the external world there are no proofs.
which we see has existence is only an assumption, even if of pracBut if I once take for granted the existence of the
and that of other people, and the external world, then this
table can be shown to these other people. Like myself they can perThe reality of the physical world is
ceive it with their senses.
therefore uncertain and relative, that is, it is not possible to prove it,
but on the other hand, it is objectively demonstrable.^
tical necessity.
table,
The Unconscious
We
perform
many
trivial actions,
doing a button, shaking
off
an
insect,
such as stroking our hair, un-
without knowing
it.
To
a large
extent these are neither reflexes, nor subcortical actions, but actions
which are performed by the cerebral cortex and are really analogous
to conscious functions. Such acts also presuppose memories. "Automatic" actions in hypnotic experiments and in pathological states
can be just as complex in thought and motility as any conscious act.
The hand may write and the mouth speak without the person having the slightest feeling that these actions originate from his own
In association experiments the train of thought often goes
psyche.
by way of ideas which are not conscious. The answer to "black"
may be "star" without there being any conscious thought of "night"
which forms the connecting link. As a matter of fact, the constellations which direct our thought are only conscious to a small
more detailed analysis shows; we often make slips in

speaking which are based on unconscious thoughts accompanying
Only a small part of what our senses perceive comes into conit.
degree, as a
sciousness, but the rest surely
not lost to our psyche. Thus, in

ourselves by perceptions which do
is
walking we constantly guide

Many perceptions come into consciousness
not become conscious.
only later on. Thus, when one is very busy, he may not hear the
striking of a clock, but when the attention is relaxed it is so well
Psychoanalysts
also differentiate a "psychic reality." This term is misleading, for they refer to ideas which are created by inner needs and are accepted
and used as if they corresponded to what we call reality (the dead child continues to live, the fire of love really bums, or the mediaeval personal God).
remembered that one can still count the strokes to about five. Other'
things become conscious in dreams and in the hypnotic state.
Unconsciously a number of complex conclusions are drawn; the so-called
intuition is partly based upon this.
We may meet a person and
an acquaintance, but we arc surprised that we
we ordinarily have for him,
ascertain
shortly
afterwards
that
it is not at all the expected
only to
mistaken
Here,
besides
the
conscious
identification, there
person.
unconscious
correct
one.
The physician autowas also present an
feel certain
that he
is
do not evince the same feelings that
matically puts the correct key into the

hospital; but as soon as he wishes to do
many
it
different locks of his
consciously there are
diffi-
Signs of an affect are frequently seen in normal persons, and
culties.
daily in pathological conditions, of which the person affected has no
knowledge.
we
And
if
we
and our fellowmen,

important decisions the decisive
post hypnotic suggestions we can
carefully observe ourselves
will frequently find that just in
elements
are unconscious.
By
also experimentally provoke actions, the motives of which remain

hidden from the person performing them. Hysterical patients may
respond to perceptions of which they do not become conscious.
Everything that occurs in our consciousness can therefore also take

In this sense there are unconscious psychic procThey have absolutely the same value as the conscious psyesses.
place unconsciously.
chisms, as links in the causal chain of our thought and action.
It
them among psychic processes,

not only because they have the same value as conscious ones,
is
therefore
necessary
to
include
lacking only conscious quality, but principally, because psychology',
and particularly psychopathology, can only be an explanatorj- science

if such important causes
of the phenomena are also taken into
consideration.
The unconscious functions are best designated as "the unconscious.'^

But in the above described psychisms this does not imply a definitely
limited class of functions
the real facts, however, are that potentially
any function whatsoever can manifest

unconsciously.
ing;
itself
consciously as well as
Neither are there special laws for unconscious think-
there are merely relative differences in the frequency of the
different forms of association.
To
be sure one
may
place into a special unconscious the main-
also hidden from our

This includes not only the congenital impulses but
also the unconsciously acquired paths of the strivings.^"
Such impulses are particularly striking when they are contrar\'
springs of our strivings
and actions which are
introspection.
"Comp. The
Collective Unconscious, p. 43.
10
to the conscious strivings through which they attain the

genic meaning as the repressed tendencies.
The unconscious
also contains the paths
same patho-
upon which the psyche
influences our secretions, the cardiac vasomotor and other activities,

even if exceptionally they sometimes become conscious and are accessible to the will in the
same sense
as
we move our
limbs consciously
*
and unconsciously.
Many
among
authors, notably Freud,
Morton Prince and
the unconscious functions also the "latent
("Engrams")
."
described.
pictures"
principally altogether different from
But these are
what we have here
others, include
memory
Latent memory pictures, in so far as
are concerned here, are dispositions without actual functions, but
we
our unconscious psychisms
are
actual
functions
just
as
valid
as
We
can include among the psychic only

or may become conscious under
conscious,
which
are
those functions
this
reason also that we do not
for
It
is
different circumstances.
those that are conscious.
designate the action of a machine as unconscious, although
it
has no
consciousness.
the relationship between conscious and unconscious it is best to assume that a function becomes conscious only
when it is in direct associative connection with the ego complex; if
To understand
not the case, then it follows an unconscious course. This assumption fits in well with all observations; nor does it run counter
this
is
to the fact that there are
all
the transitions from consciousness to
semiconsciousness and to the unconscious.
The
greater the
number
of associative connections at a given moment between the ego and

the psychism (idea, thought, action) the more conscious and at the
same time the
What we
scious."
it
clearer is the latter.
"unconscious"
call
is
designated by some as "subcon-
Philosophers define the term unconscious quite differently;
also varies in
meaning
in different authors.
THE INDIVIDUAL PSYCHIC FUNCTIONS

While taking a walk I stop and take a rest. Then I see a well
and I go over and drink some water. What has taken place in
my
psyche?
which strike my retina cause sensations, that is,

Some
I see certain colors and lights in definite spatial arrangement.
corresponding
combefore
in
a
have
already
seen
I
of these groups
order
they
acquire
certain
higher
a
related
units
of
a
bination. As
The
light rays
^'See chapter on
Memory.
11
independence and are rendered prominent as objects (trees, houses,

and from former experiences I know that there is something
in the well which I call water which can quench my thirst. That is,
the "concept" of the well with all its essential elements has been
wells),
awakened in me, while the momentary experience has only given me a

number of color spots. This awakening of former similar sensory
complexes by the new sensation is a perception. I have a sensation
of certain light arrangements but I perceive certain objects, I have a
sensation of sounds but I perceive a speech or the bubbling of the

spring, I
As
have a sensation of an odor, but I perceive the scent of violets.

The
thirsty, I have an "impulse" to drink from the well.
am
and the impulse to drink are evidently also responsible for the
fact that the well was rendered more prominent than the numerous
other objects striking the eye. But I have not only the impulse to
It also occurs
drink, but I would also like to rest a little longer.
to me that the water might be infected, that I will get a better drink
Opposed to this is the thought that I don't
in the next inn, etc.
know how long I will have to walk until I get there. The source
region of the well does not look suspicious; the impulse to quench
my thirst therefore becomes the stronger of the two. I decide to
take a drink here, but to do it only after I have rested a little longer
and am ready to continue my walk. The different impulses with
the ideas accompanying them have provoked a play of thought, a
reflection, which finally had as its resultant the decision which at the
thirst
proper time led to action.
We
have here as in other nervous functions a centripetal ^- reception of stimuli or of material, which we divide into sensations and
perceptions, and then an elaboration and a partial transformation
of the material into centrifugal functions
(decision, actions).
It is
perhaps only to a very slight degree, if at all, that there is an

elaboration sufficient to lead the incoming psychokym ^^ by preformed
mechanisms into centrifugal paths, a process surely not quite corHere the elaboration occurs in such
rectly assumed in the reflexes.
" I do not speak of "psychopetal" functions, because although there is a given
"direction" yet both incoming and outgoing functions, as far as psychology' is
concerned, take place within the psyche. It is well, however, to understand by
"center" and "direction" only symbols and as little as possible real space. On
the other hand, the paths between sense organ and brain, and between brain
and muscle, of course, must be understood in spatial sense.
^^
"Psychokym" is used to designate psychic processes conceived phj'siologically, namely, that which is conceived analogous to a form of energj-, that
something which flows through the central nen-ous sj'stem and which is at the
basis of psychic processes. "Neurokym" is used to designate the nervous processes in general.
12
a
way
that even
new
processes are created.
The
perceptions arouse
ideas which combine with the other according to definite norms (Thinking) and only the resultant of these processes as a whole determines
the centrifugal action.
we have also observed the

qualities are peculiar to
which
as
effects of two other
views always accompany
other
all psychic functions, or according to
In
the process of percepand
afjectivity.
them, namely, memory
which somehow reproexperiences
former
of
tion we noticed residua
And as a matter of
association.
in
and
in
content
duce the latter
permanent
traces ("Engrams")
behind
fact, everything psychic leaves
memories, routine
of
form
in
the
themselves
which later manifest
("ekphorized")
again, and
revived
being
like,
by
actions and the
Besides these intellectual processes,
functions,
either reproduce the
same experience, such as practiced movements

it merely in a similar manner in the
or hallucinations, or represent
form
an image after perception.
of
The
sight of the well aroused pleasant feelings, likewise the quench-
ing of the thirst; the idea of the possibility of infection aroused un-
Thus every psychic
pleasant ones.
tone (affectivity),
which
is
at the
act is "accompanied by a feeling

same time the decisive element in
decisions.
have also seen that any psychic process arouses memory

images of former experiences, that through simultaneous occurrence,
these are combined in such a manner that they again are ekphorized
together and as a whole, or as a unit, that different ideas, feelings
and strivings, influence, inhibit, or enhance each other, and finally
are combined into one resultant. These different kinds of combination
among individual psychisms we call association.
We
a)
The Centripetal Functions
The sensations are the most elementary psychic

we can observe, nevertheless they are already quite com-
Sensations.
process which
Every sensation of light possesses quality in two direcThere is the quality contrasted with sensations of other senses
not sound), and quality within the same sensory region (color).
plicated.
tions.
(light,
It further includes quantity, as the intensity of the light, the satura-
tion (mixture of the color with white)

as well as size
and the
local
mark
of direction,
and shape.
Perceptions. Perceptions arise from the fact that sensations, or

groups of sensations, ekphorize memory pictures of former groups of
This produces in us a complex of memories
sensations within us.
of sensations, the elements of which, by virtue of their simultaneous
13
occurrence in former experiences, have a particularly fine coherence
and are differentiated from other groups of sensations.'* In perceptherefore we have three processes: sensation, memory, and
tion
The
association.
hitter should be
taken
in
the sense that the sensa-
bubbling noise, has ekphorized a
tion, as of certain color spots, or the
concept, like in the case of the well, and in the sense, that the in-
dividual sensory engrams, contained in the concept of the well, have

been combined with each other before and now appear simultaneously
as a unit.
The
act of perception
is
not sharply defined.
may
statue
be
perceived merely as a statue, or as a Statue of Shakespeare, or as a

A word may be perceived as a word,
certain statue of Shakespeare.
or as
and
an English word, and
all
of a
relations
its
to
finally
word with
as
situation.
definite
This
its
meaning
identification
homogeneous group of sensations with previously acquired anal-
ogous
complexes,
with
together
nate as "apperception."
It
connections,
their
all
also
we
desig-
embraces the narrower term of
perception.
Concepts and Ideas
b)
Let us suppose that we see ripe strawberries
Concepts.
first
for the
number of them at the same time, or several at

With our sight we have sensations of certain shades
shapes and certain proportions of size. Touch and
time, either a
different times.
of color, certain
senses
kinaesthetic
give
us sensations
of
roughness, hardness,
and
weight, while the senses of taste and smell give us the taste and
odor of the
ences.
The
fruit.
Among
the berries there are similarities and differ-
dissimilar sensations occur only in seeing one or a few
berries, while those that are similar
appear again and again.
are combined in the psyche into a firm complex, so that

less
These
more
or
vivid memory pictures of the whole concept appear whenever a
few sensations somewhat characteristic of the strawberry are experienced. This whole structure of memories of constantly repeated
sensations produced in us by the strawberries is the concept of the
strawberry
or the "strawberry" as a genus.
plemented by further experiences,

strawberry grows on a plant, that
botanical relationships.
This can now be sup-
for instance,
it
is
fruit,
by seeing that the

that
it
has certain
The process of concept formation
is
there-
type photography.
speak of the "concept" of an individual thing or person, an individual strawberry, an individual person seen at different
fore similar to that of
We
also
"See below "Concepts."
14
times, at different distances
The
and perspectives, and from
residua of the repeated sensations become
unified picture containing only that which
is
different sides.
elaborated
common
to
into
and
all,
this
forms the concept of this certain thing, this certain person.

On the other hand, the concept formation can also become complex, if
more and more individual experiences
sides the strawberry
we
see
many
participate in
it.
Be-
other things which grow on plants
and are capable, with suitable treatment, to produce new

Ever>'thing that these things have in
common
plants.
again forms a some-
firmer engram structure, that of the concept "fruit."

Concepts of activity or quality are, of course, formed in the same
manner. "To go" is composed of similarities in observing many
processes together; "blue" emphazises a certain form of visual sensa-
what
The highest abstract concepts

manner without anything new in principle
tions which are frequently repeated.
are also formed in this
One person rescues his enemy, another becomes a martyr

good cause, and a third does not steal in spite of great temptaAll these occurrences have something in common which lies
being added.
for a
tion.
in our feeling tone, as well as in the significance that these acts or

omissions have for the community. What they have in common, if
rendered prominent, gives us the concept of "virtue." In ourselves
and
in the
external world
follow upon certain others.
we observe that certain events always

is common to them we call "cause"
What
and "effect" or in connection with the other relations of the things

and events among themselves, "causal relationship."
A very important task which must partly precede and partly accompany concept formation is the selection of the material. We do
not form a picture of a tree with the different perspectives of its
location and the other simultaneous experiences which were present
when we saw it, nor do we see it with all its different fronts, but
only the tree in particular in an aspect which is especially suitable
to our view. Everything else that was part of the experience in forming the concept tree
is
eliminated in the concept-formation.
ticular associations which were necessarily formed

of
the
experience,
and the existence
occasional tests, are inhibited.
This
is
of
The par-
by the coincidence
which can be shown by
only a slight indication of the
enormous work our psyche must perform
in putting together
and sep-
arating the individual engrams, even in the simplest functions.
a rule, only the positive process, the putting together,

inhibition,
or
the elimination,
ignored.^^
''See Oligophrenia.
is
is
noticed.
As
The
underestimated or even entirely
PSYCHOLOGTCAT. INTRODUCTION
15
Simultaneously with the perception of a thing or a process we

very frequently also hear the word which designates the thing. This,
then, must also be combined with the concept in a manner similar
to its individual components, though the association is distinctly not
In every person who knows the fruit, the word "strawas close.
berry" also evokes the concept of the strawberry. Language, however,
of
is
greater importance for concept formation, inasmuch
still
as with the help of the
word
of concepts once formed.
it
The
transmits to others the definitions
individual
may
easily
come to form
the concept "tree," but without the cooperation of former generations

it
would be somewhat more
form that of "plant."
difficult to
The
The
language groups therefore have different concepts.
French "manger''' embraces the German "essen" and "fressen." The
English "fish" is a much wider concept than the German "Fisch."
The German "Brunnen" resolves itself in French into "fontaine" and
then "puits." However, the importance of language for concept fordifferent
mation has also been overestimated. The child was thought to be

unable to differentiate men from each other as long as it called
each one "papa," but it can be easily shown that this is usually
wrong. Likewise, the extent of a person's vocabulary was thought
to indicate the number of his concepts and consequently the concepts of an English laborer of the lowest grade were supposed to
number only a few hundred.
But any
express concepts, and any dog have
deaf mutes form not only
many
It
was
if
he
is
only able to
that.
Untrained
concrete but also abstract concepts.
There are also people who are as rich

(higher forms of dementia), or poor
cepts.
idiot,
many more than

in
in
words as poor in concepts

words and rich in con-
also asserted that one can only think in words.
The
actual facts are that in ordinary thought one uses abbreviated symbols instead of concepts. Words are frequently used as such symbols,
but there are also very different kinds of symbols.
Different in-
numbers some use the

word, others the figure, still others conceive them in form of a
colored spot or in regard to their mere position in a numerically
dividuals prefer
different
schematized scale,
ones.
Thus
for
etc.
Concepts are not fixed; they are easily supplemented or transformed by new experiences. The concept "God" is not only different in the savage and the civilized person, but also in the child and
the adult, the educated and the uneducated. The concept of electricity is changed when one begins to study it through higher
mathematics,
etc.
In every concept formation, even the simplest,
we
see the activity
16
of the process of abstraction, that
is,
memory
aside,
pictures
are
pushed
certain classes of sensations
and
others
are
and
rendered
prominent.
Abstraction does not represent a special or even "higher" faculty,
but
it is
inherent in the nature of the nervous centre and hence be-
longs to psychic activity.
no
For
in
both of these activities there are
identical experiences, but only similar ones.
One must,
therefore,
not take too literally the statement in physiology that the same
reactions follow the
"same"
respond to similar processes
stimuli.
in the
In reality, the nervous centres
same manner; unessential
ences do not noticeably influence the reaction, that
the reaction
makes use
is,
of the process of abstraction.
differ-
the centre or
If
memory
images with associatively connected processes, such as thoughts or

actions, take the place of preformed or reflex mechanisms, then the
abstraction from these differences becomes more diversified but not
This is already the case in perception. The
different in principle.
infant sees its mother at different distances, in different projections and different clothes, and yet recognizes her as the same being,
by abstracting from these differences. It is also the same kind of
abstraction as in concept formation, when in his general perception
Although the
the child raises its mother from the environment.
infant never sees the mother alone, he always observes her together
with the room, yet he is able to abstract and emphasize the mother
That this is an important function can be seen in those
concept.
Children frequently behave very differently
cases where it fails.
toward the same persons in a different environment. In the case
of cats, one regularly observes that- they act as strangers outside of
the house to persons of their home.
That the abstraction does not merely take away from a number of
engram groups some components and combines the rest into one
sum but forms thereby a new psychic structure is self evident

and is in no way peculiar to the psyche. Thus a clock work is
as little the mere sum of its little wheels as a human being
sum of his cells and molecules ("mere sum" is precisely
is the
an
abstraction,
which
exists
as
little
in
reality
as
the
"sum"
two).
Everything that has been perceived by the senses, such as

and processes, is imagined as an ekphorized memory
picture.
In addition, the ideas contain also psychic structures which
have never been perceived by the senses. Among these we have all
possible combinations of sensory images, phantasies, wishes and possibilities, as well as the abstractions and their combinations with
Ideas.
qualities, things
ideas; indeed,
it
comprises every tiling in so far as
it
17
can become actual
in time by ekphorization and not by sense perception.^'^
The
c)
Combinations of Psychisms
We
Thought.
Associations.
We
Call Associations.
may also combine with

in
cannot
really
sharply
separated
from one another.
be
each other and
(1) Two synchronous functions may modify, enhance or inhibit
see tliem
each other.
The perception
our steps.
direct
Two
different
moral
forms; they
of the road
as
inhibits
reflection
well
a
as the obstacles
reproachable
act.
motives acting in the same direction promote the reaction.
may
Physical functions such as reflexes

directions
by accidental secondary
be influenced in
all
three
stimuli.
Simultaneous or successive experiences are connected with
(2)
each other, in so far as they have a tendency to appear together in
memory, or
in so far as the revival of
the others.
We may
many
memory or
with
add to
one of these experiences recalls
this the fact that our ideas
and concepts,
components, simultaneously appear in

thought, or follow in immediate succession. If we hear
the word rose or think of a rose, we also have a more or less clear
or
all
of
their
idea of the individual psychisms red, beautiful, fragrant, all of which
form the general concept of
One
(3)
idea
in turn suggests a verse

set
flower.
generates another.
we
We
think of roses, and this
learned about tulips and carnations.
We
out to write our name, whereupon follow the different move-
accustomed and successive order. This also explains why

is performed after a given signal.
In the psychological selection experiment we perform the required reactions, thus
to the bell signal we react with the right hand, to the optic signal
with the left. This function already resembles much the reflex process
which is also no simple transition of the sensory stimuli to the motor
apparatus, but a setting in motion, or generating the function of a
performed mechanism.
In
(4) The forms mentioned may occur in any combination.
ments
in the
a certain action
the sense of the progressive association (Form 3), the perception of

an apple generates in the child the impulse to eat it, but also the
memory
picture of the thrashing formerly provoked
and these later

function (Form
inhibit the
"For
by
stealing
it,
impulse as a simultaneous
1).
we do not think
phenomena:
Ordinarily, however,
of the following
acquisition
of all these
forms but only
the differences between ideas and perceptions, see p. 66.
18
Through temporal connections in experience, associations are

in the corresponding engrams (associations are formed).
These connections remain in existence with the engrams of the
(1)
created
(2)
experiences (engrams are associated).
(3)
the engrams of
memory images which
connected at
origin or
its
which
(6)
A new
event
may
ekphorize
have somehow become
(a)
refer to the
same experiences,
In the same manner a

whole idea is likewise associated to a former one. In the same
manner as in simple concepts whole ideas form associations among
or which
refer to similar experiences.
(c)
one another.
Association
But
another.
is
a state so far as
is
it
engrams are connected with one
also a process, through the connection of simul-
taneous experiences, through the generation of one idea by another,

as in thought, and above all through the influence of one psychism
upon another.
Associations in the sense of permanent connections originate when
or in immediate suc-
several psychisms take place simultaneously

cession, as
lightning
can be seen in the act of perceiving the association of

We must assume that everything simultane-
and thunder.
ous and successive
is
connected in the psyche, not only
because
such functions very frequently influence each other, but because they
appear connected in memory, as shown by every day experiments.
If something has eluded us, we can frequently recall it, by going
to the place where the thought or
even
if
there
is
no
logical connection
And
gotten content of the ideas.
us evince a certain selection.
experience took place,
indeed,
between the place and the
for-
yet the associations accessible to
we
Primarily
recall only experiences
which in themselves or through their connections have a certain importance for us.
In reference to the capacity to ekphorize there are
thus important differences in the associations, and perhaps also in

the elaboration of
memory
images.
Unfortunately we cannot enter
here into the investigation of these differences; at any rate affective
mechanisms cooperate
in
them.
Moreover, as seen in every other function, there is also someIf we have once
thing negative in the formation of associations.
been accustomed to write a letter of the alphabet in a certain manner, there will be a
if
we
tendency always to write
did not write for a long time.
a different form
But
of writing, then there
it
the
same way, even
we have
difficulty
later acquired
in reproducing
we think of it in due time. The present

not make psychological thinking difficult because
the earlier ones, even
medical training does
is
if
if
19
but mainly because it forms associations in other directions and thereby virtually inhibits psychological thinking.
it
ignores
it,
we consider the associations as a process of memory, we see

that what has been experienced simultaneously or in immediate sucIf
cession
is
ekphorized with relative frequency.
dent reasons, this
is
Furthermore, for evi-
also true of similar and analogous experiences.^^
The child having burned itself by a candle, is afraid of all fires.

Most associations, particularly those obtained by simultaneousness,
may
take either the course a
or b
a.
In related individual
experiences, as in the details of a lawsuit, direction plays no part
whatever, as a single component associates the main concept, which

connects them all and from it other details can result in any series
of succession.
But under
certain conditions direction
is
not a matter of indiffer-
This is particularly true of associations which are important

No matter how fluently we can
only as they follow each other.
recite the alphabet or a verse, to say it in reverse order can at first
be done only with difficulty. Many associations of motion we can
never reverse. For even if we are able to draw a letter, by starting from the front or back, we have two different motions in which
the muscles do not simply contract in reverse order. But even asence.
sociations formed
by simultaneousness may obtain a one sided
Most people who can read
tion through practice.
direc-
the printed Gothic
have not necessarily the capacity to form an image of them

by hearing them. For reasons easily understood, the direction from
the special to the general has a relative preference over, and against
letters
the reverse.
designated by
call forth
A name
it,
very easily arouses the idea of the person

it frequently happens that the idea does not
The latter element is of importance in patho-
while
the name.
logical disturbances of
memory.
Logical thinking is at first a repetition, an ekphoria of associative

connections, that were once experienced, or of similar or analogous
connections.
Every time we dig around a

is
tree
we
see the roots.
An
association
therefore formed between the idea of the tree and the root.
and the concept root comes into consideration,

associated with the tree, and what is more, it has an added
see
a tree
ing of belonging together.
If
it
we
is
feel-
In the subsequent abstracted laws of
" Similar or analogous experiences have in common partial psychisms. Furthermore, the sensibility of the psyche and possibly of the central ner\-ous system
for differences is limited. Whatever has differences below a certain limit appears
and acts as being identical.
20
logic
we
express
therefore
it
it
as follows:
has roots.
when the
circumstances,
made
in
tree has roots; this is a tree,

in this
way
in exceptional
correctness of the inference
as in "proving" something.
daily
Every
But we only think
thought and
The
millions
is
questioned,
of inferences,
action, are accomplished in a
which are
much
simpler
If one wishes to percuss a person's heart, one does not say:
way.
Every man's heart is on the left side; this is a man, therefore his
heart is on the left side, but one simply associates the customary
place with the idea, to percuss the patient's heart.
Conclusions, therefore, like thought in general, are repetitions of
identical or analogous associations as
One
we
see
them
in
life.
can prove the Pythagorean proposition through four experi-
ences which every person has gone through; from two special experiences (hypothetical lines
drawn
for this purpose)
and from nine
analogous associations, wherein, however, generally existing concepts

such as triangle, right angle, parallels, and multiplication are assumed,
and hence not enumerated.

Causal thinking
is
only an analogy of the regular sequence of two
ordinary events, or of the general sequence of two unusual events.

When it gets warm, the snow melts. An otherwise incurable discured as a result of a new remedy .^^ Of course, the terms
Thus,
"regular sequence" and "unusual event" are very indefinite.
ease
is
for the savage,
many
things are propter hoc which for us are only
Moreover, it must be determined through further experiwhether one event depends directly upon the other, or whether
both can be traced back to the same cause. The rotation of the earth
is the common cause of both day and night, although for children
and in myths, day arises from the night. A falling barometer and
rain have a common cause. Nevertheless we frequently see a desire
But
to smash the falling barometer in order to force good weather.
experiences.
ourselves
contain
also
inner
We
are
very
causal concepts
often a link in the causal chain. Through our own actions we can
We even permit our actions to
set up causes and therefore effects.
considerations.
We see causes outside of us and
these
influenced
by
be
relationships
can only be differtwo
But
these
within
us.
motives
they
are
which
seen, and possibly
viewpoint
from
the
by
entiated
through the greater complication of the apparent motives as compared
with the apparent causes.
post hoc.
ence,
a matter of fact no occurrence has only o?!e cause. The main difficulty
investigation lies precisely in the manifold preconceptions connected
with every single occurrence. However, in psj-chological reflection it is not
necessary to solve the causal concept in the sum of conditions, as useful as it
would be in medicine to apply it \vith greater clearness than is usually the case.
"As
in causal
Many
21
persons have recently attached great importance to the dif-
ferentiation
between "causal" and "final" thinking.
difference as regards logical
forms.
There
is
no
In final thinking determinants
referring to the future are taken into consideration, as in the case

of
calculating in advance
an eclipse of the sun.
But
there
is
certain difference in the goal of thinking; the final operation deter-
mines our action, while in causal thinking the explanation obtained

To be sure, the final function is the original and
satisfies our need.
usual one. The causal function acquires greater importance only in
the civilized person,
who
satisfies his
growing need for theoretical ex-
planation and who, at the same time, has learned to value the great
advantage offered him by a causal understanding of the associations

of future achievements.
Judgment consists
"Snow is
experience.
white,"
"Kant was
and indirect experiences.

word "judgment" signifies two
sions of direct
that the
in a repetition of associations acquired
a great
But
it is
things.
In
important to note
logic,
psychiatry and jurisprudence of the
in
mean
the ability to form judgments, that
is,
correct conclusions from the material acquired
judgment
is
we
capacity to judge, we
the capacity to draw
"the form in which cognitions are thought and expressed."
speak
through
man," are expres-
But
if
by experience.
In tracing back the individual thought processes to external associations we have, of course, not completely explained "thought."
When the concept "tree" is awakened in us, we do not always associ-
We only do this when this direction is deate its roots with it.
termined by a certain constellation, as in observing that the wind may
uproot the tree, or by the trend of thought, as when we think about
the nutrition of the tree. For every single idea has countless others
which are associatively connected with it. Which of these paths is
followed in a concrete case depends upon broader determinants, among
which the trend of thought and the constellation are most important.
The aim of thought is not something simple but a whole hierarchy
If I wish to write now
of a trend of ideas systematically arranged.
about associations, I must constantly have this aim before me more
or less consciously, but besides this I must also view the plan as a
whole, as far as I have worked it out, the basic thought of a chapter
and of a sentence, what I have said before, etc.
Even in such mental trends which are seemingly xevy much con-
momentary and general constellation plays a noticeable

was momentary constellation which suggested to me the
example just used in illustration. The course of ideas is not only
determined by immediate, but also by former experiences. The con-
nected, the
part.
It
22
becomes an essential factor in loose or aimless thinkwho is hungry, or vice versa one whose stomach is
overfilled, starting from any idea at all, is much more likely to hit
upon an association or an idea concerning food (dream!). A person
who is just coming from a lecture on chemistry and hears of "water"
will not easily think of water in connection with scenery or with
commercial uses.
Besides the positive effect, mental trends and constellations have
also a pronounced negative effect.
Every psychic process like every
other central nervous process, not only promotes the minor selection
stellation also
ing.
person
of like-minded functions, but
other
psychisms.
it
also inhibits the infinite
The development
of
thinking
is
number
therefore
of
also
which must not

only learn to contract the necessary muscles in proper sequence,
in this 'respect entirely parallel to that of motility,
but must also learn not to put tension in

If
we
all
the others.
from ideas of a
by instructing a test person to repeat as quickly as
the first word flashing through his mind when a word is called
free the associations
as far as possible
special trend
possible
out to him,
we then
find that the simple associations of experience
and constellation come to the surface very clearly. We thus find

associations of spatial and temporal contiguity, of similarity and contrast, of coordination and subordination, and of conceptual and sound
similarities.
Some pretend to see in the grouping of these different
kinds of associations the "laws of association." But from what has
been said above, it is self-evident that they are only a fractional
part of the determinants of our natural thinking.
The
is determined by the impulses and

wish to reach a definite aim. But even in the individual elements of thought we can see the influence of affective
needs.
It accounts for daily disturbances and even direct falsifications of logic, which manifest themselves to a slight degree in normal
principal trend of thought
the affects.
We
much greater extent in the insane.^^

The material taken up forms new combinations
persons and to a
in phantasy,
detachment from experience become
possible.
The inventor has set for himself new aims which he endeavors to attain by analogy to the familiar.
The poet assumes
greater freedom of movement, and in fairy tales and in mythology he
is thus able to put himself in an attitude contradictory to reality,
whereby
different
degrees
of
to be sure, in a senseful manner.^"
The
"See
^
associations are not peculiar to the psyche alone, but they
affectivity; delusions.
Cf. Dereistic thinking, p. 45.
can be experimentally demonstrated
esses, in
is
all
in the other central
23
nervous proc-
their qualities except the quality of consciousness.
It
true that Pawiow's "association reflexes" (conditioned reflexes) go
via the cerebral cortex, which alone
is
capable of such plastic func-
tions to a high degree, but this does not
mean that they must go
via
the psyche, and particularly beyond the conscious psyche.
The mechanism
chisms
number
may
or
may
of association, the possibility that parallel psy-
not influence each other, and that of the infinite

is taken by choice, can
of possible paths a particular one
by comparing it with the switches in an electrical

These switches may connect different machines with one another or let them run independently of each other; they can switch
them on or off. The constellation determined in our example by the
lecture on chemistry decreases something, which in the electrical
plant would correspond to the resistance in the direction of "chemThat is the
istry," and it increases the resistance in other paths.
reason why the idea "water" evokes associations of chemical ideas
The comparison with electrical
of this concept rather than others.
switches also makes it possible for us to understand a number of
other phenomena, such as flight of ideas, schizophrenic disturbance
of association, hypnotic phenomena, the existence of different personalities in the same psyche either simultaneously or side by side,
the phenomena of the unconscious, and a number of pathological
symptoms which are either denied or reluctantly admitted. One must
be careful, however, not to connect the concept of association and
switching with any idea of cerebral localization. According to our
present day knowledge it is quite possible that the individual concepts are partially (or wholly) "localized" in the same anatomical
best be understood
plant.
structure.
d)
The foundations
The
Intelligence
of intelligence
lie
in the process of association.
complex of many functions which can be differently developed

in every individual.
There is no uniform intelligence. It would
be a praiseworthy task to elucidate once for all the whole concept of
intelligence.
Besides the faculty of intelligence, it would be im-
It is a
portant to abstract correctly the following points:

to understand
what
is
(1)
the capacity
perceived or explained by others, (2) the ca-
pacity to be able to act in such a manner as to achieve

is
striving for,
and
of
new material
(logical
(3)
the capacity to
make
what one
correct combinations
power and phantasy).
All these achievements are primarily dependent
upon the numher
24
The greater the number

number of ideas and the
of possible associations.
disposal, the greater the
we can
that
of stones at our
express in the mosaic of our thinking.
finer the
shades
In the animal
series, or from the idiot to the genius, the scale of intelligence depends principally upon an increase in the possibilities of association.
Of secondary importance we consider the speed and ease in the flow
of associations.
For the scholar in his study it may not be very
important how much time he takes for his reflections. But a person in active life must be able to survey a situation rapidly and
draw the conclusions necessary
to
Intelligent achievement
for action.
also includes the proper selection of the material to be associated.
only enumerate this in the third place because this function

paratively satisfactory to the average person.
to find
many
associations;
irrelevant
oligophrenics lacking mental clearness
To
select the
appropriate material
it
is
com-
It is relatively rare
one observes this mostly in
whom we
shall discuss later.
necessary to differentiate
is
between the important and the unimportant. This is a complicated

function and depends on the survey of the whole subject and therefore, in the final analysis, again on the number of associations.
In
order to make new combinations and not merely to follow in the old
grooves, there
must be a
certain capacity to split
up the
associa-
tions into their components,^^ but one also needs a special activity
of the will
The
and thought
in the direction of controlling the circumstances.
more use is made of elaborated

thought material. The intelligent person makes far less use of concepts which are still closely related to perceptions than of inferences
greater the intelligence, the
drawn from them, and often enough he

reproduce the original experiences.
person without thinking
He
how he came
altogether
is
unable to
follows his judgment of a

to this judgment.
On
thinks his concepts with their relationships.
the
He
also
other hand,
he also resorts to short cuts; this is partly accomplished through

the arrangement of details into a uniform main concept which is
already a short cut, and partly by changing complex ideas into
symbols, which are not only used in intercourse with others but
also in thinking (e.g. mathematical signs like
schoolgirl asks her
so that the latter
may
tt,
sin, etc.).
mother for some money
join in a school picnic.
for a poor friend,
The mother
refuses,
no money herself. The girl observes that her playmate

frequently earns a few nickels for running errands. She now conveys
to her the idea that all she has to do, in order to get enough money
for the picnic, is to save this money instead of spending it, and for
since she has
"
Cf.
Concept formation,
p. 14,
and the oligophrenias.
25
this purpose she gives her a small, improvised, savings bank.
she keeps on inquiring
what she has done with

Here we deal, in the
how much money
Besides
the child has earned and
This proved to be quite successful.

place, with a characterological function
on which all that follows is dependent. The girl was not satisfied
with her mother's answer and tried to find another solution. But
it.
first
pure intelligence also had a share in this
step.
first
The
girl
had
to recognize the possibility of providing help, before she found the

solution, while a feeble-minded person
sibility
from the very beginning.
would have faced an impos-
The next
spite of the fact that
it
is
To
it
fails
in reality, in
we
make a
so frequently drilled in;
application of the thought that twenty nickels

is,
was seemingly very
step
simple, but only seemingly, for often enough
refer to the
dollar, that
that one has to save only twenty nickels in order to have a dollar.
seek a
solution
is
way
out of a difficulty, in spite of the fact that the nearest
impossible and the application of this mathematical prin-
what
from those that remain

a sage would have
considered the matter settled.
But here we have besides, the important idea of the small savings bank. This required the "feeling"
which many moralists lack, and which is of course, a purely intellectual process, that mere advice was not sufficient, that is, it
requires a complex of associations regarding the fickleness of her
friend and the desire to make it harmless. For this purpose a means
ciple i
primitive.
differentiates civilized people
After giving the advice to save,
many
was invented, with the help of imagination, to interest the spendthrift in another direction. That this solution was sought and found,
of course again presupposes the possession of a great number of ideas
regarding the psychology of her friend, and, in the long run, of people
Furthermore, there was the capacity to utilize
in general.
ideas at the proper
ences into
what
is
all
these
moment, and at the same time to sift the experiimportant and w4iat is unimportant for this par-
This latter selection requires among other things the

constant presence of the psychological ideas about the motives of
action, for it is with the guidance of these ideas that the sifting must
be done.
Intellectual as welli as characterological functions are
involved in the subsequent supervision of saving and in the dctach-
ticular case.
ment from the usual associations. The latter is particularly imwhen it is not merely a question of understanding, but
of acting, or finding new solutions.
The usual thing is the idea of
obtaining money from parents; if this is impossible thousands of
young girls will resign themselves to what is apparently unavoidable. Our heroine detached the thought of procuring money from the
portant
26
idea of the usual source and sought a different one.
ticism of the egg of
Columbus
is
The
classical wit-
a very striking example for the
Columbus could count on the fact

that his narrow-minded rivals would not be able to detach themIf it were
selves from the stereotyped ideas of the undamaged egg.
not for the strong resistance of ordinary minds against the unaccustomed, as represented by the broken end, the solution would instinctively have had to force itself upon them.
One need merely call to
mind an egg of wax.
significance of this detachment.
fundamentally different grading of intelligence is that according

This does not depend on the number of possible associations; on the contrary, in those who lack clearness one
to clearness of ideas.
many
often gets the impression that there are too
that not enough
much
that
is
are
inhibited.
On
associations, or
the other hand, there
is
not
unclear in those concepts which are formed by the
ordinary oligophrenics themselves.
Idiots do not go very far
beyond
the material existence in forming concepts and that alone relatively

protects
them against a want
of clearness.
Lack
of clearness will
appear at most if concepts are forced upon them from the outside, for the understanding of which they are too feeble.
On the
other hand, there are intelligent and even highly gifted people
who utilize many confused concepts. Under some circumstances this
may have a certain advantage for discoverers: they can deduce a
hypothetical concept from any experience without great difiiculty and
if it does not properly conform to subsequent experiences, they can
without noticeable effort, or even without knowing it, transform it
in accordance with the new conditions, that is, they can use it in a
somewhat different sense. It is self-evident that this quality is very

dangerous and can only be rendered harmless by very great intelligence.
What we mean here by confused concepts can be best explained by using the illustration of the constellations. The astronomer
knows every star belonging to Orion; to him that is a very sharply
defined concept. The layman, however, knows only a few stars of
it or only the celestial region where it is located.
But he is con-
He has an incomplete but not a confused

Conscious of his ignorance he will not make the mistake of suddenly taking an entirely different group of stars for
scious of his weakness.
concept of
it.
Orion and will not say that a comet has just entered Orion, when
in reality it does not touch Orion at all or
the unclear person
may
is
just leaving
are no definite and constant limits to his concepts; he
Oriqn when
it is
it.
But
express himself in this manner, because there
speaks of
simply a question of that legend; at times he will
27
which at another time he does not include; what the

unclear person lacks particularly is the conscious and vivid disHe who calls all psycho-motor diffitinction of related concepts.
culties inhibitions may have a clear concept of them, even if it is
add to
it
stars
unsuitable for our diagnosis.
But a person who speaks
of inhibition
two terms,
conception
unclear
of
an
that are now current in psychiatry, has
them.
There are people whose more complex concepts are all unclear in
and blocking and
does not see the difference between these
Many conceal this defect by a clever way of exmanner.

pression, but in life they fail like all the other feeble-minded.
There is
Intelligence in any sense whatsoever is never a unit.
naturally
idiots
no one who is eminent in all psychic fields, while most
Practical intelligence does not necessarily imply
fail in all directions.
theoretical intelligence and vice versa. The great difference between
school intelligence and worldly intelligence depends only partly on
this
the fact that pedagogues with their one-sided standards
are
ceiving themselves regarding the abilities of their pupils.-^
num-
Alexander von
Hum-
ber of highly gifted people were poor in school.

boldt, for instance,
of his teachers.
"was
unfit for study" according to the
And even
after the school period "worldly
de-
judgment
wisdom"
something quite different from intelligence in general. The particumathematics, languages, engineering, psychology, philosophical thinking, etc., are well known. This specialization may go
to very great lengths. Indeed there are people with one-sided genius
for figuring out on what day of the week a certain date will come,
is
lar gifts for
or for playing chess, etc.

in such cases we do not merely deal with abstract intelThe good mathematician not only has the ability to think
mathematically but also the im-puhe to occupy himself with it. But
Even
ligence.
the intellectual effects depend also
in
other
ways on
their
inter-
play with other functions, principally the ajfects. We have seen in

the case of the schoolgirl how the impulse to think and act cooperated in controlling the circumstances. A people without a thirst
for knowledge, like most of the Orientals, even though it had the
greatest intelligence and perhaps a vivid phantasy, would nevertheless
be unable to accomplish anything in the sense of our occidental

technique. The abulic schizophrenic and the over-labile organic de-
ment both appear demented
as a result of their affective disturbances.
"Unfortunately one still observes quite frequently that the result of education and school training, the mere acquisition by memorj' of the subject matter
of education, is mistaken for intellectual accomplishments.
28
Mere
clearness of thinking, likewise,
is
considerably improved
if
has the patience and the impulse to think a matter through.
by
falsified
affects
is
constantly seen in the insane.
the intellectual functions
may
one
Logic
failure of
be due to a disturbance of the equilib-
rium between reflective power and affectivity (apathy on the one

hand, and proportionate dementia on the other). Important above
all, is the influence of the feelings relating to the ego which only too
readily cause an entirely different standard to be applied to one's
own
than to other things. Furthermore, a large part of

The ability to concentrate
is due to perseverance.
the attention in understanding and elaborating things may have an
interests
worldly prudence
important influence upon intelligence. The ability to find new mafavored by a certain degree of phantasy or is perhaps identical
with it, if by "new" we do not merely mean the correct "new"
terial is
That a good memory considerably aids intelligence, that it

even replace intelligence and conceal the weakness of it, is selfevident. For, the more intelligent a person is, the less need he has
for primary memory, which reproduces experiences exactly as they
have been experienced. For the intelligent person uses deduced conmaterial.
may
fishes
a "fish" does not call to his mind a collection of all the

he has ever seen, but he has for it a very abbreviated formula
which
is
cepts;
of a zoological-scientific content.
e)
Memoey
Everything that has been psychically experienced leaves behind a

lasting trace, or engram^.
We
recognize this by the facts, that the
more often a process has been repeated

off,
(practice) the easier
that past experiences act in a modifying
way on some
it
processes, that repeated experiences are recognized as repetitions,
above
all
What
that one remembers psychic processes.
the engram represents
we do not know.
runs
actual
and
modification
In remembering something
there must be a recurrence of a function resembling a previous experience, like an idea of something perceived, or of a function almost
like
it,
like the repetition of a practiced motion.
as an ekphoria of the engrams.
That every
We
designate this
experience, including
unconscious ones, really leaves behind engrams, cannot be directly
seems very probable from off hand tests, furIn dreams, hypnosis, and in diseases,
and sometimes also in the normal states, experiences are recalled
which would otherwise be considered as impossible of recollection,
A young woman who could neither read nor write reproduced in
a feverish state Latin, Greek and Hebrew verses, of which she knew
demonstrated, but
it
nished us by chance memories.
nothing in her normal state.
clergyman,
who was
During her childhood she
29
lived with a
in the habit of reciting such sayings.'''^
person
drug store may, under certain conditions, reproduce a

great many of the inscriptions on the glass jars, even if he understands nothing about them.
Although every experience leaves an engram, those memories which
we usually utilize are really products of very complicated elaborations.
We do not form an image of a momentary vision of a certain region
hypnotized
in a
by confining
it
within the limits of the field of vision at that par-
meadow, a meadow with
ticular time, but
we image
mountains,
In short, in the available engrams, the experiences
are
etc.
analyzed
a tree, a
trees,
and synthesized according to the rules of concept
formation.
The ability to form engrams, the engraphia, was designated by

Wernicke as "impressibility" (Merkfdhigkeit) and this has been
hazily contrasted with "memory."
Memory in this connection no
longer means the whole memory, a designation for which is clumsily
lacking, but the retention of the ability to ekphorize the engrams.

It is still
unknown in what respect the latter may be regarded as a

The only thing definite is that under certain condi-
special quality.
many engrams cannot be ekphorized, and that, if a cause for

found at all, it has so far always been in something entirely
different from the nature of the engrams; it was mostly in affective
obstacles.
So far then the mere inability to remember has thus far
not shown us why the engrams are lost. A more detailed discussion
will be given in the chapter on pathology of memory.
The engrams seem to last as long as the brain is not verj' extensively and markedly injured. It is not very rare that apparently
long lost memories from childhood reappear in old age with great
tions
it
is
vividness.
its resistive
All things being equal, the older an
capacity to ekphorization.
engram the greater
Forgetting therefore
is
is
not as
due to a disappearance of the engrams, but to an inability to

them as memories or to ekphorize them by association.
The apparent paling of those pictures of perception which are
tangibly vivid is really only a substitution of the same by elaborations which are more suitable for the idea and hence more capable
of recollection.
Another way of weakening by age the capacity to
recall an engram was shown by Ranschburg.-*
Material learned by
heart consisting of similar components is more difficult to reproduce
a rule
revive
^Carpenter, Mental Physiology, p. 437, Tnibner, 1896, London.

**
Ranschburg, Ueber Wechselbeziehungen gleichzeitiger Reize usw. Zeitschrift
fiir Psychologie 67, 1913.
30
than that which
is
altogether dissimilar.
In self-observation
we
find
that to a large extent memories disappear in a manner that one is

at first uncertain which of several similar memory pictures is the
and that gradually so many possibilities offer themselves

no longer able to choose, or that one is altogether unable
to grasp the correct engram out of the great number of others. Other
disturbances and falsifications of memory are determined by the
correct one,
that one
is
affect.
There are
facts,
however, which could, in the first place, be exThus, rooms which we saw
plained by a change in the engrams.
much smaller in later life than we had

have enlarged the image with the growth of the size
Whoever studies the testimony of witnesses in court
of our body.
proceedings will be surprised how, even in very simple matters, people
will make the most contradictory statements in good faith; this
in childhood
often seem
We
expected.
naturally occurs most frequently in the case of precipitated or excited

events. But even without any particular reason the errors are often
The experiments regarding the giving of evidence, parmade by Stern's school,^^ have furnished us much
unexpected information concerning this. Every one who observes himvery great.
ticularly
self,
even
those
if
only a
little, is
familiar with the daily irregular falsifica-
which reproduce a memory not only incompletely but change

Thus the memory image of a somewhat unit also in other ways.
familiar person, garden, or of an event is frequently quite different
from the reality of it, and in time also loses regularly in correctness
and in clearness.
In all such cases, however, the original correct engram continues to exist together with the modified one. For the error is often
subsequently corrected, either through reflection or through the fact
that the correct memory involuntarily appears on some occasion. In
pathological conditions we can frequently demonstrate that the correct and the falsified idea exist at the same time.
Such occurrences prove that in falsifications of memory we do not
deal with alternations of the engrams, but with a complex process
tions
which is analogous to the creation of new ideas. How much of this

has taken place in the unconscious during the apparent latency of
the engrams and how much during the act of recalling is unknown.
Even in a sober-minded normal person the falsifications which correspond to an affect, namely, to the wishes of the individual, are very
marked. It is very instructive to reread one's diary after the lapse
One finds a great deal which he no longer
of a number of years.
''Stem, Beitrage zur Psychologie der Aussage.
Barth.
Leipzig, 1903.
believes even though
it
is
written in his
own
31
handwriting.
closer examination one finds that the version of the diary
But on
fits
least
the person concerned.
Ekphorization of engrams can be either conscious or unconscious.

Unconscious memories of ideas can only be demonstrated in a roundabout way, but well-grounded capacities, particularly of the motor
type, very easily take place unconsciously. If we were once able to
swim, we make the correct swimming motions as soon as we get into
deep water.
The ekphorias that are most frequently spoken of are the conscious memories. Without exception they are probably generated by
way of associations. The laws of memory are therefore the laws
of association. The better drilled an association, the more associaIt is
tive paths lead to an engram, the easier it is to remember.
therefore relatively easy to remember what has been brought into
many relationships, or what has been understood. An unintelligible
chaos, as for instance a story heard in a foreign language, cannot be
Likewise
reproduced.
it
is
just as impossible, in the ordinary con-
scious course of thought, to revive
all
those innumerable engrams
which we
all
the faces of the unfamiliar
take up unconsciously as
we meet on a walk.
The faculty of memory
people
very easily disturbed through such a

constellation as recalling something otherwise familiar in a new
relationship; we are often unable to do so. The affects, however, as
we
shall
see,
facilitating
is
are particularly important as
memory.
factors
inhibiting
and
Pleasurable experiences are particularly eas}"
In unpleasant experiences there is a struggle between

two antagonistic tendencies; on the one side we have the one belonging to the affect in general, which makes the memories more vivid,
and on the other side there is the tendency which strives to shut out
everything unpleasant, hence also a disagreeable memory. L^npleasant events are frequently crowded out of memory, especially if they
somehow depreciate the personality. Thus the lapse of many decades
creates the idea of "the good old times." Most important of all, however, are the actual affects, which cause only those memories to come
to the surface which are suitable for them.
Recognition is a special form of memory. If we hear or see some-
to remember.
thing for the second or third time
former experience.
One speaks
repeated sensation, but one

portant to
lection.
know
is
if
one
regularly recognize
is
it
as a
it.
It is more imthan spontaneous recolabsolutely unable to remember the
unable to describe
that recognition
Thus, even
we
of a "quality of familiarity" in the
is
easier
32
oriental
name
it, if among other

Not every one is able to form a clear
able to recognize him as soon as he sees
of Alexander, one will easily recognize
names Iskander
is
mentioned.
image of a person, but
is
him.
Orientation
f)
Present and former perceptions combine into orientation as to time

place, so that one always thinks more or less conspicuously of
and
being at a certain place and at a certain period of time, and connects his memories with these dates.
depends on memory (for
it
It is self-evident that orientation
when memory
impossible
is
is
lacking),
on perceptions (for hallucinations can produce an entirely different

place), and on attention (for if we are absorbed in thought or in conversation while walking or riding in a vehicle, we may suddenly find
ourselves at a different place than we had expected). But as pathology
shows, there is besides this also an independent function of orientation,
the disturbances of which are not necessarily proportional to the disturbances of other functions.^*' Nevertheless we find no anomalies
of orientation without a disturbance of other functions.
Orientation as to space, which is constantly controlled by the
eyes, is of course much surer than orientation as to time, which
requires an uninterrupted memory record and has only a linear
dimension.
Something entirely different

tells
us
why we
to the other people, etc.

far as
it
is
the orientation as to situation, which
are at a certain place,
This
is
what
relationship
we have
of course a function of reflection, as
depends on the understanding of complex conditions.^^
g)
Affectivity
Every psychism can be divided
into two sides, an intellectual and

remains unnoticed, but is never altogether lacking, as can be demonstrated through comparisons. For
instance, most people can immediately answer the question whether
they like better a trapezoid or a square. It can be concluded that
an
affective.
The
latter often
the mere sight of such simple figures
is
associated with a feeling of
pleasure or displeasure.
Under the term affectivity we comprise the affects, the emotions,

and the feelings of pleasure and displeasure. The expression "feel^ E.g., following an alcoholic delirium, orientation as to time and place sometimes remains disturbed a few days longer, while the other functions appear
quite normal.
" Regarding Wernicke's classification of orientation into autopsychic somatopsychic and allopsychic, see the disturbances of orientation, p. 110.
ing,"
which
is
frequently used for this wiiole group of phenomena,
For
misleading.
33
it is
is
also used to designate sensations in the lower
sensory qualities, such as feelings of warmth, somatic feelings, and
Munk's sphere
of feeling, as well as indefinite perceptions such
the feeling of someone approaching.
It is
as
furthermore used to des-
ignate the result of inferences originating in the unconscious, such
by
as reaching a diagnosis
a "diagnostic feeling,"
and
finally
it
is
used to designate complex processes of cognition, the elements of
which are not clear to us, such as the feeling of familiarity. The terms
"affects" and "emotions" are too limited in their application, and they
really do not embrace the simple feelings of pleasure and displeasure.
Affectivity
includes
somatic as well as psychic manifestations,
which are sometimes conceived as symptoms and sometimes as
effects
of the same.
It
influences
gestures
in
the
broadest sense; this
the
includes
emphasis in speech, the attitude of the body and muscular tone; it

also influences the vascular system, as in blushing, turning pale, and
in palpitation of the heart; and it also affects all secretions, such
as tears, saliva, urine
and
faeces; finally it influences
also the
whole
trophic system of the body.
On
the other hand^ affectivity
We
influences.
irritability
alcoholics,
markedly dependent on physical
is
note this in anxiety of endocarditis, in depressive
of dyspeptics, in the euphoria of tubercular patients or
and
in the affective manifestations of inner secretions.
In the psychic field
we must
first
mention the undescribable subjecand similar
tive sensations of pleasure, displeasure, joy, sadness, anger,

feelings.
Affectivity also determines our actions.
retain pleasure, that
is,
keep away from displeasure.

is
only to avert a
still
We
strive to procure
pleasurably accentuated experiences, and

If
we take upon
and
we
ourselves displeasure,
it
greater one or in order to obtain some pleasure
which we value higher than the assumed displeasure.

Affectivity has a determining effect upon action also by way of
thought which is more influenced by it than is ordinarily imagined. In
regard to its content this is shown in two ways
(1) The path is cleared for associations corresponding to an actual
affect,
i.e.
these associations are favored, while
all
the others, particu-
larly those incompatible with the affect, are hindered (the
force of the affects).
From
this
one
may
conclude:
(a)
dominating
There is a
compulsion to occupy oneself with the emotionally accentuated subject.

(Actual emotionally accentuated experiences can only be ignored in exceptional cases,
and under certain conditions they absolutely prevent
34
any thought
(In a
(b) Logic becomes falsified.
unable to take into account all the poor
chances; they do not even "occur to him," or they are deliberately disin other directions.)
state of euphoria, a person
is
One
regarded in the logical operation.

(2)
The
ignores his
own
faults.)
valuation, or the logical weight of the ideas which are in
accord with an affect, become enhanced, whereas the value of irrelevant

and especially of opposing ideas is depreciated. From this again one
may infer on the one hand, that there is a tendency to occupy oneself
with those ideas which seem important, and on the other hand, that
is a broader alteration in the logical operations.
A timid person
puts too high a value on the dangers involved and too low a value on
the good chances, if he considers them at all. An investigator whose
there
ambition depends on one of his formulated theories will continually

it, and he is unable to give full weight to the
find corroborations for
arguments against it.

The effects of an affect manifest themselves differently and have a
different significance, particularly in psychopathology, depending on
whether they are caused by a general mood, such as euphoria, sadness,
anxiety, etc., or whether they only emanate from a single affective idea.
On the whole, one can be in a different mood and yet have a complex
of ideas, which, whether it is conscious or unconscious at the moment,
is endowed with anxiety or joy or chagrin.
In the latter case not all
associations are influenced in the sense of this affect, which controls
the idea, but only those which in any
Our thinking may be
whom we
are in love.
the "complexes."
quite correct in all other respects, but
one-sided in regard to some one

lish a relationship
way touch
As a
it is very
has angered us, or some one with
complexes have a tendency to estab-
who
rule, all
between themselves and the other experiences (The
onanist imagines that every one is looking at him because of his vice)
and thus lead to the formation of false self references in both normal
and pathological people. If the thought is difficult to bear, the whole
complex can more or less be split off from consciousness and merge
into the unconscious but it does not always lose its influence upon the
psyche as a result. The effects of an affectively accentuated complex
are designated as katathymic by Hans. W. Maier.
The influence of affectivity upon thought and action becomes reenforced by its tendency to spread. In point of time the affects quite
generally outlast the intellectual process at their basis, and what is
more, they frequently continue for a long time. Besides, they easily
"irradiate" to other psychic experiences which are associated in
way
with the idea having an affective tone.
"^See the following page.
some
Thus we love the place
35
where we have experienced something beautiful and we hate tlie innocent bearer of bad news. Love often is "transferred" from Uie originally beloved person to another who bears some analogy to the former
or it may be transferred to an object, such as a letter, etc. Even in
normal conditions it may happen that the transferred affect detaches
itself from the original idea, so that the latter seems indifferent, while
the secondary idea carries the affect which does not properly belong
to it {Displacement of the affect).
If a definite affect persists and dominates for some time the whole
personality with all its experiences, we speak of a mood. The tendency
of an affect, which has once appeared, to continue and to become transferred to other experiences, as well as its influence upon thought, facilitate the occurrence of permanent moods. But the latter maj' also be
the result of physical causes, based on constitutionally determined
moods or as partial symptoms of temperaments, alcoholic euphoria,
mania, melancholia and similar states.
Positive or pleasurably accentuated affects accelerate the train of
thought, while negative ones retard
it.
As a
result of acceleration,
thought sometimes becomes changed even in content, it becomes more

superficial; -in a high degree of retardation it never reaches its object.
The
affects possess great associative power.
An
unpleasant affect
has a tendency to ekphorize former affects of a similar nature. Thus

an event, not very important in itself, may produce a great effect by
reviving affects from former situations of similar quality of much
greater emotional tone. It is remarkable that the former events often
remain unconscious in this process. In other cases the very experiences
are recalled to
memory
and then reenforce and modify

These peculiarities are of great signifi-
in the first place,
secondarily the original affect.
cance in the pathology of the neuroses.
By
which do not belong to them the affects

upon the complexes of ideas accentuated
by them. In some connections such complexes form a whole category
and between them and the other psyche there exists not only an association readiness for ideas that can be utilized compatibly, but there is
also a certain association-hostility to anything not belonging to them.
They are therefore only slightly influenced by new experiences and are
inhibiting the ideas
also exert a limiting influence
not easily accessible to criticism. If the affective tone

they are even readily repressed into the unconscious.
is
unpleasant,
If such bundles of ideas, which are held together by an affect, exert

a permanent influence upon the psyche, we call them briefly ''com-
plexes."
complex
may
thus be formed in regard to a person
who has
dis-
36
appointed us, so that everything connected with him is not only burfeelings, but it also participates in the
association readiness or in the repression which adheres to the idea of
The memory of the place where he lives produces an
this person.
dened with the unpleasant
irritable
mood and
reaction; distant ideas which
be associated with the person
call
him
would ordinarily never
to mind, or, the opposite occurs,
we find it difficult
The complexes are mostly
forgotten, repressed, so that
the whole complex
is
to recall even the
names
of his friends.
either vividly conscious, or later repressed
and unconscious.
In both
The most
cases they influence our thinking, striving and mimicry.
and many are recogand in the whole behavior of the individual. Feelings of inferiority in any sphere (insufficiency complex) which contribute to the formation of many neuroses are very important and
Such complexes
especially those with an ambivalent feeling tone.^^
common complexes
are connected with the instincts
nized in the attitude
may
even acquire a kind of independence as far as certain voices
may
represent a "greatness" that the patient would like to attain and

others may personify a weakness, which hinders him in the success of
his plans.^
An
intellectual process, a perception,
an action
in response to a
stimulus, and a thought, are all in a certain respect partial functions.

could imagine that only a part of the psychic organism participates
in these processes. In contradistinction to thi^, the affective processes
We
signify
an assumed attitude of the whole person.
They
participate in
the affective changes of all psychic activity, in the creation of uniform

striving for an aim on the part of all associations, in a general facilitation or restraint of the psychic processes, in the changing of the blood
supply in the brain, and in similar mechanisms. Intellectual and affective processes are related parallel manifestations; they represent the
Nevertheless, they
side of the same psychism.
may
proceed indepeneach
process
that
separate
so
can subsequently
the
other series. As
processes
of
other
with
associated
dently or become
local
and the general
a result of irradiation an affect may become connected with ideas to

which it was not originally related, and still remain in contact with
the original idea, but it may also be completely separated from it.
Under
certain conditions
we may form
a distinct image of the death
of a beloved person, either while the event actually takes place or later
from memory, without experiencing with it the corresponding affect.
On the other hand, the idea of mourning may be attached to a secondary
" See
p. 125.
Cf.
The
telle
classical self-portrayal of
Siaudenmaier, Die Magie
als
experimen-
Naturwissenschaft, Leipzig, Akademische Verlagsgesellschaft, m. b. H. 1912.
idea indifferent in
last
itself,
37
as to the perception of the place where
saw the deceased or to
a song.
In such a case
we
we
are frequently
unable to understand the significance of the affect (displacement). Or

the affect may become detached from the idea it belongs to without
associating itself with any other idea. There is, for example, "a freely
floating anxiety" vv^hich originally belonged to a fearful idea
and was
repressed into the unconscious; one feels anxiety but docs not
why.
from
There
this
is,
one,
know
however, an anxiety which cannot be differentiated
which
may
be of physical origin, as in circulatory

In both cases it may attach itself under
disturbances or in melancholia.
certain conditions to
all
some secondary
idea,
which
in itself
need not at
be endowed with anxiety.
show more clearly than anything else how the psyche as

always the decisive factor, and how the individual ideas,
concepts, and affects which we emphasize are only artificial classifications. The taste of a certain food may be very pleasant to one hungry
and very unpleasant to one who has over-eaten. Music, which in itself
would be considered pleasant, may be very disagreeable if it is not in
harmony with the mood of the listener, or if he is disturbed by it, or
if he happens to have very sensitive nerves, or if he is in a state of
melancholy. If a lunatic gives us a box on the ear it produces no affect
in us, but under different circumstances it may fill us with the greatest
anger or despair. Careful observation impels us to make the general
statement, that in reality we never react to a single experience or idea
with a definite affect, but that the affect is always merely a part of the
whole complex of functions which forms the actual psyche.
In human beings endowed with memory who do not merely live for
the moment, but form ideas from the past and have ambitions for the
future, the tendency to manifest themselves on the part of the ideas
and strivings, carrying a negative affect, conflicts with the opposite
tendency to keep away from the unpleasant. Thus if one has a feeling
of revenge or sexual love for one's mother, which is intolerable to a
moral person, he usually solves this conflict by shutting the idea out
of consciousness in statu nascendi. Notwithstanding this, the idea continues to exist and may influence his actions in a roundabout way, or it
may provoke symptoms. The idea has simply been repressed into the
unconscious.
Repression naturally plays a great part, in psycho-
The
a whole
affects
is
pathology.
Every affect has a tendency to act in a definite direction. Because

some one has insulted me an apparatus (chance apparatus) results in
my psyche which seeks to avenge me, just as the accommodation in
the psychological experiment creates a kind of transient reflex ap-
38
paratus, which, without any further exertion on the part of my will,

responds to the appearance of a red light with a pressure of the right
forefinger on the button, or like any resolution when formed incites
one to put
fact that
it
it
The apparatus
into execution.
has accomplished
the experiment
purpose.
its
shut off, e.g., through the

have revenged myself, or
because
finished, or it stops
is
is
it
has lost
its
purpose,
become reconciled with the person who offended me. According to the strength of the affect it has a motive power which can be
compared with physical tension of energy. If the motive power is too
weak, or if the function of the apparatus is restrained by external ciras
when
cumstances of inner opposing

"tension," remains inactive.
same or even to a
forces,
But
if
then the apparatus with
new impulses
its
are added to the
similar action, the "tension of the apparatus then
becomes reenforced, so that, under certain conditions, it finally overcomes all obstacles in an explosive manner and like an inhibited reflex
it may even shoot extensively and intensively beyond the aim.
One
then conceives the impression of an "accumulation of affects." Qualitative departure from the original purpose, in the form of simple
mimetic expressions, such as exultation, screaming, or smashing of an
innocent object, may also occur and they suffice to put the apparatus
One then speaks
out of action.
of a discharge or abreaction of the
affective tension, while the real process consists in the dismantling of
the apparatus in question.
For,
if
the apparatus
throughout
life
and
may
is
not actually put out of function,
it
remains
cause in normal people some sort of an incom-
prehensible readiness to react explosively to certain experiences; in

sick people
it
may
energy thereby.
been repressed.
personality and
provoke a variety of symptoms without losing any

is particularly true if the affective complex has
In that case it cannot be shut off by the conscious
This
may
deed, through similar
more and more
continue unrestricted in the same condition; inexperiences the complex may even acquire
Exaggerated sensitiveness to fear in an adult
new
tension.
may
thus be traced back to a repressed terrifying experience of childhood which has been furnished with tension from all similar later experiences, without any knowledge of it on the part of the patient.
Indeed, such an occurrence
similar things over
may
produce the tendency to experience
and over again.
Chance apparatus occur
also without any special affects, wherever

an intention to do something, even if it is simply a question
of finishing some thought. Secondary experiences and thoughts of the
previous day to which one often pays no attention and which appear
there
in
is
dreams also belong
here.
Habit too creates chance mechanism which
39
are particularly difficult to abolish, because they are not set for a
aim happening but once and the attainment
definite
of which auto-
matically stops the machine.

Affectivity varies greatly in different individuals and
even
must
in the
call
same person
at different ages.
a cat a cat and observe the general rules of logic in order
to get along with his fellow-men
may
mode
frequently
While every normal person
love the cat or consider
it
and the external world
in general,
The
a monstrous animal.
he
individual's
which primarily expresses itself in affectivity, is not

narrow standards as logic. It is for this reason that one
may argue, for example, whether or not the isolated absence of feeling
tone in moral concepts is to be looked upon as pathological.
The character of a person is almost exclusively determined by
affectivity: Animated and easily changeable feelings constitute the
sanguine temperament, while persistent and profound feelings the phlegmatic character; a person who does not accentuate the concepts of good
and evil with pleasure or displeasure, or who puts a weaker accent on
them than on egotistical ideas "has a bad character." Next to the
quality of reactions we must also consider the rapidity and force of the
affects and hence of the impulses. Jealousy, envy, vanity are characof reaction,
tied to such
Affectivity
teristics as well as affects.
is
also responsible for laziness,
energy, steadiness, diligence and carelessness.
From what
has been said above, the function of affectivity in our
It determines the direction and force of action, and

endurance
and irradiation, as well as through its influence
through its
logical
functions,
it provides uniformity and emphasis for
upon the
psyche
is
evident.
this action.
with our fellow-
It especially regulates social intercourse
men. Here it is important to note that we constantly apprehend and

respond instinctively to the most delicate fluctuations of affects in our
fellow-men.
We
is
strive for the pleasurable,
which on the whole consists of what
useful to the individual or the genus.
pleasurable.
The
reverse
is
true of the dis-
Exceptions to this are concerned with experiences which
are quite rare and therefore do not endanger the existence of the genus,
or with occurrences to which the race has not yet adapted itself because
of lack of time.
Thus we
find the taste of the beneficial cod liver oil
disagreeable, but that of harmful alcohol pleasant.
That
rage)
is
excessive affects
quite obvious.
may
be harmful (paralyzed with fear, blind
Compared with the
daily
and hourly oc-
currences in which, for example, a very slight anger or slight fear
is
help in overcoming an obstacle, they are rare exceptions which cannot
threaten the existence of the genus.
40
Physical pain assumes a special position.

tive processes in the
At the same time
body and
it is
is
accompanies destruc-
It
localized like a physical sensation.
and has the same

body
also a feeling or an affect
It forces us to direct our attention to injuries of the
significance.
and to ward them
off energetically.
There are also other "primitive

clearly separated from our
Monakow) which cannot be
feelings" (v.
conception, as for instance hunger.
Attention
h)
Attention
is
It consists in the fact
a manifestation of affectivity.
that certain sensory perceptions and ideas which have aroused our
If we are performing
interest are facilitated and all others inhibited.
an important experiment, we only observe what

thing else
all
is
relevant to
to concentrate on a certain
theme we
call to
every-
we
our assist-
The
appropriate associations and exclude the others.
"clearness" of observation and thoughts to which

is
it;
entirely lost to our senses.
we wish
If
ance
is
merely the expression of the fact that everything relevant
served and considered while the irrelevant
is
greater
direct attention
eliminated.
ob-
is
Hence
in
attention the "interest" inhibits and facilitates the associations in the
same way
this
is
as
is
ordinarily done
done, the greater
greater the
number
by the
affects.
The more
successfully
the intensity or the concentration, and the
is
of useful associations put in operation, the greater
the extent of attention.
A distinction is also made between tenacity and vigility of attention

which are usually, but not always antagonistic to each other. Tenacity
is the ability to keep one's attention fixed on a certain subject continuously, and vigility the capacity to direct one's attention to a new
object, particularly to an external stimulus.
We must also differentiate between maximum and habitual attention.
Many
patients habitually observe very
tate themselves
when they go
are induced to exert their
without any
If attention
maximum
But
of attention, they can
if
they
do
this
and sometimes particularly well.

directed by the will, we designate it as active:
is
we
call
it
passive.
always be active while habitual attention
The
they do not orien-
difficulties
external occurrences,
sive.
little,
to an unfamiliar place, etc.
Maximum
may be either
if
by
attention will
active or pas-
latter plays a special part in recording the daily
happenings
of one's environment.
The
success of attention
is,
of course, not merely dependent on the
but also on the general disposition of the psyche. Some people

are not capable of great concentration although they seem to possess
affect,
41
a sufficiently strong and stable affect. Exhaustion, alcoholic effects,

and many pathological states hinder concentration and tenacity. The
extent of attention
of course, also dependent on the general capacity
is,
and
to form associations,
it is
therefore not as great in people of lesser
intelligence.
The
forms.
which shows two contrasting
opposite of attention
is
On
a pupil shows a lack of tenacity in hyper-
the one hand,
if
distraction,
he may be designated as distracted if he is disturbed by every

whereas hypertenacity and hypovigility are characteristics of
the absent-minded scholar. A third form, which is pathological in its
more pronounced manifestations, is due to an insufficient capacity to
concentrate. The latter may have an affective basis, as in the case
vigility
noise,
of neurasthenia, or
it
may
be due to disturbances in association, as in
schizophrenia and certain deliria, or
it
may depend
on more complicated
conditions, such as exhaustion.
Temporary
is
distraction usually originates in a definite situation.
self-evident that
an
affect will hinder the attention
on something of quite a
is about to make a
who
of fear
may
different nature, as in the case of a schoolboy

trip
and has to do his lessons. But an affect

beyond the mark and interfere
just as easily transcend
with even an adequate

fails us,
It
from being focused
reflection.
In a critical situation attention often
the ability to concentrate
is
usually entirely lacking and fre-
quently also the tenacity, one continually wanders away from the
individual idea, or, like the pupil who is anxiously tr^nng to complete
his lesson,
one
becomes too
is
by every fly. Frequently, however, tenacity

and the individual is dominated by one single
distracted
great,
idea.
process quite analogous to attention, w^hich
conscious and permanent situation of the latter,

ness.
If
is
is
sort of un-
the association readi-
something occupies us affectively, then the most various ex-
periences will remind us of
it.
connection with this idea, even
All kinds of ideas will find associative

if it
has not become actual in thought.
A person who is afraid of being arrested will
easily be frightened
by any
The
association
readiness, like attention, can also be intentional^ fixed
on certain
one
who might
things.
Thus
also interested
in
some way remind him
may be
in many
of a detective.
searching for something in a book, but I
at random, but as soon as I strike the passage

or even something that
am
other things in the book and therefore read
is
upon which
only similar, I associate
it
have
fixed,
with the desired
subject.
if
Mere habit may also produce a sort of association readiness, even

Thus a person who is occupied with
in a somewhat different sense.
42
much proof
reading will easily notice typographical errors in other
reading.
Even
normal persons the association readiness often produces

are very much like delusions, thus a person with a
which
deceptions
thinks
that he is everywhere the subject of observation.
conscience
bad
There is also a negative fixation of attention which plays an important role in pathology. Here one does not wish usually unconsciously ^to consider certain things, or one refuses to take them into
in
consideration in reflections.
The
association hostility
makes
itself felt
in attention.
i)
Suggestion
^^
Uniformity of action is not only necessary for the individual with

but even more for a community of individuals.
Animals, even those living in herds, are apparently unable to communicate to one another ideas of a predominantly intellectual content.
Most of their communications are about the approach of prey or of
his various strivings,
danger and, as observation shows, this is done mainly through affective

display, which evokes the same affects in the other members of the
herd. It is only through the movement of flight or attack of the animal
first
seized with the affect that the others learn the direction of the
prey or danger. This is entirely

This affective suggestibility
spite of his language
most
cases.
man, in
which has been more and more developed for in-
Even the
tellectual needs.
sufiicient for
is
still
fully present also in
infant reacts appropriately to affective
when he is among
sad people, not because of the ideas at the basis of the sadness, but
because of the affective display which he perceives. Because of the
manifestations, and the adult cannot remain cheerful
between the
close connection
and because
affect
and the ideas to which it belongs

upon logic, it is self-evident
of the influence of the affect
that the ideas are very easily suggested along with the affect, quite
apart from the fact that the object of this arrangement
is
surely also
Ideas without an accompanying affect do not

"The greater the emotional value of an idea, the
In conscious suggestion, to be sure, we usually
is." ^^
to transmit the ideas.

act suggestively.
more contagious
it
deal with a "pair" of affects instead of a uniform affect; in the sug^Forel, Der Hypnotismus, 6th Ed., Stuttgart, Enke, 1911. Moll, Der Hypnotismus, 4th Ed., Berlin, Fischer, 1907.
^^The affect, however, may be present merely in the person subject to suggestion as when a remark, indifferent in itself, touches an affectively toned
complex. A person with an incurable disease hears about a miraculous cure
spoken of in an indifferent or even disparaging tone, and is immediately enthused
to try it himself.
gestor there
is
43
the affect of domination, while in the person subject
dominated or of submissive. Moreover,

and even in animals there are also identical
to suggestion the affect of being

in natural suggestions,
as well as similar reciprocal relationships of affects.
Among
enemies
the fear of the one increases the courage of the other and vice versa.
Not only thoughts
are accessible to suggestion but also perceptions,
such as suggested hallucinations, and

brain,
i.e.
by the
the glands, etc.
affects,
The
all functions controlled by the

such as the "involuntary muscles," the heart,
influence of suggestion
than that of the conscious
mill,
but
it
is
therefore
much
greater
corresponds with that of the
affects.
However, the individual suggestion is not of great importance in the

life of man.
Infinitely more important is the suggestion of
the mass, which even the most intelligent person cannot escape. The
swaying of the masses in political and religious movements is principally done by suggestion, and not by logical persuasion; frequently
it is even quite contrary to logic.
A whole nation is quite incapable of
viewing critically, or resisting suggestions which deal with the instincts
and impulses of preservation, greatness, power, and position.
The psychology of the masses has laws which are quite different
from those of individual psychology. A feeling of community is set in
motion only by impulses possessed by most individuals. The finer
feelings which are developed individually only, cannot come to expression; thus the masses possess another more primitive morality in the
good as well as in the bad sense. Whereas the feelings become enhanced through agreement, the individual's logic not only remains
without any unified connection of the mass, but it is hindered by it;
at most the mass permits it only a subservient part. Reflection, reasoning, and the creation of great intellectual and spiritual values of the
mass or of a people originate more from dereistic thinking. Due to
elementary suggestibility the "leader" in the crowd attains great power
in the discovery and accomplishment of ideas.
But sometimes he is
only the one who most definitely, most consciously, or most forcibly
perceives the chaotic ideas created by the people, he is merely the focus
of the mass psyche. The more the community increases in numbers,
the more and more does the guiding force become impelled by obscure
instincts, which are not clear to any individual and of which the majority never becomes conscious.
They are likewise difficult to grasp
objectively and resemble much more the evolutionary tendencies of the
vegetative or animal organism, or sudden migrations of animal species,
than actions with a conscious aim. Each individual of a certain race
ordinary
or period possesses the
same
tendencies, which burst forth
-^"ith irre-
44
power and stubborn persistency from the "collective unconscious," of which the generally known "spirit of the age" is a partial
manifestation. In chronological succession crowd psychology expresses
itself in traditions, legends, and similar mechanisms only what is common to the various generations is selected and retained.
Suggestion has the same significance for a community as the affect
for the individual. It makes for a uniform striving and provides it with
power and endurance.
Simple habits, as well as examples, can exert very much the same
influence as actual suggestion. One does what one is accustomed to do
without any other reason; one likes to do as other people do without
sistible
much thought
In the latter case, to be sure,
or feeling in the matter.
suggestion, particularly
mass suggestion, may
easily be a contributing
Viewed from another angle, habit also appears

Pawlow's association of reflexes (conditioned reflexes),
factor.
of
instance, secretion of saliva
is
in the
form
in which, for
associated with the sounding of a certain
by letting this note sound a few times at the time of nourishment.

These mechanisms must theoretically be clearly differentiated from
tone,
suggestion, although in reality they are frequently mixed.
We
also speak of autosuggestion, but this
upon
effects of affectivity
own
one's
logic
is
merely a name for the
and bodily function.
It
is
of greater importance in pathology.
Suggestibility
is
artificially increased in states of
are themselves produced
by suggestion.
are so limited that one only perceives
wishes, that
On
is,
as far as the test person
hypnosis which
In hypnosis the associations
and thinks what the suggestor

able to understand his wishes.
is
more power over the voluntary

The hypnotized person will guess what is
the other hand, the psyche has far
associations than ordinarily.
expected of him far better than the normal person.

sensory impressions which would be too
state.
weak
for
him
He
can
utilize
in the ordinary
He
can imagine things so vividly that he hallucinates them,

is able to shut off completely from his psyche
He has
sensory impressions ("negative hallucinations").
but on the other hand, he

actual
memories at
He
his disposal of
which he ordinarily does not know anything.
frequently also controls in a striking
tions, such as heart action, the
All these processes

if
may
manner the vegetative func-
vasomotors, the intestinal movement.
also be continued
beyond the time
of hypnosis,
desired (posthypnotic effects).
Negative suggestibility
we have an impulse
is
the counterpart of the positive.
to follow the suggestion of others,
primary an impulse not to follow or to do the opposite.
Just as
we have
as
Children at
a certain age often manifest this negative suggestibility in pure form.
In general,
we
see
it
very distinctly
in
people
who have
46
a strong positive
suggestibility, one reason perhaps being that both kinds of suggestibility are
two
same
sides of the
characteristic, but also because one is
need of protection through the negative suggestibility, the

greater the danger of becoming a prey to the positive. The appearance
in greater
of negative impulses beside the positive

It
is
of the greatest importance.
prevents us from too easily becoming the sport of suggestions,
protects the child in particular against an excess of influences,
the adult to reflect,

of
and
makes
it
it
forces
self-assertion possible at every stage
life.
k)
Dereistic
Whenever we playfully
in
it
mythology,
in
dreams
Thinking
^^
give free reign to our phantasy, as happens
or in
some pathological
states,
our thoughts
are either unwilling or unable to take cognizance of reality and follow
paths laid out for them by instincts and

this "dereistic thinking," ''the logic
totally ignores
affects.
of feeling"
any contradictions with
reality.
It
is
characteristic of
(Stransky), that
Thus the
child
it
and
sometimes the adult fancy themselves in their day dreams as heroes or

inventors or something else great; in one's night dreams one can realize
the most impossible wishes in the most adventurous manner; and in
his hallucinatory state the schizophrenic day laborer marries a princess.
Mythology finds it quite natural to allow the Easter rabbit to lay eggs
simply because it happens that rabbits and eggs have one thing in
common, namely, they are both sacred to the goddess Ostara as symbols
of fruitfulness. The paranoid finds a piece of thread in his soup which
proves his relationship to Miss Threadway. Reality which does not
fit in with such modes of thinking is frequently not only ignored, but
actively split off, so that, in these connections at least, it is no longer
possible to think in terms of reality. Thus the day laborer as the fiance
of the princess, is no longer a day laborer, but the Lord of Creation
or some other great personage.
In the sober-minded forms of dereistic thinking, particularly in
day dreams, there is very little disregard or transformation of actual

situations, and only few absurd associative connections formed. On the
other hand, dreams, schizophrenia, and to some extent mythology", exfreedom in dealing with the thought material, where,
give birth to himself. In these forms dereism
goes so far as to destroy the most common concepts: Diana of Ephesus
is not Diana of Athens, Apollo is split into several personalities, now
he blesses and now he kills, he is a fructifier and he is an artist; indeed,
ercise far greater
for example, a
God may
* Derived from de and reor (away from
reality, unrealistic).
46
he
may even be a woman
although he
schizophrenic demands damages in a
mass
the
is
ordinarily a
sum
of gold
man. The interned

which would exceed
of our entire solar system a trillion times.
calls herself free Switzerland,
because she should be
female paranoid
free.
Similarly in
other cases, symbols are treated like realities, and different concepts
Persons appearing in dreams of normal people

a normal woman with-
are condensed into one.
usually have features of several acquaintances
out being aware of
was due
it
speaks of the "hind-legs" of her small child, which
to the fact that she
had fused
it
with a frog.
Dereistic thinking realizes our wishes, but also our fears.
the playing boy a general, and the
girl
It
makes
with her doll a happy mother.
In religion it satisfies our longing for eternal life, for justice and joy
without sorrow. In the fairy tale and in poetry it gives expression to
it serves to represent the person's most
For the abnormal person it creates a reality
which is
real to him than what we call reality. It makes him
happy in his delusion of greatness, and absolves him from blame if he
fails in his aspirations, by attributing the cause to persecutions from
without, rather than to his own short-comings.
If the results of dereistic thinking seem to be sheer nonsense when
measured by realistic logic, still, as an expression or fulfilment of
wishes, as a provider of consolation, and as symbols for other things,
they possess a kind of realistic value, a "psychic reality" in the above
all
our complexes.
and
far more
secret wishes
In dreams
fears.
defined sense.^*
may also be satisbut as yet we know very little about them.

Thus in mythology, the sun which travels across the sky has feet or
rides in a carriage. In a certain sense, however, all "needs" are affecBesides the affective needs, the intellectual ones
fied in dereistic thinking;
At any rate, affectivity plays an important role in dereistic

when it attempts to give us information regarding the origin
the world and the structure of the universe.
tive.
thinking
of
development dereistic thinking seems to be different in

from empirical thinking. But in reality one finds all the transitions, from the slight deviation from acquired associations as is
necessary in every conclusion drawn by analogy, to the wildest
In
its full
principle
phantasy.
For,
thought
find
new
within certain limits,

is
independence of habitual trends of
a preliminary condition of intelligence, which strives to
paths.
And
the effort to fancy oneself into
day dreams and similar occupations are indispensable

intelligence.
**Cf. p. 7.
new
situations,
exercises of the
47
sure, the contents and aims of such unbridled mental acalways represent strivings which most deeply touch our innermost nature. It is therefore quite obvious that dereintic aims are valued
much higher than real advantages, which can be replaced.^'-' This not
only explains the peculiar barbarities of religious wars, but we can also
understand why primitives are fettered with taboo rules, and similar
superstitions, and why they exert the most painstaking efforts not to
leave a particle of their food which could give an enemy the chance
to practice harmful magic on them. We can also see why we find it
difficult to understand how the savage is willing to bear such burdensome regulations, even if we compare them with Chinese or European
To he
tivities
rules of etiquette.
which determine
from reality:
1. We think dereistically wherever our knowledge of reality is insufficient for practical needs or our impulse for knowledge urges us to
keep on thinking; this happens in problems referring to the origin and
purpose of the world and of mankind, in problems dealing with God,
the origin of diseases, or evil in general, and how it can be avoided. The
greater our knowledge of the actual relationships, the less room there
remains for such forms of thinking. Questions, such as how winter
and summer come about, how the sun traverses the sky, how the
lightning is flashed, and a thousand other things, which were formerly
left to mythology, are now answered through realistic thinking.
2.
Wherever reality seems unbearable it is frequently eliminated from
our thinking. Delusions, dreamlike wish fulfilments in twilight states,
and neurotic symptoms, which represent a wish fulfilment in symbolic
form, originate in this way. 3. If the different co-existing ideas do not
converge in the one point of the ego to form a logical operation, the
greatest contradiction can exist side by side, there is no question of
any critique. Such conditions are present in unconscious thinking and
perhaps also in some delirious states. 4. In the forms of associations
prevailing in dreams and in schizophrenia the affinities of empirical
thinking are weakened. Any other associations directed by more accidental connections, such as symbols, sounds, etc., obtain the upper
hand, but this is especially true of those guided by affects and all kinds
It will be interesting to trace the circumstances
so
marked a deviation
of thinking
of strivings.
1)
Belief
The word
is
Belief, Mythology, Poetry, Philosophy
closely related both to suggestion
"to believe" has two meanings:
'^Cf. the next chapter
on
"Belief."
"To
and to
dereistic thinking.
accept something as true
48
without logical proof," and "to consider something as probable."

confine ourselves here to the former concept.
The
We
greatest creeds in religion, politics, theories of social position,
maintained almost entirely through suggestion. Sugresponsible for the uniformity in forms and details,
and to some extent also for the motive power of belief. The origin of
belief always proceeds in accordance with the laws of the affective
esthetics, etc., are
gestion
is
above
mental stream
all
in dereistic thinking.
as a definite gratification
of
The
several great creeds serve
general affective needs, and for this
reason they are so easily suggestible and possess such great power
that in most cases
one assumes these ideas without any
logical
We
wish to know that something happens after death

we wish to feel that we can influence fate. The beatiis possidetis
who, in the face of misery, wishes to establish his position on moral
realitic value.
and the sick person who wishes

become well and therefore believes in the quack follows the same
mechanism.
We also differentiate between belief and superstition; the latter
contains a great deal of magic which operates with unknown forces,
while belief has to do more with religion which deals with our relations
to a higher being. But viewed psychologically, there is principally no
difference between them the main difference lies in the valuation which
Belief becomes pathological only
is measured by different standards.
when it dominates the psyche far too much and when it glaringly conflicts with the logical faculties and eventually also with the views of
the individual. But from this alone, and without other supporting
grounds, acts in the same way;
to
points I should not like to
make
a diagnosis.
applied to false belief or to superstition,
when
The name
it
to matters of religion, or to one's relationship to fate.
the prejudices of the people in the recent
individual for another.
Prejudice
may
war
of prejudice
is
does not refer contently
This varies from
to the prejudice of one
at first actually be based on a
mere hasty judgment; but it can only derive its power from affective
sources by way of dereism or suggestion.
Poetry and mythology satisfy the same need as belief, with the
difference that the former lays no more claim to direct realistic value
than the day dreams of normal people. Philosophy differs very little
from it, in so far as it actually is pure philosophy. (For there are some
real sciences classified under this name, such as the deduction of logical
and esthetic laws, the theorj^ of cognition, etc.) The current explanations of the optimistic and pessimistic theories as a characteristic expression of the philosophers originating them, perhaps most clearly
demonstrate the subjectivity of philosophy.
m)
Most
The
Personality,
of our psychic functions
49
The Ego
have a continuity,
in so far as the
experiences become connected with one another through menriory, and

in so far as they unite with a very firm and constantly present complex
of
memory
pictures and ideas, namely, the ego, or the personality. To

all our experiences plus the
be exact, the ego consists of the engrams of
By
we must not merely understand

our former and present volitions and
strivings; the ego thus really comprises our entire past in a very abbreviated form. Still, not all of these constituents have the same value.
At a given moment most of them recede until they lose all effectiveness,
actual psychism.
this, of course,
passive experiences, but also
that
is,
all
they are not ekphorized
The composition
others are usually, or always present.
of the ego of individual
memory
images,
may
be com-
pared to the "public" in a certain restaurant; individual frequenters

go, some are constant visitors, others come frequenth',
and still others have visited the place only a few times. It is true that
I have learned to extract square roots but in my present activity this
knowledge is almost altogether latent. Certain ideas, however, such
as who we are, what we have been, and what we are now, what we strive
for in life, must be constantly more or less clearly present. They are
part of the directive power of our daily actions. The fact that a student
goes to the class at the right time is not merely determined by the idea
of the hour and his schedule, but among other things also by that of
wishing to study, and by the point at which he has arrived in his study.
Thus personality is not something changeable. The component
may come and
parts of
its
ideas change constantly in accordance with
aims, but also in accordance with experiences.

distinction between the strivings of the
man and
There
momentary
is still
a greater
those of the child; and
life such as depression determined b3' inner causes and

even toxic influences (alcohol) may, within a very short time completely transform the affective part of the personality, which in some
In a similar manner as in severe
respects is the more important.
psychoses, the personality may go to pieces in the dream. Some parts
the destinies of
of it fall away and are replaced by others that are quite foreign to it.
Thus a dreamer who in ordinary life is unassuming may feel himself
as being King David, a gentle person may commit a murder, and a
hard-hearted
man may wallow
in benevolence.
We
also often attribute to the person a special personal consciousness or a " self -consciousness." ^'^ These two expressions contain two
^^
In popular psychology the expression ''self-consciousness" has a different but
important meaning, namely, estimation of oneself.
I"
50
former represents the continuity of the person, ^the

ego of a normal person has the feeling of being the same through life
the latter deals with the fact of rendering the person prominent and
distinguishing him from the environment, and particularly from other
sets of ideas, the
was assumed that the child had no self-consciousness, and

prove this it was argued that the child does not correctly distinguish
people.
to
own
its
is
It
person, in so far as
it
speaks of
itself in
In principle the child differentiates
wrong.
the third person.
itself
This
from everything
else
from other people just like the adult. That it speaks of itself
in the third person has its obvious reasons which may be sought in
the manner of teaching language to the child.
and
also
The Centrifugal Functions
n)
To
assert oneself or the genus in accordance with the
psychic apparatus, to
self against
it,
is
form of
would
off.
aim
of the
use of the environment or to defend one-
expressed in every psychism in a tendency to react,
In a more complicated being this finds expression

If we perceive something beautiful, we
or in a striving.
in the
make
affectivity.
like to enjoy
Besides this
it,
and
we have
if it is
unpleasant we would like to ward
number
it
which become effective

these we may mention the
of strivings
even without any external cause. Among

impulse to live, the activity impulse, the self-assertion impulse, the impulse for knowledge, hunger, and the sex impulse. The activities in
the sense of these strivings are also connected with pleasure. The inPrincipally
stincts of animals evidently represent the same thing.
there
is
really
no
line
of
demarkation between these two kinds of
strivings.
In the countless strivings and exciting experiences many conflicts

and inhibition must frequently arise. One would like to rest and at
the same time drink some water which must be brought from the well
one would like to be virtuous and at the same time get rid of his sexual
tension.
same
Even for physical reasons one cannot do many things at the

The inhibiting effect exerted by contrary impulses upon
time.
one another represents only another special case of the general law,
namely, that central functions not having a similar aim inhibit each
other. But if the force of one impulse is not very much stronger than
that of the other, there results a competition, whereby in the "reflection"
or in the "choice between good and evil" each impulse attracts associatively the material resembling
And under
to
it,
certain conditions
it
may
it,
in the sense of negative suggestion.
tional complexes
and
which
intellectually
also attract that
Thus
affectively.
is
contrary
arise different func-
which act as a whole, and of which one
finally asserts
itself
and dominates
in
such a manner that the other
is
51
"suppressed."
We designate this as the decision or the act of volition.

In a serious struggle of impulses, as for instance in a decision between good and evil, the material brought into play includes our virtues
and vices, our entire ethical training, former decisions to be good or to
disregard moral standards, as well as our experiences in former violations of ethics; in brief, it involves the whole personality; "the
decision belongs to
Thus we
it."
see that the "will"
not merely as regards

strong will,
every new
(1)
entirely dependent on the affects,
He
and
has a
swayed by
we understand quite different disweak affectivity without motive
possesses energetic feelings which are not
impetus.
positions:
power
who
is
direction, but also quantitatively.
its
it
(Abulia), ^^
By
may
(2) it
weak
will
represent a
may
evince an affectivity that
labile, too easily changeable, one
who
road to hell with good intentions, or
is
lively
but too
follows the crowd and paves the

(3)
for various reasons one
is
unable to form any decisions.
The much mooted question whether
there
is
a "jree will" in the
sense that a decision can be reached without any reason, does not
in natural science.
We
exist
see that the actions of living beings are de-
termined by the inner organization and the external influences reacting

upon them in exactly the same manner as any other happening. There
is no decision which does not have a complete causal basis in motives
and strivings. But motives and strivings are either a complex of

nervous functions, which is subject to the ordinary psj'chic laws of cause
and effect, or something analogous to these nervous processes, which depend on physical as well as psychic causes. "Motives" are causes even
though they are complicated. Science is therefore deterministic even
in those cases
where
it is
not fully admitted.
that one acts badly "because he
is
that he himself has not selected his

inherited
it
when he came
bad
own
To
we assumed
we also know
be sure,
fellow^" but
organization but that he has
into the world, or that
by some influences or other exerted on the
it
has been changed
brain.
Nevertheless, the subjective feeling of being free in one's decisions

is
not an illusion in the real sense.
own
Our
actions are the outcome of our
but as some of these contradict each other, the reaction

follows exactly our feelings in the direction of our strongest impulse.
The act of volition is therefore in harmony with the momentary- aims
strivings,
psyche as a whole, that is, with the personality, with the comwhich comprises all strivings and in which the latter can form
a resultant. TTê do what we ivish because we wish what v:e do, or to
of the
plex,
"Abulia as a consequence
of inabilitj^ to reach decisions, see p. 143.
52
it objectively: Volition and action is one process, the two sides

which are individually rendered prominent. This has an analogy
the physical sphere, namely, when all the conditions of a process
express
of
in
or a state are present, then the result or the state
a mistake to think that one could wish, that
is,
is
also present.
It is
something else.
make this mistake
act,
However, one can covet only something else. We

wherever we form an insufficient estimate of the causes, even in the
physical realms; the concept of accident is based on this. If a brick
falls from the roof and strikes the ground near a person, he says, "I
could have been struck by it."
The
dispute concerning the conception of the will
example of the power of emotions.

is
the only possible conception.
is
Scientifically viewed,
And
yet
many
a striking
determinism
people cling to indeter-
minism although they cannot even follow the thought to any
clear
conclusion, the moralist, because he has falsely based his ethics thereon,
the theologian because in spite of the contradiction with God's omnip-
otence he needs
it
for his actual ideas, the jurist because he thinks that
otherwise his laws, particularly the penal code, will be shaken. As a

matter of fact it makes no difference in practice which point of view
The penal
one holds.
code, for instance,
would not have to change a
single one of its provisions, but only a few expressions,
if it
accepted
the theory of determinism.
Among
the various impulses of
man
the nutritive impulse, which
a part of the self-preservation impulse,
is
is
greatly denatured in our
present condition and therefore difficult to study.
But the sexual im-
pulse is still clear to us. It shows us how tendencies of pleasure and

displeasure impel us to actions whose natural aim (in this case the
preservation of the species) may be unwelcome to us, or not become
conscious at
all.
This
is
the case, for instance, in the choice of clothing
approach of the sexes.

are defined as a
which
It also teaches us to understand the instincts,
aims
will be fulfilled
manner
that
certain
capacity to act in such a
and without
being
considered,
known
without
without becoming
or
and
practice.
training,
acquisition,
necessity
of
any
particular
the
The ethical impulses are of particular importance for every being
living in society. They preserve the community, and hence they often
conflict with the interests of the individuals; they also have a great
many points of contact with sexuality. But it is just as wrong to create
the impression that ethics deals with sex only, as it is incorrect to
follow an ethics of "to &ov7 one's wild oats" and to ignore altogether
the sexual restraints which are originally determined by nature. Nevertheless it is certain that the existing sexual ethics is not adapted to the
and most of the other preparatory actions
in the
demands of modern civilization. Indeed, our form
one hand and the sexual impulse on the other often
way
of sofiety on the
conflict in fiuch a
that even a theoretical solution seems impossible.
conflicts are created
53
As a
which not only are of great importance
result
social. y,
but also medically.
Other definitions of the word "impulse"
will be discussed at the
end
of the section on Psychopathology.
An
effect similar to that of the congenital impulses is exerted
chance apparatus and
The other
"motility"
we
''See p. 50.
by
habits.'-^^
centrifugal
functions,
such as "psychomotility" and
shall pass over as being self-evident.
CHAPTER
GENERAL PSYCHOPATHOLOGY
show such an infinite variety of
them into a certain scheme
and to select what is most important in them. For it must be borne
in mind that although superficially two phenomena may look alike,
they may nevertheless have entirely different meanings, depending on
their psychic environments and on their genesis. Moreover, and this
is even more true here than in physical pathology, every symptom is
The symptoms
of psychic diseases
manifestations that one
is
forced to put
really only a special part of a general process.
described in the spheres of association,
is
What
we, for example,
not simply a disease of the
associations, but a general psychic disturbance,
from which we pick
out one part, namely, that which concerns the associations.
For a scientific study of the psychoses it is necessary to distinguish

between primary and secondary symptoms. Thus a paralysis of the
abducens nerve is a primary symptom, whereas the subsequent contracture of the internal rectus and the diplopia are secondary symptoms. A certain disturbance of mental function in dementia praecox
is a primary symptom while the resulting twilight state following it
under the influence of an unpleasant experience is a secondary symptom. If a paronoic conceives an indifferent experience in the sense of
a delusion of reference, it is in a certain relation a primary symptom,
but the reaction following it, in the form of an insult which is normal in
itself, is a secondary symptom.
The last example also shows that these
concepts are only relative, inasmuch as a fundamental disturbance
often produces a whole casual chain; for the delusion of reference is
already a derivative symptom, in the particular case.
In some diseases it is of value to differentiate between principal and
accessory symptom,s. The former appear in every one of these cases
as soon as the disease reaches a certain height.
One must therefore

assume that in mice they are also present even where we do not yet
see them, that because of insufficient intensity they have not yet crossed
the diagnostic threshold. Among these we have the organic symptomcomplexes, in organic diseases, the association and affective disturbances
in schizophrenics, and the manic and melancholic states in manic depressive psychoses. The accessory symptoms, like hallucinations and
54
may
be absent in these diseases, or they

disappear at any time and in any combinations.
delusions,
1.
55
may
appear and
DISTURBANCES OF THE CENTRIPETAL FUNCTIONS
The
centripetal functions
may
be disturbed through disease of the
peripheral conducting or the central receptive organs. Under the latter

one includes the central sensory fields as well as the whole cortex as
The disturbances
the carrier of the psyche.
in the conducting organs
can naturally only be disturbances of sensation, while those of the

cortex (respectively the psyche) are almost only disturbances of
perception and the first elaboration connected with it, namely,
apperception.
Disturbances of the Sensory Organs

Disturbances of the sensory organs appear in part as accidental
complications and in part as symptoms of individual psychoses, like
paresis. On the whole they are of no importance in -psychopatholog>%
still,
peripheral irritations
may
occasionally become important by pro-
ducing hallucinations through as yet unfamiliar paths. The patient

is often unable to recognize the origin of his paresthesias, and thinks
that noises in his ear are bells, or
what
is
most common, the
sations are interpreted in the sense of illusions.
false sen-
Thus buzzing
in the
conceived as rushing water or as words, shadows and light on

the retina as visions of animals, and nervous pains as physical injuries.
Weakness of the sensory organs influences the psyche during its
ears
is
development and also
Marked
later.
short-sightedness
may
lead to a
deficiency of perspective or to a lack of consideration of a definite

kind.
Thus
the miniature paintings of the poetess Annette von Drosta
are supposed to be due to her myopia.

exerts a very
marked
Absolute bliridness, naturally,
influence on the subjective view of the world,
which in the normal person

ever, change the psyche in
is
its
in the first place optic; it does not.
how-
relations to people.
It is quite different in the case of deafness or disturbances of hear-
With the exception of the modern way of teaching the deaf and
dumb, we perceive the whole cultural achievement of older generations
ing.
directly or indirectly through hearing
and
all
environment are regulated through language.
our relations to
human
(Writing presupposes
Hence the deaf person, without special instruction, remains

a psychic cripple in the most important relations, even if he is intelligent; and as he is unable to put the correct value on the behavior of
his environment, he becomes irritable, hot-tempered, and suspicious.
language.)
56
Even acquired
difficulties of
hearing change the psyche in both of these
directions, wherein suspicion
is
most prominent and
may
even
rise to
the degree of delusions.
Central Disturbances of the Sensations and Perceptions. SenIn

are seldom disturbed through psychotic processes.
melancholic and neurotic states we often encounter a more or less
sations
general hyperesthesia.
The
patients not only suffer
much from
the
usual sensory stimuli, but they also falsely interpret the stimuli. Thus
a dim light may seem glaring, knocking on the door may be conceived
and the sound of a fountain may be taken as the hissing

steam from a locomotive. Hysterical and hypnotized
persons may, under certain conditions, react to the slightest sensory
impressions in a manner unperceived by normals.
Hyperalgesia too, is present in the same conditions and also as a
as shooting,
of the escaping
result of organic processes in the nervous system.
Hypalgesia and Analgesia are quite common; they are centrally determined and present a great many different types.
1. In coma of epilepsy and other diseases, it is assumed that there
an absence of consciousness and hence pain can be as little perceived

else.
In soporose and torpid states the threshold of feeling
is generally raised and the perceived stimulus, too, is of lesser value
than in normal states.
is
as anything
In strong affects attention may be so one-sided that one may not

even the most severe pain; thus the officer may first become cognizant of his shattered arm when he attempts to brandish his sword.
Maniacal patients often injure themselves when in an excited state
without noticing it; but when their attention is directed to the pain
as in a minor operation, they evince great suffering. The complete
2.
feel
analgesia which one often observes in alcoholic deliria, perhaps also
belongs here.
3.
Hysterical mechanisms can shut
pain or confine
it
to
off
altogether the feeling of
circumscribed part of the body.^
But
in
contradistinction to those evincing organic analgesia the hysterical
patients do not injure themselves, for the feelings are only shut off
from the conscious ego but continued to function in the unconscious
orientation.
4.
Peculiar
is
the analgesia in some catatonic patients which extends
over the whole body and can be so absolute, that intentionally or acciIt may
dentally, the patient may sustain the most severe injuries.
conscious
atindependent
of
thereby
rapidly
and
is
very
and
go
come
*This
is
masochists.
not to be confused with the pleasure in fain
some
hysterics
and
GENERAL PSYCHOPATHOLOOY
But even
tcntion.
57
here, one perhaps deals with a blocking of feeling,
of psychogenetic nature.
5.
Hypalgesias and analgesias
in general paresis are
mostly confined
to the skin, while the deeper structures remain sensitive.
can bite out pieces of skin from his hand

but he
when an
extremely sensitive
is
The diminution
losed joint.
paretic
in order to tease the attendant,
effort is
made
to
move
or absence of sensations are to
his ankysome extent

We have no
mostly dependent (but not principally so) on attention.

comprehension for this form of analgesia.
Other hypesfhesias and anesthesias are not common
in
the
Hysterical blindness, deafness, and similar afflictions are
psychoses.
Depressed patients sometimes complain

it feels like chewing straw or paper,
that all colors look equally grey as if covered with ashes, but when
one examines their sensations they are found to be normal. The same
phenomena may be produced in normal persons through a strong debased on (auto-) suggestion.
that their food has no taste, that
pressive affect.^
We
omit here the aphasic and agnostic disturbances because they
surely belong to the pathology of the cerebral cortex and not to the
symptomatology of the psychoses, even if they sometimes accompany

an organic mental disease.
Perception and comprehension show the following disturbances in
They see
idiots.
Idiots cannot comprehend anything complicated.
the elements of an object but not the whole thing. Or they recognize
pictures with difficulty or not at all, while they can readily identify the
same things
in nature
they often lack the understanding for perspective
imagery.
Perception
may
be imperject.
especially alcoholics,
may
In a clouded state, catatonics and
perceive a green head of cabbage as a rose,
a cucumber as a sausage, and an ear of corn as a fir-cone. All this is

due to the fact that they do not comprehend the color or the size in
the whole picture-complex.
On
the surface these disturbances resemble
from them through the fact that the alteration

of the picture has no meaning to the patient and is the same as falsification produced by carelessness. The mistake that brings about the
illusions,
but they
illusions
has a definite aim.
When
differ
made
difficult
by exposing
pictures for a very short time, the following will be noted:
In organic
apperception in the optical
field is
psychoses the perception needs more time and even then the patient
'
and
"The ej-es lose nothing in force

Cf. Goethe (Kanonenfieber bei Valmy)
clearness; but nevertheless it is as if the world assumed a distinct brown-
reddish tone."

58
makes mistakes. In epilepsy the behavior is the same. There

seems to be some difference but it cannot be definitely fixed. At ail
events the symptoms correspond with the general retardation of the
often
psychic processes in the patient. In both groups the tendenc^^ to perseveration expresses itself in the fact, that a later image is mistaken for
In
one seen before (paraphasic disturbances should here be excluded)
and with subjective sure.
alcoholics the answers mostly follow quickly
made and sometimes they

somehow reached the psyche. Thus mistaken
named which, although they show no optic similarity to the
ness; nevertheless mistakes are frequently
show that the

objects are
real picture
picture exposed, they nevertheless are in
some way related to
it.
For
example, the picture of an axe brings the answer shovel, or the image
In all these
of a number may evoke an entirely different number.
diseases the results
so that one
is
may
be improved through exertion of attention,
often inclined to ascribe such mistakes to inattention
which would be incorrect. In profound melancholic states the apperception must be given more time if one wishes to avoid an abnormal
number of mistakes. Manic states show nothing characteristic in the
habitual perception of their environment, and in tests conducted without
accurate
measurements.
In
laboratory
normal people:
this
experimentation
the
make more mistakes than
patients perceive things incorrectly and
probably does not depend on perception but on the
flightiness of attention
and similar
factors.
Nor
are
we aware
of
any
real apperceptive disturbances in schizophrenia; the mistakes which
occur here so often can be regularly explained by the state of complicated functions of attention, affects, and thinking.
Analogous disturbances, though not so easy to demonstrate, are also

found in the acoustic field. In organic patients particularly, one is
often struck by the fact, that questions
they are correctly grasped; this

another theme.
is
must be often repeated before
especially true
when one changes
to
The most important psychopathic manifestations in the centripetal

sensory deceptions. (Phantasms.) They are divided into
Illusions and Hallucinations.
Illusions are real perceptions pathologically changed. The striking
fields are the
of the clock
the grasped
becomes an insulting remark

hand is hurled back because it
or
is
conceived as a promise;
dead hand; people
feels like a
are seen walking on their heads; instead of the white color of the face,
looks black, and instead of the nurse one sees a waitress. The real
mistaking of personality where some one of the environment is looked
upon as a relative or acquaintance of the patient, or as the president,
it
is
rarely a pure illusion; often
it is
a delusion, as in schizophrenia, and
occasionally
Most
it
is
frequently
59
a semi- or total conscious playfulness as in mania.

it
is
a process belonging to confabulations, as in
organic psychosis.
The
ception
illusion is a caricaturing of a
it is
normal process.
In ordinary per-
we perceive all the qualities of a thing

we unconsciously supplement and those
only exceptional that
in question; the missing parts
that are falsely perceived are corrected in the sense of the whole
Thus even the normal perception
thing.
is
a sort of illusion.
It is
very
not to overlook a printer's errors, and the telephone certainly
difficult
does not give us
all
we
the consonants with the required clearness;
supplement them without being aware of it. It is only a difference in

quality, when during a markedly affective situation a tree stump is
taken for a highway man, or a fog for an apparition of an angel, and
yet the last examples can no longer be differentiated from the illusions
of insane patients.
Hallucinations are perceptions without corresponding stimuli from

Everything perceived can also be hallucinated, and indeed,
without.
this
may
be achieved in a manner, that the elements
combinations; thus a lion
composed
may have
form
wings, and a figure
free
may
be
from different persons. Besides, morbid functions apparently produce inner feelings, which never occur in any
other way.
The
of attributes
theoretical distinction between hallucinations
not always self-evident.
No
sense organ
and
illusions
is
ever quite without
a
stimulus ("Light, dust" of the dark fields; entotic noises, etc.), so that
one can almost always speak of a false interpretation of a sensory im-
pression.
As a matter
is
of fact, the so-called visual hallucinations of
alcoholic deliria are illusions based on irritations of the senson," apparatus.
But
among
the hallucinations.
come from without it is counted

In hallucinations of smell and taste one can
as the stimulus does not
hardly ever exclude sensations of smell and taste the skin

;
is
constantly
touched by the clothes, currents of air, as well as similar stimuli.

One cannot decide whether one deals with hallucinations or illusions
coming "from" the whistling of the wind or the

wagon, which are perceived simultaneously with the noises
causing them.
In most cases the differentiation is simple. Visions which are not
connected with definite objects are undoubtedly hallucinations, the same
is true of words which are heard as coming from the wall, and this is
especially confirmed in both cases when the optic and acoustic nerves
in the case of voices
rattle of the
many other stimuli.

may be graded according
furnish beside a great
Hallucinations
to three directions: the
60
clearness of the projection to the outer world, the clearness of the perception,
and the
intensity.
These qualities are independent of one
another.
The projection to the outer world is usually perfect. What the

patients see and hear they accept as impugnable reality, and when
hallucination and reality contradict each other they mostly conceive
what is real to us, as unreal and falsified. It is of no avail to try to
convince the patient by his own observation, that there is no one in
the next room talking to him; his ready reply is that the talkers just
went out or that they are in the walls or that they speak through invisible apparatus.
However, hallucinations evince all gradations. There are hallucinations which are recognized as hallucinations but are none the less
perceived with perceptible distinctness (Kandinsky's Pseudo-hallucinaothers concerning which the patient cannot say whether they
tions)
;
are visions or vivid imaginations, whether they are voices or "inspired"
thoughts ("psychic hallucinations"), and so they gradually shade off

until they reach the usual thoughts and ideas.
The patients often localize in the body the voices, and sometimes
also the visions (mostly in the chest, sometimes in the head,
and oc-
casionally even in any other part of the body).

Projection is facilitated through a high perfection of the image.
Still
hallucinations often show the vagueness of ordinary ideas although the

patient often sees, definitely, a "dog," he is nevertheless unable to tell
;
anything about the breed, color, size and the position of the dog. While
the patient himself is never conscious of this deficiency, it may furnish
the physician important suggestions that we deal here with an illusion.
One cannot, however, reason the other way, for there are also hallucinations endowed with the perfection of an actual perception.
Remarkable are the "extracampine" hallucinations which are
localized outside of the sensory field in question.
In the nature of the
thing one deals mostly with visions, the patient sees with perfect sensory
distinctness the devil behind his head, but it may also concern the
sense of touch; thus the patient feels
how streams
of
water come out
come
from a definite point of his hand. Whether
not,
extracampine
or
designated
as
from thousands of miles should be
voices which seem to
is
arbitrary.
Sometimes, and this
is
most frequent
in alcoholic deliria, the dis-
tinctness of the projection fluctuates with the intensity of the disease,

instead of real things, the convalescent alcoholics see in the hallucinations only "images"
which are shammed
for their benefit; other patients
maintain that the voices are only produced to deceive
them or they
are
"dreams."
61
such indistinct projections arc also present at the
Still
height of the disease.

Intensity fluctuates from the loudest reports of a cannon to the
hardly audible whispering, from the most glowing light to the dimmest
shadow. During actual attacks, especially in schizophrenia, the intensity
may
The
rise
and
distinctness
with the intensity of the attack.

sometimes extremely obtrusive;
fall
is
it
may, howand in-
ever, sink to dissipating cloudlike figures, to confused voices

distinct whispering, for the understanding of
to exert
all his attention.
At
all
which the patient
is
forced
events the patients seldom conceive
the indistinctness, for they understand what the hallucination
tells
them.
Of other
tioned:
qualities of sensory deceptions the following
may
be men-
the visual hallucinations of alcoholic dcliria which show a
tendency to be moving, multiform, small, and without color; the visual

hallucinations of touch, in cocaine insanity are often microscopically
small. Visions showing a tendency to become greater and greater and
which at the same time in most cases seem to come nearer and nearer
are usually connected with anxiety.
Hallucinations may be changeable or stable. The voices are often

abrupt and fragmentary. Auditory hallucinations put together in a
dramatic fashion point to alcoholism, particularly alcoholic insanity.
Connected hallucinations which fit together, accompanied primarily

by visual illusions are found in hysterical twilight states, and also in
other cases.
Occasionally one finds one-sided hallucinations, particu-
larly in one-sided lesions of the sensory organs or of the sensory fields
and tracks in the brain.

The relation to the real perception
varies.
Voices can naturally
be localized anywhere, in the next room, in the walls and in open
spaces.
Visions come in conflict with reality.
Thus, behind the
hallucinated man one cannot see anything of reality, or he appears
transparent (ghosts). A hallucinated person can be placed in the
midst of
Thus a skull may be seen over the shoulder of a

In most cases, however, the manifestations are inde-
reality.
neighbor, etc.
reality. The whole environment may be changed halhicinaThus a patient imagines himself in heaven instead of the
pendent of
torily.
observation ward.
The
patients are often cognizant of the hallucinations, not exactly
that they are false sensations, but they feel that there
strange about them.
Thus they know them through
is
something
their different
content, they state that they have feelings that they have never experienced before, for the expression of which they have to coin new
62
words.
normal
in their
They
that they see remarkable images and scenes, ab-
feel
own arms, a
woman. They
localizations, voices in the walls or in their
or in the uterus of a passing
own body
light
also
recognize the strangeness through indefinite projection to the outer
world.
The
in his ears
patient believes that he hears through his leg and not
he does not
know whether he
touches an animal or sees
it.
relation of the hallucinations to the other mental content is

remarkable. At the height of the disease the hallucinations in most
The
cases have not only the reality value which
is
unimpugnable to the pa-
have contently a compulsive power. Thus if a

healthy person would hear a command ("Kill your child"), it would
never occur to him to follow it, but the patient obeys it with or without
That has nothing to do with the form of the command,
resistance.
with the clouding of consciousness, or with the dementia, for the last
named conditions are often absent, but it is due to the fact that the
hallucinations originate from the strivings belonging to the personality
tient but they also
of the patient.
It
is
for that reason that the patients find it so difficult
Thus a paranoid patient suffering from

pneumonia does not bother about the inflammation of the lungs, but oc-
to ignore their hallucinations.
cupies herself with the hallucinated prolapse of the rectum; a real mis-
fortune is barely noticed while the hallucinated one lays claim to the
whole personality. On the other hand, patients in an alcoholic delirium
often view their conditions like an audience in the theatre, and demented schizophrenics may even constantly hallucinate and apparently
pay no attention to it.
Because the hallucinations really only express the thoughts of the
patient, be they conscious or not, it is quite comprehensible how definite
explanations are readily given to apparently incomprehensible hallucinations. Thus a patient hallucinates the word "clean,"
nothing else,
and becomes very excited over it because one means to tell her by this
word that she has soiled the bed. A great many definitely recognize
poisons in hallucinated odors and tastes, the real odor of which they
do not at all know.
This also shows the possibility of teleologic hallucinations which

give the patient good advice or
thing which would

at the last
harm him.
warn or prevent him from doing someThus the dead mother holds him back
moment from committing
suicide,
an hallucinated physical
him from throwing himself out of the window. The

Maid of Orleans is told by the Holy Virgin what to do in order to
conquer, but this only took place as long as the war situation was so
resistance prevents
simple that the
girl's
reason could grasp
similar situation prevails
when
it.
the so-called "voice of conscience"
63
criticizes the actions and thouf^hts of the patient, be they just or evil.
Sometimes warning and enticing, friendly and hostile voices, become
separated into two persons which are endeavoring to persuade the
patient.
Whereas
in one case the hallucinations
conscious personality of the patient,
appear quite strange to the
a circumstance which he uses as
a proof for the exogenous origin of the voices, "Such thing I really have
never thought of,"
in another case
The
the patient's thoughts.
they are intimately connected with
latter case
is
most pronounced
in the
so-called "thought-hearing" (wrongly called "double thinking"), where-
by the
own thoughts seem
patient's
occurs frequently during reading.
can also utter what
is
by others. This
remarkable that the voices
to be uttered
It is
contained in one or
many
lines perceived
by the
eye at the time.
Some
nothing
patients are filled with their hallucinations and can talk of
else,
while others either will not or cannot give any informa-
tion about them.
This
is
particularly true of schizophrenia where the
hallucinations or the memories of
them
are easily blocked from the
other content of consciousness.
Many
patients assume as facts even the
most nonsensical hallu-
Others seek to explain them by machines, or by distant

physical effects of all sorts. Nowadays one seldom hears of demoniacal
influences.
Some patients, who feel that their thoughts are read by
cinations.
others imagine themselves to be transparent.
Still
others believe that
hearing voices signifies the attainment of a special faculty.
Causation of hallucinations. Hallucinations accompany many

mental diseases, toxemias, marked exhaustions, and normal sleep. In
the psychoses their appearance is facilitated by an absence of sensory
stimuli, thus the darkness of the night favors visions, and the quietude
of the prison auditory hallucinations. On the other hand, real stimuli
sometimes act as exciting causes, thus auditory hallucinations may

appear even during a noise. Many patients close their ears in order
to hear the voices well, and others in order to rid themselves of them.
Occupation (distraction of attention) sometimes hinders them and
more seldom promotes them.
Exogenous experiences as well as thoughts may give rise to halluand determine their content when it is more a question of
heightening of the momentary'- disposition. Thus the patient seeing
dishwater carried past him, hallucinates the insulting remark "foodcinations
spoiler," or seeing the grass cut, he feels himself cut with every" stroke
of the scythe.
Other patients
feel
themselves "spooned in,"
if
one eats near them, or hearing a key turned in the lock they
some
feel it
64
painfully in their hearts.

hallucinations in another
hallucinations.
This
is
As
a perception in one sensory field produces
field,
one speaks in such cases of Reflex

an incorrect conception of the
certainly
mechanism.
Visual hallucinations
surroundings and
resistance).
may
They
(visions)
usually come in conflict with the
also be corrected through other senses
are therefore rare during the
day and
(touch,
in clear
At
patients, but they easily dominate delirious and twilight states.
times they lack the third dimension, and more than any other hallucinations they show an indifferent content. Thus the patient imagines
that he witnesses a theatrical performance which has nothing to do
with him.
It is quite different
express as voices
all
insulted, threatened,
with auditory hallucinations.
things that
move man:
and hears the wailing
The
In language they
patient
is
abused,
of maltreated relatives;
on the other hand, he also receives joyous promises, orders, and other
He can enter into conversation with the voices, but in most
cases he need not talk loudly to them, they answer even to his thoughts.
The voices communicate with the patient from any distance, and
through all possible hindrances by means of the most secret paths and
through apparatus, especially invented for this purpose. "The voices"
not only talk but electrify him, poison him, and make thoughts for
him; they become embodied in the persons who have any dealings with
messages.
him.
Auditor}^ hallucinations without words are not so prominent.
ecstasies, fever deliria
and especially
in delirium tremens,
In
one often
hears music and singing but otherwise one rarely encounters this type
of hallucination.
Hallucinations of smell and taste rarely appear alone. In ecstasies

in the later stages of manic paresis, they enhance the
and occasionally
great pleasure;
in schizophrenic delusions of persecution
they reveal
some disgusting and some poisonous substances, including also pitch

and sulphur. Other tastes and smells are only very rarely hallucinated.
Cutaneous sense. The sense of touch {''Haptic Sensory deceptions") hallucinates vividly only in delirium tremens, where small
animals, bugs, tight bands, and mucous threads are felt. They are also
found in connection with bodily hallucinations, inasmuch as snakes
which crawl to the genitals, blows, stabs, and similar hallucinations are
also felt by the sense of touch. The other qualities of the cutaneous
hallucinations are still more difficult to differentiate from the following:
Hallucinations of general sensations of the bodily organs are wont
to appear in great
numbers
in schizophrenia.
The
patients
feel,
how
was turned, the lung sucked dry, the
their liver
65
intestines torn out, the
how
brain sawn apart, and the joints stiffened, or
they are beaten,
Here
burned,^ and electrocuted ("physical delusions of persecution").
belong also the very
common
sexual hallucinations, which seldom cause
pure pleasure, but mostly great pain.

"nature"
is
is
drawn from him,
Women
driven inside of him.
The
patient
his genitals are squeezed,

feel
that his
feels
and
his
semen
themselves violated in the worst
way.
The physical hallucinations can be differentiated from paresthesias

mostly through the fact that the patients feel the former as "done" from
without.
Some authors
associate the physical hallucinations with the self-
preservation impulse, with the affectivity; they are supposed to be in
most intimate relation to the

but what,
is difficult
ego.
There
may
be some truth in
this,
to say.
Hallucinations of kinesthetic sensations are most frequently seen in

delirium tremens, where the patients imagine that they are at work
while they
lie in
bed.
It also
happens, that they suddenly
seat swinging under them, or see objects moving.
feel their
Schizophrenics
may
have the feeling that one of their joints is moved. Instead of expressing
themselves in voices, the thoughts sometimes manifest themselves in
kinesthetic hallucinations of the speech organs, so that the patients
imagine that they say something while in reality their speech apparatus
remains quiet. "Vestibular" hallucinations produce the feeling of
and
floating
falling.
Also pains can be hallucinated, but

entiate
them from other functional
The
it is
not always easy to differ-
pains.
hallucinations of the various senses frequently combine with
one another; thus one sees and hears a

one sees and touches objects.
As elementary
man and
feels his influence, or
hallucinations in the optic field
we
designate such
unformed visions as lightning, sparks, and cloudlike partial darkening

of the visual field, and in the acoustic field, the simple noises such as
murmurs, knocks, and shooting.
Negative hallucinations, or not to perceive an object which is accesour senses, are rare occurrences in pathology but they can easily
be produced in a state of hypnosis through suggestion.
"Retroactive hallucinations" is another name for hallucinations of
sible to
memory.
Many
authors include under the hallucinatory disturbances also the
'Continuous uncontrollable burning in the form of paresthesia
symptom
of a brain lesion.
is
mostly a

66
secondary sensations or synaesthesias. The peculiarity of the latter

the fact that sensations of one organ are accompanied by sensa-
lies in
tions of another sensory
hearing," that
field.
The most common form
is
"color
a feeling of color on hearing of sounds or the vowels
is,
("photism"). However, the secondary sensations have nothing to do

with hallucinations and in any case they have as yet no meaning in
pathology.
The theory
psychiatrists
of hallucinations
who cannot
is
There are
very instructive.
jection of ideas with perceptible distinctness
still
that a prointo space, without the
think of an hallucination,
is,
cooperation of the peripheral sense organs. For they maintain that

under normal conditions only those processes can be projected to the
outer world which are accompanied by the corresponding sensory
But since, as far as we know, we only perceive processes in
stimuli.
the cortex, directly "through consciousness," this conclusion is not
binding, and, aside from other reasons,
hallucinate
It is
when
is false,
because one can also
the peripheral sensory organs are destroyed.
then assumed that there are perception
cells
or perception
and that when they are normally put into

"strong" activity by the periphery they produce sensations and perceptions in the organ of thought (the whole cerebral cortex) and when
put into "weak" activity they give rise to ideas. If we could speak
at all about the "strength" of such processes we would say that it haa
nothing to do with the difference between perception and ideas. And
principally it has just as little to do with localizations. Even the
centres in the cortex;
simplest psychic element, as, for example, the sensory sensation of blue,
is
a far reaching psychic elaboration of the mere incoming stimulus;
just let us imagine the process of singling out the individual color feeling
from the chaos of
synchronous sensations and psychic processes in
all
The pure sensory element
general.
of perception, as the
most vivid
idea or hallucination, must perforce be something just, or nearly, as
Nor
diffuse as the "idea."
is
the most essential part in the "projection
to the outer world," in the "reality judgment," which

or in the substantiality of the latter.
hallucinations, "ideas"
in color, tone,
differ in
reality
and
may
perception,
be so clear, so sharp, so detailed and vivid
in all other sensory qualities that in this regard
they
no way from perceptions, but they, nevertheless, lack the
character of hallucinations or perceptions.
accuracy and substantiality of the psychic structure
much resemblance
not say definitely in
Conversely, the
may
be absent in
may show
most flighty ideas, that the patient could
what words a hallucinated thought was heard,
sensor>' perceptions (in fogs, dawTi, etc.),
so
lies in
In the case of artists or in pseudo-
to the
and hallucinations

67
and nevertheless it may have such an unshakcable rcahty judgment,

as if I saw my own hand in front of me in broad dayli^^ht. The reality
judgment, the substantiality of a true or hallucinated perception,
depends almost altogether on the psychic environment. The difference
between perceived and imagined space is an invention of speculative
psychology. If I looked at the table and then turned my back on it,
it still
at the
I
exists for
moment
me
in the
before,
same true
when
in the
The same
it.
look at a coin on the table and then cover
At
and
reality,
looked at
same place as
holds true
when
it.
the ideas represent reality to the naive consciousness
all events,
just like the perceptions, although one soon learns to

distinction between them.
One
also reacts to
them
make
a certain
as to perceptions
they have the meaning of timely prolonged perceptions. If I run away

from a persecutor, I need not see him or hear him ever>' moment. Thus
we understand
the continuous scale from the most abstract idea to the
one with sensory distinctness of the pseudo-hallucination. The more

one abstracts from the sensory components and from the details of a
physical idea, the lighter
is
the "sensory distinctness."
not, however, altogether determine the reality

stantiality, although
a manifestation
is
it
naturally
"real."
may
another scale, which
is
an idea regardless of
However, the distinc-
less definitely furnish substantiality to
whether the
latter
is less
has sensory vividness or not.
delicate here, in
most cases one
is
simply confronted with the
The appearance
absolute question, "real or not?"
of a saint
ceived by the normal minded modern person as a vision

hallucination), whereas the devout
latter does
contribute to the conclusion that
Besides this there
can more or
tion
The
judgment and the sub-
may
consider
it
(=
is
con-
pseudo-
as a real mani-
festation of the saint.
We
must
distinguish
two types
of hallucinations.
sents ideas projected to the outer world;
The second type represents illusionally

Thus the irritations of the optic organs
this
is
The
first
repre-
the hysterical type.
misinterpreted paresthesias.
in delirium
tremens produce
visions of animals while those of the cutaneous nerves, perceptions of
threads or needles; in schizophrenia the processes of the brain lead at

first
to paresthesias
and hypochondriacal sensations, and then change

It is noteworthy
to physical hallucinations as the disease progresses.
that the relations of the hallucinations to the ego are very close in
schizophrenia and in dreams and very
weak
in alcoholic insanity
and
even in some organic diseases. Delirious patients often regard their

hallucinations as a moving-picture show. Another remarkable thing is
the fact that the manifestations in alcoholic deliria are mostly colorless,
while similar appearances in paresis and other organic insanities more
68
frequently show color the patients speak of variegated butterflies, red

powder spread all over, and blue threads. Hence the second type
;
belongs to hallucinations only insofar as its basic sensory stimulus

originates in the body itself, whereas if conceived in the pure psychic
sense one deals with simple illusions.
Most
of the elementary hallucinations are likewise misinterpreta-
tions of irritating states of the sensory apparatus, nevertheless
it is
naturally also possible that the hallucination of shooting, of running

water, or lightning could sometimes also result from an idea.
DISTURBANCES OF CONCEPTS AND mEAS
2.
mute naturally lack the

Even shortsighted
people must perforce perceive many things somewhat differently from
those who have full vision. Some assume that one cannot remember
odors and tastes, still in many persons such memory pictures form a
part of the concepts of foods, flowers, and similar articles smelt and
Whether this or that sense predominates, undoubtedly depends
tasted.
largely on individual idiosyncrasy. In some it is the optic memory''
pictures which constitute the most important components of their concepts and hence of their thinking, in others it is the acoustic, and in
These differences are of
still others it is the motor memory pictures.
Persons
who
are congenitally blind or deaf
respective sensory components in their concepts.
importance in the pathology of cerebral localization, for a person

belonging to the extreme "visual" type having a lesion in the occipital
lobe is deprived of the most important components of his concepts and
hence sustains a greater loss in his psychic functions than one of the
extreme "auditif" type.
Due to a poverty of associations congenital defectives cannot make
full use of their experiences in the formation of concepts, and conseconnect and combine the individual memory
even of much more importance is the fact that they
do not sufficiently comprehend the concepts which others convey to
them through speech. In this respect deaf persons are worse off, even
quently are
pictures.
if
less able to
What
is
they are endowed with good intelligence. Both classes therefore form
than normal people, and they are very apt to put an
less concepts
They act like little children who may

incorrect limitation on them.
put into the same concepts, let us say, the duck and the hornet
because both fly, and regard the caterpillar and butterfly as different
animal species. They also form insufficient, unclear, and inaccurate
limitations; they cannot, for instance, distinguish between "state" and
"country," or even between "sparrow" and "finch." These wrong and
69
insufficient differentiations are, of course, much more r-ommon and more

profound in idiots than in deaf people, for the former do not note small
differences and are unable to discriminate between essentials and unNevertheless most concepts formed by idiots are not at all
essentials.
unclear; this is not only due to the fact that they form only simple
concepts, but chiefiy because they do not go far from things tangible,
and form few abstract thoughts.
However, there are types of congenital defectives, in whom the most
essential deficiency
is
a lack of clearness in concept formation, but they
have not as yet been
sufficiently studied.
defines the concept "valuable" as:
the cost),
it
will cost
even more."
Thus an
"When you knock
erethic imbecile
it
higher (raise
more remote its coman imbecile to form or to grasp

the same; he might in some case understand the idea of "family" but
not that of "state." However, it would he incorrect to state that idiots
and imbeciles form no abstract concepts, but it may be said that they
do not form complicated abstract ideas, and that frequently their
The more complicated
ponents are, the
a concept and the
less possible is it for
abstract concepts are falsely construed.
Those of a lower order may
grasp the concept of "father" and "mother," but no longer the concept
of "parents"; they can thoughtfully state:
"John
hit
me and
hit
John," but they are unable to comprise this reciprocal activity under
the term "each other" or "one another."
Here, however, the
from those of concepts.
The
This
is
language must be distinguished
not always easy, even in normal people.
and especially those

and education of the French
talk very nicely about things, of
differences of personal disposition, of education
of race are very great.

is
difficulties of
The
disposition
such, that a schoolboy there
may
which he has at most a very meagre understanding. In the German

part of Switzerland with its clumsy expression, the intelligence of
foreigners is at first frequently overestimated in our Swiss clinic Germans, who are more fluent in speech, are not unfrequently diagnosed as
manic cases, and real manic patients often seem much richer in concepts
than they are.
A good fluent speech, congenital or acquired, often disguises real
deep defects of intelligence, be it in society, in school, or even in the
highest examinations, which only goes to show how imperfect these
organizations are. In such cases one speaks of higher dementia.^ and
persons so afflicted sometimes play a great part in life. Thus a famous
"Nature Healer" belonging to this category'", reduced ever>-thing to the
;
"Cf. Also below the "Nature Healer" with his "Principle of Contrasts."
Cf below Oligophrenia.
.
70
"Principle of Contrasts," but he could not distinguish between "contrast"
and
"difference,"
between "power" and stimulus," between
"health" and "feeling of health." In more difficult matters such confusions of ideas may be encountered even in the most intelligent class;
the frequent confusions in the deductive sciences are mostly due to the
fact that two somewhat differing concepts are connected by a common
designation and are then interchanged.
Thus one may admit, that behind the properties of the psyche, there
must be a carrier of the properties, a "being." But if one then deducts
from the concept of the "being," that the psyche is punctiform, lacking
space and time, one finds suddenly that instead of the above concept
of the "being" or the carrier of the observed psychic properties, another
concept has been substituted, the origin of which one does not know and
concerning which it must be proven that it is applicable to the relation-
Another excellent false deduction can also be seen

Cancer may be caused by a cold; for all
physiological reactions, hence also those leading to cancer are conditioned by an "irritant," and cold is surely an "irritant."
Symbols or concepts having one or many common components, are
also used by normal people, but more so by patients. This gives rise to
many coarse errors of thought, for instead of conceiving something as
a mere figure, it frequently takes the place of the original concept,
ships of the psyche.
in the following reflection:
thus the
it
fire of
love
seen as red-hot, or the patient actually feels
is
burning him.
In psychoses, concepts may be profoundly distorted. "Right" to a

paranoiac is usually what suits him, and "justice" becomes
hypertrophied in the epileptic patient who feels justified in almost
litigious
killing another patient, because the other
physician in passing.
brushed against the attending
conglomerate of concepts, as well as markedly
distorted concepts are found only in schizophrenia
clouded consciousness.
and
in states of
Nevertheless one observes nothing here that
cannot occasionally be found everywhere to a lesser extent.
Many
patients experience things which are
unknown
to normal
must create new concepts. Thus a

that the "Double polytechnic" is her highest
persons, for which the patient
paranoid praecox said
and accomplishment which she claimed as her due reward,

meaning the path of
the hallucinatory influences.
New concepts are sometimes created
intelligence
or another patient speaks of the "Dossierpath,"
through the process of "condensation" in so far as attributes of

persons are fused in one.
The mental
cially in
elaboration of concepts
is
many
frequently imperfect, espe-
dementia praecox, which causes temporary mistakes, thus
71
and hoop, or even father and mother, may be identified with

The boy who phiyed sexually with the patient in her
childhood, her lover, her seducer, two physicians in the asylum to
whom she transferred her love, all these are thought of by the patient
as one person. In most of these cases we do not deal with a permanent
injury. That an advanced paretic can no longer think of a complibarrel
one
anotlier.
cated concept like "logarithm" or even "state," in
its totality, is
urally the result of a disturbance in his associations.
nat-
Nevertheless, an
actual destruction of the concept has not yet been demonstrated in the
If a patient looks upon the attendant as his sister, it is
psychoses.
not the result of a disturbance of a concept, but
it is
due to an
illusion
or delusion.
At
all events,
the anomalies in the formation, retention, and in the
transformation of concepts have not yet been sufficiently studied.
Disturbances of ideas naturally exist insofar as the psychic procDisturbances of perceptions, of memory
esses in general are disturbed.
mental stream, must secondarily lead to disturbMoreover, it actually happens that the specific quality
of ideas becomes blurred by the fact that the ideas become transformed
into hallucinations, or they are mistaken for earlier experiences.
pictures,
and
of the
ances of ideas.
3.
DISTURBANCES OF ASSOCIATIONS AND OF THOUGHT
General Facilitation of the Psychic Processes. Flight of
Ideas.
Even normal persons who are "in good humor," or "stimulated"

sometimes give the subjective and objective impression as if their
thinking process ran with particular ease. Such people have more to
say, and sometimes utter thoughts which are not habitual to them,
especially jokes, even quite daring ones. To be sure, such performances
cannot always stand the test of criticism. In pathological states,
mostly in connection with euphoria and exalted self-reliance, we often
find a morbid exaggeration of the afore-mentioned state, which is
designated as flight of ideas. Here the most striking phenomenon is
the exaggerated distractability which at first comes from within but
later also from without. The patients change their objective idea with
abnormal frequency, and in the most serious cases it follows every
thought uttered or indicated. Thus a patient wishes to tell about a
trip to the Righi Mountains and he suddenly thinks of the donkeys
which were used there before the construction of the railroad, then of
salami sausage supposed to be made of donkey meat and then of Italy
where these sausages come from. In less severe cases the patient is
,
72
able to revert to the original theme, or he merges into a thousand and
one things, being unable to bring a single thought to completion.
But,
except in the most difficult cases where the patient's thoughts can no
longer be followed, or where the intermediate connecting thoughts are
how thought is distracted. The secondary associations which also appear in normal persons but which
not uttered, one can understand
they suppress, absorb the patient to the same extent as the principal
theme.
The
reenforced distractability from without
may
be lacking, but
in
most cases it is very noticeable, in so far as every sensory impression

which impedes the flight of ideas is immediately elaborated into the
Thus seeing the doctor's watch chain he
patient's garrulous talk.
speaks about
it,
or hearing the jingling of coins he immediately talks
This enhanced distractability may also be described as a

disturbance of attention in the form of hypotenacity with hypervigility.
Both subjectively and objectively one gains the impression that the
of dollars.
flighty patients think
more
rapidly.
However, the correctness
of this
cannot be demonstrated experimentally. There is no doubt that the

patient spends much less than the normal time on the individual ideas,
which also accounts for the fact that they are insufficiently elaborated.
Thus flighty thinking is not aimless in content, although its aim is
forever changing.
It
shows a preponderance of external and word
associations at the expense of inner associations, which connect the
ideas according to logical sequence following the actual mental trend

in the
form of associations of super-order, sub-order, or causality.^
In
may
be accidental connections, as
Salami, Italy, instead of the journey to the Righi, which do not even
emanate from the sense of the word but from its sound, as seen in
place of inner associations there
association types of
Thus to the word
rhyme and word completions.
"bird" a manic patient answered: "Birds of a feather, flock together."
The
showing
following example taken from the production of a patient

flight of ideas will serve as ar^ illustration:
the president of the U.S.?"
"I
am
the president, I
Question,
am
"Who
is
the ex-president
have been a recent president. Just at present I

many towns in China, Japan and Europe and
Pennsylvania. When you are president you are the head of all, you
are the head of every one of those, you have a big head, you are the
smartest man in the world. I do testory and all scientist of the whole
of the United States, I
was
present, president of
' One of the main headings in the classification of associations is "Coordination" which includes associations of co-order, super-order, sub-order, or contrast.
Examples of super-order are "fly," "insect" "water," "ocean." E\amples of
sub-order are "forest," "trees" "animals," primates," etc. (Editor.)
world.
The
patient)
ho has black blood, yellow blood, he
woe-man,
all
a titled
is
anotlier
no man, a woman, a
"
etc."
The stimulus word "key"

have
am
(pointing to
highest court of doctoring, of practicing,
lady by birth of royal blood of rose blood
73
the
elicited
following:
"Oh you can
the keys you want, they broke into the store and found peas,
what's the use of keys, policeman, watchman, dogs, dog shows, the
spaniel was the best dog this year, he is Spanish you know, Morro
Castle what a big key they have (refers to a visit in Cuba) Sampson,
Schley, he drowned
them
all in
the bay, gay.
way, the White Way, etc." ^

One can always note a weakness
Even
judgment.
if
New York
bay, Broad-
in the patient's reflection
and
they bring to the surface some ingenious thought
and are able to utter truths which would not occur to normal persons
or which they would suppress, such productions are in most cases
extremely superficial in judgment, they are one sided and hasty, and
are deficient in some of the necessary factors. Wherever the choice of
impressions and ideas are inadequate there is also a lack in orderly
arrangement.
Whenever one
gets the impression that the patient's
achievements are above the average
it is usually due to cessation of

and not to an acceleration of his mental facilities. The
average person cannot say some things, he cannot even think of them,
because of consideration for others or himself or because an inner
critique keeps him back, the flighty patient, however, ignores such
reflections or they never occur to him, he knows no embarrassment.
Sometimes, especially before merging into a depression or into a
manic depressive mixed state, the patients firmly adhere to an apparent
aim but leave out all logical connections. Such persons limit their
productions to a series of names of persons, places, offices, etc., some
individual parts of which besides being linked through the general
superordination of the ideas, are also associated through sound
inhibition
similarities.
Flight of ideas
complex.
is
an
essential
component
of the
manic symptom-
Similar mental disturbances also occur in exhaustion and
perhaps also in toxemias.
In
all
between the individual forms, but
probabilities there are distinctions
we do not know them
as yet.
Flight of ideas does not represent a simple acceleration of associations. Liepmann endeavored to explain it on the basis of a disturbance
of attention, but one gains nothing
the other
'
*
way
by
Given by
Givên
by
it
as one can just as lief reason
and explain disturbances of attention through flight of
editor.
editor.
74
ideas.
We might venture the
following conception: Regulated thinking
conditioned by the fact that the hierarchy of the leading thoughts

inhibit all ideas not belonging to the theme. As we must also assume
is
in other cases, the inhibiting resistance obtruding itself is relative in

its
action.
As intrapsychic functions
manic patients
are only too easily stimulated in
the patients feel a bubbling over of thoughtsthe
stimulus threshold seems smaller and the relation between inhibition

and function is disarranged. In view of all that, the resistance exerted
by the leading thought no longer

are unrelated to
suffices to inhibit associations
which
it.
Melancholic Retaedation of Associations (Inhibition)
retardation of the train of thought, already noticeable in sad
normal persons, is present in cases of morbid depressions; the entire

process of thought proceeds slowly and in a laboriously subjective
manner. It is difficult, and often impossible for the patients to change
the idea controlling them; this preferred idea deals with their imagThe patients are frequently aware of
inary misfortune (monideism)
their poverty of ideas and perceive it as dreary and monotonous. Ideas
which are incompatible with the depressive thoughts can be touched
upon with difficulty or not at all; so that judgment becomes considerably warped and the development of delusions is made quite easy. On
superficial observation the patients sometimes even give the impression
.
of feeble-mindedness.
Associations in Organic Psychoses
The number
of individual
concepts simultaneously available to
patients suffering from organic psychoses
is less than in normal; this

can be most readily demonstrated when the patients attempt to do
examples in arithmetic. Whereas normally the patients were able, for
instance, to do mentally an addition of four-digit numbers, they can
now only add one one-digit number to a two-digit number without forgetting the problem. The characteristic restrictions of organic disturb-
ances
is
shown by the
fact that the selection as well as the rejection of
associations occurs mainly in the sense of the affective trend.
ever
it is
antagonistic to the particular impulse are left out.

this,
one
Where-
primarily a question of affects or impulses, the associations
may
cite
As examples
of
the former morally senile patient, who, in a state
and abuses it
some tempting object under the
eyes of a few dozen spectators and conceals it under his clothing, or
the paretic who jumps out of an upper story window in order to pick
of sexual excitement sees only the female in the child
sexually, or the paralytic
who
steals
GENERAL PSYCHOPATIIOLOGY
up a
fallen cigar-stump
(Kraepclin).
7o
senile patient
is
capable of
praising his mother as a saint and immediately thereafter merge into
another constellation and have nothing but evil to tell about her.
This restriction of thought for the time being to a specific cluster
of ideas physically speaking,
through a key-hole,
is
like
an attempt to get one's bearings
exposes the patients to the danger of committing
great stupidities; they enter into business undertakings without considering risks,
they contract foolish marriages, or commit similar
foolish acts.
When only a few ideas can be grasped simultaneously, an orderly

arrangement of them becomes difficult. Thus a patient states that he
was born in 1872, he knows that it is now 1917, but nevertheless thinks
that he was 62 years old ten years ago. He comes to this conclusion
by subtracting 10 from 72 instead of from his present age. The comay also be affected.^
Furthermore, a restriction of associations may also be due to the
ordinating associations as such
fact
that
especially
senile
patients,
and
less
so
paralytics
and
Korsakoff patients, become more and more egocentric and are particularly fond of concerning themselves with their own pleasures and
woes, often in a very petty fashion.
Nevertheless, they are much
more capable, than,
themcan still grasp them. They

are especially capable of showing a very affective and exaggerated
for instance, organic epileptics, of occupying
selves with other things, in so far as they
interest in the affairs of their friends
the patients find
it difficult
and enemies.
In conversation
to pass from one thought to another.
Even
where primary comprehension is still quite good, they answer

to a question which does not exactly belong to the particular subject,
frequently they answer only after numerous repetitions, or in the sense
of the former trend of thought. It thus often happens that they still
continue to give information about personal matters when that topic
has long been finished and when the question may refer to their
in cases
education.
Besides those mentioned there are other mechanisms which often

prevent the patients from leaving an idea. Thus in an association test
they will repeat again and again an accidental reaction word, and in
a perception test they will call a penholder a cow, if the picture of
such an animal has previously been shown them [perseveration).
The duration
of time of associations in organic patients is retarded

This is especially seen in cases of senility, where one
sees additional accessory processes, which hamper and retard the
in
most
cases.
psychic processes, such as cerebral pressure and other

"
Cf. also "Orientation," p. 32.
phenomena that
TEXTBOOK OF PSYCJIIATRY
76
Retardation shows
are not yet well understood.
itself
with especial
regularity in experimental associations; but in such cases difficulty

of comprehension
may
play a part.
Here the associations are emoand contain many lepetiideas, and partly to poverty of
tionally accentuated, very closely related,

tions, partly
due to perseveration of
The
thought.
patient finds
it
or impossible to restrict the
difficult
reaction to a single word.
made
diagnosis can frequently be
few moments from the
in a
continuous associations showing the garrulous organic type, which

would have been impossible to do before, when nothing characteristic
could be sufficiently emphasized in the description of the case.
most cases
In
a question of a slow progress of the course of ideas

with a tendency to repetitions. The utterances often express a pronounced affect in its content, which is even more marked by its emphasis.
it is
Sometimes one hears nothing but wailing or boasting, with
or without a definite theme.
through
rather than
the
through the emotional accentuation
It is
greater
mobility
and better
intellectual
coherence, that such out-pourings are distinguished from the lamenta-
whose
tions of depressive Schizophrenic cases,
affective expressions,
even when present, hardly ever conceal a pronounced rigidity. Typical

associations may be seen in the following:
"My dearest Doctor, "I'm all wrong, O God in Heaven have pity
on me. Father in Heaven be compassionate. Dear good Doctor, help
me.
Let
me
take pity.
Heavenly
out.
Why, I'm
capable of that.
father, please don't forsake
do anything
I can't
my
quite right in
else,
mind.
me.
I'm not
Will you please
dearest God.
No, no, no,
must go away, do be merciful.
Doctor, won't you be merciful?
Jesus Christ, take pity on me.
There
My
judgment
Have pity on my
every inch of me.

is
important.
is
is
wrong.
something the matter with

There is nothing else that
Doctor, do forgive
sinful self,
me
once more."
Experimental associations ^ are very characteristic in the more

pronounced cases; if there is no question of epilepsy, which exhibits
make
The impoverishment of
similar peculiarities, the associations alone are often sufficient to
the diagnosis.
All reactions are retarded.
removed
word "green,"
the green outside." As in
ideas manifests itself very clearly in reactions that are not far
from the
test word,
and
in generalities, thus the stimulus
gives the reaction, "It's everywhere; green
oligophrenic
cases,
large
number
of
the
tautologies, definitions, designations of places,

^''
Brunnschweiler,
Diss. 1912.
reactions
and the
consist
like.
Ueber Assoziationen bei organisch Deraenten.
in
But even
Ziiricher,
these tend readily to be blurred, thus the
77
word "family"
is
reacted to
with "Something in the house there." Educated patients get around

their poverty of ideas by means of near-by association of words. The
perseveration tendency often strongly preponderates.
shows
itself in
many
The
affectivity
reactions as in epileptic cases, but with a
lower valuation, sometimes
it
much
evinces itself in just bare interjections:
Complexes show
Righto Oho! righto; or table what-the-dcuce.
themselves directly and without repression. Egocentric reactions occur
frequently, and are said to be quite banal, particularly in paralytic
"I don't know of anything bad," and to consist of
cases, thus, "bad,"
reminiscences of former experiences in senile cases, thus: "mountain,"
"I
was once at Horgen mountains, from there I had to go home

from the barracks on foot." As has been mentioned, when the disease
has reached a certain stage, organic cases are no longer capable of
answering with a single word, they cannot isolate the concept, they
must tell the whole idea, or the thing which affects them.
The associations of states of organic confusion have not, as yet,
been the subject of sufficient research. But one can often recognize
even in the confusion the described type of the actual disease.
Schizophrenic (Dreamlike) Disturbances of AsoOciation
(Zerfahrenheit of Kraepelin)
Whereas the empirically acquired
structures of associations are
not loosened in flight of ideas and impediment of thought as well as

in organic disturbances of associations, their effectiveness is restricted
Neither a manic patient, nor a sound person thinks

modern Italy at the mention of the name of Brutus. But a schizophrenic, by disregarding the component of time connected with the
in schizophrenia.
of
Roman
an "Italian," or he can designate the location

and the Congo State," by again ignoring
the periods to which each of the states belong, and at the same time
exchanging in a most bizarre manner the most immediately obvious
place designation (say, "the Northeast of Africa") for one altogether
term, can call the

of
Egypt
as "between Assyria
peculiar.
Although the following two productions lack clear objectivity the

theme which happens
patients nevertheless stick almost perfectly to the
to refer to ancient history narrative of the Orient.
The
individual
seem accidental or stimulated through sound or other

factors foreign to a normal person.
They differ from flight of ideas
through the fact that a normal person can understand the individual
steps of the latter, whereas many steps that are made in a schizophrenic
train of thought are unintelligible to the normal person, or appear to
associations
78
be so bizarre, that they would never have entered his mind.

following examples will serve as illustrations:
The
"Epaminondas was one who was powerful especially on land and

He was the leader of great fleet manoeuvers and open sea-battles
against Pelopidas, but had been struck on the head, during the second
Punic war, because of the wreck of an armored frigate. He wandered
with ships from Athens to Hain Mamre, took Caledonian grapes and
pomegranates and overcame Bedouins. He besieged the Acropolis with
gun-boats, and caused the Persian crew to be burnt as living torches.
The subsequent pope Gregory VII eh Nero followed his example
and because of him all Athenians, all Roman-Germanic-Celtic races,
sea.
towards whom the priests were not favorably disposed, were burned at
the hands of the Druids as an offering to the Sun-god Baal on CorpusThis is the period of the Stone Age. Spear-points of
Christi Day.
Bronze."
(Stenographically recorded.)
The Blossom-Time
for a Horticulturist
"At the time of the New-Moon Venus stands in the August heavens
Egypt and with its rays of light illuminates the harbors of commerce,
In this historically famous city of the
Suez, Cairo, and Alexandria.
Kalifs, there is situated in the museum of Assyrian monuments from
of
Macedonia. There plantain flourishes next to maize columns, oats,

clover, and barley, also bananas, figs, lemons, oranges, and olives.
Olive-oil is an Arabian liqueur-sauce, with which Afghans, Moors,
and Moslemites carry on the breeding of ostriches. The Indian plantain is the whiskey of the Parsee and of the Arab. The Parsee or
the Caucasian possesses exactly as much influence over his elephant
The camel is the sport of the
as the Moor has over his dromedary.
Jew and the Indian. In India, barley, rice, and sugar-cane, that is,
artichoke, flourish luxuriantly.
The Brahmins live in castes on
Beluchistan. The Circassian inhabit Manchuria of China. China
is the Eldorado of Pawnees."
("Letter of a Schizophrenic")
The association is sometimes formed as a result of factors from

without even when there is not the slightest real connection. Thus
the patient explains his violent action on the ground that "the at-
tendant wears a white apron," only because the attendant happens
when the question is asked.

new ideas crop up which have no connection of any kind with what has gone before, sometimes the patient
states that they "flashed" through his mind but at other times he does
to be standing near
Not
at all infrequently
not recognize anything abnormal
about them.
If
the
last-named
79
mechanism repeatedly recurs, the mental stream becomes "distorted"

and finally coherence disappears altogether. The individual thoughts
then have no connection with one another from the point of view of
the observer, and in most cases also from that of the patient. Indeed,
it not infrequently happens that the patient never produces
any
coherent thought, as the concepts are piled together without any
logical connection. ^^
The separation
from experience naturally facilitates

which is actually based on
the very fact that natural connections are ignored.
Without the
slightest regard for real and logical possibilities, the faintest wishes
and fears are endowed with the subjective reality of the delusion.
The most usual secondary associations, vague analogies and accidental
of associations
dereistic thinking in the highest degree,
connections determine the train of thought.
Dereistic
thinking
is
usually quite unrestricted in dreams because the latter are actively

disbarred from the outer world while in schizophrenia
mad
rate
mixed with correct and
it
proceeds at
realistic directives.
In the schizophrenic course of thought one observes the most varied

disturbances.
Of particular importance are the obstructions where
away from seconds to

days ('Thought deprivation"). When the obstruction is over, a new
thought, which had no connection with the one preceding obstruction,
the mental stream suddenly ceases remaining
frequently crops up.
The
distinction between obstruction
and
inhibition
is ver>^
impor-
tant; the latter signifies depression, the former (with the reservation
stated below) Schizophrenia; superficially, however, the
two symptoms
resemble very much.
In profound disturbances the reactions to both anomalies are altogether or almost completely reduced to zero.
But even when impeded,
patients attempt to answer, the obstructions, particularly
in
acute
motion can usually be overcome only by strong and persistent effort, and even then the patient
can only produce feeble and slow motions and utter words in a low
tone.^^
In most cases, however, the two kinds of disturbances can
easily be differentiated, inasmuch as impeded patients can react just
as quickly and strongly as sound persons, once the obstruction has
been broken down, whereas inhibited patients always evince the recases, in order to express themselves in
" Cf. below, "Confusion," also the additional details about schizophrenic
thinking in the chapter on "Schizophrenia: Condensations, Displacements, and
Symbols."
"In such cases it is probably not a question of simple obstruction, but rather
of a combination with a third form of retardation of the psychic processes,
which we cannot yet emphasize (swelhng processes of the brain, etc.).
80
(If the difference does not

tarded character of their movements.
itself in spontaneous expressions, the patients can, for in-
manifest
twenty as quickly as possible, or to turn

hands quickly one about the other.)
The obstruction may be compared to the closing of a valve in a
piping system carrying a highly mobile fluid, while the inhibition is
stance, be asked to count to
their
analogous to a slowing-up of the flow as the result of increasing

viscosity of the fluid.
The
obstruction
is
a sudden stoppage of psychic
processes caused by affective disturbances, and in
Some
itself is
not a patho-
thoughts and
persons
("examination
stupor,"
normal
or
"emotional
actions even
obstructions
Pronounced
may
therefore
in all
be
observed
stupor").
in
hysterical
patients.
particularly
In
those
cases,
howand
nervous
not
sufiiciently
determined
psychologically,
where
are
ever, where they
they become generalized, or last unduly long, their presence justifies
logical manifestation.
affects bring to a standstill
in
the diagnosis of schizophrenia.
In neuro-physiology, such stoppages of one function through another are designated as "inhibitions" while in psychopathology, the
primary meaning of the word, as the above historical considerations

have shown, is something altogether different, it signifies the general
retardation of thought processes in melancholic conditions. There are,
to be sure,
still
other general retardations of the psychic processes for
which we have not yet any special designation because we have no

adequate knowledge of them. Many are named in accordance with
their causes, as schizophrenic swelling of the brain, brain pressure in
and brain-torpor. In another

spoken of in a moral sense, thus a
psychosis, or alcohol destroys the inhibitions connected with wrong
Here again the meaning of the expression tends towards its
actions.
general, toxic, epileptic disturbances,
connection "inhibitions"
are
usual physiological significance.
In superficial contradistinction to obstruction, schizophrenics often

a "crowding of thoughts"; they are forced to think. In such
cases the content subjectively seems rich and varied, and gives the
impression of a continuous mental stream. But if the attempt is made
to penetrate a little more deeply, one regularly gets the impression
feel
same thoughts. The

most cases connected with a disagreeable
The feeling of activity may, however, also be
feeling of exertion.
lacking; "something thinks" in the patients, or "some one makes them
that the patients are forced to think always the
crowding of thoughts
is
in
thoughts."
Crowding
of thoughts
is
distinguished from obsessive ideas
by the
fact that in the former the obsession lies in the subject-matter, while
m;
in the latter,
it
the process.
is in
The compulsive
81
patient cannot rid
himself of an apprehension or of an impulse, but in the schizophrenic

it is
the thinking function
itself
which
perceived as an automatism
is
or compulsion, quite independent of the content, which can be principally varied in
any way.
Furthermore, the thoughts

flight of ideas, or
may
they
may
run too rapidly, as in the case of

Such complications naturally
be inhibited.
occur regularly whenever manic and melancholic states develop in

schizophrenic
soil,
which happens quite frequently.
stances flight of ideas or depressive inhibition

specific
The
disturbance of the associations.
is
In such circummingled with the
schizophrenic lack of
concern about the aim of the thought naturally shows in some cases
frequent manifestations which cannot in themselves be distinguished
from
The
flight of ideas.
to mistake
it
inhibition occasionally causes the observer
for brevity of associations,
wnich
in
most cases belongs
number
of
available concepts diminish and consequently the mental stream
is
directly to schizophrenia
and
consists in the fact, that the
always equally ready or "brief." ^^

This is seen in important as well as in unimportant trends of ideas.
When the patient is asked to relate a fable which he has read, he is
unable to proceed beyond the next step in the story, unless he is given
an additional prod. When asked to tell about his divorce, he at first
knows nothing except: "I am divorced." "Why are you divorced?"
"She ran away from me." "Why?" "V/e did not get along." "Why."
"Because of a child,"
etc.
is to be distinguished from a
some reason or another, are not
Pathological brevity of associations

similar quality in persons who, for
willing to give information.
In schizophrenia
which, to be sure,
we
we
often find a special kind of perseveration,
are not yet able to describe as regards
we must assume
its specific
from other forms.

Accidental psychic processes, thoughts, and actions may become
stereotyped; an idea is repeatedly thought and expressed in all variaStereotyped habits
tions and connections, it is "worked to death."
are, above all, formed by emotionally accentuated complexes (see
peculiarities, although
that
it differs
"stereotypes").
Schizophrenic and dream-like disturbances of association

hypothetically traced to the same origin:
As
of attention deflect the associations
from their
may
is
be assumed, that a certain force
in the track laid out
''CLp
85.
by experience.
may
be
and disturbances
customary paths, it
sleep
necessary to keep associations
Now
it is
possible that this force
82
or "control-tension" has also been diminished or
hampered
in its action
because of the fundamental schizophrenic process.^*
Associations of Oligophrenics
The
train of ideas of imbeciles
contrast to organic impoverishment
and
But
idiots is restricted.
of associations,
it is
in
not the ob-
jective idea that determines here the choice of the reduced psychic
material.
The
ideas which are left out are those which are
uncom-
mon, and do not originate from the immediate sensory perceptions, or

those which are more complicated and do not belong to every day
experience.
The
imbecile does not forget that he can get hurt by
window, but he might have an accident as a

result of climbing down a trellis-work whose carrying strength he overestimates. An imbecile described by Wernicke was driving a wagon
which struck a rock and therefore could go no farther. He thereupon
whipped the horses instead of driving around the rock; the act of
resorting to the whip when the wagon will go no farther is really the
habitual thing to do, while it happens only rarely that there is need
for driving around an obstacle lying in the middle of the street.
Within particularly easy reach and at the same time easily stimulated
are those ideas which concern the ego. That is to say, they belong to
those ideas which are most easily thought of, a fact which gives rise,
in imbeciles, to a sort of egocentricity, which is further strengthened
by the lack of understanding for the matters which concern others.^^
jumping out
of a high
Associations of Epileptics
For obvious reasons (concomitant congenital weakness plus cerebral

atrophy) the associations of epileptics often show disturbances similar
to those of imbeciles and organic cases but in addition, they present
the specific epileptic signs, which are so characteristic that they furnish
the material for diagnosis in cases that are more or less pronounced.
Nevertheless, the line of demarkation from the organic cases
yet sufficiently distinct.
is
not
The abnormities which show themselves most
clearly in the experimental associations are as follows: the answers
come very slowly, the patients find it difficult to respond with a single
word and they frequently employ whole sentences that are often very
indistinct, containing peculiar and tortuous expressions.
The content
is poor in ideas showing tautologies, meaningless definitions, and the
" Bleuler, Storung der Assoziationsspannung, ein Elementarsymptom
Schizophrenien Allgem. Zeitschr. f. Psychiatrie 1918. P. 1.
For more details see the chapter on oligophrenia.
^''
der
83
like, and contains many affective designations among which one frequently finds opinions of value, such as good, beautiful, just, "one
should,"
and moral tendencies.
much
that of perseveration, not so
Another mechanism
observed
is
in the sense that the patient gets
stuck to a reaction, but a word, a phrase or sentence form once used

easily crops up again later on.
The entire circle of ideas gradually
becomes more and more completely narrowed down to the patient's
own
ego.
Poverty of ideas manifests itself among other things

grammatical constructions, tautoloand the like; thus, long is not short; loved what one likes is
Examples:
in senseless associations, continued
there are kinds

of
wonder to wonder. Egocentric relations: wish health;
naturally one would rather be well than sick; time would gladly
for the sake of good fortune.
spare
Examples of emotional
emphasis and affective valuation: greenish a pretty color; sweet
good; to part not beautiful; youth joy; to strike
persons
Clumsy and obscure circumstantial expressions: luckjoy
ness or something
that." Wrath man
wrathful.
Flower
the flower belongs to the trimmings of the window-plants in the dwellings of people,
that so?
point one can make a point, what one
gies,
also loved; heart
people; beatpeople; sacrifice
all
sacrifices;
it,
is
is
evil
is
strike.
ful-
like
^*
isn't
does in business,
^^
is
a stone
made, or something
^^
(wishes to say
something to the effect "sharp stone")
A type of perseveration also occurs with great frequency in ordinary conversation and shows itself in the fact that patients can hardly
get away from an idea. They repeat themselves word for word or in
tautologies, they use circumstantial modes of expression, they present
a multitude of non-essential trifles and trivialities, but they do not
lose their goal, nor can they be diverted from their snail-like paths
if
is
else
by being requested that they come to the
point.
Indeed the distractabnormally slight. The circumstantiality of
sometimes also reflected in their actions and their
ability of epileptics
their thinking is
is
entire behavior.
Whereas a sound person will, so to speak, sit down in one conmany an epileptic finds it necessary to perform
this act in the following manner: He first places the chair in a special
tinuous movement,
position, then he considers his spatial relation to the chair, then he
proceeds to place himself in the proper attitude towards the same, and
^^
Fuhrmann, Analyse des Vorstellungsmaterials usw.
Diss. Giesen, 1902.
" Ihid.
^^Holzinger, Assoz. Versuche bei Epilepsie.
Diss. Eriangen, 1908.
84
thereupon he must arrange his clothes accordingly, as for example,

he must draw apart his coat-tails, and now at last he can sit down
in a sprawling attitude.
In speech one
frequently struck by a
is
momentary hesitancy
stalling; in such cases the patients often repeat
and then they proceed
This symptom
further.
pression of a hesitating train of thought;
which often brings
resin in a machine,
and then
The
lets it
move
intensity of these
is
is
obviously the ex-
is
as though there were
to rest for a few
moments
again.
symptoms generally runs
degree of dementia; although

patients and
it
it
or
a syllable several times,
especially
it
varies very
parallel to the
much even
pronounced after attacks and
in the
same
in twilight
states.
additional part noticed in twilight states has not yet been
The
In some cases the main element shows itself in an

enormous exaggeration of the described peculiarities, in other cases
there seems to be added something new, which has been incorrectly
characterized.
designated as incoherence.
The
The
Associations of Hysteria
associations of hysteria are under the pronounced domination
Even
of the affects.
experiment shows
in the habitual states the
irregular, often very high-graded prolonged reaction-times,
sometimes no
and psycho-galvanic phenomena are very
superficial
indeed,
answer can be elicited, in content the associations are

high.^*'
Actual
affects cloud the logic in hysterical patients to a very high degree.

That which was today praised to heaven may be painted with coalblack colors tomorrow for just as many opposing reasons. In the
hj'^sterical
twilight state reality
other dream-world
tions of logic
is
systematically side-tracked and an-
created to replace
is
it;
this is helped
by
falsifica-
and sensory deceptions.

Associations of Neurasthenics
remarkable that
meaning, they
behave just like patients who suffer from acute exhaustion. For the
rest their associations have not yet been sufficiently studied and can
just as little be brought into a single purview as the morbid pictures
In the association
test
with neurasthenics
it
they often answer to the test-word instead of to
to
is
its
which the name
is
"That
a diminution of electrical skin-resistance at the appearance
of affects.
is,
there
is
applied.
85
Associations of Paranoiacs
These associations
katathymic,^' that
is
in so far as
they arc pathological, are purely
to say, they exhibit characteristic abnormalities
only in cases where emotionally accentuated complexes at the basis

of the delusional system are brought into play.
Many
things are then
brought into incorrect relationship to the delusional system.
Thus
one finds an association-readiness for certain definite impressions, delusions of reference, coordination of inappropriate material with the
and a
Wherever the delusions do not in-
logic functions, a regardless omission of contradictory matter,
false valuation of material used.

terfere, the thinking process
appears normal.
Other Disturbances of Association

Besides these disturbances of associations, which are characteristic
for definite illnesses or states, there are
no knowledge; they form the subsoil
many
we have
and many
others of which
of delirious, soporific,
confused twilight states in fevers, inner and outer toxemias, in different

brain diseases, and the
like.
Outside of schizophrenia there are also pathological brevities of the

associations: the patient always gets through with his thoughts quickly,
whether they are his own or those which have been induced from the
outside by means of questions and suggestions. The patient does not
think of related ideas even when they might have to follow of necessity, as in the case of wishing to give an account of something (indeed,
without the existence of obstructions or melancholic inhibiBesides certain dulled states of schizophrenia, such associa-
this occurs
tions).
tions are encountered in organic psychoses, in rare epileptic conditions,

in
many
light
state of
forms of soporific states, and in similar conditions.

monideism may be due to many other causes besides de-
pressive retardation; one observes this

twilight states, where
phenomenon
in all forms
patient, as for example, to set fire to something, while he has
ceptions of the cause or consequences of the action.

is
of
only one idea systematically dominates the
no con-
The same
also seen in deliria following mild cerebral concussions,
state
where any
confused idea accidentally occurring to the patient completely absorbs

him for a long time and from which he cannot be freed even by out-
ward
distraction.
It is quite clear
that in these states, monideism
something fundamentally different from what
The disturbances
previously
referred
to
toxemias, and the like, are not yet fully known.

" See pp. 34-35.
it is
is
in inhibitions.
under
brain-pressure,
86
"Confusion"
Confusion
is
not a unitary disturbance of association in the same

it is the ex-
sense as those which have been described thus far, but
pression of quite different anomalies of the mental stream which have
attained a higher grade.

picture
It is neither a unitary
symptom nor
and can even be produced by disturbances outside
a morbid
of the
realm
of the usual concepts of associations.^^
Of the familiar disturbances
of association
it is
naturally the schizo-
phrenics which most readily reach to the point of confusion, because

it is
in their
very nature to tear thoughts apart. In the acute stages

happens that not only the thoughts become con-
of schizophrenia it
primary associations to the sense

Nor do the
movements correspond to the thoughts, they may even appear disturbed in their coordination. In the same way paramimic and parathymic phenomena become connected with it.
Confusions incident to delirious and twilight states are still quite
insufficiently known.
fused, but the false connection of the
impressions already leads to illusional disorientation.
Occasionally flight of ideas

of confusional flight of ideas;
mistaking
by
in
it
may become
it is,
intensified to the point
however, necessary to guard against
for schizophrenic disturbance of associations, complicated
As every one knows, marked emotional fluctuations

normal and diseased persons lead to affective confusion at some
flight of ideas.
time or other.
The
expressions, incoherence
and
dissociation,
which often designate
confused processes of thought apply most correctly to schizophrenic

disturbances of association, but signify nothing of a characteristic
nature.
DiFFUSENESS AND CIRCUMSTANTIALITY
we have mentioned
This symptom occurs also as the
As
result of other disturbances and in any case has different origins.
long as the flighty patient can still come back to his main subject, he
may be considered circumstantial, because he works out many details
In the discussion of the associations in epilepsy
circumstantiality and diffusenessP
and secondary material which are not needed.

often the
first
Thus
striking indication of incipient mania.
diffuseness
An
is
imbecile
can be circumstantial because he is incapable of distinguishing between

and non-essentials and hence he must go into unimportant
matters as fully as into main issues. Repetitions and tautologies,
essentials
'"See below: "Hallucinatory Confusion."

^ Two not identical concepts, which, however, coincide for the most part.
characteristic
of the
circumstantial epileptic train
usually absent in manics and imbeciles.

patients
also
It is well
87
of tiiougfit,
known that
arc
senile
become circumstantial, partly because the train
of
thought gets into ruts which they are no longer capable of avoiding,
and partly particularly, because the substantiality
of the affective
tone and the narrowing of the associations making reflection
makes the
cult,
theme.
nonessentials
There are perhaps
still
appear
other
as
diffi-
important as the main
unknown reasons
for the senile
circumstantiality.
Circumstantiality sometimes originates from a feeling of uncertainty which impels the patient to add all sorts of corrective and sup-
plementary determinants.
varied states.
In this form
It is also utilized to
put
it
off
may appear
an unwished
in the
most
for decision.
Overvalued Ideas, Obsessions (Obsessive Acts)

Overvalued Ideas are ideas that always obtrude themselves into
the foreground, they are mostly remembrances of an affectful experience, but in contrast to autochthonous ideas the patients
ceive
them
do not perand contrasted with compulsive ideas are not

They are completely bound up with the personality
as strange,
felt as incorrect.
and
differ from ordinary affective ideas only in the fact that eventually
one does not get rid of them and that they have the tendency to
associate themselves with new experiences.

According to Wernicke
they are not delusions in themselves, but through morbid relationships
often give occasion for delusions. They are katathymic ideas, which
according to the current conception appear as the only essential symp-
tom
in persons that
would otherwise be considered
ing delusions.
Ziehen, howand many obtrud-
sane.
ever, also designates as overvalued ideas, obsessions,
In positing overvalued ideas the question of the exist-
ence of monomanias, which for nearly a half century appeared settled

in the negative, has once more been taken up, though in a much more
comprehensible form. In the case of an existing predisposition or

without this, is it possible for an outer experience, intensified by an
accidental cause, to provoke delusions in a psyche not really morbid?
I should like to answer in the affirmative.
But only when these "over-
valued ideas" become an active influence does one deal with a real
psychosis (compare on the one hand "belief" and on the other
paranoia). 2*
Obsessions or compulsive notions are ideas which continually

obtrude themselves against the patient's will with or without exiernal
" Some designate as monomanias not delusional forms in otherwise retained
but isolated morbid impulses like kleptomania or pyromania.
lucidity,
88
cause,^^ the content of which, however,
in states of strong affects.
is
recognized as incorrect except
Nevertheless they do not appear strange to
the personality as they are regarded as the product of one's own

They are remarkably monotonous and may be divided into
thinking.
Some people
feel compelled to put definite questions to

which are foolishly banal, such as, "Why has a
chair four legs?", some deal with insoluble problems about final causes,
such as, "What existed before the creation of the world?", some are
more or less of a religious nature, such as, "Why is God a man?", or
"How is the immaculate conception possible?", and some are of a sexual
content, which are often also plainly an element in those previously
Others have anxious ideas that the
mentioned ("Reasoning mania")
match has not been put out, or the door isn't locked. They cannot
four groups:
themselves,
many
of
mail a letter, because in spite of repeated examinations they are not

convinced that it is in the right envelope, or that there isn't a serious
mistake in it. They are afraid to touch a door knob because they
themselves
toucher").
body with
may
carry germs to others, or others to them ("delire du
If a knife is lying around,
they fear they
may
kill
some-
usually
one of their relatives.

Others fear their father may die if a spoon lies on the table in a
particular way, or if one does this or doesn't do that, in which cases
one cannot always tell whether the patients are fully convinced of
it
Obsessions that some horrible
the incorrectness of the "superstition."
crime was committed
may merge
directly into delusions of sin,
which
then also appear most frequently in states of melancholia. The phobias

are also classed with obsessions. Thus one observes an agoraphobia
or fear of open places, erythrophobia or fear of blushing,
and similar
ideas which realize the dreaded occurrence (fear of getting diarrhoea

this can be brought about
it is impossible to satisfy this need)
through the activity of the smooth muscular system which is not
controlled by the conscious will. Other phobias, like mysophobia, or
fear of dirt and eventually infection, belong to the group of delire du
where
toucher,
Some
and lead indirectly to
actions.
of the compulsive acts are the result of the compulsive ideas
and cannot therefore be separated from them.
Thus the idea that the
not locked compels the patient to try it over and over again or
ask others to examine it. Mysophobia compels one to touch the door
knob only through cloth and to wash the hands continually. The
door
is
notion, "If I do not return the
to return
it
even under
money,
difficult
my
father will die," compels one
circumstances.
Obscene contrast ideas
" They are in this way also disturbances oj the will in so

has no power to direct his thoughts to normal thinking.
far as the patient
89
compel one to utter them (coprolalia). Often the obsession and the
compulsive impulse are identical as in the impulse to kill one's child
with the nearby knife, or the thought presents itself, like a hallucination, in imperative form, "You must kill your child."
A man who has a questionable affair must turn around and look at
every "dark, tall, sturdy" woman, then also at small ones, then at all
women, then also at men, and then at street cars to read their
numbers.
Another kind of association between an obsession and compulsive
impulse was shown by a patient, who was not melancholic; he had the
obsession that he had had intercourse with his mother and the compulsive impulse to write this fact on banknotes.
Connected with the compulsion
is
a very painful affect;
not
still
all
patients can rouse themselves to the state of really desiring to be cured,

in spite of the fact that a feeling of sickness
The
is
perhaps never lacking
ideas themselves are either of a depressive
-^
content, or anxiety
appears as soon as the patient wants to resist the impulse. It is

anxiety that makes it impossible for the patient to suppress the impulse
in
spite of the fact that he
and knows better. But the

match is out, not so much to
willing
is
patient has to see repeatedly that the
prevent a
fire,
compulsive act
as to rid himself of his fear, indeed the execution of a
may
actually be connected with "a peculiar feeling of
The
voluptuous satisfaction."
fear itself often seems to be
rectly) the result of the idea (fear of germs)
the idea and
may
more
rarely
it
at times
it
(incor-
accompanies
appears as primary, in which case the obses-
if it were created as an explanation

probably true that obsessions most frequently
develop on the basis of a timid, uncertain, but conscientiously inclined
sion
give the impression as
But
for the affect.
it is
and melancholies.
Freud has attempted to explain obsessions by assuming that any
relatively innocent idea is connected with another which became
character, also in exhaustions
repressed on account of
receives the affective
conscious,
girl at
and
its
unbearable content. The former then

of the idea, which has become un-
endowment
forces itself into consciousness in place of
it.
Thus
a concert feels the impulse to micturate in the course of sexual
thoughts which she rejected as immoral;

state of affairs she
It is certain
thereupon at ever>' similar
had a phobia that she might have to micturate.
that obsessive cleanliness
may
frequently be traced to
the need for moral purity, as in onanistic pangs of conscience.
Obsessions
occur
temporarily
states, in schizophrenia,
**
At present
in
and melancholic
and frequently ver\'
neurasthenic
and also as a
special,
doubt whether there are obsessions of a pleasant content.
90
severe, disease, in people originally disposed to such abnormities
(Com-
pulsion Insanity, compulsion neurosis).
Delusions
Errors originate from the facts that similar things are considered
fish), that a simple coincidence is
rose; whale
identical (camelia
considered a regular coincidence and consequently taken as a causal
determinant
the patient became well because a charm was ap-
(e.g.
plied), or that something important
plane)
or also,
that one
is
is
overlooked
(the earth
is
deceived by the senses, and hence unusual
relations are judged according to usual relations,
around the stationary world.
Such errors
may
e.g.,
the sun revolves
be corrected by new
experiences which are enlightening to the extent that reason
is
capable
Even when a person is too

the earth, we do not call his
of evaluating these experiences correctly.
stupid to comprehend the sphericity of
conception a delusion.
Delusions are incorrect ideas created, not by
an accidental insufiiciency of logic, but out of inner need ("Delusional

need," Kraepelin)
There are no other inner needs than the
affective.
Delusions, therefore, always follow a definite direction corresponding

to the patient's affects, and in the vast majority of cases cannot be
corrected by new experience or instruction, as long as the condition
which gave origin to them continues.

Delusions, therefore, have their psychological analogy not
Accordingly the chief delusion
in error
regularly egocentric
but
in belief.
and
of essential significance for the personality of the patient himself,
is
^'^
though, of course, the forms of explanatory and secondary delusions

need not directly concern the patient. Contrasted with belief the main
difference lies in the fact that delusions are
from personal need and that they

persons are subject to correction.
may
We
formed by individuals
which in sane
relate to matters
see that the difference
is
not
when a pious person

forms his own opinion of religious matters; but when his innovations
appear altogether too gross, we designate them as "delusions of
religion," although in the forum of pure logic a new prophet might
have as much reality value as the older ones.
absolute.
Ordinarily
we cannot speak
of delusions
Delusions, therefore, originate as a result of affects inasmuch as
what corresponds
is
to the affect
is
inhibited to the extent, that
it
connection, or
it is
accepted and what
of insufficient logical force.
The
he takes account of his fortune, sees continually

difiiculties
is
opposed to
it
either does not appear at all in this
melancholic,
all
when
his debts
and
but cannot balance them with his assets, partly because he
''See below.
91
them worthless or too uncertain, and partly because he

cannot connect them in a logical procedure with the idea of his debts
and therefore cannot utilize them to overcome the idea of indebtedness.
considers
Such is the origin of the delusion of poverty. Not infrer4uently he

comes to the same conclusion by keeping back altogether the ideas
referring to exact sums, and only in a general way considers his debts.
The onanistic schizophrenic fears that his vice will become known.
If he notices that some one looks at him he thinks it is because of
his onanism, the self-evident fact that one is looked at a thousand
times without such cause, cannot be used as a counter-argument.
The
delusional affect
nature, or
it
may
may
be of a general (depressive or manic)
be attached only to a particular idea, to a complex
such as an onanistic pang of conscience.

delusional forms originate.
is
at the
same time
When
suffering
In the latter case katathymic
a person obsessed with a complex
from a general depression, a frequent
occurrence in schizophrenia, the katathymic and depressive effects
become connected.
thinks that he
that he
is
is
If
the schizophrenic
onanist
rotting because of his vice;
if
he
is
is
melancholic he
manic, he
feels
a savior of humanity.
Some of the delusions follow logically from those already existing

and do not require this mechanism. When the patient is convinced
that the physician wants to murder him and after taking medicine he
feels indisposed,
then
it is
a conclusion, based on logical probability,
that the physician has prescribed poison

the patient
is
(secondary delusion).
Or
the son of a count, consequently, his parents are only
Or the patient is pursued everywhere, no matter where

he journeys; "therefore there exists an entire organization against him,
the postal authorities open his letters and tell his address" (Explanafoster parents.
tory Delusions).
It
is
said that delusions are logically deduced from the affective
disturbance.
it
in his sins.
Thus the patient

I
feels unhappy, seeks a cause and finds

have never been able to observe this mechanism.
Other delusions are said to originate in hallucinations, deceptions

in dreams.
This is undoubtedly a question of concomitant circumstances, not of real causes. It is the false idea which
is directly generated by the disease; it may appear first as a thought,
of
memory, and
or hallucination, or
Some
memory
deception, or as a
delusions, especially
consciousness as finished products

lusion)
^^
;
[delire
suddenly appear in
d'emblee, primordial de-
others have a longer period of incubation.
*"! the patient takes
called
dream conception.
in schizophrenia,
For instance,
a critical attitude toward the content of the

an autochthonous idea {Wernicke).
idea,
it is
92
if they were watched, as if they had sinned, until

becomes a certainty. Or for years the patients make a
number of remarkable observations (self-references) and it suddenly
comes to them "as a revelation" that it all has this and that meaning.
Perhaps most frequently the delusion connects itself with external
the patients feel as

at last
it
events in such a
e.g.,
manner that the patients
at first quite correctly grasp,
a sermon, but later on, following a period of incubation of from
hours to years, they interpret the words heard, consciously or unconsciously, in the sense of the delusion as related to themselves, that is,
to their complexes.
The
following classes are differentiated according to content:
Expansive forms of delusion; "Delusions of grandeur." In the

mildest cases they rather take the form of overestimation of the ego,
the patient surpasses other people in health, ability, beauty to an
extent greater than the corresponding reality. From this we observe
all stages of real delusions, from the easily possible to what is still
conceivable up to the idea that the patient
is
capable of the most
impossible discoveries, to possess "trillions," to found

to be
God and Super-God.
new
Occasionally the environment
religions,
is
trans-
formed to accord with the idea. The patient's companions in the

asylum are mistaken for counts and potentates.
Depressive delusions refer especially to three spheres: to conscience,
as delusions of sin; to health, as delusions of disease,
and to fortune,
as delusions of poverty.
The
patient entertaining delusions of sin believes without reason to
have committed the worst transgressions or magnifies actual trivial

deeds into unpardonable sins. For these not only the patient is
punished in an appalling manner here and in the life beyond, but
also all his relatives, even the whole world.
The patient having depressive delusions of sin ^^ believes that he
has definite, and always especially awful diseases. The real disease,
melancholic depression, is denied. The same is sometimes designated
as hypochondriacal delusions; but we must be able to differentiate
between this delusion of general depression and the katathymic delusion that stands out in the hypochondriacal morbid picture especially
in dementia praecox, but also in psychopathic patients.
Usually the difference consists also in the fact that the depressive
delusion of disease postpones the worst for the future, while the kata-
thymic hypochondriac worries about the present. The depressive

patient believes he suffers from closure of the intestines and will perish
" Not
disease.
identical
with the usually katathymic hypochondriacal delusions of
93
way, while the hypochondriac asserts that

he actually suffers from intestinal inactivity and demands and expects
in a particularly disgusting
relief.
Impoverishment is often thought of in forms which cannot occur,

any rate nowadays; not only is the patient punished for his debts
and must starve, but his relatives also meet with the same fate.
In demented organic patients we see a fourth group of depressive
delusions which, though not very common, furnishes the diagnosis when
it is present,^" viz., nihilism, which roughly corresponds to the delire
de negation emphasized by the French, or delusions of negation, which
are not to be mistaken for the negativistic manifestations.
In this
case everything no longer exists, the institution, the world, the
Almighty, and the patients themselves; they have not eaten, yet they
have not fasted; they have no name, are not men, women, etc. Also
in the delire d'enormite, which occurs under similar circumstances and
is frequently connected with nihilism, the same nonsense finds expression: The patients may not use a chamber because they would flood
the entire institution or the whole world; they are swollen up so big
that they fill up the entire house and city, and choke everybody they
must swallow everyone in the institution and there are so many of
them. In a certain sense the opposite of this is micromania, which
at
also only occurs in organic depressions.

It consists in the fact that
the patients believe themselves to be physically very small; thus a
senile scholar
was afraid
so small that
it
Depressive delusion
megalomania
of chickens because he believed his
might be pecked
may
in rare cases
in melancholies,
who
different kinds of affects
This
is
be combined with a kind of
are not satisfied to be the worst
person that ever existed and ever will

the head of the devils.
exist,
but attain the rank of

where
also found in schizophrenics
appear together and express these
delusions, such as, they are the
head was
off.
Mother
God and
in parallel
same time
they are Queen of the Night.
Delusions of persecution do not belong to the depressive forms of
delusion.
The delusion of deserved punishment must not be classed
with that of the unjust persecution. The former comes from a general
the devil, or in a condensation such
of
at the
as,
depression, the delusion of persecution is a katathymic symptom, which

grows from a single emotionally toned idea. Every depressive delusion
is a symptom of a potentially transient condition, but the delusion of
persecution mostly belongs to chronic diseases. An affective, not katathymic delusion of persecution is the delusion of anxiety seen in hal**
but
At the most
it
is
it can be said that something similar

not identical.
is
seen in schizophrenia
94
lucinatory conditions such as dreams, delirium tremens, epilepsy, and

schizophrenia.
The
real delusion of persecution
the patients
uncanny ("the walls
make
they
may
at first be quite indefinite;
that things and people about them have become
feel
in
my own home
wanted to devour me")
the discovery that certain persons
make
signs to
Then
them or
.
One coughs in order to indicate that

to others which refer to them.
There are articles
the
murderer
of girls.
onanist,
or
the
comes
here
in the papers with all too plain allusions to
badly treated, the attempt
is
made
gusting treatment, the most difficult
them;
in business
they are
them through disassigned to them and
to get rid of
work
is
behind their backs. Finally there are entire

they
organizations, created for "this very purpose, the "Black Jews," as well
as the "Free-Masons," "Jesuits" and "socialists" which everywhere
pursue the patient, and make him powerless. They plague him even
are
slandered
with voices, physical influences, and other hallucinations as well as

with withdrawal of his thought, crowding of thought and other
annoyances. Not so seldom the delusion of persecution is combined
with grandiose ideas. A certain overestimation of self generally lies
at the bottom of it, insofar as the patient makes some kind of unattainable
demands and then looks
ment.
It
is
for the cause of his failure in the environ-
also said 'that the delusion of grandeur originates in the
delusion of persecution through the fact that the patient says to himself
much persecution must be some

This transformation of the delusion I have
never plainly observed. On the other hand, we frequently see that
erotic delusions turn into delusions of persecution or fuse with them,
in that the imagined affectionate lover commits sexual and finally other
atrocities on the beloved.
An erotic form of delusions of persecution is the delusion of jealousy
which exhibits several peculiarities. There are paranoiacs who have
no other delusions in schizophrenia it is not seldom mingled with other
ideas of persecution, and in alcoholism and cocainism it usually appears
as a temporary result of the poison which is not yet fully explained.
The delusion of reference, or the morbid reference to oneself, has
been distinguished as a special form of delusion. It occurs especially
in paranoiacs and paranoid forms, in which it often forms the base of
the other delusions. Such patients can relate to themselves absolutely
indifferent observations such as coughing, newspaper advertisements,
and even cosmic occurrences they think that everything occurs on their
account and interpret it in the sense of their katathymic mental trend.
Something similar also occurs in general emotional depressions. Melanthat a person
who
is
subjected to so
extraordinary person.
any misfortune
cholics especially like to believe that
95
is
the result of
their badness.
Thus one
improbable things, -to test the patient's intelligence.

says that some one fell downstairs in order to make
the patient understand that she doesn't clean the stairs properly
Some one yawns; that is to say that she is lazy.
tells
In the newspaper
The
it
is explained by the emotional effects withEvery affective idea has even in normal persons many attachments that do not correspond to reality. It is known
that any one coming into a ball room or wearing a uniform for the first
delusion of reference
out anything further.^^
time, believes himself noticed, etc.

It
has been maintained that delusions are a sign of mental weakness^

normal intelligence would see the incongruity. But it is certain
since a
that there are very capable paranoiacs evincing a complete delusional
who
system,
exhibit no other signs of intellectual disturbance.
If
one
bases here the assumption of mental weakness solely on the delusions,
one begs the question.

delusion
is
The
essential factor in the formation of a
the disproportion between affect and logical strength which
may have originated in the preponderance of a general mood, as for

example in melancholia, or in an especially strong affective coloring of
a single idea as, for example, in katathymic delusional formations, or in
the weakness of the logical capacity as, for example, in paranoid and
twilight state, or in several of these forces acting together, as, for
example, in manic paresis.
This formulation naturally indicates only one comprehensible conhave not yet been
ascertained.
There are many disproportions between intelligence and
dition of delusional formations out of the others that
affectivity that do not lead to delusions, e.g., the oligophrenias.

The
type of affectivity, the transformation of the entire psyche in associating,
perceiving,
process,
and
and
feeling,
as
in strongly exaggerated
shown by the schizophrenic

form by conditions of clouded
is
consciousness, are other important foundations of delusions.
in
A connection between intelligence and delusions exists in so far that

mentally clear patients the quality of the delusion depends on the
grade of intelligence.
sions,
mixed with
Intelligent paranoiacs ''systematize" their delu-
real facts they bring
them
into a system that
is
usually logically connected, but which Tias a flaw especially in the
memory
The content in
assumptions based on false references to themselves, and on
and here and there
illusions
itself is
in its causal connection.
usually conceivable ta others, so that paranoiacs sometimes
infect even intelligent, healthy persons.

'*' Gf. association readiness, p. 40,
and attention,
p. 41.
96
Similarly formed ideas in schizophrenia have a far weaker or
no
and in themselves readily merge into the absurd.
Thus the patient was present at Christ's crucifixion; he has made all
inventions, even those used before his birth, the bones are taken from
his body, several times he has been killed and restored to life, and
logical connection
similar absurdities.
The
disturbance of intelligence and unclear thinking express them-
selves in senseless delusions in
manic and depressive conditions of
organic patients.
manic depressive patient are usually

him up,
he strikes down a dozen keepers, he will expand his business, he will
yet become a member of the cabinet. In manic forms of paresis the
The grandiose
ideas of the
only overestimations.
He
is
cleverer than all those that lock
delusion usually merges at once into the absurd; the patient has large
armies at his disposal which will destroythe institution and the country
which he is; he is a general although he has never been in service;
in
he has invented a bicycle with which you can go around the yorld,
over seas and mountains in three minutes; he is the super-God; the
female patient
is
the mother of everybody, every hour the Almighty
takes hundreds of children from her body,
etc.
The melancholic has committed grave sins, for which tortures will
be inflicted on him as on no one else, he suffers from incurable diseases.
But the depressive senile has his brain hanging down over his head,
his intestines have been replaced by a snake, his head is made of wood.
There develop micromania, nihilistic ideas, and the delire d'enormite.
In any case one must be careful in diagnosing weakness of intelligence from the senseless content of the delusions. What has been said
holds without any reservation only for conditions, in which mental
clearness
is
not entirely absent. In twilight states, in toxemias, in

may appear even in patients who are not
fevers absurd delusions
demented, just as in dreams of healthy persons.

Occasionally a delusion that originated in a condition of disturbed
mental capacity as in a dream or epileptic delirium and which is therefore senseless, cannot later be corrected, although the intelligence does
not now appear badly impaired. Such a residual delusion may, therefore, be senseless without there being at the same time a correspondingly
severe disturbance of intelligence.
The
course of delusions
The simple affective and

and naturally disappear with the
to them. The katathymic delusions which
is
quite varied.
delirious delusional forms fluctuate
condition which gave origin
were not generated by an exceptional condition, are "fixed ideas" in

paranoia and somewhat less regularly in schizophrenia, which are
97
Even the
little even in decades and hardly ever disappear.
seemingly corrected delusions in schizophrenia should rather be considered as forgotten or pushed aside; their persistence may be shown
too often, especially in corresponding affective reactions. Besides
changed
these, one observes everywhere delusions of diverse origin, which

suddenly appear and rapidly disappear.
The relation of the delusions to the ego is usually very close. The
affect upon which it is based or the ideas themselves usually compel
an excessive, often quite monideistic preoccupation with it. A real

attempt was made to poison a paranoiac who was always complaining
The experience was not connected
in an annoying way of poisoning.
at all with the delusion and left him entirely indifferent. But in schizophrenics the affective disturbance and the splitting of the psyche,
especially in the later stages, bring
it
about, as a rule, that the ideas
leave the patient more or less indifferent, or that they become separated
from the everyday ego, which concerns itself with the necessities of
ordinary existence, and form a world of their own.
4.
DISTURBANCES OF MEMORY
Hyperf unction of memory, or hypermnesia, may probably only be

ascertained through the fact that occasionally recollections are much
more vivid and
distinct
than at other times, that they deal with details
that are ordinarily not noticed, and that they reach back to periods
that are not otherwise remembered.

deliria of senility, a
childhood
may
memory
turn up.
Thus
in a feverish
series of early youth,
disease, in
even of earliest
In a hypnotic state one can at times recall

if one again saw the things in front
complicated details as distinctly as
In a dream, also, details, that cannot be reproduced at all in

may turn up with the clearness of a sense impression.
In rare cases of schizophrenia, memory pictures obtrude themselves
in the patient in a disagreeable way, in which case they are usually
of him.
waking
state,
but slightly connected.
Much more important are the hypo functions. Theoretically,

may differentiate those of formation, of retention, and those of
ekphoria of the engrams.
one
the
In reality, however, the disturbances rarely
concern only the one or the other function, and above all we have by
no means progressed so far as to comprehend really all possible differences referring to the partial function chiefly involved.
of attention, at the time of impression,
may harm
disturbance
the recollection in
about the same way as when occurring at the time of reproduction.

I can hardly conceive of a qualitative disturbance of the engraphic
98
in the entire pathology I
and
effect,
indicate
its
existence.
On
have found nothing that would
the other hand, in senile atrophy of the
brain the engraphic effect of the experiences on the psyche is possibly

weakened, and as a result, the extensive effect must probably be
reduced also, for the diffuse extension of the influence in the brain,
which is to be assumed for numerous reasons, diminishes, and fewer
One can also conceive that the
associational connections are formed.
hypothetical elaboration of the engrams
is
is
reduced in some way, but
not yet subject to any disturbance that would indicate the fact.
we know that it certainly

many anomalies of memory, indeed there is nothing
that stands in the way of assuming that disturbances of it alone can
explain most memory defects. Recollection generally is disturbed,
From
the process of remembering (ekphoria)
participates in
when an
affect causes a diffuse blocking of
thoughts as in the case of
examination stupor. Individually it is difficult to remember that which

is incompatible with an affect connected with self-love which strives
to manifest itself. Transformations of a memory occur whenever there
is an affective necessity, which also determines the direction of the
falsification.^^
To
keit)
term
judge the unfortunate concepts "impressibility"

not very easy in pathology.
is
is
What
in reality a very complicated function
without changing the engraphy or the
is
(Merkfahig-
considered under this
which
memory
may
be disturbed,
functions in general.
This happens when for any reason what should be noticed
is
not
properly perceived or else not further elaborated, as in diseases of the

sense organs, in
to
all
forms of disturbances of attention, and in reference

in various forms of dementia where things
more complicated matters
is no lack
no associative
connections to assist in bringing them to memory. As the most striking
hypofunction of impressibility is that which is described in the organic
psychoses. Thus in extreme cases every experience, even the most
perceived are not comprehended.

of actual
engrams
important,
is
In the latter case there
of the sense perceptions, but there are
at once forgotten; a senile
woman may
be told her hus-
band has died and she will react with tears, but a moment later she
knows nothing about it, and this experiment may be repeated as often
To be sure, in the defective brain the formation

may be somehow impeded, but this is certainly not the
as desired.
engrams
tial factor,
because the organic disturbances of
memory do
of the
essen-
not confine
way promuch rather
themselves only to the period of the disease and are in no

portional to the condition at the time of impression, but
to the state existing at the time of the recollection.
^ For organic disturbances of ekphoria see below.
Furthermore, in not
99
very extreme cases most things are "noticed," notwithstanding, but only
for a short time are they capable of ekphorization. One also observes
in every patient memory islands, so to say, as shown in the fact that
some experience is never forgotten or that a recollection, that did not
seem to be there, suddenly turns up in a certain connection. Besides,
the "economy" in time, which is observed in releaming of material
apparently completely forgotten, proves the persistence of a mnemonic
after-effect,
even
in severe cases of Korsakoff's disease.
Hence, in organic hypomnesias one deals with a disturbance of
memory
that involves the
more recent experiences disproportionately

what is experienced
stronger than those lying further back, even though
during the disease

disturbance
is
Only
remembered.
is
for various reasons
often particularly poorly
this formulation covers all the facts.
probably in the ability to
The main
although the organic
recall,
reduction of the associations hinders, on the one hand, the formation

of paths, along
which the recollections can be afterwards ekphorized,
and, on the other hand, impedes the use of these paths in the process
of ekphoria.
In the same
way
a senile disturbance of attention not
only impedes the formation of engrams capable of recollection but

also their revival.
Disturbances of the retention of the engrams are not significant in

In view of the large number of chance tests which demonstrate to us not only the unlimited continuation of the engrams but
psychiatry.
their positive consolidation through age, I cannot believe that there
is
such a thing as a normal weakening, in the sense, that all memory

pictures become "weaker" with time and finally disappear entirely, thus
producing a pathological exaggeration of such a process. Nevertheless,

organic disturbances of memory are considered from this viewpoint
and justly so inasmuch as the general reduction

naturally impair the engrams in some
way but
;
changes with the clinical manifestations

It is chiefly the
is
of their carriers
must
the connection of these
certainly very complicated.
ekphoria that proves disturbed, not the preservation
of the engrams.
The disturbance
of acute
and chronic alcoholism
could also be connected with the change of the engrams. where the
recollections are rather readily brought
while the patient believes he
is
up but are inexact or wrong,
reproducing well.
But
here, too, other
explanations are more probable.
In coarse brain lesions

pictures
may become
acoustic, or optical
it
seems that definite groups of memory
affected, such as certain speech, or motor, or
memory
pictures.
But the extraordinarily
and fluctuating border of such defects makes
it
indefinite
probable, that even
psychic structures apparently so elementarj', are never totally de-
100
Btroyed; that they are therefore localized in the entire cortex, even
though their most important part, their focus, is concentrated in a
If the focus is destroyed then the engrams
definite region of the brain.
can only be ekphorized exceptionally and imi)erfectly, while destruction
of other parts of the cortex affects
them
little
or in a
manner hardly
noticeable.
Besides the organic
memory
disturbances there are also various
They show
unsystematized forms of memory weakness.
nothing that is uniform and at the present have no great significance in
psychopathology the main thing is not to confuse them with other
diffuse,
In the anamneses of schizophrenics we very frequently

find the remark that they have become "forgetful," that they no longer
"had any memory." If such testimony of relatives were taken literally,
disturbances.
one would have to conclude that one dealt with an organic mental disturbance because a real weakness of memory does not occur in schizophrenia. On the other hand, schizophrenics readily become indifferent,
inattentive, distracted,
and inhibited
in their associations, all of
which
about that they do not recall things at the desired time.

Neurotics, too, have a very freakish memory for similar reasons.
Onanists often complain of a bad memory, partly as a result of suggestion through certain books, and partly perhaps as a result of lack
of concentration, which is determined by the distraction caused through
In epileptics the memory as a rule becomes weakened
the complex.
when they already have a marked atrophy of the brain, naturally also
in the organic sense; but this peculiarity is usually concealed by a
general weakness of memory which manifests itself now here and now
there but in which emotionally colored events can be retained more
readily and reproduced in a stereotyped way.
Circumscribed memory gaps are designated as amnesias; the circumscription may be confined to content (systematized) or to time.
The former occurs in gross brain lesions in such a way that all optical
can bring
it
or all acoustic
memory
pictures disappear, or only those of substantives
or those of numerals, etc.
part of
it is
Naturally, here, too,
due to the memory pictures and what
it is
is
not
known what
merely a
difl5culty
in ekphorization; at all events, the latter plays a big part as
may
be
seen from the reconstruction of such amnesias.
In psychoses one meets with amnesias for definite events (kataDuring the experience the patient was in an ordithymic amnesias)
nary condition of consciousness and reproduced in a normal way all
other events that occurred about that time. Thus an hysteric suddenly
forgot everything that related to her physician Janet, and mistook hfra
.
for a
new
assistant physician.
In schizophrenia acts of the individual
101
and of others are "forgotten" every day, when the memory of the same
does not just suit the patient. A mild schizophrenic of Wernicke swore
in all good faith, nevertheless falsely, that he had not insulted a police-
man
(katathymic amnesia). In such cases one can usually easily

in hysterics most readily by hypin a round-about way
demonstrate
nosis
that the engrams
recollection
may
concerned have not been destroyed, since the

again appear in another connection.
In some cases the necessity exists to omit an entire period of time,
woman who wished to forget her husband

and who then recalled things only up to the time of her acquaintance
with her husband. Thus originates apparently a temporal circumscription of the amnesia but in which, nevertheless, the content is the
essential factor and which furthermore differs from the ordinary
temporal amnesias in the fact that it relates to a period of normal
as in the case of the hysterical
experience.
The rarer negative hallucinations of memory are a little different.

Thu a patient, like all the others, has received his cigars for Christmas
he smoked them up quickly and then began to scold because cigars
were given to all patients except to him. The distinction between this
and katathymic amnesia lies in the hallucinatory obtrusiveness of such
Wernicke's patient did not remember something that
manifestations.
he experienced, while upon the other the recollection forces
itself
that
something that should have happened did not happen. The latter feel
the gap in what should have happened, while the others are not
conscious of any gap.
The most frequent kind

ances of consciousness of
A
in
all
of
amnesia
is
the one that follows disturb-
kinds, especially twilight states
and
deliria.
patient wakes up suddenly after some sort of behavior otherwise not
keeping with his character, he does not

got there and what has happened.
how he
certain
moment, and then
know
He
recollection ceases,
person after a "dreamless" sleep.

estimating the transpired time
is
As
at all where he
is,
up to a
a normal
recalls things,
somewhat
as in
a rule every point of contact for
lacking;
if
the twilight state has lasted
several days, the patient usually does not feel the lack of temporal
orientation at
all,
or perceives
it
As
insufficiently.
estimates the duration of the condition, and thinks
a rule he underit is
the day fol-
lowing the one last remembered, as after an ordinary" night's
Amnesias are also not uncommon
psychopathic or in really insane patients.

prisoners, in depressive
rest.
after purely affective explosions in
This
is
seen in outbursts of
and schizophrenic excitements, and similar
states.
The amnesia
is
not necessarily complete.
There are
all
transitions
TEXTBOOK OF PSYTCHIATRY
102
from absolutely no memory up to complete recollection, just as in the

our dreams. This amnesia also resembles that following the
insofar
as it may be variable. Frequently, immediately after
dream,
waking some things can be remembered that are forgotten some time
later, and, just the reverse, an initial total absence of memory may
recall of
clear
up
in the course of the next
hours or weeks, especially when the
patient is reminded of his acts. As in every case where there is a

certain weakness of memory, a selection of the retained memories may
take place even in quite harmless cases, which is an exaggeration of
normal states, inasmuch as only what is unpleasant to the patient is
altogether or mostly forgotten. The knowledge of these incomplete
amnesias is very important because criminal acts are not seldom committed in twilight states and in case the patient shows a wavering
recollection, the judge is inclined to take simulation for granted.
Also the exact time of the beginning and ending of the amnesia
cannot always be definitely fixed, which may lead to new difficulties.
In part, but not at all invariably, such a manifestation is connected
with the course of the twilight state, in which clearer moments may
change
off
with those entirely unclear.
The amnesia may

state,
also extend
beyond the time of the abnormal
taking by preference a backward direction; this
is
designated as
This is very often the case after dreamlike or

unconscious states in consequence of head traumas or after attempts
at hanging. The patients no longer know at all that they got into the
retrograde amnesia.
trauma arid how they got there. Anteromuch more seldom and perhaps only during a
situation that produced the
grade amnesia
^^
occurs
gradual transition to lucidity which deceives the observer as to the

Here there is a prolonging of the amnesia
severity of the condition.
to the time immediately following the attack, which period
may
last
for hours or days.
During the twilight
state one usually
can easily ascertain that the
patient can recall events experienced in the

epileptics,
whose twilight
same
attack.
One
of our
states often lasted several weeks, pretty regu-
larly recalled during these attacks the occurrences of the last two days;
but from this period the amnesia followed continually the course of
time. Moreover, the memories may turn up again in the next analogous
Ûnfortunately
this term is also used for various other disturbances of

as for a condition in which every experience is at once forgotten, as
in our organic memory disturbance, without a consideration as to whether the
disturbance of recollection also extends to former experiences. It is also used
memory,
in cases like those of the epileptic, in the following paragraph, with
anterior border of the

two days.
whom
the
amnesia followed the present time by an interval of
state; this is seen not only in hypnotic
103
and hysterical twilight
states,
but also in epileptic and even toxic states. A drunkard, who in a

drunken condition has mislaid his keys, knows the next time he is
drunk where they are, etc. Also in the hypnotic as well as in epileptic
many such twilight states may be brought to light again.

In the conditions that lead to amnesias we regularly have a
markedly changed mental activity. In the hysterical states and in
states
attacks of rage and anxiety
it is
the emotional effect that produces a
different relation, in alcoholic intoxication
and
poisoning of the brain, while in organic cases
in epileptics it is the
doubtless, chiefly a
it is,
metabolic disturbance in consequence of circulatory changes, particuUnder such

larly through vascular occlusions and cerebral pressure.
circumstances apperception
is
already inadequate and
elaboration of things perceived, that
is,
there
is
still
more the
an inadequacy
in the
connection of normal associations with the individual's existing

of ideas with the help of which memories are ordinarily aroused.
of these are additional
impediments to the capacity to
sum
All
Even
recall.
a normal person could not recall the disorderly confusion that

states of dimmed consciousness present.
many
But the most important factor, which is nearly always present, is

probably the entirely different state, namely, the combination of ideas
changed as to content and form. Even the health}^ person does not
possess full control over his memory resources if he wants to make
use of them under unusual circumstances or when he is preoccupied.
It cannot therefore cause surprise if similar phenomena occur wherever
there
was a change
in the usual state of the association.
If
one no
longer remembers the events of a particular place, they often

plainly into consciousness as soon as the place
is
revisited;
come
after a
manic depressive attack recollections are often dimmed, but in the next
attack, even if decades have since passed, they may readily obtrude
themselves with most unusual clearness. We have good reason to
suppose that the amnesia for the first period of childhood may be
attributed to the powerful transformation that the personality has to
undergo in this period. That the suckling has no memory- is naturally
a senseless assumption.
The
essential factor in
of an unpleasant
many
recollection
hysterical amnesias
{or actual fact)
is
the e.vclusion
from consciousness.
This necessity has usually already provoked the twulight
state.
To
illustrate
Through clumsy manipulation behind her husband's back, a woman

has made inroads upon his fortune, on account of w^hich her husband
wanted to leave her. She now merged into a twilight state from which
104
she had excluded a large part of time of her married existence and
especially the birth of a child which occurred
when her
troubles began
and made the situation more
difficult;
herself through explanations.
After a while she became more lucid,
she could not be brought to
but only after her husband had become reconciled to her was she able
to recall her guilt and the marital difficulties; but she could not recall
the twilight state.
The
inability to recall frequently does not
lie
in the condition at
the time of the experience, but in an actual resistance to the ideas
about to be reproduced. Even in the case of experiences occurring in

clouded states only those that are unpleasantly accentuated are sometimes conspicuous.
Thus an epileptic teacher who had stolen during a twilight state,

knew nothing either of the thefts or of the epileptic attacks,
which he had while under observation in an institution, although he
had not only been led over both episodes but was also convinced of
them; at the same time he remembered well most of the details of_his
afterwards
flight to
a foreign country.
As disturbances
of ekphoria
we have
still
to mention the schizo-
phrenic states in which obstructions, abnormal mental trends, and in-
In this connection
coherence prevent the finding of the usual paths.

it
should also be mentioned that where few associations are present,
and in imbeciles, recollection may start from fewer

under certain circumstances, proceeds less readily.
Recognition has naturally become impossible where recollection in
general has ceased. Senile patients often do not recognize their nearest
But recognition is retained much longer than simple recolrelatives.
as in organic cases
points, and, therefore,
lection, for the association of a
of the
same thing
is
new impression with
memory
picture
certainly one of the strongest impressions, and
very easy to find. Thus we also see in examining the impressibility

that, although the patient is unable to repeat a name just previously
mentioned, he can, without difficulty, select it from a number of words
presented to him.
The alteration of the feeling tone and other regularly occurring

subjective additions of a perception which have not yet been described,
can under conditions so change the latter, that the object appears
Neuropaths and
is not recognized.
melancholies very often feel that everything seems strange to them,
but only seldom do they consider the things really changed, in schizostrange to us and in rare cases
phrenics, however, the reverse
As parafunctions
of
is
often the case.
memory (memory
deceptions)
in the first place, the inaccurate recollections.
They
we
recognize,
are found, as
lOo
mentioned above, in acute and in chronic alcoholism, but especially

In the latter similar memories
in organic cases and also in epileptics.
when
such a patient, for example,
each
other
can easily be mistaken for
especially when he
merge
together,
events
was twice in prison, the two
time
spent in prison
relates
about
a
then
He
is in a twilight state.
even
more
characterand
what
is
episode,
which belongs to the other
from
the
idea of
he
cannot
get
away
istic of epilepsy is the fact that
will
continue
to
relate
how
conditions
he
the repetition, and under
worked,
then
came
into
prison,
then
he was discharged from prison,
and then he was again discharged and again locked up, etc. Indistinct
and inaccurate memories are also common among those imbeciles who
in their concept formations do not firmly adhere to sensory perceptions,
whereas in the others we can often find a remarkably faithful reproduction of experiences.
On
the whole, these inaccuracies of
in pathology.
tions
More important
which are designated as
memory
receive
are the systematic
illusions
little
memory
and hallucinations
of
attention
falsifica-
memory.
memory (paramnesias) are exaggerations to the

memory disturbances which are so frecjuently
provoked through affects in healthy persons. They play a great part
The
illusions of
point of pathology, of
forms of insanity, but the greatest part is played in paranoia

and schizophrenia. There is no paranoiac who does not change his
memories in the sense of his delusions, but just here one can sometimes verify how the original memory pictures as such have not
been changed; the patient affirms, for example, "that the pastor had
preached about me. He said that I am now looked upon as an
insane person and I am not good for anything else." On intensive
in all
questioning one at
first receives,
despite all urging, the verbal quo-
tations of the pastor's speech in the
form mentioned.
But
if
the
doctor and the patient do not lose patience, one can finally show that
the pastor said: "Happy are those who are poor in spirit," but that the
patient referred to herself the words in the given sense and translated
words which she put in the pastor's mouth without realizIn the delusion of princely lineage a visit paid to the parents,
this sense in
ing
it.
perhaps insignificant, is translated by the patient as

Here, too, one can often elicit through patient
questioning of the patient that one does not deal with anything
important. In both these cases, however, the patients are not any more
which
in itself is
a visit from a minister.
convinced by these analyses, and immediately thereafter repeat their

assertions in the original form.
Melancholies entertaining delusions of sin are in the habit of

life for faults that they may have committed.
investigating their whole
106
They not only make a deadly
sin out of such trivialities as stealing
apples in childhood but they also often change the content of the
memory
in the
get into
same
In their excitement manic patients easily
sense.
with their environment.
friction
aggressors and put the others on the defense.
They are regularly the

Even during the course
of the illness, but more remarkably also, even after the attack, they
recount these experiences for the most part in an entirely different
light, they represent themselves as the ones who were maltreated, misunderstood and unjustly attacked. As they are now quite calm and,
as a rule, quite sensible, it is difficult not to believe them if one is not
At
himself well acquainted with the situation.
all
events
we know
that patients suffering also from other mental disturbance, above
all,
the clearer minded and litigious schizophrenics, behave in the same
manner
in similar situations.
systematic
memory
disturbance which
is
also determined
by the
affect is at the basis of the alternating personality.^^
Memory
one's
illusions
own person
which connect the experiences of others with
(as in the case of appersonation), merit special con-
Schizophrenics
sideration.
sometimes
aver
that
they
experienced
things which really happened, but not to them, but to their nearby
Whoever
considers himself Christ, believes that he had been

under
certain conditions, can delude himself into rememcrucified, and,
bering the details of it with perceptible acuteness; to be sure, the
greatest part of such products become unclear in consequence of the
imperfection of the sensible components and are thus recognized as
patients.
incorrect.
memory
we may put those memory

memory picture, which has no connection with a real experience, that is, the memory hallucinations
which endow a phantasy with reality. The latter must be taken in
Parallel with the
illusions,
deceptions which freely create a
the strict sense as confabulations, for they really also deserve this
name.
Objectively they represent ideas having a timbre of something
experienced or of something remembered.
Memory
hallucinations appear almost exclusively in schizophrenics.
All of a sudden memories appear which have no basis in experience.
The patient immediately begins to be abusive saying that last night

he was taken into the tower and made to go through all sorts of
gymnastic tricks, in order to throw him finally into the river. The
following days the story is continued and constantly becomes more
complicated but is seemingly arranged after a definite plan. He is
finally
"
Cf.
made
to fly
(before aviation
came
below under Disturbance of Personality.
into existence)
and goes
107
At the same time it is surely not a cjucHtion

dreams or of hallucinations of the senses, for many of these
experiences are put back to a period when the patient was C4uitc
through the whole world.
of verified
normally occupied with work or singing.
In other cases the
memory
hallucinations are less systematized and consist only of fragmentary

details.
The normal person can
normity,
if
easily read himself into this abhe thoroughly observes his dreams. A great part of the
experiences which are later put into the actual dream, are in reality
memory hallucinations and immediately come up in the associations as
memory and not
as a present experience.
Also in organic cases such real
memory
hallucination
can oc-
Thus a senile patient frequently related to us, how

he was attacked in his room last night by robbers, who tied one of
his arms on his back, and used his other arm with the hand as a scoop
to get out the gold and silver from his own money chest. Sometimes
casionally appear.
it
could be demonstrated that he neither slept nor hallucinated during
the night in which he located his adventure.
As
a matter of fact no
hallucinations of the senses have ever been confirmed in him.
In confabulations
it is
also a question of free inventions
which are
taken as experiences. They fill a memory gap, frequently turn out

to have been produced for just this purpose, and change from moment
to moment. Indeed they can be provoked and guided while memory
hallucinations can no more be changed than a delusion. One asks
an alcoholic Korsakoff patient where he had been yesterday, and
without any reflection he recounts with great accuracy that he took a
walk to the nearby mountain. If he is then asked whether he Has
not seen the doctor, one can expect with considerable certainty that in
pronounced cases, the patient will answer in the afiirmative and will
describe where he had seen him and about what they talked together.
Now and then such an invention adheres to memory, and what is
remarkable, also when real experiences are forgotten from minute to
minute.
also used for vivid memory
phantasy
manifestations of
hallucinations and for
the
concept
in the above
adhere
to
however,
schizophrenia. We must,
Unfortunately the term confabulation

half
is
conscious
given sense of the confabulation, for thus conceived it is a sign of

organic psychoses when observed in non-delirious states. It would
be good
if
the
The most
name should not be
applied to other anomalies.
vivid confabulations are seen in
many
alcoholic Korsakoff
cases; almost their whole psychic activity often consists only of con-
Many
paretics, especially the
manic types, spontaneously
confabulate in a very profuse manner.
Confabulations play the
fabulations.
108
smallest part in senile forms,
easy to evoke the
symptom
still,
if
even here
the patient
is
it is
in
many
cases quite
asked, for example,
what
he did yesterday (embarrassment confabulations).

Related to confabulations are phantasies which on occasion are
formed by everybody, and are more spontaneously produced by the
poets. Gottfried Keller's Griiner Heinrich relates in an episode which
undoubtedly created from the poet's own childhood, how when in

the abc class he was painfully taken to task for using ugly words
which he accidentally absorbed, how in his embarrassment he named
some place and name, following which, to further questions, a more
complicated scene emerged with all possible details, which he believed
was an experience from his own life.
What happened here to the future poet occurs habitually in PseudoPseudologues have a vivid phantasy, they invent
logia Phantastica.
for themselves some fairy story about princely lineage or some other
is
and act upon it. In contradistinction to confabulations

and memory hallucinations, the real worth of their phantasies becomes conscious to the pseudologues as soon as they are recalled to
them by the events, and sometimes even without this; in every case
a part of the fancies are just lies. Yet, for any long period the
desirability
pseudologues are capable of ignoring the fact that they are living in
a
dream world.
into operation,
cases that
all
This circumstance, with a great talent to put a role

which for inner reasons is regularly found at least in
come
for investigation, gives
ceive their environments,
and
if
destined to become panhandlers.
them the
Pseudologia phantastica
a general anomaly and not merely one of memory.

cases will serve as illustrations:
young man
facility to de-
they are not very moral they are

is
The
therefore
following
^^
good breeding fancied so vividly that his mother

dressed in mourning carrying a wreath of
flowers of his mother's funeral. Another young man had a quarrel with
a friend. He then pictured to himself a duel with his antagonist whom
he shot dead, and that he informed the latter's father of the unfortunate outcome of the duel. I found one prisoner in his cell projecting
a plan for an English park. He admitted that he had already prepared in his mind the speech he was to deliver to his dinner guest
on the occasion of the first hunting party.
Among the parafunctions of memory one may mention in the first
of
died, that he rode
home
place the identifying
has sometimes the

'^
memory
deceptions.
Even the healthy person

fatigued, that he had
feeling, particularly wh"en
Aschaffenburg, Die pathologischen Schwindler, Allgem. Zeitschr.
909, Bd. 66, p. 1073.
f.
Psych.
109
already experienced something that happens to cross his mind at the

An attempt was even made to trace such deceptions to
time being.
the idea of the transmigration of the soul.

in neurasthenics.
in schizophrenics
Now
and
and then
epileptics,
imagine that some comedy
is
It occurs
this manifestation
who
more
is
frefjuently
also observed
are usually peeved over
performed
for their benefit.
it
and
schizo-
phrenic that I have known, believed for a long time that whatever
he experienced he had already gone through in exactly the same way
a year before. An epileptic who in a twilight state saw in everything
that happened to him, especially visits and the doctor's words, a
weeks before, finally remarked that everything

and placed the actual experiences in a great number
former twilight states, a fact which at the time caused him marked
repetition of a few
repeated
of
itself,
excitement.
Just as the
memory
qualities are in this case connected with ideas
we
to which they do not belong, so also do
memory
find reminiscences in
and appear to the

There are learned men who at first negatively reject every new idea and then digest it consciously or unconsciously, and finally, accept it, if it suits them, but then absolutely
forget that these are no discoveries of their own, and even go so far
as to present them as new to the very people who discovered them.
Senile patients often relate a story at a social gathering as new, which
they have heard only a few minutes before from somebody else at the
same gathering. Frequently, however, the cryptomnesia embraces
the whole wording. In the beginning of this century an art critic was
once accused of plagiarism because he reproduced word for word a
criticism of somebody else. The whole state of affair points that it must
have been a case of cryptomnesia. Jung has also demonstrated
cryptomnesia in Nietzsche who verbally put a paragraph from
the Seeress of Prevorst into his Zarathustra, and what is more, in
Helen Keller's unconscious reproquite a senseless connection.^^
cryptomnesias which have lost the
patient as
new
qualities
creations.
duction of the fable of the Frost King caused her a great deal of
annoyance.
As
reduplicative
memory
deception, Pick has described a mani-
festation sometimes seen in organic patients,
which consists
in the fact
that the patients do not duplicate the actual act but double the details
of
it.
They say that they have already been examined
in the
ver>''
" C. G. Jung, Zur Psychologie und Pathologie sogenannter okkulter Phanomene, Stuttgart, Mutze 1902 Especially instructive is Flournoy's "Des Indes
a la Planete Mars, Paris and Geneve 1900.
(Etude sur un cas de Somnambulisme avec glossolalie.)
no
same
clinic
by the very same physician, having the same name, there

two such physicians and clinics,
are therefore,
5.
Wernicke
DISTURBANCES OF ORIENTATION
divides disturbances of orientation into autopsychic or
those referring to the individual's person, somatopsychic or those referring to the individual's body, and allopsychic or those referring
to the outer world.
patients in
that
is,
alcoholic
This differentiation has a specific meaning; thus

deliria are never autopsychically disoriented,
they can give a good account of their personal matters, their

and past life, whereas allopsychically they ar
residence, occupation,
usually deeply disoriented, especially as to time and place.

this classification fails to give proper
situation which
orientation.
may form
However,
emphasis on the element of the
part of allopsychic as well as autopsychic
we
Instead of somatopsychic disorientation
prefer to
speak of somatic illusions and hallucinations.

In all organic mental diseases of a higher grade, the primary
memory, and attention

comprehensive orientation itself. Orientation as to time and place, and
later also as to the situation, are falsified.
The patients are not aware
that they are kept in an institution, or of the reason thereof, nor do
auxiliary functions of orientation, perception,
are affected,
and
in addition there
is
also a disturbance of the
they recognize as such the doctors who are treating them. Not infrequently one observes in the insane asylum, that orientation as to
situation which
is
otherwise less liable to injury
orientation as to time.
This
is
falsified before
is
due to the fact that the patients do
not wish to be in such a place.

Orientation as to time and place are always present in Schizophrenia; they are often very well preserved unless interfered with
The
secondary influences such as delusions and hallucinations.
who
believes he
For
affective reasons the calendar itself is often directly
is
by
patient
Christ usually considers himself 1900 years old.

falsified.
Places are nearly always correctly recognized by clear Schizophrenics.
On
the other hand, orientation as to the situation
incorrect, at least in interned Schizophrenics.
comprehend that they are considered

unjustly confined,
sick,
is
The
in
most cases
patients cannot
they believe themselves
etc.
Furthermore, orientation can be falsified in

hallucinations and illusions.
If a
all
its
relations
by
patient sees hell instead of the
hospital ward, or a devil instead of an attendant, he cannot imagine
himself in an insane asylum.
The
strange part of
it is,
that in such
111
hardly ever in other diseases, the correct

the false one; one might say that
accompanies
mostly
orientation
on the constellation the
Depending;
orientation.
there is a double
orientation,
and often both
other
one,
then
the
patient uses now
states of schizophrenia,
together.
In
all states of
ceptions, thinking
is
vivid hallucinations which conceal the real peralso disturbed, often in a very
as for example in epileptic twilight states where
profound manner,
sometimes more
it is
pronounced than in our dreams. In some cases the disturbance of

thinking seems to be the chief cause of the disorientation, as in cases
That a schizophrenic delirium should appear
of confusion (amentia).
to last thousands of years, and a dream of a few seconds many hours,
absolutely changed course of the psychic
fits in well with the
mechanisms.
Disorientation as to time and place
constant partial symptoms of
all
is,
therefore, one of the
as deliria, crepuscular states, confusions, amentias,
Not seldom we
most
disturbances of consciousness, such
and other
states.
also find here some autopsychic disturbance (referring
to the person)
6.
DISTURBANCES OF CONSCIOUSNESS
Under the expressions "Disturbance

ing of Consciousness," which do not
nology, but for which
fit
of Consciousness"
and "Cloud-
in with the rest of our termi-
we have not yet found
substitutes,
we conceive
which the general relationship of the psychic

processes, usually including orientation, is disturbed, or in which
psychic processes are forcibly hindered from coming to consciousness." The first type of disturbance is especially found in the states
of Confusion mentioned above,^^ which may arise from very different
fundamental disturbances. Marked confusion with numerous hallucinations was also designated as Amentia. Kraepelin uses this term
a
number
of anomalies in
for a definite
morbid
picture.^^
Deliria and Timlight or crepuscular
though they are very difand not clearly differentiated
states are concepts everywhere used, even
ferently defined
by
different authors,
from each other, nor definitely limited.

What one calls Deliria are mostly states of incoherent thinking
combined with hallucinations and delusions, which show a certain
activity and run a rapid course. They usually accompany other dis'^The "conscience" of the French is a broader term than our
sciousness. Even simple delusions are "troubles de la conscience."
=^
Cf. p. 86.
'^Cf. Special part.
modern con-
112
and suddenly appear in the dark room in cases of diseases of the eye. But
in a certain sense, some states of Schizophrenia and manic depressive
eases, such as infections, fevers, exhaustions, toxic states,
may
insanity,
Disturbances of con-
also be designated as deliria.
sciousness in febrile diseases were
all
wont
to be designated as deliria,
although many of them clearly show connected ideas along the line of
complexes and, therefore, rather belong to the "twilight states." In
the newer German psychiatry the term "delirium" most frequently
The memory
stands for ''Delirium tremens."
of deliria
usually
is
imperfect or totally absent.*"
The name Twilight
State suggests especially a systematic falsifica-
He who
tion of the situation.
is
familiar with these states finds sense
and a more or less logical connection in the acts of the patient. The
onset and termination of twilight states are most often sudden, the
duration is brief, lasting from a few minutes to a few days, rarely for
weeks or months.
In the
narrowed.
(less
frequent) oriented twilight states the associations are
There seems to be present only a
to accomplish
what
is
least to the extent that
single purpose striving
necessary, while the rest of the personality, at

it
runs counter to this purpose, does not
exist.
The patients act in a definite direction, they run away, take a journey,
make a purchase, commit a crime which otherwise would be foreign to
them; they do all that without any regard for themselves or others,
even though at times, especially in the case of forbidden acts, they
endeavor to protect themselves against discoveries. During this period
if
they can be observed they usually strike one as abnormal
at times,
however, they can use correctly ordinary means of intercourse, can

associate with fellow travelers,
and can even
visit relatives,
without
betraying their condition.
The ordinary
differently
and
disoriented 'twilight states present themselves quite
yet, as daily transitions show, they are only
an exag-
In spite of a certain coherence, which might

be compared with a dream, thinking is not clear or it may even be
geration of the preceding.
confused.
The connection with the outer world
is
altogether inter-
rupted or falsified by illusions and hallucinations of the visual and

auditory types, especially the former.
mals, devils, or the Almighty with
The
many
patients see robbers, ani-
saints; they actually believe
themselves in a dream-like situation and act accordingly.
dream the content
of the twilight ideas
may
As
in the
be anxious, indifferent, or
is
much broader. They even call
occurring in clear consciousness delirium. Bouffee's delirantes are,
according to Magnan, transitory deliria in his "degenerates."
*'The
delusions
French conception of delirium
rapturous.
Anxious and
provoke the patients to acts
hostile illusions
of violence; killing even several people
citements lead to rape and murder.
is
An
113
not uncommon.
Sexual ex-
epileptic set fire to his
work-
shop in the belief that he was lighting a fire under a lime pan. States
In such states association with
of rapture are designated as ecstasies.
the outer world is so completely interrupted that an absolute analgesia
exits.
The
patients see the heavens open, associate with the saints,
hear heavenly music, experience wonderful odors and tastes and an

indescribable delight of distinct sexual coloring that pervades the
entire body.
Some
illnesses
twilight states have a definite purpose such as to represent
and the
Ganser state.
Syndromes.
like, of
The
which the best known type
is
the so-called
varieties of these forms are indicated under the
Many have their

and schizophrenics turn away
from reality because it has become unbearable. An engagement which
has been broken in reality continues in the twilight state and leads
to marriage.
Some hysterical twilight states repeat hallucinatorily an
emotionally accentuated event, especially of an ambivalent nature,
e.g. a sexual attack.
Less frequently the delights of ecstasy can be
The
causes of twilight states are very varied.
origin in an affective necessity
conjured up.
The
hysterics
basis of twilight states are the hysterical, epileptic
or schizophrenic disposition, toxic conditions, especially pathological

intoxication, also sleep, as
pavor nocturnus, somnambulism and hyp-
nogogic intoxication, less frequently
it is
migraine, concussion of the
and brain disturbances after hanging, occasionally it may also

be caused by severe excitements as in the case of psychopathies. In
hysteria the entire mechanism is psychogenetic in the toxic states of
epilepsy and schizophrenia, it is the brain disturbances which usually
brain,
All these states produce clear thinking

which becomes systematized as a result of affective aims, in consequence of which the disturbance assumes the form of a twilight state.
The disturbance of thought then has a twofold origin, one in the toxic
confusion, the other in the systematic formation with its misunderfurnish the necessary factor.
standing of reality.
It
is
self-evident, that in epilepsy as well as in
may be entirely different.

There are extreme cases in both directions, on the one hand conditions
in which the organic completely dominates the picture, and on the other
hand those which are of an entirely psychogenetic (hysterical) character and in which acute changes of the fundamental condition play no
part.
Where primary anxiety exists, as is often the case in epilepsy,
schizophrenia the relation of the two causes
the content of the delusion
is
colored in this sense.
114
Naturally, we often observe very mild twilight states and deliria,

which the thought process is only more or less unclear. These mild
forms together with deliria and twilight states may be called pro-
in
visionally turbid states.
There
is
another gradual weakening of consciousness which

must be endowed with an
still
is
shown by the
fact that external stimuli
abnormally great intensity
in order to
of this sort are called cloudiness, a
become
name
that
Mild
conscious.
may
states
also designate light
grades of the twilight states. Similar states that are somewhat deeper
and especially those in which movements are retarded are designated
as somnolence; those in which only stronger stimuli produce reactions
are called torpor or sopor; and those in which there
is
a state of actual unconsciousness,
This
psychisms.
is
is
no longer any
In the last condition one assumes that there
reaction are called coma.
i.e.,
an absence of conscious
naturally something entirely different from the
falsely designated unconsciousness in a twilight state.
In
all
these disturbances the field of consciousness, that
ber of simultaneous ideas,
is
is,
the
num-
greatly diminished; in the twilight states
is more or less systematic, in other conditions it is diffuse.*^

There is also a purely functional attempt to keep occurrences out
this
of consciousness.
ideas
it
When
attention
blocks at the same time
makes way
all others.
pleasant thoughts are automatically kept away.

fulness cannot even be thought of.
In
all
to consciousness
mood un-
In melancholia cheer-
The katathymic
bearable complexes from consciousness

category.
for a certain group of
In a cheerful
(repression)
exclusion of un-
belongs to this
these cases the functions which are not admitted
may
be entirely impeded or they
may
lead an un-
conscious existence.*^
Sleep
is
a kind of physiological disturbance of consciousness which
symptoms. I do not know

whether or not one always dreams in sleep. In our present state
of knowledge the forms of association in dreams are the same as in
schizophrenia. The psychopetal functions usually are extremely realso gives occasion for several pathological
stricted in sleep, partly in such a
reactions, partly,
main part
place
its
is
and
this is
of the stimuli
is
way
that only strong stimuli arouse
more important,
shut
in such a
way
that the
off regardless of its intensity,
taken by a smaller group, which
is
and
generally or under
certain constellations especially important.

Thus a nurse sleeps
through a great noise but is awakened by a slight respiratory change
The psychofugal connection with the outer world,
in her patient.
*^
For alternating consciousness Cf Personality.

.
" Comp. the Unconscious,
p. 8.
115
at least as far as concerns the voluntary muscular system,
is
usually
movements that make respiration easy, change uncomfortable positions, ward off stimuli from insects, etc. Movements that
limited to
are not carried out are falsely conceived through kinaesthetic hallucinations, except in nightmares, where the paralysis
is
is
and what
felt,
not quite the same thing, the interruption between volition and
motility comes into consciousness.
Falling asleep
is
is
the result of an influence, or a special act, which
put in operation by the predisposition to fatigue, a feeling which
psychically determined.
psychotherapy
The
is
is
Perhaps the only thing of importance for
the psychic participation in the initiation of sleep.
To be sure, energetic
time hinder the command
essential thing is the "suggestion of sleep."
may
mental occupation in the evening

to sleep.
But
example, one
ordinarily,
is
it
is
for a
the affects that exclude sleep.
particularly apt to remain
awake when one
is
For
pleas-
when one is afraid of not being able

when one "imagines" himself disturbed by a definite
antly or unpleasantly excited,

to sleep, or
Here the sensory impression has really no significompared with the psychic attitude. The psychotherapist must
firmly maintain that when some one cannot sleep, let us say, because
his neighbor snores, that it is his own attitude and not the neighbor's
sensory impression.
cance,
snoring that
noise
if
one
is
is
the cause to be considered.
One can
sleep in the worst
able to assume a proper attitude, and at the
same time
one can be awakened by the slightest sensory impression for which

there
is
an association readiness.
One
Millions sleep through the street
most important neurotic disundoubtedly based on the fact that emotionally

accentuated complexes, which are more or less repressed by the day's
work, make themselves felt as soon as purposive thinking ceases.
What the recuperative function of sleep is, we do not know. At
all events it is under a special influence, because, in states of depression, for example, one can dispense for many months with sleep, in
the sense of disturbance of consciousness and association, without
apparent results, while an artificial insomnia of only eight days is
certainly fatal.
Moreover a partial insomnia has few or no immediate ill effects, if one succeeds in lying quiet and not exhausting onenoises of the metropolis.
turbances of sleep
self in
of the
is
the "struggle for sleep."
The dream
is
classed with the twilight states because ordinarily
does not influence conduct.
it
Nevertheless in the sleep of no person
are the connections with the outer world maintained only through
the merely necessary centrifugal and centripetal impulses.
groaning, twisting, and through
many somewhat
Through
uncoordinated move-
116
even in sleep some internal

normally existing
motor commands permits the release of any acts corresponding to
dream images, and leads to twilight states of somnabulism, hypnogogic
intoxication, and pavor nocturnus.
Somnambulism occurs in nervous persons of all types, in epileptics,
and to a mild degree, at times in people who must be considered
ments and similar expressions one

or external requirements.
healthy; this
is
satisfies
slight increase of these
especially the case in youth.
transitions from simple
There are
movements and mumbling
all sorts of
in sleep to
more
complex acts as well as walking which sometimes takes place on the

Most frequently such little acts are performed that correspond
roof.
to the daily occupation; these are sometimes senseful and sometimes
Complexes may also find expression in somnambulism

(Lady Macbeth).
Hypnogogic intoxication (Schlaftrunkenheit) may occur during
spontaneous awakening in people who seem perfectly well, but more
frequently it follows a rough waking, which generates a dream, and
induces motility before the dream disappears. In rare cases something clumsy is then performed, indeed, under the influence of terrifying
ideas an attack or murder may be perpetrated. A variety of sleep
intoxication which is especially frequent in children is pavor nocsenseless.
It usually manifests itself in the beginning of the night
turnus.
when
ones start with an anxious cry and despite all attempts to

wake or quiet them, become mentally clear only after several minutes
or even a longer time. The syndrome is often altogether psychically
the
little
determined, in other cases

respiratory difficulties.
The
it
is
favored or absolutely induced by
twilight states of sleep are also regularly
followed by amnesias.
"Clear Mindedness" ("Besonnenheit")

In contrast with disturbance of consciousness there is "clear
mindedness," a concept that is plain to all, although it cannot be quite
In states of clear mindedness every disturbance of condefined.
sciousness is lacking, orientation is good, the affects produce neither
unconsidered acts nor stupor. The most inhibited melancholic can
think normally within the range of ideas accessible to him, and can
The most chronic
orient himself, he is so to speak, clear minded.
states of schizophrenia
do not lack clearmindedness, although, under
certain circumstances, the patients act in an entirely senseless way.

The major part of the thinking function runs along smoothly; orienta-
tion especially
many
is
good, and there
is
always a possibility of discussing
things sensibly with the patient.
The outward
indications of

117
clear mindedncss, according to Jasper, are orientation,
and the ability

on questions and to take some notice of them.
The concept is important because in clearmindedness identical
symptoms have an entirely different significance than in states of
to reflect
In twilight states the most confused
disturbance of consciousness.
delusions indicate nothing concerning the prognosis, somatic hallucinations indicate almost as
little.
In clear mindedness both symptoms
point to a grave condition, the latter especially to a schizophrenic

condition.
DISTURBANCES OF AFFECTIVITY
7.
Since the affective dispositions fluctuate greatly in different people,
they also most readily cross the borderline of the "normal."
The
psychopaths are really nearly all exclusively or mainly

thymopaths. Furthermore, since affectivity dominates all other functions, it assumes a prominent role in psychopathology generally, even
so-called
on account of its own morbid manieven more because in disturbances in any sphere, it
in slight deviations, not only

festations, but
the affective mechanisms that
first create the manifest sj'mptoms.

mostly thymogenic. The influence of the
affects on the associations produces delusions, systematic splittings of
is
What we
call
psychogenic
is
and hysteroid twilight states; repressed pain is the source

most neurotic symptoms, while displacements and irradiations
produce compulsive ideas, obsessive acts, and similar mechanisms.
Ambivalent feeling complexes, that is, viewed from the active side,
inner conflicts, which the individual cannot settle but must repress,
personality,
of
prove especially pathogenic.
To
avoid repetitions the causal
signifi-
cance of the affects will here be passed over, and only the etiolog>'
of certain
symptoms
will be briefly considered.
Only the phenome-
nology of the affective disturbances will follow here.

Many affective disturbances come, as it were, from within, from
the physiology of the brain and from the general chemism.
is
Here one
perfectly right in thinking of the "inner secretions'' in the widest
sense, without
may add
knowing anything
definite
about them.
To
this one
the affective bases of melancholia and mania, the euphoria
and most of the moody states of epileptics and

and naturally also the congenital abnormal emotional states.
The last may have a significance of their own, as in the case of "chronic
moods," or ma}'' be the foundation on which other diseases originate.
To become an hysteric or paranoiac one needs a distinct aft'ective conSuch morbid constitutions are
stitution which is usually congenital.
of chronic alcoholics,
imbeciles,
118
almost always exaggerations of the character variations of the normal
type or "temperaments."
Other affective disturbances are qualitatively correct but quantitatively exaggerated reactions to an experience, which usually have their
Thus a mother loses her child, and does
origin in the constitution.
not recover from the blow for years, remaining in mourning all the
Or she reacts
time. She shows a morbid protraction of the affect.
no longer work or eat, is

and can in no way be distinguished
from a melancholic. Here one sees a morbid intensity of the affect.
In this way certain anxiety affects may lead to affective stupor ^^ and
confusion, manifestations that make the examination of children and
oligophrenics particularly difficult, and often lead into entirely false
so strongly to her misfortune that she can
entirely absorbed in the anguish
trails.
Reactions in themselves normal may appear morbid because the

on which they are based is abnormal. A paranoiac
believes that he has made a revolutionary discovery which makes him
intellectual process
emotionally exalted, or he considers himself persecuted and becomes

In both cases the affects are normal reactions to a morbid
irritated.
is normal.
In the same
apathy in organic cases, who
do not understand many experiences and, therefore, naturally cannot
react to them. As soon as they grasp the true significance of anything the same patients react to it in a very active manner.
Morbid irradiations and affective displacements are secondary disturbances in an entirely different sense. This is shown in the following
idea; in itself the formation of the affect
way
there
is,
for example, a secondary
examples
The patient feels disgust and anxiety at hornlike soup ingredients

and other things shaped like horns because she was once frightened
by a bull whose genitals and horns particularly impressed her. A
schizophrenic woman, a patient of v. Speyer hated her landlord because he had cheated her husband. When she was taken with labor
pains in an isolated country place, instead of a mid-wife the wife of
the landlord had to assist her. The hate was transferred from the
landlord to his wife, and from the latter to her own child which she
tortured to death.
Most
continue
affective disturbances are transient episodes.
are
usually
congenital,
less
frequently
Those which
acquired,
as
the
chronic euphoria of alcoholics, the lability and some persisting euphoria

or depressive states in organic cases, as well as the perseverance
intensity of the affects in epileptics.
"Cf.
p. 80.
and
119
Morbid Depression
In general depression, all experiences, inner and outer, are toned
The milder cases resemble
with psychic pain of various kinds.
normal "downheartedness." It is not so easy, however, to read oneself
into the affective situation
has
lost
of the
profound melancholic.
He
everything that was of value to him, and nevertheless he
still worse for himself and those he loves, the worst that one
can think of. Through "diversion," i.e. an increase of sense impressions, which are really only unpleasantly toned, the pain is usually
increased, except in those cases where the feeling that the patient
does not feel well anywhere, leads to a continuous change of environ-
expects
In
ment.
many
cases perceptions take on the character of strange-
and monotony; optical impressions are double

dyed gray, things seem to stand crooked, and foods lack their peculiar
flavor. Thinking, in itself, is not only colored by unpleasant feelings,
but proceeds with difficulty, and only ideas of a painful content can
be thought out. Thoughts of a pleasant content are flighty and
transient, leaving no influence on deliberation and the general condition.
Only with great difficulty can the patient resolve to act, and
when he succeeds in making a movement, it is with great effort.
The mental stream is inhibited,** it runs more slowly and the
patient must exert effort to think out anything; a change of the
The patients always
ideas requires exertion or is even impossible.
fall back on the same ideas of a sad content or they never get rid
of them and always carry with them the same desperate thoughts
(Monideism)
Among the varieties of depression, of which we mention only grief,
To
desperation, and remorse, anxiety occupies a particular place.
be sure, it is often combined with the common forms of depresness, of uncanniness,
Anxiety may also

it merely complicates the latter.
appear in isolated form, which accounts for the fact that starting
from different viewpoints some authors wish to differentiate an absolute anxiety psychosis and an anxiety neurosis as special forms of
sion so that
disease.
it
is
Anxiety undoubtedly has different sources.
plainly connected with respiratory difficulties
In
many
cases
as seen in dis-
eases of the heart, in the respiratory organs, and in the blood.
Further-
some way with sexuality,

undoubtedly connected
fact
which
long
time
but
which Freud first made
a
we knew for a
more, anxiety
clearer.
in
Stimulated but unsatisfied sexuality leads to various forms

Frend's conception is that the sexual tension, or the sexual
of anxiety.
**
is
Cf. p. 74.
120
converted into anxiety, which may not be right, although

sexual satisfaction maj^ under certain circumstances remove anxiety,
and although anxiety appearing in attacks, as is more generally assumed, may be converted into other syndromes, such as inordinate
affect, is
hunger, attacks of perspiration, asthmatic attacks, diarrhoea, dizzi-
We also know that normal sexuality has

not seldom orgasms are generated by
and
that
component
an anxiety
hurrying
such
to catch a train, scolding from
situations
as
anxious
tasks.
In many cases of psychoses
and
difficult
a teacher in school,
an
irresistible
see
impulse toward onanism
connected with anxiety we
affect.
But
there
with
the
must be other pathothat disappears
Wherever
depression
in general originates
anxiety.
logic sources of
not
which
we
do
as
yet
know, anxiety too,
from physical processes,
ness and similar symptoms.
be generated, at least as far as we can judge at present;

in other words, in all states of melancholia of the most diverse
may
diseases.
In a more striking manner than the other affects, anxiety may

The patient may feel
without any association with ideas:
anxiety without knowing why, and be absolutely certain that there
exist
is
no ground for
itself creates
it
("free floating anxiety").
apparently conditions.
In
many
cases anxiety
becomes attached and which it

In most cases, however, one can easily dem-
the ideas to which
it
onstrate that such ideas are secondary; the anxious patient seizes
on something that might produce anxiety such as, an uncertain

financial condition, an insignificant symptom of a bodily disturbance
in himself or others, or on any mistake that he made in the past;
and even when circumstances can convince him that the ideas were
wrong the anxiety does not improve in consequence but it attaches
itself to a new idea.
Often it creates one as an anxiety delusion from
pure fancy without any external connection.
Katathymic anxiety referring to a particular member of the family,
present in normal and abnormal individuals, is as a rule the expression of a repressed wish that this
member should be
dead.
latent
by her husband whom she did

not love. Her anxiety was soon noticed even by the midwife when
she expressed the idea:
"I should only wish that nothing happen
to the child!" A few months later she poisoned it. A young woman
shows her illness through excessive anxiety for her mother. As soon
as her mother has gone out, she has to stand at the window to see
that nothing has happened to her, or to see if she is coming back. She
is strongly attached to her father and unconsciously jealous of her
schizophrenic
mother.
woman had
child
frequently and nnore
is more
symptoms than most of the other
Anxiety
physical
121
accompanied by
visibly
It is especialiy
affects.
often associated with an increased cardiac tone wliich
is
felt
the
in
chest as something heavy, pressing and often also something painful;
these
feelings
common
may
palpitation
be present even when the by no means unis
absent.
As
in
angina pectoris the pain
may
even irradiate into the left arm. In the abdomen, too, a rolling or
pulsing, or a hot stream may be felt, or the latter may appear to
rise to the head, where other bad feelings, such as knocking, pressing,
and
fullness
may
exist.
"The Anxiety"
is
often localized in
the place where one has the greatest sensation; thus one speaks of
praecordial anxiety, which
depressions, or of
is
head anxiety,
the most frequent concomitant of
all
etc.
Depression in general usually evinces distinct physical symptoms.

entire turgor vitalis is diminished, the patients appear older than
The
before,
and the metabolism and appetite become decreased.
cular tone, especially of the extensors and abductors,
the latter
move with
as
activity
is
The musdecreased,
and all show

and are as slow as possible. As a result, the
patient's posture becomes uniform, languid, and bowed, and manifests a tendency to draw in the limbs. The handwriting usually shows
a tendency to slant the letters downwards.
In some cases, especially those showing anxiety, instead of motor
little
retardation there
is
greater effort than their opponents,
a desire to express or get rid of the inner ten-
movements {Melancholia agitata). In contrast with the

common cases of melancholia some patients have no feeling of fatigue
and run around continuously and when permitted take tireless
walks.
In contradistinction to the normal we see more rarely,
that morbid anxiety retards movement and the psychic processes
sion through
generally.
is easily disturbed, in that inspiration becomes less
and connected with this are the frequent feelings of oppression.
The ipidse is mostly full and small, and the artery contracted. Anxiety
Respiration
free,
increases the blood pressure.
An increased tone
of the throat inuscles very often causes an annoy-
ing feeling of strangulation causing the patient to refuse nourishment;

it
also produces pressure in the chest.
dysaesthesias
may accompany
In addition
all
Depressions occur in the most varied psychoses.

to
it
there
tom
is
The tendency
and wdth increasing vascular disturbances

more anxious excitation. Depression is the essential sympall states of melancholia, and above all in those of manic
increases with age,
in
other possible
depression.
122
Besides these, there are certainly depressions of
depressive insanity.
Anxiety is an
other kinds which we cannot as yet characterize.
obsessive
and
obsessive acts.
of
phobias,
ideas
concomitant
important
The
We
Pathological Elated Mood
(Exaltation, Euphoria)
can differentiate two kinds of exaltation that are, however,

In simple euphoria one
all the intermediate stages.
connected by
enjoys the world and one's own existence in a particularly lively

way; sensations and thoughts are pleasantly accentuated. Among
the healthy of this type we have the sunny dispositions, while among
the sick we see some paretics not really of the manic type, less often
cases of senility, and at times, also epileptics in a euphoric mood
In the second form, which deserves more the name
{morbid euphoria)
of exaltation in a narrower sense, we also see self-consciousness and
with it an enormous enhancement of desires and claims. This naturally results in conflicts and leads regularly to severe outbursts of
anger. The conditions therefore, in which one sees this symptom together with flight of ideas and pressure activity, are designated
as mania and the affective state as manic depression. In a somewhat
milder form and without the flight of ideas we see this exaltation in
.
the
common
alcoholic euphoria.
Naturally, the pleasant accentuation
may
here, too, evince various
shades such as cheerfulness, lack of restraint, aesthetic enjoyment,
and a general
ineffable feeling of delight; the last
The
especially ob-
is
accompanying the ecstasy is

principally something quite different than manic euphoria, both in
the quality of feeling as well as in relation to the mechanism of its
origin, which in hysteria is regularly katathymic, in epilepsy usually
autotoxic, while in schizophrenia sometimes more of the one, then
served in paresis.
blissful feeling
again the other.
Corresponding to the nature of the positive affects in the normal,

mood of these patients is much more changeable than in depressed cases. They follow the different topics of conversation with
the
their affective fluctuations, but generally

state.
do not abandon the euphoric
In a few cases, however, such fluctuations
depressions in which the patients
may
be
moved
may
go as far as
to tears
by a sad
performance.
Just as
we have
retardation in depression, so in exaltation
often have a fluent course of ideas

translation of thoughts into acts
is
look younger, the turgor vitalis
is
opposite of that of depression.
up
regularly observed.
Manic
increased, the posture
The
we
to flight of ideas; the ready
other physical
is
patients
the direct
symptoms
are less
I
marked than
be
and
full
in depression,
123
even though the pulse has a tendency to
soft.
Exaltation, like depression, may appear intercurrently in every

mental disease; in manic states it forms part of the picture and in
manic depressive insanity it is a component of the disease itself. As a
chronic state
it
occurs in alcoholics, also as a partial
symptom
in
psychopathic constitutions.
Morbid Irritability
uniformly overstrong activity of
all affects
may
be the founda-
tion of an abnormal character as well as of hysterical
morbid
pictures.
and similar
Furthermore, such an anomaly occurs in the organic
psychoses and in epilepsy, and temporarily, also, in simple exhaustion where one may see all kinds of "affective crises," not only of
the endogenous but of the reactive depressive type.
one understands as morbid irritation
and
anger,
rage.*^
It occurs
exceedingly angry over

turbance.
all
is
However, what
a special tendency to ill-temper,
even in neurasthenics,
who can become
stronger sense impressions and every dis-
In the really insane
we
see
it,
as
of 'the manifestations of exaltation, then again
a more independent affective disturbance,
all
was mentioned,
it
as one
may accompany,
forms of dementia.
as
This
in part, founded on the fact that rage is the normal reaction to a

dangerous situation that one does not understand; under such ciris,
cumstances reflection
is
useless,
on the other hand, a blind
effort to
random or tear away without consideration for the environment and the integrity of one's own body, may at times save
at
strike
one's
life.
On
the contrary, in other irritable characters
we
perceive the in-
tellectual disturbance, the false conceptions of the surroundings with
morbid self-reference, as a result of the affect of irritability, and even

though these people always appear somewhat onesided or "narrowed"
they sometimes retail! an intelligence which is, on the whole, good.
Imbeciles manifest in addition moodiness which comes from
within, and easily assumes the form of irritated cloudiness of thought.
Here we see most frequently a peculiar symptom of rage, that actually
turns the action against themselves, which rarely occurs in other
The
patients.
patients tear their hair, scratch their face or destroy
other things so that they perforce hurt themselves.

tear their clothing.
their
is
own
Often they only
Such damaging of the environments, including
clothing, are very
common
in schizophrenics, at times
the result of excitations coming from within, then again
^The
disposition to anger
is
not always identical with rage.
it
is
it
124
In severe cases of schizophrenia
reaction to outer harmless experiences.
outbursts of rage and anger are often the only remaining signs of
affects,
while in the milder cases less severe irritability
indication of the disease that impresses the environment.
we
is
the only
In epileptics
often see a chronic irritability as a partial manifestation of the
general increase in intensity of the affects, and further, as a passing

state of depression in quite the
same way as
in imbeciles.
Apathy
Apathy in the sense that the affects are destroyed probably does
not occur in the psychoses; as a matter of fact we see all affects
retained in the brain in the most severe organic destructions. Nevertheless there are
many
no impulses or
affects.
show
show a
cases of schizophrenia which for years
who no
In senile patients
longer
proper understanding of this world we sometimes see a total lack of

interest in everything that occurs about them, which is much less
frequently
the
case
who
matters
in
of
personal
contact
with
them.
immersed in their misery that everything

else appears insignificant, are sometimes mistaken as apathetic.
Many of them maintain that they no longer have feelings, that they
are apathetic, because in the face of the great agony entailed in the
disease, they can no longer discern any feelings for their own family.
Melancholies,
are so
In contrast to neurasthenic irritability there is a neurasthenic inwhich no longer bothers with anything. Even more fre-
difference
quently do hysterics shut
off their
time, so that they appear apathetic.
"psychasthenics"
whom
affects
The
altogether for a shorter
chronic and totally apathetic
the French describe,
we undoubtedly would
include with the schizophrenics.
Variable Duration of the Affects
An
abnormally long duration of the affects occurs in many people

who cannot get over an ill humor and must
always carry with them, for instance, a hatred. In epilepsy, the
affects, once aroused, also persist an abnormally long time, even
when other experiences intervene. A slight annoyance may also
excite a congenital feeble-minded person for days.
Such patients
possess too slight an affective distractability.
More important and better known is the excessive lability of the
affects, their abnormally brief duration and their increased affective distractability.
Children are normally labile; they are rightly
compared with seniles; except that all organic cases should in this
respect be mentioned together. The affects are very easily aroused
not mentally deranged,
125
have a short duration; they are especially capable of
in them, but
Lability of the affects
being too easily diverted.
is
very
more advanced manic-depressive

may suffer from the same defect.
in the intervals of
beciles, too,
common
also
Im-
insanity.
Emotional Incontinence
Most
patients with too great a lability of feelings display less
They must
control than the normal.
they express
it
give in to every affect, whether
or act in accordance with
continence do not always run parallel.
it.
Yet lability and inThere are people without
who cannot control their feelings. One of our

who was none the less a pretty good workingman, could
noticeable lability
imbeciles,
not, to his sorrow, play cards, because a smiling or a sad countenance
always betrayed to the other players whether he held good or bad
As
cards so that they could act accordingly.
far as action
common
the patient usually
When
mental diseases.
in the different
accordingly.
acts
melancholies, and they resort to
an opportunity to commit
it
The
an
best
affect
is
con-
is
cerned one can say that a real control of pathological affects
is
not
present,
dissimulators
are
especially for the purpose of getting
suicide.
Affective Ambivalence
Even the normal
individual feels, as
it
were, two souls in his
he fears an event and wishes it to come, as in the case

of an operation, or the acceptance of a new position. Such a double
breast,
feeling tone exists

it
most frequently and
concerns persons,
loves.
This
is
whom
is
particularly drastic
when
one hates or fears and at the same time
especially the
case
when
sex
is
involved which in
itself contains a powerful positive and almost equally powerful neg-
ative factor; the latter conditions

of
shame and
all
among
other things, the feeling
sexual inhibitions as well as the negative valuation
of sexual activity as sin,
and the evaluation of chastity as a cardinal
virtue.*^
But such ambivalent

person.
On
feeling tones are the exception with the
normal
the whole he makes a decision from the contradictory
values; he loves less because of accompanying bad qualities,
hates less because of accompanying good qualities.
and
But the abnormal
person often cannot bring together these two tendencies; the hate
and love manifest themselves side by side without the two affects
weakening or even influencing each other in any way. He wishes
*"
Bleuler,
Bd. V. 1913.
Der Sexualwiderstand, Jahrbuch
f.
Psychoanalytische Forschungen,
126
and when hallucinations picture

desperate, but even then, besides crying he can
his wife's death
laugh over
it
for him, he is
at the
same time
it.
ambivalent complexes that influence pathology and

many expressions of the normal psyche, such as dreams, poetry, etc.
In schizophrenia they come to light quite openly. There we often
see directly the ambivalent feeling tones, while in the neuroses they
are concealed behind a large part of the symptoms.
It is chiefly
Congenital Deficiency and Perversions of Particular Affective

Groups
Congenital deficiency
is
the ethical feelings; there
almost always described as a defect of
is,
besides,
though very seldom, a defect
of the sexuality with all its affects.
False affective accentuations in the sense of perversions, in which

(sex impulse, hunger
the instinctive side stands in the foreground
impulse) are described in the chapter on impulses.*^
Exaggerations and Onesidedness of the Affective Causes,

Morbid Reactions
These
disturbances
are
fundamental
of
importance
for
the
neuroses, for the understanding and treatment of abnormal characters,
and
for pedagogics, but of lesser
hence
we
importance for special psychiatry,
shall give here only a few suggestions.
Strong affects
may
lead to disturbances of consciousness in psycho-
The
blind rage of prisoners
(prison outbreak) and

minutes
to many hours,
last
from
a
few
which
may
oligophrenics,
physical
amnesia.
Exaggerated
is
often
followed
by
known.
It
is well
pathic persons.
symptoms such
or represent
it
as fainting, or vomiting,
may accompany
the attack
alone.
The characteristic
momentary affect or
factor
may
here show
itself in
the force of the
in a lack of inhibitions, the latter occurs in
manic depressions, alcoholic effects, etc.

more chronic in psychopathic individuals delusions
formed, which disappear with a change of the situation.
definite dispositions such as
When
the effect
are easily
is
part of the prison psychoses
*^
belong here.
Instead of acting forcibly, the affect can inhibit itself and then
leads to stupor wherein thoughts and outer reactions are shut off;
*'
For Affective Disturbances of the Individual Morbid Groups see Symptomatology of the Diseases in special part.
^'Cf. especially Birnbaum: Psychosen mit Wahnbildung und Wahnhaften
Einbildungen bei Degenerativen. Marhold, Halle a. S. 1908.
or the affect alone
experience
is
suppressed, so that a particularly terrifying
calmly considered and observed but no affect
is
as in the cases of Livingstone v^^hen he
Balzy's
127
behavior
during
an
was attacked by a
earthquake.
In
lesser
is
we
(belle
The mental stream may become con-
fused as in making a speech.

Not quite identical with the affective stupor
ment which
and
degree
observe a kind of indifference in children and psychopaths

indifference des hysteriques).
felt,
is
lion
the embarrass-
is
to be conceived in the broadest sense.
only a question of a different attitude, as where
it
is
It is often
impossible to
do some'thing consciously which can otherwise be done well more or

opening certain locks and similar acts. If an
lesg automatically, as
affect
is
added, the effect
in one situation
is
is
naturally
still
stronger.
What
is
known
not at one's disposal in the other (Examination
If a special effort is made to accomplish

when one fears lest he make a failure of it, he is then
sure not to succeed, a mechanism seen in stuttering, bladder control,
impotence, and erythrophobia. As a matter of fact every act which
is more or less automatic, be it psychic or physical, is disturbed
through the interference of the conscious will. As examples we may
stupor and stairway wit).
something, or
mention the
common
chronic constipation as a result of a psychic
habit to drugs or occupation with the bowels, the
complaints
of
menstruation, and the difficulties of childbirth.
Stuporous states can become chronic in connection with definite

situations or a definite
morbid symptom,
also in the face of a certain
awkward had occurred.

manner may appear normal.
teacher or subject where something
who reacts in this

most stupid way to correct it is to bully
trary, one must make the effort to remove
yet a pupil
ing
it,
mental
in the
or in the
more
enlightenment.
On
The
the con-
the affect by kindly ignor-
intelligent patients one
attitude through
same way.
the patient.
And
can establish a different
Inner complexes also
The onanism complex, and not
act
the onanism, con-
tinually prevents the patient from concentrating on other things, so
that he gives the impression of having a poor memory.
Depressive
Thus a man is
predisposed
and becomes
more homosexually than heterosexuaJly
and exalted moods emanate from such complexes.
married life, but he cannot grasp the situation

view of his love for his wife with whom he apparently lives happily.
He finally becomes depressed but improves as soon as everything becomes clear to him and he adjusts himself to it.
Continuous false attitudes result particularly from an injury to
one's personality through acts which are considered "unjust." Y'oung
dissatisfied with his
in
128
and even children in the first years can in this way acquire
and forever continue a false attitude towards life.
Thus develops functionally an entirely different type of character,
usually unsocial, who can he differentiated from the congenital type
only through close observation, hut who can he changed hack. Of
diagnostic significance is the existence in many cases of moral
feelings from which one must naturally exclude the mere "weaknesses
Parents and teachers do
of will" resulting from flighty affects.
not understand certain reactions of the child and punish him for them.
The child conceives that as an injustice, and assumes a rebellious
attitude. Everything is then viewed under the guise of this complex
and a moral attitude is formed which particidarly fits this purpose
and runs something like the following: ''My father has been unfair
to me, he is to blame for everything. It is only just that I disgrace
him through stealing." Such reflections assume so exclusive an impeople,
portance that a regard for one's own welfare entirely disappears:

"It serves you right that my hands are frost bitten, it is just
what you wanted" becomes

ordinary
reflection,
only half conscious,

especially
by
if
analysis
at
maxim and cannot be
because
simply
all.
that
It
such
saved from lasting criminality.
all
is
the
only
by
stubborn
by
become
corrected
associations
correct treatment,
individual
can
be
young woman merges into an
"expectation neurosis" to spite her husband,
who
treated her dis-
and throughout her whole life cannot extricate herself

from the disease even after her husband died. To be sure there
were also other important factors which determined the origin
and particularly the special kind of the disease. Little children
often cannot emerge from their spiteful attitude although they are
seemingly willing and the same is true of argumentative adults;
that accounts for the favorable results that are often brought about
by outsiders.
Similar attitudes, though of lesser degree, result in young people
who possess special talents in manual skill, art, or in any other
sphere, but who are forced to learn to occupy themselves with something else.
They are dissatisfied with themselves and the world,
they are incapable of accomplishing things, they show a tendency
for all kinds of neuroses, and are forced to assume a dereistic or
negativistic attitude to the world.
The same is the case in people
who wish to go too high. Many dissatisfactions, neuroses and some
psychoses (paranoias) result from a disproportion between aim and
ability.
Bumke tells what is quite characteristic, namely, that a
gustingly,
striking
number
of students
who appeal
tq
him
for treatment be-
129
cause they are no longer capable of mental work think seriously of

qualifying for academic positions.
An
unsuccessful separation from the parents has similar results.

Also a former disagreeable experience can result in false attitudes
or a tendency to certain neurotic diseases.
Affects and impulses that cannot be gratified often find spon-
a harmless discharge, or under conscious guidance the

and impulses may be utilized for similar activities. Thus
sexual love and the childish impulse associate themselves with ordinary love for mankind and occupy themselves with charity and
nursing the sick (Freud's sublimation). Sometimes they change into
childish exaggerations as seen in the love evinced by old maids for
cats and pups; frequently, however, this does not gratify the original
taneously
affects
impulse, especially
then manifests
when
itself
the latter
is
repressed.
The sublimation
only in repeated flare-ups of straw
fire
which
can never cook the soup.
Under other circumstances the affects become stirred up in the

Every new similar experience increases the tension;
unconscious.
thus there
periences,
is on the one hand, an explosion-readiness to certain exand on the other hand, an unconscious affective search for
such processes.
child that
has once experienced great anxiety
when the experience becomes

more and more timid; it becomes
to anxious experiences and peculiarly enough it repeatedly
without understanding
it
correctly, or
repressed by the anxiety, becomes

sensitized
meets with accidents which stimulate anxiety.

becomes neurotic.
Later such a child
The hunger
for excitement of some people comes about in this

There are people who must always be doing something,
it matters little whether the situation is of a pleasurable or painful
nature.
Sometimes a decided preference is shown for the latter,
they experience "ecstatic pain," martyrlike pleasure, and forever consider themselves unfairly treated.
Every occasion is skilfully elaborated into a ''scene;" and their own misfortunes are not only relished
but decidedly more or less instigated and brought to a point.
(The
normal prototype is seen in the enjoyment of a tragedy.)
The
elaboration is often an inner one; thus any kind of experiences are
misinterpreted in the sense of martyrdom and by some patients also
in the sense of self-aggrandizement.
Many of these patients seem
abnormal only under definite conditions or to certain persons, other-
manner.
wise their reactions are normal.
.Complex ideas are sometimes mightier than the repressing forces.
One
is
then pursued by a
memory throughout
life;
any similar ex-
130
periences cause them to reappear with their entire affective load, or

they are even more or less constantly present in consciousness, dominating the mood and the inner and outer reactions (the dysamnesia
of Cecile Vogt).
Partly congenital and partly determined by complexes is the exaggerated need for change, or the impossibility to tolerate long any
No matter where the person is he is either
kind of situation.
"homesick" or in some "mix-up." After a little while every occupa-
wrong about it. On the one side the normal need

change is exaggerated, on the other there is a lack of love for
the customary.
tion has something
for
familiar feeling
is
the impossibility of getting out of one's shell,

many persons who have
or the inability to express oneself, observed in
to endure
They
much
injustice without being able to defend themselves.
conceal their feelings, are inclined to secretiveness, and easily
become untruthful despite their good character.

As everywhere else it is especially ambivalent complexes which
become pathogenic in this manner, also situations which render
prominent the negative side of a suggestion or of a tendency. If
one offers sweets to a little child and indicates by tone of voice
or in any other way that it is expected to react to it with pleasure and special thanks, he can be quite certain that the child will
It is really only a matter of accident whether the
not accept it.
machine moves backward or forward. He who reacts to a complex
with stealing is often hardly worse than another who responds to
the situation with self-sacrifice.
The difficulty lies less frequently in the events than in the
incompatibility of the characters living together.
Let us say that
the husband is a very easy going person while the wife is active and
hungry for excitement. No matter how slight the difficulty is, she
finds the need for making a scene; the more extreme her expressions,
the less the husband is able to get out of himself, which thus only
enhances her affect. This continues until the vicious circle is broken
by some small or big catastrophe.

Both under occasional as well
as under repeated or chronic in-
which not only impede the adjustment but under certain discomforts make it more and more
sensitive.
A stimulus accepted as a matter of course causes no
disturbance. Thus if we should be disturbed at home by a person
fluences there result false attitudes
making
and shaking the chair we are sitting in, any

work would be impossible, but in similar conditions of
and motion in a moving train we might be able to concentrate
a big noise
intellectual
noise
131
on any intellectual work even better than at our writinj^ table. The
baby who cannot yet think that people should be quiet for his sake
adapts himself to any noise, the wife doesn't hear the snoring of the
husband she loves, and the exertions in frames of sport are perceived as enjoyment and recreation despite the fact that it exceeds
by far the "tiring" resulting from work. A great part of the socalled neurasthenic symptoms and the whole "expectation neurosis"
Depending on the attitude assumed,
are based on such attitudes.
one becomes particularly sensitive to events which repeat themselves
or particularly insensitive, a fact which holds true also for material
or moral filth.
A very useful, though, to be sure, as little exhaustive as a sharply
defined classification
Kretschmer.
it
The
of
reaction types to difficulties,
hysteric
up and magnifies
it,
is
given by
evades the struggle, the erethic takes
the sensitive individual takes refuge in his
up various forms
of delusions and obsessions,

and the asthenic person sinks into an inactive depression.
Other details concerning morbid affective reactions will be given
later under "Psychopathic Forms of Reactions."
inner self and builds
Pathology of Affective Disturbances
The
affective anomalies are in the first place a function of the
disposition.
The
latter
is
acted upon, on the one hand, by various
can become distorted into morbid states, and on

the other hand, there are endogenous surface reactions of which the
emotional disturbances of manic depressive insanity are the most
reactions which
striking examples.
These disturbances seem to correspond to physiological (chemical)

It is nevertheless remarkable that many manic depressive patients react with abnormal force to psychic stimuli during
their healthy interval, which leads one to believe that the attacks
of the disease may be put side by side with these psychogenic
fluctuations. Moreover, a small portion of the actual manic depressive
manifestations is dissipated by psychic reasons, and it is known
that there are similar emotional disturbances which do not belong
to this disease and which are put in operation by psychic factors.
The difficulty is undoubtedly solved in the following manner: The
affects like other psychisms reenforce one another; a depression, for
example, unites the depressive associations and inhibits those of a
euphoric tendency; in this way the affect is strengthened and mainIn the same manner it inhibits in the physical sphere, for
tained.
example, respiration and digestion, it affects the pulse more unattitudes.
132
favorably, and lets loose the inner secretory processes corresponding

can again reenforce the affect. The disease causing
it, which
to
agent can attack in any preferred place of these two circular conLet us assume that in the manic depressive patient
there exists a special lability in the functions of the endocrine glands.
necting causes.
The
fluctuations of the glandular activities
may
be conditioned by
causes existing outside of them; but, as probably happens in the

periodicity, this function can also become too easily exhausted and
then again functionate too strongly. In both cases we have the usual
manic depressive attack which is conditioned "from inside to outside"
but similarly an attack results when the glands react too strongly
to an exogenously (psychic) determined depression.
Most of the emotional disturbances of epileptics and of some oligophrenics are also conditioned by some chemism. It is nevertheless a
striking fact that precisely the oligophrenics with brain lesions and
suffering
patients
particularly
brain injuries, show
tendency to
produce endogenous emotional disturbances which are mostly, though

The continuous irritability
not exclusively, of an irritable nature.
seen in those
who have
brain lesions
is
also anatomically determined.
but according to many obserAâtions it

is probable that there are also periodic emotional disturbances of a
psychogenic nature analogous to the lasting attitudes mentioned above.
It is not absolutely certain,
Any kind
of complex, let us say, dissatisfaction with parents, be-
comes half or completely repressed so that the child cannot fully

account to himself for his actions. But the need for abreaction finds
some vent through excitements or emotional disturbances and is
then followed by a calm period. By and by, however, the tension
accumulates again only to express itself in the same manner without
any new cause, or through some ordinary occasion.
The lability of organic patients is but a secondary manifesta-
For we note a slight perthe psychisms even in the spheres of memory, and the
the associations is undoubtedly responsible for the fact
tion of the general cerebral disturbance.
severance of
limitation of
that only actual situations are reacted to.
In epilepsy, on the con-
trary, all the other psychisms run a slow course; the getting
from an idea
just as difficult as the alteration of
is
The tendency
explained by
to
depression in senile patients
is
is
away
affect.
not adequately
the suggestion that depressions increase with age and
especially with general circulatory disturbances.

of paresis
an
as
The morbid
little
Also the euphoria
explained as the rare paretic depressions.
reactions require
no
from normal mechanisms, and act
special explanation, as they spring

in
an exaggerated and one-sided
GENERAL PSYCIIOPATHOLOGY
manner only
conHcquenco
in
extraordinary
of
133
occasions
or
of
disposition deviating from the normal.
8.
DISTURBANCES OF ATTENTION
The pathology
of attention
is
very complicated because
its effects
by the other functions.

Exhaustion and
many morbid states weaken the faculty of concentration. The scope
of attention is determined by the amount of associations that may
occur at the same time; it is consequently lowered in organic patients.
The exaggerated readiness of psychic processes in manic cases weakens
the inhibiting effect of the effort of tenacity upon distracting influences.
The lack of tenacity in organic cases is sometimes irregularly over-compensated by torpid retardation of the psychic processes,
so that secondary hypo-vigility goes hand in hand with lack of
tenacity.
In twilight states, toxemias and similar states, where the
mental trend becomes quite unintelligible, one can hardly still speak
of attention, even where distinct affects are present, because the inner
and outer strivings may become disconnected. The following remarks,
therefore, emphasize only the most important facts in a somewhat
schematical and simpler manner.
are
strongly
influenced
When
Ceteris paribiLS attention varies with the affects.

are labile, or
ideas,
ing
as
when the same
raising all ideas
them to
the vigility
interest
upwards
is
manic states, and lowerand lack of comprehension,
in the
zero in cases of indifference
and the
of attention naturally
distractibility
the latter
given to the most dissimilar
are quite
marked.
Tenacity need not here be diminished, because even without distractibility the subject may be adhered to; to be sure, there
are few situations in which outer and inner distractibilities are absent
for
any length of time.

If the affects are stable, the tenacity also runs high.
In Schizophrenia and exceptional states of epilepsy, more seldom
and other affections, we sometimes find a strange

mixture of exaggerated and slight distractibility. The patients react
with difficulty to questions and other stimuli, but they react to many
accidental sensory impressions such as the striking of the clock, the
entrance of a person, a word not addressed to them, or to any object
in neurasthenia
which happens to strike their eyes.
But the
epileptics
and some schizo-
phrenics will then regularly return to their former themes.
The concentration depends mainly upon

fectivity,
yet in labile affects
Whether tenacity
is
it is
the strength of the af-
usually insufficient.
good or not
in
weak
affects
and correspond-
134
depends upon the accompanying circumcan concentrate for half a

day all his small strength on a little thread which he holds in his
hand. On the other hand, he may be diverted by every trifle, because no interest to speak of restrains him. Hypotenacity, combined
ing
concentration
slight
stances.
An
with hypovigility,
telligence
schizophrenic
apathetic
are low,
is
as
a usual manifestation where

in
affects
and
in-
and
clouded states, apathetic imbecility,
other cases.
Hypotenacity, without real hypovigility, is found in Aprosexia;

is an inability to concentrate one's thoughts in reading, for
This symptom, which is not found
instance, even for a short time.
there
very frequently, occurs in neurasthenia, and in impeded nasal breathing as a result of adenoids.
Vigility
and tenacity are lowered
of torpid
cases
imbecility,
in
Chorea Minor,
also in
although here the genetic
some
factors
are
quite different.
rapid "exhaustion" of attention can be observed in
many
organic
with coarse brain lesions, also sometimes

in schizophrenics during the acute stages. On the other hand, it often
takes organic patients a longer time to concentrate their attention
cases, especially in those
on the very subject desired. It is for this reason that perception

experiments with such cases turn out very badly at first, but after
some time the results are betterj until the exhaustion reappears and
the patients again do badly.
The scope
of attention
is
diminished in organic cases and in oligo-
phrenics because of a restriction of associations, and in melancholic
and paranoid patients as a
result of one-sided interest,
and
in epileptics
In all forms of paranoia or paranoid

states we also have as an important symptom the systematized
vigility, the morbid association readiness for those events which might
as a result of both factors.
be connected with their delusions.^^

In organic patients, the habitual attention is earlier and more
The patients, for
strongly disturbed than the maximal attention.
instance, may seem completely normal as to attention during a
demonstration, but at the same time they are disoriented
ward where they have been for weeks, they cannot locate
their bedroom or their bed, because they do not register anything
that happens about, and even to them, if they have no special reason
for being attentive. And what is more, the memory and the compreclinical
in the
hensive functions of orientation
may
still
be adequate in these cases,
so that the mistake can safely be ascribed to the faculty of attention.

**
Cf. Delusions of reference, p. 94.
The
patients observe, as
it
135
were, nothing, unless attention
is
forced
upon them through some circumstance, then they behave, however, in

quite a normal way. This teaches us that intensity, at least, of maximal attention can be good, in spite of the markedly diminished field
of associations.
Tenacity of attention in organic cases is mostly lowered; the

cannot continuously occupy themselves with one thing; they
pa>tients
and
digress
find
simultaneously, very quickly.
tire
also
it
difficult
But the same
to transfer their thoughts
They evince
to
patients
another subject
same time hypotenacity and

In the manic stages of
hypovigility may be hidden by the distractibility of the
offered to them.
(secondary)
paresis,
hypovigility
flight of ideas,
yet
it
of
at the
attention.
can usually be demonstrated through examinaaffairs cannot
for the patients after discussing their personal
tion,
quickly answer a question about their school-knowledge, nor are they

even able to understand it correctly, and this happens even where the
psychic processes in general function very quickly.
of presbyophrenia
The
excited states
can also cause an over-compensation of hypo-
vigility.
In the schizophrenics, the relation of active and passive attention
is
what
the reverse to that of the organics.
is
going on around them, even
if
They
register excellently
they do not pay any special
it; but if they should have to concentrate their attenthey could not succeed, sometimes they are hindered by block-
attention to
tion,
and at the same time they often cannot hold a subject.

In some cases of schizophrenias, especially in crowding of thought,
in fatigue, in hallucinations and delusions, in phobias and other obsesings
sions,
and
in the pathological readiness for association, the direction
of attention
is
obsessive.
In ordinary fatigue, the power of concentration and tenacity are

usually very much diminished, whereas the distractibility seems to
be enhanced in varying ways.
There is a tendency to explain many other manifestations on the
basis of disturbances of attention,
and as a deficiency of attention
may
be responsible for all sorts of stupidities, such deductions

can be easily constructed, but just for these reasons most of these
explanations have no scientific value.
9.
MORBID SUGGESTIBILITY
total lack of suggestibility does not perhaps occur except in such
patients
who
evince an utter lack of comprehension and
who no
longer
136
react to stimuli.
marked diminution
who
occasionally in imbeciles,
of suggestibility
Schizophrenic patients are often
training.
we
observe
are then naturally incapable of

little
or not at
all
any
re-
sponsive to direct suggestions, but in most cases they still react very
Wherever
slightly to the general attitude of their environment.
individual
groups of affects are lacking, suggestion in the corre-
sponding sense
is
Moral
naturally impossible.
idiots
cannot be in-
fluenced in a moral sense, or irreligious people in a religious sense.
who look at the good side of everywith a feeling of happiness can hardly be
Paretic patients in a manic state
thing and accentuate
it
brought to accept a sad situation.
The exaggerations
produce
it
of suggestibility are
more important.
experimentally in a state of hypnosis.
Many
We
can
people are
by nature as susceptible to all influences as a soft piece of dough.

Fatigue and emotional experiences show a temporary disposition for
suggestibility.
Patients in manic states or those suffering from organic
disturbances as well as alcoholics are easily influenced by suggestions.
enhanced by the lability or resonance of

also through any decrease in the
faculty which normally counteracts suggestions.
All things
Just as suggestibility
the
so
affects
critical
it
is
is
heightened
being equal, the more thoughtless a person, the more suggestible
he
is.
Morbid suggestibility may lead to induced insanity, also to psychic

and neurotic epidemics, to participations in crimes, and similar acts.
Hand in hand with positive suggestibility, there is in most cases
also an increase in the negative suggestibility.
Like children, senile
patients are now wilful, and now open to the most stupid promptings.
Paranoid patients allow themselves to be easily fooled by
people who have their confidence, whereas they are absolutely inaccessible to other persons.
In schizophrenic cases we often find command automatism and echopraxia, that is, high degrees of suggestibility
combined with a pronounced negativism.
The so-called auto-suggestion is an important source of morbid
states.
No
neuroses are possible without
its
cooperation ("Imaginary"
Thus a girl in a street car sees an eczematous eruption

on the hand of another passenger and becomes very excited because
diseases).
it
unconsciously touched her "complex" referring to her paretic or
luetic father; she
then develops an eczema-like eruption in the same
place as the passenger.^"
traumatic patient fears that he can no
longer support his family and hopes to assure his existence through
^
Friedman
u.
Kohnstamm, Zur Pathogenese
scher Krankheit, Zeitschrift
f.
d. ges.
Neur.
u.
u. Psychotherapie bei BasedowPsych. Or. 23, 1914.
He
a pension.
137
observes himself anxiously and by this very means
A girl fears lest her menand thus causes i temporary amenorrlifjea.

To be sure, auto-suggestion may have the opposite favorable effect
which is curative in nature. These examples show that positive and
negative suggestions are really not true opposites, and that both
creates the necessary morbid symptoms.
strual period fail to appear,
together are nothing but emotional effects.
10.
DISTURBANCES OF PERSONALITY
Every mental disorder changes the personality in some sense if

The manic patients become reckless and actively
exaggerated, the paranoid and in most cases also the paranoiac patients lose their general interests in life and live only in their delusions, the epileptic concentrates on his physical well-being and his
petty affairs, the intelligent person becomes stupid and thoughtless
as a result of a dementing process, and so on.
The inner disturbances of personality are not as comprehensible.
Thus an ordinary citizen imagines himself an emperor. "What he
knows of the Emperor, he feels as part of his person: appersonation.
Even hypochondriacal ideas can be acquired in this way; thus, the
medical student in his first term of clinical experience, hearing a vi\-id
description of some disease of the heart and seeing it demonstrated in
one or several patients, becomes so deeply impressed that under certain conditions he feels that he has the same heart trouble (Morbus
Medicorum).
Less frequently the personality loses some of its component parts.
It naturally happens that certain events of one's life are forgotten;
not altogether.
especially true in schizophrenic patients
this is
of their disagreeable experiences,
the
commitment
of
which they
who
forget a part
and often deny bona
later regret.
fide actions,
This does not, however,
concern things that belong to the essence of the personality.
On
the other hand, the most important components are often replaced by
others; thus
John Smith becomes President Harding,
or Christ
(see
below)
special type of disturbance of personality
is
the alternating
known as dual consciousness. Let us consider a

hysterical woman who until now has lived a mediocre existence. For
some known or unknown reason she falls into a hysterical sleep,
personality, also
and on awakening she has forgotten her entire previous existence;

she does not know who she is, where she has lived until now, and
who the persons are whom she sees around her. Notwithstanding
138
this change, the ordinary faculties of walking, speaking, eating, the

use of clothes and other things are usually transferred to the new state
("etat second"). Whatever the patient needs for her intercourse with
other people she learns very quickly.

a change; formerly a serious-minded
Her
character, too, undergoes
now becomes frivolous

and pleasure-seeking. After some time, she again merges into a state
of sleep, and on awakening the patient is back in her first state.
She has no realization of the intervening time; all that she remembers
Such
is that she went to sleep, and has now awakened as usual.
changed states may appear alternately for years. While in the first
state the patient only remembers the former first states and when
in the second she always recalls only those of the second series.
More frequently, however, it seems that in the second state the
patient can recall the first (normal) series, but while in the first
girl,
she
state she cannot recall the second (morbid) series.
pen that eventually the second state
way cause
there
may
will
many
may
also hapthis
In quite rare cases
a transformation of the personality.
be an alternation of
It
become permanent, and
such states, each with
its
very
and special memory group (personality) as many

as twelve have been observed.
As a matter of fact, cases of pure
dual personalities are very rare. Yet their theoretical significance
is very great, for they show what marked changes can be brought
about by a systematic elimination or intercalation of association paths.
It is not alone in hysteria that one finds an arrangement of different personalities one succeeding the other; through similar mechanisms
schizophrenia produces different personalities existing side by side.
As a matter of fact, there is no need of delving into those rare though
most demonstrable hysterical cases; we can produce the very same
phenomena, experimentally, through hypnotic suggestion, and we
definite character
also
know
that in the ordinary hysterical twilight states the
memory
which the patient shows an amnesia

can be retained or can be aroused by suggestion.
of former attacks, concerning

in her
normal
The
state,
splitting off of parts of
a personality in transitivism pro-
ceeds in a different manner; here the patient's
own
experiences become
detached from him, and are ascribed to another person. A patient;

for example, sees a terrifying image and screams aloud; but he
then imagines that the apparition did the screaming. A woman has
an operation on her
toe,
during the long drawn out delirium of the
narcosis she continually asks the nurse to look after her bed-neighbor,
because the latter
is
having bad pains
in her toe.
person dreams
during the night before he has diarrhoea that pamphlets which he
has to send out suffer from diarrhoea.
It is quite
common
to displace
139
which we have ourselves in our dreams to other persons.

Transitivism is an almost common occurrence in schizophrenia; the
patients are convinced that the voices which they hear are also heard
feeling
by others
the
in
same way; they frequently
actions to others; thus,
if
others; their thoughts are thought
ascribe
they read something,
by
others,
strange disturbance of personality
is
it
and so
they are
still
by
de-personalization, in which
They seem
must look
quite different to themselves, and feel that they

if
own
on.
the patients have lost the definite idea of their ego.
mirror to see
their
really done
is
in
themselves, and even then their
the
own
images appear strange. This disturbance manifests itself especially

through the fact that the patients do not feel their own will power
and strivings, they feel like automatons; sometimes they are indifferent to
it,
pleasant.
but in most cases they perceive this state as extremely unThis syndrome appears in schizophrenia, perhaps also in
neurasthenic-like states of psychopathic patients, and in a less pro-
nounced degree
It
states.
is
it is
also observed transitionally in epileptic twilight
often connected with the analogous feelings of strange-
ness in regard to the outside world.
In schizophrenia one sees a great
many
forms of transformations
which I only want to mention a few types. The

patients suddenly imagine that they are Napoleon, and some entertain the idea without giving up their past life; it is merely an
of personality of
addition to their past
life.
In other cases they shut
off at least
who have
thing incompatible with the delusion; thus, those
every-
grandiose
ideas state they were not born in the locality in question, they did
not go to school there, but in some mysterious
way
circumstances
them to play the part of John Smith for some time, but now
they want to re-establish their sovereign authority over Europe. In
forced
other cases, the former personality ceases to exist; sometimes, but
by no means always, they have interwoven the past of Napoleon with

the present of their momentary delusional personality. Others have
become Christ, or even God. The latter mechanism is not a rare
occurrence in paretic patients, but in most cases it exerts no influence whatever on their actions, whereas schizophrenic patients
sometimes
When
may
heart, such a
it,
as he
act in accordance with the change of personality.
expressed astonishment that he
god said to
had written
strange that
we
it
me
knew
the whole Bible by
that there was nothing unusual about
himself;
and to
my
remark that
perceived nothing of his omniscient
spirit,
it
was
he an-
swered that he had sent out his spirit among mankind, and now so
little was left for him that he had come into the asylum, but that
140
he could recall his spirit at any moment, only he would not do so

out of compassion for poor mankind. Other patients imagine themselves transformed into animals and even into things, and yet they
usually do not adhere to one idea. Just as a patient can be the
Pope, the Emperor, the Sultan, and eventually God in one person,
he can also be a pig and a horse.
Nevertheless the patients rarely
follow up the logic to act accordingly, as, for instance, to bark like
a dog when they profess to be a dog.

the truth, they behave as
symbolically, in the same
if
the
Although they refuse to admit

is only to be taken
expression
way perhaps
as
when
man
is
insultingly
called a pig.
an ordinary occurrence to see schizophrenic patients

most illogical way with people whom they
Under certain conditions, and in a certain sense,
love or admire.
they are their beloved, they had the same experience as they, and
It is quite
identify themselves in the
they play their beloved's part. A non-schizophrenic patient of v.

who loved only limping women, could not resist the
Krafft-Ebing,
impulse to imitate such a limping woman.
Some schizophrenics have altogether lost their personality. Formerly they have been so-and-so, but now they are somebody else,
and their former personality may be in some other person. Under
such circumstances it may happen that they speak of themselves in
the third person, for they have the feeling that they are no longer
the person whom they have designated as "I."
Temporary transformations
of the person into
another, as, for
example, into potentates or saints, occur occasionally in the different

twilight states.
Nowadays
there
is
much
tion of the personality.
talk about 'the preservation or annihila-
Kraepelin's paraphrenics are supposed to
from schizophrenia, the arteriosclerotic and luetic psychoses

from simple senile dementia, and the latter from the most disturbed
differ
paretics, in the fact that the personality
By
served.
that
existing strivings
we understand the
and aims
characteristics in general.
is
not
much
injured,
insanity, there
is
is
fairly well, or better pre-
active continuation of the hitherto
of action, as well as of the
more important
In organic diseases, where the personality
which
is
especially the case in arteriosclerotic
surely no lack of affective changes in the sense of
knows something about it,

Having been an
honest man he does not now turn into a scoundrel; when he is no
longer able to support his family he perceives it painfully, and his
lability,
or irritability, but the patient
and he even often endeavors to combat
his faults.
external appearance remains relatively good, in so far as his mental
141
That accounts for the fact that these

is not disturbed.
people are in no immediate need of asylum treatment, and when they
are sent there it is frequently only in consequence of a single special
clearness
circumstance, such as a danger of suicide, or confusion.

The schizophrenic disturbance of personality is much deeper and
more
Even when the organic patient changes into a

and his strivings often change only too much, yet
and strives for in a single moment is the expression
far reaching.
different person
what he
feels
On
the other hand, the schizophrenic

something contradictory, and do something that he has not desired and even despised. His personality can
divide itself; now he acts and thinks like a great man, now like a
scholar, or in another manner, and his hallucinations and delusions
of his whole actual psyche.
may
at the
same time
strive for
it.
There are forever different strivings,
which embody themselves in such personalities.^^ Very frequently
A
the direction from and to a person is no longer distinguished.
paranoid patient fears in her depression that she is being harmed;
then also correspond to
she
is
then
commanded by
the voices to help others instead of that
help should be given to her as might have been expected. Everyday

experience shows that both ideas are identical to the patient and
that
it is
not necessary to add a logical connecting link.
become a
patient wants to
persecuted
professor, but he complains that people
force him to be a professor.

In severe cases of schizophrenia, a high degree of disintegration of
personality results because the uniform striving and the uniform
memory complex become destroyed; the patients babble and show
no coherence in thoughts and wishes, indeed the borderline between
want to
own person and the environment is blurred. As in appersonaand in transitivism concepts which do not belong to the person
become connected with him, and vice versa. Thus the strongest associations may finally detach themselves, while any other ideas may
become associated with the person, if in such cases one can still speak
their
tion
of a person at
all.
In general, the schizophrenic personality suffers in the following different ways:
Through dementia, the
restrictions or perversities
through the disturbance of the uniform direction

of the striving and acting, and the disturbances of will which force
schizophrenics into actions that they do not strive for at all.
of the instinctive
life,
In most of the disturbances of personality one deals w'ith a

ting in the direction of the affective needs, that
is
split-
to say, with simple
emotional effects which in themselves are verj^ violent, or become

-
Cf. Complexes, pp. 35-36.
142
overpowering in a morbid
soil; this is seen,
for instance, in paresis,
God
where, owing to the restriction of associations, the wish to be
Almighty
is
put into reality without any further ado, also in schizo-
phrenia particularly after the structure of associations has already
become loosened;
in
the latter
cases the
complexes can actually
acquire sub-personalities with some sort of independence within the
Depending on the circumstances the patient is this or that

what is still more frequent, he hears in the voices,
now the expression of this complex (the wish to be a Prince) and at
another time that of another complex (to be condemned as an onanist).
psyche.
personality, or,
am
not sufficiently clear about depersonalization, because cases
common. In part we probably

have to deal with the same process which we see in the melancholic
patients, to whom external things appear strange, perhaps because the
feeling components are so strongly falsified. But if the patients are
not conscious of their own volition-impulse it must be due to the
blocking of an inner feeling, the mechanism and causes of which is
giving reliable information are not very
not just clear.
DISTURBANCES OF CENTRIFUGAL FUNCTIONS
11.
Actions as the final link in the chain of psychic processes are

naturally inadequate to the situations
if
the sensations, deliberations
upon which they depend are inadequate. He who is conby false perceptions, and imagines that robbers are breaking
or feelings
trolled
in
when
his nurses are coming, will defend himself.
Some
halluci-
nations influence the patient directly, and often in a forceful
way;
he has to act in the sense of the hallucinations even if he realizes

that he does thereby something detrimental to himself and to others.
This mode of action does not always need the form of commands.
Thus, a periodic patient named Mantel, who was locked in his room,
repeatedly heard the words: "Mantel, thou strong hero." Whereupon
he reacted by demolishing his room, to show his annoyers that he
was
really so strong.
To
be sure, the hallucinations instigate only
those actions for which a tendency already exists; but this does not
need to be the tendency of the conscious personality; indeed, it may

even be incompatible with it. At the same time there are hallucina-
which there is little or hardly any impulse,

and in later stages of schizophrenia the patients regularly refuse to
obey their hallucinations, in spite of the fact that they believe in them
tions foi the obedience of
as strongly as ever.
The
so-called hallucinatory excitements in schizophrenia are also
GENERAL PSYCHOPATHOLOCiY
worthy of mention;
here,
under the impresnion
(jf
143
false perceptions,
the patients suddenly become abusive, strike blindly, or commit any

other acts of violence. To be sure, in most cases one does not know
to what extent the hallucinations are only a part of the symptoms of
the whole excitable action, and to
what extent they are the cause
of the violent outburst.

If thinking
is
disturbed so that
it
aims toward action,
sets incorrect
He who
entertains the delusion that
then the acts also are

people want to poison him will in most cases react to it, which is quite
correct from his viewpoint, but pathological from the observer's. An
false.
aimless or feeble-minded thinking will condition aimless or feeble-
minded actions. If the thinking of the psychopathic and insane deviates from the average thinking, it means in most cases a deterioration
of quality
the actions of the real insane persons are nearly always of
inferior quality or of negative value.
In exceptional cases, however,
mere psychopaths the anomaly leads to new values. ^^

Action is for the most part influenced by afjectivity, if one at least
agrees with us when we designate the force and direction of the im-
and especially
in
pulses, or of the "will," as partial manifestations of the affects.
He
happy, sad or furious, will react accordingly. Fear can make

a person motionless and rigid or limp, it can urge him to aimless
flight, or merely to a restless manifestation of the affect, such as restlessly walking to and fro, or to brutal acts of violence. The last named
are especially striking when motility is otherwise practically absent
who
is
and the anxious or depressed patient suddenly gives vent to his feeling
by destroying some object or even by committing a murder. Such
reactions to unbearable tension are designated as raptus.^^ The absence of ethical feelings brings to the surface
Lability of feelings and emotivity
capricious.
Absence of
diminishes the
"Weakness
make
anti-social
actions.
the actions unsteady and
weakness of the same

and makes them weak. The expression
feelings in general or
impulses,
of Will" designates three totally different things:
lack of will impulses due to a weakness of the
affect-s,
(1)
or a lack of
steam pressure in the engine, abulia as a result of apathy. (2) Inconsistency of the aims in the face of very vivid, but too labile affects,
which make its bearer dependent on outer influences; a slight push
causes the engine to run backwards too easily, when it should go forward, which is due to the fact that the direction-switch is too easily
Frivolous people and those who are unable to act in
movable.
"Comp. remarks on
of
Genius, p. 171.
" There is also a raptus in schizophrenic patients which

sudden impulses without affective tension.
is
merely an execution
144
accordance with their
own
resolutions are congenitally weak-willed in
manic and organic patients become so through their illness.

This kind of weakness of will can also be ascribed to an exaggerated
suggestibility, which only partly coincides with the lability of affects.
(3) Incapacity to make decisions through counter reflections and impulses in persons who are too conscientious and too deliberate in
everything, and in those who are in a depressed state.
Wherever one does not observe any, or very slight expressions of
this sense;
will,
one speaks of stupor; in such cases thinking
is
usually at a low
ebb; indeed, in some states the disturbance of thought as such

in the foreground as in the emotional stupor of imbeciles.
may
Stupor
no uniform syndrome, but an outer form of manifestation of the
be
is
fol-
lowing different states: maximal apathy, inhibitions, obstructions, over-
powering through fright or anxiety, and cerebral torpor of any kind.

Thus we find stupor, especially in schizophrenia where apathy, blockings, inhibitions, and sometimes cerebral torpor appear together, furthermore in epilepsy, in organic diseases, and in manic-depressive inhibitions. Nevertheless, in regard to the latter, it must be observed that
one does not like to call melancholic inhibitions stupor, if, as is usual,
they are distinctly connected with signs of severe physical pain.
Melancholia attonita, as it was formerly called, is usually a catatonia,
with or without depression.
Stupor resulting from strong affects
(emotional stupor) we find in its highest development especially in
hysteria, and to a lesser degree very frequently in forms of congenital
feeble-mindedness.
hyper-function of the will in the sense of special strength
is
naturally difficult to establish, because a person seems to us the

healthier, the stronger his will
pathic cases
we sometimes
is.
Yet, in hysterical and other psycho-
see a force of impulse, of endurance,
capacity to bear pain, which far exceeds the normal.
phrenic patients sometimes develop a special energy or will,
when they
instance,
eyes, or
pull out their
own
symptoms
as, for
teeth, squeeze out one of their
do something similar without being analgesic.
lation of
and
Also schizo-
The dissimu-
of disease, especially in melancholies, points to
of manic patients who

and accomplish much has
also been regarded as a hyperfunction of will. We also mention here
the hyperkineses of many catatonic patients (see below) which in
everything else are principally separated from them.
A morbid facility of the capacity to make decisions is observed in
manic patients and under mild alcoholic stimulation. Also in affects
which compel actions such as fury, or fear, but here it is naturally
an enormous force of
will.
constantly want to do
all
The occupation urge

sorts of things
145
one-sided, acting only in the direction of the affect; every idea which
has a centrifugal component leads straight to action. The possibility

of an accurate reflection is hereby always diminished; the actions
become precipitated.
is
the case,
more
all
easily
The
If reflection
is
primarily inhibited the reverse
things being equal; any kind of stimulus leads to action
and more quickly.
ability
make
to
decisions
melancholic states, secondarily
is
it is still
feeling of insufficient reflection
primarily
badly impaired
in
more diminished through the
and especially through the general
unpleasant accentuation of all the possible objective ideas. If the

patient is inclined to go in the open air he feels it as something too
terrible; if he thinks of remaining in the room, that too, seems just
as unbearable. In apathy no decision can be taken, because the impulse
is
same
lacking; the
is
the case in torpor, where
In states of obstruction, as long as
processes are low.
it
all
psychic
exists,
the
physical processes are interrupted either altogether or especially in the

direction of the decision, and nothing happens. But there can also be
too
much
Whoever
thinking.
inclines to take
into account every
imaginable possibility can hardly arrive at a conclusion. A certain

onesidedness is necessary in action; one must give up advantages in
big or small matters and must be able to risk something, if one wants
and with the necessary force. The ambivalence

an obstacle to the decision. If one loves and
hates at the same time without summing up the positive and negative
feelings into a unified difference, one is torn to both sides and does not
The so-called psychomotor exget any results even in deciding.
citements and inhibitions naturally concern the whole psyche; in any
to act at the right time
of the feeling tone
^*
is
case they are not strictly confined to motility, but distinctly influence
also the need for action, the ability to make decisions, and the facility
of the transition of the excitement over the true centrifugal paths.
The manic
pressure activity (the urge to occupy oneself) expresses

the fact that the patients can never permit themselves to
In milder cases it is
rest; something has to happen all the time.
merely a quantitative increase of action that is observed, which can
itself in
by a normal person, such as an increase of busiin more severe cases it comes to excesses
thus one notes a thoughtlessness in all spheres of action, and finally
there is a destruction of objects and a building up of new combinations from the material acquired; there is a constant smearing,
screaming, jumping and similar acts. Taken singly, the aims usually
change very quickly under these conditions; nothing is finished, and
also be accomplished
ness activity or similar acts
" Cf.
p. 125.
146
even in mild cases one notes a lack of perseverance in the business

manic patients. The pressure activity is naturally also
disburdened through talking. The patients are very talkative and
they can not really get away from their talking which becomes more
enterprises of
and more incoherent {LogorrhoBa)
The
depressive inhibition of action causes actions to be avoided as

more severe cases altogether, or if motions and
far as possible, in
actions
still
dominating
exist,
they represent the monotonous discharge of the

that of anxiety.
affect, especially
The highest degree of inhibition of motion is designated as attonity.

For long periods the patients really make no active movement. They
have to be dressed and undressed like puppets, they have to be fed
with a spoon or even with the tube, their saliva is not swallowed, but
drools from the corners of their mouths, and even the movements of
the eyelids can stop.
Such
states nearly
always belong to the schizo-
phrenic stupor, especially of the depressive type.
There
exists also a simple schizophrenic akinesis,
which we cannot
accom-
at present very well refer to other disturbances because the
panying symptoms seem insufficiently developed. In contrast to this

we have the schizophrenic hyperkinesis where the patients are in constant motion, but yet do not seem to "act." Without any apparent
reason, as far as we can learn, without any motive known to themselves, they are actively violent, they are destructive, they throw
themselves or only their limbs in the air, they play tricks, etc. Nevertheless, both subjectively and objectively the action appears to be intended: it is a psychic motion impulse without motive, one might say,
a kind of convulsion of psychomotility (but not at all a motor spasm
in the usual sense).
The mere pressure motion shovM he distinctly
differentiated from the pressure occupation of the manic patients
which always has a meaning. The attempt has been made to classify
also verbigeration as an analogous "cramp of the speech centre," but
it is not particularly often combined with hyperkinesis.
The concept of jactation refers more to the outward appearance.
Here also we deal with mere motions, which are especially weak; at
most they represent rudiments of actions and have quite different
causes.
now
Under
described
certain conditions hyperkinetic states in the sense just
may
to agitation caused
be called jactations; the term
may
by fear or other uncomfortable
also be applied
feelings, or the
tossing about in pain; but the concept corresponds best to the
ments
move-
in cerebral irritations, as seen in meningitis or acute delirium.
In schizophrenia there
actually calls to
is
sometimes a motor parafunction which

at all events it is not genetically
mind apraxia, but
GENERAL PSYCHOPATIIOLOGY
147
analogous to the organic syndrome of this name; it resembles more the

opposite actions produced during shock or distraction:
Thus, the
patient wants to put the spoon into the phice, but with uncertain move-
ments he takes it in a strange way first in one hand, then in the other,
where he turns it around, until at last he places it on his knee; or
instead of the spoon he grasps anything else which happens to be at
hand. When walking, his legs move in an uncertain way, in various
long steps, not exactly towards the goal. Kraepelin grouped analogous
disturbances of a lighter grade under the term: "loss of gracefulness."
As the patient is simultaneously moved by different feelings, and as
they are badly suited to the ideas, all actions often appear unreal,
artificial, and affected, and as the associations of ideas also in regard
to the carrying out of the movements do not proceed in usual paths,
they acquire something of the bizarre.''^
Sometimes movements, that is, actions, become stereotyped, in
which case quite different mechanisms may come into play. Catatonic
patients sometimes cannot get through with a movement manifoldly
repeated, such as wiping the face, or scooping up their soup, or they
do not think of stopping even after they have finished these acts. A
strong accompanying affect can easily stereotype an action which then
continues to repeat itself without any voluntary effort on the part of
the patients. In the course of time, it generally becomes more or less
shortened in form, or it changes in regard to place. Thus an original
onanistic movement of the pelvis may finally change into a shaking of
the head. In this, and in still other ways stereotyped movements
originate in catatonic patients, which often last for decades and seem
absurd to the patient as well as to the observer. Customary acts may
undergo changes which then become stereotyped. For example, the
patient taps seven times on his coat at every button he is about to
close; he shakes hands in quite a strange way {Variation stereotypes,
mannerisms)
There are still other mannerisms besides the variation stereotypes
of which the following may be mentioned: independent clownish ges.
tures, spreading out of fingers, also bizarre expressions of every de-
scription, exaggerated style of dress

finally
morbid expressions of
and
affects,
hair, caricatured elegance
exaggerated pathos, and
and
self-
bad
As many show an indication of these changes at puberty, an
attempt was made to regard them as symptoms of puberty, which were
fixed and exaggerated by the disease.
satisfied attitude; in short, the patient evinces all the faults of a
actor.
When
language becomes stereotyped
" Cf. below, "mannerisms."
it
is
called
verbigeration.
148
Here quite
senseless
words and sentences, at
least for the actual situa-
tion, are constantly repeated, often in a striking tone which
is
also
stereotyped.
Besides the stereotypes of motion there are those of posture, the

patients always assuming exactly the same position, and of place;
they want to
sit,
or stand, or
walk always
in the
same
place.^''
The stereotypes, in the sense amplified so far, belong to the catatonic symptoms, and outside of schizophrenia occur perhaps also in
organic patients; but
cally of
the same
it is
value.
not at all certain that they are then genetiIn any case the perseveration in the organic
which we see most typically in coarse brain lesions, especially

in aphasic patients, is something quite different from stereotypes. The
patients cannot rid themselves of a word which they have just heard,
or which they have just said, and repeat it constantly when they wish
patients,
And even when the patients execute a simple

merely
to think of something, this impulse may
wishing
such
as
action,
against their will in the path of the
proceed
conditions
certain
under
thought
of immediately before.
one
in
the
or
action,
preceding
to say something else.
Other stereotype-like manifestations are the homogeneous actions,

which some epileptic patients perform in post-epileptic twilight states,
the repetitions of terrifying experiences through hallucinations, and
(mostly abbreviated) actions in the twilight states of the hysterical
The manifestation of a lasting strong affect, like the stereoor wailing of depressed organic patients, the tics,
screaming
typed
patients.
some actions which have become automatic, and the movements of

all these movements which outwardly resemble the schizoidiots,
phrenic stereotypes have quite a different genesis and meaning.
Parafunctions of the will attach themselves mainly to the so-called
The
impulses.
who
nutrition-impulse has been stunted in the cultural being

and when he wants to starve himself to
rarely feels real hunger,
death he
is
forcibly fed.
This impulse
is
also very indirectly satisfied,
in so far as one learns to write at the age of six, in order to earn his
living
from ten to twenty years later. Even the impulse of self-preseris no longer at its height with us, either with regard
vation in general
to the individual, or his family, or his race.
The
suicide-impulse,
which under simpler circumstances very rarely occurs even in pathoThe sex
logical conditions, has become a calamity in our asylums.
impulse has been preserved only in some measure of its original form,
and is pushed back by culture in different ways, such as through
chastity,
monogamy,
asceticism,
and birth
control.
But
this impulse
breaks through with elemental force and creates in the individual those
'"'
For more
details
Cf chapter on Schizophrenia,
.
become pathogenic.
inner conflicts whicii mostly
ethical or the altruistic impulse, although just
to a certain transvaluation.
now
149
Preserved
it is
tiie
is
being subjected
In place of the primary impulses there
are others, which are particularly active, such as the impulse for
knowledge, and tend more towards the preservation of civilization

than life.
The morbid disturbances of the nutrition-impuhe are not so important in psychiatry. Beside excessive gluttony of the paretic and
we
and in catatonics a peculiar lack of

an aversion to eating and drinking resulting
in a total abstinence for any length of time.
Besides these, nervous
patients evince peculiar cravings (picae) and schizophrenics a tendency to swallow all kinds of things, even their own excrement (coprophagia), which is sometimes accompanied by gustatory enjoyment and
sometimes not.
The sex-impulse has a special pathology, which will be dealt with
idiots,
find in depressions
appetite; indeed there
is
in the special psychiatry.
The
ethical impulse varies constitutionally
from the "genius of altruism" to the moral
idiot,
who
is
devoid of
all altruistic feelings.
The
expression "impulse" has quite a different meaning,
speaks of "morbid impulses."
if one
In most cases this word refers to the
impulses for actions, which are accomplished unexpectedly, without

real reflection or with inconsistent reflection, or without the assent
Such actions are often distinguished by

and regardlessness of the interests of others,
as well as of their own. But even under the name of impulsive actions,
one includes chiefly different symptoms of various grades. Thus one
speaks of the morbid impulse to set fire to places {Pijrornania) of
the stealing impulse {Kleptomania), the murder impulse and similar
pathological states. These disturbances will be described later on under
of the
whole personality.
violence, hastiness, skill,
the heading of "Impulsive Insanity."

All impulsive actions have one thing in
common, namely, they are

and aimful willing.
carried out without the cooperation of reflection
The expression "Impidsive Actions" expresses only a part of the

same thing, that is, it refers to various indefinable kinds of actions
This may be
form of incomprehensible "afTective-actions" in emotional persons, or actions which are conditioned by inner motives of which the
subject himself is not sufficiently conscious, and this is especially the
case in schizophrenics. Some sudden obsessive actions are also often
inaptly called impulsive, and of course also the raptus observed in
carried out suddenly and without proper deliberation.
in the
melancholies.
150
Certain pathological actions, like obsessive and automatic actions

are abnormally related to consciousness or to the will.
Obsessive actions are conscious actions running counter to one's
will, and proceed from an inner impulse which the personality
own
In most cases the resistance is connected with fear

resist.
some other vague uneasiness, to the influence of which the personality finally yields, in the same way as a physical pain forces a
person to do something which he does not wish to do.
cannot
or
Impulses tov/ards indifferent actions, to the extent of compulsiveexclamations of indecent or sacrilegious words (Coprolalia), occur
like
frequently in different states.

like
murder
In so far as they refer to serious crimes,
of relatives, they are rarely irresistible outside of schizo-
Indeed, one deals most frequently with apprehensions lest
phrenia.
one might do something, rather than with real impulses.^^ To be sure,

those apprehensions are nothing but effects of impulses repressed into
the unconscious.
Automatic Actions are not directly noticed by the patient himself:

he neither
executes
feels
that he wishes to accomplish the action, nor that he
some time, he takes notice of it

by observing and listening. This occurs in schizothis way windowpanes are frequently broken,
If the action lasts for
it.
like a third person,
where in
and beating administered, but automatic actions may also
be present in an especially clear formation, in forms of hysteria and
in artificial trance-states, where they may appear in complicated and
Here the mouth speaks, reproduces apparently the
senseful actions.
thoughts of the spirit, preaches, and the hand writes. Most people
can apparently be quickly educated to automatic writing by skilful
suggestors I know of a quack who made all his patients automatically
write out their diagnosis and the remedies to be applied. Every
"medium" in spiritistic circles does automatic speaking, and in religious epidemics (preachers in the Cevennes and others) automatism
draws quite a large circle of followers. It is easy to understand that
phrenia,
clothes torn,
such people acquire the idea that they are possessed of a spirit
(Demonism)
If the latter expresses what they consciously think or
.
a good spirit, otherwise it is a bad one; it is not at all

unusual to observe that the patients frequently have to do exactly just
what they do not want to do as, for instance, to utter ugly or sinful
words [Automatic Coprolalia).
A very good description of a schizophrenic patient is the following:
wish, then
it is
"Suddenly Dolinin (the writer himself)
felt,
that not only without
his wish, but even against his will, his tongue begins to express loudly
"Cf. obsessive
ideas,
and Compulsion Neurosis,
p. 87.
151
and at the same time most rapidly that which in no case should
have been uttered. At the first moment the patient was perplexed
and frightened by the very fact of this unusual occurrence, because to
be suddenly and obviously aware of a wound up automaton in oneself
is per se disagreeable, but when he began to grasp the meaning of what
his tongue chattered, the horror of the patient increased, because
it
showed that he, D., openly confesses his guilt to a serious political
crime, sometimes ascribing such plans to himself which he had never
Notwithstanding this fact, his will did not have the
entertained.
power to restrain his tongue, which had suddenly become automatic}'^
Within the automatic actions there are different mechanisms. It
may happen that something is executed which the patient wishes to
but he does not feel the will impulse nor its accomplishment.
he wants to eat, to give his hand, to walk, or when he merely
would be ready to do so, his limbs carry out the action, and yet he
do,
When
it has been accomplished at his instigation

His limb can also carry out something, his mouth
can say something, which the patient might not wish. He feels the
impulse, wants to resist, but has no power; the innervation of his
muscles is directed by another will. From this there are all transitions to the obsessive actions, and the other will is naturally not a
strange one, but a repression of the patient's own striving (in Hysterics, Schizophrenia).
Not a few automatic actions remain also
has not the feeling that

(in schizophrenia).
unconscious in execution,
for
instance,
when
hysterical
woman
crushes rose leaves against her temple during conversation as a symbol

of the thought of her lover's death,
temple.
Such automatisms
may
who
shot himself through his
also be the prototype of
many
schizo-
phrenic stereotypes.
Automatic actions which are formed by practice evidently have

quite different mechanisms.
ing and indeed in
actions which
we
all
In walking, riding, cycling, piano play-
our occupations we carry out a number of simple
As
somebody may do
neither start consciously nor direct consciously.
a rule, these are willed actions, but not always;
something which he wôuld not carry out consciously, as to pick his

nose in company, to show a sign of disdain, and similar
acts.
Similar to such actions are some of the apparent stereotypes of

organic patients which evidently pass off automatically in most cases,
but represent actions which already have been practised before the
disease, like the incessant twirling of the moustache, etc.
The
list
can
still
be completed by some types w^hich although
^ Kandinsky in Jaspers, AUgemeine Psychopathologie,

Berlin, 1913.
p. 121.
Julius Springer,
152
markedly differing from each other, however, have these in common:

sometimes they are carried out quite consciously, sometimes quite automatically, sometimes they are done only in partial consciousness; and
sometimes they are only the expression of a mood. The twirling of
thumbs, scratching of the head in healthy people, and the swaying of
idiots represent some examples.
Just as in outer actions, thinking also may proceed compulsively
and against the will of the patient. If an
or automatically, without
idea continually keeps on obtruding itself against the will, we deal with
an obsessive idea. But beside this form of obsessive thinking there is
another quite different form

in schizophrenic patients,
of-
compulsive thinking, which only occurs
and rarely
in epileptic equivalents
where
the patients feel that "it" thinks in them often the same thoughts
that they themselves think spontaneously, but often the thoughts
are quite different; sometimes there is a confused crowding as in the
"thought crowding" of schizophrenic patients. Hence in such cases
the thought process as well as its contents are withdrawn from the will.
The theory of the automatic actions can easily be understood from
conception
our
of
psychic
processes.
The
associative
connection
between the conscious ego-complex and the functions of acting is lackThe impulses to action are direct effects from the unconscious
ing.
acting upon the motor functions. The complexes from which they
logically originate can be demonstrated by the analyses of accessible
Automatic actions of various kinds can be experimentally
patients.
produced in hypnosis.
Half automatic, though to a certain insufficient extent accessible to
the will, are the tics, which according to Oppenheim are movements
of a reflex, defensive, or expressive nature, which have deteriorated
these we have the displaying of the
and closing of eyelids. They are morbid
because they are repeated again and again without apparent motive.
into compulsive acts;

teeth,
The
long.
clenching of
among
fists,
patient can resist the impulse for a short time, but not for very
Tics are naturally quite stereotyped.
for an action carried out sometimes consciously, and

sometimes compulsively, can also come from without, as, for instance,
in automatic obedience, that is, the compulsive-like or also automatic
The impulse
obedience to requests for simple actions of all kinds. The patients

carry out any commands whatsoever, even also if it is against their
will, as, for example, putting out their tongue when they know that
a pin will be stuck into
it
action can also be given
and
echolalia.
Although
(Schizophrenia).
by means
this
of
The impulse
example alone, as
symptom
is
for such
an
in echopraxia
so closely related to auto-
GENERAL PSYCHOPATHOLOCJY
matic obedience that Kraepelin makes
it
a part of
153
have never
it,
The echo-
seen the two peculiarities run parallel in development.

practic patients imitate whatever strikes
of their surroundings.
As
far as
them
we know,
it
in the actions or
words
partly a question of
is
hysteria-like mechanisms, as seen in the echopraxia of primitive peo-
most cases of schizophrenia, and partly a matter

of an incapacity to get away from a conceived idea, so that instead
of giving an answer the question is repeated, or instead of a new action
the preceding act is imitated (organic echolalias and echopraxias).
ple,"^^
and certainly
in
In the latter case the patients usually wish to do or to say something

quite different, but the impulse turns into a
wrong path.
In hysteri-
form, or schizophrenic echopraxias, the person does not "wish" to do
something different;
it is
not a question of a derailment of an impulse
actually desired, but of an influence of the conscious or unconscious
wish itself.
According to Kraepelin, the phenomenon of
fiexibilitas cerea
(wax-
commonly called catalepsy, also belongs to automatic obedience. The patients make no movement of their own volition; but if they are placed in no matter how uncomfortable an attitude
like flexibility), also
they maintain
Thus, the patient can hold his

longer time than a normal
person could do voluntarily; usually they gradually sink without
trembling, and without any evident exertion on the part of the patient.
it
for a very long time.
limbs in an extended posture for a
Some
much
Most
moving of their
was modelled.
patients ofTer a certain resistance to the passive
limbs, which gives the impression as
move
patients, however,
what is wanted of them.

Much more frequently one
if
wax
statue
their limbs at a slight push, as they
guess
finds in patients
whose movements are

an arm is somewhat
obviously quite normal, that
if,
brusquely raised upwards,
remains so for a long time
it
for instance,
{Pseudo-
flexibilitas).
The
schizophrenic and hysterical catalepsy can be psychically in-
fluenced to a high degree, which
a psychic
symptom;
still
there
makes
is
it
probable that
a probability of
its
peripheral tendency to tonic muscular disturbances.

are too
little
essentially
it is
being based on a
The
other forms
known.
Besides the
flexible,
there exists also a rigid catalepsy.
Patients
evincing a stereotyped attitude must naturally keep the corresponding
muscles in constant tone, and every passive change of the same is

often energetically resisted, giving the appearance of a wooden statue.
In the Malays thp compulsory imitation of simple actions
Latah, in Siberian tribes as Miryachit.
is
described as
154
The apparent counterpart of automatic obedience is negativism,

which, however, frequently appears with symptoms of automatic obediNegativistic patients refuse to do exactly what is requested
ence,
or expected of
them (Passive negativism), or they do the opposite
(Active negativism)
so that in pronounced cases
what
it is
possible to direct
wanted of them. Negathem

always
connected
with
an irritated response
but
not
tivism is often,
and
consequently
with a tendency to
without,
from
to all influences
infrequently
negativism
expresses
itself in the
Not
violence.
anger and
an
effort
start
make
to
an
action,
when a
patients
the
fact that
counter-impulse, or only a mere blocking appears and hinders them
by requesting the opposite of
in its execution.
It
is
also probable that quite
different impulses
In this way, negativism can also express
(cross-impulses) interfere.
itself
against
its
is
own impulses
(Inner-negativism).*
Centrifugal disturbances have especially
many
relations to schizo-
phrenia while they recede in other diseases, or only appear as a natural
consequence of other disturbances. The schizophrenic morbid pictures

which they appear in the foreground are called catatonias, and
in
the symptoms, which associate here particularly often in various com-
symptoms. But the latter partly in

somewhat different form, may also occur
now and then in other diseases. Catatonic symptoms are: stereotypes
(of action, of attitude, of space, and verbigeration) mannerisms, automatic commands with waxlike and rigid catalepsy, echokinesis and
echolalia, mutism (see below) negativism, impulsive raptus, the catatonic form of stupor, and the disturbances of the will in the stricter
binations, are called catatonic
other genesis, and partly in a
sense.
In general the will
is
indirectly influenced
perceptions and thinking, and

affects.
more
directly
by the disturbances of
by disturbances of the
In catatonia there are disturbances of the will in a different
sense.
What we
paths.
The
call will
seems to merge independently into wrong
what the conscious part of their ego

what they recognize as good; yet these
patients cannot do
would wish, they cannot
will
actions are not automatic, but conscious,
are also willed
by a
split off
part of the
and
in a certain respect they
will.
The
ances have here been particularly emphasized:

akinesis, impulsive actions,
following disturb-
Hyperkinesis and
automatisms, negativism, and obsessive
actions.
The
most
ajfective manifestations inadequate to the feeling belong al-
entirely to schizophrenia.
What
impresses us in the affective
conduct of the patient outside of schizophrenia

'"
For further
details
is
conditioned by the
about negativism Cf Schizophrenia.

.
155
abnormity of the affect itself; an exaggerated manifestation is based

on an exaggerated affect. In schizophrenia one cannot so easily judge
from without to within: behind a tragic pathos there may be a very
At the same time the manifestations
light or even no affect at all.
easily strike a false note which is often sensed with true instinct by
naive persons, and by very small children. Very frequently one observes an unmotivated laughter, which sounds artificial, and from
which we can easily recognize that it is not the expression of a real
gaiety.
It can also be easily distinguished from the convulsive laughter of hysterical patients.
In lesions of the thalamic regions one finds
occasionally obsessive laughter or crying in consequence of any psychic

stimuli with, or particularly without, a corresponding affect.
The abnormities
of the
the content of speech.
mental trend are naturally expressed in

noteworthy, however, that not only in
It is
aphasic, but also in schizophrenic patients, the speech utterances
may
be quite incomprehensible {confusion of speech, "word salad," schizophasia), while the corresponding thoughts remain clear as shown by
the orderly behavior and work of the patients.
Formally, the vivid speech of the manic patient expresses his

euphoric excitement, the retarded and low speech of the melancholic
his depressive inhibitions, the babbling and stammering speech of the
idiot his sensory and motor awkwardness, the inarticulate, syllable
stumbling speech of the paretic, his disturbances of coordination, and
the hesitating, singing speech of the epileptic, the dullness of his affect
and mental stream. The different dysarthrias in apoplexy and other
organic disturbances of the brain do not directly belong to our field
of research, as they are only accidental complications of the psychoses.
A persistent not speaking is called mutism; it is variously determined by negativism, delusions, and by hallucinatory prohibitions to
speak, but mainly by the fact that schizophrenic patients have nothing
to communicate to their environment, and that they do not even take
notice of questions put to them.
The handwriting shows quite analogous disturbances. Orthographic

and grammatical mistakes, wrong corrections, and blots, give evidence
Imbecilic awkwardness and paretic
of the patient's psychic defects.
disturbances of coordination impress on the handwriting a mark which
is easily recognizable; the same is true of the manic mobility and
excitability as well as of the melancholic inhibition.
Some
schizo-
kinds of strange letters and flourishes,

orthographic peculiarities, abnormal formations of lines mixed with
The content of the writunintelligible signs, and similar peculiarities.
phrenic handwritings contain
all
ings gives us just as important enlightenment as regards the psychic
156
life
of the patient as the spoken utterances; often
it is
even more im-
portant, because in writing the patients are by themselves and are

more free in expression. A skilfully dissimulating paranoiac used to
on toilet paper; and as his wife, who

of his disease, collected these docuconsequence
suffered severely in
for divorce and guardianship.
material
necessary
ments she obtained the
confide his delusions only
CHAPTER
PHYSICAL SYMPTOMS
Among
the physical
symptoms those
of a neurological nature are
especially important, because on the one hand
many
psychoses are
partial manifestations of an organic affection of the central nervous
system, and on the other hand the functional neuroses are mental diseases.
Although
the semeiology,
symptoms
it is
we
a matter for the neurological clinic to deal with
mention here some of the most important
shall
for orientation.
Paralyses occur in the organic brain diseases, especially in idiocy,

paresis,
and
of course, mostly peripheral.
and are of hysterical
Many
In the latter case paralyses are,
in Korsakoff's disease.
paralyses
genesis,
result
in
Psychic paralyses occur
even
if
found
less
frequently
than hysteria.
There are aleo primary
in cases other
contractures.
(hysterical) contractures.
Real convulsions occur in epileptiform, paretic, catatonic, and hysattacks.

Huntington's disease is always accompanied by
choreic movements. In ordinary chorea the psychic disturbances sometimes rise to the height of a psychosis. The slow athetoid movements
which ordinarily confine themselves to a limb or to half of the body
terical
are
manifestations of brain lesions in postencephalitic idiocies
apoplectic dementia, and other similar cases.
or
Other convulsive mani-
festations are chewing motions
and grinding of teeth in idiots, in

The European sleeping sickness (Encephalitis lethargica) shows all sorts of hyperkinesias, particularly a stiffness of the muscles of mimicry which is not the same
organic patients, and in acute delirium.
as the schizophrenic "rigidity" but as

difference
and lack of energy,
it
it is
cannot in
often associated with in-
itself
be differentiated from
schizophrenia.
Disturbances of coordination of a very definite form belong to

the picture of paralysis, while bad coordination of motion in general,
and higher grades of oligophrenias.

Tremors very frequently accompany the psychoses. Thus we have
the fine, even tremor in uncomplicated chronic alcoholism and in some
to the middle
cases of schizophrenia, the various kinds of coarse tremors in all
organic diseases, such as the severe forms of alcoholism and delirium

157
158
tremens, the febrile toxaemias and some cases of exhaustion. A form

of organic tremor is especially seen in simple senile dementia and quite
Irregular tremors are often only
regularly accompanies this disease.
a sign of some form of excitement.

With the exception of the Babinski, the cutaneous reflexes are
More important are the
practically of no significance in psychiatry.
tendon or deep
by the cerebrum
prsecox; this
psychoses.
reflexes,
is
the latter are increased wherever control
disturbed, as in idiocy, in hysteria, also in dementia
phenomenon is naturally most pronounced in the organic

The crossing over of the patellar-reflex to the other leg
most frequently to the adductors (contra-lateral movement),

reflex
if
the
can be elicited through the tibia or patella, indicates with rea-
sonable probability an organic disturbance. Through affections of

the peripheral nerve and the cord the exaggeration can be overcompensated even to the total disappearance of the reflexes (Alcoholic
Korsakoff, tabo-paresis)
In the diagnosis of hysteria some people attach import,ance to the

absence of the pharyngeal-reflex. This reflex is also absent in bromism
and in many normal persons, depending entirely on the examination.
The disturbances
depend on the organic
of the pupilary-reflexes
In paresis, one usually finds rigidity to light (ArgyllRobertson's phenomenon), but it is also an important sign of other
syphilitic affection of the nervous system; it may also occur transiaffection.
ently in organic forms of alcoholism and also in sleeping sickness.

Catatonia seems to favor functional pupilary disturbances which are
as yet incomprehensible.
Anesthesias and analgesias have already been mentioned,

hyperesthesias
(p. 55).
also
Paresthesias can have an organic origin in
degenerations of the central or peripheral nervous system, or they
can be psychically determined. Slight degenerative and toxic processes seem to produce changes in the physical sensations in cases of
schizophrenia, which in turn give cause for hypochondriacal delusions
and interpretations in the form of physical hallucinations.
The remaining physical functions
are effected in
some cases by
the psychic alterations (loss of appetite in depression), in others they

are organically determined
and
in still others
by the underlying
disease, such as paresis,
they are the cause of the psychic alteration (Base-
The insomnias which

have very divergent connections.
Menstruation often stays away for some time in acute psychoses;
dow
psychoses, athyroidism, cases of amentia).
regularly
accompany the acute
states
at least the subjective sensations of menstruation such as pain,
very
uncommon
in chronic diseases
etc.,
are
where the patients no longer think
PHYSICAL SYMPTOMS
of the function this
is
159
particularly the case in schizophrenia.
In cases
of debility where, on the contrary, such things are very important, one
many
finds
when
menstrual
physiological act
it is
difficulties.
Childbirth proceeds very smoothly
the disease absorbs the patient to such an extent that the

is
not disturbed by the psyche.
essentially the interference of the psyche
This shows that

which makes the func-
tion of childbirth so remarkably burdensome.
former confinements needed
Even women who
artificial assistance are
at
wont to go through
easy births in the psychoses, unless serious anatomical hindrances are

way. The potency with the libido is diminished in some de-
in the
pressions, in morphinism, in
many
schizophrenics, in the excited initial
stages of organic psychoses, especially in paresis; but in senile cases
whose sexual impulse seems almost extinguished the potency and

libido are sometimes increased.
In chronic alcoholism, only the libido
is enhanced while the potency is diminished in most cases.
At the height of the depression there is an absence of tears. In
schizophrenia
all
secretions
the most varied ways.
may
be disturbed quite capriciously in
In cases of refusal of nourishment and nat-
urally also in diabetic psychoses, one often finds acetone in the urine.
Metabolism
markedly influenced in a most incomprehensible manand dementia prsecox where one frequently
notes fluctuations from extreme marasmus to excessive obesity and
is
ner, especially in paresis
the reverse.
In acute diseases the bodily weight usually diminishes,
and increases during convalescence.

For the rest one knows a lot of details about disturbances of digestion, of metabolism, and of the blood picture, but as yet ver>' little
that is constant, that is sufficiently comprehensible, or that would
contribute to the understanding. The temperature is normal in almost
all
psychoses, but one also observes febrile attacks, particularly in
paresis,
where
and in hysteria where it is

Subnormal temperatures are sometimes
marasmic conditions, in cerebral affections, and also
it is
cerebrally conditioned,
psychogenetically induced.
encountered in
without any explanation in schizophrenia.
The heart and vasomotor system remain
uninfluenced
in
no
psychoses, except perhaps in paranoia.
In paresis, perhaps also in senile processes, and in schizophrenia,

one sees tabetic and other rarefications of the bones. Other trophic
disturbances such as the tendency to otohaematoma and decubitus
are variously determined in organic diseases.
With the aberration

basis of
many mental
into false paths,
of the cerebral predisposition
which
is
at the
merges
great number of patients carry with them manjdiseases, the physical development, too,
160
malformations, or surely more than the average of those mentally

normal, from a subnormal bodily height, deformed skull, badly formed
ears
and
palates, irregular position of the teeth or insufficiently de-
veloped teeth, to the abnormal length of the vermiform appendix.

For a long time great stress was laid on these "degenerative signs"; in
individual cases it is hardly permitted to draw any conclusion about
the psyche from either their presence or absence. On the other hand,
they predominate as a whole in oligophrenics, in epileptics, and crimiThey have apparently somenals, and less in other mental diseases.
thing to do with injuries of the germ and point to a teratologic origin
The diseases which are sometimes described as "deof the disease.
generative psychoses," namely, paranoia and manic depressive insanity
are very frequently found in persons of particularly good physical
development.
CHAPTER IV
THE MANIFESTATIONS OF MENTAL DISEASES

A
psychosis
fest itself in
is
generally a complicated structure which
may mani-
very different ways, not only from one patient to another,
but in the same patient at different times.
The manifestations were
formerly taken for the diseases themselves/ and even yet

practical value to emphasize
them
as pictures of
morbid
it
is
states
of
and
as syndromes.
MORBID STATES
The manic state: On the affective side one observes an exalted
and very changeable mood which is especially easily transformed into
anger; in thought, there
accessory
as
is
flight of ideas, centrifugal pressure activity;
symptoms one not
seldom
sees
overestimated and
grandiose ideas.
The expressions "mania" now usually means the manic state of

manic depressive insanity. In countries speaking the Romance languages or English it still designates generally any excitement especially
when it evinces itself in motor expression.
When the euphoric excitement gives a feeble and stupid impression,
some still speak of it as Moria. Distinct flight of ideas need not be
present,
Moria occurs especially when manic attacks are subsiding,
and in lesions of the frontal lobe. To be sure, exalted moods in dementing psychoses of any kind frequently also manifest a similar
appearance.
Depression or Melancholic states with a painful accentuation of

experiences, retardation of thought
all
and
of the centrifugal functions.
As accessory symptoms: depressive delusions.

The expression "Melancholia" designated for
form
emphasized by
Kraepelin, and is now also used to designate the depression of manic
depressive insanity by those who have fused the two morbid pictures
a long time the
of melancholia of the "involutional period," especially
into one.
Kahlbaum
deserves the credit for having made a deliberate and sharp difbetween "conditions" and '"diseases," even though in his time the
position of science had not yet made it possible to circumscribe natural morbid
pictures more exactly.
^
ferentiation
161
162
The manic and
the melancholic (depressive) states
common
we
see almost
manic depressive insanity, also

accidentally more or less frequently in most other mental diseases.
Delusional insanity refers to acute conditions in which delusions
and hallucinations or even only one of the two symptoms dominate
the picture to such an extent that the patient loses his pose, and
in pure
form
in the
cases of
frequently also his orientation.

The expression is now rarely applied to chronic conditions.
When
combined with it, or, what is usually

the same thing, when one deals with an onset of manic depressive
insanity, one also speaks of manic or melancholic insanity.
What for a time was called delusional insanity ("Wahnsinn") were
a distinct emotional fluctuation
is
mostly hallucinatory excitements of schizophrenia. We still use the

name only for the forms of manic depressive onsets, which cannot be
otherwise classified, in which hallucinations and illusions more or less
conceal the fundamental complex; we use it at times for similar schizophrenic pictures.
Meynert once believed that under

described a particular disease.
He
name ("Wahnsinn") he
this
later substituted for it the
term
amentia.
The term Confusion
is
ambiguous; in the
the thought disturbances described above
incoherence and dissociation.
first
place
it
designates
that have no limits as to
But more complicated
conditions
of
very different origin are also designated in this way, being conceived
at times as syndromes, at times as pictures of conditions and at times
as diseases. According to Ziehen, confusion is a symptom complex,
consisting of disorientation, incoherence of the course of ideation
and
motor incoherence. The ''diseases" designated as confusion corresponded approximately to the newer amentia of average degree.
Here we use the expression only for the above named mental
disturbances.
symptomologically about the same

what is still so called belongs nearly
altogether, in part to our amentia, and in part to schizophrenia.
Only conditions that last for a long time and that are conceived as
"Hallucinatory Confusion"
as the broader amentia
is
therefore,
Like confusion, it cannot be

sharply defined symptomatically from twilight states and the deliria,^
concepts, that we cannot as yet dispense with entirely. Transient confusion, twilight states and deliria, be they pronounced or merely indi-
an
entire disease are called amentia.
cated,
we
called "clouded states."
'Cf. p. 86.
='Cf. p.
HI.

Acute delirium
now
is
a rare brain disease.
It is evidently
different infections or on schizoplirenio processes,
on
and
in deliria, convulsive manifestations,
in
1G3
based
and shows
most cases
itself
in a rapidly
ending death.
Hallucinosis
is
Wernicke's designation for acute hallucinatory con-
ditions in which, in contrast with the deliria
and the greater part
of
the twilight states, orientation and, in part, clearness, are retained

(alcoholic hallucinosis).
Dreamy
state
is
nothing but another
Transitory psychoses
name
for twilight state.
are attacks which appear and disappear
They
suddenly, with disturbances of consciousness of brief duration.
occur
manifold
the
in
psychopathic
(Magnan's
states
boufTees
delirantes) with or without affective or toxic cause, then too, in latent
and manifest forms of

epilepsy.
Many may
At times they
Stupor
'^
is
and
real psychoses, especially in schizophrenia
be included in the concepts of twilight states.
are the cause of crimes.
a state of various origins that occurs especially
in
schizophrenia, then in hysteria, epilepsy and also in auto-intoxication,

etc.,
rarely in
drome seen
manic depressive
insanity.
Emotional stupor
is
a syn-
in different conditions, especially in the different kinds of
"nervosities," in the widest sense,
and
in the oligophrenias.
Stuporous forms with almost complete immotility are designated as

Attonity. This is usually a catatonic condition; but a melancholia
attonita has also been distinguished; whether the latter exists, i.e.,
whether the retardation of merely depressive conditions may rise to a
continuous immotility,
is
questionable.
Under cloudiness we understand
different conditions of narrowed,
unclear, slowly performed thinking, in which stimuli are lacking or

at
any rate merge
into the background.
Such conditions are seen
in
slumber, in fever, in epilepsy, in schizophrenia, and in organic states

of all kinds.
part of these pictures naturally
may
just as well be
called stupor.
The
picture of the condition of hypochondria consists in continuous
attention to one's
own
state of health with the
tendency to ascribe a
disease to oneself from insignificant signs or also without such.
It
occurs in dementia praecox, in depressive and neurasthenic conditions,

in initial stages of organic psychoses
in psychopathic states of all kinds.
(arteriosclerosis, paresis),
and
AVe no longer recognize hypo-
chondria as a disease.
Catatonia as such
*
is
a manifestation of schizophrenia.
Formerly in their excited forms also called transitory manias.
"Cf. pp. 143-144.
But cata-
164
tonic
symptoms
also occur in organic mental diseases, in epilepsy
and
in fever psychoses.
Paranoid symptoms is the designation for hallucinations and dewhen they appear in a state of mental clearness and without
lusions
(primary) fluctuations of the affects.
"Acute (hallucinatory) Paranoia" was conceived by Ziehen and

others as a disease.
The majority
of these so called conditions belongs,
in our opinion, to the acute manifestations of schizophrenia.
Religious mania, or
religious delusions; it
is
mania
Nevertheless some observers
nounced delusions of
Dementia
religiosa,
is
any mental disease with
thus mainly a question of dementia prsecox.

still
designate a melancholia with pro-
sin as religious
(feeble mindedness)
is
mania.
not a uniform condition.
deals here with a purely practical conception.
Whoever
One
fails in life
is demented.
In a scientific sense
no uniform dementia, but only an oligophrenic, epileptic,
organic dementia, i.e., forms which in their entire character are very
different from one another. The diagnosis "dementia" is scientifically
never sufiicient; one can diagnose only a particular kind of dementia.
As psychopathies we designate the mass of congenital or at any
rate permanent psj^chic deviations from the normal which have not
yet been included into any other class, and which exist chiefly in the
borderline between health and disease. Among these one naturally
finds many undeveloped real mental diseases, especially latent schizophrenia. Many believe that they connect a well defined conception
with this expression, but they are certainly mistaken.
Degeneration.^ "Degenerates" are usually about the same type as
psychopathies, namely, individuals who intellectually and especially
affectively react differently from the average. "Degeneres superieurs"
(superior degenerates) are psychopaths who stand above the average
in some line and can maintain themselves in the world.
It is only
just to state that famous men belong to this class.''
because of intellectual insufficiency

there
is
SYNDROMES
Syndromes are
genetically.
complexes
of
symptoms that belong together
part of such pictures as manic depressive insanity,
eventually with their corresponding delusions, represent at the same
time such syndromes.
tom complex,"
'Cf.
'
One
speaks, furthermore, of an "organic
also called the Korsakoff
sympsyndrome and understands by
p. 201.
For some
etiological designations see
end of the chapter on Causation.
this
165
term the sum of the psychical fundamental symptoms of a
diffuse
atrophy of the cortex, or of a general lowering of the function of

the cortex through shock or injury of the brain.*
The Katathymic
delusional formation,
with clearness in other respects, which
is
i.e.,
a delusional formation
not due to a general moodi-
ness but to a definite "complex," or a particular experience,
is
a syn-
combined with hallucinations forms the

paranoid syndrome, which is to be distinguished from the paranoid
drome
It alone or
in itself.
constitution.
The
latter
type of personality readily refers the actions
of others to himself, or interprets
them
in the sense of a definite atti-
tude (suspicion, persecution, grandeur) without progressing to the distinct formation of a real delusion.
We can also mention here the
hysterical and neurasthenic symptom complex,'^ the compulsive symptoms, the anxiety psychosis and anxiety neurosis, also the fright neurosis,
the expectation neurosis and the twilight states, because they
mechanisms on different foundations such

and epileptic. Under the twilight states
several types are to be distinguished, which permit of fairly good
differentiation on the basis of their psychic genesis: thus we have the
Ganser Syndrome, which represents a "mental disease," in the form
of acting and thinking in a manner which is the reverse of the normal;
the buffoonery syndrome in which the patient plays the fool in the
are all produced
by
definite
as the psychopathic, hysteric,
"vulgar" sense;
^^
puerilism,"
when the
patient behaves like a
little
and the pseudo-dementia in which the patient "knows nothing."

Moreover, wishes are not only realized through the twilight states but
also hallucinatorily in the twilight states, inasmuch as the patients
dream themselves into the desired situation. The wish to be insane
and to appear irresponsible is fulfilled through the Ganser state which
is a mental disease, or the wish to be innocent and pardoned is realized
in the prison delirium which dehides the patients with the fact that
child
they are innocent or forgiven.

achieved by the ecstasies.^-
The maximum
of wish fulfilment
is
These syndromes are also called Purpose
psychoses.
Among
fugues)
the twilight
states
the
wandering mania
deserves special consideration.
ning away that
It
manifests
(poriomania,
itself in a
run-
completely aimless, or dominated by a single confused and uncontrollable idea; at times it is merely motor without
is
''Cf. p. 230.
* For the kinds of manifestations
see the corresponding diseases.
^"As in spoiled children, the buffoonery observed in schizophrenia
tionally be used as a means to hide the despair.
" Not to be confused with infantilism.
"Cf.
p. 113.
may
excep-
166
any consideration
running; at times
for the outer

it is
world except what
is
necessary for
externally inconspicuous, the act seems planned
with correct use of transportation and with the possibility of contact

with other people; at other times it is done in a way that it can be
placed between these two extremes. The milder forms are rather
psychogenic and may therefore occur everywhere, even in hysterics and
ordinary psychopaths, especially in those who are young, as a result
of an exciting experience, a temptation, or an unbearable situation.
The
severer forms belong chiefly to epilepsy, while those
way between
the two classes belong in the
Querulousness
there
is
activity
is
main
who
are mid-
to schizophrenia.
generated by an exalted self-consciousness where
and lack
of understanding for the rights of others
this
occurs in schizophrenia, paranoia, manic depressions of long duration,
traumatic neurosis, and prison confinements. Aside from the affective

explosions of rage (prison outburst), confinement produces conditions
which on the one hand the patient imagines himself pardoned,

hand persecuted by those about
him. Syndromes that are put in motion by a definite situation, as
prison psychoses, Ganser, etc., transitory affect psychoses, and eventually also querulousness, are also comprehended under the name of
in
acquitted, or innocent, on the other
situation psychoses.
Further syndromes are "attacks," such as the epileptiform in the

narrower sense with petit mal, Jacksonian epilepsy, paretic, and catatonic attacks.
Hoche wanted to supplant the
pictures of diseases that are
still
too fluctuating by the theory of the syndrome, urging that one should
be satisfied with a diagnosis of the latter. But even the syndrome

theory is by no means complete; the identical syndrome has an entirely different significance for therapy and especially for practice,
according to whether it occurs in an hysteria, or epilepsy, or schizophrenia; besides we now know altogether too much about the "diseases" in the ordinary sense to be able to disregard these conceptions
without a severe loss to science. On the other hand, it would be an
advantage to carry out a syndromistic treatment of those symptom

complexes that are only deviations from the normal average either in
predisposition, as in psychopathic conditions, or in reaction as in neuroses, purpose and situation psychoses, and paranoias.
CHAPTER V
THE COURSE OF MENTAL DISEASES

Few
generalizations can be
diseases.
The
made concerning
the course of mental
congenital mental diseases run a "course" only to
tlie
show acute syndromes or sometimes progress

puberty, or that they combine with a new disease such as epilepsy,
extent that at times they

as in
schizophrenia, alcoholism, or atrophy of the brain.
In acquired psychoses one frequently speaks of prodromal stages,

but here as in most cases they represent nothing but such mild morbid
symptoms, that a diagnosis

depression,
are:
is
exaltation,
The most frequent of these

nervous symptoms or
impossible.
eccentricities,
changes of character, in which the new attitude may resemble the

many healthy people, and in itself, therefore, does not
necessarily seem morbid. To be sure, all the real signs of mental discharacter of
eases
in
less
marked form may
also
have the significance of
prodromes.
The "beginning
of the actual disease"
is
usually furtive
if
one does
not designate acute episodes in chronic pictures as "the" disease, as

frequently used to happen and even
states,
At
all
and similar processes are
The
now
occurs in the onsets of manic
events certain deliria, hysterical twilight

in the real sense acute.
mostly chronic, even in the sense of psychiatry,

which also designates as acute diseases depressions extending over a
period of years, provided they regain normal balance. Here the term
"acute" has come to mean approximately something transitory- while
the term "chronic" something incurable. In organic psychoses, which
after a long while end in death, one usually avoids the division of
entire course
is
acute and chronic, as far as the disease
is
concerned.
During the course one encounters acute shifts, acute onsets, exacerbations and remissions. Shifts are rapidly appearing aggravations of
the disease; the concept usually indicates that the given aggravation
Shifts are often connected with some
itself.
and other accessory symptoms, which except for
injury may recede to former states.
Paresis and
does not usually equalize
form
of excitement
the given lasting
schizophrenia are usually
first
recognized as diseases during such

167
168
have furtively transformed the patient for some

many of these shifts assume the form of
schizophrenic manias and melancholias, of catatonias, and other syndromes that were formerly considered special psychoses. Exacerbations are aggravations in general, especially such as readjust them"shifts" after they
In dementia praecox
time.
selves.
Among them
one
many
observes
excitements, or twilight states
(e.g.
psychically
determined
in schizophrenia), that are
not
directly connected with the process of the disease, but are only transient
reactions of the diseased psyche to certain stimuli.
generally disappear, leaving no trace of themselves.
To be sure they
The term, exacer-
bation, does not usually designate the acute attacks that belong to
the morbid picture, such as the moodiness and twilight states of

epilepsy or the manias and melancholias of manic depressive insanity.
All the mentioned transient states of chronic diseases, taken together,
may
Between the aggravations there

assume intermissions in forms
like manic depressive insanity depends on the conception.
With
Kraepelin, Magnan and others, we designate the whole permanent
state of manic depressive insanity as the disease, and the acute appearbe designated as acute onsets.
are remissions ; whether one
ances
may
may
also
also alternate with one another in regular sequence so that
mania follows melancholia and the
latter follows
mania,
etc.,
eventually
with normal intervals after the mania or after the melancholia or
Such formations are called circular or cyclic forms. Outmanic depressive insanity they occur occasionally in schizophrenia and also in paresis.
after both.
side of
How many
tics
very
insane patients are cured depends in institutional statis-
much on
the quality of the cases received into the hospital,
otherwise primarily on the physician's conception of cure.
a schizophrenic patient
whom some
who
is
Whether
perfectly competent socially, and in
remnants of the disease can only be demonstrated after

may be considered as cured or not, is a matter
of taste. I would rather not call him cured, in view of new aggravations that usually appear later, such as the question of marriage, and
similar consequences, although I am aware that the disease may also
"definitively remain quiescent." Delirium tremens, which in hospital
statistics often shows a large percentage of cures, is, to be sure, as a
rule totally gone at the discharge, but not the alcoholism that lies at
its basis, i.e., the disease is cured but the patient is not.
In residual
schizophrenic states "cures" sometimes take place even many years
after the patient has long been given up; this occurs in some without
any visible reason, in some as a result of a febrile disease, or a change
of environments, and similar things.
a minute examination,
THE COURSE OF MENTAL DISEASES

Cure with a defect
tion, suitable only to
just as a healed
by
also spoken of
by formulating the concep-
few cases, that the acute disease has
wound
definite "residual
is
leaves a scar.
symptoms," as
"psychic scar"
left
may
a defect
be formed
which
no longer cor-
in the case of a delusion
in spite of returned clearness following a delirium
rected.
169
is
and multiform that it may be

was formerly desigfrom the primary disease that
If the psychic scar is so severe
considered as a disease in
itself,
the morbid picture
nated as secondary to distinguish it

formed it ("secondary dementia," "secondary paranoia").
The
con-
must now be given up as in such cases it is nearly always a

question of dementia pra>cox, which does not change its nature.
Nearly all organic mental diseases and some severe cases of other
forms, e.g., of catatonia end in death.
Of the remaining a small part
ception
indirectly ends fatally through suicide, unhygienic living, refusal of
nourishment, exhaustion from restlessness and insomnia, injuries, and

infection.
In making the prognosis we have to differentiate the "direction

prognosis" and in chronic diseases,
in
addition, the
"extent prog-
Organic mental diseases run in the direction of a definite

dementia and end in death; the epileptic and schizophrenic follow the
nosis."
direction of other kinds of dementia and usually do not end in death.

Within the realm of schizophrenia there are again different directions
such as the paranoid, catatonic dementia, etc., that have to be considered in the prognosis. Not less important is often the "extent
prognosis,"
i.e.,
how far the disease will progress within

Will the disease soon come to a stop, or will
the prediction
a conceivable period.
there be some improvement?
Will the patient become socially in-
competent through dementia?
Or
in spite of the disease?
will he be able to
And under what
maintain himself
circumstances?
In dementia
praecox, epilepsy and the severe forms of manic depressive insanity

these questions
sible
must often be put and sometimes
with considerable probability.
their answer
is
pos-
CHAPTER VI
THE BORDERLINES OF INSANITY

Nowhere is the question: "sick or not sick?" put so often, in such
an inexorable manner and with such heavy consequences as in the
judgment of mental conditions. But the given question is false. There
are no borderlines of insanity, no more than for any other disease.
In every person a tubercular bacillus occasionally takes hold; one or
may even divide once or twice. How many
the other of the microbes
must be present, how much living tissue must have been destroyed before the individual should be called tubercular? Or beginning with what degree of susceptibility is the ''predisposition to
bacteria
No
tuberculosis" morbid?
Still
more
senseless
one will want to answer such a question.
the question about well and sick where
is
it is
not
a case of something added but of a plain deviation from the normal.

Where is the borderline between healthy stupidity and morbid feeble-
Where
the boundary between normal and supernormal

boundary line is lacking here, then there are
extensive fields in which the conceptions "sick" and "healthy" are not
at all applicable, as little as the various shades of light in a photograph
can be divided into black and white; most of them are gray as a
mindedness?
size of
body?
matter of
is
If the
fact.
That the people and jurisprudence repeatedly demand an answer

to such senseless questions from the psychiatrist
is due to the consedo not want to know whether a person is

healthy or sick, but they want to know whether he is to be taken
seriously, whether he is to be committed to a hospital, whether he
is responsible and capable of acting, etc., and all that they want to
infer from the confirmation "sick or not sick?"
This method of inference is in itself wrong, not only because in a very wide zone the conceptions sane and insane cannot be applied at all, but also because
there are patients that need not be committed, that may have good
ideas, that are not incapacitated, that are not irresponsible.
Today
Schizophrenia and paresis may frequently be diagnosed before one
would care to act upon the social consequences of such a confirmation,
and with the refinement of our diagnostic resources such cases will
always increase. On the other hand, under certain circumstances a
quences.
They
really
170
THE BORDERLINES OF INSANITY
171
may for a definite period have lost his

an extent, that he is neither responsible nor
capable of action. And one will often have to decide within the
border zone according to external circumstances, since the same degree
of feeblemindedness, that does not harm the day laborer, at all, inpsychopath,
who
not insane,
is
ability to reflect, to such
capacitates the
The whole
man who
has inherited a large business.
The
"disease" and there cannot be any.
only cease
no definition of
can
difficulty lies in the fact that there is
when the ambiguous and
fruitless controversies
indefinite concept
is
entirely ex-
enough to examine how a person is and reacts, and

draw conclusions from the facts, instead of from a concept, and then
It is easy
cluded.
determine our actions accordingly.
Where chapters
of the code contain_more_deiaild_jde.ciiptions of
the concept_jif_-disease, ' theyVary greatly according to the conte?

as the concept of insanity has become at all practical,
it
rests
not on medical or psychopathological criteria, but on the idea of social

inca;mcity. That is why, from practical points of view, the neuroses
whichRrfTprrT rly p y r Jxic dis t^nses, arp nn t^jnohiHpd inJ-nnnnity^ wVifrr
ii
they do not lead to severe syndromes like clouded states.
All the
more
they belong to theoretical psychiatry because they are comprehensible
known to differBut much more severe
only psychopathologically and have to be accurately

entiate
them from the other mental
diseases.
mental disturbances, as those in coarse brain diseases and in infections,

are usually not classed with the psychoses. From a medical point of
view the basic disease is taken as the only thing important; socially,
these disturbances have no significance especially because of their
brief duration, unless an important legal transaction happens at this
time.
Hence we
shall use the expressions sane
and insane only
in very
pronounced cases and otherwise, in so far as we are compelled to. At

the same time, in the aberrations like mental debility, or psychopathy,
we shall take the capacity required under the given conditioiis as a.
criterion to determine the boundary of disease.
But as soon as an
acquired disease is definitely proven, even though by few and relatively mild symptoms, we shall speak of "disease in the medical sense''
and shall then have to put the questions, whether any conclusions and
which ones are to be drawn from this finding after a consideration of
all the
A
genius
circumstances.
question which touches

is
a disease or not?"
many
people deeply
Lombroso
know
all
we should
like to
know.
this,
"Whether
was
a disease,
it
Now
we do
But matters stand about like
while others have indignantly rejected this view.
not
is
asserted that
here, too,
172
1. Genius is an aberration like any other; that it is much less

common than undesirable deviations is self-evident, because few defects
One only becomes a genius
in disposition can make a man useless.
this:
when
a large
veloped.
number
of attributes are simultaneously very highly de-
may
Genius
therefore run just as
little
true to strain as a
particularly fine variety of peach which as a single aberration
accidentally cultivated by the gardener.
2.
The tendency
was
to aberration
Every domestic animal and every
usually involves the entire organism.
plant, which can be cultivated along a definite characteristic, deviates
more readily in another direction. Those who are psychically abnormal have (in the average) many physical "stigmata of degeneration"
and those who are physically abnormal have (in the average) many
psychic defects.
In the aberration of genius
we
therefore, as a rule, also
which we must
3. Besides, there is a connection between genius and mental abnormality:
The normal philistine is adjusted to the conditions in which he was
born, and balances with their little changes without thinking or noticing
much in the process. The psychopathic individual cannot adapt himfind relatively frequently other
abnormal
qualities,
usually give a negative value (sensitiveness, nervousness, etc.).
self so well, or
not at
all;
he reacts to
difficulties resulting
therefrom
he may take refuge from the demands, in hysteria

himself
or neurasthenia, or he may create an imaginary world
through grandiose and persecutory delusion, or aggressively by
either
by evasion,
for
at-
tempts to adapt the external world to his necessities, or by both together.

Whoever would like the outer world different in large or
small matters is compelled to ponder over it and strive for inventions,
social betterments, etc.
If he is also sufficiently intelligent, the facility
of avoiding the usual paths may be directly conducive to finding someOften the lack of adaptability lies rather in inner diffibecause the different tendencies do not equalize themselves
thing new.
culties,
but lead to a lasting inner schism.
Such people
may combine
the
contrasts in dereistic thinking or obtain satisfaction from without;

if
they have the other necessary qualifications, they become poets or
artists.
It
is,
therefore, not chance that
famous men are
so frequently
the offspring of unlike parents, whose tendencies do not fuse into a

unified whole in the psyche of their descendants, but throughout their
lives strive in different directions.
more
Poets and musicians must also be
sensitive than other people, a quality
the daily tasks of
life
and often attains the
which
is
a hindrance to
significance of a disease.
CHAPTER Vn
CLASSIFICATION OF
One
MENTAL DISEASES
shows
class of the psychoses
itself as a
morbid reaction to an
and an
affective experience, as a prison psychosis to a confinement,
hysterical twilight state to a jilting on the part of the beloved {reactive
psychoses, situation psychoses)
In the other class there
is
morbid
process in the brain, that conditions the psychosis (process pychosis,
But no division can be based on these classes

because the two symptomologies intermingle.
The terms "organic" - and "psychogenic" indicate similar differ-
progressive psychosis) }
With the organic one naturally
ences.
also classed the toxic psychoses
from changes of metabolism, hormones, and from infections

and poisoning in the narrower sense. The idea of the Psychogenic is
not clear to many. It is said that psychogenic manifestations, too,
must "naturally" have an anatomical substratum; indeed, an anatomical change has even been postulated for things like hysterical paralysis
resulting
of the arm.
That
is
wrong.
An
hysterical paralysis as such has only
substrata, which in themselves are not pathologic; but as the foundais a nervous system anatomically
formed from that of the normal disIn a house there are doors and windows so that at times
position.
they may be opened, at other times closed. If they are open or
closed, it is in itself no derangement of the structure; but if they close
or open too slowly or too easily, or if there is a rogue who brings it
about that they move too slowly or too easily, or who breaks them
or opens them when they should be closed, and closes them when they
should be opened, those are changes that may be compared with the
tion of the hysterical disposition there
chemically somehow differently
anatomical.
Endogenous and exogenous psychoses cannot be sharply differtwo factors mingle or combine in their
effects but because the two concepts in themselves have no definite
entiated, not only because the
imd Psychose bei der Dementia PrEecox,

Psych. Orig. XIV. S. 158.
*The word "organic" designates here a much broader conception than in the
expression "organic psychoses" which in order not to have to coin a new
name I use for those psychoses that are based on a diflferent reduction of
brain elements.
^
For
Ztschr.
f.
details see Jaspers, Schicksal

d. ges.
Neur.
u.
173
174
limits.
Idiocy, whether stationary or progressive,
in relation to the patient
ence on a parent.
If
but
may
may be
endogenous
be the result of an exogenous influ-
schizophrenias are based on autointoxications,
they are exogenous in relation to the brain but endogenous in relation

Nevertheless Bonhoeffer's investigations of the exogeto the body.
nous reaction types in toxic states and infections have been very
enlightening.
The attempt has
also been
made
to classify on the basis of causes;
and traumatic psychoses have been

But this principle cannot be carried out because some
differentiated.
causes produce very different morbid pictures, as syphilitic paranoid
states and paresis, alcoholic insanity and alcoholic Korsakoff's disAnd conversely, the same morbid pictures might be produced
ease.
by different causes, thus Korsakoff's diseases may be due to alcohol or
carbonic oxide gas. That the idea of causality is not clearly limited
need not nowadays be explained in detail.
Under Kraepelin's guidance the course of diseases has been particularly emphasized, thus the same terminal state was supposed to be
proof that two different groups (not diseases) were formed which are
entities even in other respects, and will probably remain so for us.
We refer to dementia prsecox and manic depressive insanity. It is
nevertheless impossible to base a classification of morbid pictures only
on the course of the disease.
According to a more recent theory of these two groups of psychoses
one observes even in normal people a syntonic ("cyclothymic") reaction type, in which the whole personality uniformly participates in a
definite and relatively vivid affect, suitable for the situation of the
moment, and the train of ideas follows substantially quite logical laws,
in that the affects disturb it only by connecting and overvaluing what
conforms to it, and by inhibiting and undervaluing what opposes it.
If at the same time the physiologically conditioned mood remains uniform throughout life and maintains an average pace, the representaIf it permatives of this type then pass as the most normal people.
for example, alcoholic, infections,
nently deviates to euphoric or depressive paths,

a chronic
mood;
if
the
mood
fluctuates
its
carriers are then in
(alwaj's for physiologic rea-
sons), those so afflicted are cyclothymic, or in the pronounced cases,
manic depressive. Studies of heredity show us, that the peculiarities

mentioned, somewhere belong together, that they represent a uniform
super quality, the "syntone," in which, although the individual sub
groups follow by preference a similar heredity, they can nevertheless
substitute one another in almost every family.
sanity, Cyclothymia, chronic depressive
Manic-depressive in-
and manic moods, appear as
CLASSIFICATION OF
exaggerations
other
or
MENTAL DISEASES
deviations
of
"normal"
syntonic
175
reaction
types.
Whereas the relationship of even the uniform (most normal) sy.^tones to the morbid fluctuations was first demonstrated by Kretsr-hrner,
the "schizoid" peculiarities of healthy persons was long known. Thus
there
a lack of uniformity of the affectivity, actual coexistence of
is
and a slight deviation of the assoHere too one must differentiate the
various qualitative or quantitative sub groups, which are frequently
inherited as such, but still change frequently within the main type.
Among those one finds persons who are dereistic, who show an affective
different, nay, contrasting strivings,
ciations from the usual paths.
who are
Now, even
poverty,
etc.
irritable, eccentric,
if
paranoid, schizophrenic, schizoid,
the schizoid reaction appears mostly abnormal
following the canon which
normality, that too has as
we have made for ourselves about psychic

much biologic significance as the syntones:
Psychic new creations, inventions, political and religious revolutions

almost always owe their existence to it. Exaggerations or caricatures
of this reaction type
tions.
come
into existence as schizophrenic manifesta-
But whereas according to our present,
still
very limited knowl-
edge, the manic depressive attacks are designated as "functional,"

at least the more serious schizophrenias are connected with tangible
cerebral changes; hence the most marked deviation from the normal
seems to be here in the first place not merely a strong fluctuation but
something new, still even in this relation it is nevertheless possible
to form a parallel syntone, at least hypothetic ally, between manicdepressive and schizoid-schizophrenia.
Every man then has one syntonic and one schizoid component, and
through closer observation one can determine its force and direction
and can also put it in relation to his heredity, if the members of the
family are known.
Either both or only one of the reactions
gerated in the same individual.
pure manic-depressive
quently, however,
we
The
may
be morbidly exag-
extreme cases then belong to the
and the pure schizophrenic
diseases.
Fre-
find distinct mixtures; preponderating manic-
symptoms and the reThese mixtures have been known to psychiatrists for a long
time, but they have been guided by it only in the prognosis and treatment of the disease but not in naming it. Except in the rare extreme
cases we now no longer have to ask, is it manic-depressive or schizophrenia? but to what extent manic-depressive and to what extent
schizophrenia? Confronted with such mixed forms we can say that
if the schizophrenic components, though distinct, do not definitely
depressive types with schizophrenic accessory
verse.
176
follow the paths of dementia, the prognosis is still good, at least as

regards the present attack, otherwise it is bad; for the manic depressive
is almost always transitory.
For not only would the schizophrenic-like symptoms in all manic
depressive forms owe their existence to schizophrenic components, but
conversely most of the melancholic and manic states in schizophrenics
would probably be an expression of the manic depressive components;
they would really have no direct connection with the schizophrenic
In many cases the latter connection could always be made
process.
with the greatest probability by studying the heredity.
The theory has also some bearing on other diseases, namely, organic
psychoses. Poisons coming from without (alcohol, infections), as
from within (uraemia), will set free more schizoid symptoms, if the
schizoid factors of the individual are stronger, and more manic depressive symptoms, the more syntonically the patient is predisposed.
This would thus furnish us with the explanation not only for the mixed
forms of manic-depressive and schizophrenic symptoms, but also for
the admixture of manic depressive or schizophrenic symptoms in quite
As far as our experience goes this theory can be
different diseases.
part of the disease
The preponderance of euphoric or

fully applied to senile dementia.
even manic symptoms in general paresis requires a special explanation:
Does the disposition to manic behavior also contain a disposition to
the localization of the spirochites in the brain?
Or what seems more
probable, does the paralytic process or toxin produce a tendency to
euphoric reaction?
That under these circumstances the paraphrenias must all be added

is self-evident.
One thinks less of the fact that
also the essential factor in all neuroses rests on schizophrenic mecha-
to the schizophrenias
nisms
ment
one
may
think of the splitting
of one impulse
by the
off,
the pinching
off,
the arraign-
other, the inability to adjust to certain
situations (or better the will not to adjust oneself)
etc.
To
be sure
the syntonic components play some part in the formation of even these
morbid pictures. Thus to produce a hysteria in the ordinary sense

must be a tendency to a labile affectivity in order to accentuate
one's own personality; a more depressive affectivity in the same
schizophrenic mechanism would lead to "neurasthenic" pictures. If
the affects are very constant and maintain themselves in a more central
position, a paranoia will develop in a schizoid mental type as a reaction to inner and outer difficulties (Studies in heredity seem at last
able to furnish the long expected proof of the relationship between
A simple uncontrollable affecforms of paranoia and schizophrenias)
tivity which leads to all sorts of primitive reactions, such as crying,
there
CLASSIFICATION OF
window breaking, scratching up
veneration, has
its
MENTAL DISEASES
177
the husband, extravagance in love and
origin in the syntonic components.
The fragmentary theory
here presented
is
for the present only
an
hypothesis; but could be demonstrated with remarkable elegance in a

large
amount
of material of healthy
at least as far as
hardly be doubted.
two psychic types
It is
also
and sick people;
its
correctness
general features are concerned can therefore
its
even more important when we find that the
show a
certain predilection for definite physical
more complicated and

than those based on psychic spheres; but Kretschmer's
constitutions; to be sure these connections are

less definite
Pyknical physical type,
e.g.,
must somewhere show a particular
rela-
tion to the stronger syntonic reaction types.
In recent years anatomical investigations have carried us forward

very nicely, in that, for instance, a clearly circumscribed picture could
be distinguished of dementia paralytica, of various forms of senility,
and of several diseases that may be designated clinically as epileptic.

As in somatic pathology we are not accustomed in psychiatry to
apply concurrently different principles of classification, and through
the services of Kraepelin we have attained in barely two decades a
point of view, which compared with the earlier one, is entirely satisfactory.
Even though, as everywhere else, there is much we should
know in order to see clearly, and though there are surely still many
diseases that we do not know, nevertheless compared with the complete helplessness of previous years we have achieved a point of view
from which it is possible to gain new ground steadily.
Therefore I follow, as far as possible, Kraepelin's classifioation,
which is now pretty well understood in the whole world, even if it is

not everywhere accepted, while all other schematizations are viable
only in certain schools.
Combinations of psychoses are
still
schizo-
be taken with
fever-
insufiicintly studied.
phrenic or a manic depressive patient
may
delirium, delirium tremens, paresis, or dementia senilis;

is
not at
all
schizophrenia.
rare, especially
in
women where
it
is
alcoholism
symptom
of
In such cases the symptoms of the two psychoses
combine and under certain circumstances as
in
the interconnected
hallucinations of the schizophrenic delirium tremens, thej' fuse into a
Sometimes one disease apparently forms

no pronounced second disease but a mere
predisposition colors the symptoms.
unified
and peculiar nuance.
the essential picture
there
is
^ For more information see Kretschmer Korperbau und Charakter. Springer,

Berlin 1921, and Bleuler: Die Probleme der Schizoidie und der Syntonie, Zeitechr.
f. d. gesam. Neurol, u. Psychiat. 1922.
178
Recently an attempt was made to place the classification of the

psychoses on an entirely different basis by emphasizing the various
I
factors participating in the causation, development, and course.
made the effort to initiate these viewpoints also here but had to desist
from
it.*
Even
if
presented
it
only the most important combinations would have been

would have been so complicated that not alone the be-
ginner would have had

other hand
if
symptoms,
it is
one
is
much
trouble in understanding them.
On
the
well acquainted with the present grouping of the
no longer a clever feat to recognize and
sufficiently
same patients such conditions as congenital debility, alcoholism, manic states, and perhaps even the beginning of
If the new demands would be followed many repetisenile dementia.
Moreover our knowledge is by far too
tions would be unavoidable.
meagre for such description. Thus in the case of apparently catatonic
symptoms in organic psychoses, we must, for example, first find out
whether and to what extent they are based on the same schizoid
mechanisms as in schizophrenia before we can say in a given case
that the morbid picture is colored by a schizoid disposition. We do
differentiate in the
not know the somatic (toxic?) part, that probably conditions the
tendency to euphoria and mania in paresis, and consequently cannot
tell to what extent an induced paretic mania results from the disposition, etc.
Besides, the diagnosis in the present sense
portant factor.
If
we formulate
still
remains the im-
our findings in such words as "or-
ganic disease," "''epilepsy," "manic depressive insanity," or "neurosis,"

at the same time drawn from it the most important practical
we have
and theoretical consequences, which at least for the present cannot be

substituted by any other theory. What would be the use of recognizing an hysterical mechanism, if we would not know whether it developed on a schizophrenic, paretic, epileptic, or on a mere nervous
constitution?
And
if
instead of calling a disease schizophrenia
we
would have to describe all the individual mechanisms which we see

acting in unison, we would hardly ever get through, and we would
then still have to keep the whole story in our heads, in order to decide
upon the prognosis and treatment. Also the two latter deductions
could be the same as in any other psychosis, which is composed of
quite different individual syndromes, that is, it would look quite
different in the description, but would become attached to the former,
without anything further, through the diagnosis of schizophrenia.
The first thing to consider in the "Strata-diagnosis" ("Schichtdiag*
Comp.
also the
end of Chapter
IX on
"syndromes,"
p. 198.
CLASSIFICATION OF
MENTAL DISEASES
179
is the constitution, whereby there is tendency of

understand only something acquired through heredity, although
it is natural to suppose that some qualities, as e.g., the weakness of
an endocrine gland, can be just as well acquired as congenital. But
nose") of Kretschmer
late to
the constitution even in this narrow sense

acting only in one way.
It acts
is
by no means a factor
pathogenetically
when
it
gives direct
an amaurotic idiocy, to a schizophrenia, or a manic depressive

insanity; it acts "pathoplastically" (Birnbaum) when as a schizoid
disposition it determines the formation and the kind of delusions in an
organic disease, or when it causes an alternation of manic and depresorigin to
sive
moods
in the
same
In the latter case
disease.
the course of the external morbid picture, and
can determine the severity of the disease

outcome.
The concept of disposition includes the
also all the not familiar factors, congenital
come into consideration, such as poisons,
physical diseases of various kinds.
it
it
influences besides
is
assumed that it
and
in its manifestation
and with it
and acquired, that may
infections, traumas and
constitution
It acts exactly like the constitu-
tion: pathologically, pathoplastically,
and determines the course and
the severity of the disease.
particularly conspicuous side of the disposition
is
the character,
which acts pathoplastically; thus certain ideas of persecution and

grandeur are only possible in definite strivings and in definite characterological relations to the environments; the economical person be-
comes miserly in
But
senile dementia.
by
an alcoholism, but also
probably through the fact that certain diseases, like paranoia or even
paranoid conditions, i.e., diseases w^hich are made up, as it were, of
delusions, would not have broken out, if the character would not have
indirectly the character also acts pathogenetically, not only
assisting in the acquisition of a syphilis or
assisted in determining the possibility of delusional formation.
neuroses too require a
soil of
The
a definite character foundation.
However, the character may also be the result of a morbid diswhich later leads to a psychosis (schizophrenia, manic de-
position,
pressive insanity, epilepsy), or
it
may
be the partial manifestation of
the disease (oligophrenia, schizophrenia epilepsy), or
that
first
caricatures
it is
the disease
emphasizes definite features of character, exaggerates, or
them
(a punctual
and conscientious person becomes quer-
ulous in old age, the generous becomes thoughtless, and the one
is
who
somewhat below par morally becomes an unscrupulous criminal
as
a schizophrenic).
Quite independent of the disposition, as far as
its
psychic expres-
180
sion
is
concerned,
is
the part played by individual cerebral processes
which change the material foundations of the psychic

the
first to
cortex,
be
named
is
in very different diseases
which
life.
Among
the diffuse atrophy of the brain, that

is
is,
its
the most essential factor for
the structure of the psychic picture of the symptoms and quite independent of all other manifestations and dispositions determines what
;
we
clinically
call
"organic mental diseases."
In reference to the
psychosis the cerebral alteration acts pathogenetically, while in reference to the symptomatology pathoplastically. That the localization,
must exert a formathe

picture,
of
which we consider
distributions
on
the
tive influence
of the process leading to the atrophy
and the kind
as accessory manifestations, is self-evident. But as yet

little about it to give these factors serious consideration.
we know too
The invasion
of the spirochites exerts a tendency to euphoria; certain senile processes like cerebral pressure determine a torpor of all psychic processes.
Multiple sclerosis (and epilepsy) and other organic brain diseases

dispose one to hysteroid symptoms, while paresis and senile dementia
often cause
them
to recede.
Circumscribed injuries of the brain also come into consideration

both in regards to causation as well as formation. Lesions in the
basal ganglia diminish the energy from the impulsive life (sleeping
sickness) other lesions at the base of the frontal lobe lead to moria,
;
facetiousness,
and a tendency to mischievous
teasing.
Other circum-
scribed lesions in the basal ganglia determine a labile affectivity, while

all
destructions of parts of the brain are likely to produce irritability
and transient moodiness.

Congenital dispositions also influence the form of the symptoms
in these cases, in that the force of the schizoid functions adds to the
picture schizophrenic symptoms, and pronounced syntony manic de-
symptoms; the other dispositions of character also color the

That former experiences, e.g., delusions, can color the organic,
pressive
disease.
and that poisons (alcohol) can influence the

is well known.
entire psychic picture even
here,
More
difficult
is
in the psyche,
tion
showed
but only in the same direction as the epileptoid foundabefore the appearance of the disease in the patient
itself
himself or at the same time in his blood relationship.

fore
do well here to reserve our theory
Still
more complicated are the
too there
is
The
marked change
the formation of the theory in epilepsy.
epileptic process (chemical or anatomical) produces a
We
shall there-
for a while.
relations in schizophrenia.
a disposition, which psychically shows
itself as
Here
an embryo
of the later insanity, then there are elementary disturbances in the
CLASSIFICATION OF
thought apparatus, wliich are
still
MENTAL DISEASES
181
hard to understand, somewhat
lat^.-r
or in acute shifts there are distinct organic changes in the brain and
on the top of this as accessories there develops the entire polymorphous

complex of the schizophrenic manifestations, as reactions of a sick
organism, or as deviated functions of the psyche.
Besides the epileptoid and schizoid characteristics, which have
some connection with the disease itself, other qualities of character
must naturally co-determine in many directions the outward appear-
ance of the psychosis.
Some
toxins, like alcohol,
morphine, and cocaine, act causatively
and at the same time formatively,
so that one can tell the cause
from
the picture; in their manifestations these poisons are also definite
forms of psychic disturbances.

When different causes producing definite symptom complexes cooperate, for instance, a spirochite invasion and an alcohol poisoning,
it is
customary to view the one disease as the essential and the ad-
mixtures of the other as a "coloring" of the same.
In a delirium
tremens we sometimes find the signs of paresis, in senile dementia
those of alcoholism. As a matter of fact, it concerns here a mixture
of two diseases, of which, to be sure, the one without the other would
come to light. Similar conditions prevail when only disand not a pronounced disease complicate the main psychosis.
Febrile deliria, and delirium tremens, are influenced by schizoid
factors, schizophrenia by alcoholism, in that, e.g., the hallucinations
and delusions become more united. A schizoid disposition or schizophrenia and the effect of alcohol mix with a uniform picture, in acute
alcoholic delusions, in so far as the tw'o components are even much
less separable than the alga? and fungi among the lichens.
often not
positions,
The psychosis
in individual
or the disposition can also counterbalance the other
symptoms: organic psychoses loosen the blockings and
other catatonic manifestations of schizophrenia.

acter can be turned into
There are also
definite
its
The
original char-
opposite.
syndromes ("diseases") which are produced
On the other side it has

been said that similar causes may produce different pictures of disease, depending on the reaction type of the patient.
Thus a fever, an
by
definite
causes or cerebral processes.
alcoholic poisoning, a delirium tremens, a paresis, even a
pressive attack will set free schizophrenic

individual.
Depending on the
evoke twilight
states,
disposition,
symptoms
psychic
manic dea
The
schizoid
influences
hysterical attacks, a neurasthenia, a
phrenic attack, or chronic delusional formations.

is
in
will
schizo-
correct concept
that a disposition and a chance cause manifest themselves in the
182
morbid picture
in just such cases,
or,
what
is
the same, that two
causes participate in the formation of the picture.
Individual diseases are direct products of the disposition: they are
nothing but the expressions of the congenital disposition, which manifests itself at a certain age (amaurotic idiocy, process shifts of schizoWe assume that in accordance with fate
phrenia, arteriosclerosis).
the disease would here break out under all circumstances. Nevertheless in the individual case some still think of chance causes, which
have at
least participated
(reenforcing, hastening the outbreak)
in the success of
were necessary to
in
some way
the disease.
set free the disease, or
Precisely in arteriosclerosis one always looks for external
causes.
Besides, the layman, and even now many physicians still have the
same idea about the appearance of a disease, to which one is predis-
posed, as about the appearance of a running nose through a cold.

addition,
when
it is
psychic injuries.
there
is
In
a question of the psychoses one thinks mostly of
But
as far as
temporary injuries are concerned,
not the least basis in experience for such an assumption.
People who consider it quite obvious that any unfortunate occurrence

"can drive one crazy," and that confinement in the insane asylum
will "surely
make one
crazy," mistake transient reactions for perma-
Only where the harmful

permanent can it sustain a permanent reactive psychosis:
delusion of being pardoned in life-prisoners, paranoid, or damage suit
neurosis.
And when we speak in such cases of a "disposition" for
the concerned diseases, the expression means here something quite
nent maladies resulting from dispositions.
influence
is
different
than the disposition for schizophrenia or for arteriosclerosis,

nothing but the germ
which
in the light of hitherto conceptions is
of the disease, whereas in the latter examples the disease represents
only an accidental special reaction to a general reactive predisposition.
As
by "occasion for
same time
require here more
to the very different things that are understood
something"
("Anlass"), and
formative meanings
it
what causative and
conveys,
is
too familiar to
at the
than a few suggestions. In the vocation of the saloonkeeper there is

the "occasion" for becoming an alcoholic, in the war, for dreaming
or hysterical manifestation, in fever or in a nephritis, there
is
the
occasion for a catatonically colored delirium, in alcoholism for the
outbreak of epilepsy, in Bright's disease for an amentia, in a fracture

of the head of the femur or in an exhaustive disease for a senile
dementia, and in childbirth for a schizophrenic
shift.
The
latter con-
nection as well as the hysterical manifestations with their causes belong

in the sphere of the psychogenetic,
which are not unknown
in the
CLASSIFICATION OF
MENTAL DISEASES
183
present time; an exaggerated or qualitatively abnormal stimulus in

a corresponding disposition leads to a psychosis or neurosis; the
same
happens in the case of a normal stimulus, if the kind or force of the

reactivity is abnormal.
Still more could be said about the "structure of the psychosis";
the material mentioned should show only about what points of view
come into consideration, and how complicated are the various factors
influencing one another.
Analogous points of view could also be
considered in the study of the demolition, improvement, and flattening
down
of the diseases.
CHAPTER
Vm
THE RECOGNITION OF INSANITY

In the diagnosis of insanity in general
it
is
hardly ever possible
to obtain in a single examination a complete morbid picture, or to
follow a general plan of examination.^
would worry or
tional times
it
is
examination.
hallucination,
One would never
irritate the patient unnecessarily.
feasible to
When
it is
And
finish
and
only at excep-
keep to a definite procedure in the

symptom to us, e.g., an
the patient indicates a
usually advisable to follow the trail at once.
Often,
few cardinal symptoms and of

necessary and possible under the
too, wê are forced to verify only a
the
others
as
much
as
is
still
circumstances.
But in this respect one must not be too modest; the more one
knows, the more certain the d iagnosis and the m nrp dpfiTiite-iim-hpTppeijtic-Baegûresy^ Theliumah psyche is so complex that much that at\
irst seems a sure symptom of a definite mental disease is not infrequently explained as something else when all the circumstances are
known. )^ frequeTitly--suffices^ to make_ oiily-H'e dlHgn o s ia of -4b
disease without, however, ascertaining the particular psychosis.
when an excited, or violent, or fasting, or suicidal

committed to a hospital as quickly as possible. The
eventual necessity of a neurological, ophthalmoscopic, and general
physical examination should always be borne in mind.
Since a general examination is not possible as in somatic diseases
where one begins at the head, and ends with the feet, the only thing
to do is to follow up those symptoms which one was called to treat
This
is
patient
the case
is
to be
* Plans for examination

have been devised which naturally take into consideration ever>'thing existing and, for that reason, must give a too large number
of view-points. It may be a good thing for a beginner to read them through
carefully and note ever>'thing that might be considered. But in the examination
one must be able to hit upon the selection necessary for the special case,
not only in the interest of the patient, but especially of the physician who
otherwise, as experience shows, easily neglects the important point. This important point, namely, the examination of the chief symptoms with their theoretical and practical associations, simply does not permit of schematization and,
therefore, compared with the remaining trifles in the scheme, necessarily falls
itself
short.
184
185
or that immedifitely strike one's eye, and think of those diseases that
can produce such manifestations, and then look around for other signs
of the disease.
If the suspicion is neither positively
nor partially con-
firmed, then other possibilities will have to be considered.

to
do
this, it is
of at least the
The kind
place,
if it
more important individual
of questioning
is
In order
necessary to carry in one's head the symptomatology
is
diseases.
of the greatest importance.
must not
at all possible, one
In the
finst
irritate the patient until
the most important information has been obtained.
It
is
much
better
An examina-
to gain his confidence, naturally without taking
him
tion under false pretenses should be avoided.
If a patient
in.
does not
examination can be made, perhaps occasionally, as if

by accident, a question may be put to him as "Does this hurt?" or
something similar and so induce the patient to speak. One can
observe much in both the mental and physical field without the
talk, a physical
patient's noticing
it;
thus one can become accustomed to notice the
pupilary reactions in an ordinary conversation.

in
mind the whole
situation as
it
One
will
appears to the patient.
always keep
The
identical
question with or without introduction may, in one situation or another,
be a very good one, or such that

examination.
"How much
is
it
makes the patient
twice two?"
may
unfit for a further
be a good question but
under other circumstances it may suggest to the patient another question, viz., whether the physician is crazy.
A test of the sense of pain
with needle pricks is something entirely different if the patient is
distracted or not, if one dashes at him with the instrument, or first
begs him to indicate whether he notices the prick, etc. In short, in
these matters one must have some practice and above all native tact
and comprehension of the situation and the consequences, otherwise
all special directions and details are useless.
One must never forget that the examination in the clinic,
where the examiner usually knows the patient and where the entire
situation facilitates many questions, is entirely different from the
examination in a first consultation. The latter requires much greater
care.
Naturally, whenever possible,
anamnesis.
If this
is
a good
can materially
one endeavors to obtain
possible before the examination,
it
many cases one then needs only

important data by the patient to be sure of the
diagnosis.
But even after the examination one must not hesitate to
supplement or obtain the anamnesis, because only now does one know
shorten the entire procedure, since in
a confirmation of
its
in all respects the drift of the situation.
not be too gullible.
No
anamnesis
In this matter one must
is entirely impartial; purposely or

186
accidentally with good or bad intentions, a great deal is invented both

on the good and the bad side. One should be especially careful about
an anamnesis which is obtained from the patient himself. Correctly
used, it frequently furnishes an absolutely clear diagnosis despite the
patient's wishes.
Something entirely different from a single examination is a comwhich is usually necessary in giving
a professional opinion. Here one must be assisted by the other departments which the clinic offers and possibly by other specialists,
such as the examinations of the eyes, ears, blood, fluids, etc. This
technique must be acquired in institutions or at least from textbooks.
Such examinations can usually only be done in institutions.
The intelligence examination will be discussed in the chapter on
plete examination or observation
Oligophrenia.
If a case is
not clear without
it
and under
all
circumstances,
if
one must handle the patient oneself, a minute physical and especially
neurological examination must not be omitted.
In patients
who
are inclined to assume tense attitudes or
who
are
otherwise awkward, the patella reflexes are best taken not with the
knees crossed but with the feet somewhat forward and the whole sole
resting flat on the ground.
If they are absent, they
be obtained by Buzzard's method, that
is,
by
can sometimes
raising the heels in this
position with the point of the foot left on the ground.
In testing the pupillary reflexes the beginner often makes mistakes.

directions recommended for avoiding them are contradictory;
The
clinical experience, one's
must help
special case
One does
lighted.
light,
sense, care
and adaptation to the
well to observe the pupillary reflexes while conversing
with the patient.
and
own good
along.
In doubtful cases the room should be darkened
Restricted sources of light, especially the pocket flash
are likely to result in false reactions.
Touching the
lids is often
responded to by patients with irritability or stubbornness. One should

be careful not to confuse in the insane, light and accommodation
and psychic reactions.

For examination of cerebrospinal
psychoses in general
(p.
fluid see the section
Clinical experience alone can teach the technique of
nations.
mimicry
One must know from observation what

is;
on organic
238).
mental exami-
a blocking or a rigid
whoever would depend on theoretical descriptions
make
will be
Most
symptoms are exaggerations of normal mechanisms; for that
reason one must not only see them, but also evaliiate them. Whether
helpless before the patient,
psychic
or
the
crassest mistakes.

an
affective stupor, a blocking, or a speech disturbance
187
is
pathological
cannot be described, and still less whether these matters are pathognomonic of a particular disease. Clinical experience, too, must teach
one to understand the descriptions with the necessary grain of salt.
Words cannot do more than seize upon a pronounced "typical" facies
from the endless variety of psychic manifestations; only observation

can decide to what extent such an example should be generalized and to
what extent not.
As
far as the individual functions are concerned, attention should
be called to the following
Whether the patient
is
oriented, usually
necessary, a few questions will
Even
the
make
shows of
itself.
When
for certainty.
layman can recognize sense deceptions usually from some
contradiction with ordinary experience, although in individual cases
one will have to prove the reality of the perceptions.
may
hallucinations
great
many
be recognized by the fact that they cannot be
described in such detail as a perception.

often hallucinate only
Like dreamers, the patients
what matters to them; they can
whom
see a part of
belongs than
Concerning the voices, the patient at times gives only
the sense; the hallucinator cannot say which of several synonymous
expressions he has heard, or even when he states it positively, he frequently contradicts himself in repeated accounts. Upon exact quest'oning the illusions often are differentiated from reality as "pictures,"
or "inner voices," or something similar. But there are many exceptions; the visual hallucinations of delirium tremens are especially
a body, but then rather imagine the person to
it
perceive him.
distinguished for their detailed elaboration.
Direct questions concerning hallucinations are frequently incorrectly answered in the negative
whom
one does not yet know,
rectly through such questions as
disturb
you?
Do
(denial,
it is
inhibition)
with patients
advisable to inform oneself indi-
"Do you
sleep well?
Does any one

much?"
the neighbors concern themselves with j'ou
etc.
Similarly in delusions.
Where
their content does not prove incor-
one should, when possible, test their objectivity.
rect
from the
But
this is not the only criterion and, precisely considered, not at all
first,
a delusion
futile
mistake involves also an incorrect judgment, and

chance correspond with reality. It would be really
to examine the objective foundation of a jealousy delusion; the
the decisive one.
may by
decisive factor
is
the patient's subjective confirmation of
his firm conviction he offers
it.
If for
no other grounds than that his wife's
bed was once particularly warm, that twice
in succession the
same
188
her as she was leaving the house, that she looked frightened
the patient came home unexpectedly, then it is a question of
man met
when
delusions whether the wife
In
many
is
in reality faithful or not.
cases, perception
is
One can
One will notice
whether one must repeatedly
naturally tested indirectly.
easily see whether people see and hear correctly.
how
quickly they comprehend questions,
explain things, and for
what
reasons.
Optical
comprehension can
also be tested by reading; especially convenient for this examination

are suitable pictures that are not too large, which one quickly uncovers,
must know what may be

person.
normal
expected from a
In most cases the associations need not be specially examined;
every conversation, especially when one lets the patient talk, is an
association test. Milder flight of ideas becomes evident, if one stimulates the patients somewhat and lets them tell what interests them.
The association experiments which are ordinarily unnecessary have
to be practised somewhat if one wants to use them.
Memory is already tested in taking an autanamnesis ; many questions can be put in such a way that they will throw light also on this
The memory for happenings in the course of the examinafunction.
covers, but in this connection one
and then
examined by again asking the patient after a

in the beginning and by having him
little
him. Isolated numbers of from
been
given
have
that
repeat examples
whole
sentences very often cannot
or
and
rare
words
digits
four to six
when they are somehealthy
persons
even
once
by
at
be reproduced
that the patients
make
sure
all
events,
one
must
At
what excited.
degree comprecertain
and
to
a
said
to
them
what
was
understood
tion (impressibility)
is
while what was discussed
hended
it.
can be examined directly only in very few cases;

one can always see how the patient reacts; furthermore one can
give him an opportunity to show a difference in his reacAffectivity
tion
to
important matters and to
trifles,
and to exhibit morbid
lability, etc.
For anomalies
of the impulses one
must usually
question,
if
they
are not indicated in the anamnesis; but perversions like homosexuality
and similar anomalies are often indicated
in the
whole behavior and
in the dress of the patient.

If in order to test different functions
and recount a
ence, are especially well adapted for

repetitions.
demands:
one wants the patients to read
story, the following illustrations, according to our experi-
The
first,
it,
obviously because they contain
exacts the easiest and the last, the most difficult
189
The Donkey Loaded with Salt
A
and
donkey, loaded with
for a
got up he
felt relieved of
had melted
applied
it
salt,
had to wade a stream.
few moments lay comfortably
He
in the cool water.
down
fell
When
he
a great part of his burden because the salt
Longears noted
in the water.
advantage and at once
this
the following day when, loaded with .sponges, he again
went through the same stream.

This time he fell purposely but was grossly deceived. The sponges
had soaked up the water and were considerably heavier than before.
The burden was so great that he succumbed.
A remedy does not do for all cases.
Neptune and the Laborer
day laborer worked along a stream.
By
accident his ax
and, as the stream was so deep that he could not get
the bank and
bemoaned
it
fell in
out, he sat
on
his fate to the river god.
Neptune took pity on the man's poverty, dived down and brought
up a golden ax. "Is this yours?" he asked the laborer. The latter
honestly answered "no." Suddenly Neptune dived down again and
appeared before the woodcutter with a silver ax. To this one, too, the
made no claim. For the third time the god dived and brought
up the right iron ax with the wooden handle. "Yes, that is it. That
is the right one.
That is the one I lost," the laborer exclaimed joylaborer
"I only wanted to test you," replied Neptune; "I
fully.
you
are as honest as
you
them to you."
The honest man told
are poor.
There, take
all
am
glad that
three axes; I
present
these
wanted
purposely threw his ax into the stream.
bemoan
his fate to the river
golden ax.
One of
and for this reason he
Hardly had he begun to
this story to several acquaintances.
to misuse Neptune's goodness
He
god when the
asked, "Is this the one that
quickly exclaimed, "Yes, that
latter
fell
appeared with a
into the stream?"
He
and grabbed for it. But Neptune

denounced him as a shameless liar because he wanted to deceive even
a god and turned his back on him. With him disappeared the golden
ax and the laborer had to go home without even his own ax.
Honesty is the best policy.
is it,"
Miser Trick
The inhabitants of Cufa were considered the stingiest Arabs. Once

one of them heard that in Bassora there lived a miser from whom all
stingy ones might learn something. When he came to him he frankly
190
confessed the reason for his visit. "You are welcome," said he from
Bassora; "we will go to the market and shop."
They went to the baker. "Have you good bread?" "At your
and white as butter!" "You see," said the

man from Bassora to him from Cufa, "Butter must be better than bread
because bread is compared with butter. We will, therefore, do better
service, gentlemen, fresh
buy butter."
They went to the butter dealer and asked if he had good butter.
"At your service, butter as fresh and sweet as olive oil!""You hear,"
said the host, "The best butter is compared with oil, this will therefore
to
be better."
"Have you good oil?" "Of the

to the oil merchant.
and clear as water!" "Hoho," said the man from Bassora
I still
to him from Cufa, "according to that water is the best of all!
have a whole barrel at home with which I will serve you liberally."
In fact he served his guest nothing but water since water was
better than oil, oil better than butter and butter better than bread.
"Good," said the miser from Cufa, "I did not come here in vain; I
have learned much."
Under certain circumstances one can draw conclusions concerning
They went
best, light
attention, impressibility, registering in general,
if
after the patients
have been some time in a room unknown to them, one has them close
their eyes and then asks them to tell what objects are in the room.
One must never
forget to obtain a clear idea of the attitude of the
patient toward the examination.
Some
errors are not due to inability
but to emotional stupor, indifference, negativism, and ill will. Characteristic of embarrassment in examinations are answers in which
the given material
is
mixed up, as when
in figuring, single figures in
the problem are put into the answer, etc.
Moreover, neither in the diagnosis nor in any other examination
must the
totality of the objective
and subjective conditions be over-
In the complicated psychic mechanisms the identical manifestations have under different circumstances an entirely different
looked.
significance.
Senseless delusions indicate in the clear average patient
an existing dementia, but not in the oligophrenic, or in the delirious

patient.
Somatic hallucinations only when accompanied by clear
mindedness are sure to demonstrate a schizophrenia. Catatonic symptoms in acute conditions becloud the prognosis little, in chronic conditions they have a bad significance.
A "rigid" affect may indicate an
examination stupor or schizophrenia. "Negativism" in a sensitive
person may be the result of the physician's demeanor or of some other
part of the situation.
delirious patient with
whom
it is
difficult to

establish a relationship
form attacks.
symptom
But
us a rule, a schizophrenic or he has epilepti-
is,
exceptional
in
191
cases such
may
behavior
be a
of a light delirium.
Such a patient who
days showed an otherwise typical

back on us, gave either no answer or
He was a vagrant of rather exaggerated
short, rejecting ones.
joviality, who had often been locked up for trifles and considered such
measures as unjustifiable, especially too, his commitment to the clinic
because they had lied to him about it. In the mild development of
the delirium he was conscious of these circumstances, and on account
of which fact he later explained his reaction.
Some psychic symptoms also occur in diseases which we do not
for the three
alcoholic delirium turned his
describe
here,
such
as
traumata,
fevers,
eclampsia, and similar diseases.
What
heart
is still
diseases,
more important
one must never expect the reverse, namely to see in a given
uremia,
is
this:
moment
important symptoms of a disease. One must never, for example,

if there is no affective disturbance, therefore it is not
a case of Schizophrenia. Indeed under certain circumstances even in
a pronounced psychosis one can temporarily find nothing morbid. A
negative finding without prolonged observation, therefore, never proves
all the
conclude that
that the patient
is
normal;
it
only indicates an absence of proof of the
disease.
Simulation and Dissimulation.

nearly so
common
as the
Simulation of insanity
is
not
Those who simulate inpsychopaths and some are
layman supposes.
sanity with some cleverness are nearly all
Demonstration of simulation, therefore, does not at

is mentally sound and responsible for his
actions. The decision as to whether there is simulation must in most
cases depend on the evidence of the absence or presence of inimitable
symptoms. Those who have not had long experience in hospitals for
the insane, and present a consistent morbid picture, rich in symptoms,
actually insane.
all
prove that the patient
are not resorting to simulation.
If the deception
parent, observation in an asylum
mask"
is
must be required
not readily transin order to '"un-
the person.
is, moreover, proven by inconsistencies, clumsy exagand by a representation of a morbid picture, that exists only
in the layman's imagination (Beware of unconscious simulation as in
the Ganser and buffoonery syndromes, puerilism, etc.). A supposed
insomnia can be controlled by watching the patient at night. Ex-
Simulation
gerations,
citements that entail exertion cannot be continued very long because

of fatigue; in thrashing about with or without convulsive
movements
One can
the simulator plainly takes care not to hurt himself, etc.
192
also suggest that this or that
symptom
that belongs to the disease
is
whereupon the simulator usually hastens to complete the

picture.
These are a few indications. All details cannot be described,
as one would have to repeat the entire symptomology from this ôint
lacking,
of view.
by day and
very thorough uninterrupted observation,
On
night, is important.
simulator and, on the other,
it
will usually
The
of the attempted deception.
the one
first
hand
if
possible both
this will tire the
produce
many
evidences
glance often arouses a suspicion
when one notices that the patient who has just been
admitted acts in an excited and confused manner and at the same
time attempts to orientate himself by glancing about and following
carefully everything going on around him.
of simulation
It
is
more
difiicult to
or even insane people.
judge simple exaggerations in psychopathic

Here, too, the line of demarkation between
conscious simulation and disease
is
as faint as in the case where the
unconscious acts the part,
e.g.,
therefore, one cannot decide
how much
deception and
At
Ganser syndrome.
in the
of the "simulation"
how much emerges from
is
times,
conscious
the unconscious as a product
of the disease.
Much more
frequent than simulation one observes dissimulation
of a mental disease.
Melancholies
make
it
appear that they are cured
in order to carry out suicide; other patients, so that they will not be
limited in their activities or to obtain an opportunity for carrying out

their plans, etc.
This dissimulation on the patient's part
only a concealment of thoughts and symptoms which they
regard as signs of insanity.
themselves
sick.
is,
naturally,
know
others
For they themselves do not consider
CHAPTER IX
DIFFERENTIAL DIAGNOSIS
In differentiating the psychoses one has to keep in mind that most
and syndromes may occur in

must therefore look in addition to these for
concomitant specific symptoms and for specific shades of the syndrome.
None of the diseases have specific symptoms and except perhaps
from the course they take, they should therefore be diagnosed
only by the careful exclusion of other diseases ("negative diagnosis"), such as manic depressive insanity, paranoia, hysteria, compulsion neurosis, and the psychopathic conditions.
Specific symptoms of amentia, uremia, and many other rarer diseases are not yet
known.
In the differential diagnosis also one cannot expect to find at any
of the individual pictures of conditions
different diseases; one
particular
moment
all
the differentiating characteristics; and there,
symptoms are to be valued only in connection with the

psychic environment. The psyche offers so many possibilities that
through a chance constellation a symptom of one disease, considered
specific, may sometimes be imitated by another.
Our language, even,
cannot cope with the wealth of manifestations and must designate
too, nearly all
names; the pressure activity

mania, in presbyophrenia, in paretic and several other organic
different things with identical or similar

in
and that in delirium tremens, are of entirely different varieties

and cannot be differentiated by brief designations.^ Whoever follows
diagnostic catch words without paying attention to constellations and
nuances will go wrong any moment.- Also the diagnostic observations
in the special part of this book make no claim to completeness but
emphasize only that which might be insufficiently stressed in the
symptomology of the disease, especially in the diagnosis. The essentials for the diagnosis must be gathered from a knowledge of the entire
disease.
The following remarks, too, are only to be utilized in this
dehria,
sense.
^ In many twilight states, too, and in erethic idiocy there are syndromes which
could be called pressure activity.
'
Cf also footnote,
.
p. 84.
193
194
COMPILATION OF THE DIFFERENTIAL DIAGNOSTIC

SIGNIFICANCE OF INDIVIDUAL SYMPTOMS
Disturbances of Perception
Sense perception
retarded and
is
often
the organic
in
falsified
psychoses, and in a very similar but not identical sense in epilepsy;

in alcoholism
it
becomes inexact, but no retardation

In
without apparatus.
all
is
seen
cloudings of consciousness
it
when
tested
can be
dis-
turbed in various ways.

In jorms of idiocy the synthesis of combined impressions
the patients see and comprehend the unit but cannot
complete picture.
At times
recognized, even perspective
Real
illusions
may
is
work
affected;
it
the meaning of simple pictures

is
into a
is
not
not understood.
occur everywhere, and are especially prevalent
in clouding of consciousness.
Of the hallucinations those
referring to sight usually preponderate
in disturbances of consciousness such as delirium, twilight states, etc.;
mental clearness they are rare.

In chronic conditions of schizophrenia accompanied by clearness
auditory and somatic hallucinations predominate; under these circumin
stances the latter are characteristic of the disease.
and
and taste occur especially

delirium tremens, and in various twilight
illusions of smell
also in
Hallucinations
in schizophrenia,
but
states.
Characteristic of delirium tremens are in the
first
place tactile
then the numerous visual hallucinations, which are

multiple, moving, and mostly colorless, often representing particularly
hallucinations,
Along with visions

and see threadlike objects,
wires, ropes, spittle, and streams of water. Auditory hallucinations,
in pure delirium tremens, have noticeably often the character of
music, which is otherwise rare. If verbal auditory hallucinations are
small or diminutive objects, especially animals.
of this sort the patients frequently feel
prominent,
it is a question of complications, especially with schizophrenia or with alcoholic insanity.
Auditory hallucinations of a dramatically connected character that

refer to the patient in the third person indicate with great certainty
abuse of alcohol and occur in acute alcoholic insanity and in alcoholic

schizophrenics.
Microscopically reduced hallucinations of sight and touch belong

In sniffing cocainism, one frequently observes tangibly
to cocainism.
distinct voices, visual illusions,

'
Cf
also p. 56.
and vividly colored
visions.
195
In manic depressive and in organic psychoses, visual and auditory
common. In organic patients they are much

more frequent at night than in the daytime.
Visual and auditory hallucinations in themselves have no specific
hallucinations are most
they
significance;
the ones
are
may
that
occur in every mental
disturbance.
Disturbances of Association
Flight of ideas occurs in the different manic states, at times in
exhaustion, otherwise hardly ever; thus in epileptic excitements
it
is
extremely rare.
Inhibition of associations, retardation and inability to rid oneself
of a sad subject
which
may
run to monideism
thought
may
inertia,
and toxic
is
a partial manifesta-
Other form-s of retardation of
tion of the various depressive states.
occur in various diseases such as brain pressure, organic

states.
In schizophrenia and under certain circumstances also in hysteria

we find blockings as an exaggeration of a mechanism that occurs
in every healthy person; moreover, some or all of the influences
that otherwise guide associations
partly
in
bizarre,
and partly
often
are
lacking,
which
disconnected
entirely
in
results
chains
of
ideas.
In epilepsy ideation is slow and hesitating, the mental content becomes restricted to the ego, there is an inclination to affective colored
associations especially to those containing judgments of value, and
further to perseverations, tautologies and to circumstantiality in particular; the patients do not easily get rid of a subject without thinking
it
out in
many
directions.
In organic conditions, too, there

there
is
is
frequently a retardation of
the restriction of the
number
a tendency to perseveration and
is
all reactions.
of
ideas
But more important
simultaneously possible.
Especially readily absent are those ideas that contradict an actual purpose,
whereby organic dementia
is
most strikingly characterized.

is also limited
but what
In oligophrenics the range of associations
is
lacking belongs to the complicated associations, the attainment
of
which requires a higher psychic
extraordinary.
The
activity,
patient thinks of
what
and to those that are

is plain, tangible and
ordinary.
In paranoia, and in a certain sense in hysteria also, some associations are facilitated
and others are
inhibited, according to whether
or not they harmonize with the purposes that are interwoven with
the disease.
Aside from this there are no anomalies of association.
196
Orientation as to place and time is disturbed in advanced organic
mental diseases, and generally in delirious and twilight states of all
In schizophrenic twilight states correct orientation often exists

The other patients know where they are and what
falsified.
kinds.
with the
time
it is,
unless chance circumstances falsify these concepts.
Orientation as to situation
is
as a rule naturally also incorrect
if
place and time are registered incorrectly; but in addition it may be

disturbed in every hindrance to judgment, or as a result of manic
ideas or similar anomalies.
Autopsychic orientation, the personality with

family, occupation, dwelling place,
etc.,
relation to the
its
most readily
is
falsified
in
dreamlike twilight states. It is striking the way it

remains intact in the deepest delirium tremens, while an apparently
sensible paretic or a schizophrenic readily declares himself to be the
and
paresis
in
emperor or a particular
saint.
Disturbances of
Memory
memory becomes inexact; katathymic

whose content apparently is not far removed from
are not rare. In dementia alcoholico-senilis and in Korsa-
In chronic alcoholism the
memory
reality,
illusions,
an organic memory disturbance. After

is incomplete and very inexact; after
uncomplicated acute alcoholic insanity it is good. After pathologic
drunkenness there is usually amnesia. The tendency to phantastic
koff's
disease there
is
also
delirium tremens remembrance
stories is heightened in delirium
and to
tremens to confabulation-like excuses,
real confabulations.
The memory of the organic group is characterized by an especially

marked, or exclusive confusion of the more recent memories. The
void is often filled by provoked (perplexity), or spontaneous confabuAmnesias after dehria, and confusions are not rare even
lations.
after mere excitements.
The schizophrenic memory retains all experiences; but blockings
and other affective reactions in a given moment very often make it
impossible for the patient to utilize his engrams. As there is no elaboration
of
memory
perceptions
in
certain
chronic
stages,
the
schizophrenic
often retains insignificant details better than does the normal
memory.
Memory
frequent.
In
spite
hallucinations
of
the
and
frequent
twilight states amnesias are rather rare,
complete.
katathymic
occurrence
and
still
of
illusions
are
deliria
and'
more rarely are they
197
memory becomes
In epilepsy the
unsystematically poor. Complete

an ordinary occurrence after twilight states.
Hysteria at times very markedly transforms memories in accordance with the momentary affective requirements. After twilight states
amnesia is apt to be complete, but it is relatively easy to remove it
by suggestive influences.
In the paranoiac, memory illusions, combined with the morbid selfreference, form the most important foundation of the delusions.
In oligophrenics memory varies greatly. All things being equal,
the incomprehensible is naturally retained less readily than the comprehensible, and the patients understand poorly the very things that
appear interesting to the normal; but hand in hand with this there
is often a noticeably good reproduction of unelaborated material.
In conditions of melancholia the past life is readily explored for
Small errors are transformed into unpardonable crimes; if
sins.
none are found, they are invented as a sort of memory hallucination
or partial amnesia
or
is
memory illusion.
Even during manic
morbid behavior
is
later readily justified through trans-
memory and by
putting the blame on the environDuring and after confusions seldom accompanied by flight of
formations in the
ment.
conditions but very noticeably after them, the
of the patient
ideas, the
memory
is
very incomplete.
Amnesias are to be expected after all disturbances of consciousness

and after transitory psychoses generally, that is, after hysterical and
epileptic attacks and twilight states, confusions of all kinds, toxemias,
especially drunkenness.
After similar conditions of schizophrenia (twi-
light states, hallucinatory states with
not always defective and
is
when
dreamlike episodes), memor\'
it is, it is
usually only partly
is
so.
Amnesias as to content referring to events, the recollection of which

and hysteria.
at the time disagreeable, are frequent in schizophrenia
Affective Disturbances
The
affectivity
is
labile in organic patients, in alcoholism, in hys-
and in the later intervals of many manic depressive

Acute displacement of the affective attitude (moods)
manic or melancholic appearances is seen in alcoholism,
teria,
of
uncommon
alcoholic
melancholia,
in
also
shows the very common
in the rather
psychoses,
organic
phrenia (very common), in epilepsy which
cases.
in the sense
in
schizo-
and
manic depressive
of brief duration
is
irritable depression, in
insanity, in hysteria, in all kinds of psychopathic states, especially in
the cyclothymias, and in oligophrenics wîere
it
duration and often manifests irritable moods.
is
as a rule of short
198
The organic affective disturbances regularly show lability, accessory moods, which are preponderatingly manic in paresis and melanIn alcoholic Korsakoff's discholia, especially in the senile forms.
ease besides lability, there usually is also a euphoric basal mood, which
is not apt to disappear until the later stages of crossness and irritation.
In schizophrenia the affects cease to function altogether in severe

and someAt times
times not; when they are present, they are often rigid.
cases; in milder cases affective reactions sometimes appear
they are absent just at the most important events, whereas trifles
are normally accentuated. In many cases irritation up to the stage
of unbounded rage is the only reaction which one sees for a long time;
in
mild cases irritation
may
be the only striking symptom.
Ambivalence
thymia and paramimia are not infrequent.
is
Paranowhere
Besides these, one also sees mel-
so conspicuous as in schizophrenia.
ancholic and manic affective fluctuations.
In the epileptic the affects are easily stirred, readily attain an

abnormal intensity but last abnormally long. At the same time they
Fitful moods of an irare massive and not finely differentiated.
probably never lacking.
ritated, depressive or euphoric character are
The manic
depressive
patient
in
the
between manic
interval
or depressive attacks often has lability of the affects or lasting states

in the sense of milder
manic or melancholic moods.
In hysteria one sees slight outbreaks during which there is heightenReactions to similar stimuli are
ing and falling off of the affects.
quantitatively and also qualitatively different, depending on chance
intervention.
In paranoia the affective state corresponds to the content of the

real or delusional experiences.
The
Among
must
more minutely.
affective anomalies that
at the root of the disease cannot yet be described
lie
oligophrenics there are excitable and torpid types; briefly
we see in normal and psychopathic perand only when possible they run within wider limits. Besides,
many cases evince the same moods as epileptics.
all
the variations occur that
sons,
In
all
forms of dementia there
is
a tendency to outbursts of anger.
Some Special Syndromes

States of stupor occur most frequently in schizophrenia, next in
hysteria, and besides in melancholic states, in the mixed
epilepsy,
states of
manic depressive
insanity,
and
in
paresis.
Tivilight states are seen in epilepsy, hysteria
and
in schizophrenia,
occasionally perhaps in manic depressive insanity, then in the various

toxic states (as in the pathologic drunkenness), in states of ordinary
199
(somnambulism,
etc.), following cerebral concussions and hangvery severe migraines, and even as states of excitement of
purely affective origin in psychopaths (jail outbursts, fugues, etc.).
sleep
ing, in
Symptoms
of the Catatonic type.

Symptoms which from their
appearance must be designated as catatonic,"* besides occurring in schizophrenia appear also in the organic psychoses; furthermore catalepsy is not rare in epilepsy and is also said to have been
external
noticed occasionally in hysterical twilight states, in oligophrenia, and
manic depressive insanity. Something, that must be called echolalia

an apparently very different origin, besides occurring in
schizophrenia and the organic psychoses (very rarely) appears also
in epilepsy, hysteria, and oligophrenia.
in
in spite of
Epileptiform attacks, besides occurring in the epilepsies appear in

schizophrenia, paresis, presbyophrenia, some forms of arteriosclerosis,
alcoholism, including delirium tremens, as affective epilepsy in psycho-
and outside of psychiatry,

uremia and eclampsia.
pathies,
in all coarse cerebral diseases, in
Paretic-like attacks occur in all coarse brain diseases, especially
when they
involve the cortex.
Compulsive ideas and eventually compulsive impulses we see rather

frequently besides in the independently considered compulsion neurosis
and compulsion psychosis, also in schizophrenia, but pretty rarely in
the various depressive states.
Uremia may also simulate the psychic symptoms as well as most

symptoms of an organic brain disease or of epilepsy.
physical
Eclampsia, too,
*
Cf
p. 153.
may
for a short time act exactly like epilepsy.
CHAPTER X
CAUSES OF MENTAL DISEASES
I.
Germinal Predisposition.
diseases converge in one family
It was always known that mental

and lack in another, and that in the
families with mental diseases the members that are not really diseased very frequently show certain deviations, which often run in the
direction of the disease. To be sure those families are rare which on
careful search prove entirely free, and the cases with only a few
Nevertheless the
diseased members are always the more common.
family predisposition is surely one of the most important determinants for the development of mental diseases.^ To be sure a predisposition alone need not find expression in disease, even when it
undoubtedly shows itself in the particular individual through minor
deviations from the normal and through transference to the descendants.
Either there are different grades of hereditary predisposition
or the predisposition does not "develop" in all into a pronounced

disease, or both cases
may
occur.
Besides,
we have
to presuppose
some predispositions which in themselves are not diseased but still

form necessary or at least furthering determinants in the development
Not every inebriate becomes a "psychic"
of exogenous diseases:
alcoholic and not every luetic becomes paretic; but certain psychic
peculiarities that are discoverable in most candidates for alcoholism
and paresis and their families indicate that inherited factors play
a role even in exogenous diseases.
Formerly it was necessary to assume a general neuro- and psychopathic family predisposition that might express itself in the most
variegated nervous and mental diseases and psychical peculiarities.
But
since
KraepeUn taught us
to recognize natural boundaries be-
tween several clinical pictures, the concept of psychotic heredity began to be more and more clearly divided into several predispositions,
among which may be mentioned in the first place the big groups of
A part of
schizophrenias, epilepsies and manic depressive insanity.
^
The conspicuous significance of predisposition shows itself

twim where occasionally both members become sick
insanity oj
and with very similar symptoms, and what

they do not live together.
200
is
more, that
especially in the
at the
same time
may happen even when
201
the psychopathies as well as most of the neuroses proved
tcj
be the
and simpler forms of these hereditary- groups.

Very recently the attempt was made to apply the Mendelian laws
to the hereditary mental diseases and endeavor to make it probable
that these are transmitted recessively according to the Mendelian
type. But the theoretical and practical difficulties are far too great
to have produced something useful so far.
We are far from understanding what is involved. With the endless shades of morbid predispositions, from the slight peculiarity of character up to the most
pronounced insanity, it is out of the question that the predisposition
lighter
to a psychosis or even the disease itself should be a plain indication
that can be present or absent only as a whole;
we would
rather say
assumption of a
mechanism, which may be provisionally designated as "intermediary
heredity." ^ Furthermore the small number of children and the long
that
at
present
we cannot
dispense
with
the
duration of a generation increase the difficulties of the survey in

these studies to a particularly high degree.
Besides these lasting family predispositions "Degenerations" are

spoken of. The term designates very different but very vague ideas,
and most observers are so little conscious of this that they do not at
all express themselves about it, but secretly permit one meaning to
pass over into the other, or suddenly substitute one for the other.
These concepts may be arranged into four classes, two relating to the
family, and
two to the individual:

assumed that some families degenerate through the different generations, that they become more and more incapacitated and
generate severer forms of mental diseases, until they die out. Morel
even supposed that this occurs so regularly that it was possible to
It is
1.
prognosticate definite diseases for each of the last four generations.
As
a matter of fact there is really no such regularity
and we cannot
say anything worth while either about degeneration or regeneration.
Furthermore the Mendelian conceptions which are clear and hold good
for certain conditions present an insurmountable opposition to such
views. In more recent times morbid predispositions were progressively
(not regularly) produced, throughout generations, by means of poisons.
2. It has also been customary for some time, regardless of the
progressi"'-eness of the predisposition, to designate families in which
insanities are very common, as degenerate, especially if the healthy
members also show striking peculiarities.

3. Depending somewhat on this concept,
'
Bleuler,
Arch.
f.
Mendelismus
b.
constitutional peculiarities
Psychosen spez. bei der Schizophrenia. Sheweiz.
Neurologie und Psychiatric.
Vol.
I.
Ziirich 1917.
202
in the individual
are designated as "degenerative," in which
usually the impression
is
made
But actually the most
used.
as
case
a definite concept were being
if
different deviations
from the normal
in
directions are so designated, provided they are not included in
all
one of the familiar morbid pictures.
In this sense all families burdened with heredity and their individual (abnormal) members are
degenerates.^
There are also degenerative psychoses that are again divided
4.
into
two very
different classes:
(a) those
that show the characteristics
described in classes 2 and 3, that develop, or are supposed to develop from an abnormal constitution (Paranoia, "periodic forms"),
or where serious peculiarities of character are observable as causes
morbid picture (degenerative hysteria),

Such diseases as have the tendency to "degenerate" i.e. they
show a tendency gradually to become worse, to degenerate into dementia as seen in our schizophrenias so far as they really merge into
or concomitant of the "real"
(b)
idiocy.
One should avoid working with such an ambiguous conception as

The concept of degeneration would
its designation.
most readily fit blastophthoric conditions, the most marked developments of which we call teratologic, and the milder forms perhaps
degeneration and
might include
all
kinds of predispositions even those of psychoses.
many abnormal members like those abnormal inmentioned in class 3 we call psychopathic; those with a
Families with
dividuals
tendency to definite mental diseases like those mentioned in class i,

or with less pronounced peculiarities in the sense of a psychosis we
accordingly manic depressive, schizoid, or epileptoid families.
name
Race
is
an important consideration
for the origin as well as for
we know very
we find
in the present culture races; but whether, and to what extent, more
insanity occurs, or more remain alive, and how much the damaging
the formation of the diseases, even though at present

little
that
is
definite
about
influence of natural selection
gated.
Many
Slavs, Turks,
immune
The
it.
great
number
of insane
amounts to, has not yet been investiNorth Africans, Abyssinians, South
peoples, notably
and Australian aborigines, are entirely or to a high degree
to paresis, although syphilis
is
common among them.
Still
our ancestors more than four generations ago were also apparently
immune
and,
on the other hand, the Japanese who are far
closely related to us are
now
as subject to paresis as we.
less
The more
or less extensive use of alcohol does not explain all these differences.
Dementia precox, epilepsy and

'
Magnan's idea
idiocies also
seem to occur
of degeneration is a combination of 2
and
3.
in lower
203
races as with us, the first, to be sure, in somewhat different forms.

Kraepelin observed among the Malays an absence of the catatonic
forms;
far as
could ascertain the same
modes
among negroes and Indians
as
of appearances are concerned that could be observed
as pronounced catatonias on just walking through institutions and

in questioning physicians
and head nurses.
The same may be
said
here of suicide, whereas just the Germanic race and especially the
Saxons are very frequently victims of suicide. It is said that Jews

are especially predisposed to manic depressive insanity and psychoAccording to a very experienced older psychiatrist they
neuroses.
did not develop paresis until they took to "Christian customs and
Christian champagne"; in general, race and manner of living, that is to
say culture, are
II.
difficult to separate.*
Blastophthory.
It
seems that even with sound parental pre-
germ may be so damaged in its development that the

descendant becomes (mentally) diseased. Such influences are ascribed
especially to debilitating diseases, poisons (alcohol!), and infections.
But in the last, among which syphilis comes into prominent condisposition the
sideration, one cannot properly separate the transference of the dis-
ease to the child from the germinal damage.
assumptions are opposed by a few definite
In this
many
field
facts.
III.
Germ Fusion. There are a few cases that seem to prove that
an unsuitable fusion of healthy germs ("germinal enmity") can generate diseases; thus a couple produced only microcephalics, while
each of the individual parents had healthy children with another
Also marked differences in the character predispositions of
mate.
the parents make themselves felt, according to all we know, in a cer-
tain lack of equilibrium in the descendants.

cases this
may become
the foundation
of,
To
achievements, especially the artistic; generally
unpleasant supplement to
neurotic.
The
life
be sure, in individual
and the impulse

it
is
and one that readily erupts
intermingling of races,
even those
to.
great
nevertheless an
into the
closely
related,
worse results although, at least according to superficial

observations of masses, the West Indian negroes, in whom a white
streak is easily noticed, are a tribe so capable of enjoying life and
so unburdened with any sense of responsibility that one may well
often has
still
ask whether
humanity.
it is
not
we who
constitute the unsuccessful variety of
Relationship between parents
But
it
(inbreeding)
is
also
much
feared.
turns out that, in spite of the experience of animal breeders,
who have
to reckon with
many more
*See below, American Negroes.
generations, that under
human
204
conditions injury through intermarriages
is
not demonstrable unless
a summation of a common predisposition to disease in the

vulgar sense, or a cumulation in the Mendelian sense. In Incas, the
Pharoahs, the Ptolemys, propagated themselves through numerous
there
is
generations by marriages between brother and sister, and an intermarriage within a healthy family in every event offers better chances
than the intermingling of doubtful or perhaps diseased foreign blood.
Nevertheless, in view of the many cases of deaf mutism and
of optic atrophy observed in intermarriages as well as the experi-
ences with animal breeding
it
behooves one to observe a certain
caution.
IV.
Foetal Diseases.
The embryo, too, may be harmed by disroom in the pelvis, by traumatic occur-
eases of the mother, lack of

rences, as well as
by intrauterine
world as an idiot or
on the mother harm
Undoubtedly sorrow
tion; and a psychic
psychopath.
diseases, so that
To what
it
comes into the
extent psychical influences
the foetus, has not been scientifically determined.
and other chronic depressions may disturb nutrishock perhaps through a spasm of the uterine
vessels
may be noticed by the foetus to such an extent that it may
find a vent in wild movements with change of position whereby in-
juries of various kinds are conceivable.
The categories I to IV are often designated as "endogenous causes.'^

But only I, the pathological germ predisposition, is really endogenous;
the remaining, at least in relation to the family, are exogenous, and
in relation to the individual they may be called what one pleases.
In studies of heredity
together.
It is
all
four categories were hitherto usually thrown
very important for future research that this should
no longer be done.
If all people were designated as "burdened" who have among their
blood relations (parents, grand-parents, children, brothers and sisters,
aunts and uncles) members who suffer from mental or nervous diseases,
alcoholism, apoplex>% abnormal character or have committed suicide,
then according to Diem ^ 67% of the healthy and 78% of the insane
who are admitted to institutions are burdened. But the difference becomes greater, if one counts only those burdened with insanity
(7: 38%) or with abnormal characters (10: 15%) and still greater, if
these categories are supplied merely to the direct burdening (through
the parents), since only 2% of the healthy have insane parents as
against 18% of those who are mentally diseased, and 6% abnormal
characters against 13%. Apoplexies and nervous diseases are observed
" Die
psychoneurotische Belastung der Geistesgesunden
kranken, Arehiv. fiir Rassen-und Gesellschaftsbiologie 1905.
und der
Geistes-
205
frequently in the families of the insane than in those
less
who
are
healthy.
Nowadays
tical affairs
it
heredity
is
talked about too much, although in prac-
is
not often considered.
Many
people actually
make
hard for themselves because on account of a hereditary burden

they are afraid of getting sick or being sick. As a matter of fact,
families in which the majority of the members are sick are rare.
life
Furthermore a sort of regeneration is possible, even though we do not

feel at all clear about this term, and above all the difference between
those considered burdened and those considered healthy is not so
great, because on careful examination abnormalities are generally to
be found also in the latter. It should not be forgotten, also, that many
diseases have no hereditary significance, as for instance most acquired
forms of idiocy and paresis. Furthermore, a sick member of an otherwise healthy family is usually less dangerous even as a patient than
a relatively sound member of an otherwise heavily afflicted family.
In the former case the exception may be determined by an acquired
disease, in the latter it may represent a chance aberration upwards;
both variations are not true to kind.
For questions of eugenics
Forel described the risk as follows: that a family in which insanities occur, but which in spite of this maintains itself, is not to be
feared; while members of a declining family should not marry or be
married.
V.
The exog-enous causes
affecting
the
individual
sometimes
create disposition, sometimes they precipitate the disease either as a
necessary consequence
(carbon monoxide) or as the cause
(psychic
reasons), or as one of the various necessary conditions of the disease

(sypKilis
in paresis).
It
is
furthermore to be kept in mind that
while individual causes frequently produce definite morbid pictures,

(e.g.
traumatic neuroses; alcoholism, paresis)
ing on the disposition

conditions, the identical
and the constellation

(major)
causes
may
nevertheless, dependof
other contributing
generate and occasion
morbid pictures, such as different traumatic neuroses, hysteria

and neurasthenia in certain conflicts, and various alcoholic forms. The
same psychic influence may release a schizophrenic attack in one person, a neurosis in another, a manic attack in a third.
Furthermore,
depending on the disposition the cause may be indifferent, thus a
woman predisposed to cyclothymia can become manic through a
psychic influence or through a childbirth, and the epileptic disposition
can probably be developed into pronounced epilepsy just as well
by a trauma as by alcoholic poisoning. It can be seen from the
illustrations that no decided distinction is to be made between causadifferent
206
and merely precipitating conditions but we must understand that
live
it
is
a different matter
when
fright neurosis
or carbonic
oxide
poisoning develops in a healthy person than when the disease becomes

"manifest" through a psychic influence, in a latent schizophrenic or
manic depressive
patient.
But intermediate
cases
make
impossible
it
to carry out a sharp separation.
Among
the exogenous causes discontinuation of soothing with the
natural nourishment
Moreover
is
to be mentioned
know something more
should like to
all
although here, too,
also,*^
we
definite.
diseases are to be considered that directly affect the
and in childhood above all polioencephalitis

and meningitis, which create oligophrenias, psychopathies, epilepsies,
and organic diseases. Scleroses, tumors, and other brain diseases
brain, such as traumata,
cause different pictures.
Infectious diseases
may
change the anatomical
consistency of the brain, as cerebral lues, paresis, encephalitides, and

lyssa, or
they
may
affect its function
through poisoning as in fever
psychoses, and in the forms of "delirium acutum," or they

directly disturb its nutrition as in syphilitic
vessels.
may
in-
diseases of the blood
Besides the fever psychoses, infectious diseases can probably
precipitate schizophrenic
"shifts."
Other physical diseases which in respect to the brain may be called

exogenous not seldom cause mental diseases; carcinomatous dyscrasia
and perhaps stomach and bowel disturbances can also produce states
of confusion; diabetes seems to favor depressions; through the neuritic
processes in the brain it can bring about Korsakoff's syndrome, and
through acetone poisoning delirious conditions. Of course, diabetes
is also frequently only a parallel manifestation of the mental disease,
Hypo-function of the thyroid gland
e.g. in organic brain diseases.
causes myxedema and cretinism; a certain complicated hyper-func-
The
tion causes Basedow's psychoses.
with the psychic,
but they
other glands are also connected
very
are
far
from being
suflBciently
understood.
Of the external poisons alcohol

is
responsible for 20 to
35%
is
of the
to be particularly mentioned.
male admissions to the
and probably makes alcoholics of 10%
of the
men
outside,'^
It
hospitals,
but
it
also
complicates, co-determines, or aggravates other psychoses, especially

epilepsy, traumatic neuroses,
and
numerically a vastly minor role

*
is
paresis.^
A similar even though
played by ether, opium, morphine,
Bunge, Die zunehmende Unfahigkeit der Frauen, ihre Kinder zu stillen. 7.

Rheinhard, Miinchen 1914.
Schweizerische Statistiks. Sanitarisch-demographisches Wochenbulletin, 1903,
Aufl.
'
und Internationale Monatschrift zur Bekaempfung der Triiiksitten,

'The influence on posterity was discussed in Part II.
1904, p. 183

and
207
Other poisons that enter into consideration here are

carbon monoxide, pellagra and ergotine.
Sonie also wish to
blame here tobacco, which is probably an unjust view. Lack of vitacocaine.''
lead,
mines acts
Among
like the poisons, as in the case of Beri-beri.
other diseases those of the sense organs, especially that
of hearing, are to be mentioned
the latter do
Thus paranoid
psychic influence.
harm
and
distrust
rather through their
irritability result
from
defective hearing, heart and vascular diseases occasion anxiety states
and atrophies of the brain, while kidney diseases are often at the
foundation of amentia.
Exhaustion
that hunger in
also
is
its last
said to produce insanities
stages causes deliria.
there
is
no doubt
That over-work, which
frequently mentioned may bring on mental diseases, is not to be

assumed; it usually conceals politely our ignorance of the causes,
a good physician works much more than most of the patients that come
It is more proper to assume that the
to him because of over-work.
congenital "morbid exhaustiblity" expresses the predisposition to
psychoses. But usually it is emotional difficulties that "exhaust the
nervous energies," or the slowly advancing schizophrenia deludes the
patient with a feeling of exertion and over-exertion. Among ten thousand Serbs captured in the late war, who were all subjected to the
most miserable state of maximum over-exertion and severe underis
nourishment, only five became insane.

exhaustion, _at least,
psychoses.
may
be crossed
Weakness from acute
Therefore,
off
loss of
the
blood
list
is
acute
of the
physical
causes of
also not a cause of
psychoses, according to statements that I have received from surgeons.
Among
mentioned; but as yet

Concerning the so-called Tropical
mania which is naturally a collective term for different things, it is
not even certain to what extent it is really brought on merely by
the heat, and to what extent by the use of alcohol and by other
diseases, and by the feeling of being absolute master of life and death
living conditions climate should be
we do not know
among savages
Occupation
its
influences.
(a sort of Caesar mania).
may
cause poisoning, thus employees of the alcohol
industry readily become alcoholics, and persons occupied with the
In the army many psychopaths

from exertion than from psychic causes. Some
occupations, such as school teaching and acting, are said to dispose
healing art become morphine addicts.
succumb to disease
less
' Most
recently the use of cocaine in the form of snuff powders is ver>rapidly gaining the ascendencj' with the demi-monde and its associates.
"According to Kraepelin exhaustion is the excessive consumption or insufficient replacement of the active substances, while fatigue is the accumulation
of waste matter that has a paralyzing effect.
208
people to mental diseases.
But what
more
is
be the case
likely to
is,
that affected or rather psychopathic people show a preference for

certain callings, just as no occupation or tramping
by morbid or insane individuals.
According to the classification of
many
among
single persons
more regular
life
civil conditions
the insane, and
of the married, in sexual
slight protection against disease.
But
it
it
is
and the same
afflicted w^hen
young.
is
selected only
there are a great
plausible that the
and other
respects,
is
should be remembered that
half of all the patients, the oligophrenics, cannot

their disease;
is
marry because
true of those schizophrenics
who
of
are
Other abnormal individuals do not marry be-
cause of various psychic reasons, and people
who
are divorced are
Thus there remain only the widows and

widowers that could demonstrate the danger of being single and it
is really said that the latter become sick more frequently than the
often not normal.
ver>^
married.
According to experience civilization, so called, is one of the most

important breeding places of mental diseases.
The "higher" the
scale of civilization the
more insane are noted.
Of
course, this
is
in part misleading because the care of the helpless that civilization
demands simply does not permit them
to perish as they do under
no doubt that our kind
natural conditions.
Nevertheless there
of civilization does
favor the disease causing agencies, of alcohol
is
and in America it was discovered that the negroes, who as

had no percentage of insanity worth mentioning, become insane
in greater numbers the more they approach the manner of living
of the whites, and that in the northern states where thej^ are quite
acclimated they also attain the same morbidity.
Furthermore, it
and
lues,
slaves
cannot very well be otherwise than that the elimination of natural

selection gradually increases the number of abnormals.
As far as
the neuroses and obvious psychopathies are concerned, it goes without saying, that under complicated living conditions, where a conscience
and
feeling of responsibility exist
they must more frequently
let
and are continually needed,
us say come to light than in carefree
and unconcerned people. That those who lead the parvenu life of
commit race suicide in doing so, has been known for
a long time, but the path from the normal to extinction probably
a metropolis
traverses in part mental degeneration.
Furthermore, just as in domesti-
cation of animals the artificial construction of

will
produce
all sorts
of deviations
human
from the normal.
relationships
Though
difii-
an important circumstance that education is

now fraught with infinitely more dangers than in primitive times
cult to evaluate, it
is

when the
ones did not
little
soil
2(J9
the curtains and could not break the
statuary.
Naturally this
is
not the place to go into the details of the com-
plicated conditions of the artificial deterioration of race hygiene in
a big city;
sufficient to
is
it
know
that insanity increases with the
density of population.
Great significance has always been ascribed to sexual conditions,

it is not to be denied that at times a case of gonorrha-a in a
college boy who still has a sense of decency may release a depression
that must be designated as morbid. Diseases of the feminine genitals
are still more frequently blamed and for that reason operated upon
but without valid proof. The most severe blame is attached to onanism,
which is supposed to cause all neuroses and some of the more serious
mental diseases, and the patients themselves like to support this
and
view.
by
But we
care-free
harm'.
see that
insane
is
it
patients
carried on to an incredible high degree
and moral defectives without
visible
Direct bodily injury can hardly be proven unless one wishes
more or less painful feeling of weakness in the

back that suggests similar menstrual complaints and not seldom seems
to regard here the
The real conditions are about as follows: Onanism

an unnatural gratification of the most important instinctive impulse
of mankind which can be carried on very easily and consequently
leads not only to over-indulgence but would endanger the existence
of the race if there were no inhibitions against it.
It is thereto follow excesses.
is
fore comprehensible that our instincts are so ordered that our feeling
revolts
against
ligious
command
ful
it.
This
feeling
is
supported by
social
and
re-
and, perhaps, most strongly, even though in a harm-
way, by a literature that pictures
for the adolescent in the
most
horrible colors the consequences of the evil, in order to extort
money
from him
of
appear,
for
cures.
we usually
Thus where anxiety

also
find
concerning onanism which
is
states
and ideas
sin
accentuated ideas of self-accusations
thought at
least,
even
if
not always
Onanism then becomes the unpardonable sin, and we see,

moreover, that the fear of having harmed oneself becomes the cause
expressed.
many neurotic conditions, which can improve as soon as this fear

removed." Naturally the useless struggle against the bad habit
and the resulting loss of self-respect result in very harmful factors.
However, onanism is often a symptom of disease, especially when
it is overdone or carried on in early childhood; or as a result of
schizophrenic shamelessness it becomes apparent not only because
of
is
^Bleuler: Der Sexualwiderstand. Jahrbueh

V, 1913.
f.
Psvchoanalyt. Forschungen
BA
210
it is
also because
more frequent but
it is
practiced without fear before
others.
With a
abstinence
but
some nowadays
emphasis
certain
among
also
include
sexual
the causes of neuroses and even of mental diseases
The daughters
again without any proof.
of
certain classes,
catholic priests, as well as other chaste people, really offer sufficient
but
refutation;
become
must be admitted that the general attitude has
it
many
so frivolous that in
places, at least
almost only psychopaths remain chaste.
come
sick, it is surely
Among
wrong
to
If
then
among
many
the males,
of these be-
blame their continence.
the sexual functions menstruation has a certain causal sig-
nificance for the psychoses.

of maturity
is
It
rarely happens that the beginning
marked by conditions
similar to twilight or schizo-
phrenic states, which recur a few times at intervals corresponding

to the menstrual period but disappear with the regular setting in of
the menses,
without leaving any psychopathic traces.
menstrual moodiness which
is
not
be heightened to a degree that

depression;
at
events
all
often at this time.
uncommon
may
suicides
in
Later the
"normal women" might
be designated as melancholic
among women occur
noticeably
States of confusion also are said to occur with
In addition the menstrual period can set
or without impulsive acts.

free fairly regular attacks of
manic depressive insanity, while existing
psychoses are very often temporarily exacerbated at this time.

it
is
a plain confusion of cause and effect,
flow, so
common
if
at the beginning of an acute psychosis,
sented as the cause of the insanity.

definite sense has not
But
the cessation of the

is
repre-
"menstrual insanity" in any
been demonstrated in spite of different attempts.
The name puerperal
(psychoses, those psychoses that appear during
delivery and
up to about four or six weeks after it, are contrasted on

the one hand with pregnancy and lactation psychoses, and on the
other hand the term is used to designate all of the three forms. But
there are no special puerperal psychoses either in the wider or narrower sense of the term. Nevertheless pregnancy in psychopathic
aside from the most different neurotic symptoms, may
obviously also condition melancholic depressions in both psychic and
somatic ways, or in both together. The delusions of such a psychosis
usually refer to the pregnancy and future of the child and disappear
after delivery without leaving any traces.
It rarely causes the exacerbation of a schizophrenia, otherwise it is probably a case of
chance coincidence of pregnancy and insanity.
Cases of amentia
resulting from exhaustion, hemorrhage, or infection are said to appear
in child bed. According to my experience it is nearly always a case
women,
211
of schizophrenia which becomes manifest or a schizophrenic exacerbation, the release of
Even
lines.
which
is
to be explained mostly
tated by parturition.
The
along psychic
may sometimes
a manic depressive attack
lactation psychoses have
be precipi-
little
practical
significance.
At the time
of the female climacterium a slight accumulation of
exacerbations of different psychoses shows

it
men mild
see in
the
period
of
itself;
it
also brings with
About a decade
a particular tendency to depressions.
later
we
also
but long lasting curable depressions that belong to
involution
(climacterium
virile).
Real
climacteric
psychoses in women, which formerly were not uncommon, have dis-
appeared from the literature of the last few years.

For the remainder, the sexual life has much to do with the causation of mental diseases, especially of the psychoneuroses by way
of psychic influences; but we are far from being clear concerning
the degree and kind of its effects.^^
Among the other psychic causes an unsuitable education is certainly to be mentioned; as a matter of fact it is always being discussed although to be sure very little is known about it. We have
good reasons, however, for the assumption that many neuroses originate
through the aid of poor educational influences.
In later
life it is
only affective influences stirring the mind deeply
or for a long time that enter into consideration as causes of neuroses
and psychoses.
ses
To what
extent care and sorrow produce real psycho-
not yet known; no doubt the importance
is
of
their
role
is
exaggerated by the layman, whereas dissatisfaction, the feeling that

life
has been a failure and, above
sense) causes flare-ups of neuroses
all,
erotic difficulties
and exacerbations
(in the
wider
of the psychoses.
In psychopathic persons terror, anger, or despair can produce excite-
ments of blind rage with subsequent amnesia or stuporous states

which quickly pass away.
(emotional psychoses, anxiety deliria)
Imprisonment precipitates different psychopathic conditions, also such
resembling paranoia; it is also said that operations produce mental
diseases. This is undoubtedly very rare.
Modern accident laius arouse imaginative desires and have consequently become the most important causes of traumatic neuroses
in the wider sense. Other transient mental and nervous disturbances
,
originate in great catastrophes, as in earthquakes.^^
The
public often fears infection from the insane.
"Concerning the Freudian viewpoint

on neuroses.
" Cf Fright neuroses.
.
Cf.
some observations
It
does not
in the chapter
212
On the other hand energetic patients can impart

mania to the apparently healthy who live with them {induced
exist in this form.
their
To
insanity).
be sure, occasionally even the entirely healthy are
dragged along by insane

insanity there are
litigants or reformers.
Thus from induced
the intermediate stages to psychic and nervous
all
epidemics, such as chorea major, tic epidemics in schools, and re-
that certainly'
epidemics,
ligious
may
attack
even well balanced
natures.
Childhood disposes to brain diseases, and above all to polioen"Child (psychoses" sui generis are not known, unless one
so designates oligophrenias which are to be attributed to diseases of
infancy, paresis which comes from hereditary syphilis, and the epilepsies
Schizophrenia also, and more rarely
that break out at this age.
cephalitis.
manic depressive
in
childhood
and
are
insanity, at times begin in early childhood.
comparatively frequent in
infection; occasionally they
toms,
of
Deliria
intoxication
show at these times catatonic symp-
catalepsy), which have no deleterious significance under
(e.g.
Hysterias in childhood are frequently mono-
these circumstances.
symptomatic and have

than those of adults.
The
cases
disposition
less
to
the character of a psychic general disease
mental
disease
increases
explosively
with
puberty; and where neither alcoholism nor paresis constitutes an

essential part of the disease, the disposition decreases slowly from
the twenty-fifth year and quickly between thirty-five and forty.
A "puberty psychosis" peculiar to the period of development is not
yet known, unless the above mentioned coincidences previous to the
inception of menstruation are to be called so. What used to be so
designated were usually schizophrenias.
During manhood the
alcoholics, paretics
and paranoiacs become
manifest, then, also the traumatic cases from comprehensible external

causes.
The
period of involution brings with
it
a small increase of schizo-
phrenic conditions, a more considerable increase of depressions, and
then a number of
by Kraepelin.
less
But
common
diseases,
some of which were described
the period of involution is to be sharply differ-
entiated in this respect, as well as in general, from senile degenera-
the two processes
may
touch each other.
tion,
even
it is
a re-formation for another stage of
if
more than two decades
life;
Like puberty,
the normal matron for
is still a capable person.

on the contrary, is a reiro-formation, a dying out. If
the retro- formation of the brain precedes the retro-formation of the
other organs, it shows itself clinically in the pure form of dementia
Senility,
213
Moreover, arteriosclerosis and presbyophrenia, while not enmost commonly met with it.
The male sex is disposed more than the female to idiocy and
epilepsy, and less to neuroses and manic depressive insanity.
If
alcoholism and paresis primarily affect men, this is due to their
manner of living; that they prefer this manner of living, is again
based on sex. On the whole more men are taken into the insane
asylum; but their numbers are generally less than those of women, besenilis.
tirely peculiar to senility, are still
cause the alcoholics are usually quickly discharged and the paretics
die.
Among
the older insane patients there are more
of the greater longevity of the sex.
women
because
CHAPTER XI
THE TREATMENT OF MENTAL DISEASES

IN GENERAL
The treatment will here only be considered as far as it concerns
the requirements of the practicing physician and as far as its discussion, independent of clinical demonstration, may be of some use.
Concerning the neuroses reference must be made to textbooks on

neurology}
As yet very little is done for prophylaxis, and without a change
The
of the general attitude and legislation very little can be done.
Some
more severely burdened should not propagate themselves.
have recommended "social sterilization"; others have challenged ''the

infringement upon human rights" and found it useless. Many diseased and degenerates are themselves quite willing to undergo the
operation, and though the opportunity may not be very frequent,
it
may
Moreover the idea
be of use in individual cases.
of expansion,
and that
as long as the
now
is
just
what
is
is capable
do not fear it: because
not completely changed, the
feared.
current attitude
is
danger of overdoing exists almost only in so far as the practice would

get ahead of the development of the ideas and consequently might
for a long time discredit these measures. I would begin with compulsion in the case of incurable criminals
the case of other
more
and on the basis of consent in

and then gradually alter
serious psychopathies,
the general attitude and legislation in accordance with experience.
But
if
we do nothing but make mental and
physical cripples capable
and the healthy stocks have to limit

children because so much has to be done for
of propagating themselves,
the
number
of their
the maintenance of the others,

pressed, then unless
we
if
will get
natural selection
new measures our
is
generally sup-
race
must rapidly
deteriorate.
Also the deleterious influences that act on the germ, among which
the living conditions in large cities, should be seriously attacked.
I class
To
quote Kraepelin: "It must also be the sacred duty of physicians
Comp. especially the chapter on Psychotherapy by Mohr in Lewandowsky,

Handbuch der Neurologie, Julius Springer, Berlin. And Schultz, Die Seelische
^
Krankenbehandlung (Psychotherapie).
Fischer, Jena 1920.
214
IX
GENERAL
215
to increase gradually the pressure of public opinion in such a way

that the resolution will be formed to take up the battle against alcohol
same emphasis and the same resort to remedies

All "Back to nature" movements also are to be supported much more energetically than heretofore, but not to the bogey that is called nature.
Even in our industrial age the race sustaining power of agriculture could be utilized
and
syphilis with the
as in the battle against tuberculosis."
for prophylactic measures.
We
many
purposeful bringing up might perhaps prevent
a neurosis.
nervousness and morbid characteristics grow directly

from an inadequate training and must therefore conclude that proper
see, at least,
influences with training of the will

to
become habituated
hardened within sensible limits
many who
and particularly
of the character
and
to tolerate the disagreeable, including pain,
all
that could preserve from sickness
are not too severely burdened.
vocation will also furnish a certain protection.
careful selection of
It is also conceivable
that the timely solution of inner conflicts in the milder schizophrenic

process could postpone the breaking out of secondary symptoms,
i.e.
of the manifest insanity.
In pronounced disease the chronic cases should be differentiated

from the acute. The chronic cases, for the great part, are to be
trained to normal conduct and work; but since besides physicians
few people understand such a training, its direction is still the task
for medical men.
The layman, even when he is ever so well meaning and intelligent, still forgets too easily the difference between sick
and well, and thinks he can work with logic and indignation and
kindliness, as is properly the case with the healthy. But just in those
things that matter, the sick frequently have a false logic and still
less do they understand indignation at their acts, which they consider proper. Or can gratitude be expected when they do not at all
value our sacrifice or only negatively,
i.e.,
when they take them
as
Here it is a question of carefully ascertaining the

patient's general modes of reaction and especially those toward particular individuals, and then act as seems best in the particular situation, and not from a sense of justice, or anger, or sentimental sympathy.
An indispensable means of training is icork, which also renders
incalcuable services against many symptoms. Whoever considers himself too good for this or whatever kind of work he could still accomplish is not good enough for it. But also in the beginning of mental
chicaneries?
diseases, especially of schizophrenias, one should not permit
be dropped at once without some definite reason.

the ability of the patient,
it
When
work
to
adapted to
usually does more good than so-called
216
rest and recuperation, and this is particularly the case in many light
melancholias such as the physician will most probably have to treat in
his private practice.
Mental work, also, is not to be excluded on
though
principle, even
it
frequently not applicable,
is
But the worst
of practical than inner reasons.
is
more because
"the poison of
laziness" (Rieger).
Milder chronic cases can be sent with very good results to a

is braced up from time to time^
where he receives the necessary remedies, and where a special effort
Psychiatric clinic where the patient
is
made
to
make
the external conditions bearable.
In acute diseases the object of obtaining a cure

consideration, but unfortunately
we cannot do
as
is
much
of
uppermost
as
we should
down the
In individual cases special psychiatry has to lay

necessary rules.
like.
An
important question
hospital for the insane?"
is
"Which patients
Naturally,
all
those
are to be committed to a
who cannot be kept
out-
side because they are too dangerous to themselves, to others, or too
Some can be properly
disturbing.
treated only in an institution be-
cause they themselves or sometimes their relatives oppose a proper

management of the case. Where the danger to the patient's fortune is
the chief indication, a legal guardianship can at times take the place of
an institution or shorten the
Not seldom
stay.
patients
must be
in-
terned, not because their conditions directly require itj but because
It is also
their relatives are worn out by taking care of them.
not unusual that the family exerts a directly harmful influence on

the patient, hence the indication for institutional care lies in the
existing conditions.
To
is
intern an insane patient compliance with a
number
of formalities
Every
necessary, which unfortunately vary in different states.
physician who
these
settles
down
local formalities;
apt to encounter
certificate
is
many
required.
must therefore be
if
to practice
he waits until the occasion arises he
difficulties.
In the state of
carefully filled
it
must
also
is
In almost every state a physician's
New York
it is
a legal act and
out with the required data.
sides the petition to the court, signed

tive,
should injorm himself about
if
possible
Be-
by the nearest rela-
contain a physician's certificate signed by two
qualified examiners in lunacy
who must examine
the patient conjointly
within five days of the presentation of the petition.
must contain information about the
Such a
certificate
patient's legal standing
whether
financial standing
is charged with a criminal act or not, his

whether he has relatives who are able to pay for his maintenance in
the hospital (if not committed to a private institution) and the
he
THE TREATMENT OF MENTAL DISEASES IN GENERAL
217
physical and mental states of the patient, whether he
is dangerous
whether he shows hallucinations, delusions,
depression, exaltation or other abnormal signs. It is often not possible
to make a definite diagnosis after one examination but for purIt is merely a question
poses of commitment this is not essential.
whether the patient is insane and unmanageable at home. The neces-
to himself
and
others,
sity for institutional care
must
every case be specified.
in
(Is the
patient dangerous to the community, does he refuse nourishment, has
he suicidal tendencies, etc.?)
Without the
legal
commitment no insane patient
to a state institution, so that
it
is
will be
advisable to inquire
admitted
the
first of
Not
hospital superintendent whether the patient can be received.
all
hospitals are in position to receive patients at all times.^
So much for the administrative

at the institution should receive
ment
of the patient, his
details.
all
In addition the physician
the data required for the treat-
outward behavior, presence or absence of
particular inclinations or impulses, so that a harmless patient does
He
not have to be sent at once to the observation ward.
should
also obtain the anamnesis, information concerning the patient's past

its success; whether the patient was given narcotics
on the trip to the hospital, which kind, and in what doses? Hyoscine
can give the appearance of a pupillary disturbance and lead to a
wrong diagnosis. It is best not to give narcotics on the first day if
one does not know whether the patient has already been given the
same. Sometimes the physician has no time to ascertain all this and
make a note of it. Then he sends with the patient a preliminar}certificate with the necessary data and states that the detailed report will be sent on the following day.
treatment and
Moreover the hospital physician
will be grateful to get not only
the practically necessary information but also that which
may
be
sci-
entifically interesting.
In bringing a patient to an institution one should not resort to lies

and false pretenses; that would make a beneficial treatment impossible
and especially in the case of patients who have some self-respect, it
would permanently disturb the entire relationship with their relatives.
In an emergency it is better to use force or a hypnotic, which
is more readily forgiven by the patient.
But force is ver^* rarely
necessary
when
the proper procedure has been
part of the patients can be persuaded,
if,
followed.
without losing one's
large
own
This is not necessary in most of our big cities where psychopathic hospitals
or pavilions are maintained for obsei-vation, treatment and commitment when
necessary.
'
218
on grounds of
any
enough
people
are
and that there
self-possession, one explains the decision for a hospital
necessity; but
it
must be
discussion whatsoever
present
is
told so decisively that they feel that

useless,
who would be capable
face of resistance.
It should not
rarest case that logic itself

of the individual
When
of putting the thing in operation in the
who
the patient
makes
be forgotten that
the patient yield;
it is
it is
only in the
the personality
applies the logic.

is
in
hospital,
the
family physician
quently has to continue his function as advisor of the family.
fre-
The
questions about private or public institutions, about visiting the patient
and taking him home must

it
is
difficult to give
all
be advised by him. In this matter

One must guard against giving
general rules.
advice without knowing exactly the actual state of the case.

is
It
best to get in touch with the hospital physician; moreover, in such
cases professional courtesy is of greater value to the patient and. his
family than to the professional relationship.

cian should
know
At
all
events the physi-
that manic depressive patients are frequently taken
out too soon, and schizophrenics very rarely, unless other considerations
than the patient's condition come into account. Only in exceptional
cases is home-sickness an indication for taking the patient home;
usually what the patient and relatives take as such is not home-sickness at all. The patient does not feel at ease anywhere and then
the cause is sought in the separation from home. Patients who are
cured hardly ever urge to be sent home. The dreaded "living with
other markedly insane patients" is sometimes an unpleasant experience but it is not a hindrance to the cure.
It is very harmful if
visiting relatives give the patient hopes of coming home or of anything else that cannot be fulfilled later. Moreover, visits are sometimes harmful; they frequently disturb an acute patient, especially
in the beginning when he has to get used, to the institution, I should
like to call attention to the younger children who almost without
exception overcome home-sickness after a few days, but on condition
that they are not visited. But even in the case of chronic patients
visits interfere with the adjustment to the new home even where they
are carefully and tactfully carried out.
The selection of an institution is frequentty not easy. Where

overcrowding has not become excessive, public institutions are generally the ones that accomplish most for the least money.
This is
naturally counterbalanced by the fact that there is frequently less
comfort and less consideration for the wishes and moods of the individual.
latter may also he an advantage.

All private sanafrom being well equipped for restless patients. Sometimes
The
toria are far
IN
GENERAL
219
because of the "odium," or from false pride relatives want to avoid

money to this idea that would be
better applied in other ways, e.g. during the period of recuperation.^
public institutions and sacrifice
But
it is
self-evident that good private institutions can offer much,
especially to spoiled patients, that they are deprived of in a public

institution.
But
more
it is
difficult to
carry out a rigid training there
than under the inexorable rules of a general institution (care should

be taken especially in deprivation cures, see morphinism).
Some patients, e.g. oligophrenics and cases of schizophrenia that

have run their course, can often be trained with success or also
kept for a long time in a private family, with a doctor, teacher, or
In some places private family care is publicly organized
also for the poorer classes and has proved to be very successful. The
guardians are preferably farmers or former nurses and attendants
minister.
from hospitals.
The
disease itself can only be attacked directly in a few cases such
as cerebral lues
and
epilepsy.
dementia prsecox, an
On
the basis of chance experience with
artificial fever
has been produced by the injec-
{Wagner von Jauregg).

can be advantageously replaced by somnifen.
tion of bacterial toxins
The
ever,
Tertian plasmodia
how-
toxins,
seem to neutralize the spirochites in paresis.

In despair the family often assumes expensive treatments in cases
of incurable patients that set the family back financially and thereby
make
a later proper treatment of the patients impossible.
grave wrong.
should not be
It
forgotten that
This
curable cases
is
are
usually cured for the m.ost part by time.
Against emotional fluctuations, distraction sometimes has an effect

To argue with the patient about his delusions
only in milder cases.

is
nearly always useless or harmful.
own viewpoint from

the future to prove
who
With the exception

'Such an odium
One should not conceal
the patient but at the most,

is
it
should be
his
left to
right.
of the psychoneuroses, mental diseases offer
especially entertained in reference to our State Hospitals,

problem for the consulting psychiatrist. It is easy
enough to dispose of the wealthy patients, thej' are invariably sent to private
sanatoriums, and of the greater part of the poor, who go to state institutions,
thus furnishing no
is
little
often at his wits' end to know what to do with middle class patients
afford a first class sanatorium and would under no circumstances
go to a State Hospital. I have known families who actualh- became ruined
financially in their zeal of maintaining a praecox in a third rate private sanatorium. The State Hospital could have offered them just as good, in my
opinion much better service, but owing to the mediaeval prejudices which our
newspapers continually change into modern garb, the average person is still
horrified when a public institution is suggested.
(Editor.)
but one
is
who cannot
220
Manic
for psychotherapy in the narrower sense.*
and similar cases recover from the attack, organic cases
But just in the case
perish, while schizophrenics live on uncured.
of the latter it is of especial importance, whether one understands
them, and can think oneself into their condition, only an extensive
occupation with psychopatholog^-, delusional and symptomatic formations, blockings and inhibitions, can assist in this. Suggestion, whether
direct or concealed, will always be carried on, just as in medical
practice and in life generally. In some cases hypnosis may make many
no
field
fertile
depressives,
things easier,
On
ancholia.
e.g. in
residual conditions like insomnia following mel-
the whole,
its
because as Forel expressed
significance in real psychoses

it,
in hypnosis one
brain, which in the case of mental diseases
is
not great,
is
works with the patient's

an ineflBcient instrument.
most important psychical means of therapy is patience,

calm, and inner good will for the patient, three things that must be
One
of the
absolutely inexhaustible.
From
definite "procedures" in the case of psychoses in the
sense, very little
is
narrower
to be expected even though milder cases at times
are favorably influenced in hydrotherapeutic institutions where one

exercises care.
On
harm.
careless application of cold water
may
do decided
the other hand baths of normal or near normal bodily
temperature are an important help in the treatment of restless and

sometimes also of depressed patients. Excitements are often reduced
by a bath a feeling of tiredness without a real reduction of psychical
;
and physical capacities makes the patient more accessible. But even
in those cases where this result is not visible the tepid bath (35 to
36 C.) is an excellent resort for the patients who can constantly
occupy themselves with the water and thus remain harmless to themThe introduction
selves, to others and to the objects about them.
of the continuous baths, used also in some institutions throughout
the night, and the use of wards for sleepless patients, has given the
modern insane asylum a much better appearance. The depressed
patients also are frequentty better off in the bath;
warm
bath,
taken at night, is especially conducive to sleep.

Cold packs are also frequently applied, and the patient is kept
in them for about twenty minutes until he gets warm or even for
many
hours.
The
latter is only resorted to in the case of
good con-
psychotherap}^ according to definite methods, such as that of Freud,

Dubois, hypnotism, etc. It is self-evident that "psychotherapy" in a wider
sense is practiced by ever>' psychiatrist, I should almost like to saj^ not as such.
"
In contradistinction with the neuroses. Even those who are not very skilled
in hypnosis will find that such cases as monosymptomatic hysteria or enuresis
are frequently readily susceptible of this treatment.
*
That
is,
IN
GENERAL
appearance, and psychical condition.
trol of temperature,
221
Occasionally
they also have a soothing effect. But if the arms are not wrapped
up, they are not tolerated for long, ju^t by those patients; who need
packs most; and if they are put under the blanket this procedure, according to
my way
of thinking
and that of
my
patients, becomes,
under
the guise of medicine, the worst means of restraint that exists.
much
therefore avoid packs as
as possible.
Very many patients, especially the depressed, also schizophrenics

not occupy themselves, and mild manics are best off in bed;
if they want to occupy themselves, there is no objection to reading,
Every modern institution has a
writing, and feminine handwork.
number of wards where the patients remain in bed day and night under
constant surveillance, but there must be a definite indication for
who do
one should not merely feel that "patients should be in bed."

In chronic cases work is to be preferred if it is possible.
If patients are very excited or annoy and injure others, they are
this;
under eertain circumstances isolated. Nowadays there are physicians,

and there were even more ten or twenty years ago, who regard isolation as an atrocity. With discrimination, properly applied, I consider
In the case of manics who do not
it a blessing for all concerned.
necessarily soil everything
it is
And
the preferred therapy.
at night
probably every healthy person would prefer to be alone in a room,

even if it is called a cell, rather than in the company of many lunatics.
Other means of restraint are to be applied most rarely; but when
there
sider
is
it
a special indication, as in the treatment of a fracture, I con-
wrong to
let
the patient become a cripple because of considera-
tion of principle.
Where
artificial feeding is necessary,
be kept in a private house.
the patient can only rarely
well nourished person,
if
he remains in
bed, can go without food from five to seven days without harmful
One
unless he has previously put himself on half rations.
should not bother with rectal feeding and similar emergency measures.
effects,
On
the other hand there are sometimes roundabout ways by which

may be given the patient; thus some will eat secretly,
nourishment
if
food
is
necessary,
is left
within their reach as
it is
if
in a reclining or sitting position firmly
during the process.
by
accident.
best done through the nose.
Then a
If
The
it
at the posterior wall of the throat
here on the insertion should be
held
is
inserted into
a little
The bending
push. From
just goes through.

is
is
enough to preclude a struggle
well lubricated soft tube
the wider nostril, so thick that
tube feeding
patient
forced
by
made somewhat
quickly, so that the
patient has not time to guide the tube into the mouth.
222
In any case, it is often well to wait for the pharyngeal reflex

and as soon as it begins, to shove the tube into the oesophagus. It
is then inserted into the stomach, and through the auscultation of a
little air, blown in by balloon or mouth, one makes sure of the correct position of the tube. Lack of reaction by the patient, especially
in the case of catatonics, is no guarantee that the tube is not in the
trachea. When the tube is withdrawn the tube should be pinched shut
so that nothing flows into the larynx.
The
simplest thing to inject
milk and half as many eggs as a deciliter of milk. After a prolonged fast one may pour in five deciliters at the most the first time,
Two daily feedings
later one liter of milk and five eggs at a time.
will then usually suffice. The state of nourishment, digestion, vomiting,
is
Medicines may also

are naturally always to be watched carefully.
be mixed with the food and in case of a longer period of illness a
different food, in fluid or semifluid condition, will probably be given
in place of, or in addition to, milk.
If the patient
causes special trouble, he should be committed to an
In case of narrow nostrils the insertion of the tube
institution.
through the mouth may sometimes become necessary, also to wash

out the stomach after poisoning. In the case of patients who offer
resistance one must use a gag and be sure to protect one's fingers;
then insert tenderly but without fussiness the left index and middle
back of the epiglottis which is pressed forGuide the tube between the two fingers directly to the
entrance of the oesophagus, which can only be forced in this way
by a soft tube against the patient's will.
Electricity, massage, climatic influences cannot be used as yet.
Nor can hardly anything be gained by a definite manner of nourishment; special additional indications naturally excepted (compare also
therapy of epilepsy). On the other hand strong nerve stimulants such
as coffee and tea should be avoided, and above all alcohol has so many
disadvantages that the little benefit which here and there is sometimes
fingers until reaching the
ward a
little.
claimed for
it
does not enter into consideration.
Hypnotics can never be dispensed with entirely; in institutions

they must often be given because of the other patients whom an excited patient keeps awake.
Certainly the less one uses, the better;
but if one is careful, that is, if one never gives it daily for any length
of time and changes the drugs, one will not have any unpleasant experiences.
To be sure one must watch the urine for the effect on
the blood when administering Sulfonal and Trional. Chloral Hydrate
is still one of the best drugs when given in doses of 2-3 Gm. (Blood
pressure!) and eventually in smaller doses together with mor-

IN
GENERAL
223
Of the newer drugs Veronal (0.5 to L5; eare nephritis!)

and Veronal of Soda (0.5 to LOj are particularly useful. The latter
may also be given in enemas. Trional and Sulfonal are also given;
phine.
the former acts quickly but not continuously, the latter slowly but
and very readily shows a cumulative
effectively
Hence LO
effect.
Trional can sometimes be combined with 2.0 Sulfonal to obtain an im-
mediate and, at the same time, a more lasting effect. In the case
of excitations of not too long duration a certain calming effect can
be attained with Sulfonal, if it is frequently given (the cumulative
The
effects manifest themselves by disturbances of coordination).
and
Trional,
those
Sulfonal
with
the
exception
of
of
specified doses,
may be exceeded without danger with patients whose reaction is known.
In real excitations energetic doses should be administered or none
at all; one should be glad if anything at all produces results. Paralde-
hyde
and more, always through the mouth) would be

the best hypnotics if it did not have such a bad taste and odor.
(5.0 per dose
one of
In single doses
long period.
it
Amylene hydrate
administration and
epilepticus; but
when given
entirely harmless, but
is
as
it
(2.0 to 5.0)
it
is
cannot be given for a

well adapted for rectal
sometimes successfully used especially in status

must be well diluted with starch or something similar
is
an enema, otherwise
it
attacks the mucous
membrane
of
the intestines.
as
Many recommend alcohol as a hypnotic. It is the pleasantest, but

it may become a habit it is the most dangerous and least effective.
do not think it worthy of physicians to prescribe a drug which is

most pleasant but most dangerous and ineffective.^
In nervous excitements resulting from fatiguing W'Ork bromide in
smaller doses is excellent (1 to 3 grammes to be taken evenings all
at once, or perhaps still better in two doses, but it must be thoroughly
I
In milder depressions
diluted).
ones not at
all
Opium and
it is
more rarely
effective, in severer
(comp. Melancholia).
opiates are not hypnotics.
But
indirectly
by removing
fear and psychic pain they can have a calming or even hypnotic effect.
In psychoses, however, they do not achieve by far what their effects
on the healthy would lead one to expect. With the exception of a few
cases, their use can be dispensed with, and because the danger of
habituation to opiates is very great, especially with psychopaths,
there
is
good reason to avoid them as much as possible.
To
give opiates
supposedly necessary for any other reason to prescribe alcohol as a

should be prescribed like any other remedy in definite doses and
for self-evident reasons without the patient knowing it, as: Spir. Vin. 30.0.
If
it is
medicine,
Aqua
it
130.0, Syr. Liquir. 40.0.
224
to an excited patient to facilitate the transfer to an institution

hardly ever of any use but it constantly occurs nevertheless.
is
Hyoscine (Scopolamin, Euscopol) hypodermatically in doses of

1 mg. (above the maximum dose!) is best in such cases; if the
patient's reaction is known and the drug is fresh, more may be given,
up to 1.5 mg. It has a decidedly better effect in combination with
morphine ten times the dose of hyoscine and in frequent use this
addition overcomes the harmful influence of hyoscine on the digestion.
If one gives smaller doses of hyoscine (about 0.3 mg.) as some recommend, one can add more morphine, e.g. 0.015 g. per dose. Within
more recent times somnijen has been used both as a hypnotic and
0.8 to
(40-50 minims internally; some give bigger doses). The

more exact medications are still to be determined.^
Among particular symptoms which the practicing physician has to
sedative
deal with, undeanliness should be mentioned. Many mechanical arrangements have been constructed, particularly for the unclean bed
cases, and all have been given up. The best thing is immediate cleanIn many patients, esing, day and night, after every evacuation.
pecially those not paralyzed, smearing of feces can be done away
with, if every evening, if possible at exactly the same time, they are
enema and urged to move their bowels.

Formerly it was thought necessary to do much to prevent masturbaThis struggle, which is not only useless but which also keeps
tion.^
the attention of the inmates of the institution directed to the evil, I
gave up long ago and am glad of it. But at all events care must
be taken that onanistic acts are not carried on openly and do not
anger the others or infect them. In cases where the patients themselves are struggling against the impulse, medium doses of bromide
(2.0 to 4.2 per day) are sometimes effective. Epiglandol, which to be
given an
is better, can also diminish the impulse.

For a treatment of the danger of suicide see manic-depressive
sure
insanity.
If operations
question of
life
on the iiisane are to be undertaken, unless it is a

and death which makes immediate action necessary,
one should obtain the consent of the relatives or of the guardian,

perhaps of a counsel named for the purpose. The practice in this
case is pretty well free from trouble; the theoretical difficulties, however, are numerous; there are foolish people who do not wish to deprive a person incapable of action of "the disposition of his
body" and would rather deprive him

^
See also Treatment of Schizophrenia.
'
Comp.
p. 209.
of life or limb
own
than amputate

a couple of gangrenous toes against his will.
IN
The
GENERAL
reduction of a dis-
location, the proper treatment of a fracture naturally
to the "operations" in the specified sense; this
lumbar punctures which require considerable
is
225
do not belong
not true, however, of
Every beginner
skill.
does well in these matters to ascertain exactly the customs or require-
ments valid
in his district.
The
interruption of pregnancy ^ requires special indications.

In
depressions of pregnancy ^" the intervention frequently only causes
the patients severe reproach and the condition
by mere waiting with
is
aggravated, while
sufficient oversight the psychosis
regularly
is
However, the psychogenic

depressions or situation melancholias of girls and women for whom
cured, not seldom even before the delivery.
the child will
make
difficulties are theoretically to
be judged differently.
Such diseases can naturally be cured by the removal of the cause;

but with our present views and laws this cannot be a sufficient indication for abortion. Even in the case of schizophrenia and oligo-
may be advanced, the

on in exceptional cases. It is
the case of early and severe eclamptic or choreatic
phrenia in spite of
all
the valid reasons that
sacrifice of the child is only decided
quite different in
psychoses.
In
Germany and
in Catholic districts, according to the
weight of opinion, a special indication (danger of a diseased progeny

in the case of the insane and idiots; reaction of nursing difficulties
on the condition of the mother) does not properly exist. In the
Protestant part of Switzerland the sensibilities of the people
an attitude that
is
more favorable
to abortion
and
should
demand
let social
considerations count with the legal. Plain legal determinations exist

nowhere; one has to fall back on local and customary interpretations.
At all events, it is wise not only to weigh carefully all the circumstances that enter into consideration, but to consult an experienced
colleague.
Psychiatric indications of premature birth are more rare
and simpler.
^ Comp. E.
Meyer, Klinstliche Unterbrechiing der Schwangerschaft bei Ps>'chosen (mit Einschluss der Hysterie und Neurasthenie). Med. Klinik 191SL
No. 7 u. 8.
" Cf. pp. 210-211.
CHAPTER Xn
THE SIGNIFICANCE OF PSYCHIATRY

The
frequenc}' of psychical diseases
is
fairly great.
Some
are of
the opinion that about two per thousand of the population is pronouncedly insane; but this does not include those "who were insane,"
the mental defectives,
who
are
more than again
as
numerous as the
manifestly insane, and most epileptics. And it is not to be doubted

that the facts exceed by far the estimate. The most exact enumerations give about one percent of the population as insane
From an
phrenics.
investigation of conscripts
Maier goes
and
oligo-
so far as
In its insane asylums alone Germany

it to twô percent.
has to care for more than one hundred thousand insane. According
to statistics obtained by the National Committee for Mental Hygiene
there are about two hundred and fifty thousand patients in the hosto raise
pitals for the insane in the
United States.
New York
State supports
about forty-three thousand patients in its State Hospitals.

But the estimated pecuniary loss to the individual is not less than
the loss to the people generally. The paretic who has made a position
for himself and has a family and then permits both to go to pieces
is
a frequent occurrence, the
who
same
is
seen in the case of the hebe-
maintained at the expense

and the state and who retards the former economically.
Added to this, is the peculiar significance of insanity. The psyche
is the essential element in man, not only from a religious but also
from the viewpoint of natural science. Strong muscles and solid bones
are still agreeable attributes for those who have them, but one can
direct a world without even having arms and legs, while a slight
disturbance in the psychic mechanism can change the strongest man
phrenic,
for a half century has to be
of the family
into a pitiable object of care or into a dangerous
enemy
of society.
importance
much more than other diseases; they spread their harm to wider
circles and they rob the patient himself of his independence in alf
It
is
for this reason that the psychoses attain their social
men. They falsify or destroy his social posican no longer maintain himself, and he loses his qualifica-
his relations to his fellow

tion.
He
tions as a legal subject.
insane, but
if
What was
the insane person
said applies only to the recognized
is
226
not recognized, the consequences

are often
more
serious for him, above all for the family,
many
In
times for society.
soon as the diagnosis
227
and some-
cases unbearable conditions improve as
made.
is
Hence the great and sometimes dreaded import of psychiatric expert opinion.
And
the significance of psychological and psychopathological conis always becoming greater.

The penal code whose old
siderations
standards are no longer adequate for modern viewpoints and conabout to forge new weapons for itself in the battle against
ditions, is
the enemies of society.

if
the conclusions
This can only be accomplished with success

are based on studies and
drawn about criminals
application of psychiatric methods of investigation and psychiatric

prognostication.
In
civil
jurisprudence psychical conditions are ever
becoming more important; the psychological problems, which the antiquated insanity code presents to the judge and the expert, are already
so large and so numerous that the profession will have trouble to
meet them. A jurisprudence without a thorough psychological training
is becoming more and more insufficient.
The same is true in other sciences. Our ethical instincts are no
longer equal to the modern conditions of life and like the other instincts
become inadequate with a progressive civilization; indeed, under
certain conditions they even become harmful, (e.g. the instinct of
revenge).
Religions which since Buddha have regarded ethics as
their domain, no longer have the general influence that they had in the
last two thousand years. A conscious ethics can naturally spring only
from the intimate study of the social psychology of man.
History is at last beginning to become psychological and consequently a comprehending science, because it is the product of the
human
psyche.
Pedagogy
is
getting ready to derive benefit from a penetrating study
of the soul of the child.
In the last half century our literature has become immeasurably

more psychological, even though in this respect it has not yet caught
up with the French and Russian. Poetic compositions and especially
their creators, themselves, can only be properly understood by an
extensive psychological study.
particularly
fertile
field
scientificalty
borderland between the normal and disease.
and practically
is
the
The normal and average
man
is the product of adaptation to conditions and must consequently

always hobble along somewhat behind the requirements. He dare
not conspicuously develop a single characteristic at the expense of

others, because he is
above
all
the physical forebear of the future
228
generations and as such must be able to bequeath in proper proportion all psychical gifts needed
thered by those
who
by
But
society.
civilization is fur-
are developed in a one-sided manner,
outwardly specialize themselves,
wardly and
of labor, and by those who are not
who
sufficiently
who
in-
carry out the division
adapted to be
satisfied
with everything that exists.

of
deviation are countless, the useful pos-
sibilities are naturally few.
Thus the bad prophets, the clumsy world

who are inspired by all sorts of
But while the
lines
fanatic partisans
reformers, the
unrealizable dreams, and those
who
are really regarded as sick are
and will continue to be the majority of the abnormal. To recognize

them in the morbidity of their inner life is a problem that is practically important, that could contribute materially to the improvement
of our public affairs.
The study
of race
and mass psychology, which
is
dominated by
such people, should complete this knowledge. Psychopaths and insane, such as Mohammed, Luther, Loyola, Rousseau, Pestalozzi,
Napoleon, and Robert Meyer, have influenced the course of our civThe psychic epidemics from
ilization in a fateful or beneficent way.
dances
of
St.
the
Vitus
to the twitchings of modern
the crusades and
school children, and the
religion, politics,
and
numerous sectarian and party movements in
art, all represent
the readily discernible peaks
of the fluctuations of ideas, in which the psychic
life
of races expresses
itself and from which the achievements of individual leading spirits

grow as advanced pathfinders, as complements or as negatives to the
general current.
For the physician a psychological training is nowadays particularly

necessary. While the naive practice of medicine was always in great
part psychic, and the quack even yet partly heals and partly shears
his patients by following psychic lines, the development of the exact
methods of modern times has diverted the physician from psychical
conceptions; indeed, as Adolph Meyer expresses it it has engendered
an actual "Psychophobia." But theory and practice are suffering
severely from this, when one side of a man is neglected and to be
sure it is the one which through ideas and affects is the chief regulator of all bodily functions, and which alone decides the relation
between physician and patient. The good practitioner is still preponderately the good, though usually instinctive, psychologist. The
origin and disappearance of "Neuroses" goes by way of the psyche.
The control of diseases of accidental origin, which cost the exchequer
millions, and which make permanent cripples of many people, is only
possible since their psychic origin has been grasped, and the mani-

good
festations of a
many
other diseases in the single individual are
modified and modifiable by the psyche.
menstrual
229
The usual
digestive
and
part entirely psychogenic diseases.

not less necessary to the happiness of
difficulties are in large
Mental hygiene
in the family is
physical
hygiene; in short, a complete physician must
than
mankind
complete
individual.
understand the
experience
has
shown
here as everywhere, that it is difficult,
Now
yes, impossible to obtain insight,

is
considered.
That accounts for
if
only the commonplace, the normal
the fact that psychology in the past
all these purposes, but was

Only the newer schools such
Hence what is
as those of Marbe and Stern tend in this direction.
important we shall only recognize from the study of the growing
psyche of the child and, above all, from the aberrations of those
already developed in psychopathology. At this time one of the most
important, if not the most important path to a knowledge of the human
soul is by way of psychopathology.
could not only not contribute anything to
positively a hindrance to better insight.
CHAPTER
Xm
THE INDIVIDUAL MENTAL DISEASES
LV. THE ACQUIRED PSYCHOSES WITH COARSE BRAIN

DISTURBANCES. THE ORGANIC SYNDROME
Kraepelin has here differentiated injuries and diseases of the brain
for practical reasons syphilitic diseases are separated from the
and
latter.
Among
the syphilitic conditions again the most important,
been emphasized because of
paresis, has
With the
practical individuality.
senile
symptomatic, and
forms and the real Korsakoff
its historic,
disease resulting from intoxication (alcohol,

etc.), it
this,
has in
common
a large part of the symptomatology.
thought of
first
CO,
lead, bacteria toxins,
the diffuse reduction of the brain and with
when the organic psychoses
These three forms are

are mentioned.
But they
include also the various forms of degenerations of the nervous system,
such as the
etc.
glioses,
multiple sclerosis, cerebral changes in tabes, tumors,
They alone have
in
common the "organic syndrome," which with

memory defect was also designated as the
a one-sided emphasis of the
Naturally it can also be found in

Korsakoff symptom complex}
other brain diseases, as soon as they result in a diffuse cortical lesion.
If the cortex as a whole is only functionally damaged by a trauma,
these symptoms may again disappear "curable Korsakoff" the same
is true in an intoxication with adjustable
anatomic disturbances
(delirium tremens).
Only
weakening of
whereas certain affective disturbances can already manifest themselves in cortical brain lesions, most frequently when it
affects the thalamic region.
Irritability and a tendency to all sorts of
temporary moodiness, again in the direction of anger and rage, are
the most common persistent manifestations in most focal lesions of
the brain, but in diffuse disturbances as well as in lesions in the
thalamic region, the general affective lability would seem to be more
marked.
diffuse disturl)ances of the cortex cause a real
intelligence,
^Korsakoff's disease
nervous system.
showing similar
is
and central
incorrectly transferred to other diseases
really a toxic neuritis of the peripheral
The name was then

memory disturbances.
230

231
THE ORGANIC SYNDROME

The
diffuse reduction of the functions of the cortex results in definite
symptoms, which only vary

and the diseases.
Memory:
worse
is
All things being equal, the
recollection ranging
the older
a
it is,
the
less
greater poverty
despairing
(real)
in detail according to the circumstances
the
up
fresher an engram, the
to complete absence of impressibility,
memory
of thoughts
confabulations,
fill
their
while the
who evince
memory gaps with
Patients
disturbed.
is
often
more productive
going beyond this, revel in spontaneous pseudo-recollections.
ones,
Transi-
tory confusions or other disturbances of consciousness (attacks of
all
kinds) are frequently followed by amnesias.
The extent of associations simultaneously possible is restricted.^

The choice of the latter is chiefly decided by the affects, that is, by
the momentary strivings. One of the first results of this is an absence
of the critical faculty
and a disturbance
of judgment.
Recall the
who jumps from a high window to get a cigar butt, and the
one who steals an object when everyone is looking and then care-
paretic
fully
conceals
it.
Another paretic
stole
front of a wine shop in bright daylight,
when he became
tired,
a barrel of wine from in
and rolled
homewards;
it
he begged two policemen to help him, and
they went so far in their good nature as to give him his way. A
paretic physician threatened to run away from us; he said that he
could accomplish this very easily in the following way: he would
go walking with us, and then he would step aside for a moment
and not return. When the organic patient in a state of euphoria
comes to an institution and finds a nice room and a friendly attitude,
he very frequently overlooks the entire internment with
of force,
and declares that he
will
its element
remain there for such and such
A paretic finds an old bag, cuts up several new ones to

then gets the idea to make it big enough to reach the ceilPatients at the height of their disease only exceptionally acquire
a time.
mend
ing.
it,
wisdom
through
experience.
In
every
institution
acquainted with the variations of the paretic,
who
one
is
well
for several years
visit with the words:

"Next Tuesday my wife will come and take me away."
Complicated pictures can sometimes no longer be grasped in their
context; the patient counts up details and in this respect then reminds
has greeted the physician at every
one of imbeciles.
Cf. p. 100 and following.
'Cf. p. 74.
'
232
The
various intellectual abilities do not disappear uniformly, but
at present no other rule can be stated except that especially developed
and practiced
abilities
escape the general deterioration the longest.
bookkeeper can be markedly demented in all other direcA paretic

tions and yet surpass many a healthy person in addition.
The
senile
physician,
who had
when
previously
made
quite a
name
for himself as a chess
he seemed completely childish, could

"In
still announce to a less skilled player at the opportune moment:
ten moves I will checkmate you on this particular square," and he
player,
in all other respects
was nearly always right.

The psychic processes are usually more
or less retarded, even aside

from the torpid conditions evidently directly based on the disease
But the retardation can, in certain respects, be over-comprocess.
pensated by manic moods with their rapid succession of ideas. Sometimes the patients evince distinct difficulty in passing from one topic
In the later stages the tendency to perseveration exists,
to another.
in severe cases so strongly, that a patient, for example, answers the
most varied questions about his personal details with "61," after he
has given the year of his birth with this number. Intercurrent stronger
associative disturbances are the bases of the deliria and states of
confusion.
Of the disturbances of euphoria those individual concepts are

naturally most strongly affected which are in themselves difficult of
access, indefinite,
and hard to determine.
In place of them the patients
reproduce simple, vague and general ideas such as: "building" for
sunmier house, "man" for carpenter. Their answers to questions are
also characteristically indefinite as
do you come from now?"
"Where
"I have
shown by the following: "Where

come forward from in back there."
"Why, it is in this city." Such answers

manner of intentional evasion but with a good
natured sincerity. The patients are evidently satisfied with them and
expect the questioner to feel the same about them. Very often the
form of the answer is influenced by the mood: "In what ward are
we now?" "In a nice one." "What sort of people are they?" "The
right sort of people."
In other cases a more or less conscious emis
our institution?"
are not given in the
barrassment
is
shown, which, however, does not really change the char-
acter of the answer: in the case of questions concerning the date, the
patients have not seen the newspaper or the calendar just of today,
or refusing to recognize the significance of the question, they turn to a
companion and ask him to give the answer,

especially marked in cases of senility.
The
affectivity
is
labile;
it
manifests
etc.
This symptom also
itself
is
more strongly and
233
quickly than normal (emotional incontinence) but emotional excitements pecter out more readily, either spontaneously or because the
:
patient
lively
In the latter case, too, a
led to think of something else.
is
mood may be supplanted by another without leaving any
trace,
often in a few seconds; the actual emotion dominates the patient

absolutely.
Trifles
make him happy
or desperate.
seriously attempted suicide because her husband
To
was
paretic
woman
late for a meal.
the extent that the insight for complicated relations
is
absent,
these, naturally, can no longer become accentuated with feeling.
feeling reaction
is
easily restricted to certain fields also
The
by the de-
crease of associations, and the patients appear indifferent, although the

defect
is
not really in the affective element.
naturally expresses
general brain torpor
the affectivity; on the other hand,
itself also in
other patients have an exaggerated general excitability, and conse-
The
quently also an affective excitability.

naturally
among
in
As
those most difficult to suppress.
cannot easily or at
trast ideas
egotistic
interests
are
these patients
think of other corrective ideas, especially con-
all
conjunction with their egotistic
egotistic in their thoughts, feelings
and
acts.
ones,
This
is
many appear
particularly evi-
dent in the simple senile forms while in erethic and manic conditions,
which occur- especially in paresis, the more varied change in thinking
over-compensates this tendency.
;
It is usually said that the ethical feelings of the organic patients
and very markedly. I believe this is wrong. Some of

commit all sorts of crimes, but to the extent that they were previously decent according to my experience
they commit them because they no longer have an insight into the
entire situation and its consequences. If they can be made to comprehend what they have done, they regret it in the normal way. If
deteriorate early
these patients, no doubt,
they previously had anti-social tendencies, the disappearance of inhibitions naturally permits these to become more easily dangerous.
The cooperation of this labile affectivity with

makes purposeful action impossible.
flective ability
sideration, tact, piety,

right, feeling of sexual
when they
are present.
aesthetic
shame
Any
all
sensibility,
these
may
sort of impulses
the restricted re-
Tenderness, con-
sense of duty, sense of
any moment, even

from within and without
fail at
are translated into action without any restraint.
Acute manic and melancholic moods, lasting for months and someThe mood, chronic throughout the
times longer, appear frequently.
may also be a morbidly euphoric or depressive.

Corresponding to this condition of affectivity and the restriction
entire course,
of associations, the positive as well as negative suggestibility
is
height-
234
ened; on the one hand such people are easily influenced and, on the
other hand, they are stubborn.
Apperception is retarded and unclear. The patients require more

time to recognize pictures and often deceive themselves anyway failures to recognize are sometimes caused by perseverations. Things read
Questions to the
are easily perceived imperfectly and incorrectly.
;
patient often
must be repeated and are sometimes answered
in the
sense of the previous trend of thought.
Orientation as to time and space often also, the autopsychic,
The
disturbed.
patients
lack the "inner clock."
to,
which
is
is
of these
whether they or others are being
patients no longer differentiate
spoken
Many
When
also a part of disturbed orientation.
pre-
sented at the chnic, for example, many, like patients in alcoholic

delirium, answer regularly,
when one speaks
to the audience.
from the restricted extent, is made diflBcult;

this is seen more in the habitual and the passive than in the maximal
and the active attention. The intensity of the latter may be normal,
even if the extensity has already suffered severely. Sometimes
vigility is reduced at the same time with tenacity.
aside
Attention,^
If Delusions are present,
they obtain as a rule the character of
Among
senselessness in the severe cases.
the depressive delusions one
commonly exaggerated ideas referring to diseases; the delire

d'enormite and nihilism when present are especially characteristic.
observes
Hallucinations usually affect sight and hearing.
Corresponding to
the brain process other kinds of parasthesias also occur, which, under
certain circumstances, attain a similarity with real (body-) hallucina-
This
tions.
in
state
usually
is
of
delirium.
brought
Many
about
of
hallucinate at night, while during the
through
misinterpretation
are excited and

day they are quiet or actually
our patients
sleep.
With depressive
months,
for
is
patients, screaming throughout the night, lasting

not rare, and generally, stereotyped whining and com-
plaining are nowhere
more pronounced than
here.
Severe anxiety attacks with senseless or confused reactions, pushing away, clinging, brutal, and often clumsy attempts at suicide, hiding
away, hitting at random, etc., are in part results of the brain disease,
and
in
part
apparatus; at
probably
all
results
of
disturbances
of
the
circulatory
events they are most frequently seen in sufferers
from .arteriosclerosis.
Besides, various kinds of delirious, perhaps also of tmlight states
occur,
which under no circumstances manifest the same
*Cf.p.
134.
genesis.
We

find
them
as
intercurrent
symptoms
of
paresis;
in
235
arteriosclerotic
psychosis especially after the inception of diffuse softening,
The organic psychoses
etc.
are usually accompanied by phynical
symp-
toms, which are, in part, the result of the brain affection (paralyses,
trophic
disturbances),
marasmus, neuritis).
hands and the organs
in
An
part
concomitant
manifestations
(senile
irregular coarse tremor, especially of the
of speech,
is
most constant.
As physical symptoms one often designated also the "nervous"

manifestations which can mark the beginning of every organic insanity.
Among these we have: pressure in the head, headache,
parasthesias, flickering of the eyes, buzzing in the ears, etc.
Later
they are in part concealed by the deeper psychotic symptoms or in

delirious conditions they are misinterpreted as illusions and delusions
referring to the body.
The disturbance
memory
most often characteristic of the

Here one sees cases in which the
For
limits of absence of memory may be determined to sonie extent.
instance, the patient does not remember anything that occurred in this
century. After a while the memory gap extends back to the nineties
If only memories of
of the last century, then to the eighties, etc.
youth are present, they often have a greater freshness than under
normal conditions; they may even attain an hallucinatory^ vividness
so that the patients believe they live over scenes which in reality took
of
is
simple forms of dementia
senilis.
place seventy years ago.
In arteriosclerotic forms irregular fluctua-
tions of
memory
disturbance, both as regards content and time, readily
In paresis the difference in the ability to recall earlier and

is sometimes not so striking as in the senile forms,
but it can be invariably demonstrated, even though sometimes it first
appears only when the dementia becomes deeper. Alcoholic Korsakoff's disease when it is acute usually shows at first a well defined
occur.
fresher experiences
limit of the ability to recall at the beginning of the disease; the patients
have at
their disposal nothing that occurred since
viously they recall pretty completely.
However,
what occurred prethis
demarkation
becomes blurred rather quickly, in that earlier experiences also are

not remembered at all or incorrectly. In the magic form of paresis
and alcoholic Korsakoff, confabulations often appear altogether without any restrictions. In many torpid forms of the senile psychoses
confabulations are almost absent. Other things being equal it increases and decreases with excitement and activity.
The absence of the critical faculty appears to be, on the whole.
more pronounced in paresis than in the senile forms, where the personality with
its
strivings in relation to the elementar\^ disturbance
236
often better preserved, to the extent that a miserly old man, for
example, is not easily talked into making gifts, etc. The uncertain
is
answers, which are to disguise the dearth of ideas, are found most
frequently and in a most pronounced form in the simple senile dements.
Coarse brain lesions lead most readily to marked perseverations.

The productivity of the delusions in manic paresis is enormous but
Moreover the phantasy formain the other forms it is very limited.
is usually very vivid, elseKorsakoff
alcoholic
tion in paresis and in
where
it is
The
rather reduced.
lability of the affects also occurs frequently as the result of a
hemorrhage in the thalamic region; it may then remain as an isolated

symptom, in that the intelligence is not affected at all or only after
months and years. In paresis there is a marked tendency to euphoric
moods, and in the senile forms to depressive moods. Alcoholic Korsakoff cases are usually very euphoric for a long period.
Apperception
is
often preserved
much
longer in the simple senile
forms than in paresis.

Certain variations of the organic forms are often determined by
congenital predisposition of the brain thus emotional people, especially
;
members of families with manic depressive tendencies, more readily

have affective forms of paresis and of the senile psychoses; indeed,
even the depressive or manic dispositions become particularly marked
by the addition of the brain disease; paranoid forms occur in patients
who have always been
distrustful
and inclined
to false interpretations,
while schizophrenic forms in those who originally belong to the schizoid

type, etc. Nevertheless the kind of process has its influence also;
thus paresis inclines to euphoric states, arteriosclerosis to depressive
and anxiety
states; delusions of stealing
festation, not a constitutional
symptom,
is
an organic-senile mani-
etc.
Corresponding to the underlying brain disease the outcome of

organic psychoses is usually fatal. Intoxication psychoses, like Korsakoff, can improve more or less, or after a slight improvement remain
In spite of a course which is progressive on
essentially stationary.
the whole, remissions in paresis and in the arteriosclerotic forms may
go very far; in the latter the particular improvements can also last
only a few days or hours; but then they are usually more frequent
and constitute an important element of the entire picture; this is
probably the only occasion on which one can properly speak of "Lucid
The prognosis of particular senile diseases will be
intervals."
discussed later.
differential diagnosis of the
the beginning.
The
disease
organic psychoses
is
not easy in
must already have attained a
certain
237
height before a large part of the disturbances mentioned become eviOrientation, for example, in patients whose sensorium is clear
dent.
only falsified in the more advanced stages of dementia. But it may

happen that intelligent witnesses in court pronounce a man entirely capable of action who, literally, mistakes niglit and day and
is
also
wants to go to
his office at eleven o'clock at night
On
in the forenoon.
lies in
and
closes his office
the other hand in senile dementia the difficulty
the fact that normal senility indicates similar symptoms:
know
does not
lability
at
what stage
of
memory
One
disturbance or of affective
one should count the beginning of the disease.

must sometimes serve as criteria.
In these cases
practical reasons
If
a pronounced melancholic condition
exists,
then a petty reaction
to minor affairs like a belated meal, or a striking affective distraction,
perhaps by a joke, point to organic lability.

More important still is the nonsense of the delusions and here especially the form of nihilism and of the Delire d'enormite. Disturbances
of orientation may naturally only be evaluated in cases where it occurs
in a clear sensorium.
Nocturnal excitements with sleeping by day
must be weighed carefully because they also occur elsewhere, e.g.
sometimes in schizophrenia. Slow functioning of the psychic processes, even though of a somewhat different kind, occurs in epilepsy,
where one also sees blurred perception and perseveration.
States of organic unclearness can be recognized most conspicuously
by a good affective rapport with a declining intellectual rapport; this
is differentiated from epilepsy by the fact that fluctuations of emotional
Usually the patient
reaction readily occur.
any obviously
since
it
is
foolish action,
which
if
way
we
fold
it
is
eagerly occupied with
to be designated as imaginary,
not based on hallucinations.
The
patient endeavors, for
he succeeds, which he rarely does,

for him, he nevertheless continues in exactly the same
example, to fold the comforter,

or
is
to fuss around with
if
it.^
Frequently while the diagnosis of the organic disease

possible, the specific manifestations, especially physical
neuritis, pupillary
not yet
like
and speech disturbances (Korsakoff, paresis) permit
a definite diagnosis of the special psychosis.

reverse holds true; that
is,
More
frequently the
the "organic psychosis" can be generally
recognized while the specific symptoms of a definite form are
The
is
symptoms
still
lack-
view of the fact that there are

also organic psychoses resulting from brain diseases which are not
yet known.
An important means of recognizing and differentiating organic dising.
latter is especially true in
"Comp. presbyophrenic
delirium, pages 290
and
294.
;;
238
turbances of the central nervous system is the examination of the

cerebrospinal fluid. The lumbar puncture also has therapeutic signifi-
cance in various diseases. But one must be cautious, especially in brain

tumors, because of the danger that the medulla oblongata may be
pressed into the occipital foramen, and in traumatic neuroses, in which
new complaints may be attached to the

The technique of puncturing should,
operation.
in the interest of the patient,
be learned by practical demonstration and initial practice under superTo refresh the memory the following points are mentioned
If a line is drawn on the patient's back connecting the two
here:
vision.
crests of the ileum, then directly over
and under
this line one finds
the space between the third and fourth and the fourth and fifth lumbar
vertebra^, respectively, one of which is selected for the puncture. This
is
the region of the cauda equina, so that injury of the cord
sible.
Disinfection of the region
is
impos-
must be most carefully done. The

ten cm. long and as thin as possible
puncture needle should be at least

the elastic instruments of platiniridium are the best. In the insane
it is often an advantage to puncture them while in a sitting position,
because
it is
excited than
easier to hold them,
when they
and because they are usually
less
are put in a reclining position; in both cases
is the very decided flexion of the spinal column

("hump back") because then the inter-vertebral spaces open; but the
spinal column must not be turned laterally because the location of the
spinal canal is then more difficult to find. The sitting patient is best
placed so that he sits backwards on a chair and throws his arms around
its back; an attendant kneels in front of him and holds his legs sym-
the most important item
The puncture is made either in the middle line

under the third or fourth lumbar spinous process which is
located with the finger of the free hand. The direction of the puncture
should be slightly oblique tending upwards; the lateral method peneIn the first case
trates a little deeper, one cm. beside the middle line.
one has the great advantage that one must puncture directly in the
middle line without a lateral deviation, while in the lateral puncture
metrically upwards.
directly
the correct estimate of the angle requires
more
practice; on the other
hand, in the median puncture one must go through the hardest part
of the ligaments which occasionally may deceive with a resistance
equal to that of bone.
Frequently the puncture
then a slow withdrawal of the needle
suffices to
is
made
too deep;
permit the outflow
had apparently not been reached.

For purely diagnostic purposes six to ten ccm. should be withdrawn
of the liquor which
in cases of paresis one can usually go a little higher without disagree-
able consequences.
Rapid
decline of high pressure even after a slight
'

emptying indicates clanger because
of defective
239
communication between
the cerebral fluid and spinal canal.
one wants to measure the pressure of the liquor, one must natfirst and with the patient lying on his side.
One attaches to the needle a sterile tube of small calibre with a glass attachIf
urally do that
lifts it as long as the fluid in the glass attachment rises, then

one measures the height from the point of puncture with a scale held
The normal height varies between 90 and 140 mm. HÔ.
alongside.
In case of very high pressure the withdrawal should be retarded and
ment,
ended before
has come to the normal height.
After the puncture

bed for 24 hours in about a horizontal position.
If there is slight temperature or headache or heaviness in the head,
as occasionally happens, he should remain in bed two or more days
it
the patient should
lie in
and take, perhaps, some pyramidon (0.2 to 0.3 per dose).

In the normal person the fluid is clear and colorless; intermixtures
of blood resulting from the puncture settle quickly when permitted
to stand. (Sera containing blood are naturally useless for the Wassermann reaction.) In yellowish discolorations that do not come from
bleeding of the puncture, bleeding of the brain should be thought of
and pachymeningitis. Countmust be done as soon as possible,
especially, then of cerebral inflammation
ing the celhilar elements of the fluid
as otherwise they turn to sediment;
it is
best done with the blood cell
chamber as modified by Fuchs-Rosenthal, which has a depth of 0.2 mm.

instead of 0.1 mm.; as a stain, for example, one can use Methylviolet
The normal number is to 5
0.2, Acid. acet. glac. 1.0, Aq. dest. 50.0.
cells in the cubic millimeter; 6 to 10 is suspicious; what exceeds this
number may be considered pathological. A psychosis with an increase
of the cells
dividual
is
cell
generally paresis.
If one wânts to differentiate the in-
forms, one had better stain according to well
methods after the
fluid
psychosis usually indicate
mann
known
is
centrifuged. Plasma cells found in a
Still more important is the Wasserparesis.
reaction of the serum, in which the evaluation with different
doses of liquor
is
frequently necessary.
In paresis the reaction
usually strong; in lues of the central nervous system

weaker.*'
Chemically, Nonne's "Phase I"
is
it is
significant:
is
frequently
About
to
2 ccm. of the fluid are mixed with an equal amount of a saturated
aqueous solution of
ammonium
sulphate, not
warmed:
In central
syphilogenous diseases a discoloration or at least an opalescence ap-
which proves the increased presence of globulin and nuclein.

then boiled the remaining albuminous elements precipitate
(Nonne's "Phase 11") but the latter examination is better made with
pears,
If
it
is
"See page 248.
240
Nissl's graduated tube, in
which 2 ccm. of the fresh
fluid is replaced
by
ccm. of the common Esbach reagent and then centrifuged for one
half to three quarters of an hour the precipitate gathers at the bottom
of the tube and can be removed; the normal liquor hardly contains
1
more than
0.2 to
0.35%
of
albumin; in pathological conditions a two-
fold or greater increase frequently occurs.
Phase
I is regularly positive
in paresis, congenital
(opalescence)
medullary tumors, a little rarer in tabes and other

luetic forms of the central nervous system, only in some cases of brain
abscess and other diseases of the brain, spinal cord, and its meninges.
According to Kajka ^ the chemical diagnosis may be carried fur-
syphilis, in extra
ther.
The
Globulines, which already separate
solution of
ammonium
sulphate
when
28%
saturated
added, indicate acute meningeal
is
inflammation but do not exclude tubercular or luetic processes. The

whose presence proves paresis,
euglobulins (fibrinogen, fibrinoglobulin)

still
separate with reagents saturated to
33%.
The pseudoglobulins
only occur in chronic lues cerebri and only become visible with the
application of a solution saturated to
I.
40%.
^-L^
INSANITY IN INJURIES TO THE BRAIN
In the confusing mass of external pictures resulting from brain

A few types that I
still misses a systematic viewpoint.
mention, following Kraepelin, may give an indication of what occurs
injuries one
in this connection.
Concussion of the brain with
its
symptoms
collapse, vomiting, etc., is familiar to physicians
of unconsciousness,
from the study of
surgery.
Traumatic delirium or commotion psychosis. A delirious state

sometimes follows directly after the accident or brain concussion in
which disturbance of memory of the organic type, or traumatic in uninjured brains of curable Korsakoff,
is
usually plainly recognizable;
sometimes it is connected with nervous symptoms like headache, dizziness and with focal symptoms that do not always indicate a tangible
anatomic brain injury. The state of affectivity varies. The disease
usually lasts only a few hours or days, occasionally several weeks,
the last especially when it has developed only after days or weeks
Later one observes usually a lack of memory with
after the trauma.
a tendency to retroactive amnesia.
'Munch. Med. W.
S. 1915, p.
105.
Besides Kraepelin, comp. Schroder, Geistesstorungen nach Kopfverletzungen,

Enke, Stuttgart 1915.
*

As
transitional states during improvements,
a chronic state, that can attach
itself to
241
and more frequently as
the trauma immediately or
after a longer latent period even without a
commotion psychosis, we
Common
notice different pictures of traumatic states of weakness.
them are rapid exhaustion," irritability, tendency to spontaneous and reactive moods, up to the most intense anger, which is
in part labile and in part of a more torpid persistent affect; more
rarely we notice a stupid euphoria with a mania for joking (Moriaj.
Not rarely epileptic attacks appear in which the typical epileptic
to
most
of
dementia
may
occur (traumatic epilepsy).^"
tonia can last for a long time.
Even
Pictures similar to Cata-
after a long time subdural or
cerebral bleedings with the consequent manifestations can occur.
Not very
rarely milder injuries to the brain cause indefinite
symp-
toms that give the appearance of a neurosis.

In children injuries to the brain readily lead to idiocy, especially
to the irritable forms with moods.
Berger^^ differentiates
mentia, and
(1)
commotion psychosis,
traumatic twilight
(3)
state.
He
(2)
traumatic de-
divides
commotion
psychosis into (1) hallucinatory confusion, (2) those with the Korsa-
symptom,
koff (=organic)
(3)
those with a manic tinge, (4) those
with catatonic symptoms.
The treatment
of these conditions unfortunately
is
not very suc-
In the delirious forms the only thing that can be done
cessful.
is
to
await recovery and protect the patient from himself. In the chronic
forms it is important to abstain from alcohol which enhances the symptoms and causes excitement. It should also be kept in mind not to
give
such people
epilepsies
may
be
cocaine
injections
released as a result.
(dentist!)
The
because
permanent
excision of a scar from
the brain (more frequently from the meninges), leaving perhaps an
opening as a pressure vent,

in the
epileptic
is
said sometimes to effect a cure especially
forms; perhaps more frequently the same
may
be
Under certain conditions, e.g. in continuing to add numbers, many of these

patients seem to tire less than the normal, apparently because they do not
concentrate.
^
The numerous "war epilepsies" do not confirm these peace epilepsies.
However, on the one hand, the time since the war is still somewhat short on
the other hand, the various brain attacks which do not belong to our concept
;
of epilepsy are here included for the present, because it is not quite possible
to differentiate them, as the different kinds of attacks frequently change from
case to case and even in the same patient (comp. e.g. Jacksonian Epilep. p. 342).
Cf. also Forster on later clinical experiences with bullet injuries of the brain
in the Handbuch der arztlichen Erfahrung im Weltkrieg, Barth, Leipzig, 1922,
IV, p. 198.
" Trauma und Psychose. Springer, Berlin, 1915.
242
of a bone splinter irritating the brain.
by a removal
effected
Bromide
sometimes effective against irritability. It is still more important

to be extremely considerate of the patient and to avoid every irritating
circumstance. Headache and similar symptoms frequently only beis
come worse through treatment, while ignoring it may make the conmore bearable. In addition a suitable selection and education
of those persons who are wont to come in contact with the patient is
necessary. It is taken for granted that the patient is trained and
practiced in a line of work carefully adapted to his abilities.
dition
n.
INSANITY IN BRAIN DISEASES
These psychoses also have little significance for psychiatry. The

is essential from a practical viewpoint is usually the basic
disease; but the psychosis must not be overlooked because of the possibility of its being mistaken for other mental diseases and neuroses.
thing that
Diffuse nutritional disturbances of the cortex in every case result in

the organic syndrome.
In connection with the psychical disturbances4a~thLjy^rious forms

of meningitis, Kraepelin discusses the insanity in cases of brain tumors.
Here too the most
different disturbances
have been described, and
the connections between the tumor and the psychosis are not often
may remain with hardly any psychic symptoms

run a course without any severe manifestations.
Brain pressure retards all reactions, but need not disturb them in any
other way. I have seen a case in which it might take five minutes
before the patient answered a simple question; but the answers were
appropriate. Of theoretic interest, even though still incomprehensible,
is the frequent occurrence here of the "facetiousness," which perhaps
clear.
Large tumors
or at any rate
may
appears as a local symptom of the base of the frontal lobe.
It
is
according to Schuster, tumors of the corpus
interesting also that,
collosum are regularly connected with psychic disturbances.
Where pronounced
it is
psychical morbid pictures are found in tumors,
usually a case of the organic
feelings,
Korsakoff
memory
symptom complex
(lability of the
for
comprehensible
disturbances,
reasons, because the nutrition of the brain
Under circumstances
still
etc.)
is
easily disturbed in toto.
unknown, catatonic symptoms
may
also be
connected with brain diseases, especially with tumors.
The
disturbances of the psyche in multiple sclerosis are mainly
those of the organic psychoses.

is
In the
field of affectivity, irritability
often in the foreground; in other cases
depression.
In most cases the diseased
it is
is
euphoria, or the reverse,
animated by psychogenic

symptoms;
neurotic
therapy
since these are amenable to the right psychovery important, and usually very easy, to recognize them.
it is
may
In later stages delusions and delirious conditions
The
243
diagnosis
is
Huntington's chorea, which

important.
also be seen.
based on the neurological signs of multiple
knew
The transmission
almost always hereditary,
is
more
is
a family in which four generations were so afflicted.
is
usually of the same variety.
But not seldom other
severe cerebral disturbances such as epilepsy, idiocy,
found among the
sclerosis.
relatives.
The psychic and motor
etc.,
are also
manifestations,
as a rule long unrecognized, appear stealthily mostly in the second

to the fourth decade, occasionally
still later,
and rarely
Such
earlier.
persons are often considered inattentive and careless and are blamed
appearance of which the motor-choreatic

The chorea in
once pronounced, looks exactly like Sydenham's dis-
for their clumsiness, in the
disturbances participate just as well as the psychical.

itself,
when
it is
ease, only the
movements
are mostly less brusque.
sphere one observes an organic dementia.
marked
is
indifference to the disease
generally noticeable.
When
In the psychic
Often, however, there
and about
their
own
affairs
is
which
the patients are no longer capable of
speaking and writing they usually take no pains at all to make themChanges of mood are not so rare but they
selves otherwise understood.
probably never attain the degree of a melancholia or a mania.

Death results in the course of a few decades during which the severe
mental
affliction either progresses steadily or
The brain shows markcc!)y
diffuse
shows minor fluctuations.
changes of the nervous
ele-
ments, which as yet have not been sufiiciently investigated to permit

of
an anatomical diagnosis.
Kraepelin includes in here the amaurotic idiocy of Tay and Sachs,

which affects mainly Jewish children in their first year. It is not a
form of idiocy but a peculiar brain degeneration involving the visual
apparatus including the retina and ends in death in several months
or years.
An
organic brain disease, which affects the cortex relatively
little
syndrome, is Encephalitis lethargica, the European sleeping sickness, which has no connection whatever with the African sleeping sickness. Anatomically it is a poUenccphalitis in which there is a round cell proliferation of the vessels and
Its favorite
in which more rarely there are also slight hemorrhages.
and
for that reason lacks the organic
location
is
around the Aqueduct of Sylvius but
it
also spreads to the
canal root ganglia and their surroundings and invariably descends into
the spinal cord but
matter entirely
free.
it
probably does not leave any part of the gray
The
physical
symptoms
are paralysis of internal
244
and external eye muscles, sometimes
also paralysis of the facial nerve,
parasthesias not only in the form of itching,
etc.,
but also pains and
burning, paralyses in general, and mild muscular rigidity.
The
de-
velopment of the disease is from several days to weeks; fever appears

mostly at the height of the disease; it is frequently not particularly
high and may disappear after a few weeks.
Psychotic symptoms of a toxic rather than organic character
appear chiefly in the initial stage. Thus one observes: motor restlessness, which sometimes lends a choreic character to the movements.
This is frequently accompanied by deliria, which resemble the ordinary
fever psychoses, but because of their complex character they may be
readily taken as hysterical, especially before the temperature rises.
In severe cases they increase to the point of apparent confusion. Somewhat later the clouded state often assumes the character of occupation
In
deliria, which alternate with the ever-increasing lethargic state.
milder cases one sees at least occupation dreams. Except in the most
severe cases the patients can be roused from their sleep and, after the
disappearance of the initial deliria, evince their meataJr-dearness, even
though strikingly uninterested in their own condition as well as in the
environment.
Left to themselves at the height of the disease they
invariably go to sleep aga4n. The^yperkinetic deliria of the begin-
ning are easily mistaken for catatonic especially because, in spite of

existing affects, the facial expression regularly has something rather
stiff
about
it,
and because the torpor may assume a
real cataleptic
The occupation deliria may occasion its being mistaken

The disease often results in death in the early
for delirium tremens.
weeks, in many other cases later, even after more than two years.
About two thirds recover almost entirely in the course of a greater
number of weeks or months. But the rigidity of the pupils is often
said to remain permanently.
The differential diagnosis is based
appearance.
mainly on the proof
symptoms: parasmovements and above all dis-
of the following encephalitic
thesias, hyperkinesis v/ith chorea-like
turbances of the eye muscle and eventually of the optic nerve; also
then the mania for sleep with the possibility of being aroused to an
intellectually clear condition.
What
excites the disease
the treatment
is
in.
Among
is
and the manner of infection are unknown;
symptomatic.
SYPHILITIC PSYCHOSES
the infectious diseases of the brain and
the most important.
To be
its
meninges syphilis
sure even without the confirmation of
245
a luetic process in the central organs there are already disturhanccH

at the beginning of the secondary stages of lues, which are designated
The latter are due in part to the psychic effects

which nowadays is no longer taken so light heartedly,
and in part probably to the direct weakening or poisoning influence
of the virus, which to be sure we cannot as yet define more exactly.
as "neurasthenic."
of the infection,
Manifold signs of milder disturbances of the nervous system, .such

as dizziness, headache, diminished pupillary reaction to light, an increase in the cells and albumin in the spinal fluid, which are frequently
a result of an antiluetic treatment, lead to the supposition that as a
some unknown early alteration of the brain or of the
third factor
meninges can produce or condition symptoms resembling those of

neurasthenia.
Sometimes the thought of being infected and the fear of the conseThere
quences of lues form the conspicuous part of the picture.
develops a hypochondriacal neurasthenia, altogether or mainly psychoan eager searching for morbid symptoms that might be
According to some, hysterical pictures are also
said to be produced by the infection.
genetic, with
ascribed to syphilis.
In other cases, according to Kraeyelin, one deals with a general

nervous uneasiness, increased difficulty in thinking, irritability, disturbance of sleep, pressure in the head, vague and alternating feelings
and
pains, later on anxiety feelings, pronounced depressions, dizziness,
clouding, difficulty in finding words, transitory paralyses, disturbances
and a rise in temperature. The latter group

might perhaps be ascribed to the third cause, or to
of perception, nausea,
of manifestations
some direct anatomical or chemical disturbance in the cranial content.

For a second group of syphilitic psychoses which are about equally
frequent in men and women we have an anatomical basis among those
one observes gummata, slowly progressing meningitis, and luetic vascuIn most cases one of these processes predominates, but
lar diseases.
;
the disturbance
is
rarely limited entirely to one of them.
The vascular
most often found alone but it frequently accompanies

alteration
meningitis and both together are often found in an affection which is
primarily gummatous. The combinations and the changing intensity
and location of the processes produce a great variety of the clinical
is
pictures, but the anatomical findings are as yet only roughly paralleled
with the
clinical.
The Gummata
in
themselves naturally produce the identical symp-
toms as other brain tumors

zation.
Luetic meningitis
in the region
of equally rapid
is
growth and similar
locali-
mostly localized at the base, especially
where the various optic nerves have their
exit, it
moves
246
'
rarely; also affects the convexity
The
variety of
and then usually to a
lesser extent.
symptoms caused by meningitis naturally depends on
the increase of the pressure and the luetic process, or on whether the
disturbances of nutrition extend to the cortex or not. The diseased pia
is
usually thickened, clouded, infiltrated with round
cells,
and shows an
increase in connective tissue.
The vascular changes

non-luetic
the
in
themselves produce symptoms similar to

They can affect more extensively
arterioscleroses.
The
either the large or the small vessels.
shows
itself in
syphilitic vascular disease
the larger arteries in an exuberance of the cells of the
intima and adventitia, in the former to the extent of occluding the

The elastica becomes split apart. The process has a certain
lumen.
tendency towards regeneration, but when the arteries of the brain are
involved, the region they supply is usually permanently injured in
the way of a simple gradual destruction of the nervous elements with
an
and hemorrhages.
and seems to extend from it
infiltration of the glia to the extent of softenings
The
process
is
most marked
in the pia
to the cortex.
In contradistinction to paresis one notes here a massive infiltration of the entire vessel with round cells,
among which
the plasma
a small minority or are absent, while in paresis the

marked infiltration of the vessels with plasma cells is particularly
cells constitute
characteristic,
to this disease.
and the extensive exuberance
What
is
also characteristic
of the intima
is
is
foreign
the more circumscribed
dissemination in contradistinction to the diffuse disturbances of paresis.
The
luetic arteritis of the smaller vessel often consists in
largement and proliferation of the
cells in
but without an infiltration of round

structive processes one also finds
cells.
an en-
the adventitia and intima

Side by side with the de-
newly formed vessels
in the pia
and
in the brain.
The brain substance is naturally injured in the most varied ways

both qualitatively and quantitatively by the alteration of the vessels
and the meninges.
The organic-nervous symptoms can assume
pretty nearly
all
forms
that are produced by the contents of the cranium and the spinal canal.
The most frequent symptoms encountered are reflex disturbances of

the pupils, pressure symptoms with clouding of sensorium, desire for
sleep,
etc.,
and apoplectiform and epileptiform attacks as well as
attacks showing a Jacksonian character.
those of the organic psychoses.
The
to those of arteriosclerotic insanity

in
The psychic symptoms
are
specific peculiarities are similar
for the self-evident reason that
both diseases the cortex needs not be affected in toto.
The
per-

sonality
retained for a long timc.'^
is
outward demeanor and take part

so
much
in
The
247
patients maintain
external events.
Judgment
tiieir
is
not
disturbed; thus a far-reaching insight into the disease exists,
As in arteriosclerotic insymptoms, both as to time and number,
times even considerable clearness.
in quiet
sanity, here, too, the psychic
many good individual functions cause surprise when

found where others have been lost; moody fluctuations can appear
temporarily, regardless of the general course toward improvement or
are lacunary:
aggravation.
After
all this,
expected.
It also
no sharply distinguishable morbid pictures can be

happens that a genuine brain syphilis can be fol-
lowed later by a real paresis. Kraepelin makes the following distincForms with brain pressure, mostly based on gummatous
tions:
growths, clinically not essentially differentiated from diseases resulting
from other brain tumors, and the syphilitic pseudoparesis (corresponding approximately to the post syphilitic dementia of Binsiuanger)
In the latter it is most frequently a case of a morbid picture very
similar to the sim-ple demented form of paresis in the physical spheres
;
besides the rigidity of the pupils to light, the frequency of irregular
paralyses of the ocular muscles, and disturbances of vision are the
most important
may
to be mentioned.
Disturbances of speech and writing
be present but they then are of a different type from that of
paresis.
Much
rarer
is
the delirious confusion of
classed with syphilitic pseudoparesis.
Marcus which
is
to be
It manifests itself in rather
sudden organic deliria with symptoms of insomnia, confusion, anxiety,

mistaking the environment, hallucinations of hearing and sight, mostly
of a terrifying content, active excitement, and acts of violence against
Besides these one also finds organic
one's own person and others.
nervous symptoms.
Other forms resemble expansive paresis.
The prominent feature

an organic memory disturbance (''Korsakoff'').
Syphilitic pseudoparesis takes an entirely irregular course; it can
be stationary for years. The outcome in all cases, when no antiluetic treatment intervenes or wdien this is not effective, is an organic
of the fourth group
is
dementia combined with paralysis. The patients die of intercurrent

diseases, or from weakness, or cerebral attacks, or marasmic pneumonias,
The
not be
etc.
differential diagnosis
made
provement
"Cf. pp.
between pseudoparesis and paresis can-
at once in individual cases with absolute certainty.
Im-
in the course of antiluetic treatment does not exclude the

139-282.
248
element of coincidence.
The
probability favoring cerebral syphilis
is
the lighter intensity and extent of the psychical disturbances. It

may also be worth noting that in paresis milder psychic symptoms
have in most cases preceded the physical

symptoms, while here both groups usually appear together.
of "the neurasthenic" type
According to Plant the following should be especially considered:

in the blood proves lues; its absence permits the exclusion of the possibility of cerebral lues with a probability of 80%. A
Wassermann
fluid in the advanced stage of

an organic (meningitic) process
in the central nervous system; the same holds in Nonne's Phase I.
pronounced pleocytosis of the spinal

lues (not in the initial stage) proves
Wassermann
in the spinal fluid proves the luetic affection of the central
nervous system; contrasted with the invariably strong reaction in

paresis (already plain in 0.2 ccm. of the liquor) it is here weak; the
Lues cerebri may be excluded with
fluid must be tested up to 1.0 ccm.
great probability
when
there
is
no Wassermann in tested
fluid,
an
absence of Wassermann in the blood, an absence of pleocytosis, and,
with least certainty, when there is a failure of the globulin reaction.

Apoplectic cerebral lues is supposed to be the commonest of the
syphilitic psychoses.
mon
It presents
about the same pictures as the comit appears most often at an earlier
post apoplectic dementia, but
time of
life,
bilities of
shows a greater desultoriness and regenerative possi-
the symptoms, and then again as a sign of brain lues
it
shows frequent paralysis of the eye muscles as well as pupillary

disturbances.
Furthermore there is a luetic epilepsy which differs from the other

forms by the existence of lues, its appearance late in life, occasional
(not invariable) cure through antisyphilitic treatment, and finally
by disturbances
An
of the eye muscles.
entirely divergent
form without plain psychic organic symptoms
has been described in detail chiefly by Plaut, as hallucinosis of

syphilitics, but he did not establish with entire certainty the concepIt is a question of cases which as yet are
tion of a particular disease.
not to be differentiated clinically from mild paranoid types with
senseless delusions, voices, very rarely other hallucinations.
Halluci-
nations referring to the body probably also occur; the patients some-
times
feel as if
they were hypnotized.
However, pronounced
specific
schizophrenic symptoms, especially actual dementia, are absent. Depressions with ideas of sin and, more rarely, exaltation of a minor
degree, but
still
with grandiose ideas, are also met.
a certain feeling of sickness.
The
course
is
Usually there
similar to
many
is
cases of
schizophrenic paranoid types and shows irregular fluctuations
up to
249
hallucinatory excitations, which, however, remain without disorienta-
Cures do not seem to occur in spite of antisyphihtic treatment.

Sometimes one also notes paralytic manifestations, pupillary disturbances, bladder weakness, disturbances of speech and writing, dizziThe disease usually breaks out more
ness and other cerebral attacks.
than ten years after the infection.
tion.
Plant also described similar acute cases with symptoms of anxious

and delusions of persecution without disorienta-
excitation, with voices

tion,
which lasted from 18 days
The most important
to 10
syphilitic
months and usually recovered.
affection
of the
central
nervous
Dementia paralytica. Contrasted with the other luetic diseases it has some peculiarities in common with tabes and is not seldom
associated with this disease as taboparesis. But besides this there are
"Tabes psychoses" which neither clinically nor anatomically belong
to paresis. They mostly show mild indications of organic symptoms,
especially lability, but also disturbances of memory, attention, etc.
In all other respects they take very different forms. Following Kraepelin affective and paranoid forms are mostly differentiated, of which
the latter are the more frequent.
system
is
The
affective pictures manifest themselves in persistent moods, in

form of depression,, irritability, or abnormal euphoria. The
paranoid jorms develop vague delusions, usually of persecution, intermingled at times with delusions of grandeur; they also have hallucinations of hearing and occasionally of sight, more rarely of smell and
taste and of body sensations.^^
Even in the chronic course, these conditions show a rather marked
fluctuation; on the other hand cases are not rare in which the disease
manifests itself only in acute shifts of such hallucinations and delusions mostly with anxious excitements extending to the point of
delirium.
Between these forms there are all combinations and transitions, i.e. cases in which the delusions continue more or less in the
clear state and now and then one also observes deliria. In clear mental
the
states all these patients are usually allopsychically oriented.
The much more frequent occurrence
of disturbances of the visual
nerves in tabes with psychoses than in mere symptoms of the spinal
cord makes
it
probable that the tabes psychoses also are based on a
variety of cerebral lues.
Hereditary syphilis also generates numerous brain diseases, which

symptoms, they range from simple nervous-
are associated with psychic
ness
up to
idiocy, epilepsy, infantile paralysis,
and other progressive
forms of dementia which have not been properly described as yet.

" Cf. pp. 64-65.
250
According to Kraepelin a part of the luetic idiocies already originated within the uterus, chiefly through meningo-encephalitis; others
develop later, some suddenly, others gradually; later they may again
become stationary. Local disturbances of the brain texture, e.g.

through arterial occlusion, naturally leave pictures similar to those
of acute encephalitis. According to some about 10% of idiocies
are conditioned by syphilis.
disturbances,
vehemence,
maliciousness,
Under
In some, besides severe or very slight
one finds chiefly anomalies of character,
intellectual
and uneducability
cruelty,
certain circumstances paranoid pictures
general.
in
also appear.
In all
mostly impaired; the children
develop late, remain weak, small, or deformed. The luetic cerebral
symptoms may appear at any time, but most frequently in the first
these forms the entire constitution
But
years.
infantile paresis
very rare cases the outbreak
may
is
is
first
begin in the second decade; in
said to have been delayed to the fourth
or fifth decade.
The
diagnosis of paresis in children rests on the
The
same
principles
proven
therapy or by the anatomical
examination. At all events the specific origin is indicated with great
probability by the demonstration of syphilis, such as direct luetic
as in adults.
other hereditary syphilitic forms are
as definitely syphilitic
manifestations,
positive
lower
semicircular
by the success
edges
of
Wassermann, Hutchinson's
middle
the
of
first
upper
namely,
triad,
incisors,
keratitis
parenchymatosa, and sudden deafness in childhood, further by the eye
symptoms and by the

IV.
fluctuating progressive course.
DEMENTIA PARALYTICA
Dementia paralytica, which
is
commonly
incorrectly called soften-
ing of the brain and in science briefly, paresis,
brain disease with the general
symptoms
peculiar physical manifestations.
is
a peculiar syphilitic
of the organic psychoses
and
mostty runs a course of a few
It
years and ends in death.
Besides the above mentioned
^*
psychical peculiarities which differ-
entiate paresis from the other organic psychoses, there are
but as yet
it
to formulate them.
On
Just as in tabes
(Arg>'ll-Robertson)
gishly or not at
all,
or better preserved.
Cf pp. 235-236.
.
others,
still less
the other hand the physical
specific signs.
"*
still
has not been possible to isolate them clearly, and
that
is,
we
symptoms
of paresis are plain
find reflex rigidity of the pupils
the pupils react to light slowly or slug-
while reaction to accommodation
The
is
usually longer
pupils are frequently unequal, abnormally

dilated or abnormally contracted,
251
and not seldom changed
Psychical pupillary reaction (to pain, mental exertion)
is
in
form.
also im-
paired, but not to the extent that these disturbances would show a
proportionate relation to the reflex rigidity of the pupil or to the stage
of the disease.
The remaining
tendon reflexes
have nothing characteristic about them; the
reflexes
in
simple paresis are naturally exaggerated because
their control through the cere-
brum
diminished;
is
with
plicated
when
there
is
when com-
tabes,
that
is,
an interruption
of the peripheral spinal reflex

arc,
they are absent at least in
the lower extremities.
The coordination
of
muscu-
lar action suffers in a striking
manner which
is
most pronounced in the delicate adjustments of the movements of
speech.
Individual sounds are
badly formed, successive sounds

are "run together," the patient
prolongs
the
semi - vowels,
sounds and syllables are omitted,
repeated,
(stuttering
of
or
misplaced
and
syllables),
occasionally the sound compo-
nents of a word are changed.^^

The psychic disturbances are
naturally
also
inattention
present,
impressibility or amnestic
culties,
since
and weakness
make
of
Fig.
1.
pression.
The
It
typical flabby paretic exas if the mimetic
looks
modelling had been erased by excessive

retouching, while the eyes betra\' an affective life. If the ej'es are covered, the
face looks like that of a sleeper. Asymmetrical noso-labial folds.
diffi-
repetition as well as spontaneous speech
more
difiicult.
Especially in the later stages, the voice easily becomes trembling,
monotonous, and towards the last speech is usually slow, babbling,

and hardly comprehensible.
In many cases the tone of the mimetic muscles decreases, the nasolabial folds seem wiped out (often more so on one side), the finer
"Ziehen speaks of "hesitating speech." It is, of course, correct to say that
paretics speak slowly as soon as coordination becomes seriously difficult
but
the term should be limited to the entirely different epileptic speech disturbance
;
to which
it is
better suited.
252
mimetic movements are lost. As a result the face assumes a flabby

and stupid expression, which often enables one to recognize the paretic
immediately. Even earlier tremors of individual groups of the facial
muscles are sometimes seen ("Heat lightning").
The tongue is often put out hesitatingly and shows tremors of
individual muscle groups.
The handwriting is changed in an analogous manner to speech.

Aside from the frequent coarse and irregular tremors of the organic
brain affection the lines do not go where they should; the letters become abnormally
large
and long and unequal; curves are made with

corners, etc.; pressure
is
The psy-
irregular.
chical
difiiculties
are
as follows: omissions,
repetitions, interchange of letters, syllables

and
words,
wrong
blotting,
cor-
rections, incorrect syntax, the

fit
the
end does not

beginning
the sentence
nally, only
scribbling
2.
of
fi-
illegible
produced.
Disturbance of the
Paretic.
In spite of a strained pose, expressed in the frown and eyes, the part of the face
below the eyes remains flabby.
Fig.
an
is
and,
gait usually
plain
becomes
somewhat
later,
unless tabes with

characteristic signs of the psychosis precedes.
The
foot misses
its
its
mark, deviating now to the front, now to the rear or side ways.
Thus the walk becomes irregular, swaying, with legs spread apart,
and at the same time weak, and in certain respects spastic (but not
in the sense of spastic spinal paralysis with its difficulty of freeing the
tip of the foot
from the ground)
Inequality of the two sides, "hangIn the last

is not rare.
ing" of the entire body to the left or right

stages walking
is
generally impossible.
Gradually the entire muscular system attains a condition of extreme spastic paralysis; the patient becomes entirely helpless. The
involuntary muscular system is also affected: swallowing becomes
difficult and impossible the intestines no longer advance their content
;
more frequently incontinentia
alvi et urinae exists, the latter often
together with paralysis of the bladder.
253
UÂOfi^
Paresis.
Paretic script. Disturbance of coordination is espethe H., the former showing it by the intemiptions in
the lines, numerous but vain efforts to continue the strokes. This is particularly
seen in the letters r and in the word beautiful, which is hardly legible. In example
(b) one sees besides some reduplications of strokes and letters and a fusion of
Figs. 3a
and
b.
cially plain in the
letters, etc.
M. and
254
The blood
in
most cases shows a positive Wassermann, the liquor
cerebro spinalis nearly always. The latter ^^ is mostly under increased

pressure and because it contains globulin it is clouded by the addition
of an equal
amount
saturated solution of
of
ammonium
sulphate
abnormal amount of albumin

(Nissl reaction with the Esbach reagent) and shows always a hyperlymphocytosis, in which the presence of plasma-cells especially (and
eventually broken-down cells) is said to be important for the special
(Nonne, Phase
I)
it
also contains an
The number
diagnosis.
of cellular elements
may
rise in paresis to
several hundred in the cubic millimeter.
The above mentioned physical symptoms must be classed with

symptoms of paresis, even though in very rare cases
the fundamental
may be only indistinctly evidenced throughout the entire course.

Neither in the time of appearance nor in regard to their intensity
is there a definite correlation with the psychic defects, and they may
they
Disturbance of coordination
appear earlier or later than these.
is
not seldom found afterwards in earlier specimens of the patient's handwriting, and the pupillary disturbances especially may manifest themselves years before the outbreak but
may
be lacking in a pronounced
psychosis.
Among
the accessory physical
most frequent.
They resemble
symptoms the
paretic attacks are
those of other severe brain diseases.
Mostly, but not always, they appear suddenly; consciousness is usually

lost and then convulsions appear, in part general, in part somehow
There is
localized, sometimes also they are of the Jacksonian type.
no "striking blindly" as
may
is
so
common
last for seconds or for days,
They
in epileptiform attacks.
and consciousness often returns before
the convulsions cease.
Besides these attacks, which are characteristic of gross brain lesions

in general,
mere fainting
The
may
spells, epileptiform
and apoplectiform attacks
or monoplegic paralyses,
which mostly have a spastic character and need not be based on ascertainable anatomic lesions, even when they no longer disappear, which
Attacks of fever lasting for hours or days may be
is the exception.
based on abnormal conditions of the heat centers or on a sudden inoccur.
crease of the
latter
leave half sided
spirilli.
Aside from decalcification of the bones various kinds of trophic

disturbances occur.
Decubitus cannot sometimes be avoided in the
final stage, not only because of the paralyses and uncleanliness but
because of trophic changes.
the application of violence.
"Comp.
pp. 238. etc.
Othaematoma may
also appear without
THE INDIVIDUAL MENTAL DLSEASES
255
The weight of the body is strongly influenced by the diseaHe; the

euphoric forms are mostly well nourished, sometimes till death; but
usually marasmus appears in the final stage of the disease. Other
cases are marasmic from the beginning.
The
appetite
at times excessive, at times lacking, as a rule
is
fluctuating with the prevalent

especially in the
Sleep
is
mood exaggerated
very variable; in
of the
all
in the quiet stages preceding the
in the last stage the nights easily

is much rare.
The sexuaUty is
gorging often exists,
demented stage
manic form.
excited states
deep dementia
become
is
naturally brief;
it is
mostly normal;
it
restless.
Pathological sleepi-
ness
forms the libido
is
usually changed; in the beginning of the manic

mostly increased, later potency disappears first,
then, also, the desire.
Like tabes, paresis also

which, however,
may
vision, in the course of
ness
is
an exception.
is
sometimes accompanied by optic atrophy
fluctuate strongly in a striking manner, that
months becomes worse and
is,
better; total blind-
Paralyses, mostly transient, of individual eye
muscles are not so rare (especially in the incipient stages)

degenerations of individual nerve roots may occur.
definite
Sensory symptoms in the form of headache, ordinary" and "ophthalmic" migrain, and other parasthesias are not rare and are prominent,
especially in the preparatory stage, where they are taken for neuritis
and rheumatisms. The very frequent hypalgesia or analgesia which
mostly affects only the skin, is diagnostically important.
Among the psychic accessory symptoms endogenous affective
fluctuations of the manic or melancholic type dominate the external
picture so frequently that they have been used as characteristic of
sub-groups.
Hallucinations (almost entirely of sight and hearing) do not play

a large part; most cases run their course without them.
Only rarely
are illusions prominent for any length of time.
On
the other hand delusions are frequent and are mostly connected
They are not nearly so fixed as in the

paranoid conditions, and especially in the manic forms they change
with the emotional shiftings.
in extent and intensity with the strength of the affective fluctuations

and the weakness of judgment; they also increase through preoccupation with them. The patient has the idea that he owns twenty horses
as soon as he has imagined this, it is not enough and he owns one
hundred, then two hundred, etc. Delusions may also be provoked or
modified by remarks: The patient is asked whether he did not have
a rank in the army and he readily becomes a general- They are sense-
256
less,
partly because of the enormous exaggeration, partly qualitatively:

become rich by purchasing a house with a mort-
paretic wants to
gage of $70,000, that pays $1600 interest; he wants to earn a million

with a toboggan slide: "Admission with a bottle of fine wine two
dollars." Another buys for his own use one hundred cases of macaroni and all sorts of perishable things in similar quantity, he orders
"a boat load of champaign."

In some cases severe focal symptoms are noticed, indefinitely circumscribed paralyses of the cerebral type {facial nerve inequality especially of the lower branch is very frequent) aphasic and apractic dis,
In the later stages manifestations of irritation as

smacking the lips, grinding the teeth and other spasmodic, more or
less coordinated movements sometimes appear.
Especially in the final stage, symptoms also occur that externally
turbances, etc.
look the same as those of catatonia and cannot as yet be properly

from them; they show themselves in manifestations
differentiated
which one
inclined to designate as verbigerations, stereotypes,
is
and
echopraxias.
rule paresis results in death within a
As a
Course.
few years.
so-called cures, which are mentioned in the literature of the
The few
(wrong diagnoses? long remissions?). In rare

may last a decade or even longer and
even without a plain remission a case may be drawn out for many
That is so rare, however, that it should not be considered.
years.
The galloping form may result in death after an excitement lasting
subject, are doubtful
exceptional cases a remission
eight days.
probably always gradual, even in the case where an

makes the disease manifest to those around it.
Pupillary disturbances as well as transformations of character in many
cases can be shown to have taken place a decade before the actual
outbreak and symptoms like those of neurasthenia may for a few years
The
onset
acute attack
is
first
exclusively announce the severe disease.
But when the

simulate a cure.
is once noticeable, extensive remissions may

This hardly ever occurs in the simple demented
paresis
form.
The
may
different manifestations
sequence.
In the prodromal stage,
i.e.
appear
in
an entirely irregular
before the disease
is
recognized,
pupillary disturbances and those of writing, and transformations of

character, are
most frequent.
neurasthenic symptom, a paralytic
attack, or another physical sign
may
a pronounced psychic syndrome,
e.g.
begin the action just as well as

a senseless or criminal act.
For
the later stages, too, no rules can be set up, except perhaps that the
267
excitements in severe dementia naturally readily assume the character

of confusion.
As the most frequent premonitory symptoms should be mentioned

the pupillary disturbances and in complication with tabes the absence
of the patella reflex, then irritability, anxiety, excessive ambitions or,
the
unusual weakness of
reverse,
will,
twilight
states
lasting
for
minutes or hours, very similar in appearance to the epileptic, often

with some incorrect act, attacks of dizziness, fainting spells, transient
double vision, temporary failure of speech, sleep disturbances and
especially the neurasthenic syndrome.
The
same in the different forms; nonabout by the affectivity (euphoric in

most cases, depressive or indifferent in others), and by the existence or
absence of erethic conditions. The individual morbid pictures will
be discussed below.
Death results in the uncomplicated cases from marasmus with or
without pneumonia. Paralysis of the bladder and decubitus give
last stage is essentially the
essential differences are brought
occasion for infections of
lowing
and
respiration
may
Paralytic attacks
Paralysis of the muscles of swal-
all sorts.
may
produce
pneumonia
Many
also prove fatal.
patients
and choking.
come to grief
because of their motor or psychic deficiencies; suicides occur in the

depressive,
more rarely
The duration
in the simple forms.
of paresis
is
difficult to
determine.
The
better the
anamnesis the further it can be dated back, not so seldom to a decade

before the manifest outbreak. From this period on the disease lasts,
on the average, about three years; the shortest course runs in the
agitated forms. In all forms, except the agitated, single cases may
be protracted over a very long period; the maximum noted so far
in one case is thirty-two years.
Grouping.
To
present the different clinical pictures of paresis,
main types have been differentiated into which most cases can
be classed. But there are continuous transitions from one form to
another.
The individual case, however, remains usually, not unexfour
ceptionally, within the type of the
form
it
has once assumed.
In the simple demented form, stronger exaltations and depressions, delusions, and confused states are lacking.
On the other hand
1.
besides the typical organic dementia
it
exhibits as a rule the different
physical symptoms, especially attacks.
that the patients very

simpler this
is
the later
At
For self-evident reasons
much
it is
else is noticed
than
gradually decline in their occupation
the
usually recognized rather late.
it is
seen,
demented, awkward, and weaker.
first
not
then they become more
and more
258
2.
or expansive form, also called the classical form,
The manic
type recognized, often becomes manifest

through a very acute manic attack with a feeling of intense joy and
power, flight of ideas, enormous impulse to activity in which the most
senseless delusions of grandeur betray the deep seated disturbance
because
it
was the
of intelligence.
first
The
patient
is
not only God, but possibly a super
and with millions of ships as large as Lake

Superior, he constantly brings home diamonds from India, hunts on
the moon, has invented a bicycle, with which in three minutes one
can ride over land and sea around the earth, etc. He is a general,
salutes everybody at the railway station and whoever does not respond
to the salute he wants to have shot. Paretic women are the most
beautiful that were ever on earth, all human beings are their own children whom God brings forth every second from their womb. The
imagination does not always reach so far, and in the later stages of
God, he possesses
trillions,
dementia the evaluation of the possession sometimes takes the place

The patient boasts that every month he kills five
of its magnitude:
or six pigs; he can lift a half a hundred weight; he tells that he has
inherited a dollar or that he has a fine hat at home, with the same
if he owned the earth.
Delusions of grandeur, pressure activity, and lack of critical attitude are often expressed in inventions which are usually colossal non-
satisfaction as
sense.
At
times, however, something less stupid
may
result.
Thus
a man suffering from paresis invented a mixture to freshen up high

hats temporarily and supported himself with it for two years after
he had become useless for other work. Another speculated on the
rise
of cotton prices while a
fall
was
generally expected and
won
nearly half a million francs.

3.
The melancholic
or depressive
form usually begins
the fluctuations also are rarely so great.
come out
of their depression.
take the form
The
less
acutely;
patients usually never
delusions are just as senseless but
and especially
of
defined in various ways.
of ideas of impoverishment, of sin,
the hypochondriacal and

4.
The
The
nihilistic types.
rather rare agitated form
is
should like to include here only those cases in which one sees violent
motor excitements with confusion and failure to recognize the environ-
ment, without a manic condition; in addition hallucinations and

Furthermore one
illusions of hearing and vision invariably occur.
also finds coarse cerebral irritating manifestations such as gnashing
of teeth, convulsive movements, later carphologia.
The
disease thus
runs a course resembling the picture of the old "acute delirium"; the
patients exhaust themselves after a week or more and therefore usually
259
succumb during the first attack. In milder cases the disease drags
along for months and in very mild cases remissions may even occur.
Other observers designate also as agitated those cases of manic
show marked excitement and rapidly succumb to exhaustion, cases which, corresponding with the virulence of the morbid
paresis which
process,
show more confusion and agitation than mania and pressure

From the two forms described those that run a rapid fatal
from one to a few weeks, are distinguished as galloping paresu.
activity.
course,
In the common classification one does not find euphoric paresis

though showing a persistently exalted mood with some
which,
grandiose ideas, never reaches to the height of a manic condition.
To
may
be regarded as an intermediate form between simple

and manic paresis into both of which it extends without limits but
be sure,
it
because
it is
to emphasize
the most frequent form, at least with us, I should like

it
particularly.
Of the related forms one should mention the cyclic, in which manic
and melancholy states alternate for a time with or without intervals
of
an indifferent mood. It is very rare.

Many cases, which later are to be classed mostly with the depres-
somewhat less often with the simple form, are conspicuous because of an extended incipient stage, closely resembling neurasthenia
sive,
and frequently mistaken
for it.
If the nervous symptoms are permasometimes called neurasthenic paresis.
A paranoid form is rarely met which for several years impresses
one as paranoia and only then takes the usual course. The picture
may also be complicated by depressive moods and corresponding
nently prominent,
it is
delusions,
Tabo-paresis
is
the designation for the rather frequent association
of paresis with tabes;
it is supposed to be peculiar also in the entire

combination of the paretic symptoms, in so far as it runs a slow course
with less pronounced real paretic manifestations.
A catatonic variety has also been distinguished but it is still an

open question on what the addition of catatonic or apparently catatonic symptoms is based (the occurrence of paresis in a case of schizophrenia or in a schizophrenic disposition?).
Some
which in other respects are different, incline to stupor

weeks or years. Here it is possible occasionally, but
not always, to prove a complication with a previously existing
lasting
cases,
for
schizophrenia.
Morbid Picture of the Manic Form. In individual but rare cases,

occulo-motor paralyses, pupillary rigidity to light, diminution of the
tendon reflexes precede the acute outbreak several years. The ocular
260
by antisyphilitic treatment; but the

often.
These cases then have a pause
less
improve
other symptoms
real
which
the
onset does not differ from the
after
years
of several
paralysis can usually be cured
usual outline that follows.

A man, mentally and physically robust, begins
complain of "nervous"
symptoms; a
little
or fatigue, either general or locahzed,
comes
This
irregular.
is
e.g.
now and then to

headache or head pressure
in the eyes; his sleep be-
considered natural and
is
ascribed to over-
work. Treatments at times seem to bring about a temporary improvement, sometimes none; a review of the history extending over longer
periods would show that the uncomfortable condition gets rather worse,
and the ability to work decreases. Topalgias or any other pains,
which are interpreted and treated as nervous or rheumatic, are sometimes quite prominent.
At the same time,
many
or even a few years earlier there begins in
cases a very gradual transformation of character that
stealthy that
usually overlooked.
it is
now and then seems
The
selfish or careless in
careful
is
so
head of a family
a particular act, perhaps,
contrary to his previous disposition, he engages in a careless business

transaction or without sufficient reason he at times does not feel like
going to work.
An able country doctor gives up his practice he wants to be a surgeon and enters a clinic as an assistant but fails in spite of other good
qualities because he does not learn to control asepsis sufficiently. Then
he buys a second house and arranges it as a sanitarium that prospers
Another physician begins enthusiastically and with
for a few years.
great success to carry on abstinence propaganda, but then leaves
;
become the head of a cooperative private institution

Both physicians after a few years are stricken
with pronounced manic paresis.
Later in the disease intellectual disturbances become plainer, even
though in the incipient stage they are rarely noticed and still less coneverj'thing to
with a doubtful future.
sidered morbid.
once figured in
The physician who took over the new

all
institution
seriousness that he need only prescribe double the
length of stay in the sanatorium to his patients, then he would have
many inmates, and this he did several years before the disbecame manifest; later he was still capable of picking up in a
clinic a considerable knowledge of psychiatry and of establishing a
twice as
ease
thriving city practice.

Intelligent relatives are first conscious of the increasing lability of
the feelings, at times in the sense of irritability, at times rather in the
sense of sanguine temperament with emotional flights,
up and down.
201
Shortly before the outbreak one notices trespasses against good morals;
the patient begins to cheat at cards or he becomes sexually ofTcnsive
or commits crimes.
There
is
reason to suppose that such prodromal symptoms arc
not lacking in any case; but they are not always noticed.
cases the acute manifestation usually surprises the family.
In mont
Within a few weeks, often even within a few days, a manic condimood, tireless
pressure activity, and flourishing delusions of grandeur. The patient
tion attains its highest point with flight of ideas, exalted
feels
capable of anything, undertakes senseless transactions, makes
inventions, becomes engaged to three
women
at the
same time,
for
whom
he bought three identical brooches with stones made, in order

to send them to all three on the same day. Whoever hinders him is
brutally treated as an enemy; it comes to noisy scenes, peace and
decency are violated, and then the patient is quickly taken to an instiHere right at the beginning one often finds, in mild or pronounced form, the symptoms referring to speech, pupils, and hypalgesia
tution.
of the skin.
The absence
quickly, the patient
around.
Thus
is
of critical faculty usually increases very

God, the President, or Pope he throws millions
;
a chemist discovered the fourth dimension: "right
left,
two dimensions, front rear, two more, equals four, strange that the
world had to wait for me to find this egg of Columbus."
Such patients are restless day and night; they tear up things, rattle,
sing, and scold.
After a few months the manic condition usually dies down and gives
way
to a quiet euphoria.
The
symptoms
physical
also
may
subside,
complete disappearance. The patient now considers

himself cured, he has a certain insight concerning his excitement, and
corrects the worst delusions but considers the attack not so severe, or
In some cases, which
as the self-evident result of confinement, etc.
are described as rareties, he may for a few years regain complete
in rare cases to
capacity for work.
Usually, however, he
is
more
or less
markedly
re-
duced, affectively too labile and uncritical, but, in spite of this, he

may be considered healthy by his relatives. And herein lies a great
danger. If he has not ruined his fortune at the beginning of the attack,
he is now in danger of doing so. IMoreover it is sometimes noticeable
that he does not observe the rules of social intercourse; he may go
to sleep at a gathering and pass the matter by with indifference.
The remission usually lasts a greater number of months then there
;
sometimes follows a manic condition similar to the first, more

quently a milder excitement with increased dementia. This game
be repeated several times.
number
of delusions are retained
fre-
may
and
262
'..'..
jjvv.
Si;.-:-
->.;'....;.
Fig.
4. Cortex
-.S
in paresis.
i-^.'
''".'
.
Cells stained.
./*
^.. ^j,;*;:
;V..--.'
'
Disturbance of the layers.

Infiltration of small
ing of the pia.

Enlargement of many vessels.
the pia and walls of blood vessels.
l-'-r.-;'''
.-
-M
,./
Thickencells into
203
produced at every opportunity, even during the remission: "Tomorrow

In many cases such ideas are produced
I dine witli the President."
in ever increasing numbers and in even more senseless quality, and
Educated patients
are mingled with the products of confabulation.
endeavor at the same time to retain their bearing; but they do not
succeed in every respect; they easily become filthy, and lose their
With or without external causes excitements arise; if
self-control.
the physician, as
is
often the case,
thing, the latter promises to
regiment, a billion soldiers,
have
who
must
his
refuse the patient some-
head cut
will shoot
down
off;
he summons a
the physician and
But very soon he is friendly and

Excitements from within usually last longer, sometimes
the institution and the entire city.
happy
weeks
again.
or months.
In the meantime paretic attacks
may
occur from which the patient
mostly recovers very well.
As times goes on, the weakness of judgment and lack of critical

more marked, new material is less and less produced
faculty becomes
the patient
still
repeats in a stereotype fashion his old ideas
he indus-
and becomes unclear in all respects.

He becomes entirely incapable of comprehending the environment;
he does not know where he is, and what happens about him. Even
without aphasic disturbances it ultimately becomes impossible for
him to comprehend even the simplest requests, let alone comply with
triously gathers all sorts of refuse,
The physical symptoms take the upper hand, his speech becomes a hardly comprehensible babble, his helplessness in all respects
becomes worse, the patient has to be kept in bed more and more, he
cannot attend to any of his needs himself, he becomes unclean, partly
from psychical indifference, in part from paralysis of the sphincter
muscles or from incontinentia paradoxa. He chokes easily, or in great
gluttony he shoves in so much food that the mouth cavity and throat
them.
are completely stuffed.
The
is mostly noticeably good for a long time,

In some cases marasmus occurs during the final
The end
stage; and in rare cases it is followed by marked obesity.
state of nutrition
often until death.
finally results from an attack, a simple cortical paralysis, a terminal

pneumonia, decubitus with infection, or a fracture resulting from
the osteoporotic bones; in the majority of cases death comes without
the patient being conscious of his misery and without the disappear-
ance of his euphoria.
Morbid Picture of the Depressive Form. Many of these patient-s,

simply because they are timid, exhibit the "nervous symptoms" at an
early stage and to a
marked
degree.
Such patients are frequently
264

treated for several years as neurasthenics.
265
Ultimately, however, one
notices the decline of the ordinary psychic functions, or the paretic
physical symptoms.
in
The
depression becomes worse, coming either
attacks or progressing gradually;
it
is
usually
connected with
An
attempt at suicide often brings the patient into the institution.

There he is terribly unhappy, he feels that he has committed every sin, he is punished in an appalling manner here on earth
as well as in the hereafter, the world has come to an end or has never
existed, his entrails have been consumed, and his limbs are wooden;
"I have large legs, I no longer have any legs, I do not exist." Some
anxiety.
Paresis.
Fig. 6.
Gliosis at the cortical edge
and around a smaller blood
vessel.
bear their fate with a certain outward calm and remain in bed, others
run about, cling to everything, push away, scream incessantly, until
death relieves them.
The
picture of simple paresis
out nervous symptoms,
is
more monotonous.
With or with-
often slowly in the course of several years,
work and
forgets
to pay
careless,
and
He becomes flighty
in his social conduct.
becomes
money.
He
any
his club bills or gets served without having
often more rapidly in a few wêeks, the patient fails in his
with his clothes, although he neglects himself,

scolds if everything is not according to his wishes, buys four umbrellas
at once without knowing why, or cannot find his way in the city. The
selfish,
dissatisfied
266
cook puts too much salt into the food or none at all, or pours petroleum
on the salad and puts sugar into the soup; later she throws into one
pan "everything that is

senseless shape and size.
in the larder."
A woman
The wife
knits stockings of
patient brought into the institu-
Aside from this,

tion five pounds of cigar butts in her coat pockets.
the mental and physical basic symptoms gradually become plain; the
latter often follow paralytic attacks which seem to be here particularly
The
frequent.
Fig.
7.
patient mistakes places, calls a seal a sleigh ride, etc.
Paresis:
Infiltration of
round
cells into
a cortical blood vessel.
Mild excitations are sometimes observed.
The
patients
change
their vocation several times, they are little concerned with time
and
they get up in the middle of the night to take senseless
custom,
e.g.
walks.
Frequently they indulge in drinking and sexual excesses.
The simple demented
paretics usually
come
to the institution in
nothing acute that can become

regenerated, extensive remissions are very rare in these cases. Usually
a seriously reduced state.
As there
is
they are entirely lacking and the mental and physical decline begins
pretty quickly.
The euphoric form most

fluctuations in a good
slighter,
and especially
closely
resembles the manic, only the

or they -are
and a bad direction are lacking,

never attain the height of a manic
state.
The
THE INDIVIDUAL
MIONTAI. DI8EASKS
207
delusional productions arc also less and invariably have the identical
character as those in classic paresis.
Morbid
picture of agitated paresis. The course of this form

by the following specific case.
may
be illustrated
become less reliable in the last twelve

inventions
and speculations he has squandered
unfortunate
with
years
Suddenly
he
becomes more restless, stays away
fortune.
little
neat
a
substantial baker has
from home very often, though to be sure he gives definite excuses, he

no longer wants to tend his oven himself, etc. Several months later a
hallucinatory delirium breaks out very suddenly, voices
to undress completely, to partake of only three
command him
mouth fuls
of food at
Brought into the instieverything

he
hands
lays
on, pours the soup
tution, he throws together
into the plate and back into the bowl and then again into the plate
until everything is on the floor day and night he pounds on the doors,
tears things up, jumps around, attacks the attendants in a brutal way,
fails to recognize his surroundings, and does not permit his attention
His talks appear entirely incoherent. Beto be held in any way.
each meal, and to cut
off
three of his fingers.
sides he has the physical signs of paresis.
After about a week he
is
completely exhausted, permits himself to be kept in bed, at first with

the aid of hypnotics, but he is still in incessant motion, which in the
meantime quickly appears weaker and less systematic and after

another week he dies from exhaustion.
Anatomical Findings. In paresis the nervous elements of the brain,
and often those of the spinal cord also gradually disintegrate, and
to be sure in different ways, without anything in
common
to the de-
known. The arrangement of the ganglia

The glia grows profusely
cells in rows and layers seems disturbed.
in the cells and fibres and in such a manner that these elements seem
This increase
to be increased and enlarged, that is to say thickened.
can readily be differentiated, even on superficial examination, from
the increase of the glia in senile forms, by the degree of the increase,
and specially by the marked thickening of the elements. INIitoses of
structive processes being
the glia cells are not rare.
The sheaths
of the
smaller vessels of
(and even of other organs) are infiltrated with

which usually show the character of plasma cells. This
the cortex and pia
round
cells,
latter finding is said to be characteristic of paresis, as it only
is
met
elsewhere in the African sleeping sickness and, according to v. Monakow, in multiple sclerosis. Other frequent alterations of the vessels of
an atheromatous or other degenerative character are probably com-
The formation of new capillaries

In the tissues are sometimes found the red
plications.
is
often plainly observed.
cells
described by Nissl,
268
"very elongated, uncommonly narrow formations, at times curved,

which consist almost only of a single bright nucleus with several
nucleolar bodies, beyond which the body of the cell extends at both
more and sometimes less." Their significance is not

Lately spirochites have been demonstrated in the central
ends, sometimes
yet evident.
organs by Noguchi and others.

Macroscopically the brain is diminished,
than 1000 g., the surface has frequently lost
of an atrophying process;
fissures widened.
in
its
very old cases to less

smoothness as a result
the convolutions are narrowed, and the
The white substance
is
of a dirty discoloration
and
often contracts in the plane of incision, if its severer atrophy is not

concealed by (Edema of the brain. It is striking that for the clinical
an anatomical substratum is not always found.

a
case of Lissauer's paresis, in which very acute
it
is
sometimes
But
manifestations have affected circumscribed,
cerebral
violent
with
shifts
focal manifestations
regions, especially in the occipital region.
The
findings in the pia do not stand in a definite relation to those

But the usual findings are as follows The pia is thick-
of the brain.
ened and opaque;
it
often shows adhesions, sometimes to the cortex,
come off
it, parts of the upper cortical layers
and sometimes to the adjacent folds so that one can
only go through the median fissure or the fossa Sylvii with the help
Microscopically one observes an increase of the pia tissues,
of a knife.
round cell infiltration (especially plasma cells) and the identical
so that in peeling
(decortication),
changes in the small vessels as in the cortex.

Nowhere is Pachymeningitis haemorrhagica found so frequently as
A certain weight
in paresis, and often the dura adheres to the skull.
has been attached to the fact that the diploe is frequently lacking.
Naturally the spinal cord shows secondary degenerations as a result of the changes in the brain, but very often there are primary
alterations similar to those in the brain.
The
above
peripheral nervous system sometimes shows chronic degenera-
The
tions.
all,
aorta
is
mostly luetically altered.
The other organs also,

more definite char-
the liver, are usually not normal; but
acteristics are still lacking.
The ordinary manifestations
of lues
and
remarkably rare (except in the vessels) in paretics.

Causes. The disease which is now differentiated from the other
organic psychoses as paresis is in the same sense as tabes, a "meta-
their remnants are
syphilitic" disease,
i.e.
at the present time
it
is
a late manifestation
of lues, hardly ever associated with ordinary luetic
uninfluenced by antiluctic treatment.

officers
According to
about 4 percent of syphilitics are
symptomg, and
statistics of
afflicted later
army
with paresis.
269
Severe or mild, thoroughly or superficially treated syphilis may be

It is not, however, without reason that some speak
followed by paresis.
of a special "lues nervosa"
which
dispose one to tabes or paresis.
is
said to run an easy course and to
supposed to be transmitted as
in married couples is not
so frequent that the element of chance be excluded; it is more likely
that cases of paresis with a common source of infection favor this
such with
its
peculiarity.
It is
However, paresis
Since tertiary manifestations are practically never found

having paresis, and as secondary symptoms of lues, also,
are infrequently noticed in the anamneses, it may be assumed that
the mild forms of lues are especially predisposed to paresis. But it
conception.
in people
may
be that the tertiary and the metasyphilitic symptoms are mutually

At all events it is striking that in marital infection from
exclusive.
Fig.
8.
Paresis.
a paretic the lues

case.
What
is
Plasma
latent
cells
on the wall
much more
of a capillary.
frequently than
is
otherwise the
the personal predisposition to this kind of brain lues
is,
no one knows; that paresis is the psychosis of the healthy brain has
been supposed with just as little reason as that it appears only in
cases of psychopathic heredity.
However, in the previous history of
many paretics a very unsteady manner of living is found, and Savage
once called attention to the fact that the}- have mostly taken wives
of a markedly sexual type. Where this type is the exception as in
Switzerland, this can be confirmed. Reichardt claims to have demonstrated a small cranial capacity as very frequent in paresis.
That mental exertion is an important factor has not been proven.

But it is probable that alcoholism plays an important part among
those predisposed, because paresis is extremely rare among those who
have been total abstainers from youth. On the other hand there is
a racial predisposition which we do not as yet understand. Among
270
the natives of the Balkan States

Abyssinians and Australian negroes
it
it
is rare; among African Arabs,

seems practically never to occur;
with the Japanese it is said to have become more frequent only in

the last decades; with the negroes of North America it was formerly
rarer,
tricts
now
it
than in
especially frequent.
is
the race as such,

cause,
As
e.g.
The deciding
but the manner of
cities.
It
much
is
rarer in rural dis-
factor, therefore,
living or
is
probably not
some added determining
a second infection of a different sort.
names mental exertions,

none of these assumptions
precipitating or secondary causes one
heat, traumata,
and other
influences, but
have even been confirmed. The various injurious consequences of the

war have, as far as known, conditioned no noticeable increase of
Nevertheless injury in the service, be it in the sense of
paresis.
causation (precipitation) or in the sense of merely aggravating the
disease, was assumed after over-exertions, head trauma, infectious
Scientific proofs of such connections are still lacking."
diseases, etc.
Paresis appears most frequently from about eight to twenty years
and those
two years)
after the syphilitic infection; but there are also belated cases
that become manifest after a fewer
The
number
of years (up to
disease, therefore, occurs in the period of
after the
man
most active endeavor,
(maximum between 35 and 45)

great social significance. To be
has established a family
and thereby attains an especially
sure there are cases of infantile paresis, that are based on hereditary
lues and that mostly run a course following the type of the simple
demented form. In contradistinction to many other manifestations
of hereditary lues they break out mostly after the sixth year, indeed
in some cases not until around the age of twenty.
In accordance with its nature the male sex is much more frequently afflicted than the female, but the morbidity of the latter is
rapidly increasing, especially in the large cities, where the proportion
is
one to two, while the average proportion
four.
women
Men
are afflicted relatively
in the lower.
more
may
in the
be
still
upper
about one to
classes, while
Cases of infantile paresis are naturally equally
divided between two sexes.
Pathology.
of
plasma
The
cells in
finding of spirochites in the brain tissues and
the walls of the vessels shows that
of a direct manifestation of lues in the brain.
it is
Whether
a question
it is
a par-
ticular species of spirochites, an inherited predisposition of the patient,
" Compare especially Bonnlioffer, Die Dienstbesehadigungsfrage in der Psychopathologie.

Die Militariirztliche Sachverstandigentatigkeit auf dem Gebiet
Vol. 1. Fischer, Jena
des Ersatzwesens. Vortrage
redigiert von Adam.
.
1917, p. 86.

or later additional infiucnocs that
case of lues
is
not known.
terpreted; that paretics are
make
271
a case of parcsiH out of a
Racial dispositions
may
be variously in-
somewhat more burdened with psychoses
and neuroses than the normal, even though less burdened than the
insane, and that they themselves, for the most part, had something
psychopathic about them even before, seems to point to endogenous
influences; on the other hand, the additional effects of alcohol point
It is interesting that cases of paresis
to exogenous.
from manic de-
pressive families have a particular inclination to the affective forms,
while those with schizophrenic relatives get, by preference, paresis
Besides alcohol we do not
colored in the sense of schizophrenia.
know
any contributing causes that are favoring or necessary to the origin

of the disease.
In the prodromal stage
Diagnosis.
it
is
necessary to seek the
premonitory symptoms enumerated above,^* among w^hich migrain

with or without scintillating scotoma may be mentioned when it has
rather suddenly appeared in the critical age, and is not inherited;
furthermore
and above
The
all
all
premonitory symptoms of tabes, such as the
crisis
pains of uncertain origin falsely interpreted as rheumatic.
organic disease
is
associations, the dementia
confirmed by the affective state and the
by the lack
of
critical
faculty and the
kind of delusions, and the paresis in particular by the
somatic
symptoms.
The
may
diagnostic significance of the individual psychic sj'mptoms
be inferred from what has been said.
Prodromal violations of
by people formerly decent are perhaps the only
ones that should be particularly mentioned here.
The physical symptoms without certain proof of an existing mental
ethical principles
disease can in themselves be generally decisive.

acteristic
pupillary
disturbance
in
common
Paresis has the char-
with the
other
luetic
psychoses and tabes; encephalitis lethargica also at times leaves pupils

light.
Unequal pupils occur persistently in
normal people, then also in catatonia, but they usually change quickly,
while in paresis they change at the most in the course of weeks and
months. Sluggishly reacting, or rigid pupils are often found in the
alcoholic psychoses with an organic element, very rarely in the hysteric
that are irresponsive to
with contraction of sphincters, then in the epileptic in the course of

the attack, etc. One must hear the paretic speech disturbance but after
that, one very rarely mistakes
it.
The
stuttering of imbeciles
thing entirely different; here the sounds
may
is
some-
be inexact but they are
not misplaced and are not run together; on the contrary they are
" Cf.
D. 257.
272
combined
less
than
The
in skilled speech.
dysarthritic disturbances of
other organic brain diseases have not yet been sufficiently described,
even though they are in most cases easily differentiated from those of
One has to think only of the hesitating and singing of epileptic
speech to recognize it when it is developed. Yet slightly developed
speech disturbances in paresis and epilepsy can have a certain
paresis.
similarity.
The speech disturbance must often be looked for. For this purpose
one finds useful some test words which make a great demand on coAbove all "Third riding artillery brigade," or "Elecordination:
tricity," or "Methodist Episcopal Church," where the patient usually
gets stuck on the p and s sounds, or "Around the rugged rock the
ragged rascal ran." Such long test words as "Constantinopolitan
ladies" are not as good as those cited, and test more the psychic
qualities like attention and correct reproduction, than coordination.
One must
errors.
particularly learn to distinguish between psychic
He who
and speech
instead of "Third riding artillery brigade" repeats
without coordinating disturbances "third artillery brigade" is, to be

Furthermore, it
sure, usually an organic case but seldom a paretic.
must be considered that many patients by strained attention succeed
even with difficult words, while in ordinary conversation they fall

down on more simple ones; or the paretic, who has been examined by
several physicians in succession,
is
specially practiced
words and, therefore, reproduces them particularly
In
many
test
On
the
may
in itself cause the downfall even
from paresis
in the speech stunts of the tests.
other hand anxious attention

of those not suffering
in the
well.
cases this danger
may
be circumvented by permitting the
patient to read something aloud, and this can be done with better
when the patient is not aware that his speech is tested.

The handwriting cannot always be evaluated because it is changed
a similar manner by other diseases, and the results of severe trem-
results
in
bling are sometimes difficult to distinguish from those of disturbances

of coordination.
But the examination
of the handwriting
need not
be dispensed with, and in cases where the diagnosis is definite the examination of previous handwritings is sometimes the safest means of
determining how long ago the disease began. Moreover, in an existing
psychosis it can at least present evidence of a cerebral affection, which
most cases indirectly assures the existence of paresis. Neurasthenics

and other excited people, also, sometimes make mistakes in handwriting
both as to quality and quantity that are difficult to understand. But
they can easily correct them; on the other hand the person afflicted
with paresis leaves most of his errors uncorrected, he also cannot readily
in

find
them and when he does make
273
corrections they are very often
wrong.
Paralyses are also significant
acquired wliich,
e.g.
when
it is
certain that they have been
in the case of facial inequalities, is not
always
easily determined.
Paralytic attacks are often mistaken for apoplectic attacks but in
Apparently severe attacks

with consequent paralyses and very rapid complete recover^' point to
the latter the protracted twitchings arc rare.
paresis.
To be sure the easiest way to make the diagnosis at present is

through an examination of the cerebro spinal fluid. If pieocytoses,
Nonne and Wassermann,
nosis
is
are found in an existing psychosis, the diag-
as good as settled.
To
be sure tabes can produce the identical
manifestation; but their existence only increases the probability of

paresis because with the rarity of "tabes psychoses" in the narrower
mental disease combined with tabes,
sense, a
In some exceptional cases of paresis the
is
times be negative for a shorter or longer period

in stealthy or stationary stages or in
Cave:
very probably paresis.
Wassermann
;
this
is
findings
may
at
mostly the case
very slowly progressing varieties.
In the secondary stage of syphilis one sometimes observes in
the cerebro spinal fluid the same findings as in paresis, but

nificance
is
that
it is
the part of the central nervous system and

at this period
is
its
only sig-
a transient mild cooperation in the infection on

its
integuments.
Paresis
extremely rare.
The differential diagnosis of manic paresis from the manic attack

manic
depressive insanity rests on the demonstration of the physical
of
symptoms, also on a thoughtlessness and lack of regard in all actions
which are exaggeratedly out of proportion to the excitement, and
above all on the foolishness of the delusions. Mistaking individuals is
rather a trick with manic depressives; whereas paretics believe in
their fictions. But particular care must be taken in the case of initial
outbreaks during manhood, because paretic symptoms that are lacking
today may appear tomorrow. At anj' rate in a pronounced manic
always present.
from states of melancholia rests on the same
state of paresis the delusions are nearly
The
differentiation
principles.
As against schizophrenia the diagnosis
is
often not easy,
when we
have mere conditions of excitements with a senseless and confusional

trend of ideas which do not assume a distinct and specific form. Individual catatonic signs, which under such circumstances usually cannot
be anaylzed, are not yet evidence of catatonia, but affective
and lack
of intellectual
and
stiftness
affective rapport, furnish such proof.
Since
274
many paretics were always pronounced psychopaths,

may often only confuse instead of enlighten. Here, as
so
pathies,
it
is
often of decisive importance,
if
from a
the anamnesis
in all psycho-
definite time a
change of the psychic attributes in the sense of paresis can be ascertained or excluded.
As against
two psychoses
middle age, they are
epilepsy, only the specific signs of the
when
epileptic attacks appear in
can be decisive
mostly not pronounced in any direction, and therefore there are cases
where for a time one wavers.
Because of the tendency of paretics to excesses the alcoholic forms
frequently give occasion for doubt. Korsakoff's disease as an organic
psychosis has the most important psychical symptoms in common with
;
paresis,
but the neuritis and the lack of the specific paretic signs
(pupillary disturbances also occur there!)
usually remove the
diffi-
sometimes the mode of onset of the disease also helps the

diagnosis. But the peripheral neuritis is not always present. Alcoholic
pseudo paresis causes still greater difficulties. I have never seen pronounced delusions of grandeur accompany it, but it is said to occur in
rare cases. Progression during abstinence instead of gradual, and at
culties;
time for paresis. To be sure the

examination of the spinal fluid is a quicker way.
Not at all seldom it is a delirium tremens that first brings the real
case of paresis into the institution. The former passes away, the latter
least partial, regression decides in
progresses.
The paranoid forms
of dementia paralytica are very rare,
here I would like only to call attention to them;

still
barely pronounced, then
for
the
sO'
symptoms
that
are
time the differentiation from
paranoia or paranoid states can only be
The
if
made by lumbar
from brain tumors
is
puncture.
self-evident, only
it must be mentioned that there are slowly growing, infiltrating gliomas

which may run their course entirely under the picture of a simple
paresis with indicated local symptoms.
Without a lumbar puncture
one can miss the diagnosis up to death, and it is just in the case of
suspected tumor that the puncture is dangerous.
From the remaining organic psychoses paresis can be certainly
differentiated only by the physical symptoms (including the fluid),
even though pronounced paretic grandiose delusions alone permit the
diagnosis without too great a risk.
To draw the boundary line between neurasthenia and paresis is one
of the most important problems.
The complaints are frequently the
same
for a long time.
ing from weakness of
The neurasthenic supposes, e.g. that he is suffermemory but when he is examined for it nothing
;

is
found, or instead one sees affective
memory
difficulties;
275
he fears he
from "softening of the brain" and thinks he has a speech

disturbance, but the hitter shows itself, when it is present at all, to be
graduated not according to the articulatory difficulties of the words,
is
suffering
but according to the momentary degree of anxiety.

portant
is
Especially imthe attitude of the patient toward these symptoms. The
neurasthenic pictures everything as more difficult than
it
is;
to hear himself consoled but is not quieted immediately, or at
he likes
all.
The
paretic usually does not take matters so seriously; he very readily
somewhat
offers excuses: Just at present
he
the examination or he
anything similar. And when, in

anxious, he remains inconsistent and
is
is
tired or frightened
by
chilly or
depressive cases he really
is
readily neglects the physician's directions which the real neurasthenic
does only
when he
Above
the neurasthenic shows an exaggerated self-observation and
all
is
bothered by several "Systems of Treatment."
is accustomed to attribute an exaggerated importance to the symptoms

while the paretic usually appears indifferent and exhibits a striking
incapacity for self-observation.
This difference is also seen in the
depressive conditions with retained intelligence
(e.g.
in
the manic
depressive states).
Treatment.
syphilis
and
Prophylaxis consists in the avoidance
alcohol, the latter, because
the chances of infection, on the other hand because

It has not
develop into paresis.
ment
of, or
on the one hand

it
combatting
it
increases
helps lues to
been proven that the energetic treat-
of erupted syphilis betters the chances against later affliction
with paresis.
It is not a rare technical blunder to prophesy the

approaching paresis (or tabes) to patients with pupillary rigidity or
absent patellar reflexes.
If later difficulties are to be anticipatedj a
responsible person should always be informed of the possibility of
the future outbreak of such a disease; the patient himself,
down anyway
at the critical
who breaks
moment, should be spared and, when
possible, his wife also.
The treatment
hopeless.
of
pronounced paresis as a disease has so far been
Antisyphilitic treatment as well as salvarsan are ineffective.
Very recently successes have been reported from the infection of

patients with tertian plasmodium (Wagner v. Jauregg)
An early diagnosis is most important, in part to save the expense
of ruinous and useless treatments, in part to secure the existing estate.
When cases of paresis come into hospitals, they have, in great part,
impaired their estate severely as a result of their grandiose delusions
or
of
the
dementia.
It
is
the
duty of the family physician to

Above all there is danger in
instigate the necessary steps in time.
276
the long remissions upon which judges and relatives like to look as a
cure, whereas the existing feeble-mindedness and the euphoric mood
new
as well as
shifts
impair the patient's capacity for independent
action.
The obvious general rules of treatment should be followed in the

excitements as well as in the stage of helplessness. In anxiety states
opiates often render good service. Careful oversight of the bladder is
essential, as otherwise paradoxical incontinences
may
remain concealed and

Many patients can
lead to paralysis or rupture of the bladder.
under favorable circumstances be treated at home as soon as it is

certain that they will permit themselves to be managed, and will not
endanger their estate or compromise themselves by sexual excesses
or criminal acts.
In paralytic attacks a simple conservative attitude

patients are protected from
above
all
harm through
against uncleanliness.
collision
Artificial feeding
is
some
of the liquid food
out or
when they
gag.
is
is
inhaled into the lungs
best; the
resorted to only
in cases of necessity; the patient will not die at once
but with these helpless patients the danger
is
and rubbing, but

from inanition
especially great that
when
the tube
is
Nutritive enemas are often not retained.
taken
When
necessary an infusion of a physiological salt solution beneath the skin
can at least maintain the supply of water at the proper level. If the
relatives demand "that something be done," ice-packs applied to the
head are advisable, and amylenehydrate or paraldehyde or chloralamide are said to reduce sometimes the violence of the convulsion.
The first two drugs can also be given as an enema in a vehicle that
protects the bowel (chloralamide 4.0 to 6.0 (!), Amyli 4.0, Ap. dest.
150.0; or Amylenehydrate 4.0 to 6.0 Aq. dest. 60.0, Mucil Gummi arab.
30.0 for enema). Heart stimulants are also given, when a collapse is
threatened.
But I do not have the impression that the attack runs
its course the worse in any respect whatever, if the patient is not
bothered at
V.
all.
SENILE AND PRESENILE INSANITY (SENILE

PSYCHOSES)
Under the name of senile psychoses Kraepelin includes the presenile

and senile mental disturbances, among the latter separating arteriosclerotic insanity
from
senile
dementia with which he also classes
presbyophrenia.
The
presenile forms are as yet symptomologically as well as sys-
tematically entirely obscure.
It
has not even been definitely proven

that there are such forms.
period of involution since,
No
c.^,.
greatly from this time on and
occur in this period.
277
doubt certain forms are favored at the

depressions and anxiety states increase
possible that certain psychoses
it is
The morbid
still
pictures here considered as presenile
are with difficulty separated from the senile forms, in part because a
few of them also evince an organic character,
in part
because naturally
in case of a protracted duration a senile brain alteration may very

easily be added to the presenile, in which case the furtive development
of the organic
symptom
for a long
time easily conceals the fact that
something new has stepped in.

The conception of "Involution" which
"presenility,"
is
is
infused with the idea of
sometimes conceived in the sense of a regression that
ends with death, sometimes in the sense of transition to a new age,

The designation "Involutionary Psysimilar to the "climacterium":
based on the latter conception, directing attention to a

difference as opposed to the senile psychoses.
The actual senile (psychoses, that we know, all have a definite
tendency to progress, or expressed anatomically, to the gradual destrucchoses"
is
tion of the brain.
That there
are not also curable psychoses belonging
But with these I should

is naturally not excluded as yet.
not like to class "senile melancholias" with mild organic features or
organic confusions and deliria, because on closer examination it is
to senility,
always found that after the disappearance of the striking symptoms

is, in the sense of dementia senilis, a weakened individual.
the patient
Therefore, I conceive such storms as intercurrent manifestations of a

senile brain degeneration, just as in
pronounced
senile
dementia and
analogous to the acute appearances in paresis and schizophrenia, and

theoretically I place the major disease in the foreground, even though
there are cases where the restoration of equilibrium has practically
the significance of a cure. On the other hand Kracpelin usually places
the practical result in the foreground and designates many senile

melancholias with nihilistic delusions or other organic manifestations
as curable, as long as the psyche
is
not as yet materially damaged
otherwise.
Furthermore other psychoses,
like
manic depressive
shifts,
which
do not belong to the senile; here the

disposition lies in the native constitution and not in the age.
The senile psychoses offer three different classes of anatomical
findings: arteriosclerosis with its effects on the nervous system
{arteriosclerotic insanity), simple atrophy of the brain {dementia
senilis in the narrower sense) and spherotrichia {Vcrdrusung') with or
also oecur at this age, naturally
'without alteration of the neuro-fibrils
{presbyophrenia)
With the
278
first
and
last alteration there naturally also
appears regularly sooner
or later a nutritive disturbance of the entire brain and besides, the

three processes can, from the beginning, be combined in all possible
We
combinations.
rarely have pure forms in practice.
above all anatomically the diffuse reduction

and symptomatologically the complex of the
The latter alone are present in the
"organic psychic" symptoms.
The
essential thing
is
of the brain substance
simple senile forms. In arteriosclerotic insanity there are also neurological cerebral manifestations and the psychical defects for a long time
have something lacunar about them. In the presbyophrenic forms the

picture is complicated by excitation and some other symptoms.
The three senile forms have within the organic group a common
differential diagnosis, which, as against paresis, is decided chiefly by
the absence of the paretic signs (speech, pupils, fluid, blood Wassermann) As against alcoholic Korsakoff the decisive points are the lack
of the signs of alcoholism and, up to a certain degree, neuritis. The
.
remaining organic diseases (brain tumor, multiple sclerosis, etc.) carry

which are wanting in the psychoses
their particular neurological signs
previously mentioned.
The alcoholic Korsakoff patient is as a rule euphoric in the beginning but not manic as in classic paresis. The deeper moods of the
senile patients are in the great majority of a depressive type.
Organic depressions, especially senile, externally often closely
resemble late catatonias since they are rebuffing (like negativism),
mutistic, and have moods and fits (like the stereotype forms). The
general specific signs, especially
in the beginning.
For purposes
memory
tions are especially of service, which, to be sure,

selves only in little noticeable
movements
in reality
it
abdomen
is
entirely
still
be absent
good affective reacmay manifest them-
of the corners of the
then also the accumulation of organic delusions:

purgatory, the
may
defects,
of recognition the
mouth
million years in
a sewer, it is blown up like a baloon (^hile

empty and contracted). Such ideas are not
is
excluded in dementia prsecox but are very rare.
number
of therapeutic viewpoints also are
common
to the group.
Like paresis they jeopardize the fortune and the legal relations gen^
erally. Therefore in every individual case the question arises whether
a legal guardianship should be instituted.
Beware of the advice that the patient should give up the accustomed
occupation without a substitute, unless it is absolutely necessary.
Senility often becomes a disease only as a result of the sudden cessation
of the ordinary attractions of
life.
Interning in an institution should be
much
less
frequently recom-

mended and should be
in a case of paresis.
less often
279
permitted to become protracted than

has a home, under ordinary
If a senile patient
circumstances he should be able to remain there.
Only when acces.sory

symptoms (restlessness, confusion) or danger for himself and those
about him appear, when he is melancholic, when he handles light and
fire carelessly,
leaves the gas jet open,
is
inclined to sexual attacks,
threatens his wife and children,then only should he be placed in an

If the
institution.
danger
is
past,
it
should be seen to
it
that he
is
again brought into normal condition.
The nightly deliria which are very annoying to all concerned may
sometimes be overcome by hypnotics but not nearly in all cases.
Besides the ordinary remedies bromidia may be recommended here
which contains a happy combination of narcotics precisely for just
such cases. Its formula is a secret; how to compound it is stated
below.^^
But the remedy can be compounded in every drug store.
Only the preparation then looks cloudy and must be shaken. Ris
recommends for the "reversed daily program" (restlessness at night,
sleep during the day) that 0.03 opium be given evenings around eight
o'clock; after one or two weeks, sleep would occur at night, when the
remedy can be omitted until further needed. In severe cases two doses
(6 and 8 o'clock) should be given; a triple dose daily (4, 6 and 8
o'clock) should rarely be necessary.
Presenile Insanity
Under
this
name
are
described entirely
different,
insufficiently
and characterized pictures: 1. rare subacute cerebral degenerations which result in death or dementia often after a few months
of senseless delusions, delirium, usually anxiety conditions, and which
are to be classed with diseases of the brain. 2. more frequent 7nelancholy conditions of varying appearance, usually improving (see manicdepressive insanity and climacterium virile) 3. prett}' frequent paranoid and catatonia-like forms, the former passing more chronically, the
latter rather in shifts, but on the whole with a bad prognosis. A part
classified
but not
to
my
all of
the third category are belated schizophrenias.
According
experience, Kraepelin's presenile delusions especially belong to
dementia prsecox.
Arteriosclerotic Insanity
Arteriosclerotic insanity has verj^ manifold
itself.
ways
of manifesting
Usually arteriosclerosis of the brain with different symptoms
"Ext. Cannab. Ind. Ext. Hyoscyami

Aq. dest. ad 250.0.
hydrati aa 50.0.
fluid,
aa
0.5.
Kal. bromat. Chloral-
280
is
Very few cases gen-
present before a psychosis can be mentioned.
erally reach the psychiatrist.
Arteriosclerosis in itself does not con-
happens when there is a diffuse reduction

from transient delirious conditions and
the emotional disturbances from large brain lesions).
The neurologic cerebral symptoms consist of head pressure, headdition a psychosis
this only
of the brain substance (aside
ache with marked fluctuations, dizziness, fainting
spells,
buzzing in the
and all possible

symptoms such as hemiplegia, hemianopsia, and aphasic and
ears, scintillating before the eyes, eventually paralyses
focal
apractic disturbances etc.
The
latter manifestations of organic de-
and can regenerate

they need not be based on hemorrhage and
terioration are in the beginning usually unstable
very decidedly
(i.e.
softenings)
In very
many
cases other
symptoms
also appear as a result of
arteriosclerotic changes in other organs, especially the kidneys
and the
heart.
As long
disease
is
as the psychic
symptoms do not dominate the
also designated as "the nervous
jorm
picture, the
of arteriosclerosis of
the hrain."
The psychic symptoms like the physical begin very insidiously and
come and go in the beginning. The patients often feel something
like a void in their mind, their initiative weakens, it becomes difficult
for them to rouse themselves to action. Their endurance is diminished,
the accustomed attention is trying to them, they tire much more
readily than they used to. These symptoms invariably have a painful
But
effect whereby the morbid picture is again made more serious.
undoubtedly there also exists a primary tendency to depression and
to an anxious conception of experiences, often even to severe anxiety
conditions, which evidently are frequently the direct result of circula-
tory disturbances of the brain.
This stage
may
last for
years without material aggravation.
theless the affectivity usually
emotional incontinence
is
becomes more
Never-
labile in a certain sense;
plainly developed.
The
patient's interest
becomes narrowed and the tendency to depression inhibits somewhat

the emotional fluctuations; nevertheless it is evident how they can
react in all directions in the sense of irritability and psychic
pain, and in periods of improvement also in the sense of joy and
longing, and what is characteristic is the fact that they react even
to
trifles.
Gradually disturbances of memory, especially for recent experibecome more pronounced, at first only on certain occasions, as
on seeking a name, etc. later it is more generally noticeable, but always
ences,

up and down.
oscillating
Confabulations
may appear
281
but are rarely
numerous.
As a
picture
for
result of many fluctuations in the course of many years the

may become more and more serious. Anxiety states lasting
minutes or weeks can assume a delirious character with failure to
recognize the environment, dreadful delusions of being cut up, burnt,

buried alive, usually as punishment for sins. The patients struggle
for breath, yell, accuse themselves, strive to get
attempts at suicide.
melancholia.
conceive
The
away, and make brutal

is a tendency to real
In the intervals also there

patients
everything
as
become
courageous, they are timid,
less
and
painful,
form
depressive
delusions,
especially also of a hypochrondriacal type.
Other delirious states are rather rare
in the simple forms,
but they
more frequent in the apoplectic types.

Apperceptive ability and attention are only gradually changed
are all the
in
the sense of the organic syndrome.
Orientation at
first suffers
only spasmodically and finally
tirely destroyed, the physical strength
is
it is
en-
impaired, the patients finally
remain bedridden and die of marasmus or of apoplectiform attacks.

Apoplectic Forms. Very often the entire disease has its origin in
the attacks or these chiefly determine its course. Here one deals with
hemorrhages as well as softenings. The first attack occurs after
arteriosclerotic prodromal stages of varying intensity and varying
duration, or also in people who were still entirely well, with the usual
symptoms of headache, irritabilities, dizziness, fainting, and consequent general symptoms and focal manifestations, the latter remaining
or regenerating according to their location. Depending on the general
nutritive condition of the brain and perhaps also on the localization of
the focus, the psychical signs of diffuse brain atrophy can sooner or
later supervene. According to my experience, lesions especially in the
region of the pons seem to be deleterious, although at first they produce
the least change in the psyche (circulatory disturbances starting from
the vascular centre?).
On many
cases, however, the
psyche remains
for years disturbed so little that the patients are properly regarded as
mentally sound.
cases also,
and
Only the
affectivity
change
is
often plainly changed in these
Often
immediately after the stroke the patients can be made to cry and even
to laugh much more readily than before. In many cases they feel this
as positively unpleasant; real compulsive laughing and compulsive
crying, i.e. mimetic expressions to which no real felt affect corresponds
qualitatively and quantitatively, is a rare local symptom emanating
from the thalamic region.
this
is
in
the direction of lability.
282
Otherwise dementia apoplectica is not materially different from

simple arteriosclerotic dementia without apoplectic strokes with which
it
is
connected by transitional forms with rare or frequent minor
attacks.
Both forms may be complicated by moods (nearly always depressive), and especially by irregular, fluctuating anxiety-melancholic
states.
Invariably the personality with its strivings is maintained for a

relatively long period; even when the patients already appear decidedly
demented they are not much changed in the fundamental aims of their
will, only they no longer understand everything and they permit themselves to be dominated more by their affects. The symptoms of deterioration also are ''lacunary," i.e. as to time and in respect to special
functions they are entirely irregular, present or absent in part; thus
good
memory may be
surprisingly present in complete helplessness of
may be evinced side by side

with completely narrowed ones. While in paresis, dementia senilis and
presbyophrenia, one can infer with great probability from the general
the ability to recall, and correct judgments
condition as to individual abilities, in this case
it
would be very
deceptive.
Individually the pictures are naturally very different according to

the location and diffusion of the lesion on the one side and according
to the intensity of the general cerebral atrophy on the other.
Concerning the course of

that
first,
all
forms Kraepelin emphasizes the fact
the decrease in the elasticity of the vessels produces troubles
in the adjustment of the blood apparatus to the

this
adjustment
is
momentary needs;
particularly infinitely graduated in the brain.
This
naturally also impairs the capacity for functional adjustments and
consequently produces the exhaustion, the
difficulties in
doing things
and perhaps, also a part of the early affective disturbance. It, finally
produces wrong reactions of the vessels, sometimes surely local
paralyses of the vessels, which causes the transient local troubles and
many fluctuating general symptoms Later one observes an insufficient
blood supply of circumscribed regions which are ever increasing in
numbers, sometimes even embracing the entire brain (e.g. in sclerosis
the entire circulus Willisii) with the various consequent manifestations,
and
hemorrhages and softenings resulting from
in the third place the
the breaking of the arterial walls and the blocking of the lumina.
The outcome
is
death following organic dementia.
not occur when the course
The duration
Age.
is
of the disease
Arteriosclerotic
The
latter
may
shortened by apoplexies and other attacks.
may vary from
a few weeks to two decades.
insanity appears most frequently between

But cases occur even in the
by a family predisposition.
the ages of 55 and 65 years.

are mostly conditioned
Both sexes are about equally represented

functionally limited morbid picture
is
forties
they
in the apoplectic disturb-
ances, in the other forms, according to Kraepelin,
2H;i
7L5%
affect
men.
arteriosclerotic epilepsy,
which usualy appears very early in the various localizations of arteriosclerosis and sooner or later leads to dementia.
It is said to occur
mainly in alcoholics.
Concerning the anatomy of arteriosclerotic insanity nothing can
really be added to what has been said. Most of the varieties of arteriosclerotic thickening through proliferation of the vascular cells, hyaline
degeneration, etc. are found in the most different distributions, and as
a result of these there
degeneration and a
capillary
is
local destruction of the nerve tissue through
("perivascular gliosis"), through
filling in of glia
and large hemorrhages, through
most cases there
is
softenings,
and besides
in
a diffuse reduction of the brain substance as the
expression of a general metabolic disturbance.
The sum
of countless
small lesions can perhaps also have the same effect as a complete
diffuse disturbance. The entire brain is invariably atrophied at death
;
it is
reduced on an average by about 150
g.
The
pia
is
often thickened
with connective tissue, but hardly infiltrated or adherent.
The
it is
etiology of arteriosclerosis
for the
is
not only a disease of civilization;
found
in prehistoric races.
importance.
On
At
all
its
most part
still
obscure;
traces are said to have been
events the family disposition
is
of
the basis of experimental facts, tobacco has been
blamed very recently; alcohol for a long time. Furthermore the

attempt has been made to include among the causes of arteriosclerosis
a
number
of circumstances such as conscientiousness
overexertion and laziness, and

sufficient proof.
many
and
dissipation,
other things, but as yet without
In the ordinary cases, where the Wassermann is negano part; as yet we do not possess sufficient
tive lues probably plays
knowledge to differentiate anatomically the ordinary

from the specific in all cases.
As
arteriosclerosis
precipitating causes debilitating diseases are to be mentioned,
as in simple dementia senilis; the brain, the blood supply of which
might just suffice under ordinar>^ circumstances; can then no longer

obtain nourishment and atrophies in toto or in certain places to such
an extent that the psychic symptoms break out. Stronger affects,
especially depressive ones, often induce the rapid appearance of the
arteriosclerotic syndrome; the connecting link is probably the inadequate regulation and adaptive insufficiency of the vessels.
Naturally in pronounced cases the diagnosis is relatively easy.
284
In the beginning
it is
based on the different neurological symptoms
with their characteristic change.
The hardening of the

More severe sclerosis of
cerebral vessels
is
not always easy to diagnose.
the arteries of the body offers a certain prob-
can just as well

hardening
pronounced
in
other
organs,
just as the
be free in the case of
reverse occurs. Importance is properly attached to increase of blood
pressure, slow pulse, to its abnormal increase after slight exertions
(climbing on a chair or bending ten times), then especially to the
marked differences between systolic and diastolic pressure. The
normal figures (measured according to Recklinghausen) are minimum
ability of similar changes in the brain; but the latter
pressure to 100
mm.
Hg.,
maximum
pressure 160
mm.
Hg., resp. 140
and 220 cm. HsO.

From paresis which is sometimes combined with arteriosclerosis,
it can be differentiated by the absence of the physical signs of paresis,
especially pupillary rigidity which is never found here, negative
Wassermann in the blood and fluid, absence of pleocytosis and globulin
reaction in the fluid,^** absence of expansive delusions and excessive
Manic states hardly occur in arteriosclerotic insanity.

euphoria.
Anatomically there need not be in paresis a thickening of the vessel
walls, while the infiltration with plasma cells is foreign to arteriosclerosis.
From dementia
ticularly
senilis and presbyophrenia it is differentiated parby the fluctuations in the course and by the presence of the
signs of arteriosclerosis.
points.
When
Heredity also sometimes
offers differential
there are no circumstances that favor cerebral atrophy
such as a manic-depressive constitution, congenital weakness of the

brain, alcoholism,
and heart
troubles,
years speaks against mere dementia
an age of
senilis.
But
less
it is
than sixty-five
self-evident that
the various senile processes frequently take place together.
Senile dementia and, to a
much
still
higher degree, paresis alter the per-
and fundamentally than arteriosclerosis; the

entire functions of memory, of the critical faculty, etc. are damaged
in senile dementia and paresis while arteriosclerosis at least for a long
time manifests itself in a "Mosaic of individual symptoms."
From brain syphilis arteriosclerotic insanity is differentiated by
the absence of the neurological signs (eye troubles, etc.) and by the
sonality
earlier
serological signs of lues.
Because of our ignorance of the etiology we cannot

against arteriosclerosis. It is undoubtedly
good to avoid tobacco and alcohol. Still, pronounced arteriosclerotic
Treatment.
carry on
much prophylaxis
^"Increase of albumin occurs, as
it
seems, but no globulin reaction.
285
insanity is in many cases a grateful object of treatment. Mild, slowly

progressing disturbances are often markedly improved and there is
also occasion to prove that this
not chance but really the result of
is
treatment.
It is very often possible to free the patients
from
all
the p.sychic
and physical exertions that they cannot bear, that is, from those
burdens which according to experience aggravate their condition. If it
is not known what the patients can stand, it is necessary to try them
Neither the psyche nor the heart should be overtaxed.
out carefully.
As
far as possible the patients should be protected against affective

If the heart does not
disturbances.
not without
care (digitalin;
treatment with
sensible
We
respond
it
should be treated but
once in a while perhaps strophantus,
digitalis
hardly
increases
the
etc.:
danger of
have had good results with diuretin in small doses,

Anxiety states can also be combatted from
the psychical side with opiates or at the same time with heart remedies.
Very often, too, a bromide preparation, especially sedobrol, produces
calm; it can be combined very well with small doses of iodide. Iodide
is generally given and under certain circumstances it probably has a
certain effect on the arterial walls or, at any rate, on their regulation
and, as has been lately supposed, on the viscosity of blood also. At
present many are afraid of such big doses as 3.0 per day, and prefer
apoplexy).
e.g. 0.5
also
three times a day.
smaller doses,
e.g.
up
to 0.5 per day.
a few weeks or months until there

cation.
is
All drugs should be stopped after
new
indication for their reappli-
For example, an iodide cure can perhaps be given once
ever>'
year.
Proof
useful;
is
lacking that any of the usually recommended diets are
excessive
meat
diet
is
said to be injurious.
claims to have observed benefits from a diet with
Lewandoivsky
little
salt.
At
all
events the patient should guard against overfilling his stomach either
-^
with solid or liquid food. Stimulating substances as well as alcohol
should be avoided on principle.
The psychic
consolations,
is
treatment, which should calm the anxious patient with

especially important.
But under all circumstances, as soon as the condition permits, the

attempt should be made to keep the patient busy. In the beginning
of the disease before employment has been given up, this usually succeeds without much difficulty by having the patient do a smaller
amount of his ordinary work. If this is not possible, other work must
be sought for him that holds his interest. Exercise in the open, adapted
"Total abstinence from alcohol is a condition
Wiener med. W.S. 1910, p. 626.)
(Pilz,
sine
qua nan in any treatment.
286
to the strength of the heart,
way
is
naturally to be recommended.
fairly tolerable conditions are often obtained for
Naturally this
is
also the case
when
its
own
accord, after
it
years.
the arteriosclerosis has been
complicated by an involutionary depression independent of

heals in time of
In this
many
has
made
it,
which
the picture appear
too serious.
Strenuous measures, like hydrotherapeutic treatments, especially

thermal cures, are naturally to be avoided. To prevent apoplexy in
pronounced arteriosclerosis, everything is to be excluded that increases
the blood pressure or leads to a rush of blood to the head, especially
hot baths, excessive eating and drinking,

a cerebral hemorrhage
is
etc.
Experience shows that
occasionally connected with such influences;
but too much cannot be expected from these regulations.

In arteriosclerotic epilepsy besides bromides, iodide may also be
given. But it is usually an incurable disease.
In accidents following sudden cerebral diseases the family physician's most important psychiatric problem often is to obtain a clear
idea of the patient's mental condition; because he sometimes has to
decide his testimentary ability either for present purposes or later in
Care must be taken not to mistake aphasic

for confusion and
dementia. In all cases where it would be a question as to the patient's
responsibility for his actions pains should be taken to get in contact
with the patient through the most various means of understanding.
Since wills frequently are attacked only after years have elapsed, pains
must not be spared to make exact notes of the case.
court as expert or witness.
or paraphasic
symptoms
(including paragraphia)
Senile Dementia (Simple Dementia Senilis)
Even though
fifties,
it
the normal regression of the brain begins in the early
does not usually become plainly noticeable until the last
decade of the normal span of life. The earliest sign we meet with in
in many people even before the end of the sixth decade
most cases
is
a certain inability to assimilate the
new
ideas of others.
Such per-
sons become passively neophobic even though they are still capable
themselves of creating new combinations of ideas to a limited extent.
But
after a while the entire ability to assimilate
man
and
is
weakened; the
what goes on in the world; his

thoughts, now egocentric, are withdrawn to the more personal necessities, both in emotional and intellectual relations.
The feelings become
more labile, and react to trifles; more protracted moods readily occur.
In social intercourse some cases show a tendency to empty chatter,
old
is less
less interested in
others to torpid monosyllabism.
Besides excessive suggestibility one

is
struck by a stubborn intractablcness.
but the entire
memory becomes
Not only
poorer, at
first for
287
the impressibility
names and
similar
which are otherwise also particularly difficult. The inability

to understand and recall new experiences, the relatively or absolutely
efforts
easier reproduction of the old
general trait that
memory
memory
material in connection with the
more
makes them into laudatores temporis acti. All psychic processes become more trying and slower, particularly in proportion to their complexity.
That the capacity for
practical work declines under these conditions is self-evident.
pictures of a pleasant character can be
readily revived than the unpleasant,
Simple senile dementia is said to be a simple exaggeration of these

in a mildly indicated or pronounced form are found
in nearly every person who attains his normal end through "weakness
symptoms which
of old age."
As the
first
morbid symptom there
often noticed a change of

of caricaturing personal
is
character, sometimes at first in the sense

peculiarities; a sense of order develops into
picayune pedantr}', firmness
into stupid stubbornness, care into distrust,
Then
ness.
obtuseness which here also

tion
economy
into filthy stingi-
as in paresis there comes the falsely so-called ethical
and elaboration
is
a combined product of imperfect concep-
of experiences
and ideas and perhaps

;
time there appears the lability of the affectivity with

negative and positive suggestibility:
"The
old
man
is
its
at the
same
heightened
a child."
The
sometimes marked by sexual excitation.

Men, who have long been impotent, "feel young again" and under
certain conditions actually perpetrate excesses. Others remain more or
less impotent but the libido is enhanced.
Then the memory fails more and more and just in simple senile
dementia this often occurs in an entirely systematic manner; the more
recent an experience, the sooner it is forgotten; (usually it is still
"noticed"; but is capable of being recalled only for a short time). At
first single experiences of the immediate past, which naturally is also
the period of disease, are irregularly forgotten; these gaps increase
slowly and with fluctuations; they coalesce until the last years disappear from the memory at first in part, then entirely. Then in the
course of years the limits of recollection are pushed back farther and
beginning of the disease
farther
and at
woman, who
is
last the patients live only in their childhood.
in the ninety years of her life
An
old
had changed her residence
several times, at first believed herself in her last residence, then in the
she returned to her birthplace. Another

coming from school. It is very common for senile
women to give their maiden names, to believe that they have just
next to
last, etc., until at last
patient
was
just
288
recently been confirmed and to have no recollection of their marriage

life.
The most important events, such as the
can be told to the patient in this stage several
times within a few minutes and they always conceive the information
as something new with the corresponding emotional reaction; they
and
their entire adult
husband's death,
etc.,
themselves are untiring in recounting the same news; in severe cases

they not only do not know what they experienced the day before, but
under certain circumstances forget everything from one minute to

another. Sometimes, however, experiences that intimately concern the
personal complexes are retained like memory isles; it may be an unjust
accusation or an attempt to obtain money from a stingy old man, etc.
As in paresis practiced streams of thoughts also are sometimes still
capable of relatively good reproductions.
Lively natures fill up the memory gap with spontaneous confabulations, they tell fantastic stories of what they have accomplished and
experienced; in torpid natures the symptom has to be provoked by
questions. Many of these people do not like to say "I do not know"
and produce an answer invented for the occasion which they themselves
believe.
The range
of ideas
markedly restricted, even though the lack of

and then much later reaches the high degree
is
critical ability rarely,
as in paresis.
In the
first
years the patients usually try to act as usual; only
up the active relations with the

become clumsy, unsteady and finally
torpid and depressive cases give
environment.
But then
entirely senseless.
actions
Because of their lack of -thoughtfulness they permit
themselves to be misled into stupid financial transactions and uncalled

for
gifts
and bequests.
Seniles
are
favorable material
for
legacy
hunters not only because they will die soon but especially because they
are helpless against clever external influences.
the fortune
is
frequently
made by way
The attempt
of marriage in
to obtain
which case the
many patients offers a good opportunity. In

many cases the external forms are retained for a long time.
A woman entirely unknown to me, about whom I was consulted, received me as a female acquaintance (although she could see very well)
she entered into a conversation with me in the usual social phrases
heightened sexuality in
a great
without making a single slip, aside from the fundamental fiction, she
asked what my children were doing, said that it pleased her that I
had at last come again, and remarked that it was cold but pleasant
weather,
etc.
Some do not
feel
comfortable anywhere, especially at night.
With-
out purpose, or with unclear ideas, or to look after their things, they
THE INDIVIDUAI. MENTAL DISEASES
289
wander about the house spook-like with u li^ht and consequently often
become dangerous. In the hist stage real deliria are usually added,
especially those occurring at night; the patients then live in hallucinations of experiences of
youth but also
in other
adventurous and, usually
in emotionally accentuated phantasies.
Perception and attention are gradually changed in the sense of the

organic disturbance.
Orientation
is
disturbed rather late, often at
The
night, then also during the day.
year
told
it is,
often not even the century, and
them they
transiently at
when
know what
the year has been
are not capable of reckoning their age, usually state
incorrectly, even
do.
first
patients no longer
when they know
it
the year of their birth, as they often
They can mistake day and night though
in the nightly excitations
they want to go to their customary daily occupation more frequently
than they mistake the day for the night. Sometimes they themselves
feel that they are in a confused condition; one of our patients has
maintained for two years that she is at home and sleeping, and that
her being here and everything she experiences here is only a dream.
In the last stage disorientation also affects the simplest situation.
Then
it is
particularly characteristic that anxious senile patients,
when
they have to be lifted or carried, grab hold everywhere of people and

doors and every object that they can reach, wherebj' they naturally
increase the danger of falling.
The
large majority of seniles
have only these basic symptoms;
it is
a case of simple senile dementia analogous to simple paresis and simple
demented schizophrenia.
But
these people rarely
come
to the insane
asylums; their death is awaited in their families and in the poorhouses.

But various accessory symptoms can change the picture and often
make
institutional care necessary.
some are more
more
Even among
The
lively.
the simple senile cases
torpidity can increase

which the patients who are
in continuous activity combined with a talking mania can hardly be
made to rest. The mild affective displacements which are frequent
in old age can rise to melancholic and manic conditions, of which the
torpid, others
to stupor, the liveliness to an erethism in
first are very frequent, the second rather rare {senile melancholia and
mania)
The depression is frequently accompanied by anxiety though
perhaps less often than in the arteriosclerotic forms.
In such affective conditions delusions are invariably formed, and
depending on the mental state they are either delusions of insignificance
or greatness. The latter is always very weak and does not attain the
multi-colored and fantastic magnitude of the paretic delusion. In the
depressive delusional forms the delusion of poverty usually recedes
.
290
before the horribly developed delusions of sin and hypochondriasis.

These are often accompanied by nihilistic ideas and ideas of enormity,
which are specific in organic diseases, and occasionally also by micromanic ideas, the patients believing themselves or some parts of their
bodies to be very small, which gives them occasion for anxiety and
The mere poverty of ideas is shown in
justification of the anxiety.
the following complaint; "I must make so much water; the nurse will
not empty the chamber; what will happen? I have such parched feeling and what if the nurse will not give me any water? And when this
jacket
dirty,
is
then they will send
Very often these

suspicion,
robbed
Even
self-reference
something quite
is
me
one that
is too thin."
mingled with delusions of
affective delusions are
and
of
persecution; the delusion of being
common
in senile diseases.
in otherwise simple forms delirious conditions
tions occur in the final stage.
then be noticed earlier;

hallucinations.
it is
with hallucina-
Individual hallucinations
may now and
generally a case of auditory and also visual
Hallucinations
of
smell
and taste are
patients see and hear dreamlike transactions
rare.
The
for instance, they live in
a previous activity, or like presbyophrenics, they busy themselves with

mixing everything up, packing their beds and all their things together,
in order to go "home," etc. The term "occupational delirium" is also
used in this connection, but in the forms of senile dementia not complicated with alcoholism the picture is entirely different from that in
delirium tremens.
In the latter there is an uncertain complicated
pseudo-activity in individual, not really connected parts. The patients
believe that they are sitting in a bar-room, that they are writing,
driving, while they may be lying on their backs in bed, or if they are
walking about they do notice that something is wrong, whereas in
the senile patients, it concerns mostly real acts, even if they appear
decidedly purposeless.^^ Many, even those who are relatively clear,
collect useless rubbish, they go to the street to look for things that
the children have carried away, "they look for something, upset the
bed, tear open the mattress, mix up the horse hair, tear up the linen,
frequently cover themselves with it in a phantastically senseless
manner" (Fischer). If they are not confined to the bed they busy
themselves incessantly with something that, though producing little
that is comprehensible, always pursues some idea. It is only with the
complete decline, that the stereotyped movements come which correspond to the previous occupation (washing and sewing motions, etc.)
The patients then often become unclean, not only because of carelessness and paralysis, if not carefully watched they readily begin to
" Comp.
p. 237.
291
play with the excrements. Such conditions, which in their higher

developments must be designated as severe deliria, occur at first most
frequently at night or they last, as transient excitations, for days and
weeks, or finally, near the end, they form a chronic condition that may
continue for months and years.
Other accessory symptoms result from local disturbances
in the
brain which are not directly a part of the disease but naturally appear
frequently as a result of the arteriosclerosis that exists at the same
time;
ances.
among these we have paralyses, aphasic and apractic disturbThe spinal cord is usually also involved more or less, so that
the sphincter muscles and the (lower) extremities also are no longer
controlled properly.
The handwriting of a simple senile dement
Fig. 9.
ing regular tremors.
The
of the lighter grade, showpatient took great pains to WTite very carefully.
The physical symptoms

clumsiness,
stiff
symptoms which
among which we find:
are otherwise chiefly basic
correspond with the general cerebral atrophy
weak motions, and
finally
marasmus.
INIetabolism
is
retarded very early, the appetite frequently disappears, the handwriting becomes shaky and in many cases is clumsy in other respects.
Sometimes the tremor is entirely regular but rather coarse. Other
manifestations, as the shrinking and the decrease in the elasticity of
the skin, the arco senilis in the cornea,
etc.,
are expressions of the
general decrease in vitality, to which the brain atrophy also belongs;
they are, therefore, parallel manifestations, which in relation to the

brain disturbance may be developed to very different degrees.
On the basis of these accessory symptoms different forms have been
distinguished.
If there are
no accessory symptoms at all, we have senile demejitia

form of dementia senilis. The forms
displacements, such as the senile melancholias and
in the narrower sense, or the simple
with affective
292
manias, are probably the commonest among the institutional cases.

That these names designate only the acute pictures with which the
patient usually comes to the physician, need not be so important,
because as indicated, the moods are usually
still
recognizable in the
quiet period also.
The forms showing a
clear sensorium with delusional formation
senile paranoia (or

paranoid forms of dementia senilis) they are not frequent. Such
people think they are spied on by neighbors, teased, robbed especially
by those living in the same house, they find everywhere references to
and eventually hallucinations are designated as

;
themselves, and confirmation of their ideas in voices, etc.

In dementia senilis, as in paresis, catatonic-like forms have been
inasmuch as one observes stereotype movements and attiand echolalia. Many of

these cases, as the anamnesis and other symptoms show, are undoubtedly (latent) schizophrenics that have become senile. In others the
stereotype movements prove to be remnants of habituated movements
(twisting the moustache, scratching). What gives the impression of
verbigeration is often plainly nothing but the incessant expression of
the identical feeling that always dominates the patient, as in such an
expression as ''Oh, God, help me!" or it represents an organic preservation in which the patients want to say something else but invariably
slip back into the once trodden path. The echolalia may be an organic
disturbance which is probably somewhat differently conditioned than
in schizophrenia. But as yet we do not know enough, and can only
insufficiently analyze these invariably severely demented patients, in
order to make an exact differentiation in the individual case between
schizophrenic and organic-catatonic symptoms.^^
The course of simple dementia senilis is usually very slow; it may
extend over a decade. The weakness sets in very gradually; not even
the year in which senility merges into disease can be regularly determined. With minor fluctuations the dementia and the physical weakspoken
of,
tudes, verbigeration, flexibilitas cerea, stupor,
ness gradually increase; extensive remissions are not to be expected

here.
Also the paranoid forms with complete clearness usually run a

decidedly chronic course, but the delusions are subjected to some-
what severer and more frequent

conditions
can
sometimes
fluctuations, so that really bearable
alternate
with
those
that
are
almost
delirious.
Acute
shifts
with total confusion can appear very early and under
certain conditions can disappear after a few

"^
Compare
p. 236.
weeks or months, so that

Wernicke
soon,
may
e.g.,
new and
Senile
But even
talk of cures.
if
293
the patients do not die
definitive exacerbations are to be expected.
manias and melancholias can
heal, the
the melancholias less frequently.
But many
disposed to gradual improvement.
However, the
remains, even though
manias very
senile
dementia then
often noticeably of slight force.
it is
often,
of the latter are also
But
as in
paresis the affective forms tend to a lasting displacement of the affects,

since after the storm has run its course a milder euphoric or depressive
mood
up
remains.
Senile melancholia can even maintain itself for years,
same plane of melancholic depression.

Anatomically senile dementia proves
to death, on the
to be a diffuse reduction of the entire
As
central nervous system.
in paresis
the convolutions are narrowed, uneven

at the surface, the ventricles are wid-
ened, at death the entire brain
duced just as
much
as
in
is
re-
arterio-
sclerosis.
The pia
is
clouded
but hardly
really opaque, just as little
is
it
in-
filtrated.
The ganglion cells disappear in

ways. They dissolve, they
different
Fig. 10. Pyramidal cell in a

simple dementia senilis. The well
preserved fibrils (clearer in the
specimen) form a net about the
fat droplets that fill up and bulge
out a part of the cell.
undergo fatty or pigmentary degeneration, and vacuoles are formed in them.

The glia hypertrophies, but more as to
the number of the elements than in
thickness of the fibres or in size of the
cells
and
in contrast with paresis the cells usually
delicate,
remain thin; mitoses are rarely seen (except

In addition, debris and products of cells are natu-
and the
in acute lesions).
remain relatively small
fibres
rally found.
The
causes of senile dementia are
still
quite obscure; undoubtedly
The maximum
and eighty years. The
the hereditary disposition plays a part.
of the disease
the age between sixty-five
disease afflicts
lies in
both sexes about equally.
Early waning of the trophic energy of the brain occurs especially

(sometimes as early as in the forties), in akoholics
("Dementia alcoholica senilis," Ford, with transition to chronic
Korsakoff of earlier age), in manic depressives, and in endocardiacs.
in oligophrenics
Not
rarely acute debilitating diseases, like pleuritis, or fracture of
the neck of the femur,
etc.,
occasion the outbreak.
294
The most difficult thing in the diagnosis is

from "normal" senility. Where the line should be
drawn is arbitrary. For forensic purposes one must depend on the
practical considerations; all things being equal, a wholesale merchant
should be declared insane and incompetent even if he shows less severe
disturbances than a day laborer in the same state. Indeed, under rare
circumstances a few harmless delusions will not yet induce us to declare
Dijferential Diagnosis.
to differentiate
it
the patient practically as mentally unsound, while naturally in the
medical sense
all
such cases are pathological in the same
way
as those
showing a noticeable affective displacement.

The disease is distinguished from arteriosclerotic insanity by the
absence of arteriosclerotic and local manifestations, by the more general affection of all functions, and the greater steadiness of the course.
But the frequency of the combination of both diseases may cause
difficulties which are fortunately chiefly of a theoretic character only.
The melancholic and manic states are recognized as senile by the
organic signs of the disease, the lability of the affects, and the senselessness of the delusions, etc. The weakness of the memory is sometimes
revealed by the fact that the affects exert an abnormal influence over
it.
Thus a melancholic patient in the incipient stage of senility, whose
memory otherwise appears to be still completely intact and who is also
still capable of work to a considerable extent, may be noticed by the
fact that he forgets
(it
while he retains very well
is
not a blocking)
all
Treatment: For the prophylaxis of

ing that can be done except to avoid
above
all alcohol.
pleasant experiences,
senile
all
dementia we know noth-
the ordinary nervous injuries,
Besides the physician must be careful not to create
may
act as causes. Old people suffering from a fracture

neck of the femur, whenever possible, should not be long confined
situations that
of the
all
those that correspond with his mood.
to the bed, etc.
When
The
the disease has once broken out
it
naturally cannot be cured.
general principles of therapy in the senile psychoses should be
symptomatic. 2*
Presbyophrenia
Presbyophrenia, the classification of which to be sure varies according to the author and even in the
same author at
different times,
is,
according to some, a special morbid picture, according to others a

variation of dementia
senilis.
question, a morbid picture
typical cases
" Sec
p. 279.
is very^
is
According to the present state of the

best called presbyophrenia which in
well characterized.
It
its
always presents the general
THE INDIVIDUAT. MENTAL DISEASES
295
signs of dementia senilis, but shows Ijcsidcs a peculiar excitation and

an alteration of thinking that extends beyond the ordinary senile disturbance. The patients are always engaged in an apparent activity;
as long as they walk and can orient themselves at least in their immediate surroundings, they fuss about incessantly, things are misplaced, carried to another place, everywhere something is looked for,
and all of this, without anything being really accomplished. If the
patients are weaker, they cannot lie in bed decently even there they
are occupied, they sit in any old way, and stretch their legs out of bed.
With uncertain but eager motions the bed clothes are pulled together,
;
twisted together, tied into disorderly
bundles or only
moved and
rubbed together (the patient "is

washing") Despite a good affective
rapport with the surroundings, persons, places, situations, and times
of day are mixed up, just as much
.
as the bedding.
As long
as the pa-
can talk there is a certain

talkativeness, behind which, however, there is no flight of ideas untients
something manic exceptionally

at all events they
less
supervenes;
readily lose the thread merely be-
cause of weakness of memory.
For
the most part they get a special
"Washing" presbyophreIn spite of the demented expression one can see the eagerness
Unfortunately the
in the activity.
resuhs of the occupation, the disorder of the bed, are not visible in
Fig. 11.
aic.
kind of speech disturbance in which

at times they no longer find the
words,
or
misplace,
repeat,
and
mutilate them, and cling to single

syllables that either do or
the picture.
do not
belong to the word, and produce alliterations and permutations, as well

as logoclonus, etc., but at the same time, at least in the beginning and
when
stimulated, they give entirely correct answers.
An example
cited by Fischer'-^ illustrates this best: ''iMother of

God, Virgin Mary, our lord, our dord thour dord, dord, dord dord,
de
dede deOh now just
listen,
blessed fruit of the body, give us
day your our ours, holy Mary pray for usars, so that we much.
Our Lord our dord so that we shall do much. Come you lousy
fellow come quly, dosoorly sanctify our lord, you lousy fellow, than
art among women, the fruit of the body, Jesus well yes, that is the great
this
.
^'Ein
Zeitsch.
f.
Beitrag
zur
d. ges.
Neur.
Klinik imd Pathologie der presbyophrenen

u. Psych. Bd. 12, 1912, p. 125.
Demenz.
296
one, but thou thinkesest holiest our Lord, our lord, then
and here
is
certainly certainly sanctified himself himself, but thou felt for the
sinners
and have
made forbad and
and misdeeds our lord, our lord has

,"
body well he has give it ever.
sanctifieth all sins

fruit of the
Typical epileptiform attacks are not rare in presbyophrenia. Hallucinations and delusions, concerning which more exact information is
naturally not easily obtainable frequently exist, but are not at
all
necessarily as a determinant for these peculiar confusions.
In the cases thus classified one finds in the brain regularly, and
numbers, the senile plaques of Fischer (spherotrichia), the significance of which is not yet clear.-'' In the other forms
in especially large
they rarely occur, so that the morbid picture
is
kept together even
anatomically to a certain degree.
Kahlbaum, who coined the name presbyophrenia, understood it to

senile psychoses; Wernicke made a morbid picture of it which
mean
he identified symptomatologically with Korsakoff's disease so that the

conception corresponds approximately to a "simple senile dementia,"
Kraepelin then required relative retention

mental process and even of judgment, without
keeping strictly to these qualifications. Fischer found somewhat later
in his anatomical spherotrichia a definite morbid picture, and he also
put the disease parallel with Korsakoff, but in many of his cases it
went bejônd Korsakoff in the far greater alterations of thinking, and
it corresponded in part with the one pictured above.
But finally pretty
nearly every dementia senilis which is colored to a considerable extent
by accessory symptoms came to mean for him presbyophrenic
dementia, thus the melancholic, manic, paranoid, and catatonic forms
(ever>i:hing with the exception of his "arteriosclerotic pseudopresbyophrenic dementia"), which correspond practically with the forms of
the torpid forms excepted.
of the order of the
our erethic arteriosclerotic insanity.
Not
to
be separated from presbyophrenia
for
the
present
is
Alzheimer's disease in which one deals with a dementia, beginning

early, in the sense of presbyophrenia,
but which in a few years leads
to a particularly high degree of dementia with aphasic, agnostic, and
symptoms and finally results in death. In exceptional cases

break out in the forties. The anatomical findings correspond
qualitatively about with presbyophrenia but it is very intensive; there
apractic
it
may
is
a general cerebral degeneration with destruction of the fibrils
numerous
senile plaques;
or the other of the last
Course.
and
but cases are also included in which the one
two distinguishing features
is
lacking.
The presbyophrenic forms usually exhaust themselves
"See below anatomy.
297
within one or two years, often already in a few months after the disease has become manifest. Tiie more acute the cases, the more are
fluctuations to be expected; many of the slower ones run an entirely
straight course until death.
Fig. 12. Cortex in presbj'ophrenia. a. Cross sections of large senile plaques,

Degenerated fibrils stuck together, c. Fibrils stuck together into the form of a
fihng as the remnant of ganglion cell.
b.
Anatomically besides the general brain atrophy with hypertrophy

{Fischer's "Spherotrichia," "senile plaques," Simchowicz)
Their significance as yet is
in no way clear.
Formations are involved that appear threadlike or
of the glia the senile plaques are characteristic
.
298
Fig. 13.
Fig. 14.
Presbyophrenia.
Presbyophrenia.
Senile plaques in the brain cortex.
Senile plaques.
More
strongly magnified.
roll themselves together in balls, and include nervous and gliose elements in a trancformed condition; they usually form conglomerates
that can far exceed a ganglion cell in size and are scattered everywhere in the brain.
209
In a large part of the cases with senile plaques one can see a severe
is not visible in ordinary senile
dementia. The fibrils bubble up and drop together into irregular
disease condition of the fibrils which
forms.
Sometimes,
in
e.g.,
Alzheimer's disease, they form peculiar
tangled bundles.
Pronounced presbyophrenia can hardly be

compared with alcoholic deliria. In part the
that way by accompanying alcoholism. In most
Differential Diagnosis.
mistaken.
It is often
deliria are colored in
cases
it is
purely a question of imperfect differentiation.
Deliria with
hallucinations of sight are not necessarily alcoholic
For
deliria.
of
this diagnosis all or, at
the symptoms must be
above
all
rate,
most
But
the state of consciousness and the reac-
tion rate in both diseases
is
so different, that usu-
made at the first glance. The

can be roused much more easily, and has
ally the diagnosis
alcoholic
any
characteristic.
is
a quick conception and rapid reactions; the senile
demented rarely gets into proper touch with the

environment and his percejDtion is slow. Perhaps
the good-natured rapport also, which is rarely
entirely lacking even in the deeply confused senile
but
is
rare in the confused alcoholic, can be utilized
-p
r_Xormil
cortical cell.
ing of the
Stain-
fibrils,
the diagnosis.
To recognize it immediately
one must have seen the difference between the presbyophrenic eagerness
in
for occupation
and the alcoholic occupation delirium.
Especially the slower reaction capacity, the mood, and frequently

also the age, distinguish the presbyophrenic as well as every other
senile delirium
from the alcoholic Korsakoff.
The causes of presbyophrenia are unknown.

The treatment of the unyielding disease is purely symptomatic.
VI.
THE TOXIC PSYCHOSES

1.
The Acute Toxemias
Among the acute toxemias Kraepelin includes Uremia which is

important inasmuch as epileptiform attacks occur in it, and because
The uremic psychosis
it can stimulate any cerebral local symptoms.
as such usually runs its course with a picture of various deliria, whose
specific peculiarities, if they have any at all, are not yet kno\s-n; it
proceeds in the majority of cases to a rather sudden death.
Eclampsia of pregnancy and child bearing is recognizable by epi-
300
leptiform attacks, besides which there are also occasional delirious

conditions.
In carbon monoxide poisonings after the patients emerge from

the narcosis, they may run their course with a picture of twilight states
Central and more peripheral paralytic manilasting for hours or days.
If the patients do not recover
festations often complicate the disease.
entirely, then the organic symptom complex, accompanied usually by
conspicuous severe memory defects and depression, remain as an expression of the diffuse destruction of the brain tissue.
first
and the
toxic sleep
later
Between the
developments of the symptoms several
days or even weeks, free from disturbance, may intervene.

Of the remaining toxemias we unfortunately have more toxicological
than psychiatric knowledge. Only alcoholic inebriation is more
exactly known even though we should know still more about it. Its
every day forms are ignored by psychiatry but several unusual kinds
;
of manifestations require special consideration:
Pathological Drunkenness
The
acute effects of alcohol are, as
is
^^
well known, individual and
very different according to chance circumstances. Sometimes such

fluctuations lead to quite abnormal reactions which, as far as they are
of practical importance,
are gathered together under the
Even "maudlin drunkenness"
pathological drunkenness.^^
mal reaction but
it is
name
of
an abnorPathological states of drunk-
not included here.
is
enness are sudden excitations or twilight states set free by alcohol,

usually with a mistaking of the situation, often also with illusions and
and excessive
hallucinations,
affects,
mostly of anxiety and rage.
In
individual cases the entire morbid process can transpire in hardly a
minute but
Among
lasting
it
usually lasts longer, up to several hours.
the predisposing factors that are regularly found, there are
and accidental causes.
pathic dispositions, above
all
To
to Heilhronner, frequently hysteria
" Heilhronner.
the
first
epileptic
(e.g.
belong
all
kinds of neuro-
and schizophrenic, according

among prostitutes), and cere-
t)ber pathologische Rauschzustande.
Miinch. Med. Wochen-
schrift 1901, S. 962.
" The name "complicated drunkenness" has been proposed because every
is supposed to be pathological.
But the ordinary name, aside from
its theoretical justification, is of practical value especially in the courts, because
there it is a question of "morbid or not morbid?" Formerly one spoke of
"mania ebriosa" and similar terms. "Senseless intoxication" differs from pathological drunkenness in the fact that in the former no qualitatively unusual
symptoms have to be visible.
drunkenness

bral traumas.
It
is
self-evident that the disposition
is
301
not to be
mistaken for alcoholic intolerance, in which small quantities have a

disproportionately strong effect but without the inebriation having
Chronic alcoholism also can lay the
to be qualitatively abnormal.
foundation for pathological drunkenness since many drunkards first
become disposed to it when they have reached a higher degree of
alcoholic degeneration.
To the transient dispositions belong all influences that weaken the

body, such as over-exertion, waking at night, excessive heat or cold,
then, as is well known, affective excitations, sexual excitement, and
"drinking oneself into a rage."
Under such circumstances very small quantities of alcohol, such as

two glasses of beer, can often provoke an attack. At first one does
not notice anything wrong with the patient, then he begins to be
irritated or anxious in order to rave and storm against persons and
things about him. The paroxysm is sometimes set free by any occasion, an exchange of words, an attempt to direct, the intervention of
a policeman, or without visible cause the drunkard hurls himself at
some one just entering. Thus a student suddenly hurled a full salad
dish at a classmate's head; it was evidently due to a spasm of ocular
accommodation; his comrade seemed to him so tremendously diminished in size that he wanted to make certain where he was and how
big he was.
It also happens that at first these persons go to sleep
and then wake up in a rage, or when they are awakened feel themselves threatened and seize a knife.
The confusion is sometimes begun
by an epileptiform attack. Even though rarely, attacks of this character may occur also during the paroxysm; according to Heilbronner
there are also pathological states of drunkenness whose motor manifestations consist chiefly of senseless rhythmic movements.
In these excitements alcoholic disturbances of coordination, such
Usually the
as paralysis of the tongue and staggering,-^ are lacking.
head
is
extremely congested, and one
of the carotids.
stare.
Under the
more rarely
The
The
may
also observe the pulsation
is often somewhat of a
and hallucinations of sight, and
expression of the eyes
influence of illusions
of hearing, the conditions of tlie surroundings are mis-
patients are usually markedly disoriented, sl:iowing

"anxious phantastic fears," and are dominated by terrifying delusions
of reference.
More rarely they act on the basis of some isolated,
taken.
usually unclear conception, as in somnambulism, and set
fire
to a
'^
To be sure, this is partly due to the fact that one does not like to include
drunkenness with coordination disturbances, among the pathological. But in
this case, also, there are no sharp divisions.
302
house in a rather peculiar way, etc. {alcoholic twilight state). The

picture may also resemble delirium tremens or acute alcoholic insanity.
Nearly always the scene is ended by a protracted narcotic sleep
from which the patient awakes with a dizzy head, but as a rule,
without any recollection of what has happened. In less frequent cases
the amnesia is not complete, or it appears later, perhaps in the course
of the following day, at times only after the patients have already
admitted having committed a crime.

There are people who have such attacks only once in their lives;
others, especially heavy drinkers, may be so afflicted very frequently.
But, as far as I know, the above described alcoholic effects are always
the exception in the same individual; he also has spells of normal
To be sure there are drunkards who, finally, in nearly

every drunken spell get "drunken hallucinations/' sometimes in the
sense of delirium tremens, sometimes more in the sense of alcoholic
drunkenness.
insanity or of alcoholic jealousy, but here the reaction
much milder
it
one.
Even where
there
is
fighting, raging
is
usually a
and stabbing,
does not occur so blindly but with a certain consciousness of purpose
and with a consideration

If pathological
have a great
The
of real things
and persons.
drunkenness recurs in the same person, they often
similarity.
differential diagnosis is
based on the demonstration,
first,
of
the dispositioUj then of the disturbance of orientation (in which naturally the proper recognition of single persons, or of a single street, is
all excluded), then of the externally unmotivated anxiety or
anger (the latter can apparently originate in a quarrel preceding the
drunkenness, which in reality caused the disposing affective agitation)
then on the demonstration of false perceptions, the lack of disturbance
not at
and perhaps the continued raging when the patient

put to bed (ordinary drunkards usually fall asleep very quickly).
When the critical sleep is not followed by the amnesia, then it will
be difficult to assume pathological drunkenness without other, very
plain morbid symptoms, such as hallucinations and disorientation; on
of coordination,
is
the other hand
it
must be
especially emphasized that ordinary drunken-
ness not rarely completely wipes out the
memory. If it can be demonwas so small that normally
strated that the quantity of alcohol imbibed

it
does not cause any manifestations of intoxication, then the pathocannot be disputed, although this does not yet directly
logical element
demonstrate the disturbances of reflection.

Treatment. In case the patient still raves when he comes to the
physician, restraint can rarely be avoided. Efforts to convince the
patient through talking does not help. In one case, however, a col-

league
was able
to put a patient to sleep
in the act of destroying his room,
303
by hypnotism, while he was
whom we had
previously hypnotized
Of the narcotics only hyoscine (with morphine) is to be

used; but even the largest permissible doses leave no certain effect.
into sleep.
On
when
the other hand,
necessary, one can resort to a real narcosis

if the heart can be carefully watched.
through ether or chloroform
The Chronic
2.
Intoxications
Chronic Alcoholic Poisoning"
A.
The Simple Drinking Mania

alcoholism and drinking mania should be distincannot abstain from spirituous drinks even when
Theoretically
guished.
He who
he realizes that
it
would be better not to drink, he who habitually
oversteps the measure which he himself considers proper,
is
a drinking
maniac; he who shows other psychic results of drinking or physical

alcoholic signs, is an alcoholic. But the two diseases cannot, however, be sharply separated, if only because the drinking mania on the
one hand, if it is primary, usually leads in time to alcoholism, and on
the other hand it appears secondary as a symptom of alcoholism, so
that both syndromes are mostly encountered in association.
In other drug manias ^ like morphinism, it is not so essential to
distinguish the mania from the consequences, because only the chronic
morpho-maniac takes too much morphine, and as a rule he also shows
soon the other symptoms of morphinism. But as alcohol is generally
taken for enjoyment and nourishment, there are plenty of people who
become alcoholics who usually do not drink more than what they and
the environment consider right, that is, they become alcoholics without
being drinking maniacs.
This becomes most striking, when such people
get delirium tremens on the occasion of an injury or pneumonia, which,
to be sure, one then prefers to designate as "fever delirium."
Under drinking mania we therefore include
all
those cases
the basis of a disposition, or habituation cannot give
who on
up the enjoyment
it to a "harmless"
do not show the symptoms described under
the manifestations of chronic alcoholism.
If added signs of chronic
of alcohol, despite better insight, or cannot reduce
amount, but who
(still)
poisoning supervene,
As
in the case of
we
designate the disease as chronic alcoholism.
any other mania the drinking mania
afflicts
particu-
Psychological and national economically it would be of interest to go

deeper into the study of the "Tobacco mania." The latter, however, is of
slight significance medicinally.
'"
304
larly psychopaths of every description; but there
the essential factor in
many
is
no question that
is based on
cases of simple habituation
our drinking customs and the false view of the harmlessness or even
the usefulness of regular enjoyment of spirituous drinks. As a matter
of fact one should not go too far in tracing things to "psychopathies."
whom
one cannot find some deviations from the

them? We shall therefore speak of a "simple
drinking mania," where the mania is not yet complicated by other signs
any one
Is there
in
normal or even verify
of poisoning, regardless .of some, though

pathically predisposing factors.
The treatment
of the drinking
mania
is
not considerate, psycho-
the same as that of chronic
alcoholism.
have since the time

been described under the name of chronic
alcoholism. There are physical and psychic symptoms, of which the
former are of special importance for the psychiatrist, because proof
of their existence can make the layman comprehend most readily that
of
The symptoms
Magnus Huss
a "disease"
is
of chronic alcohol poisoning
(1852)
involved.
dilatation of the blood vessels, especially in the face, which

in milder cases also causes the skin to appear more red, is generally
The
known. In some severe cases the dilatation of the veins on the nose
and the adjacent parts of the cheek is especially conspicuous; finally
the color may turn more into blue and in some cases acne rosacea
develops. But in most alcoholics there is no such a marked
disfigurement.
The
excessive use of alcohol
of arteriosclerosis.
The heart shows an
is
mentioned as one of the causes
know whether
do not
this
is
right.
alcoholic fatty degeneration
which
may
heal
with abstinence and reappear with the resumption of drinking. It

is the most important cause of the usual symptoms of inadequate
circulation, irregular pulse and enlargement of the heart ("beer
heart")
chronic myocarditis also
in inebriates
disease that
evidently found more frequently
is
usual in alcoholism but
is
otherwise not at
all
chronic catarrh of the stomach; cirrhosis of the

practically always alcoholic, while fatty degeneration of the
frequent
liver is
is
than in others.
is
the real
^^
liver is frequently so.
It
is
supposed that there
is
an alcoholic atrophy
of the kidneys.
General nutrition varies greatly.
In the severe cases there
is
either
a bloated appearance or more or less pronounced marasmus, the former

chiefly in the beginning, the latter in the later years of the disease.
^ What
is
otherwise so called
is
usually
a nervous
affection.

The
well nourished shapes are said to keep
305
more to beer and wine, the
ethers are said to be whiskey drinkers.
In the advanced stages, functional disturbances are nearly always

Well known is the tremor which under ordinary circum-
present.
stances
regular and fine and only in severe cases develops into a

it is usually most marked when the
is
coarse disturbance of motion;

patient
is
sober,
and may
force
him
to drink his first glass in the
ing directly from the table because he might spill
The
patients often
know
instinctively
how
it
morn-
with his hand.
to render the trembling
Fig. 16. Handwriting of a chronic alcoholic of 63 years, who drank heavily,

mostly whiskey for about 45 years. The characteristic tremoi-s are plainly visible,
and increase with fatigue, as shown in the last lines of the two examples.
harmless or to conceal it thus if the physician extends his hands and

spreads out his fingers and requests the patient to imitate him, he
;
extends his hands but does not spread out his fingers because they
would show a
quested to do
(greater) tremor; the patient has to be especially reso.
In some cases the affection can be completely
neutralized for a short time by mere self-control.
The tremor rarely also affects the eye muscles in the form of
nystagmus.
Besides, twitchings in various muscle groups are seen now and then,
a tendency to cramps in the calves of the legs, and in the severer stages
306
the drunkards become weak, their walk
is
unsteady, the face becomes
as flabby as in the paretic.
In the stage where the patients come to an institution the pupils

may also be unequal, but after some abstinence
nearly everything is normal. Alcoholic optic atrophy with a paling
often react badly, they
of the temporal side of the papillae

it
relatively rare.
is
and color scotoma
is
known, though
chronic paralyses of the eye
rarer are
Still
muscles.
The deep reflexes are often increased according to the state of

anatomical degeneration; more rarely they are diminished or absent.
In the sensory field one often finds on closer observation a local
reduction of sensitiveness in individual skin areas, especially those of
the lower
leg,
as
a result of the degeneration of particular skin
branches; more deeply vague pains appear which are likely to be

treated as rheumatic.
heavy head,
dizziness,
mouches volantes,
buzzing in the ears and similar affections are usually signs of the continued acute poisoning.
The
is
digestion often becomes irregular.
only produced by alkaline saliva,
of chronic alcohol poisoning (in
Sleep
is irregular,
is
Vomitu^ matutinus, which
common and
women, pregnancy
is
pretty sure sign

to be excluded)
at times poor, restless, at times heavy.
grades of alcoholism manifest themselves
among
Higher
other things also in
the need of imbibing the necessary "night cap" before retiring.
Potency declines in the later stages and often sinks to nearly nothwhich in the beginning is usually strongly aroused,
usually maintains itself longer. There is a diffuse atrophy of the
ing; the libido,
testicles in the severer cases.
Single epileptic attacks
may
indicate the severity of the cerebral
poisoning; they follow particularly after especially heavy drinking

bouts, but in
mere alcoholism they are not nearly so common as
in
delirium tremens.
In the descriptions of the psychic disturbances "ethical degenera-
"moral coarseness" are

important to state that this characterization in the manner in which it is usually expressed is not true to facts.
tion," the "blunting of the finer feelings," the
invariably emphasized.
The
alcoholic,
companion
warm
who was
It is
originally decent, remains the pleasant, cordial
in his singing society
and
in drinking circles; he
tears at his neighbor's misfortune,
can shed
become wildly enthusiastic
about political or any ethical purposes not only can he state, but even
feel what is good and bad; he can give wonderful advice to others;
if he is an artist or poet, he can create works of art that indicate a
On occafine sensibility even in the realm of ethics and good taste.
;

where the
sions
until a fairly
this,
affectivity
is
not involved, his judgment
advanced stage of the
the description of
is
307
quite good
But notwithstanding
the disgusting coarseness and the inconsiderate
disease.
is not mere fiction; such people act thoughtunder the influence of the affect and are coarse under certain
circumstances, e.g. at home, where they have to feel the expressed or
mute reproaches of the family, at work where they cannot hold themselves and which they subordinate to their drinking pleasures, and
actions of the alcoholics

lessly
in a quarrel in certain stages of drunkenness.
inebriates
made up
is
of those
who are still capable of finer

who have "gone to the dogs"
who were
feelings.
The
great majority of
originally well disposed
and
Besides them there are others,
in all respects;
some are weaklings who
always permit themselves to be misled into following the customs of

their environment and to whom vulgarity in this way becomes a habit;
others are sick persons whom alcoholic atrophy of the brain has made
into irritable and thoughtless children of the passing moment.
The
third class consists of those
morally deficient but who

otherwise restrain them a
psychiatrists
is
who
are naturally coarse and generally
through alcohol, the inhibitions that

little.
To be sure most of our work as
with this class, but their vulgarity does not result
lose,
from alcohol it is only made apparent and increased by it. Only the
last two categories correspond with the usual picture.
The three mentioned constitute the main forms between which, and beside which,
there are transitions and combinations that can be readily ipaagined.
It is because on suitable occasions alcoholics can command in all
sincerity the finest sentiments, that these people become dangerous
and attractive; they are not hypocritical in this respect. They can
still occupy important public positions without attracting attention
to themselves, even though at home they beat their wives, walk naked
They believe on approinto the kitchen before their children, etc.
everything
for their families,
priate occasions, that they want to do
finer promises.
make
still
can
can show the loveliest remorse and
;
Whoever does not know them

themselves believe in their own
well,
must
uprightness.
them because they

But with the first change
believe
in the external situation the fine feeling also gives

is
way
to another that
just as sincere and that takes hold of the entire
man
just
as
much.
mother
of thirteen children
is
stricken with cancer of the
womb.
The alcoholic husband visits her solemnly every Sunday in the hosFinally it is too much for him to spend
pital, bringing her flowers.
the few pennies and he demands that his wife be sent back. At home
he maltreats her as before and, as the carcinoma has a strong smell,
308
he regardlessly indulges at the table in the gruesome joke that now

they had potatoes and crab (cancer) for dinner.
The following was brought to light in a court case: After partaking of cider and four deciliters of whiskey an alcoholic had misused
one of his children and had attempted to misuse the other in his wife's
He had boasted to his wife that on her communion day
presence.
he had taken her innocence. He sent another child to the mother with
the news that he was about to tear out all the hair from the pubes
He had beaten his wife's
(this in the most disgusting expressions).
body black and blue, and wounded her head, scalded her with hot water
and peed in her face (perhaps to treat the wound without a doctor).
The beating lasted two days, in which time the children had to hold
the mother once so that he could hit her with a rope. At last the
woman
could escape in her shirt to a neighboring house; the
man
remained at home. After two days a neighbor brought him some milk;
one could not let him starve. Then the villain was so penitent and
shed such bitter tears that the neighbor, a farmer, began to weep
also, brought the wife and the children then everybody deeply touched
The affair with the children was brought before a
cried together.
The above mencourt, where the man maligned his wife outrageously.
tioned beating was not at all extraordinary, only the misuse of the
children had been a novelty.
Because the customary descriptions consider completely only the
naturally coarse group and present only the darker side of the far
larger group of those originally decently disposed, the diagnosis is
usually mistaken; one does not dare to designate as an alcoholic one
whom one has just seen conduct himself so nicely and considerately.
And, on the contrary, many coarse individuals, who among other things
drink, are considered alcoholics which they are not, or in whom at
least the unpleasant psychic characteristics are not the result of
;
drinking.
The
alcoholic ethical defect, therefore, does not consist in the loss
change of the feelings generally

domination of the entire man, his mental stream and his
will, by every momentary mood, by the affect of the present moment.
We have the same condition as in the so-called ethical defects of the
organics; only in alcoholics the duality is much more apparent because
of ethical feelings but in the abrupt
and
in the
the intelligence in
loss of ethical
itself is still
well preserved, while in the paretic the
may
appear as a partial symptom of the
standards
general dementia.
The most important change

fore,
their
lability
in the feelings of alcoholics
with which
is
is,
there-
always associated a heightened
309
emotional coloring of
all experiences and, with this, the complete

domination of the affects. The patient can make himself endlessly
sad over the condition of his business, over the misfortune that he
has brought on his family, but shortly after he sits in the saloon, a
carefree and cheerful companion, and a short time after that he can
become enraged and with word and deed deeply injure his best friend.
Practically, the ethical value of such a man is, to be sure, the same
as that of a pronounced moral defective; because what good does it
do his wife, if at one time he is tender, only to misuse her again immediately afterwards? To do good requires time; a clumsy act, mali-
ciousness, a misfortune, can occur in the excitement of a
One
a
girl,
moment.
of Benoit's alcoholics at a dance gets into a jealous rage with
so that she leaves him.
In desperation he hangs himself,
down and immediately continues dancing.

The affective flightiness naturally also makes
is
cut
steadiness of endeavor
and action impossible.

plans, to let
Drunkards are easily inclined to take up new

the old ones fall and finally not to accomplish anything
worth while. The lack of a consistent mood deprives them, in the

realm of character, of the endurance and perseverance of their endeavors and, in the realm of intellect, of a consistent purpose. And
because reflections also are under the influence of the affects, the reviewing of complicated situations, in which the affects play a part,
e.g. the state of one's own affairs, must suffer as well; essentials and
details are no longer differentiated because both are strongly colored
by the feelings.
With this leveling of the feelings in the direction of enhanced vividness the striving for something higher must naturally suffer also or
be completely suppressed. The gratification of immediate wants satisfies the patients.
This also finds expression in the ethical reactions;
the alcoholic who has celebrated blue Monday is ashamed to go to
work on Tuesday and bums the entire week; he consider it a disgrace
to enter an institution for alcoholics and overlooks the disgrace of his
alcoholism.
Also the weakness of will of alcoholics is chiefly based on the aft'ecThey can break the most serious promises five minutes
later, have no endurance anywhere, and for the latter reason in the
severer cases leave their positions so readily, partly to take another,
tive lability.
work no longer suits

becomes apparent earliest and
partly without any definite aim, merely because
them.
The weakness
of will naturally
most pronounced fashion in relation to their appetites.

and especially the alcoholic fickleness have still another
cause, to wit, the protracted euphoric attitude of the affcctivity which
in the
All of this
310
makes
possible for the patient to feel even misery as good, or at
it
than the normal person does. A circumstance as important as commitment into an insane asylum is treated by most
drunkards for perhaps a week as a bad joke. The patient is "in the
hotel where the big fools are treated"; "he has quarrelled a bit too
least as less evil
much with
his
chamber maid
This euphoric
The
of drinking.
mood
is
(his wife)."
also indissolubly connected with the ideas
great mass of
and misery appeals
filth
to
them
even with clear insight after many months of abstinence,

The contempt of
as something lovely which has to be "renounced."
society, and to be cast out among the lowest set which he formerly
looked down on with disgust, all this no longer matters to the patient
To be sure a colossal vanity still remains
his sense of honor is gone.
affectively,
but not in the right place. Such people boast with their mouths but
They brag of the number of empty glasses, of their
not with deeds.
firmness toward their wives' admonitions, but also of things that do
not exist, of their ability, knowledge and achievements, and of their
As long
honesty.
as a drunkard
the euphoria in his system
it
is
still
has this alcoholic fickleness of
impossible to inculcate in
honest pride in real and worth-while achievements.
appears very gradually in the course of
him an
It usually dis-
many months
of total absti-
nence, although after a few weeks in the insane asylum one usually
observes a somewhat heightened irritability which
due to a clearer
is
realization of the enforced confinement.
By
all
these affective disturbances the reflection also
Whoever devotes
weakened:
his feelings to ever
never succeeds in thoroughly thinking out anything to
whoever
in
lets
is
indirectly
changing purposes,
its
conclusions;
himself be dominated by his affects, always thinks only
terms of these affects; whoever
is
led,
especially
by a morbid
euphoria, to look at things only from the good side, cannot evaluate
bad chances, and continually shows wrong judgments.
But
there are besides direct alcoholic disturbances of intelligence
that are not brought on in this roundabout manner, even though for
many
years they are not so evident.
The
associations
become shal-
lower and more of the external type; the typical bar-room jokes with
their
word
associations illustrate that sufficiently.
But
in
more
ex-
treme cases the associations become at the same time more limited;
it is for this reason that the patients find it irksome to deliberate on
complicated matters, even though there are no affective hindrances.
What
It is then difficult for the alcoholic to reproduce exactly.
he tells is easily distorted by changes and additions. Especially striking is the need for a causal rounding out of a situation. In the fable

of the
why
donkey loaded with
salt/^^ e.g.
the donkey went into the water
the burden was too heavy, etc.).

necessity
and the greater capacity
many
(it
This
is
alcoholics inject a reason
was warm, he was
and
sitting
still,
indulgence in alcohol,
for excuses.
As
is
known, there is
Heat and cold,
every vocation without exception
and
it
is
thirsty,
connected with the greater
nothing that would not do as an excuse for drinking:

exercising
311
peculiar that
ju.stifies
men with academic
training as well as illiterates abate these reasons in the identical words
and adhere to them with the same faith. But in other matters also
is distinguished by the great necessity for excuses and
the drunkard
the great ability in inventing them.
Hand
in
ing there
is
hand with the heightened affectivity and dulness of thinkthe tendency to morbid self-reference. Even people still
quite well preserved take the donkey and the water in the above mentioned fable as a reference to themselves.
The exaggerated
self-references form one of the roots of the alcowhich at first is directed toward relatives and then
against all who would like to exert an elevating influence on the
patients, or who have to suffer from their doings, while on the contrary
in the society of even the most degenerate drinking companions a
complete feeling of confidence holds sway which among other things
This characteristic becomes the
leads to many business indiscretions.
more dangerous as alcoholics have an exaggerated positive and also
negative suggestibility, corresponding to their affectivity. "Whoever
knows how to get in with them, can use them, as he pleases; in other
matters, especially in regard to admonitions and related things, they
are obstinate and stubborn.
The memory of alcoholics become inexact. In tests these people
do not give fewer answers than ordinary people, often more, but among
them more wrong ones. It is the same in life: often they are no
longer capable of thinking of things exactly as they are. Only in
the later stages of the severer cases there is added very gradually, as
something radically new, the memory disturbance of the organic
psychoses with its weakness for recent events. It is a sure sign of
brain atrophy and, with this, of the impossibility of complete
holic suspicion,
restoration.
This is sufficient to make liars of alcoholics. Numerous affective

causes lead them to excuses, to misrepresentations; on the other hand,
they cannot sufficiently imagine things exactly as they
tion of their
own and
are.
Justifica-
other people's acts involuntarily enter into their
thinking and the euphoric liveliness excites their ideational association

''See p. 189.
312
to such an extent that the necessary phantasy
moral and intellectual criticism
is
is
never lacking, whereas
suppressed during this entire time.
Female inebriates because of readily comprehensible reasons lie still

more consistently than men. How many of the lies are conscious
and how many they believe themselves for the time being cannot be
readily determined.
large part of the psychology of alcoholics
is
bound up with the
peculiar attitude of the patients toward their surroundings. In spite

of all their blustering it can easily be demonstrated that alcoholics
always
feel
themselves to be on the defensive toward everybody
who
does not drink, an attitude which even many moderate drinkers evince
in the presence of every abstainer, but which in immoderate inebriates
in
time actually dominates the entire psyche, and stimulates a real

and lies. They have reason to mistrust just these
necessity for excuses
decent people and those who mean well by them, and to hate and annoy
them; they are particularly sensitive and irritable in their presence,
while with bums who cannot reproach them they feel at home. Thus
they not only get into bad company and altogether away from decent
people, but they are ruined more and more by being accustomed to
intercourse with degenerate elements. Concerning the more intellectual
field it should be added that the patients cannot even dare to see things
as they are; otherwise they would appear too miserable in their own
eyes.
The
attention has a limited tenacity, partly because of the lability
of interest,
partly too especially because patients are more easily
The
latter shows itself everywhere, especially in their work.

In the uncomplicated cases orientation remains normal.
In severe cases perceiption also is disturbed in the same sense as in
delirium tremens, only to a lesser degree; the patients easily misread,
fatigued
they mistake pictures on brief exposures, and they hear incorrectly.
Many
down
in
have any sexual relationship show delusions

which are quite peculiar in form. They fluctuate up and
alcoholics that
of jealousy,
direct proportion to the
relatively sober times
it
may
amount
of
alcohol
imbibed.
disappear entirely, in intoxication
In
it
becomes stronger and entirely senseless; not only chance spots on the
bed but also those on the toilet can prove the wife's faithlessness.
Illusions and memory deceptions often promote the delusion, rarely,
and almost only during inebriation it is also helped by hallucinations,
especially of sight; the husband sees that his wife winks at a man
passing on the street; he has watched her through a hole. But at
first these suppositions, produced with complete conviction,, do not
hold ground; they become uncertain or dissolve completely when one
313
wants to ascertain wliat the patient has found out for himself. Jealousy delusions often lead to murderous attacks on the wife. But
toward actual unfaithfulness many of these patients are hardly
sensitive.
Many
reasons are given for the genetic explanation of the jealousy

The alcoholic loses his potency, while the libido still exists;
delusions.
the marital relations are bad; the wife's love is impaired, if it has
not entirely vanished; through his absence in the saloon the husband
gives her many opportunities to be with other men; he treats her
badly and
ness.
is
not himself scrupulous in the matter of marital faithful-
All these elements produce or increase jealousy under other
circumstances also.
a difference that
From
is
But between jealousy and delusion there

not explained by
another, though
much
all
is
still
these reasons.
rarer form of alcoholic delusion, origi-
nates the self -surrender to the police on the grounds of having com-
mitted some crime, usually one that was sensational at the time, rarely
one that does not exist. The patients want to confess and demand
punishment.
In the cases that
could follow more closely,
certainly or probably alcoholism on top of schizophrenia
it
was
(this is to
say, incipient alcoholic hallucinosis).
Morbid
Picture.
The drunkard
is
man who
cheers himself up,
Gradually he takes more

and more time from other purposes, especially his work, and more
money from his family and business. He is irritated by actual or
merely probable reproaches, under certain circumstances he becomes
senselessly enraged by them, especially when he has just been drinking.
Later he regrets what he has done, but not deeply or for long.
and ugly scenes recur more and more frequently. He "fluctuates between unmanly weeping and dishonorable indifference" [Kraepelin)
the latter taking up the greater part of his time a carefree humor of
drunkards, which is easily transformed into irritability or pangs of
In his exalted self-conceit
conscience, dominates him most frequently.
he believes himself to be something extraordinary, thinks he works
harder than everybody. But this overestimation does not, however,
or forgets his sad thoughts with alcohol.
lead to real delusions of grandeur.
More and more he
forgets honor, good
he speaks and acts, he does not hinder his
manners and decency; when
own dignity. He discusses

The dignified man who
the most intimate family affairs at the bar.
faultlessly proper finally becomes outwardly untidy, and

even loses his sense for the poor appearance of others.
In his more intimate dealings, that is. where it is not a question of
was formerly
established standards, the drunkard no longer considers the rights of
314
From
others.
even when he admits a part of his
his wife,
faults,
he demands as her self-evident duty all consideration and love, while

he himself can do as he likes; if he conducts himself badly, it is only
the result of her lack of understanding.
He
has an entirely wrong conception of his cravings it is right and

it is right because he earns money (even
;
necessary for him to drink;
when
the wife really supports the family) because he is the man,

because one has to have some enjoyment; it is necessary as otherwise one cannot work. As far as he indulges in it, drinking is harmless;
other people drink too, and
some one
else is to
more than
still
blame, not he.
If at times
or perhaps through special enlightenment he
he.
In every case
through some bad luck
in a position to judge
is
only touches him in
moments of moral
dumps, an unpleasantness he seeks to remove as soon as possible
with alcohol. Hundreds and thousands of times he promises either
himself somewhat better,
it
in all seriousness or in a hypocritical
man," only to break
With
way
to reform, "to be a better
his promises just as often.
this all he ruins his family
As
maltreats, are afraid of him.
life.
The
children,
whom
he
a rule his financial condition suffers.
In the lower classes the wife often has to support the entire family;
the husband drinks up what he earns and extorts with threats and
maltreatment the wife's hard earned pennies, for which she has de-
No
prived herself of sleep.
him
He
in this.
is
law,
much
less public
The wife
maltreats his wife, one reads in the police reports.

entirely at his
opinion, hinders
not dangerous to the public generally, he "only"
mercy and leads a
life
that
is
is
usually
worse than that of the
average slave in very different times.
The worst
acts, to
of these people do not
Many
pital
of
gives
longer
be sure, occur during intoxication but
come out
patients
the
room
many spend
to
get
only
of this state for
into
jail
small
their last years
intermittently.
part.
many
days at a time.
Of
those
The
who
hoslive
or decades in poorhouses and
asylums.
The female
male companion
than the latter, not
only because she is less frequent, but especially because as a rule she
is much more seriously psychopathically predisposed.
It then becomes
in fate.
She
is
inebriate differs not a little from her

also
difficult to isolate
much more
what
is
difficult to picture
characteristic of alcoholism in the individual
most different directions. To be sure,

examination one finds the identical abnormalities
But the attitude is different. Contrasted with the men
cases that are abnormal in the

in the psychologic
as in men.
the female patients are taciturn at least toward the people
who
are
315
concerned with their tdcoholiism, they seek to conceal their inner

all or only to a very moderate
degree, and when one does not believe them, they are accustomed to
thoughts, do not admit drinking at
make
the most definite and serious protestations, even
when they have
frequently been caught in the act.
This conduct,
like the severer
psychopathic condition,
explained by the absence of the drinking compulsion in
is
woman
readily
for her,
custom does not transform a vice into a virtue. She mu^t be much
more abnormal before she drinks so much (if the modern bottle beer
maintained at the present level, it will, to be sure, diminish
furthermore she cannot boast of her "prowess" like
the man; the entire situation shows her at all times that she is doing
something that should not be done.^^
In pronounced schizoids the drinking mania and alcoholism frequently show a special characteristic. Such people lead a secluded
life, and create disturbances only in the form of outbursts of irritability,
business
is
the difference)
the affectivity as well as the contact with the environment remains
inadequate, even in the higher grades of alcoholism, a real ability to

discuss the
mania does not
exist.
Nevertheless after a long sojourn
and proper treatment (consistent action

without many words, for the rest to be left alone, no irritation) will
produce an essential improvement in most cases. ^*
in the hospital (at least a year)
Course.
The
disease as a rule creeps in entirely unnoticed; in
when
cases one cannot tell within ten years
many
These
people just gradually drink a little more or they gradually become less
capable of resistance against the same quantities, and at all events the
characteristic symptom complex is only formed in the course of years.
With this all, many maintain themselves as good commonplace people
as they only need continue living at the ordinary pace, they have
nothing new to learn and need not exert themselves especially until
the more or less premature death ends all.
Only a small part get
plain alcoholic dementia as a result of brain atrophy.
it
really began.
In this course there are often pretty strong fluctuations in part as

the result of some insight and some effort toward moderation, in part,
however, as the result of the intervention of third parties or other

change of circumstances. But on the whole there is an unchecked
decline, in
many
cases to the lowest
human misery
patients usually drag their families with
the decline
^That
^
is
only to a certain grade of
description
Bills wanger,
may
not hold true for
all
K. Ueber schizoide Alkoholiker,
U. Psychiatrie, 1922.
Springer, Berlin.
into
which the
more favorable cases

feebleness which substitutes
them
in
American female
Zeitschrift.
f.
d. ges.
inebriates.
Xeurologie,
316
bar-room gossip for recreation that elevates the mind and

finally also lets
it
Theoretically most alcoholics are
Prognosis.
spirit,
and
take the place of work.

still
curable at a
time when their disease has long been obvious to the layman. Only
when in spite of energetic attempts they are no longer capable of
seeing and feeling the misery that they are bringing to themselves
and their family, or when stealthy memory defects indicate brain
atrophy or also when the innate disposition is ethically untrainable,

then the inebriate must be given up because nothing can be done for
him. To be sure, he usually has to be given up because the more
intimate or distant connections do not
begin too
Thus the majority
late.
want
to intervene at
of inebriates
all,
or
sink deeper and
deeper and are ruined after they have for decades made the family
is tied to them unhappy in every respect; often the cause is
which
alcoholism
offer a
more frequently
itself,
diminished resistance.
in a quiet or erethic
it
is
other diseases to which they
small number spend their last years
form of alcoholic brain atrophy (dementia-alcoNot seldom the end is suicide,
holico-senilis, see organic diseases).
usually during an alcoholic depression, occasionally too during some

other emotional state.
According to Rose the cranial bones are frequently

In the cranial cavity one often finds in the more severe
cases, that the pia is clouded and thickened; occasionally (but not
nearly so frequent as in paresis) there is also pachymeningitis hsemorrhagica. The brain itself in advanced cases is plainly reduced in size.
Anatomy.
thickened.
The ganglion cells show at an early stage different forms of degeneration.

The glia is increased as to the number of cells and fibres. The
ependyma of the fourth ventricle often shows granulations. In some
of the nerve
and
finds, as a rule,
glia cells as well as in the walls of
much
fat.
The organs show
blood vessels, one
in different
ways
alcoholic
degeneration.^^
Depending on the methods of admission in the hosinsane, male alcoholics constitute from 10 to
35% of the admissions (not of the population). But this is no
measure of the distribution of alcoholism. Only a very small part
Frequency.
pitals
for
the
of the patients get into institutions.
degree of alcoholism, recog-
nizable on close inspection in Central Europe,
is
quite usual in the
one only wants to count the cases from

where a noticeable injury of the individual is apparent, then there
are naturally no figures at one's disposal; but whoever keeps his eyes
second stage of maturity.
If
open will probably consider alcoholism as the most frequent disease

"'Comp.
p.
303
ff.

of
317
men, aside from cold and such triviul thin^^s. In Switzerland about
of the men dying between forty and sixty are desij^nated by
16%
Naturally the figure
physicians as alcoholics.
greater.
is
in
much
reality
In the remaining parts of Central Europe conditions are

^
probably the same
Hardly anywhere
Causes.
is
as
much known
concerning the causes
of disease as in the case of alcoholism, and yet nowhere
dispute than just here.
In the
first
is
there
more
place there are two kinds of con-
upon which alcoholism thrives; the first represents

a disposition causing or impelling one to partake of spirituous drinks
in larger quantities, the second represents a lower degree of resistance
toward the quantity partaken of, in which case the resistance of the
genital disposition,
brain
is
of especial significance for psychiatry.
Under our conditions difand the weakness toward the ever-present temptation and seduction. Here one
The
first
group
is
not homogeneous.
ferent dispositions cultivate the active impulse to drink
finds in the first place those with a congenital
weakness of
will.
Others
surrender to alcohol because they have no reason for not doing so;
they are coarse and morally dull and seek momentary pleasures. Less
boon companions who fall victim to alcohol

enormous numbers; most of these people not only are not psycho-
offensive are the cheerful

in
pathic, but belong to those
who
react to
life
syntonicalty,
who
are also
from inner resistances and inhibitions; it is therefore absolutely

wrong to assert that only psychopaths become drinking maniacs or
alcoholics, and that they must drink because they otherwise cannot
free
adjust themselves to the world.
Others take to drinking for the oppo-
reason because they are not capable of getting out of themselves or

of ridding themselves of things disagreeable in some way. Alcohol ensite
As mere comhave not to my surprise seen

any actual alcoholics in the hospitals for the insane and in the inebriate
sanatoria. Persons having pure complexes even if they frequently
narcotize themselves in a striking manner probably do not drink conables
them
to forget or frees
them from
their inhibitions.
plex diseases in the psychoanalytic sense
tinually enough to
become
real alcoholics.
IMoreover,
it is
also possible
that the pronounced alcoholic, like the organic patient, loses the ability
Many have some other difl5culty of adjusting
to split off complexes.
^Ônly a person who has delved into the matter can form a proper conception of the social and economic significance of alcohol. For this purpose Germany spends yearly about two million marks pre-war currency little Switzerland
spends daily nearly a million francs, much more than the costs of mobilization.
For these sums are purchased disease, misery, crime, reduced working hours and
weakened capacity for work. Comp. Hoppc, Die Tatsachen iiber den Alcohol,
;
3rd Ed.
Calvary, Berlin, 1904.
318
life; some have ambitions that are beyond their ability

and never act because they are always planning, others do too much,
themselves to
but do
it
senselessly, the third has "nervous" troubles, etc.
class also belong
alcoholism
is
many
To
this
that suffer from mild mental diseases, in v/hom
not the cause but the result of the disturbance.^^ Conwe find the strong men who believe
trasted with the class of weaklings
they can stand everything and thus indulge excessively in alcohol.

Many, perhaps the greatest number of alcoholics, are the complete
victims of our drinking customs; to be sure, the latter are rarely seen
in institutions; but one sees them by chance all the more in the ordinary
walks of
life
and as
The second
carriers of various other diseases.
group, those incapable of resistance,
we can
describe
We only know
not homogeneous ones) in which the brain reacts to the quantity of
drink imbibed in the sense of pronounced chronic alcoholism. We
that there are peculiar dispositions (certainly
still less.
cannot determine
why
in one, drink ruins the liver, in another the
heart, in the third the regulation of metabolism, in the fourth the brain,
in the fifth all these organs,
and why many others can stand the same

without becoming alcoholics in our
quantities of alcohol fairly well

sense.
Both
dispositions are only exaggerations of weaknesses that
nature generally
is
liable to.
human
craving for poison like alcohol exists
everywhere; but those races which in the course of their development

through thousands of years have had at their disposal a certain quantity of this mode of gratification have adapted themselves to it; they
are temperate.
But modern industry and means
of
communication
Only
have nearly everywhere surpassed adaptation, hence the misery.

a generation ago Italy
was
still
a temperate country;
now many
of
her insane asylums admit the same percentage of alcoholics as our own.
It
is
self-evident that
it is
alcoholic, not only because
possible that every brain could
we can
become
narcotize everybody with alcohol
but because we see everywhere the identical toxic effects of alcohol.

I doubt whether the average capacity to resist alcohol has declined
But
in the last centuries as
The various
many
the families of drunkards
which
suppose.
dispositions manifest themselves also in heredity.
we
find very diverse
in perhaps half of the cases
abnormal
become manifest
In
dispositions,
as the father's
alcoholism.
Among
the predisposing causes the most important
is
our drinking
" Ferenczi is of the opinion that alcoholism is generally a substitute for

repressed sexual desires (abstinence would then be a compensation for sexual
weakness). In reality no one lives a better sexual life than the average alcoholic,
319
custom, which has developed from both these dispositions witli the
assistance of our specific social conditions. This custom represents
the indulgence in alcohol as something lovely, useful, necessary, and
self-evident, so that it requires some strength to withdraw from its
influence.
As a camp follower
of the drinking custom,
is
the capital
invested in the alcohol industry whose millions have organized very

skilfully the
inducements to drink.
and seductions that come
Of the well known opportunities
into consideration for the individual
should
By
mothers of spoiled sons bad company

is most often considered the criminal; but this is usually unjust because
one is rarely compelled to associate with bad company. But in reference to drinking the accusation is too often true; drinking companions
like to
emphasize only a few.
are, to begin with, so decent that the
the evil connected with
them nor can he
inexperienced neither notices

foresee the danger that
is
in
One goes to these gatherings for a worthy reason, and

does not consider how unworthy a few hours or perhaps a decade later,
store for him.
it
may become
in alcohol; that
it is
is
also said that trouble
and misery can be drowned
true only in exceptional cases; trouble and misery
are the results of alcohol and then, to be sure, by
means
of a vicious
they constitute an excuse to increase the evil with additional

I know of no case where increased wages have reduced the
alcohol.
circle
use of alcohol and statistics prove the opposite.

What quantities of alcohol are necessary to produce the disease
depends on the personal disposition, perhaps also on the quality of

nourishment and manner of living generally. One person may become
physically and mentally a pronounced alcoholic while perhaps one of
his companions drinks several times as much and nevertheless remains
The nimiber and strength

Whoever gets drunk on small
within the so-called norm.
of the inebria-
tions is immaterial.
quantities will
hardly ever become an alcoholic; whoever as a general thing lives

moderately will never become so, even though ever>^ year he is found
several times in the gutter. But whoever regularly imbibes larger
quantities,
risks
a chronic poisoning,
even
though
he
is
never
intoxicated.
Differential Diagnosis.
Alcoholism can be associated with ever>-
other disease and then one of the two is often overlooked. Other
symptom complexes such as paresis, schizophrenia, fever deliria. etc.,
Schizophrenics, who are at the same time
most frequently mistaken for mere alcoholics. If they
are sent to insane asylums, no great harm is done. The mistake is
more serious in homes for inebriates, where they usually do not know
how to handle schizophrenics, and in home cures, where the treatment
can be tinged by alcohol.

inebriates, are
320
of the patients should legally
that of mere alcoholics.
and medically be
Among
entirely different
from
the less noticed signs of the basic
schizophrenia the unrealistic seclusion from social intercourse is important; the inebriate who does not know what to say and withdraws
from the other patients in the institution is no mere alcoholic.
Many psychic symptoms of alcoholism resemble the paretic and
may
even be organic, because the

.^^
In older persons
intoxication also produces a kind of brain atrophy
organic
symptoms
the question
generally; they
how much
of the disease
is
senile
and how much
is
alco-
holic, can often not be decided on theoretic grounds.

Chronic manic patients are readily mistaken for alcoholics; more
rarely the reverse
is
the case.
The
flight of ideas,
of the disturbance independent of the use of alcohol,
even in
certain.
the fluctuations
and
its
persistence
abstinence or strict moderation makes the diagnosis of mania

The absence of these symptoms in spite of careful observa-
tion excludes
it.
Naturally the anamnesis often gives at once definite
information.
from normal health is most diffiRegular quantities, which in Europe are considered moderate,
cult.
plainly change the appearance of the aging person; whoever has a
With
little practice can ascertain the same in reference to the psyche.
a
"normal"
and
since
the
us a little alcoholism, therefore, belongs to
^^
daily
eight
liters
Munich Court has decided that to drink from six to
is not yet immoderation, one must not imagine the "little" as being
very small. I would, thereforej have alcoholism in the sense of medical
Whoever
practice begin there, where practical reasons demand it:
plainly harms himself or his family through the use of alcohol and who
cannot he made to realize this, or who no longer has the will or the
strength to better himself, must be considered an alcoholic. Among
The
differentiation of alcoholism
the signs of harmfulness one naturally understands also the physical

and mental symptoms of chronic alcoholism in the psychic sense. That
this
somewhat narrow, but
includes also the drinking
for practical purposes valuable definitipn,
mania
is
not only true, because drinking
mania and alcoholism condition each other, but also because practically
and legally they are a unit.
There are people, also, who, without distinct signs of alcoholism,
behave badly for other reasons, e.g., congenital disposition, and do not
manage their affairs properly; alcohol only aggravates their condition
Such people must not be mistaken for alcoholics; the
still more.
prognosis and treatment are entirely different here.
" Cf. alcoholic
paresis.
"Internationale Monatschrift zur Bekampfung der Trinksitten, 1897, Jahrg.

7, p.
239.

It
was said that he
suffers
321
from alcoholism who regularly imbibes
alcohol before the effects of previous doses have disappeared.
But
cannot at all be taken strictly, since in psychologic investigations

such effects can be demonstrated twenty- four hours later and even
this
much
longer,
and no one
will
want
to designate as alcoholic one
drinks a few glasses of beer every twenty-four hours.
Then
who
again,
who has a craving for alcohol and

cannot be a test, because the criterion is,
in the first place, the evaluation of the reasons which should restrain
from indulgence. The ordinary habitue of the saloon does not drink
as much as he does because he cannot help it, but because he knows
he
is
to be considered an alcoholic
cannot
resist
it.
But
this
no reason, or cannot appreciate any, that should keep him from

doing
so.
That alcoholism should be measured
scientifically
standard from that used in other diseases
is
with a different
naturally nonsense.
In a
an alcoholic who exhibits sure signs of

alcoholism; whoever shows mild signs is a mild alcoholic; whoever
medical sense every one

exhibits serious ones
is
is
a serious alcoholic.
The consequences
to be
inferred from this vary according to the case: practice will be infinitely
more
lax than science, which cannot permit herself to be falsified by
affective or opportunistic viewpoints.
Naturally the entire affective symptom complex
is
not in
itself
to be inferred with certainty from single symptoms, since organic diseases and congenital dispositions can have a similar appearance.
One
can most readily make a diagnosis from the liveliness of the reaction
in many failures, from the characteristic evasions, and from the causal
elaborations.
one has a
time to observe the patient, then naturally his

is important.
Patients who improve after a
few weeks in the institution, who plainly change their character for
If
little
reaction to abstinence
the better and quickly get worse after indulgence, are in the main
alcoholics.
The diagnosis is very materially supported by phj'sical symptoms

and the anamnesis. But in taking the latter one has to be very careful
not only because nowhere except in sexual matters does one ever get
such false reports as in the matter of alcoholism, but also because
who are brought to insane asylums have not always been
alcoholics
psychopathies.
Erhen
states that the alcoholic
ness of the oscillations in

*
common
tremor has the rapidity and finewith that in diabetes, nicotine
Diagnose der Simulation Nen'osen Symptome.

Wien, 1912.
Berlin,
Urban
&
Schwa rzenberg.
322
poisoning, lead, zinc, mercury, sulphuric oxide and in convalescence
These tremors are more severe when the

weaker when the fingers are moderately bent; as
distinguished from paralysis agitans the fingers among themselves do
serious
after
diseases.
fingers are spread,
not
move synchronously;
easily,
but
Care
is
in
not at
less so or
alcoholism the
all in
tongue also trembles
metallic poisoning.
also necessary in judging the dilation of the facial blood
There are very temperate or abstinent people who have a

red nose and only a very small fraction of inebriates can be diagnosed
in this way.
Treatment. The experience of a thousand years proves that training to moderation is a utopia. In the first place the treatment has to
solve three problems: Above all the quasi-physical dishabituation from
the need of alcohol. This is easier than is generally supposed. It is
vessels.
only an exception
when the
alcoholic in the hospital for the insane feels
smoker for tobacco or the morOf the abstinence manifestations I only know
a real need of indulgence, as does the
phinist for his alkaloid.
the coarse trembling.
Still
others are mentioned,
e.g.
sleeplessness,
and certainly among several dozen inebriates, one perhaps will not
sleep as much as he would like, for the first few nights in the hospital
for the insane. But in the first place there are other reasons for this;
secondly, many inebriates slept irregularly previous to this, and usually
under abstinence they not only sleep better but even normally. It is,
therefore, necessary very decidedly to advise against giving soporifics
merely because of this indication. It is just these people who must be

thoroughly rid of the habit of taking drugs for slight discomforts.
It is still supposed that the sudden deprivation of alcohol kills these
people. This is directly contrary to the facts.
The omission of alcohol kills nobody, it is only the use of it that does.
Protracted abstinence is not harmful; out of 279 patients discharged from the Ellikon
Sanitarium who relapsed, 62 (22%) died in the first twelve years;
of 295 cured and improved discharges 5 (1.7%) died.
Therefore the first indication is the immediate removal of the
injurious matter.
More
difficult is
the associative dishabituation,
of the association of ideas that incessantly impel
i.e.,
the breaking
toward drinking; in
those better disposed, it is especially hard to break the associative
identification of alcoholic indulgence with everything beautiful and
ideal that has been experienced in the past (old college men!), and
to form newer associations corresponding to realities.
It is necessary
on the one hand to associate the patient's misery and those of others
with drink, and on the other hand to connect the conceptions of
32:5
righteousness, ability, work, and liappiness with the anti-aleohohc idea.
more time
Still
is
needed for the training of character geruiraUy, the
habituation to regular work, the cultivation of resistance to the incessant temptations, the development of self-control, of joy in real
achievement, and of pride of the right kind.
The
is
best
way
to satisfy all three indications
is
a sanatorium which
not just a resort for inebriates but where the patient
is
skiifully
treated by pedagogic and psychologic methods, and where the superin-
tendent
is
imbued with the
lofty purpose of his cause.
The
patient
and should not be accepted

if he does not bind himself in advance for this length of time.
But
with us he can leave in spite of his pledge, if he wants to; therefore,
the superintendent must have personal influence enough to retain the
large part of the patients. Brewers, saloonkeepers and others in the
alcohol industry should only be accepted when some guarantee is
given that the business is to be transferred to some one else before the
patient leaves the institution; one cannot be an abstainer and saloon-
must
persist on the average for about a year
keeper at the same time.
The
hopeless, or those with a morally de-
fective disposition should be kept
much
away from
alcoholic sanatoria as
as possible, because they endanger the cure of others.
In milder cases associations for total abstainers under good leadermay suffice. But naturally they offer much fewer opportunities
and, in addition, they have the disadvantage which must not he under-
ship
estimated, of dragging along until they are incurable, cases which in

themselves are hopeful. Where the danger of postponement is not too
great and where admission to a sanatorium for alcoholics
is
difficult
may
be tried. If one has a

choice of several associations, then, aside from the personality of the
In
director, that one is to be recommended that is most consistent.
or impossible, one of these associations
Blue Cross does a world of good, it has the

fundamental error of demanding total abstinence only from inebriates
and those who want to help them. This reduces it to a mere crutch
and makes of the patient a second rate person who is in need of one.
Whoever cannot adopt the platform, self-evident in the light of all
the facts, "that drinking causes much misery and practically no benefit,
and hence it is better for all mankind to dispense with it," such a
man is always in danger of trying, by means of drink, to elevate himThe reformed drunkard must feel
self to the rank of superior persons.
at ease in his decency and must not, like the turtle in the ball room,
spite of the fact that the
get
homesick for the mire.*^
"The Good Templars, the Opponents of Alcohol and, in most places, the
Catholic Abstinence League are consistent abstinence associations.
324
These alcoholics who lack the insight to permit themselves to be

cured willingly must be put in restraining institutions, that is, at
It is a blessing for many a drunkard if he
present, in hospitals.
perpetrates something real serious or gets an attack of delirium
tremens, because then for once, he can be subjected to treatment.
Therefore, where the statutes do not make it impossible, and by way
of exception, where there is an intent to cure the patient, one should
make the most of such opportunities and recommend the hospital.
But the patient hardly
gets there before a drive
is
made
against the
"unjust" incarceration, either by himself or those like him, or by friends

disposed to moderation. Then it is necessary to stand firm. Unfortunately the wife usually has the decision in her hands,
i.e.
the most
is the one who has most to fear from

and who loves him or has loved him, and for that reason
is most readily deceived by the solemn protestations that appear in
quantity two or more weeks after the commitment. Then in addition,
reasons are advanced that unfortunately seem to have weight with
those not so close to the patient: "The man is not crazy at all and
therefore does not belong in the insane asylum; among the insane he
will have to become crazy; he has to be given a chance to show that
he wants to do better and can do better," etc. Thus the wife usually
weakens, even though at the time of commitment she gave solemn
assurance of her firmness. But if she can remain firm, so that the
husband never feels her doubts and if she avoids many visits as long as
he is anxious to go home instead of to an alcoholic sanatorium, then it
unsuitable person; because she

his revenge
may
still
go well with those patients
who
are at all curable.
sure, as a rule after the stage of facetious euphoria
To
be
and solemn prom-
ises, there is a third stage of irritation and threats to be withstood,

that gives the useful insight that the promises are in vain one has to
know this in order not to be frightened, because it is only a matter of
;
firmness to
make these
manifestations disappear quickly.
threats of suicide are to be ignored.^^
The ordinary
After one to three months the
patients are usually transferred to a sanatorium for alcoholics.
To
be sure, individual cases have to remain in the hospital for years

and, if they have sufficient endurance, they may be cured anyway.
"There
are only two sensible answers to threats of suicide: either to ignore

is to do the opposite of that which the threat seeks to accomplish,
or commitment to the observation ward of an insane asylum. If one acts differently the threat becomes the worst sort of fetter that makes decent people
them, that
the weak tools of brutal rascals.
It is well to think of this in the treatment of
moral defectives also. To be sure, one has to be able to take it upon oneself
that in many thousand cases one useless and harmful life may find its end on
luch an occasion.

To
be sure, the hospital must be equal to
places such patients
still
get alcohol, or
it
is
its
made
325
In
task.
plain to
many
them that
only for them are the benefits of alcohol injurious, or they are ^îven
It may be that such institutions are
positions as bartenders, etc.
not bad in other respects, but at
all
events they are incapable of
curing inebriates.
Guardianship also
ing to the
is
a palliative
German and much more
also be a factor in the cure.
But
when properly handled.
according to the Swiss code
Accordit
should
as long as the majority of guardians
themselves closer to the inebriate than to the abstainer, naturally

is to be expected from this; but even now this device has a
feel
much
not
certain benefit
if
the right kind of guardian
is
found, and with the
spread of better ideas this advantage will grow more and more if
the court of guardians has the legal means to compel a cure. Naturally
if the wife becomes the guardian of the inebriate.
remedy or as an auxiliary to a cure hypnotism has
been recommended. It has the danger of diverting physician and
patient from the real problem. Therefore I do not use it here, although
there may be cases where it is very useful.
The chemical remedies recommended are humbug.
Whether the patient is at home or in any kind of institution, the
it is
always a mistake
As a
principal
treatment of his environment

himself.
That
so
many
is
just as important as that of the patient
curable inebriates are lost
unfortunate patience of the wives
who
is
the fault of the
cannot, before
it
is
too
late,
minds to a measure that hurts their pride. The family

physician should endeavor to direct to the right place the patience
which here only does harm; furthermore he must take care that after
make up
their
recovery the patient's wife remains abstinent with him.
Incurable alcoholics are a terrible burden for their families and the
Kraepelin recommends hospitals as a place of confine-
community.
But to me the present arrangements of the hospitals do not

seem suitable for the patients, nor do the present laws meet the scientific demands.
Forel and others therefore demand that special institutions be arranged for them in which they are bound to earn by labor
at least as much as they need. This would have the advantage of
being a solemn warning to the attitude of the alcoholic that everyone
is powerless over him.
It would obviate many crimes and other
dangers and disadvantages, and would offer the possibility of belatec
cures through protracted compulsory' abstinence and training which
might return to society after years and years many a man apparently
ment.
lost.
Strange to say in the case of alcoholism the
modem
physician has
326
to be told that the most important part of the therapy

laxis.
But one must
It is
soil
the prophy-
remedy helps:
recommend moderation:
It is nonsense to
on which alcoholism flourishes.
abstaining from alcohol.

the very
is
realize that here too only the right
the complete eradication of alcoholism
is
possible,
The
if
limitation, even
the determination
no other avoidable disease that brings so much

Therefore it is the physician's duty ^^ to be
informed at least as exactly in this matter as in the case of infectious
The textbook of psychiatry can only point out this duty.
diseases.
is
There
there.
is
misery to civilized people.
There are people who are afraid of the result that a better insight
would compel them to avoid spirituous beverages themselves. To putit mildly, this would be no loss to the individual .physician
for many
of his patients it would be a gain, because only the abstinent physician
can cure inebriates; for the community it would be a blessing. Who;
ever avoids abstinence in spite of insight into
seems a
sacrifice,
calling, is
its benefits,
because
it
lowers the medical profession which, as no other
accustomed to
sacrifice life
and personal advantage
for the
benefit of others.
Unfortunately it is just the physicians, who in the matter of alcohol

have to make good the much harm that previous generations have
done. The theories that were advanced especially in the middle of
the last century concerning the properties of alcohol as a strength and
blood producer, as a preventative of infection and dispeller of fever,
have, it is true, been given up by science, but all the more have they
become part and parcel of common knowledge. And the charge must
be made against physicians that, though at the time they eagerly
disseminated the prejudice, they now do far too little to remove it
and, instead, still do much to support it. Every (public) prescription
of alcohol, even though in itself indicated," is harmful, partly for the
patient, partly for the
that alcohol
is
community because
it is
irresistibly interpreted
And unfortumade where physicians
beneficial or necessary for the healthy.
nately mistakes in practice are
still
being
instigate the cured inebriate to again indulge in alcohol
lead
him with
and thereby
his family into misfortune.
Delirium Tremens
There are several acute psychoses of a plainly specific character

based on chronic alcoholism. The most important of these is delirium
*^
The study of drinking customs and everything connected with them is
otherwise very useful also; it reveals a wonderful insight into human psychology,
especially of the power of affectivity over thought.
"Proof is, as yet, wanting that there are indications for alcohol, i.e. that it
cannot be substituted by something else.
327
almost only after many years

we have seen it in young
people in the early twenties who were addicted to drink from two to
four years; so far they have all proved to be latent schizophrenics.
Even in children and young people for whom the physician has pretremens, drinker's insanity.
It occurs
of indulgence in alcohol; but occasionally
scribed large quantities of alcohol, the delirium
may
break out after
a few years; but fortunately such cases are very rare.
The attack
is
usually precipitated by special occasions: any weak-
ening factors such as any of the acute diseases, especially those with
fever (pneumonia, exacerbations of alcoholic catarrh of the stomach,
influenza, etc.), excessive
and continued drinking, or a trauma may
induce an attack.
Bonhoeffer believes that the latter are less the cause

than the result of the incipient alteration of consciousness and foresight; but the operating surgeon also does not fear the disease without
reason.
Abstinence from alcohol
is also said to produce delirium tremens.

very decidedly contradicted by the experience in sanatoria
for alcoholics and in insane asylums, in which every alcoholic is kept
abstinent from the time of entrance. According to my experience,
But
this is
and that of others, in hardly one case in a thousand does the delirium
break out, which could not have been demonstrated previously with a
fairly good anamnesis or examination on entrance, while, on the contrary,
many
abstinence.
cases,
As
already clearly diagnosable, recover in spite of
far as I
know, the individual cases cited to prove the
contrary are described and evaluated in an extremely uncritical
man-
Only Bonhoefjer's statement is worthy of discussion that very

frequently in the first days of confinement, especially in the case
of tramps, the delirium breaks out; but since the same deprivation of
alcohol in sanatoria does not have the same result, the difference must
lie in the other circumstances, and these are really not far to seek;
one can mention the psychical influence of confinement, the bad
hygienic conditions, the forbidden nourishment, the sudden deprivation
Have not many of these
of liquids and perhaps still other factors.
ner.
people permitted themselves to be caught because the delirium was

already in the incipient stages?
brought with
it
a reduction of
Sudden increase
whiskey
whiskey boycott in
in the cost of
deliria, as did the
Wigert '^^ ascertained that the suppression of the

whiskey traffic during the general strike in Stockholm was followed by
a small increase of cases of delirium tremens in Stockholm; instead of
Breslau in 1909-10.
^The
frequency of delirium tremens in Stockholm during the prohibition

f. d. ges. Neur. u. Psych. 1910. I. Bd.
of alcohol, August-September, 1909, Ztschr.
Orig. S. 556.
328
an average
of 4, 6
and a
maximum
of 9, 16 cases
came to
notice in the
week, one in the following week, then no more until the re-opening
of the saloons. But the author did not examine the individual cases,
so that here too it is not even proven, first, that these delirants previously had days without alcohol and, second, that the addition of
first
other factors (lack of work, hunger) is very probable. But if the

improbable assumption that these were cases of abstinence deliria is
to be taken as valid, it remains proven by this investigation that
abstinence deliria, even when they occur, are so rare that it would
be a mistake to consider them a factor: Among the many thousand
inebriates who were suddenly forced into abstinence in a city which
consumes 4.4 million liters of whiskey in a year, there were at the most
a dozen cases.
Sometimes, but not always, delirium tremens is preceded for weeks

months by premonitions: Sleep is cut short or disturbed by
terror, moroseness, irritability and uneasiness appear; the last may be
or even
heightened to real anxiety which appears to be psychically unmotivated.
Occasionally dizziness
occur-s.
All actions are restless.
The
tremor quickly becomes coarser: single hallucinations usually of

sight then occur, which are frequently in stable form; generally these
prodromal sensory deceptions need not have the specific character
of pronounced delirium tremens: A black dog follows the patient every
time when he comes from his morning's drink, two policemen stand
behind the closet whenever he comes home, etc. Sometimes the
hallucinations plainly betray their origin in the irritated condition of
the nerves. The patient sees shadows with high lights, he has sensations of itching or of being stabbed.
These hallucinations scare the
patient, although usually they are first recognized as such until they
pass over into the hallucinations of the developed delirium.
The latter ordinarily breaks out rather suddenly at night, often
awakening in terror or even in complete sleeplessness.
Hallucinations of a very characteristic coloring are most prominent
and involve in the first place sight and touch. The visions are
fine
movable, mostly colorless and have a tendency toward

Furthermore, hallucinations of touch and vision both
very frequently have the character of wires, threads, water sprays and
multiple,
diminutions.
other elongated things.

are frequent.
Elementary
visions, sparks
and shadows,
If auditory hallucinations are present, the patient
frequently hears music
etc.,
most
(especially often with a very decided beat),

very rare in other psychoses. At the same time one also
observes elementary hallucinations, especially in the form of reports
and shots, but also buzzing, roaring, hissing, etc. Words and sentences
which
is
329
are sometimes heard but never appear in the foreground; during the
entire course of the disease delirious patients can visually enter into
relations with hundreds of hallucinated persons that are all speechless.
Whenever auditory hallucinations formed an important component

the morbid picture, then in our cases
of
has so far always been a question of a complication with schizophrenia. Now and then hallucinations of smell and,
Not
somewhat more
frequently, of taste are observed.
at all rare are hallucinations of the kinaesthetic sensations
of the sensations of position.

feel
it
When
the patients
sit,
and
they suddenly
the stool sway to one side, the floor moves under them; while they
are lying in bed, they believe themselves at
The
some
work
in a sitting or upright
seem to
probably a part of these hallucinations. Individual somatic
hallucinations can usually be accounted for on the basis of neuritic
position.
move
feeling that
real objects, that are at rest,
is
parasthesias interpreted through illusions.
At the height
of the pronounced delirium the hallucinations of
vision, in spite of a noticeably blurring of the coloring, are distin-
guished by great vividness and plasticity.

able in neighborhoods
This
is
particularly notice-
where on the whole descriptions of visual
when alcoholics tell of their halluthem with a striking vividness and

the forms and movements with the hands as if they were
experiences seem very colorless; but

cinations, they usually describe
indicate
"A play is performed" for the

still seeing everything before them.
milder patients; delirious patients always see the movies; scenes with
ballet dancers, etc., are thrown on the screen for them.
But both the
especially
if
distinct
and
indistinct visions
may
suddenly disappear,
the patient, under a less lively concomitant hallucination
of touch, grabs in the air when he wants to seize or strike at a vision.

This gives an opportunity for all sorts of explanatory delusions. A
delirious professor took great pleasure in proving to us what a shabby
thing modern advertising is; one should just take notice, now he had
in his hand the finest advertisement which he read to us; now he
made a motion, and everything had disappeared.

Small movable and multiple things are usually represented in
reality by small animals, like mice and insects, hence these are among
the most frequent hallucinations of alcoholics. Besides these one often
only
sees here also animal visions of the
may
most various kinds;
pigs, horses,
appear either reduced or in life size; sometimes, too,

there may be animals "that do not exist" in exi;remely phantastic combinations. In entirely the same way I have noticeably often heard depicted on a board hallucinated on the wall, passing menageries of all
kinds of animals, usually large ones, but in some cases reduced to about
lions,
camels
330
the size of a cat, which entertain the patients very well.

are frequently reduced, but they
The
may
People, too,
also appear life size.
hallucinations of the different senses readily combine; mice
and insects are not only seen but also touched when the patient grabs
them or when they crawl over his skin. Money is gathered together
and carefully placed into a hallucinated pocket. The patient sees
passing soldiers and hears the band music; he sees and hears some one
shooting at him he fights with hallucinated assailants, whom he hears
speak and more rarely also touches.
;
The
optical sense deceptions of delirium tremens are livelier than
in other deliria.
In moments of hallucinating, reality does not
the patients take the
window
exist;
for the door, the stairs for the street,
and consequently are in danger of falling; instead of the wall of the

room they see the open field, bump their heads and get a mortal
meningeal hemorrhage.
Besides the hallucinations visual illusions occur in vast quantities;
those of the other senses are less frequent.
sons and things.
He
The
patient mistakes per-
misreads, often producing complete nonsense,
but frequently only inserting wrong words that have some logical cone.g. closet instead of box, eggs instead of
nections with the real text,
and similar things. It is peculiar that at times delirious pahave read aloud disconnectedly or entirely senselessly, can,
nevertheless, later repeat the real text correctly.
Hallucinations and
illusions can often be provoked and their content determined by suggestion; under certain conditions both at the beginning and the end
of the delirium where spontaneous sense deceptions are not present.
One presses on the eye ball (according to Liepmann) and asks the
patient what he sees. If he sees nothing or merely elementary light
manifestation, one asks him, for instance, if he sees the dog, which is
often successful in making him believe that he perceives such an animal
and he can then describe it exactly. One hands him an unused sheet
of paper from which he usually reads disconnected nonsense but occasionally also whole stories or business letters. When requested to do
so he carries on a lengthy conversation on a disconnected telephone
with a distant place. It may also happen that three hallucinating
patients who are in adjoining bath-tubs hallucinate about the same
fish which they want to catch and which jumps from one tub into the
butter,
tients that
other.
Perceptions are disturbed in other respects also.
The
patients
very readily mistake pictures after a brief exposure, and sometimes in

this case as in reading they do it in a manner that hardly occurs elsewhere; instead of the correct object, they name another which has some
relation to it but no external optical similarity. For instance, instead
331
of spectacles, they think they sec an opera glass; instead of a cat, a
mouse; a
It
is
bird's egg is designated as a nest; a shovel as
"two picks."
often very easily determined that paraphasic disturbances are
not involved.
but in its stead
This shows that the "actual perception" was correct

an overcharged associated idea comes into conscious-
Frequently the color of the picture is disregarded; the green

head of cabbage in Mcggcndorfer's picture book "Nimm Mich Mit'*
is more often than not taken for a rose (moreover this is not rarely the
case with non-alcoholics also). The cucumber in the same book has
ness.
even been mistaken for a sausage.

Gregor and Roemer found in one case that perception was retarded.
Contrasted with this it is striking that a brief exposure (uncovering
and covering the picture with the hand without apparatus) in complicated cases does not at all, or not materially, aggravate the result
as
compared with the longer exposure.
with the constant visual deceptions orientaBut this is not merely the result
tion as to place is disturbed severely.
In the last days of a somewhat drawn-out
of the hallucination.
delirium one now and then sees orientation fail, without the presence
of an hallucination and even without a memory deception which could
It is self-evident that
explain this.
Orientation as to time
is
also
disturbed during the
duration of the delirium, in severer cases even beyond this, so that

the patients state the wrong year, etc. Often the length of the
delirium appears
much
greater to the patients than
it
really was.
pure cases of delirium are oriented. They

know who they are, what position in the world they occupy, what
sort of family they have, where they live, etc.
Attention is profoundly disturbed. Left to themselves, the patients are occupied with their hallucinations and do not bother themBut if they are spoken
selves much with what goes on about them.
Autopsy chicaUy,
all
Presented before students at a

they usually conduct themselves in such an orderly manner
to sharply, they can be distracted.

clinic
that
it is
possible,
difficult to
if
show the coarse
the attention which
is
peculiarities of conduct.
It
is
constantly striving to wander
is
make even
psychological experiments with alcoholic

Left to themselves they are immediately occupied
delirious patients.
with their hallucinations. Even when they collect themselves, the
kept awake, to
field
of thought is very narrowed, consequently the ability to con-
centrate, attention, tenacity,
and
vigility,
as well as the limits of
these are greatly reduced.
The mental stream in delirious

At all events
ciently investigated.
patients has not as yet been sufl5far too few ideas are present.
The
332
patients talk according to the
simple contradictions.*
They
in complicated reflections,
momentary
need, without even feeling
are no longer capable of participating
which accounts
for the
marked absence
of
the critical attitude as contrasted with the promptness of the answers.

It is particularly striking in the case of the senseless hallucinations.
patient can very quietly state that somebody has chopped off his
hands and head; another patient said that he has been decapitated four
times, etc.
In contrast perhaps to
show
all
other cases of delirium and crepuscular
*^ an unusually quick reaction

exevoked with an incomprehensible rapidity, and
not alone in the matter of drinking, but in all other directions. Thus
the patients want to get away; their attention is called to the fact
that they have no trousers, whereupon they at once respond: "Yes,
that damned office boy always steals my pants; I have often told him
about it." Or his wife has taken away his shoes so that he cannot
go to the saloon, etc. Another always trembles so severely "when the
wind blows." To the question what the patient had done with his
pants, I once received the answer: "They are at home. I never wear
pants in summer."
If the delirium is complicated by epileptiform attacks or any severer
organic disturbances, this readiness may then be lacking and, on the
contrary one now observes a heaviness of perception and reaction.
Lasting delusions are rarely formed.
These patients naturally
believe in their hallucinations and endeavor to explain them; but
usually the delusion vanishes with the change in the sense deception.
states they
in conversation
cuses, especially, are
Most
frequently the patients retain for a longer period persecutory
accompanied by anxiety. They tell how different people have

made holes in the wall and squirt water or poison through them, etc.
The memory is deeply disturbed. Even during the delirium the
deliria
patients recall only a small part of all that they have experienced;
above
all
the time sequence of the experience
disrupted
is
invariably completely
(except in cases that have originated on a foundation of
Here the most complicated experiences are reproduced

days with great clearness, and the objective control, as
far as this is possible, may be a sort of guarantee for the correctness
of the recollection). Also after the delirium, the memory as a rule is
very incomplete but by mentioning experiences one can sometimes get
schizophrenia.
for several
See below among the excuses.

As in perception laboratory experiment with associations shows a retardation of reaction. This is probably explained by the difficulties inherent in the
experimental situation.
*"
*'

the patients to recall individual scenes.
But even then
333
larger or smaller
distortions are rarely lacking.
Also positive memory disturbances arc probably always combined

with delirium tremens, having the characteristics of opontaneous and
despairing confabu'ations. The patients tell a lot of things which they
have experienced neither
in reality nor in hallucination,
their real experiences into entirely
new
and bring
connections.
Recollections from the time preceding the delirium are usually good.
The
affectivity has specific characteristics.
In spite of the fact
that the patients always find themselves in situations not suited to
them, rarely attaining what they want (entirely similar to the dream
state), and are bothered rather than entertained by their visions, they
bear everything with an evident humor.
the silly improbabilities
(impossibilities
Often they themselves

for the spectator)
feel
of their
They can take nothing seriously except for a moment,

they behave in this manner in the case of some clumsy treatment that
irritates them, or in the case of anxiety hallucinations that readily
hallucinations.
The majority of these patients suffer from

combination of anxiety with euphroic humor (grim
present in most cases, and does not occur in this way any-
lead to dangerous attacks.

anxiety.
And
this
humor) is
where else.
Corresponding to the lively feelings and the lack of a critical attitude there exists a marked suggestibility. One can usually talk the
patients into believing without any difficulty that yesterday they did
this and that, and were in one place or another. The easy provocation
of hallucinations has already been mentioned. The patients respond
to requests with excessive acquiescence, they stretch their legs much
too high when one wants to test the patella reflex, etc. But still other
mechanisms must assist in the production of similar manifestations.
For instance, in psychological tests one should be wârj^ of presenting
the same test units several times in the same sequence because other-
wise the patients readily answêr in the sense of this sequence. Consequently there exists in contrast to the memor\^ disturbance an abnormal
capacity for habituating associations, in a direction not more exactly
known to us.
The conduct
is
so characteristic that the
delirious alcoholic
recognized at a distance with practical certainty.
He
is
is
incessantly
one can put him to bed a hundred time a day and yet he is
always out of it: the patient "is on the run." In an uncertain trembling
way something is alwâys being done pressing on real and hallucinated
locks, knocking the bed around, bracing against the wardrobe because
it wants to fall over, picking up money, mice and spiders are caught,
restless;
334
mouth and
With comical detail
avoids wires drawn through
hallucinated saliva threads or hair are pulled out of the

rolled up,
and other threads are spun
off objects.
the patient treads over a stretched cord,
the
air, clings
to pieces of clothing, while he mistakes their different
and wants to use the shirt as a pair

who keep it locked,
bangs against it, calls "Open up," etc. He wants to go away, has to
go at once to a certain street, where he has important business. But
on the whole very little is said in contrast with the high degree of
motor restlessness.
Occupation deliria are frequent which may be evenly divided as to
content between business in the saloon and business in his line of
work. The coachman drives a wagon or cleans the horses, the baker
partSj takes a sleeve for a pocket,
He
of pants.
supposes people behind the door
^^
cjU
Xyj
<^
Fig. 17. Handwriting of a delirious patient. Fairly

and marked inequalities of pressure. The second line
coarse, irregular tremors

is
more marked
as the
result of fatigue.
kneads the dough and takes bread out of the oven, the carpenter planes
wood, handles boards, etc. Then again the ward is taken for a barroom, the orderly for a waitress; the patient orders beer; sometimes
he gets it by way of hallucination and can drink it with satisfaction.
But frequently he
gets
angry that nothing
to forget his misconduct the next
things are done; the shirt
is
is
moment.
often torn.
brought and scolds, only
great
his big toe for a cork, screwed the cork-screw into it

pull at
it
for dear
many
saloon keeper at
foolish
home took
and began to
life.
Severer cases remain in bed longer but have the same ideas; the bed
with
its
pieces of bed clothes then represents the largest part of the
environment, falsified by illusions;

carpenter's bench, etc.
The
it
is
wagon with
patient has to catch
little
a horse, a
animals from
the bed spread; occasionally he reads entire stories which are supposed
to be on the linen.
weakness increases, the deliria become frothing, the patients

coarse tremulous movements, which are difficult to interpret,
If the
only
335
make
pull at the spread or pick at the sheets.
movements, gnashing of
The
teeth, etc.,
delirious patient does not
may
In fatal cases convulsive
also be present.
become unclean except toward the
end.
Among
the physical
but whose
severity
is
symptoms which
are never entirely lacking
not always in proportion to the intensity of the
psychical disturbances, the most noticeable
tremor which
The
is
pulse
evident in
is
all
the coarse, irregular
is
movements, as well as
in speech.
usually rapid, fluttering, irregular and, at least in
severe cases, weak.
In spite of this the blood pressure
is supposed to
be increased as long as no collapse threatens. The heart weakness
is not merely a case of the chronic disturbances of the alcoholic, but
evidently of an unknown toxic substance that appears and disappears
with the
face
is
deliria.
In contrast with the alcoholic facial congestion the
usually pale and at the same time covered with sweat so that
The
the patients often appear markedly troubled.
highly colored; at the height of the attack

of albumen, in
some cases
seldom some sugar
The
is
larger quantities
The deep
urine
always
is
usually contains a trace
and
for a longer time; not
found.
pupils often react poorly
irregular.
it
they
may
also be
reflexes are usually exaggerated
unequal and even
in case of neuritis
they are naturally diminished; on admission to the hospital they are

often still lively, on the following day diminished or absent.
The temperature, even when no complications

usually somewhat high; in rare cases
the patients die of hyperpyrexia
Typical
epileptiform
attacks
it rises
are
present,
is
to over 140 F. so that
(Delirium tremens febrile).
may
initiate
or
accompany the
delirium; usually they are single attacks.
Sometimes there are evident signs of neuritis or at least neuritic

thus one can elicit pain through pressure over the nerve
trunks and muscles, there may also be weakness and even pareses.
I have frequently observed inflammation of the optic nerve; also
irritations,
central organic signs such as disturbances of coordination or cerebellar
ataxia; but they are often difficult to see on account of the
tremor.
In
many
cases there
is
a complete analgesia which
marked
is
often
very unpleasant especially in surgical cases: The patients want to

walk about when their legs have been recently amputated or
their bones broken, they tear off their bandages and dig into their
wounds.
At the height
of the attack sleep
is
entirely absent or
is,
at any
336
rate,
very
Moreover the excitements are invariably severer
brief.
at night than during the day.
The
Course.
and ends
disease usually runs a course from
in recovery, often following a usually
comes gradually.
in other cases recovery
tremens
to four days
critical sleep
have not seen a delirium
The slower
longer than fourteen days.
last
two
very long,
the recovery
more probably are organic disturbances in the sense of

Korsakoff connected with it. Deliria, which are further protracted
proceeds, the
into the second week, are probably

cially true
(if
always complicated;
runs
If the disease
its
typical course, the hallucinations gradually
become more and more blurred and

they at
this is espe-
those in which after improvement a sort of relapse occurs.
first lose
the value of reality
less
;
numerous.
Often, however,
the birds are no longer alive but
performed and finally are thrown on

by a magic lantern.
Perhaps in between one and two percent of the uncomplicated
cases the patients die of heart failure. Moreover the initial diseases
(pneumonia with pus, etc.) may naturally end fatally. The mortality
statistics from different places are not comparable because, depending
on conditions of admission, some institutions admit mainly complicated
or mainly uncomplicated cases. But there are statistics in which the
fatalities still reach 26 percent. I cannot account for this in any other
way than by supposing that mistakes were made in the treatment.
stuffed, the scenes are especially
the screen only optically as
if
After the delirium there naturally remains the chronic alcoholism.
The anatomical
findings justify the assumption that in every alcoholic
delirium some components of the brain are destroyed.

the delirium
disease.
is
Some
In severer cases
followed by alcoholic feeble-mindedness or Korsakoff's

delusions
may
persist for a longer time until they are
forgotten rather than corrected.
According to some, "alcoholic para-
may become superimposed.

The attack of delirium tremens may recur; in the course of several
years the same patient may pass through a dozen or more deliria. But
noia" and chronic hallucinoses
such
people
who
relapse
several
times
invariably
become very
demented.
Besides the typical cases there are abortive ones which show only
few symptoms, such as very slight confusion and marked tremors
or a few hallucinations. They pass away completely in one or two
days. Then there are deliria which from the very beginning show a
chronic character. The patients usually remain oriented, hallucinate
almost only at night, even then not always, and sleep in between times;
during the day they can, under certain conditions, even perform simpler
tasks.
Such
deliria
can last four weeks and are to be differentiated

from the
337
which a complication with Korsa-
fully developed attacks in
koff's disease is responsible for a protracted
In schizophrenics, delirium tremens
is
convalescence.
somewhat modified.
The
Auditory hallucinations are prominent (somatic hallucinations are, as far as my experience goes, not
exactly frequent). But above all the deliria are more connected j for
days the patients experience complicated scenes.
deliria often expose complexes.
Such a patient very dramatically described

prison and in the insane asylum in thirty-six pages:
had to
see there,
made my
hair stand on end.
with every kind of dreadful animal and
human
his
experiences
"What
ir
suddenh
Forests, rivers, ocean^

figure,
which no human
eye ever saw before, whirled by incessantly, changing
work shops
At both
off
with the
which horrible spirit figures were working.

sides the walls were nothing but a single ocean with
thousands of little ships on it; the passengers were all naked men and
women who indulged themselves to the tempo of music, whereat every
time a pair had satisfied themselves a figure stabbed them from behind
with a long spear so that the ocean was colored blood red; but fresh
droves always came. ... A train from which many people alighted.
Among these I heard the voices of my father and my sister K. who
came to deliver me. I plainly heard them converse with each other.
Then I heard my sister whisper again with an old woman; I called
She called that she would do
to her for dear life to deliver me.
it but the old woman did not let her go, warning my sister that thereby
she would bring misfortune on the entire household, but that nothing
Amid prayerful tears I awaited my death.
was happening to me.
The silence of the grave prevailed and spirit figures surrounded me in
droves; at last one of the spirits came and held his watch in front
of my eyes at a certain distance merely indicating to me that it was
not yet three o'clock as none of the figures were permitted to speak."
Then there were long negotiations among the relatives of the patient
who wanted to ransom him, at first with smaller sums, then with larger
ones. Other voices debated how they would do away with the patient.
Then the relatives w^re induced to go on ladders and thrown
into the castle mote where they were heard crying and choking. The
wife of the jailer came, cut off his flesh piece by piece, beginning at
his feet and going up to his breast, fried and ate it.
She poured salt
on his wounds. On a wildly swaying scaffold the patient was drawn into
the various heavens up to the eighth, past choruses of trumpets, who
proclaimed his fame. At last because of some terror he was again
consigned to earth.
People sat at a table and at and drank
things with the most marvelous aroma but a glass was handed to him,
of all callings, in
338
Thereupon
it disappeared into nothing and he suffered great thirst.
he had to count and figure out loud for hours (objectively: verbigeraIn a little flask a divine drink was handed to him but when he
tion)
wanted to take it, it broke and the content flowed between his fingers
like threads of glue. Later a great battle was fought between his tormentors and his relatives of which he saw nothing but heard blows
and groans, etc. Then scorpions came, drawn on long threads. During
the entire journey to the institution, which was also not recognized
by the patient, his sister sat on the roof of the wagon and always
cried out the same words. In the institution was a man who always
squirted him with urine so that the patient had to freeze severely.
Anatomy. As a sign of the poisoning one finds throughout the entire
brain diseased and degenerating ganglia cells and fibres, which are
The fibres are said to degenerate
not, however, evenly distributed.
;
numbers especially in the motor centres and in the cerebellum.

Punctiform hemorrhages are frequently seen and belong to the degeneration of the blood vessels. As a result of death from heart failure
there is also a venous congestion of the entire cranial content.
Naturally the clinical signs of chronic alcoholism are found in the brain
in large
and the other organs.
The
sclerosis
and discoloration of the heart
probably connected with the acute disease.

The causes were mentioned at the beginning. Protracted drinking
must have prepared the ground, and the disease afflicts chiefly, even
though perhaps not entirely, drunkards who indulge in whiskey, either
muscles
is
exclusively, or in addition to other alcoholic liquors.
The most frequent age

thirty
and
the former,
fifty,
many
The pathology
disease
for the
and the maximum
is
is
accordingly between
closer to the latter figure
than
cases even occurring after fifty.

of delirium tremens
is still
entirely obscure.
sure, it is not a question of direct alcoholic poisoning,
To
be
but of a toxin
(apparently clinical), which in consequence of a protracted indulgence

in alcohol in the case of a definite personal disposition, is set free as a
At all events not only is the nervous

system poisoned but also the heart and perhaps also the kidneys,
and other organs.
result of fortuitous impairments.
The character
of the hallucinations is fully explained
tating states of the optical and tactile apparatus.
The
more peripheral
Complex hallucinations are very rarely
by the
irri-
slight participa-
tion also of the psyche indicates a
origin of the sense
deceptions.
involved.
If
most
of the sensory^ disturbances are auxilliary to the complexes, complica-
with schizophrenia may with great probability be inferred.

In most cases the patients are hardly or not at all participating spec-
tions
339
tators of their hallucinations, or they conceive of the annoyances that
the animals cause
them
as comical misfortunes.
Only the anxious hallucinations have a
different significance.
They
are evidently the expression of the somatic fear, caused by weakness
and perhaps also directly by the poisoning, the anxiety

as in a dream or in fever by hallucinations.
The
accompanying euphoria and the ready humor are a part of chronic
of the heart
expressing
itself
alcoholism.
The
diagnosis
is
The
usually very easy.
In the
be considered:
first
must have had an opportunity

moreover, the drinking
is
following points are to
place, the entire appearance, which one
to see; then the anamnesis, in which,
sometimes denied
every
in
way
the phj^sical
signs of alcoholism, the coarse tremor; the type of hallucinations, a
combination of visual and
both
tactile; in
one frequently finds
fields
threadlike structures; in the visual field the hallucinations are multiple,
moveable, and
colorless,
manifesting themselves especially in the form
of animals with a tendency to dimunitiveness
the retention of auto-
psychic orientation; the promptness of the psychical reactions; the

(relative)
capacity of being aroused from the delirium; the scarcity
of complex contents, and the intermingling of
As
far as I
have seen, the fever
deliria,
complex
for delirium tremens, are invariably
reaction
lacking.
is
But
many
there are
psychiatry does not as yet
know them
humor and
anxiety.
that are so often mistaken

deliria in
which the rapid

deliria, and
kinds of fever
all.
important to note that because of accompanying alcoholism

conditions may obtain "alcoholic coloring." The connected
other
any
It is
hallucinations of schizophrenics which
are
also
visually
especially
have been mentioned above. Living visions, etc., mingle with

other morbid pictures, e.g. in epileptic twilight states.
Treatment.
Unfortunately delirium tremens usually must be
home
treated at
or in the general hospital. But the physician must
plastic
not forget that to cure the alcoholism at the same time wôuld only
be possible
if
the patient
is
brought to a suitable hospital for the
insane.
The prime
condition of a proper treatment
patients can very readily do harm.
In the
hallucinate differently than any one else
*^
;
is
supervision.
first place,
The
because they
or they consider themselves
attacked or insulted; they are jealous of their wife and resort to
weapons; or they handle weapons
in
dentally injure themselves or others.
the
*"
manure hole
Comp.
p. 328.
such a manner that they acci-
One
of our patients
to hide from the animals.
jumped
into
In surgical cases the
340
The
analgesias constitute the most serious danger.
To be
to keep the patients in bed.
but
if
orderlies should try
sure they always get out again
they are permitted to wander at will in a room not specially
adapted, too
much damage may
readily be done.
If the patient be-
kept in bed more easily fortunately so, because

just at that time the stay in bed conserves the strength. The incessantly
repeated request that they remain in bed and go to bed is an excellent
comes weaker, he
means
is
of diverting
them that does not
much. Instead of the

This is naturally also a
questionable whether by
irritate
bed the tepid bath is often recommended.

good place for the patient to stay; but it is
itself it shortens the delirium or has a quieting
treatment the patient
he
may
is
damage
tear his shirt,
influence.
With proper
violent only in exceptional cases; to be sure
the door, etc.
It only
comes to a real
fight in case of clumsiness or impatience on the part of the attendants,
or in case of severe anxiety hallucinations; but these too are amenable

to quieting influences.
The second important point

near a collapse, the heart
functioning of the stomach
is
diet,
is
patients are
too scanty, the
disturbed by the catarrhal condition;
is
the patients do not take the time to
eat, or refuse
nourishment because
All these indications call for a milk
will be poisoned.
they fear they
The
the nourishment.
is
poisoned, the urine
which needs not be exclusively
so,
except in case of complicated
One should
cirrhosis of the liver or nephritis.
offer the patient
milk
in addition to the ordinary foods, from one to several quarts a day.
Since they are used to swallowing fluids, a drink

to get
them
relatively easy to digest.
probably has the
Everything
effect of
It
else is secondary.
all,
is
is
the easiest thing
at the
tending to rid the organism of poison.
be compelled to give hypnotics.

until the crisis
is
same time nourishing and

promotes somewhat diuresis and thus
to take; the milk
In a private home one will usually
They do
little
passed, which practically
good, probably not at
means when they
are
no longer necessary; to be sure, one can perhaps at this time induce

the critical
sleep
few hours
earlier.
Chloral,
sulfonal,
trional,
methylal, amylene hydrate, and paraldehyde are used, of which espe-
recommended.
For the threatened collapse cardiac stimulants are also given.
cially the last is to be
If I
found this necessary, I would, e.g., prescribe digalin.

The question has been much discussed whether alcohol should be
given.
It
is
certain that since the larger quantities of alcohol
been dispensed with, the mortality has decreased greatly;

did help individual patients with alcohol, a greater
killed
by
it.
if
have
one really
number would be
Consequently in more recent times delirium tremens
is
341
But it is not to be denied that at times one

which with us are to be seen only in people that
come from East Europe, might be carried through the crisis by alcohol.
In a single case that I observed myself, I can interpret the result in
that way. In other cases where I permitted myself to be influenced
by relatives or other circumstances, no benefit but probably harm could
be noted. But I assume that only the larger doses, which nowadays
are hardly ever used, are directly dangerous. // one feels compelled to
treated without alcohol.

of the severer cases,
give alcohol, the taste should be disguised as the patient will other-
wise carry over into the chronic alcoholism the professional sanction
of his conviction that the stimulus
is
necessary for him}^
Alcoholic Hallucinosis
(Kraepelin's hallucinatory insanity of drunkards)
(Wernicke's acute hallucinosis of drunkards)

Alcoholic insanity
tremens.
is
It manifests
in
have a peculiar character:

of several or
many
many
respects the opposite of delirium
itself chiefly in
auditory hallucinations, which
In most patients
people not present
it is
who
a case of the voices
discuss the patient in a
they discuss him in the third

These voices
speak
to him.^
person; much more
plans as to
him,
make
sins,
scold
him
of
his
threaten him, remind
his family
and
torture
torment
perhaps
and
how they will catch him
patient,
with
the
them
side
of
or
some
also.
Some egg the other on,
connection
cases
the
very
acute
In
try to defend him and save him.
dramatically elaborate dialogue; that
is,
rarely do they
usually less organized; in place of more quiet scenes there is a conSometimes the voices are rhythmic, partly s^'nfusion of voices.
is
chronous with the pulse, and partly with an external sound, e.g. the
ticking of a watch, as "You are a fool, you are a fool" [Bonhoeifer)
or they take the form of rhymes and satiric verses about the patient.
Frequently the patients hear their own thoughts or answers to them,

or one ascertains what they are doing or criticizes their actions.
Besides, especially in the beginning, one seldom fails to note sounds,
such as buzzing, snapping of gun triggers, striking of
cracking, and
sounds of horses' hoofs, all of
which
is
rifle
bullets,
related to the
patient.
For prescriptions see p. 223.

However, even in the most pronounced cases, it is also quite usual for the
patients to try to communicate with those hallucinated persons who take their
part, and to obtain answere from them.
*
""
342
Of the hallucinations of the other senses visual deceptions occur

most readily, one of the acting persons is seen behind a door or somewhere in the dark. Visions similar to those in delirium tremens may
also
appear intermingled with the others.
squirted at, or blown
at,
Skin sensations, being
are also said to occur; hallucinations of smell,
and especially somatic hallucinations, probably belong to a

fundamental schizophrenia.
Delusions of persecution correspond to the hallucinations. There
are people present who mock the patient, punish him, want to do away
with him, and under certain conditions there are also some who take
his part. Usually the patient does not feel entirely innocent; besides
enormous and unjust accusations, real mistakes are held against him,
among others, e.g., his drinking; but everything is exaggerated. Invariably there are delusions of reference, this or that real person, but
especially this or that event, being brought into connection with the
machinations against the patient. Isolated ideas of grandeur are very
rare. The delusions do not constitute a compact, carefully thought out
picture, the patients are just being persecuted by a gang; but the
taste,
improbabilities are not noticed,
much
To
less explained.
be sure, at
an explanation. Their enemies have machines, with

which they listen in on the patients and through which they speak to
them; they want to poison them in some way. Supernatural accomplices, such as God, angels, devil, hardly ever occur.
At the same time the patients remain oriented and in spite
They do not misof the delusions they generally remain clear.
take the real environment into which they put the hallucinatory
times there
is
experiences.
Attention appears to be nearly normal; one can carry on a systematic conversation with the patients; to be sure they are easily
diverted by the voices.
Normal
thinking, as far as
it
can be tested,
appears not to be changed outside of the delusions.
The dominant affect is anxiety, which is not lacking in any case

and usually dominates the whole behavior, which at most only temporarily corresponds to the situation which subjectively is often
The
altogether desperate.
resigned to their fate
the police and
demand
or,
patients are relatively indifferent, often
instead of defending themselves, they go to
the punishment of their persecutors.
I cannot
an expression of the supercharacteristic of drunkards, or whether there does exist any-
decide whether this incomplete reaction

ficiality
is
where a consciousness of the unreality of the experiences. At all events

in a large number of cases as in delirium tremens the alcoholic humor

343
remains at the same time with the anxiety. In spite of this suicide
In cases taking a chronic
is not rare, especially in the first stage.
course irritability also appears; but I have not seen real outbursts
of violence.
The
suggestibility so
pronounced
in delirium
here, at least in regard to the hallucinations.
tremens
The
wanting
is
patients do not
themselves be diverted from anything; on the contrary, they feel
let
the necessity of proving their ideas to others.
Memory
is
even better than could be expected
in all cases good,
in the confusing variety of experiences.

it
the patients can recount a
Confabulation
is
The behavior
number
During the disease and
rare.
of the patients
strange thing they do
is
is
to all appearances proper;
to evade their enemies,
when
to be sure they
In
all
Many even travel about,

may barricade their room
In the asylum they submit to the regulations as far
by the hallucinations. The physician

and
recognized as such,
does not belong to the enemies, and the
as they
is
whatever
a defense against supposed attacks.
other respects they retain their composure.

in the hotel.
after
of details in an orderly manner.
are not prevented
hallucinated scenes are, in contrast with delirium tremens, outside of
the
room
in
which the patient
is
situated.
Bonhoeffer actually speaks
of a "clear-minded delirium."
the
The physical symptoms are insignificant.

symptoms of the basic chronic alcoholism
It
is
a striking fact that
are sometimes not visible
on the average far less pronounced than

In very acute cases, which in other
respects also have a tendency to mingle with delirious symptoms,
coarse tremors and similar signs of alcohol may also be present.
Sleep is invariably disturbed but hardly ever entirely lacking as in
at all; at all events, they are
in all other alcoholic diseases.
delirium tremens.
Course. Alcoholic insanity usually breaks out very acutely; premonitory signs need not have preceded but ma}" be present in forms
similar to those in delirium tremens, the hallucinations always appear
rather as noises than as visual deceptions, in addition there may be
anxiety, and irritation; furtive transition of the prodromal symptoms
into the real delirium in the course of a few days or even weeks occurs
only rarely. The outcome is probably always by lysis, it may be after
a few days or after months.
Repeated attacks in the same patient are not rare.
As a
rule the disease passes over into recovery.
drome never follows typical
alcoholic hallucinosis.
Korsakoff's synIt is a question
344
whether the delusions and hallucinations can continue to exist in a
At
chronic form.
all
events
when
rarely occurs, except
it
there existed
previously a paranoid or otherwise a latent schizophrenia.
According to the course one can distinguish with Kraepelin an

acute and a subacute form, the former of which lasts from several days
two or three months. But transiThe two types are also plainly differentiated
to several months, the latter about

tional forms are not rare.
symptomologically
is
in the subacute
form every indication of confusion
usually lacking; the hallucinated scenes are in this case elaborated
to the greatest extent and

consistent
may
be carried on for months in a very
The remaining
and unified manner.
alcoholic
signs
are
very apt to be lacking here. On the contrary, in the acute cases the
alcoholism is more pronounced; even coarse tremors and gastric symp-
toms
also are not so rare.
The
voices are
more confused, more
fragmentary, and speak to the patient oftener,

tions; here the
e.g. in
peculiar,
case of denuncia-
rhythmic expressions and repetitions occur, and finally
only mixtures with delirium tremens symptoms are present which
predominate to such an extent that one cannot

the case should be ascribed.
Thus the symptom
picture of alcoholic hallucinosis
changeable than that of delirium tremens.
The
at once conspicuous.
But anxious
is
much more
cases taking a slow
manner
course behave themselves outwardly in an orderly
they do not react to the delusions
may
to which disease
tell
so far as
they can run about without being

restlessness, defensive measures, or
The most acute are

and hallucinations that they take too
surroundings and on superficial inspection
stories of persecutions easily betray the patient.
so dominated
little
by
their delusions
consideration of their
appear confused without being
The
cations
disease
is
so.
not frequent and, disregarding the different
of psychosis
in
different
places,
occurs
rather
classifi-
irregularly.
According to Kraepelin the proportion to delirium tremens is 1 to 3,

according to Schroeder, (Breslau), 1 to 20, with us in Switzerland
about 1 to 44.
According to Kraepelin alcoholic hallucinosis afflicts women
relatively frequently.
The age
of the patients
is
on the average
less
than in delirium
tremens, according to Schroeder between 30 and 35 years.
The cauê and pathology
are
still
entirely unclear.
In cases with the ordinary sub-acute course which I have seen

so far, I could always demonstrate with certainty or great probability
that besides the alcoholism a long standing schizophrenia was present.
The
(rare)
acute attacks in
my
experience were
all
at least a little
345
abnormal in the direction of schizophrenia, although the connection

was less plainly pronounced.'"''
here
The
differential diagnosis of alcoholic hallucinosis as such
As a
is
usually
anamnesis alone points to the disease, but

the diagnosis is further confirmed by the vivid and connected hallucinations.
I know of no psychosis with dramatically connected and
elaborated auditory hallucinations, which speak of the patient in the
third person, in which there is no alcoholism.
Also the particular
vividness of the hallucinations with persistent clearness and orientation
indicates the alcohoHc coloring with certainty.
The only difficult
question is whether a pronounced schizophrenia is in back of it. Where
neither in the anamnesis nor in the picture itself pronounced schizophrenic indications are found (lively somatic hallucinations, affective
very easy.
rule the
disturbances), the prognosis should not be considered bad, even
the schizophrenia
is
certain; the latter
is
when
very rarely subject to an
exacerbation during the insanity.
Treatment. Because the patients, at least in the beginning, are

very strongly inclined to suicide, and during the entire course are very
burdensome, treatment in an institution is nearly always indicated.
Under favorable circumstances the alcoholism can then be treated

at the same time.
Alcoholic Psychoses with Organic
Symptoms
Even delirium tremens is a distinct poisoning of the nervous system

with indications of peripheral neuritis, frequent organically conditioned
eye symptoms, and acute alteration of nervous elements in the brain.
However, here the psychic manifestations predominate and they are
apparently more the expression of a functional poisoning of the central
nervous system than of the slight destruction in it. In contrast to
this are the purely alcoholic neuritis and the (rare) alcoholic myelitis,
where only an anatomic disturbance seems to be present and where,
at the
Now
same time, the psyche remains
the acute injury to the tissue
entirely or almost entirely intact.
may
chiefly afflict the brain or itbe localized only in the brain, and we then deal with a Korsakoff
psychosis, the main characteristic of which is the organic symptom
complex, usually combined with neuritic manifestations.
In other
may
cases the process, besides being localized in the cortex,

in the centers that control the inner
is
also localized
eye muscles and speech coordina-
^ Alcoholic hallucinosis could therefore be a mere syndrome of schizophrenia

This would be borne out by the circumstance, that under
induced by alcohol.
other conditions the generally disjointed auditory hallucinations of schizophrenics

readily become connected through indulgence in alcohol.
346
which produces a picture similar to paresis, or alcoholic pseudoBetween these borderline cases, distinguished as types, there
are all kinds of transitions and mixtures, and the number of the combinations is further increased by the fact that such processes may also
tion,
paresis.
be chronic or sub-acute; this

of the cutaneous nerves
an entirely chronic course.

the peronei,
may
may
especially true of the degeneration
Neuritis in individual nerves, especially in
begin in sub-acute form;
Korsakoff variety, and

variety
is
and the rheumatoid pains which regularly take
still
also
more frequently
psychoses of the
of the
pseudoparesis
To
be sure there
take months for their development.
are also mild, "abortive" cases.
In reality we therefore meet all kinds of combinations of chronic

and acute neuritis, and cerebral organic and toxic manifestations (the
organic syndrome corresponds to the organic-cerebral processes; the
delirium tremens syndrome corresponds to the toxic-functional procthe entirely pure cases are not even the more frequent, but as
ess)
a rule one of the syndromes stands in the foreground. Delirium tremens
is especially often connected with the diseases having an acute onset;
;
they
may
The
be neuritic or pseudoparalytic or of the Korsakoff variety.
division of the acute forms into delirium tremens, Korsakoff,
pseudoparesis, polioencephalitis superior does not therefore presuppose
a distinct and fundamental separation.
It
differences in the localization, intensity,
and the time
is
not yet
known whether
of
development
are due to the influence of the identical poison, or whether they are
due to combinations of different poisons.

On the more neurological side two forms are conspicuous that must
be mentioned: The internal and even the external eye-mv^cles may be
especially severely affected. The cases that I have seen ran their course
with a somewhat protracted and not very pronounced delirium tremens.
They healed in several weeks or months. Then Charcot distinguished
the (two sided) alcoholic neuritis of the peronei with paralysis of the
anterior foot muscles and consequent sinking of the points of the feet
(steppage gait). It seems to occur chiefly in those that drink the
higher grades of liquors.
The Alcoholic Korsakoff Psychosis {Chronic
alcoholic delirium
according to Kiefer and Bonhoeffer).
The Korsakoff psychosis
^^
in the majority of cases begins with a
delirium tremens that recedes somewhat slowly and leaves behind the
It does not correspond with the facts to designate
organic syndrome.
symptom complex" as the

symptoms belong to it.
only the "amnestic

all
other organic
^See
p. 230.
characteristic feature;

Nevertheless the
memory
defect
cases the patients forget from one
experienced; at every visit they
is in
the foreground. In pronounced
moment
tell
347
what they have

same things. But
to another
and ask
for the
sometimes single elements, especially confabulated ones, are retained

for a long time. In most cases at the beginning there is a plain boundary line at the period of the onset of the disease in which what
happened previously is still remembered. But the line is usually
blurred in time; as in other organic diseases the memory defect can
finally extend back very far. For example, some live again in the time
of their military service and, with the exception of smaller islands,
have forgotten what happened after. Only when the disease has
improved a little do the patients sometimes notice the memory defect
and endeavor to help themselves with memoranda. Previously they
conceal it from themselves with the most flourishing confabulations;
they never appear at a loss for words, narrate spontaneously, and on
occasion, all sorts of invented experiences, usually such as are
still
conceivable.
The
general opinions which the patients have formed in the course
of their lives are not lost, neither are the simpler acquired aptitudes,
etc.
In the ordinary cases,
also, the patients
have no
diflBculty in
finding words.
In the beginning the
months or years
or indifferent.
mood
is
usually alcoholic-euphoric;
after
change in various directions and become morose

In other respects the affectivity is very labile and
it
may
easily stimulated in all directions.
Orientation
is
disturbed to a high degree.
The
patients no longer
have any conception of time relations and as to location,
also,
they
In spite of this the

about entirely free from care, because they do not
only get along somewhat after a longer time.
move
patients
notice their deficiency.
The apperception
of sense impressions
is
retarded and
is
readily
falsified.
Active attention seems very good in conversation; the passive
is
reduced.
patients tire very easily of all mental exertions.
In the beginning the patients are fairly active; but they retire
more and more, and their initiative, as well as their interest in their
surroundings and sometimes even in their own welfare, declines.
There are also somnolent and stuporous cases, usually as a result
The
of
more severe organic
affection, especially in the region of the corpora
quadrigemini.
On
the whole only the
symptoms
of deficiency
become chronic
348
(such as the organic dementia, and not the delirium, the stupor, etc.),
but
now and then one
on states of confusion, and

more protracted, but not elaborated,
preferably those of being robbed or persecuted, and at
a grandiose idea. In patients that are quite demented these
also finds later
especially individual passing, or

delusions,
times also
may
appear senseless; the

In a few cases I
have seen pictures of a schizophrenic variety following later, but
these patients were previously already abnormal, so that it was probably a case of a combination of alcoholic Korsakoff and schizophrenia.
The physical symptoms, aside from the signs of chronic alcoholism,
are those of a general neuritis, thus we have: pains, paralyses,
delusions as well as the confabulations
patient
is
"Emperor
of Rothschild"
(Schroeder).
atrophies, contractures of the muscles of the eyes, of the vagus region,

of the nerves of deglutition,
During the
is
and more rarely
of the bladder
and
colon.
delirious stage sleep is naturally disturbed; afterwards it
usually normal.
In the beginning the metabolism

chronic stage
it
is
is
usually disturbed.
In the
normal, or the patients actually weigh more than
before.
Frequently, especially in the beginning of the course, epileptiform

attacks are found.
Course and prognosis. Ordinarily there are premonitions of the

which are the same as in delirium tremens. The delirium
then breaks out, usually with a pronounced tremens character; in
single cases it takes other forms also. With slow fluctuations it subRarely, there is a chronic
sides, leaving behind the simple Korsakoff.
development that takes several months or even more than a year. Such
cases, too, may improve decidedly or even recover.
The stuporous form is probably always acute.
In the course of about a year, sometimes a little longer, sometimes
sooner, a part of the manifestations invariably disappear but least of
In some cases the recovery reaches as
all the affective disturbance.
But
far as complete ability to work and practical rehabilitation.
most of the patients remain more or less organically demented even
disease,
though they can be used
The
neuritic
disappear
sometimes with remarkable rapidity.

vidual muscle groups persist.
Some
many tasks
much more
in the institution for
manifestations
But
frequently,
at times atrophies of indi-
patients die in the acute stage, in part from weakness of the
heart, in part
from paralysis of the vagus or from choking and similar
accidents.
Anatomy.
Anatomically one finds as the sign of the Korsakoff
349
psychosis a diffuse disintegration of nervous elements in the brain; in

severer cases this
connected
is
an inflammatory reaction of
Other
cells proliferate.
with
smaller vessels that form offshoots and whose
vascular changes occur also,

of
the
vascular
e.g.
one
disease
As a
hyaline degenerations.
numerous
notes
result
hemorrhages.
small
Besides these one naturally finds also the disturbances of chronic

alcoholism.
and
Pathology,
Compared with
cause.
the
more
delirium tremens the anatomically conditioned Korsakoff

It also
disease.
It
is
appears a
ing to Chotzen there

of
little later, chiefly in
striking that relatively
it afflicts
decidedly rarer.
it
still
It has
With our condiamong men is
cases.
greater in that Korsakoff
also been noticed that infectious

of alcoholism,
seem to favor the
diseases,
disease,
and
frequently appears after repeated delirium tremens, which
indicates that a poor resistance of the nervous system
But one can
factor in the disease.

of the
fifties.
one case of Korsakoff to about twenty cases
is
marasmus, higher grades

that
the forties or
the female sex severely; accord-
male delirium tremens, but only two female
tions the difference is
functional
the severer
is
women
that I saw, most or
all
is
a concomitant
also think of the kind of poison;
consumed
cordials,
and
it is
known
that the essences of the liquor can cause neuritis.
The
is
Even during
usually easy.
the initial
delirium tremens one usually notices a reduced ability to be aroused,

the absence of quick reaction, and a difficulty in grasping simpler
questions
which
does
Compared with the

in so far as
it
not readily
occur
in
the
simple
other organic diseases the course
is
delirium.
important,
shows on the one side improvement with abstinence, on
the other side progressive dementia, even though there be fluctuations;

then, too, the delusions
Against paresis
sible to
is
and confabulations only rarely become senseless.

It becomes impos-
the negative spinal-Wassermann.
keep apart the influence of the different causes, when arterio-
sclerosis or old age contribute to cerebral changes.
Korsakoff-like complex in head trauma,
it is
As against the
to be noted that usually
the latter begins in an acute form and improves quickly or heals,
whereas the trauma may also be the result of the incipient Korsakoff.
An exact anamnesis is therefore of special importance.
Treatment.
A lasting deprivation of the responsible poison is
naturally necessary and this can almost only be achieved in a hosMoreover, the excitement at the beginning, and then especially
pital.
the disturbance of orientation and memory, which
make the patient

incapable of taking care of himself properly, usually necessitate treatment in a custodial institution. After partial improvement some cases
350
can be cared for in public almshouses, but the tendency to alcoholic

indulgence remains which readily causes new shifts.
Alcoiholic
As
alcoholic pseudoparesis
Pseudoparesis.
we
designate a Korsakoff
V^^hich
as a
result of special localization imitates the physical signs of paresis,
especially
the
pupilary and speech disturbances.
The
differential
diagnosis from paresis enters into consideration especially
when the
patients are brought to the hospital because of delirium tremens and
the organic
symptom complex remains
after the delirium has passed

probably always, the flourishing ideas of
In most
away.
grandeur are lacking in pseudoparesis. Real manic states probably
do not belong to it; the continued progress of the disease in the
institution speaks for paresis; however, in the beginning of the disturbance only the spinal Wassermann can definitely decide the
Alcoholic paresis may improve and in some
differential diagnosis.
cases the recovery may be complete.
Kraepelin designates as "alcoholic paresis" the simple combination
of paresis with alcoholic symptoms, especially the hallucinations of
cases,
delirium tremens.
Others use the expression in the sense of alcoholic
pseudoparesis.
Probably because the concept of paresis has become clearer we

have not seen for ten years any disease that we could designate as
alcoholic pseudoparesis.
Polioencephalitis Superior.
The
encephalitic changes, even in the ordinary Korsakoff,
show a
certain preference for localizing themselves around the third and fourth
from the caudate body to the anterior part of the red

In some
cases a hemorrhagic encephalitis of this region constitutes the sole
or, at least, the chief disturbance.
The corresponding morbid picture
belongs rather to the pathology of the brain than to psychiatry.
Nevertheless these cases not seldom get into insane asylums because
in the beginning they are confused and at times somnolent and comaParalysis of the external, and occasionally of the internal eye
tose.
muscles is especially noticeable, and at the end of the first week or in
the second the patients usually succumb to general paralysis. Some
cases remain alive and may then recover or go over into a symptom
picture similar to Korsakoff.
It is difficult to designate it from
ventricles,
nucleus, especially in the nuclei of the eye muscle nerves.
encephalitis lethargica.
351
Alcoholic Leukencephalitis of the Corpus Callosum
Marchiafava and his pupils have described an alcoholic disease in

which the fibres of the inner two thirds of the corpus callosum in their
Other brain localities also,
entire extent disintegrate after a while.
may
especially the anterior commissure,
also be slightly affected.
In
Korsakoff, similar processes are said to have been found occasionally,

so that here too, perhaps, there
But the
may
be nothing new.
and results in death in from

two to six years; first a gradual organic dementia appears, often
combined with epileptiform attacks later there is also confusion death
results in coma and marasmus.
affliction is rather chronic
Chronic Delusions of Jealousy in Alcoholics and Alcoholic Paranoia

Alcoholic delusions of jealousy usually fluctuate with the quantity
imbibed liquor and ordinarily disappear quickly with enforced

abstinence in the institution. In very rare cases it appears to survive
the misuse of alcohol and even to become incurable.
of the
Additional delusions and hallucinations, especially of hearing, may

also attach themselves to it so that a complete "alcoholic paranoia" is
present.
This, nevertheless, cannot be differentiated from the paranoid
forms in which the specific schizoid symptoms are not very pronounced.
At
is
all
outcome requires a special predisposition, and what

must be one that even previously expressed itself in distrust,
events, this
more,
it
stubbornness, or characteristics evidently of a schizophrenic variety.
By
far most of the cases diagnosed elsewhere as alcoholic paranoiacs

had to consider with certainty as schizophrenics, who also were
alcoholics, and whose hallucinations and delusions had in part an
As a matter of fact they were really sick before
alcoholic coloring.
drinking
made
itself felt.
Nor
is it
conceivable that the alcoholically
conditioned insanity could take root and that especially the alcoholic
delusions of reference could persist independent of excessive indulgence
but the material at present available makes the assumption of an

At all events it would be
actual alcoholic paranoia unnecessary.
relatively ifidependent of the quantity of drink consumed.
Dipsomania
There are psychopaths with decidedly differing tendencies who
from time to time become moody. If they endeavor to help themselves
352
symptoms in time become more intense and

same time so closely associated with the alcohol
idea that at those times the patients succumb to an absolutely irresistible impulse to drink. These moods are difficult to describe and are not
at all the same in different patients. A certain world sorrow, a sort
of anxiety, and irritability toward everything that comes along are
out with alcohol, the
frequent,
and
at the
rarely lacking, but do not constitute the essential element; an inde-
scribable feeling of dreadful discomfort, a condition "that cannot be
endured," overpowers the patient. Thinking becomes circumscribed,

perhaps also a little unclear; whether merely because of the affect or
independent of it as a concomitant manifestation, I do not know.
To
counteract this condition large quantities of alcohol in the most

are consumed, occasionally
different forms, preferably concentrated,
and even petroleum. But as a matter

improved little or not at all by indulgence
Some have the drink brought home to their rooms, most
in alcohol.
of them go to the saloon those whose sense of shame is still retained
go to one that is distant or secluded, where they do not meet friends;
others go from one saloon to another. Most of them, while drinking,
are shy; a few bluster or quarrel. Real inebriation does not occur.
After about from two to eight days, the attacks pass over; the patients
find themselves, usually after a sleep, anywhere at all, either in a
also other things, such as ether
of fact the condition
is
saloon, or in the gutter, or in the police station.
Whatever they carried
with them has usually been converted into alcohol; sometimes they
have only the most necessary clothing left. Recollection is usually
imperfect; the head
They
are
is
now ashamed
confused as after an ordinary severe drink.

of the past,
make
the best resolutions but
without success.
In the intervals, that may last several weeks but also many months,
most of these patients are temperate, and some are abstinent. But
there are also chronic alcoholics who at the same time are dipsomaniacs
or who, as it seems> have become dipsomaniacs through alcohol. The
among them can retain their positions or obtain new ones

when necessary.
The disposition for dipsomania we do not understand as yet; it is
probably not uniform. The majority of the patients are psychopaths
who cannot as yet be classified. Others are epileptics or at least in their
entire psychical make-up epileptoid; there are also schizophrenics
among them. Furthermore depressions of brief duration may provoke
similar symptoms in cases that we must number with maniac depressive
better class
insanity.
Brain trauma,
also,
may
obviously constitute the foundation
353
of the moods; in one of these cases we observed that the symptoms

were connected with poriomanic tendencies.
As
exciting
causes of the individual case, anger, and at times
over-work are mentioned; wliether rightly so, I cannot decide.

events the disturbance usually comes entirely from within.
The
At
all
moods are often noticed soon after puberty; most

come for treatment in early or late manhood.
The differential diagnosis is as a rule easy. The patients ordinarily
describe the compulsion very clearly, and the difference in conduct
in the good and bad periods is uncommonly striking.
Nevertheless
Age.
first
of the patients
many
very
alcoholics are sent to us as dipsomaniacs,
which they are
who commit excesses only on certain occasions,

perhaps on pay day, and who can otherwise control themselves, or
they are unrestrained and wavering natures who simply at times go
not; they are people
wild and at times take hold of themselves.
Without treatment the
But our
epileptic
intervention also
bromide
is
affliction
is
grows worse as time goes along.
not any too successful.
In cases that seem
only exceptionally effective, at times, perhaps in
depressions of another kind the results are better.

are obtained
possible
when the
entire
and the patient
is
manner
of living
is
The
best results
regulated as far as
permitted to undergo a large number of
attacks without alcohol, under the protection of a closed institution.
The
depressions then gradually become weaker and less frequent.
since
it
But
takes years to accomplish this, one usually loses patience
before a cure
is
attained and after the
again at the beginning.
first
new
One, therefore, often
excess one has to start
tries to
keep the patients
outside the institution during the intervals, with the intention of watch-
ing or interning
them
this does not get one
as soon as the attack
very
far,
is
impending.
But even
because at the given time the patient
all, no will power.

And the relatives
no longer summons sufficient energy for immediate action when
the last bad attack has been somewhat forgotten.
has insufficient insight and, above

also
Alcoholic Epilepsy
In particularly predisposed persons acute alcoholism excites epileptiform attacks; in cases of chronic alcoholism
typical attacks, especially
when any
we
frequently see some
accessory brain disturbance, such
as delirium tremens, Korsakoff, Leukencephalitis supervene.
Here the
But
occasionally one finds alcoholic epilepsy appearing in their mature
years, which in other respects runs a course about the same as the
attacks are probably nothing but
symptoms
of the alcoholism.
354
and usually develops very slowly into
ordinary genuine epilepsy
dementia of an
It is probable that the ordinary attacks in alcoholics, which are
especially brought along by delirium tremens, do not come from true
epilepsy, but from other poisons which are of the same nature, as, e.g.,
that of delirium tremens. For the other cases one must presuppose
epileptic character.^^
a particular disposition to epilepsy and often the presence of the

diseases
may
be accidental, or the epileptic character
may have
two
pro-
duced the disposition to alcoholism. Among those stricken with epilepsy in later years, say after thirty-five, men are in a large majority
and as a rule they are alcoholics; furthermore cases which otherwise
closely resemble the former still seem to be cured in the beginning by
abstinence.
One is therefore probably compelled to recognize in
alcoholism the essential casual force of such diseases, that
is,
to pre-
suppose an alcoholic epilepsy in the actual sense.

The treatment is the same as that for ordinary epilepsy,
absti-
nence, eventually also bromides; in those cases which I could observe

for
some time, which
to be sure were not numerous, the latter
remedy
accomplished nothing.
Alcoholic Melancholia
Not very rarely alcoholics suffer from depressive conditions which

cannot be distinguished symptomatologically from a melancholia of
manic depressive insanity, even though the delusions usually remain
merely rudimentary. But they do not last so long, only about two
weeks. Perhaps still briefer attacks are not so rare but they naturally
hardly come to the notice of the physician.^*
alcoholics
may
be attributed to this depression.
several times in the

lished
by the
same
patient.
The
Some of the suicides of

The attacks may recur
alcoholic character
is
estab-
fact that with abstinence, even with temperance, they do
not develop.
B.
The
chronic use of morphine usually leads to a
able manifestations.
'
Morphinism
Productive ability in
If others assert, that the "alcoholic epilepsy"
signs of genuine epilepsy in

of the disease than
is
its
all
number
of disagree-
lines
reduced,
is
it
does not present the psychic

have a broader concept
course, they probably
indicated here.
^ Prolonged "drunkard's misery," and severer "moral remorse of the morning

after," cannot be distinctly separated from alcoholic melancholia.
355
becomes especially unequal; with increasing fatigue endurance can be

Memory
artificially forced only by incessant doses of the alkaloid.
becomes inexact. Even in organically well disposed characters there
appears an astounding tendency to prevaricate which is not at all
limited to obtaining morphine and to whatever else is connected with
the craving. The morphinist who comes to an institution swears by
everything dear to him that he has no morphine with him. But one
usually finds very considerable quantities of
it
divided in the clothing,
any of the accessible body cavities, or in

With every powder or flask that one finds, the protesta-
in the soles of the shoes, in
any
utensil.
tions are repeated: that
is
And
positively the last one.
they
lie
to
themselves just as well, because they submit to the treatment to be

cured, but they at once make every arrangement in advance so that
they can be cured only against their own exertions. The character
The sense of duty is
also changes for the worse in "other respects.
the patients become
and weak willed in other respects also. The ajfectivity is
fluctuating but rather from within than from without as a reaction to
dulled or at least yields to even slight difficulties
careless
certain concepts.
The mood
is
very varying on the whole, corre-
sponding to the distance in time from the last injection. Anxiety

feelings may occur also. In severe cases delirious conditions are said
to occur, somewhat similar to delirium tremens. But it is probably
a case of mixed effects
from other poisons, especially alcohol or
cocaine.

slight disturbances of
consist of tremors, in severe cases also of
coordination which are general, affecting the
organs of speech, and even the eye muscles.
Parasthenias of
all sorts
appear, pains or indescribable sensations, buzzing in the ears, and

The pulse becomes irregular in the
sensations of heat and cold.
various
conditions;
irregular; diarrhoea
beating of the
may
heart
is
frequent;
alternate with constipation.
digestion
is
In severe cases
in the course of years the skin becomes

poor
in spite of frequent tiredness during
grayish and
under certain conditions to zero
decline,
the day. Libido and potency
a definite
marasmus develops
sallow.
Sleep
is
menstruation ceases.
All subjective complaints except in verj^ severe cases are banished
at once by a new dose of morphine. Slowly or quickly, according to
the constitution, the body always finds weapons to destroy the poison,
increased doses of which are consequently necessary. With this the
complaints increase and the possibility of obtaining a sufficient amount
becomes less.
The increase of the dose, therefore, has practical limits which most
of the alkaloid
and injecting
it
in sufficient quantities
356
frequently, perhaps, fluctuate around one
gramme
a day, and very
rarely exceeds a few grammes, even though daily doses
grammes are said

But with the
to
larger
physically, socially,
make attempts
doses
the
and especially
patients
are
consist of pains in
severely
in their productive ability.
to reduce the doses, but few succeed to
The manifestations
extent.
up to twenty
have been observed.
all,
They
any considerable
of abstinence are too unbearable.
any place at
injured
They
often in the entire body, trembling,
yawning, perspiring, nausea to the extent of vomiting, diarrhoea,

palpitation and poor pulse to a degree endangering life, and then a
feeling of anxiety
and unrest which
is
perhaps the worst feeling of
Deliria also are said to result from abstinence.
Such a craving
all.
for
morphine must be one of the most painful conditions possible. If no

more morphine can be obtained, taking nourishment remains almost
impossible, and there is loss of weight; only after several days does
the recuperation follow.
We
do not know positively on what the abstinence symptoms are
based.
Causes. Most morphinists are psychopaths from the beginning.

Even highly gifted and famous men have succumbed to the craving,
and some of them retained their elevated station for a long time in
spite of
it.
one has to
It is strange that
call attention to the fact
that they, no more than the alcoholic geniuses, are famous because
men of genius are simply

from ordinary men; on the one hand they are geniuses, on
the other they are inclined to various abnormalities which we may
they have taken to the poison, but that
different
designate as weaknesses.
The
accidental causes that lead to the
habit are usually pains which are treated with morphine; but then,
too, there is a certain euphoric reaction
by the
first
brought about immediately

Naturally the majority
dose, that tempts to repetitions.
of the patients are medical people; the lower classes contribute only
a small number because morphine
number
is
of cases the doctors are at fault,
very expensive.
who
In a large
give useless injections of
morphine and even place the syringe in the patient's hands. Physicians
addicted to morphine are especially dangerous, because in the alkaloid
craving as in alcoholism there
is
a desire for similarly disposed asso-
and for proselytizing. For example, we used to have women's

clubs in which indulgence in morphine was the binding tie; whether
they still exist I do not know.
As the morphinist usually either specifies another disease or does
ciates
not go to a physician at
all,
diagnosis from the symptoms.
one
is
rarely in a position to
make
the
But one must always have morphinism

in
mind when one meets people who
times, appearing anxious, run down,

times,
especially
after
the disease.
many
One
are very differently disposed, at
weak and
trembling, at other
they have absented themselves
minutes, being cheerful again.
The
357
for
few
sallow gray skin often indicates
finds the injection scars the
more readily because
patients do not take the time for aseptic measures, even injecting
through the clothing and thus inducing abscesses in large numbers.

The morphine cannot always be detected in the urine. If one wants
to examine former morphinists to ascertain whether they are cured
or relapsed, nothing can be done except to institute a close surveillance.
The prognosis
is
discouraging; definite cures occur but constitute
To
a small minority.
be sure, a number of these people maintain
themselves externally in their positions; but few are

efl&cient,
still
completely
they oscillate between suffering and euphoria, and even when
they can work
it
depends only on the morphine syringe. Many are

Their entire energy is consumed in
ruined physically and socially.
When
obtaining morphine.
there are obstacles in the
they are overcome with astonishing
skill in
which
way
of this,
lying, theft,
and
fraud are not feared.
The treatment demands in the first place the deprivation of the

morphine. The most rational way should be the sudden deprivation;
cannot bring myself to cause any one such suffering; besides
life.
If one takes a few weeks, in milder
cases only one week, one prolongs the suffering but reduces it very
considerably; this can be done if one takes the pains to control personally every request for morphine either during the day or during
but
it
involves some danger to
the night and
when
necessary, but then only, to administer himself
the effective dose immediately.

If cocaine
has been taken at the same time, it can nearly always

In the beginning of the treatment
be omitted at once with benefit.
one seeks to ascertain whenever possible the patient's previous daily

dose of morphine in order to reduce it at once to one third or a half.
The patient will usually greatly exaggerate the size of the dose. It
to be recommended that the patient be informed from the very
beginning that the size of the injected dose will never be told to him.
is
to he to him, one puts a stop to all grumbling

and above all one avoids the anxious excitations and worriment as
to whether the patient can get along with a certain quantity, questions
which arise as soon as the patient sees that one does not let him
suffer unnecessarily.
It is most earnestly necessary to warn against
sanatoria with which one is not thoroughly acquainted.
If one wants to do anything for the abstinence manifestations, one
Then one does not have
358
warm baths for the restlessness and sleepLocal cold applications may under certain circumstances
reduce the heart action; vomiting and hyperacidity of the gastric
juices are combatted with pieces of ice and alkaline water; milk with
ice, later with concentrated nourishment, can sometimes still be fairly
should prescribe prolonged
lessness.
e.g., with tannalbin

Hypnotics should be given only in extreme cases. But
cocaine and similar drugs should never be substituted for the morphine
which would only be adding the devil to Beelzebub.
One cannot expect 'much assistance from the patient. Even the
bravest are dominated by the fear that one will let them suffer too
well digested; the diarrhoea should also be treated,

injections.
much and
demand
therefore readily
morphine than they themselves
in
way
every
possible
more
Attempts
find necessary at the time.
to obtain the alkaloid for themselves, especially by bribing the attend-
common.
ants, are very
vision
hermetic and absolutely reliable super-
Outside of a closed institution the
therefore necessary.
is
deprivation cure can only be carried on in exceptional cases.
None
of the chemical remedies that are supposed to mitigate the
deprivation have proven of value; most of them are simply frauds.
After the dishabituation from morphine there remains the more

important and difficult task, the training of character to overcome
the disagreeable without the aid of a chemical crutch. To be sure it
is
rarely possible to
namely, morphine
remove altogether the firm disagreeable

it
seems as
if
organic changes in the nervous system had built
compel
very common.
indulgence
the
in
morphine.
certain hold
mended by Kraepelin,
association,
not only psychic but actually chemico-
is
up mechanisms that
Relapses
are
consequently
obtained by the promise, recom-
to place oneself in confinement for a few days
each year for careful observation.
If possible,
one should naturally
try to regulate external conditions so that depressive influences are
avoided.
When
physical diseases threaten, the patient should,
if
possible, be put to bed, in order to reduce the temptation to obtain
morphine.
It
is
self-evident that all other poisons, especially alcohol,
are to be avoided.
In incurable cases it has been recommended that the indulgence

be kept at a moderate amount which might be accomplished with
patients who cooperate a little by having them- take treatment each
year in a sanatorium, in which the dose which has grown slowly in
the
interval
is
again reduced.
But one must
carefully
consider
which really
patient,
and
those
about him
is calculated to make the physician, the
indifferent to a serious and infectious mania.
whether one wants to enter on such a compact with
evil,
359
The prophylactic measures should be self-evident; one should never

use morphine without a very exact indication and especially never
for any length of time, and under no circumstances put the hypodermic
needle in the patient's hands. It is also inadvisable to tell him that
when there is no necessity for doing so. Where
danger one should write on the prescription, "Ne Repetatur."
Furthermore no one should prescribe morphine for himself or give
himself morphine even though he has it in his possession. At all events
every physician addicted to morphine, as long as he is not cured,
he
is
there
getting morphine
is
should be excluded from practicing.
Related to morphinism are opium eating and opium smoking.

The manifestations and treatis of any importance with us.
ment of opium eating do not differ essentially from those of morNeither
phinism.
Concerning opium smoking we know
0.
little
that
is
certain.
Cocainism
Several different types of cocainism can be distinguished which,

however, cannot be sharply distinguished, and also do not exhaust
There is a memory disentirely the manifoldness of the pictures.
after
a relatively brief misuse
coming
to
Korsakoff,
similar
turbance,
from a few weeks to a few years, with excessive irritation, lack of

will power, facile flight of ideas and a preoccupation with various
of
tasks that leads to nothing.
Under
certain circumstances disturbances
of coordination similar to those resulting from a state of alcoholic

intoxication are also observed, there is a decline in strength, the skin
becomes sallow and flabby, potency vanishes, and sleep becomes very
The picture can show a great similarity to paresis but
disturbed.
one regularly misses the rigidity to light of the pupils. All symptoms,
even the memory disturbance, disappear pretty quickly with abstinence.
In many cases there develops a cocaine insanity, characterized by
extremely small hallucinations of sight and touch, in the form of
mites and other parasites, which the patients sometimes want to
demonstrate to us through a microscope under the impression that they
have made a great discovery. One of our patients saw the cells of
his retina functioning
and drew
scientific
and therapeutic conclusions
therefrom. Voices are rarer in these conditions and some delusions

of persecution are sometimes present. But in other cases the latter
are in the foreground, especially also in the form of uncontrollable
delusions of jealousy {Kraepelin) in which the voices play a more
,
important part.
clear
But
in
both conditions the patients are mentally
and orientated; the persecuted patients
may become
dangerous.
360
The
psychosis usually develops within a few weeks, the hallucina-
tions disappear in
from about one to two weeks after the deprivation
may
the poison; the delusions
of
last considerably longer.
As sudden as an explosion cocaine snuffing has spread as an epidemic of unsuspected danger; this is especially seen among the demimonde and artistic circles but also among university and college men.
It is brought about usually by being led into it by others, more rarely
by the snuff powders for coryza which contain cocaine and can be
This should be forbidden. Since
obtained without a prescription.
the dose is usually raised up to several grammes a day, on the
one hand large fortunes may be endangered and on the other hand,
those that gather the large profits are induced to become eager
tempters.
According to Hans W. Maier the manifestations after the
first
doses are usually slight dizziness and headache which, however,
quickly supplanted by a feeling of extraordinary well being.

this the patients feel mentally stimulated
which they really
usual,
practical results usually
ideas
may
are,
but as there
amount to very
also be noticed.
Many
then
is
With
and more productive than

is
a lack of endurance the
little.
slight flightiness of
dreams
for hours in vivid
lie
without, however, losing altogether their critical attitude toward them.
In others illusions and hallucinations, above

of hearing, quickly appear.
inate.
all those of sight but also

Rapidly changing small objects predom-
splitting of consciousness, similar to that in schizophrenia,
permits the addict of the poison a certain insight into the morbidness
of the perceptions but in the next
reality of these
moment they again
morbid manifestations.
believe in the
strong suggestibility brings
about that entire groups may enjoy themselves with hallucinations

members have in common. At the height of the poisoning
the phantasies are usually wish fulfilments. During abstinence the
phantasies assume a threatening and fearful character which, with
stomach troubles and creeping skin sensations, lead to new doses.
it
that the
Only
the
after protracted use does the critical attitude disappear altogether,
associations
become disconnected and develop
into the
above
described cocaine insanity.
The
libido sexualis disappears quickly in the
on the contrary,
it is
heightened to a desire for
man, while
in
women,
all sorts of perversities.
Physically the large, slowly reacting pupils are noticeable; nervous

palpitation annoys the patients; dryness in the throat often compels
them
to drink excessively; the appetite disappears and finally there
results
marasmus with
fatty degeneration of the liver:
Heart
collapse,
paralysis of respiration, and suicide at times end this sad condition.

The
prospects of a cure for cocaine taking are
still
361
darker than
those for morphinism because relapses are even more common.
There are no serious abstinence manifestations. Withdrawal of

is therefore regularly to be brought about at once.
But
usually still other poisons, especially morphine, have been used in
addition, which then necessitates an even longer protracted withdrawal treatment. But even in plain cases, the after treatment, the
education, requires a long duration with close supervision (for over
the cocaine
half a year)
INFECTIOUS PSYCHOSES
VII.
In cases of infection the activity of the brain may be disturbed by

an unlimited number of different influences, such as many kinds of
toxins and antitoxins and a normal metabolic products induced by
these, perhaps also weakness, fever, etc.
Our observations cannot at
all follow the manifoldness of the pictures that must result from these
influences.
We know
corresponded so
little
only coarse differentiations which, however,
to the differences of the causative factors, that
the monograph on these conditions (Bonhoefjer) had for weighty reasons distinguished only syndromes.
that
we can
The author proceeds on the theory
distinguish different symptomatological steps while the
individual infections can in no
the clinical pictures.
Thus he
way be brought
into connection with
distinguishes deliria, epileptiform ex-
citements (appearing and ceasing suddenly), twilight states, hallucinoses (hallucinatory states without noticeable disturbances of thinking
and orientation), amentia pictures; the latter are at times more hallucinatory, at times catatonic, and at times of an incoherent character,
then the Korsakoff type, and delirium acutum. For details I must
refer to the original. ^^
The only thing to be emphasized as of practical importance is that in fever psychoses symptoms may occur which
according to our present methods of investigation cannot be distinguished from the catatonic. A catatonic morbid picture may, therefore, under certain circumstances be a fever psychosis {Amentia in the
sense of the term employed by Bonhoefjer)
As
of theoretic interest
it
may
also be mentioned, that Bonhoefjer
observed a recovery from infectious Korsakoff which came suddenly

after a few weeks.
Kraepelin does not like to surrender entirely the conception of the

connection of cause and
The
effect.
following division follows his
classifications.
^Âschaffenburg.
Handbuch der
1911, Spezieller Teil III. Abt.
1.
Psvchiatrie.
Halfte.
Deuticke,
Leipzig
u.
Wien,
362
Fever Deliria
A.
At the height
of febrile diseases
we
unfortunately have been examined very
Four grades are distinguished:
of view.
break out, which

from a psychiatric point
The prodromal state with
see deliria
little
1.
discomfort, dullness of the head, sensitiveness, anxiety dreams,
-etc.
and hallucinations, especially of sight and also of hearing, in which the patients, either spontaneously or by being spoken
to, become capable for a time of orientating themselves and in a general
way of becoming relatively clear. The hallucinations are often transferred into the real environment, thus the mother may see her little
The patients become restless and are usually
children at her bed.
cheerful or moodily depressed. 3. In the third grade the entire environment is mistaken. There is complete confusion with lively emotional
and marked pressure activity. 4. Manifestations of
outbursts
paralysis gradually appear. The strength to move and express feeling
declines; the patients remain lying on their backs, mumble to themselves, pull at the bed clothes, and pick things until they die, often
2.
Illusions
in a complete coma.
Individual epileptic attacks are rarely seen.
The content
of the deliria
is
as a rule dreamlike.
Usually
it is
case of complex deliria which intimately concern the patient's ego.
In pneumonia and perhaps also in other diseases the transition to

anxious conceptions indicates the incipient cardiac insufficiency. In
alcoholics the
delirium
is
alcoholically
animal visions are
tinged,
especially frequent, etc.
The fever deliria, like most infectious deliria, are usually more
pronounced at night than in the day.
Prospects. Children become delirious relatively easily, so that the
psychic disturbances are not of particularly great significance in them.
Women,
But
also, are said to
in adults the
become
delirious sooner
the special severity of the infection and with
However, the
than temperate men.
completely developed deliria indicates as a rule
first
stage
is
it
of little significance
the danger to
life.
and many patients
recover even from the third, since, parallel usually with the decline
of the fever, they become clearer and lose the hallucinations.
But
sometimes the delusions outlast the disease a long time I know a colleague who long after an attack of typhus requested a friend on the
;
money which, since the fever delirium, he believed

The duration of the delirium depends on the disease;
street to return the
he had lent him.

as
it is
usually a case of acute infections and the psychosis, as a rule,
only appears at the
crisis of
the disease,
it
usually ends as early as
the second week either by recovery or death.

The treatment
is
363
naturally that of the fundamental disease.
times ice on the head seems to have a quieting
effect, as
Some-
do small doses
Due to the fundamental disease hypnotics should be given

many cases cool baths which should naturally be of
short duration are effective. To be sure, supervision is necessary; the
patients may come to grief or do harm.
of opiates.
with care.
In
B.
Infectious Deliria
Besides the deliria that come and go with the severity of the fever
there are others that seem to be independent of the fever itself since
they appear before or after
it,
or do not run parallel with the fever in
their jfluctuations.
Mostly in typhus but also in other diseases we observe the initial

deliria which Aschaffenburg has divided into two groups: a paranoid
with delusions of reference and persecution, hallucinations, and depression that is usually anxious or sad and a second form that quickly
;
rises to a
complete delirious confusion with
flight of ideas, sense
decep-
and vague delusions, more frequently anxiety, and above all

senseless pressure movements. The two forms are not sharply differen-
tions
tiated
the
first
may
go over into the second.
They usually
last
only a
few days and may disappear or become ordinary fever deliria. I have
seen a paranoid form in typhus persist far into the period of
convalescence.
The
differential diagnosis is not easy;
not quite
fit
into
any other symptom
but such initial deliria do

In the excited form
picture.
one might think of catatonia or epilepsy; the existence of flight of

ideas guards against the second diagnosis the absence of schizophrenic
symptoms makes the former improbable.
Like Kraepelin I saw several influenza deliria of a typical neuritic
character, in which parasthenias were interpreted illusionally. At all
;
it is mostly a question of a schizophrenic

mental stream, which appears all the more
similar to the schizophrenic because irritations of the nervous system
readily give occasion to a kind of physical hallucination the affectivity
invariably, however, continues to fluctuate.
Optical illusions sometimes make one think of delirium tremens. States of febrile deliria
readily become mixed, as many patients lose orientation when they
events, in grippe psychoses

sort of dissociation of the
are left to themselves, especially at night.
The content
of the deliria
and delusions is regularly taken from emotionally toned complexes.

Fever deliria without a schizoid character, often with motor restlessness and a tendency to violence, also occur.
In my experience all grippe psychoses which do not look from the
364
very beginning like schizophrenia are curable (that is to say if the

schizophrenia does not just happen to appear at the same time as the
infection)
The
typical picture of the Chorea
sent a fairly uniform picture.

ness,
lability
irritability,
of
Minor Psychosis
^^
seems to pre-
In the beginning one notes sensitivethe affects, and fatigue;
vigility
The memory becomes poor
tenacity of attention decline.
and
or at least
Thinking then becomes very

and suddenly interrupted; sense deceptions and delusions
supervene, and in severe cases it may go as far as complete confusion
and disorientation. In spite of the severity of the disease, which
permits the choreatic movement to become especially pronounced, most
of these cases, as far as I know, are cured, the delirious state disappears
first, and the chorea a long time after.
Cases of chorea gravis show
their character from the very beginning in the sudden rise of the
disease and in the initial prostration of strength.
Paralyses soon
ppear and death follows after two or more weeks. In cases not
ûite so severe it may sometimes result in a state of psychic deficiency.
the patients appear very distracted.
laborious,
The treatment for all cases of infectious deliria is that of the fundamental disease, with careful supervision, avoidance of excitement and
occasions for doing harm to oneself. In chorea gravidarum, which is
not to be taken lightly, abortion
a physical breakdown, this
is
is
indicated, at least
often followed
by a cure
when
there
is
in a few days.
Some, however, recover without any interference.
The
delirium acutum belongs to the infectious deliria of a different
origin.^^
condition appearing with the febrile attack and developing a
and high grade confusion with dreamlike sense illusions,

change of mood, lively motor excitation, and disconnected delusions, is called collapse delirium by Kraepelin.
violent state
flight
of
ideas,
Acute Confusion, Amentia
C.
In infectious diseases, puerperal fever, and especially in chronic

may not always show itself through examination of
the urine, one finds states of confusion, which ordinarily last for weeks
nephritis which
or
months and
as yet
have no certain positive diagnostic sign. They

name of Amentia which formerly included all
are designated with the
^ Naturally only the
is referred to here which originates on the

(Rheumatism). Unfortunately hysterical epidemics in schools manifesting themselves in abnormal movements and similar
things are also still called chorea. The medieval Chorea St. Viti, or chorea
magna, was also psychogenetic.
basis
of
"See
bacterial
p. 163.
real chorea
infection

possible kinds of confusion, especially also
They may
phrenia.
they
may
belonging to schizo-
disappear, but as a result of the basic disease,
also lead to death.
The conception
exclusion.
many
365
The
diagnosis can only be
made by
of confusion or of incoherence are alto-
gether too equivocal to be used in differentiation, especially from

schizophrenia.
name
of
Where
Kraepelin's conception
dementia praecox, the disease
is
is
combined with the
very rare.
Besides infection
and autointoxication, exhaustion was formerly considered as one
of
the factors.
Biswanger
classifies the
"exhaustive psychosis" as follows:
1.
Ex-
haustion stupor in mild grades, and acute curable dementia in severe

2. Exhaustive amentia.
3. Delirium acutum exhaustivum.
These forms, too, cannot be characterized sufficiently. The names
give an idea of the external picture.
grades.
D.
Infectious States of Weakness
After infectious diseases some patients recover very slowly. For

weeks or months they remain morose, easily exhausted, have difficulties
in thinking, and do not like to exert themselves either mentally or
physically. They are, however, mentally clear and externally adjusted (''acute dementia"). In most cases recovery still takes place,
but now and then the condition is serious. Hallucinations, delusions,
and rather severe anxious or depressive moods supervene and the
patients remain permanently demented.
The anatomy of these psychoses is insufficiently known. But
there are cases, e.g. after typhus, smallpox and scarlet fever, with circumscribed brain lesions, which have also often manifested focal symptoms. Sometimes diffuse disturbances are present, especially after
influenza and sepsis, and at times, also, after typhus.
It is then a
case of infectious Korsakoff, usually with polyneuritis, which is distinguished from the alcoholic form by less vividness of the psyche
stuporous confusion is not rare and if life is preserved, is said to
disappear more frequently than in those of alcoholic origin.
VIII.
THYREOGENIC PSYCHOSES
Psychoses in Basedow's Disease

Basedow's disease
is
not rarely accompanied by psychoses which,

Hysterias often accompany the
however, have no uniform picture.

basic disease
rasthenia,
and the frequently present syndromes, similar to neu-
may become
so severe that the paralysis of energy takes
366
on the character of a psychosis. Besides, one also observes depressions with anxiety states and milder forms of mania.
Most frequent,
however, one finds pronounced chronic states similar to catatonia
with marked excitements, dissociation of thoughts, confused and sometimes symbolized delusions, hallucinations of hearing and sight, eventually of smell and taste, and perhaps even of physical sensations.
Neither in the descriptions nor in the few cases that I have seen myself
can I distinguish them absolutely from catatonic states, as the difference consists only in the absence of a pronounced schizophrenic
The affectivity remains livelier, the stream of thought is
coloring.
not so disconnected, catatonic symptoms are rare or not so pronounced,
may
also occur in patients who have no Basedow

year or more become demented in the typical
schizophrenic manner.
The hysterical and neurasthenic syndromes improve usually with
the Basedow. The depressive and manic forms may also disappear
etc.
All of this
and who
after
regardless of the Basedow,
and rarely accompany the
entire disease,
although moods of some sort naturally are hardly ever lacking.

catatonic variety does seem capable of improvement, but
it
may
The
not
and readily becomes incurable.

The causal treatment depends on the Basedow condition, whereas
the symptomatic treatment is that of the special psychic syndrome.
fluctuate at all
Myxcedema
(Cachexia Strumipriva)
When the thyroid is completely removed, or severely damaged

anatomically or functionally by a disease, a very definite physical
and psychic symptom complex results. The subcutaneous cell strucand degenerate in a specific form. Thus the skin
then becomes generally thick and puffed, but especially in the face
and on the back of the hands and feet; even the nose and tongue
become bigger. This gives the face a plump expression. Pressure of
the finger leaves no fingerprint as is the case in simple oedema. The
tures proliferate
skin takes on a
muddy
pallor,
it
becomes dry, and
scales easily; the
hair on the head, but especially on the body, falls out; the teeth also
become
brittle
or fall out;
the extremities become cold; the body
temperature sinks below normal, and the pulse becomes slow and weak.
Also movements become slow; the same
is
also true of the facial
mimetic expression which makes the patient look still more stupid.
The finer movements under certain circumstances are also disturbed
The voice becomes
in their coordinations, as, for example, writing.

grating.
Muscular strength
is
diminished, sensibility
367
dulled; some-
is
times actual hardness of hearing occurs. Paresthesias very often

supervene, especially headache, and later a feeling as if the limbs have
gone to
The
sleep.
symptom
essential psychic
is
the retardation of
all
processos
and then especially the translation
of thinking, of decision,
of the
movement; even very simple functions may require many

times the normal time, thus putting the hands on the neck may require
45 seconds. Memory for recent events becomes bad. The patients
notice their deficiency and are consequently depressed in their moods
latter into
occasionally real depressions occur but the other affects are clearly
retained.
Sometimes one also notices dissatisfaction and distrust
which may rise to the extent of delusions. In severe cases illusions
and hallucinations of hearing, sight, smell and taste also occur, under
certain circumstances even compulsive states.
The severest cases
finally develop into hallucinatory confusions;
at the
same time the
physical strength declines and the patients die, often in convulsion.
Treatment.
Continued administration of thyroid extract, best
the form of ready
made
the symptoms.
is
It
tablets,
given
may
first in
in
cause a total disappearance of
doses of 0.1 to 0.3
of the gland
g.
per day, but the physical strength and the heart have to be watched
very carefully.
If necessary, the
ease disappears, the effective
dose
may
minimum
be increased.
If the dis-
dose should be ascertained.
Endemic and Sporadic Cretinism

If the thyroid
gland
is
already absent in childhood or
tionates insufficiently, a specific kind of idiocy develops.
if
it
Such
funcchil-
dren remain torpid, psychically as well as physically; they are slow
and awkward
in thought
and movement.
Initiative
is
reduced, and
almost entirely lacking. Nevertheless the

patients have feelings, and remain good natured, even though at times
they are stubborn. A certain timidity can be demonstrated in most
in high grade cases it
of
them and
is
this accounts for one of the reasons
slow in learning to walk; but talking also

present knowledge goes the intelligence
is
is
why
such children are
hindered.
As
far as our
not as characteristic as in
the other forms of oligophrenia of which this disease forms a causal

subdivision.
The
Further details will therefore be found in Chapter XIV.

few associations, not sufficient over-sight;
patients have too
during their whole
life
they give the impression of a non-intelligent
Because of their awkwardness and their lack of initiative they

can only perform easier kinds of work. The memory remains good
as far as the patients have a conception of the happenings about them.
child.
368
They love and fear and hate on the basis of their experience, they
take a lively interest in their environment, and are grateful if one
occupies oneself with them. Thus one can get a very good affective
relationship with them.
or zero.
Some
cases
The
sex impulse in the higher grades
may show
suspicion, delusions
is
weak
and hallucinations,
but such accessory psychoses which usually have a chronic character

are not at
all
frequent.
^\
"
Fig.
On
18. a Cretin.
Age 30
years.
the physical side their small stature
Height 112 cm.
is
most noticeable.
Some
than a yard high. The rump and the extremities contribute about equally to this anomaly although the extremities sometimes appear especially short. The skull and facial formation is
remain
less
characteristic.
nose
is
is
less
The base
of the skull remains short, the root of the
deep and broad; the nose
than the breadth.
is
very short; sometimes the length
The ethmoid bone
is
strikingly broad on
369
account of which the distance between the two eyes becomes large.
often remains relatively short. During youth the
skin has all the si^ns of myxa'dema " that sometimes disappear in
the third or fourth decade; the skin then becomes wrinkled. But even
The upper jaw
Fig. 19. Two Cretins in

and 49 years.
earlier
The
Height 118
(left)
and 120 cm.
(right).
50
horizontal wrinkles in the forehead are rarely lacking.
genitals as well as the secondary sexual signs develop late
ically
may
marked
profile.
and functionally, or remain at a
not appear.
In
men
^Cf. previous chapter.
childish stage.
the beard remains thin or
is
anatom-
INIenstruation
usually entirely
370
absent the voice
;
is
rough and rasping.
In manj^ cases there
is
hardness
of hearing or deafness, in part as a result of middle ear trouble, in part
also as a result of
some trouble
In endemic cretinism
pronounced; dwarfishness
in the labyrinth.
the athyroid signs are on the average
less
The hypophysis is in many cases enlarged,

Usually there is a more or less enlarged goitre in
rarer cases the thyroid is reduced; it may even be entirely absent.
is
especially less extreme.
but not always.
The
;__
latter is the usual thing in "sporadic cretinism."
According to the degree and relative conditions of individual cases

Extreme cases are those cretins
different forms may be distinguished.
which are purely physical, purely psychical,
purely deaf and dumb, and those in which all
three symptom groups are developed to the same
marked extent. The merely deaf and dumb are
usually not classed with the cretins although
according to all we know they belong to it;
however,
it
is
impossible
individual
in
cases
separate
them from other congenital forms
of deafness.
According to the grade one speaks
to
of a full
cretin,
half cretin,
and cretinoid or
cretinous types.
Course.
Some
of
these
patients
are
cretins; but in most cases the disease
nizable only in the course of the

year, reaching
20.Extrememyxoedematous
FiG.
ly
cretin
woman,
years old.
99 cm.
44
Height
its
for estimating age
born
recog-
or second
climax in a few years and
then becoming stationary.

children mentally,
first
is
The
patients remain
and the physical indications

are lost to a great extent.
The greatest change is the disappearance of the

Myxoedema in the milder cases. They offer
little resistance to other diseases and rarely attain old age.

Sometimes brain atrophy with the symptoms of senile dementia appear
very
very early; I could diagnose them in patients in the forties.

Pathology. There is no doubt that a part of the symptoms of
cretinism, especially the physical symptoms, are the result of the hypofunctioning or a-functioning of the thyroid.
Myxcedema
is
identical
with the same manifestations in athyroidism. Endemic

occurs only in goitre regions. Thyroid medication may cause an
cretinism
improvement
in all manifestations.
that the psychic symptoms do not at
symptoms.
There are physical
are psychically
still
On
all
even of real high grade, who

In goitre regions we meet im-
cretins,
well developed.
the other hand, it is striking

run parallel with the physical

who
beciles
exhibit the psycliical character of cretinism but
endemic cretinism
in
who
are
Hardness of hearing and deafness,
physically regularly developed.
which
371
at least half of the patients, are

are common in goitre
afflict
absent in other forms of athyroidism, but

regions,
among
the non-cretinous inhabitants.
Hence, between goitre,

is an etiological
psychical cretinism, and hardness of hearing, there
connecting link, or besides the goitre an additional cause

assumed, or both manifesta-
may
be
have a parallel origin in

Wagner von
cause.
Jauregg assumes that not only
tions
common
a quantitive, but a qualitative
disturbance of thyroid function

also plays a part.
The
growth
very
retardation
is
late
bony
of
connected with the

of
ossification
the
diaphysis cartilage (until with-
and the
in the fourth decade)
long period of open fontanelles.
The
causes of endemic cre-
tinism like those of goitre are
not yet
known
It prob-
to us.
ably has some connection with
drinking water,
the
of
what
Other
kind we
also
are
probably
infactors
general
improvevolved.
A
do not know.
ment
of the social
contemptuous challenging
other
changes invariably produces a

decrease of cretinism.
recent times
many
facial
expres-
(veiy rare for a cretin woman).

She could only grunt but for several decades she fooled nearly all new doctors
in the institution with simulated diseases
(scratch wounds among others), need of
care and by attracting attention to her
sion
and hygienic
without
conditions
Fig. 21. Cretin woman in a state of

Hence the
excitation, mosth^ irritation.
In most
ovun personality.
believe that
is an infection from one

person to another or a transmission through infected material that
there
clings to the house or to a dirty bed.
Sporadic cretinism probably has various but not exactly known

In most cases the athyroidism is congenital; but the thyroid
causes.
gland
may
may
occur everywhere, but
also be injured subsequently, e.g.
certain places,
e.g.,
hardly be diagnosed.
in
it
is
England.
by
infectious diseases.
It
evidently particularly frequent in
In cretinous neighborhoods
it
can
372
The
is
very easy in pronounced cases; who-
Formerly the
term had a broader and less distinct application, and other forms of
idiocy with physical malformations were also included. The Mongolian types that also have a broad nasal base can be mistaken in
ever has seen a cretin can always recognize the type.
youth
for light cases of cretinism; but their adipose layer has a dif-
ferent character from that of
myxoedema.
Later, as contrasted with
the cretins, they become very active. In Nanosomia, or Nanism the

entire body remains small without any great change in the proportions
and as such is not accompanied by idiocy; in Micromelia the retardation
in
growth almost only
affects
the extremities; foetal rachitis
causes entirely different deformities and, like
all
the above mentioned
forms, lacks the myxcedematous degeneration of the subcutaneous

cellular structure.
In infantile cretins the treatment may still achieve very much.

in doses of about 0.5 g. daily or every other day is given, in
Thyroid
With
larger children naturally a correspondingly larger dose.
this
medication the patients may develop entirely normally; the mental

condition, to be sure, often remains impaired even though it improves
in older cretins an increase of activity but not of intelligence may be
Growth may
attained.
is
set in
even at the end of the twenties.
It
interesting that in endemic cretinism a thyroid cure often has a
lasting effect while in the sporadic
where the gland
is
entirely missing
the remedy must always be repeated.
Good
hygienic treatment
IX.
is
also important in all cases.
SCHIZOPHRENIAS (DEMENTIA PRAECOX)
After paresis was excluded from among the "functional psychoses"

and the other organic forms followed of themselves, for seventy years
theoretical psychiatry stood entirely helpless before the chaos of the
most frequent mental

ideas, was the first to
diseases.
Kraepelin,
following
Kahlhaum's
symptomological differences between the

acute forms that passed over into "secondary dementia" or "secondary
paranoia" (dementia praecox), and the mild forms (manic-depressive
find
and these differences were to the effect that in the severe

forms symptom groups occurred that were lacking in the others but
not the reverse. But a number of diseases taking a chronic course
from the beginning, which were formerly regarded as something entirely different, proved to be identical with the acute psychoses which
insanity),
terminated unfavorably. Moreover, a large part of the acute syndromes which did not run into dementia, which in the beginning were
373
exactly like the malignant forms and in the after stages showed, on
exact inspection, more or less pronounced anomalies which only
differed quantitatively
from the severe secondary forms, were also
same psychoses. All these pictures showed more or

less numerous examples of these symptoms, very differently grouped in
the individual cases. But whereas, a manic depressive attack turns
identical with the
out favorably, one might say always, the prognosis of an attack of

dementia pra3Cox is really not always bad, since in very many cases
after the exhaustion of a shift only slight changes of the psyche call
attention to the disease. But these peculiarities have the identical
character in severe and mild cases,
the entire group
is
i.e.
the course of. the prognosis of
the same, while the degree of dementia to be ex-
pected or the extent of the prognosis is not determined by the mere

recognition of the disease. As the disease needs not progress as far
as dementia and does not always appear praecociter, i.e. during
puberty or soon
after, I prefer the
name
schizophrenia.
may come to a standstill at every stage and many of

symptoms may clear uq) very much or altogether; but if it proThis disease
its
gresses, it leads to
a dementia of a
Even though we cannot
definite character.
as yet formulate a natural division within
the disease, nevertheless schizophrenia does not appear to us as a

disease in the narrower sense but as a disease group, about analogous
with the group of the organic dementias, which are divided into paresis,
One should, therefore, really speak of schizophrenias
senile forms, etc.
in the plural. The disease at times runs a chronic course, at times in
shifts
may become
it
stationary at any stage or
may
regress a certain
distance, but probably does not permit of a complete restitutio
integrum.
It
is
ad
characterized by a specific kind of alteration of think-
and of the relations with the outer world that occur

Moreover, accessory symptoms, with a specific coloring
in part, are something very common.
ing and
nowhere
feeling,
else.
A.
Among
The Simple Functions
symptoms the disturbances of association ^^ are

The normal associative connections suffer in
any other kinds take their place. Thus links of association
the basic
especially important.
strength;
following one another in sequence
may
all
relation to one another
The
following associations
lack
so that thinking becomes disconnected.
are typical:
"I found the money.//
me some
^See
ice
water.//
pp. 77-78.
"No,
"Doctor, doctor, doctor.//

I
was never
here, no, no.
Please give
The bastard
374
swiped
my
Oh, oh, oh. Jack (attendant) you think

Baking Powder. Hell, no!
handkerchief.//
you're smart.//
"I've eleven of National
Take that thing away. Lucille, stop crying. Who the devil cares
he eats. What did you do with Jennie? My word, my word, the
devil you did," etc.^
At the places designated with // in this example the chain of
thought is entirely broken, perhaps at other places also. This makes
the whole thing illogical and incomprehensible. The formal coherence
Nothing was said to the patient to stimulate
is also torn asunder.
if
this production;
patient
it
who had
seemed as
he reacted to hallucination.
if
a good education used good English
when
This
his at-
tention could be held; this entire production corresponds to the dislocation of the whole stream of thought.
Another example is the following: "Sea water, deep lake, foundaDavos, Switzerland, I will get there too, I have a high
inland lake, please, please, do we have high tide. Inland water very
cold and quiet. High lake, deep lake, negligeant." ^
The lack of connection frequently finds expression in the answers
"Why don't you work? (at house-work)." "I do not
to questions:
know French." Here only the form of an answer to the question is
tion, Interlaken,
preserved; the content lacks every connection with the latter.
Sometimes only some

thoughts are lacking.
This
of
the
may
numerous threads that bind our
find expression in the changeableness
of the conceptions, even of the commonest the father

speak of himself as the mother of his children. This idea forces
itself, for example, into the place of the proper father idea because he
is just speaking of the loving care of the children, which is more
frequently associated with the mother than with the father; at the
same time the diSierence between himself and the mother (his wife)
and unclearness
may
no longer
The
exists.
ideas "land"
in a peculiar
way
and "globe"
or
their connections
in the following illustration:
are
patient
treated
is
given
four small pieces of card board which can very easily be put together
to
make
and
the figure of a church.
calls it a
new land
He makes
a new "globe."
a senseless figure out of
it
^^
In regard to the progressive stream of thought compare "Brutus

Italian" (p. 77), where the relations with ancient times are
supplanted by relations with recent times, or: "Have you any sorrow?"
was an
~ Given by Editor.
" Pfersdorff, die Gnippierung der sprachlichen Assoziationen.
Psych, u. Neur. Bd. XXXI. 1912. S. 356.
Mon.
Schr.
f.
^K. Schneider, Ueber einige Klinisch-psychologische Untersuchungsmethoden

usw. Zeitschr. f. d. ges. Neur. u. Psych. O. 8. 1912. S. 586.

"No."
"Are your thoughts heavy?"
"Yes, Iron
375
heavy."
is
"Heavy"
here suddenly used in a physical sense with a disregard for the
is
actual connection.
expression become
the situation
Thus the chain of thought and the entire mode of

somewhat bizarre. There is also a separation from
when a seamstress thinks
she throws a kiss every time
she wets the thread with her mouth.
The incompleteness
of ideas facilitates the formation of condensa-
which are consequently unusually frequent in schizophrenia.

Various lovers, various places of residence are no longer kept apart;
sometimes one lover and one place are the representatives of the entire
tions
total conception, at other times others.
But
in this connection the
used in another sense

than the ordinary one. No collective ideas originate for the patient
through such condensation; he thinks he has an individual idea and
expression "total conception" (Sammelbegriff)
only the observer
is
conscious of the fact that in the idea are con-
cealed different separate entities.

are
"Steam
is
Further examples of condensations
sail" from steam ship and sail boat, and "gruesor" from
"God is the ship of the

gruesome and sorrowful or the sentence:
the desert, and camel,
God,
desert" where ideas from the Bible about
obtained
for the useful animal,
with the figurative expression elsewhere
are slung together into a senseless sentence.
Often one idea appears for another: displacement of ideas.^^

A patient had left in disgust her position as "support" of the housewife; now she gets an uncontrollable antipathy toward everything
that resembles a support or a cane.
but it can also originate in any associative

are mistaken for each other because they have some
takes place in the affects
manner: two men
In these cases the displacement
resemblance: the superintendent of the insane asylum is substituted for

the superintendent of the training school. A paranoid female "is a
Billy-goat,"
Christ
i.e.,
she
is
= lamb = Billy
united with her beloved minister:
Minister
goat.
form of displacement is the symbol which plays an important part in dementia pra'cox, not in its ordinary application but
in such a way that it takes the place of the original idea without the
special
patients noticing
it:
thus the patient sees
fire
or
is
burnt, that
is,
he
hallucinates as realities these things that to the normal person are
symbols of feelings and thoughts of love. He has "heard" that the

superintendent "has stuck his tongue out at him." This is taken
although he only
literally (to mean that the tongue was stuck out)
hallucinated that he was laughed at.
A catatonic woman hears the stork clapping in her body; that
,
Comp.
p. 118, the
hornformed things.
376
means she is pregnant. A patient is the moon, the wife is the sun.
The wife and the sun represent the thora and justice; the moon is the
sword. The relation of the woman to Dr. B. is Psyche and Amor.
The woman is the goddess of love; she can heal the sick.
Not only may there be an absence of secondary threads of the
mental stream but also of the central idea. There is no visible purpose for writing "Blossom time of Horticulture." ^^ Thus one fre
quently receives letters from patients that describe everything imaginable that is about them or happens to them; they even mention the
trade-mark on their pen but neither the reader nor the patient himself
knows why such commonplace things are written down. Besides
letter writing comprehensible and incomprehensible things are expressed orally and in writing without any purpose, and in the same
way all sorts of unmotivated acts are performed. Through this
change of objective and of the inner association, the train of thought
sometimes resembles the flight of ideas; but the absence of an objective becomes noticeable through the lack of an emotional value while
in flight of ideas the objective is merely changed.
As a result of the lack of an objective, the train of thought readily
merges into by-associations so that at times mere alliterations become the deciding factors as in "boots beauty." Naturally in this
case some other idea besides the alliteration has influenced the train
of thought but since the same patient, like others also, was accustomed to make similar associations the alliteration cannot be an
;
accident.
Sometimes apparently senseless associations are explained by connecting links that do not come into the patient's consciousness but
nevertheless
woman
may
be guessed by the observer.
Thus when a young
answers "sweat shop paradise" to the stimulus word "tree,"
she refers to her
unhappy
love affair in a sweat shop, where she
tree
paradise, the comof knowledge

Such mediate associations become evident
much more in the association experiment than in ordinary thinking.
Through all these disturbances thinking becomes illogical, unclear,
and, when many such mistakes follow one another in a series, thought
becomes dilapidated and incoherent. This dilapidation is still more
increased by a peculiar kind of distractability. In conversation the
patients sometimes appear difficult or impossible to divert because they
enter very little into what one tells them; in spite of all injected questions they continue their train of thought, but, on the other hand,
they are brought to a topic, totally irrelevant to the subject in hand,
"sinned" for the
plexes
" See
of her
p. 78.
first
disease.
time
3??
by any accidental things that happen to affect their senses, such as

The normal directives through questions
from without and purposive conceptions from within are incapable of
the ink-well, or a noise.
holding the train of thought in the proper channels.
by an
are governed
affect,
if
If the patients
they begin to scold, distractability
is
often entirely lacking.
Conspicuous also
is
a morbid tendency
to
generalizations,
the
transference of a thought, or of a function generally to other spheres.
Delusions that could only originate concerning a particular indiwhom they have no inner connection at all. The patient has been irritated and strikes the guilty
vidual are transferred to others with
person but he does the same to others who happen to be near. A

stereotype action is not only provoked by definite circumstances in
which it has a comprehensible significance, but later it is also per-
formed without a recognizable occasion and
An
continually for years.
finally
it
repeated
is
obstruction that originated as the result of
the influence of a definite complex also spreads to other subjects, fre-
quently to the entire psyche and also outlasts the occasion any length
of time.
Thus reasoning
is
naturally impaired to a great extent.
Logical
operations with incomplete or improperly limited concepts and ideas
wrong results. Deviations from the ordinary train

by experience also usually lead into wrong directions.
When unrelated ideas are brought together in any connection, wrong
results always follow; this is especially true in the ever>^ day senseless
motivations in which any chance idea is supposed to offer the reason
The patient breaks windows, "because the physician
for a morbid act.
readily give the
of thought given
is
just coming"; he laughs "because the physician
when confronted with the
the dresser";
laughed,
previously
he
says
he
did
is
just clearing out
fact that he
it
because
had already
the
things
were
bad actions are motivated by the fact that the

patients are held in an institution and it never does any good to
tell them that the causal connection, if there is any at all, is just the
still
in
it.
All sorts of
reverse.
It is especially important, that in this
weakness of associations
as in every other, the affects obtain a greater domination over the train
of thought.
Wishes and fears control the trend instead
of logical
connection; thus the most senseless dehisiotis are formed and the
road
is
cleared for exaggerated dereistic thinking with
away from
reality,
its
its
turning
tendency to symbolism, displacements, and
condensations.
Among
the formal disturbances of the mental stream the obstruc-
378
most striking ^^ and when they

occur too readily or too often or become too general and too persistent,
they are positively pathognomonic of schizophrenia.
tions (deprivation of thought) are the
The
feeling of "thought pressure" should then be mentioned, in
which the patient has the feeling that he has to think, where against
his will "it" thinks within him, and where thoughts are incessantly
"made" for him; all of this is usually accompanied by an unpleasant
feeling of strain.
In
many
cases there
is
away from one
a tendency to perseveration, the patients do
more words and thus,

same idea, series like the following may occur: "Love, dove, name, dame, sane, love, dove, names,
dame, same, love, dove, going back, going back, going back, going
back, same. ..." In such cases thinking is usually temporarily or
permanently very impoverished. It is not yet known to what extent
not get
topic or from one or
aside from a sensible adherence to the
disturbance of association is connected with the tendency to

stereotyped expressions that show themselves in thinking as in acting.
this
In
But
moody
states one naturally finds flight of ideas or inhibition.
besides this in acute cases a non-depressive inhibition
is
not so
which obviously arises from a general aggravation of the central

processes through some chemical or physical anomalies such as cerebral
rare,
pressure or inflammation.
In such inhibitions, but even otherwise, we find rather frequently

abnormal brevity of the associations. Such schizophrenics are always
quickly finished with every train of thought without
out in a normal way.
but this
is less
its being thought

This also accounts for impoverished thinking,
in the sense of a limitation of the
themes than
in the
sense of incompleteness of the individual ideas.

Afjectivity.
dementia"
is
In the severer forms of schizophrenia the "affective

In the sanatoria there are
the most striking symptom.
who for decades show no affect no matter what

happens to them or to those about them. They are indifferent to
maltreatment; left to themselves they lie in wet and frozen beds, do
not bother about hunger and thirst. They have to be taken care of
patients sitting around
in all respects.
Toward
their
own
delusions they are often strikingly
indifferent.
In
less
severe cases
number
we
still
see affective expressions, sometimes
them; but they are circumscribed. Especially often

we find only irritability which is pathologically exaggerated. The
negativistic patients are therefore impossible to maintain outside of the
institutions because they quickly become enraged about everything
quite a
*^Seep.
79.
of

and
yell
and
fight.
The mild and
side are simply considered sensitive
379
latent schizophrenics on the out-
and moody people who are hard
to get along with.
Sometimes but not always in otherwise totally indifferent women,

mother love is completely retained, and in more intimate association
with the average patient one
still
sees
many
affects, e.g., pleasure in
and games at the institution, laughing at jokes, even joy in

artistic performances.
But the finer feelings, based on complicated
processes, are naturally more impaired than the elementary.
The
ethical sense does not seem to be especially affected although it
suffers from the general indifference and obtuseness.
In those cases also where we see livelier affects, the entire conduct
festivals
generally has the character of indifference, especially in important
matters; their most vital interests, their
own
future, as well as the
fate of the family leaves the patients entirely cold while cakes brought
at visits are often eaten with relish.
In the beginning of the disease

very mild cases and in late forms the weakening of the affects is
not always visible; on the contrary in individual cases an oversensitivein
ness in various directions
schizophrenics
who with
health of mankind, etc.
may
be observed.
Then
there are active
great zeal improve the universe or at least the
But on
closer inspection one finds in all these
cases at least partial defects of
affectivity,
indifference
in
certain
important matters, temporary reduction of emotivity or contradictions in the interplay of the finer feelings.
sometimes speak of simple indifference,

because there exists a plain fundamental mood of euphoria or depresTherefore
sion or fear.
one cannot
Nevertheless the schizophrenic clogging usually makes
under these circumstances also since the mood shows no

modulation; entirely independent of the train of thought the patients
remain in the emotional state determined from within; nothing is
important to them, nothing is sacred to them. The general attitude is
'T don't care," sometimes purely so, at times with a depressive or
especially with a euphoric coloring.
itself
felt
Moreover one
of the surest signs of the disease
is
the incapacity
One can speak with
to modulate the affects, or an

the patients about the most various subjects without noticing a change
affective rigidity.
which is especially noticeable in manic moods where one

usually finds very marked emotional fluctuations, while in the less
mobile depressive moods, the schizophrenic peculiarity is not so
of affect,
conspicuous.
If affects are present,
it
they often do not
last.
In acute stages
cr\' and whine
happens, that without any external reason, patients
380
and
and scold
rejoice
in
immediate succession.
association of ideas which
It is a case of a
chance
are followed for a short time and are
connected with affective expressions that correspond qualitatively

but are exaggerated quantitatively, just as if an actor were to present
Real inability in the sense
all his emotional roles one after another.
that the affects might change very quickly with the mental trend,
directed from within or without, does not belong to the picture of
A sudden outburst, e.g. of anger, may be frequently
schizophrenia.
it is not very easy to divert the affect, even though

one has the feeling that it is "skin deep."
If a change of affect occurs it often takes place more slowly than
in normal people; the affects follow slowly after the ideas or they
observed but then
appear very capriciously. One does not quite know why they appeared
now and why they took this form.
Under no conditions has the affectivity disappeared altogether.
By touching on the complexes one can very often provoke, even in
just
apparently very indifferent cases, lively and adequate reactions, and in

the dereistic ideas of apparently merely vegetating patients one
finds fulfilments
of active wishes
and endeavors or even
of fears;
the analysis of schizophrenic delusions and logical mistakes shows
that thinking
people.
The
is
dominated more by the
entire affectivity
may
affects
than
also reappear
it is
in healthy
when an
organic
brain disease (senile atrophy, apoplexy) complicates the schizophrenia.

Hence it may be assumed that the morbid process as such does not
attack the affects, but they are functionally only prevented from
appearing, somewhat in the same manner as a child that is suddenly
placed in a strange environment
an
may merge
into a stupor without
affect.^
The
affects
may
also appear changed qualitatively in such a
way
that what should produce joy provokes sadness or anger, and the
But sometimes only the manifestations are
reverse parathymia.
inadequate; the patients experience joy from a present but complain
same time
Moreover the
at the
paramimia\^'^
affective expressions ar& usually
somewhat unnatural,
Consequently the joy of a schizophrenic

expressions of pain leave us cold. This
and
his
transport
not
us,
does
becomes especially plain if one has occasion to observe the reaction
Just as little do the patients
of little children to such expressions.
sometimes react to our affects. Thus one speaks of a defect in the
exaggerated, or theatrical.
Comp.
Livingstone, Baelz, p. 127.
" Concerning the schizophrenic unmotivated laughter

atisms.
see
among
the autom-

emotional rapport, which
is
381
an important sign of schizophrenia.
One
emotionally more in touch with an idiot who does not utter a

word than with a schizophrenic who can still converse well intellectufeels
who
ally but
The
their unity.
as her
inwardly unapproachable.
is
affects themselves, like their expressions,
patient
own but hated

weeks was
for several
who had murdered
have frequently
lost
her child, which she loved
as the child of her unloved husband, afterwards

in a condition in
which she wept
in
desperation
^W^^^^^^
:
I
^r
vTtikij^HHELîki^^^^^^^^HI
^K.
Fig. 22. Hebephrenic who dictated "Epaminondas" (p. 78), the affected imagination of the facial expression which usually has nothing to express is significant.
Once I even saw such a

shown on the two sides of the
the unity of the feelings are more
with her eyes and laughed with her mouth.

splitting of the emotional expression
face.
Milder disturbances of
frequent.
Affective disturbances in the form of acute manic, depressive, or
anxiety moods, are not rare in dementia prsecox.
But they belong to
the accessory symptoms.
Parathymias are often indissolubly connected with the alteration

Coprophagia and the most various other aberrations
from the normal nutritive instinct, previously unnoticable sexual
of the impulses.
382
perversions, lack of the impulse of self-preservation are very frequent

manifestations.
Ambivalence. The synchronous laughing and crying are a partial

manifestation of schizophrenic ambivalence. The schizophrenic defect
of the associational paths makes it possible that contrasts that otherwise are mutually exclusive exist side by side in the psyche. Love
and hatred toward the same person may be equally ardent without
influencing one another (affective ambivalence).^^ The patients want
at the
same time to eat and not to eat they do what they do not want
what they want to do (ambivalence of the will; ambi;
to do as well as
H
P
'..
Rigid, benign mimicry in an erotic catatonic patient.
Fig. 23.
in the
you," and "I
'
Pl^
tendency)
1
1
u
^^^BHII^Lii^^l^^l
am
same moment they think,
not a
human
''I
being like you."
am a human being like

God and Devil, parting
and meeting are the same to them and fuse

ambivalence).
into one idea (intellectual

In the delusions too, expansive and depressive ideas
very frequently mingle in multicolored confusion.
The "unimpaired"" functions.
Sensation,
memory,
orientation as
to place and time, and motility are not directly disturbed according
to our present
methods
of investigation.
obtains wrong answers to simple questions,

this is
due to special causes:
*See p. 125.
The
To
be sure one frequently
e.g.,
about orientation, but
patients answer incorrectly because
383
of negativism, or because of sheer mental laziness they talk nonsense,
and memory as a
or they falsify orientation
result of delusions or the
requirements of complexes.
Perception, as well as orientation,
hallucinations and illusions.
But
and twilight
in the deeper deliria
it is
may
be indirectly falsified by
strange that schizophrenics even
states usually
show the proper
orien-
Although they imagine themselves
tation together with the morbid.
they nevertheless
in a prison or in hell or in a church,
ward
other connection that they are in the
know
of the insane
some
in
asylum;
although they look on and treat the visiting parents as devils, nevertheless they can later tell that their parents
patients
know
that the wife and child
whom
have been there; the
he murders are his house-
hold relatives; but he knows "also" that both are devils
("double
orientation").
Thus while
all
orientation as to time and place are not disturbed at
and temporarily, orientation as
or only indirectly
own
situation
is
to the patient's
very frequently disturbed, in asylum patients
rule practically disturbed, deficient,
cases can the patients understand
and
why
falsified.
Only
it is
as a
in exceptional
They
they have been interned.
consider themselves improperly treated, take an entirely wrong view

of their relations to their family
delusions,
their
own
situation,
and to
That
their social standing.
those of persecution, befog the conception
especially
self-evident.
is
The autopsychic
of
orientation also
sometimes in which case the personality '^^ is changed.

The patients usually reproduce their experiences just
as well as normal persons do, frequently even better inasmuch as
they take note indiscriminately of all details, while the normal person
does not take the irrelevant into consciousness at all. Paranoid patients
suffers
Memory.
can often
learning
is
tell
the dates of
.Accomplishments
like
duction
sorts of trifling happenings.
piano playing,
decade be practiced as
The
all
retained as well as in the normal
if
and similar
feelings)
of the material.
is
after
it.
an interval of a
therefore very good.
much that is
momentary general
be disturbed;
be blocked or the
may
School
longer apply
nothing had intervened.
registration of experiences
may
etc.,
who no
But repro-
related to the complexes
condition
(lack of
may
clearness
does not generally permit of a free disposition
Besides, the patients very frequently appear "for-
getful," as they do not remind themselves at the right time of what

they should do; the housewife forgets to cook, the man forgets to go
to business. But these are not disturbances of memory but the results
of the schizophrenic "distraction."

*See below.
384
Motility also does not show any disturbances either in respect to
We
notice in the
most delicate
movements, e.g. violin playing, no motor disturbances

tremors and catalepsy are here disregarded, some of the
(the frequent
strength or in respect to coordination.
latter
having
been classed with the disturbances of motility).

B.
(a)
Dereism.
The Complex Functions
Schizophrenics lose contact with reality, the mild
cases inconspicuously in one respect or another, the severer cases lose

it
completely.
He
tells
patient believes the physician wants to
her the contrary every day, but this
is
marry
her.
entirely ineffective.
The
in the hospital but much too long.
audience jeers; but this does not bother her and when at last she has
The patients make
finished, she takes her seat completely satisfied.
Another sings at a concert
countless requests of us, orally and in writing, to which they do not
expect any answer at
all,
although very often immediate necessities,
They want to get out; daily they press

when the door is opened it does
go away. They insistently demand a certain
like their release, are involved.
the door-knob hundreds of times and
not occur to them to

visitor;
when he comes, they do not bother with him.
In place of this they live in an imaginary world of
all
kinds of
wish fulfilments and persecutory ideas. But both worlds are a reality
to them; sometimes they can consciously keep the two kinds separate.
is the more real to them; the other
an imaginary world. Real people are "masks," "hastily constructed
people," etc. According to the constellation, in cases of medium severity, at times the one world, at times the other is in the foreground.
Indeed there are patients, though they are rare, who can translate
themselves at will from one to the other. The milder cases move
more in reality; the severest can no longer be torn out of the dream
world, even though for the simplest purposes like eating and drinking
In other cases the dereistic world

is
a certain contact with reality
is still
retained.
Naturally active attention is as a result of lack

(P) Attention.
It is all the more striking
of interest often permanently very weak.
that passive attention
is
usually not only not disturbed but appears
more active than normally.
At any
interval or external occupation
the patients usually register excellently what goes on about them,
and can make use
of the material perceived.
Sometimes, especially in the beginning of the disease, the patients

make every effort to collect their thoughts, but they do not succeed.
This probably involves
in
part functional disturbances, about like
those in cases of distraction, but besides there
are
certainly
also

general impediments to thinking.
In the latter case intensity as well
arc disturbed,
as extensity of attention
but here,
The tendency
invariably less than the active.
385
tocj,
the passive
of individual cases to
exhaustion also permits the function to weaken readily.
In other respects, corresponding to the character of the disease,

attention
is
Tenacity as well as vigility
very variable.
may
fluctuate
upwards and downwards. Patients, who for a long time cannot give
attention in any way, are suddenly capable of planning a complicated
plan of escape,
The
(y)
etc.
Will.
good
many
of the patients suffer
from weakness
of will, in the sense of apathy as well as in the sense of lack of per-
This
sistence of the will.
But under
bornness.
is
frequently accompanied by a
with great energy, so that the term hyperbulia

In overcoming pain,
fitful
stub-
certain conditions definite aims can be held to
e.g. in
is
really applicable.
cases of self-mutilation, the will sometimes
appears abnormally strong.

In addition to thinking, the obstructions naturally also inhibit
But the inner splitting of the will is most

The patients want something and at the same time want
or when they want to execute an act, a counter impulse
and execution.
willing
significant.
the opposite
or
purpose
cross
The
shackled.
intervenes;
subjectively
the
will
often
appears
patients believe they think and act under the influence
of strange people or powers (being hypnotized; compulsive acts, auto-
matic
acts,
command automatisms,
The Personality.
(8)
etc.).
Aside from very severe hallucinatory states,
know who they are. Sometimes, to be sure, the belief

that they are some one else predominates, and does not permit the
the patients
recognition of reality to appear.'^"
__J
stamp
in the first place from the disturbance of afTectivity: indifference on
the one hand, uncontrolled affects on the other; then from the associative disturbances, which on account of obscurity and aimlessness and
(e)
Schizophrenic Dementia. Schizophrenic dementia gets
its
the interference of by-paths, lead to inadequate, incorrect, senseless,

bizarre,
and
associations
silly
still
results.
But even
in severe schizophrenics
many
take a proper course and though naturally, other
things being equal, more complicated and finer functions are
more
readily disturbed than the simpler and coarser ones, nevertheless the
ordinary failure of a particular function does not depend on its difficulty. A schizophrenic may be unable to add correctly two numbers of
two digits and immediately afterwards extract a cube root. The severer
For the severer disturbances of personality see among the accessory
symptoms.
386
schizophrenic dementia
so
much by
distinguished from the milder dementia not
is
the fact that
it
fact that numerically there
The
or easy.
self
may
turn out excellently, but
nevertheless be utterly incapable of
Under
properly in the simplest relations.
may
by the
a decline of functions, be they difficult
is
so-called intelligence test
may
the patient
also afflicts the simpler functions as
managing him-
certain conditions he
may fail to underhe wants to be discharged from the asylum. Where his complexes are involved he is
impervious to argument, insensible of the most obvious contradictions
understand a philosophical
treatise,
but he
stand that he must conduct himself decently
if
of logic, as well as of the conceptions of ordinary reality.
phrenic
not downright demented, but he
is
is
The
schizo-
demented as to certain
times, certain constellations, certain complexes.
The products
pronounced schizophrenia
of
in literature
and
usually have the character of the demented or bizarre, which
by a hollow pathos.
rarely concealed
work
Not
person does not dare exhibit in their nakedness.
and even a certain

(t,)
first
a certain impulse to poetic activity,
may
be readily deduced from
Where the
the disturbance of the affects and the associations.

are prostrate,
cases
is
acts
and
in
affects
the very severe
factors of reality, dilapidation, sudden notions
the middling
characterize
cases live like other people, only
In
dominates the patient, he no longer bothers with the

of initiative, the absence of a definite aim, the
many
peculiarities,
noticed.
done, where
Lack
outer world.
ignoring of
or nothing
little
dereism
rarely schizo-
ability otherwise lacking.
Schizophrenic activity
Activity.
of art a peculiar
can utter truths which the normal
or the patients
phrenic excitement produces at
art
not
In -individual cases a slight
degree of deviation from the normal gives the

attractiveness,
is
all
cases
of the
their position
we
entire
and
find
an
cases.
now and then
insufficient
attitude toward
calling, or
severe
and
The milder
the abnormality
is
motivation of individual
The
life.
without reason
fail to
patients
change
appear at their
moody, and inclined to pout and scold. In the

many can be very good working machines,
but even on the outside, many whose view has been narrowed by the
work, are
irritable,
organization of the asylums

disease are
still
their condition.
woman
considered ideal workers, until a stupid act reveals
teacher suddenly
sews stockings to the carpet,
Where
accessory
symptoms
as,
lies
down
in
a well, a
young
etc.
for example, hallucinations, delu-
manic or catatonic syndromes are present, these primarily determine action and conduct.
The excited cases in asylums are very unpleasant: Yelling, scolding,
sions,
387
fighting, destroying, all sorts of uncleanliness, are every
day occur-
many;
rences with
special peculiarities, coprophagia, scraping the walls
and beds, refusal of food, impulse to
make
suicide, self-infliction of injuries,
the treatment of individual cases especially difficult; but v/ith
the improvement of the technic of treatment,
and with increased
understanding of the patients these matters are becoming more rare
and
of shorter duration.
C.
The
Accessory Symptoms
The accessory symptoms complicate
the fundamental picture, at
times permanently, at times only in transient appearances.

(a)
Sense Deceptions.
Characteristic
of
schizophrenia are the
hallucinations of bodily sensations in clear mental states; besides there
pronounced preference for auditory deceptions in the form of

words (voices). Visual hallucinations are very frequent and lively
exist a
in the acute stages, otherwise rare.
Tactile hallucinations occur almost
only in combination with bodily hallucinations and as partial manifestations of a complicated perception (snakes, being struck).
Decep-
tions of smell and taste and of the kincesthetic senses occasionally
obtrude themselves.
The
humming,
patients hear blowing, roaring,
rattling,
thundering, music, crying and laughing, but above

speaking,
calling;
people and
all
shooting,
whispering,
they see individual things, landscapes, animals,

impossible figures; they smell and taste all sorts
all sorts of
and unpleasant things; they touch things, animals, and

fire, and bullets; they feel all
the tortures and perhaps all the pleasant things also that our bodily
of pleasant
people and are struck by rain drops,

sensations can transmit.
Elementary hallucinations of hearing are rare and influence the

little.
The voices usually speak in abrupt words and short
sentences; long, connected scenes are signs of accompanying alcoholism
They
or, in rare cases, of twilight states, and hysteroid additions.
patient
scold, threaten, console,
also say the opposite of
they
criticize
as ''voices of conscience," or
what the patient
wills or thinks.
In the case
becoming loud, on the contrary, what is thought at

the moment by the patient is spoken out. The voices come from all
sorts of places, from heaven and hell, or from ordinary places, where
of the thoughts
people are; but they are also situated in the walls, in the
one ear,
ones in the
The
air, in
the
Perhaps they use only

or the good voices are heard in the right ear and the bad
clothes, or in the
body
of the patient himself.
left.
hallucinations of bodily sensations offer an endless variety.
388
The patients are clubbed, burnt, stuck with hot needles, their
made smaller, their eyes are pulled out, the lungs are sucked
legs are
out, the
taken out and put into another place, the body is pulled
apart and pressed together like a harmonica, a bullet runs along
the top of the skull from the base to the top, the brain is sawed apart,
liver is
the heart beat
decreased or increased, the urine
is
But above
held back.
all
is
drawn out
or
the joys of normal and abnormal sexual
more frequently, all sexual indecencies that

the semen is drawn off, the outer and inner
genitals are burnt, cut, torn out, women are violated in the most
The sexual
refined manner, are forced to intercourse with animals.
satisfaction
and,
still
can be imagined are
felt;
element in the sensations

instead
of
the
sexual
is
often disguised; a female patient feels,
act,
that
hobby horse
is
in
the
bed.
Sexual experiences are transferred to the heart, to the mouth, to the

nose, etc.
Hallucinations of sight are rare in chronic conditions and when

a head, angels
present are usually fragmentary and disconnected;

as large as wasps,
and hands appear before the patient, sometimes also
a sexually symbolic animal, a snake, an elephant, a horse.

delirious conditions
hell,
an
entire
background
is
a castle, a dungeon, all with acting inmates.
reality
may
In acute
hallucinated; paradise,
At the same
time,
be hallucinated out of the way, or illusioned to correspond
with the hallucinated milieu; in more clear cases some of the pictures
are injected into reality, and in an altogether clear consciousness
all
are so injected.
Where
it is
possible to hallucinate, illusions also appear; but they
are less important than the hallucinations.
Sometimes the two forms
of sense deception cannot be distinctly separated.
The
deceptions of the different senses, especially in acute syn-
dromes, combine very readily with one another.

ence scenes, see persons act, hear
them speak,
or taste their poisonous or pleasant presents.
The
patients experi-
feel their influence, smell
In mentally clear chronic
and somatic hallucinations combine. The

sense deceptions appear most frequently when the patients are left
to themselves. But there are exceptions; now and then they appear
They are often provoked by
especially disturbed during work.
another sense impression: the patient sees the physician come into
the ward and at once hears him utter a command that concerns himself; the key turned in the lock is felt painfully in the breast {reflex
stages, usually only voices
hallucinations).
Not
so rarely the hallucinations are
dependent to
a certain extent on the will; the patients ask questions out loud or in
thought; they are answered for them; they put themselves into certain

situations
389
where the sense deceptions appear, or into others, where
they are free from them.
The
intensity of the hallucinations
may assume
all
degrees, from
the least whisper to the terrifying thunder tone, from the slightest
abnormal
feeling to the
In the same
way
most unbearable
pain.
the clearness fluctuates within
maximum
limits.
Frequently the false perceptions are really very obscure. But the
patients do not notice it because the meaning of these perceptions is
plain to them in advance; they hallucinate the meaning much more
than the word. When they are pressed to reproduce a voice word by
word, they often do so using different words in immediately successive
times; but the sense, e.g. of the denunciation, remains the same; a
distinct smell comes from snake-poison or from morphine, etc.
The same is true of the projection to the outer world, which is quite
indefinite for the patient,
much
oftener than he at
first notices.
On
closer inquiry it often turns out that the patients do not differentiate
between vivid thoughts and real voices, between ideas and prepared
pictures and (hallucinated) objects, and do not feel the necessity of
doing so. Extracampine hallucinations occur most frequently, especially in schizophrenia.
the value of reality of the hallucinations for the

They usually believe in the
patients usually holds as self-evident.
In spite of
this,
and when these come in conflict

with actuality, it is the latter whose reality they reject, or at least
doubt. Hallucinations, the morbidness of which is recognized in spite
voices with unshakable conviction,
of the vividness of the deceptive perception
(pseudo-hallucinations),
occur most readily in the visual sense.
Thus the patients cannot

in
ordinary
impressions.
learn to
readily evade their hallucinations, while
one can ignore a large part of the normal sense

Only after a long while some of the more intelligent
life
pay no attention to the sense deceptions.
Most
of the patients,
who in spite of all hallucinatory annoyances gradually become quieter,

in time adjust themselves to them in such a way, that they transfer
themselves into another world, into a separated part of the ego, which
is
decidedly cut off from reality.
Thus they can work
quietly or
otherwise adapt themselves to the asylum routine although they hear

voices incessantly and are tortured physically.
Contrasted somewhat with this persistence of the schizophrenic
the peculiarity that, as soon as another train

Even
of thought is present, they are readily shut off or split off.
with
their
hallucinations
patients who are almost incessantly occupied
hallucinations there
is
and are influenced by them, consequently cannot even with the best
390
intentions give
any account of them when they are questioned about
them.
The patients have the most various conceptions of the manner in

which the hallucinations originate. Often they are tortured with
Formerly it was
complicated machines or telepathic influences.
Special talents also, "second hearing," enable the patients
witchcraft.
to hear voices.
Not
rarely the need of an explanation
is
entirely
lacking.
The attitude of schizophrenics toward

varied.
Many
their hallucinations is
most
adjust themselves to them, others even quietly amuse
themselves with them
but very
many
react with excitements, threats,
schizophrenics sometimes
occupy themselves in accordance with their imaginings or they submit
passively to everything; they lie around catatonically, partly with a
consciousness of the absence of reaction, partly as a result of kinaesthetic hallucinations with the belief that they are doing something,
like the normal person in a dream.
and
violence.
(P)
In acute twilight
The schizophrenic
Delusions.
the impress of the
illogical.
is
not
felt.
their friend Jones, but besides "he
patient himself
is
delusions
show
in
most cases
In the delusions themselves contradictory
and absolutely unrelated ideas can

contradiction of reality
The
states,
exist together; the
The physician
may come
as
is
most decided
same time
at the
Thomas
or Smith."
long since dead but he lives in the asylum.
woman
swallowed the whole world with every gulp; a

many times. Often the ideas are
extremely indefinite. He has one hundred thousand dollars, which
occasionally, without noticing the contradiction, he estimates as ten
Many ideas are intended entirely symbolically; a female
dollars.
patient "is" the cranes of Ibycus because she is "free from blame and
error," and "free," that is, she should not be confined.
The individual delusions have little or no logical connection among
themselves; they often constitute a real "chaos of delusion." But
usually they readily become organized in accordance with affective
The patients want to be more than they are and this then
needs.
results in the delusion of grandeur. They do not get what they wish for,
and as they themselves do not want to admit that they are incompetent,
catatonic
patient has had his head cut off
the result
is
the delusion of persecution.
In respect to content the most prominent part

cutions.
in the
Jesuits,
is
played by perse-
Particular individuals, relatives, superiors, the physicians
asylum, but especially complete plots, the free masons, the

the "Black Jews,"
mind
readers,
"Spiritualists,"
persecute
the patient with voices, slander and annihilate him, subject him to

all
the tortures which objectively
tions
we
391
ascribe to the bodily hallucina-
(physical delusions of persecution).
The
delusion of grandeur permits the patient to be a genius or
some other great person, such

Christ, or prophet.
as an inventor, count, Kaiser, pope,
This delusion
is
usually mixed with that of persecution.
always present
in
rarely
altogether pure but
is
Erotic aspirations are nearly
women, and very frequently in men. If they are

is usually at the same time involved, at least
the foreground there
in
in
exaltation of rank; they have a lover who is socially

above them; envious people are at fault that he has not as yet married
women, an
them.
The
delusion of jealousy also
may
be schizophrenic.
The
delusions of poverty and sin usually exist only in depression. However,

delusions of self-accusation may also be the expression of suppressed
wishes or merely the result of chance associative connections. Thus
In a
a patient falsely accused himself of having violated a girl.
village,
where there had been several
fires,
a schizophrenic got the
idea that he had caused them. People who in case of a sensational

crime falsely surrender to the police as the criminals are usually
alcoholic schizophrenics.
Autopsychic delusions are very frequent; the patient is not at

all the person for whom he has been taken, but an entirely different
person; his name is not the one shown in the documents, he was
frozen in a bathtub and
is
here
changeable, at times a virgin, at
anyway; a young woman "is intertimes a woman." Other patients are
changed into animals, a delusion which to be sure rarely persists in

Sometimes the ego also is changed. Then again it is
clear states.
not the patients at all who think and act, but strange powers in them
(Demonism)
forms of delusions, above all the delusion of
persecution, draw their sustenance in large part from an uncontrollable
delusion of reference. Everything that happens can have some refAll schizophrenic
erence to the patient, not only what people do, but external events also:
a thunder storm, a war, etc.
Usually the delusions are self-evident truths to the patient. Some

patients, to be sure, themselves feel in a certain connection the absurdity or the peculiarity without, however, being led to make a correction.
The reaction to the delusion is sometimes adequate, in the sense that

the persecuted ones complain and defend themselves, or the megalomaniacs want to carry out their presumptions; one wears a high hat
to show his dignity as "inspector of the asylum" another strikes any
person at all whom he considers a persecutor; or to ward off the
;
secretive "influences," counter measures of a magical character are
392
But much more frequently the conduct of the patients is

They really do nothing to attain their goal; the emperor
and the pope help to manure the fields the queen of heaven irons the
patients' shirts or besmears herself and the table with saliva.
resorted to.
inadequate.
may
be carried over into the

But usually they
disappear with the other acute manifestations even though a schizophrenic hardly ever attains an entirely objective attitude toward a
delusion. A delusion formed in chronic states is usually retained a
long time, often for life, even though it is rare that it does not in
Delusions formed in acute states
quieter states as "residual delusions"
(Neisser).
time experience additions and transformations which, however, only in

exceptional cases change
it
materially.
At
all
events in the stages
where the withdrawal from reality clouds the

judgment most seriously, we find the wishes most frequently gratified
by the delusion of grandeur, while previously the impediments to
wish fulfilment came more into consciousness and occasioned ideas
of persecution.
One of the commonest and often very rapid transformations is the one where the beloved becomes the persecutor. With
a change in the surroundings delusions that are attached to them are
sometimes forced into the background for a short time; but soon the
new environment seems the same as the old and attracts the previous
of higher dementia,
delusions to
The
itself.
delusions, in large part, turn
up
in the
form of hallucinations,
many suddenly spring from the unconscious as primordial ideas; many originate in a dream in which case
it is significant that the patients often know the genesis without on
this account entertaining any doubts as to the correctness.
To be
sure, manic and melancholic shifts of mood form corresponding ideas.
Occasionally hyper(y) The Accessory Memory Disturbances.
others as visual deceptions;
mnesias appear, in which individual recollections turn up with special

vividness, sometimes with the character of compulsion.
Memory
gaps or amnesias occur, more frequently, e.g. after deliria, but also
after merely psychically conditioned excitements.
But paramnesias
most common, in the form of illusions as well as in the form of

hallucinations of memory.
A patient who inwardly is not entirely
satisfied with her husband accuses herself of having slandered him
dreadfully. Many find in print what they have thought some time
ago. What others have written, they have written about long ago.
It is very common that patients who do not get along with those
about them believe afterwards that they have endured many hardships on their account, while in reality they were the aggressors, or
nothing special has happened at all. Memory hallucinations are very
are

common. Suddenly, while playing
and complains that yesterday at a
cards, a patient
when they
it
(8)
may
are once present, they
him and he was beaten."

much rarer. '^ But
be consistently retained
many
a patient imagines every time something happens
e.g.
occurred exactly in the same
previous
off
deceptions through identification are
years, so that
that
becomes excited
particular time, which he really
spent very quietly, his clothes were taken
Memory
393
way on
the same date of the
year.'^^
The Personality.
Loss of a feeling of activity and the inability
to control the thoughts often rob the schizophrenic ego of essential
Disturbance of associations and

components (depersonalization)
morbid bodily sensations make it appear entirely different from what
it formerly was, so that their changed condition is made conscious
to the patients; they have become a different person, or they must
.
at least "find their
the ego
when
own
self
for short periods."
The
restriction of
contrasted with other persons, even things, and abstract
may
many
conceptions,
be obliterated; the patient can identify himself not
only with
other persons, but with a chair, or a
staff.
His
more parts; the one set of his

John
Smith, the other to his new
the
real
ascribes
to
he
experiences
and
is named Midhat Pasha.
in
Charenton
born
which
was
personality
moment.'^*
definite
personality
at
a
Others become a new
Objectively the personality suffers from the marked independence
recollections are split into
two
of the individual complexes.
or
On
ordinary occasions a patient
may
appear normal. If he is brought around to his delusions, he is altogether

different, with a different character, with a different logic, with a
different expression.
On
the other hand
many
severe catatonics
may
complexes and
be completely opened up, by a discussion

change their conduct, so that temporarily the disease can hardly be
of their
Towards some persons many schizophrenics are outwardly normal, toward others they are brutal, or shut-in, or negativistic.
But in this case it is not as if the change were willed or even
demonstrated.
There simply exists an entirely different shift; feelings

and impulses, and even associations, which dominate in one picture
are inhibited in the other, and in their place others substituted. Both
I
dissociation products of the personality can exist side by side.
observed this most clearly in a patient who, as a rule, while she listened
to a reading and comprehended it faultlessly, or even while conconscious.
" Compare further

" See p. 108.
p. 105.
"For negative memory hallucinations see p.

"Comp. p. 391, the autopsychic delusions.
101.
IV^
394
versing with us, entertained herself with her pathological creations
by whispering quietly or making
gestures.''^
nowhere so frequent as in schizoVery commonly, the patients are convinced that those about
Transitivistic manifestations are
phrenia.
them
also hear their voices, sometimes even that they undergo the
A patient has holes in her hands

and maintains that the nurse also has holes in her hands. A patient
strikes himself twenty times in the belief that he is striking his
physical persecutions with them.
enemies.
hebephrenic patient believes when he does anything,
scratches his face, that he does not do
whom
at
it
all,
e.g.
but some other person
he sees in front of him.
A woman who nursed her husband,

from intestinal cancer, believed that she had the
same disease, whereby her disease first became manifest. The bed
Appersonifications are rarer.
who was
suffering
neighbor of a
woman
patient died; she, thereupon, considered herself
as having died.
In twilight states, or in attacks of rage the patients are often

entirely different people as to character
and
ideas.
Change
of per-
sonality of the most different kinds are often indicated, not only
attitude
and conduct, but occasionally
also
by
by
different speech; one
personality speaks in a low tone, the other in a loud tone; one articulates childishly, the other normally.
Most schizophrenics do not show

(e) Speech and Hand-writing.
anything striking in their speech, but among our asylum patients
Frequently the speech
disturbances of this function are not rare.
is changed: the patients speak a great deal, often without
saying anything and without a comprehensible reason; others no
At times
longer speak at all (Mutism), and for different reasons.
impulse
they offer the information that ideas of sin forbid them to speak.
just this content requires a
But that the delusions should have

cause lying further back,
e.g.
negativistic tendencies;
also be temporarily hindered
by obstructions.
reason for protracted mutism
is
lost
speech
undoubtedly, that the patients haye
contact with the outer world and have nothing to say to
If the patients speak, the tone
low, too fast, too slow, falsetto,
may
The most important
may
it.
be abnormal, too loud, too
humming, grunting,
staccato, rushing,
happens that patients do not open the mouth to speak,

as a result of which understanding is naturally reduced to zero. Then
again speech may be without any affect, monotonous, or embellished
in some way.'^^ Speech mannerisms often express a definite complex,
etc.
It also
"Compare
also the double orientation, p. 111.
" For verbigeration
see under stereotypism.
395
the child complex in diminutives and high voice, social aspirations

in the use of foreign words and intonations, that are supposed to be
superior. A catatonic woman, even in her clear states, usually spoke
J4t-îfJ--'
XitÂT ^JZJcJ, .A.^w^-^^^.^'^-r^^
^T^/c^TT. .-STTlvC'
;2l
/TVl'Âii-C-M
'"tA^ Û.
Ji'-kji
.-r^-lLj
.^^
i^-A-u-'l^C
.^ -^^^^'^^ ''"'"^ (^^^
'^^^^^
JC
cx_
i"r.Tl,
(^k/)^^
>^
Fig. 24.
Writing of a hebephrenic. The script changes from small to big
hand, words are frequently underlined and some changed and scratched out.
an ordinary Zurich German, but concerning her disease always in

Gall dialect; when her husband was discussed, she used
vulgar expressions and curses; on the subject of "America." which
the St.
1.
)r&n
'ii'
2.
<h^1c^
V,v,
c^^.^..^
^=4}
V.
1. i_iJ-^- S->vuiM. VocTCa*. vôr\ik<^
2.
2~^
OTKnC^X
i,,
2-
2-
2-
-2-,
Incomprehensible, conFig. 25. Letter written by a schizophrenic patient.

taining stereotype expressions, neologisms, of words and numbers, and peculiar
figures.
396

was
connected
with
her
aspirations,
she
used
397
educated,
decent
expressions.
Frequently ideas are designated by other words, "courageous"

by "rowdy," a wall clock by "buffet," or neologisms are formed, in part
CV^-e>-'Jo-r>)
Qo^
^î<_*C^Q_ ^^;>O^CrvÂ<^
VA>Jl^C>^^
Fig. 26.
Flourishing writing of a paranoid praecox patient who shows grandiose
feelings of the aristocratic type.
for existing ideas, in part
for the designation of
new
conceptions.
"Double polytechnic" means the inclusive idea of all the patients'

aptitudes and the rewards belonging to them; one gives the patient
pain "on the cosmos path," At times grammar fails them {paragram-
398
Many
matism).
words are used incorrectly, thus
e.g.
frequently the
word "murder" that designates all the tortures that the patients suffer.
"I am England" means: "England belongs to me."
At times only words are used or written, which have no meaning
for us (Word Salad) or the patient speaks a particular "artificial
language," sometimes with the pretense that it should be understood.
The written expressions correspond to the oral. Abnormalities of
style of all sorts are frequent.
The handwriting
decorated or entirely affected;
not rarely changes very
denly, as
letters, of
if it
came
words, of
it
from another person;
all sorts of signs
it
is
sometimes over
much
sud-
contains repetitions of
(written verbigeration)
omissions,
and peculiar orthography. The arrangement of the writing, and the folding of the paper are often
striking.
In catatonic "unclearness" accidental mistakes occur,
especially the omission of letters, the contraction of two words into
one (In't instead of I not), contamination by later words that the
or excessive use of punctuation,
writer already has in mind.

(^)
Physical symptoms are usually not pronounced; but some-
times one comes across signs of cerebral pressure which

in part to
an oedema
in the skull,
and
is
to be ascribed
in part to a special "brain
inflammation."
The weight of the body shows large and unaccountable fluctuations;

marked addition of fat is especially frequent during reconvalescence
from acute attacks. During catatonic states we frequently have a
a
severe disturbance of metabolism; the picture looks like an infection:
thickly coated tongue, tremors, rapid decrease of weight and strength
even when
sufficient
nourishment
increased temperatures.
cerebral inflammation,
is
given,
The metabolic
may become
and sometimes
also slightly
disturbances, as well as the
fatal.
The
functioning of the intestines and the different glands in most

chronic cases is, as far as we know, normal, but under certain conditions very irregular; constipation
ments, polyuria with penuria.
may alternate with frequent moveHigh grade ptyalism and parched
mouth occur in the same way.

The functions of the vaso-motor system are perhaps most
changed. Without comprehensible reason the pulse may
livor
and cyanosis often occur, which
strikingly
fluctuate;
in rare high grade cases
may
go as far as blue-black coloration of the hands and feet. Then again

the head or any other circumscribed part of the body is overheated,
another part is cold. (Edemas of a striking consistency appear on the
feet, in the face, on the wrists, occasionally also on very unusual
Menstruation is often disturbed, but more in the sense of
places.
^r^
^1
399
y^
1'!^
^^
0?
*i
-Q
35
2 S
400
reduction than in hyperfunctioning.
Especially in acute stages
it
usually ceases for a time.
But the subjective menstrual troubles
common
women
in mentally healthy
sign that
they
are
psychically
hardly occur here, an important
conditioned.
impotent or there is at least a reduced

Naturally during acute shifts sleep
Men
are
sometimes
libido.
is
usually disturbed; in con-
trast with this one sees at times a protracted desire for sleep.
Chronic
patients sleep normally at times, at other times they are kept excited
through the night by hallucinations.

The manifestations of exhaustion vary greatly; especially in the
beginning they form at times a prominent symptom. At every task,
become tired and conseback on as complete an inactivity as possible, sometimes

ifter a hard struggle against the evil.
On the other hand others
hardly feel any tiredness, either at work or at the exertions caused
by the excitations or the hyperkineses.
Of the motor symptoms there are still to be mentioned the frequent
aggravation of the idio-muscular contractions and fibrillar or muscular
twitching in the face, then fine tremors. Coarse tremors occur only
3specially thinking, the patients immediately
[uently fall
in acute disturbances with weakness.
The
gait in severe cases
in respect to length
is
often striking as aimless, and irregular
and duration
of the step.
Organic paralyses do
not belong to the picture of schizophrenia, but hysterical forms of

all
kinds do, even though they are not particularly frequent.
The deep
reflexes are usually exaggerated.
pupils are often pathologically dilated, rarely
In acute conditions the
and probably only
in
chronic patients excessively contracted; more frequently, but transiently
and variably, the pupils are unequal.
Usually the psychic
pupillary reflexes are absent.'^^
Besides the hallucinations of bodily sensations parasthesias of
all
kinds are very frequent and often constitute for a long time the only
symptoms of the disease. Worthy of note is an analgesia which occurs
not too rarely and which
is
sometimes quite complete.
It
is
responsible
for the fact that the patients readily injure themselves purposely or
accidentally.
Sometimes catatonic attacks occur which show two extreme types

with every possible intermediate forms. On the one side one observes
attacks that appear purely psychical, evincing a hysterical form; on
the other side there are organic attacks with disturbances of consciousness,
interference
with
the
thought
processes,
involuntary
evacuations, and occasional residual mild paralyses of speech, facial

" For catalepsy see below among the catatonic symptoms, p. 403.
401
Fig. 28. Letter written by schizophrenic patient who is controlled by senseless

ideas of grandeur.
The patient has invented a new language which one can,
however, occasionally decipher. Thus for INIanhattan State Hospital he writes,
"Nehat hsiat." One can also recognize in the 2nd line, the words "New York,"
the 2nd of April; and in the 3rd line "Dr. Heyiuan" (the superintendent of the
hospital). Occasionally one can also find correct words. The patient is a native
'
American.
402
letters,
Fig. 29. From the note book of a chronic catatonic. Verbigerations in
childish drawings in spite of the fact that the patient can really draw quite well.

nerve, or hemiplegia.
If the
403
patients are not entirely unconscious
they are delirious in the sense of a more or less perceptible

hysterical twilight state. Besides there are fainting spells, and especially typical epileptiform convulsions also.
with
this,
Physical deformities
(stigmata)
are
frequent than in the normal persons but
obviously
much
less
somewhat more
frequent than in
and criminals.
The Catatonic Symptoms.
idiots, epileptics
With this name a number of symptoms were designated which at the time helped to formulate a definite
(ri)
They
conception of catatonia.
may
readily occur singly, but
it
not improbable that they nevertheless have an inner connecis
tion in the sense that they occur
most frequently with a certain

condition of the brain that
is
at
the foundation of catatonia.
Catalepsy (waxlike
flexi-
and
pseudoflexibility,
bility,
rigid catalepsy).'^
Most
of the severer catalep-
schizophrenics
tic
attitudes
nite
for
assume defimonths and
one stands at the window

on the tips of the toes of one
years
holding up the other

and both hands. Others
sume a particular attitude
foot,
leg
asin
Usually these forms

are associated with rigid cata-
bed, etc.
lepsy.
2.
ing
Stupor.
origin
is
Stupor of varyvery frequent in
acute conditions but
move
may
Fig. 30. Spontaneous attitude of a

catatonic, at fii-st lasting, then only assumed when the phj-sician appeared.
also characterize a chronic stage for decades.
speak little or not at all, and generally limit

intercourse with the outer world as much as possible. Cataleptics are
naturally all stuporous.
Many appear depressed ("^lelancholica
The
patients
attonita").
little,
In severe cases there are usually verj' numerous hallucina-
tions of all senses with a falsification of the outer world
and the
environment; the patients are in a dream land.

3.
Hyperkinesis.
''See p. 153.
Many
catatonics are in incessant motion: they
404
nod the head, hop, hammer on the bed, throw themselves about, dash
themselves on the head, let themselves fall backwards over the foot
end of the bed, climb up wherever they can, all in a peculiar manner
that seems purposeless.
4.
sions
it
Stereotype Expressions.
prevalent in
is
may
for decades
all fields.
The
It
inclination to stereotype expres-
may
just as likely be transient as
provoke the identical movements and the identical
attitude.
Move-
Stereotype
ments: Rubbing the right
hand over the
continuous
with
rubbing
thumb
left
decades;
for
the
right
hand over the middle

the
along
finger
of
running the
breast;
all
edges;
tapping with the foot on

certain
knocking
places;
on a particular part of
the bed; turning about
the vertical axis
with a
particular position of the
arms,
etc.
Some
stereo-
types have the character

of senseless acts:
pulling
out the hairs at certain

places, sticking the finger
the
into
ing
Fig. 31.
who
Permanent
in spite
of all
attitude of a catatonic,
measures finally suffered
from a pretty severe kyphosis.
off
the
smearing
way, twist-
anus,
in a particular
clothes,
ripping
the buttons.
Stereotyped Attitudes:
many
catatonics
who
lie
bed hold the head

away from the pillow in a position which the normal person could
not endure very long, or they draw the knee up to the chin, or
stand rigid like an Egyptian statue; they hold the legs spread apart,
stare for weeks at the same spot, under certain conditions with an
extreme awry position of the ejês.
in
Stereotypes of Place.
The
patients
particular place, always walk exactly the
want to remain only in one

same paths in the garden, so
that these become trodden down, or they touch the wall at certain
places, thus leaving
marks
of this constant
wear and
tear.
THE INDIVIDUAT. MENTAL DISEASES

A
stereo-
particular
type
"snout
the
is
which the
are held protruded
ward.
cramp"
lips
in
The
405
for-
of
stereotype
speech, or verbigeration,
always repeats the same

sentences,
or
words
often entirely
This
ones.
senseless
not to be
is
confused with such incessantly repeated ejacu-
"Oh
as
lations
Kill
me!"
God!
which are
etc.,
the expression of a persistent depressive affect.
In those playing music
one
repetitions
finds
lasting for years of the
same
figure
{musical
verbigeration)
Thoughts, wishes and

hallucinations
become
may
also
sterôtj^ped.
Some
of the
stereo-
type expressions have a

comprehensible content:
one
will
the
represent
movements of a shoemaker because the lover

was a shoemaker; another the
balancing
in
the quadrille because the
met in a
quadrille.
In two cases
snout cramp was the ex-
lover
was
first
pression of contempt for
the surroundings.
Usu-
ally the patients are not
conscious of the
ing,
and at
Fig. 32. Stereotype, catatonic attitude with

closed eyes. It imitates some complex of greatThe expression of the face is vapid.
ness.
mean-
least during the phase
when
stereotypes were present, I
406
have never obtained
direct information about them.
Only the assoan
ciation experiment, subsequent or indirect remarks of the patient,
exact objective anamnesis, and similar things, can enlighten us.

5.
Many
Mannerisms.''^
for years try to
will
something
patients assume certain poses;
imitate Bismarck;
others
else that is extraordinary, nearly
want
to
e.g.
one
represent
always in a pompous,
But sometimes only particular acts

over-embellished in some way: Before partaking of
caricatured manner.
artificial,
are changed or
taken on the fork seven

taken into the mouth; in
dressing, before making any slight movement, the cloth is rubbed
food the plate
is
struck three times, food
times and thrown
off
again before
it
is
is
f
1
I
MB
Figs. 33a and 33b. "Snout cramp" in a catatonic with alternating manic and
melancholic days. Change of phase very decided, often from one minute to the
other, (a) on a melancholy day, (b) on a manic day.
several
times;
before she
sits
the
patient walks
down on
it.
are used with affected intonation.

is
attached.
the
little
6.
tom
The hand
finger
is
Negativism
To
all
words an "is" or an "ism"
improperly extended in greeting or only
offered.
is
of schizophrenia.
to remain in bed;
is
about the chamber three times
In talking diminutives or foreign words
if
a very frequent and very disagreeable symp-
When
the patients should get up, they
want
they should remain in bed, they want to get up.
Neither on command, nor in accordance with the rules of the hosdo they want to get dressed or undressed or come to meals or
pital
'
According to Ziehen "Variational
need not become stereotyped.)
*"
See p. 154.
stereotypes."
(But
all
mannerisms
407
leave their meals; but
if they can perform the same acts outside

somehow contrary to the will of the environdo them. Of their own accord they do not go to
of the required time or
ment, they often

the toilet; if they are brought there, they hold back the excrements,
in order to soil the bed or the clothes immediately afterwards. They
eat the soup with
with the soup spoon.
fork or with the dessert
Many
resist all influences
spoon, the dessert
with
all
their mij^ht,
often with excited scoldings and fighting; thus negativism becomes

a source of attacks of rage. It can develop into a real impulse to
an active impulse to anger incessantly those about them

most ingenious manner; the patients hide their things
and then maintain that the orderlies have stolen them or
have not given them to them, etc.
In some cases one can
tease, into
the
in
with
certainty
forbids
him
bring
to do
it,
the
patient
or orders
to
him
do
the
desired
to do the opposite
act
if
one
{command
negativism)
Many
patients are negativistic toward their
negativism)
as soon as they
want
own impulses
(inner
to perform an act, an inhibition
or counter impulse appears so that they do not perform the simplest

acts like eating.
and must
The spoon is arrested

put down again.
half
way up
to the
mouth
finally be
In purely intellectual matters also, negativistic tendencies are

very disturbing, since with every thought the patients must also
think the opposite: "I am in the hospital, no, I am not in the
hospital" (intellectual negativism). Even the voices can continually
say the opposite of what the patients want or think, or they can
two contradictions.*^
However, even the most pronounced negativism is not absolute;
toward certain persons it is usually greater than toward others.
Often it only becomes apparent in the intercourse with the personnel
Sometimes it is
of the hospital, but not with the other patients.
provoked when the complexes are touched.
To a certain degree
Negativism is a complicated symptom.
"negative suggestibility" is a normal characteristic, which is often
recite the
disagreeably conspicuous especially in little children, in that they

That negativism in, schizophrenics is
reject all sorts of things.
especially pronounced,
we
are ignorant.
may
But
it
be due to a fundamental cause of which

undoubtedly connected with dereism
is
which makes every external disturbance
felt
as
unpleasant.
But
understanding of the environment, the enduring of

counter measures such as the confinement, naturally produce a
the
deficient
" See
also ambivalency, p. 286.
408
Sometimes, especially in women, sexuality with

attitude.
marked ambivalence contributes its influence, and leads the
patients to reject what they really want.
The patients themselves can usually give no explanation of the
The explanation by means of voices or delunegativistic attitude.
hostile
its
sions
is
naturally not sufficient because usually the reverse
case, in that the content of these
symptoms
is
the
is
conditioned by the
existing negativism.
Command Automatism and
Echopraxia. As an outward consometimes found in our patients an

automatic obedience to given commands, even when the patients
really resist, e.g. if one orders them to stick out their tongue and
threatens to pierce it. Besides, in confused as in tv/i7.
trast
to negativism there
is
light
states,
and
echopraxia
echolalia occur at times.
Automatism (including
8.
compulsive phenomena). No-
where do we find automatic

action
frequently
so
as
in
schizophrenia and in the most
various degrees of connection
Apmove-
with the conscious ego.^^

parently
insignificant
ments such as lifting the arms,

assuming the position of the
Fig. 34.
Grimmacing
crucified, screaming, then real
catatonic.
"actions"
as
win-
breaking
dows, tearing clothes, smearing, often take place without the conscious
To be sure, occasionally it goes as far as arson,

murder, or suicide; some of these serious anti-social actions are per-
will of the patient.
formed so clumsily that one gets the impression that an inner
resist-
ance prevents the actual attainment of the purpose.
Automatic impulses
may
also change a
complicated piece of knitting
is
made
normal willed
action, e.g. a
incorrectly against the will of
who knows the pattern well.

Automatisms of speech lead only rarely
the patient
in schizophrenia to
com-
bined utterances; instead they sometimes produce incomprehensible
hodge podge.
Verbigeration
may
also be classed with these as generally
the greater part of the stereotypes
run
off
automatically.
often has the distinct character of compulsion.
"Comp.
p. 150.
Coprolalia
409
There is also a schizophrenic

compulsive thinking, a compulsive
remembering, even a compulsive
Among
cessation of thought.
laughter
is
especially
the
compulsive
disturbances
affective
frequent;
it
rarely has the character of the hysterical laughing
mimic
soulless
but that of a
fit,
behind
utterance
which no feeling is noticeable. It

may often be provoked by allusion
Sometimes the pato a complex.
movements of
("the drawn
tients feel only the
the
facile
muscles
laughter").
Contrasted with hysterics and

compulsive
neurotic
usually
schizophrenics
patients,
give
little
thought to their automatisms. It

simply happens, they cannot help
and with that they are satisfied.

sure, some struggle against
it and feel the obsession, and still
more believe themselves possessed
and infiuenced by their persecutors.
In the latter case they not rarely
adopt defensive measures to prevent themselves from carrying
it,
To be
them
wood
sticking a piece of
out, e.g.
into the
mouth
to prevent the
utterance of unseemly words.
The automatisms
ceived
as
actions
the
scious;
complexes
the
uncon-
on
which
they are based can be often demonstrated in the analysis of accessible patients.
9.
35.
Manic
schizophrenic
made
herself a
and twigs and
besides holds with both hands the
lower part of her dress which has been
wreath
are to be con-
of
Fig.
woman who
out.
has
of
grass
twisted into the shape of a sausage.

In bed she holds in front of herself
the linen twisted in the same way.
Interest in the process of photography
conceals the otherwise rigid facial expression.
Impulsiveness. Schizophrenic
impulsiveness
is
ifestation of the
Some
not a uniform
symptom but
a frequent
morbid actions which originates
method of man-
in different sources.
of the impulsive actions are automatic, others are aft'ective
actions, "unloading" in the case of
an emotional tension
in
which the
410
more and more uncomfortable. Something must then

way; they scold or fight or tear up only to quiet down after
minutes or days. With this may also be included the ''explosion in
prisons" observed in latent schizophrenics. In the same way the sudpatients feel
give
den outburst of rage, which is frequent in schizophrenia, leads to impulsive acts. Many sudden acts are based on the disturbance of association; it is a case of unmotivated notions which are carried out'
without resistance.
The course of schizophrenia is frequently in({}) Acute Syndromes.
appearances
terrupted by acute
of entirely different manifestation and
To
origin.
with
these belong:
Shifts of the pathologic process, frequently
catatonic-hallucinatory
or
stuporous
manifestations;
simpler
exacerbations of the chronic condition, mostly with paranoid or catatonic syndromes,
abnormal reactions to emotionally toned experiences,
especially in the form of hysterical twilight states or attacks of scold-
part of the manic or melancholic displacements of mood are

probably by-products of the morbid process. Then also there are
ing.
naturally conditions that do not depend at
on the disease
perhaps
it, as
periodic
but complicate it
moodiness which may belong to an accompanying manic-depressive
The acute appearances may last hours or years. Severer
insanity.
forms also, that give the impression of independent psychoses, may
all
directly
or at the most are released by
break out suddenly, one might say from one minute to the next. An
exacerbation of the schizophrenic process favors the appearance of
psychogenic symptoms; thus the manifestations combine indiscriminately.
Melancholic and manic states often constitute the first manifest

syndrome of the disease, but they may also supervene later. They
usually last months or years and appear as a combination of the melancholy, or
it
may
be a manic triad with schizophrenic symptoms.
The depressive
anxiety, but
it
affect
appears
in this
rigid,
and
case
is
frequently combined with
superficial, the utterances being ex-
aggerated and often pathetic; the delusions strike one as altogether

too senseless.
Occasionally one finds a combination of senseless de-
lusions of grandeur with the depressive delusion.

The disturbance of
thinking is very ex-treme and may lead to an absolute monideaism,
which probably does not occur in simple melancholias.

The manic states are similarly characterized. The fresh joyousness
of the manic is lacking; outbursts of rage often appear completely
The rigidity of the affects is particularly noticeable in

With the flight of ideas one observes dilapidation, and
schizophrenic associations. The manic pressure activity
unmotivated.
this case.
bizarre

411
readily becomes an incomprehensible pressure motion; silly tricks
may
Hallucinations and delusions are

But the delusions are usually more flighty than in
be added to the peculiar actions.

generally present.
the depressive states.
Of
special importance are the acute catatonic pictures in
catatonic
symptoms mingle
In akinetic
indiscriminately.
which
forms of
move little or not

they do not take care of themselves, let the saliva dribble out^
never swallow spontaneously, and soil themselves. Peculiar poses are
attonity, of stupor, of flexibilitas cerea, the patients
at all
sometimes retained for a long time. Usually complete mutism exists.

conditions are now and then amenable to temporary psychical
influence so that an act may be performed or an answer given. Mutistic
patients at times make themselves understood in writing.
Often this
is accompanied by a coated tongue and fuligo.
Vasomotor symptoms
most frequently and severely, complicate just this picture.
In the pronounced hyperkinetic forms the patients are in motion
But such
day and night:
They climb around, turn somersaults, hop over the beds, knock
twenty times on the table, then on the wall, balance themselves, bend
their knees, throw themselves into the air, strike, destroy, force the
arms in the most twisted position possible between the radiators of
the heating apparatus, and they are unmindful of burns they scream,
;
sing, verbigerate, scold, laugh, cry, spit,
cheerful; they take
at
all,
lay
movements,
it
down
any object
make
faces, sad, terrible, or
move it in any way

and make a thousand other
into their hands,
in another position
of which, to be sure, the individual patient usually limits
The movements
are always somewhat

an object, they do it in a particular
way as it is not ordinarily done; they climb into bed from the head
end and with most unusual acrobatic flourishes or they let themselves
fall into it, etc.
The movements are often made with great strength,
nearly always with the exertion of unnecessary muscle groups; indifference to themselves sometimes appears as great as that toward the
animate and inanimate enviroment. Many patients are also always
in motion but it is slower, more clam-like, and more dream-like.
The
akinesis may be interrupted by sudden catatonic raptus, in which the
patients do some kind of harm, from the breaking of a pane of glass
to a brutal attempt at murder or suicide. Analgesia often increases
the danger and indifference of these patients, to themselves and others.
himself to a certain number.
abnormal.
If the patients lift
In severe catatonias the psychic state is usually altogether unclear.

give no account of themselves or even lie in a complete dreamOften there
world. The affectivity is usually difficult to make out.
Many
412
are indications of various contradictory feelings but none seem to pene-
Subjectively also no describable
trate.
mood
exists except a frequent
indifference.
The buffoonery syndrome
not always easily separated from cata-
is
In this syndrome the entire picture is taken up with

tonic states.
playing demonstrative striking tricks, and with giving wrong answers;
like the
Ganser twilight state it probably only occurs as a reaction to a

from which unconsciously one wants to escape through
situation
insanity.
in
If
to
the
an acute appearance hallucinations and delusions prevail
extent
symptoms
of
fully
phrenic insanity.
Here the
the preceding group.

is
disturbing
clearness,
are absent or insignificant,

affectivity
The mood
we
is
call
and
if
the
catatonic
the condition schizo-
usually less injured than in
frequently has definite coloring and
often slightly modifiable.
In the face of unbearable situations, most frequently in disappointed love, schizophrenics retreat into a
pleasant reality
is
split off
and
exists for
twilight state; the un-
them only secondarily;
place another world, frequently with frank wish gratification,
The
ined.
is
in its
imag-
patient marries her lover, he visits her every night, she
becomes pregnant and bears a child. But not nearly all of these
patients are happy. They cannot flee entirely from reality and, consequently,
most
come
into conflict with
intensively,
it
outwardly.
and the imagined happiness
Shutting
is
off
succeeds
therefore least dis-
turbed in the religious ecstasies.^^
The behavior of those in the twilight state varies. Some live their
dream quietly in bed or even under the covers. Others stalk about
an unintelligent manner, as they have a false conception
environment and hence get into conflicts. Invariably double
orientation plainly exists. The outcome is usually by lysis. While
like ghosts in
of the
the twilight states in hysteria or epilepsy usually last only hours or

days, the schizophrenic sometimes extend over months, under certain
conditions into the second year.
much more
Nevertheless, corresponding to their
rarely leave behind a serious
aggravation
origin,
they
of the
permanent condition than do other acute syndromes of the
schizophrenia.
In prisoners held
for examination,
but occasionally
in
other cases, the condition manifests some signs of Ganser's syndrome.
While the twilight

is
states are
formed on psychic foundation, there
a form of "unclearness" which has an organic character and has
bad prognosis. The patients

do not let themselves be aroused
to be noticed because of its particularly
are in an unclear twilight state, they
^See
p. 113.

by psychical
influences, in spite of the fact that one
contact with them, and they often
The
questions.
These patients
willingly
make
contaminations,
of orientation
preserved.
make every
is in
effort to
413
intellectual
answer our
train of thought
is slow, unclear and fragmentar>\

simple calculations; in writing they unorthographic and grammatical errors, contractions,
fail
even
etc.: at
may
in
same time hallucinations and disturbances
the
be lacking.
Affectivity also
Nevertheless the condition
is
very
may
be relatively well
difficult to distinguish
from the more psychogenetic forms.

We still have to mention states of confusion in which the incoherence of the train of ideas dominates the whole picture, and where one
observes exogenous and endogenous attacks of rage, delirious syndromes, and states of wandering (fugues), at times as a result of a
special brain disturbance, at times more of an hysterical nature or as
a reaction against unpleasant experiences or merely as a pathological
fancy.
derers.
considerable part of army deserters are schizophrenic wanDipsomanic moodiness may also appear occasionally on a
foundation of schizophrenia.
The
D.
Subdivisions
Although schizophrenia
is
probably not a homogeneous disease,
are not yet able to divide
it
into natural subdivisions.
we
Nevertheless
order to orient oneself in the external forms of the constantly

changing morbid picture, four forms have been distinguished, according to the presence or absence of definite symptom groups. They are
not nosological units and from patient to patient and in the same
in
patient pass over into one another, so that a schizophrenic
may
be
admitted into the asylum, e.g. as a hebephrenic, may remain there

for years as a catatonic and may finally be released as paranoid.
But
most patients remain permanently within their group.
Where
1.
delusions and hallucinations
go together in schizophrenia
are
the two
symptoms usually
in the foreground, one speaks of the
paranoid type or dementia paranoides.^* The paranoid type can develop after any melancholic, manic, catatonic acute initial onset (''secondary insanity" of the older authors), or can begin immediately as
such. In the latter case the entire course is as a rule chronic throughout.
During a stage of discomfort in which ideas of reference gradmore definite, there develops in the course of years a
ually become
**The
mean
all
quickly
attitude.
up to the eighth edition of Kraepelins manual, does not

paranoid forms of dementia praecox but a particular sub-group which
forms confused delusions but no catatonic changes of the external
latter term,
414
complicated pile of delusions, which are only connected by the general

tendency of persecution or (much more rarely) of grandeur or of
hypochondria. However, the beginning may also manifest itself by
finished primordial delusions that seem to come from a clear sky,
which then increase and are only later followed by distinct ideas of
reference and hallucinations. Many of the patients keep out of
asylums for a relatively long time, others alternate between freedom
and commitment, and others again lose the external control so early
and so severely that they have to remain in asylums the greater part
Especially in the last, single or even many catatonic
of their lives.
symptoms very
easily complicate the picture.
To this class belong some of the litigious schizophrenics who de-;

mand police protection against imagined injuries, and in spite of all
refusals cannot cease with their complaints.
Others may be classed
as cases of simple schizophrenia because their attitude seems to rest
more on the determination
Some
to be always right than on a real delusion.
of the cases mentioned
by Kraepelin among the presenile
delusions of injury are according to our conceptions belated paranoid
forms.
Paranoid.
Railroad employee.
Medium
intelligence.
At
first
worker where he rose to train conductor. Always particular, silent. Toward the end of the thirties he began to
be mistrustful toward his wife. At the same time a better position
with the owner of a factory who was a free-mason was offered him by
intimation from a workingman who was very "sympathetic" toward
him; finally other positions right in the lodge were also offered him.
Years ago he was supposed to have seen a free-mason in a compromising situation (in reality a woman had merely entered a railroad compartment after him) some allusions were supposed to be made to it
in the newspapers.
But he had kept quiet about it and now the freemasons want to reward him for it. Because he did not accept the
reward, they persecute him. Furthermore years ago he once made
unfavorable remarks about the free-masons. All sorts of things are
said to him on the street in passing; remarks are also made elsewhere
which he only understands later. At night he hears voices. In a
spinner, then railroad
mysterious way his thoughts are read. The free-masons are after
women; they use his wife also. He demanded from her with threats
the money that she had obtained in that way; once he wanted to cut
open her stomach with a razor. His sister-in-law is sometimes pale

and sometimes red; that is on his account. Theatricals and thoughts
are made for him while awake and especially while dreaming. During
the night he is questioned; only in the course of the day does this come
415
Because he maltreated his wife and did not

into his consciousness.
work any more, he was brought into the hospital. There he showed
the same picture for years, at time quiet and capable of work, at times
in milder excitations
persecutions.
with scolding and incessant complaining about
All sorts of poisons arc put into his food; he feels
them
body; they want to murder him; especially at night,

sperma, human blood, urine, "pollen," and horse manure are put into
his body in various ways; one spits into his mouth; one hypnotizes
and magnetizes him, and brings him into a "latent" state where one
working
in his
cannot breathe.
with this they
The people here have a staff like

make him powerless, rob him of his
want to castrate him, extract
his semen, cut
urethra, distend the sexual canal, cut
sexual organs, and pinch
him
all
up
up
magnet
potency.
staff;
They
smash his
up the inner
his lungs,
his buttons,
over his body.
bum
Voices threaten to
against his will, his daughter has been admitted

masons; he is accused of having used her in various positions;
the government, the church, the whole international society, his wife
and his own mother and the physician are combined with the freemasons; the physicians have obtained millions to hold him in the
asylum; he, himself demands 30,000 fr. damages per day for the confinement and he figures up everything exactly. He keeps a record of
all the hallucinatory maltreatments; they demand that he become a
free-mason; he does not want to and therefore they persecute him.
At other times he wants to become a free-mason but then they will
not admit him at all. For a long time he said in a stereotype manner
to everybody a hundred times a day, "If you please," by which he
meant to say on the one hand nothing, and on the other, he put various
interpretations into it.
He should be admitted to the free-masons or
he should be permitted to have intercourse, etc. When he sees a
woman, he is compelled to prove his potency; then he can join the
masons. Then he can only be prevented by force from undressing
himself. He wants to enter an a\aation race from Petersburg to jMoscow, he invents flying machines, improves trolley cars, makes countless contributions to the physicians and officers of the hospital.
Once
he tore away a toe nail because the scissors were not good enough to
cut it off. For a large part of the time the patient is in the quiet
ward. He shakes hands with visitors in a friendly way, even though
often with a slight, superior smile.
Schizophrenic Litigious Woman. Excellent worker in a hat business.
Was a good pupil but wanted to get somewhat higher up in
the world; as a farm girl she attended a vocational school for women
to learn finer work. Then she had various places as cook and housecut out his eyes;
to the
416
maid; at thirty-two she was housekeeper for a doctor who was just
Now she affirms that on the very first day
establishing a practice.
he became intimate with her and promised to marry her. The further
His relatives
details are still more improbable or entirely impossible.
wanted to prevent him from marrying her. He should make an arrangement with her. On the first day he told her she had the right
(These can be only memory deceptions.)
to object if he married.
She would have to make good her claim or be silent. After about nine
months the physician discharged

the people were talking too
worked
her, according to her version, because
much about
in different places, at last
their relations.
She then
mostly with a hatter and from time
to time reminded the physician of his promise.
When
thirty-four
years old she once had a headache, pains in the eyes, an "attack like
a stroke," trembling
cian
all
who was supposed
over the body.
She was treated by the physi-
to have renewed his promise.
When
she read the announcement of the physician's marriage.
thirty-six
Then
she
good payment" and took a position in his

neighborhood. He was supposed to have had a simple wedding to
indicate that he really loved the patient. Then she wrote to him
frequently, called him names and then also preferably his wife, at
"Jail-bird," "shabby hotel frequenter," "whore,"
last on post-cards.
"Mrs. Louse," are among the better expressions. She became unreliable in her work and even when she made big mistakes she claimed
Then she began suits in all the courts which naturally
to be right.
could not entertain a complaint without evidence of probability, when
it concerned entirely abstruse demands.
The courts were then vilified:
"His Honor the Judge is idiotic." Finally the physician was compelled to sue for slander whereupon the patient was examined. During the examination she was absolutely incapable of discussing her
complaints. She was not fully certain of the time sequence of all her
experiences but otherwise she had a good memory and good orientation.
She recounted impossible assertions of the physicians and the judges,
who had said she was right (memory deceptions). She really did not
want anything from the physician "she only wanted the physician's
wife to have a chance to get away with an honorable reputation."
Since the physician did not answer, he admitted her claims. Either
he had to do that publicly and send his wife away, or he had to dispute
it and keep his wife."
She stoutly maintained that as long as he
made none of these declarations, his marriage was void and his wife
was a concubine. The doctor had made her (the patient) a promise
of marriage that held for life; with the other he was only engaged.
She was incapable of seeing that the doctor's wife was entirely inno-
demanded "her
rights or a

cent toward her.
her
affair,
Presented at a
clinic she
417
began at once to talk about
taking for granted that the auditor
knew
everything.
Of
course she had to be pronounced irresponsible; she was placed under
But she did not want to accept the verpay the trial costs which led to a number of scenes with much
noise and spitting at the marshal, etc.
She scolded us too in various
Nevertheless she was not brought in for four years until
missives.
a guardianship and released.
dict or
she forced her
way
into the police station,
being thrown out, continued
it
made
a big scene and, after
with increased energy.
It
was reported
that she had worked regularly and had spoken sensibly about indifferent matters.
But
as soon as she touched on her affair, she
confused, excited and hard to understand.
became
She did not want to work
was put to bed and ordered to cease her written litigations.

There she pulled herself together and after a stay of six months could
again be discharged. But in the following year she came back because she had made a scene before the justice of the peace and promised she would do it every day until the doctor was summoned to court.
This time with us she did not cease her protesting, made a lot of noise,
ran after the physician in her shirt in order to scold him. She was
taken out by the poor relief society, which should long ago have taken
charge of the impoverished invalid, and as yet she has not returned.
Her last greeting was: "Sow dogs, sons of bitches, alienists send me
my clothes to X. St. ... promise of marriage belongs in the courts.
I will reproach the poor relief society until the matter is brought to
court."
Hallucinations were not observed, on the other hand many
illusions, perhaps also memory hallucinations.
She also told many
things about us that we had never done; e.g. that the physician in
charge of the division had said that she did not belong in an insane
asylum. The schizophrenia shows itself, among other things, by the
until she
confused nonsense of her representations in court, the absolute incapacity for discussion and also, by the decline of the strength to
work, and by the occasional incapacity for discussion even in her

All this counts all the more because she was formerly intelligent.
2. If catatonic symptoms are permanently in the foreground the
work.
picture
is
called catatonia.
large part of these forms begins with an
acute attack; under certain conditions the psychosis
one
moment
to another,
some catatonic
is
revealed from
other cases begin with a chronic attack, with

mutism or mannerisms, and remain
and acute conditions alternate. Fol-
peculiarities, e.g.,
chronic, while in others chronic
lowing acute catatonic attacks a tolerable condition

the cases that begin furtively
all
may
again recur;
have a bad prognosis without any
remissions that are worth mentioning.
418
Catatonic State. Nineteen years old. At first a bar-keeper; then

he worked in many different places; at last in a dye factory. In spite
of the fact that he was a Catholic, he had recently joined the Salvation Army.
He came into a meeting in shabby, dirty clothes. He
began to pray but very incoherently.
He had
learned something
wonderful; Noah's ark was coming; he was compelled to speak.
was
Then he
It
had previously run

In the factory he had refused to touch any other
after the sun.
colored silk but white. Some days later he came to a musical rehearsal and began suddenly to read a psalm. He was requested to
be silent. Suddenly he stood up, stood in front of the others and
"Do you believe that the devil is
said with a staring expression:
tied? Do you believe that the devil is tied? He is tied; he is tied."
He repeated the last words several times, becoming louder each time.
When he saw that the others did not join in, he exclaimed: "You are
enslaved; tomorrow I will go into the heart of the city and begin
to pray." Then he became quiet again. The following day he did
not come to dinner and began to pray in his room with a roaring
voice.
At night he went to a friend's room, stood there rigid in a
difficult to silence
him.
peculiarly twisted pose, the one
held over the head, and
made
arm
stiff,
told that he
stretched out straight, the other
peculiar face.
Then he suddenly
memorandum book. When the latter

refused, he called him Judas.
Had he come to betray Christ with a
kiss? He tried with all his might to kiss him.
He then got down
wanted to write
in the friend's
on his knees and began to pray in a dreadfully loud voice. Getting

said:
"Now all is over," and had a normal expression
but immediately continued that he was crucified, he had been called
for something special, he was Christ.
He told that when he was in
bed a spirit had come from above and another from below, and a great
power had come over him. He demanded that all present eat of his
Then they would understand him. When brought to the
bread.
clinic, he quieted down quickly, became half aware of the impropriety of his conduct and thinking, but remained indifferent, did not
want to leave the asylum, and had to be transferred to another.
Depressive Catatonia. Continuous hearing of voices. Teacher,
who had previously seemed quite normal. At thirty-four for the
first time he was irritated and sleepless, and occasionally had dizzy
spells for a year; then there was a delirious stage.
After a stay of
twenty-eight weeks in a sanitorium he was "cured" After a year
and a half he had a similar attack. Then he was once more a good
teacher, felt well and cheerful. During a trip to Tyrol with friends
when forty years old he felt that his ideas were getting hazy, he could
up suddenly he
419
not speak any longer, and again entered the sanatorium.
Here he
most of the time and believed they wanted to bury
alive.
He had many hallucinations of hearing. He believed his
dreams were real experiences, ate poorly, vomited. After a temporary
improvement in the fifth month he wanted to go through the window,
and reproached himself; at the command of the voices he threw his
wedding ring out of the window, whereupon he was taken to the clinic.
Here he lay m bed in a deep stupor, maintaining a peculiar position.
He saw pictures on the wall, children and women, who were kissing;
but most of all he heard voices and felt that something was being
done to his body. He had threads about his hand, especially on the
ring finger, that drew together.
His penis was being operated on
'so that the indecent sensations would disappear."
The voices tell him
that he had denied his God and had perpetrated a lust murder. "Lust
murder is sexual desire." He is not a human being; he is decapitated.
Depressed but rigid expression. Catatonic raptures; jumps up suddenly, breaks a window, etc. After eight months' duration of the
attack there was a sudden reversal to a euphoric mood and orderly
conduct: he spoke and wrote of his gratitude to his creator and the
physicians, of how he was drawn to his home, how unutterably glad
he was to stand again in the school room, a disciple of Pestalozzi, of
the bursting energy of youth, and the plans of a returned spring tide,
But he did nothing to get out. Eleven months after the beginetc.
ning of the attack he was discharged, took up his school work and for
six years always remained euphoric and apparently a good teacher.
Since then a similar attack, lasting only three months; then he returned to his former state. The voices warn him in school when he
want to say something silly. Thus, objectively and subjectively, he
was
him
in a stupor
gets along well.
Unmarried woman, a chambermaid from a

much. Twent^'-nine years
old.
After her mother's death she suffered from over-exertion and
money losses. She believed falsely that a cousin wanted to marry
her and always waited for him. After several months, manic excitations occurred which increased during eight days. She sang in an unseemly way, wrote a note to the effect that her brother-in-law should
not bother her all night. Violent. She said she had to die all the
time and was not being buried. She believed all men wanted to do
her violence. Following moods of marked excitement, she cried. In
the reception ward of the clinic she lay down on the floor and de-
Manic Catatonic.
psychopathic family.
Intelligent, has read
scribed a beautiful vision (ecstasy).

self to
Nevertheless she permitted her-
be diverted, and then she became completely oriented,
felt
420
very happy, declaimed that she had faith, which would help her withstand all trials, etc. She spoke in the same tone of the fact that she
wanted
to die; in the bath she tried to dive under the water.
Then
again for some time she remained rigid, the arms stretched upward,
with a tense facial expression. When touched she jumped up enraged,
stuck out her tongue,
etc.
pronounced
At times the
flight of ideas.
schizophrenic element could not be recognized in the manic; then
again pathetic expressions that were repeated endlessly. The nurse

brother, at others her sister and at the same time
was sometimes her
She was most quiet when
a third person.
Tore up a great
isolated.
Indications of negativism; did not shake hands with the physi-
deal.
him her cup that he should hold it. For a time she
climbed about on the edge of the bed with a tense face and tightly
pressed lips (she later maintained she had to play the part of a
monkey). In the room she ran around in a circle, waved her hands
cian but handed
to keep time.
She has been made insane by powders; she was being
After a while she quieted down; after six months she

could be discharged, and by outsiders was considered cured. After
another six months she returned in a similar condition. Now she be-
electrocuted.
came rapidly demented.

ible,
Though
she remained euphoric but irrespons-
she breaks windows, tears things, fights, turns somersaults, hears
many
voices,
task.
If
and becomes
less
and
one has voices, one calls
one should "stirk," that
is,
less
it
capable of doing the simplest
"Stirking."
The
voices say that
one should "rattle" the windows.
Catatonia with Religious Delusions.
farm hand, twenty-one
years old; came to the asylum because he had assaulted the minister of
his village, as he declared because the minister
had designated
his
own
son as "Messiah," while the patient had in the last few years "undergone the Messiah's suffering" and now wanted to be the real Messiah.
The
patient had been a quiet, not unintelligent boy.
few years
previously he had become pious, went often to the minister and re-
had told, in writing and orally, of visions (angels, Messiah, and

Once he demanded urgently that the minister change his
In the asylum he at
(patient's) name, that is, take him as his son.
first spoke much of the minister and his family, but chiefly in another
sense; even since his school days he had been in love with the minisThe angel materializations have the features of his
ter's daughter.
cently
God).
daughter.
The God
materializations resembled in part the minister,
in part the patient's grandfather.
sexual intercourse with several
daughters and also with his wife.

the daughter.
Once the voice
As Messiah he had the
women and
with
all
right of
the minister's
Once he saw himself married to
of one of the daughters called:
"Oh,
421
me with a kiss from his mouth." Later he hallucinated the daughters as being successively in his bed and having intercourse with them, wherein he experienced heavenly raptures. Occathat he would kiss
sionally he
was
also "Priest
minister's daughters.
But
King" which
he
felt
signified possessor of the
the minister's resistance
more and
He
thought the latter wanted to leave him only his wife, and
himself beget a Messiah with the daughters, so that the Messiahnic
dignity would remain in his family.
In materiahzation he saw the
more.
Fig. 36. Chronic catatonic women.

Both react to the taking of the picture
with a sidelong glance. The patient at the left has a pronouncedly compressed
mouth. The one crouching at the right half closes her eyes. The entire picture
(aside from the attention to the picture taking) is one of continuous repose.
minister's daughters pregnant.
the minister.
and
strike the minister, "because he
ters."
voice told
him he should assault
Finally he was impelled by the spirit to take a club
would not
let
him have
In this connection his arms raised automatically.
(or always?) the
morbid
religious aspirations are a
his
daugh-
As
usual
symbol of sexual
strivings.
In addition another complex was satisfied:
Tuberculosis
raged in the family and the patient himself suffered from lung trouble
the penetration of the spirit within his breast at times made him well.
;
422
The
patient very quickly
phantasies, stood
mute
wove himself
into his sexual religious
for several years in peculiar positions
and
died five years later of tuberculosis.
Catatonic after Castration. Wife of a physician. From a family

of high standing but somewhat peculiar. At nineteen a fall from a
"Traumatic hysteria" of short duration. Engaged at twentystair.
two, while taking a walk she wanted to
jump
into the water because
During her
first pregnancy often

apparent
cause. Always
bowel
trouble
without
Bladder
and
depressed.
cheerful,
little
afraid
of
housework,
but
was
a
excited
particular,
"hysterical
twenty-eight
ovary
trouble,"
later
when contradicted. At
degeneration
bilateral
cystic
with
a
normal
because
of
ovariotomy
recovery. At home after eight days she acted as usual. Then went
She
to a resort to recuperate from which she returned depressed:
and
mother,
she
real
woman
was
perjurer,
could no longer be a
a
justice was pursuing her, she saw and heard the district attorney, etc.
Attempts at suicide. Then stupor, mutism, refusal of nourishment;
of a
little
discussion with her fiance.
at intervals there are times
months she
came
when
she speaks normally.
After several
to the asylum: mutistic but going about excited; at
times she took the physician to be her husband, at times for the
asylum physician. She heard her mother and children in the corridor.
Rigid position for days, staring into the distance, mutistic. Between
times excited, strove to get out of bed to the window or the washRefusal of nourishment. Sees a horse's hoof. After a few
stand.
days suddenly pleasant, clear concerning the environment, sensible conFrom now on continuous
versation but often sudden obstructions.
change of condition: sometimes quietly inhibited, at others excited;
She wants to write
also clearer moments with conversation and music.
beginning.
sometimes
does
not
beyond
the
Expresses
sometimes
but
get
love, sometimes hate for the physician, both with a strong sexual element. Often retention of urine to the extent of catheterization. Frequent refusal of nourishment. Always many voices; her husband's
head has been knocked off; she is at the North Pole; especially frequent
is the idea, "I have been robbed; everything has been taken away from
me, my money, my name." She feels a key in the genitals, wants to
take the keys from the nurses. Her husband is married to the nurse.
Then for several months incessant change between timid agitation
with frequent violence, hits and bites, mild stupors. Scratches her face
and feet. Special agitation on the anniversary of her marriage and
on the anniversary of her last attempt at suicide. Later negativism,
marked shrewishness, rigid face, uncertain walking, back and forth,
usually without any purpose, then again times with verbigeration:

423
now" or "no, no" or "dc, dc, de." After sixteen months

was discharged at first to a physician, then home. There she was
very changeable, at times cheerful and apparently normal, then for
hours verbigerating while walking up and down stairs; ran to the street,
"he, he, he,
she
spoke to strange children as her own, then for days excited, violent.
In the meantime at the table she can be the hostess to perfection.
Sometimes unclean. After nine months she returned to the asylum
where for years she has been very dissociated. Her mood is usually
She is married to the doctors and

Goes through countless confinements.
elevated but rigid.
men
of station.
all
the other
The
nurses
are at times her daughters, at times the wives of her husband,
and
She prepares for her engagements to be

married, in that she paints her eyelids and brows with shoe-blacking.
She dresses her hair peculiarly. She has an engagement to sing
Mignon. At other times she is continually under the bed-clothes.
should, therefore, be beaten.
Memory
deceptions: The nurse once had an affair with her husband.

Patient has once been proclaimed queen of Switzerland at Basle. Fre-
quent mistaking of persons. After a while she became incapable of

any work; nevertheless at intervals she still has good days when she
occupies herself somewhat. Psychologically it is interesting that she
always was peculiar. Her husband was ambivalent to her. (Attempt
at suicide while taking her first walk with him.
Depressions when
her
first child
other wives.
was born. Later her husband has been beheaded, has

She has other husbands. When visiting she is hostile
toward him, when staying at home she

teroid troubles of the ovaries after the
is
fall,
usually very kind.)
Hys-
and
After
after the births.
was an aggravation clearly connected with the

no longer a woman, no longer a mother. She has
been robbed of everything, of the keys also, which are the symbol
of the power of the house-wife but at the same time evidently of the
genital of the man and of the man himself. The nurses have robbed
her of the key and they have robbed her of her husband; these are
identical for her.
Then we observe the compensations: She marries
the most distinguished men; she bears countless children, becomes
young again as Mignon, becomes queen of Switzerland. Excitements
the castration there

mutilation; she
is
during commemoration days.
Catatonia with a Cycle of
Two Days.
Intelligent girl, but always
reserved, after puberty to a striking degree, in spite of a cheerful dis-
At twenty-four an apparently happy marriage with a very

man; but she herself was stubborn and irritated. At the birth
position.
patient
of the third child, being thirty-eight years old, a melancholic condition
with ideas of sin
she had not taken care of the child.
At forty-seven
424
first few days there was no reaction.

two weeks in which she remained practically motionless, then changed into melancholia with unclear, fragmentary ideas of sin, she was being punished; heard many voices; very
she lost her husband; for the
Then
a stuporous condition for
rigid expression; at intervals cataleptic; then attacks of fear with noise
and a
About a year
away.
striving to get
later the patient begins to
alternate regularly with days on which she
negativistically rigid
is
and stubborn and others on which she is relatively approachable and

For a long time there was
pleasant, sits at the table and pulls silk.
a three day cycle instead of a two day, there was one depressivestuporous day, one irritable day, and one euphoric. Otherwise the
two day cycle has lasted twelve years. Besides there is a negativism,
varying in degree with different persons. She tries to shake hands
but withdraws again; she is erotically jealous when others are greeted
pleasantly; she
is
brief associations.
married to the physicians in the asylum. VeryAn attempt to take her home had to be given up
on the second (irritable) day.

Catatonia with Rapid Dementia. Teacher. The mother was temporarily and is now again in an asylum; in the interval latent schizophrenia for about twenty years. The patient was always somewhat
peculiar; at school uneven; many pranks; kept to himself very much.
Busied himself with different problems, such as socialism, and Schiller's
Robbers. Was apprenticed to store-keeper but did not stay long.
Then worked in various places. Once for nine months in a business
school, then he went to a high school. Once went suddenly to Berlin
where he stayed a month without doing anything. Then he entered a
normal school in another canton, where he managed to stay for the
At first he was a teacher in a
final examination (age twenty -two).
private institute, then in a primary school which he had to leave because the pupils did not learn anything and "had nose-bleed if he
merely touched them." Then he wandered about Ziirich and was
arrested and brought to the clinic because he broke into a tramway
station to sleep there, although all his brothers lived in the neighbor-
hood.
At
first
he was entirely indifferent, then
much
excited.
Pre-
sented at the chnic he came in laughing loudly with his hand to his
nose.
During the
recital of a story he
saw on the table the story
of
the "Miser's Piece," and then wove a disconnected word mixture with
the word "Miser."
When
heavily into a chair,
sits
coaxed he becomes quiet,

there disinterested.
lets
himself drop
Then he rocks on the
remains rigid and stares in front of

When
a lot of noise, sits down.
"That is so." At the mention
I described his conduct he remarked:
chair, smiles to himself, suddenly
himself.
Then he
gets up,
makes

word mixtures he added, "It is an
thing in the room is worms. I am the
of
Italian
ox-mouth
425
The only
dish.
("Where
director of the seminar.
I am
are we?") In an evolving hemisphere. C'est monsieur Jardin.
and
stamps
plassus."
Stands
up
palandes
versus
a patient. That is a
hard on the platform, screams in an oratorical tone: "Oh, my dear
Blapsen, you are my dearest Klapsen." He must go away he walks
away singing quietly, "One has left." Hops down from the platform,
makes a lot of faces, lies on the floor, permits himself to be shoved
and smiles blandly. After this he remains mostly quiet, and mute;
;
all sorts of positions,
he stays in
partly in bed, partly up.
Makes
all
then he
Once he
and prattled absolutely disconnected nonsense. To a
Once he fell down sudvisiting schoolmate he never said a word.
Then
flexibilitas cerea.
time;
denly and lay there quite rigid for some
word
incomprehensible
speeches
of
again he made extremely affected
verbisometimes
salad. After a while he became quieter, sat around,
gerating.
For a long time he asked the visiting physician the stereo"Isn't Aunt Grite coming yet?" To the aunt he wrote
type question
urinated in front of the toilet-door;
sorts of faces.
made a
noise
Today,
-
To
in the seventh
of July, 1914.
our dear Aunt Grite
from
Hans Jacob and Max.

Dear Kind Aunt Schiifeli:
hope you no longer have to work so hard for the capitalists in St.
I still hope to find in the
wiedikon, a position as upper
socialistic centre of the world in Ziirich
grade teacher for Italian children although I was brought here against
my will per (police automobile) "by the watch dog of clericalism for
the Zurich ministers (K)" and here I have to perform work of not
I
Gall; because here in Burgholzli (hospital)
the least use; although
it
known
is
that I
am
a licensed practicing
teacher of the Swiss Confederation.
Brother Hans has helped
me
in
forming the sentences of this
letter
you are aware a very faithful abstinent resembling you

personally and individually more than I.
as he
is
as
Signaturely I can only then excuse
which
my own
love of nature
was
it
as I got here in a milieu, in
violently stolen only with technical
means and in contradiction to the laws of the milieu. So

long as I don't get the power over these "accursted" laws and conditions (As Hans calls them) I can accept them only hypothetic ally as
devilish
technical-devilism."
426
Chronic Catatonia.
good house-wife of retiring disposition,

speak less and less and in the
course of a few months ceases to speak altogether. Notwithstanding
this she takes care of her housework ver\'^ properly for another year.
Then other difficulties appear: she becomes irritated, untidy; negativism prevents her from doing just what she should do, or she does it
wrong. In the hospital she at first works very decently, keeping silent,
but loses more and more weight, becomes more negativistic, unclean,
tears things up, begins to fight and after about three years sinks into
a state of stolid negativism so that she remains only an object of care,
and rather difficult care at that. Among other things she had taken on
some mannerisms, had some hallucinatory excitements in which she
marked by few
peculiarities, begins to
scolded loudly.
3.
Schizophrenics with accessory syrrvptoms of different kinds and
varying strength have retained the old name Hebephrenia, although

it
no longer
fits
the present conception.
The Kahlbaum-Hecker Hebephrenia was

relatively quickly at the time of puberty
various affective disturbances,
e.g. it
a dementia which began
usually ran
its course with

began with a manic attack, and
;
it
was supposed, was further characterized by the symptoms

is affectation, pathetic expressions and mimicry,
boyish pranks on the one side, affectation of mature wisdom
besides, as
of callow youth, that

delight in
and the desire to be occupied with the highest problems on the
But we can
ties
also find these
that break out
symptoms
late, if their
other.
in schizophrenias of other varie-
complexes signify an attempt at
self-
elevation and being great.
In the present conception of hebephrenia the age of the onset
is
unimportant, even though most of the cases become sick during and
soon after puberty. It now constitutes the big trough into which are
thrown the forms that cannot be classed with the other three forms.
Hebephrenia with Manic and Depressive Attacks. She had lost her
mother early and was brought up in an institution where she remained
as an attendant. Always retiring and rather particular but with pleasant manners. At thirty-six, when the father had to be taken care of,
she reproached herself for not doing enough for him and that she had
sinned by him. There was no improvement after a stay at a sanitarium; thoughts of suicide; once she stole around a fish pond, remained all night in the woods and then returned unobser\'ed to her
asylum. When brought to the clinic, she at first seemed rather stiff
and apathetic, then depressed, but complained that she was the poorest
of all the inmates, lost and abandoned by God and man.
She did
not sleep and was confused in the head. The upper part of her face
427
looked depressed, the lower was rather smiling.
She showed frequent

There were many voices. Stereotype striking about
with the arms. She identified various things, e.g. the different physicians with one another.
She was only three days old. The first day
was "when the first immoral act occurred" as a small child, "the second
corresponded with the second immoral act, the third is the present
when she has to die." She is also "here three days or three weeks."
The director of Burgholzli is also the head of her former institution.
Whomever she sees now, she has seen previously but as another person.
All mankind must become different (probably first as a very small
child).
The body is poisoned. She will be murdered and the murderers will go unpunished; at first she will be put in hot water and
then cut into pieces. Her sins have earned immortality for her. Incessant voices concerning which she can give no account. Obstrucobstructions.
tions.
To
indifferent
questions
paresthesias of the intestines.
she
gives
prompt
Many
replies.
In the course of a year gradual im-
provement up to complete capacity for work. Two years later, twentynine years old, there was a manic attack, in which she gossiped about
her relation with the director of the institution so that he lost his
position.
As a manic depressive she was brought from another instimonth she could already be discharged. A
tution to us but after one
year later she returned in a manic condition after having been at
She states she had worked too hard, had had stomach
had been contradicted too much; she wants ever\^body to
obey her. Rigid mania with dancing and singing, tearing of clothes
and scolding. But her face does not change whether she jokes or
scolds. After half a year she could again be discharged and remained
away fourteen months. Then she merged in a new euphoric mood
with great indifference toward the commitment and everything that
happened or was said to her. At times she was extremely manic,
noisy, smearing and tearing.
She began consciously to annoy physicians and nurses. At intervals she was again very decent. Between
laughter she can suddenly cry. "She would not marry Doctor M.
(former asylum physician)." After seven months in a rest resort she
was discharged, returned a year later for the fifth time with rigid
euphoria from which she soon calmed down. She has now sat about
different places.
bleedings,
for years inactive but quiet.
Depressive Hebephrenia.
Nurse.
Pleasant, intelligent
girl.
Re-
fused several offers of marriage; she was afraid of marriage, of births.
Nevertheless she blames her sister because of the hitter's warnings
man.
was with us as
for the cause of the failure of a certain relationship with a
her twenty-ninth to her thirty-second 3'ear she
From
a con-
428
scientioue nurse.
Because of physical diseases she resigned and then
held various other positions.

tive,
After a while she became tired, sensi-
considered herself annoyed, in part rightly
others because of her irritabihty.
She
so,
felt herself
because she angered

getting
weaker and
weaker; work became too hard for her. When she was to take over
another ward in the hospital where she worked, she became afraid
and left. She was dissatisfied with the reference. She planned suicide
and consequently at thirty-seven was brought to us. Here she was
or less depressed, had entertained mild ideas of reference. Now
and then she heard some voices, was at times bothered by memories
of her youth that crowded up in her. Then she was better; she was
afraid to leave the hospital; but after thirteen months she could be
discharged to take a position. She did her work well but soon found
it too hard, took several other positions, but could make up her mind
with difficulty and after eight months had to be brought back to the
clinic.
She had lost much of her energy, had a certain insight into
her disease but only at times, spent much time in bed, worked little.
Work was too much of a strain for her; at times she spoke listlessly
of going away, but was always afraid when it came to the point, was
very sensitive even toward her relatives. After about a year she was
again discharged. Since then she has been in different positions but
more
has been in
difficulties (four years).
Paranoid Form. As a child

While in a foreign boarding school a "nervous disease" appeared for which she was treated
Hebephrenia with Transition
somewhat
apathetic.
to the
Lost her parents early.
But she was seized with a

and had to be taken away from him
unsuccessfully for a year, with persuasion.
morbid
feeling for the physician
She came to another physician's house, then to a

where she busied herself with house-work. At twenty-four
she went to England to board where she had several sentimental and
pious friendships. "For convalescence and also for work" she returned
to Switzerland at thirty-three, then went to a relative in America, let
a friend of his cheat her of her money, but returned in time to Switzerland, because she had lung trouble.
Later she was operated for an
intestinal growth.
In the hospital she was depressed and cut her
throat with a pen-knife, whereupon at thirty-five she was admitted
to the clinic. Here she was fearful, liked to stand at the door in her
shirt, called to everybody that passed that she had to go on the street
Finally she did not want to put anything on, tore her
in her shirt.
She had to be tube fed, and
shirts because they were too beautiful.
When the door opened, she always thought now
slept very little.
some one was coming to torture her to death. She did not want to
almost with force.
relative

urinate because she
was being watched through the windows.
429
Active
auditory and somatic hallucinations concerning which, however, she
spoke
little.
After four months she was somewhat quieter.
But the
She always was glad to return

from visiting relatives. The voices tell her they are not the right
relatives.
She has to be assured that she has not a cat and a dog in
her bowels. During sleep she is transported to many places, once
with the room and all to a river, then again to a place where there is
snow. "The furniture has wilted because of the rays from her green
eyes." After a while the sad mood changes to a mildly manic which
in the course of a year makes way for a very apathetic one, but always
with brief fluctuations upward and downward. She is to be destroyed
purposely, she hears many voices, mistakes people, is afraid to go into
the open where there are people who shoot her; the physicians do
dreadful things to her body. Nevertheless with mild protesting she
The friend from
is very pleasant, as far as her indifference permits.
America, in the form of a nurse, has sneaked up to her. She is given
poison and disagreeable things to eat. Her uncle was in a tree oppovoices forbade her to speak loudly.
site
her
window and wanted
to shoot her
but an angel protected her.
The nurses
Her passport has been forged. An illegitimate child
has been put over on her. Men, dressed as nurses, come in, bind her,
She
is
being hypnotized, cats' eyes have been put into her.
talk about ber.
on the head, hypnotize her, pour poison into her eyes, throw
Aside from this she is very quiet, busies herself with
womanly tasks and copying.
Hebephrenia with Fatal Results. Intelligent business woman. At
Afterwards a good worker but
flineteen a melancholic depression.
never very energetic. At thirty-eight work became too much for her.
Attacks of insomnia, anxiety, and reticence; when making purchases
she often could not find words at all, or could not speak on other occaThen showed ideas of fearful observation and reference. A
sions.
hit her
stones at her.
stay in a private institution did not help, nor did her leaving it help
any. After two years the patient was brought to the clinic, where
within a few days she became euphoric. At the same time she was
indifferent, untidy, concealed books, played a few bars from sheets of
music and then threw them on the floor, etc. Nevertheless she main-
ward where she worked a little without doing

Once she wrote home a verbigerating letter. An attempt to
take her to her family failed since she did not work at all and was very
untidy, did not even dress herself and did not comb her hair. Brought
back to the asylum she remained mildly euphoric but always worked
less, became more and more untidy, kneeled or lay down on the floor
tained herself in the best
much.
430
when she thought
She endeavored to give her laziness

Later she was occasionally unclean, deposited
her feces in unsuitable places. After a stay of six years in all, being
an
herself alone.
aristocratic tone.
became anxiously depressed with a

make a noise in long and
endlessly repeated sentences; with this there was sexual excitation.
In the course of two months there was a return to the status quo ante.
But soon she became sick again with fever without any physical signs.
She had a temperature of 104 F., which subsided after five days and
gave way to subnormal temperatures (down to 96.8 F.) Her strength
forty-five, she rather suddenly
desire to go away, to hold on to things, to
failed rapidly.
To be
was noticeably
strong, not rapid but often irregular.
the neck
(or negativism)
diminished,
at
Coma.
acute stage.
scopically
times
exaggerated.
Death
Rigidness of
patella reflex very changeable, at times
No
Babinski.
Rapidly spreading decubitus in
analgesia.
measures.
sure her pulse even shortly before her death
spite
after a duration of twelve
of
Several
all
times
preventive
days of the entire
In the brain, nothing was found maroscopically; micro-
marked
increase of the glia in the cerebrum in all parts
without any changes in the ganglion cells.

Schizophrenic Hypochondria. Very able farmer's girl, intellectually
and physically above the average for obvious reasons she did not have
;
much
Father and grandfather had suffered for years with

cramps."
Patient was a very good silk weaver; she had
"stomach
the more difiicult work as well as the accounting; she lived with her
brother.
She positively refused offers of marriage; "she could not'
make up her mind," "was afraid of marriage." A few intimate friendships with girls; even in the asylum she composed a poem of "friendship" that betrayed strong homosexual components. When she was
forty-seven, her brother died. Now she was "overworked," and had
stomach trouble, soon had to give up altogether. She went from one
doctor to another, obtained the most different diagnoses, stomach and
bowel weakness, decay in the stomach, membranous colitis, multiple
schooling.
gall stones, cirrhosis of the liver, floating kidney, later also hysteria.
The medicines
that she took "were poison to her" and with electrical
treatment, massage, persuasion and other nice things, within a few
years wasted her fortune of 10,000 francs so that she became a public
charge. At last she came to us from another asylum where they could
She was fifty-four years old, physically perfect

and strong. She complained about sluggishness of the bowels, blocking
of all secretions, enlarged womb, which presses on the bowels, the
contents of which were rotting; terrible pains, valvular trouble of the
Treatment by ignoring or diverting her brought it
heart, etc., etc.
not get along with her.

about
herself not to ask for treatment.
with the reservation that

If
was with us that she again worked daily
in the six years that she
and usually resigned
we
431
Nevertheless
did not understand her serious malady.
one speaks to her about her disease, she scolds about her suffering
and the treatment. But within a few seconds she can be made erotically
friendly. For instance, she lies there half dead in pain; one asks her
to dance and she joins in until she is dizzy.
While talking about
the disease she sometimes has a pronounced paranoid look and always
a strong Veraguth sign; both disappear immediately when she is
diverted.
Once I let myself be persuaded to give her a laxative
because she maintained she never had a movement. She persisted
in
maintaining this in spite of several stools daily
and never complained
as
much
as at this time.
she got a
little
thin
She did not return
from a walk, and has since remained with relatives (two years).
She masturbated very much. Distinguished from hysteria: Complete
and
to
not given the opportunity to talk about
it.
indifference to everything that does not belong to her disease,
the disease also
if
she
is
The only rapport with her
is
concerning the disease and then
of a simple erotic nature which
is
in
marked
gence in other respects and her good manners.
on
entirely dereistically without
making
it
is
contrast with her intelli-
In the ward she lived
herself noticeable, associating
If she complained of the

Sometimes
she plainly showed
nurses, she did not make a scene.
delusions
were
too senseless for a
The hypochondrical
rigid affects.
altogether with the other schizophrenics.
Absolute inability to discuss or be influenced in regard to

her disease (the slight improvement was only gained by indirect
means). Psychically, her libido remained attached to her brother,
hysteria.
whom
she usually associates, as soon as she talks of marriage.

In contrast with her usual indifference toward everj^thing that does
not concern her disease, she can cry when she remembers him. When
to
he died, she
lost all
emotional connection
work
also
became too much

stomach and
for her; "over-exertion" with subjective troubles of the
bowels. Some chance remarks of the patient indicate almost certainly

that the imagined uterus enlargement sprang from the desire for
children and that the bowels, as is frequently the case, represent the
uterus.
Hebephrenia with Alcoholism. Baker and formerly a saloon keeper.

intelligence. Always given to rage, is coarse. At twenty-six
he had his own business, which gradually declined. At thirty-eight he
heard voices, became anxious, barricaded the doors; at night looked
for man that pursued his wife found her bed in disorder, suddenly sawheads.
Attempted suicide for the reason that his license would be
Medium
432
withdrawn, because many unclean things walked in his saloon. For

this reason he was brought to the hospital; came home improved,
drank nothing for a while, worked well but reproached his wife for
having been interned. Then he began to drink again, again had the
jealousy ideas, but only when he was drunk. Worked irregularly.
Because of violence, he was again brought to the clinic. He could not
understand a fable clearly, had all sorts of drunkard's excuses, but
was less capable of discussion than ordinary drunkards, and sometimes
made very peculiar movements. Affectivity was at first still labile:
tears in his eyes over the interning, then again rigid and indifferent.
Now and then peculiar movements. After seven days he went to
another hospital with the diagnosis of hebephrenia and alcoholism.
there he was discharged after twelve weeks. This time, too, at
From
first
everything went well for a short time while he abstained from
became worse. Jealousy delusions and acts

give up his business because, while
drunk, he threw bread and other things out of the window and insulted
his customers. He worked as a baker's assistant and then for weeks
not at all. Now and then it was noticed that he did not speak. The
jealousy ideas became steadily worse. In the vilest words he asked
the children about his wife's infidelity. Furthermore, he laid match
sticks together in a particular way and said mysteriously that meant
something. Because of maltreatment of the wife he was brought back
On admission he showed complete blocking.
(aged forty-seven).
Later acted as formerly. After a few days he went to another hospital.
The next year he was brought in again with mutism, and compressed lips. On the outside he had called attention to himself by
all sorts of senseless acts; e.g. he had stood in front of the street
car and had waved his handkerchief. Discharged again, he was
conspicuous, worked very httle, made all sorts of faces so that people
were afraid of him, beat his wife and children. Nevertheless only
after nearly five years he was returned in a state of alcoholic
He was transferred to another
and schizophrenic dementia.
alcohol, then he continually
directed against the wife.
He had to
hospital.
Where only
symptoms are visible, we speak of schizoprimary dementia of earlier authors). It is

usually a case of a dementia in the sense of schizophrenia that increases
gradually in the course of decades.
The anamnesis invariably indicates that the disease has been mistaken for many years; it was a
latent schizophrenia. But since this form also, like every other, need
not progress to the point of recognizable dementia, there are undoubtedly latent schizophrenias, too, that never become manifest. One not
4.
phrenia simplex
the basic
(the

rarely meets with
with patients
it
433
in relatives of the manifestly diseased, or in visits
who come because
of
some "nervous"
trouble.
always somewhat
had various hobbies. At school in the course of
time matters became worse. His discipline relaxed. But not until
he was fifty was it pointed out to him that matters could not go on
Instead orf seeing it in this way, he demanded several
in that way.
increases in salary from the authorities.
At last he had to resign
and then entered into incessant litigations "about his rights"; the
authorities had to get him a good position. He was completely incapable of seeing the material and formal impossibility of this fulfillment.
At last he threatened to thrash the authorities, and was sent to the
clinic as dangerous. Here he permitted himself to be somewhat calmed
externally, and after eight months could again be discharged. On the
outside he has been getting along for nearly twenty years, by occupying
himself with subordinate farm work.
Kraepelin recently formulated a somewhat more exhaustive
Schizophrenia Simplex.
Teacher.
Intelligent but
peculiar, retiring,
grouping:
Dementia simplex, corresponding to the hitherto established

2. Foolish dementia, corresponding generally to the Hebephrenia of Hecker and well designated by "the name. 3. Simple depres1.
group.
dementia often has a preliminary stage lasting for

retire, become peculiar, and brood.
Only
in about twenty percent does a milder schizophrenic depression with
ideas of sin and persecution and often too with catatonic symptoms
break out without such an introduction. A fairly large number of
sive or stuporous
years in which the patients
the patients afterwards merge into a tolerable condition "without severe

dementia but the attaeks may recur. The stuporous dementia includes
many of our catatonics with a depressive stage, but perhaps also the
Hebephrenics. 4. Depressive dementia with delusional formation have
;
symptoms but on the average run a more chronic course, have

somewhat worse prognosis and show the delusions more conspicuously. 5. In the circular form excitations and depressions alternate;
similar
they usually lead to severer dementia.

to which, perhaps, this
name might
(There
is
another formation
better apply, since
it
runs
its
course in evident manic and depressive attacks which are sharply differentiated from better intervening states, or from those which, in the
beginning, are very good)
6. In the agitated form one observes continuous excitements with compulsive acts, senseless movements and a
general exalted mood.
(This form seemed to Kraepelin the most fre.
quent with the natives of Java.) 7. Forms with periodic attacks of

confused excitation that usually begin and end very acutely, which
434
usually do not last long, only a few weeks, and are combined with a
marked
tion.
8.
loss of weight.
Not
rarely they are associated with menstrua-
Catatonia, including the severer cases of the disease hitherto
designated by this
name by
Kraepelin.
9.
The paranoid
forms, corre-
sponding to our paranoids and divided into dementia paranoides gravis

with a severe decay of the psychic
life,
disturbances of the feelings and
will, as well as loss of external bearing, and into paranoid or hallucina-
tory feeble-mindedness, in which the hallucinations are in the fore-
ground, but in which the fundamental personality has suffered
(dementia paranoides mitis)
As
10.
less
the tenth form, speech confusion
(schizophasia) should be distinguished, running
its
course with very
severe speech disturbance up to a complete word salad, but with relatively slight
still fairly
impairment of the other
faculties, so that the patients are
capable of work, at least within the asylums.

E.
The Course
It is impossible to describe all
Pretty nearly
all
the various courses of schizophrenia.
imaginable combinations of courses
the recession of a severe dementia.

special frequency; the course
that requires
many
which
may
occur except
Nevertheless two types recur with

is
chronic from beginning to end,
years for development, and the manifest type,
beginning with an acute onset, and leaving behind secondary demented

or paranoid states.
But the acute syndrome need not leave behind an
increase of the dementia,
and on the other hand, the dementia as
well as the formation of delusions
between, the acute attacks.
may
progress after, as well as
Forms taking an
entirely chronic course
belong especially to the simple schizophrenia and to certain catatonic
ways
of manifestation, also to the typical paranoid forms.
In every course exacerbations may appear at any time, but after

the disease has lasted from two to three decades they are pretty rare.
Complete arrests of the diseases are not frequent in asylum patients.

In the course of decades an increase of the dementia can usually be
noted.
Among the more mildly afflicted, who maintain themselves
outside of asylums, some seem not to go beyond a certain stage of
the disease.
Improvements also
may
occur at every stage; but they relate
primarily, to the accessory symptoms.
Schizophrenic dementia
itself
But to be sure all acute syndromes show

a tendency to disappear, and chronic hallucinations and delusions
may also regress, though much more rarely. Psychoses which, from
no longer actually
regresses.
the beginning, run a course unth a picture of a chronic catatonia, are

Excited patients calm down as a rule in the course of
quite hopeless.

years, in part because inwardly
435
and outwardly they become used to
the hallucinations and to the dissociation, or also because the sense
deceptions decline in numbers and intensity.
The sudden and
transient akalmias in the severe acute as well as
in the chronic conditions are noteworthy.
highly excited, especially
may, with or without external cause, appear entirely

normal from one minute to the next, only to fall back after hours or
a confused, patient
days into the previous condition.
The
qualitative course
is
somewhat more
regular; the majority of
cases from the beginning to the end remain within their category,
even though a change from catatonic to paranoid forms and in every

other direction is more frequent than in the various forms of paresis.
The beginning
of schizophrenia
is
Even
in reality usually furtive.
though the disease often becomes obvious to the relatives first through
an acute attack, a good anamnesis usually reveals certain previous
changes of character, or other schizophrenic signs. Whether the in-
combined
an expression of a disposition,
or the actual beginning of the disease, cannot be decided.
In many
clination to retirement, often noticeable even in childhood,
with a certain degree of

cases the disease itself
skill
irritability, is
makes
itself felt
and of capacity to work; in
pulsive neurotic
symptoms
treated unsuccessfully.
acts are
much more
by a gradual decline
of acquired
comand
immediate
others, neurasthenic, hysteric, or
are for years mistaken for the disease
Anomalies of character and
single
conspicuous.
In a small number (under one percent) the outcome
is
death from
cerebral inflammation or from the cessation of metabolism.
Other
patients die from the indirect consequences of schizophrenia, from
from carelessness, and suicide.

mentioned but with satisfactory hygienic
no more to be feared in asylums than in those mentally
injuries that are intended, or result
Usually phthisis
measures
it is
is
also
sound.
small part
is
"cured" to such extent that only a very careful

may observe a certain
inspection shows any signs of the disease; one

irritability,
some remnants
of the delusions,
Nevertheless there are a great
many
some
"social cures."
peculiarities,
etc.
Under the condi-
tions in our hospital one can figure that only about one third of the
more severely demented and more than half of the others remain
fairly capable of work for a considerable time, or permanently.
Catatonia, especially in men, has a somewhat poorer prognosis than the
other forms; pupillary symptoms also seem to occur chiefly in the
more serious brain affections; and whenever it is ascertained that the
patient showed previously an "abnormal" character the prognosis is
436
less favorable.
purer they are.
The
But
more completely, the

we unfortunately have
twilight states regress the

aside from
no basis at the beginning
what was
said
of the disease for the prognosis of its duration.
Terminations according to Kraepelin
Among the terminations Kraepelin mentions the following forms,

which naturally are not clearly defined from one another.
1. In simple feeble-mindedness the defects above all influence the
2. Halluaffectivity, whereby a certain ability to work is retained.
cinatory feeble-mindedness is similar, but is permanently accompanied
by individual sense deceptions the nature of which the patients recognize more or less, so that their external conduct may, in the main,
3. The dementia paranoides mitis is characterized by
still be orderly.
delusions and hallucinations, which, as distinguished from the previous
group, are very numerous. 4. The drivelling dementia shows a severer
unsteadiness of the train of thought with senseless delusions and sense5. The dull dementia approaches the quiet of the grave,
less speech.
even though individual patients perform simple tasks, and occasionally
excitations and more positive symptoms like stereotypisms, etc., are
hardly ever entirely absent. 6. The silly dementia expresses itself
in greater activity with a usually cheerful mood and silly actions.
7. The dementia with mannerisms is similar; here, however, peculiar
deflections of volitional acts (like hopping about on one leg, stereotype positions, etc.) stand in the foreground of the morbid picture.
8. Negativistic dementia is characterized by the strength of the impulsive resistances.
F.
What
Is
Included under the Term
Under schizophrenia are included many atypical melancholias and

manias of other schools (especially nearly all "hysterical" melancholias
and manias), most hallucinatory confusions, much that is elsewhere
called amentia (our idea of amentia is much narrower), a part of the
forms consigned to delirium acutum, motility psychoses of Wernicke,
primary and secondary dementias without special names, most of the
paranoias of the other schools, especially
all
all
hysterically crazy, nearly
incurable "hypochondriacs," some "nervous people" and compulsive
and impulsive patients.
The
diseases
especially
distinguished
as
juvenile and masturbatory forms all belong here, also a large part of
the puberty psychoses, and the degeneration psychoses of Magnans.
Many
prison psychoses and the Ganser twilight states are acute

syndromes based on a chronic schizophrenia. If we still come across

reactive psychoses included under this head, then
it is
437
due to defective
diagnoses, not to the classification of a system.
Latent schizophrenias are very
common under all conditions so that

much more extensive term
the "disease" schizophrenia has to be a
than the pronounced psychosis of the same name.

for studies of heredity.
At what
stage of the
This
is
important
anomaly any one should
be designated as only a "schizoid" psychopathic, or as a schizophrenic

all be decided as yet.
At all events, the
mentally diseased, cannot at
name
latent schizophrenia will always make one think of a morbid

psychopathic state, in which the schizoid peculiarities are within
normal
Social uselessness, catatonic symptoms, hallucinations,
limits.
delusions
make
certain the practic?J diagnosis of the acute mental
disease.
Paraphrenias. Kraepelin attempted to separate from the paranoid

forms of schizophrenia, as a special morbid group, those in whom
the personality was better retained, and whose feelings, will, and
the external behavior are directly slightly changed; the incorrect
actions are determined by delusions. In the paraphrenia systematica
more or less connected delusions are conspicuous; they show, in the
first place, the character of persecution, but later, beginning with a
definite period, they become associated with grandiose ideas.
Para-
phrenia expansiva presents a light manic lasting mood, and, corre-
sponding with
it,
luxurious ideas of grandeur from the very beginning.
memory decepThe paraphrenia phantastica (paranoid dementia in the old
In paraphrenia confabulatoria the delusions appear as

tions.
narrow sense)
^^
frequently develops even in a few months into quite
a stable picture with a
number
of alternating senseless ideas of grandeur
and persecution, with an enormous number of somatic hallucinations,

often quite senseless speech, but a less conspicuous outward behavior,
and under care a more or less continued productive capacity. A
diagnostic differentiation of the paraphrenias from the other acute or
chronic mild paranoid forms was never possible. Moreover our investigations, as well as the course and heredity, show the definite relationship of most,
G.
if
not
all
these cases, to the schizophrenias.^
Combination of Schizophrenia with Other Diseases
Schizophrenia may be combined with other psychoses; it may undoubtedly originate on top of oligophrenias (Propfschizophrenia),^^
""See p. 413.
*'
Conip. Schizophrenia, p. 177.
" Moreover, manj' Propfschizophrenias represent probably a distinct disease.
At all events intercourse with most of these patients is maintained by way of
the affects.
438
and may be followed by senile psychoses. Occasionally also a paresis,

more frequently alcoholism, eventually with delirium tremens or
hallucinosis, complicate the picture. There is probably also a mixture
of manic-depressive insanity, and of epilepsy with schizophrenia. The
associations of these two diseases with dementia prsecox are undoubtedly multiform and not at all clear, no more than the delimitation of
the combined from the simple forms with only apparent mixture
symptoms.
H.
Diagnosis
The diagnosis of schizophrenia in the ordinary cases is Very easy.

The peculiar, moody, abrupt, and scanty affective rapport often points
to the disease at the
first
glance; furthermore, the inability to discuss
matters that deal with subjects that the patient is otherwise conversant with. Also many accessory symptoms like the above described
delusions, the hallucinations characteristic in their
way, especially the
physical sensations, pronounced catatonic symptoms,
all
make
possible
examination does not yield definite indications one should carefully ask whether there are people who annoy
the patient, whether there is anybody in his neighborhood who is
a quick recognition.
hostile to him.
to light.
symptoms
If the
Often a secretive persecutory mania will then come
But nowhere as much
as in schizophrenia are all individual
evaluated in terms of their entire psychic environment.

In case of cloudiness of consciousness the identical manifestations are
to be
not nearly so valuable as evidence as in the case of apparent clearness.
Catalepsy also occurs in epilepsy, in hysteria, then again in cerebral

diseases, and as a concomitant manifestation of bodily diseases, e.g.
uremia in children. In negativism the impulsive variety has to be
differentiated from those forms of rejection based on other reasons.
In any schizoid character any other psychoses can easily bring to

Beginners are then easily inlight a few schizophrenic symptoms.^
clined to see only the schizophrenia. Of the physical symptoms only
the lack of psychical pupillary reaction has a more definite significance.
One may never
directly exclude a schizophrenia.
Only prolonged observation
will
often
guard against confusing
schizophrenia with manic-depressive insanity.
All manic-depressive
symptoms may appear in schizophrenia but not the specific schizophrenia symptoms in the former disease. The simultaneous existence
of grandiose ideas and depressive delusions indicates schizophrenia.
From paresis and dementia senilis it is definitely differentiated by the
absence of the signs of the organic psychoses (eventually by the examComp. p. 177.
439
ination of the cerebro-spinal fluid).

Coarse cerebral lesions may
sometimes simulate a schizophrenic picture for a considerable time.
A stupor may occur in an imbecile as a result of an unusual situation,
e.g. in
case of a judicial examination.
From
epilepsy
it is
differentiated
by the striking schizophrenic anomalies of the affects, then

on the other hand by the absence of the epileptic hesitating mental
trend, the epileptic speech, and by the adhesiveness of the feelings.
In the anamnesis of epilepsy the picture is usually dominated by the
especially
attacks, in the dementia prsecox, even

is
when attacks
dominated by the psychic disturbances.
persists only a short time, e.g. a fractional part of
month, as the schizophrenic.

especially
when
are present,
it
Epileptic catalepsy usually
an hour, never a
In epileptic cloudings of consciousness,
brain lesions are the basis of the disease, paresthesias
sometimes occur which are elaborated in a dream-like manner and
may
simulate schizophrenic hallucinations of the organs.
The various
alcoholic psychoses not rarely originate on a schizophrenia which they
then complicate. The differentiation from hysteria and neurasthenia,

which at the beginning of the disease involves many pitfalls, is negative, as in
manic-depressive insanity.
in all three diseases,
toms
we presuppose
we presuppose hysteria and

when a minute examination has brought to light hysterical
of this disease are demonstrated;
neurasthenia
or neurasthenic but no schizophrenic

of
As psychogenic symptoms occur

when specific symp-
schizophrenia
ideas,
auditory
hallucinations
symptoms. Dementia, disturbance

and permanent delusions with
unclouded consciousness exclude the neurosis.^

Especially difficult
is
the delimitation of reactive syndromes, or
logical peculiarities in psychopaths.
us
tell
how pronounced
As yet we have no standard
to
the sj^mptoms must be to enable us to assume,
or exclude, a schizophrenic process.
In these cases one will assume
when more definite signs of it are present, but

Young people are nearly
will be careful not to want "to exclude" it.
always schizophrenic who want to become something out of the
ordinary just at the time that they are really failing, and who then
schizophrenia only
believe that
etc.)
by particular
tricks (thinking out something to the end,
they can free themselves from the situation and then neglect the
essential thing in favor of the means.
Oligophrenics
who
get
symptoms that
are of a paranoid nature or
similar to those of catatonia are sometimes impossible to differentiate,
because just here the diagnostic standard for such manifestations and
even the limitation in principle of oligophrenia

Compare the differential diagnosis
*
Comp. paranoia, limitation.
**
in chapter
on
^^
are
hj^steria.
still
uncertaia
440
I.
The
Prognosis
course of the disease runs in the direction of the described

The special directional prognosis is decided with some
dementias.
probabiUty by the assignment of a case to one of the sub-groups.
The
extent prognosis
is
much more
uncertain.
Many
cases after the
show such a slight

defect that they may be considered practically cured; others become
demented quickly and to a high degree. To the latter belong with
first
shift,
certainty
under certain conditions even
all
later,
chronically beginning catatonias, probably also the rarer
mental confusion in the sense previously explained. All

acute syndromes may regress to the former state. Very severe acute
conditions with profound disturbances of consciousness are, therefore,
not in themselves hopeless. But the cardinal symptoms regress very
In
little, and of these, the disturbances of association least of all.
acute conditions the most important consideration is to determine
how far the actual schizophrenic process has progressed. The more
the schizophrenic picture of associative and affective disturbance protrudes from behind the transient acute symptoms, moods, stupor,
and hallucinations, the worse the prognosis the more a picture resembles a pure mania or melancholia, the better the prognosis. Naturally
this does not make it very good because this observation only determines that as yet no dementia has set in, but not that it cannot set in.
The anamnesis also often gives important basic points. Good remissions after earlier shifts warrant, with considerable probability, the
On the other hand,
expectation of another extensive improvement.
the confirmation of an extensive dementia already existing before the
actual shift excludes any considerable improvement, because improvements over the earlier conditions are only rarely found after an acute
onset; exacerbations of the various grades are very common.
cases
of
favorable sign, especially plain in
women,
is
the retention of
decency in acute conditions, while a visible loss of the feeling of

decency in a clear sensorium and otherwise orderly conduct is a sign
of poor prospects.
But the reverse inference would not be at all
justified, namely, that absence of a feeling of decency in acute condi-
bad outcome, and that the presence of decency in a

good one.
Actual chronic conditions are capable of little improvement; only
we do not always know what is chronic. There are patients who for
many years are at the same stage of excitement but still give the
impression, more or less, of being acute and are then again surprisingly
capable of improvements; after ten or twenty years in rarer cases,
tions indicates a
state of mental clearness indicates a

may
apparently entirely unsocial patients
441
be discharged as again
Moreover the increase of dementia is often to be

externally
taken
as an improvement; the patients gradually become
their delusions and voices and consequently
indifferent
toward
more
quieter; under certain conditions they even become more capable of
capable of work.
work.
In
many
cases the hallucinations decline after a while to the
point of disappearance.
The tendency
an
to relapses
interval lasts, the less a
is
new
hardly to be estimated.
shift
is
to be feared.
The
longer
After a standstill
two decades there may still be a quietly progressing decrease of

ability to work but only rarely new attacks. The climacterium, pregnancies, and especially the puerperium, present a certain danger to
women.
of
K.
Great importance
dening.
Among
is
Causes
undoubtedly to be attached to hereditary bur-
the direct ancestors of the patients, psychoses, espe-
cially schizophrenia, are
Most frequently one
much more numerous than with
the healthy.
find in families schizoid characters, people
who
who in
who
comfortably dull and at the same time sensitive, people

a narrow
manner pursue vague purposes, improvers of the universe, etc. Natuare shut-in, suspicious, incapable of discussion, people
rally nervous diseases also occur in the
often because
many
are
families of schizophrenics,
milder schizophrenics are so called.
Some family
relationships with a certain kind of epilepsy, that as yet cannot be
characterized
more
definitely,
seem to be present.
schizophrenias where an hereditary disposition
is
Besides there are

not to be found in
spite of exact information concerning the family.
In probably three fourths of the cases the personal disposition

itself during youth in an dereistic character inclined
already expresses
to seclusion, then in other peculiarities
and deviations from normal
small percent of the pronounced diseases themselves go

back into childhood. Most of them become manifest from puberty
thinking.
up
to the twenty-fifth year; from thirty on, the morbidity sinks rapidly
women, to a low second peak at the time of the climacterium. Only the chronic paranoid forms show a preference for
breaking out rather late, especially around the fourth decade.
to rise again, in
Among the external conditions pregnancy and, more readily, confinement at times precipitate attacks of schizophrenia, also perhaps
acute infections, but not frequently, then any psychic factor, especially
an unfortunate love-life. But we must assume that the disease is not
engendered by such conditions but only made manifest. Onanism
442
and over-work are both blamed as causes, absolutely without anyNeither the grippe nor the war have added to the
justifiable reasons.
existence of schizophrenia.
L.
Frequency and Prevalence
Aside from the oligophrenias and alcoholism, schizophrenia is the

most common mental disease. In our asylums it is found in 23 percent
of the men and 39 percent of the women and the difference in the
relative numbers is due almost entirely to the excess of paretics and
As the schizophrenics are at the same
alcoholics among the men.
time the incurable and the long-lived patients, they may constitute
three fourths of all the inmates in any asylum that does not admit
many
cases of idiocy.
The
it
disease occurs in all races
and
seems that among primitive people
in every stage of culture.

it
assumes
less
But
frequently the
character of catatonia.
M.
Anatomy and Pathology
We do not know as yet on what the pathologic process is based.

In acute stages various kinds of changes in the ganglion cells are found.
In old cases the brain mass is reduced a little; many ganglion cells,
especially in the second
and third
sometimes the
the cells and the axis-cylinder look diseased.
The
fibrils of
glia is regularly involved:
layer, are
changed in various ways;
various changes of
increase of the small cells; there
is
its
cell varieties,
a deposit of pigment and other
and other things

up together nor interpreted
catabolic materials, increase of the finer glia fibres

besides.
The
findings cannot as yet be lined
as to their causes and effects.
Naturally one thinks
first
influences of the sex organs
halden reaction
it
of toxic disturbances, especially of the
and the thyroid
was supposed that
also.
With the Abder-
signs of the reduction of these
two organs were pretty regularly found, naturally with the reduction
of other organs, especially of the brain and then the suprarenals.
The supposition of an (hereditary) schizophrenic predisposition,
which at present is being considered most, meets with many difficulties.
Our total knowledge would be completely comprehensible if it were a
case of a chronic infection or intoxication by means of a generally
distributed agency or of something teratological.
In certain acute conditions the morbid picture is evidently conditioned chiefly by the anatomic or toxic processes, in the manner of
the deliria in meningitis, fever, or intoxications.
eral or localized, paralytic
Also the rarer, gen-
symptoms and the manifestations
of brain

pressure, originate in
an organic process which
chronic course by only a few

ances,
and
symptoms
free
may
indicated in the
more
like tremors, pupillary disturb-
irregularities of metabolism.
seems to set
is
443
In other respects the process
some associational weakness,"^ which, however,
in
from one moment to another from zero to

maximum; and hence already shows the influence of some psychic
factor; furthermore the schizophrenic associations have not as yet
been differentiated from the functional changes of the mental trend
in the dream and in distracted attention.
The remaining symptoms
its
results
fluctuate
The content
of schizophrenia are secondary. ^^
and delusions
is
of the hallucinations
conditioned katathymically by the complexes; un-
pleasant complexes are repressed, as in normal people, into the unconscious
and from there cause delusions and sense deceptions. Affective

under such conditions in normal people, and all
rigidity is also seen
other affective disturbances occurring in schizophrenics are also noticed

especially in the
dreams
of
normal people.
N.
Most
Treatment
all, or at any rate

asylums only when there are
special indications, which to be sure appear frequently, e.g, in acute
attacks, because of disturbing conduct, violence, danger of suicide,
schizophrenics are not to be treated at
outside of asylums.
They belong
and then especially temporarily
in
for purposes of training.
They should
be discharged as soon as possible, because later they are gotten rid

of
much
less easily;
because not only the patients but the relatives
more adapt themselves too quickly to the sequestration.

The loss of affective rapport makes itself felt in this respect also.
Expensive treatments, that are of no use anyway, should be cautioned
against, above everything. Moreover the economic and moral interests
of the healthy members of the family should not be sacrificed for a
hopeless treatment. On the other hand, the supreme remedy which in
the majority of cases still accomplishes very much and sometimes
everything that can be desired is training for work under conditions
In seriously affected patients one
that are as normal as possible.
must not be afraid to prescribe such unremunerative work as cutting
wood, carding wool, making boxes, copying any sort of simple work.
perhaps
still
It is self-evident that psychical
tation
obstacles to improvement, as irri-
by impatient treatment, arousing jealousy
with a happily married
member
b}^
having them
In addition the following details should be considered.

"Bleuler, Storung der Associationsspannung.
See
p. 55.
live
of the family, etc., are to be avoided.
îtschr.
f.
For young
Psychiatrie, 74, S.
1.
444
work simple vocations should be selected

and practical activity, and not to theory and dereism.
Schizophrenic whims for some calling or activity should not be mistaken for special qualifications. Sometimes a quiet discussion of the
frequent conflicts concerning onanism may contribute to produce calm
and probably also in the future, to the avoidance of severe pathogenic
schizophrenics capable of
that lead to
life
complexes.
When
the sensitive spots of the disease have been discovered, not
only can the physician more easily exert a calming influence, but those
about the patient can avoid many exciting influences (conversations

about the sister's marriage, visit of a particular man whom the patient
loved, etc.).
After the outbreak of the disease those about the patient are to
be informed that the delusions and Sense deceptions, as far as they
do not lead to unpleasant actions, are to be taken quietly and without
Some
discussion as merely morbid manifestations.
of the patient's
physical complaints are of a purely psychogenetic nature and are to
be treated by suggestion; others, like some headaches, sleeplessness,

accumulated pollutions, probably depend more directly on the morbid
process and
may
be treated with medicines, as long as the patient
not habituated to drugs.
Bromide
will
state of general nervous excitability, even

If after the decline of
lessly,
and especially
an acute
if
is
often help to remove the

if
not the real excitement.
shift the patients continue to act sense-
their nutrition
becomes reduced so as to excite

fileep sometimes produces
apprehension, an 8 to 12 days Somnifen half

excellent results.
To avoid any unpleasant
initial
manifestations
it is
best to begin with an injection of Hyoscine 0.001, with Morphine 0.01.
When
the patient
patient
is
injecting
is
narcotized, that
is,
about half an hour
given one ampule of Somnifen in both

it
and
deeply under the skin or into the muscle.
hours another ampule, and later according to need.

so deeply that the patient, left to himself,
is
left
is
Sleep
later,
the
right arms,
After 6 to 8
is
drowsy or
either spontaneously or through instigation sufficiently
maintained
asleep, but
aroused to
take nourishment, to attend to his wants, and especially for psychic

treatment. The latter is most important; one can get the impression
that in his helplessness the patient has the need to appeal to some
one; negativism and refusal of nourishment can thus be
disappear or can be markedly weakened.
made
to
In some cases the remedy
seems to bring about directly acute hallucinatory shifts, which have

not yet been thoroughly described; here sleep will have to be maintained to a deeper degree. Poor physical condition seems to be no
contraindication; the patients usually gain in weight during this

When
treatment.
patient
from
is
a shift of the disease has run
its
445
course and the
nevertheless not freed from delusions or impulsive acts or
his fear of life
and work, a change
good
of residence often has a
but not to a sanitarium where one gets accustomed to laziness.

Even mild cases should not be left entirely to themselves. They need
some one who busies himself with them in a tactful way without
effect,
them, who watches them unobtrusively, gives them support,

and trains them as much as is necessary, and as much more as is
In more serious cases the tendency to become automatic
possible.
can often be used and the patients held at least externally to an orderly
existence if not at useful work. With increasing dementia, more and
more simple kinds of work have to be found.
There are cases where abortion may be resorted to, followed under
certain conditions even by sterilization, for which, however, there must
irritating
be such very definite indications, as visible aggravation through

pregnancy, uncontrollable sexual inclinations, etc. I never saw any
good results but sometimes bad ones from the persistently proposed
castration.
X.
EPILEPSY
In a number of diseases that run their course with psychical symp-
toms the epileptiform attack
them the
call
epilepsies.
is
the most striking manifestation;
Among them
a fairly well characterized
we
group
includes about three fourths. of the cases; the others are insuflficiently
ical
more plainly differentiated first by an anatomstudy by Alzheimer. ^^ The main group, which is the only one
that
we can
known and were
really
give attention to here,
is
called genuine epilepsy, a
name
that should really include the other forms too and distinguish all of
epilepsy," or the epileptiform attacks
them together from "symptomatic

in other diseases.
Such attacks
tumors, scleroses, paresis,
may
occur in
arteriosclerotic
all
grain diseases
insanity,
(e.g.
presbyophrenia,
and schizophrenia), as well as in toxic conditions, e.g. through alcohol,

Genuine epilepsy is
ergotin, and in eclampsia and uremia.
characterized not only by the chronically repeated epileptiform attacks,
lead,
but
it
also
peculiar to
develops a considerable number of psychic symptoms

Furthermore it frequently shows "abortive" or other
it.
variously formed attacks, from which the disease

just as clearly as
may
be diagnosed
from those attacks designated as epileptiform.
The
Bericht der Jahresversammlung des

**Die Gruppierung der Epilepsie.
Deutschen Vereins fiir Psj^chiatrie 26/28 April 1907. Allg. Ztschr. f. Psychiatrie,
Bd.
64, S. 418-
446
may altogether be in the backbe totally absent without making the diagnosis impossible for that reason. Nearly all cases of genuine epilepsy also show
a common anatomical finding. Nevertheless the differentiation from
other forms of epilepsy is not yet sharply defined, and it is easily
possible that the group thus delimited will also, on closer examination,
latter,
considered as "typical" attacks,
may
ground or
be separated into subdivisions.

In cases in which the symptoms of epilepsy and schizophrenia are
mingled clinically, Tramer also found anatomical signs of both diseases.
What
typical in the attacks designated as epileptiform
is
is
the
sudden, often actually "lightning-like" onset of a convulsion of the

entire muscular system, which has at first a tonic, and then a clonic
character; it lasts not more than a few minutes,^* and is associated
with a profound disturbance of consciousness, which leaves the impression of a complete loss of consciousness.
The attack is often preceded by prodromata which last a few

more rarely days; most frequently they are represented by
"moods," but also by any ill feeling, more rarely hallucinations and
hours,
In most cases these prodromata disappear in a trice
twilight states.
with the attack.
The attack
itself is
often initiated
by an aura.
This most
fre-
quently consists of any kind of paresthesias, a pain, a feeling of cold,

or being blown at (hence the
"a wheel
is
name) which, however,

,
turning in the stomach"; then
it
may
is
not so frequent;
be initiated by real
and also, noticeably often, by those

show the tendency to approach the patient
hallucinations, especially of sight
The
of taste.
visions often
and get larger and

ness disappears.
free
aura
by the
may
larger; the
moment they touch
his breast, conscious-
In the rare "reflex epilepsy," whose attacks are set
irritation of a scar or
some other pathological
focus, the
begin as a sensation in the particular part of the body.
In
some cases complicated scenes are hallucinated. The psychic aura may
also consist of sudden moods or subjectively felt disturbances of
thought. There is beside a motor aura, consisting of all sorts of clonic
and tonic, usually circumscribed, convulsions, lightning-like twitches, or
complicated automatic movements, as, especially, aimless running (aura
cursoria)
it
rarely goes as far as complicated acts like undressing, etc.
As the muscles
of expiration
and those closing the
glottis
are
" Relatives often speak of attacks of longer duration. This is due primarily
to the fact that the terrible scene leaves the impression of a longer duration.
Moreover the intermingling of the two phases with the stuporous after-effect,
or the confusing of the attack with the status epilepticus, also contributes to
this idea.
447
stronger than their antagonists, at the beginning of the general con-
vulsion the air
is
usually pressed out through the closed vocal
thus causing the characteristic scream.

terrible
scream of
fear,
Much more
belonging to the psychic, that
is
rarely
it
slit,
is
to say, cursative
aura. With the scream the patient usually drops like a log without
any regard for danger. An absolute immovable rigidity probably never
occurs; a more strongly contracted group of muscles overcomes the
opposing muscles and thus produces a slow movement; often one side
especially
predominates, then the other.
In the tonic
state
livor
naturally occurs, in severe cases, up to a terrifying dark blue; after
about a half a minute one sees jerks in individual muscles that spread
After a while one
usually notices, in the chaos of movement, a certain purposeful corapidly and go over into wild clonic convulsions.
ordination becoming visible, especially in the sense of defense.

events,
the movements become weaker until
At
all
complete quiet takes
some jerks of declining severity follow. Coordination,

and to a certain extent the ability to move, usually return only
place; usually
gradually, in the course of minutes or also after a
Only
much
longer time.
appear suddenly or as
early as the cessation of the motor attacks; usually the thoughts are
gradually collected and with numerous fluctuations in the degree of
clearness. Orientation, at first falsified, becomes clear first in respect
to individual things, later on being spoken to, and then in other
in exceptional cases does consciousness
The patient does not awaken as if from nothing, but as if

he were coming out of a dream state.
Sometimes circumscribed
paresthesia, and more rarely paralyses, remain for some time.
respects.
is whipped into foam by the movements

and also by the strong mouth-breathing that appears
after the tonic convulsions this foam is frequently colored with blood
because the tongue gets between the teeth. If one can examine the
In severer attacks the saliva
of the tongue
pupils during the attack, at the very beginning one usually finds miosis,
but later pronounced mydriasis and rigidity, w^hich after the attack
make way with varying speed
for the
normal reaction.
During the
attack some patients sometimes involuntarily pass urine, very rarely

feces.
During the attack and usually even at the beginning of the

movements and facial expression indicate a dream
the patients do not react to exiêrnal stimuli; the reflexes too
stage in which
state,
disappear for a considerable time; the Babinski sign is often present.

the post-epileptic clouded consciousness lasts for hours and
When
days instead of a few moments or minutes, or when noticeable actions

are committed in this state, it is considered an independent postepileptic tmilight state.
After the clouding of consciousness but often
448
also immediately after the attack a stupor or actually a
appears, sometimes also flexibilitas cerea.

ing of perfect well being
is
decidedly rare
coma usually
After the awakening a feelon the one hand the patient
usually feels nervous irritation, and on the other, he feels "knocked

out," even
when he has not really hurt himself. The pulse often keeps
The Babinski sign may continue into the next
fluttering for hours.
day.
In the same patient the various attacks

resemblance.
may have
a photographic
In falling the patients land on the same part of the
body; the aura
is
as a rule of the
same form;
in the post-epileptic
twilight state the identical sense deceptions are perceived,

identical acts are
The
is
attacks
performed
may become
in the
same
and the
succession.
abortive in the most diverse ways; this
especially true with the development of dementia
when everything
Furthermore the tonic or clonic states

may be reduced to a mere indication; the movements may from the
beginning have the character of an action, even though it be irregular.
Mere fainting spells also may be abortive epileptic attacks. If consciousness disappears for only a few seconds without the patient
falling down, and is usually accompanied by pallor, more rarely
blushing, and if it is often combined with a staring gaze, sometimes
also with some movements of the lips or tongue, one speaks of absences
or petit mal, in contrast to grand mal, or the pronounced attack. Sometimes the disease shows itself in rapidly disappearing attacks of dizziBesides these most frequent "attacks," there are many other
ness.
minor symptoms of the same significance that cannot all be enumerated.
In all these minor attacks there is hardly ever an absence of a disturbance of consciousness, which appears suddenly without a prodromal stage, partly in the form of an (apparent?) diminution of consciousness, and partly in the form of twilight thinking, or in the
obtrusion of a certain thought, etc. Thus a patient suddenly gets up
from a meal and masturbates; another urinates in the ticket box.
Concerning pure hallucinatory states we get information only when
the amnesia is lacking: thus the entire surroundings suddenly disappear
for the patient, and instead he sees some rapidly moving cats.
The typical attacks at times follow one another so quickly that
the patients do not recuperate in the interval: status epilepticus. In
severer attacks of this sort the temperature then rises to unusual
height (109 F.) and the patients die in coma or from aspiration
pneumonia.
as a rule
The
becomes
less vigorous.
psychical disturbances.
even before the disease has
Epileptics are as a rule psychopathic,
left its characteristic
mark on them,

large part of them, especially
of the
forms
afflicted
449
while young,
actually have brain disease or are imbeciles.
But specific psychic

which as a rule increase
peculiarities are connected with
epilepsy,
with the duration of the disease.
Ac(;ording to the degree one speaks
of an epileptic character, epileptic psychopathic constitution,""'
and
in severer cases, of epileptic dementia.
The most conspicuous anomaly concerns
the affectivity, which remorbid degree, and at the same time shows the peculiarity,
that an existing affect lasts a long time and it is difficult to divert it
by new impressions; it is not merely irritability that shows itself in
acts to a
this
the
manner but the other affects, as attachments, or joy, all take

same course. The patients as a rule have a very decided mood,"
and the unimportant very readily takes on as strong an emotional tone

as the important. It is not true that some feelings, as, e.g. the moral
feelings, atrophy.
On
the other hand, there
is
found a disproportion-
ately strong affective coloring of conceptions that concern "righteous-
An
ness."
increased interest
is
But the
devoted to the patient's ego.
egocentric trend of thought also has an associative root besides the

affective.
and most noticeable of all the mental stream,

markedly retarded and run heavily, and if the flow of speech may
be taken as a measure, they preferably take place in a hesitating
and jerky manner. The contextual peculiarities of the mental stream
are most plainly revealed in the experimental associations where
All psychic functions,
are
one observes: retardation, poverty of ideas, a tendency to repetition

in form and content, to form definitions, difficulty in reacting with a
single word, frequency of egocentric references, emotional accentuation
of the
are
preferred
indicative
of
ideas,
and the
emotion;
in
selection
this
of
respect,
words that
reaction
there
is
particular
preference for affective evaluation, as seen in the frequent use of good,

beautiful, bad, dreadful;
one also notes a difficulty in finding the
expression with a tendency to awkwardly formed expressions of their
own invention.'^
Not only the manner
of speaking, but epileptic thinking also has

something unclear and indefinite about it; the limitations of concep-
tions
and ideas become blurred; general notions supplant the
Two
different
apprehensions cannot be kept apart.
The
special.
definite
**
Many mere psychopaths have the same affective habitus as pronounced
epileptoid or as the less correctly designated epileptic character, especially when
the patients come from families with evident epileptic members.
*
Concerning moods that come like attacks see below.
*'
For
illustrations see p. 83.
450
virtue of frugality
right thing."
is
designated by the phrase,
squirrel "is
now
"Where one does the

Even
a rabbit or a cat or a fox."
mathematics 16 + 16 is "about from 32 to 34."

In speaking and writing we have the same peculiarities: The
patient does not get anywhere with his talking, not only because of
its slowness, but especially because of its circumstantiality, which must
depict all trivialities in repetition and in manifold expression of the
same idea in different forms. Besides this the manner of speaking is
verbose and clumsj'', and always vague. As to content the patient
clings to the simple and the present. The ideas are limited to what
immediately concerns the patient; his personality including the disin
ease; then the
members
of his family ("family gossip," "family boast-
ing"), his clothes ("whining about clothing")
which the patients,

carefully in
many
if
and a number of
trifles
permitted, like to carry about, usually packed
papers or clothes, each carefully tied with a string,
as photographs, letters, a worthless ornament, etc.
Affectively and
hence associatively, the patients are to a high degree egocentric. The

consciousness of their inferiority, the need of support and of putting
the salvation of their personality in the foreground, of clothing vague
and also with intense

assuming a vapid
weal and woe in corre-
ideas with pathetic, beautifully coined phrases,

feeling
all
these give
them the opportunity
piety in religious circles, and of dressing their
of
sponding formulae ("God nomenclature"). With the unintelligent this

succeeds the more readily, because in their indistinct concepts and
ideas they are satisfied with generaliites to which they attach an
affective rather
itself,
among
than an intellectual content.
The
egocentricity shows
other ways, in the fact that they are incapable of evalu-
ating the interests of others; whatever causes
them joy and
anger, they
consider similarly important and emotionally colored for others.

is
It
quite characteristic that frequently they take the physician aside
with a solemn mien to
tell
him
secretly something
commonplace
or
something that was known long ago.

Perseveration and the difficulty of diverting them to another sub-
by Wernicke:
"Martha Glockner." "How old are you?"
"Martha Glockner." "Where are we now?" "Martha Flockner."
"How old are you?" "Twenty-two years old." "Where are we now?"
"Twenty-two 3'ears old." "What is your calling?" "Twenty-two years
ject are illustrated in the following conversation reported
"What
old."
is
your name?"
"Who am
I?"
"Cousin George."
Circumstantiality and the tendency to tautology are shown in the

following letter (whose dialect and orthography have been extensively
corrected)

"My
dear Director:
send you
my
451
best regards from the bottom of
my heart good health and

God's blessing and I respect you and I thank you from the bottom of
my heart and I wished all of this for the director and the minister,
and I wished this all for your relatives all of this and I beg you from
the bottom of my heart that you send the letter to Riiti which I handed
my
heart and wish you from the bottom of
week and the parents in Riiti I send. I sent my heartfelt wishes

and I respect them too and thank them too and wish them from
the bottom of my heart good health and God's blessing and the sick
and the healthy also and I have the greatest home sickness for his
services and sermon and bible lessons and all prayer books were in
me. ..."
in last
also
Ulrich gives a brief illustration of the unctuous emotionalism:

"I am the dear young lady Miss X. X. from X., Parish of X.,
Canton X., Switzerland." She wanted the physicians to explain to
her daily that she was the dearest and best Miss X. X.; she pressed
people's hands as much and as emotionally as possible, the left as well
as the right. She always wished one a dear good Sunday, a dear
good day of the week, whatever it might be, a dear good night's rest;
if one responded to her good wishes, she answered with satisfaction:
"That is the right way."
The egocentricity shows itself in the following answer to the ques"Last Christmas I
tion, "What is the significance of Christmas?"
received an apron, I wanted a skirt from my mother; she did not
give
it
to me."
Thus the conduct
of epileptics
but to those about them
it
is
to
all
appearances well regulated
readily becomes
somewhat
trying, as
much
because of their fussiness, as their adhesiveness and their clinging

to trivialities.
However one can very
readily establish a satisfactory
and not unpleasant rapport with them; where one does not get on
with the average epileptic, there is some mistake in the treatment.
They
are as clinging in their demonstration of affection as they are
persistent in their affect of offense.
They do not
release for a long
one forgets to greet them, it can dampen

their spirit for days. They busy themselves as long as they possibly
can even though not very much is produced; in the wards the more
time the proffered hand;
if
demented patients actually become a nuisance on account of their

clumsy readiness to help during the war the same zealousness showed
itself in their "war spirit"; it made them forget any consideration of
their disease and led them to try again and again to reach the front.
When left to themselves, their unsteadiness is very great. Because
;
452
they take everything to be too important and especially because of

anywhere permanently many become
their moods, they cannot remain
tramps.
The momentary mood also dominates primarily their attitude
toward the disease, which is at times regarded as something very bad

and then as improved or cured. However, their main afflictions as well
as their various secondary ailments are always a matter of extraordinary importance to them, which they like to discuss incessantly, be
it to obtain sympathy or help, or to boast of how well they are getting
on. But in the main the "epileptic optimism" (Rieger) prevails, that
is, even the more intelligent, in spite of all accidents and warnings,
never take permanent consideration of their disease; they get into
situations that are dangerous to themselves or undertake work and
responsibilities that they cannot possibly carry out.
The
attention of epileptics, corresponding to their affectivity, shows
a reduced vigility (distractibility), but a good tenacity; at the same
time
it is
very uneven at different times.
Even though many
details,
especially affective experiences,
are
remembered for a strikingly long time, nevertheless the memory after a

while becomes bad but not in a recognizable systematic way; recent
and old impressions are equally forgotten. Besides, it becomes blurred;
experiences are associated with other connections; frequently
as
far
actual
as
paroxysmal
memory
(the
illusions
it
goes
amnesias belong to the
state).
Orientation, except in conditions of
most advanced dementia which
only a few attain, and in twilight states,
is
good.
Perceptions readily become unclear; like organic cases the patients
more time than normal persons and easily make mistakes.

Furthermore, the after-effects of previous influences interfere (Persev-
require
eration)
For example, they mistake a picture
visual impression.
But the unclearness
in
terms of a previous
is not a result
of the perception
of inadequate peripheral sensory functioning; the patients are at least
capable, despite their fussiness about minutise,
the differences between two similar lines,
much
e.g.
of distinguishing
better than are healthy
Often the patient cannot follow complicated relations and

Sometimes there is a big difference between
the conception of single words and an entire sentence.
The speech of epileptics is often so characteristic that the diagnosis
can be made from it; it is slow, hesitating, in which case syllables are
people.
rapid changes of ideas.
make any progBecause of the slowness, and because the individual vowels
often repeated several times and the patients cannot

ress.^*
**
To
differentiate
it
from stuttering
festations of the speech muscles.
it
does not show any spasmodic mani-

show a
and
453
and the unaccented syllables are

becomes somewhat singsong. With this the tonal modulations are clumsy and rare, hardly
ever finely shaded, so that the speech at the same time seems somewhat
monotonous.
The degree of these speech disturbances may var>'
decidedly in the same patient: at the approach of an attack or in a
often
stressed as
rising
much
twilight state
falling
as the accented, their speech
it is
usually particularly pronounced.
Chronic hallucinating hardly ever occurs in epileptics. On the

other hand, under the affective influence delusions are very frequently
formed, especially of being treated unjustly. As a rule they are forgotten or corrected in the next opposite mood, but, like the delusions
produced
in the twilight states,
they may, in exceptional cases, have
a longer duration.
Besides symptoms of permanent epileptic degeneration,
we
regu-
larly find in the psychical field also transient manifestations which,
at least in part, are certainly equivalent to the attack.
In the course
permanent symptoms are especially pronounced.

In the first place we find the twilight states which most frequently
occur post-epileptically, but may also take place pre-epileptically and
of these, the
instead of the attack ("Equivalents").
They usually begin
quickly,
often very suddenly, and disappear again within a few minutes or

hours, after having lasted for hours or days.
weeks or even months, are
for
hallucinatory delirium.
The
rare.
Epileptic deliria, lasting
The most
frequent form
is
the
patients hallucinate and have illusions,
especially of sight, but also of the other senses, concerning another
environment, or at any rate, other influences from without, and react

Among the hallucinations red ones (partly as fire or blood)
to these.
occur with noticeable frequency.
very similar to our dreams.
The
content, in other respects,
part of the deliria
is
is
alTectively indif-
More frequent are those with an anxious or angry affect

ferent.
which readily lead to brutal acts of violence against the individual
himself and others; sexual excitements are the basis of Ripper murders,
Besides fearful visions of hell and the
or frequent exhibitionism.
devil, there occur much more rarely ecstasies which are completely
beyond the reach of reality and blissful erotic-religious hallucinations
of all the senses. Pronounced twilight states can be influenced ver>'
little; but under certain conditions one can get in touch with the
patient; however, one gets few answers, and few sensible ones. Thinking
is
usually profoundly disturbed
^^
very simple answers are more
easily obtained than complicated ones; under certain conditions the
patient can figure 7 plus 18, but no longer 7 times 18, because he can
"See
also p. 83.
454
no longer add 56 and
The
70.
associations run toward side-tracking
as in dreams, while in other respects the heavy, everywhere halting,

epileptic train of thought
is
strongly differentiated from
ing and schizophrenic thinking in spite of
ments of ideas and words.
Sound associates
patients but not actual flight of ideas.
dream think-
inexactness in disarrange-
its
The
occur in
also
many
twilight states leaves, in
most cases, a partial or complete amnesia.

Between the attacks, milder states of obnubilation are most frequent, in which sensory deceptions are entirely absent, orientation as
to place and time is disturbed little or not at all; on the other hand,
the relation with surrounding persons
attitudes are very
common.
is
usually falsified.
In the most
common
Hostile
types there
is
feeling of pressure to talk, together with strongly retarded thinking
and impeded word selection, and vague, unclear, poorly defined ideas.
At the same time sound associations and the reception of chance
material from without into the trend of ideas which never leave the
same
circle
may
simulate flight of ideas for the beginner.
and the absence

condition. Vagueness
tion
persons,
so
that
Persevera-
of real distractibility readily reveal the true

of apperception leads the patients to mistake
they
even
identify
themselves
with
others
in
transitivism.
Outwardty very
different are the clear twilight states in
which
the patients seem clear to the observer but are, in reality, extremely
restricted associatively and carry out any dreamlike action.^""
But
with Heilbronner I would like to attribute most of these conditions
to hysteria, even when they occur in epileptics as they not seldom do.
Sometimes a patient suddenly

not want to go.
With
Mere anxiety
finds himself
on a street where he did
attacks are often epileptic equivalents.
consciousness pseudo hallucinations

appear in the form of attacks, e.g. figures
who with long arms reach for the patient, an animal, the devil, or
slightly
(especially of sight)
when
in a pleasant
twilight state
clouded
may
also
mood,
may
angels, or beautiful
women.
form of a stupor of varying

degree, or continuous identifying memory deceptions may dominate
also take on the
the picture.
Furthermore somnambulism may be a (rare) epileptic symptom.

Of especial importance are the moods which are probably not
lacking in any epileptic (but which also occur in other psychopaths,
oligophrenia, and in schizophrenia).
There may be euphoric moods
of especial good feeling, often with the idea of being finally cured of
the epilepsy, but without flight of ideas (usually as a precursor of
""See
p. 112.

attacks).
Or depressive moods with or without
fear
455
which resemble
completely a melancholic mood, relatively seldom with a suicidal

impulse but very frequently with the emphasis on the incurability,
or it manifests itself in the best known mood, namely irritation, in
which, on the one hand, the patients are irritated by everything that
takes place and, on the other, conduct themselves in a very presumptu-
ous and impudent fashion so that conflicts are unavoidable. The moods
may appear suddenly and be suddenly brought to an end (especially
by an attack, the precursor of which they then were), or they may

appear furtively and last hours or several days and rarely even
longer.
common, especially headache, pains

kind
of
nervous manifestations which disand
any
here and
furthermore, one observes
character;
paroxysmal
the
show
tinctly
suddenly, attacks of
disappear
appear
and
that
troubles,
stomach
on others, also
or
attacks
impulsive
onanism
without
passion with or
fluctuairregular
spasms.
The
manifestations
of
other
twitchings and
graphic
the
in
frequently
found
which
are
tremor
tions of a more severe
Mere
paresthesias are also

there,
registration of epileptics are also included here.
may
occur in isolated form or irregularly intermingled; furthermore, like the attacks, they often repeat themselves
in a similar or actually identical form.
In the physical field also we find anomalies that belong to epilepsy.
All these syndromes
In the first place a number of congenital malformations show the

"degeneration" or the brain disease.
In the blood are found cytological and especially chemical peculiariwhich, however, fluctuate greatly in the same patient, and still
more in different cases so that as yet no clear picture can be obtained.
The entire metabolism and with it the chemistry of the urine is abnorties
mal, but cannot as yet be described in a uniform manner. It seems

fairly certain that after the attack poisonous substances are excreted.
known on what the

ous ways is based; however,
It is
not
sensitiveness to alcohol in the

it
most vari-
can be connected with the intolerance
of alcohol after injuries to the brain.
Like the other nervous processes, movements are often performed

But bodily
clumsily, and perhaps also with uncertainty.
strength remains for a noticeably long time either good or very good.
slowly,
The
course of the disease
is,
on the whole, progressive, at least in

The attacks need not
respect to the permanent psychical condition.

increase; often they even
become milder or rudimentary^
in time.
between the number and severity of the attacks and

dementia does not exist. Marked dementias may also appear with
direct connection
456
Some
a simple petit mal.
cases remain stationary, others
cured, especially with suitable treatment.

or decades are not so rare;
have attacks
it is
well
known
in earliest childhood, then
again during puberty.
Among
become
Pauses extending over years
who
that there are patients
seem cured, only to be
the milder cases
many
afflicted
recover defi-
from the attacks while the epileptic character

remains, or under certain conditions even develops more strongly
together with intellectual dementia. There are also epileptics who
have quite a number of attacks every year and nevertheless with
or without therapy do not become demented and whose character
remains relatively good.
The number of attacks differs greatly. In milder cases only a
few convulsions and twilight states may occur during their whole life
others produce several in a single day; in especially bad times they
even have many, rarely a hundred and even more. Many patients,
nitively, others only
especially in the beginning of the disease, are stricken, only or chiefly,
during the night and do not at

some the attacks are scattered,
know
that they are epileptic. In

they appear more in series.
The prospects in case of a pronounced, interparoxystical dementia
are naturally bad, even though at times a regulated therapy produces
all
in others
improvement to the extent that the subsidiary manifestations

appear.
certain
percentage,
especially
of
those
puberty, lose the attacks spontaneously and become
afflicted
little
dis-
after
or not at all
Undoubtedly a timely interference may extensively

improve many a case or even cure it and prevent further decline.
Here the prospects depend especially on the psychic condition. Extensive improvement or cure can be expected only in case of a slightly
demented."^
affected psyche.
The duration
Many meet
of
life
is
considerably
shortened by the disease.
with an accident during the attack, others die from an
early marasmus which is regularly connected with more severe dementia and cerebral atrophy. Epileptics who from birth were afflicted
with some brain disease naturally have a weak physical endurance.
Anatomical Findings. Epileptics are comparatively rich in stigmata of degeneration ^^ and other dysplasias strikingly frequent one
observes in the brain among other things ganglion cells in the white
substance, Cajal's (foetal-) cells in the upper cortical layer, as well as
other disturbances of development. As a foundation of the later dementia one finds a distinct, even though not a high grade atrophy of
;
"^ I have a decided distrust of

Socrates, or even Napoleon.
'"'
Cf. pp. 159-160.
the
diagnosis of epilepsy in
Mohammed,
457
the brain with different fonns of degeneration of the neurons, and as
an increase of the glia fibres, which, as distinguished

from paresis, remain on the whole fine, usually arrange themselves in
bunches in the interior of the brain and cover especially the surface
characteristic,
with a thick
felt of chiefly
tangential fibres, which have
tion with the deeper layers.
The
glia cells are
little
changed
connec-
in different
ways, readily increased and carry many catabolic products. What

relation these findings have to the disease is still entirely unknown as
is
the significance of the frequently found sclerosis of one or both of
ammon
the
horns with degeneration of the nerve
cells
and hypertrophy
of the glia.
In death following status epilcpticus one finds, as a rule, a higher

pressure in the cranial cavity partly because of cerebral cedema and
especially of the meninges, partly, too, probably because of cerebral
inflammation.
Causes. Epilepsy has its roots in the congenital constitution.
Hereditary burdens with mental diseases, psychopathic conditions
with familiar nervous degeneration and especially with epilepsy itself,
show the connection with a diseased
kin.
That the
"epileptic char-
acters" in such families often represent milder forms of the
ease
is
to be assumed.
The various kinds
same
of epilepsy, also,
dis-
have un-
fortunately not been kept separate in the investigations of heredity.
An
important role
is
played by the alcoholism of the parents, probably
that of a cause and not merely as a sign of a morbid family disposition.^"^
According to more recent investigations epilepsy
is
supposed
to have a connection with the familiar left-handedness, and not merely
because left-sided brain lesions at the same time dispose to
handedness and to epilepsy.

early epilepsy,
individual
life
many
epilepsy
cases
may
'Âs the
Wassermann
left-
reaction shows in
are based on hereditary
lues.
In the
be acquired from every possible brain
disease, from the uterine porencephalus, the infectious encephalitides,

and the traumata up to arteriosclerosis (the latter, however, is relatively rare) and from all sorts of poisons, especially alcohol and lead.
Whether an epileptic disposition must have existed in such patients is
not yet known. If a brain lesion is once present, cocain can precipitate an epileptic attack which may then repeat itself.
(Caution! According to Ulrich, Novocain may on the contrary be used as a local
,
anesthetic.)
The causes
^'^
of the individual attack are, as a rule, internal; never-
Stuchlik, tjber die hereditaren Beziehungen zwischen Alkoholismus und

Epilepsia, Diss. Zurich 1914, und Korrespondenzblatt f. Schweizer Aerzte. Basel
1914.
458
back and precipitate attacks (a

However, ordinarily
supposed to have released the attack is not the
theless psychic influences can hold

festival,
remedies with a suggestive effect)."*
the anger which
is
In his moodiness because of impossible

it.
demands, presumptuous conduct and irritability, the patient has
brought about the anger. Individual attacks are often precipitated
by excesses of all kinds and even by relatively slight alcoholic inThe famous moon phases have no influence; on the other
dulgence.
hand atmospheric conditions seem to be able to effect slight fluctuacause but the precursor of
tions in the frequency of the attacks.
Forms, Range.
As yet we have too
little
anatomical experience
to differentiate the described groups sharply from other diseases with

epileptic
all
attacks.
Especially must the question be raised whether
the "curable" cases, or those running their course with unnotice-
ably little dementia, or the very mild cases, generally are identical
with the inevitably progressive ones. As an uninterrupted shading
from the most favorable to the worse cases is perceptible, it is possible
but not certain that
all
or
many
of the curable
stationary cases represent only milder forms
and (apparently)
same disease.
of the
Cases with entirely different symptoms (more acute degeneration of

the nervous substance) are naturally to be excluded eo ipso.
Traumatic epilepsy as a result of injuries to the brain frequently
resembles the forms described, but it is quite evident that the organic
dementia frequently contains an admixture of the psychic and physical
signs of cerebral trauma. There are also milder cases which improve
or remain in a quiescent state.
The
reflex epilepsies cannot as yet be assigned to any classification.

Jacksonian epilepsy is not an epilepsy in our sense; but it very
often is transformed into such as the attacks assume the epileptic
type and the psychic manifestations change their nuance in the sense
of epilepsy.
In arteriosclerosis and presbyophrenia the epileptic attacks are

probably only partial manifestations of the main disease although in
one case of arteriosclerosis
In the same
way
belong to this disease.
whom
I also
found the epileptic
gliosis.
the epileptiform attacks of schizophrenia naturally
But there
are noticeably
many
patients from
one gets the impression that schizophrenic and epileptic symp-
toms have intermingled.^"^

"*
According to
Hauptmann one observed
epileptic attacks in the
hysterical attacks).
"=Corap.
p. 446.
(that
is,
no
from
in the milder forms)
war during an alarm or charge attacks
(differs
469
Kraepelin also distinguishes a "Residvxil epilepsy," recurring epileptiform attacks without a progressive course in brain scars and similar
disturbances.
The eclampsia
of children often resembles the epileptic attacks;
but the tonic stage

weakly, pronounced.
is
more
most
often
strongly, the
clonic
much more
do not become
epileptics, it is not known whether the two diseases are connected and
Spasmophilia is no primary stage of
in what way they are related.
But
as
of those children
epilepsy.
Dipsomania and alcoholic epilepsy^'"^ Most dipsomaniacs do not

seem to become severely demented, even when they have the epileptic
habitus.
On
the basis of two clear cases Kraepelin would like to class with
amok of the Malays, in which the patients sud-
epilepsy the running
down
random until they collapse or, which is more frequent, are shot
down or made harmless in some other way. The monotonous repetition of the same psychic syndrome in the various patients seems to me
denly run through the streets with drawn daggers, cut people
at
^^
to point to the material influence of a psychogenic factor.
Friedmann's Disease, which the author wants to designate with

name of Narkolepsy, consists of very frequently
recurring attacks of prolonged psychic rigidity or confusion without
the already assigned
loss of consciousness
with a turning upward of the eyes.
It occurs in
and disappears with age without dementia. Kraepelin would

like to class this disease with hysteria. At all events it does not belong
to our genuine epilepsy as some authors suppose.
Many also want to include Migrain with epilepsy. But it is a
syndrome which may occur in the most varying functional and organic
children
diseases of the nervous system.
On
the other hand, the affective epilepsies
(Bratz)
or reactive
epilepsies (Bonhoeffer) are important psychopathic states with strong
which psychic influences may more or less frequently

Kraepelin observed them especially in
unsteady people who were inclined to wander and swindle, and he
Bromide does not seem to influence
calls these epileptic swindlers.
affectivity, in
lead to epileptiform attacks.
affective epilepsy in the
Occurrence.
same
Epilepsy
specific
in
way
as
it
does the genuine form.
the older, wider sense of the term, to
be sure, is a frequent disease in all ages and in all races. "With us

undoubtedly several per thousand of the population suffer from the
"'
^'"
See Alcoholism, pp. 351-352.

Cf. Brill, Piblokto or Hysteria
and Mental
Diseases, Vol. 40, No.
Among
8.
Peary's Eskimos.
Journal of Nervous
460
According to whether or not one includes the infantile conmost cases begin in the first or second decade. The male
sex predominates considerably, particularly when the disease appears
in mature manhood; here it is evidently a result of alcoholic effects.
Recognition. In many cases the patients report nothing, or nothing
They come to the physician
characteristic, concerning the attacks.
because of nervous symptoms, changes of character, unrecognized or
disease.
vulsions,
abortive twilight states; then the recognition is not easy. But frequently they bring with them a complete diagnosis or a clear anamnesis.
Even though
the individual attack does not permit of recognition,
nevertheless a disease in which for years such attacks have occurred

in
is
somewhat
an epilepsy, and
definite intervals is invariably
nothing important in addition,
if
there
will be a genuine epilepsy.
The
symptoms
positive findings of the psychic
confirm the diagnosis.
it
will in
most cases quickly
Typical absences, except at times in brain
tumors, occur almost only in epilepsy and are, to that extent, more
During
characteristic than the big attacks.
more advanced chronic
also in
is
usually especially evident as against other disturbances
the organic)
is
epileptic excitations, but
conditions, the slow, hesitating reaction
^^
:
"A
patient
not an epileptic" (Vogt)
to the clarification.
who responds
It offers
quickly to
all
my
(except
objections,
Often the anamnesis can contribute much

evidence that the attacks already existed
earlier, or narrates experiences
that point in that direction, such as
bed during sleep

knocked out in the morning,
tongue bites of unknown origin. But one must not expect to find
frequently tongue scars; even severe wounds of the tongue sometimes
heal without a mark; scars from injuries to the body are more freisolated bed-wettings in later years, falling out of
(usually without
waking up)
feeling
Heredity of a similar kind
quent.
Under
certain
conditions
may
the
organic mental or brain disease
may
also be considered.
dift'erential
diagnosis
from
an
for a time be difficult, because,
and absences, the psychic symptoms

and attacks of confusion) of the two morbid groups
also be similar.
In this case, after a minute physical and
aside from the convulsive attacks

(associations
may
psychic examination, the discovery of the specific signs of one or the

other disease must finally decide.
From dementia
proecox, aside
tion forms, the diagnosis
is
from the mentioned mixed or transi-
usually easy.
should notice especially the hesitating speech

clear
and
Cf
furthermore the uniform,
real affective state in the epileptic, as against the artificial
state of the schizophrenic

"'
In the twilight state one

;
also brain injuries.
which
is difficult
to interpret.
The
difficult

distractability
must not be mistaken
461
for affective rigidity:
can
if
violently deprive a person in a euphoric twilight state of his beloved
without his changing his affective attitude even a little bit, this
behavior differs from the schizophrenic attitude by the fact that the
epileptic defends himself but in reality is not distracted at all, even
trifles
intellectually.
Minor
or
traits
He
has therefore no reason for changing the
by themselves may
affect.
often facilitate the diagnosis
also
make it certain; thus an apparently totally confused person in

who in this state continually handles in both hands a care-
motion,
fully folded handkerchief
always an
Among
to
the more striking
both diseases:
neologisms.
without disarranging the
But
symptoms the following

symptoms
The symbolism
and conceptions
the most senseless
The
word formations than
epileptic
in
is
and
by
it
as
schizophrenia.
in
It
In schizophrenia the indefi-
altogether unbalanced.
many
conceptions
while the demented epileptic finds

limitations.
common
of epilepsy does not lead to the
remains rather a peculiarity of thinking.

niteness of the ideas
are
are plainly distinguished
delusions or even to hallucinations,
clear
probably
tendency to symbolism, unclear ideas,
the
as a rule the
different nuances.
fixed
folds, is
epileptic.
entirely
Besides
normal ones occur,
difficult at
all
times to create
neologisms consist rather of poor
genuine new creations; ''unquitted love"
probably an epileptic formation:
is
"Dossier path" for the secretive
manner
of persecution and "Anona" for morphine are schizophrenic.

Mistaking an epileptic crepuscular attack of rage for the manic
destructive impulse
of distractibility
is
and
avoided,
among
flight of ideas
other things,
by the absence
(but one must not associate the
circumstantiality in which the patient
is
not distractible and does
not forget his goal as well as the liability to interruption, with the goalshifting flight of ideas).
The attacks
are
well
distinguished
from the hysterical;
it
is
especially important to think of the tonic-clonic type, the brief dura-
tion of these phases, the tongue biting

rigidity of the pupils.
and other
injuries,
and the
Involuntary passing of urine and feces hardly
occurs in an hysterical attack.

after the attack excludes
mere
Ankle clonus or the Babinski sign

According to Bosshard^^^
hysteria.
in a pronounced epileptic attack there is regularly found a leucocytosis

which differs from the "work-leucocytoses," by the early appearance
Under certain circumstances
of lymphocytosis and mononucleosis.
the pulse, remaining good in spite of an apparently serious condition,
gives evidence of hysteria; also the facts that the patients are accessible
"
Uber Leukocytenvermehrung bei
epilept.
Anfiillen.
Diss.
Ziirich
1917.
462
to
influences,
the
consideration
for
themselves
and^ others
struggling and falling, as well as the reacting pupils,
ments are foreign to the
all
when
these ele-
The marked dependence
epileptic attack.
of the hysterical attack on external influences,
and the
slight
dependence
of the epileptic syndromes, can with a careful evaluation of circum-
In
stances often alone suffice for the diagnosis.
should not be forgotten that in epilepsy
all
all
other respects
hysterical
it
symptoms may
occur.
The same
from simulation.
signs help to distinguish the attack
Attacks of dizziness
may
also occur in the nervous, arteriosclerotics,
and generally in all brain diseases, even though rarely in the same
development as in epilepsy, with the brief duration, and the sharp,
sudden limitation.^^"
Under
certain conditions
it is
impossible for the
moment
to distin-
guish the epileptic twilight state from the pathological drunkenness,

especially because epileptiform attacks occur in both,
and alcohol may
precipitate epileptic syndromes.
From
the epileptic twilight state to the
oligophrenics there are so
many
moods and
excitations of
under certain circumsome time, whether mere
transitions, that
stances the question has to be left open for
oligophrenia or combination with epilepsy
is
present.
In judicial cases one can resort, with the patient's consent, to the
of having the patient take bromide in medium doses for
about three weeks, then suddenly stop the drug and give him well
salted foods, or besides the foods, at least one ounce of cooking salt
in one day. In latent epilepsy this may sometimes provoke an attack.
The pathology of genuine epilepsy is, in spite of all the works
devoted to it, still entirely unknown.
It may be a constitutional
degeneration of the brain, something teratological; the frequent
physical stigmata of degeneration, the Cajal cells and the other brain
findings, which may, however, be secondary, would point to this.
In
accordance with the present humoral pathological views, it or at least
the convulsive attack with its equivalent is to be considered a result
of an autointoxication.
The chemical examinations of the blood and
remedy
urine favor this in spite of their lack of uniformity, but above all the
observation, that
when
in patients that
have preparoxysmal moods
the attacks are suppressed with bromide, these moods are easily pro-
longed until an attack
is
permitted.
The convulsive
attack, therefore,
seems to have the significance of a crisis, and as the urine is said to

be more poisonous immediately after the attacks than otherwise, this
crisis might be chemical.
""
For absences, compare above, pp. 447-448.

One can
it is
well,
which can be verified

something to do with the epilepsy;
also think that tlie brain pressure
in the status epilepticus
but
463
may have
however, to differentiate the
known
clinical manifestations
of brain pressure from epilepsy.
one
Physiologically
must conclude that the brain cortex and
deeper locations together participate in the production of the attack.
Treatment.
hinder
the
Nothing can be done by way of prevention except to

of degenerates, and work against alcoholic
marriage
indulgence.
In the treatment of the disease itself bromide is the most important

and the only chemical remedy of significance. It is given as potassium
bromide (the cheapest) or as sodium bromide, which avoids the effects
of the potassium which, however, are not very noticeable, or
it
may
be given in the form of a mixture of ammonium, sodium and potas-
sium bromides
in equal parts in doses of
(in children, of course,
correspondingly
from 3 to 8 grammes a day
less).
One
tries the
dose after
which the attacks disappear or are reduced to a minimum;

beginning, perhaps in the course of the
little,
first
year,
it
may
in the
be reduced
but later this dose is retained continually for years; best of

Omissions and variations are soon paid for in the cases
all forever.
A fatal status epilepticus often follows a

important that the salt be given largely diluted,
that can be influenced.
sudden omission.
is
about two decileters per gramme, because otherwise the stomach is
affected, and the patient too easily becomes tired of the remedy.
The effect can be increased bj^ the reduction (not deprivation) of
It
grammes per day). As a large quantity of

taken up in soup, about 20 grammes, the latter may be salted
with bromide or most palatably, by substituting a bouillon of sedobrol,
table salt (from 5 to 10

it is
a combination of sodium bromide and soup spices. In this form the

remedy is gladly taken, does the least harm, and otherwise, too, seems
to have the best results.
In severe cases Ulrich gives successfully
Sedobrol combined with Chloral-hydrate 0.5 to L5 grammes daily,
given in the evening, especially in night attacks.
Bromism
by
by
is
usually better combatted by doses of table salt than
larger reductions of the bromide or

arsenic;
in
case of open
its
withdrawal (furthermore
wounds mercury
plaster
or
mercun.-
ointments).
Not only the regular taking of the remedy but the regulation
manner of living is important, in w^hich excesses in
the whole
and affective stimuli, must

must be forbidden. Other
and strong condiments, as well as meat diet, should
directions, in work, food, drink, recreation,
be avoided.
Alcohol, even in small doses,
stimuli like caffein
of
all
464
many cases a diet with large quantities of milk seems

To recommend marriage, as is often done, and not only by
be restricted; in
useful.
the laity, should be branded as a crime.
Some cases which do not respond to bromides may improve by

Luminal taken evenings in one dose of 0.05-0.01. It can eventually
be combined with bromides. But one must not continue to give this
narcotic for years, and like bromide it should not be suddenly stopped.
As without confinement epileptics readily make the rigid enforcement of the treatment difficult because of their moods and fits and
strong reactions to light discomforts, it is often wise to have them
put into an asylum where the stay should last many months, a year,
or even more.^^^
If
one sees that a substantial gain can no longer be
obtained with bromide, which is usual in the advanced cases, who

Where
e.g. hang on in the insane asylums, it should be given up.
is always occasion for friction with
and when a status makes the use of bromide
necessary it is obviously more effective in patients not habituated to it.
Of the numerous surgical interferences already undertaken against
epilepsy, there have survived only the operations for irritating
peripheral scars (a very rare cause of epilepsy), of brain scars and
exostoses of the inner cranium, and "pressure relief" by trepanation
with the greatest possible prevention of new bone formation. But
these cases too must be treated with bromide before and after the
medications do no good there
these
moody
patients,
operation.
In epilepsy after brain injury severe physical and mental exertion

Therefore, when possible, the
the appearance of attacks.
patients are kept busy much under the maximum of their capacity.
In exceptional cases the single attacks may be checked by binding
of the member in which the aura appears with an Esmarch bandage,
favors
or
by extending an aura convulsion.
Other interferences, from with-
out or from the patients themselves, are at times successful only in

exceptional cases.
Usually the attack must be permitted to run
its
Against the status epilepticus amylenehydrate (in form of

an enema in some vehicle) in doses from 5 to 6 grammes is effective;
perhaps still better is bromide plus chloral hydrate (e.g. Potassium
course.
Bromide
hour up
2.0,
chloral hydrate 1.0 to 2.0, to be repeated every half
to the
maximum
dose of chloral), perhaps combined with
baths of almost body temperature.^^^

"* For details, see Ulrich, Beitr. zur Techn. der wirks.
Brombehdlg. Korresp.
Basel 1914, Nr. 21.
Bl. fur Schweizerarzte.
"- In the local asylum for epileptics as a result of the bromide treatment with
a reduced
salt diet
no status has occurred
for years.

465
Against injuries during the attack nothing much can be done prowarn the patients usually in vain to be sure
phylactically except to
not to get into situations in which an attack
When
a certain part of the head
tected
by a protective covering.
prevent
many
accidents, but not
is
may become
repeatedly injured,
it
dangerous.
can be pro-
Careful supervision can naturally
of the proximity of the attack often
whom the aura warns

have the time to get themselves
Patients
all.
still
into a secure position or to call the protecting orderly. Besides obvious

measures he has to be especially careful that the patient does not
choke in the state of sopor when the tongue falls backwards.
MANIC-DEPRESSIVE INSANITY
XI.
Group of the Affective Psychoses
^^^
In not a small number of psychoses, displacements of moods are in

the foreground and the remaining fundamental
symptoms can
fre-
quently be so exactly deduced from the affective anomalies that mild

cases cannot be distinguished symptomatically from normal affective
On closer
fluctuations.
explanation
is
inspection, to be sure, other cases
show that
this
nevertheless not sufficient, and that the disturbance of
the affect represents merely the most conspicuous
symptom
of
general transformation of the psyche that cannot as yet be compre-
The
hended.
diseases are not progressive
and never lead to a dementia
that could be compared with that of the organic, epileptic, and schizo-
phrenic forms.
As
to the affection of the intellectual activity
it is
question of equalizable disturbances, which for the most part look

like
accompanying
the
intellectual
manifestations
of
exaggerated
affective fluctuations.
According to our present knowledge the basic symptoms are:

1. Exalted or depressive moods.
2. Flight of ideas or retardation of the mental stream.
3.
Abnormal
facilitation or retardation of the centrifugal functions
of resolution, of acting, inclusive of the psychic elements of motility.
and pressure activity on the one hand

and centrifugal retardation on the
In
other hand (melancholia) are the most frequent combinations.
the cases that reach the psychiatrist these syndromes nearly always
occur in the forms of attacks and the intervals seem to be about
normal; but it may also be a case of a persistent peculiarity which
As accessory syryiptams there
is then invariably of a lesser degree.
Euphoria,
(mania)
flight
of
ideas,
depression, associative
,
^ Not
to be mistaken for the reaction psychoses.

466
occur also delusions and hallucinations (almost only of hearing and

and "nervous" manifestations.
sight),
The mood
The Manic Attack.

exalted feeling of
of the
manic attack consists of an
The
euphoria, and cheerfulness.
self,
patients feel
happy, "overjoyed"; and experiences are colored with pleasant feelings; they are insensitive to depressive experiences; minor "unpleasantnesses" are more readily felt, and especially everything that hurts
the patient's enhanced feeling of self; and because in his over-estimation
of himself he is constantly making demands that cannot be fulfilled,
he is always in a state of discord, anger and rage, with his environment. Moreover, the mood of the manic is very fluctuating; with great
outbursts
follows every slight variation of the imagination, but in
it
pronounced mania
it
does not easily descend by
the depressive or anxious.
On
to depression, that last a quarter of an hour,
two days, are not at

directly reduced.
To
all rare.
when
of reaction to
an hour, or sometimes
Sensitiveness to physical pain
is
not
be sure, the patients frequently do not notice
pains; when, however, they have
operation
way
the other hand, endogenous reversals
the attention
is
e.g.
to be subjected to a slight
directed to the injury, they can even
be very tender.
The thinking of the manic is flighty.^^* He jumps by by-paths

from one subject to another, and cannot adhere to anything. With
this the ideas run along very easily and involuntarily, even so freely
that it may be felt as unpleasant by the patient. In severer cases the
patient is also bothered with a consciousness of unclearness, and an
inability to arrange his thoughts and think them out. Aside from the
severest forms only, where it looks as if the patient's speech and finally
the listener's intelligence could not follow the wild racing of the ideas
(flighty confusion),
individual ideas.
ciple.
one finds as a rule the thread that connects the

not in prin-
It is not a case of incoherence, at least
The thinking
is
incomplete and flighty but not "unclear" in
the sense of psychopathology.
Up
to
advanced stages of the disease
one can converse with the manic, and more than in his normal times,
he displays a rapid grasp and evaluation of the opponent's weakness,

giving quick, witty, or sarcastic answers, or pettifogging logic.
Transiently in the course of an attack one
may
observe a disturb-
ance of thought having a certain similarity to a dream.^^^ It may

persist for hours or days, in exceptional cases also during the entire
phase, and shows subjective or objective unclearness of
logical connections, the nature of
"*See
'""
To
all ideas and

which has not yet been studied.
p. 71.
be distinguished from complicating hysterical trance-conditions.
467
Disturbances of apperception do not become noticeable in ordinary

Reactions to remarks and changes of situation generally
are rapid and from the patient's point of view correct. To be sure,
intercourse.
in
an experimental
test,
disturbance of perceptions.
make many
errors, which, howand not by an actual

The orientation as to time and place,
the patients
ever, are to be accounted for
by
"flightiness,"
except in the severest cases of flighty confusion, also remains undisturbed.
Naturally, the situation
is
invariably incorrectly estimated,
inasmuch as the patients usually consider themselves "particularly

well," and in any case cannot understand the restrictions of their
freedom of action.
The attention is characterized by an extreme distractibility from
without and within.
Just as the ideas readily appear and crowd up, they also translate
themselves readily and of necessity (but without a subjective feeling
Interest in everything
of compulsion) into resolutions and actions.
is at the same time leveled upwards
A thought is aroused; without
any consideration for the object of thought at hand, it is pursued until
it is supplanted by another.
The patient sees something and grasps
it; he notices that the physician wears a glass eye and at once calls out
in the first moment of meeting:
"But you only have one eye," which
the one-eyed Dr. Jolly Sr. makes use of in diagnosing his cases; the
idea crops up that something should be done, and without the noticeable intervention of consideration and resolution, he acts. Obstacles
are not
felt.
from pressure
The
The
patients cannot be without occupation; they suffer
activity.
external picture varies according to the severity of the disease
from mild manic excitability to "frenzy." In the submanias the patient

is more active than usual
in small and big affairs he gets many plans
that he at once seeks to carry out; he gets up especially early to take
long walks or take part in some athletic sport; he makes inventions,
poems, wants to improve something in the universe, mixes in every;
thing imaginable that does not concern him, travels about, or enlarges
his business;
his mother's burial
arrangement.
becomes an extraordinary-
bank employee, w4ien
w\ar threatened,
festive
made
pro-
posals to his government for securing the supply of silver, and suc-
ceeded in being sent to Rothschild in London.
young
girl for
the
time comes to a federation of women's clubs and as a president

of the federation is being sought, she at once indicates that she is
prepared to accept. In associating with strangers or persons of note,
first
may conduct himself as if with intimate friends.

Because of lack of restraint and his presumptions he gets into trouble.
the sub-manic
468
Often during the entire duration of the attack he indulges in litigations.

his good nature also manifests itself in a particularly lively
fashion; a bug alone on the street arouses the patient's sympathy, and
he carries it to a bakery where he buys a trifle in order to let it loose
But
Against excesses of
there.
kinds,
all
especially
When
wastefulness, inhibitions are lacking.
sexual,
alcoholic,
called to account, the
patient not only has excuses but "good reasons" for his conduct ("folie
raisonnante")
Because
because of the falling
of the
more rapid flow
even though something worth while
and when the patient
cases
The heightened
is
and especially
is
produced only
in
very mild
otherwise talented in this direction.
sensibilities naturally
in the rather higher
If
of ideas,
off of inhibitions, artistic activities are facilitated
grades,
have the
effect of furthering this.
institutional treatment
becomes
necessary, the patient keeps the ward, the physicians, and the attend-
ants constantly on the go.
arrangements very
fine,
He makes
but wants to
jokes,
wants to
help, finds
make improvements; he
many
protests
against the "restraint" even to the extent of severe outbursts of rage
with the destruction of everything within reach; but violent acts
toward persons are noticeably
perhaps occasional slaps in
rare, except
At night the patient keeps on singing, or makes a doll

Female patients, in greater numbers
of life size out of the bed, etc.
and more regularly than the male, are conspicuous for their marked
eroticism, going as far as the most shameless acts. In spite of all, one
the face,
etc.
can easily get a good rapport with the patients, as if with spoiled
children, whom one likes.
("How goes it with you?" "Very well.
Everything pleases me and I can run well," "Run" being a fiighty
association to the verb "goes" in the question.)
In the highest grade of mania frenzy (Tobsucht) appears permanently; the patients are in "incessant activity," tear up, destroy, in
order to construct with the remains anything at
all,
a costume, a statue,
a relief of Switzerland; they smear, scold, howl, sing, hop; nothing
completed, one "fragment of an action" supplants the other.

expressions do not
In
all
forms,
become
it is
is
The
really senseless.
only by
way
of exception that one does not find
a great talkativeness up to incessant logorrhcea as a partial manifestation of the pressure activity.
In severer cases the sentences are no
longer completed, because before that can be done there

a
new
idea to be expressed.
Citations from
are intermingled; occasionally, too, a
new language
hand-writing shows the same disturbances, there

ness,
mixture of various languages; the writing
sorts of things are sketched with
it;
in
is
always
available languages
all
is
is
spite of
is
invented.
flightiness,
The
uneven-
helter skelter, all
many
attempts at
THE INIMVIDUAL MENTAL

aesthetic
decoration, sometiiinf^ very dirty
produced.
bility, a
But above
all
is
in
and disorderly
469
is
finally
the hand-writing shows the patient's excita-
very important attribute
part of the writing
JJISEASES
in respect to the
treatment: a large
the beginning, entirely or relatively, weil
arranged and then becomes more and more morbid.

a very general attribute in mania.
The
Excitability
is
patients are quieter, the fewer
the stimuli affecting them, and the fewer their opportunities to express
The curve of hand-writing pressure shows

and rapid movements. More exact examination of motility
shows that the movements progress easily and quickly the maximum
of strength, at least in ergographic tests, is less than in the healthy.
It is the lack of consideration for everything and the psychical energy
of the movements that make the patients appear stronger; this is
especially accentuated by the endurance and the absence of a feeling
the impulse to activity.

energetic
of exhaustion.
As accessory symptoms
in these ordinary
forms of mania, there
more rarely
and taste (touch or bodily sensations are hardly ever present)
but they have little influence on the picture. Ideas of over-estimation
are rarely absent, and frequently it goes as far as delusions of grandeur,
the content of which does not really become senseless, but remains at
least imaginable. The most absurd grandiose idea that I saw was that
of a Swiss who thought he would become emperor.
But one must
are also illusions and hallucinationc of sight and hearing,
of smell
take great care not to mistake ordinary playfulness for delusions, for
which the patients very readily give occasion, especially so in their,

every day "mistaking of persons." The patients designate the people
about them with other names, which is often based on any slight internal or external resemblance, and retain the fiction for a long time;
but if one remains suspicious one can probably offer proof in all cases
that it is a case of some kind of joke. On the other hand, the feelings of
being injured and unjustly treated may often resemble a delusion of
persecution, which, however, at the first glance
is
usually distinguished
from the paranoiac and paranoid delusion of persecution by a lack

of fixations and by the whole manner of expression.
Nervous symptoms are vers' rarely lacking in the manics, but
obtain
little
significance in the euphoria.
dominate the picture, or if the thought disturbance

advances to. unclearness and to the formation of confused delusions,
we speak of manic insanity, even though the euphoria is mixed with,
transient states of anxiety and depression.
There are also cases (very rare), where delusions and hallucinations
merge into the background, but the disturbance of thought deviates
If hallucinations
470
(^}
Figs. 37 (a)
and
(b).
Marked
excitability
and
/^^3^5^.^>;^^^ ^y^^^ -^^^î^^Ci;^^^^^-^^
pressure activity in a very flighty manic patient.
471
472
at the height of the disease
from the
get in touch with the patients
flight of ideas.
in incomprehensible
One cannot really

ways they become
violent, externally they have a certain resemblance to excited catatonics but all schizophrenic signs are absent, while the thought dis-
turbance cannot yet be characterized.

Melancholia.
The depressive phase colors all experiences painfully; often anxiety is added (sometimes in the form of prcBCordial
however, the patients like to complain that they have no
anxiety)
;
emotion; everything seems colorless, and strange.
"Colorless" also
Fig. 38. Facial expression of a melancholic.

Position of the head and the
glance are lowered. The furrowed skin of the forehead is drawn more strongly
than ordinary.
often refers to perceptions, but the ability to distinguish colors remains
normal.
The mimic
with very
a
little,
phrenia.
fails
little
expression
is
painful, desperate, anxious usually
mobility; but as the conceptual content changes just
one cannot speak of the "rigidity" of the affects as in schizoIn more severe cases the mimic secretion of tears invariably
to function; the patients distort the face, sob, all just as in
crying, but the eyes remain dry.
A
inates
third
mimic sign of depression generally origmain fold of the upper lid at the edges of its inner
contracted upward and a little backwards, so that the arch is
particularly noticeable
when
is
the
there changed to an angle (Veraguth)

The
association of ideas
is
and hiborious to the patients;
retarded."
it
473
Thinking becomes slow
revolves monotonously about their
misfortune^ "I think but do not get anywhere. I busy myself all the
time with something and torture myself because I cannot progress"
But to the extent that the affect does not cut off certain
(Wernicke)
.
ideas, the melancholic patients
can more readily get a proper view of

when in milder
the more complicated relations than can the manics,

cases
a certain objective interest induces them to do
activities
are retarded.
made
that
As
to content, all thoughts
that do not harmonize with the psychic pain, so
comes to a pretty complete monideism.
it
Fig.
upper
difficult
All psychical
In more severe cases even retardation of
sensory perception can be demonstrated.

are
so.
39.Veraguth's fold
lid in depression.
of
the
Fig. 40.
Normal fold of the upper
lid.
Apperception also is less defective than in the manic. Melancholies

do not make mistakes in reading. To be sure, the threshold values
in apperception tests seem, according to Kraepelin, to be heightened.
Orientation is good except in the dreamlike cases into which
melancholias seem to merge more frequently than the manias.
Attention remains concentrated on the imagined misfortune; distractibility is difficult or impossible; even within the melancholic
idea, attention
moves with
difficulty; it does
not pass readily from
one topic to another.
The
centrifugal junctions are very seriously impaired.
Irresolution
may grow to an unbelievable extent; a patient may want to change

her place at the table, lift up the chair, and then require half an hour
to decide whether and where she should place it.
Movements become trjang, slow, and weak. The limbs are as
heavy as "lead." Movements require just as much exertion as does
thinking.
""
See
p. 74.

474
More
mania one observes
frequently than in
symptoms
The devil appears
They hear themselves
as accessory
delusions and hallucinations (of sight and hearing).
at the window, makes faces at the patients.

condemned, they hear the scaffold erected on which they are to be
executed, and their relatives crying who must suffer on their account,
or starve or otherwise perish miserably.
But the
delusions especially are never absent in a pronounced
case and always as delusions of economic, bodily, and spiritual ruin.
The patients think that they became poor, and it does no good to
show them their valuables or their balance in the bank; that has no
Debts are there anyway, or demands are to
significance for them.
The patients have a
be expected that will wipe out everything.
severe, incurable disease acquired through sin, naturally not a
This delusion
cholia.
with the depression

tract,
and
contraction of the throat connected

in
difficulties
swallowing prove to them
a closing of the oesophagus, inactivity of the digestive
is
and
melan-
supported by feelings of uneasiness in the
The convulsive
digestive tract.
that there
is
number
of other severe disturbances.
The
patients have
sinned in a dreadful manner; even the Grace of Christ cannot save
them; they have perpetrated especially the sin against the Holy
Ghost which can never be forgiven. "Even when I drink a little cold
They
water, it is stolen and I have eaten and drunk so much."
involuntarily examine their whole life to find such crimes; they
transform slight mistakes or even entirely innocent acts into the
In the form of delusions of reference they sometimes
greatest sins.
attach new ideas to what goes on about them. It is their fault that
the other patients are sick, that one has died; because of
them the war
broke out, because of their sins people must despise them; every one
talks about them; in this world and the next they must be punished,
usually in the most terrible way.
The melancholies have deserved
their tortures in contrast with the "persecuted."
In a milder melanappear now and then that things are not so

an expected punishment may appear unjust. In other
may sometimes appear, in the endlessly complicated
human psyche, a real idea of persecution, e.g. even in
but to melancholia belongs only the depressive dehi-
cholia the feeling
bad as
all
that;
cases also there
workings of the
healthy people
may
whose variations in
sions,^^''
nificance
are
entirely
and prognostic sigkatathymic delusion of
genesis, in diagnostic,
different
from
the
persecution.
Not
at all rare are compulsive fears, transitory or lasting through-
out the entire phase,

"'Seep.
92.
e.g.
doing some
harm
to the loved one, or
com-
475
pulsive thoughts, often of a coprolalic or sacrilegious nature. Unjustifiable self-reproaches may assume a compulsive form before belief
in their correctness
Among
comes
in
and transforms them
the other accessory
into delusions.
symptoms the nervous ones should be
mentioned again which, however, in connection with anxiety, the

tendency to ideas concerning diseases, and the painful coloring of all
experiences take on a far greater significance than in mania; the
patients often complain chiefly about all sorts of weaknesses, black
spots before the eyes, roaring in the ears, headache and other
parasthesias. The beginning of the disease often gives the impression
of "Neurasthenia" (as do the mild forms during the entire course.)
Passing hysteriform syndromes also occur, e.g. fainting spells, attacks
of dizziness,
and crying
spells.
Their behavior corresponds to the disease. In certain relatively

milder cases, the patients try by mechanical, incessant work to keep
away the anguish and probably at the same time make up for their
supposed derelictions. But usually the ability to work declines rapidly,
which, in turn, naturally increases the patients' pain. Even in moderately severe cases hardly any work is done. It may become too complicated for the patient to get from one bed to another (Kraepelin)
they sit or lie about, and move only very little it may even go as far
;
Sometimes they
as stuporous immobility.
Under
hardly spontaneously.
still
reply to questions, but
certain conditions they can
still
copy
but can no longer write a letter. In severe cases orthographic and

grammatical errors also occur. But a letter often shows the preservation of intelligence,
concerning
contact
is
all
by
its
situations
correct form, and by the clear inquiries

even in patients with whom intellectual
prevented by retardation.
Even when
a decision has been put in operation, the patients are
not satisfied with
it;
whatever has been done, has always been just
the wrong thing.
Where anxiety predominates it often expresses itself in restless

movements such as striving to get away, or clinging to people; more
rarely in loud wailing, etc. {Melancholia agitata, activa). But in regard to other actions and thinking these patients are retarded neverThere may also be impulsive masturbation and, under certheless.
tain conditions, attacks of excessive hunger as observed in the nervous,
are not rare accompanying manifestations of the anxiety. As Raptus
melancholicus one designates the manifestation wherein otherwise retarded patients suddenly do something with great energy- only to
return to their previous external calm; but wherever I myself observed
these manifestations,
it
involved catatonics.
476
Speech is quiet, slow, as brief as possible, often up to complete

mutism. Only rarely does one observe an endless, monotonous whining.
In the same way the hand-writing shows in its pressure curve, weak
and greatly prolonged movements (Kraepelin)
Nearly all melancholies have suicidal impulses and would perish
if they were not guarded.
In the simple cases of melancholia siryiplex the depressive retardation dominates the picture.
The patients are sad, anxious, see only
the bad side of everything, suffer from their inability to work, and
announce that they are tired of life. Here especially a mild form of
depersonalization is comparatively often noticeable in which the
patients conceive the outer world as well as their own person as something different and strange. Peculiar illusions of persecution bother
the patient (it is just as if the corridor were crooked, the light doubled,
the whole house reduced in size). They can no longer get the right
idea of their home and their relatives.
Compulsive ideas, too, are
more noticeable here than in the severer forms. Delusions and especially hallucinations
may
If the retardation
little
be lacking in the mildest cases.
becomes severe so that the patients speak very
and no longer take care of themselves, the picture
is
then called
depressive stupor.
In the severer cases delusions are invariably present and

stand in the foreground.
At
the
may
same time the hallucinations usually
but not always increase.
The
depressive attack, also, because of the increase of the hallucina-
tions or the thought disturbance,
may assume
appearance [melancholic insanity).

picture that
less
would soonest deserve the name
shows at once that
following
As an
may
it
a paranoid or delirious
morbid
and neverthe-
illustration of a
of paranoid,
belongs to manic-depressive insanity, the
serve as a characteristic picture:
Stock broker, born 1847. Three near relatives melancholic. Quiet,

In 1889 sleeplessness, anxiety, increasing inability to
keep books. After a while distrustful; then ideas that his letters
able, reliable.
were being taken, that poison was being given to him, and as a result
People wanted to drug him,
of which he no longer could see well.
said
to be syphilitic; people
and have him endorse notes. He was
taken
from
him.
Attempted suicide.
knew it; everything was being
and some
misprint
in
the
newspaper
Then taken to insane asylum. A
"Everybody
has
refer
him.
to
utterances of others were supposed to
him.
being
cooked
especially
for
turned against me." Bad food was
He complained about everything and everybody and was very obtrusive. The physician gave him rheumatic pains in the shoulder; he
477
Fig. 41 is the handwriting of the same patient who furnished the material for
37 (a) and (b), just as he mei'ged into a state of depression. Here the patient
shows a very scant productivity, and in contradistinction to his former euphoria
he now describes the classical feelings of melancholia toward the end of a manic
condition. Content full of feeling.
Contrasted "^-ith his former writing mania,
there is a retardation in the movements, shown by the slanting lines.
complained, cried and whined.

Fairly rapid cure after one year.
Hallucinations could not be proven.
Then complete health.
He improved
In 1898, after an operation on his son, he was excessively

concerned, anxious, sleepless; melancholic ideas of povertj' which.
his business.
478
however, were soon entirely supplanted by delusions of persecution.
The
and the greatest occurrences indicated that he was being

life was in danger.
He had to be answerable
for everybody that did anything for him. On the whole he considered
himself innocent, and only rarely had a melancholic idea of sinfulness.
This time he saw ''something horrible" on the floor, because of which
he became afraid and violent. He thought that the physician injected
poison into him with the stethoscope. On his birthday he awaited
death; fear of a "nameless misfortune." His surroundings changed into
animals that threatened him (but besides this there was still a certain
understanding of what was real and possible). Then again he refers
least
persecuted and that his
He
everything to himself.
all sorts of
is
being persecuted,
things put into his food.
With
The
made fun
of, is
having
pictures on the wall have
these one can put ideas into his head.
This
Later for several years following, there
was a plain hypomanic condition with unimpaired ability to work and
clear insight. In 1915, again an entirely similar attack in which the
a reference to him.
attack also lasted a year.
patient died.
Mixed
The three cardinal symptoms of mania and

and depressed mood, flight of ideas and mental
retardation, pressure activity and inhibition of the will, represent three
States.
A.
depression, exalted
pairs of contrasts.
The corresponding
thought process, and of centrifugality
functions of
affectivity,
of
changed
in the disease as shown in types so far presented, and as they are in
their minor development in the normal. But besides the positive fluctuations in the one field there may be negative ones in the other, and
what is more they may occur in all of the six possible combinations
which aside from the two main groups, melancholia and mania, result
from the mutation of the three pairs. The most important of these
mixed forms are: the depressive "anxious m/inia" (the affect is negative, while the thought process and certrifugality are positive), in
which with depressed affect combined with ideas of sin, the patients
speak and write much and complain that the thoughts come of themselves.
In "excited depression" (affect and thought process negative,
centrifugality positive) one has sought to include the picture of melancholia agitata. But this is incorrect; the agitation is nothing but
the expression of anxiety and with it the other centrifugal functions
are plainly retarded. The "mania with impoverished thought" (affect
and centrifugality positive, associations negative) frequently occurs
during the decline of a severe manic stage. Outwardly the patients
seem easily moved, readily make a noise, feel good, but do not perceive properly; try to speak but cannot say much and repeat them,
are, as a rule, similarly

selves.
As a
transition to this there often appear in the manifestation
same
endless narratives of the
From
places.
479
sort of thing,
names
of persons, or of
the inhibition of the mental and centrifugal functions
affect, there originates the picture of a coagulated mania

("manic stupor") in which the patients, though they have a cheerful
expression, are immovable, unless at times at any opportunity they
and a positive
unsuspectingly play a trick.
B. Another kind of mixture of positive and negative deviation
may
same psychologic function which we have

artificially limited.
Within the limits of thinking retardation and
flight of ideas may occur side by side, whence originates heaviness
of the mental stream combined with sudden changes, and frequent
also originate within the
sound associations (as
in certain stages of alcoholic effects).
ture of despair and cheerful self-contempt

as grim humor,
ideas
"humor
and depression
(the patient
is
is
of the gallows."
is
^^^
mix-
designated by Kraepelin
mixture of grandiose
also said to occur in manic-depressive insanity
persecuted by the emperor and king; he desires a
romantic death and similar things, Kraepelin).
Kraepelin presents
normally strong and yet very much
prolonged; this indicates high pressure with a retardation of movement. Oneof my female patients covered all available pieces of paper
with writing but in a depressive manner with markedly sloping lines.
Her affect, too, was a mixture of depression and exaltation. The
pressure activity, combined with muteness, not at all rare in schizoa hand-writing curve which
phrenia,
supposed to have been noticed here
is
patient I
is
saw
in
also.
two attacks a protracted pressure
In one female
activity
(long
walks) with the absence of a feeling of exhaustion with negative

signs of all other functions.
The mixed
conditions of both
of the individual phases, but
may
forms are not rarely transitions

also appear as independent
plete phases; they then constitute, even
if
com-
the confusions with schizo-
phrenia are disregarded, a more unfavorable formation of the morbid

picture, run their course slowly and recur often, after they have barely
calmed down.
A part of the symptomatology is common to both phases, as has

already been shown us by the absence of coarser disturbances of perception, of orientation, and of the nervous symptoms.
In the psychic
of the
During and
^'This
and
field
mention should again be made of the condition

to be affected very little directly.
memory which appears
after the attacks, the patients recall the essentials of
what
is entirely different from the similarly designated mixture of aaxiety

drinker's euphoria in Delirium tremens.
480
happened in the course of their duration, but there is rarely lacking

The
a more or less extensive transformation of the recollections.
former manic patient can no longer imagine that he was so unpleasant,
and in good faith represents most of his conflicts as justifiable reactions to unjust and awkward attacks, and often with such skill that
he even convinces others.
The
severer the flight of ideas was, the
fiiliii
^
^-^-^^mw^/ym
Fig. 42. Mixed condition in a debilitated case. Inconstant euphoria. Motor

retardation which crowds out the euphoric expression of the face but nevertheless
permits the patient to decorate herself with necklaces made of mountain ash
berries.
more difficult to be sure, is the orderly ekphoria of the experiences,

and for this reason also obscurities and gaps appear. It is significant
that individual manics believe after recovery, that they had really
suffered from melancholia, because- the few brief intercurrent depressions and the most striking inner difficulties are remembered much
better and appear much more important than the cheerful total manic
condition.
To
be sure these recollections
may
point to
and physical pain which we did not observe during the
many
a psychic
excitation.

There often
481
exists in the healthy periods a hick of interest or a
any attention to the morbid processes,

which forgetting is produced or at any rate simulated.
Melancholies, who as a whole have a somewhat better recollection
than the manics, may very easily repress very much, and often just
the most important things. This even occurs when in the course of
an attack they have definitely resolved that this time they will think
of this and that during the free period, e.g. of the relation to the
physicians. Often at the beginning of a later attack, the recollection
of an earlier one turns up so vividly that the patients feel it very
positive disinclination to devote
as a result of
unpleasantly as a disturbing compulsion.

delusional forms
is
usually
defective
The
recollection
and greatly
falsified,
of
the
under
certain conditions totally lacking.
Insight into the disease
is
usually lacking and
is
never complete
during the acute phases, although in case of more frequent repetitions

the patients may themselves seek the institution as soon as they find
it
necessary.
The manic
invariably estimates his
own worth much
Frequently the patients

have a relatively good insight of previous attacks, but not of the
actual one, which they alwaj^s consider "something very different."
too highly, the melancholic infinitely too low.
In both phases the hallucinations are usually confined to sight and

and often have little vividness. The patients themselves
hearing,
sometimes describe them as "manifestations."

obtrusive as e.g. in dementia praecox.

portant.
of
They
are also not so
manic depressive insanity are not im-
In euphoria the turgor
vitalis is naturally raised; a patient
a broken up individual may appear

twenty years younger the next day when he has merged into a manic
mood, and then present a vigorous bearing and good appearance. All
vegetative functions adapt themselves to the situation. The exalted
person usually has a good appetite and effective metabolism; submanics who eat regularly and do not exhaust themselves with inces-
who
in a state of melancholia
is
sant movements consequently usually gain; more severe manics, to

be sure, lose, partly also because they do not take the trouble to eat
enough, and instead use their food as material to satisfy their pressure
activity instead of their hunger.
once had an experience by
exception, where a manic could be saved from death only

forcibly kept in bed, because his heart did not keep
ties,
so that e^'ery
up with
now and then he developed hydrops
There was no endocarditis.
way
of
by being
his activi-
universalis.
In melancholia the appetite fails, the

bowels are also often sluggish; as a rule there is a loss of weight;
an increase of weight, with very few exceptions, indicates recovery.
482
Pronounced increase
in strength
without accompanying recovery indi-
cates a different, especially a schizophrenic, foundation.
In both phases sleep
is
poor, often so poor that a normal person
would rapidly break down under
it;
the function of recuperation
must
take a different course in the disease than under normal conditions.

Examinations of body temperature, of the blood, urine, and
metabolism generally have as yet yielded no regular findings.
Notice-
ably often one finds sugar in the urine during the attacks.
Pulse and respiration correspond approximately to what one expects from emotional excitations and depressions of normal persons.
Menstruation often disappears, to -reappear toward the end of the

attack.
The
reflexes are
sometimes increased; in the manic state they are
said to be rapid, in the melancholic slower.
Manic
"analgesia"
is
the result of changed attention.^^^
The
that
intervals.
Between the attacks most patients show so
pathologic that one speaks of "normal intervals."
is
theless there
is
seen in many, especially
when the
little
Never-
disease has existed
a long time, a distinct lability of the emotional condition, partly as

a reaction to external conditions with irritability and exaggerated
excursions in the direction of euphoria as well as depression, partly,
however, as passing fluctuations from within, which Kraepelin con-
rudimentary attacks. In individual cases only a very small

all manic depressives
this goes so far that the patients
lose their ability for social functioning; they are no longer capable
of adapting themselves sufiiciently to others and lack all stamina for
independent work. In contrast to this the ordinary "intelligence tests"
do not show any evident decline. In the periodic manics there frequently develops in the intervals a protracted mildly manic temperament; in those patients with mainly or exclusively melancholic phases
there develops a protracted depressive mood of minor grade. Of these
types there are all transitions to those who from youth onward appear
mildly manic or melancholic and then are preferably afflicted with
phases having similar signs.
Course. In the majority of the cases the disease becomes manifest
through the first attack between fifteen and thirty, but at times may
first show itself in the eighties.
Individual cases go back to childhood
but every child which in youth seemed a little cyclothymic does not
by any means later become manic-depressive; the anomaly may lose
siders as
percentage of
itself.
In general the attacks repeat themselves at varying intervals; im"See
p. 56.
483
mediately after the expiration of one, another may appear, or decades

elapse from one to another. Naturally under these conditions it
may
may
also
But
there are patients with
happen that
in the course of a single life only
whom
for
many
one appears.
years one can count
on a more or less regular succession. If the intervals are about equal

and not too long and the attacks of the same kind, one speaks of
mania and periodic melancholia; as cyclic (or circular)

insanity are designated the types in which mania and melancholia with
periodic
or without free intervals follow in regular succession.
For the quality
of the attacks also
longer one can oversee the patient's

series
we do not know any

life,
which are made up of the same kind
the
rule.
The
more rarely one
finds
of attacks.
melancholia increases with age, while mania decreases.
On
the whole
Severe manic
attacks are likely to occur in the same patients with severe melan-
submanias and submelancholias correspond in

For a long time many patients have attacks that resemble one
cholic attacks, while
turn.
another very exactly; one even speaks of a photographic exactness of

the repetition.
One
of
my
''paranoids" each time took
delusions formed in an earlier attack to develop

ventor, reformer)
The
single attack, aside
them
up again the
further
(in-
from the mixed conditions
of the transition, usually keeps itself within the
same category.
But
in severer attacks with otherwise clear states in respect to both phases,
confusion states lasting fifteen minutes or hours are not entirely rare,
which on the one hand, the patients whine senselessly, throw themon the ground, take no consideration of decency, and are inaccessible to any advice, and on the other hand, senselessly rage and
struggle.
According to Kraepelin patients with mere depression are
more frequent; those with mere manias are the rarest.
The individual attacks usually last many months, a half year to
a year, the melancholic probably on the average somewhat longer
than the manic; upward deviations to several years are frequent, up
to ten or more years very rare. By way of rare exception, individual
patients have a tendency to complete their attacks in one or two wrecks.
Prodromic symptoms frequently take the form of general discomfort
which is taken to be neurasthenic, and strangely enough not rarely in
the forms of neuralgias which may have all the marks of a definite
in
selves
nerve inflammation,
e.g.
sciatica or intercostal neuralgia.
patient of
Schuele hallucinated a gray bird every time at the beginning of the

attack.
Mania
is
preceded sometimes but not always by a really de-
pressive introductory stage.
The
ascent
is
gradual, in severe attacks
not very rarely in two periods, as after about two or three weeks'
duration a remission occurs, which, however, is soon followed again
484
by a severe aggravation. Then the disease usually remains at its

Recovery sets in gradually and with fluctuations, in melancholias frequently so; better days appear, which after
a while recur more frequently and show a more evident decrease of the
symptoms. During the falling off of the mania the inhibitions then
height for a long time.
taking place simulate a "dementia" for the inexperienced.

rarely the character takes on an unpleasant nagging.
attack there often follows a more or

or at least a feeling of exhaustion.
Not
so
After the manic
less severe depressive after-stage,
After melancholic phases the pa-
tients often feel "better than ever," are more active and pleasant
than before, and that not only for months, but even for years. The
rare sudden fluctuations occur especially in cyclic cases, in which the
patient may change the phase from one day to the other. But transitions from, and toward the normal conditions, may at times also appear
suddenly by way of exception.
Concerning the general prognosis little can be said as yet. The
individual case recovers. Very rarely does a patient stay over in the
asylum, because the intervals become so brief that a discharge cannot
be considered. Every now and then a case makes his home in the
hospital and remains there willingly even when the intervals are
longer. Longer series of attacks seem to have a tendency to decrease
the intervals with age.
But
in general the admissions decrease quickly
between 45 and 50, and

few of our regular customers
later remain free at least from
in the forties, in spite of a slight increase
after the period of involution
from early manhood.

more severe attacks.
The
we
see only a
Therefore
many
quality of the attacks sometimes seems
in old age; the
manias are
less strong, the
somewhat more severe
melancholias rather con-
fused; probably the delusional forms also increase a
During
'the
acute phase death
may
chiefly as the result of suicide, otherwise
some
suicides take their families with
occur,
little.
among melancholies
from intercurrent diseases;
them ("family murder"), in

Manics die at times from ex-
order to save them too from misery.

haustion or from injuries which they will not permit to be treated.
Manic-depressives have a certain tendency to suffer relatively

early from arteriosclerosis, or other brain atrophy.
Protracted Displacing of Mood. To manic-depressive insanity belong the high and low spirits, which on the one hand do not last
long, and on the other do not attain the degree of a morbid mood.
For the
latter reason they rarely
come under psychiatric observation

now and then a fluctuation
in spite of their frequency; nevertheless
of the
mood
rising to a pathological degree demonstrates the
con-

nection with the entire group, which moreover
heredity.
The
made
closer
by
following forms can be distinguished:
Constitutional ill-temper or depressive disposition ("melancholic
mood"), a protracted dark emotional coloration
making
difficulty in
2.
is
485
resolutions
of all life experiences,
lack of self-confidence.
Constitutional excitement or manic disposition ("manic mood").
The manic temperatment of such people disposes to overhasty acts

and to a thoughtless manner of living in general, when it is not
and a particularly
For that reason we find here on the one hand snobbish,
inconsiderate, quarrelsome and cranky ne'er-do-wells, who have no
staying powers in their transactions, but on the other hand "sunny
dispositions," and people endowed with great ability, amounting
sometimes to genius, and not rarely gifted with artistic ability who
Such a man, e.g. was the founder of
possess a tireless energy.
restrained by a particularly sound understanding
good morality.
"Physiognomies," Lavater.
3.
The
4.
Cyclothymics, in
irritable
mood.
whom
with despondent impotence.

other people
who do
periods of energetic euphoria alternate
Among
these too are found artists and

Moebius has given good reasons for
Whether H. von Kleist should be called
great things.
counting Goethe with these.
manic-depressive or cyclothymic
5.
The
constitutional
is
arbitrary.
disposition
may
also
change,
especially
around the time of puberty. David Hess was depressive as a boy,

then said to himself one time: "Now I am no longer melancholic,"
and remained until death in a manic mood; his sister, from youth up,
was always "like quicksilver." Lavater too wâs sensitive in youth,
"bashful," as was a famous still living scholar with a manic mood.
A woman up to about her twentieth year seemed noticeably cheerful, lively in the pleasant sense, then for a time mildly depressive.
Her membership in the manic-depressive group was proven by a
melancholia lasting several years which began at forty-one, after
which for ten years she was lively and very energetic, bore hea^y
blows of fate admirably, to be melancholic again at 54 for three
years.
As '^milder forms" periodic conditions are also to be mentioned,

which take a course under the picture of neurasthenias or stomach
neuroses or headache.
Conception.
produces
readily shows itself in other

in the
form of
is a lasting anomaly that

mania and melancholia and also
Manic-depressive insanity
fluctuations in the sense of
ways
as a lability of the sensibilities, or
habituail shiftings of the
mood.
Everything that goes
486
with this
is
shown by the examination
points to an equivalence of
So far everything
is
of the family disposition
the outlined disease
all
readily comprehensible
which
pictures.^^**
but there are certainly
of a different origin
which we cannot as yet distinguish as such
from the manic-depressive.
Therefore in regard to the differentiation
moods
we are not altogether certain where one of these other causes might
cooperate, and, on the other hand, this fact must make us hesitate to
endeavor to explain the attacks merely on the basis of predisposition.
Some of these moods are undoubtedly purely psychogenic others have
a physical foundation, as in paretic or senile processes, in dementia
praecox, and in disturbances of the inner secretion (Basedow manias
;
Physical diseases, especially cardiac and vascular
and melancholias).
disturbances, produce depressions; incipient fever, chemical remedies

like alcohol
and tuberculin generate conditions, which have at
Now
great resemblance to mania.
is it
least
necessary for the appearance
of such effects that there be always or at least in
many
cases a manic-
depressive disposition? Is cerebral atrophy often or always or never

the sole cause of the accompanying depression in senile forms? Are the
cyclic forms of schizophrenia all
We
cannot answer
If all along
all
mixed forms of the two diseases?
^^^
these questions.^"
we have placed
the affective fluctuations in the fore-
it was with the understanding that they are only the most
conspicuous expression of the more general psychic disturbance. For
it is true that the more important symptoms such as flight of ideas,
ground,
pressure activity, associative and centrifugal inhibitions, which alone,

besides the actual mood, are usually tangible, are indicated in every
strong affect and may, therefore, be conceived as exaggerations of the

"emotional effect." But opposed to this is the fact that the three
symptom groups need not
at
all
correspond quantitatively to one
another even in the ordinary cases, thus the centrifugal retardation,

e.g. even with painful mood that remains the same, may oscillate not
only from one case to another, but also in the same patient. It is, for
example, usually relatively more severe in young people than in cases
of the involutional period; but above all the mixed states prove that
the derivation of the entire picture from an affective fluctuation does
not tally at all, or only to a slight degree. Then, too, especially in the
thought disturbance
many symptoms
transcend the emotional
effect,
""
Compare the
"^
There are certain forms which symptomatologically give the impression

mixed forms, but are a unity at least in the
relation to the syntony of normals, p. 174.
of manic-depressive-schizophrenic
family disposition.
Concerning the psychogenic release of true manic-depressive attacks, see
pp. 132-489.
487
which on closer inspection are more frequent in the apparently simple

cases also than would appear from the descriptions; only one cannot
Complaints about the
as yet grasp and describe them properly.
obtrusive crowding up of a mass of ideas, the interference with the
arbitrary direction of thought, the obscurities that belong to the flight
of ideas
and which
in individual cases with a
may
of ideas or retardation
mere indication of
flight
go as far as confusion and dream-like
and paranoid symptom complexes, paresthe"neuralgias,"

all
of these prove a positive number of disand
sias
turbances which must be of the greatest importance for the explanaBehind
tion, but which as yet have eluded our comprehension.
expressions,
dispositions,
exhaustibility,
irritability,
the customary
states, the hallucinatory
inner secretion, there

or nothing at
little,
concealed in manic-depressive insanity very
lies
all,
that
is
matter of fact or even intelligently
connected.
Extent. Kraepelin's idea of manic-depressive insanity

circumscribed.
selves
The
and especially
transitions
in the
same
is
pretty well
among them-
of the
various forms
patient,
and the hereditary conditions
prove the homogeneity of all the different pictures. The group cannot be sharply delimited from many mere psychogenic distempers in
psychopaths, and from the melancholias not to be included as yet. A
natural boundary also probably does not exist between the habitually
moody and
the ''psychopathic personalities," especially between our
and the
Of the conceptions
irritable cases
excitable
among
the psychopaths.
of other classifications several correspond to
individual forms of manic-depressive insanity or they disagree with

it.
The "mania" and "melancholia"
belong to our disease, but
all
of
German psychiatry naturally

name of non-German
diseases with this
authors do not; they include a large part of the excited and depressive
forms of other psychoses
also, especially of schizophrenia.
Probably
everything designated as periodic neurasthenia, recurrent dyspepsia,

etc.,
also belongs entirely to manic-depressive insanity; also attacks
and Friedmann's neurasthenic melancholias. The

"acute" and the "periodic paranoia" correspond in part with our manic
of hypochondria,
and depressive delusional forms,
for the greater part, to be sure,
with
schizophrenic hallucinoses, similarly the majority of the amentia cases

of the classifications other than Kraepelin's.
manic-depressive or cyclothymic;
if
Some
of the litigants are
one has a good anamnesis, they
are easily recognized; as distinguished from the paranoid litigants

they have times in which they keep themselves very quiet, and even
see the senselessness of their previous conduct and regret it also the delusional system does not remain homogeneously centered.
A part of
;
488
the patients coming to the physician because of compulsive thoughts

are depressive types.
"Melancholia" requires a special consideration. It is self-evident

many of these afflictions fit in the above class. But, as was
indicated, there are other depressions and it does not seem reasonable
to bunch all the appar:ently independent depressions of the period of
involution and class them with manic-depressive insanity. Formerly
Kraepelin actually endowed the melancholia of the period of involution
with a nosological independence as melancholia katexochen which,
however, can no longer be sustained in the differentiation of that time.
But the reasons for the separation were nevertheless very weighty.
These forms have in great part a much more protracted course. They
grow very slowly, often for one or two years, readily remain in their
height for several years and again require a long time to decline. The
that very
retardation
is
frequently concealed
by a great
restlessness;
really
agitated forms are frequent even though probably rarer than in the
senile melancholias.
Then they
Single attacks are very
common
regress
much
less
in these cases.
wishes, one can conceive of the thing in this
than the others.
To
be sure^
one
if
way; that with increasing
age and most especially in the period of involution, the disposition for
depressive attacks and for agitated and slowly developing forms in-
an attack occurs merely

and usually in the described form. But one often gets the
impression that something else is involved; this is true also in the socalled "climacterium" virile," a depression common to men, which
runs its course in this form but is usually mild, which appears at the
end of the fifties, even at the beginning of the sixties, rarely makes
an asylum necessary, but nevertheless plainly reduces the joy of
living and the ability to work, and usually presages another disease
(arteriosclerosis!), but disappears in two or three years without
leaving a sign. As long as we do not know the "nature" of the affective
psychoses, only hereditary investigations have any prospect of throwing
light on the subject. At present this separation is just as impossible,
as an inner grouping of the cases which undoubtedly belong together
creases, so that with a slight predisposition
at this age
in the wider classification.
Purely psychogenic depressions which occur in psychopaths who

are not manic depressive and attain the height of a disease are very
rare.^^^
As a
definite cause of manic-depressive insanity
we know only
inherited disposition where the different forms of the disease

stitute
"^
one another.
See
p. 537.
The one member
of the family
is
may
the
sub-
cyclothymic,
489
But
the other periodically melancholic, the third circular, etc.
in
some families one or the other of the two phases predominates. I

knew a family in which for five generations quite a number of members
had committed suicide at the time of involution. One can take for
granted that about
ception of "taint"
80%
is
of all these patients are tainted,
that equivalent anomalies are found in other
The endowments
One
the con-
members
way
of the family.
of the patients are often noticeably good, espe-
cially along artistic lines also,
sensitiveness.
if
not too limited, and in large part in such a
also finds
which
is
probably connected with their
more manic-depressives
upper
in the
than in the lower.

According to sex about 70% of the patients are women.
Kraepelin found among the Javanese little tendency to depression,
instead more to excitation. In the large insane asylums of Costa Rioa
with Indian inmates and in Jamaica with colored inmates, one does
not count at all on suicide, although I was told in both places that
many years ago one had occurred. The Jewish race is evidently
strongly disposed to manic-depressive insanity. Within that race also
the frequency entirely aside from changing delimitations varies
greatly, in German Switzerland it is very small, in middle Germanyclasses
it is
higher.
^^*
supposed that brain lesions generate the disease, especially

we still have to include in manic-depressive
But up to the winter of 1919-1920 we know of no injuries
It is also
the delusional forms, which

insanity.
to the brain incurred during the
war that could have
led to
manic-
depressive manifestations.
Individual attacks in large part come from within. War did not
But one cannot doubt that now and then (I
seem to release them.
10%) they can be released psychically; thus in a

good family, who probably in a moody state married an
insignificant man, and during many years always had a manic attack
every time the attempt was made to have her join his family until
the husband died.
Manias also occur at times after the puerperium in women who
otherwise, as far as their lives can be investigated, have no attacks;
then as menstrual insanity where they last only from eight to fourteen days. In one case of my observation an attack did not occur
at every menstruation but the attack never came without menstruation.
estimate about
woman
of
^Ît is disproportionately high among the Jewish admissions of the Manhattan State Hospital, N. Y., which contains a rather mixed element of Jews.
Cf. Brill & Karpas, Insanity Among Jews, N. Y. Medical Journal. Oct. 3. 1914.
Also Kirby; Race and Psychopathology, N. Y. State Hospital Bulletin, March
1909.
490
Milder depressions are not rare in pregnancy but as a rule disappear

with the birth.
make a diagnosis from a symptomatic investione obtains a good account of preceeding attacks with healthyintervals. But if the anamnesis is lacking or if it is a case of a first
It is often possible to
gation
if
attack, then manic-depressive insanity can be recognized only
by the
elimination of other diseases. There are no specific signs of the affect

psychoses; everything occurring in manic-depressive insanity can also
be seen in other diseases.
no
specific
one
may
symptoms
If,
however, in spite of exact observation

is found in such "mood,"
of another psychosis
decide on manic-depressive insanity.
But
since a catatonia
may
run a course for some time without distinct specific

signs, one must not, at least in the first week, decide with certainty on
manic-depressive insanity. Signs, which symptomatologically should
be called catatonic, are said to occur here also; but at all events this
or a paresis
is rare.
Special difl5culties are presented
by the paranoid and
delusional
forms; there only protracted and careful observation will make it

possible to drop the suspicion of dementia prsecox. On the other hand,
differentiation
from paranoia, for which the form was not so rarely
made easy by the evidence of the depression.

Cases of dementia praecox are often mistaken for mixed forms.
Only a more prolonged and exact observation with a weighing of all the
mistaken,
is
usually
circumstances, and sometimes a good anamnesis, will guard against
When in doubt one should remember that the pronounced

mixed forms, especially the manic stupors also, are much rarer than
this error.
similar schizophrenic conditions.
Incipient paresis can be differentiated
by the physical
signs
and
the senselessness of the delusions and by the examination of the spinal
But hypochondriacal ideas, even in case of a good intelligence,

can well strike the physician as somewhat senseless, since in such
matters the healthy person also often has very peculiar notions.
Manic excitements can be differentiated from the epileptic even
in a brief examination by the flight of ideas which does not occur in
epilepsy, and by the absence of the signs of epilepsy, especially the
slow mental process, the obscurity and peculiarities of speech.
Some hysteric symptoms may occur in manic-depressive attacks,
Pronounced
especially when they are also present in the intervals.
and stubborn but isolated hysteriform symptoms point with probfluid.
ability
to
complication with
Manias that belong
organic
or
to hysteria probably do not
that there are such depressions.
schizophrenic
exist;
but
it is
diseases.
possible

A
differential
diagnosis
491
from psychogenic depressions is sympBut on weighing all the circum-
tomatologically not possible as yet.

stances, especially the
after the recovery
Treatment.
family anamnesis also, one
make
The
will,
especially
the diagnosis with considerably certainty.
predisposition might be eradicated by forbidding
the begetting of children in manic-depressive families.
It is a question
whether this would be wise because a large part of these families

maintain themselves in spite of all and even do distinguished things.
The seriously sick naturally should not marry, not even in the free
intervals; at all events I would not like to advise anybody to select
a manic-depressive mate, as the difficulties for the healthy partner are
often greater than for the one afflicted. But I must state that in spite
of this, things go well in individual cases; the able and pleasant afflicted
partners, when necessary now and then, take treatment in an insane
asylum, and in the intervals may be excellent companions.
Also for the prevention of the individual attack not rnuch can
be done, because it usually comes about without external occasion.
Nevertheless the avoidance of excitements and excesses of all kinds
is good in other respects also, if it can be achieved.
With pronounced manics nothing can be done except to send them
to a hospital. There the attack most easily runs its course in spite
of all irritations because of the confinement.
As
far as possible irri-
tants should be kept away; isolation, which
still
gives the patient a
chance to entertain himself somehow with trifles, is the therapy which

should be applied whenever possible. As distinguished from schizophrenia a ^'degeneration" resulting from isolation is not to he feared.
If it is not feasible, then the supervised continuous bath is the best
place for the patient to stay.
Occasionally artificial feeding
may
be
necessary.
The milder cases which one cannot resolve to send to a hospital

They have the tendency to ruin their fortune, their honor,
their health
a girl of good family, in six attacks only came to the
hospital after she was pregnant they bother others, enter into litigations, and through sexual relations, engagements, etc., make also others
unhappy. Under certain conditions a legal guardianship, where that
is possible, can prevent much harm.
But the guardian has a difiicult
are a trial.
task and his most effective intervention probably

patient to an asylum.
larly in the
submanic
is
In addition there are rare cases
to bring the
who
particu-
stage, in spite of difficulties with the environment,
have made a fortune by their initiative and inventions. But in general

it is very risky to let submanics go their way
they always seek more
excitements and just these should be avoided.
;

492
For melancholia also supervision
On
many
in a closed hospital is the right
from suicide, and

even from starvation. But just in such depressions without other difficulties the family physician will not always be able to disregard the
objections of the patient and the family to institutional treatment.
thing.
the outside
of the patients perish
But he should only assume the
responsibility
if
the external condi-
Against the danger of suicide strict supervision

should be prescribed; but it does no good merely to say this generally,
even though it be done most impressively. It must be made plain to
the relatives that at least two attendants must relieve one another,
tions also warrant
it.
that both attendant and patient,
e.g. will
go to the toilet and that at
such times also supervision is to be carried on; because if the patient

wants to take his life, he uses just those occasions of which one later
"But it was only for a moment." Usually the windows must

be secured, and when possible the patient should live on the ground
In the milder cases an orderly who sleeps very lightly may
floor.
sleep beside the patient, perhaps placing the bed so that the patient
says:
can get away only over him. Especially dangerous is the period of
convalescence when the impulse to suicide is still present, at least in
the form of attacks, and the patient's energy is no longer very inhibited,
while the vigilance of supervision usually
supervision
more
is
lets up.
Where
a continuous
not found necessary the physician must see the patient
or less often, usually daily, according to the fluctuations, to
inform himself minutely from those about him concerning his condition in order to be able to intervene at the right time.
Supervision is made much easier by protracted bed treatment,

which is also indicated for other reasons in severe cases, but which
becomes a torture in milder cases who have the ability and feel the
necessity of moving about in the open and even busying themselves.
In anxiety melancholias one can

attack with an opium cure: opium or
within three or four weeks up to 1.0
make the attempt to shorten the

now pantopon in increasing doses
Opium (0.2 Pantopon), or a little
more; from one to two weeks after this high dose has been reached,
one should go down just as slowly whether or not the attack has
improved. Because if one has not accomplished anything then, the
remedy is no longer effective but may make an opium addict of the
patient.
Against sleeplessness hypnotics (not opiates) will have to be given

then. The patient who usually does not want to eat, must
now and
be fed sufficiently, perhaps by the tube.

stipation mild laxatives are to be used
Against the frequent con-
and what
is
more important
493
to prescribe daily attempts, exactly regulated as to time, to go to
the
toilet.
''Distraction" can attain
some mitigation only
in the
mildest cases;
they usually do harm; the most beautiful music can have no good
influence if the patient reacts to it with mental pain. Also all other
kinds of complicated conversations are usually harmful, even if they
can divert for a minute, because afterwards a reaction usually
sets in.
Here a careful testing is the right thing. The effect is best attained
by work which does not tax the patient mentally or demand any
decision from him. In general it is very important to relieve the patient
of all decisions, even of those that are simple, and involve trifles,
until an extensive improvement has taken place.
In pregnancy melancholias the question of abortion is often put.
There are individual cases where the measure has had good results."'
In contrast with the schizophrenias early discharge from the asylum
Many of the patients get worse outside;

is to be guarded against.
even in the asylums one has the experience that they do worse if they
are placed too early in a better ward.
XII.
PSYCHOPATHIC FORMS OF REACTION (SITUATION

PSYCHOSES)
In case of any kind of disturbances within the psyche the affects

must function differently than otherwise and may then generate
also
morbid syndromes.^^
Congenital
anomalies,
brain injuries,
brain
processes of all kinds, disturbances of nutrition, toxins, infections,

finally chronic
and
emotional effects themselves constitute in their multi-
colored manifoldness and in the most different combinations the foundation on which the abnormal reactions occur.
Where
definite processes,
like the schizophrenic, or coarser organic brain changes, be at the base,
the reactive syndromes are classed with the symptomatology of these

diseases
from which they usually derive
specific peculiarities
phrenic delusions, although originated in the same
way
(schizo-
as the para-
from the latter; schizophrenic twilight states from the

where the abnormal reaction is based on a congenital
disposition, the attempt has been made to distinguish it
often in
connection with the disposition as a special "disease" [neuroses,
In such cases it is usually the abnormal domination of
paranoia)
the affect, i.e. its excessive influence on the selection of the associations,
sometimes also only the relative weakness of the logical faculties,
noid, differ
hysteric, etc.),
^ Comp.,
''
Comp.
however,
p. 126.
p. 225.
494
perhaps also of the affective inhibition

origin of
morbid symptoms
possible.
(e.g.
make the
moral) which
But qualitative deviations
of the
affects as well as the intelligence, special sensitiveness in a particular
direction, crankiness in thinking, etc.,
may
also be the essential basis
However, the affectivity with its

unlimited possibilities of variation is always the decisive factor while
the narrowly confined intellectual functions are overwhelmed or only
abnormal reaction form.
of the
participate in a secondary role.
Most syndromes can
Many
attacks of rage
Prisoner outbursts)
momentary
(e.g.
confusions,
by means of the under-
best be kept distinct
lying mechanisms.
are simply exaggerated affective effects:
and
attacks of screaming, stupor,
fright neurosis.
Here the
easily aroused
dominating affectivity or inadequate ability to deliberate
is
main
the
condition (Primitive race, "the nervous," oligophrenics, schizophrenics,

It is a case of "primitive reactions"
epileptics).
among
other things
may
But
some complex
(Kretschmer)
also in those not otherwise disposed to such reactions,
generate a particular sensitiveness: unre-
quited love, incessant "pin pricks," unworthy attitude,

rarely ambivalence
is
More
etc.
the cause; thus in excessive anxiety for certain
people, or in too violent or too protracted grief for some lost relative,
where usually the unconscious feeling of some advantage derived from
the loss causes the exaggeration by
way
of a sort of feeling of sin.
a rule patients of the latter sort are persons of
Another mechanism
things
many
is
more
As
sensitive natures.
the false connection to which
sexual abnormalities are to be ascribed:
among
other
pupil in a
classroom has his attention called to onanism by another pupil and

at once makes an attempt. The teacher sneaks up and pulls him by
the ear.
At
this
moment
the orgasm takes place and the result
is
that
the patient can never obtain sexual satisfaction unless he himself or

his beloved holds his ear (Aschaffenburg)
In an analogous
way
the
various form of fetichism originate, naturally only in a psychopathic
disposition, probably in connection with weak sexuality.

An eleven
year old patient of Frank suffered since his fifth year from incontinenta alvi, especially in the forenoon at half past ten. Psychoanaylsis
revealed that six years ago at this hour, having to go to the
toilet, he
where hot fat was sprayed on his
chest.
In his fright he defecated in his clothes. Cure resulted from
this explanation.
Other chance associations produce e.g. headache,
always after some particular occurrence, because the first time headache appeared after it. This kind of connection may originate, especially in children, even without the essential cooperation of an affect;
then it is merely a case of habituation or association reflexes.
went to
his
mother
in the kitchen,
495
Unbearable situations or those wished to be otherwise may be

delusionally transformed by the disease (delusional reaction), or cir-
cumvented
in reality {"Flight into disease").

The latter procedure
an existing schizophrenic process sometimes makes the disease
manifest, but above all it leads to the neuroses, which is accomplished
in case of
by the fact that the unbearable ideas with their affect are split off
from consciousness and "repressed" into the unconscious, where they
make themselves noticeable by supplementing morbid symptoms.
Delusional Reaction: In an hysterical or schizophrenic twilight
state the patient hallucinatorily marries the lost lover; in delmsicms of
grandeur unrealizable wishes are gratified. In paranoia and paranoid

demsions of persecution the cause of one's own failure is projected into
the environment, the blame
is taken from the ego and besides the

by means of ascribing malice to the other
one seeks, on the one hand, to fulfill wishes
latter is relatively elevated
people.
In litigiousness
that in reality can be fulfilled with difficulty or not at all, and, on the
other hand, one conceals the opposing rights of others and the diflBculties of achieving one's
own demands; one
also overvalues one's
rights and, along with this, the importance of oneself
one's
fies
own
sensitiveness
and joy
in oppressing
litigious delusion of paranoia, of the paranoid, of the
and thus
others.
own
justi-
In the
submanic attack,
this affective effect extends to the complete falsification of logic; the
kind of reaction, the "choice of the disease," depends here on the

psychic constitution of the patient and very little or not at all on
the occasion.
Difficulties of intercourse
who
of persecution in those
with the environment lead to delusions
are hard of hearing.^"
A special attitude is taken by the mechanism of induced insanity:

the taking over of a patient's delusions by a previously healthy person
and especially suggestion. But there too an
must be assumed, which permits the acceptance
as a result of persuasion
affective predisposition
of delusions having a definite direction.
By means
of flight into the disease one achieves definite aims

through the disease; by an attack of rage one achieves a yielding; by a
fainting spell, a new hat; and by the more protracted disease one gets
a pleasant sojourn in a sanatorium. By means of all these one can at
the same time compel consideration, secure care and tenderness, obtain
power over others who have to adjust themselves to the disease, extort
an allowance, evade tasks from the simple household duties up to the
terrors of the trenches.
culties;
^'
See
one keeps
p. 533.
But above
off self-reproaches
all
one circumvents inner
diffi-
from consciousness; by means
496
of a
symptom one
identifies oneself
with the beloved, or represents
symbolically the union with the beloved
who
does not care for the
patient.
Such external aims
of the neurosis are
pose, the fictitious accounting to oneself
is
very simple; the inner puroften so complicated that
we
cannot go into details here. Only this should be mentioned, that

naturally the neurosis is usually a poor solution from the subjective
point of view also, as is shown by the fact that neurotics themselves
condemn the evasion of difficulties by this means, because they do

not admit the purpose of the device either to themselves or to others.
Even the attack
of rage
which under these circumstances represents
a primitive reaction, sensible in principle, often overshoots the
much
mark
becomes most unpleasant for the patient. In order to

get the hat, one must have a real fainting spell; to be excused from
work, one has unpleasant symptoms; the pensioned neurasthenic has
to renounce all joy of living. Whoever becomes a thief out of revenge
against the father or commits arson because of an unbearable situation,
gets into jail; whoever achieves the companionship of the beloved
symbolically is as little satisfied as the hungry dreamer who thinks
he eats, and whoever satisfies his ambivalent feelings by imagining
a sexual attack, which, though it arouses sexuality at the same time
causes disgust, only gets hysterical vomiting out of it.
When we speak of flights into disease, as a sort of purpose of the
neuroses, this should be understood with some reservation. A more
primitive reaction passes away and has no subsequent significance.
But it becomes a neurotic symptom, difficult to combat, if it is released
If physical, purely reactive symptoms, like
for definite purposes.
so
that
it
paralysis of the vocal chords or the leg, trembling
when
in danger,
diarrhoea or fainting from fright, vomiting from disgust, do not disapaffects, or when they always recur without an
adequate occasion, then there is involved something different in principle from simple reactions; there is a positive quantity added, which
pear with the releasing
as a rule consists of some necessity for being sick.

is
applied to this,
it is
If the
term ''wish"
The most
to be understood in the widest sense.
decent person occasionally has an impulse to take what does not
belong to him or do something sexual that

does not enter his head to act on this.
Not
is
not permissible; but
at all
it
seldom the patho-
genic wishes are entirely unconscious, while in the patient's conscious-
ness the opposite impulse
is
not only important but solely dominant
or solely present.
The "morbid gains" are usually easily found on closer inspection.

They are plain in the war and income neuroses, in the twilight states

of
commitments
"mass hysterias" or "imitative
for examination; in
hysterias" they are based,
among
497
other things, on the desire, on the
one hand, to be in the swim, and, on the other, to be distinguished from

In school epidemics freedom from school is a special con-
the mob.
sideration, but in addition also the
making
oneself important
and the
imitation of everything conspicuous.
Naturally there are diseases of a neurotic kind, for the origin of

which, at least in principle, an advantage
primitive reactions, the suckling
who
is
not necessary.
Many
perishes from anorexia in an
unsympathetic environment, the homesick nurse-maid, the dog that

starves on his master's grave, the girl that always gets pains in the loin
when she
lies
in the grass after she
had
lain in the
open during an
illegitimate birth, the false connections of the sex impulse, the fever
when this is taken to be the

accustomed tuberculin, all these are illustrations. But in the ordinary
neuroses one always finds on close inspection an advantage from the
that appears after the injection of water
disease.
But there must be something besides that permits the nervous to

take refuge just in disease, while there are other means of evading
the difficulties. To be sure, it should be remarked that this evasion
lies close
lings,
at
and
hand
is
in
our super-Christian age with
particularly encouraged
the bringing up of children.
But
it is
its
petting of
by many families
probable that
bring the hysteric to the expediency of disease
thus
weak-
especially in
other forces
still
many
intellectual
constellations, then the experience that with his strong affective reac-
tions
which at times appear even to the layman morbidly exaggerated,
he often accomplishes his purpose, and perhaps there
is
certain
weakness toward the idea of disease. All of this Kohnstamm brings

together under the name of weakened "health conscience," which says
as much as a long explanation, and which therefore I wôuld not like
to dispense with, though many object to it because "hysterics are again
having some odium attached to themselves." This objection is based
on an entirely wrong conception, which one cannot sufficiently guard
against.
There is not involved a defect in the sense of "morality" or
a weakness of the conscious psyche which one can make responsible
and blame, and it is a serious theoretical and still more serious practical
mistake, merely on the basis of neurotic symptoms, to reproach a
patient with not wanting to get well.
A few additional references should be made to the individual
mechanisms of the neuroses. Besides in the "neurotic excitations" we
find merely exaggerated or primitive reactions, e.g. in heart, symptoms,
paralyses of the legs, or the vocal chords, in hysterical vomiting, in
498
diarrhoea from fright, and in fainting spells.
Hysterical twilight states
are usually to be conceived as exaggerations of the emotional effects

that make way for desired associations and exclude the undesired.
Others are repetitions of emotionally accentuated experiences, that are

undertaken, partly because they are ambivalent and have a pleasurable
(twilight states as repetitions of sexual attacks), partly
component
because they are bound up associatively with definite affects. Moreover, many syndromes that come in the form of attacks are released
in accordance with the scheme of the association reflexes, whereby the
momentary
necessity for the disease withdraws as a pathogenic factor;
the sight of a cap of a certain shape releases palpitation or an anxiety

attack, because the critical person wore such a cap. Any chance event
"recalls" a sexual attack,
whereupon
this
or less caricatured form in a twilight state.
is
lived through in a
Such connections
more
may
be
to the patient, without on that account losing their reality.
known
'
the simple ^'reflex enforcement" (Kretschmer)

the trembling reflex may be released under circumstances which would
not be possible in the normal. For the neurosis, as for the affect and
Very elementary
also
is
for suggestion, there are available
many,
especially physical
mecha-
nisms, over which the conscious will has no influence. Many symptoms,
like nervous palpitation, fainting spells, throat spasms (globus), and
perspirations,
mechanisms,
are released by the setting in motion of preformed

Certain
also the "hysterophilic syndrome." ^^^
thus
and impeded thinking, originate

Hence a syndrome consisting of depression, sleeplessness, loss of appetite, impeded
thinking, and palpitations during all mental or physical "work" (I
purposely avoid the term "exertion") is so common in damage suits
following accidents. In a characteristic manner the craving for an income determines the disease, and the fear of being without means of
others, such as headache, insomnia,
otherwise especially easily under the influence of ideas.
support determines
its finer
shadings (the patient not only has a desire
for support but also the fear of having to be without
work and
in-
Other reactions must first have existed in the imagination, in

order to become capable of assuming an hysterical form. It is not easy
come).
directly to suggest to oneself
and others vomiting,
diarrhoea, perspira-
but it is quite possible if appropriate situations,

such as having eaten something disgusting, feeling heat, and of terrifying situations are pictured in detail. Thus even the nervous person will
tion, or palpitation,
most easily get those symptoms from imagination (auto-suggestion),

that he has already experienced (pains in the back as a repetition of
earlier
"
rheumatism), or he will
See
p. 543.
utilize
an existing trouble, any other-
499
wise insignificant deficiency in an organ (stomach!), in order to make

it {"physical complaisance")
Some physically conditioned
a disease of
disease
is
(especially in the case of children)
blephorospasms.
may
afterwards continued
most frequently perhaps whooping cough, chorea, and
psychically,
Instead of being "utilized" directly, a predisposition
also be strengthened or actually
when
made by some added
the pouring of water
factor:
heard in case of a
bladder that is strongly retentive of urine, coughing of children with
whooping cough when another child coughs, coughing spell as a result
of sudden embarrassment in case of a latent irritation in the larynx.
A number of nervous symptoms are symbols (paralysis of the
Desire to urinate
is
organs of swallowing, because one cannot "swallow" the father's demands), others are transformations, perhaps " subliminations" of suppressed desires (one of Pfister's patients was an enthusiastic practitioner of nature healing only
when he
identifications with persons
whom
practiced coitus interruptus)
or
one envies or loves.
chance look may release a neurotic symptom, but only when it

The sight of a skin eruption will only
itself with a complex.
induce the hysteric in spite of her disgust to have the eruption itself
when it reminds her (in the unconscious) of the paternal syphilis.^^^
connects
Sometimes the
the boy
who
affect
becomes displaced from one idea to another;
years ago stole apples without having any pangs of con-
science torments himself morbidly over the matter after he has begun to
masturbate.
The thought
that of onanism; the latter

itself to
of stealing apples
is
is
more endurable than
therefore repressed but
its affect
the idea of theft and gives to this a morbid severity.
attaches
In such
and similar ways do compidsive ideas originate.

Another process functioning alone or more frequently in connection
with other mechanisms is the one mentioned above ^^^ of the apparent
accumulation of affects.
Not all exertions or tendencies of the wishes and fears are pathogenic to the same degree. The most important are the sexual and those
that involve the self-importance of an individual.
connection of the neuroses with sex, especially of the hysterical
forms, has been assumed for thousands of years, as the old

hysteria shows.
To
be sure at
first
sense of the lack of satisfaction
name
one thought only in the coarsest
of
the animal sperma desideratis
(z= uterus), then about the middle of the preceding centur>' of condiof irritation that had their origin
{Romberg was the leading representative
tions
^See
p. 136.
"^ See p. 3S.
in
the
(female)
of this view).
genitals
But even
500
previous to this, some {Lepois in the 17th century) had conceived

the disease as a nervous disease and later as a brain or mental disease,
and especially since Briquet, who carried it out systematically, this
view gained ground rapidly, until in the last decade of the 19th century
But with this all, until the most recent
it became the most general.
times, the essence of hysteria for most people was lust and lying,
although one was visibly concerned "to deliver the poor invahds from
the odium of the sexual origin of their sufferings."
But then the sexual reappeared in the form of the Freudian doc-
which placed youthful sexual experiences and repressed sexual

and perversities at the root of the disease. This theory has
The following is certain:
both ardent opponents and supporters.
Since the instinct of hunger is usually satisfied indirectly in civilized
man, the sex instinct is by far the most important. There is good
reason for the opinion of the poet and people in general that the
trine,
desires
love
aim
is
the highest.
But our
demand very
much more im-
cultural conditions
unnatural limitations of the impulse, and what

portant it is in itself ambivalent and bound up, with strong inhibiIt thus leads to a number of
tions and even affects of anxiety .^^^
external
and internal
conflicts, of
is
which, however, the latter have the
tendency to take place partly or entirely in the unconscious, the place

where the neuroses are generated. Sexual dissatisfaction, but not
merely in the earlier physical sense (in an exceptional case one may be
satisfied by a love affair or by a marriage without coitus), is an important factor in the creation of the neuroses. Now whether for the
predisposition to a (chronic) neurosis such a sexual factor is also
necessary under
all
circumstances cannot yet be decided.
It
is
sig-
nificant that the severest effect of fright in the absence of a particular
predisposition rarely goes
beyond the acute vasomotor-neurotic com-
and that the more careful examination of neurotics reveals as a

rule (traumatics and war cases excepted) sexual conflicts, and that
the disease may often be explained by these. In the symptomatology
of schizophrenia also, sexual conflicts play an important part; in
plex,
women
usually the essential part.
On
the other hand, a traumatic
neurosis seems to us so plainly derivable from a struggle for an income

that at present there is no reason in the case of these diseases to inject
also a sexual predisposition.
It is also certain that neuroses
cured without directly considering sex.
can be
If a satisfying life-work is
provided, then naturally a counter-protection against injuries from sex

is
also obtained.
Der Sexualwiderstand.
Forschungen. V, 1913, S. 442.
"^'Bleuler,
Jahrbuch
f.
psychanlyt.
und psychopath.
601
In spite of the fact that some of Freud's particular assertions will

not be maintained in the face of further experience,
it is very wrong
was the fashion, and it is unscientific
to allow the emotions to play such an important part in the matter.
Just as the doctrine of hypnosis and suggestion, opposed in its time
in almost the same emotional manner, and in part, with the same
to belittle this investigator, as
arguments, nevertheless laid the
first part of the foundation of a

psychopathology, so Freud has produced a great many fundamentals which have already given the science an entirely different
scientific
and this even in his opponents to the extent that they

structure
Without them psychopathology would
go into psychology at all.
not have progressed. Much of what Freud offered was, as is usual
in such cases, not absolutely new, but he was the first to wôrk it
out into such clearness as to furnish a practical idea as the foundation for further studies.
To
these belong the role of the unconscious,
the request on principle of comprehending psychologically
all
psychic
symptoms and the demonstration that this comprehension may be

often gained by the observation of all psychic connections, also in
the unconscious activities, in the dream, etc.; the clear conception of
repression, of the ubiquity
and
significance of inner conflicts, of the
unlimited after-effects of earlier affective experiences, of the transference of the affect to conception originally foreign to
it,
of the intel-
though
lectual conception of condensation, of the greater emphasis, even
not yet
explanation, of the ideas of conversion
full
of repressed affects into physical
symptoms), and
(transformation
of abreaction; then
the departure from the custom of ignoring the sexual

as possible even in scientific matters,
slightly exaggerated)
life
as
much
and the emphasis (even though
of the significance of sex.
Besides sex, the complex to put oneself over, to distinguish oneobtain power over others is important. Many a neurosis serves
complex primarily by compelling those who are about to act in
self, to
this
accordance with
it.
If the self-estimation is not recognized
or to disease
others, there develop
from
attitudes of spite that lead to changes of character ^^^

the young woman mentioned above ^^^ was badly treated
by her husband;
made
by
many
this the
after a scene she states that he should be told he
had
her sick; she developed an obviously nervous fever of short
duration and then a severe expectation neurosis, from which she herself suffered
years
'"
is
See
unspeakable pains, and which only now after forty-four
beginning to disappear.
p. 128.
'''See p. 128.
That was the punishment
for the
502
husband.
But
this
but also toward
peculiar
method
God
way
of
making
misery: one always sees to

only in
little
of reacting
is
used not only toward people,
or fate; the "purpose"
it
is
then just
oneself important
that one
is
things but one magnifies
is
spite,
finding joy in
the victim of injustice, usually
it
into a big affair, mild perse-
cution mania, nervous symptoms, reasons for changing one's position,

etc.
An
Other symptoms again are compensations for feelings of inferiority.

individual poorly endowed in certain directions wants to cover
his mistakes
and appear to be extraordinary
in just that respect
and
for this reason seeks refuge in the neuroses.^^*
Conversely the suppression of

selection of the
morbid attitudes.
artistic impulses, talents in general,
wrong vocations, sometimes lead to neuroses and
all sorts of complexes, which are by chance created by the

(bad treatment in a subordinate position), may release
But it is important that clear unambiguous
neurotic mechanisms.
endeavors, wishes and their definite suppression rarely lead to neuroses,
but almost only to ambivalent complexes.
Not entirely unimportant, unfortunately, is the iatrogenic origin
The physician solemnly diagnoses "enof neurotic manifestations.
Besides
situation
largement of the heart," whereupon the patient
is
frightened and
breaks down until the X-ray photograph resorted to by another physician relieves
to
whom
him
of his nightmare.
The stomach
neurotic
is
not rare,
a particular food had been forbidden, because of a digestive
disturbance "due to a
weak stomach," who then
in terror consults a
and has some dish forbidden him by each in turn,

until he is at the point of starvation and with or without a physician's
assistance makes up his mind to eat what he pleases.
The essential part of the mechanisms that generate neuroses almost
without exception functions in the unconscious, as is indicated by the
string of physicians
fact that the control of our conscious personality
does not extend
nearly so far as the neurotic influences (activity of the glands, production of a twilight state, etc.).^^^
control
much more
The
hysterical psyche yields the
to the impulses lying in the unconscious, or other-
wise expressed: these are relatively stronger in the hysterical psyche
than
in the
Thus
normal person.
the psychology of the affectivity
and the unconscious give

and of many psychotic
the key to the understanding of the neuroses

^^
Comp.
especially the works of Alfred Adler.

of hysteria to his pithiatism, i.e. to con(conscious) will, cannot be accepted.
'''^Therefore Babinf<ki's limitation

ceptions which are accessible to the

symptoms;
"everybody
the corresponding
is
603
mechanisms are present in every person,
capable of hysteria."
The healthy person
also
has
wishes in his unconscious, which conflict with his conscious personality, some of which now and then manifest themselves in "the psycho-
pathology of every day
life," i.e. in errors, forgetting,
and
in dream.s.
must be, in
order that its results can be exaggerated into neurotic symptoms.
In this respect acute injuries relatively seldom produce an effect and
primarily only an acute effect, chronic injuries more easily produce
lasting symptoms; but the most readily effective disease producers
are acute, serious experiences after a chronic impairment of resistance
and the gradual accumulation of restrained affects. But when a
protracted or general neurosis is developed from a transient symptom,
then there usually exists not only some conscious or unconscious wish
to be sick or to transjorm reality by means of the phantasy, but a
But the
healthier a person
psychopathic predisposition
is,
also.
the stronger the affect
Even pronounced
during earthquakes and similar catastrophes were seen
fright neuroses
onl}^ in
psycho-
The wish alone, be

During the last
neurosis.
all
produce
a
it ever so strong, cannot at
hell
the
by
some disease,
had
the
wish
freed
from
war thousands
to be
certainly
not because
did
appear
in
most
cases
but the disease
not
unconscious,
the
i.e.
other
opposing
considerations.
One,
of moral and
7nust know the path to definite symptoms in order to travel along it.
By means of trembling during fright from a shrapnel explosion many
were shown the path from now on the unconscious remembrance of it
could again release the trembling reflex, as often and as long as was
pathic people, and there too they passed away.
necessary.
All the chronic impacts also could finally
not frequently
even
hystericise the person wuth healthy nerves,
though
i.e.
make
it possible for him to produce hysterical symptoms, perhaps along the

path of mere physical nervous weakening, but in any case by means
of the fact that the future patients experience in themselves the sensa-
tion of a
of
number
of
morbid or "nervous" symptoms,
for the release
which they have now found the path of association.
The concept
of hystericising thus contains the dispositional factor, which manifests itself in some weakening of the resistive capacity, and in road
building between the idea and the symptoms.
The above material distinguishes only certain types. In reality
the most different dispositions, mechanisms aiid syndromes inter-
mingle and influence each other.
Therefore it is impossible on principle

produce a division of the iieuroscs into properly defined entities, be
it according to disposition, releasing causes, mechanisms, or syndromes.
In this case one must clarify the various possibilities, and then see in
to
504
them is realized.
monosymptomatic hysterias of
the particular case which of

are
the
e.g.
many compulsion
Relatively pure cases

children,
many
of the
For the remaining

the disposition and mechanisms should be described, which is not postrembling neuroses,
sible to a sufficient extent;
neuroses.
besides, one should also
know
the
more
frequent groupings of dispositions and symptoms and their connections,
which unfortunately has not been adequately attained. Nevertheless

we understand fairly well why hysterical symptoms frequently occur
in "nervous" characters: without excessive domination, facile irrita-
and
no hysteria can develop.

combination of hysteriform symptoms with
pseudologia is at once comprehensible. Both syndromes want to sham
something for themselves and others; they require an affectivity of
strong effective force but labile, an easily influenced spirit and an
bility,
lability of the affects,
Also the
frequent
exaggerated self-esteem.
which represents a
fundamental mood, etc.
plex,
The (pseudo-) neurasthenic symptom comconnected with a depressive
failure, is usually
Just as among themselves, the psychopathic reaction forms cannot

be sharply defined from other morbid groups also, and especially not
from the psychopathies on the basis of which they develop, so that
it is
often arbitrary whether in a morbid picture one wants to emphasize
the psychopathic disposition or the released reaction symptoms.
There
probably are constitutional, one-sided homosexuals; but in bisexuality

chance connections and attitudes determine whether the homo- or the
Many place the
heterosexual components shall finally dominate.
hysterical
anomaly
character in the
foreground,
others
some
of "the impulsive people" lies in
teristics, in
others
it is
a reaction system.
pulsive forms in the original morbid states
the
symptoms; the
in the native charac-
Kraepelin includes the comwe include them with most

;
At all events one should talk of

when on the top of the "nervous^' or
of the others in the reactions, etc.
hysteria and neurasthenia only,

"psychopathic" foundation there is a distinctly acquired morbid attitude, or when one wishes to impress the patient with the possibility
or expectation of
Among
an improvement.
the psychopathic reactions
we
distinguish: the
symptomatic
forms of paranoia, of the delusions of persecution of those

hard of hearing and of induced insanity, the reactive changes of
character, the reactive impulses (states of wandering, kleptomania,
intellectual
pyromania, the neuroses, and among these hysteria (pseudo) neurasthenia, the expectation neuroses, and the compulsion neuroses, but we
want to call attention again to the fact that it is merely a question
of
an
artificial
separation of syndrome groups, which, genetically and
505
usually intermingle and pass over into one another.

same syndromes also occur on the basis of process psychoses,
especially in schizophrenia and in a more limited manner in epilepsy;
symptomaticalily
But
the
only
when they apparently occur "independently" can they
be consid-
For practical reasons two groups are circumscribed

the prison psychoses and the traumatic neuroses.
ered as neuroses.
etiologically:
In the compulsive forms the prospects are not very good.'"'"
we speak only
In
and neurasthenia: Their

curability depends primarily on the severity and extent of the psychothe
following
pathic predisposition.
of hysteria
If the disease is
only a partial
symptom
of a
twisted character which cannot get along either with people or with
fortune, naturally little can be expected; for even
were cured
it
would
still
leave a very sick person.
defects alone also hinder the cure.

tion should be
made
as
much
if
the
More
symptoms
serious moral
Especially in children a distinc-
as possible between the generally abnor-
hysterical syndromes and those with a good constitution, who

from nervous symptoms only under the pressure of circumstances.
mal with
suffer
The former
are almost incurable; the latter with proper treatment
usually regain their health quickly and in later
life
rarely
become
sick again.
Concerning the curability of the two neuroses in themselves, or to

speak concretely, of those cases not associated with other abnormities,
there
is
a difference of opinion according to whether one does not in-
At
clude the nervous disposition in the conception.
symptoms
neurosis does not lead to dementia.

exists
events the
all
are all curable even though all are not really cured.
when
to be cured.
The worst
the patient, consciously or unconsciously, does not
One simply can
The
obstacle to a cure
want
neither directly stimulate the inadequate
energy so that the patient takes up the struggle of existence even under
unfavorable conditions, nor can one often improve the situation so that
no reason
for being sick exists.
But most
patients are improved
treatment or are freed from their symptoms.

sition is not cured, if, as
very common, whereby
is
usual,
still
it is
congenital.
Hence
other reasons cooperate
constituted according to our desires, especially
by
Naturally the dispo-
when
relapses are
(life
cannot be
the desire consists
wanting to shine without continuous achievement). It must not

if the energy, wrongly applied for purposes of the
disease, is led into channels that are proper and commensurate with
the patient's endeavors, such people w'ith their undivided application
of their ability can accomplish more than the healthy. What hinders
their activity is simply split off, and the far-reaching domination of
in
be forgotten that
^See
special discussion.
506
the vegetative functions by the psyche instead of being used for the
production of physical morbid symptoms
is
used in the service of the
While formerly they could not sleep, they now do not

need to sleep much; the system of metabolism that permitted the
hysteric to retain his weight with a very small amount of nourishment
may with a slightly different application become a very useful
new
task.
inexhaustibility of strength.
The
general diagnosis of the psychogenic reactions
is
based, in the
on the recognition of the psychogenic mechanism which is

usually not difficult. The most important and also the most difficult
part of the diagnosis, consists in the exclusion of a somatic (or
first place,
psychotic) foundation by means of a careful investigation. The same

mechanisms dominate schizophrenia, are frequent in epilepsy and all
organic brain diseases, and
diseases.
reactive
may
Therefore one must
and what cannot.
in this place
it
It is impossible to
enumerate the details
hardly to be regretted because one could not

anyway, and only he who besides some experience
but this
get finished with
be released by any sort of physical

as exactly as possible what can be
know
is
appearance of the morbid pictures possesses the general conceptions of the nature of the reactive symptoms can manage to get along.
But even the most experienced will occasionally have to leave a diagin the
some time.
If one finds signs of schizophrenia or of

matter is settled, but if a physical disease
also exists, it may be difficult to recognize the kind and the significance
One should keep in mind that the
of the psychogenic elements.
neuroses leave the ideas intact and do not produce obstructions without
nosis open for
paresis, then to be sure the
Hysterical indifference is
a comprehensible affective foundation.
very rare, and may be usually differentiated from the schizophrenic
by means of its perspicuous genesis and its yielding to influence.
Rigidity of a pronounced affect will probably hardly ever be hysterical.
With the neurotic and especially with the hysteric one usually has a
pronounced affective rapport, be it positive or negative. Whoever does

not show the physician any deeper feelings in the course of a protracted
examination
The
that
it
is
no mere nervous
case.
general treatment will be mentioned here only to the extent
concerns the neuroses.
very few cases.
Where
The
disposition can be influenced in
conditions of weakness of any sort are present,
one will naturally combat them. It is more readily conceivable to

remove the conditions out of which the syndromes grew or were nourAbove all, wherever possible, a life work should be provided
ished.
for the patient in which not only the external conditions are to be
considered but also the internal which induced the patient to decline

a
life
The
work.
will or the desire to be sick should,
if
507
posnible, be
overcompensated by positive endeavors which presume health.

For the rest, one can attack the symptoms by direct suggestion
with or without hypnosis; or one can conceal the suggestion in any
other remedy or procedures, if possible in such as under the given
conditions really have a curative effect in any incidental matter
(climate, mountain climate, water,'" etc.). If the patient feels better
Spontaneously or with skilfull instigation
externally, he gets along.
he makes plans for the future; briefly, he changes his attitude so that
a subsequent reduction of physical energy cannot do so much harm.
For (apparently) localized symptoms local treatment should not if
possible be undertaken, because it would frequently strengthen the
patient's idea that the disease is localized there; still less will one
lower oneself to resort to fictitious operations. Miraculous remedies,
from any sort

help.
of
mystery
pills
up
to a pilgrimage,
may
naturally also
In the form of Dubois' "Persuasion" one can combine the sug-
and patient are unconscious with a

and enlightenment. This depends on the taste of the
patient and still more on that of the physician. Psychoanalysis which
brings the morbid mechanisms into consciousness or causes an "abrecaWhere it can be done, one will
tion" of them cures many cases.
"subliminate" the pathogenic impulses, divert them into similar but
useful channels and supplant associations having a morbid effect by
gestion of which both physician
sort of training
more favorable ones. Isolation is often important or at least separation from an environment which is impressed by the patient's suffering
or shows sympathy with him especially in the case of severe hysterias
of children, this measure is usually a necessary condition of the cure.
;
On
the other hand, the deliberate ignoring, the refusal to be impressed
by apparently the severest symptoms, is an excellent remedy. A hysterical attack and many another symptom is really an exhibition.
If one takes care that the spectators disappear at once when the
exhibition begins (preferably by isolating the patient) then the entire
arrangement is usually deprived of justification for existence, and it
In general if by changing the inner
is given up in the shortest time.
,
or outer circumstances one can

"^^
Drugs as
possible.
They
make
the neurosis
futile,
naturally
much
direct remedies against neuroses are to be avoided as much as

divert both physician and patient from the true conception of
the disease. If they have no effect, they have for that reason ah-eady done
harm. If by chance they are effective, the cure is bound down to them and they
have to be continued mildly until a change of conception renders them inFor
effective.
It goes without saying that morphine should not be given.
incidental purposes one will naturally not want to dispense entirely with chemical
remedies: Bromide for sleeplessness, iron for accompanying anemia, etc.
508
gained.
is
^Where physical
to increase
it,
be
resistance has been reduced, one will try
to deprive the disease of its foundation, or effec-
it
tively to support the suggestion of health.

If
matters improve, then a thorough training must follow in which
a sensible
manner
of living
proper initiation into
life.
the only decisive thing,

patient.
is
Some think that
must not be forgotten and thereupon a
What one does in the neurosis is a detail;

how one does it, and how one stands to the
for this reason they
have to become friendly
with the patient, others consider this dangerous; if only there is a

personal relation to the physician, one can overwhelm or impress or
persuade the patient or use suggestion on him; here too the remedy
is a detail.
It goes without saying that for psychotherapy generally
and
for the
application of every individual remedy special innate
qualities are necessary, in

is
which respect unfortunately many a quack
must be proand
the many accompanying
superior to the trained physician; added to this there
fessional experience, exact observation of the individual patient

his
manner
of reacting,
and the weighing of
conditions that have to be considered.
Prevention. The congenital neurotic disposition cannot be readily

combatted except by the avoidance of the marriage of "neuropathic"
people.
A disposition acquired by disease or by unfavorable life
experiences usually disappears without our intervention. One cannot
evade the inner and outer conflicts at will; on the other hand, they
can be subdued by creating a purpose in life; to be sure the normal
person does not have to do this consciously, and on the other hand
many a severe and characterless psychopath will be unable to form
one or hold to it. But in the cases that lie between these extremes it
depends on the attitude and the circumstances, matters that to some
extent can be controlled. One can create a purpose in life or have
one pointed out by another person. Every task is interesting as soon
as one has gained sufficient associations in connection with it. Here
one should not forget that most hysterics, like women, are more easily
interested in things having a directly affective element, especially in
personal things.
ing
On
the other hand, a rigorous disciplining of think-
by dealing with tangible
realities
can counteract the emotionalism.
But the 'health conscience" above all is amenable to educative influences. Whoever from youth onward is accustomed to treat his feelings
of ill health as an inferiority and disagreeableness, whoever in childhood experience no advantage but always only obstructions from
dis-
produce a neurosis. One has to create a "pride

in health" (Gesundheitstrotz) even during the training of childhood,
and where this has been neglected the physician should make it up
ease, will not so easily

as far as possible
509
but this feeling must not be mistaken for the health

who want to keep well by means of some
nonsense of psychopaths,
system and are therefore incessantly on the watch for symptoms
of
health and disease.
For the prophylaxis
in the case of psychopathic children
Ziehen
gives the following noteworthy rules:
L Total abstinence from

up to and including puberty.
2.
coffee, tea,
Supervision of the sexual
alcohol, spices
and tobacco
life.
Hardening by cool rub-downs and cool baths; habituation to

pain and exertion; regular gymnastics (eventually also sports). Careful restraint of the development of the phantasy (supervision of read3.
ing, care in leaving
them
alone, etc.)
favoring
(collections of all kinds, construction,
from models or from nature, open
The
daily routine in
4.
all
all objective occupations

drawing; later also painting
games with other children, etc.).

by a definite schedule.
air
cases should be regulated
Attendance of a public school
is,
as a rule, preferable to private
instruction.
5.
In case of unfavorable
the parents, coddling
parental
home
home
conditions (unfavorable example of
by the parents,
etc.),
education outside of the
in a private school or in a suitable boarding place or
in the country with a teacher, physician, or minister should be pre-
scribed;
in
(schools
more severe cases the
with
medical
so-called
supervision),
like
pedagogical
those
first
sanatoria
founded
by
Kahlbaum, should be considered.

Habituation to obedience and self-control by means of a calm
Passionate scolding is almost never successful.
Corporal
punishments also are rarely effective nevertheless they are permissible
to the same degree as in the case of normal children.
Other punishments (deprivation of pleasure, etc.), are not only allowed but when
6.
severity.
sensibly applied are, as a rule, effective.

1.
As the
to
clinic
present
Paranoia
can only rarely exhibit paranoiacs, it is in place here

more detailed examples for purposes of
somewhat
orientation:
Delusions of Persecution. Engineer, born 1855. Father was an

unsteady farmer, who did not like to work, during manhood felt himself persecuted in a vague way and hanged himself during an attack
of delirium tremens.
The father's father was a drunkard. Three
brothers of the patient are unmarried, unsteady like the father; two are
relatively steady, one is a drunkard.
One sister is married, normal,
510
has children.
toward
Patient was a capable, cheerful boy, but somewhat shy
Mechanic's apprentice, then in a technical school,

then a skilled mechanic. Hoped to become distinguished. The future
strangers.
partner of the machine factory
S.
was
his schoolmate.
At the
final
examination of the technical school the patient exhibited a drawing,

which he expected would make a name for him, but he was keenly
disappointed when it was praised and then forgotten. He was a good
marksman but even for his prizes he received too little recognition.
He thought of journeying to the Cape of Good Hope with his brother,
got as far as Marseilles, heard there that no steamer would leave. The
brother travelled by way of Genoa, but the patient returned home,
took a position in a branch of the firm S. in England but felt uncom-
him
now the firm R. would
was made to him that his present
fortable after a second, larger firm, R., in his native
a position that he refused.
be put out about

position be
it.
made
When
He
town
offered
believed that
the offer
secure for three years, he suspected that the firm
wanted to take advantage of him, and left his position. Then there
began a wandering existence for twenty years contrary to his will:
when he had a good position, he heard remarks that he was ungrateful
toward the firm S., that he was an engineer who did not know algebra,
and similar things. In reality they were random remarks that he
wrongly applied to himself and memory deceptions in which to accord
with his delusion he changed something in words he had heard. Some
one said, "You will soon see"; he referred this to himself as a threat.
He was in all sorts of places in Europe and America, and several
times returned temporarily to an old position, but he was always
driven away by such remarks.
He devised reasons why the firms
and
S.,
with the assistance of the association of former engineering
students and in other ways, pursued him to take revenge on him, and
same time to make use of his talent. "They simply gave the
assignment to an agency and had me persecuted."
People were supposed to have ascertained where he was going and
sometimes even to have sent the news in advance. Once he defended
at the
himself in an insulting letter to the firm, which naturally understood

it.
Often he felt safe for a time in some new place,
he had to write home, it began again because the postal authori-
nothing about
but
ties
if
opened his
letters
and gave
his address to his persecutors.
restaurants people put their heads together
when he
entered.
In
Special
arrangments were made to make him acquainted with women, who

should tempt him to all sorts of excesses so that he could then be
exposed as a high flyer. Often care was taken that he did not get a
position until he had used up all his savings this was done so that he
;
511
would become dependent on his new employers. Because his money

had to go anyway, he began to drink Rhine wine and smoke Havana
cigars and habituated himself gcneraliy to drink more than was good
In America he got married but did not take his wife with
for him.
him when he was again "driven away," and more or less forgot her.
Several times he wanted to start his own business but never got beyond
the purpose. With the laborers he conversed little; he was too proud
to do it. Once, when he returned to ZUrich he felt that he was being
observed by a sanitary policeman. That was possible because he had
sent his photograph to Zurich. He wrote an essay on a Utopia which
was no better than similar efforts but of which he was very proud.
A few months before his admission to Burgholzli in 1897 he was a
His fellow employees began to smirk,
construction draughtsman.
sometimes to laugh, all on his account. His superiors annoyed him.
Once a drawing was lost; he was pointed to as the guilty person.
People peeped through the key hole when he washed his privates in
the water closet, and told others about it. People "made a big fuss
about a few youthful errors" and said everj'where that he masturbated.
In this way he lost his honor and the possibility of making a living,
because no one wanted to employ a person of that sort. He would be
a scoundrel if he had tolerated this and so he shot his superior from
ambush. In the hospital for the insane his conduct was normal externally. At first he was visibly frightened at the result of his shooting.
After he had openly stated the above motive ôr several days and
claimed to have acted in self-defense, he framed excuses which he evidently believed himself (gun went off accidentally, then again that he
had been confused, etc.). On the whole he was distrustful, friendly,
worked in the printing shop of the hospital and besides tried to make
all sorts of inventions (a milling machine which was usable but already
equalled by one just as good, a steam engine without a swinging piston
At first he tried to
in which, to be sure, something was still lacking)
carry on his studies "as secretly as possible"; after a while he became
accustomed to the society of the others.
He spun out his delusions in various directions. In the remissions
could
also correct some things; thus he once thought "Messrs. R.
he
only
wanted to watch him but not persecute him"; "they simply
and S.
from
fixed ideas." But soon after he took up the old system
suffered
again. New delusions also turned up: in his ward there was a homoNow people nudged and winked that he too was perverse.
sexual.
Furuncles that he had on his neck had been injected into him by the
orderly. In his ward there were by chance several former employees
of his last firm.' They probably had to observe him, etc.; the delusion
.
512
form of memory deceptions. S. had

Chapters of a certain law had been
used against him (this at a time when this law did not exist at all).
He thought the murdered superior had dismissed him in disgrace,
while in reality the patient had resigned. At certain times the delusional system merged into the background; at other times he occupied
himself entirely with it, at the same time developing it further.
Noticeably early the patient showed signs of psychical senility.
With this there now came more pronounced ideas of greatness that
could not very well be sustained logically any longer: A second court
One judge or another had promised
of justice would liberate him.
him to take up his cause. An uncle had left him a house and later an
enormous fortune. Finally he suspected that he was not his father's
son.
All of this was supported in the form of memory deceptions.
Even previously, 1907, he had escaped, but in spit of the fact that
he had been helped with money, he only got as far as France and there
thought it best to return to the asylum of his own accord. Without
feeling that in this way he had hurt his position, he thought he had
now proven that he could be discharged, and he planned to become a
also developed retroactively in the
already persecuted him in school.
store-keeper.
Pathology:
An
excellent
man
with a certain amount of inventive
ability cannot execute his ambitious plans because he has too little
He thinks that a good drawing that he exhibited

and a few medals that he won at rifle shooting should immediately
open the way to distinction. Conversely, when in Marseilles there
was no boat to the Cape of Good Hope and, likewise, when after his
escape from the asylum he had trouble in making his way, he lost
In sexual matters he was just as weak; he was married
his courage.
but simply abandoned his wife, not with deliberation but just because
He refused an offered position, found out later that
it happened so.
he should not have done this and then thought that the people who
offered him the position began to annoy him. They had assigned his
persecution to an agency. The delusion has developed into a system
and was supported by incessant ideas of reference and newly created
memory deceptions. Now this plain case of paranoia also has two
enduring energy.
complications that belong to other diseases; in the nineties the patient

had, during the course of his paranoia, a brain disease, probably a
gumma, and
brief period.
at that time
was no longer as good

reason the
a few
was not quite clear in his thoughts for a

his memory, on very careful inspection,
formerly. It may be assumed that for this
From then on
memory
as
deceptions appeared so easily, which already after
days attached themselves to his act of murder, at
first
motivated
513
by himself in an entirely clear manner. The same may be said of

Moreover he had committed alcoholic
his premature mental senility.
the
murder, and had undergone a mild
excesses in the weeks preceding
At that time, but only then, did he
alcoholically tinged delirium.
It must be assumed that this unenergetic man would
hallucinate.
never have gone as far as to shoot his persecutor without this alcoholic
excitation.
Grandeur with Delusions of Persecution:

Daughter of aristocratic but not well to do parents, born in 1848,
brought up at home with a classical education, is said to have covered
Associated with
in three months the work of each year in college.
She wanted to investigate a definite, important historical
scholars.
subject but permitted herself to be diverted and wrote something
Then she undertook a new historical problem which she
different.
gave up to care for her sick parents. At the same time she had pleasant social intercourse with acquaintances and friends. At thirty-six
she went to a brother, whose wife had died, to keep house for him, but
paid him her board to be on an equal footing with him. Two years
In the meantime her feminine instincts
later she was again at home.
"I felt that at bottom I was disposed to be very
were aroused:
domestic; although I again plunged into society, nevertheless I did not
know what to do with myself." She wanted to become a nurse but in
some way did not get along with the authorities. In a sort of desperaErotic
Delusions of
tion she let herself be driven into marriage with a less aristocratic but
evidently very refined man.
As
days before the wedding

However, the marriage was
late as eight
the future couple discussed a separation.
consummated but was soon followed by a legal separation. Later when

I remarked to the patient that her husband had acted very generously
in the matter, she thought: "According to what I saw, he did. AccordAs the
ing to what I heard later but cannot prove, he did not."
patient was a Catholic and thought of marrying again, the separation
gave her qualms of conscience. Probably a little later she formed
But
the delusion that the archbishop had annulled her marriage.
before she was separated she believed that men of high rank wanted
to marry her. They themselves, as well as other people, had proven
this by their "hints." But nothing happened because intrigues against
it had been undertaken and she was being slandered.
She defended
herself against this. Insanity was suspected. A psychiatrist evidently
on the occasion of the separation, had given an opinion to that effect.
She wrote to him that he was a scoundrel and she then believed that
he had thereupon given a second opinion, declaring her sane.
She
was then put under guardianship and was afraid of being committed.
514
Even during
the trial she fled to foreign countries and wanted to have
herself certified to
by a psychiatrist; but when she ascertained that
he was known in a city where one of her supposed admirers lived, she
was convinced that with the help of the courts he wanted to surrender her. She then went to a Swiss University where, as she thought,
she was slandered as crazy and syphilitic and in other respects. As
she feared being interned, although there was no reason for it, she
once fled to another university and obtained her Ph.D. magna cum
laude. Thereupon she looked for positions but found none, travelled
around everywhere, in other parts of the world also, always felt herself pursued, especially when she sent off a letter; she wrote a pamphlet
on German justice embodying her delusions. Meanwhile she again

imagined proposals of marriage from prominent people, intercepted
telegrams, opinions, and acts of people of the highest rank, of which
nothing in reality existed. Everything influenced her being either in
a friendly or hostile manner. After a while the patient calmed down
somewhat but always believed herself pursued by everybody that had

had anything to do with her. She produced articles and, which was
significant, liked to write
case
is
about secret
societies.
Characteristic of the
the fact of the predominance of scientific interests over the
she had kept house and had reached the critical age.
Only then did she have a desire for a home of her own but at the
same time also for an elevation in rank; an unfortunate marriage not
based on any erotic feelings; delusions of being desired in marriage
by people of distinction, imaginary failure of a marriage because of
intrigues and slanders. In spite of the patient's very high intelhgence
and her education, she was absolutely incapable of correcting the most
erotic until
senseless delusions even
when confronted with them,
as, for instance,
that a psychiatrist in a university to which he did not belong
demanded
her dismissal, that in America she could be brought into an insane
asylum by a nurse without any further formalities, etc.

was capable of obtaining her Ph.D. magna cum
this all she
The way
hints
is
gave
me
But with
laude.
she herself described the origin of her combinations from
very pretty:
"I heard the whole thing bit by bit;
a hint, then another, and
now one
put this story together
like
mosaic."
Persecutory Delusion and Litigiousness. Author, born 1857 college

;
education; since his twenty-fifth year hard of hearing and then deaf.
He worked
on a newspaper, had a good income, was generous toward

and sisters but saved nothing for himself. In early youth
there were also a few signs of frivolity. Because of the expense of
his education, he had given up his claim to his share of his father's
his brothers
THE INJJIVIDUAL MENTAL DISEASES

estate, as a second brother
had done.
Toward
515
the end of the nineties
he became more sensitive. He no lonjêr got along with the sinter

with whom he lived and with his colleagues on the newspaper; resigned
tried to obtain a position in a foreign place but failed.
and
made
adventurous,
if
He
then
not exactly gigantic, business plans that were
Then there
quite foreign to his previous calling and became poor.
began a struggle for existence, i.e., for a legacy that was supposedly
so large that he could live on it if he had to. He tried to retract his
waiver of his father's estate. When the father made a will he nevertheless left him one third of the estate that he would have had without question; he went home, raised a riot, and wanted to compel the
writing of another will. He attacked the existing will with all sorts
of pretenses, maintained that the father had promised him not only
his own share but also that of a deceased sister; he stole papers from
his father.
in-law
After the father's death, which followed soon, a brotherthat he wôuld pay him more
made an arrangement with him
than his share
if
he would be satisfied and give up the papers.
the patient did not give up the papers and soon
demanded more
But
(be-
cause he could not live on what had been promised him). In court
he accused his sister and brother-in-law of fraud, duress, concealing
the estate, perjury
and other crimes. As the courts did not decide

were attacked, partly in countless petitions and
the newspapers; the latter in such a manner that
in his favor, they too
appeals, partly in
he convinced people of note of the injustice of the judiciary. He also

got into litigation with his own lawyer, refusing to pay him his fee.
To be sure, here and there he lied; but on the whole he believed
He did not notice that he never proved
in the justice of his cause.
anything.
He
readily
moved
share; proof: otherwise he
in a circle:
The brother-in-law got
would not have raised a
his
riot; the brother-
otherwise he W'Ould not have obtained

anything (naturally the nonsense of these conclusions is concealed
Facts necessary for the purpose were simply
in a mass of words).
The letters that did not suit the patient
invented (memory illusions)
he declared to be forgeries; he knew at once who dictated them.
in-law raised a riot; proof:
In this case the disturbance of thought extends to mathematics.

patient is not capable of figuring a problem of practical im-
The
portance to himself:
If
six
brothers and sisters have to divide a
fortune of 50,000 Fr. in such a
way
that three obtain only the legal
He mixed up everything
and always mistook the ideas
A
in such a way that something big for himself always turned up.
discussion lasting several days could not enlighten him. Other con-
minimum, how much does each obtain?

about the legal
minimum and
total,
516
ceptions also, that were simple for him, became unclear where
it
coin-
Thus he would not keep apart the laws of

He could not identify the same
inheritance and the laws of sales.
events when they concerned himself or an opponent. His unconscious
but solely decisive "logic" was an affective one: He was in want; his
brothers and sisters were better situated; he needed the inheritance
much more than'they. The understanding was present only to support
He formed ideas without any reason
the realization of this wish.
cided with his purpose.
whatever
(chiefly
relations)
what
memory
deceptions but also suppositions concerning
contradicted his ideas
logical connection.
He was
was simply not brought
entirely incapable of discussion.
into
It
was
that the court and his brothers and sisters defrauded
a certainty for him

him; for him everything followed from that.
He
could not, conversely,
prove the crime from the facts. For him the crime was the axiom
from which he started. He could not see the viewpoint of others
who demanded proof. For him everything was "logically demonstrable,
proven, self-evident, not requiring proof; he has experienced
on his
it
own body."
After the appointing of a guardian and the rejection of his suit
the patient still remained active for some time; convinced, among
others, a well-known, distinguished author of "the fact that
he had
found no protection in psychiatry," but seemed to have calmed
somewhat
after a while.
At
all events,
down
unlike the pure litigant, he
has given up his court actions. It is significant that he prefers to write

about super-men a la Napoleon.
The Wagner case; Delusions of Grandeur and Persecution;
Multiple murder and Incendiarism}^^ During the night from the third
to the fourth of September, 1913, the
years old, murdered
Headmaster Wagner, thirty-nine

and his wife while they were
his four children
sleeping; the following night he set fire to several houses in another
where he had previously been a teacher, and was shooting at

the male inhabitants, of whom he killed nine and seriously wounded
Even as a boy he was easily insulted, ambitious, conceited.
eleven.
Later he had poetic plans for reforming the universe. His sexuality in
respect to the animal impulse was strong, but he had a "disinclination"
toward marriage and evidently no parental instinct, even though he
loved his children in an ordinary human way.
His highly developed self-esteem had been deeply depressed by a
Later (1901), under
futile struggle of many years against onanism.
the influence of alcohol, he had let himself be carried away to sodomy,
village
After Gaupp, Zur Psychologie des Massenmords, I. Bd. 3. Heft der Verbrechertypen. Edited by W. Gruhle and A. Wetzel. Springer, Beriin, 1914.
517
and then had a dreadful feeling of sin with incessant fear of contempt
and arrest, which soon brought about delusions of reference and the
conviction that the inhabitants of the village knew of his crime and
spoke about
it.
His accusations against himself he transferred to his family; all

"Wagners" should be exterminated; then his hatred extended to all
mankind, above all to the inhabitants of his district who had treated
him badly. He condemned himself doubly, in part as a man unworthy
of this life, but in part as a genius whom he honored as at least equal
to the greatest poets, but whom he also ranked as equal and superior
to Nero, and, on the other hand, compared with Christ. Transferred
in 1902 to another place, he enjoyed relative quiet for six or seven
years without, however, ever ceasing to build up further his delusional
system. But then, according to his opinion, the remarks and contempt
continued there also. The result was the plan, even then developed in
every detail, to murder his family as much because of reasons of racehygiene as from pity, and then set fire to the village where he was
first employed, and destroy it with all its hypocritical inhabitants.
The first necessity was the extermination, the "redemption" of his
children; but the revenge against, and contempt for, the village occupied him no less. His wife he had to kill because of pity. For a
person like him there are special laws. He had not only the right
but the duty to do this. His plan was a "humanitarian matter." For
four years he postponed the execution of the bitter task. But when he
was later transferred to a third locality and there felt himself the
In
centre of bar-room gossip, he executed his plan systematically.
was completely ambivalent:
his feelings, as in his self-estimation, he
he could not witness the killing of a chicken, did not like to see blood
generally.
In the insane asylum also he was so soft during the visits
he denied them to himself, and with all this, he had

made and also executed the bloodiest plans.^^^
The modern morbid picture of paranoia was created by Kraepelin;
according to him it is characterized by "the furtive development, re-
of relatives that
sulting
from inner causes, of a
lasting,
immovable delusional system
accom^panied by the complete retention of clearness and order

in thinking, willing, and acting."
Formerly many kinds of diseases
that
is
were designated by this name.
Toward
the end of the last century
was believed that the essence of the disease was to be found in the
more or less isolated disturbance of the understanding; as every delusional idea and every hallucination represents such a disturbance,
most mental diseases could be included in this, and this was preferably
it
**
Comp.
p. 531, his
remarks on the brutality of weakness.
518
On
done.
the basis of this stereotyped conception acute forms with
As such acute syn-
delusions and hallucinations were also included.
dromes usually belong to schizophrenia which
later readily exhibits
chronic delusions, the theoretical confusion of acute and chronic conditions,
different in principle, could not appear as senseless
patient's bedside as
lin's
it
really was.
But the morbid
at the
pictures of Kraepe-
paranoia and the acute forms of insanity that were included

much as typhus and a fracture of the leg,
belong together about as
both of which hinder walking and keep the patient in bed.

There was a better development of the paranoia concept among
the French, who in penetrating studies clarified the psychology of
the forms of delusions but could not exclude dementia precox, and
sought classifications according to the content of the delusion.
The essence of paranoia is the delusional system, i.e. a structure
of delusions that all have a certain logical connection and contain no
inner contradictions, even though the logic
pelling.
That the delusion nevertheless
as not only
insufficiently
supported,
is
not in
strikes
all
com-
cases
the normal person
but also as senseless,
is
due
and the shutting off of criticism. Year

in and year out, no matter in what corner of the world they are, the
patients are pursued by a conspiracy of people, or they would have
made great inventions, the practical elaboration and utilization of
which is being hindered, or they are high servants of the crown, prophets, etc., who want to establish their claims.
Only the persecuted patients are as yet known more exactly; our
chiefly to the false premises
description, therefore, is only to be carried over to the other forms
with care.
The
false premises are
morbid references
to the self,
and memory
In a certain direction the patients have an exaggerated

readiness of association; they bring a number of entirely indifferent
or unimpeachable occurrences into relation with themselves. Children
deceptions.
run after the wagon in which the paranoiac is riding; they mock
or show the high position that he will hold. Some one coughs;
is a sign that he must be on his guard or that he does not belong
or that another should be on his guard for him. Some one yawns
;
him
that
here
that
two people are together and laugh, then they

In the newspaper there is an expression that
he has used recently; therefore the entire article is stolen from him.
A higher official has looked up at his window; he has an important
mission for him or he knows that he is the future sovereign. The
means that he
is
lazy;
if
are laughing about him.
minister preaches about Judas: the whole congregation

(the patient)
was the person meant.
On
knew that he
the street everybody looked

at
him
significantly.
519
Between the event and the interpretation
in
the sense of the self-refercnoe delusion there usually intervenes a latent
period of from hours to years, most frequently of about a day.
While
the healthy person usually works over his experiences subsequently

(consciously or
more commonly unconsciously)
in
the sense of a
many
sided connection with reality and a correction of possibly wrong conceptions, th^ paranoiac connects his perceptions during the latent period
with the delusions and
falsifies
them
in the
same
direction.
Sometimes the patient's assertions seem so senseless that one has

what extent sensory illusions are involved. Beside the most
commonplace occurrences the patients are also accustomed to tell
some that are altogether impossible. To illustrate: In spite of the
to ask to
fact that they
came
into the theatre without a sound, the entire audi-
ence looked around at them; the minister spoke of things that he

could not possibly know from ordinary sources; a respectable person
Of course here and there
stuck his tongue out at them.
real illusions
may
play a part as in every healthy affect. But whenever I could

investigate carefully I found that sensations and perceptions were
absolutely correct, but the patient transformed them, of course often
immediately after the perception, and later in his tninking he operated

only with these transformed pseudo-perceptions which he took to be
real.
Hence there are already involved here added memory deceptions
which, to be sure, occur also in normal people. There are people who
only subsequently falsify their recollections in the sense of offenses.
The complicated memory illusions which represent complete trans-
seem clearer to
act
At
us.^^
this
and that consultation which
supposed to have said that the patient

was sound, that the expected elevation in rank would occur in one
year. The waiter brought the patient a glass of brandy; later he is
convinced that the brother-in-law who is accused of poisoning served
really took place, the physician
him.
His wife met a certain
is
man on
the stairs; later he believes she
were understood and replied to.

Between the event and the complete transformation there usually
made
signs to
him
in passing that
intervenes a considerable lapse of time, at least a night, often much

more, a year, even a decade. Supported by continually repeated "ex-
periences" of this sort, the patient must come, in an entirely logical

way,^*^ to the conception that people have something particularly
in
mind about him, he
goes further and
knows
also ichat they
have
""See pp. 105-106.

^" In the paranoid form of dereistic thinking the logic must also be included,
but it is here essentially supported by the fact that the elementary- impulses
run in the same direction; the wish to be something special is already at the
root of the disease.
520
They want to persecute him or prepare for his future elevaand he knows why they proceed in this manner. The latter he
has naturally not been able to conclude in a compelling manner; but
"as the chief factor is a certainty for him, inferences based on probability
which he considers certain suffice for him. A general criticism is impossible. To be sure, occasionally he may admit that one or another
in mind.
tion,
of his partial ideas
But
is
not sufficiently proven or even that
for that reason everything else
it is false.
nevertheless a certainty beyond
is
a peradventure.
Outside of the delusional system and everything that refers to it,

and train of ideas are sound according to our means of investi-
his logic
If he
gation.
is
otherwise intelligent, he can be a minister, architect,
or high school teacher and, aside from indirect difficulties resulting
from the delusions, can do very well
in his calling.
In everything con-
nected with the delusions, paranoiacs are very gullible about corroborating statements and, on the other hand, readily distrust everything
that does not suit them.
shows
disease,
it
It
seems that this feature also frequently

it because, beginning with the
outside of the delusion, be
itself
has become generalized, or because
it
belongs to the patient's
individual character.
In
the
other
functions
also
one
can
no
recognize
primary
disturbances.
Sensations and perceptions are sound. Hallucinations are nearly

always lacking; but one must not say that they are entirely excluded
because that is not the case even in normal people; but in paranoiacs
there are occasionally strong excitements or also ecstasies that
may
run their course with hallucinations. When this is the case hearing
and sight are probably affected most; in severe acute conditions perhaps also smell and taste.
Memory, aside from the illusions, is good. Memory hallucinations
Naturally the one-sided interest of the
will probably not occur.
patients
also produces
gories of
memory
one-sided preference for individual cate-
material.
Orientation as to place and time always remains normal, except
perhaps in the very rare psychogenic twilight states.

Attention corresponds to the preoccupation with the delusions; if
these are once taken for granted it is normal. At any rate, one can
call the readiness of association for everything that can be utilized
by the delusion a one-sided tendency

all
of the attention.
monotonous
not always the case; nearly

paranoiacs permit themselves to be diverted at least sometimes,
trend of ideas
and many
still
is
mentioned, but that
is
have other considerable interests outside of the delusion.

The
refuge he
who has
dent
on direct observation to be primarily nor-
affectivity appears
Naturally one
mal.
is
who has
also persecuted
new place of
The megalomaniac
from Heaven or the presi-
just discovered that in a
depressed or irritated.
is
just received a sign of his calling
feels well satisfied.
521
But
this corresponds to the
reaction as far as the affect alone
is
considered.
normal affective
It is said that the
know that this is true in the ordinary

The normal person also is irritated by incessant annoyances,
on the average much more than most of these patients, who tolerate
a remarkable amount of disagreeable things.
Then there are parapatients are irritable; I do not
sense.
noiacs
who were
already irritable before the disease broke out which
therefore not at
all the cause, perhaps, however, the result of the

temperament. But one also finds calm dispositions among paranoiacs
I have not as yet seen any sanguine dispositions.
Paranoia is said to destroy morality. Strictly interpreted, that is
not the case. The moral feelings as such are not touched. But the
whole morbid logic is so one-sidedly influenced by the delusion that
the patients often cannot either 4ecognize or feel the just rights of
others.
Furthermore, their own cause is so very much the only important, I might say the only sacred, thing in the whole world, that
a few lies and acts of violence also disappear in the face of it, and
is
are furthered
An
and
sanctified
by the great purpose.
inner classification of the paranoia forms can as yet be
only according to the content of the delusion,^*^ which
is
made
naturally
again conditioned by the natural disposition and other internal and

external presuppositions.
The forms most frequently met by the
physician are those involving injury, which again are divided into
delusions oj 'persecution, the
commonest form, paranoid
litigiousness,
who
him advance
At the same
and delusions of jealousy.
The persecuted one
sees hostile people
in life because of jealousy or
any other
will not let
selfish reasons.
time they bother him, slander him, deprive him of his positions, try
to poison him (no physical persecutory delusion).
Wherever the
patient goes, he is met again by persecutors, disguised or not, or at
any rate by the
results of their work, in the
form of
letters, incitation
of the people in the neighborhood, or expressions of contempt.
The
or at
litigious
paranoiac has as a rule at some time lost a law suit,

result of it has not quite obtained his rights as he
any rate as a
expected.
He now
tries again, loses
once more, goes to every higher
^*Â natural systematization would have to be based, in the first place,

the peculiarities of disposition on which the paranoia is founded and then
the reconstructing psychical mechanisms.
on
on
522
is not satisfied even by the last, but again finds reasons to

upon a new method of trial. At first they are ordinary causes
action, but then new material motives are added: On the one hand
court but
enter
of
the judges will not stand for everything, respond with penalties against
the accused, let unjustifiable complaints lie, or do not investigate the
way
the patient expects.
On
tated, accuses the judges
the other hand, the latter becomes
and
finally all officials that
irri-
have dealings
with him of prejudice, violation of the law, and conspiracy. He denounces his own lawyers and those of his opponents, whereupon an
action is begun by the other side. Thus the material is far from
being exhausted; on the contrary,
it
is
constantly increasing until
commitment or a guardianship gives the judges rest, at least for a

while. Whatever unpleasantness occurs to the patient is felt as a grave
What
injustice which the whole world must set right or avenge.
they themselves do to others they do not notice at all. The worst
scoldings and slanders from their own side they cannot evaluate
and are completely astounded and indignant when the opponents react
In their logic the laws contain almost only what can be
to them.
What
^jturned to their advantage.
the one case
all
is
characteristic here
others invariably originate.
With
is
that from
this the litigious
paranoiacs are usually not only clever pettifogers, but they also
acquire an extensive knowledge of the laws, which to be sure they
Whoever, after wading through countless tons

slight mistake .in an opinion or in a report,
being attacked by them because of it.
interpret one-sidedly.
of documents,
may
be sure of
The
makes a
litigious delusion
may
appear in organic connection with a
purely paranoid system of delusion and in this way give proof that it
should not be separated from paranoia: A mechanic, fifty -three years
sued for divorce from his second wife, who was a drunkard, and
his case. In describing a scene with his wife, who irritated him,
he had used an expression in court that anyway he was a "bad actor."
In the judgment, in translating the slang expression into more elegant
diction, it was stated that he had himself admitted that he was a
old,
won
it was inferred that the wife alone was

not altogether at fault and that he should contribute to the cost of
The expression angered him and he demanded a reversal of
""action.
"brutal man," and from this
the judgment; he did not recognize the divorce at all, visited his wife
repeatedly in a demonstrative manner, went through all possible and
impossible appeals, denounced the authorities, neglected his work and
finally made considerable debts. Thus he had bought a suit with the
assurance that
dealer to press
it
would be paid
him
for the
for,
then he himself instigated the

pressed, he proposed the
money on being
;
523
and when the creditor came to him to attempt to obtain a

friendly settlement, he threw him out of the house. Thus the patient
had to be brought to the hospital. He was a jovial, fundamentally
really a good-nuturcd man, who would like to have succeeded a
courts,
little
better in the world without, however, having the strength to
accomplish this (the usual inner discord of the paranoiacs). In one

respect, to be sure, he had accomplished something; "he, the simple
laborer,"
had been able
in the
town meetings and at the
elections to
have his opinion prevail against respected citizens but he still

mained the simple laborer while one of his opponents rose to
re-
th^
highest position in Switzerland; another achieved the second highest

position (painful
wound
to his vanity).
attitude of the drunken husband.
Toward
In reality he
other hand, she conducted herself in such a
way
his wife he
still
had the
loved her; on the
that he had to obtain
a divorce, and in spite of his age he thought of a better marriage
Hence the complex
(second conflict).
ments
in the case
he himself asked
sensitiveness
toward the judg-
that he won; hence the non-recognition of the divorce

for.
In his consciousness, to be sure, the reason was
His distinguished political opponents want to revenge themselves on him; they induced the judges to render such a decision so
that every woman who would like to marry him would have occasion
to inquire of them concerning his brutality, and so that they could
different.
thus lower his standing and hinder him in remarrying. But as the
man was euphoric and not distrustful, his delusion developed in a
As he had everywhere been treated with

when in his actions and in his incurring
debts he over-stepped the bounds, his opponents did not really mean
somewhat unusual
direction:
noticeable indulgence, even
wanted to prevent their part in the

matter from being exposed in court. Therefore he believed that behind
his back they paid all his debts, and in order to try them again and
again, he made debts, sold his furniture that had already been put
to do so badly by him, or they
up as
security, etc.
The
jealous patients are probabty for the
holic jealousy
most part womea
delusion does not belong here).
They
(alco-
find evidence
everywhere that their husbands deceive them with many other women
with the old laundress as well as with the beautiful daughter of the
neighbor they have affairs, give them money, etc.
Hypochondriacal delusions also are said to occur in paranoia; as
yet I have not seen them.
The forms of delusions of influence are never wholly free from an
admixture of more or
less
pronounced ideas of grandeur.
patients have an exalted feeling of self-importance; they
All such
consider
TEXTBOOK-OF PSYCHIATRY
524
themselves extraordinary in some particular

delusion
is
partly connected with
it,
others whose path they cross, etc.
line.
The persecutory
because they arouse the envy of
On
the other hand, where the
grandiose delusion dominates, the feeling of persecution

lacking; sometimes, especially in erotics,
it
is
only rarely
approximates the main
delusion in significance.
Among the megalomaniacs we must first mention the inventors who

appear in every branch of mechanics. Often some of the ideas are
not at all bad, but some weakness in their planning is overlooked
while it is just on this that the entire failure depends. Before Zeppelin
and the Wrights, dirigible airships were decidedly favorite objects of
invention a half century earlier it was perpetual motion.
-^ Allied to the mechanical inventors are the discoverers in all scientific
Here one already sees more frequently confused things.
fields.
Entirely free in their combinations are the prophets in religious and
political fields nvho often find many followers and obtain a certain
amount of importance (Illustration: Lomhroso, The Man of Genius).
With these probably should be classed the above mentioned mulPotapkine, who infected pretty nearly the
tiple murderer Wagner.
;
entire population of his village (in the province of Orel, Russia) with
his teachings
them
so
about a return to a primitive
that numerous punishments
state, or at least influenced
for
anti-religious
acts
were
administered.^*^
The
geneologists or interpretateurs filiaux of the French, the para-
noiacs with the delusion of high descent, realize the everyday dream
of so many children, which has also found expression in the fairy tale;
they have merely been stealthily handed over to their poor parents or
given to them to bring up in reality they are children of the nobility
;
but for some fantastic reason, made more or less plausible, they are
not brought up in the circumstances to which they were bom. Only
a certain time or event is awaited for them to be returned to their
proper social position.
The erotics believe themselves loved by persons of the opposite sex
of higher rank, often of the highest; they pursue him with every possible kind of messages that they are ready for the honor, or they enter
his residence by stealth or force, where they demand to be treated as
husband or wife. That they do not succeed in this is naturally due
to the intrigues of others, to wickedness which is usually thought out
more or less definitely in detail in the paranoic manner.
All these forms are markedly egocentric; the entire delusional
system turns about the patient, his wishes and his fears. But other
**'
Monatsschr,
Kriminalpsychol.
II.
1905/1906, S. 493.
525
forms can also be thought of. Tlius I know a minister who for many
years has the delusion that the children of his neighborhood are
maltreated by their parents. From what I know the case can only
be brought under the head of paranoia. The delusion would be comprehensible if one supposes that the patient suffers from repressed
sadism or masochism.
The course of paranoia is always most chronic. Some of the
patients, but not all, were on closer inspection noticeable even earlier
for selfishness, misinterpretation of the acts of others, and sensitiveness.
ând
The prodromal
stage
is
practically never observed by physicians,
the relatives also can usually give no good account of
it,
as the
For
patients at this time are nearly all inclined to be very reticent.
the customary descriptions in the books the paranoids
much
rather
than the paranoiacs have served as models. No dependence can be

placed on the statements of the patients themselves because just in
by a vast number of memory

illusions.
At all events many cases require a greater number of years
to develop, in that the persecuted at first become only distrustful and
these connections they are deceived
""are
still
capable of recognizing at least a kind of uncertainty in their
conclusions, but after a while there comes to

is
then never
delusions,
lost.
Similar
is
the case in
whose haughty over-estimation
them the
many
certainty which
forms of grandiose
and
of self
of their secret
hopes are slowly and easily hatched out as ideas of greatness. But in
both kinds an "illumination" can suddenly permit the disease to
become manifest. In litigious patients it is usually to be dated from
the
first
court decision
but the delusions and the entire litigation are
usually developed completely only in the course of years.
Paranoia frequently breaks out
first in later
manhood
according
two thirds of the cases after the thirties but there

are also cases which become sick around the twenties.
In all forms, periods (usually long ones, lasting months and years)
of stronger delusional formation and corresponding reaction alternate
with quieter phases, in which the patients are more capable of getting
along with other people and of being active in their calling. Most of
these excitations and mitigations seem to come from within outward;
to Kraepelin in
others, chiefly in the persecuted, are connected especially often with
a change of residence, after which the patients at
but
first feel safe;
become attached to the new surroundings; often a letter that the patients have written produces the change.
They considered themselves concealed; now^ their address has become
after a while the old delusions
known through
authorities,
the addressee or through the indiscretion of the postal
and the chase begins again.
Thus many
travel
from
526
place to place during their whole
lives, always going as far as possible

and in this way get all over the earth.
In the insane asylum at Washington, I was told that the capitol of
the Republic especially attracts paranoiacs from the whole earth
because they expect help from the President of the United States.
There is surely no cure for paranoia. Those cases described in
the literature of the subject can without doing them violence be con-
from the one
just inhabited,
sidered as schizophrenia; least of
all
On
the case of Bjerre.^**
the
other hand, improvements appear with age, either because the patients
finally
come to
see that they carry
on a useless
struggle, or because
during the involution the energy declines, so that they are
and because
less active,
of their passivity get along better with those about them.
As was said, most paranoiacs during the years of incubamore or less reticent more expansive characters with an
inclination to delusions of grandeur may be exceptions. At the height
Conduct.
tion are
of the disease
we have
to keep distinct
how they conduct
themselves
and social life, and how they carry on their

Conduct is about normal as far as it is not influenced by
delusion.
the delusion. The degree of influence varies greatly from one patient
to another. In the one the delusion takes up the largest part of their
time and interest; almost in every social gathering some partial delusion crops up and makes the patients noticeable. At the other extremes
in their ordinary business
there are calm, quiet natures that continue to work in their calling even
though with difficulty; they change their place of residence now and
then or do something else incomprehensible on the outside, but they
may remain unnoticed by most people, sometimes even by those near
to them; but in the same patients also the conduct changes as a rule
in the course of months and years.
Within the limits of non-paranoiac activity the patients conduct
themselves normally. They never lose control. But in the pursuit of
their purposes they also conduct themselves on the whole like other
people who would have to achieve a similar object. Prophets, to be
sure, often indicate their mission by appropriate dress, hair and beard.
But most of the patients are extremely inconspicuous. Real excitations which would be pathologic in themselves through their severity
and through the disruptions of the train of thought occur, if at all, only
as brief episodes.
On
the other hand,
many
of the persecuted, for
comprehensible reasons, are ordinarily cranky, irritated, and

In the pursuit of their aims nearly
degree of passionateness.
^ Zur
Many
all
show a
persecuted patients react with eva-
Radikalbehandlung der chronischen Paranoia.

Jahrbuch
Deuticke, Leipzig and Wien.
analyse usw. Bd. III. S. 795.
irascible.
certain, often a high
fiir
Psycho-

sion, threats, scolding, insulting letters,
Those
and appeals
527
to the authorities.
from grandiose delusions often use the press in a prolific manner.

In general many paranoiacs actually become "graphomaniacs." Actively persecuted patients readily become persecutors
suffering
(persecutes persecuteurs)
If the patient
can no longer resort to legal measures, he
seizes
on
"self-defense," either shooting his opponent, or, not rarely, assaulting
a distinguished person in the hope that publicity will compel an

impartial investigation and thus at last bring the true facts to light.
In rarer cases, in improvers of the universe and prophets, acts of
violence belong to the delusional system, as in the Wagner case; the
religious paranoiac David Lazaretti died in 1878 in a battle with government troops.
Frequency. In hospitals, paranoia is a very rare disease, so that
some psychiatrists doubt its existence; not one percent of admissions
can be assigned to it. But outside it is not such a great rarity. It is
always some special occurrence (an assault, a trial) that brings the
patients to the psychiatrist. --
According to Kraepelin, paranoia chiefly
afflicts
men (70%); my
experience also coincides with this.
The
diagnosis of paranoia
patients
know which
is
not always at
all
easy in practice.
of their ideas are considered
The
morbid by others
and can conceal or weaken them so that they can be defended. The
delimitation in principle from mere psychopathy is often absolutely
impossible where the delusion^lhas centered itself on a class of ideas
that are beyond proof, as in the case of founders of religion, politicians,
and philosophers. Indeed, one can even enter into disputes concerning
the morbidity of scientific discoveries and mechanical inventions that
are entirely new, even if so many real inventors were not considered
"crazy," as far as they are not really sick in some wây. For even
a crazy man may sometimes invent something worth while. jMoreover,
an idea may, by chance, correspond with reality and nevertheless be
a delusion.^^^ For the diagnosis two things must be considered:
1. The logical proof of the idea by the patient, which in the morbid
cases shows incorrectible mistakes in the premises as well as in the
logic, to
the extent that certain parts of a discussion are inaccessible,
and important and self-evident counter arguments simply cannot be

appreciated.
But with this, the momentary affective state and the
"' It happened that a paranoiac believed himself poisoned with corrosive
sublimate and corrosive sublimate was really supposed to have been found in
the beer in the chemical laborator\', because, as was ascertained later, the
reagents were contaminated.
528
must be taken into consideration. The

normal people also, and a weak
patient's general intelligence
affect accounts for defective logic in
intelligence even without paranoia will not be able to grasp complicated

relations.
2.
The
cancer-like extension of the delusion to ever widening areas
and the far-reaching domination by the delusion of the entire personality in its behavior and its strivings.
Some one may write a
proof as convincing as
it is
disputable that the seat of the soul
is in
the
sympathetic system; but he is not a paranoiac as long as he does not

ascribe an abnormal significance to this "discovery" and does not find
new evidence
for
it
everywhere where none
vidual ideas of reference and the
memory
is
to be found.
illusions,
The
indi-
even when according
to their content they are possible, often prove on closer inspection to
be distinctly morbid, inasmuch as what corresponds to the delusion is

often carried out with utterly impossible definiteness and impossible
details, while what does not belong to the delusion is not related at
all, is not even perceived by the patient, is not experienced, and on
demand can be supplemented only in a defective, unclear, and uncertain
manner.
Anatomical findings that might belong to paranoia have not been
found.
The
Limitation.
litigious
paranoiac can usually be readily dis-
tinguished from other litigationists by his immovable consistency and

especially
to the
by the circumstances that
first
unfortunate litigation.
all his
complaints can be ascribed

is usually recognized
The paranoid
and the inner conby the hallucinations, the disturbance of the affect,
and by other schizophrenic signs. Only in case of a very furtive
easily
by the
logical impossibility of the delusion
tradictions, then
beginning can these peculiarities be so little developed that one is in

doubt for a while, or even incorrectly diagnoses paranoia. The manicdepressive delusional forms can be recognized first of all by the affective
disturbances, the flight of ideas or the retardation of thought, by the
inconsistency of the delusions and by the entire picture.
The not
very rare belated forms of paranoia are to be differentiated from the

senile
paranoid forms by the strong, consistent delusional system, and

Thereof symptoms that indicate cerebral atrophy.
by the absence
fore the differential diagnosis i% in paranoia also a negative one:
Delu-
sional systems, besides which no signs of another disease can be found,
are to be considered paranoic.
With these
the
differential diagnostic observations the delimitation of
morbid pictures
"Abortive"
cases
of
is
at
the
paranoia
same time
are
essentially
supposed
to
have
disposed
been
of.
seen.

Now
(Gaupp.)^'^'^
there certainly are katathymic delusional forma-
tions that correct themselves.
But
would not
call
paranoia because a proper demarcation of the concept

then
when
529
the incurability, which
is
is
these diseases
attained only
an important sign of nearly
cases, is included in the denotation of the concept.
The
all
abortive cases
probably also lack the important sign of the general extension of the
ideas.
Some of the abortive and "milder" paranoias (Friedmann)
are probably mild manic-depressive delusional forms. The "periodic"
paranoia belongs partly to our schizophrenia, to a
less
extent to manic-
of
The paranoia completa (Delipe chronique a evolution systematique

Magnan) belongs to the schizophrenia group (paranoid or
paraphrenic).
The
alcoholic paranoias are toxic psychoses sui generis,
exist at all,
and are not to be included
The formulation
in the
if
they
paranoid groups.
which is said
probably based on the mistaking of memory
of a paranoia originaria (Sanders),
to begin in childhood,
is
deceptions.
There are besides paranoia-like diseases which as yet have been

little observed; they are perhaps involutionary diseases; there is
also the delusional formation in those hard of hearing,^*" and in oligophrenics: Many feeble-minded only come to the asylum because of
the development of ideas of persecution, which are not quite systematized but which also do not degenerate to the complete nonsense
and the symbolic foolishness of schizophrenia.
Usually, but not
always, there are hallucinations of hearing at night, sometimes also
too
those of sight, rarely of the other senses.
symptom complex and

dementia. The affective rapport
catatonic
It does
not go as far as the
just as little to a severe progressive
especially
is
preserved; the patients
also retain their external bearing in so far as the direct reaction to
the persecutions in the form of attacks of rage and scolding does not
make them
unsociable.
Occasionally also disconnected grandiose ideas
appear besides, or in place of, the delusion of persecution. It is not

improbable that this is a case of paranoia upon which the oligophrenia
puts
its
particular impress, in that
of the delusional system.
But with
it
prevents a logical development
this conception also the diflficulty
from Pjropj -paranoid remains.

Conception of Paranoia. The delusional system of paranoiacs is a
psychic formation that gives the appearance of a simple exaggeration
of differentiation
"'Ueber paranoische Veranlagung imd abortive

Nervenheilkunde und Psychiatrie 1910, S. 65.
"'See p. 533.
Paranoia,
Zentralbl.
fur
530
of
normal
processes.^^^
but not continually
The normal
so.
individual reacts in the
Everybody has
well as insufficiency of logic as soon as he
The manifestation becomes
same way
false references to oneself as

is
in
an affective state.^*^
it cannot be
pathological only because
and especially because of the tendency to spread generally,

and the unintermittent continuous working of the affective mechanism
corrected,
once put in operation.
The only known symptom
of paranoia, the
delusional formation, proves to be a reaction form to certain external
and internal
situations.
At
all
events,
it is
not a direct result of any
must
assume that at least in the milder cases the disease would not have
broken out without releasing an external situation, or at least would
not have assumed the same form. For the origin of the disease determines the symptomatology in manifold ways.^^ To be sure, one will
presuppose that here too there are such serious dispositions that even
everyday and unavoidable difficulties would have set free the disease
such patients under any circumstances become paranoiacs, while
others become sick only in the face of serious conflicts.
Invariably we see at the root of the disease a situation to which
the patients are not equal and to which they react by means of the
disease: The young man feels in himself the impulse to achieve and
be something worth while, but because of an intellectual or especially
characterological weakness he does not get as far as he would like.
He is not sufficiently indifferent to ascribe the failure to fate and to
let it rest on himself; still less has he the strength to admit his own^
mistakes to himself and make them clear to himself. Then according
to the everyday method he blames the environment and merges into
the delusion of persecution, or in case of a more cheerful disposition
he fulfills his wishes in phantasy and works himself out of reality into
process in the brain or of a constitutional degeneration, and one
the delusion of grandeur.
The young woman who wants
to get married but
natural instinct to love and attract a
man
who
lacks the
finally thinks herself loved
without any action on her part, and as in the fairy tales devised for
children supposedly sexless, she is loved by one who at the same time
brings her promotion in rank (which is obviously felt as the chief
thing).
Since reality cannot be shaken off altogether, here too ideas
of persecution are usually added, while besides the real delusion of
persecution the ideas of greatness persist, unclearly and perhaps gen*"
That
is
the reason
line between paranoia

"" See p. 95.
^^
Comp. above
why
not only in practice, but in principle also a sharp
and the normal and mere psychopathy cannot be drawn.
the illustrations.
531
erally undeveloped, as mere efforts toward greatness.

Thus there is
probably no paranoiac (and paranoia-likej delusion of greatness
without delusions of persecution, and no delusion of persecution without ideas of greatness or at least aspiration to greatness, and the difference between the two forms becomes relative.
I therefore believe
I
may
here include the delusion of grandeur in the consideration,

it has as yet been very inadequately investigated.
The "ex-
although
alted feeling of self" which
is
ascribed to paranoiacs of various kinds
is,
therefore, probably a necessary condition for the origin of the disease.
But
feeling
should like to add that according to everything I know, this

must be opposed by a feeling of insufficiency, probably re-
Whoever collapses without this inner conflict has no occasion for a delusion of persecution,
pressed, before the paranoia can originate.
and also probably cannot produce the energy to separate himself

from reality.
The multiple murderer Wagner himself felt the
diflEiculty of his situation and expressed it in a remarkably correct
way:
"You
will therefore
man who
is
understand when
robust in body and soul,
the fighters, the criminals

all CIS the
and
go into ecstasies over the
when the
strong, the indifferent,
the beasts impress me.
opposite of myself.
In this writing I
am
I think of them
not using what
I have read, as I am in general a very independent spirit.

I wâs not
tempted by the 'fashionable philosopher,' and on this occasion I want
to remark to the Nietzsche followers that the key to a comprehension
of his writings is weakness.
The feeling of impotence brings forth
the strong words, the bold sounds to battle are emitted by the trumpet
called persecution insanity.
The
and good-will.
ture, does not exist.
man
The
signs of the truly strong are repose
strong man, about
whom we
Furthemore, there
is
palaver in our litera-
no such thing as the strong
tamer of the populace. The strong individuals

fuss do their duty. These have neither the
time nor the oecasion to throw themselves into a pose and try to be
something great."
It is probably not an accident that in all closely observed parain the role of a
are those
who without any
noiacs, all of
which
may
them persecuted,
found a peculiarly weak sexuality
point to an insufficiency of the impulses generally or to
inner inhibitions.
The
would therefore consist:

dominating affectivity which, however, in contrast
with the hysterical disposition, is persistent and stable and
2. in a strong feeling of self which, however, is opposed by some
1.
disposition for paranoia
in a very
inferiority,
and
532
3.
ffict
in external difficulties that increase or provoke this inner con(which probably wanted to be repressed)
4. there must exist a maladjustment between the understanding

and the affectivity so that in certain matters the latter obtains the
lead.
But this maladjustment without the other peculiarities would
only lead to katathymic delusions or hysterical moodiness, etc., but
not to paranoia.
see
more
clearly.
Many
investigations are
But at
all
events there
needed before we can
still
is
not merely one but several
dispositions that correspond to the above conditions
the picture of paranoia
may
and out
of
which
grow.^^^
The disposition for paranoia does not have to be the same as the
"paranoid character," which likes to relate the actions of the environment to
itself
and interpret them
in
an
manner and with
evil
seriously undervalue the rights of others as against
this
own.^^^
its
Ferenczi finds the causes of paranoia in the repression of homosexual impulses; his line of proof
is,
however, altogether
insufficient.
Formerly the French included paranoia among the monomaniacs,

in the belief that there was involved a very circumscribed disease of
the psyche. A debate as to whether or not monomaniacs exist is
useless, as it depends on the conception, while in this case the facts
are fairly clear. Likewise there is no sense in discussing whether
the intelligence of the paranoiacs
is
retained because outside of the
delusion they think correctly, or whether the patients are demented
because in the delusions they produce nonsense and cannot correct
Behind the paranoia there was also supposed to
disease
1.
(brain degeneration).
it.
exist a process
In favor of this could be mentioned:
the not rare appearance of prodromes, before the releasing and
symptom determining
unyieldingness
of
situation takes place,
the
delusional
system.
usually takes place in advanced age, and
2.
3.
4.
the incurability and
the
beginning
which
the remissions and
exacerbations occurring from within independently of conditions.
But
we have an example in the traumatic cases of how

psychogenic causes when they are permanently effective produce a
lasting morbid picture furthermore, in the expectation neurosis which
does not become cured without treatment. In an analogous way one
can make it at least probable in paranoia, that the causes, the inner
and outer splitting, cannot be removed. That the disease frequently
appears in later years could be caused by the fact that only then do
these conflicts become definite. The youth may always still have
for the incurability
"'
Comp.
also p. 177.
Carriers of the paranoid character are psychopaths of various kinds, but
especially frequently latent schizophrenics and blood relations of schizophrenics.
^'^

hopes of getting up
failed.
And
in the world,
533
even though here and there he has
the fluctuations from within require a
more exact
still
confirmation, as perhaps external factors or purely psychogenic re-
understanding oneself, can none

There are cases of delusional forma-
sults of the inner "elaboration," of
the less determine such changes.
tion similar to paranoia that run quickly into a cure which, however,
do not usually
^^^
come
Because when
to the physician's attention.
only transient and chiefly exogenous reasons are present, they must
become cured before the deception develops

Treatment. Nothing can be done for the
the best of
Some
it.
more one wants to
into a disease.
disease.
One has
to
of the patients are best left to themselves.
help, the
worse
it
is.
One must
interfere
make
The
when
they become violent or waste their fortune, in the former case by commitment, in the second case a guardianship may suffice at times. When
possible one should avoid protracted institutional treatment because
this only
makes the
patients
all
the more embittered against the whole
world.
The Delusion
2.
of Persecution of
the Hard 0/ Hearing
and the deaf and dumb frequently do not

about them, consequently they become
irritable and distrustful and, with or without excitement, they come to
false conclusions about the environment.
In some cases, especially in
elderly women, this develops into a more connected paranoia-like
morbid picture, usually with ideas of persecution which rarely, however, attain full certainty and show more the character of anxious
apprehension. Memory deception, illusions, and occasionally probably also hallucinations, confirm the delusion and increase the
The hard
of hearing
sufficiently understand, those
difficulties.
The
disease runs a chronic course with fluctuations
although through
amenable to
skilfull
and
is
behavior of the environment
incurable,
it
is
still
influences.
Allers observed similar cases
among
prisoners of war,
not understand the language of their environment.
It
is
who
could
significant
that here recovery took place as soon as the patients understood and
were understood.
3.
Litigious insanity
is
Litigious Insanity
in the first place a
syndrome, which occurs
in various diseases, such as schizophrenia, manic-depressive insanity,

*"
Comp.
p.
529 Friedmann, Gaupp.
mediate cases of
this sort.
myself
know
several typical
inter-
534
certain abnormal character dispositions,
and
also in paranoia.
If one
simply speaks of litigious insanity, the paranoiac is meant by it. In

spite of the fact that this form of paranoia shows some peculiarities
when compared to the others, I prefer to adhere to Kraepelin's former
conception and treat
it
with paranoia, not only because of the inner
connections, but also in order to avoid double description of the very
numerous common features

4.
in both
morbid groups.
Induced Insanity (Folie a Deux)
happens that paranoid or paranoiac and rarely hypomanic pacan make those with whom they live close together
believe in their delusions, but they so infect them that the latter under
conditions themselves continue to build on the delusion; at all events
they remain blind when confronted with the contradictions from
reality, they have the same deceptions of memory and eventually even
illusions and hallucinations as the one who became afflicted first, and
pass through paranoid or hysteroid excitements. This is called induced
It
tients not only
insanity.
But the individual followers of a prophet who represents an undemonstrable view will be declared insane only in the worst cases,
although usually none of them can be considered responsible or capable
of action in matters connected with the induced view.
The primary inducing patient
is in such cases an energetic charThose induced are mostly his blood relations, more rarely it
concerns husbands, which throws light on the significance of familiar
dispositions.
They often take active part in the development of the
delusional system, also enhance one another in the development of
symptoms (the same psychological process as in cumulative criminality).
But above all they cooperate in the morbid reactions to the
acter.
outer world, such as the querulousness, cursing or violence, or they
withdraw together,
restricting contact with the
world to the most
necessary minimum.
Through timely interference, i.e. a separation from the diseased

most of the induced cases can rapidly be cured. There are exceptions, however, which then lead one to suspect that they too suffer
from an independent disease in which only certain manifestations, like
the content of the delusion, were determined by induction.
In reference to paranoia-like epidemics, there are some showing
such hysteriform symptoms as: ecstasies, convulsions, major hysterical
attacks, chorea magna, visions, and other hallucinations of an hysterical character, and automatic preaching.
Not rarely both series of
symptoms exist together.
focus,

The
5.
Mental Disturbance
Reactive
It is only natural that
manifest in prison; this
is
535
of Prisoners
some mental disturbance should become
Some
especially true of dementia prajcox.
are directly set free as a result of the confinement as delirium tremens,
become recognized during detention, or

break out there, as in the case of paresis where the connection between
confinement and psychosis can at most lie in the fact, that the latently
existing psychosis leads to the crime or to let oneself be detected, and
then becomes manifest in prison.
Besides these, there are definite syndromes which are directly prein the alcoholic; others first
cipitated
by the confinement and carry the mark
of this origin in the
They naturally
which may, however,
course and in the individual symptoms.

the basis of certain dispositions,
originate on
differ
very
markedly. In some kinds of psychopathies and pronounced chronic

mental diseases, above all in schizophrenia, then in epilepsy but also
in others, the various pictures might appear, each depending on the
psychic constellations. Among other things these strongly depend, on
Those syndromes which mimic
the situation of the imprisonment.
acutely an insanity, as the Ganser
symptom complex,
in the first place diseases of detention
pending
trial,
are naturally
while the chronic
pictures belong to the imprisonment following the sentence.

It is not
yet possible to describe
mentioned:
(a),
(b),
and
(c).
all
forms.
Exaggerated
The
following
may
be
affect reactions at the
They begin mostly soon after the confinement, partly

an explosion of the gradually accumulated worry, and partly on
the occasion of any irritability. They manifest themselves especially
frequently in an attack of rage and cursing with blind destruction
(Prison crash), or in an anxious depression with vague delusions of
In most cases these conditions pass over rapidly,
sin and persecution.
the prison crash usually in a few hours. An affective disturbance
which lasts longer and which occasionally appears even after longer
confinement is the stupor, which has an hysterical character.
A simulation of insanity, as imagined by the layman, which
(d)
controlled
by the unconscious, is the Ganser twilight state,^^^ and
is
confinement.
as
the clown syndrome;
^^^
the puerilism seeks to represent a childish
dementia."
(e)
In long continued confinements
psychogenic depressions and excitable
we
observe in the
first
place
states as a reaction to the un-
'" See p. 545.
^Bleuler, Das Faxensyndrom.

gang 1910-11, S. 375.
"*See p. 545.
Psychiatr.-Neurol.
Wochenschrift,
12,
Jahr-
536
pleasant situation, to which also belongs Vischer's barbed wire disease

of
war
prisoners/^"
A queruloiisness with more or less prononced delusions, in

which the patients imagine themselves unjustly treated and hence
react with all plausible statements and protests, and under conditions
(f)
also with violence.
One of the most frequent syndromes in long detention is the

(g)
imprisonment complex, which originates in quite the same manner
in various dispositions:
Either gradually or with a sudden inspiration, with or without hallucinations, the patients imagine themselves
innocent,^"^ liberated or pardoned.
But
as they are not liberated in
reality they develop delusions of persecution
the public prosecutor, and the courts.
The
about the environment,
delusion attains tangible
certainty through hallucinations of the different senses, especially of
and strikingly often also of smell (poisoned gases are blown

and taste; these are supported by deceptions of
memory and dreams of severe maltreatment which are taken for reality.
The participation of the two components, liberation and persecution,
hearing,
in
into the cell),
may
appear in very different ways.
In one case one delusion dominates,
The syndrome resembles very much the paranoid and can only be differentiated from it with certainty by the
outcome. As a rule it disappears after the patient has been discharged
in
another the other.
from prison or transferred to the insane asylum.

Next to the confinement querulousness Kraepelin mentions as a
prison psychosis the ''delusion of persecution with local coloring"
(regularly with hallucinations) and Ruedin's so-called "presenile delusion of being pardoned," which until now has only been observed in
life prisoners after they have been confined for a long time.
As the
first is mostly associated with ideas of liberation and the second with
ideas of persecution, the two states may be conceived as variants of
the prison complex, determined by different outer and inner conditions.
The presenile delusion of pardon is incurable.
Kraepelin's prisoner's insanity (Gefangenenwahnsinn) appears soon
after the the arrest, and shows a mixture of depressive and grandiose
ideas, which do not however become fixed, and a slight clouding of
consciousness.
It becomes cured after discharge or after transference
into an insane asylum.
Treatment. The general prophylaxis consists naturally in a possible avoidance of conflicts and in restricting of solitary confinement,
"" Vischer, Die Stacheldraht Krankheit, Zurich, Rascher 1918.
"* Even in other cases the crime or the sentence are subsequently
shut
off
from memory.
completely
537
the special prophylaxis in an intelligible consideration of the situation
and the
as
it is
who are all, as

The proiKJunced psychosis
peculiarities of the prisoners,
paths in
all
directions.
it
were, psycho-
heals, in
so far
not an exacerbation of an otherwise existing chronic state, at
any rate in the most acute forms. Most of the others recover regularly by transference in a better milieu (hospital) which takes
more consideration of the disease than of the "object of punishment."
Psychoses pending examinations, which serve the (unconscious) purpose of attaining a discharge, or cessation of the trial as a result of
The
insanity, do not naturally recover easily during the procedures.
most important conditions
for the recovery are absent in cases of the
specific diseases of life prisoners.

6.
Under primitive
The
Primitive Reactions
reactions Kretschmer
'^^^
includes the exaggerated
or false simple affective reactions like screaming,

affect stupor, reactive depressions
attacks of rage,
("homesick"), the rare manic-like
and similar reactions. Whether one should also add

to it vasomotor syndromes and other physical symptoms matters very
These reactions already occur in animals, then in chillittle here.
dren, in insane and neurotic patients of all forms, and among the most
varied psychopaths, and what is more, they occur also in such who
reactive states,
in other matters,
e.g.
intellectually,
stand very high.
Like in the
prison crash, they frequently appear as independent transitory disSuch cases are usually ushered in with deep disturbances of
eases.
consciousness with or without hallucinations.
They
last a
few min-
leave behind a pronounced or absolute
most a few weeks, and

amnesia and full insight. "Exogenous Reaction types." These originate on the different psychopathies but only on the basis of actual
mental diseases (schizophrenia, epilepsy, organic states, etc.). As
they are relatively complicated, they can also be united into one
concept with the reactive depressions and exaltations.
utes, at
7.
Reactive Depressions and Exaltations
Reactive depressions, which become aggravated to a mental disIn so far as they

ease, are quite rare in the light of present views.
to the psychiatrist, they are mostly partial manifestations of
other diseases, especially of manic depressive insanity, and naturally
Also seniles who are incapable of
of psychopathies and neuroses.
come
helping themselves can react with melancholic states of short duration.
Reactive manias we do not know.
^Der
sensitive Beziehungswahn.
Julius Springer, Berlin, 1918.
538
The
8.
Reactive Impulses (Impulsive Insanity of Kraepelin)
Various impulsive actions, which, among other things were also

described as impulsive insanity and formerly as monomanias, have
changed into reaction forms
in the great
majority of cases.
Still
one
observes externally the same acts as a result of organic brain disturbances, of epilepsy, of alcoholic poisoning, and similar diseases,
and, moreover, the actual reactions sometimes act

of such disturbances of consciousness.
dispositions,
schizophrenia.
especially
tures they develop on the soil of
all
first
on the basis
Others are based on psychotic
As independent morbid
pic-
kinds of psychopathies.
Those that are most frequently observed almost only among men
as states of wandering
(Fugues, Poriomania)
are of
an epileptic
nature, or are due to cerebral traumas; others occur in schizophrenias.
Pure reactive impulses

time
life
may
be habitual or
may
appear only once in a
the latter especially in puberty.
The most common
is
undoubtedly the impulse to
set fire
(pyro-
mania), which we observe most frequently among young people who

find themselves (subjectively) in an unbearable situation, above all
among half grown servant girls, who were torn away from their own
family and can find no emotional contact with the new place. Notwithstanding the impulsive element in regard to the main object, the
will to set fire, the pyromaniac often premeditates his act and does
it with a certain refinement, so that some are not immediately deIn such cases it mostly concerns a crime committed only
tected.
once, but it may, however, be repeated a few times, or even many
times. The perpetrators of the act cannot give, as a rule, any adequate
reason, unless the prosecutor examines it into them the act is so little
their own that even if they are otherwise of a normal nature they
cannot even display the proper regret. The nearest explanation is the
one that by setting fire to the house in which it was unbearable for
them they wished to force some change for themselves. Regardless
^
of the fact that this could have been effected in many other ways
the explanation cannot at all be applied to all cases, e.g., where fire
;
is
set to houses of strangers.
in
In some cases the unbearable situation lies in a sexual affair or

unhappy sexual aspirations.^^^ Others experience direct sexual ex-
citements through setting or watching the
fire.
Alcohol also plays a
A very intelligent girl in the same situation destroyed dishes; this was
accomplished according to the Freudian unconscious manner, partly during short
attacks of fainting, until the connection became clear to us.
"" Another form of unburdening is the suicide (Comp. Jaspers, Heimweh und
Verbrechen. Diss. Heidelberg, 1909).
^'^

great part.
Some
set fire only wliilc
every inebriation, without showing any
drunk or
otlier
durinf^
539
some time
recognizable causes.
of
To
be sure menstruation also furnishes a disposition for it.

The act is sometimes preceded by distinct moodiness with anxiety.,
"homesickness," digestive, and similar disturbances. During the ac-
complishment of the act some seem to be
in a
kind of twilight state,
while others reflect and go through a conscious struggle between their

impulse and their morality. In some the impulse comes suddenly
and
is
at once put in operation, leaving no time for an actual reflection.
To
be sure, pyromania appears in very diverse dispositions.
of these people
normal
do not even seem very morbid and can
Some
later lead a
life.^''^
More
rarely one observes
young servant
girls
who when
in the
situation mentioned above kill the children entrusted to them,
and
the impulsive poison mixers, likewise only of the feminine sex,
who
are apparently governed by entirely different motives.
Kraepelin counts also among his impulsives some of the anonymous

which some are readily recognized as hysterical phantastic persons, who at the same time find sexual gratification from their
letter writers of
pen
activities.
More common
are the kleptomaniacs, at present especially in the
The latter (it seems that only the feminine sex

way) succumb to the refined stimulus of the displays
in stores and steal both necessary and unnecessary articles; it would
often seem that it is done only during the menstrual period.
The
form of
shop-lifters.
is afflicted
in this
kleptomaniacs in the old sense cannot even otherwise
and here again
resist the
impulse
done regardless of whether

they can make use of the things or not, they hoard them, give them
away, destroy them, and under conditions they even return them to
of appropriating things,
the rightful owners.

spects be quite good.
The morality
it is
of such people
may
in other re-
In some cases a connection was demonstrated
between the act of stealing and sexual feelings, but on the whole we
do not know the genesis of kleptomania. Disturbances of consciousness and especially hysteroid twilight states sometimes accompany the
crime.
One can then just as well speak of stealing during hysterical
attacks as of kleptomania.
It is quite obvious that one
must guard against too frequent diag-
One must demonstrate not only an impulse in

but a morbid impulse. The easiest diagnosis is made
nosis of kleptomania.
the usual sense
'^Comp. Schmidt: Zur Psychologie der Brandstifter. in Jung's Psychologische

Abhandlungen. Deuticke, Leipzig- Wien, 1914, and Brill: Psychic Epilepsj', Long
Island Medical Journal, January, 1907.
540
in the cases
thief has
where even quite useless objects are
made no
stolen, or
use of the things stolen, or returned
where the
in some
them
way.
Kraepelin mentions the buying maniacs (onioeven buying is impulsive and leads to senseless
contraction of debts, with continuous delaying of payment until a
catastrophe clears the situation a little a little but never altogether,
because they never admit all their debts. According to Kraepelin,
As a
last category
maniacs) in
whom
always involves women. The usual frivolous debt makers,

way wish to get the means for pleasure, naturally do not
belong here. The particular element is impulsiveness; they "cannot
help it," which sometimes even expresses itself in the fact that not-
here, too,
who
it
in this
withstanding a good school intelligence, the patients are absolutely

incapable to think differently, and to conceive the senseless conse-
quences of their act, and the possibilities of not doing it. They do
not even feel the impulse, but they act out of their nature like the
which devours the leaves.

Here one might also add the morbid collectors, who senselessly
sacrifice much time and money to a hobby and without any other
moral weaknesses they very easily get to stealing.
caterpillar
9.
The
The
Reactive Changes of Character
reactive changes of character only attract attention
when
the
may
be designated as an aggravation. In most cases they

in childhood, but may then continue throughout life unless
corresponding measures or fundamental changes in the environment
change
appear
bring about recovery.

transformations.
If
But even
later
age
is
not
immune
to such
one does not conceive Michael Kohlhaas as an
actual paranoiac and one wished to follow instead Kleist's description
he would be one of these types.^^^

10.
A.
The Neurotic Syndromes ^^*
Hysterical Syndrome.
"Hysteria""^
As the hysterical symptom complex one designates the more massive

symptoms and those with conspicuous psychic connections,
neurotic
'"
For further details see pp. 127-128.

Concerning the general conception, origin, prognosis and treatment, see the
introduction to Chapter XII, p. 493.
"^ Cf the observations concerning the "Neurosen."
For further
pp. 493-494 f
details on hysteria see especially Lewandowsky, Die Hysterie, Berlin, Springer,
1914.
For the prolific symptomatology with discussion of the older or more of
the somatic conceptions, see Binswanger, Die Hysterie, Wien, Holder, 1904.
^"

that
541
to say, on the pure psychic sphere there are the psychogenic
is
twilight states,
and on the physical sphere, the anaesthesias, hyperand contractures, the formations of
esthesias, paralyses, convulsions
pimples and
blisters,
genetic vomiting,
common
psychogenetic hemorrhages,
if
such
exist,
psycho-
and the many other analogous manifestations.
In
symptom
with the ("pseudo") neurasthenias,'"" the hysterical
complex presents the paresthesias and the abnormal influences of the

vegetative organs, including that of the vasomotor system.
The psychic and the physical hysterical symptoms, e.g., a contracture and a twilight state, seem to have no direct association at first
Nevertheless one can build up a useful concept only for all
sight.
the mentioned symptom complexes, for they are produced through the
same reactions in equally predisposed people, and although it is true
that the psychic manifestations can occur alone, equally directed
psychic anomalies occur next to the physical, always at least by
way
of indication.
Physical Symptoms.
The
expression "physical" in the sympto-
matology of hysteria as well as in the other neuroses has a different

meaning than usual. In the hysterical ansesthesias it is a question of a
pure shutting ofT of incoming impulses not even from the psyche, but
from the momentary consciousness (something like in paying attention to a process, one does not perceive another) and in changed func,
tions of organs
like
it is
a question of the psychic influence of these organs,
pain producing tears, shame causing blushing, and anxiety stimuIn other words it is a question of things
lating the intestinal activity.
which
in
other connection
one calls psychic, but which
are
best
designated as "psychogenic physical symptoms."

Charcot has assumed that a number of physical symptoms, especially the ariaesthesias,
reflexes,
are constant
and the absence of the palate and conjunctival
symptoms
of hysteria
(not of the hysterical
and he therefore designated them as "stigmata," thinking

that one can diagnose through them the existence of hysteria even if no
other symptoms were present. This is undoubtedly false. He who
is careful at the examination not to influence by suggestion seldom
disposition),
finds the stigmata; however, the existence of psychogenetic anaesthesias naturally proves that there
it
is
a great auto-suggestibility
the possibility or the probability, that other psychogenetic
and with
symptoms
Some also spoke of psychic stigmata and understood

also exist.
thereby the psychic peculiarities leading to hysteria, especially the
affective lability but also the peculiarities of character, which were
falsely called hysterical.
'""
See
p. 558.
542
The
things,
psychic origin of armsthesia and hypercesthesia, among other

proven by the fact that they correspond in their demarka-
is
anatomy. Thus a hand, a forearm, a

body exactly limited in the middle line, is anaesthetic; and all that, must under ordinary conditions not at all show
Notwithstanding anaesthesia and
the consequences of ansesthesia.
^''
and
analgesia of the hand, the patients do not injure themselves
tions to the patient's ideas of
cuff,
or a side of the
can do delicate works. Kinesthetic ansesthesia does

any ataxia; indeed, in most cases the patients know
disturbance, until the doctor's examination calls their
(except where the anaesthesia has a direct object, as
not give here
nothing of the
attention to
in
it
some trau-
matic forms). The other results of stimulation of the anaesthetic

areas are very diverse, the pain reaction of the pupils remains intact
in most cases, but the reflex changes of the blood pressure can be
absent; even shock through severe irritation of the anaesthetic abdominal organs may not appear. Analgesia is often associated with
slight or absent
hemorrhage
galvanic skin resistance.
in
On
minor
injuries,
and
in raising of the
the other hand the cutaneous reflexes
are mostly not changed, especially those that are inaccessible to the
Also the reflexes of the mucous membranes behave differently (the absence of the pharyngeal reflex in the
normal and in psychogenic patients seems to depend on the kind of
examination as well as on the mode of reaction of those examined).
will like the cremasteric reflex.
That the symptoms may under psychic influences easily change in

intensity and extensity is quite evident from the above.
The anaesthesias may effect any of the qualities such as touch,
warmth, pain, sight, taste, etc., but not very frequently are they all
Besides neuroses, mostly monocular and with reeffected together.
tained pupilary reaction, there
may
occur color blindness or a nar-
rowing of color. Characteristic of psychogenic origin is especially the

"tubiform" field of vision whose surface magnitude does not increase
with the distance. Hearing is very seldom effected in peace time
If definite boundaries are not fixed through suggestion of
hysterias.
the examination, the hysterical disturbances of sensibility change very
and intensity as soon as one varies the tests

somewhat by distraction and various combinations of suggestions.
The local hyperaesthesias need no description. Especially to be
mentioned are the general painfulness in movements {Moebius
Akinesia Algera (Comp. Expectation Neurosis), clavus, torticollis hys-
strongly in limitation
tericus, neuralgias, vaginismus, pruritus, etc.).
at all events to be traced to

^^
Comp.
as a contrast
some
Morvan's
Some
of the pains are
sort of cramps, so also the frequent
disease.
543
globus hystericus, the sensation of a ball ascending from the pelvic

region to the throat, and vaginismus.
Valley's painful spots like the
hysterical zones can be suggested to the patient.
The famous "ovaria"
probably a product inspired by the doctor, even

pressure spots seem to have certain peculiarities.
is
The tendon
reflexes are
mostly exaggerated,
if
if
the concerned
they are not dimin-
by an accidental cause, like stupor, weakening of the legs

through long paralysis, and through similar factors. The reactions
of the pupils are normal as a rule, still one rarely finds exceptions,
which are not yet quite understood; contracted and rigid pupils are
probably based on a contraction of accommodation.
The reflexes of the skin and mucous membranes are uncommonly
changeable; anaesthetic places are not all always without reflexes.
Of motor symptoms one should mention pareses, paralyses, and
ished
contractures. The paralyses are again not anatomical but affect

muscle groups which belong together psychically, that is, a part of a
limb, but the paralysis
is
especially of definite functions
(as astasia
abasia, or paralysis of deglutition; with the exception of aphonia, disis rare, more frequently one observes
some sort of tics).
Of the organic functions the sympathetic and vasomotor system
(heart!) are frequently and deeply altered.
turbances of speech (stuttering)
may also occur, in the form of pimples,

and bleedings (Stigmatized ones) at all events there is a
psychogenetic fever as was demonstrated among other things by the
experiences of lung specialists who injected aqua destillata instead of
tuberculin and obtained a rise of temperature.
Trophic disturbances
blisters
From
the gastro-intestinal canal one observes besides the globus,
also anorexia
tion
may
and vomiting as favorite symptoms; but any other func-
be concerned.
syndromes under the name of hysterophilic ailments, or diseases which occur independently on an unpsychogenic basis, but can also originate on a psychogenic path, e.g. migraine,
epileptiform attacks, asthma, membranous enteritis, and occupation
Lewandowsky
stresses here
cramps.
On
the purely psychic sphere one would mention in the
first
place
the following permanent symptoms, which though essentially belonging to the disposition are also reenforced by manifest hysteria:
Lability of the affects, moodiness,
momentary
reactions in all rela-
with exaggerated affective outbursts in various directions. The

latter display mostly something of the theatrical; one has the feeling
that the real affective force displayed does not quite correspond to the
tions,
544
amount
and
and that the threat
heard from
is seldom
accomplished. Laughing and crying spells without any clear motivaIt is also remarkable how lightly, on the whole,
tion are not rare.
so
of crying
many on
tears,
of suicide
every occasion, though often put in operation,
the hysterics carry their troubles
many
in
of
them
it is
evident that
they are actually pleased to play the part of being sick. That may
go so far that they wish to acquire real diseases,^''^ or that they are
willing to injure or castrate themselves, or permit an amputation
Under
{furor operatorius passivus).
may
certain constellations hysterics
temporarily or lastingly appear indifferent, poor in feelings, just
like in
an
effective torpor.
The suggestibility of hysterics is familiar. But there was a time

when these patients were described as being particularly impermeable
to suggestions from others
The
auto-suggestible.
positive
The
against this, they were said to be especially
truth
lies in
and a strong negative
it
In
is very variable.
hard to collect themselves. Other-
attention corresponding to the affectivity
severe diseases the patients find
wise
the fact that they have a strong
suggestibility.
it
mostly depends on the interest
in the different relations
it
may
be excellent or also very bad.
The memory
by the affectivity the not rare conand pseudologia phantastica produces a

stronger similar disturbance. "Distraction," while experiencing something and also in reproducing it, will influence the function of memory.
Furthermore, amnesias are left sometimes by violent excitements, and
regularly by twilight states.
The intelligence can be good or bad. But judgment is often clouded
by the affect.
The sexuality of hysterics can be judged still less than that of
is
easily falsified
nection between hysteria
others;
we
there are
tude to
see
all
extremes; especially
many who
it,
whereas psychosexually they
The attack
like
among
the female hysterics
are frigid in coitus or even take a negative atti-
symptoms
affective experience, to
may
be very sensitive.
regularly associate themselves with
which belong also physical
such as are subject to compensation.
some
injuries, especially
In the hysterical twilight states
the patients, in the most pronounced case, imagine themselves in an
have
remarkable adventures, they are kidnapped by robbers or in states of
ecstatic euphoria they are received in heaven, etc.
They often repeat
exciting scenes which they have actually experienced, such as sexual
attacks and similar experiences. Other twilight states fulfill wishes
entirely different environment, in the desert, or in heaven, they
*"The one who
simulates, wishes to appear sick, the hysteric to be sick."

that cannot be granted in
life,
or at least exclude a great unpleasant-
ness with everything connected with
Twilight states with discon-
it.
nected confusions are also supposed to occur; at
anxious hallucinatory states with
and animal
faces
figures,
in
545
all
which
sorts
of
all
events one sees
grimacing
cannot imme-
terrifying
logical connection
diately be discerned.
produced in the Ganser syndrome,

and whose clear purpose, to
the observer, is to escape punishment or at least a long sentence. Systematically the patients do many things in the reverse way; they
attempt to put in the key with the ward up or with the ring; when
it is in the lock they turn the wrong way
they rub a match with the
wooden side or on any part of the box except where it should be rubbed
to the question, how much are
they say: 5 or 7 or any number
under 10, only not the correct one, they read on the clock 12 for 6,
3 for 9, they have two noses, etc.
Related to the Ganser syndrome is the "hysterical puerilism" which
Seemingly pure nonsense
whose sense
is
is
to represent a psychosis,
2X3
in
some inconsistent manner plays the
The
weeks.
not at
all,
child
counts coins clumsily and incorrectly
the pieces but not the value
day
little
and can continue
for
patient calls himself Johnny, speaks in infinitives, or
at best he counts only
he draws childish figures, plays the whole
like a little child, lets himself be distracted
looks for his mother, and eventually states that he
At the same time he does
by any
is
triviality,
12 years old, etc.
also other things incorrectly
and
in
the
reverse way, things that children would correctly understand, he does
not recognize his relatives, and shows a very inadequate flow of associations.
There may also be analgesia up to absence of the corneal
reflexes.
The syndrome has thus
far been described chiefly in punished
military persons.
Analogous
symptomatology, even
on account of outer condiis Wernicke's Pseudodementia. The patients, most of whom met with accidents, mimic
mental weakness; they are unable to answer the simplest things, the}'
rarely produce nonsense, but they do not know, or are not sure; they
use childish excuses, which resemble those of organic patients; they
do not know the date because they have not seen the calendar. To
the question of 5 X 6, they simply put together the 5 and 6 to make
In serial statements they easily make mistakes, they turn things
56.
around and leave gaps. The impressibility is bad. Besides, one finds
psychogenic anaesthesias, and vasomotor manifestations; the Romberg
tions
test
any
it
is
in
if
runs a half or entire chronic course,
frequently very characteristic
effort to
balance themselves.
they
let
The mood
themselves
is
fall
without
often dull and de-
546
all or one must wait for it a long

accumulation of traumatic forms with
all sorts of variations and mixtures, the name pseudo-dementia was
extended to pictures, which besides the symptoms mentioned also show
the Ganser syndrome, psychic-apractic and many other psychogenic
symptoms. What is characteristic for all these formations aside from
the changeableness is the disappearance of the memory for elementary
pressed.
Recovery does not come at
Since the war with
time.
its
knowledge and experiences, which remains intact in
the
organic
disturbances.
Also oriented twilight states occur in hysteria. They frequently

even months; according to character the patients are
last quite long,
different people; to be sure they follow a certain plane (e.g., stealing
or traveling;
many wandering
states also belong here), but without
and frequently in contradiction with their

own character. At the same time they behave in an orderly way,
and correctly grasp the environment in its simpler relationships, so
that they do not always impress one as ill. In these as well as in the
clouded twilight states, thefts, arsons, and similar crimes may be
any regard
for the future
committed.
The
hysterical twilight states of various kinds are often initiated
by a moodiness of many hours; they last from minutes to days, rarely

longer, and are regularly followed by complete amnesia.
Following twilight states or as equally justified manifestations
stuporous states with flexibilitas cerea
may
sometimes appear.
We
then see somnolent states lasting from seconds to years ("Narkolepsy" when they suddenly fall upon the patient and do not continue
long; such attacks may also be of another nature, to wit, epileptic).
Reaction depressions, too,
may
occur in hysteria, but here they are
only of short duration (days, weeks) moreover there
may
be transient
attacks of anxiety with physical symptoms, like a choking in the

throat,
and the highest oppression.
Even without the actual twilight states ideas can sometimes become so vivid that they are taken as hallucinations; it mostly involves visual disturbances. Where auditory deceptions occur to a
great extent without disturbances of consciousness,
it is
not a question
of pure hysteria.
Mainly
in hysterical people
do waking dreams occur, which tem-
porarily so control the patient that they have to be designated as
morbid, because they hinder him from taking account of reality.

How far purely hysterical delusional formation can go is not
yet determined; at all events, they depend on the psychic milieu.
Even
in our state of society a hysteriac
can imagine herself gravid,
547
signs of pregnancy, including colostrum, except the enlarged
present
all
uterus,
and cause her husband, a highly regarded
practitioner, to take
into the house the obstetrical nurse for a definite term.
But if she
should expect a Christ as her delusional child, the patient would be a
schizophrenic if that happened in enlightened communities.
In the
same way, those patients are schizophrenics who
in our country or in
our times state that instead of a child they carry a toad or a snake.
One also speaks of hysterical mania, melancholia, and insanity. It
is possible that sometimes through a certain treatment the affective
may
relation to the environment
manic attacks
sition
in people
who
resemble an insanity; furthermore,

same time have a hysteroid dispo-
at the
(hence in a combination of both diseases) run a course with
vivid visual hallucinations which remind one of hysteria, but
what is
what was formerly so called
daily are schizophrenics according to my experience. The few times
that I thought that I had to drop this rule; I made a false diagnosis.
As hysterical attacks one describes general motor manifestations
with all kinds of movements (not spasms of individual muscles), buffoonry, and rigid states; the arc of a circle, supporting oneself on head
and heels, is favored. Beside the more or less incoordinated moveotherwise so designated and especially
ments, one frequently finds stronger or weaker hidden and caricatured

representations of any kind of experiences or wishes, so that such
attacks could just as well be added to the twilight states.
from case to case the manifestations have no

the individual attacks in the same patient
They can
Looking
definite character, but
may
absolutely resemble
any length of time, and repeat themselves

any number of times, a thousand or more in one day, but the pulse
and general condition are influenced only remarkably little.
Next to such motor attacks there are also simple fainting and dizzy
spells, which are probably due more to vasomotor origin.
Even more than in any other neuroses sleep is here xery irregular,
sometimes it is absent, sometimes very good and exaggerated, and
sometimes it comes inopportunely.
Hysterical Twilight States. 42 years a bookkeeper.
Always
somewhat nervous. Not brought up by the family. Not understood
by the family, but she does a good deal for them; she is also otherone another.
last
wise charitable.
the wedding.
Her
fiance died of paresis in Burgholzli shortly before
Since then she kept up some contact with the hospital.
Lately she had to keep house for and nurse her brother,
a divorce
and was
from diphtheria.
also
To
many, but there got
ill;
she also
had to care
who obtained
for a child suffering
recuperate, she took a trip to a friend in Ger-
into a
mess of trouble.
After she had once taken
548
a glass of wine against her habit, she began to dig up some graves in
the cemetery, but later knew nothing about it. But she merged into
other confused states and for that reason she came to the clinic, where
at first she had attacks at different times of the day. She imagined
herself in the cemetery, heard the dead, and saw now adults and now
children.
left
They came
to her, some even into her bed, whereupon she
the bed so as not to make
it
uncomfortable for them.
Dead
children
called to her that she should dig them up.
periods she
knew nothing
of
during her unclear periods.
While during her good

the twilight states, she recalled them well
single suggestion during the twilight
states had the effect that she could also recall
them
in her
waking
state;
to be sure, in the course of the next weeks they again lost in clearness.
Later she had an attack every night regularly between 12 and 1 (ghost
hour)
Once she called the dead, telling them that they can all come,
.
was room for all. Then she said:

Thereupon she went to sleep. In another
attack she kept herself awake, saying that all the dead were strangers
and that all acquaintances were missing. Through one hypnotic treatment the twilight states were cut short and the headaches which continued disappeared later only after many seances. The very first hypnosis had been complete and deep. But after another patient next to
her was hypnotized who did not merge into deep hypnosis, it was then
impossible during this period of hospital residence to get her beyond
this stage of hypnosis.
Later she had various hysterical physical
symptoms, once an hysterical torticollis; a surgeon mistook it for a
caries and wanted to apply a plaster bandage and keep her in bed for
several months, which would have cost her her position. A few hypnotic treatments cured it. For some years she has obtained consolation
and relative good health from Christian Science.
Hysterical Physical Symptoms. A girl, who was brought up in low
moral surroundings and was subjected to various sexual attacks, suffered among other hysterical symptoms from vomiting after tasting
milk. It turned out that it originated from the fact that a stable
servant, from whom she had to get the milk, wanted to force her to
receptio seminis in ore. She had abdominal pains when she sat on the
damp grass and attributed it to "catching cold." But during the
the
room was
"Now
large enough, there
they are
all
here."
performance of an abortion she lay on the cold grass, hence the association, which was revealed only on examination.
She had to vomit
after the visit of a friend: the latter once related to her that she too
went through an abortion. The patient herself had attempted an
abortion with tobacco suds, after which she had a terrible spell of
vomiting. She had pains frequently in the right biceps "due to over-
649
in ironing "during bad weather": On account of masturbatic

compunctions she once squeezed her arm between the bed and the
wall. The pain really came after masturbating, with a definite com-
work"
plex of ideas.
All these
and the
rest of the
symptoms permanently
disappeared (now twenty years) after the connection was made clear
to her in hypnosis. A part of the girl's statements could be verified
by investigation, and especially also by an examination of court

and without exception proved to be perfectly correct.
A nurse girl, 20 years old,
Hysterical Convulsive Symptoms.
brought up in respectable surroundings. Good intelligence, but quite
At 12 years meninearly in life not frank and somewhat moody.
From about this time she committed minor thefts at home.
gitis (?).
She was discharged from two places for dishonesty then she was with
a procureress in Paris and then got a position as nurse girl. At 17
years hysterical attacks with violence; then again muteness and even
deafness. In the night she got attacks of screaming and convulsions.
She was discharged from an insane asylum as cured after three months,
and then she was learning dress-making for five months, where she
behaved faultlessly. When she again had twitchings she came to an
aunt whom she was to help in business, but she ran about instead and
and brought home phantastic stories, how she conducted a secret bureau
under the direction of negroes, and similar tales. She stole considerable sums of money, formed an alliance with a young man, to whom
she told stories about having a fortune, but which, as always in such
cases, at this time it was still in the hands of her aunt, the countess.
She simulated a burglary attack and was examined in court. Then
for many days there was absolute closure of the jaws and rigidity of
tongue, which lasted 56 hours; she could, however, make herself
understood by writing; there were twitchings in her limbs. By means
of a few hypnotic treatments we definitely mastered the hysterical
symptoms (now ten years). She was a year in very strict service,
but held out bravely; then learned quickly the most important office
work and has held for nine years a well paid office position.
Ganser State. 24 years coachman. Arrested on account of fraudurecords,
lent security in horse dealing.
After admitting participating in the

buy a
crime, he gave false answers at the examination; he did not
was a servant, not a coachman, he did not know his family

name, he was not married, had no children, was 28 years old. He gave
the wrong year, and did not know where he was. On admission to
hospital he answered in the same way, but on request he immediately
gave correctly everything that he had in his pockets. Later he counted:
1, 2, 4, 7, 9, 11, etc.
On the watch he mistook the big for the little
horse, he
550
He
hand.
wished to open the match box by pressing on the long
then on the cover and the bottom and finally pushes

interest is the following:
If
it
together.
side,
Of
questioned in the tone of an examination,
one always received false answers during the twilight state, e.g. he was
when asked in a sympathetic and pitiful tone about
not married; but
poor wife, then he was just as definitely married, praised his wife,
and told about his marriage journey, but when immediately thereafter
he was again questioned in the examination tone he again forgot
his
everything.
Even
in such criminal cases the
Ganser symptoms can represent a
shutting off of an unpleasant situation, a simulation of oneself, and

not only a simulation in the presence of the judge. After a few days
the patient became clear, but had a retrograde amnesia for the crime
and the
arrest.
After the latter was explained to him he attempted
then he resigned himself to his fate.

Hysteria with Pseudologia. A 16 year old
suicide
girl, mother prostitute,

She herself was therefore brought up by strangers.
Intelligence distinctly below the average. She was never very easy to
manage, and as she advanced in age she became more spiteful, more
garrulous, and more addicted to lying. She began to tell how she was
maltreated by various prominent people she gave so many details and
spoke with such conviction that five of them were detained for examination.
Contradictions in her statements soon created suspicion as
to the truth of her assertions. Thus it came to trial. Here she not only
repeated the stories but added much that was new; she told how she
was maltreated during the attacks, how her ribs were broken, how the
defendants at the examination were forced to sit on iron chairs, their
hands tied to the back, how strictly every one of them was punished,
and how as a result of a complaint that she has nevertheless withdrawn
a clergyman was taken to prison on account of poisoned bonbons, so
that now he was a street cleaner. She also related how she set fire to
a house and was caught in the act, and how in the ensuing struggle
she sustained a broken leg, and she almost knocked out a woman's eye.
At the same time she modelled both the content and expression according to the scheme of blood and thunder romances. During the examination she showed now and then hysterical absences, in which her
eyes became veiled, her look remarkably rigid, she sat motionless for
a few minutes, only to arouse herself later as from a sleep, and knew
nothing of what happened during the attack. The gynecological examination showed an old defloration. In the course of a few years she
father vagabond.
became considerably
better, although she
times did some mischief.
As she had
remained sensitive and somehope of being discharged
little
661
from the hospital because of the danger of illegitimate children, she

finally demanded continually an oophorectomy, and because no attention
was paid
to her, she experienced such violent ovarian pains before
each menstrual period that one had to give in, and the operation was
done under due process of the law. Since then she has been decidedly
calmer and more balanced and after ten years of internment she could
be discharged to a private family where she behaves well and earns
through work a part of her maintenance.
The Limitation of the Concept of Hysteria, although it would not
be very sharp, considering
be sufficient,
into
it
so
if
its characterization,^"'' it
would nevertheless
one were not in the habit from the olden times to stuff
many
other things, and above
all
things that should not be
Thus one should not include in it the strong affectivity

seen among savages, or the phenomena of becoming perfectly rigid
from a knock on the door, or the twilight like loss of clearness, and
similar states, or the mass epidemics (chorea Germanorum, tremor
taken into
it.
epidemics in schools), or simple primitive reactions in attacks of rage.
Quite different are the monosymptomatic hysterias of children, where

in
most cases the
false connection
is
as important as the purpose of
war tremors, the traumatic hysterias,

and the various psychical and physical symptoms of the peace time
the disease, the monosymptomatic

hysterias.
Traumatic Hysteria, as far as our present knowledge goes, is not

from the other forms of hysteria however, in those following
accidents in peace time, attacks of twilight states are rarer than in
different
ordinary hysteria; indeed, the details of the general structure of the

hysterical picture strongly depend on the influences causing the disease,
so that relatively frequent different
symptoms stand here
in the fore-
In injuries of peace time, attacks, paralyses and twilight

states are comparatively rare; the war brought an unfamiliar accumulation of paralyses with tremors, which are due to exertion and
ground.
fright.
Example
of a traumatic hysteria without
damage
suit.
imbecile got into a marsh from which he could not get out.
marked
Since then
he was unable to cross more open places like rooms and streets. He
feels his way by touching with his left foot forward, and after con-
With it he
assumes a bent swaying attitude, balancing himself with his arms. The
disease would almost be monosymptomatic if at the same time the
patient had not given up almost altogether his active associations to
the outer world; he cares little about anything and permits himself
siderable fumbling he slightly drags along the right foot.
""^
See
p. 540.
552
only to be fed. Perhaps that was his morbid gain. The treatment
produced very slight results.
Hysterias in children without marked change of character are
mostly monosymptomatic.
The clumsy name Hystero-epilepsy originated at a period when
epileptiform attacks were still looked upon as neuroses, and when they
could not be differentiated. Beside the ordinary epilepsies with lesser
striking hysterical symptoms, there are such who in addition show
hysteroid attacks. Furthermore, there are hysteriacs, though they are
extremely rare, who can imitate or produce an epileptiform attack.
The first is an epilepsy, the second a hysteria. What is usually called
hystero-epilepsy is hysteria with severe motor attacks, which were
One also speaks quite unnecesfalsely added to the side of epilepsy.
sarily of hystero-neurasthenia when there is a mixture of symptoms
showing shades of both diseases, which naturally occurs frequently.
The limitation of Neurasthenia must start with this disease, which
analogous to its original conception, though it is not a nervous exhaus-
mimics such. He who seeks to attain the aim of the neurosis

by representing the breakdown with symptoms that are objectively
tion, still
intangible
who
a neurasthenic, but he
is
constructs the disease into a
how the utilized mechanisms

differ. The war hysteric makes a permanent symptom out of his tremor
or the difficulty of hearing due to grenade shock. The environment
through too much or too little observation often causes the disease
to express itself in one concept. But above all, it is a strong personal
demonstration
a hysteric, no matter
is
need for expression and a more active character with a circumscribed

feeling of inferiority in real accomplishments, which decides the
"selection of the neurosis" in the sense of hysteria. Whereas in hysteria all affects occur,
and quite particularly a strong
feeling of self,
neurasthenia always has a depressive undertone, which also manifests

itself
in the
symptoms
(pains,
hypochondriacal feelings and ideas,

However, one
sensitiveness to the extent of transient ideas of injury).

is
not so accurate with those distinctions in the presence of the layman.

notorious, whereas "neuras-
As the name hysteria designates something
thenia" transforms the defect into something distinctive, the courtesy
from the time of Beard favored the
of the doctor has
latter designation
in his practice.
Much
that
is
bad has been attributed to the "Hysterical Char-
acter"; prominently mentioned are egoism, lying, vanity, unbridled

affectivity,
and
lasciviousness.
What
carried
away by the excitement
of
is
true in this matter
is,
that
means that they are occasionally

the moment. Furthermore, it may
hysteriacs are affective persons, which
553
be said that for comprehensible reasons there is a certain inclination

to make oneself noticeable in some way, which exists in the hysterical
disposition more frequently than elsewhere. As they have to play a
part,
it is
preferably people with a tendency to exaggeration, conceal-
ment, and lying that become markedly hysterical; at
all
events, in
and exaggerated. For the rest

can be good or bad, junt as
hysteria
in
character
the moral part of the
inconsiderate egoists we
the
most
with
in other people. Side by side
capable
of sacrifice, notwithpeople
most
encounter among hysteriacs
activity lies
altruistic
impediment
to
certain
standing the fact that a
hysteria,
without
and
occurs
Pseudologia
in their kind of affectivity.
both
have
a
pseudologia.
Because
even more frequently hysteria with
process
(for
the
the
mental
vivid affectivity, and a peculiarity of
present not describable), and because both represent deviations from
the normal, they occur more frequently together than would be the
case if it were merely accidental. For fellow beings whom they love,
hysteria such a disposition
is
utilized
hysteriacs are often capable of
much
sacrifice.
They
can, however,
occupy themselves with an abstract humanitarian problem with

and success, wherein some, to be sure, go off on a tangent
(zoophiliacs). Medically conceived, some saints are typical hysteriacs.
If a hysterical woman forges documents in favor of a charitable institution, it is in all probability vanity and not egoism that comes into
also
zeal
play.
In certain relations Ziehen
is
right
when he says
that hysteriacs
show objective interests. This is especially the case among

women, but the hysteriac has still greater need for a personal relationship than the normal woman.
The necessary conditions for the Origin of hysteria can perhaps
be characterized in the following way, as far as the distinct features
rarely
are concerned:
(1)
under given circumstances the patient
is
not able
to realize his strivings on normal paths, (2) a weakness of the health
determines the tendency to create for oneself a makeshift

on the path leading to the disease. (3) The capacity to produce for
oneself neurotic symptoms, i.e. to produce a stronger development of
the schizoid capacity for splitting of the personality. This shows itself
conscience
^^
in the capacity to split off,^'^ in the inability to abolish altogether

"'
See
p. 496.
difference between the hysterical and schieophrenic splitting cannot be

described in brief.
see it in the examination of schizophrenia. In the latter
next to the affective splitting there is still a primary or at least a splitting of
the associations, which is independent of the affects, and which e.g. may lead
to the falsification of simple concepts, which never happens in hysteria. But
even the more affective splittings in schizophrenia, which can be comparable
to those of hj^steria, are more lawless, worse determined, more massive, and
"^The
We
554
suppressed strivings, and in the coexistence of contrary strivings.
Feel-
by consciousness can still be utilized by the

psyche, in that, e.g., a number called out to the patient but not heard
by him may appear as an optical hallucination. In the hysterical
The
twilight state one can write automatically, and even preach.
ings that are not perceived
"untrue" part of the strongly affective expressions, like in that of

schizophrenia, probably consists in the fact that split off ideas, which
are incompatible with the affect in question, continue to functionate
in the psyche
(4)
and
inhibit
to a certain extent, or even alter
it
it.
strongly domineering but labile affectivity, which in a given
moment
and at the same time

an abnormally strong manner in its
mild manic temperament with vivid wishes, and ihe
gives the mastery to one single striving
directs the association of ideas in

sense.
(5)
need to assert one's personality.

to the inner
difficulty of adjusting oneself
of the health
many
schizophrenic
conscience are at the bases of
appearances)
The
and outer circumstances, and the weakness
The "capacity
all
neuroses (and of
to create for oneself neurotic
symptoms"
a broader concept than that of the capacity to split the psyche.
is
To
this belong also
memories of former diseases and a physical comvaso-motor system, conscious and un-
plaisance,^"^ a readily excitable
conscious
accidentally
mechanisms such as
acquired
connections,
ideas
with
reflection
spasms of the smooth muscular tissue,

trembling of the voluntary movements, etc. All these possibilities can
help to produce neurotic symptoms in general; but only in hysteria
secretions,
(and neurasthenia) does the special splitting capacity play a particularly big part, regardless of its close connection with the other indi-
cated mechanisms.
temperament
is
For the formation
of hysteria the labile-manic
especially necessary.
Notwithstanding
all
transitions
In one
Two Groups
of Hysteria can be
which the
most important element is the personal need for self-expression; this
gives rise to the development of the symptoms. The pronounced hysteriacs in the ordinary sense suffer from this form; they show the
"hysterical" or rather "nervous" and labile character also during the
times when they are free from symptoms, as well as the marked change
in the manifestations, which originate from complexes rather than
causes. In reference to the disease, it matters here very little whether
one observes today a disturbance of sensibility, or a paralysis, or an
distinguished quite sharply.
it is
the disposition, of
then again not so pure and sharp as in hysteria, so that the worst contradictions
can actually exist together in the psyche. The schizophrenic psyche is infinitely
more split than the hysteric. A hysteric affect lays claim to the entire conscious
psyche; what contradicts it, is totally split off from consciousness.
"*See pp. 498-499.
555
The second type is represented by most

Here the most important factor in the origin
is the affective event of the cause which creates a definite symptom.
It is mostly produced by the path of Kretschmer's reflex enforcement
in the widest sense, and by a desire which also needs the capacity to
produce a symptom, bring it to tlie surface, and at the same time give
attack, or a twilight state.
of the
it
war
hysterias.
permanence.
The
second type in men.
first
type occurs especially in
The forms
women
while the
which association reflexes (constipation following enemas, blephoraspasra following inflammation of the
eyes) are the essential factor, and the aforementioned exaggerated
reactions of primitives,^^^ I would detach from hysteria, although the
transitions to it are very easy.
The Recognition
differentiation
in
of hysteria is given in the discussion above
from pseudoneurasthenia
important element
is
not important).
(its
The most
the general diagnosis of the neurosis, the psycho-
is
and the demonstration of the absence of another

mechanisms cooperate (schizophrenia,
epilepsy, brain diseases, etc.), or of a physical disease which gives
cause to hysterical symptoms, as e.g. ulcer of the stomach, or phthisis.
In detail one might call attention to the following: The hysterical
attack is sharply distinguished from the epileptic,^^* if hysteria could
not occasionally give rise to a real epileptiform attack in the same way
genetic reaction form,
disease in which the hysterical
as in the case of affective epilepsy (to be sure, this has not yet been
definitely confirmed)
or
if
a hysterical patient could not imitate, con-
sciously or unconsciously, an epileptiform attack, which
quite possible in hospitals.
is
naturally
Hysteria does not follow the tonic-clonic
phases, nor the temporal limitations of the epileptic attack.
The movements may have any kind of character. Injuries occur only if required'
by the purpose of the disease. Babinski's sign is always absent, rigidity
of the pupils almost always.
The vaso-motor system rarely cooperates: the pulse remains good; the attack may sometimes be followed
by an hysterical sleep but not by an exhaustion.
The
makes the diagmade definite only after careful

diseases. One should especially look
strictly systematic acts in the twilight states
nosis of hysteria very probable, but
it is
exclusion of specific signs of other

for the many prompt reactions of hysteriacs.
Wherever the twilight
wherever an insanity is played,

the relation to the surroundings is unusually characteristic, especially
when questioned. The patient acts as if he understood nothing, but
under conditions he answers promptly, and even if falsely, the answers
state as such has a purpose, that
"'See
p. 537.
"*Comp.
the latter.
is,
556
are none the less definite, whereas in
must search
most
of the other unclear states
Frequently the patient acts

as though he does not see the examiner despite his faultless grasp of
the environment; one can quite easily notice that he does not wish
the patient
for the thoughts.
to answer, inasmuch as in spite of the fact that externally he meets
one half way, either in a hostile or negativistic behavior, he makes

effort to grasp the questions
no
Like a great
many
and to search
for
an answer.
others, I care nothing about the absence of the
so-called stigmata.
To
the experienced physician certain hysterical types often betray
themselves with great certainty by
little signs which cannot all be

enumerated; thus female patients who immediately speak of their suffering with erotic smiles and elaborate the examination into a little
scene are regularly hysterical.
For Prognosis and Treatment
B.
see pp. 505
and following.
The So-called Neurasthenic Syndrome.
Neurasthenia and
Pseudoneurasthenia
The name neurasthenia was originally taken literally. In the

form of neuroses so designated it was assumed that there was an
exhaustion of the nervous system as a result of a long continued
exaggerated activity; later the same was also assumed as a result of
normal activity in a congenital morbid exhaustibility. However, there
are exhaustive diseases; but because they do not represent neuroses
in any sense they rarely come to the psychiatrist, not frequently to the
neurologist, and even the general practitioner sees them less often
Overexertion and exhaustion certainly are only
than is supposed.
rarely causes of neuroses, and never of psychoses, as the war has at
last shown to those who did not wish to see it.
A general decline of
strength is no neurosis. People who toil hardest, who with a few hours
of sleep and at that frequently interrupted through attention to the
children, regularly do a day's work of 16 or more hours, year in and
year out, only exceptionally become neurasthenic. And the (pseudo-)
neurasthenics who come to the doctor have in most cases worked less
than he. What usually produces the so-called neurasthenia are affective difficulties. These can, however, become enhanced by overexertion
to be sure, one does worse in his vocation when one is exhausted; but
these are secondary matters, just as in the case of congenital exhaustibility of the nervous system with which one wishes to save the concept
in the everyday constitutional cases; for as soon as such patients
become enthusiastic about any idea they are able to accomplish

temporarily or persistently as
Hence neurasthenia
is
name should
much
iisually
or even more than the average man.

a pseudoneurasthenia, and only that
were not too long.
be used for it, if it

Neurasthenia in the actual sense of the word
only in order to
from
make
557
will
be discussed here,
possible the differentiation of pseudoneurasthenia
this side.
Actual Neurasthenia, Chronic Nervous Exhaustion
Nervous exhaustion included by Kraepelin

ponopathies can naturally manifest
ing to
its
itself in
in the activity neurosis,
various ways, and accord-
it is also mixed with various symptoms of physical

Of neuropsychic manifestations one notes especially fre-
nature
exhaustion.
quently the following: increased exhaustibility, difficulty in psychic
bad memory), moroseness, irritable mood, and

upon all possible trivial symptoms as serious dis-
activity (subjectively a
a tendency to look
Some
eases.
of the old hypochondriacs are exhaustive neurotics.
the physical side
we
On
head up to localized pain,
find: dull pressure in the
also a feeling of physical weakness, all sorts of paresthesias, a strong
and imperfect digestion; as a rule,

now this, now that symptom, all
of which have been mentioned under pseudoneurasthenia.
If properly treated, it runs a course of weeks or months, usually
with fluctuations, and ends in recovery. To be sure, relapses are not
rare, especially where the causes cannot be removed.
Besides mental and physical exertion, one may also think of insuffluctuating pulse, poor appetite
poor sleep; one also notes besides,
ficient sleep as
one of the causes, although insufficient sleep
be the result of a true or false neurasthenia
may
also
one should also consider
the predisposing factors, be they in the constitution, in physical diseases, or in similar disturbances.
The
differential diagnosis is especially difficult
when
it is
a question
of schizophrenia (where, disregarding the actual schizophrenic
symp-
toms, due consideration must be given to the absolute or relative indifference to the future and to the treatment) of cyclothymic depressions,
where the exhausted patients are more accessible to soothing words
and distractions than depressive cases, of the beginning of paresis, and
,
of latent phthisis.
Treatment:
The
patient should be removed from the causative
relationships; he should take better care of himself
(sleep), but he
should not be educated to worrisome self-observation and to continued
laziness; despite the physical genesis of the disease, psychic influence

is
important (encouragement, and education, eventually with hypIn marked excitement and insomnia moderate doses of bromide
nosis)
S58
To
(15 to 45 grains) are excellent, administered every evening.

relapses, the external conditions should be regulated
avoid
whenever pos-
sible; here an improvement of the affective situation

important as the reduction of the work.
is
usually as
The (Pseudo) Neurasthenia
Whereas the
origins,
with
its
just described true neurasthenia with
its
preponderating physical manifestations, and
physical
its
cura-
by simple care and strengthening no more belongs to the

psychoses than a "typhus" in which the psyche participates, pseudoneurasthenia, on the other hand, with its psychic genesis of the disease itself and of all its symptoms and its purely psychic suggestibility,
It is comparatively more
is as much of a mental disease as hysteria.
frequent than the nervous exhaustion and represents, as mentioned^ a
definite form of flight into disease, which for itself and others shams
(unconsciously) the nervous breakdown, and for that reason shows so
bility
much resemblance
to the exhaustion.
Concerning the special neuras-
mechanisms one should particularly mention the marked inner

conflict in decisions and in work, and to be sure the too early insertion
thenic
of
the
exhaustion
valve
(one
feels
exhausted
even before
it
is
necessary)
The
following are
its
most important symptoms: psychic and
sensory irritability, fearfulness, inability to concentrate, forgetfulness,

persistent
and transient
states of anxiety, dizziness, insomnia, paraes-
thesia, topoalgias, headaches, often
with pressure in the head, muscular
weakness, tremors, occupational cramps,
all
kinds of digestive dis-
sometimes also bulimia and polyphagia, constipation,

eventually with membranous colitis, pollutions, spermatorrhoea, ejaculatio prsecox, impotence, particularly frequent and almost never
lacking are cardio-vascular symptoms like abnormal irritability of the
heart, tachycardia, congestions, hyperaesthesias, etc. Although not constant, the mood is nevertheless mostly depressive, and the idea of the
disease and its symptoms is always of a depressive tone.
Depending on the preponderating symptom complex, it was cus-
turbances,
tomary to distinguish psychic, motor, dyspeptic, angioneurotic or

cardiac, and sexual forms, to which may be added the etiological group
of the traumatic forms; many authors add also the phobias to
neurasthenia.
The causes were already alluded to in the general observations.^"^

The extent of the cooperation of sexual excesses, especially onanism
and coitus interruptus, and to what extent that takes place on psychic
"'
See
p. 493, etc.

paths,
is
To
not yet quite clear.
hand
the one
559
be sure, depleting diseases can on
instigate the flight into the disease,
and on the other

can indicate the sensations, the exaggeration of which may
evince the actual morbid picture.
hand
it
In the diagnosis it is necessary in the first place to exclude a

physical disease; here one should think also of tuberculosis, lues, and
poisons like CO, which produce similar pictures. Paresis and schizo-
The depressive phase of cyclothymia

mistaken by many for neurasthenia. The man who makes many
notes, who is always afraid that he did not tell the doctor enough, or
that his reports were too incorrect, is mostly a neurasthenic; for the
disease would have no sense if it were not important.
The prognoses are very different; they depend on the individual's
disposition and on the possibility of removing the outer and inner difficulties even after the treatment is over.
The "constitutional" forms,
who were incapable from youth to adapt themselves to reality, natuphrenia should also be excluded.
is
rally present a difficult prognosis; others
who
did not
know how
to
help themselves for the time only can be permanently cured by a few
suggestions,
or encouragement,
eventually through the
explanation
that their fear of the results of onanism are unfounded.
The treatment does not

"tonic" measure
and
in
may
differ in principle
from hysteria, although
somewhat
better suggestive force,
here exert a
mixed forms with
real exhaustion
may have
a direct causal
effect."^
C.
Following one or
The Expectation Neurosis
many bad
experiences in any kind of event (read-
ing, writing, swallowing, urinating,
after having been dazzled
strong light, or surprised through a loud noise,
etc.,
by a
into infinity),^"
the patient predisposed in this sense becomes dominated by the idea

that he can no longer accomplish the function in question, or that he
must
suffer pain
through
it,
and this idea becomes a reality. This

complex of movement, cramplike addi-
results in paralysis of a definite
movements, or painful parsesthesias. Besides speech stuttering

which under conditions should be included in this category, one notes a
number of other forms of "stuttering" (stuttering in wâlking. writing,
urinating, etc.) psychic impotence naturally also belongs here, likewise
Moehius's akinesia algera. I would also add to it the numerous gastric
tional
"" See p. 506.
^"The expectation neurosis can also be a relique of a physical disease,

organic paralysis of deglutition.
e.g.
an
560
neuroses, where the patient cannot tolerate certain foods
them
until his
menu
and avoids
card becomes reduced to an intolerable
starvation, and then
minimum
through energetic advice

or to the point of
convinced
that
he
can
eat everything
as a
he allows himself to be
Unfortunately
it
not
rare to find an exis
rule with good success.
pectation neurosis as a result of a pessimistic statement of the doctor.
finally
The
expectation neurosis usually develops slower than the traumatic
shows a certain resemblance, and also cannot be

However,
sharply differentiated from many hysterical syndromes.
stuttering
developments
for
example,
the
thus,
there are characteristic
neurosis, to
which
it
walking in contrast to the hysterical abasia: the expectant neurotic

can still make an effort to walk, but he then becomes lame or gets pain,
whereas the abasic patient is altogether incapable of attempting to
walk. Moreover, the expectation neurosis has a "monosymptomatic
circumscription," which also expresses itself in the frequent return to
Sometimes it is also
full normality after the syndrome is cured.
certain
phobias,
at the roots of which
from
difficult to differentiate it
in
disagreeable experiences are not seldom revealed.
syndrome the expectation complex may appear in any other

neurosis and also in psychoses; indeed, in schizophrenia it can dominate
the picture for decades in the latter case, to be sure, there is more than
one expectation symptom.
As
improper treatment the suffering usually becomes aggravated and continues indefinitely. But once the diagnosis
is definitely made, it is possible to bring about a cure in a few weeks
or months through a definitely laid out psychic treatment such as
Left to
itself or in
enhghtenment, calming, and reeducating. Even in schizophrenia a

cure (of the syndrome) is not excluded, although it is rare.
D.
The common
The Compulsion Neurosis
diagnostic sign of compulsion neurosis, according to
a vivid feeling of domination or fear indicated by ideas

themselves. At the same time the incorrectness of the
obstrude
that
Kraepelin,
content
is
is
usually recognized.
In the compuhive ideas any kind of idea obtrudes
itself; it
may
be
a musical motive, the idea of a funny face, a ghost's hand, an odor, a

It frequently concerns disvoice, of which one cannot rid himself.
something disgusting, immodest processes, blasit may be in the form of questions (questioning
mania, reasoning mania). The content of the questions may be indifagreeable
phemous
things:
utterances, or
ferent, e.g.
how
the furniture of a
room was arranged, why a
table
is

rectangular,
what
is
the date of newspaper lying in the street; other
questions concern the creation, infinity, (jod, the Virgin

also all sorts of sexual problems.
some
selves into
Some compulsive
Mary; then
ideas force
them-
sort of action, as in the case of the arithmomanias,
the obsession to count everything possible, or to
with any number that presents
The
561
make
calculations
itself.
obsessive fears (phobias) concern
some threatening misfortune,
such as the fear of being struck by lightning (Kerauno-phobia) of

being robbed, of being attacked by an animal, of meeting with an acci,
dent while riding, of injuring oneself and others with a sharp object
which happens to be near (aichmophobia) of being killed by some
,
object falling from above, of contaminating oneself with dirt, bacteria,

bichloride of mercury
and thus make
oneself
and others
sick.
Precisely
those thoughts which are especially terrifjang to the patient come up
most often; thus one observes blasphemous ideas in the religious, and
murders in the chicken hearted, etc.
Kraepelin also includes here the somewhat peculiarly appearing
phobias of space, claustro-, nyctophobia, fear of traveling, and fear of
tunnels.
The fear of responsibility expresses itself in the compulsion to

examine repeatedly whether a match thrown away no longer burns,
whether the doors of closets are locked, whether letters are sealed, or
whether no mistake was made in the calculation (doubting mania, jolie
du doute). Other patients are obsessed with the idea that they must
always be particularly careful not to overlook anything; they might
Others fear lest they should forget
e.g. hear some one calling for help.
names and are thus constantly compelled to think of them and
Others are afraid of their working
repeat them [onomatomania).
tools,
or
entertain
some
fear
of
beginning
their
work
{aboulie
projessionelle)
The fear of guilt usually consists in the fact that the patient
imagines that he might do or has done something wrong or clumsy;
this is not only accomplished deliberately through commission or omission, but the patients also fear that they might destroy their beloved
ones through a thought ("omnipotence of thought," which shows a
predilection for the compulsion neuroses)
Then
there are phobias that
the patient must hang himself on a certain hook or that he must steal.
In the phobias of contact with people [homilophobia) the patient fears

e.g.
tion
that people direct their attention to him; here belong the examinafears,
the
phobias
blushing (ereuthrophobia)
would see the
slit
connected
;
with
clothes
and the fear
of
a teacher had the phobia that the children
of his pants.
562
The
patient usually reacts very strongly to these phobias
in part,
by avoiding all opportunities of coming in conflict with the fear, and

by acting in the sense of the phobia. Thus when there is a phobia of
bacteria, they constantly wash their hands, and touch nothing that
In aichmophobia they look
anybody else might have touched.
everywhere
needles,
for
order to see whether one
they
open their
letters
thirty
times
in
not wrongly addressed, they cross the
is
twenty times forward and backward, and similar acts.

was compelled to mow the same place
73 times in succession. Others have definite defense movements and
magic-like protective formulae, which they must utilize on all such
threshold
One
of Kraepelin's patients
occasions.
The primary
more
obsessive impulses, in so far as they lead to action, are
rare; Kraepelin believes that, principally, they are something dif-
ferent, for it
thing.
Still
is
usually a question of fearing that one could do some-
there
is
no doubt that obsessive impulses sometimes occur

Many add here also
with action, even outside of dementia prsecox.

the maladie des
tics,
coprolalia,
echokinesis,
miryachit,
and other
phenomena.
It
is
the anxiety which in
all
cases drives the patients to actions
Frequently the patients can somewhat control the

obsessions, but they are then afraid of the anxiety (phobophobia)
or to omit actions.
How
doubt and impulse are connected is shown by the folAlready when in college the patient had the impulse
to tell any one of his teachers that he is an ass or to write it on paper;
later he had the impulse to set fire to the curtains and the provisions in
his business, to embrace every feminine person, to stick a pointed
instrument into every bald head, and to put glass into the pans. At'
the same time he had doubts whether he had already performed this
nonsense; he had to pick up all pieces of paper in the street to see
whether he had not written anything against the honor of others; he
was to go to the stores to see whether he had not set fire to them, etc.
He began to study medicine, but the thought obtruded itself that all
patients could be well by the time he will have passed his examination, and he would then have to starve (he had an income).
He
changed to the study of theology and then he feared that he could
perhaps show his tongue from the pulpit. Dozens of such ideas prevented him from becoming something, although 'he finally began to
study law.
As a rule, the patients recognize the incorrectness or the nonsense
of the obsession, and struggle against it, whereas the delusional patient
closely
lowing example:
struggles urith his idea;
still
despite this insight there
is
some
sort of
563
it is something like the man who "in daylight mocks at ghosts

not desirous of hearing about them at night." At the height of
the affect they may merge for a short period into an indiisputable
belief;
but
is
delusion.
Besides these obsessive forms, the special enumeration of which

could be immeasurably increased, one also speaks of obsessive affects,
obsessive inhibitions, obsessive feelings, obsessive hallucinations and
similar phenomena.
it
do not quite know what there
is
tangible about
to understand.
The compulsive
who
feel timid,
neurotics are mostly individuals of
and not sure
The mood shows
conscientious people.
little
energy
of themselves, but they are diligent
and
a tendency to depression and
The intelligence is strikingly often above the normal.

The physical symptoms of compulsion neurosis are of all possible
fearfulness.
and vasomotor manifestations;
nervous
there
are
also
hysteroid
disturbances.
The
course of compulsion neurosis
is
a very dragging one.
Fluctu-
ations in intensity can occur, the content can change, while the fear
remains the same.
The beginning
Still
the picture on the whole
of the disease
very often at puberty;
in the
may
is
very monotonous.
already be indicated in childhood,
majority of cases
it
occurs before the age
Sometimes it can be dated from a definitive event, something like forced washing by sympathetic instructors, or religious
scruples at the first communion. At the period of involution a gradual
improvement usually occurs up to a kind of recovery.
The first cause is the hereditary neurotic disposition which frequently manifests itself in the family in a similar way. As to its
of 25 years.
distribution
fluctuate
among the
sexes,
from 29 (Janet) to
the statements in reference to
60%
men
(Kraepelin)
The psychic mechanism and with it the precipitating causes are

insufficiently known.
One was always struck by the connection
still
with sexuality, and Freud would trace

In any case affects from the original
ferred to other ideas.
affects
may assume
Frank
'^^
all
cases to sexual complexes.
initial idea are often
here trans-
has also demonstrated that repressed
compulsive significance through new and similar
experiences.
The compulsive syndromes occur in the most varied dispositions and

manic depressive insanity, and dementia praecox, but only when they seem to have originated indediseases, especially in neurasthenia,
pendently on a psychopathic basis docs one call the picture comjndsion

"* Affektststorungen,
Berlin, 1913.
Studien iiber ihre Atiologie und Therapie.
Springer,
564
Corresponding to
neurosis}''^
its
genesis, it
is
mixed with
often
all
kinds of other nervous and hysterical symptoms.
Outcome.
In true cases of compulsive neurosis a cure is not easily

Patient education, mental gymnastics following Oppenheim,
or Dubois's persuasion are supposed to have some success.
I have
attained.
seen some complete cures, at least from the practical side, by psychoanalysis (following Frank).
compulsion neurosis
It is a striking fact that "independent"
seen only in people
is
that disease, and that the
who can permit
symptoms always go only
themselves
so far as the cir-
cumstances (and the doctors) permit; moreover, in the war, where it

disregarded, it is said to have disappeared. Kraepelin justly warns
was
against tearing
away
these timid patients, lacking in energy, for an
unnecessary long period from their vocations.
They should
better be
accustomed to work and activity and trained to be energetic.
E.
The Accident Neuroses
The psychic disturbances which
originate
directly
from brain
are organically determined diseases with local and general
injuries
symptoms.
The
latter include especially
marked
irritability, intoler-
ance to alcohol, and from mild to severe epileptoid moodiness and

mental unclearness; in addition there are more or less localized headaches
and other
parsesthesias.
These
diseases
are
naturally
not
traumatic neuroses}^^
By
name one understands diseases which psychically

through the excitement of the accident or otherwise as a
the latter
originate
^^^
result of the same, but they can naturally become connected with direct
traumatic or toxic influence (carbon monoxide, in explosions). From
the outwardly different forms Kraepelin has emphasized four pictures
which designate the most important directions of the causation and

with it also the symptomatology; to be sure, they cannot be sharply
distinguished.
(a)
The
fright neurosis.
This name the author now
for the pathological reactions to the experience of a
still
uses only
profound catas-
" The typical cases have so much about them that is schizophrenic in appearance and heredity, that one cannot suppress the suspicion that they are actual
schizophrenics whose symptomatology exhausts itself in compulsive syndrome.
"" See
p. 240.
^*^Some, especially Oppenheim, assume for at least many cases a more physical basis, some molecular change of the nervous system through a physical or
psychic "concussion," resulting from an extremely strong stimulus, indeed one
even speaks of traumatic reflex paralysis. Following the war experiences these
things are quite secondary.
565
trophe (earthquake, mining accident).'**^ Beside.s ntuporous inhibitions

come about various grades and kinds of disturbances of conscious-
there
Orientation becomes disturbed; in mild casee

one observes distractibility, forgetfulness, and marked fatigue; in
severer cases it may come to dehrious states of an unclear character,
often with quite senseless acts. Sleep is poor as a rule and disturbed by
Palpitation and all the other signs of vasomotor
terrifying dreams.
ness with excitements.
lability,
furthermore trembling and dizziness, complete the picture and
usually continue longer than the delirious states.
The
latter last
from
hours to at most a few weeks; but even more chronic symptoms are
wont to disappear regularly in a few months at the latest. For the
period of the strongest excitement there
Under
certain conditions the
is
most profound
an amnesia in most cases.

is supposedly capable
fright
of producing a direct lethal effect.
The
difference
from hysteria consists
in the fact that the
morbid
manifestations represent here only a strongly exaggerated but qualita-
normal reaction to a frightful experience, whereas hysteria proown symptoms. The hysteric has a reason for being sick
and for showing quite definite symptoms, while the fright neurotic has
not; that accounts for the qualitative difference and particularly also
tively
duces
its
for the indefinite long duration of the hysterical reactions.
Recoveries of fright neurotics come as a result of time and rest, and

calming measures, also raising of self-confidence, and similar means.
Concerning the pseudo-dementia following an accident see p. 545.
(b)
Most
of the psychiatrical
show the picture

as
"a,
and
accident cases of peace practice
of traumatic neurosis
^^^
which Kraepelin characterizes
depressive or morose moodiness with woefulness, weakness of will,

all
sorts of physical
morbid manifestation partly
of a general
The patients regularly complain of

poor memory; but by objective examina-
nervous nature, and partly local."

difficulty in thinking
and of
tion the disturbance cannot be demonstrated, although thinking
retarded, and
if
is
the patients are put to mental or physical strains, even
of only a mild degree, unbearable
added manifestations rapidly show
themselves, which in part are also otherwise present.
The symptoms
are as follows: pains, especially in the head, but also elsewhere, and
palpitation with an objectively rapid pulse.
Thus
efforts to
work
feared and at least as long as the patients are under observation
movements
are restricted
if
possible, so that the patients sit
are
all
around
Stierlin.
Uber psycho-neuropathische Folgezustiinde bei den Uberlebenden
Diss. Zurich 1909 oder
der Katastrophe von Coiirrieres am 10 Miirz 1906.
Monatschrift f. Psych, u. Neur. Bd. XXV.
The expression is unfortunately also used for "fright neurosî^" and by
Hamburger also for psychogenic pavor noctumus.
566
more inactively, they walk only slowly, not only avoiding exertions
but also firm attitudes and all excitement. Besides the army of vasomotor disturbances, including dermographia and dizziness, the severer
cases
are
regularly
tortured
also
by an objectively demonstrable
insomnia.
Tests in continuous arithmetic, especially those done in Kraepelin's

laboratory,
show that
a true increase of fatigue (in contradistinction
to organic brain disturbances) does not exist, but that a greater part
of the behavior
same shows
For the
is
explainable through a lessened effort of the will.
The
motor activities.
further multiform symptomatology we must refer to the
textbooks on accident diseases.
The traumatic neurosis is wont in most cases to drag on for quite
itself also in registering
a long time, or
ment, possibly
it
may
even be incurable, unless a satisfactory
settle-
one sum, puts an end to the misery.
in
The Damage Suit
Litigants. In some individuals who suffered

through accident, the struggle for an income becomes active.
Not only do they imagine themselves wretched, but they also con(c)
injuries
and defend themselves against it,

by exaggerations and falsifications, as by non-recognition of
the court's decisions and by incessant appeals, in which finally libels
and threats are not lacking.
The 'damage suit litigant is probably incurable as long as an award
in his favor is to be obtained, and when the litigation has continued
sider themselves unjustly treated
as well as
a long time the prospects are probably rarely bettered through settle-
ment
in the
therefore
is
paranoid character of these patients.

the prophylaxis.
The more important
(d) Traumatic hysteria can be described together with the ordinary hysteria some peculiarities which correspond with the origin are
not important in principle.
Conception of the Accident Neurosis. With the exception of the
;
fright neurosis these diseases
damages."
The
mainly originate from the "struggle for
fear of the front (in war) has (consciously or uncon-
sciously) a similar significance. In the accident neurosis in peace time

the anxious idea to be sick and incapable of earning a living is in the
foreground, which could in a measure be compensated by an award (or
settlement sum)
"If I should become well the compensation would

be gone; the disease may also return, for it is so bad." Hence the
constant care of oneself and the avoidance of every effort to regain
the capacity for work. Through anxious expectation certain groups
:
among
those
are especially headaches^ cardiac symptoms, and sleeplessness,
The
of paresthesias can then be produced with relative ease

anxious avoidance of
all
567
exertion of will leads to a lack of energy
and hindrances in thinking, so that the relatively uniform structure

of the morbid picture in the principal components can be easily understood. In the damage suit litigants the desirous ideas are in the foreground; such people were happy to have met with "their accident"
and now the deserved fortune
is
kept from them.
This explains the
reaction.
The enormous mass experiment
of the war has furnished corroboramost striking manner for those who .still
had any need for it. It was known, even before, that without a "morbid gain" even a trauma produced no neurosis; that even injuries like
a fracture conditioned a longer working incapacity in pension receivers than in others, but where no pensions rewarded the lasting disease
tion of this conception in the
(in the case of different laws, in the non-insured, in
trophies, in duel
and sport
injuires), there
elemental catas-
was never anything
of a
traumatic neurosis to be seen, and that where a monetar^^ settlement
was customary, the

received.
disease
continued
only
until
the
money was
In the war, therefore, where there was not only the prospect
of a pension, but also of freedom from the horrors of the front, an

enormous amount of material was observed, in whom the severer
injuries produced no neurosis, although that alone was sufficient to
incapacitate from service and furnish a pension, and that prisoners of
war, with few exceptions that could easily be explained, remained free
from neuroses. Significant are also the cures (and eventual relapses)
through suggestive influences.^^*
To
be sure, there are
still
other motives for a traumatic neurosis be-
and fear of the front, but for some reasons they recede into
the background in the present laws. All those morbid gains which produce the neurosis may sometimes also become active here; the injured
may have a special interest in showing what a misfortune was produced
by him who was the cause of the injury, etc.
In the damage suit hysteria we must have in mind still other determining cases besides the desirous ideas, be it a permanent disposi-
sides pension
tion to hysterical expressions, be

of
trauma,
But
all
it
in the factor at the basis of the
kind
example, fear producing a tendency to tremors.

three forms must be afraid to work because their income will
as, for
so constant that a traumatic neurotic
be thereby diminished.
This
who makes an
work and accomplish as much

must always arouse the suspicion that it is a
is
earnest effort to resume
as circumstances permit
question of an organic disturbance, or at least of a complication of

the neuroses with
^^Comp. Naegeli,
some other malady,
especially a brain injur^^
Unfalls- und Begehrungsneiirosen.
Stuttgart
Enke
1917.
568
The
very
2%
statistics
concerning the frequency of the accident neuroses give

They may appear in perhaps from 1 to
different numbers.
damage
of all
have
little
suit
With the kind
accidents.
of injury they
connection, although traumas which affect the head will for
conceivable reason preferably settle there. An essential cause lies in

the disposition, which causes certain people to give up their own exertion, in order to live as parasites; frequently it is the
environment,
which systematically nurtures the desirous ideas, especially the wife.^^^

Unfortunately the chief cause of the disease is frequently the unskilfulness of the doctor, especially at the beginning of the treatment.
supporting with all means the positive suggestion, the

doctor pities these people, making the patients and himself important;
if he considers the consequences as serious and prognosticates a long
If instead of
if he "treats" too much, voluntarily advising against work,

and indicates that serious consequences may first follow later, etc.,
then it is not to be wondered at when there is an outbreak of the
Warning must be sounded
"iatrogenous" neurosis or psychosis.
against the not nearly limited advice, "to be careful of oneself," which
duration;
sometimes defers the cure for a long time also

is
needed,
it
in other diseases.
If care
should be given in as accurate doses as any other remedy.
produced by the insurance societies and their

desist from worrying and irritating the
insured patients; they exact foolish conditions, like the one that the
On the
patient must not work as long as he draws compensations.
contrary, it is good if these people can through work add a little to
their incomes and even earn a little more than in healthy days. Frequently the injured are first driven into the disease by unnecessary
worse
effect is
investigators,
who do not
litigations for the rightful compensation.
possibly rapid, definite,
and somewhat noble settlement will usually prevent the neurosis; the
same may be accomplished by the opposite way, namely, the indisputable non-recognition of the right to compensation. Psychologically
these two latter methods are naturally identical, for they both destroy
the desirous concepts of the neurosis.
Although the pathology of traumatic neurosis

all
simple in individual cases to
make
expert testimony, and the therapy.
is clear, it is
not at
the diagnosis, to decide upon the
The insurance
laws, the influence
good and bad advisors, as well as some other things, very strongly
complicate the state of affairs. It is the duty of every physician to
of
orient himself through special textbooks
and courses concerning
all
these relations.
In cases where after definite regulation of the claims the will to

""
Comp. the
characteristic fairy tale of the fisherman
and
his wife.

569
work does not spontaneously remove the still existing hindrances, it

requires skilful management to lead the patient back to work. It may
e.g. be well to advise the patient to take up first some new occupation
as something lighter.
If after this long idleness he is then unable to
accomplish as much as those who are practiced in this work, and if
he still tires rapidly, it is quite clear even to himself, and leaves no
depressing
best,
effect,
and the demand
for the work,
which he understands
then comes without any further interference.
Xm. THE PSYCHOPATHIES

The psychic
deviations from the normal which do not give the
impression of pronounced insanities, which are based as a rule on

heredity, but occasionally also on a former mild brain disease, are
designated by various names, but are always vaguely differentiated.
They
are spoken of as degenerates,^^'' constitutional cases, original
anomalies, psychopathies,
abnormal characters,
most cases.
peculiarities are in the foreground in
average or great intelligence,
it
has
little
etc.
Even
The
if
affective
there
is
an
regulating influence on the
actions.
We
have here to deal with deviations from the normal in all possible
and mixtures. Hence psychopathy is only in so far a uniform
concept as it embraces psychic deviations from the normal that are not
limited in any other way; but it is always incorrect to say that "the
psychopaths" have this or that quality. According to the nature of the
thing, they cannot have any definite limitations and no symptoms that
are common to ali. Every individual is really again something special.
Nevertheless certain principal features and correlations frequently
repeat themselves, so that for the purpose of the discussion some types
can be particularly emphasized without doing too great violence to
directions
But one must be quite clear that it involves only artificially

differentiated pictures, and that next to these pictures and between
them there exists in reality an infinite shading of variations, transitions,
and combinations.
From what degree of the intensity and the grouping of the symptoms one wishes to designate the psychopath as sick is arbitrary, and
from what degree one no longer wishes to consider him as a psychoreality.
path, but as insane,
is
not seldom the same.
really only in the social sense
Many
psychopaths are
"not insane"; before the forum of
avoid the name and concept of "degeneration"; comp. p. 201. A part

what is so called was recently brought into connection by Xacgeli with the
more fruitful concept of mutation.
"We
of
570
natural science they suffer from the same anomalies as many insane,
only in slighter degree they are paranoid, schizoid, latent epileptics,
;
cyclothymic,
etc.
many
them do not
really come to the doctor on account

on account of the false reactions conditioned
by it, which frequently assume the form of ordinary neurotic symptoms,
but still more frequently any other kind of irregularities which have
not yet been emphasized. Some are really inseparably mixed morbid
pictures of congenital and reactive anomalies. This is true of most of
the sexual aberrations, which are false attitudes on an abnormal disposition, wherein now the one, now the other factor predominates.
Of the endless varieties we can here give an indication of only few
types, in which limitation I adhere to Kraepelin, without, however,
adopting strictly his classification of original morbid states and psycho-
great
of
of their constitution, but
pathic personalities.
Kraepelin conceives the psychopathies as circumscribed inhibitions

which he puts in contrast with the general inhibitions
of development,
(oligophrenias). Although such disturbances certainly exist, and the

development in later age blurs some of these symptoms of the disease,
the theory is probably premature and in any case does not embrace
the entire group. In all domesticated creatures there are many, and all
sided deviations from the normal, and certainly also in human beings;
it is therefore probable that the majority of the psychopaths belong
Besides, much too much may be explained

through infantilism, and above all, the concept of the evolutional
inhibition is still quite unclear as soon as one wishes to apply it to
the facts, and in relations simpler than those of psychiatry it is really
only rarely of use. These are only a few indications of objections to
to this class of deviation.
this theory.
The treatment of the psychopathies is not a very grateful task, for

one cannot naturally change them one must try to get along with them.
;
At
up to a certain degree
and especially to a prophylactic avoidance of situations that
are dangerous for them, and under favorable conditions fairly tolerable
all
events, excitable patients can be educated
of control
situations
may
be attainable for some.
for the individual as such
and the
must determine the behavior.

citement should be kept
It is quite obvious that
away from such
know and feel that there

excesses when carried to a certain
lutely
automatically bring
its
Rules can hardly be given,
peculiarities of the environments
unnecessary ex-
must absoa limit to the tolerance of their

degree, and that a transgression will
people, but they
is
counter measures whereby neither excuses nor
subterfuges, in fact, no discussions whatever, will be permitted.
It is
o71
usually best to ignore the smaller things, even
if in cases where an
sometimes very useful to start
from little things; in any case, a neglect of consequences will always
have to be reckoned with. As everywhere else it is particularly important to create an interest, an aim, for which the patients could
strive, whereby definite traits of character, even if no virtues in them-
actual education
selves, such as
is
not impossible
it is
vanity and pride, should often be
made
servedly, but should be developed within proper bounds.
use of unreIf the patient
shows a hopeless apathy towards useful occupation, he can perhaps

be interested in sport, art, in some scientific hobby, or in something
In
similar; at the same time real work must never be neglected.
most cases it is impossible to educate the patients in the milieu in

which they grew up; they must be taken elsewhere. But we have
not as yet enough people who have the will and the necessary skill to
assume this task, be it in a sanatorium together with others, which
is not dangerous only if "the others" are not also moral defects, or in
a private family. The closed institution can in some regards accomSome
plish much more than the open one; it is used much too little.
of the moral idiots are treated by the penal code, but this is neither
But our views and
to the advantage of the patient nor to society.
laws and arrangements do not as yet permit any proper treatment
of so many cases who could otherwise be well managed.
However, in many cases one should follow the important rule, to
do that which is necessary, or promises some results, and not that
which might induce feelings of revenge, coddling, or useless sympathy.
A.
Nervosity
Under nervosity Kraepelin understands a "permanent injury- to

work as a result of an inadequate predisposition in the spheres
activity of the emotions and will. It is, on the one hand, mainly a
life's
of
question of a defect in the ability to resist emotional influences, and.

on the other hand, of an insufficient power of will. This is regularly
associated with a lack of equanimity in the development of the entire
The development of intellect is frequently good,
psychic personality."
or very good.
The
chief disturbance is in the sphere of affectivity; the patients
react stronger to inner as well as to outer influences.
"Everything gets
on their nerves"; they are easily worried, or also easily pleased. It is

especially on this account that the unfreedom of the will originates.
"They lack the trustworthy guide through a firmly formed channel."
In addition, one observes a progressive fatigue which does not at
Some inspiration or any other
all seem to show itself in all positions.
572
favorable affective state can often keep

fatigue
is
away the
fatigue for a long
must be questioned whether the heightened

not to be regarded as an emotional effect rather than a
time, so that in
some cases
it
constitutional anomaly.
Thus the capacity to work is irregular and on the whole considerably diminished; nevertheless the patients are usually inclined to
overestimate themselves.
The memory is often unreliable and uneven. The phantasy readily
gets the best of the ideas relating to reality.
Sexuality plays a par-
ticularly big role.
These conditions naturally show no barriers to either healthfulness

Moreover the prodromata of quite different mental diseases, especially paresis and schizophrenia, resemble these nervous
manifestations, often to the extent of being mistaken for them. In all
cases one must therefore also think of these psychoses and exclude them
through the anamnesis and the absence of their specific symptoms.
or neuroses.
Besides these general persistent manifestations there are also

quite morbid features,
hysterical signs,
idiosyncrasies, nervous
dyspepsia,
many
insomnia,
and similar symptoms.
In most cases the disease usually shows itself already in

childhood, frequently reaching its height in youth, but in many cases
Course:
it
shows later a gradual
decline.
In his classification Kraepelin finds
65% men,
probably because
such anomalies disturb a woman less in her usual callings, and consequently the physician sees less of her, or because she is designated
as hysterical.
Naturally the treatment
is
essentially a psychic training; at the
same time the external conditions should be regulated

sible.
great
as
much
as pos-
Among medications bromide should be mentioned, which, in a

many attacks of moodiness and (apparently) exhaustions and
irritating weaknesses, frequently gives quite
good results after a few
doses as well as after prolonged use.
B.
Among
The
Aberrations of the Sexual Impulse ^^^
the sexual aberrations onanism
is
so
common
that
it is
what extent it is really abnormal. At all events it is

if it appears in early childhood (under certain conmorbid
considered
,^^^ already during the first year), or
spontaneously
comes
ditions it
controversy to
^^ Krafft-Ebing, Psychopathia Sexualis.

Stuttgart, Enke, 14 Ed. 1912. English
Translation of the Tenth German Edition, Samuel Login, N. Y., 1908.
^^ Not so rarely servant girls criminally stimulate the genitals of the little
ones entrusted to them, in order to calm them or to gratify their own sex plea8~
ures and thus habituate even normal children to onanism.

when
practiced excessively, and
it is
when
it is
573
used as a substitute for
the normal sexual relation not only on account of moral but also for
("onanism of necessity").
other reasons
Moreover
regularly also the actual sexual abnormalities.
It is
it
accompanies
not only per-
formed through the excitation of the sexual parts but under conditions
through a mere activity of the phantasy which leads to the orgasm
("psychic onanism").
Naturally onanism easily becomes harmful, because it gives every
opportunity to excesses, because it deflects from the normal sexual
aim, and above all because the feeling of guilt and the constant unsuccessful struggle against the "vice" consumes the psychic power,
diminishes self-confidence, and gives cause for hypochondriacal and

neurotic
symptoms often
of the severest kind.^*^
In the treatment of onanism, severe punishments, long sermons, and
mechanical restraints are mostly harmful, and perhaps never useful,

whereas diversion through play and work, arousing of other interests,
and a healthy conviction of natural attachments have often made one

If transient states of sexual
forget the bad habit relatively easily.
excitation are at the basis of the onanism,
e.g. in schizophrenia, one can

sometimes ease the patient's struggle with daily small doses of bromide.
From onanism must be separated the state of being sexually in
love with one's own figure and person, the narcism, which Freud considers as a normal passing stage of sexual development, and which is
supposed to be found at the root of some psychoses and neuroses.
The normal attraction of the other sex can degenerate into a morbid
impulse of exhibitionism, in which even where there is an opportunity
for
normal sexual
relation, the patients find their true gratification only
in exhibiting their genitals
covered)
(eventually parts of the body otherwise
with or without simultaneous onanism.
In imbeciles, the
exhibitionism not rarely furnishes a substitute for the inacessible coitus.
For reasons that are not quite obvious

mental diseases, sometimes in epilepsy
Fetichism
is
it
frequently occurs in organic
in the twilight states.
a pathological exaggeration of the normal transference
of erotic feelings to parts of the
body and objects
of the beloved person
(hair, "braid-cutters," pieces of clothing, especially shoes).
The ob-
always acquired in a legal manner but are

often needlessly stolen simply because the theft seemingly contributes
They are said to stimulate sometimes by
to the sexual gratification.
looking at them, but in most cases they are brought into contact with
the genitals and used for onanism. Normal coitus is usually not
desired some, however, use the fetich to make themselves potent.
jects in question are not
"
Comp.
p. 209.
574
Voyeurs find their gratification
in
watching coitus in others, the
Renifleurs by inhaling the odor of urine and the Coprolagnists through
intimate contact or even through swallowing of excrements.
Another form of displacement
in the object
is
pedophilia, or the
which occurs
perhaps most frequently as an acquired anomaly in senile dementia.
(It is not rare also among imbeciles faute de mieux).
desire for relations with children of the opposite sex,
As pederasty one
designates at present only the gratification of
with male individuals through coitus in ano. It is less common

than the talking about it would lead one to believe.
Sadism ^^ is an exaggeration of the erotic pleasure in dominating
a
man
and torturing which is especially so frequently displayed also by the

male in animals. Masochism ^^^ is the caricature of (feminine) yielding
and a certain erotic pleasure in suffering pain. The peculiarity becomes
pathologic through the fact that it becomes exaggerated and is then no
longer a concomitant phenomenon of the erotic act, but an independent
aim.
Individuals so afflicted find the only or at least the necessary
gratification in causing, or in suffering, pain. The two abnormiseldom found isolated; usually they are associated in the same
individual even though as a rule one strongly predominates. Sadism
means to
ties are
and masochism are also designated as active and passive algolagnia.

The name sodomy like that of onanism has displaced its meaning. It
now designates exclusively the relation with animals which is not really
due to morbid alteration of the impulse but is regularly practiced faute
de mieux, especially by half mature people, lonely shepherds, imbeciles,
and also by some feminine persons who live intimately with their dog.
Transvestites feel well only in clothes of the other sex, without
being homosexual.
In rare cases the sexual aberrations, as well as the force of the

impulse, show a periodic character in so far as they appear from time
to time, but usually only for a few days
the normal (or sexually weak) behavior.
and then again make room
More
for
frequently they appear
only under the effect of alcohol.

The various kinds of parasexuality are usually connected with a
premature appearance of the sex impulse and hence can become known
very early, frequently at the age of three or four. Most of them are
incurable in part simply because such patients, following their feelings,
actually consider their form of sexual impulse as the only pleasant
one and therefore dread a "cure," as much as a normal person dreads
castration.
^ Named
'"^
Named
Marquis de Sade, a writer

Sacher-Masoch who portrays
after the
alter
afflicted
this
with this disease.
anomaly
in
his novels.

The theory
of sexual aberrations despite
quite obscure.
still
The majority
its
575
extensive literature
is
of its bearers are also otherwise
psychopathic, but in the most varied directions.
The moral qualities

have no direct connection with the sexual abnormalities; nevertheless
the psychiatrist naturally recognizes a selection in which the moral
defects dominate.^^^
The diagnosis is usually easy. But one must not imagine that
every sexually abnormal person himself knows his condition; one mu.st
bear in mind that all sorts of mixed and transitional cases may occur
and furthermore that the limitation
of the
normal sexual activity must
be stretched pretty far; in this sphere one must not be surprised at

anything and consider nothing impossible.
Treatment. In milder cases something can still be accomplished

through proper training, eventually through hypnotism: But even
when
the possibility of cures
may
not be excluded, they cannot be
attained in most cases, because the technique
such a patient
is
not married,
how
is
a ven,^ rocky one.
shall one gradually initiate
If
him
normal sexual intercourse, without exposing him to new, moral

and other dangers? Where something is to be attained through selfcontrol, one does well under all conditions to train the patient to
abstain from alcohol, not only on account of the effect on the inhibition
into
of the impulse, but also because alcohol sometimes first permits the
perversion to come to the surface.

Special consideration
must be given
to homosexiuility
or contrary
sexual impulse, or uranism,^^^ the sexual love for persons of the same
It is gratified in various
sex.^*
ways, sometimes through mere com-
panionship or looking at the person, but
much more
frequently also
kinds of excitations of the genitals; in contrast to this
through
all
there
a feeling of indifference or disgust towards contact with the
is
With such people
opposite sex.
all
sexual desires, actions, as well as
the day and night phantasies are directed to the same sex.
As
matter of fact homosexual love shows the same signs as heterosex-ual

love but shows, particularly frequently something strikingly ecstatic
and
exalted,
although
^"
it
and only very exceptionally is it lastingly monogamous,

by no means free from manifestations of jealousy.
is
See below Homosexuality.
^^
From Venus urania following this terminology Ulrich calls the male
homosexual "urning," and the female "urninda." The corresponding name for
heterosexuals, which is, however, little used, is "Dioning" from Diona, the mother
of Venus Pandemos.
"^ Hirschfeld, Homosexualitat des Mannes und Weibes, Berlin, Marcus, 1914.
Cf. also Chap. XI, in Brill's Psychoanalysis, Its Theories and Application, 3d
;
Edit.,
W.
B. Saunders, Philadelpliia.
576
Noticeably frequent the orgasm takes place without friction. Abnormal practices such as cuni-peni anilinctio and other kinds naturally
play a greater part here than in heterosexual gratification; pederasty
(immissio penis in anum) is more frequently rejected with disgust
than desired. A mingling with the various other abnormities such
as fetichism, sadism, masochism,
shame manifests
itself particularly
a very exaggerated manner,
demand
is
not rare.
is
The
feeling of
toward the same sex and often in
an indication how
rated from the positive impulse.
aggerated sexual
eta.,
little it is
The common
to be sepa-
existence of an ex-
only a partial manifestation of the very
changeable affectivity, which readily fluctuates between the highest

pleasure and deepest pain on the other hand the aggravation to anger
;
and worry recedes comparatively in contrast to the positive and negative esthetic feeling, which causes delight at the sight of a loop colored
in accordance with one's wishes, or makes it ''unbearable" to be in a
room, which is not furnished according to one's taste.
The
tertiary psychic
and physical sex characteristics
of the
same
sex are often slightly developed or even substituted by those of the
other sex.^^^
The
the feminine in
all
feminine attire)
following are to be noted:
in taste, in thinking, in
number
entire behavior of a large
woman
inclination towards
mimicry, and in gait in the

it is something common
;
of urnings
to see a slight indication of the feminine

of the
An
possible spheres, in work, decoration (preference for
up
to a complete imitation
The man with
the reverse can be seen in the urninda.
a slightly developed beard, high pitched voice or broad pelvis and the
virago are relatively more

those of normal sexuality
partial manifestations
common among homosexuals than among
nevertheless these anomalies of the physical
markedly recede
in frequency
when
contrasted
with the psychic manifestations. According to Fleischmann the latter

are found in 24% of his male homosexuals, where he includes apparently very slight deviations from the average.
Only
in exceptional
cases are the genitals abnormally formed.
All homosexual peculiarities
the earliest age.
The boy
show themselves very frequently from

games, and hangs on his mother's
likes girls'
apron strings, and the girl runs around with boys. Early sexual development is quite usual, in which the abnormal direction can as a
rule be seen from the beginning.
The ethical feelings are just as differently developed as in those who
are sexually normal; still, at least in asylum practice one finds comparatively
many
morally defective urnings next to those of high stand-
^ "Androgynous" = men
women
with feminine build of body and "Gynandrous"

with masculine build of body.

ing.
That they are on an average
577
especially prone to lying
is
cer-
tainly largely the result of the false position into which they are forced
of human society, which are formed
on heterosexual patterns.
Also in the intellectual spheres one observes in these people all
nuances; abnormities in all directions are as common as among other
by the general customs and views
psychopaths.
Most homosexuals are neurotic in some manner. Excluding the

secondary sex characteristics of the other sex, one does not find
physical "stigmata of degeneration" more frequently than in normal
people.
Formerly there were disputes as to whether homosexuality is a

no need of discussing this. Whether it is a disease,
vice; there is
belongs to the sphere of foolish questions, especially as long as the
concept of disease cannot be limited and
quences one should deduct from
More important
it is
not
known what
conse-
it.
the investigation, whether it concerns a conand hence avoidable disturbance.

In favor of an acquired disease aside from many empty reasons
about which one reads ^^'^ are: some other sexual anomalies, especially
fetichism, can hardly be explained differently than through an accidental association of one of the first sexual excitements with an unusual
object.
It is quite natural to assume a similar origin for homosexuality, for at present it is hard to imagine how nature happened
to produce so frequently such an anomaly, which seems to contradict
the manifoldly confirmed view that the germ glands determine the
other sex characteristics. It is moreover noted that mutual sexual
activity takes place in prisons and in all other places where persons
of the same sex live alone in close contact more or less deprived of
the other sex. There are also schools where homosexuality is considered something more superior than the proletariat service of Venus
vulvigata and thus seem to have a certain recruiting force. Psychoanalysts wish to trace the anomaly among other things to a strong
attachment for the mother, and as a matter of fact one can sometimes
find indications that such patients find it particularly hard to detach
themselves from the mother.
All these reasons are in no way valid; none of the modes of origin
ever brought forth can hardly even be assumed in a great number of
patients, except the attachment to the mother which has not yet been
followed up in a sufficiently large material. If it should really be
is
genital or an acquired,
"'
Here
also belongs the hearsay concept concerning the acquisition of peder-
astic "habits" as a result of sexual oversatiation.

578
found regularly, it would still not yet prove that it is the cause, for it
also be confirmed somehow, and what is more, according to our
present knowledge, in something that we cannot designate as a congenital "disposition." And even if it were certain that fetichism owes
its origin to merely accidental occurrences, it still cannot be imaginable
without a previously existing foundation, and precisely in homosexuality an analogous explanation will not quite fit, if only because a
great number of those who are later sexually normal must have experienced their first sexual stimulations in connection with their own
must
sex (boarding schools!).

If the reasons for the acquisition of the
anomaly are quite
insuffi-
on the contrary, very many weighty indications showing that the essential root of homosexuality lies in the congenital constitution, and what is more not only in the sense that the direction of
the sexuality was not firmly established and that an accidental experience determined the false tendency, but in the sense that the homosexual foundation itself forms the constitutional factor. Here we have
cient, there are,
in the first place the fact that
many more
urnings carry along signs of
the other sex in the physical sphere than would be justified by the
assumption of an accidental determinant of sex directions. Moreover

on closer inspection the direction of the sexuality can frequently be
recognized already during the first or the second year of life, and at
all events in the majority of the urnings it is already determined at a
time when the sexual feelings in the narrow sense play no big part
according to most patients no part at all. Most urnings are finished
products at the third or fourth year at the latest. Moreover one can
hardly understand how through the mere feeling to be an urning an
inclination should arise to assume in all other relations the customs
of the other sex.
The urnings have to do with men, and, following
what one otherwise sees under pathological conditions, would therefore
much rather identify themselves with men and avoid everything
feminine, if a primary disposition to feminine behavior would not
hinder them in
this.
It is also characteristic
that homosexuals are sometimes entirely
ignorant of their abnormity until they pass pubescence
become aware
of
it
by accident, while
when they
in the acquired sexual aberration
as a result of an outer experience the precipitating cause usually remains conscious, and above all nothing can be noticed during the many
years of this latency period between cause and effect. How firmly
nature determines the direction is shown by considerable experience.
Thus most of the homosexuals grow up in an environment which suggests a direction of the impulse contrary to their own and are still not

changed by
it;
v/hcrcas heterosexuals,
women occupy
tionship witli
happy
who because
to be able to return to
of a lack of rela-
same sex
tliemselves witii the
women.
579
for
many
one follows up
the families of homosexuals one will, to be sure, find only in about
8% the same heredity, but exceptionally frequently one will observe
years, are
a special lack of fixation of the sexuality, which

bers takes different abnormal
vidual and very frequently
abnormity
sexuality,
at play
is
is
is
directions,
in different
but persists
in
the
memindi-
That some physical

proven by the descendants of homo-
particularly strong.
also
which according to Hirschfe'd
is for the greater part deeply

should also not be overlooked
about the frequency of homosexuality
degenerated in various directions.

that according to
it is
If
we know
all
It
not directed by outer circumstances, but
where; according to Hirschfeld
is
fluctuates
it
about the same everyaround 2% of adults.
Of course it also occurs among animals but not much can

ferred from this as long as no numerical points of support
.be
in-
for the
frequency are found. Against this there is another biologic reason,

namely, the continual succession from the pure heterosexual to the
bisexual and from this to the pure homosexuality through all possible
intermediate stages, not only in regard to the direction of the impulse
but also in regard to the physical and mental qualities in general,

in so far as they are connected with sex. I would not know how the
accidental connection of the sexual impulse could produce such equal
shading.
That the theory

the discussion
itself,
had most experience,
in sixes
still
is
and
I
if
like
feel
and sevens can be gleaned from

others and especially those who
many
inclined to seek the essential factor of
homosexuality in the congenital direction of the impulse, it is on the

other hand again very clear that in cases of a fluctuating sexual direc-
may have
tion accident
And
a deciding influence.
such a fluctuation
man shows immemost genuine "Dioning" has his homosexual

com-ponents, and no schizophrenic have I yet studied more accurately
without striking against it.
(But I cannot agree with Freud and
Ferenczi, who maintain that these homosexual components are an essential part of the disposition to schizophrenia,
the heredities of homosexuality and schizophrenia are not related.)
For the present therefore the only hypothesis that can be formulated with any probabihty
is that uranism is a biological manifestation.
If it is proven that
2% of the people are e^'e^y where burdened by it, than it may
perhaps be caused by an hereditary mechanism similar to the one that
exists
indeed a thorough study of the impulse
life
of
diately that even the
to 100
women
106
men
are born.
This could also be reconciled with
580
the remarkable circumstance that homosexuality does not die

despite the fact that
it
hinders procreation to a high degree.
out
The
newest investigations concerning the changes of the physical and

psychic sex characteristics by implantation of germinal glands of the
other sex in castrated individuals may perhaps throw some light on
the subject.^^^ It can be imagined, for example, that in the bisexual
disposition the germ glands too are hindered by the sex determining
causes from choosing between 'two extremes but that there is a suppression of one factor by another, which is never complete and under
circumstances can still change in accordance with the determination
of the development of the individual's germinal glands.
At all events
the sex hormones also exert an influence on the psychic direction of
the sexual impulse.
If uranism is a biological manifestation, it is different in principle
from the so-called degenerations, which represent a more accidental
The other psychic anomalies
fluctuation about the normal point.
frequently associated with it which we do not differentiate from the
usual psychopathic symptoms, form no hindrance to the theory. However, if the theory of the biological nature of the anomaly which is
almost only supported by the numerical constancy of the occurrence

should
not
confirmed,
be
this
naturally
would not furnish
any
reason for changing the view concerning the congenital nature of

homosexuality.
The
diagnosis
is
self-evident in
most
cases.
One must be
careful,
however, not to mistake for homosexuality an occasional inclination

to homosexual acts,
and not to
classify the bisexual intermediary stages
with one or the other extreme.
Treatment
in the sense of attempting a cure
the milder cases, that
is,
in bisexuals
is possible only in
("pseudo-homosexuals"), who
can be educated by hypnotism or psychoanalysis to the extent of resorting to normal activity and even live in happy marriage.
The pronounced cases had to be considered incurable up to the
present.
Recently, however, Steinach cured a case by castration and
human testicle. Naturally the method is still

Meanwhile the patients must be taught to resign
themselves to their fate. To know their position and not feel obliged
to struggle against it internally is in itself a relief for many. The
physician can do even still more in regard to calming the patient. In
the first place he can do something for the nervous symptoms which
are provoked by the difiiculty of the situation in general, and espeimplantation of another
to be confirmed.
^" See Steinach und Lichtenstern, Umstimmung der Homosexualitat durch

Austausch der Pubertatsdriisen. Miinchen Mediz. Wochenschrift 1918, 145.
581
cially by the struggle with sexuality, the fear of prison, the worry
about one's honor and that of the family, etc. Persons of delicate
feeling who are especially endowed ethically and religiously reproach
themselves severely, which can be reduced to a bearable measure by
enlightenment. Besides this, stress must be laid on the psychic treatment of the nervousness in general. Some nervous symptoms seem
to come directly from the enforced sexual abstinence (which I do not
recognize as a cause of disease in healthy persons).
the
place a question of the attitude taken.
first
Here too
He who
is
it is
in
inclined
assume chastity as something obvious suffers little or not at all. He

strikes his head against the wall, who consumes himself in the
internal struggle, who looks for excuses in himself not to remain chaste
will naturally be made neurotic by it.
In the sense of this reflection
the doctor must educate his patient if he permits himself to be
to
who
educated.
As
by any occupation that would fill one's

it is the same as in other neuroses.
To be sure, it is more difficult to educate a homosexual to abstinence
than the average dioning. For their sexuality is in most cases abnormally excited and their nervous system reacts more strongly.
I know
homosexuals who had themselves castrated and are now happy to be
released from the struggle and fear of the prison. Many cannot conceive, however, how one can give up a pleasure of life which the rest
of humanity conceives as the highest.
In many cases entering a homolife,
to the value of diversion
or
by
sport, philosophy or art,
sexual "relation" signifies in the
and the
if
neurosis.
But the
first
place a release from the struggle
difficulties
hardly ever remain away even
they came only as a result of a desire for change and
faithlessness.
It
is
all sorts of
also not always easy to slip through the meshes
of the law, although according to Hirschfeld only one out of 10.000

falls into
the hands of the public prosecutor; more, however, get into
the clutches of blackmailers.
To
be sure, some find their satisfaction
committing anything punishable.

Emigration to other countries where the urning activity is not punished
is only rarely to be recommended.^^
The punishment meted out to homosexuals in the United States,
in relationship with a friend without
Germany,
in Austria,
and
in
most
of the cantons of Switzerland
be designated as unjust from a physician's point of view.^^^
is
to
It is also
unworthy, and what I reproach it most with is the fact

no use, but hurts also those who are sexually normal
through the prying into sexual relations, and breeds the immeasurably
inconsistent,
that
"*
it
is
of
Concerning the for and against see Hii-schfeld.

said of England and the United States.
""The same may be
Editor's
note.
582
greater evil, namely,
blackmailing.
significance
against seduction, the
The law should only proceed

of which,
in
my
experience,
is
highly exaggerated, for in most of the seduced that I have seen there
was nothing
to spoil.
Naturally the urning
is
not irresponsible as such, notwithstanding
the fact that the normal person frequently defends himself by pleading
Nevertheless, here where the
irresistibility of the sexual impulse.
not only abnormal in its direction, but in most cases also in

where a mass of other psychic anomalies cooperate, the
and
quantity,
is often permanently or temporarily passed, and
responsibility
of
limit
are therefore always in order in the presence
circumstances
mitigating
law-giver
who began with wrong premises.
misunderstanding
of a
impulse
is
Abnormal
C.
The
Irritability
react to influences from without in a very
irritable types
acute and exaggerated manner, which takes the form of attacks of rage
lasting mostly a few hours, despair with suicide, anxiety attacks, or
also stuporous states.
adequate.
Some
During the attack
reflection is altogether in-
cases are practically in a twilight state
the
memory
is later markedly clouded; jealousy and alcohol are especially frequent

causes for the precipitation of the morbid exaltation.
D.
The unstable types
Instability
by a lack
are distinguished
of persistency of
the affective functions accompanied by an exaggerated resoluteness

of will as a result of inner and outer momentary influences they repre;
sent persons
who
them become
are readily changeable
frivolous
criminals.
by
their milieu.
They range from
the
Many
of
actively
temperaments.
His father was a good man, but too
A
fortune.
The mother was irritable,
the
family
and
wasted
bombastic,
irritable to the apathetic
24 year old merchant.
moody, and weak-willed.
Her
father
was fickle-minded and
also
squandered his fortune; he was a bigamist. The patient himself received an irregular sort of schooling, but was a good scholar; after
his father's death he had to be apprenticed in a business house where
he purloined a considerable amount of money from the stamp bank.
He then got into a reform school, where he did well and because he
had a good voice he was also allowed to take singing lessons. Already
A little later he spent
at puberty he left here and there unpaid bills.
more than a year with an aunt whom he could pump in a remarkable
manner, so that she had to withdraw into an attic and start again to
earn her living by handwork, while he kept for himself a bedroom

and parlor and
lived very high in general.
He was
in
583
some business
houses and apparently had a number of engagements as an opera

singer, but could not remain anywhere, partly, but not always, because
he contracted debts with which the police were concerned. One complaint was dropped because he acted more like an irresponsible fellow
than a fraud; in some others where he seemed to have obtained money
fraudulently it did not even come to court. By presenting to the
authorities a forged contract he even deceived the orphanage (at the
Finally he became engaged to a
age of 23 years).
also of a
girl
from whom he received big sums, partly

under false pretences, partly by other means, in the expenditure of
which she sometimes participated. She finally had to bring charges
against him. Thus the patient came to be examinedt We found a
very good intelligence, but a slight moral defect which prevented
him from feeling sorry for his bad deeds. Nevertheless his past life
showed that he made repeatedly good resolutions and worked well
for short periods in new places, until he was again overcome by
temptation, which was usually the case after a few weeks or months.
Outwardly he had an elegant appearance and usually felt sure of
himself.
But his affectivity showed at the examination an overhastiness and a marked inability to bridle his will to the demands
of the task and hold it at the necessary height until the task was
solved.
Just as in life, it also showed itself in very simple tests
in which he never could concentrate his attention long enough, and
somewhat
light character,
never could follow resolutions to the end. In his wTitten work he

sometimes began quite well but then lost the thread, or he became
unnecessarily brief and stopped without having finished.
financial matter he
was not himself
sufficiently informed.
About his
Whether
he signed a note for 600 or 700 francs he did not notice. Neither he
nor his bride could tell with any accuracy how much he got away
from her. Even a simple example in arithmetic at first rattled him,
although he was good in calculations. When he was forced to throw
light on his crime he not only became uncertain and mixed up ever>'lie senselessly and against his
which are even now considered
more in the light of recklessness towards a much too gullible person
than as an actual crime, we had to consider him as responsible, but
This was done with the
as unfit to take care of his own afTairs.
hope that the firm hand of a guardian might lead him into better
thing, but quite uselessly he
own
interest.
For
began to
his fraudulent acts,
paths.
To
be sure, instability
so also with
all
is
not rarely mixed with other anomalies,
grades of moral oligophrenia.
Such a case
is
recog-
584
nized by the following letter which
how
is
given as an illustration to show
deductions can be drawn from written expressions:
Dear Mother:
Am
Thursday in the hospital for the insane, Burgholzli

Your loving letter before you left Hinwil was received and it has pleased me very much mother dear to hear that in
spite of my foolish pranks you have not given up hope, I thank you very
much for it, and I feel sure that better times are in store for us. I am
pleased to be up here, the food and attendance is excellent, I can also
amuse myself nicely so that time passes very quickly. I hope that I
As I see from your letter you have
shall soon be allowed to work.
a sore foot, I wish you a rapid recovery so that you shall soon be
allowed to visit me. The visiting days are Sunday, Tuesday and
Friday from 10 to 11. When you come bring along Mr. Huber, I
would like to see him again, you know that he expected from me only
what is good. Dear mother send me next week a package with apples,
some chocolate, and some cigarettes, Camels 20 for 25 cents, one is
allowed to smoke when one has something to smoke, please don't forget
On the way from the
it, let me know how everything is at home.
station to this place I saw Rosa Meier over on the Pfauen, she saw me
I hope dear mother that at least by
too, perhaps she told it to you.
next Friday you will be able to walk again so that you can come to
I always have a good desire for fruit.
see me.
In the hope of seeing you and a package, I am with greetings,
since last
(Ziirich),
Ward
B.
Your
The
style is clear, intelligible, simple,
of education very good.
This difference usually
loving son Arthur.
and considering the degree
The orthography, however,

signifies that the writer is
is
not so good.
not incapable of
learning and understanding, but that he did not have the required
The same is shown

know the number
Arthur also in other things;

which one
hears so often that even very strong imbeciles can automatically repeat
them, but he is well able to recount in succession the cantons through
which one has to pass in 'a certain journey.
The expressions "loving letter" and "dear mother" in the text
denote that he is seeking an affective relation with his mother; this is
also shown in "I thank you very much for it," and in the mention
To what extent Arthur
of the sore foot and in the wish for recovery.
actually loves and misses his mother cannot be quite definitely concluded from the letter alone; however, one rather gets the impression
zeal at school.
thus he does not
in
of the Swiss cantons
585
a real emotional relation existed for her, and from his other
behavior towards her, we know, that he really still loves his mother
as
if
in a certain sense.
But how
far does this love for his mother, his penitence,
He knows
and the
that he has committed
foolish
good resolutions reach?
of
spite
in
hope
give
up
not
did
mother
his
acts; he is pleased that
better
that
sure
feels
he
and
it,
for
her
to
grateful
that, he is very
here that
times are in store for both of them. It is important to note
about
bring
to
him
to
is
up
it
that
mind
his
does not at all enter
it
he has
these better times, that he has to work with himself, and that
he
asylum;
the
and
fate
him
by
upon
to take on a training forced
later fare better.
sees only the pleasant side of things, and that he will
excellent food,
the
about
except
say
to
nothing
About this place he has
He then gets to his mother's

well.
but expressly for the purpose
recovery
rapid
sore foot; he wishes her a
here
he does not lack the neceshim
that she should be able to visit
tells her the exact visiting
immediately
sary associations in which he
like another entertainalso
would
he
But at the same time
times.
enough for him so he
not
is
mother
ment; he wants Mr. Huber; his
to the bad combelong
not
does
thinks of telling her that this man
and that one can amuse himself
which he otherwise "gets." Then he would also like apples,

recovers
chocolate and cigarettes; but he cannot wait until the mother
he even
and
things
these
him
the use of her foot; she should send
package
this
expected
he
impatiently
underlines the word send. How
pany
in
shown in the hope he expressed later, that the mother should be

to be sent
able to come next Friday, whereas he expected the package
things
about
interest
of
bit
a
even before. He would then like to show
is
not
home, but here all further associations are lacking; he does
adds
he
cigarettes
the
about
inquire about anything special, whereas
meeting, but
the brand and the price. He then feels like telling of a
position,
present
his
to
reference
only as an occurrence without any
to show
opportunity
excellent
whereas that could have furnished an
met
who
Meier
Rosa
seeing
of
whether he really was ashamed or not
at
again
a reform school to a hospital. He then
only
expressly
but
recover^-;
returns to the hope of his mother's
visit only in order
the connection that she visit him soon, and the
him on the way from
him the
to furnish
his mother.
is
is
fruit,
and not as
a fulfilment of his
yearnmg
for
and
This connection is repeated again in the last sentence
purpose
its
as
well
as
letter
emphasized, with which the
particularly
ended.
From
all sides
of the pleasure.
the waiter thus returns again and again to the idea

A certain affection towards the mother is ex-pressed.
586
by his behavior, and

But all this has only a passing
and secondary significance. The main thing is the pleasure, he thus
shows himself more and more changeable in affects, and towards the
most important things superficial, without persistence, always returning again to his pleasures. With obliging and grateful mimic, he
always asks for something on every visit; now it is for some trifle,
now for his discharge. About the main thing, the improvement and
the measures and time required for it, that does not enter into his
head. As the young man is not without moral feelings, as his misbehavior was due to weakness, and not to direct impulses, and as he
is in some ways manageable in the asylum, the prognosis is not yet
very bad at his age, but only on condition that he will be confined
Corresponding to his instability, he
in the asylum for a long time.
has until the present never stuck to work without being forced everywhere he ran away; a certain stability must be forced upon him in
part from without, and in part it may be expected by maturing his
character which is still somewhat childish.
also the recognition that he has actually hurt her
that he will change for the better.
E.
Special Impulses
Among the impulsives Kraepelin includes the not quite regular

groups of squanderers, wanderers, and dipsomaniacs.
Frequently in spite of good intelligence, the squanderers simply
cannot at
all
manage pecuniary
matters.
Sometimes with great clever-
ness they contract debt over debt, ruining themselves and frequently
many
other people with
whom
The wanderers according

not
feel
they come in contact.
to Kraepelin are restless people
any place and move from place to
place.
that the pathologic wandering impulse
nor even a uniform syndrome.
many
are
who do
contented anywhere; they therefore cannot endure staying in

It
is
must be added, however,
neither a uniform disease
Besides the types just mentioned there
others, e.g. the jolly business schemers; furthermore people
place, but who ''soon become bored"

most varied categories, who get into
trouble everywhere and hence run away; poriomaniacs, who through
hysterical, schizophrenic, and epileptic moods and unclear states, are
who
with
find it pleasant in every

it;
new
sensitive types of the
driven into the open.
no uniform category .^
Kraepelin then also adds the gambling mania and the collecting
mania and brings the whole class in relation to affective epilepsy.
The dipsomaniacs,
'"
Comp.
p. 351.
too, represent

The Eccentric
F.
The psychic life of the

ment. Awry conceptions
587
(Versciirobene)
eccentrics lacks uniformity
and correct judg-
of relationships, incorrect logical operations,
expression bring them outpeculiar views and frequently also modes of

they cannot yet
wardly near to the latent schizophrenics, from whom
such types can also

be easily distinguished, although it is certain that
the only representative.^
be based on congenital anomalies. They are
aberrations in whom the afjectivity is apparently
of the constitutional
not altogether or preponderatingly disturbed.
PSEUDOLOGIA PhANTASTICA
G.
(LiARS
AND SwiNDLERS)
^"^
from an exaggerated
planlessness of the
and
activity of their phantasy with unsteadiness
vanity m
tendencies,
flowing
Always in the sense of their high
will.
themthink
they
sexuality,
any direction, irritability, ambition, and
unthe
forgettmg
that,
and roles
selves so well into fancied positions
determmed
be
to
actions
structures, they allow their
All the pathologic liars
and swindlers
suffer
reality of these
at their disposal they

by them. If they have no strong moral feelings
and swindlers. For
must naturally degenerate into panhandlers
hysterical symptoms is very
conceivable reasons a reenforcement with
.^^
It is remarkable that on two occasions
not necessary
frequent but
of actual psychoses
have seen the syndrome appear as a forerunner
pronounced a way that for a
(paresis and dementia pra?cox) in so
long time I overlooked the

for
''Dr of
^"^
patient
who
studied theolog>'
dictated
with money obtained fraudulently. He
out,
send
however,
business letters which he did not,
as
away
gave
he
money for theatre tickets, which
a big rapid press,
many
disease.
and
of
title
the
assumed
some time and also solved a price problem,
bought
bureaus,
Jurisprudence," quickly opened many business
Illustration:
law
main
Henneberg's
fictitious
all
and wasted much

seemingly free
tickets.2*
H.
Constitutional Ethical Aberrations
moral oligophrenics, moral

(Enemies of society, antisocial beings
Moral Insanity.)
idiots, and imbeciles.
beings represent, to be
Enemies of societv, asocial and antisocial
term is only
inclusive
The
class.
sure, pathologically no uniform
^"
See pp. 108-9.
-zSTorenslchen und
XXV. Jahrg.
XXV. Jahrg. S. 2S2.
Chante-Annalen.
Psych. 1902,
*'*
Beurteilung der P^ûdologia phantastica

en-enheilkunde und
375. Ref. Zentralbl. 1. J.
klinisch-^n
For further example, see pp.
108-9.
588
held together by practical and social viewpoints; various predisposiA good picture of the varieties of criminals
tions may lead to crime.
The chance,
and opporaffect,
bad people; they go off the track
under the influence of a situation which they cannot control because
of changeable feelings, lack of reflection, slight moral weakness and
is
given to us by Aschaffenburg.^^
tunity criminals are really not such
them
reason that Aschaffenburg conceives
It is for this
similar defects.
as criminals of the
The chance- criminal does harm
moment.
as
a result of carelessness, the affect criminal can kill or injure his ad-
versary as a result of just indignation or rude excitement, while the

opportunity criminal may steal from the bank when he finds himself
in
any financial
The
distress.
real criminals in increasing degree of
dangerousness commit individual crimes with cold reflection {premeditated criminals) the recidivistic criminal allows himself to be
;
drawn
into
many
such acts, but
is
The
honestly.
life of
an honest
however, to work again in the

and can generally behave quite
able,
intervals with relatively good will
man
is
altogether incompatible with
that of the habitual criminal; nevertheless
it is
due more to negative
motives that the latter remains a criminal, e.g. distress, when he has
been out of work; but he prefers the not to steal to the not to work.
The professional criminals have positive impulses to crimes as such,
which they perform like the violinist his art; they live on crime only.
There are many specialists among them, e.g. the house burglars, the
pickpockets,
It
is
etc.
show some
quite obvious that the first three classes frequently
lack of morality, while the others lack something of

ethical defect
is
they
However the
not the only, and frequently not even the essential
factor in their aberration; they are just as

directions:
it.
may
abnormal
be unstable, weak,
labile,
in so
many
irritable,
other
eccentric,
unclear, debilitated, etc.
The
degree
of
dangerousness
depends
among
other
things
on
whether, and in what degree, the anomalies, especially the moral defects, are
associated with positive
activity.
The merely
bad impulses and especially with
heartless person will cause pains to others
he can gain some advantage thereby; but he

the pains of others will
make
who
if
takes pleasure in
a direct effort to torture his fellow
no use to him. One can steal out of sheer laziness and out of a lack of moral feelings, or out of positive pleasure in
gaining a livelihood in this way. In every case all these people in
time take an attitude against society, which defends itself against
beings, even
if it is
of
"^Das Verbrechen und seine

S. 179.
Bekampfung
II.
Aufl. Heidelberg, Winter, 1906.

them by
reprisals.
Many
finally
conceive
them.selves
589
as
pioneer
freedom and justice against a hypocritical and violent order

of society. A dread of orderly work or at least a lack of a persistent
capacity for work is common to almost all the various kinds of criminal
fighters for
natures.
The
intelligence of the antisocial beings
frequently bad than good;

stupid.
That
many
of
them
is
very diverse;
more
are
it is
more
eccentric than
a lack of moral affectivity will cause difficulties to think-
ing in ethical spheres
is
self-evident.
There
is
perhaps a uniform
quality which manifests itself as moral impulse and as moral understanding, in the
same way
as the impulse for music or mathematics
standing and a good development of social
is
good moral underfeelings would then have
preferably associated with special endowments.

to occur together or be absent together.
The moral defect is as a rule congenital and also inherited, even

though as a result of brain injury there may arise not only irritability,
but also a certain lack of consideration for others and even a pleasure
in teasing.
In milder cases the patient may improve somewhat in
proper environments, but hardly after the twentieth year. However,
one should not forget that in children even repeated criminal acts, quite
apart of those caused by the milieu (stealing among the Spartans, or
at the command of foster parents) need not always be a sign of a bad
development of the moral feeling. Such people who are simply spoiled
by the milieu are in a measure still educable,
A great many asocial beings show already in youth the type of
mind that they will represent later. A great many of them are backward in school even if the intelligence is good, because they do not
adapt themselves sufficiently, and show too little diligence or attention.
In rare cases one finds unusual accomplishments in a single direction.
Many are lazy, inclined to steal, and to lie, they are cruel to animals
and human beings, they are full of demands, and either through intention or neglect they spoil their own belongings and those of others,
they are vain, unreliable and egotistic. They cannot yield to authority,
and run away when something does not please them; punishments are
not feared; as a matter of fact neither cake nor the whip produces
any visible effect. In putting through some bad pranks they develop
cunning and energy, they rapidly learn from others the bad things, but
with difficulty or not at all the good ones, and instinctively seek bad
company. A premature sexual impulse in normal or perverse direction
is almost always the rule.
How logic becomes weakened in the same sphere with the moral
feelings is given by Hanselman in a typical example:
An apprentice
590
comes home late at night and soils his bed and Sunday suit by vomiting
and is reproached for it by his master. He then related it and added
impudently: "A master who calls me lousy is no man for me; he has
not learned any manners." Here we see at first quite a different estimation (in the main affective, but also intellectual) of his own action
and that of the master, then a lack of associations in a manner peculiar
The patient does not understand that the situation
to oligophrenia:
demanded the calling down. The first error gives force to the mean-
As severe
ing of the other.
as such going off the track seems, yet
does not alone prove the deep antisocial disposition.
The
it
suggestion
and its organs can

(Compare the war attitude of
of the environment, the attitude towards society

in itself
produce such logical jumps.
whole nations.)
Many
of these children are physically
they show
many
malformed
in
some way;
"stigmata of degeneration."
Aside from the types described in other places as the unclear,

who often become criminals, there is one
unstable, and pseudologs,
group under the various types of asocial and antisocial beings that
can in some measure be differentiated. I refer to those in whom the
feeling tone of all ideas concerned in the weals and woes of others is
stunted {moral imbeciles) or is entirely absent (moral idiots) both
;
groups together would be designated as moral oligophrenics.^^^
Sym-
pathy with others, instinctive feelings of the rights of others (not one's
own) is absent, or is inadequately developed. At the same time the
other kinds of emotional feelings can be perfectly retained, or likewise
can only be affected in a certain degree, for the absolutely apathetic,
the "unemotional" naturally do not become dangerous criminals.
ever, the degree of
of
danger varies greatly;
it
How-
depends on the existence
bad impulses, and the vividness of the activity.

Until now I have never seen moral oligophrenia without finding a
qualitatively similar defect in the nearest relatives, mostly in one of
Moral defects
it is not always easy to show it.
appearing after brain injuries or in mild schizophrenia have quite a
the parents, although
different character.
*" As moral insanity Prichard designated some time ago diseases in which the
"moral" factor in the broad sense of the English expression, seemed to be
affected. Such patients acted wrongly although no confusion of thought was
demonstrable. This included in the first place the submanias (folie raisonnante
German
of the French), then also the obsessive impulses and other diseases.
psychiatry adopted the name in the sense of a defect of the moral feelings.
Both the name and the concept have become discredited because they had been
manifoldly abused practically and theoretically. The concept should not, however, be dispensed with in psychiatry, because it designates a definite disease;
but everj'body agrees that a substitute should be found for the name.
591
Peculiarly enough there arc still some people who for dootrinary
reasons maintain that there are no such moral defeft.s without intellectual weakness, which must be the basis of thf; badly developed
Well, one can naturally find in every man, and
morality.
much
still
some way defective, some slij^ht

normal. But such intangible finding
little is proven by the fact that among
easier in one otherwise already in
deviation from
what one
calls
actually proves nothing; just as
the criminals
many moral
who
allow themselves to be caught one finds a great

It is quite certain that the moral state has
defectives.
no relation to the height of
intelligence, that there are
intellectual
oligophrenics with a well developed moral sense, and that one meets
moral
idiots in
pathologic
whom
one can demonstrate neither any other kind of

nor a mental disease, nor any explainable
disposition,
intelligence defect; but one
must not look
for the latter in prisons
only.
Moral
idiots
criminal."
The
form the neucleus

latter embraces,
of Lombroso's concept of the "born

however, in unclear association also
e.g.
the excitables and unclear ruffian or people
with epileptoid characters.
The author has moreover asserted many

who is a sort of latent
the child. But only a small part of the
other criminal natures,
strange theories, like that of the "reo nato,"

epileptic, atavistic,
and
like
born criminals in any
way
we know
it is
nothing, and
resemble epilepsy; about atavism in
man
absolutely false to confuse the tendency of
a murderer with that of a primitive warrior, that of the thief with that
normal from an environment which has another sense of

Nor is it true that the born criminal is like the child. The
of the
property.
normal child has
altruistic feelings as
this direction; the only thing
it
soon as
it
can express
itself in
does not understand sufficiently
is
the
complication of the relations, so that the feeling tone must be absent

in
some situations where it would manifest itself without anything

who examine the magnitude of things from all
further in adults
sides.
Despite these weak spots and
its
poverty in logic Lombroso deserves
great credit for having set going the study and treatment of the criminal in place of the simple repression of the crime.
there
codes,
is
is
at least a
more general demand
which are quite inadequate
for a
change
Thanks
to him.
in the criminal
for the present needs,
and the way
being paved for a general improvement.

I.
The
fighting
The Contentious
(Pseudo-litigious)
maniacs stand between those who
feel in the right
and
forever appeal to the law, on the one hand, and the paranoid litigants,
592
on the
This middle form cannot be differentiated from the
other.
former; but
is
that although
quite definitely separated from the other

it
leads to false conceptions
it
by the
facts
never attains the form
of a real delusion, that the disease does not continue to progress, but
simply the temperament that leads to many fights which

need not necessarily be connected with one another and cannot be
given up, when the patient finally recognizes the uselessness or some
that
it
is
of the dangers of a certain fight.
Unimportant as well as important
differences equally involve the whole person, for the patients are too
have any feeling and understanding for the rights of

others. All acts of others running counter to their own demands they
conceive as malicious, or as personal insults. Their character shows
an enhanced feeling of self, "a mixture of sensitiveness, regardlessness
Their own affair they feel as the
and arrogance" {Kraepelin).
they
consider it a ''duty" to carry it
very affair of justice and
sensitive to
through.
The understanding
narrow
ness.
of the patient varies, but
field of vision,
Like in
and with
it
affective people the
all
most of them have a

and strong alert-
a certain cunning
memory
manner that the experience becomes changed
is
in
disturbed in the
the sense of the
patient's feeling of self.
The "development,"
Through constant
if
one
may
speak of such in this disease, varies.
fighting with certain neighbors
who
give tit for tat,
the patients naturally merge into an incessant state of irritability which
makes
their
anomaly look worse.
or especially into
To
Transference into more favorable
new circumstances
gives
them peace
be sure, they regularly neglect their callings.
ternal
reasons
it
almost always involves men;
character live through
The
it
in quarrels
for some time.

Probably for ex-
women
of
similar
within the family.
from the paranoid forms is very charcompared by Kraepelin with the difference between the
theoretical difference
acteristically
traumatic patient,
who
as a result of a single experience remains so
must feel sick, and the hypochondriacal patient

who now discovers that, and now this sign of disease.
The recognition is in most cases not difficult, but its differentiation
from the normal is not easy. Some of the people so designated show
manic moods of a chronic nature. These differ, however, from others,
mostly by a certain kindness which becomes mixed in all quarrelThey are able under conditions to speak quite well of their
ings.
enemies and become reconciled to them after the worst kind of
constituted that he
brawls.

XIV.
593
OLIGOPHRENIAS (PSYCHIC INHIBmONS OF
DEVELOPMENT)
The study
of the associations
and memory have shown us that
the brain or the psyche holds so firmly the individual experiences

as well as their connections, that whatever
is
^"^
experienced simultane-
ously or in immediate sequence forms a uniform memory structure

which can again be ekphorized through every individual engram. Thus
certain classes of engrams, simultaneously acquired, form associations
with one another.
Associative connections of a different kind are
also formed between new and former experiences and then between
the same ekphorized engrams, and thirdly, the memory pictures are
brought into connection with one another in memory and thought.
The formation of engrams varies comparatively little. Most animals
have a memory, but in principle it is obviously only for those experiences which they can use. Idiots form engrams of everything. But the
development of the associative connections fluctuates within the widest
limits,
we may say, from the animal and idiot, to the genius, for intelligence depends chiefly on the manner of the possible associations.
Hence in the pronounced psychisms of inhibited developments we
deal, as it were, only with a want of associations. ^^
Wherever the
poverty of the same inhibits the progress of the person, depending on
the degree of disturbance, we speak of idiocy, imbecility, or debility,
morbid pictures, which Kraepelin comprises under the name of
oligophrenias.
ment"
is
The
parallel expression "psychic inhibitions of develop-
a misconception.
well as other things
may
Intra- and extra-uterine brain diseases as
result in the
same poverty
of associative connections as in inhibition of
of the possibilities
development in the struc-
ture of the brain.
One must, however, sharply
distinguish
jrom the brain develop-
ments, the development of the psyche, or the acquisition of experience

material in childhood, without which the most endowed structure would
remain
sterile.
With the help
of the associative connections, the indi-
vidual engrams of the sensations are raised to concepts and ideas by

the childish psyche.
This "psychic development," the gathering and
*" Individual
experiences range from the simplest sense perceptions (green,

flat form, the position on the plant, etc., which make up the concept of leaf)
to individual actions which in their totality form a complicated scene.
**The possibilities of psychic connections must naturally depend in some way
on the number of the anatomical elements in the brain; however, 0114: does well
not to bring into relation the process oj association with the aneitomic ''association systems" oj the brain.
594
arranging of experience material, naturally becomes insufficient

the receptive organ
is
when
All oligophrenias are, in this respect,
disturbed.
inhibitions of development.
Moreover, some also think, more or
less clearly,
that just as the
physical strength continues to grow after birth, the
same holds true
it
psyche as far as its disposition is concerned; that normally

progresses during the whole of childhood while in the oligophrenics
"remains still." If we disregard the training of functions, this idea
is
quite confused, and, in part, certainly false.
for the
it
Such a development has nowhere been comprehended on a purely

intellectual sphere.
On
the other hand,
we
are familiar with the fact
that the emotional lability and the fiightiness of volition observed in

the
become transformed
child
the
into
definite objective desires of the adult.
more
To
stable
feelings
and
be sure, there are some
quite rare forms of diseases designated as "Infantilism" which retain
the infantile characteristics, but such grown-ups show a very

distinction
from real children.
marked
Besides, infantilism as such does not
by any means represent a clear cut picture of a disease. It is often

mixed with signs of mental debility, with sexual abnormities in which
the sexual aim manifests itself in playing instead of in the sexual act,
and in an unchildlike impulse to "play" the child.^^
To
be sure, one frequently speaks erroneously of a deficiency in
intellectual development.
eight year old child
But
and stops
if
an imbecile attains the level of an
there,
it
does not signify that this "stop"
due to the fact that the ontogenetic development progressed from birth to this point and stopped, but it means that the
capacities possessed by the patient from the very beginning suffice
to elaborate the material into such a complication as one would put
before an eight year old schoolboy. Again it is quite another matter
if a hitherto normal child becomes afflicted with some brain disease
and then cannot learn anything more complicated, remaining, as
it were, at a standstill.
But here we deal with a child who was permanently intelligent, who became permanently stupid.
Oligophrenias differ from all other mental diseases through the fact
is
essentially
that as a result of insufficient assimilation of empiric material, scanty
and inadequate ideas and concepts are formed in childhood, and that
as a resu'.t of a permanently existing poverty of the associative connections,
even the
actual
em^piric
material
cannot
be
adequately
elaborated.
Although
=""
we deal with a general disturbance

weakness of intelligence alone stands out
in the oligophrenias
of the cerebral cortex, the
Cf Hirschfeld, Sexualpathologie, Weber, Bonn,

.
1917, p. 29.

symptoms
as the principal
595
For the weakness of
of these diseases.
not only of the greatest practical importance, but the

very cerebral anomalies that come into consideration represent in a
intelUgence
certain
is
quite
relation
uniform simplification of the intellectual
apparatus, whereas other functions like the instincts and affectivity
need not necessarily be affected, or even when deviating from the

normal they radiate into the most dissimilar directions and show
nothing that is typical of imbecility. As a matter of fact, affects
euphoria or anger are the same
like
the animal, at least as far as
functions
The
show
in the genius, in the idiot,
we can
in
colossal quantitative differences.
oligophrenias comprise not only the congenital disturbances
but also those that were acquired in early childhood.
why even
Despite the
many good
practical
science should not be satisfied with such a
summary
multifariousness of
reasons
and
observe, whereas the intellectual
all
these diseases there are
judgment. The weakness of the associations and the existence of the

disease during the bringing up stamp the whole group with something
and what
characteristic symptomologically,
of
common practical importance.

The oligophrenias are, in part,
and even
weakness
in cases
it
may
where a
definite
is
more, with something
simple aberrations of the normal,
morbid process produces the mental
The
be hardly perceptible.
pathological group can-
not therefore be separated from the normal into which it gradually

changes through mental debility and narroivness or through stupidity.
But even within
these entities there are only fluctuating transitions on
One
a psychic basis.^"
of
a higher degree
who
are
absolutely
designates as idiots in a general
who cannot
unfit
socially;
as
those
who can
still
mix
in
human
patients
any school knowledge or
acquire
not advance beyond the position of
way
imbeciles
common
society
patients
school
who do
graduates,
and can even perform some
subordinate services, and as mental debility one diagnoses those
come
who
or
who
to a standstill in the development after the public school or
can still maintain themselves somewhat

they fail when confronted by the average
of little medical, but of greater forensic
in simple relationships
independently; that
is,
demands.
is
Debility
significance.
Other
criteria
with marked limitations are really of no value, for
the simple reason that the various spheres of intelligence

different heights in the
viduals
who
same
patient.
are unable to talk, or
who
attain
Idiots are supposed to be indi-
are unable to execute a verbal
""The etiological anatomic division is quite

number of distinct pathological pictures.
great
may
diffarent;
here one can see a
596
order, or
who show pronounced
fluous to say of imbeciles:
physical deformities.
"That, as a
If is quite super-
understanding oi
numbers hardly goes as far as ten, when the patient can learn to count
mechanically even up to 100." Sollier as well as Ziehen make a moral
distinction between the
contrary to
defective,
all facts;
and
two
classes in favor of imbecility.
imbeciles
idiots as
rule, their
may
This
is
be morally as high as they are
malevolent as they are kindly.
The only
difference lies in the fact that the lighter grades, the imbeciles, rarely
come
to the physician, while the idiots are always in need of care.
Some
often obtain a scale of the grade of imbecility through a

Thus a patient is said to
compaiison with children of a definite age.
have reached a level of an eight year old child, and with the BinetSimon ^^^ test one can really delude one into the formation of such a
parallel.
But one must remember that the child has an enormous
advantage over the imbecile, as it quickly learns more new experiences
it has the paths for new understanding and all he needs is to bring
them in contact with experience. On the other hand, the imbecile
has the advantage of having numerically more widespread experiences
which thus enable him to move about more freely, as, for example,
to make a journey, or do some work, in which the child is still helpless.
The intelligence of the normal child is therefore never on the level of
the imbecile. Certain complications of thought are still inaccessible
to the child because it lacks experience, while in the case of the
imbecile the complications of thought are lacking because he is deficient
in the capacity to absorb complicated experiences.
Symptomatology. Idiocy can be recognized without any difficulty.
The treatment, too, is more in line with nursing and education than
medical interference. It would, therefore, be superfluous to give here
a more accurate description of severer forms, and the subsequent
psychopathological remarks will be devoted, in the first place, to
imbecility. Still whatever is said of the latter is also true of idiocy, if
the defects are markedly exaggerated, and of mental debility, if the
defects are minimized.
Perception and apperception are

the diminution of the
association
little
of
naturally often produce severe injuries.
disturbed directly through
ideas,
whereas complications
disease which is at
The brain
^The idiot was also compared to an animal, and was .said to evince an
"animal-like dementia." Of course, both an animal and an idiot have smaller
capacities of association than the normal person, but the animal brain is a
simpler machine excellently adapted for the required situations, whereas the
idiot's brain is a more complicated but unsuccessful or spoiled apparatus which
has an insufficient adaptive capacity. A chronometer does not sink to the level
of an hour-glass just because it is badly constructed or because it is spoiled.

the basis of oligophrenia
is
597
very frequently connected with disturbances
of the senses, especially that of hearing, which not only affects per-
ception and apperception, but also extremely retards or
makes even
the whole psychic development impossible.
Oligophrenias which are not complicated by diseases of the sense
organs often show some dullness of the sensations; in any case the
perceptions are often correspondingly somewhat retarded. The threshold of differentiation
is
patients never learn to
Some
as a rule quite high in all spheres.
know
perspective or pictures in general; thus
a compass is a globe, and an hourglass is a bottle.

They do not
understand scenes pictorially represented because they see only the
detached elements. They see "a man holding the hand of the other
who
is
man," but they cannot
in bed; here stands a
see the connection
of the elements, namely, a physician at the bedside.
Association of Ideas.
The
oligophrenic has not the capacity to form
the necessary number of associative connections
and what is somekeep them in mind simultaneously at a given

moment. He thinks more in unelaborated sensible terms than the
normal person, and he thinks only of customary things which frequently occur, and of simple matters which require few associations.
He abstracts poorly, i.e. he forms only simple concepts, some of which
are incorrectly abstracted, but he is not able to form any abstraction
to
thing different
in the specific sense.
Nor has
the oligophrenic the capacity to separate
ideation complexes once formed; that
is,
he has no ability to "reproduce
in different order the material formerly acquired"
Ignoring that which
is
(Hoche).
not of frequent occurrence and making
better use of customary material causes a kind of insufficiency of
memory.
This
is,
however, only secondary and the actual defect lies

The latter may simulate under
only in the lack of associations.
on the head of a nail
many
memory
defect, as
when
times in succession.
This
certain conditions an absolute
a spider
is
jumps
not because
the spider "forgets" that the nail head
is not edible, but because it

cannot distinguish this particular black spot from other black spots
which usually represent flies. To react to it differently than to flies
the spider would have to perceive

it
its
particular qualities or to associate
then with the details of the environment.
many
Both conditions require
associations.
Yet to a certain degree the number of associations can be replaced

by the frequency of the experience. Thus the perceived details of the
nail-head or the individual sensations of the environment may suffice
to form a distinction even where there are relatively few associations,
if
the sensations are constantly repeated in a
way
that
now
one.
.598
now another detail will become

To be sure, an animal rich in
firmly associated with the edibility.

association will acquire right at the
the connections necessary for the particular purpose.

Accentuating the characteristic elements, the abstraction, as discussed
above, is also facilitated by a repetition of the same experience, i.e.
first
experience
all
most
customary
the
fact
that
the
for
accounts
That
characteristic elements.
material is always more realizable even where there is no question
many
repetitions of similar experiences will perforce develop the
of facility of
memory
in the sense of practice.
Another example would be the case of an oligophrenic who repeatedly allowed himself to be duped by the same or similar April-fool
jokes. His associations centered only on the joke, but he did not con-
new
nect his
experiences with the idea of the critical day.
Under
certain circumstances he was also unable to form sufficient abstractions to distinguish the jokes from what was intended to be serious.
However, when the same joke was very frequently repeated, the
and the weakshould

not have been.
where
he
minded patient became
depend
on
the
number
of assotherefore
memory
the
The effects of
deception finally
did bring about the association,

suspicious, even
ciative connections, altogether regardless of the fact that ekphoria gen-
erally
easier, the
is
more association paths
it
has at
its
disposal.^^^
Moreover, the poorer the associative connections, the more repetitions

are necessary before the psyche can utilize a complicated situation
through memory.
Hence
it is
mainly the everyday events that come

is unable to use in his reflection the
into being in the oligophrenic; he
uncommon material.
The poverty of
impedes the formation of concepts

combination of many actual
more, they must be not only of the present
association
because the latter naturally require a
and what
experiences,
but
is
The more abstract a concept the more commust be made. That is why there is an absence of higher
also of the past.^^^
binations
abstractions.
essential is
Many
formed because the

from the unessential. For the essential
concepts are also falsely
not differentiated
which constantly repeats itself in the various

which
are
composed into a uniform concept, or subseexperiences
which
attaches
to itself the fundamental deductions.
quently that
(popular)
concept
of "leaf" is held together by the
Thus the
grows
out of a plant, whereby all the
the
structure
which
flatness of
element
is
either that
other attributes can change.
element
is
the destruction of
=^Cf. p. 31.
'" Cf p. 13, etc.
.
In the concept of "poison" the

life
resulting
from taking
it
common
into the

body.
Whoever does not connect together
all
599
the more important
experiences of leaves and poisons can never have a correct concept of

these things. What is more, a great part of the concepts is not inde-
pendently separated by the child, but is brought about by language.

This particularly necessitates many associations and accounts for
the fact that imbeciles find
and to correct
their
own
to take over strange concept.s
it difficult
in speaking with others.
represents also a separation of the ideas

material.
too
much
from
The
abstraction
the ordinary concrete
Because inhibited, the ideation material consists in only

of concrete individual pictures instead of an elabora-
sum of ideas. But if some general concepts are once formed,

owing to their easy accessibility (similar to those in organic cases),
they are very frequently used where they are inapplicable (e.g.
"implement" instead of "shovel").
tion of the
The separation
of the ideation complexes can take place in the
positive or negative sense:
The
detailed experience, as for example
the green color in the concept "leaf,"
green and other colored leaves, or
may be dropped, for there

may be emphasized as
it
are
the
essential distinction, like the characteristic form of all oak leaves,

through which the detail is recognized. The separation is effected
through new experiences. Thus if one has seen green leaves only,
then the form of the leaf as well as its position on the plant become
firmly associated with the color green.
One only imagines green
leaves.
But then one notices a red leaf. He who possesses many
associations of ideas will
form and
position, but he
still
now
the idea of leaf with its

has besides two separated ideation
associate
complexes, one with the green and the other with the red color
component. Following the usual laws, the second will inhibit the
first in so far
as
green; the latter
it
is
disagrees in the partial
therefore "separated."
component with the idea

If,
conversely, in
many
oak leaves the form is always repeatedly perceived, despite such

differences in size and color, we then say that in the concept complex
"oak leaf" the figure is accentuated and separated from the general
concept of the leaf. On the other hand, the imbecile does not view
simultaneously the structure of color, form, and position, and therefore shows a tendency to ignore some individual components and to
overestimate others.
If
one of them,
let
us say the color green,
made
a special impression on him, then the red leaf will not stimulate in
him the association of the green leaf. The two experiences continue
side by side disunited without influencing each other, or he may ignore
the color and then fuse them into one concept, but it does not come
to his consciousness that there are green
and red
leaves.
In both
600
cases the structures as a whole remain stable.
But
vidual components from the sensation complexes
to single out indiis
as important a
fundamental condition of concept formation as putting them together.

It is also an essential part of the process of abstraction and at the
same time one of the fundamental conditions of reason.
The difficulty in differentiating the structure, owing to a lack of
understanding of the important element, explains the apparent contradiction that on the one hand the patients often cannot associate
to an individual quality despite the fact that frequently they repeatedly
stick to a mere partial manifestation. The patient takes all men with
yellow buttons as policemen because he was unable to form the correct
concept of a policeman, and the buttons have especially impressed
him; he can associate only to them; on the other hand, he is not able
to distinguish between a beech leaf and an oak leaf because he is
incapable of isolating the individual quality of the various formations
of the borders.
Experimental Associations are so very characteristic in the oligophrenias that they can be used for diagnostic purposes. But a more
The
precise examination can be done only in the torpid forms.^^*
retarded course of psychic reaction can be measured here, because
even with perfect understanding of the experiment and without stupor
the reaction time may be prolonged to double. The poor capacity for
abstractions is shown through the fact that the patients find it hard,
indeed, for the most part they are altogether unable, to respond
Words and concepts occur in life
to the stimulus with one word.
only in association and can only be isolated artificially. This cannot
be done by torpid oligophrenics, and accounts for the fact that

instead of an isolated concept they express a whole idea. Thus the
stimulus word "to light" brought the reaction "The baker lights the
But they do not even grasp the stimulus word
wood."
but something like the question:
concept,
about
?" or
"What
is
the meaning
as a separate
"What do you know

?"
As the only similar

new situation
experience happened in school they easily confuse the
with the one in school and often answer according to the rules,
examples, and phrases studied there, even if the answer is quite incorconsists of snow). As they are unable to associate to
rect (Winter
a mere word, and must put everything in one connection, their inner
associations are
'^*
more numerous than
in
an intelligent person.
The
Wehrlin, Uber die Assoziationen von Imbezillen u. Idioten. Diss. Ziirich

Also Jung u. Riklin Diagnostische Assoziationsstudien, Barth, Leipzig
1906.
1906. For the general application of the association experiment in mental cases
as used by the Ziirich school see Chap. VIII of Brill's Psychoanalysis, Its
Theories and Application, 3rd Ed. Saunders, Phila.

content
especially rich in explanations
is
and above
all
GOl
in definitions
The following will

of the concept mentioned by the stimulus word.
cells, where one
of
consists
prison
light;
to
Lamp
illustrate it.
locks
up
useless people;
The
each other.
wreathyou
father
he
see
head part; war when two countries fight

may also be given through examples:
explanation
it
threw me
Turn festival; sick I was already

down the stairs.
at the
once
sick;
from the many repetitions in content

applied where they do not fit; the
frequently
and form, which are
by a synonym or it is slightly
replaced
be
then
stimulus word may
serves for a great many
expletive
an
Frequently
varied (cat kitty).
"man" which in the
word
the
of
true
especially
This is
answers.
but serves here
indicator,
complex
a
speak,
to
intelligent person is, so
man; swim
the
(head
thought
of
poverty
the
frequently to conceal
The poverty
of ideas results
More frequently than healthy persons,

can swim).
at all, and this is especially the
associations
oligophrenics find no
does not always mean
reaction
no
words;
in somewhat unusual
The vagueness and
stupor.
emotional
an
it is merely a question of
the
man
the
case
that
lack
expressions frequently
of clearness of the concepts and manner of
(wedding serves for
manner:
dramatic
come to light in the most
grandmother older
are;
children
many
amusement; familywhere
part; star
component
tree
sugar;
has
mother; sweetwhen a girl
from the
idea
the
of
removal
insufficient
The
a part of heaven).
of
consists
sing
To
thus:
seen,
concrete material is also sometimes
the patient (emonotes and song books. The slight bewilderment of

peculiarities.
various
through
itself
tional stupor) often expresses
oligophrenic diswhole
the
describe
naturally impossible to
It is
Some
varieties.
turbance of intelligence, and especially all its infinite
functions.
principle
various
the
of
examples should illustrate the defects
only
Christ
of
knows
patient
The
The Adhesion to the Concrete:
have
"We
Tell?)
Wilhelm
was
(Who
what he saw on pictures.
and children
played him in the neighboring town; masked women
now still
and
Altdorf,
in
up
put
were there too." Or: "One Tell is
Confederates?)
three
the
know
you
another statue in Burglen." (Do
"0 yes, there were three men who raise their hands high and stretch
The difference between Catholics and Protestants
their fingers so."
standing
fact that the Catholics have Christ on the cross
consists in the
(Where does one go when he dies?) "In the cemetery

there a new church."
near the church in Seebach. They have made
they prick? One was
"Don't
(What is this? [picture of hedgehog].)
thinking the normal
customary
in
on our ground in the fall." Even
distinguished from
are
which
ideas
mostly utiUzes elaborated
on the
person
streets.
602
the concrete.
He
thinks of a certain person as a brutal character,
whereby he does not have to know whence

the imbecile he
is
that person
this idea originated; to
who gave him
a beating at a certain
place.
The Inability
to
Get
Away from
the
Customary:
"You make
divide an apple for three persons?)
(How can you
four pieces, give one
and one remains." ^^^

Bad Formation of Abstract Concepts: ''Helvetia is the woman who
is copied on the coins, and always walks around Switzerland to kill
those who wish to harm it." "Freedom is when one has no debts."
piece to each
"Religion is when one goes to church." To be sure, such defects are

not seen at their best in the provoked definitions, which even in the
healthy person do not exactly correspond to what one wishes to convey, but in the occasional use of such concepts.
of justice, but understands
by
The patient speaks
only the deserved punishment and
it
not also the merited reward; he speaks of religion and includes in it

came to his meal at the proper time. Or a patient
the fact that he
speaks of states and territories and mixes them with cities, towns,
and countries, showing that he has no clear concept of either a state
or territory, and that his knowledge of a city or town is only fair.
Poor Abstraction Capacity: The patient has learned to calculate

by means of match sticks but is unable to do the same problems with
He writes: "In the garden the weather is always nice"; he

unable to imagine the idea of garden when he is not in it. A short
story read, as, for example, a fable, he often relates in the subjunctive
eggs.
is
mood, because he cannot
have read that.

from a complex of
ideas, the patient is then altogether unable to answer only this
question.
He is forced to bring in the whole connection and thus
sometimes fails to answer the question either directly or by implication.
(But how were you annoyed?)
"Because I am just conservative. ..." This was given to the question as to the relation of
If one questions
rid himself of the idea: I
him concerning a
definite detail
the conservatives to the liberals.
Just as oligophrenics are unable to disregard a greater complex
a new idea into new conhe can say correctly the numbers
of ideas, just so are they unable to bring

nections.
The
patient can count,
in succession, but despite
count also his own
fingers.
all
i.e.
effort
One
he cannot actually be
made
to
of Kraepelin's patients has learned
to cook quite well in a bigger kitchen, but
when
she
was
later in
another home of only three, four people, she served just as
many
^"Cf. also the example of the driver who didn't think to drive around a
stone lying in the street but beat the horse, p. 82.
003
When
the patients
eggs as she formerly did for a whole round table.

are confronted with
new
tasks, or
environment, the thoughts
when they
many
in
are transferred to a
of tliem almost stop
new
(emotional
stupor)
Frequently the patients grasp even

they have merely heard,
all
the details of the stories
the story of Wilhelm Tell, but cannot
e.g.
reproduce them without help, because the logical connection has not
become clear to them. Some form quite incorrect combinations:
Moses
fed five thousand
Peter?)
"He crowed
very characteristic
men on
the
three times."
Mount
Where
of Olives.
(Who was
vivid phantasies exist
and distortions are often made up:
additions
Gessler put a pole right across the street, Tell was to have walked
under it. The people who killed Christ were uneducated. The forbidden tree in paradise bore poisonous fruit, and Adam was punished
because he would not go to the tree.
Low grade imbeciles cannot understand a clinical examination
(They are here "to give information").
Next to great Gullibility, there is still a greater inability to pick

up information. Only in simple things do oligophrenics become wise
through experience. For they really do not understand the connections
and do not know what the problem is. Nor can they transfer one
experience to another even
if
the situation
also hindered because the patients are not
knowledge,
e.g.
they believe that they
is
know
Instruction
similar.
aware
is
of the limits of their
everything.
when
she was told to put

She thought that no one could be so stupid
as to pay her something for being obliged to take care of her money.
Another defective could not be convinced that a certain foreigner
was not weakminded because he mispronounced some sounds and
because he used expressions different from the vernacular used exclusively by children and imbeciles.
Many of these persons are altogether unable to grasp that an
answer must be correct.^^^ They answer at random, nod afl&rmatively
to everything that they do not understand, etc.
Particular difficulties are encountered in comparing and differentiating. The more extreme defectives cannot at all understand questions
of differentiation, such as what is greater? which would you prefer?
servant
girl
considered
it
a bad joke
her savings in a bank.
To many
it is
Thus to the
you food? the
impossible to put a question theoretically.
question, If your mother wêre dead,
who would
give
answer was "But my mother is still living." Or to the question. If

you buy a coat for $36, how much change will you get from 50?
"*
Like children in their
first
years and primitive people.
604
was "$15," upon which the patient
the answer
insisted,
because he
once bought there a coat for $35 and received $15 change.
Or, a twothan a one-dollar bill and two halves of a dollar,

because one "must change it and one then gets too little back."
Judgment and Understanding of things and relations are naturally
insufficient, and that accounts for the mistakes which rapidly increase
with the complication and unusualness of the objects to be judged.
Except in the very simple combinations, such as stealing and getting
a whipping, the patients are impeded when it comes to include the
Higher points of view are
past and take account of the future.
naturally not formed and not understood.
Some milder imbecile can still acquire some Vocation with the
A peasant may be able to do the
necessary practical knowledge.
farm work correctly, but in maDiy things he is unable to say why it is
done in this way. The imbecile can do much more than he knows
in contradistinction to the normal child, where the reverse is the case
dollar bill
is
(Kraepelin)
less
At
mostly very
all
events, the capacity for practice in all things
Hoche aptly enumerates the

cile as follows:
he
his
is
terests;
is
intellectual peculiarities of the
imbe-
paltry, sticks to one thing, perceives concretely;
and dependent
in the
conduct of
life
he overestimates
personality, shows a strong development of the egoistic in-
he
is
of strangers
etc."
"He
inconsistent
own
is
slight.
gullible
and to
and shows a slight resistive capacity to the will

own, and eventually evinces abnormal impulses,
his
2^^
Not so seldom the intelligence shows itself quite unharmoniously.

There are some gaps, which are not, however, very striking or then
there are special gifts, as for music, mathematics, for the observation
of the weather, for good optical perception and reproduction in
An imbecile was able to draw the Strassburg

Cathedral with hundreds of details which he has seen only once years
drav/ing, painting, etc.
before.
The Mode of Expression of imbeciles is naturally awkward and

depends on the degree of the deficiency. Most idiots show a marked
weakness even in simple grammar, and in the highest grades speaking
ceases altogether.
Some, even the more
intelligent,
never learn to talk,

Imbeciles
although they hear and understand (auditory muteness).
speak in a circumstantial manner because they are unable to pick out
and omit the
unessential,
and show
preference for familiar phrases.
Orientation as to Place and Time continues to be good, in so far as

"' Binswanger und Siemerling, Lehrbuch der Psychiatric, 3rd Ed. Fischer
Jena 1911, p. 224.

the patients are able to perceive such relations.
way.
far without losing their
Not
Many wander
605
about
these patients are in position
all
In any case, most of those who are at all

familiar with numbers have a concept of an hour, day, and year. If
to judge time correctly.
one should no longer be able to differentiate between day and night

he would certainly also be so stupid that no kind of understanding
could be had with him.
Bad is often the orientation as to position which they sometimes

judge quite falsely and as to the meaning of their own person which
Fig. 43.
Imbecile,
He could repeat whole sermons

Despite the strong vivacity and the many folds the
somewhat microcephalic.
after once hearing theni.

facial
expression
is
very simple, and coarse.
they easily overestimate.
On
sonality from others;

it
is
if
the other hand,
it is not correct to say

not yet separated their perthey speak of themselves in the third person,
that there are oligophrenics
who have
due, like in children, to quite different reasons.
The
Affectivity varies extremely; eveiything that occurs in non-
oligophrenics can also be found here.
But
in these aberrations
from
the type there are deviations from the average as well as extremes.
There was a preference for classifying oligophrenics into dull (apathetic),
and excited
(erethic) types, the former of
to be in the majority.
But there
are just as
many
which are supposed

transitional forms.
606
represent those who on account of their emotional

abnormity attract more attention and hence are more observed. To
The two types only
be sure, the affectivity easily gives the impression of being more

erethic than
it is,
intelligence.
The
because of the slight control exerted through the

lability,
upon some oligophrenics a

causes.
Most
which
not rare and which impresses
is
may
childish character,
be due to
many
show a preference for a definite

affective state. Thus the cretins
of the etiological forms
without complications,
all
move
about clumsily but are jolly people;
most
are
lively
in
of the microcephalics
and
easily
excitable
who
those
directions;
all
have cerebral lesions are disposed to irritability and endogenous moods, etc.
It
is
that
self-evident
oligophrenics
the
incapable
are
of
gradating their finer feelings, for

the latter represent reactions to
modulations of complicated
finer
ideas which the patients
The
facial expression
is
lack.
therefore
undeveloped, just as in a clumsy

looking drawing, but an additional factor in
Fig.
44.
Imbecile
showing foohsh
laughter. Although he expresses a certain amount of astonishment or expec-
most cases
is
the
inadequate motor coordination.
Even
the tone of speech expresses
modulations of affects only in

coarse outlines.
In some, not
tation besides the effect of laughter, the

expression is uncommonly coarse and
uninhibited.
It does not express any
pla> ot thought. The expression is the
opposite ot "spiritualized," it is the
exclusively torpid oligophrenics,
punch
pain, which as a rule
ot figure type.
there
is
marked
insensibility to
may
be of
central origin.
Very frequently, especially in actual brain diseases, one observes

depressive or irritable, seldom euphoric moods, which often cannot
be distinguished from those of epilepsy; sometimes they are accompanied by headaches and other paresthesias and even by lighter confusions.
Moods resulting from outer causes are just as frequent.
Some come
to the physician on account of attacks of rage, which in

part are comprehensible reactions to a situation not understood, but
in part represent exaggerated answers to a usual stimulus.
607
Corresponding to the affcctivity the attention is very varied; to be

it is most frequently normal.
Many severe cases impress one
sure,
with a strong hypervigility which makes them incapable of resisting

every noise, every fiy coming into their
the shghtest distraction;
of vision distracts them.
field
It
is
conceivable that education as
well as useful occupation are deeply hurt by
it.
In some the attention
very quickly.
flags
Just as in
position
of
But
same pacannot
it
marked
inequalities in the dis-
various
the
of the
feelings
tient.
aberration, there are
all
rr"
be
said that definite classes of

feelings are especially lack-
ing
The
developed.
or
moral
compara-
feelings
tively seldom suffer
gophrenics
if
oli-
who do not come
to the attention of doctors
are
included
also
these
here;
naturally
feelings
cannot accentuate any of
more complicated con-
the
cepts because the patients
love,
to form the
Attachments and
even gratitude, are
quite
commonly
unable
are
same.
seen,
al-
though they are markedly

reduced as a result of a lack
in oversight.
It
evident that,
all
is
also self-
things be-
ing equal, a low intelligence
can only
trol
insufficiently con-
impulses and affective
fluctuations.
Fig.
45.
A 45 3'ear? pyrgocephalus
(steeple-shaped skull) an erethic female idiot,
without clear speech but

attend to her own wants.
who
can, however,
Cretins are as
a rule quiet and kindly disposed, but not really apathetic. With the
majority of oligophrenics one has a vers^ pleasant emotional relation,
just like parents with children.
Sexual feelings and impulses are usually present. A great many

A complete absence of the sexual feelings
mostly occurs in cretinism, but here it is not rare.
of the patients masturbate.
The memory
in oligophrenics, like the affectivity, fluctuates
from
608
very bad to phenomenally good, but the majority are by far in the
middle zone. It is not correct to say that as a class these patients
have a bad memory. On the other hand, it is quite obvious that things
which they do not understand, and differentiations which they cannot
grasp, are badly retained in the head
exactly like in other people.
Nevertheless just
among
imbeciles
there
are
striking
exceptions;
some remember well things which they do not understand, and some
after one hearing, retain in memory a whole sermon verbally and
Fig. 46.
Microcephalic
middle grade.
with good imitation of accentuation. Like in non-idiots, a particularly

good memorv^ for numbers, optical impressions, and similar things is
readily connected with special talents in corresponding directions.^^^
Following moods, confusional attacks, and even after strong excitements, perfect or partial amnesias are not rare.
Of the psychic accessory symptoms only the actual excitements
"' For the explanation
of the
insufficient use of experiences, see
apparent memory weakness as a

under association of ideas.
result
of
609
and moods are to be mentioned. But then there are complications,

which in any case are often directly connected with the disease. Thus
above all there is epilepsy, then all possible psychopathies and neuropathies, especially
hysteroid manifestations;
katathymic delusions which
may
furthermore, there are
resemble an unintelligent paranoia
but often connected with hallucinations, and under certain fonditions

can be cured. Whether the
schizophrenia sometimes also
observed is only accidental,

having been grafted on oligophrenia, is not yet known.
Physical Symptoms.
The
deeper the oligophrenia the
more frequent and the more

pronounced are the physical
anomalies encountered idiots
;
are only exceptionally well
formed people.
the disease
is
part of
directly
con-
nected with the disease of

the
such
brain
as
micro-,
hydro- or macrocephalus. As
a result of cerebral and spi-
nal cord diseases the limbs
malformed and paraOther symptoms are

the accompanying manifesare
lyzed.
tations
ease.^^
loosely
of
the
Still
brain
dis-
others
are
connected with the
mental disturbances and are

signs of the bad foundation
in general; among those can
be mentioned pyrgo-, and
scaphocephalus,
all
possible
Fig.
j'ears
47.
High
grade
microcephalic.
25
head circumference
Height 150 cm. In an idiot asylum
old,
the
greatest
40 cm.
he was anxious, irritable, uncleanly, crying,
biting, and scratching.
Subjected to better
treatment he was a clean, erethic idiot. He

understands requests and can express simple
ideas in sentences, also slightlj- useful in the
house.
"stigmata of degeneration,"
smallness from the beginning of youth ranging up to dwarfishness,
malformed and poorly developed teeth, deep horizontal fold in the
great many dystrophies are

forehead, chronic skin diseases, etc.
associated with abnormal functions of the endocrine glands, of which
the thyroid, hypo- and epiphysis are especially important. ^Nlany of
"*
See pp. 367-8 for the cretin habitus and the signs of congenital syphilis.
610
these patients not only remain small, but resemble children even in
The ages
their general physical formation.
guessed as
much
of elderly idiots are mostly
too young; "they do not age."
The movements are badly coordinated in the severe cases. Speech becomes unwieldy, frequently there is
stammering and
The
ing.
and secondary
closes
badly
The perception and
and
The
may
the
soft
sound).
(nasal
imitation of the
refinements of speech in
directions
primary
syllables are often in-
accented,
sufficiently
palate
lisping, rarely stutter-
distinctions between
its
various
especially be disturbed.
gait of idiots, if at all possible,
awkward, and clumsy; the patients

have not learned to use only the
is
necessary muscles in quiet attitudes;
they waddle and walk too heavily;

elasticity
and grace are absent. Where

is deformed one observes
the labyrinth
the characteristic disturbances.

rarely there
is
Not
a finer or even coarser
tremor sometimes during motion, and

sometimes even at rest.
The knee reflexes are almost always exaggerated.

The Behavior. The most severe
cases of idiocy are perfectly helpless.
They
lie
or
sit
around
like children;
they are regularly unclean.
Depend-
ing on the temperament, they play or

are unruly, they are noisy, strike one
FiG.
48.
paralysis,
another,
Cerebral
showing the
tj'pical at-
titude of the right upper extremity.

Slight atrophy of the right
surrounding.
selves,
motions with their
frequently accompanied
sounds.
especially
Erethic idiots
if
they are
by
movements; they rock themshake their heads, and make
fingers, etc.
These movements are

and grumbling
definite grunting, crying,
who cannot
still
anything at all in the

Many of them, and still
fewer of the higher grade idiots, have

definite
leg.
definite playful
or
infantile
be educated are a great plague,
capable of going about.
They grasp every-

thing,
they
soil
and destroy things througli carelessness and
611
also
intentionally.
Those standing on a higher
level lack "bearing"; the
hanging jaw.
the open, sometimes gaping mouth, frequently evince a lack of psychic

energy.
Even those who
are fortunately not so often erethic and approach
to the middle level of imbecility are not so easy to manage, because
they forever harbor some design; intentionally or unintentionally, they

are up to something, they run away, steal, and fight. Sexual crimes,
exhibitionism, murderous attacks
up to
lust murders, are not so rare.
The more quiet ones, if they can keep themselves clean and eat alone,
can be managed like children.
The sex character shows itself in all of the various classes in a
remarkable and pronounced manner. Feminine idiots wish to have
attention and invent for this purpose every possible trick they scratch
themselves, so that the physician should have to treat them, etc.;
even the best of friends are jealous of one another. It frequently
happened that I had to pull out teeth simply because I performed
this operation on one of the fellow inmates. Male idiots tease and fight
readily, even though there is no enmity between them.
At play as at work many of them continually become more and
more stimulated until they can no longer stop and finally merge into
;
excitement like some children.
In so far as they are not hindered by criminal tendencies, imbeciles of
and
higher standing with an orderly bringing up
social order,
and most
of
fit
in the family
them can make themselves somewhat
useful; in cases of special talents or in other good conditions the}'
can even earn nice sums. One of my patients did verj- well as a
"landscape painter" at a watering place by manufacturing always
the same picture cards in great numbers.
Many imbeciles feel the need to show that they are not so stupid;
that is, they have a strong "intelligence complex" which results
not only from the inadequate self-cognition but directly from the
which they compensate. To be sure, the

as an overestimation or as an idea of
insufficiency, is also found in other patients and in healthy people.
Crimes are not seldom committed by imbeciles, and that not only
by those brought up with difficulty and by moral defectives, but also
by those who are otherwise kindly disposed; in their faulty valuation
of things, slight occasions may often lead to murder and especially
arson.
(We have already spoken of sexual crimes.) A slight quarrel
with the employer may provoke a suicide^ a simple reproach for somefeeling of insufficiency for
intelligence
complex, be
it
612
thing wrong, an act of arson.
An
imbecile
was displeased because
brother and sister-in-law were talking nearby, so he set

house.
may
How
a lack of
judgment and comprehension
fire
of the situation
lead to a violent act was shown by a mental weakling
maintained himself independently
for years.
his
to the
He went
to a
who has
comrade
Fig. 49.
Female idiot with an enormously undeveloped muscular system; the
skin was tightly stretched so that e.e. there was no longer any conj\mctival sac.
Height about 120 cm. She looked no different in life than she looks here as a
corpse.
She never attained the weight of 120 kilos. She could make herself
shghtly understood through speech. Imbecilic excitements on emotional bases.
Was able to knit. Died at about the age of 40 jêars. Her twin sister is exactly
the same.
who had an account
in
and warted to buy a

The comrade naturally
row and, as he was threat-
a delicatessen store
sausage and bread on the former's account.
hesitated, whereupon the patient created a

ened with the police, he walked out and broke a show window. Mental
weaklings naturally ver>' readily imagine themselves in an untenable
situation and may then commit the crimes described above.-^^
^ See
p. 538.

Deeper congenital
Course.
The
early.
613
children
fix
idiocies are mostly recognized very

on nothing, do not grasp after objects, do not
laugh, and remain backward in everything that is called psychic, and

mostly also physical development. To be sure, in some cases the oligophrenia first starts after birth in consequences of a brain disease, especially encephalitis
time at school,
and meningitis.
others
still
Many
when they
lighter forms fail for the first
are about to apply the material
learned in their apprenticeship, or even later on going out into independent existence, or in the army, where they attract attention not
only through ignorance, but also through stupor, and desertion.
Women
become
easily
men
tutes,
prosti-
alcoholics; both fre-
quently get on the
streets.
sudden event like the death of

the parents, which puts the patients on their own feet, sometimes brings the disease to the
surface;
other
likewise
tasks, a change of place with
may
relationships,
bring
new
new
on a
stupor, or anxiety rising to con-
fusion with delusional ideas,
and
even hallucinations.
The marked
diversity of the
quantitative course depends on

the disease lying at
Some
tion.
its
founda-
backward only
are
comparison to other children,

but continue to catch up to some
Fig.
in
extent.
Others continually be-
come worse,
especially
at
pu-
fingers.
50. An idiot playing with her

She is grown up but cannot
Somewhat
talk.
presence
graphed.
of
stupefied features in the

the act of being photo-
berty, regardless of the other standard which results from the new
tasks.
Among these "progressive oligophrenics" one especially finds
Sudden or gradual aggravations may appear even

is not known; in any case there are slowly
hereditary lues.
later,
the cause of which
progressing cerebral degenerations of various kinds. The vital force

of oligophrenics, especially of idiots, is poor. On the average they do
not get
old.
The
easily become
have seen them as early
with pronounced brain atrophy.
They
their fifth decade
causes
of
ill
oligophrenia can
be
divided
into
the
as in
following
classes:
I.
In one class
it
is
a matter of various faDiUij predispositions,
614
which manifest themselves
in this
way
it
the last link of a progressive degeneration.
and not proven.

II. There are
also
germ
said that oligophrenia
is
This concept
is
is
not clear
through alcoholism of the parents
injuries
(procreation while drunk?), syphilis, and
still
other diseases.
General diseases of the mother and her pelvic organs may

under certain conditions, even though quite rarely, bring about a
III.
malformation of the skull and the brain.

IV. Brain- and general diseases of the fuctus and the child, above
all meningitis and encephalitis, as well as any brain injury.
''
^^^T^.*.^
^
^^^^^^r
''^^^--'^H^^^^^^^^^^^^K
'^^^^r-^
^^K-^^B
1
Fig. 51.
Half sided
microgyria in a mild imbecile with hemiparesis.
The names (taken from Weygand) may
give an idea of the special
diseases:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Psychic defective states in early youth due to lack of education.

Psychic defective states due to an absence of some of the senses.
Psychic weakness due to an inhibition of disposition.
Idiocy on the basis of inflammator}^ brain diseases.
Idiocy on the basis of inflammation of the meninges.
Idiocy through hydrocephalus.
Amaurotic familiar idiocy and related disturbances.

Tubercular hypertrophic sclerosis.
Mongolianism.
10. Infantilism:
Infantilism due to heart disease.

Infantilism in intoxications and infectious diseases.
615
11-16. Glandular infantilism.
12.
thymico-lymphaticus and idiotia thymica.

Thyroid disturbances (Dystliyroidismj.
13.
Dysgenitalism.
14.
Hypophysis disturbances (Dyspituarism) acromegaly.

Hypophysary dwarfishness.
physary disturbances.
Adrenal disturbances.
11. Status
trophia adiposo-genitalis.
15.
16.
Pluriglandular diseases.
17.
Syphilidogcnic idiocy and infantilism.
18.
Alcohol and weakmindedness in childhood.
19.
Athetoid Idiocy.
20.
26.
Chorea and weakmindedness.

Spasmophilia and epilepsy.
Idiocy and rickets.
Chondro-dystrophia and weakmindedness.
Steeple shaped skull and weakmindedness.
Dementia prsecox in childhood.
Dementia infantilis.
27.
Manic
21.
22.
23.
24.
25.
DysEpi-
depressive insanity in childhood.
degeneration and inhibitions of development.

Neurasthenia and infantile inhibitions of development.
30. Other diseases of the central nervous system in connection
with psychic inhibitions of development.
Many of the forms concern more boys than girls.
Special Forms. Still two more states of idiocy are described, which
do not altogether fit in with our cases of oligophrenia and should better
be put under the original morbid states or under the psychopathic
28. Hysterical
29.
personalities.
The Uncleai" Ones.
There are cases which are not at all so poor

form unclear concepts. They have not as
yet been particularly described. The unclearness seems to be conI.
in associations,
and
still
nected with a lack of firmness in the association complexes, so that a

concept, or an idea has at this moment this limitation and in the
following
Most
moment
quite another, without the patient being aware of
who are related to

many phantasies and
of these cases are active natures,
it.
the manic
are quite
temperament. They have a great
unsteady in their desires and actions.--^
"He
Illustration: Carpenter builder, owner of his own business.
rarely answers a question clearly and directly, even where it would
be to his advantage and where there is no reason for evading it. He
*^
Cf. pp. 26, 68, 68.
616
usually says something else from which one must figure out the answer.
He designated it as a libel on the part of X. when the latter, as a
witness,
confirmed the fact that the patient smoked at his work,

This indistinctness is one of the reasons
which he admitted himself.
for his absolute inability to judge himself
After
have, for example, recounted to him
his wife
and he admitted them
a good husband, that one like

of fact, just as in the former
and to
all his
in part, he could
him she
asylum he
realize his faults.
rude actions towards

still
say that he was
will never get.

is
even
still
now
As
a matter
'pretentious'
and pleased with himself."

When he came to the hospital he believed that he had Fr. 25,000
in cash, while his wife had to exert the greatest effort to save the
business from bankruptcy. He believed that it would be easy to put
And then
make us believe that
To be sure, he had
the business in a flourishing state, but could not say how.
he again spoke in the same sense and wished to
he conducted the business better than his wife.

once himself confirmed the fact that his guardian had saved his
houses for him.
He
know whether his machinery was mortgaged. He

know how much he owed on his property. He signed notes
and had no idea how he would pay them. He made a direct demand
did not even
did not
that his wife pay him back Fr. 25,000 but could not substantiate
On what
it.
grounds he would base his claim when he would sue

his wife for the return of his business he had no idea.
Once he went
legal
so far as to assert that there
because the business was
was no need
of getting the business
His foolishness in allowing himself

to be sued by the Woman's Clinic for a small sum, he does not even
realize now. As he was angry because his wife went to the clinic he
refused to pay, but failed to understand the consequences, namely,
that in so doing he did not hurt his wife, but the innocent clinic and
above all himself. So also when he incited the workingmen against
his own business merely to cause his wife difficulties.
Just as foolish
was his action in the hospital when he refused to give a history of
his life, or to object to his temperature being taken when he was
And the worst of it is the fact that even now after four
sick.
years he is not able to recognize the mistakes he then made in
his.
anger.^^^
The lighter grades of this and similar disturbances are designated

Von Guden as higher dementia, according to Hoche as "parlor
dementia." It concerns people who usually absorb the school material
since
quite well, under certain conditions even excellently, and can even use
"" Cf. also the
Nature Healer,
p.
69 and below.

it
in certain combinations,
failures in
life.
but
Their behavior
617
of great activity they are
in
spite
is
the reverse of the oligophrenics;
they have
much knowledge and can do
good, even
if
nothing.
Endowed with a
not with a very exact memory, and with a more or less
readiness of speech, they fool many a teacher; indeed, they may pass
their college examination and even higher ones.
Above all, they
have a great
adapt themselves quickly to circumstances

In certain relations they are instinctive psychologists and thus very able to "do" the people.
One finds among
ability to
but only externally.
themome very
successful swindlers. If their oral and printed psychic

products are more closely observed, one finds repetitions of ideas of
others in newer arrangements and more confused formations of the
same.
A young man
a lecturer;
had gone so far

to examine
when he had
in
another college that he became
officially a girl
who was
illegiti-
mately pregnant he could not understand how this was possible; he

took an umbilical cord for -a fcetal ventral fin. Another held political
speeches, but among other things he was rigid and firm in believing
that the only aim of the other party was "to make the people stupid."
A third was a nature healer; he wrote a mass of pamphlets, had an
enormous income and maintained so many disciples that they formed
many sections of a society, which existed for years, to spread his
This patient wrote the following, among other things:
truths.
"Transparency with the help of self-cognition and world cognition
can only be produced in so far as the person is transformed into a
love glowing condition." He wanted man to become transparent so
that his diseases could be seen. "In the glow, bodies if they don't
become transparent they are at least translucent, hence also in the
glow of love." Such is the unclearness of the concepts and logic of
such people.
II. Another form into which the higher dementia merges without
any demarkation is the relative dementia. Not always, although
frequently, there exists also here a certain unclearness of thinking.
The most
however, is a disproportion between striving and

There are people whose understanding suffices for a
usual attitude of life, and often even for one a little above the average,
who, however, are too active, and constantly adjudge to themselves
more than they can grasp, and therefore commit many stupidities and
suffer shipwreck in life.--^
The psychic ^^* diagnosis of idiocy is self-evident; of most cases
essential,
understanding.
-^ Bleuler, Verhaltnisblodsinn.
Allgem. Zeitschr.
Reimer, Berhn, 1914.
f.
diagnosi$ at the basis of the brain disease
is
gerichtliche Medizin. Bd. 71.
^ The
Psychiatrie
ii.
here omitted.
Psj-chisch-
618
of imbecility it is also easy it first becomes difficult in the lesser pronounced forms and in cases of mental debility.
However, high grade cases have also been confused with schizo;
phrenia.
Disregarding the combination of both diseases
(grafted-
schizophrenia) one must consider the kathathymic delusional format

tions of oligophrenics,
which can only be diagnosed from grafted para-
noia by the absence of definite schizophrenic signs, and by the fact that
it
may
disappear altogether.
of movements of many idiots cannot really

be mistaken for the stereotyped movements of catatonics, if one has
seen both forms. They have the character, if not of a deliberate,
yet of a willed act like the dangling of a leg; they do not give the
The stereotyped form
impression as
if
they ran side by side with consciousness and contently

more elementary. The answers to the
are also easier understood and
when examined in school,

what he was doing now, what his father was doing, frequently betray
the defects by the slowness and unclearness of the understanding and
by the circumstantiality of the answers.
The stammering and other speech disturbances of the imbeciles are
not seldom mistaken for paretic speech. The elisions of the latter,
the stumbling of syllables, and the addition of these signs in certain
usual questions concerning birth, what he did
coordinating difficulties are nevertheless
still
easy to recognize.
In
contrast to this one rarely observes in the oligophrenics an inability to
away from
get
the individual sounds;
more often there
is
a gliding
over, a swallowing of the sounds; moreover, the organic connection of
the successive sounds
is
often absent;
it is
as
if
they begin to learn
a foreign language.
can be psychically diagnosed in early childhood;

laugh, who do not grasp for shiny objects and
in general react insufficiently are idiots. Severe cases of malformations
of the head frequently enable even the layman to recognize the
Only
children
idiots
who do not
disease.
As acquired dementias may
in
some
relations externally injure
the actual thinking in a manner similar to those of oligophrenics,

one of the most important diagnostic means is the proof of the insuf-
and knowledge in youth. By assuming a

and a full receptive capacity through the senses,
then possible to draw conclusions from the existing knowledge
ficient acquisition of ideas
definite schooling
it
is
its acquisition, that is, one

can find out to what degree of complexity material has been received
during school time, to what degree it was understood and could be
elaborated upon. But it should not be forgotten, as often happens,
concerning the intelligence at the time of
THE INDIVIDUAL MENTAL

that the knowledge test
for
it.
is
JJLSEA8E8
not the intelligence test but the material
schizophrenic, an organic patient, or epileptic
in the stages
619
when an examination can
still
be
made
will
who
is still
not lose the
more complex and markedly abstract concepts which he has formerly

acquired. The lack of such acquisition can thus demonstrate oligophrenia. But one must be experienced to know what to expect in this
direction in the various circles of average people, and especially must
it
not be forgotten that a person
may
be above the average in one
sphere and at the same time below the average in another.
In both cases one must consider the interest, and the attention
One can remain back at school not only on

account of insufficient intelligence, but also when one does not pay
In the same low intelligence
attention, or does not exert himself.
applied to the learning.
one who has the need in life to follow up the causal relations can know
more than another who is indifferent in this relation.
Moreover the patient may suffer from an examination stupor, he
may not be at home in a special sphere, he may be somewhat negativistic, or, as often happens at examination, he may have the bad
will to make himself appear stupid, and finally he may on the contrary
pass excellently all such tests and fail completely in the one standard
examination which goes throughout life. The latter may be due to
the following variety of causes: his weakness may lie more in the
sphere of the affectivity or of the will, or he may have little understanding for just practical ideas, or his impulses may give him problems and lead him into situations for which even a good intelligence is
not big enough.
Similar situations are frequently observed in schizo-
phrenia, where under certain conditions the patient will be able to
do cube root with ease, and fully understand the whole procedure, but
is
incapable of dressing himself properly.
The
cases of mental debility
and the poorly endowed healthy per-
son are distinguished from each other not by the amount of their
knowledge but by the measure

knowledge independently.
of their ability,
their
It
is
as such but of intelligence as a guide through

latter direction
The
is
decisive factor in all difficult cases
In the deeper standing imbeciles the
some purposes.
incomplete sentences,
^ Wagner
1947.
ability to use
life.
And
only in the
the mental weakling necessarily defective.--^
which must be taken here with particular

useful for
by the
not a question of intelligence
fill
One can
in
is
therefore the anamnesis
care.
Bind
tests (p. 596) are quit-e
also request the patient to finish
Ebbinghause's unfinished
von Jauregg, Gutachten.
text,
Wien, Klin. Wochenschrift,
explain
1913, 26, p.
TEXTBOOK- OF PSYCHIATRY
620
pictures, interpret proverbs,

tests are only useful
and as
tion;
it is
when
and repeat and explain
fables.^^^
Such
circumstances are taken into consideraprecisely the beginner who is sure to lack the perspecall
that come into consideration, one is explicitly

warned against the careless application oj the tests. Moreover the
manner of answering is much more important than the content. The
tive of all matters
test
examinations furnish very good occasions for the state of intelliitself under conditions, but it does not necessarily do so.
gence to reveal
In
however, all these things are of secondary imAll the theoretical tests can be passed faultlessly, while the
all lighter cases,
portance.
patient
is
perfectly unfit to
manage
his
own
affairs.
It
is
not a ques-
and actually his understanding of his own

his whole past, in order to see how he behaved
tion to test theoretically

business, but above all
himself here.
What
Life
is
really the only sure touchstone.
here said concerning theoretic examinations should only
is
be considered as illustrations and suggestions for individual procedures.

It is impossible to prescribe all that
case.
It
is
to be
examined
in the individual
not always of special importance what one talks with the
is
how one observes and how one concludes. Here as in

no other place the physician mu^t set aside his own reason, and depending on the condition of the case he must omit some tests and
insert others.
The most important thing is always the judgment of
patients, but
the observations
is
as
much
and
inquiries.
Despite
all rules
a test of the doctor's intelligence
the intelligence test

as
of
the patient's
intelligence.
But
all
that was said here refers only to the original state of in-
by which it is customary to
understand only a rapid examination of school knowledge and at most
also the knowledge of life, in cases of acquired forms of dementia,
especially with the object of excluding a dementia praecox, is absurd;
to try to make a diagnosis through it is impractical.
Procedure of the Intelligence Tests. The first thing to do in making
an intelligence test is to try to get in contact with the patient so that
he should not merge into an examination stupor or fall into a negative
attitude; one therefore attaches the conversation to something quite
natural, perhaps by questioning him about his health, his sleep, or his
situation. And according to the patient's reaction a subject is chosen
which he is most likely to take up. The differences between the sexcG
are also to be noted; on the whole, more practical and psychological
knowledge is expected in women than theoretic and exact knowledge.
telligence; to use the "intelligence test,"
For further detail see Ziehen, Die Geisteskrankheiten des Kindesalters.

Reuter & Reichard, Berlin, 1915.
^^''

Too much cannot be expected
of
them
in
concepts
G21
relating
to
geography and geometry.
One
tell about his family, what

One can then enter into his school
knowledge by asking him how he was at school, what subjects he liked
In this way it can be ascertained whether he was left back.
best, etc.
allows the patient, for example, to
the father does, and similar things.
When
he relates something from history,
how much he knows, but how he
it is
elaborates
not most important to see

it,
especially whether he
recounts details in phrases which he has perhaps learned by heart, or
betrays a review of things gained through independent grasp and

judgment, or whether he repeats something that is of current opinion,
often possible to find out to what extent the pawork out the essentials and whether he has a sharp
grasp of things or not. One also notices whether he relates things
diffusely or whether he is able to condense them.
To hang on the nonessential, on the perceptible, and in connection with the other symptoms
etc.
Just here
tient
was able
it is
to
also to omit the logical intermediate connections without noticing
shows
Especially
imbecility.
suitable
for
differentiating
it
between
phrase-like repetitions and fully understood elaborations are questions from biblical history
and from the simpler dogmatic theology
("Why
In geography
did Christ die?").
it is
characteristic of
many
oligophrenics that they are well oriented as to their environment in

so far as they have learned
or do not
know
it
through experience, but become unclear
as soon as they are asked something that they should
have learned from theory. Even elementary knowledge in cosmic geography such as how day and night come about, or darkness, etc., need
not be expected with certainty from every healthy person nevertheless
even here the answers are characterized by good understanding on the
one hand, and the opposite in the case of oligophrenics. In calculating one frequently finds that in practical life they have the capacity
to get through with current buying and selling examples and card playing while they fail in simple theoretical examples. Rarely is the case
;
what was taught in school

manner they studied it, but cannot apply
it to practical life.
The latter patients seem at first the more intelligent but they are more helpless in life. In testing in mathematics,
like in everything else, one should begin with easy examples and proceed to the more difficult (first ask patient to count coins, addition
and subtraction, then multiplication. The tables are usually a mat-
reversed, in that the patients repeat only
and reproduce
ter of
in the
memory and
cannot solve 2
14
it
14.
Then go
2,
There are imbeciles who

and
but can easily solve, for instance,
not of understanding.
to division and finally to fractions).
2X2
622
The
patient
is
then allowed
the fables from p. 189.
to
read something simple,
one of
e.g.
Oligophrenics are in most cases easily differen-
by the schoolboy's way of readmore complicated words, etc. The
tiated from later acquired psychoses

ing,
by the
difficulties in rarer or
reproduction of the content
is
not so easily judged because disturb-
even a normal person, when

can read whole pages without grasping anything.
In most cases one can quickly orient himself to an extent that he
can save himself the questions which are too easy or too hard for the
ances of attention easily play a part here
excited,
special case. But in order to obtain as far as possible an exact measurement of the height and the manner of the understanding, it is
necessary among other things to put questions which also seem some-
what
difficult.
The
latter often causes people to say that
we ask
the
patients things which even a healthy person cannot answer, and that
we
incorrectly diagnose mental weakness from this sort of not
know-
Regardless of the necessity for restriction, such questions should
ing.
nevertheless not be avoided, because

ing and not knowing but of
how
realize himself that he does not
conceal his ignorance?
How
it is
not only a question of know-
the patient answers.
understand the thing?
Does he not
How
does he
does he help himself out of difficulties?
Such observations rather than direct questions enable one to recognize easier the psychic height of the not severe cases of imbecility, and
it is particularly the unclear cases which can be discovered best in this
manner. What one asks is indeed really not so important as what
one concludes.
Already from the oral examination it is possible to write a life
history from which one obtains without anything further the degree
of school education, also the conception of
and many other
life,
the wealth of the asso-
The mode of writing with

its awkwardness in letter formation and grammar and content is often
The patient is then allowed to see
characteristic of oligophrenia.
ciation of ideas,
things.
simple pictures, and one observes whether he differentiates between
more rarely, which one knew only

from description, such as strange animals, plants, etc.
Then one uses pictures which represent a situation and observes
whether the patient grasped only the detail or the whole meaning.
current things and those occurring
If,
as exceptionally happens, the examination has thus far failed
to display the patient's capacity for abstraction,
discovered to what extent the patient
is
i.e. if it
has not been
able to form abstract concepts
and use them, an attempt should be made to talk to him directly about
abstracts (work, sleep, jump, memory, glance, poverty, joy, beauty,
bravery, state, redemption), but great care must be exercised in doing

Even healthy persons
it.
623
are not able to define easily the
common
definition.
How
One can then start a conversation about things of life.

he judge his relationship, eventually his crime? Does he
where the material comes
for his
own trade?
significance of the individual manipulation? etc.
here and there from his work?
What
does
know from
Does he know the
Why
did he run
does he intend to do?
How
does he wish to get out of this muddle?
Very good starting
points,
indeed often the diagnosis, can be
obtained through the association experiment.
One must guard
in everything against taking glibness of
tongue or
ape-like reproduction for knowledge or even understanding; moreover
one must watch for clearness of ideas especially in people who are
endowed with a fluency of speech.^^^ If the patient has no stupor
one must verify the degree and extent of his attention, fatigue, etc.
Furthermore, the affectivity must be accurately observed; one should
For this purpose it will somealso see in how far it controls the logic.
times be necessary to bring up at the end of the examination, when
there is nothing more to spoil, emotionally accentuated themes, such
as hurling at the patient merited reproaches, etc.
The
second, often
more important, part
behavior at work and
leisure,
consists in ascertaining his
during the observation, and in his past
life.
The
per
actual oligophrenias are very frequent diseases;
1000
of
the
population
physician has really very
little
them.
to do with them.
belongs
to
more than one
Nevertheless
the
The unclear types and the relative dementias do

They are all incurable, but here
and there still somewhat educable; but more than taking measures
of guardianship can hardly be applied to them with any success. Early
Treatment.^^^
not come so often to the physician.
intervention by transferring the patient into an environment which
and consequently keep him away

wrong waj^s may produce a certain improvement.
Against the disease itself up till now only in cretinism (Thyreodin)
will take account of his peculiarities
.from all
can something be done, perhaps also in congenital syphilis.

Otherwise it is simply a question of care arid education. Both
must be understood in a special way. A certain amount of adaptability is possessed by almost all patients even also by the severer
In consequence of unfavorable treatment, especialh' in cases
idiots.
""Compare the example
^^Cf. also:
Wien, 1914.
of uncleamess, p. 615.
Th. Heller, Piidagogische Therapie fur Arzte usw.
Leipzig
u.
624
of beating or coddling, some patient may become a dangerous and

harmful individual, the control of whom will necessitate many people,
but who under proper treatment may act like a lovely child. Where
dangerous tendencies exist commitment is naturally necessary. Of
special importance in the lighter cases is the selection of the right
vocation, which should better make too little, than too many demands
on the abilities and energy of the patients. Many parents wish to
go too high.
Also in later life it is especially important that the patients have
a position in life suitable to their abilities and temperament; too high
demands are always harmful. But even in the cases who are seemingly most hopeless one should not forget that in most cases some
improvement is possible, very often much improvement, if the patient
is put into the right hands.
Some of the educational institutions for
oligophrenics are very useful.
In excited cases of hydrocephalus a lumbar puncture or even a
puncture of the ventricle may give temporary alleviation. The first
operation can even be periodically repeated.
Where there is a tendency to sexual excesses, sterilization or castration may take the place of permanently confining the patient. But
one must govern himself regarding this advice according to the views
of the environment and follow the legal forms, such as the consent of
all concerned, the guardian, or counsel ad hoc, etc.
Finis
INDEX
Abdcrhalb, rnaction, 442,
Abortion, 222, 445.
Alcoholic paresis, 350.

Alcoholic p.seudo-paresis, 350.
Alcoholic psycho.ses, 299.
Abreaction, 38, 39, 501.

Absences, 448.
Abstraction, 16.
Abulia, 51, 143.
Accessory symptoms, 54.
Accident neurosis, 564.
Activity, disturbances of, 141.
Acute confusion, 364.
Alcoholic twilight state, 302.

Alcoholism, acute, see Intoxication.
Alcoholism, chronic, 303.
Algolagnia, active and pas.sive, 574.
Alternating personality, 137.
Altruism, see ethics.
Alzheimer's disease, 296.
Acute course, 167.

Acute dementia, 365; curable, 365.
Acute (hallucinatory) paranoia,
Amaurotic idiocy, 182,

Ambitendency, 382.
Ambivalencv, affective,
Aoasia, 543.
organic, 345.
164,
487.
Affect reaction, see Affective result.
Affect stupor, see emotional stupor.
Affective actions, 149.
Affective
effect,
morbidity
Affective
Affective
Affective
Affective
Affective
effects,
one-sidedness,
126;
of, 493.
exaggeration
of, 494.
grade, 102.
Amuck, 459.
Amylene hydrate,
in
enemas, 223,
276.
Analgesia, 56.
Anonvmous
result,
Affects, affectivity, 12, 32.

Affects, deficiency of, 126.
Affects, displacement of, 35, 37, 118, 499.
distractibility of, 124.
disturbances of, 117.
dominating forces of, 33.
examination of, 188.
lability of, 124.
occurrence, 197.
Agitated dementia, 436.
Agitated depression, 478.
Agitation, constitutional, 485.
Agoraphobia, 561.
Aichmophobia, 561.
Aim
of thought, 21.
Akinesia algera, 542.
Akinesis, 146.
Alcohol, as therapeutic agent, 223, 326,
341.
in brain traumas, 241.
Alcohol delirium, chronic, 346.

Alcohol epilepsy, 353.
delusions, 351.
hallucinosis, 163,
intolerance, 301.
melancholia, 354.
paranoia, 351.
Amentia, 163, 193, 364.

Amnesias, 100; anterograde, 102; retro-
577, f.n.
Anesthesia, 57.
exaggeration of, 126.

Affects, abnormal duration of, 124.
Alcoholic
Alcoholic
Alcoholic
Alcoholic
Alcoholic
125, 130; schizo-
phrenic, 382.
Androgynous,
epilepsy, 459.
perversions, 126.
psychosis, 465.
243.
letter writers, 539.
Anxiety, US, 119.
Anxiety deliria, 211.

Anxiety neuroses, 165.
Anxiety psychoses, 165.
Anxious mania, 478.
Apathetic oligophrenia, 605.
Apathy, 124.
Apoplectic cerebral lues, 248.
Apoplectic insanity, 281.
Apperception, 13; disturbances
Appersonation, 137.
Apraxia, 146.
Aprosexia, 134.
Arithmomania,
of. 57.
561.
Arterio sclerotic insanity, 276, 277.

Artificial feeding, 221.
Artificial language. 398.
Association, 12. 17; brevity of, SI. So.
Association disturbance, 71 occurrence
;
in,
195.
Association
Association
Association,
Association
experiment. 41.
hostility. 42.
laws of, 41.
mediate in schizophrenia,
376.
341.
Association readiness, 41
in delusions
of reference. 95.
Association
reflexes,
hysteria, 554.
625
23.
494.
49S;
in
INDEX
626
Association tests, 188.
Associations in oligophrenia,
82,
597,
et seq.
Astasia-abasia, 543.
Centrifugal functions, disturbances
Athetoid movements, 157.
Centripetal functions, disturbances, 55.

Cerebral concussion, 241.
Cerebral inflammation, 242.
Cerebro-spinal fluid, 238; in cerebral
lues and luetic pseudo-paresis,
247, 248 in paresis, 254.
Character, 39, 128.
epileptic, 445, et seq.

hysteric, 547.
paretic, 254.
Attention, 4.
Attention, blocking of, 135.
disturbance of, 133.
Attitude, false, 127.
Attonity, 146, 163, 411.
Auditory muteness, 604.

Aura, 446.
Autochthonous ideas, 91, f.n.
Automatism, automatic actions,
Child paresis, 250, 270.

Child psychoses, 212.
Childbirths in mental diseases, 159; as
causes of, see puerperium.
Childhood, disposition to psychoses,
212.
8,
150,
Chloral, 222.
Chloralamid (in enemas) 276.

Chorea, Huntington's, 243.
Chorea gravidarum, 363.
152.
in schizophrenia, 408.
Autosuggestion, 44.
Chorea gravis, 363.

Chorea magna, 363.
Chorea minor, 363.
Chorea St. Viti, 363.
Choreic movements, 157.
Barbed wire disease, 536.

Basedow's disease, 365.
Baths, 220.
Bed treatment, 221.
Beer-heart, 303.
Belief, 47.
Beriberi, 207.
Bladder, stuttering of, 127.

Blastophthoria, 203, 559; prophylaxis,
214.
Blood-pressure (arterio-sclerosis), 284.

Bodily weight, 159.
Borderlines of insanity, 170.
Brain diseases, insanity, 242.
Brain injuries, insanity, 240.
Brain tumor, 242.
Brevity of the associations, 81, 85.
Bromide, 223; in cerebral traumas, 241.
Bromidia, 279.
463.
Buffoonery syndrome,
165; in prison
psychoses, 535; in schizophrenia,
412.
Burdening of heredity,
Buying maniacs, 540.
Buzzard's method, 186.
of,
142.
Attacks, 166.
catatonic, 400.
Bromism,
Causal thinking, 20.

Cause, concept, 19, 20.
Causes of mental diseases, 200.
200, 203.
Chronic course, 167.

Circular dementia, 433.
Circular forms, 168.
Circular insanity, 483, see
Cyclic
in-
sanity.
Circumstantiality, 86, 450.

Civil condition, as cause of psychoses,
208.
Civilization as cause of insanity, 207.

Classification of mental diseases, 173.
Claustrophobia, 561.
Clavus, 542.
Clear-mindedness, 116.
Climacteric psychoses, 211, see Involution psychoses.
Climacterium as cause of insanity, 211.
Climacterium
virile, 211, 488.
Climate, causes of psychoses, 207.

Climatic treatment, 222.
Clouded
states, 162.
Cloudiness, 114, 163; in schizophrenia,

412.
Cocaine, following brain injuries, 241.
Cachexia-strumipriva, 366.
Carbonmonoxide poisoning,
299.
Catalepsy, 153.
Catatonia, 417, 434.
Catatonia, chronic, 434.
Catatonic states, 412; in fever, 361.
Catatonic symptoms following traumas,
199; in child psychoses, 212.
Catatonic-like symptoms, occurrence,
199; in paresis, 256.
Catatonic symptoms, 148, 154, 199, 403;

in paresis, 256.
Cocainisra, 359.
Collapse delirium, 364.
Collecting mania, 586.
Collective unconsciousness, 44.
Collectors, morbid, 540.
Color-hearing, 66.
Coma, 56, 114.

Combined psychoses,
Command
193.
automatism,
152,
schizophrenia, 408.
Command negativism, 407, 408.
Commitment,
216.
154;
in
INDEX
Commotion
Degeneres
psychoses, acute, 240.
Compulsion neurosis
(199),
560;
505,
Freud's explanation, 89.
Impulsive insanity and CompuLsion
Compulsive
acts, 68,
149,
150, see
neurosis,
affect, 561, 562.
fears, 561, see Phobias,
hallucinations, 563.
ideas, 87, see Compulsion neurosis;
differentiated from crowding of
thoughts, 80.
impulses, 89, 561, et seq.
laughter, 409.
compulsive phenomenon
processes
syndrome,
flpVPg
Confabulation, 106, 107, 231, 333.

Confusion. 86, 113-114, 162.
acute, 301.
delirious in syphilis, 247.
flight of ideas, 466.
hallucinatory, 436.
of space, 2.
Constellation, 21, 22.
Constitutional depression, 484;
excite-
ment, 484.
Contentious, 591.
Contractures, 157.
Conversion, 501.
Convulsions, 157.
Coordination disturbances, 157.
Coprolagnia, 574.
Coprolalia, 150.
in
schizophrenia,
381.
Cretinism, 367.
Criminals, classification, 587, 588; congenital, 591.
Ciyptomnesia, 109, 110.
Curing with defect, 169.
Cyclic forms, 168.
Cyclic insanity. 483.
Cyclothymia, 485.
Damage
Damage
evolution
ayBtcma-
tique, 437, 529.
Delire d'emblee, 91.

Delire d'enormite, 93.
Delire de negation, 93.
Delire du toucher, 88.
Delirium, 111, 162.
Delirium, acute, 162, 364, 436.
Delirium, exhaustive, 365, 436.
Delirium in schizophrenics, 413.
Delirium nocturnal in organics,
234,
279.
Delirium tremens, 326.

Delusional insanity, 162; acute (amenDelusional
in.sanity,
hallucinatory
of
dnmkards,
341.
insanity, manic, 469.
insanity, melancholic, 476.
insanity, schizophrenic, 412.
need, 90.
reactions, 495.
Delusional
Delusional
Delusional
Delusional
Delusional
Delusions, 90.
Delusions, recognition of, 187.
Delusions of being pardoned, presenile,
536.
Consciousness, 2.
disturbance of, 2, 111.
double, see person.
149;
superieurs, 164.
Delire chronic a
tia), 365.
165.
Concepts, 13; disturbances of, 68.

Condensation, 375.
Condition reflexes, see Association re-
Coprophagia,
627
suit litigants, 566.

suit neurosis, 498, 564.
Deafness, 55.
Debility, 593.
Decision, 11, 51.
Decision capacity, disturbances of, 144.
Decortication, 268.
Degeneration, 164, 201.

Degeneration psychoses, 160, 202, 436;
stigmata of, 160.
Delusions
Delusions
Delusions
Delusions
Delusions
Delusions
the
Delusions
Delusions
Delusions
of drunkards, see alcoholism.

of grandeur, 92.
of injury, presenile, 279, 414.
of jealousy, 94.
of paranoiacs, 521.
of persecution, paranoid of
hard of hearing, 55, 533.
of poverty, 93.
of reference, 94.
of sin, 92.
Dementia, 164, 365.
Dementia, acute, curable, 365.
Dementia, alcoholico-senilis, 293.
Dementia, dull, 436.

Dementia, higher. 616.
Dementia, negativistic. 436.
Dementia
paralvtica, 230, 249, 250.

agitated. 258, 267.
anatomy,
267.
catatonic form, 259.

causes, 268.
classic, 258, 259.
course, 256.
cyclic, 259.
depressive, 258, 263.
diagnosis of. 236, 236.
euphoric, 259.
expansive. 258, 259.
foolish. 433.
galloping, 259.
grouping, 257.
infantile, 250, 270.
Lissauer's, 268.
melancholic, 258, 263.
INDEX
628
Dementia neurasthenic,
Drunkard's
259.
paranoid, 259.
pathology
of, 270.
physical symptoms, 250.

psychic symptoms, 230;
simple demented form, 257.

stuporous, 259.
treatment, 275.
Dementia paranoid, 414, 437.
Dementia
Dementia
prsecox, 372.
post-syphilitica, 247.
Dementia, schizophrenic, 385.
Dementia, secondary, 169, 372.
Dementia senilis, 230, 276, 279, 299.
Dementia, simple, 433.
Dementia senilis, treatment of, 278.
Dementia, traumatic, 241.
Dementia, with mannerisms, 436.
Demonism, 150, 391, see Obsession.
Depersonalization, 142, 476.
Depression, 119.
Depression, constitutional, 484.
Depression, reactive, 537.
Depressional, excited, 478.
Depressive delusion, 92.
Depressive delusion of disease, 92.
Depressive dementia, 433.
Depressive disposition, 485.
Depressive states, 161 ; in schizophrenia,
410.
Depressive stupor, 476.
Dereistic thinking, 22, 45, 79.
Diagnosis of
51, 52.
in&anit3', 184, 193.
Differential diagnosis^ 193.
Dioning, 575,
f.n.
Dipsomania,
351, 586.
Direction prognosis, 169.
Discussion, capacity of, 438.

Displacement of the affects, 35, 36, 118,
119, 499.
Disposition, 182.
Dissimulation, 192.
Dissociation, 86.
diminished in epiDistractibility, 41
lepsy, 83; exaggerated in mania,
;
of activity, 142.
of the impulses, 149.
of the person, 137.
in writing, 155.
Dizziness, epileptic, 448.
Double consciousness, 137.
Double orientation, 383.
Double thinking, 63.
Doubting mania, 561.

Dream-like disturbances of association,
77.
Dreamy
states, 165.
Drinking
ism.
mania,
Delirium
Eccentrics, 587.
Echokinesis, 562.
Echolalia, 152.
Echopraxia, 152; in schizophrenia, 408.
Eclampsia, 299; in children, 459.
Ecstatic pain, 129.
Ectasies, 113, 165; in schizophrenia, 412.
Education, as cause of psychosis, 211;
as prophylaxis, 215.
E'go, 49 (see disturbances of person).
Ekphoria, disturbances
see Chronic alcohol-
of,
12, 28.
Electricity as therapeutic agent, 222,

Elementary hallucinations, 65.
Embarrassment, 127.
Emotional incontinence, 125.
Emotional psychoses, 211.
Emotional stupor, 80, 118, 163.
Encephalitis lethargica, 243.
Endogenous causes,
Enemies of society,
173, 204.
588.
Engrams, 12, 28, 29.

Engraphic disturbances,
99.
Epidemics, psychic, 211.

Epilepsy, 332.
Epilepsjr, alcoholic, 353.
Epilepsy, arteriosclerosis, 283, 286.
Epilepsy, reactive, 459.
Epileptic associations, 82.
Epileptic character, 449.Epileptic equivalents, 443.
psychopathic
constitution,
Epileptic
449.
Epileptic swindlers, 459.
Epileptiform attacks, 445.
Epileptiform attacks in arteriosclerosis, 283.
Epileptiform attacks, occurrence, 199.
presbyoattacks,
in
Epileptiform
phrenia, 296.
E'quivalent epileptic attacks, 443.
Erethic oligophrenia, 605.
Ereutrophobia, 127, 561.
Ethical materialism,
71.
Disturbances
Disturbances
Disturbances
Disturbances
see
accessory,
255.
Determinism,
delusions,
tremens.
Drunkard's misery, 354 f.n.
Dualisms, 3.
6.
Ethics, 52, 128, 148.
Euphoria, 122.
Exacerbations, 168.
Exaltation, 122.
Examination stupor
= emotional stupor,
80.
Excitable, 582.
Excited depression, 478.
Excitement, constitutional, 485.
Exhaustion, 123, 207; nervous, 557.
Exhaustion as cause of psychoses, 207.
Exhaustion stupor, 365.
Exhaustive psychoses, 365.
Exhibitionism, 573.
INDEX
Hearing, disturbances of, 55.

Hearing, hard of, deluwioHH of persecu-
Exogenous causes, 205.

Expansive delusion, 92.
Expansiveness, 92.
Expectation neurosis, 127, 165, 560.
Explanatory delusions, 91.

Explosion readiness, 129.
Extracampine hallucination,
Familiarity, quality
629
60.
of, 31.
Family boasting, 450.

Family care, 219.
Family gossip, 450.
Family murder, 484.
Fear of blushing, see Ereutrophobia.
Fetichism, 494, 573.
Fever delirium, 362.
Fever, psychogenetic, 543.
Final thinking, 21.
tion, 533.
Hebephrenia, 426.
Hereditary syphilitic psychoses, 249.
Heredity, 174, 200.
Hesitancy in speech, 84.
Higher dementia, 616.
Homilophobia, 461.
Homosexuality, 575.
Hunger for excitement, 129.

Huntington's chorea, 243.
Hyoscine, 217, 224.
Hypalgesia, 57.
Hypasthesia, 57.
Hyperalgesia, 56.
Hypera-sthesia, 56.
Hyperbulia, 144.
Hyperkinesis, 146, 403, 411.
Flexibilitas cerea, 153, 403.

Flight into disease, 495.
Flight of ideas, 71.
Folie a deux, 534.
Folie du doute, 561.
Folie raisonant, 468, 590, f. n.
Free floating affects, 36, 120.
Hypnosis, 44. 220.

Hypnotics, 222.
Hypochondria, 163, 436, 557.
Hypochondriacal delusion, 92; in para-
Free will, 51.

Frenzy. 161, 468.
Hypochondriacal neurasthenia
Fright neurosis, 165, 564.
Fugues, see wandering mania.

Gait stuttering, 559.
Gambling mania, 586.
165, 545; in prison
psychoses, 536; in schizophrenia,
Ganser syndrome,
412, 436.
Genius, 171.
destruction,
see Blastophthoria, 203.
Germinal hostility, 203.
Germinal predisposition, 200.
God-nomenclature, 450.
Graft hebephrenia, graft schizophrenia,
437.
Grandiose delusions, 92; of paranoiacs
(495), 524.
psychoses, 245.
Germinal
Gumma
f.n.
Habits, 44 (494).
Hallucinations, 59; diagnosis of, 187.
Hallucinatory confusion, 163, 436; trau-
matic 241.
Hallucinatory dementia, 434.
Hallucinatory excitement, 142.
Hallucinosis, 163
acute in drunkards,
;
341 in syphilitics, 248.

Haptic sense deception, 64.
Harmony, preestablished, 6.
Head anxiety, 121.
Health conscience, 497.
;
Health
116.
noia, 523.
Friedmann's disease, 459.
Gynandria, 577
Hypermnesia, 97.
Hypnogogic intoxication,
spite, 509.
in
svph-
245.
Hysteria, see Psychopathic reaction
forms, 493, 540; traumatic, 566.
Hysterical, 436, 547.
Hysterical amnesia, 546-547.
Hysterical associations. 84.
Hysterical attacks, 547. 554. 555.
Hysterical character, 552, 553.
Hysterical conditions in syphilis, 245.
Hysterical insanity, 547.
Hysterical melancholia, 436, 547.
Hysterical syndrome. 540.
ilis,
Hysterical twilight state, 544. 547.

Hystero-epilepsy, 552.
Hysterophilic diseases, 498, 543.
Iatrogenic neuroses and psychoses, 502.
Idealism, 5.
Ideas, 13; disturbances of, 68.
Identification. 499.
Identifying memor\^ deceptions. 108.

Idiocy, 593; amaurotic, 243; following
traumas, 241.
Illusions, 58.
Imbecility, 593.
Impotence, psychic, 127, 560.
Impressibility, 29; disturbances.
1(X);
examination, 188.
Impulse, 11, 50-51; morbid. 148-149,
562; examination of. 188.
Impulsives, 586.
Impulsive actions. 149.
Impulsive insanity. 538.
Impulsivities, schizophrenia, 409.
Inadequate
affects. 154. 380.
INDEX
630
Incoherence, 86.
Indeterminism, 51, 52.
Individuality, see person; disintegration of the individual. 141.
Laughter, compulsive, 409.

Lavage, 222.
Lethal ending, 169.
Induced insanity,
Leukencephalitis of the corpus

losum, alcoholic, 351.
Liars, morbid, 587.
212, 495, 534.

Infantilism, 165, 594.
Infection, psychic, 533.
Infectious deliria, 363.
Infectious insanity, 361.
Infectious states of weakness, 365.
Influenza deliria, 364.
Inhibition, 79.
of action, 146.
of development, 593.
Inhibitions of associations, 74, 373, 378;
distinguished from obstruction,
Initial
79.
deliria
in
infectious
Letter-wTiters.
539.
cal-
Lissauer's paresis, 268.

Litigious delusions. 166, 495, 521, 533;
after accidents, 566; manic depressive,
paranoic,
521;
487;
schizophrenic, 414.
Logorrhea, 146, 468.
Loosening of the affects. 29.
Loss of blood as cause of insanity, 207.
Lues cerebri, 244, 247.
Lumbar puncture, technique, 238.
diseases,
Malformations, 160.
363.
Insane asylum, 216; for alcoholics, 324.
Manhood
Insanity, hysteric, 547.

Instability, '582.
Instincts, 52.
Intelligence, 23;
Mania, 161, 465,

Mania, anxious,
disturbances, see
De-
mentia.
Involution melancholia, 488.

Involution psvchoses, 211,^212. 276.
Irritability, 123; abnormal, 582?""~~->-
mood,
as a disposition to psychoses,
212.
Intelligence examination, 620.

Intermissions, 168.
Internment in the insane asylum, 216.
Interpretateurs filiaux, 524.
Intoxication, alcoholic, 300; senseless,
300.
Involution, 212, 276.
Irritable
anonymous,
|t
485.
Jacksonian attacks, 166.

Jactation, 146.
Joint reflexes, 158.
Joking mania. 241.
Joy in pain, 502.

Judgment, 21 psychologic,
21.
Juvenile psychoses, 436;

psychoses.
see
Puberty
91,
senilis, 289.
Manic
Manic
attack, appearance, 348.

depressive insanity, 193, 372,
465.
Manic insanity, 162, 469.
Manic moods, 485.
Manic state, 162; in schizophrenia,
410.
Manic stupor, 479.
Manic tendency, 485.
Manifestations of mental diseases, 161.
Mannerisms, 142; in schizophrenia,
406.
Masochism, 574.
Mass epidemics, psychic, see psychic
epidemics.
33.
165.
Materialism,
5.
Maudlin drunkenness,
Korsakoff, alcoholic, 345. 346; after carbon monoxide, 299; in brain diseases, 241 in cocainism, 359.
Korsakoff, curable, 230.
Korsakoff's disease syndrome, 164, 165,
;
230, 241.
Lactation psychoses, 211.

282.
Latah, 153 f.n.

Latent schizophrenia, 432.
in, 478, 479.
164.
Massage, 222.
Masturbatic psychoses, 436.
Masturbation, see Onanism.
Keraunophobia, 561.
Kleptomania, 149.
Lacunary disturbances,
poverty of thought
religiosa,
Mass psychology,
Katathj'mic, 34.
Katathymic amnesias, 100.
Katathymic delusion,
487.
478.
Mania ebriosa, 301 f.n.
Mania, hysterical, 436, 547.
periodic, 483.
300.
Melancholia, 161, 472. 487.

Melancholia activa. 475.
agitata, 121, 475, 478.
attonita,
144,
schizophrenia. 403.
Melancholia, hysteric, 547.
involution, 488.
periodic, 483.
senilis, 289, 291.
simplex, 476.
Melancholic insanity, 162, 476.
Melancholic moods, 485.
Melancholia
163;
in
INDEX
Melancholic
161
stato,
Bchizo-
in
phrcnia, 410.
Memory,
12, 28.
Memory
disturbances,
Neurasthenia, 493, 552, 557, ft scq.;

hypochondriacal
in
Hyphilitica,
245.
97;
occurrence,
Neurasthenia, sexual, 558.

Nf'iua.sthenia .yndromf-, 165, 493, 556.
196.
hulliKiinations, 106.
illusions, 106.
test, 188.
Memory
Memory
Memory
Mendelian heredity,
631
Neura.sthenic association.s, 84.
Neunusthenic melancholia, 487.
Neurokym,
201.
Meningitis, 242.
Meningitis luica psychoses, 245.
11
f.n.
Neuro.ses, 176, 493; see HyHteria, Neura.sthenia, P.seudo-neura.-thenia.

Nihilism, nihili.stic delusion, 93.
Nonne, 239, 248, 254.
Menstrual disturbances, 127.

Menstrual psychoses, 210.
Menstruation, 210; cause of manic de-
Nutrition impulse, 148.
pressive attacks, 489,

psychoses, 210.
Metabolic disturbances, 158.
Obedience, automatic, 152;
Metabolism,
539;
Obsession, see Impulsive insanity and
120.
Compulsion neurosis.
see Compulsion neurosis,
differentiated from crowding of
Metasyphilitic diseases, 250.
Micromania,
Micromelia,
Obsessions,
93.
372.
Miryachit, 153
Nyctophobia, 561.
of
f.n.
Mistake and delusion, 90.

Mistaking of personality, 58; in mania,
469.
thoughts, 80.
Obsessive laughter, 409.
OKstruction, 79; of associations, 79.
Occupation as cause of insanity, 207.
Mongoloid, 372, 614.

Monideism, 74, 85, 119.
Occupation neuroses, 557.

Old age as cause of psychoses,
Monism, 4.
Monomania, 87 f.n., 403.
Moods, constitutional, 485;
Oligophrenia, 593.
Oligophrenic associations, 82.
Oligophrenic, moral, see Moral idiocy.
Omnipotence of thought, 561.
epileptic,
132, 454 irritable as a permanent

state, 484; manic, 122, 131, 485;
oligomelancholic,
119,
485;
;
phrenic, 606.
Moral, see ethics.
Moral idiocy, 587.
Moral imbecility, see Moral idiocy.
Moral insanity, 587; see Moral idiocy.
Moral oligophrenia, see Moral idiocy.
Morbid euphoria, 122.
Morbid
gain, 496.
Moria, 161; following traumas, 241.
Morphine, see Opiates.

Morphinism, 354.
Motilitj' psychoses, 436.
Multiple sclerosis, 230, 242.
Mutism, 155; in schizophrenia, 394.
Mythology,
47.
Myxedema,
366.
Nanism, 372.
Nanosomia, 372.
Narcism, 573.
Narcolepsy, 459, 546.
Negative hallucinations, 44, 65.
Negative memory hallucinations, 101.
Negative suggestibility, 44; disturbances of, 136.
Negativism, 154, 406.
Nephritis, cause of amentia, 365.
Nervosity, 571.
Nervous exhaustion,
557.
212.
Onanism,
127, 572.
as causes of psychoses, 209.
Onanism, psychic, 573.
Onanism, treatment of, 224.
Onanism of necessity, 573.
Oniomaniacs, see Buj'ing maniacs.
Onomatomania. 561.
Onsets, acute, 167.
Operations in the insane, 224; as cause
of mental disease, 211.
Opiates, 223.
Opiophagia, 359.
Opium, see Opiates, 223.
Opium smokers, 359.
Onanism
Organic, 173.
Organic
Organic
Organic
Organic
affectivity. 232, 233.

associations, 74.
psychoses, 230.
syndrome.
231.
Orientation, 32; disturbances, 110;

currence, 196.
Original morbid states. 569.
Original paranoia, 529.
Otahspmatoma,
159.
Over-exertion. 207.
Over-valued ideas.
87.
Pachvmeningitis Haemorrhagica, 268.

Parabulia. 148.
Parasramatism. 397.
Paraldehvde, 223.
oo
INDEX
632
Parallelism, psycho-physical, 6.
Paralyses, 157.
Paralytic attacks, 254; occurrence, 199.
'
^J'aramnesias, 105, 108.

Paranoia, I'SS, 504, 509.
Paranoia, abortive, 528.
Paranoia, acute, IM, 487.
Paranoia completa, 437, 529.
Paranoia-like diseases, 529.
Paranoia originaria, 529.

Paranoia periodica, 487.
>^
Paranoia senilis, 292^'
Paranoiac associations, 83^
Paranoiac character, 532.
Paranoid, 413.
Paranoid
Paranoid
Paranoid
Paranoid
Paranoid
.J'aranoid
Piblokto, 459.
Picae, 149.
Pithiatism, 502 f.n.

Plaques senile, see Spherotrichia.
Plasma
cells
(paresis), 267.
Poetry, 47.
Poison-mixers, 539.
Polioencephalitis superior, 350.
Ponopathies, 557.
Poriomania, 165, 586; see Wanderers.
Post-epileptic twilight states, 447.
dementia, 247.
Potency, 159.
Poverty of thought, 478.
Post-syphilitic
constitution, 105^
Precordial anxiety, 121, 472.

Pregnancy as cause of the psychoses, 210.
melancholia, 476.
Premature
mental weakness, 434.
Presbyophrenia, 230, 277, 294.
schizophrenia, 323<^
Presenile
of
Presenile
Pressure
symptoms, 16V
syndrome, 1S8.
Paraphrenias, 437.
Parasexuality, 574.
Parasthesias, 158.
Parathymia, 380.
Paresis, alcoholic, 350,
Paresis, see dementia paralytica.
Patellar reflexes, test, 186.

Pathological drunk, 300.
Pavor noctumus, 116
Pederasty, 574.
Pedophilia, 574.
Perceptions, 10, 12; disturbances, 56;
occurrence, 194.
Periodic drinkers, see Dipsomania.
Peruiodic insanity, see manic depressive
delusions, of injury, 279, 414;
pardon, 536.
insanity, 276, 279.

activity, pressure occupation,
145, 334.
Primary dementia, 432.
Primary diseases, 169.
Primary symptoms,
Periodic mania, 483.

Periodic melancholia, 483.
Periodic neurasthenia, 487.
Periodic paranoia, 487.
Perivascular ghosis, 283.
Persacutees persecuteurs, 527.
Perseveration, 57, 75, 83, 148; in schizophrenia, 81.
Person, personality, 49.
Personal consciousness, 49.
Personality, annihililation of, 140; disdisturbances
integration of, 141
;
137; dual, 3, 137; in arterioparainsanity,

sclerotic
282;
phrenia, 436; schizophrenia, 436.
Petit mal, 166, 448.
of,
Phantasy, 22.
Pharyngeal reflexes, 158.
Philosophv, 47.
Phobias, 88, 561.
Phobo-phobia, 562.
Physical complaisance, 499.
Physical delusion of persecution, 65; in
54.
Primitive reactions, 494, 497, 498, 537.

Primordial delusions, 91.
Principal symptoms, 54.
Prison
Prison
Prison
Prison
complex, 536.
outbreak, 535.
psychosis,
(126), 436, 535.
syndrome, 535.
Prisoners' delusions, 536.

Prisoners, mental disturbances in, 535.
Process psychoses, 173.
Prodromata,
insanity.
.schizophrenia, 390.
Physical symptoms, 157.
birth, 225.
167.
Prognosis, general, 169.

Progressive psychoses, 173.
Projection to the outside, 389.
Prophylaxis, 214.
Pseudo dementia, 165, 545.

Pseudo fiexibilitas, 153.
Pseudo hallucinations, 69, 389.
Pseudo litigants, 592.
Pseudologia phantastica, 108, 587.
Pseudo neurasthenia, 504. 556, 557-558.^

Pseudo paresis, alcoholic, 350; syphilitic,
247.
Psyche, 1.
Psychiatry, significance of, 226.
Psychic hallucinations, 60.
Psychic scars, 169.
Psychoanalysis, 501, 507.
Psychogenic, 173.
Psychogenic diseases, reaction
forms,
493.
Psychokym,
11.
Psychology of the masses, 43.

Psychopathic forms of reaction,
Psvchopathic personahties, 570.
493.
Psychopathies, 164, (193), 504, 569.
INDEX
033
Psychotherapy, 220.
Puberty, causes of psychoses, 212.
Puberty, disposition to psychoses, 212.
Puberty psychoses, 212.
hebephrenia, 426.
Puerilism, i65, 535, 545.
illusions, .388.
Puerperal fevers, cause of amentia, 365.

Puerperal psychoses, 210, 493.
Pupillary reflexes, 186.
intact functions, 384.

]at(;nt Hchizophn.'nia, 4.32.
memory, 383, .392.
mortality, 384.
orientation, 382-.3S3.
paranoid, 413.
paranoid dementia, 434-436.
Purpo.se p.sycho.ses, 165.
Pyknical type, 177.
Pyromania,
149.
438; extent, 442.

funflamental syriiptoin.s, 373,
diagno.sifl,
hallucination.'-:,
.'187.
Querulance, 125.
paraphrenias, 4.37.
pathology, 442.
Race, disposition to psychoses, 202, 203.

Raptus, 143; melancholicus, 275.
Reactive epilepsy, 459.
Reactive psychoses, 173, (436)
perception, .383, 387.

person, 385, 393.
physical symptoms, 398.
prognosis, 440.
sensory deceptions, 387.
simple, 432.
simple functions, 373.
simplex, 433.
speech, 394.
subgroups, 413.
treatment, 443.
unclearness, 412.
Reality,
7.
Reasoning mania, 88, 560.

Recognition of insanity, 184.
Reflection, 11.
Reflex enforcement. 498.

Reflex hallucinations, 64; in schizophrenia, 388.
Reflex paralysis, traumatic, 565 f.n.
Reflexes,
158;
differentiation
from
psyche, 1.
Relationship of the parents, 204.
Religious delusion, 164.
Remissions, 167, 168.
Renifleurs,_574.
Reo Nato, 592.
Repression, 35, 37, 113-116, 501.

Reduplicative memory deception, 109.
Residual delusion, schizophrenia, 392.
Residual epilepsy, 459.
Restraint, 221.
Retrograde amnesia, 102.
Sadism, 574.
Schizoid, 175, 437, 441.
Schizophasia, 155.
Schizophrenia, 155, 372.

accessory symptoms, 387.
activitv, 386.
affectivity, 155, 378.
ambitendency, 382.
ambivalency, 382.
anatomy, 442.
associations, 77, 373.
attention, 384.
catatonia, 417.
catatonic symptoms, 403.

causes, 441.
combinations, 437.
combined functions, 384.

concept, extent, 436.
course, 434.
delusions, 390.
dementia, 385.
dereism, 384.
will, 385.
writing, 394.
Scopolamine, see Hyoscine.
Second hearing, 390.

Secondary delusion, 91.
Secondary dementia, 169.
Secondary diseases, 169.
Secondary insanity, 169.
Secondary sensations, 66.
Secondary symptoms, 54.
Secretions, 159.
Sedobrol, 463.
Selection of vocations, as prophylaxis^
215.
Self-consciousness, 49.
Self-presei-vation impulse. 148.
Self-reference, 92, 95.
Senile dementia, see Dementia senilis.
Senile insanity. 230, 276; treatment,
278; see Dementia senilis.
Senile mania. 289. 291. 292.
Senile melancholia. 289. 291. 292.
Senile paranoia, 289, 291. 292.
Senile plaques, see Spherotrichia.
Senile psychoses, see Senile insanity.
Senility as a cause of insanity, 212.
Sensations. 11, 12, 56.
Sense deceptions, 41; recognition of.
187.
Sensor>' organs, disturbances of, 55.

Separation from parents, 129.
Sexual aberrations, 472.
Sexual abstinence, causes of psychoses,
210.
Sexual anomalies. 494. 572.

Sexual anxiety, 119, 120.
INDEX
634
impulse, 52; disturbances of,

572; in hysteria, (499-500), 544.
Sexual neurasthenia, 458.
Sexual relations, causes of psychoses,
Sexual
Threats of suicide, 324
444.
Spitefid attitude, 128, 501.
Squanderers, 586.
Status epilepticus, 448.
Stealing impulse, see Kleptomania.
gait, 345.
Stereotypes, 147, 151; in schizophrenia,

404, 408-409.
Sterilization, 214.
Stigmata in hysteria, 406.
Stomach neuroses, 485.
Stupor, 126, 144; manic, 479;
rence of, 198.
Stuporous dementia, 433.
Stuttering, 127, 452 f. n., 559.
Stuttering in writing, 560.
occur-
disturb-
ances of, 135; remedy of, 220.

Suicide, complicated, see Family murder.
Sulfonal, 223.
Superstition, 48.
Swindlers, pathological, 587.
Symbol, 46, 70, 499.
Synasthesias, 66.
Syntonic, 175; reaction types, 177.

pseudoparesis,
see
paresis.
ps5'choses, 249.
Tabo-paresis, 249, 259.

Teliologic hallucinations, 62.
reflexes, 158.
Twilight states, 112, 162, (494).

Twilight states amnesias, 101, 102.
Twilight states, epileptic, 453.
Twilight states, hysterical, 544.
Twilight states, occurrence of, 198.
Twilight states, schizophrenic, 412.
Twilight states, traumatic, 241.
Twins, insanity in, 200 f.n.
Pseudo-
Uncleamess of the
ideas, 26, 68; in oligophrenia, 615.

.Unconscious, 8, 502; collective, 33.
Uranism, 575 uming, 575 f n.
Uremia, 191, 193; compare also amentia.
;
Syphilitic psychoses, 244.
Tendon
542.
Unclear ones, 615.
Syntony, 174.
Tenacity of attention,
Trional, 223.
Trophic disturbances, 158-159; in hys-
Uncleanliness, 234.
164.
Temperaments, 35.
Temperature of body,
teria, 543.
Submania,
32;
Traumatic dementia, 241.

Traumatic epilepsy, 241, 457.
Traumatic hysteria, 551, 566.
Traumatic neuroses, 564.
Traumatic reflex paralysis, 564 f n.
Traumatic states of weakness, 241.
Traumatic twilight states, 241.
Treatment of mental diseases, 214.
Trembling, 157.
Tremor, 157.
Tubular field of vision,

Turbid states, 114.
Turgor vitalis, 122.
Sublimation, 98.
467.
Suggestion suggestibility,
Transference of affects, 35.

Transformation of delusion, 94; of the
personality, 139.
Transitivism, 138.
Transitory psychoses, 163.
Traumatic delirium, 240.
114.
Sopor, 114.
Speech confusion, 155, 434.
Spherotrichia, 277, 296.
Spirit of the times, 43.
Tabes and
365.
Toxemias, acute, 299; chronic, 304.
Somnambulism, 88.
Somnifen therapy in schizophrenia,
Syphilitic
f.n.
Tics, 152, 562.

Torpor, 114.
Torticollis hystericus, 543.
5, 6.
Syndromes,
3.
17.
12,
Thymopaths, 117.
Thyreogenous psychoses,
Somatic approach, 499.
Steppage
of cognition,
80, 152; in schizophrenia, 378.

Thought deprivation, 79, 378.
Thought hearing, 63.
574.
Somnolence,
Theory
the
Thought crowding,
Snout cramp, 405-406.
Sodomy,
affects, 37-38.
Tertian Plasmodium malarise in

treatment of paresis, 275.
Thinking,
209.
Shifts, 168.
Shop-lifters, 539.
Significance of psychiatiy, 226.
Simulation, 191.
Situation psychoses, 166, 493.
Sleep disturbances, 158.
Sleeping sickness, 243.
Solipsism,
Tension of the
159.
40.
Variation stereotypes, 147, 403-406.

Vascular diseases, see Arteriosclerotic
insanity and luetic psychoses.
Verbigeration,
schizoin
146,
147;
phrenia, 405.
Veronal, 223.
Vigility of attention, 40.
INDEX
Wandering
Visions, 64.
215.
Voices of conscience, 62, 387.
Voyeur, 574.
Wanderers, 586.
546.
mania,
(fugues;
Vitamines, 207.
Vocation, selection of as prophylaxis,
Waking dreams,
635
446;
165;
in
in hysteria
schizophrenia,
413.
Weakness
Will,
of will, 51.
conception
of, 52;
disturbances
143-144; freedom of, 52.
Word-salad, 155, 398.
Work as a therapy, 215; in schizophrenia, 444.
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UNIVERSITY

Digitized by the Internet Archive

2010 with funding from

Lyrasis IVIembers and Sloan Foundation

DIRECTOR OF THE PSYCHIATRIC CLIKIC, ZURICH

AUTHORIZED ENGLISH EDITION

THE MACMILLAN COMPANY

By the MACMILLAN COMPANY.

All rights reserved no part of this book may be

up and printed. Published January, 1924.

PRINTED IN THE UNITED STATES OF AMERICA BY

after about five years in the

entered Burgholzli, the clinic of psychiatry at Ziirich, I found a

Having been accustomed

sented by Kraepelin, Professor Bleuler's ways impressed

interesting but also as

scope and result. Professor Bleuler was the

and farther reaching

methods were applied to all accessible patients, and the Freudian

with a strong feeling of satisfaction that

omit this subject for the present.

of the Zurich school are too well known to be mentioned here.

He lays stress on the

whole human being."

Gregory, Director of the Psycho-

pathic Pavillions of Bellevue Hospital and Professor of Psychiatry at

N. Y. University Bellevue Medical

and Dr. M. B. Heyman,

the Superintendent of the Manhattan State Hospital,

of handwriting specimens of patients in his hospital.

appearance of a translation of Professor Bleuler's textbook

supply a need long

his twenty-five years' service as a teacher at the

been a most indefatigable worker and painstaking

investigator in the field of psychopathology and his

contributions and original observations have brought

an outstanding leader in the progress of

Bleuler's monographic studies

have already been

with an admirable symptom-analysis, and psychological interpretation

edition of the textbook which appeared in 1916

crystallization of Bleuler's long experience as a teacher

reception accorded the book

fact that four editions have already appeared.

The book marks

a notable advance in psychiatry in that

phasizes sharply the contrast between the older descriptive psychiatry

work which, as already intimated, marks a

advance beyond the boundaries of the Kraepelinian psychiatry. To

Concerning the Theory of Cognition

Individual Psychic Functions

Concepts and Ideas

Mythology, Poetry, Philosophy

Disturbances of the Centripetal Functions

Disturbances of the Sensory Organs

Central Disturbances of the Sensations

Perceptions (Hyperesthesia, Anesthesia, Analgesia.

Disturbances of Concepts and Ideas

Disturbances of Associations and of Thought. ...